Perioperative remedial antiviral therapy in hepatitis B virus-related hepatocellular carcinoma resection: How to achieve a better outcome

BACKGROUND

Although the benefits of antiviral therapy for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) have been proven, researchers have not confirmed the differences in patient outcomes between patients who received preoperative antiviral therapy for a period of time (at least 24 wk) and patients who received remedial antiviral therapy just before radical resection for HBV-related HCC.

AIM

To investigate the efficacy of perioperative remedial antiviral therapy in patients with HBV-related HCC.

METHODS

A retrospective study of patients who underwent radical resection for HBV-related HCC at the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to June 2019 was conducted. Considering the history of antiviral therapy, patients were assigned to remedial antiviral therapy and preoperative antiviral therapy groups.

RESULTS

Kaplan-Meier analysis revealed significant differences in overall survival (P < 0.0001) and disease-free survival (P = 0.035) between the two groups. Multivariate analysis demonstrated that a history of preoperative antiviral treatment was independently related to improved survival (hazard ratio = 0.27; 95% confidence interval: 0.08-0.88; P = 0.030).

CONCLUSION

In patients with HBV-related HCC, it is ideal to receive preoperative long-term antiviral therapy, which helps patients tolerate more extensive hepatectomy; however, remedial antiviral therapy, which reduces preoperative HBV-DNA levels to less than 4 Log10 copies DNA/mL, can also result in improved outcomes.

[Silent pulmonary shadows]

An elderly woman with a 1-year history of pulmonary shadows was admitted because of intermittent cough and sputum production for 2 months. Chest computed tomography (CT) scans showed bilateral consolidations and ground-glass opacities, with areas of low attenuation inside consolidative opacities on the mediastinal window. Previous history of radiotherapy for nasopharyngeal carcinoma and long-term use of a compound menthol nasal drops provided were important clues to the diagnosis. CT scan-guided needle lung biopsy and bronchoalveolar lavage were performed, and lipid-laden macrophages were confirmed in both bronchoalveolar lavage and lung tissue. Final diagnosis of exogenous lipoid pneumonia was made on the basis of her risk factors for aspiration, history of oil exposure, and classic radiological and histopathological features. Symptoms improved after discontinuation of causative exposure. It is important for clinicians to raise awareness of exogenous lipoid pneumonia and other aspiration lung diseases.

[Diffuse thickening of bronchial walls with multiple nodular mucosal protrusions]

A 58-year-old woman presented with a six-month history of nasal congestion, sore throat and cough, and a five-month history of dyspnea. She had a history of xerostomia for one year. On examination, the bilateral submandibular gland and parotid glands were enlarged. Parotid and anterior cervical lymph nodes were palpable. There were rales in both lungs. The rest of the physical examination was unremarkable. Sialographic analysis showed normal caliber in the main duct, stenosis in secondary ducts, and dilation in the proximal ducts. Minor salivary gland biopsy demonstrated periductal lymphocytic infiltration. Chest computed tomography (CT) showed diffuse thickening of the tracheal and bilateral bronchial walls. Bronchoscopy revealed macroscopic multiple nodules mainly in the trachea and bilateral main bronchus. Endobronchial biopsy showed lymphocytic infiltration in the bronchial submucosa. She was diagnosed with Sjögren's syndrome and treated with glucocorticoids. The dose of prednisone was started at 30 mg/d and tapered gradually. Following treatment, the patient's clinical condition improved dramatically, with shrinkage of the enlarged lymph nodes, bilateral submandibular and parotid glands. A repeated chest CT scan revealed improvement of the tracheal and bilateral bronchial thickening. Multiple nodules in the airway regressed, as evidenced by repeated bronchoscopic examination. The final diagnosis was a large-airway disease associated with Sjögren's syndrome.Among airway diseases in Sjögren's syndrome, peripheral airway diseases including bronchiolitis and bronchiectasis are common; however, central airway lesions in Sjögren's syndrome, especially with macroscopic nodules, are rare. In this case, we demonstrated tracheal and endobronchial nodules in Sjögren's syndrome as determined by clinical features, CT scan, bronchoscopy, and response to therapy.

[Efficacy evaluation of short-term personalized vestibular rehabilitation in the treatment of acute unilateral vestibulopathy]

Objective: To explore the efficacy and effective node of short-term personalized vestibular rehabilitation (ST-PVR) in treating acute unilateral vestibulopathy (AUVP). Methods: A randomized controlled trial was carried out. The AUVP patients who were admitted to the First Affiliated Hospital of Zhengzhou University from July 2022 to March 2023 were selected and randomized to the vestibular rehabilitation (VR) group and control group via computer-generated randomization. Standard care was the medical treatment with betahistine and prednisolone. Meanwhile, the VR group received ST-PVR. All the patients completed the baseline assessment and underwent follow-up assessments at 1 month and 3 months after the treatment. The assessments were consisted of spontaneous nystagmus (NYS), Romberg test (ROM), head thrust test (HTT), visual analogue scale (VAS) for vertigo, dizziness handicap inventory scale (DHI), activities-specific balance confidence scale (ABC), caloric test using video-electronystagmograph (VNG), and video-head impulse test (vHIT). The measurement data that did not conform to normal distribution were represented by M (Q1, Q3). Generalized estimating equation (GEE) was used to analyze the influence of the ST-PVR on the values of these clinical indicators and the VR grading score. The values of clinical indicators and the VR grading score were compared between the two groups at each follow-up point. Results: Seventy-one AUVP patients were included, with 35 cases in the VR group [14 males and 21 females, aged 51 (33, 55) years] and 36 cases in control group [17 males and 19 females, aged 46 (34, 59) years]. There were statistically significant differences in the impact of ST-PVR on the values of clinical indicators between the two groups (ABC: β=10.89, P<0.001; VAS: β=-1.64, P<0.001; DHI: β=-8.70, P<0.001; NYS: β=26.73, P<0.001; vHIT: β=1.41, P=0.047; the VR grading score: β=1.03, P=0.045). The assessments of the VR group in the positive rate of NYS [14.3% (5/35) vs 50.0% (18/36), P<0.001], ROM [48.6% (17/35) vs 55.6% (20/36), P<0.001], directional preponderance (DP) [34.3% (12/35) vs 75.0% (27/36), P<0.001] and DHI [26 (22, 32) vs 36 (30, 60), P=0.001] were significantly lower than that of the control group at 1 month after the treatment. The results showed a statistically significant difference in ABC [88 (80, 90) vs 76 (61, 88), P<0.001], VAS [2 (1, 3) vs 3 (2, 5), P<0.001] at 3-months after the treatment. The VR grading score of the VR group was improved significantly than those of the control group at 1 month after treatment [21 (17, 21) vs 16 (13, 20), P=0.001]. Conclusion: ST-PVR could improve the results of clinical indicators and VR grading score of the AUVP patients effectively after 1 month of the systematical treatment, and alleviate the symptoms and signs of dizziness in the acute phase as early as possible.

[A case of follicular lymphoma with recurrent fever and pulmonary infiltrates]

We reported a case of a 65-year-old male who had been treated with obinutuzumab and chemotherapy for follicular lymphoma. He was infected with SARS-CoV-2 after the second course of therapy. He developed fever, cough and bilateral pulmonary infiltrates. His nasopharyngeal swab became negative only temporarily after repeated courses of antiviral therapy, and the symptoms and pulmonary infiltrates waxed and waned. He presented to our hospital with exertional dyspnea and hypoxemia after his nasopharyngeal swab was positive for SARS-CoV-2 for the fourth time. He had an elevated serum lactate dehydrogenase and a positive 1, 3-β-D-glucan test. The PCR test for Pneumocystis jirovecii in the sputum was positive. The patient was diagnosed with persistent COVID-19 and Pneumocystis jirovecii pneumonia. He responded well to the combination treatment of antiviral medication, convalescent plasma, trimethoprim-sulfamethoxazole and corticosteroids.

[Application of autoregressive integrated moving average model to predict and analyze the incidence trend of mumps in Jiangxi Province]

Objective: To predict and analyze the incidence trend of mumps using the Autoregressive integrated moving average model (ARIMA) in Jiangxi Province. Methods: The ARIMA was used to model the number of mumps cases per month from 2015 to 2019 in Jiangxi Province. The number of mumps cases in 12 months was predicted and was compared with the actual reported cases in 2020, 2021, and 2022, respectively. Results: The optimal model was ARIMA (0,2,1)(1,2,0)12. The predicted number of cases was significantly higher than that reported in 2020, 2021 and 2022. The number of reported cases of mumps in 2020, 2021, and 2022 decreased by 54.02%, 63.40%, and 66.09% compared with the forecast. Conclusions: From 2020 to 2022, the reported incidence of mumps in Jiangxi Province was significantly lower than the predicted incidence. Considering that it was related to non-drug intervention measures and changes in immunization strategies, it was suggested to strengthen mumps surveillance further to better cope with the epidemic situation of mumps.

