Phase II clinical trial of neoadjuvant anti-PD-1 (toripalimab) combined with axitinib in resectable mucosal melanoma

BACKGROUND

The outcome of patients with resectable mucosal melanoma is poor. Toripalimab combined with axitinib has shown impressive results in metastatic mucosal melanoma with an objective response rate of 48.3% and a median progression-free survival of 7.5 months in a phase Ib trial. It was hypothesized that this combination administered in the neoadjuvant setting might induce a pathologic response in resectable mucosal melanoma, so we conducted this trial.

PATIENTS AND METHODS

This single-arm phase II trial enrolled patients with resectable mucosal melanoma. Patients received toripalimab 3 mg/kg once every 2 weeks (Q2W) plus axitinib 5 mg two times a day (b.i.d.) for 8 weeks as neoadjuvant therapy, then surgery and adjuvant toripalimab 3 mg/kg Q2W starting 2 ± 1weeks after surgery for 44 weeks. The primary endpoint was the pathologic response rate according to the International Neoadjuvant Melanoma Consortium recommendations.

RESULTS

Between August 2019 and October 2021, 29 patients were enrolled and received treatment, of whom 24 underwent resection. The median follow-up time was 34.2 months (95% confidence interval 20.4-48.0 months). The pathologic response rate was 33.3% (8/24; 4 pathological complete responses and 4 pathological partial responses). The median event-free survival for all patients was 11.1 months (95% confidence interval 5.3-16.9 months). The median overall survival was not reached. Neoadjuvant therapy was tolerable with 8 (27.5%) grade 3-4 treatment-related adverse events and no treatment-related deaths. Tissue samples of 17 patients at baseline and after surgery were collected (5 responders and 12 nonresponders). Multiplex immunohistochemistry demonstrated a significant increase in CD3+ (P = 0.0032) and CD3+CD8+ (P = 0.0038) tumor-infiltrating lymphocytes after neoadjuvant therapy, particularly in pathological responders.

CONCLUSIONS

Neoadjuvant toripalimab combined with axitinib in resectable mucosal melanoma demonstrated a promising pathologic response rate with significantly increased infiltrating CD3+ and CD3+CD8+ T cells after therapy.

[Immunotherapy advances for lung cancer combined with chronic obstructive pulmonary disease]

Lung cancer is a major public health problem worldwide, with high rates of morbidity and mortality. It often coexists with chronic obstructive pulmonary disease (COPD), the diagnosis and management of which often receives insufficient attention. In particular, the presence of COPD has significant implications for the clinical management of lung cancer patients. This review systematically assesses the influence of COPD on the efficacy of immunotherapy and the occurrence of immune-related adverse events in patients with lung cancer, identifies existing challenges and proposes avenues for future research in this field.

[Characteristics of genetic variants in 134 patients with Acute myeloid leukemia]

OBJECTIVE

To analyze the characteristics of genetic variants in 134 patients diagnosed with Acute myeloid leukemia (AML).

METHODS

Clinical data of the 134 patients with AML (non-acute promyelocytic leukemia) initially diagnosed at the 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from June 2017 to June 2022 were retrospectively analyzed. Potential variants of AML-related genes were detected by next-generation sequencing, and the frequency of variants was analyzed by using SPSS v26.0 software, and likelihood ratio χ2 test and Fisher exact test were used for data analysis.

RESULTS

The patients had included 72 males and 62 females, with a gender ratio of 1.7 : 1 and a median age of 51 years (9 ~ 86 years old). One hundred twenty patients (76.1%) had harbored at least one genetic variant, including 26 (19.4%) having a single variant, 27 (20.1%) having two variants, and 49 (36.6%) having >= 3 variants. 32 (23.9%) had no detectable variants. Genetic variants detected in over 10% of the 134 patients had included NPM1 (n = 24, 17.91%), FLT3-ITD (n = 21, 15.67%), DNMT3A (n = 20, 14.93%), CEBPA (single variant; n = 14, 10.45%), TET2 (n = 14, 10.45%), and NRAS (n = 14, 10.45%). The patients were also divided into low risk, intermediate risk and high risk groups based on their chromosomal karyotypes. The mutational rates for genes in different groups have varied, with 19 patients from the low risk group harboring variants of NRAS (n = 4, 21.05%), KRAS (n = 4, 21.05%), and KIT (n = 2, 10.53%); and 96 patients from the intermediate risk group harboring variants of NPM1 (n = 24, 25.00%), FLT3-ITD (n = 20, 20.83%), DNMT3A (n = 18, 18.75%), CEBPA (n = 12, 12.50%), and TET2 genes (n = 12, 12.50%). The mutational frequencies for the 19 patients from the high risk group were ASXL1 (n = 7, 21.05%), NRAS (n = 3, 15.97%), TP53 (n = 3, 15.79%), and EZH2 (n = 2, 10.53%). A significant difference was found in the frequencies of KIT, NPM1, FLT3-ITD, DNMT3A, and ASXL1 gene variants among the low-risk, medium-risk, and high-risk groups.

CONCLUSION

AML patients have a high frequency for genetic variants, with 76.1% harboring at least one variant. The frequency of genetic variants have varied among patients with different chromosomal karyotypes, and there are apparent dominant variants. KIT, NPM1, FLT3-ITD, DNMT3A, and ASXL1 may be used as prognostic factors for evaluating their prognosis.

Two novel heterozygous variants in RecA2 domain of the DHX37 cause 46,XY gonadal dysgenesis and testicular regression syndrome

INTRODUCTION

The pathogenic variants in DEAH-box RNA helicase DHX37 are one of the major causes of 46,XY gonadal dysgenesis and TRS. To date, only 13 different missense variants have been reported. We report two additional cases with different clinical presentation carrying two novel variants in the DHX37 gene.

CASE PRESENTATION AND RESULTS

Case 1 (4.4-year-old boy), presented with significant micropenis and cryptorchidism and was diagnosed as TRS. Case 2 (13.5-year-old girl), had a 46,XY karyotype with female external genitalia and was diagnosed as GD. Two novel DHX37 variants affecting the RecA2 domain, p.G478R and p.L627F, were identified in these cases. Both variants identified in the probands were also present in their unaffected mother.

DISCUSSION/CONCLUSION

Our findings broaden the variant spectrum of DHX37 in 46,XY DSD individuals.

A novel corporoplasty technique with a urethral plate flap in hypospadias repair

OBJECTIVES

To report a novel corporoplasty technique with a urethral plate flap in hypospadias repair and evaluate its safety and efficacy for ventral lengthening.

METHODS

Data were retrospectively collected from consecutive patients with hypospadias who underwent urethral plate flap corporoplasty between July 2021 and March 2022. All patients underwent hypospadias repair using the Duckett technique. The corporoplasty procedure involved the following key steps: the half-spongiosum of the urethral plate was harvested as a flap (with a pedicle attached to the corpus cavernosum); a transverse incision of the tunica albuginea was made adjacent to the pedicle; and the flap was patched onto the corporal defect.

RESULTS

The study included 10 patients, with a median age of 20 months. The initial meatal location was penile in two patients, penoscrotal in four patients, and scrotal in four patients. The median ventral curvature was 45° after degloving and urethral plate transection. The median ventral lengthening distance proportional to penis length was 0.21. During the median follow-up of 13.8 months, complications occurred in three cases, including two cases of fistula and one case of urethral stricture with secondary diverticulum. No cases of recurrent ventral curvature, meatal stenosis, or urethral dehiscence were noted. Postoperative ultrasonography showed a good continuation of the tunica albuginea and integrity of the stratum spongiosum at the corporoplasty site.

CONCLUSIONS

Urethral plate flap corporoplasty is a simple and effective ventral lengthening procedure. The novel corporoplasty technique allows for anatomical and architectural repair of corporal disproportion.

[A combined regimen based on bortezomib and glucocorticoids for 6 patients with recurrent/refractory immune thrombotic thrombocytopenic purpura]

Objective: To observe the efficacy and adverse reactions of a combination therapy regimen based on bortezomib and glucocorticoids in recurrent/refractory immune thrombocytopenic purpura (iTTP) . Methods: Six patients with recurrent/refractory TTP were included and treated with a glucocorticoid and two courses of bortezomib-based regimen. The clinical remission status of patients, changes in ADAMTS13 activity/ADAMTS13 inhibitor, and the occurrence of treatment-related adverse reactions were observed. Results: Of the 6 patients, 2 were males and 4 were females, with a median age of 21.5 (18-68) years. Refractory TTP was found in 1 case and recurrent TTP in 5 cases. Glucocorticoids were administered with reference to prednisone at 1 mg·kg(-1)·d(-1), and gradually reduced in dosage after achieving clinical remission. Bortezomib is subcutaneously administered at 1.3 mg/m(2) on days 1, 4, 8, and 11 with a 28-day treatment course consisting of 2 courses. Six patients achieved clinical remission after receiving bortezomib as the main treatment. ADMATS13 activity returned to normal in all patients with TTP after treatment, and the ADAMTS13 inhibitor turned negative. Thrombocytopenia is the most common adverse reaction after treatment, with other adverse reactions, including peripheral neuritis and abdominal pain, but ultimately all patients returned to normal. In a median follow-up of 26 (9-41) months, 5 patients maintained sustained remission, and 1 patient relapsed after 16 months of bortezomib treatment. Conclusion: Combination therapy of bortezomib and glucocorticoids has a satisfactory therapeutic effect and controllable adverse reactions for recurrent/refractory iTTP.