[Hypercapnia under controlled mechanical ventilation in patients with high-risk acute pulmonary thromboembolism]

Objective: To evaluate the variation of arterial partial pressure of carbon dioxide (PaCO₂) in patients with high-risk pulmonary embolism under mechanical ventilation. Methods: We retrospectively analyzed the cases of high-risk pulmonary embolism who underwent intravenous thrombolysis in Peking Union Medical College Hospital from January 1, 2012, to May 1, 2022. The enrolled patients were divided into a mechanical-ventilated group and an active-breathing group according to whether they received invasive mechanical ventilation or not. The level of PaCO₂ under active breathing between the two groups, the changes in PaCO₂ before intubation, after intubation and after thrombolysis in the mechanical-ventilated group were compared. The 14-day all-cause mortality of the two groups was calculated and compared. Results: A total of 49 patients with high-risk pulmonary embolism were enrolled, including 22 patients in the mechanical-ventilated group and 27 patients in the active-breathing group. Before intubation, PaCO₂ in both groups was lower than normal without statistically significant difference between the two groups. After effective thrombolysis therapy, PaCO₂ in both groups recovered to the normal range. In the mechanical-ventilated group, PaCO₂ significantly increased 11-147 min after intubation and returned to the normal range after thrombolysis therapy. The 14-day mortality in the mechanical-ventilated group was 54.5%, while all patients in the active-breathing group survived. Conclusions: Under mechanical controlled ventilation, patients with high-risk pulmonary embolism could represent hypercapnia which resolved after effective thrombolytic therapy. In mechanical ventilated patients with sudden-onset hypoxemia and hypercapnia, the possibility of high-risk pulmonary embolism should be considered.

[Nontuberculous mycobacteria infection and pulmonary alveolar proteinosis in a patient with hematopoietic defects]

A 28-year-old male with a history of leukopenia was admitted with complaints of fever, cough, and dyspnea for 3 months. Initial work-up identified reduced circulating levels of granulocytes, monocytes, lymphocytes, and NK cells. Computed tomography revealed bilateral reticulonodular opacities and mediastinal lymph node enlargement. Peripheral blood culture and mediastinal lymph node aspiration yielded Mycobacterium avium. Genetic testing revealed a heterozygous germline GATA2 mutation (c.1187G>A, R396Q). Despite standard anti-mycobacterial therapy, the patient's dyspnea worsened and subsequent imaging studies revealed diffuse ground-glass opacification. A transbronchial lung biopsy confirmed the development of pulmonary alveolar proteinosis. Bone marrow transplantation had not been performed due to the unavailability of suitable donors. The disease progressed after whole lung lavage, and the patient died at the age of 31 years from respiratory failure. The current case report emphasized the importance of raising awareness about the rare GATA2 deficiency, which is characterized by hematologic abnormalities, primary immunodeficiency, and pulmonary alveolar proteinosis.

[Clinical and prognostic analysis of acute pulmonary thromboembolism in the elderly]

Objective: To analyse the clinical characteristics and to explore the prognostic factors of acute pulmonary thromboembolism in the elderly. Methods: The medical records of inpatients with acute pulmonary thromboembolism discharged from Peking Union Medical College Hospital from January 1, 2012, to February 1, 2019 were retrospectively reviewed. The eligible patients were divided into elderly group (≥ 60 years old) and non-elderly group (<60 years old). The clinical symptoms, complications, laboratory results, pulmonary embolism severity index (PESI) and mortality were compared between the two groups. Mortality was further compared among elderly patients of different age groups. Cox regression analysis was used to analyze the risk factors of 7-day and 30-day death in elderly patients with pulmonary embolism. Results: A total of 503 patients with acute pulmonary embolism were included, including 279 cases in the elderly group and 224 cases in the non-elderly group. The incidence of cardiac arrest was higher in the elderly group compared with non-elderly group, while the incidence of chest pain and hemoptysis was less common in the elderly group. The proportions of comorbidities, including diabetes, hypertension, and coronary heart disease were higher in the elderly group while the proportion of autoimmune diseases was higher in the non-elderly group. In terms of prognosis, the PESI score and 7-day and 30-day mortality in the elderly group were higher than those in the non-elderly group. The mortality of elderly patients increased with age. Cox univariate regression analysis showed that infection, hypoalbuminemia, hypocalcemia, elevated cardiac troponin(cTnI), elevated N-terminal prohormone of brain natriuretic pepride(NT-proBNP) and PESI grade were associated with 30-day death. Multivariate Cox regression analysis showed that PESI grade and decreased serum calcium concentration were independent risk factors for 7-day death of pulmonary embolism in elderly patients. PESI grade, decreased serum calcium concentration and infection were independent risk factors for 30-day death. Conclusions: The mortality of elderly patients with pulmonary embolism was higher than that of non-elderly patients, and the mortality increased gradually with age. PESI grade, decreased serum calcium concentration and infection were independent risk factors for 30-day death of pulmonary embolism in elderly patients.

[Waxing and waning pulmonary nodules and cavities]

We reported a case of vascular Ehlers-Danlos syndrome presenting with recurrent pulmonary hemorrhage. A 22-year-old man was admitted for intermittent hemoptysis and chest pain during the past 18 months. Computed tomography of chest showed bilateral nodules and cavities with halo sign. Inflammatory markers, including erythrocyte sedimentation rate, C reactive protein and interleukin 6, were within normal range. The microbiological and pathological examination of bronchoalveolar lavage fluid and CT-guided percutaneous lung biopsy failed to draw a diagnosis. The pulmonary lesions waxed and waned despite empirical antibacterial, antifungal, antimycobacterial, and anti-parasite treatment. Video-assisted thoracoscopic lung biopsy showed pulmonary hemorrhage, hematoma, ossification, and fibrous nodules, suggesting vascular Ehlers-Danlos syndrome. The molecular testing revealed a heterozygous missense variant in the COL3A1 gene which confirmed the diagnosis of vascular Ehlers-Danlos syndrome. The patient had no skin hyperextensibility or joint hypermobility. During 3-year follow-up, there were no evidence of other vascular or organ involvement except he had intermittent minor hemoptysis. Through this clinical pathological discussion, we aimed to remind pulmonologist to consider the possible diagnosis of vascular Ehlers-Danlos syndrome in young patients with recurrent hemoptysis and waxing and waning pulmonary nodules, cavities, or cysts on CT scan who has neither obvious systematic inflammation nor effective reaction on empirical antimicrobial therapy. Molecular testing should be carried out as soon as possible in a suspected patient to avoid unnecessary invasive examinations.

[Clinical effects of free transplantation of expanded thoracodorsal artery perforator flaps in reconstructing cervical cicatrix contracture deformity after burns]

Objective: To explore the clinical effects of free transplantation of expanded thoracodorsal artery perforator flaps in reconstructing cervical cicatrix contracture deformity after burns. Methods: A retrospective observational study was conducted. From May 2018 to April 2021, 11 patients with cervical cicatrix contracture deformity after burns who met the inclusion criteria were admitted to the First Affiliated Hospital of Air Force Medical University, including 3 males and 8 females, aged 5 to 46 years, with a course of cervical cicatrix contracture deformity of 5 months to 8 years. The degree of cervical cicatrix contracture deformity was degree Ⅰ in one patient, degree Ⅱ in nine patients, and degree Ⅲ in one patient. In the first stage, according to the sizes of neck scars, one rectangular skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 200 to 600 mL was placed in the back. The expansion time was 4 to 12 months with the total normal saline injection volume being 3.0 to 3.5 times of the rated capacity of expander. In the second stage, free expanded thoracodorsal artery perforator flaps with areas of 10 cm×7 cm to 24 cm×13 cm were cut out to repair the wounds with areas of 9 cm×6 cm to 23 cm×12 cm which was formed after cervical cicatectomy. The main trunk of thoracodorsal artery and vein were selected for end-to-end anastomosis with facial artery and vein, and the donor sites were directly closed. The survival of flaps and healing of flap donor sites were observed on the 14th day post surgery. The appearances and cicatrix contracture deformity of the flaps, recovery of cervical function, and scar hyperplasia of donor sites were followed up. Results: On the 14th day post surgery, the flaps of ten patients survived, while ecchymosis and epidermal necrosis occurred in the center of flap of one patient and healed 2 weeks after dressing change. On the 14th day post surgery, the flap donor sites of 11 patients all healed well. During the follow-up of 6-12 months post surgery, the flaps of ten patients were similar to the skin around the recipient site in texture and color, while the flap of one patient was slightly swollen. All of the 11 patients had good recovery of cervical function and no obvious scar hyperplasia nor contracture in the flaps or at the donor sites. Conclusions: Application of expanded thoracodorsal artery perforator flaps can restore the appearance and function of the neck, and cause little damage to the donor site in reconstructing the cervical cicatrix contracture deformity after burns, which is worthy of clinical reference and application.