[Clinical diagnosis and treatment of hereditary thrombocytopenia and purpura: a report of five cases and literature review]

Objective: To report the clinical manifestations and laboratory features of five patients with congenital thrombotic thrombocytopenic purpura (cTTP) and explore its standardized clinical diagnosis and treatment along with a review of literature. Methods: Clinical data of patients, such as age of onset, disease manifestation, personal history, family history, and misdiagnosed disease, were collected. Treatment outcomes, therapeutic effects of plasma infusion, and organ function evaluation were observed. The relationship among the clinical manifestations, treatment outcomes, and ADAMTS13 gene mutation of patients with cTTP was analyzed. Additionally, detection of ADAMTS13 activity and analysis of ADAMTS13 gene mutation were explored. Results: The age of onset of cTTP was either in childhood or adulthood except in one case, which was at the age of 1. The primary manifestations were obvious thrombocytopenia, anemia, and different degrees of nervous system involvement. Most of the patients were initially suspected of having immune thrombocytopenia. Acute cTTP was induced by pregnancy and infection in two and one case, respectively. ADAMTS13 gene mutation was detected in all cases, and there was an inherent relationship between the mutation site, clinical manifestations, and degree of organ injury. Therapeutic or prophylactic plasma transfusion was effective for treating cTTP. Conclusions: The clinical manifestations of cTTP vary among individuals, resulting in frequent misdiagnosis that delays treatment. ADAMTS13 activity detection in plasma and ADAMTS13 gene mutation analysis are important bases to diagnose cTTP. Prophylactic plasma transfusion is vital to prevent the onset of the disease.

[Kinetics of SARS-CoV-2-specific antibodies among inactivated COVID-19 vaccine recipients, SARS-CoV-2 natural infection cases, and breakthrough cases]

Between August and September, 2021, this study included 605 SARS-CoV-2 natural infection cases and 589 SARS-CoV-2 breakthrough cases from Nanjing and Yangzhou, as well as 690 inactivated COVID-19 vaccine recipients from Changzhou, China. In SARS-CoV-2 natural infection cases, the age range was 19-91 years (median age: 66 year), and the medians(Q₁,Q₃) of IgG titers were 0.19 (0.06-1.31), 3.70 (0.76-69.48), 15.31 (2.59-82.16), 4.41 (0.99-31.74), 2.31 (0.75-13.83), 2.28 (0.68-9.94) and 2.80 (1.00-9.53) at one to seven weeks after SARS-CoV-2 infection, respectively. In SARS-CoV-2 breakthrough cases, the age range was 18-76 years (median age: 45 year), and the medians(Q₁,Q₃)of IgG titers were 1.93 (0.34-26.67), 38.87 (7.90-121.0), 75.09 (11.85-123.70), 21.97 (5.20-95.58), 13.97 (3.47-46.82), 9.56 (2.48-33.38) and 4.38 (1.87-11.00) at one to seven weeks after SARS-CoV-2 infection, respectively. In inactivated COVID-19 vaccine recipients, the age range was 18-87 years (median age: 47 years), and the medians(Q₁,Q₃)of IgG titers were 16.22 (15.84-33.42), 5.35 (2.96-13.23), 3.30 (2.18-6.18), 3.14 (1.16-5.70), 2.77 (1.50-4.52), 2.72 (1.76-4.36), 2.01 (1.27-3.51) and 1.94 (1.35-3.09) at one to eight months after SARS-CoV-2 infection, respectively. The results suggested that IgG antibodies increased gradually within two weeks after SARS-CoV-2 infection, then declined gradually at three to seven weeks in SARS-CoV-2 natural infection cases. In SARS-CoV-2 breakthrough cases, IgG antibodies increased rapidly within two weeks, then declined gradually at three to seven weeks after SARS-CoV-2 infection. Additionally, IgG antibodies decreased rapidly within three months, then decreased gradually and remained at a low level within three months after immunization.

DNA methylation and waist-to-hip ratio: an epigenome-wide association study in Chinese monozygotic twins

PURPOSE

Epigenetic signatures such as DNA methylation may be associated with specific obesity traits. We performed an epigenome-wide association study (EWAS) by combining with the waist-to-hip ratio (WHR)-discordant monozygotic (MZ) twin design in an attempt to identify genetically independent DNA methylation marks associated with abdominal obesity in Northern Han Chinese and to determine the causation underlying.

METHODS

A total of 60 WHR discordant MZ twin pairs were selected from the Qingdao Twin Registry, China. Generalized estimated equation (GEE) model was used to regress the methylation level of CpG sites on WHR. The Inference about Causation through Examination of FAmiliaL CONfounding (ICE FALCON) was used to assess the temporal relationship between methylation and WHR. Gene expression analysis was conducted to validate the results of differentially methylated analyses.

RESULTS

EWAS identified 92 CpG sites with the level of P < 10^- 4 which were annotated to 32 genes, especially CADPS2, TUSC5, ZCCHC14, CORO7, COL23A1, CACNA1C, CYP26B1, and BCAT1. ICE FALCON showed significant causality between DNA methylation of several genes and WHR (P < 0.05). In region-based analysis, 14 differentially methylated regions (DMRs) located at 15 genes (slk-corrected P < 0.05) were detected. The gene expression analysis identified the significant correlation between expression levels of 5 differentially methylated genes and WHR (P < 0.05).

CONCLUSIONS

Our study identifies the associations between specific epigenetic variations and WHR in Northern Han Chinese. These DNA methylation signatures may have value as diagnostic biomarkers and provide novel insights into the molecular mechanisms of pathogenesis.

[Diagnostic value of rapid antigen testing for the detection of SARS-CoV-2 infection]

Objective: To investigate the diagnostic value of rapid antigen test based on colloidal gold immunochromatographic assay for the detection of SARS-CoV-2 infection in symptomatic patients. Methods: From May 20 to June 5 2022, 76 hospitalized children and their 55 accompanying family members with confirmed SARS-CoV-2 infection in the COVID-19 isolation unit of the Children's Hospital of Fudan University (designated referral hospital for SARS-CoV-2 infection in Shanghai) enrolled. Their nasopharyngeal swab specimens were consecutively collected. The samples were tested for SARS-CoV-2 nucleic acid by real-time quantitative. SARS-CoV-2 antigen was tested by immunochromatography. The correlation between the antigen detection results and the change of the cycle threshold (Ct) values were evaluated, as well as the sensitivity and specificity of SARS-CoV-2 antigen detection at different periods after the onset of the disease. Kappa consistency test was conducted to investigate the consistency between the 2 diagnostic methods. Results: Of the enrolled SARS-CoV-2 symptomatic infections, 76 were children, including 41 males and 35 females, with an age of 5 (2, 9) years; 55 were accompanying families, including 8 males and 47 females, with an age of 38 (32, 41) years. All 478 samples were simultaneously tested for SARS-CoV-2 antigen and nucleic acid. In any period from disease onset to negative conversion of viral nucleic acid, the overall sensitivity of the rapid antigen test was 48.2% (119/247), the specificity was 98.3% (227/231), and antigen test and nucleic acid test showed moderate consistency (κ=0.46, P<0.05). The sensitivity of antigen test was 100% (82/82) when the Ct value was ≤25. And the sensitivity of antigen test was 8/10, 4/15 and 8.3% (3/36) when the Ct value was 26, 30 and 35, respectively. All antigen tests were negative when Ct value was >35. During the period of 1-2 days, 3-5 days, 6-7 days, 8-10 days and >10 days after onset, the sensitivity and specificity of SARS-CoV-2 antigen test were 5/8 and 5/5, 90.2% (37/41) and 5/5, 88.9% (24/27) and 2/5, 45.0% (36/80) and 94.1% (32/34), 18.7% (17/91) and 98.9% (183/185) respectively. The Ct values of nasopharyngeal swabs were<26 during 2 to 7 days after onset, 28.7±5.0 on day 8, 34.5±2.9 on day 13 and > 35 after 14 days, respectively. Conclusion: SARS-CoV-2 antigen test in the patients with SARS-CoV-2 infection shows acceptable sensitivity and specificity within 7 days after onset of disease, and the sensitivity was positively correlated with viral load and negatively correlated with onset time.