[Subcutaneous nodules, mediastinal and hilar lymphadenopathy]

A 52-year old man was admitted to our hospital because of dyspnea on exertion for 2 months and subcutaneous nodules for 1 month. Chest enhanced CT showed bilateral hilar and mediastinal lymphadenopathy. Bronchial alveolar lavage fluid revealed a CD₄⁺/CD₈⁺ T cell subsets ratio of 4.3 and culture for acid-fast bacillus (AFB) was negative. The pathology of skin nodules and transbronchial needle aspiration biopsy guided by endoscopic ultrasound (EBUS-TBNA) revealed non-caseating necrotizing epithelioid granulomas with negative acid-fast bacilli staining and periodic acid-Schiff staining, which was compatible with sarcoidosis. The patient was diagnosed as sarcoidosis and glucocorticoid was administrated. The subcutaneous nodules were improved. However, the lymph nodes were enlarged instead of shrinking after 6-month therapy. The failure to respond to glucocorticoids raised the possibility of sarcoidosis complicated with tuberculosis infection. The patient received anti-tuberculosis therapy. Lymphadenopathy responded within 4 months, and there was complete regression after 18-month treatment. The patient was followed up for 5 years and repeated chest CT scan showed that the sizes of bilateral hilar and mediastinal lymph nodes were normal.

Efficacy and safety of sirolimus early conversion protocol in liver transplant patients with hepatocellular carcinoma: A single-arm, multicenter, prospective study

Mammalian target of rapamycin (mTOR) inhibitor as an attractive drug target with promising antitumor effects has been widely investigated. High quality clinical trial has been conducted in liver transplant (LT) recipients in Western countries. However, the pertinent studies in Eastern world are paucity. Therefore, we designed a clinical trial to test whether sirolimus can improve recurrence-free survival (RFS) in hepatocellular carcinoma (HCC) patients beyond the Milan criteria after LT. This is an open-labeled, single-arm, prospective, multicenter, and real-world study aiming to evaluate the clinical outcomes of early switch to sirolimus-based regimens in HCC patients after LT. Patients with a histologically proven HCC and beyond the Milan criteria will be enrolled. The initial immunosuppressant regimens are center-specific for the first 4-6 weeks. The following regimens integrated sirolimus into the regimens as a combination therapy with reduced calcineurin inhibitors based on the condition of patients and centers. The study is planned for 4 years in total with a 2-year enrollment period and a 2-year follow-up. We predict that sirolimus conversion regimen will provide survival benefits for patients particular in the key indicator RFS as well as better quality of life. If the trial is conducted successfully, we will have a continued monitoring over a longer follow-up time to estimate indicator of overall survival. We hope that the outcome will provide better evidence for clinical decision-making and revising treatment guidelines based on Chinese population data. Trial register: Trial registered at http://www.chictr.org.cn: ChiCTR2100042869.

[Diagnostic value of surgical lung biopsies for diffuse parenchymal lung disease:re-evaluation and new insight]

Surgical lung biopsy (SLB) has been clearly recommended for the diagnosis of diffuse parenchymal lung disease (DPLD) in major guidelines because it provides the largest and most informative tissue samples. However, with the use of new non-invasive or minimally invasive tools in the diagnosis and treatment of DPLD, the dominance of SLB as the gold standard in the diagnosis of DPLD has been questioned, the diagnostic value of SLB for diffuse parenchymal lung should be re-evaluated.

[Diagnostic value of surgical lung biopsies for diffuse parenchymal lung disease: the change of disease spectrum in the past 28 years in a single institution in China]

Objective: To investigate the changes of disease spectrum in diffuse parenchymal lung disease (DPLD) diagnosed by surgical lung biopsy, and to explore the diagnostic value of surgical lung biopsy in DPLD. Methods: Four hundred and fifty-five consecutive DPLD patients, who underwent surgical lung biopsy in Peking Union Medical College Hospital during the past 28 years, were analyzed retrospectively. Results: There were 211 males and 244 females. The average age at biopsy was (45±14) years. Four hundred and eleven cases (90.3%) were diagnosed by pathologic findings. Four hundred and forty-one cases (96.9%) were diagnosed by clinical-radiologic-pathologic multidisciplinary discussion. The 30-day mortality and 90-day mortality were 2.4% and 3.3% respectively. The disease spectrum included interstitial pneumonia in 209 cases (45.9%) (nonspecific interstitial pneumonia in 105 cases, usual interstitial pneumonia in 33 cases), other miscellaneous DPLD in 166 cases (36.5%) (including hypersensitivity pneumonitis in 49 cases), tumor in 39 cases (8.6%), and infectious diseases in 27 cases (5.9%). In the three consecutive periods (1993-2002, 2003-2012 and 2013-2020), the number of biopsies was 76 (16.7%), 297 (65.3%) and 82 (18%) respectively. The disease spectrum changes over time: in the above three periods, the percentage of interstitial pneumonia in DPLD was 68.4%, 45.1% and 28%, other miscellaneous DPLDs were 22.4%, 39.4% and 39.0%, the tumors were 2.6%, 7.4% and 18.3%, the infectious diseases were 5.3%, 5.1% and 9.8%. Conclusions: This study presented the changes of disease spectrum in DPLD diagnosed by surgical lung biopsy through single center real-world data, reflecting the progress of clinicians' understanding of DPLD and interstitial pneumonia. Surgical lung biopsy is still valuable for some difficult and complicated DPLD cases.

Diagnosis and treatment of acute graft-versus-host disease after liver transplantation: Report of six cases

BACKGROUND

Graft-versus-host disease (GVHD) following liver transplantation (LT) is an unpredictable complication with poor outcome. However, consensus regarding the diagnosis and therapeutic regimen for the disease is yet lacking. The present study summarized the clinical experience on the diagnosis and treatment of acute GVHD (aGVHD) following LT and reviewed the pertinent literature.

CASE SUMMARY

Between January 1^st, 2000 and December 31^st, 2020, a total of 1053 LT were performed in the First Affiliated Hospital of Xi’an Jiaotong University. Six recipients developed aGVHD with clinical symptoms of fever, rash, diarrhea, and pancytopenia. The incidence of aGVHD was 0.57%. The median time from LT to the clinical presentation of aGVHD was 22.17 d. The median time from the beginning of the clinical symptom to histopathological diagnosis was 7.5 d. All six cases underwent treatment of immunosuppressant adjustment, corticosteroids, human normal immunoglobulin, and antithymocyte globulin/IL-2 antagonists. Despite intensive treatment strategies, 4 patients were deceased due to sepsis, multiple organ failure, and cerebral hemorrhage. The remaining two cases were discharged as treatment successfully. However, one died because of tuberculosis infection on the 6th month of follow-up, the other one was alive healthy during 30 mo of follow-up.

CONCLUSION

The rapid diagnosis of aGVHD is mainly based on the time from the first symptom, histopathological features, and the donor T-lymphocyte chimerism. Our cases report highlights massive corticosteroid therapy and age difference between donors and recipients could accelerate to aGVHD. Moreover, gut microbial interventions and donor-targeted serotherapy may provide novel therapeutics.

[Relationship between the ideal cardiovascular health behaviors and factors and newonset heart failure]

Objective: To explore the relationship between the ideal cardiovascular health behaviors and factors and newonset heart failure. Methods: It was a prospective cohort study. People who attended the 2006-2007 physical examination of Kailuan Group Company and with complete data of cardiovascular behaviors and related factors were eligible for this study. A total of 95 167 participants who were free of valvular heart diseases, congenital heart diseases and a prior history of heart failure were included. Basic cardiovascular health score (CHS) of each participant was calculated. Participants were divided into 3 groups according to CHS. Group 1:CHS<8 (n=26 640), Group 2:8≤CHS<10 (n=35 230), Group3:CHS≥10 (n=33 297). The general clinical data and laboratory test results were collected. The outcome was defined as the first occurrence of heart failure at the end of followup(December 31, 2016). Cox regression model was used to determine the association between baseline CHS and the risk of newonset heart failure. Results: After a median followup of 10.3 years, the incidence of newonset heart failure in the group of CHS<8,8≤CHS<10,CHS≥10 were 2.7%(729/26 640), 1.8%(651/35 230) and 1.1%(360/33 297),respectively. After adjustment for age, sex, history of myocardial infarction, history of atrial fibrillation, income, alcohol consumption, education and the use of antihypertensive, cholesterol-lowering, glucose-lowering medications, compared with the group of CHS<8, the Cox regression model showed that HRs of the group of 8≤CHS<10 and CHS≥10 were 0.68 (95%CI 0.61-0.75), 0.49 (95%CI 0.43-0.55), respectively. Cox regression analysis after removing each single cardiovascular behavior or factor showed that the HR value range ability was as follows:systolic blood pressure(HR=0.78,95%CI 0.74-0.82), body mass index(HR=0.78,95%CI 0.74-0.82), fasting blood glucose (HR=0.77,95%CI 0.73-0.81), total cholesterol(HR=0.76,95%CI 0.72-0.80), physical exercise(HR=0.72,95%CI 0.69-0.76), smoking(HR=0.75,95%CI 0.71-0.79) and salt intake(HR=0.73,95%CI 0.69-0.77). Conclusion: CHS is negatively associated with the risk of newonset heart failure, and there is a dose-response relationship between the two indexes.

Efficacy, Safety, and Correlative Biomarkers of Toripalimab in Previously Treated Recurrent or Metastatic Nasopharyngeal Carcinoma: A Phase II Clinical Trial (POLARIS-02)

PURPOSE

As yet, no checkpoint inhibitor has been approved to treat nasopharyngeal carcinoma (NPC). This study was aimed to evaluate the antitumor activity, safety, and biomarkers of toripalimab, a new programmed death-1 (PD-1) inhibitor for recurrent or metastatic NPC (RM-NPC) refractory to standard chemotherapy.

PATIENTS AND METHODS

In this single-arm, multicenter phase II study, patients with RM-NPC received 3 mg/kg toripalimab once every 2 weeks via intravenous infusion until confirmed disease progression or unacceptable toxicity. The primary end point was objective response rate (ORR). The secondary end points included safety, duration of response (DOR), progression-free survival (PFS), and overall survival (OS).

RESULTS

Among all 190 patients, the ORR was 20.5% with median DOR 12.8 months, median PFS 1.9 months, and median OS 17.4 months. Among 92 patients who failed at least two lines of systemic chemotherapy, the ORR was 23.9%. The ORRs were 27.1% and 19.4% in PD-L1+ and PD-L1- patients, respectively (P = .31). Patients with ≥ 50% decrease of plasma Epstein-Barr virus (EBV) DNA copy number on day 28 had significantly better ORR than those with < 50% decrease, 48.3% versus 5.7% (P = .0001). Tumor mutational burden had a median value of 0.95 muts/mega-base in the cohort and had no predictive value for response. Whole-exome sequencing results from 174 patients revealed that the patients with genomic amplification in 11q13 region or ETV6 genomic alterations had poor responses to toripalimab.

CONCLUSION

The POLARIS-02 study demonstrated a manageable safety profile and durable clinical response of toripalimab in patients with chemorefractory metastatic NPC. An early decrease in plasma EBV DNA copy number correlated with favorable response.

A Genetic Variant of the BTLA Gene is Related to Increased Risk and Clinical Manifestations of Breast Cancer in Chinese Women

BACKGROUND

B and T lymphocyte attenuator (BTLA), an immunoinhibitory receptor, is shown to suppress the lymphocyte activation. Several studies addressed the relationship between the BTLA rs1982809 polymorphism and the risk of cancer.

PATIENTS AND METHODS

To identify the effects of this polymorphism on the risk of breast cancer (BC), this study examined Chinese women from China, Jiangsu Province. This study involved 324 patients with BC and 412 controls.

RESULTS

We observed that the BTLA rs1982809 polymorphism elevated the risk of BC. A similar finding was also shown in the subgroups of premenopausal women and those aged < 55 years old. In addition, this polymorphism was correlated with the estrogen receptor status, C-erbB-2 status, Ki-67 status, TNM stage, and tumor size of patients with BC.

CONCLUSIONS

Collectively, the BTLA rs1982809 polymorphism shows a significant association with elevated risk and clinical features of BC in Chinese women. Further studies involving other races are urgently needed to replicate these findings.

Synchronous parathyroid adenoma, papillary thyroid carcinoma and thyroid adenoma in pregnancy: A case report

BACKGROUND

There is a common pathologic relationship between parathyroid adenoma and thyroid cancer, but this relationship is infrequent in pregnant patients with primary hyperparathyroidism (PHPT).

CASE SUMMARY

A 27-year-old gravida 1 woman was transferred to our hospital at 16 wk of pregnancy. She was diagnosed with parathyroidoma, papillary carcinoma of the thyroid and thyroid adenoma and was managed surgically. Both the mother and the newborn were stable after a right inferior parathyroidectomy and total thyroidectomy. The healthy infant was delivered at the 40^th week of pregnancy. The mother had no evidence of recurrence over three years of follow-up.

CONCLUSION

Awareness of concomitant PHPT and thyroid diseases may help in managing patients with a history of hypercalcemia.

Simulated model of RAPID concept: highlighting innate inflammation and liver regeneration

Background

The resection and partial liver segment II/III transplantation with delayed total hepatectomy (RAPID) concept is a novel transplantation technique for removal of non‐resectable liver tumours. The aim of this study was to establish a simulated RAPID model to explore the mechanism involved in the liver regeneration.

Methods

A RAPID model was created in rats involving cold ischaemia and reperfusion of the selected future liver remnant (FLR), portal vein ligation, followed by resection of the deportalized lobes in a second step. Histology, liver regeneration and inflammatory markers in RAPID‐treated rats were compared with those in controls that underwent 70 per cent hepatectomy with the same FLR size. The effects of interleukin (IL) 6 and macrophage polarization on hepatocyte viability were evaluated in an in vitro co‐culture system of macrophages and BRL hepatocytes.

Results

The survival rate in RAPID and control hepatectomy groups was 100 per cent. The regeneration rate was higher in the RAPID‐treated rats, with higher levels of IL‐6 and M1 macrophage polarization (P < 0·050). BRL hepatocytes co‐cultured with M1 macrophages showed a higher proliferation rate through activation of the IL‐6/signal transducer and activator of transcription 3/extracellular signal‐regulated kinase pathway. This enhancement of proliferation was inhibited by tocilizumab or gadolinium trichloride (P < 0·050).

Conclusion

The surgical model provides a simulation of RAPID that can be used to study the liver regeneration profile.

[The differential diagnosis for novel coronavirus pneumonia and similar lung diseases in general hospitals]

Novel coronavirus pneumonia was a novel coronavirus infection that has dominated pulmonary infection since December 2019. The main manifestations were fever, dry cough, shortness of breath, normal or leukopenia in peripheral blood and changes in chest CT and in severe cases, multiple organ failure might occur. The National Health Commission, PRC has revised the consensus on diagnosis and treatment seven times in a short period of time, indicating the growing understanding of the disease. Patients with novel coronavirus pneumonia usually had history of travelling or living in the epidemic area including Wuhan within 14 days before onset, or have been exposed to patients who had fever or respiratory symptoms from the epidemic area, or had clustering diseases. However, novel coronavirus pneumonia was becoming more and more blurred after vanishing epidemic. The diagnosis and differential diagnosis of novel coronavirus pneumonia were challenges not only because of large number of tourists increasing dramatically after the relieving of epidemic, but also patients with other diseases from different areas to search for medical care. In this article, the clinical and chest imaging features of the novel coronavirus pneumonia were reviewed and compared with other infections and non-infectious diffuse pulmonary diseases. We try to find the similarities and differences among them, and to identify clues to the diagnosis of novel coronavirus pneumonia, so as to ensure accurate diagnosis and treatment.