[ABC prognostic classification and MELD 3.0 and COSSH-ACLF Ⅱ prognostic evaluation in acute-on-chronic liver failure]

Objective: To investigate the ABC prognostic classification and the updated version of Model for End-stage Liver Disease (MELD) score 3.0 and Chinese Group on the Study of Severe Hepatitis B ACLF Ⅱ score (COSSH-ACLF Ⅱ score) to evaluate the prognostic value in acute-on-chronic liver failure (ACLF). Methods: ABC classification was performed on a 1 409 follow-up cohorts. The area under the receiver operating characteristic curve (AUROC) was used to analyze MELD, MELD 3.0, COSSH-Ⅱ and COSSH-Ⅱ score after 3 days of hospitalization (COSSH-Ⅱ-3d). The prognostic predictive ability of patients were evaluated for 360 days, and the prediction differences of different classifications and different etiologies on the prognosis of ACLF were compared. Results: The survival curve of 1 409 cases with ACLF showed that the difference between class A, B, and C was statistically significant, Log Rank (Mantel-Cox) χ²=80.133, P<0.01. Compared with class A and C, χ²=76.198, P<0.01, the difference between class B and C, was not statistically significant χ²=3.717, P>0.05. AUROC [95% confidence interval (CI)] analyzed MELD, MELD 3.0, COSSH-Ⅱ and COSSH-Ⅱ-3d were 0.644, 0.655, 0.817 and 0.839, respectively (P<0.01). COSSH-Ⅱ had better prognostic predictive ability with class A ACLF and HBV-related ACLF (HBV-ACLF) for 360-days, and AUROC (95% CI) were 0.877 and 0.881, respectively (P<0.01), while MELD 3.0 prognostic predictive value was not better than MELD. Conclusion: ACLF prognosis is closely related to ABC classification. COSSH-Ⅱ score has a high predictive value for the prognostic evaluation of class A ACLF and HBV-ACLF. COSSH-Ⅱ score has a better prognostic evaluation value after 3 days of hospitalization, suggesting that attention should be paid to the treatment of ACLF in the early stage of admission.

[A multicenter cross-sectional study of quality of life and nonsurgical treatment in patients with knee osteoarthritis]

Objective: To explore the influencing factors of health-related quality of life (HRQoL) in patients with knee osteoarthritis, and to analyze the non-surgical treatment of knee osteoarthritis. Methods: Demographic variables, treatment modalities, imaging data, and 12-item short form health survey (SF-12) scores of patients with knee osteoarthritis in orthopedic outpatient departments of five hospitals in Beijing from December 2017 to November 2018 were collected to analyze influencing factors of HRQoL and non-surgical treatment. Results: A total of 2 034 patients were included. There were 530 males (26.1%) and 1 504 females (73.9%), with a mean age of (59.17±10.22) years. In terms of physical quality of life, female patients with knee osteoarthritis had lower physical components summary (PCS) compared with male patients (β=-0.521, P=0.036); patients aged ≥64 years had lower PCS than those aged<55 years (β=-0.636, P=0.026). Patients with an education of more than 12 years had higher PCS than those with less than 10 years (β=1.063, P<0.001). Compared to patients with mild clinical symptoms, the PCS of patients with moderate clinical symptoms was lower (β=-0.860, P=0.002), while the PCS of those with severe clinical symptoms was much lower (β=-1.126, P<0.001). Patients treated with combination therapy had higher PCS than untreated patients (β=0.731, P=0.005). In terms of mental quality of life, compared to patients engaged in sedentary work, the mental components summary (MCS) of patients engaged in mild manual labor jobs was lower (β=-0.712, P=0.015); Compared to patients with a Charson comorbidity index of 0, patients with a Charlson comorbidity index ≥ 2 had lower MCS (β=-1.183, P=0.007). In the past 12 months, 648 (31.9%), 143 (7.0%), 406 (20.0%), 680 (33.4%), 343 (16.9%), 681 (33.5%), 170 (8.4%) patients had used non-steroid anti-inflammatory drugs (NSAIDs), acetaminophen, glucosamine/chondroitin formulations, physical therapy, articular cavity puncture injection, traditional Chinese medicine treatment and exercise therapy, respectively. Total of 451 patients (22.2%) received monotherapy and 889 patients (43.7%) received combination therapy. Conclusions: The major non-surgical treatment methods for patients with knee osteoarthritis in Beijing are NSAIDs, physiotherapy and traditional Chinese medicine. Combination therapy is used more frequently than monotherapy. Physical quality of life is related to gender, age, education, severity of symptoms and treatment, while mental quality of life is related to occupational labor and comorbidities.

[Evidence-based research and prognosis of novel coagulation factor Ⅺ inhibitors in venous thromboembolism]

Thrombosis is the main cause of the development and progression of venous thromboembolism(VTE). Anticoagulant therapy is the cornerstone for the prophylaxis and treatment of VTE, and it has evolved mainly through indirect thrombin inhibitors, direct thrombin inhibitors, vitamin K antagonists and new oral anticoagulants. Although safety is improving, the risk of bleeding remains a non-negligible side effect of current anticoagulation therapy, especially in patients with higher bleeding risk. Studies of the coagulation pathway have found that FXI is not involved in the initiation of hemostasis, but promotes thrombus growth and stabilization primarily through feedback activation of FⅪ by thrombin. Further studies have found that inhibition of FⅪ significantly inhibits thrombus formation and only affects hemostasis slightly. Recent studies have confirmed the efficacy and safety of FⅪ inhibitors in the prevention of VTE in patients after knee replacement. In addition, the safety of FⅪ inhibitors has been further confirmed by the studies of FⅪ inhibitors in people with higher bleeding risk. FⅪ inhibitors may be the most promising anticoagulant drugs in the next decade.

Mental health status of children with disorders of sexual development and their correlates

Disorders of sexual development (DSD) refer to the congenital abnormalities of chromosomes, gonads, or gender anatomy. Children with DSD usually experience more stress. The present study aims to evaluate the mental health status of children with DSD, and to explore the potential relevant factors. We included 30 children with DSD and 30 age- and gender-matched children without DSD as the control group. All the children and their parents completed the scales of the Hamilton Anxiety Scale (HAMA). Children over 8 years old (n = 22) completed the Screen Scale for Child Anxiety Related Emotional Disorders (SCARED), the Depression Self-rating Scale for Children (DSRSC), and the Egna Minnen av Barndoms Uppfostran-own memories of parental rearing practices in childhood. DSD children had significantly higher somatic anxiety, mental anxiety, and total anxiety scores than the control group (p &lt; 0.001). The scores of the SCARED, anxiety, and depression subscales of DSD children were higher than those of control children (p &lt; 0.05 and p &lt; 0.001, respectively). The correlation analysis showed that the score of generalized anxiety was positively related to age and entertainment. The regression analysis showed that age was a major factor that affected generalized anxiety in DSD children, and neuroticism was a major factor of anxiety disorder and separation anxiety in DSD children. Children with DSD have obvious anxiety problems, which are associated with family environmental factors (entertainment, success, and conflicts) and age. It is important to focus emphasis on emotional stability in children with DSD for detecting anxiety-related emotional disorders early.

[Sacubitril/valsartan attenuates left ventricular remodeling and improve cardiac function by upregulating apelin/APJ pathway in rats with heart failure]

Objective: To investigate the effect and mechanism of sacubitril/valsartan on left ventricular remodeling and cardiac function in rats with heart failure. Methods: A total of 46 SPF-grade male Wistar rats weighed 300-350 g were acclimatized to the laboratory for 7 days. Rats were then divided into 4 groups: the heart failure group (n=12, intraperitoneal injection of adriamycin hydrochloride 2.5 mg/kg once a week for 6 consecutive weeks, establishing a model of heart failure); heart failure+sacubitril/valsartan group (treatment group, n=12, intragastric administration with sacubitril/valsartan 1 week before the first injection of adriamycin, at a dose of 60 mg·kg^-1·d^-1 for 7 weeks); heart failure+sacubitril/valsartan+APJ antagonist F13A group (F13A group, n=12, adriamycin and sacubitril/valsartan, intraperitoneal injection of 100 μg·kg^-1·d^-1 APJ antagonist F13A for 7 weeks) and control group (n=10, intraperitoneal injection of equal volume of normal saline). One week after the last injection of adriamycin or saline, transthoracic echocardiography was performed to detect the cardiac structure and function, and then the rats were executed, blood and left ventricular specimens were obtained for further analysis. Hematoxylin-eosin staining and Masson trichrome staining were performed to analyze the left ventricular pathological change and myocardial fibrosis. TUNEL staining was performed to detect cardiomyocyte apoptosis. mRNA expression of left ventricular myocardial apelin and APJ was detected by RT-qRCR. ELISA was performed to detect plasma apelin-12 concentration. The protein expression of left ventricular myocardial apelin and APJ was detected by Western blot. Results: Seven rats survived in the heart failure group, 10 in the treatment group, and 8 in the F13A group. Echocardiography showed that the left ventricular end-diastolic diameter (LVEDD) and the left ventricular end-systolic diameter (LVESD) were higher (both P<0.05), while the left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) were lower in the heart failure group than in the control group (both P<0.05). Compared with the heart failure group, rats in the treatment group were featured with lower LVEDD and LVESD (both P<0.05), higher LVEF and LVFS (both P<0.05), these beneficial effects were reversed in rats assigned to F13A group (all P<0.05 vs. treatment group). The results of HE staining showed that the cardiomyocytes of rats in the control group were arranged neatly and densely structured, the cardiomyocytes in the heart failure group were arranged in disorder, distorted and the gap between cells was increased, the cardiomyocytes in the treatment group were slightly neat and dense, and cardiomyocytes in the F13A group were featured similarly as the heart failure group. Masson staining showed that there were small amount of collagen fibers in the left ventricular myocardial interstitium of the control group, while left ventricular myocardial fibrosis was significantly increased, and collagen volume fraction (CVF) was significantly higher in the heart failure group than that of the control group (P<0.05). Compared with the heart failure group, the left ventricular myocardial fibrosis and the CVF were reduced in the treatment group (both P<0.05), these effects were reversed in the F13A group (all P<0.05 vs. treatment group). TUNEL staining showed that the apoptosis index (AI) of cardiomyocytes in rats was higher in the heart failure group compared with the control group (P<0.05), which was reduced in the treatment group (P<0.05 vs. heart failure group), this effect again was reversed in the F13A group (P<0.05 vs. treatment group). The results of RT-qPCR and Western blot showed that the mRNA and protein levels of apelin and APJ in left ventricular myocardial tissue of rats were downregulated in heart failure group (all P<0.05) compared with the control group. Compared with the heart failure group, the mRNA and protein levels of apelin and APJ were upregulated in the treatment group (all P<0.05), these effects were reversed in the F13A group (all P<0.05 vs. treatment group). ELISA test showed that the plasma apelin concentration of rats was lower in the heart failure group compared with the control group (P<0.05); compared with the heart failure group, the plasma apelin concentration of rats was higher in the treatment group (P<0.05), this effect was reversed in the F13A group (P<0.05 vs. treatment group). Conclusion: Sacubitril/valsartan can partially reverse left ventricular remodeling and improve cardiac function in rats with heart failure through modulating Apelin/APJ pathways.