[The clinical features and prognosis of interstitial lung disease patients with positive anti-neutrophil cytoplasmic antibody]

Objective: To investigate the clinical features and prognosis of interstitial lung disease patients with positive anti-neutrophil cytoplasmic antibody. Methods: The patients with interstitial lung disease who visited Peking Union Medical College Hospital from March 2006 to March 2016 were divided into three groups: interstitial lung disease with ANCA-positive(ANCA-ILD), connective tissue disease associated interstitial lung disease and interstitial pneumonia with autoimmune features (CTD-ILD/IPAF) and idiopathic interstitial pneumonia (IIP). The three groups were analyzed in terms of clinical manifestations, serology, lung function, imaging, survival and recurrence. Results: Two hundred and seventy four patients were enrolled and 38 (14%) were ANCA-positive of whom 16 were male and 22 were female. The age of 38 ANCA-positive patients was (59±10) years and the follow-up time was (52±31) months. Seven among the 38 ANCA-positive patients died and the death rate is 18.42%. The ANCA-positive patients with interstitial lung disease have higher onset age (ANCA-ILD:59±10,CTD-ILD/IPAF:52±10,IIP:53±11,H=19.29, P<0.001), lower hemoglobin (ANCA-ILD: 129±21, CTD-ILD/IPAF: 138±15, IIP: 140±19, H=8.17, P=0.017), higher erythrocyte sedimentation rate (ANCA-ILD:45±35, CTD-ILD/IPAF:26±24,IIP:19±22,H=19.73, P<0.001), lower lung function improvement rate after treatment (ANCA-ILD:31%,CTD-ILD/IPAF:59%,IIP: 39%,χ(2)=11.74,P=0.003), lower absorption rate of CT lesion (ANCA-ILD:61%,CTD-ILD/IPAF:82%,IIP:67%, χ(2)=9.23,P=0.010) and higher death rate(ANCA-ILD:18%,CTD-ILD/IPAF:6%,IIP:12%, χ(2)=7.16,P=0.028). Conclusions: There are significant differences in clinical characteristics between ANCA-positive patients and other types of pulmonary interstitial disease. And both the treatment effect and the prognosis is poor for the ANCA-positive patients.

[Characteristics and prognostic value of peripheral blood T lymphocyte subsets in patients with severe influenza]

Objective: To investigate the characteristics and prognostic value of peripheral blood T lymphocyte subsets in patients with severe influenza. Methods: This was a single-center cross-sectional study in influenza patients admitted to Peking Union Medical College Hospital from August 2017 to April 2018. Peripheral blood lymphocyte subsets were detected by flow cytometry in both patients and 108 healthy controls. Influenza patients were divided into mild group and severe group. Severe patients were further classified into alive and fatal subgroups. Results: A total of 42 influenza patients were recruited in this study, including 24 severe cases (6 deaths). The remaining 18 cases were mild. The peripheral blood lymphocyte counts and lymphocyte subset counts (B, NK, CD4(+)T, CD8(+)T) in either mild patients[795 (571,1 007), 43 (23,144), 70 (47,135), 330 (256,457), 226 (148,366) cells/μl respectively] or severe patients[661 (474,1 151),92 (52,139), 54 (34,134), 373 (235,555), 180 (105,310) cells/μl respectively] were both significantly lower than those of healthy controls [1 963 (1 603,2 394),179 (119,239), 356 (231,496), 663 (531,824), 481 (341,693) cells/μl respectively]. Meanwhile, the T cells and CD8(+)T counts in fatal patients [370 (260,537) cells/μl and 87 (74,105) cells/μl] were significantly lower than those in severe and alive patients [722 (390,990) cells/μl and 222 (154,404) cells/μl]. CD8(+)HLA-DR/CD8(+)and CD8(+)CD38(+)/CD8(+)T cell activating subgroups in mild cases[(53.7±19.2)% and 74.8% (64.1%,83.7%) respectively] were significantly higher than those in severe cases[(38.5±21.7)% and 53.3% (45.3%,67.2%) respectively].Moreover,CD8(+)HLA-DR/CD8(+)count in severe and alive group was higher than that in fatal group [(46.1±19.1)% vs. (18.2±14.6)%, P<0.01]. Logistic regression analysis showed that CD8(+)T cell count (OR=0.952, 95%CI 0.910-0.997, P=0.035) and CD8(+)HLA-DR/CD8(+)T (OR=0.916, 95%CI 0.850-0.987, P=0.022) were both negatively correlated with mortality.Peripheral blood lymphocyte counts in mild cases rapidly decreased within 1 day after diagnosis, and returned to the basic level one week later. Conclusions: All peripheral blood lymphocyte subsets (T,B,NK) in patients with influenza are significantly reduced. These findings are consistent with the immunological characteristics of respiratory viral infections, in which peripheral lymphocytes (especially T cells) migrate to respiratory tract in the early stage and circulate to the peripheral blood after recovery. The activated CD8(+)T cell counts in peripheral blood are negatively correlated with the severity of disease, which could be considered as a prognostic indicator of severe influenza.

[Impact of change of ideal cardiovascular behavior and related factors on healthy vascular aging]

Objective: To investigate the impact of change of ideal cardiovascular behavior and related factors on healthy vascular aging(HVA). Methods: This study was a multi-center cross-sectional survey. Six thousand three hundred and sixteen participants who underwent at least 2 healthy examinations from 2006 to 2015 at 11 hospitals, including Kailuan Hospital and so on, and examined brachial-ankle pulse wave velocity (baPWV) during 2010 and 2016, with available information about cardiovascular behavior and factors were included. The cardiovascular health score (CHS) was calculated. Basic CHS was collected from the first examination. The second CHS derived from the healthy examination in the same year of baPWV examination. Change of cardiovascular health score (ΔCHS) was calculated. Participants were defined into 5 groups according to ΔCHS, namely ΔCHS≤-2 (n=2 166), ΔCHS=-1 (n=1 284), ΔCHS=0 (n=1 187), ΔCHS=1 (n=860), and ΔCHS≥2 (n=819). Participants' characteristics, value of baPWV and proportion of HVA were compared among different groups. Multiple logistic regression analysis was used to investigate the association between ΔCHS and HVA. The ΔCHS was recalculated and included in multiple logistic regression analysis model again after each component of the cardiovascular health metrics was removed separately in order to investigate effects of removal factors on HVA by observing changes in effect values. Results: The percentage of the participants with HVA in the group of ΔCHS≤-2, ΔCHS=-1, ΔCHS=0, ΔCHS=1 and ΔCHS≥2 were 23.3%(505/2 166), 27.8%(357/1 284), 28.7%(341/1 187),31.9%(274/860) and 33.9%(278/819), respectively. After adjustment for age, sex, income, education, alcohol consumption and the basic CHS, a significant positive association between ΔCHS and proportion of participants with HVA was observed (OR=1.50, 95%CI 1.44-1.56). Multiple regression analysis after removing each single cardiovascular behavior or factor showed that the OR value decreased as follow systolic blood pressure (OR=1.04, 95%CI 1.00-1.09), fasting blood glucose (OR=1.14, 95%CI 1.09-1.18), physical exercise (OR=1.16, 95%CI 1.11-1.21), salt intake (OR=1.17, 95%CI 1.12-1.22), body mass index (OR=1.18, 95%CI 1.13-1.23), smoking(OR=1.18, 95%CI 1.13-1.23) and total cholesterol (OR=1.20, 95%CI 1.16-1.24). Conclusion: The improvement of every ideal cardiovascular behavior and factor is associated with the increase of the proportion of HVA population.

Safety, efficacy and tumor mutational burden as a biomarker of overall survival benefit in chemo-refractory gastric cancer treated with toripalimab, a PD-1 antibody in phase Ib/II clinical trial NCT02915432

BACKGROUND

High tumor mutational burden (TMB-H) is correlated with enhanced objective response rate (ORR) and progression-free survival (PFS) for certain cancers receiving immunotherapy. This study aimed to investigate the safety and efficacy of toripalimab, a humanized programmed death-1 (PD-1) antibody, in advanced gastric cancer (AGC), and the predictive survival benefit of TMB and PD-L1.