Toripalimab (anti-PD-1) versus High-Dose Interferon-α2b as Adjuvant Therapy in Resected Mucosal Melanoma: A Phase II Randomized Trial

BACKGROUND

No standard of care for mucosal melanoma (MM) in the adjuvant setting has been established. Meanwhile, relapse-free survival (RFS) is only about five months after surgery alone. This phase II trial aimed to compare toripalimab vs. high-dose interferon-α2b (HDI) as an adjuvant therapy for resected MM.

PATIENTS AND METHODS

From July 2017 to May 2019, 145 patients with resected MM were randomized (1:1) to receive HDI (N = 72) or toripalimab (N = 73) for one year until disease relapse/distant metastasis, unacceptable toxicity, or withdrawal of consent. The primary endpoint was RFS. The secondary endpoints included distant metastasis-free survival (DMFS), overall survival (OS), and safety.

RESULTS

After a median follow-up of 26.3 months, the numbers of RFS, OS, and DMFS events were 51 vs. 46, 33 vs. 29, and 49 vs. 44 in the toripalimab arm and the HDI arm, respectively. The median RFS were 13.6 (95%CI: 8.31-19.02) months and 13.9 (95%CI: 8.28-19.61) months in the toripalimab arm and HDI arm, respectively. The DMFS was not significantly different between the two arms (HR: 1.00, 95%CI: 0.65-1.54). The median OS was 35.1 months (95%CI: 27.93-NR) in the toripalimab arm, with no significant difference in all-cause death (HR: 1.11, 95% CI: 0.66-1.84) for the two arms. The median sums of the patients' actual infusion doses were 3672 mg and 1054.5 MIU in the toripalimab arm and HDI arm, respectively. The incidence of treatment-emergent adverse events with a grade ≥ 3 was much higher in the HDI arm than in the toripalimab arm (87.5% vs. 27.4%).

CONCLUSION

Toripalimab showed a similar RFS and a more favorable safety profile than HDI, both better than historical data, suggesting that toripalimab might be the better treatment option. However, additional translational studies and better treatment regimens are still warranted to improve the clinical outcome of MM.

[Characteristics of SARS-CoV-2 Omicron infection in children imported from Hong Kong]

Objective: To understand the clinical characteristics of children with SARS-CoV-2 Omicron infection imported from Hong Kong Special Administrative Region. Methods: This retrospective study was conducted to collect the data including clinical manifestations, outcomes and vaccination of 107 children with SARS-CoV-2 Omicron infection imported from Hong Kong Special Administrative Region to be admitted to the designated referral hospital in Shanghai from February to March 2022. According to the occurrence of clinical symptoms, the cases were divided into asymptomatic group and symptomatic group. According to the age of diagnosis, the cases were divided into <3 years group, 3-<6 years group and 6-<18 years group, and the clinical manifestations in different age group were analyzed with t-test and Mann-Whitney rank-sum test. Besides, to analyze the effectiveness of vaccination against SARS-CoV-2 Omicron infection in different age group, the cases aged 3-<18 years were also subdivided into unvaccinated group, 1-dose group and 2-dose group, and the relative risk (RR) was used to demonstrate the effectiveness. Results: Among the 107 cases, 66 were male and 41 were female, with infection age of 10 (5, 14) years. There were 29 cases in the asymptomatic group, and 78 cases in the symptomatic group, and no significant difference in the age of infection was observed between the 2 groups (11 (6, 14) vs. 10 (5, 14) years, Z=0.49, P>0.05). And there were no severe cases in symptomatic group. The length of hospitalization was (18±6) days, and was longer in symptomatic group than that in asymptomatic group ((19±6) vs. (16±7) d, t=0.17, P=0.030). Eight-two cases (76.6%) had a history of epidemiological exposure and, among whom, 81 cases (75.7%) were associated with household transmission. Among symptomatic group, 57 cases (73.1%) had fever and 20 cases (25.6%) had cough. Of the 74 cases undergoing chest CT examination, 17 cases (23.0%) showed mild abnormalities. Of the 83 cases who received the lab tests, 23 cases (27.7%) had white blood cell counts<4×10⁹/L, 3 cases (3.6%) had C-reaction protein >8.0 mg/L, and 6 cases (7.2%) had slightly elevated aspartate transaminase and alanine aminotransferase. Among the 92 children aged 3-<18 years, 31 cases were unvaccinated, 34 cases received 1 dose, and 27 cases received 2 doses. The interval between the last vaccination and infection was 2.2 (0.6, 6.0) months; the interval between the last vaccination and infection in the 2-dose group was longer than that in 1-dose group (6.0 (4.5, 7.3) vs. 0.7 (0.3,2.0) months, Z=3.59, P<0.001).The risk of symptomatic infection was reduced by 45% (RR=0.55, 95% CI 0.35-0.87) with two-dose vaccination compared to non-vaccination in cases aged 3-<18 years. All these cases recovered completely. Conclusions: Children infected with SARS-CoV-2 Omicron are usually mild or asymptomatic. Household transmission is the main pattern of infection with SARS-CoV-2 Omicron in children. Two-dose SARS-CoV-2 vaccination in children aged 3-<18 years can provide partial protection against disease caused by SARS-CoV-2 Omicron.

The Effects of Dual-Task Training on Cognitive and Physical Functions in Older Adults with Cognitive Impairment; A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Individuals with Alzheimer disease and dementia experience cognitive decline and reduction in physical capabilities. Engaging in cognitive challenges and physical exercises is effective in reducing age-related cognitive and physical decline. It is believed that physical activity in the context of cognitive challenges might enhance the process of neurogenesis in the adult brain, but how effective are such interventions? Is there enough evidence to support that dual-task training is more effective than cognitive or physical training alone? To what extent can such training improve cognitive and physical functions in patients at various stages of cognitive decline?

METHODOLOGY

This systematic review with meta-analysis summarizes the emerging evidence of dual-task training for enhancing cognitive and physical functions in older individuals with cognitive impairment, dementia or Alzheimer's disease. A systematic search was carried out in MEDLINE, PubMed, EMBASE, and Cochrane Library with the following search terms: randomized control trials, dual-task training, SCD, MCI, dementia, and Alzheimer's disease.

RESULTS

A total of 21 studies with 2,221 participants were identified. The results of dual-task tanning intervention are summarized as change in global cognitive function; SMD = 0.24, (P= 0.002), memory; SMD = 0.28, (P = 0.000), executive function; SMD = 0.35, (P = 0.000), attention; SMD = -0.19, (P = 0.1), gait speed; SMD = 0.26, (P = 0.007), dual-task cost; SMD 0.56, (P = 0.000), and balance; SMD 0.36, (P = 0.004).

CONCLUSION

Primary analysis showed a small-to-medium positive effect of dual-task training interventions on cognitive functions and medium-to-large positive effect on gait functions and balance.

[Application of trifoliate flap design of radial forearm flap in reconstruction of defects after mouth floor cancer resection]

Objective: To evaluate the effect of trifoliate flap design of radial forearm flap in reconstruction of defects after mouth floor cancer resection. Methods: From June 2016 to December 2019, 12 patients with defect after resection of mouth floor cancer were treated with trifoliate flap design of radial forearm flap. All of these patients were T2 stage, included 9 well-differentiated squamous cell carcinoma (SCC) and 3 moderate differentiated SCC. The defect size ranged from 8.0 cm×6.0 cm to 5.0 cm×4.5 cm after resection of tumor and neck dissection. All defects were repaired with trifoliate flap design of radial forearm flap. The flap size ranged from 8.0 cm×2.0 cm to 4.0 cm×1.5 cm, the donor site was sutured directly on Z plasty. Results: All flaps completely survived well. Both the wound and the donor site were stage Ⅰ healing. With the average follow-up of 38.6 months, the swallowing and speech function were satisfactory. Conclusions: Trifoliate flap design of radial forearm flap can effectively repair the postoperative defect of mouth floor cancer, and the donor site can be directly sutured on Z plasty. This technique can avoid forearm scar caused by skin grafting and the formation of the second donor site.

[Efficacy and safety of venetoclax combined with azacitidine versus CAG regimen combined with decitabine in elderly patients with relapsed acute myeloid leukemia]

Objective: To compare the efficacy and safety of venetoclax (VEN) combined with azacitidine (AZA) versus CAG regimen combined with decitabine (DAC) in elderly patients with relapsed acute myeloid leukemia (AML). Methods: From January 2018 to August 2020, the clinical data of forty-five elderly patients with relapse AML at the First Affiliated Hospital of Soochow University were retrospectively analyzed, including 31 males and 14 females. The median age was 66 (60-80) years old. Eighteen patients were administrated with VEN and AZA, while the other 27 were in CAG with DAC. The complete remission (CR) rate, partial remission (PR) rate, total remission rate (ORR), adverse events and overall survival (OS) were compared between the two groups. Results: At the end of the treatment, the ORR in VEN with AZA group was 77.8% (14/18); including 11 CR and 3 PR. In CAG with DAC group, the ORR was 37.0% (10/27); including 8 CR and 2 PR (P=0.007). Subgroup analysis suggested that VEN with AZA had a higher ORR in patients stratified as intermediate and poor-risk (P=0.013) or with DNA methylation mutations (P=0.007). Main adverse events in both groups were bone marrow suppression, infections, nausea and vomiting, anorexia and fatigue. Grade Ⅲ-Ⅳ cytopenia developed in lower incidence of VEN with AZA group, such as leukopenia (66.7% vs. 100%, P=0.002), anemia (50.0% vs. 92.6%, P=0.002), thrombocytopenia (72.2% vs. 96.3%, P=0.031) and neutropenia (61.1% vs. 92.6%, P=0.014). In addition, less grade Ⅲ-Ⅳ infections occurred in VEN with AZA group (66.7% vs. 33.3%, P=0.028), as well as grade Ⅲ-Ⅳ gastrointestinal events (40.7% vs. 11.1%, P=0.032), grade Ⅲ-Ⅳ fatigue (55.6% vs.11.1%, P=0.003) compared with CAG with DAC group. The 1-year OS in VEN with AZA group versus CAG with DAC group was 42.9% and 31.6% respectively (P=0.150). Conclusion: VEN combined with AZA proves favorable efficacy and tolerablity in elderly patients with relapsed AML.

[Comparison of alignment and position of prosthesis between portable accelerometer-based navigation device and conventional instrumentation in total knee arthroplasty with valgus deformity]

Objective: To explore the differences of alignment and position of prosthesis between portable accelerometer-based navigation device (PAD) and conventional instrumentation (CI) in total knee arthroplasty (TKA) with valgus deformity. Methods: Patients with knee osteoarthritis and valgus deformity who underwent primary TKA in Peking University Third Hospital from January 2017 to December 2020 were enrolled in this retrospective study and were divided into PAD group and CI group according to the surgical instruments. Five male patients and 44 female patients were included with a mean age of (67.2±7.0) years. The differences in preoperative general data, preoperative and postoperative alignment between the two groups were studied. Results: A total of 49 patients (25 patients in the PAD group and 24 in the CI group) were enrolled in this study. There were no statistically significant differences in gender, age, height, weight, body mass index, surgical side, preoperative hip-knee-ankle (HKA) angle, preoperative HKA angle deviation, Keblish classification and Ranawat classification between the two groups (all P>0.05). There was no significant difference in the accuracy of postoperative HKA angle (2.0°±1.4° vs 3.0°±2.2°, P=0.082), coronal femoral component angle (CFCA) (1.5°±1.2° vs 2.1°±1.6°, P=0.144) and coronal tibial component angle (CTCA) (1.2°±0.8° vs 1.3°±1.0°, P=0.695) between the two groups; but the standard deviation of the above-mentioned three indices in PAD group were all smaller than those in CI group. The rate of outliers of postoperative HKA angle of the PAD group was smaller than that in the CI group (P<0.05), but there was no significant difference in the rate of outliers of CFCA and CTCA between the two groups (both P>0.05). Conclusion: TKA assisted by PAD can provide good alignment and prosthesis position in patients with valgus deformity, and it is superior to TKA with CI in terms of precision and rate of outliers of postoperative overall alignment of lower extremity.

[Effect of the acetabular cup positioning and leg length restoration after total hip arthroplasty using robotic-assisted surgery system]

Objective: To assess the improvement of the robotic-assisted total hip arthroplasty (rTHA) regarding the acetabular cup positioning and the leg length restoration. Methods: Clinical data of 246 patients undergoing primary unilateral THA from September 2019 to June 2021 in Peking University Third Hospital were retrospectively reviewed, including patients treated with rTHA (n=113) and conventional THA (cTHA) (n=133). Thirty-seven male patients along with 76 females were enrolled into the rTHA group with a mean age of (62±9) years. In comparison, the average age of cTHA group was (60±12) years with 59 males and 74 females. The postoperative inclination and anteversion of the acetabular cup and the rate of acetabular cup within the Lewinnek and Callanan "safe zone" were documented and analyzed. For the patient with normal or surgically restored contralateral hip, the leg length discrepancy was also measured and compared between the two groups. Results: The overall mean postoperative inclination and anteversion was 39.0°±5.5° and 14.1°±5.1°, respectively. No statistically significant difference was found between the rTHA and cTHA group regarding postoperative inclination (39.3°±2.9° vs 38.7°±7.0°, P=0.383) and anteversion (13.4°±4.3° vs 14.7°±5.6°, P=0.054). In rTHA group, 97.3%(110/113) of the cups were implanted within the Lewinnek"safe zone"(75.9%(101/133) in cTHA group) and 94.7%(107/113) were within the Callanan"safe zone"(66.2%(88/133) in cTHA group), and those were both higher in rTHA group (both P<0.01). There was no significant difference in postoperative leg length discrepancy between the two groups (P=0.445). Meanwhile, 29(23.0%) cases of cTHA group had leg length discrepancy more than 5 mm, and it was 9.7%(9/93) in rTHA group. Conclusion: It indicated the benefit of rTHA in acetabular cup positioning as well as the leg length restoration.

[Robotic assisted artificial hip and knee arthroplasty is an inevitable trend in the future]

Artificial joint arthroplasty, such as total hip and total knee arthroplasty, is one of the most successful procedures in orthopedics. The quality of life of these patients can be improved significantly through relieving pain, correcting the deformity and improving joint function. Although hip and knee arthroplasty currently are routine surgeries for patients with late stage joint diseases, post-operative complications like leg length discrepancy, dislocation or instability, limp and uncertain reason pain are still common. The position of the implants plays important roles in all these complications. Robotic assisted joint arthroplasty can not only provide 3D pre-operative visual planning, but also can assist to fulfill the pre-operation plan perfectly. But the current joint arthroplasty robots cannot carry out automatic personalized pre-operation planning, and also have the shortcomings of low efficiency and high cost etc. However, based on their current performance and with the help of artificial intelligence and better algorithm, we believe that joint arthroplasty will be more and more precisive, intelligent and minimally invasive, which is an inevitable trend in the development of joint surgery.

[Comparison of alignment between computer assisted surgery and personal specific instrumentation in total knee arthroplasty]

Objective: To explore the differences of alignment and operative time between computer assisted surgery (CAS) and personal specific instrumentation (PSI) in total knee arthroplasty (TKA). Methods: Patients with knee osteoarthritis who underwent unilateral primary TKA in Peking University Third Hospital from June 2019 to April 2021 were enrolled in this prospective study and were randomly divided into CAS group and PSI group with random number table. The differences in preoperative general data, operative time, preoperative and postoperative alignment between the two groups were studied. Results: A total of 80 patients were enrolled in this study, including 40 patients in the CAS group with an average age of (68±6) years (male/female, 6/34 cases) and 40 patients in the PSI group with an average age of (69±6) years (male/female, 5/35 cases). There was no significant differences in gender, age, height, weight, body mass index, surgical side, preoperative hip-knee-ankle (HKA) angle, and preoperative HKA angle deviation between the two groups (all P>0.05). The accuracy of sagittal femoral component angle (sFCA) (1.7°±1.2° vs 2.5°±1.4°, P<0.05) and sagittal tibial component angle (sTCA) (1.2°±0.9° vs 2.3°±1.8°, P<0.01) of the CAS group were both smaller than those in the PSI group, but there was no significant difference in the accuracy of postoperative HKA angle, mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibia angle (mMPTA) between the two groups (all P>0.05). The precision of postoperative HKA angle and sTCA of the CAS group were both smaller than those in the PSI group (2.0°±1.0° vs 2.6°±1.7°, 1.2°±0.9° vs 2.3°±1.8°, both P<0.01), but there was no significant differences in the precision of mLDFA, mMPTA and sFCA between the two groups (all P>0.05). The rate of outliers of postoperative HKA angle (10.0% vs 27.5%, P<0.05), sFCA(5.0% vs 20.0%, P<0.05) and sTCA (2.5% vs 22.5%, P<0.01) of the CAS group were all smaller than those in the PSI group, but there was no significant difference in the rate of outliers of mLDFA and mMPTA between the two groups (both P>0.05). CAS group had significantly longer surgical time than the PSI group ((81±12) min vs (52±8) min, P<0.01). Conclusions: CAS is better than PSI in overall coronal alignment and sagittal position of the prosthesis after TKA. However, CAS requires a longer operation time.