PATIENTS AND METHODS

We reported on the AGC cohort of phase Ib/II trial evaluating the safety and activity of toripalimab in patients with AGC, oesophageal squamous cell carcinoma, nasopharyngeal carcinoma and head and neck squamous cell carcinoma. In cohort 1, 58 chemo-refractory AGC patients received toripalimab (3 mg/kg d1, Q2W) as a monotherapy. In cohort 2, 18 chemotherapy-naive AGC patients received toripalimab (360 mg d1, Q3W) with oxaliplatin 130 mg/m2 qd, d1, capecitabine 1000 mg/m2 b.i.d., d1-d14, Q3W as first-line treatment. Primary end point was ORR. Biomarkers such as PD-L1 and TMB were evaluated for correlation with clinical efficacy.

RESULTS

In cohort 1, the ORR was 12.1% and the disease control rate (DCR) was 39.7%. Median PFS was 1.9 months and median OS was 4.8 months. The TMB-H group showed significant superior OS than the TMB-L group [14.6 versus 4.0 months, HR = 0.48 (96% CI 0.24-0.96), P = 0.038], while PD-L1 overexpression did not correlate with significant survival benefit. A 77.6% of patients experienced at least one treatment-related adverse event (TRAE), and 22.4% of patients experienced a grade 3 or higher TRAE. In cohort 2, the ORR was 66.7% and the DCR was 88.9%. A 94.4% of patients experienced at least one TRAE and 38.9% of patients experienced grade 3 or higher TRAEs.

CONCLUSIONS

Toripalimab has demonstrated a manageable safety profile and promising antitumor activity in AGC patients, especially in combination with XELOX. High TMB may be a predictive marker for OS of AGC patients receiving toripalimab as a single agent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02915432.

[Survey of exposure to second-hand smoke in residents aged 15 years and over one year after implementation of tobacco control regulation in public places in Beijing]

Objective: To monitor the second-hand smoke (SHS) exposure in residents aged 15 years and over in public venues, indoor workplaces, on public transportation vehicles and at home in Beijing and evaluate the effect of Beijing Tobacco Control Regulation. Methods: Data from 2014 and 2016 Beijing Adult Tobacco Survey were used. The surveys covered 16 districts in Beijing. The study subjects were selected through multi-stage cluster sampling with probability proportional to population size, and data were collected by using electronic questionnaire in face-to-face household interviews. A total of 8 484 and 9 372 valid questionnaires were collected for the surveys in 2014 and 2016, respectively. Statistical packages SPSS 20.0 and R 3.4.4 were used for data analyses. After weighting the samples using complex survey designs, the SHS exposure rates in different places in adults of Beijing were estimated. χ(2) tests were performed for the comparison. Results: The SHS exposure rates of residents aged 15 years and over in Beijing who visited health care facilities, government buildings, universities, primary and secondary schools and restaurants declined from 12.8%, 19.7%, 24.3%, 32.8% and 65.7% in 2014 to 6.2%, 10.8%, 12.5%, 19.1% and 32.5% in 2016, respectively. The SHS exposure rates in bars/nightclubs were 89.5% in 2014 and 80.3% in 2016. From 2014 to 2016, the SHS exposure rates declined from 35.7% to 20.0% in indoor workplaces and declined from 3.9% to 2.5% on public transportation vehicles. The SHS exposure rates at home were 39.8% in 2014 and 37.6% in 2016, respectively. Conclusions: The SHS exposure rates in public places declined obviously in Beijing after the one year implementation of Beijing Tobacco Control Regulation, indicating the effect of the regulation implementation.

Warm ischemia time and elevated serum uric acid are associated with metabolic syndrome after liver transplantation with donation after cardiac death

AIM

To describe the prevalence of posttransplant metabolic syndrome (PTMS) after donation after cardiac death (DCD) liver transplantation (LT) and the pre- and postoperative risk factors.

METHODS

One hundred and forty-seven subjects who underwent DCD LT from January 2012 to February 2016 were enrolled in this study. The demographics and the clinical characteristics of pre- and post-transplantation were collected for both recipients and donors. PTMS was defined according to the 2004 Adult Treatment Panel-III criteria. All subjects were followed monthly for the initial 6 mo after discharge, and then, every 3 mo for 2 years. The subjects were followed every 6 mo or as required after 2 years post-LT.

RESULTS

The prevalence of PTMS after DCD donor orthotopic LT was 20/147 (13.6%). Recipient’s body mass index (P = 0.024), warm ischemia time (WIT) (P = 0.045), and posttransplant hyperuricemia (P = 0.001) were significantly associated with PTMS. The change in serum uric acid levels in PTMS patients was significantly higher than that in non-PTMS patients (P < 0.001). After the 1^st mo, the level of serum uric acid of PTMS patients rose continually over a period, while it was unaltered in non-PTMS patients. After transplantation, the level of serum uric acid in PTMS patients was not associated with renal function.

CONCLUSION

PTMS could occur at early stage after DCD LT with growing morbidity with the passage of time. WIT and post-LT hyperuricemia are associated with the prevalence of PTMS. An increased serum uric acid level is highly associated with PTMS and could act as a serum marker in this disease.

In-fiber Mach-Zehnder interferometer with piecewise interference spectrum based on hole-assisted dual-core fiber for refractive index sensing: erratum

This erratum is presented to correct Fig. 3 in [Opt. Express26(15), 19091 (2018)].

[One year after the implementation of 2015 Tobacco Control Regulation on persons aged 15 years and over tobacco use in Beijing]

Objective: To understand the current status of smoking and smoking cessation in persons aged 15 years and over in Beijing and evaluate the effect of 2015 Beijing Tobacco Control Regulation. Methods: In 2014 and 2016, based on the principles and methodology of the Global Adult Tobacco Survey. A total of 50 communities or townships were selected from 324 communities or townships in Beijing through multistage cluster sampling, and 2 community (village) committees from each community or township were selected with the method of probability proportional to size (PPS). A total of 100 surveillance sites were set, and 100 households were selected from each surveillance site by using simple random sampling. Data were collected through face-to-face interview from the eligible family members aged 15 years and over with the assistance of a tablet computer. Statistical analyses were conducted by using complex sampling analyses module of SPSS 20.0, with weights as a combination of sampling weights, non-response weights and post- stratification weights, for the calculation of current smoking prevalence, daily smoking prevalence, smoking cessation rate, etc. Results: A total of 8 484 and 9 372 valid questionnaires were obtained, respectively, in 2014 and 2016, with the response rate of 86.5% and 96.5%. The current smoking prevalence in persons aged 15 years and over was 23.4% in 2014, and 22.3% in 2016. According to the 6(th) national census data, the current smoking population decreased by 199 000 in Beijing. The proportion of daily smokers declined from 20.7% in 2014 to 19.2% in 2016. The daily number of cigarettes consumed by current smokers increased from 14.6 in 2014 to 15.4 in 2016. The smoking cessation rate was 14.9% in 2014 and 16.8% in 2016. The proportion of current smokers who had at least one smoking cessation attempt in the past 12 months increased from 22.3% in 2014 to 23.2% in 2016, and the proportion of current smokers who planned to quit smoking increased from 11.6% to 15.5%. Among the current smokers who had visited doctors in the past 12 months, the proportion of those having smoking cessation advice was 58.9% in 2014 and 59.2% in 2016. In 2016, among the current smokers who had attempted to quit in the past 12 months, 36.8% were aware of the smoking cessation clinics, and 29.5%were aware of the quitline. Among those who were aware, only 7.7% had actually visited the cessation clinics, and 5.5% had used the quitline. Conclusions: After the implementation of 2015 Beijing Tobacco Control Regulation for 1 year, the current smoking prevalence in persons aged 15 years and over showed decreasing. It is necessary to further prompt the expansion of smoking cessation service to cover more current smokers.

[Pulmonary metastatic angiosarcoma presenting with diffuse alveolar hemorrhage: 9 case reports]

Objective: Pulmonary metastatic angiosarcoma is a rare, fatal disease that often presents as diffuse alveolar hemorrhage(DAH). In this report, clinical characteristics of pulmonary metastatic angiosarcoma were retrospectively reviewed. Methods: A total of 9 patients with angiosarcoma who presented as DAH were enrolled. Clinical data included age, gender, symptoms, smoking status, physical exam findings, pulmonary function tests, and radiology. Results: All patients were male with median age 41 years(range, 22 to 57 years). The most common symptom was hemoptysis(9/9). Other symptoms included dyspnea (5/9), cough(3/9), chest pain(3/9), fever(2/9,) and edema of the lower extremity and oliguria(4/9).The common misdiagnoses were tuberculosis(4/9), vasculitis(3/9) and other infection(1/9). Chest computed tomography showed bilateral,random distributed different-sized nodules(9/9),as well as ground-glass areas (9/9).The hearts, mainly right atrium, were the most common primary locations(7/9).Cardiac mass was the first manifestation in five patients by echocardiography(5/8).Two atrial masses were identified by computer tomography pulmonary angiography and magnetic resonance imaging respectively. Transbronchial lung biopsy failed to find malignancy. Computer tomography guided transthoracic needle biopsy was difficult to perform in most patients. Eight patients were diagnosed by surgical biopsy, either by lung biopsy(4/8) or cardiac biopsy(4/8).The median survival period was only 3 months after surgery. Conclusion: Metastatic pulmonary angiosarcoma should be considered in patients with DAH and multiple glass ground opacity and nodules on chest CT. Careful cardiologic monitoring is necessary. Surgical biopsy is reliable for diagnosis.