Negative associations of morning serum cortisol levels with obesity: the Henan rural cohort study

AIMS

To evaluate the associations of morning serum cortisol levels with obesity defined by different indices in Chinese rural populations.

MATERIALS AND METHODS

A cross-sectional study was performed including 6198 participants (2566 males and 3632 females). Serum cortisol was collected in morning and quantified by liquid chromatography-tandem mass spectrometry. Obesity was defined by body mass index (BMI), body fat percentage (BFP), waist-to-height ratio (WHtR), waist circumference (WC), visceral fat index (VFI) and waist-to-hip ratio (WHR). Both multivariable liner regression, logistic regression and restrictive cubic splines models were used to estimate the gender-specific relationships between cortisol levels and obesity defined by different indices, respectively.

RESULTS

After adjusting for potential confounders, serum cortisol was negatively associated with different obesity measures, except obese females defined by BFP (for instance, overall obesity defined by BMI, Quartile 4 vs. Quartile 1, odds ratio (OR) = 0.25, 95% confidence interval (CI):0.15, 0.41 in males, and OR = 0.58, 95% CI: 0.42,0.80 in females, central obesity defined by WC, OR = 0.52, 95% CI:0.39,0.69 in males and OR = 0.63, 95% CI:0.51,0.77 in females). Similarly, restrictive cubic splines showed the nonlinear relationship between high levels of cortisol and different obesity indices. Furthermore, ROC curve analysis indicated that cortisol could improve the discrimination of model with common biomarkers.

CONCLUSION

Morning serum cortisol were negatively related to obesity defined by different indices in Chinese rural populations. In addition, cortisol could be as a biomarker for prediction of obesity in males.

Real-world effectiveness and rheumatologist satisfaction with secukinumab in the treatment of patients with axial spondyloarthritis

OBJECTIVES

To assess the effectiveness of secukinumab in patients with axSpA treated in routine clinical settings in 5 European countries.

METHODS

Retrospective analysis of a cross-sectional survey to assess real-world effectiveness of secukinumab in the management of axSpA and rheumatologist satisfaction with treatment in France, Germany, Italy, Spain and the UK from March to December 2018. Outcomes collected included patient demographics, clinical characteristics and rheumatologist- and patient-reported satisfaction with secukinumab treatment.

RESULTS

Five hundred thirty-five patients receiving secukinumab for more than 4 months were assessed, 359 of whom were diagnosed with AS and 178 with nr-axSpA. Rheumatologist assessment of disease status at treatment initiation indicated that 39 (7.3%) had stable/improving disease. Secukinumab treatment for 4 months or longer resulted in 515 (95.9%) patients judged as stable/improving. Treatment was associated with benefits from initiation to assessment in terms of BASDAI (6.2 vs 2.8), 44-joint count score (9.7 vs 6.6), rheumatologist global VAS score (56.9 vs 23.0) and patient global VAS scores (64.4 vs 25.5). These benefits for key clinical outcomes were sustained for periods of 12 months or longer. Patient-reported outcomes on health status using EQ-5D, global functioning using the ASAS health index and overall work impairment via WPAI were sustained over the treatment period, while patient and rheumatologist satisfaction with secukinumab treatment remained very high at 80.2 and 91.2%, respectively.

CONCLUSION

Consistent benefits across multiple clinical and patient-reported outcomes were seen with secukinumab treatment in patients with AS and nr-axSpA treated in routine clinical settings across five European countries. Key Points • In routine clinical settings across five European countries, secukinumab treatment resulted in improvements in a wide range of clinical outcomes including physician-reported disease severity, disease status, pain, BASDAI, 44-joint count score and global VAS scores. • Key clinical and patient reported outcomes were sustained for a 12-month period or longer with secukinumab treatment. • Rheumatologist- and patient-reported treatment satisfaction was high with secukinumab.

Novel androgen receptor gene variant containing a frameshift mutation in a patient with complete androgen insensitivity syndrome

A variety of mutations in the androgen receptor (AR) gene are linked to androgen insensitivity syndrome (AIS). AIS is the most common specific cause of 46, XY disorder in sex development. Here, we reported a patient which presented as a female with 46, XY karyotype and normal female external genitalia. The patient was diagnosed with complete AIS caused by a novel mutation (NM_000044, c.2678-2726del, p. Pro893Leufs*35) in the AR gene. Targeted exome sequencing was used to detect the patient's androgen receptor gene mutations. Sanger sequencing was used to validate the mutation. This study showed that a novel mutation of the AR gene can cause complete AIS; the study also broadened the AR mutation spectrum and indicated that targeted exome sequencing could help facilitate the diagnosis of complicated disorders in sexual development.

[SHOX2 promotes migration, invasion and stemness of bladder cancer cells in vitro]

OBJECTIVE

To explore the role of human short stature homeobox 2 (SHOX2) in regulating the migration, invasion and stemness of human bladder cancer cells.

METHODS

We analyzed SHOX2 gene expression in bladder cancer and adjacent tissues based on TCGA database. Univariate survival analysis of SHOX2 gene expression in TCGA-BLCA data was performed using GEPIA. The probable function of SHOX2 was predicted using GSEA. Human bladder cancer T24 cell models of SHOX2 knockdown or overexpression were assessed for changes in migration and invasion abilities using wound healing assay and Transwell assay, and their cancer stem cell-like characteristics were evaluated using tumorsphere formation assay and colony formation assay. Western blotting was used to detect the expressions of epithelial mesenchymal transition (EMT) markers Ecadherin and vimentin and the TGF-β signaling network component TβR-I in the cells.

RESULTS

SHOX2 expression was significantly higher in bladder cancer tissues than in the adjacent tissues (P < 0.05), especially in paired tissue specimens (P < 0.01), and was negatively correlated with the overall survival of the patients (P < 0.05). SHOX2 gene expression was correlated positively with EMT-related (P < 0.05) and stemness-related gene signatures (P < 0.01). In T24 cells, SHOX2 knockdown significantly suppressed cell migration and invasion, which was significantly enhanced by SHOX2 overexpression (P < 0.01). The cancer stem cell-like characteristics of T24 cells was repressed by SHOX2 knockdown but significantly enhanced by SHOX2 overexpression (P < 0.01). SHOX2 knockdown induced morphological changes of the cells into epithelioid cells, whereas SHOX2 overexpression induced a mesenchymal morphology of the cells. SHOX2 knockdown increased E-cadherin expression and decreased vimentin and TβR-I expression, while SHOX2 overexpression increased the expressions of vimentin and TβR-I in the cells.

CONCLUSION

SHOX2 promotes the migration, invasion and stemness of human bladder cancer cells possibly by regulating EMT via the TGF-β signaling pathway.

Research on sleeve gastrectomy for the treatment of rats with type 2 diabetes mellitus and the regulation of ghrelin and intestinal lesions

OBJECTIVE

To explore the effect of sleeve gastrectomy on type 2 diabetes mellitus (T2DM) in regulating ghrelin and intestinal lesions.

MATERIALS AND METHODS

Specific pathogen free (SPF) Wistar rats were injected with streptozotocin (STZ) after giving a high-sugar and high-fat diet, to establish a T2DM rat model. The rats were randomly divided into a sleeve gastric excision group, a non-surgical group and a fake surgical group, with 10 rats in each group. The weight, blood glucose, glucose tolerance and ghrelin hormone of rats were compared. The feces of rats in each group at the 8th week after surgery were collected, to extract the total bacterial deoxyribonucleic acid (DNA). The bacterial 16S universal primer was used to expand the 16SrRNA V46 conserved region. The total Polymerase Chain Reaction (PCR) products were sequenced by PE101-bp to classify the gene and genera.

RESULTS

The weight of the rats after sleeve gastrectomy significantly decreased (p <0.05). The area under the blood glucose curve and the area under the insulin curve were significantly smaller than those in the non-surgical group and the fake surgical group (p <0.05). Compared with the sleeve gastric excision group, the abundance of Phylum Firmicutes was higher, that of Bacteroidetes was lower. Compared with the sleeve gastric excision group, there were more genera in the fake surgical group and the non-surgical group. The genera with higher abundance in the three groups were Lactobacillus and Bacteroidetes. Compared with the sleeve gastric excision group, the fake surgical group and the non-surgical group had higher abundance of Phylum Firmicutes (p <0.05) and lower abundance of Bacteroidetes (p <0.05).

CONCLUSIONS

To sum up, sleeve gastrectomy can reduce the weight of rats in T2DM rat model, lower blood glucose levels of rats in the model and improve insulin resistance levels. The related mechanism may be related to the upregulation of ghrelin and intestinal flora.

Evolution of AITR family genes in cotton and their functions in abiotic stress tolerance

Abiotic stresses are major environmental factors inhibiting plant growth and development. AITRs (ABA-induced transcription repressors) are a novel family of transcription factors regulating ABA (abscisic acid) signalling and plant responses to abiotic stresses in Arabidopsis. However, the composition and evolution history of AITRs and their roles in the cotton genus are largely unknown. A total of 12 putative AITRs genes were identified in cultivated tetraploid cotton, Gossypium hirsutum. Phylogenetic analysis of GhAITRs in these tetraploid cottons and their closely related species implicate ancient genome-wide duplication occurring after speciation of Gossypium, and Theobroma could generate duplicates of GhAITRs. Duplicated GhAITRs were stably inherited following diploid speciation and further allotetraploidy in Gossypium. Homologous GhAITRs shared common expression patterns in response to ABA, drought and salinity treatments, and drought tolerance induced in transgenic Arabidopsis plants expressing GhAITR-A1. Together, our findings reveal that duplicates in the GhAITRs gene family were achieved by whole genome duplication rather than three individual duplication events, and that GhAITRs function as transcription repressors and are involved in the regulation of plant responses to ABA and drought stress. These results provide insights towards the improvement of abiotic stress tolerance in cotton using GhAITRs.

Imaging Simulation of Charged Nanowires in TEM with Large Defocus Distance

In transmission electron microscope (TEM), both the amplitude and phase of electron beam change when electrons traverse a specimen. The amplitude is easily obtained by the square root of the intensity of a TEM image, while the phase affects defocused images. In order to obtain the phase map and verify the theoretical model of the interaction between electron beam and specimen, a lot of simulations have been performed by researchers. In this work, we have simulated defocus images of a SiC nanowire in TEM with the method of electron optics. Mean inner potential and charge distribution on the nanowire have been considered in the simulation. Besides, due to electron scattering coherence loss of the electron beam has been introduced. A dynamic process with Bayesian optimization was used in the simulation. With the infocus image as input and by adjusting fitting parameters the defocus image is determined with a reasonable charge distribution. The calculated defocus images are in a good agreement with the experimental ones. Here, we present a complete solution and verification method for solving nanoscale charge distribution in TEM.

[Clinical analysis of liver chemistries in children and adolescent with 2019-nCoV infection]

Objective: To describe the clinical features of liver involvement in children and adolescent with 2019-nCoV infection. Methods: The clinical data of 77 hospitalized cases admitted to the Children's Hospital of Fudan University were collected from January 19 to November 28, 2020. The characteristics and risk factors of abnormal liver chemistries in children with laboratory-confirmed 2019-nCoV infection were analyzed. Results: Of the 77 cases, 44 were male (57.1%) and 33 were female (42.9%), with a median age of 10 years. 27(35.1%) were asymptomatic, 28(36.4%) had mild illness, 22(28.6%)had non-severe pneumonia. Hydroxychloroquine was used in 7 cases. Of the 75 children without underlying diseases, alanine aminotransferase was elevated in 1 case (1.5%, during hydroxychloroquine therapy), aspartate aminotransferase was elevated in 7 cases (10.3%), alkaline phosphatase was elevated in 7 cases (28%), and total bilirubin, direct bilirubin, albumin, international normalized ratio were in normal range. There was no statistical difference between the pneumonia group and the non-pneumonia group in term of liver chemistries (P > 0.05), same as between the elevated erythrocyte sedimentation rate group and the normal group. There was no aggravation of liver injury in the child with biliary atresia. The child with epilepsy showed no abnormal liver chemistries after infection. Conclusion: Children with 2019-nCoV infection had mild clinical symptoms with few cases of liver injury. The abnormal liver chemistries in children with COVID-19 infection may be related to the underlying disease and the use of antiviral drugs.

Identification of risk factors associated with numerous reoperations following primary hypospadias repair

INTRODUCTION

Complications remain the top evaluation priority subsequent to hypospadias repair. Complications vary in further management, and usually require one or more reoperations. Patients and/or their parents concern not only with the success rate of reoperation, but also with the risk of numerous reoperations.

OBJECTIVE

To identify the risk factors associated with numerous reoperations following primary hypospadias repair.

STUDY DESIGN

Data were collected retrospectively from patients who underwent reoperations for complications following primary hypospadias repair at a single institution from August 2008 to October 2017.

RESULTS

A total of 507 patients required reoperations following 2754 primary hypospadias repairs. Eventually, 486 patients were eligibly included with a median age of 2.2 years. The median follow-up period was 6.5 years. Preserved urethral plate urethroplasty for primary repair (including Snodgrass, Onlay and Mathieu techniques) was performed in 307 (63.2%) patients, Duckett technique was performed in 121 (24.9%) patients, and staged urethroplasty (including staged Duckett, Byars and Bracka techniques) was performed in 58 (11.9%) patients. The complications included 302 fistulas, 108 dehiscence, 50 urethral strictures, 18 meatal stenosis, 38 diverticula, 24 mild recurrent ventral curvature and 23 severe recurrent ventral curvature. A total of 363 (74.7%) patients needed 1 reoperation, 87 (17.9%) needed 2 reoperations, 19 (3.9%) needed 3 reoperations, and 17 (3.5%) needed >3 reoperations. Ordinal logistic regression demonstrated that severe recurrent ventral curvature, urethral stricture, dehiscence and primary staged hypospadias repair increased the risk of numerous reoperations, with odds ratios of 75.991-fold, 36.967-fold, 11.765-fold and 3.074-fold, respectively. In contrast, diverticulum decreased the risk, with an odds ratio of 0.443-fold.

DISCUSSION

Our data demonstrated significant heterogeneity in the risk of numerous reoperations for each complication. Severe recurrent ventral curvature conferred the highest risk of numerous reoperations, followed by urethral stricture, dehiscence. In additional, our data showed an increased risk of numerous reoperations following primary staged repairs. Identification the risk factors confers advantages in the assessment of postoperative outcomes and anticipation of future reoperations.

CONCLUSION

Severe recurrent ventral curvature, urethral stricture, dehiscence and primary staged hypospadias repair were associated with numerous reoperations following primary hypospadias repair.

Nanotechnology for catalysis and solar energy conversion

This roadmap on Nanotechnology for Catalysis and Solar Energy Conversion focuses on the application of nanotechnology in addressing the current challenges of energy conversion: 'high efficiency, stability, safety, and the potential for low-cost/scalable manufacturing' to quote from the contributed article by Nathan Lewis. This roadmap focuses on solar-to-fuel conversion, solar water splitting, solar photovoltaics and bio-catalysis. It includes dye-sensitized solar cells (DSSCs), perovskite solar cells, and organic photovoltaics. Smart engineering of colloidal quantum materials and nanostructured electrodes will improve solar-to-fuel conversion efficiency, as described in the articles by Waiskopf and Banin and Meyer. Semiconductor nanoparticles will also improve solar energy conversion efficiency, as discussed by Boschloo et al in their article on DSSCs. Perovskite solar cells have advanced rapidly in recent years, including new ideas on 2D and 3D hybrid halide perovskites, as described by Spanopoulos et al 'Next generation' solar cells using multiple exciton generation (MEG) from hot carriers, described in the article by Nozik and Beard, could lead to remarkable improvement in photovoltaic efficiency by using quantization effects in semiconductor nanostructures (quantum dots, wires or wells). These challenges will not be met without simultaneous improvement in nanoscale characterization methods. Terahertz spectroscopy, discussed in the article by Milot et al is one example of a method that is overcoming the difficulties associated with nanoscale materials characterization by avoiding electrical contacts to nanoparticles, allowing characterization during device operation, and enabling characterization of a single nanoparticle. Besides experimental advances, computational science is also meeting the challenges of nanomaterials synthesis. The article by Kohlstedt and Schatz discusses the computational frameworks being used to predict structure-property relationships in materials and devices, including machine learning methods, with an emphasis on organic photovoltaics. The contribution by Megarity and Armstrong presents the 'electrochemical leaf' for improvements in electrochemistry and beyond. In addition, biohybrid approaches can take advantage of efficient and specific enzyme catalysts. These articles present the nanoscience and technology at the forefront of renewable energy development that will have significant benefits to society.

NORAD regulates proliferation and apoptosis in cardiomyocytes under high-glucose treatment through miRNA-150-5p/ZEB1 axis

OBJECTIVE

The purpose of this study was to uncover the potential role of non-coding RNA activated by DNA damage (lncRNA NORAD) in the disease progression of diabetic cardiomyopathy (DCM) and the underlying mechanism.