In-fiber Mach-Zehnder interferometer with piecewise interference spectrum based on hole-assisted dual-core fiber for refractive index sensing

We demonstrate theoretically and experimentally a novel in-fiber Mach-Zehnder interferometer (MZI) with piecewise interference spectrum. The interferometer is constructed by splicing a short section of single eccentric hole-assisted dual-core fiber (SEHADCF) to two single mode fibers (SMFs) with a lateral-offset. Due to the offset splicing and the small distance between cores, different core modes in two cores of the SEHADCF can be excited to form interference at the different wavelength ranges. The discontinuous region of the interference spectrum can be employed as a mark to identify the order of the interference valley. The in-fiber MZI is experimentally investigated as a refractive index sensor, the sensitivity of 353.9 nm/RIU is obtained in the RI range of 1.335 ~1.395. The in-fiber MZI with a high sensitivity has a great potential in biological and chemical applications. Especially, due to the ability to identify the order of interference valleys by the discontinuous region, the proposed in-fiber MZI can improve the reliability of fiber sensors in remote monitoring applications.

[Effects of microRNA-34a on regulating silent information regulator 1 and influence of the factor on myocardial damage of rats with severe burns at early stage]

Objective: To explore the effects of microRNA-34a on regulating silent information regulator 1 (SIRT1) and influence of SIRT1 on myocardial damage of rats with severe burns at early stage. Methods: (1) Twenty-four Sprague-Dawley (SD) rats were divided into sham injury (SI) group, simple burns (SB) group and SIRT1 agonist (SA) group according to the random number table (the same grouping method below), with 8 rats in each group. Rats in groups SB and SA were inflicted with 30% total body surface area full-thickness scald (hereinafter referred to as burns) on the back, and rats in group SI were sham injuried on the back. Immediately after injury, rats in groups SI and SB were intraperitoneally injected with normal saline of 50 mL/kg, and rats in group SA were intraperitoneally injected with normal saline of 50 mL/kg and 1 mg/mL resveratrol of 50 mg/kg. At 6 h post injury, abdominal aortic blood was collected to make serum and myocardial tissue of rats was collected. (2) Myocardial cells of twelve neonatal SD rats were collected and divided into microRNA-34a mimic control (MMC) group, microRNA-34a mimic (MM) group, microRNA-34a inhibitor control (MIC) group, and microRNA-34a inhibitor (MI) group, which were respectively transfected with gene sequences of mimic control, mimic, inhibitor control, and inhibitor of microRNA-34a. The microRNA-34a expression level and protein expression level of SIRT1 in myocardial cells were respectively detected by real-time fluorescence quantitative reverse transcription polymerase chain reaction (RT-PCR) and Western blotting. Another batch of myocardial cells were divided into microRNA-34a inhibitor control+ burn serum (MCB) group, microRNA-34a inhibitor+ burn serum (MB) group, and microRNA-34a inhibitor+ burn serum + EX527 (MBE) group. Myocardial cells in group MCB were transfected with gene sequence of inhibitor control, and myocardial cells in the later groups were transfected with gene sequence of inhibitor of microRNA-34a. After transfection of 48 h, myocardial cells in group MBE were cultured in Dulbecco's modified Eagle's medium (DMEM) solution for 6 hours, with serum in group SB of volume fraction of 10% and final amount-of-substance concentration of 1 mol/L, and myocardial cells in the other 2 groups were cultured in DMEM solution with serum from rats of group SB of volume fraction of 10%. The protein expression levels of myocardial cells of SIRT1, cleaved-caspase-3, and Bax were detected by Western blotting. (3) Myocardial tissue from (1) was collected to detect expression levels of microRNA-34a and mRNA of SIRT1 in groups SI and SB by real-time fluorescence quantitative RT-PCR. Morphology of myocardial tissue of rats in groups SI, SB, and SA was observed with biological image navigator. The mRNA expression levels of interleukin 1β (IL-1β) and tumor necrosis factor (TNF-α) of rats in groups SI, SB, and SA were detected by real-time fluorescence quantitative RT-PCR. The expression levels of cleaved-caspase-3, and Bax of myocardial tissue of rats in groups SI, SB, and SA were detected by Western blotting. Data were processed with one-way analysis of variance and least-significant difference test. Results: (1) After transfection of 48 h, the expression level of microRNA-34a of myocardial cells in group MM was 4.67±0.92, significantly higher than 1.03±0.04 in group MMC (P<0.01); the protein expression level of SIRT1 of myocardial cells in group MM was 0.35±0.06, significantly lower than 1.12±0.11 in group MMC (P<0.01). After transfection of 48 h, the expression level of microRNA-34a of myocardial cells in group MI was 0.26±0.07, significantly lower than 1.33±0.07 in group MIC (P<0.01); the protein expression level of SIRT1 of myocardial cells in group MIC was 1.12±0.16, significantly lower than 1.74±0.34 in group MI (P<0.01). At 6 h after culture, compared with those in group MCB, the SIRT1 protein expression level of myocardial cells in group MB was significantly increased (P<0.05), while cleaved-caspase-3 and Bax protein expression levels of myocardial cells in group MB were significantly decreased (P<0.05). Compared with those in group MB, the SIRT1 protein expression level of myocardial cells in group MBE was with no significantly statistical difference (P>0.05), and cleaved-caspase-3 and Bax protein expression levels were significantly increased (P<0.05). (2) At 6 h post injury, compared with that in group SI, the microRNA-34a expression level of myocardial tissue in group SB was significantly increased (P<0.01), and the mRNA expression level of SIRT1 of myocardial tissue in group SB was significantly decreased (P<0.01). At 6 h post injury, myocardial cells in group SI arranged neatly with normal nucleus and no inflammatory cells infiltration; myocardial cells in group SB arranged disorderly, with no abnormal nucleus, and obvious inflammatory cells infiltration; myocardial cells in group SA arranged neatly, with normal nucleus and little inflammatory cells infiltration. At 6 h post injury, compared with those in group SB, the mRNA expression levels of IL-1β and TNF-α, and the protein expression levels of cleaved-caspase-3 and Bax of myocardial tissue in groups SI and SA were significantly decreased (P<0.01). Conclusions: The microRNA-34a expression level of myocardial tissue of rats with severe burns at early stage increases, which decreases the expression level of SIRT1, and increases the expression levels of IL-1β, TNF-α, cleaved-caspase-3 and Bax, leading to obvious myocardial damage. Activation of SIRT1 can alleviate myocardial damage of rats with severe burns at early stage through decreasing expression levels of IL-1β, TNF-α, cleaved-caspase-3, and Bax.

Hypothermic machine perfusion with metformin-University of Wisconsin solution for ex vivo preservation of standard and marginal liver grafts in a rat model

AIM

To compare the effect of University of Wisconsin (UW) solution with or without metformin, an AMP-activated protein kinase (AMPK) activator, for preserving standard and marginal liver grafts of young and aged rats ex vivo by hypothermic machine perfusion (HMP).

METHODS

Eighteen young (4 mo old) and 18 aged (17 mo old) healthy male SD rats were selected and randomly divided into three groups: control group, UW solution perfusion group (UWP), and UW solution with metformin perfusion group (MUWP). Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), interleukin-18 (IL-18), and tumor necrosis factor-alpha (TNF-α) in the perfused liquid were tested. The expression levels of AMPK and endothelial nitric oxide synthase (eNOS) in liver sinusoidal endothelial cells were also examined. Additionally, microscopic evaluation of the harvested perfused liver tissue samples was done.