MATERIALS AND METHODS

Cell viability, 5-Ethynyl-2'-deoxyuridine (EdU)-positive ratio and apoptotic rate in human cardiomyocyte cell line AC16 undergoing treatment of normal-level (NG) or high-level glucose (HG) were assessed at first. NORAD level in HG-induced AC16 cells at different time points was detected by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). Subsequently, cell viability, EdU-positive ratio, and apoptotic rate in HG-induced AC16 cells overexpressing NORAD were evaluated. Next, subcellular distribution of NORAD was examined, and Dual-Luciferase reporter gene assay was performed to clarify the interaction among NORAD, miRNA-150-5p, and ZEB1. At last, rescue experiments were conducted to clarify the role of NORAD/miRNA-150-5p/ZEB1 axis in influencing the proliferation and apoptosis in HG-induced AC16 cells.

RESULTS

Results revealed that HG treatment suppressed the proliferative ability and stimulated apoptosis in AC16 cells. Besides, NORAD was time-dependently downregulated in HG-induced AC16 cells, and it was mainly distributed in cytoplasm. In addition, the overexpression of NORAD enhanced proliferative ability, attenuated apoptosis, and increased Bcl-2/Bax ratio in HG-induced AC16 cells. Finally, NORAD/miRNA-150-5p/ZEB1 axis was verified to protect the malignant progression of DCM.

CONCLUSIONS

NORAD is upregulated under high-level glucose treatment. Overexpression of NORAD protects DCM development via miRNA-150-5p/ZEB1 axis.

MiR-155-5p promotes renal interstitial fibrosis in obstructive nephropathy via inhibiting SIRT1 signaling pathway

Protection against renal fibrosis is important for the management of obstructive nephropathy. We researched the roles and possible mechanism of miR-155-5p in renal interstitial fibrosis, which may provide a potential endogenous target for renal interstitial fibrosis in obstructive nephropathy. Herein, NRK-49F cells were transfected with miR-155-5p mimic, miR-155-5p inhibitor, SIRT1 plasmid and/or SIRT1 siRNA. The unilateral ureteral obstruction (UUO) model was built with male C57 black mice and administrated with SRT1720 by tail vein injection. Levels of miR-155-5p, SIRT1 and relative proteins (TGF-β1, α-SMA, Collage I and fibronectin) in NRK-49F cells or mice kidney tissues were measured with quantitative reverse transcription polymerase chain reaction or Western blot. The target gene of miR-155-5p was analyzed through TargetScan and dual-luciferase reporter assay. Mice kidney tissue was stained with Masson trichrome. It was found that miR-155-5p overexpression promoted the expressions of fibroblast related proteins expression and inhibited the SIRT1 expression in NRK-49F cells, while miR-155-5p silencing had an opposite effect. SIRT1 can bind with miR-155-5p. MiR-155-5p inhibited the level of SIRT1. Fibroblast related proteins were up-regulated by miR-155-5p and down-regulated by SIRT1 in NRK-49F cells, while the up-regulatory effect of miR-155-5p was reversed by SIRT1. MiR-155-5p expression was up-regulated and SIRT1 expression was down-regulated in the kidney tissue of UUO mice. SRT1720 attenuated the fiber deposition, up-regulated SIRT1 level and down-regulated the levels of fibroblast related proteins in UUO model mice. To conclude, miR-155-5p promotes renal interstitial fibrosis in obstructive nephropathy via inhibiting SIRT1 signaling pathway.

[Blood loss in total knee arthroplasty using computer-assisted navigation or 3D-printed patient-specific instruments]

Objective: To compare the perioperative blood loss in patients undergoing a total knee arthroplasty (TKA) across three different techniques: computer-assisted navigation surgery (CAS), patient specific instrumentation (PSI) and conventional instrumentation (CI). Methods: Ninety consecutive patients with severe knee osteoarthritis who underwent unilateral primary TKA in Peking University Third Hospital Orthopedics Department from January 2018 to December 2018 were enrolled in this prospective study. The patients were randomly divided into three groups (30 case in each group): CAS-TKA group, PSI-TKA group and CI-TKA group. The study measured intraoperative blood loss, total blood loss, hidden blood loss, decreases of hemoglobin and hematocrit, and the post-TKA blood transfusions in the three groups. One-way ANOVA was used to detect the differences among the cohorts, and LSD was used for the post-hoc test. Results: The overall intraoperative blood loss of all patients was 6 ml (5~8 ml). The mean total blood loss and hidden blood loss in CAS-TKA group, PSI-TKA group and CI-TKA group was (1 147.0±301.8) and (1 140.1±301.9)ml, (1 044.3±454.1) and (1 038.5±454.0)ml, (1 154.0±483.6) and (1 145.3±482.7)ml, respectively; there was no significant differences among the three groups (F=0.639, 0.616, both P>0.05). There were no patients who received allogeneic blood transfusion. There were no significant differences in decrease of hemoglobin and hematocrit among the three groups neither (both P>0.05). Conclusions: Compared with conventional TKA, CAS and PSI does not increase the total blood loss of TKA. However, they both demonstrate a potential benefit in reducing blood loss of TKA.

[Application of thoracoscopy-guided thoracic paravertebral block for analgesia after single-port video-assisted pulmonary lobectomy]

Objective: To investigate the effects of thoracoscopy-guided thoracic paravertebral block for analgesia after single-port video-assisted pulmonary lobectomy. Methods: From December 2019 to April 2020, 60 patients receiving single-port video-assisted pulmonary lobectomy at Ningbo Medical Center Lihuili Hospital were selected. The patients were randomly and equally divided into control group and paravertebral block group using a random number table. Patients of paravertebral block group were injected into the thoracic 4-5 intercostal, paravertebral 1 cm using 0.375% ropivacaine (20 ml) with thoracoscopy-guided at the end of surgery, while patients of control group were given patient controlled intravenous analgesia (PCIA). Postoperative visual analogue scale (VAS) and Ramsay sedation scale were recorded at 6, 12, 24, 36, 48 h after the surgery. The incidence of postoperative adverse reactions, additional dose and times of pethidine, the time to resume eating, the rate of postoperative active cough, the first time to get out of bed after surgery and postoperative hospital stay of two groups' patients were recorded. t test and chisquare test were used for statistical analysis. Results: The VAS score of paravertebral block group were lower than those of control group at all time points (all P<0.05). The Ramsay sedation scale of paravertebral block group were higher than those of control group at all time points (all P<0.05). The additional dose and times of pethidine of paravertebral block group were (8.2±2.3) mg and (0.2±0.1) time, which were lower than (87.8±15.3) mg and (1.8±0.3) time of control group, the differences were statistically significant (t=28.91, 34.37, all P<0.05). Incidence of nausea, vomiting and pruritus of paravertebral block group were 10.0%, 6.7% and 0, which were lower than 40.0%, 30.0% and 13.3% of control group, the differences were statistically significant (χ(2)=7.20, 5.45, 4.29, all P<0.05). The rate of postoperative active cough of paravertebral block group was 33.3%, which was higher than 10.0% of control group, the difference was statistically significant (χ(2)=4.81, P<0.05). The time to resume eating, the first time to get out of bed after surgery and postoperative hospital stay were (6.5±0.4) h, (20.9±3.1) h and (4.6±1.0) d, which were lower than (8.5±0.7) h, (28.6±4.8) h and (6.1±1.3) d of control group, the differences were statistically significant (t=13.47, 7.39, 4.19, all P<0.05). Conclusion: Thoracic paravertebral block under thoracoscopy-guided can effectively reduce the postoperative pain of single-port thoracoscopic lobectomy, with fewer adverse reactions, and is beneficial to postoperative recovery.

Impacts of extreme summers on European ecosystems: a comparative analysis of 2003, 2010 and 2018

In Europe, three widespread extreme summer drought and heat (DH) events have occurred in 2003, 2010 and 2018. These events were comparable in magnitude but varied in their geographical distribution and biomes affected. In this study, we perform a comparative analysis of the impact of the DH events on ecosystem CO₂ fluxes over Europe based on an ensemble of 11 dynamic global vegetation models (DGVMs), and the observation-based FLUXCOM product. We find that all DH events were associated with decreases in net ecosystem productivity (NEP), but the gross summer flux anomalies differ between DGVMs and FLUXCOM. At the annual scale, FLUXCOM and DGVMs indicate close to neutral or above-average land CO₂ uptake in DH2003 and DH2018, due to increased productivity in spring and reduced respiration in autumn and winter compensating for less photosynthetic uptake in summer. Most DGVMs estimate lower gross primary production (GPP) sensitivity to soil moisture during extreme summers than FLUXCOM. Finally, we show that the different impacts of the DH events at continental-scale GPP are in part related to differences in vegetation composition of the regions affected and to regional compensating or offsetting effects from climate anomalies beyond the DH centres. This article is part of the theme issue 'Impacts of the 2018 severe drought and heatwave in Europe: from site to continental scale'.