RESULTS

AST, ALT, LDH, IL-18 and TNF-α levels in the young and aged liver-perfused liquid were, respectively, significantly lower in the MUWP group than in the UWP group (P < 0.05), but no significant differences were found between the young and aged MUWP groups. Metformin increased the expression of AMPK and eNOS protein levels, and promoted the extracellular release of nitric oxide through activation of the AMPK-eNOS mediated pathway. Histological examination revealed that in the MUWP group, the extent of liver cells and tissue damage was significantly reduced compared with the UWP group.

CONCLUSION

The addition of metformin to the UW preservative solution for ex vivo HMP can reduce rat liver injury during cold ischemia, with significant protective effects on livers, especially of aged rats.

Experimental evaluation of liver regeneration patterns and liver function following ALPPS

Background

The underlying mechanism of liver regeneration after Associating Liver Partition and Portal vein ligation (PVL) for Staged hepatectomy (ALPPS) is still unclear. The aim of this study was to evaluate the relationship between future liver remnant (FLR) volume, liver regeneration characteristics and restoration of function in an experimental model of ALPPS.

Methods

An ALPPS model in rats was developed with selective PVL, parenchymal transection and partial hepatectomy (step 1), followed by resection of the liver (step 2). Three different ALPPS groups with FLR sizes of 30, 20 and 10 per cent of total liver volume were compared with sham‐operated controls and animals undergoing resection of left lateral lobe and 90 per cent PVL with respect to morbidity, mortality, liver regeneration and function.

Results

Three of 15 animals that had ALPPS with 10 per cent FLR (ALPPS10) died after step 1. Ascites developed in two of five rats that had ALPPS with 20 per cent FLR and in three of four animals in the ALPPS10 group after step 2. Although the relative increments in FLR size and growth rates were highest in the ALPPS groups, small FLR size was associated with a sustained increase in levels of serum aminotransferases and bilirubin, a lower albumin concentration, severe sinusoidal injury, increased expression of proliferation markers and increased activation of hepatic progenitor cells after step 2.

Conclusion

There is discordance between FLR volume increase and functional restoration after the ALPPS procedure.

[The clinical characteristics of pulmonary benign metastasizing leiomyoma]

Objective: Pulmonary benign metastasizing leiomyoma (PBML) is a rare entity that leiomyoma of uterus metastasized to the lung. The clinical characteristics of this rare disease were analyzed in this article. Methods: The detailed clinical records of 7 patients diagnosed as PBML at Peking Union Medical College Hospital between January 2001 and June 2015 were reviewed. Results: All patients were women with median age of 44 years (range 28-62). Symptoms included dyspnea (2/7), chest pain (1/7), cyanosis (1/7), cough (1/7) and bloody sputum (1/7), while 4/7 cases were asymptomatic. Six patients had the past-history of leiomyoma of uterus 20 months to 14 years ago among whom 5 patients received hysterectomy. Chest CT showed bilateral, random-distributed multiple round solid nodules, or diffuse-distributed miliary nodules, or single solid nodule, even some small cavities. Extra-pulmonary metastasis was found in left superclavicular lymph node (1 case) and right heart (1 case). Histological tissues were obtained by video-assisted thoracic surgery lung biopsy (4/7), mass resection on tricuspid valve (1/7), transbronchil lung biopsy (1/7), and CT-guided percutaneous lung biopsy (1/7). Pathology showed an interlacing pattern by spindle cells having elongated nuclei without cellular atypia. Ki-67 index was less than 1%. Molecules such as smooth muscle antibody, estrogen receptor (ER) and progestrone receptor (PR) were positive in immunohistochemistry staining. Neither letrozole nor zoladex was effective. Two patients responded to bilateral adnexectomy, presenting as shrunk nodules. No relapsed disease was seen in one patient with single nodule after resection. There was only one patient with disease-related mortality, whose chest CT showed milliary nodules. Conclusion: Although CT findings of PBML are similar to malignancies, the clinical outcome is good. Despite the positive expression of ER and PR, the effectiveness of hormone related treatment is limited. And periodical follow up is suggested even to those uneventful patients.

[Effects of human amniotic epithelial stem cells-derived exosomes on healing of wound with full-thickness skin defect in rats]

Objective: To investigate the effects of human amniotic epithelial stem cells-derived exosomes on healing of wound with full-thickness skin defect in rats. Methods: (1) Human amniotic epithelial stem cells were isolated from the amnion tissue of 5 full-term pregnant women in Department of Obstetrics of our hospital by the method of trypsin digestion, and their morphology was observed. The third passage of cells were stained with rhodamine-phalloidin for cytoskeleton observation. The third passage of cells were identified with flow cytometry through the detection of expressions of cell surface markers CD29, CD31, CD34, CD90, CD105, SSEA3, SSEA4 and immunity-related marker human leukocyte antigen-D related site (HLA-DR). The third passage of cells were also assessed the ability of adipogenic and osteogenic differentiation. (2) The third passage of human amniotic epithelial stem cells were cultured in DMEM medium supplemented with 10% exosome-free fetal bovine serum. Exosomes were isolated from culture supernatant by the method of ultracentrifugation and represented with scanning electron microscope for morphologic observation. (3) Six adult SD rats were anesthetized, and four 1 cm×1 cm sized wounds with full-thickness skin defect were made on the back of each rat. The wounds on the back of each rat were divided into control group, 25 μg/mL exosomes group, 50 μg/mL exosomes group, and 100 μg/mL exosomes group according to the random number table (with 6 wounds in each group), and a total volume of 100 μL phosphate buffered saline, 25 μg/mL exosomes, 50 μg/mL exosomes, and 100 μg/mL exosomes were evenly injected around the wound through multiple subcutaneous sites, respectively. The wound healing rate was calculated based on measurement on post injury day (PID) 7, 14, and 21. On PID 21, the healed wound tissue of each group was collected and stained with HE to observe and count skin accessories, and the arrangement of collagen fibers was observed with Masson staining. Data were processed with analysis of variance for repeated measurement, analysis of variance of randomized block design, one-way analysis of variance, and Bonferroni test. Results: (1) The cells, which were isolated and cultured, displayed typical cobblestone morphology with many microvilli on cell surface. Among the cells, the positive expression rates of CD29, CD90, SSEA3, and SSEA4 were above 50.0%, and the rate of CD105 was 8.0%, while the rates of CD31, CD34, and HLA-DR were almost 0. The cells could differentiate into adipocytes and osteoblasts. The above results revealed that the cells cultured were human amniotic epithelial stem cells. (2) Human amniotic epithelial stem cells-derived exosomes were round or oval vesicles with diameter from 50 to 150 nm. (3) On PID 7 and 21, wound healing rates of the four groups were close (with P values above 0.05). On PID 14, wound healing rates of 50 and 100 μg/mL exosomes groups were (89.8±4.3)% and (92.0±4.6)% respectively, significantly higher than the wound healing rate of control group [(80.3±6.4)%, P<0.05 or P<0.01]. Moreover, the wound healing rate of 100 μg/mL exosomes group was significantly higher than that of 25 μg/mL exosomes group [(83.3±5.1)%, P<0.05]. On PID 21, the numbers of skin accessories in 50 and 100 μg/mL exosomes groups were 4.3±1.4 and 5.1±1.6 respectively, obviously more than those of control group and 25 μg/mL exosomes group (respectively 1.4±0.5 and 1.8±0.6, with P values below 0.01). Well reorganized collagen fibers were observed just in the healed wound tissue of 50 and 100 μg/mL exosomes groups. Conclusions: Human amniotic epithelial stem cells-derived exosomes can promote healing of wound with full-thickness skin defect in rats.

[Effects of hypoxia on the phenotype transformation of human dermal fibroblasts to myofibroblasts and the mechanism]

Objective: To investigate the effects of hypoxia on the phenotype transformation of human dermal fibroblasts to myofibroblasts and the mechanism. Methods: The third passage of healthy adult human dermal fibroblasts in logarithmic phase were cultured in DMEM medium containing 10% fetal bovine serum for the following five experiments. (1) In experiments 1, 2, and 3, cells were divided into normoxia group and hypoxia group according to the random number table, with 10 dishes in each group. Cells of normoxia group were cultured in incubator containing 21% oxygen, while those of hypoxia group with 1% oxygen. At post culture hour (PCH) 0 and 48, 5 dishes of cells were collected from each group, respectively. mRNA expressions of markers of myofibroblasts including alpha smooth muscle actin (α-SMA), type Ⅰ collagen, and type Ⅲ collagen of cells were determined with real time fluorescent quantitative reverse transcription polymerase chain reaction in experiment 1. Protein expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen of cells were determined with Western blotting in experiment 2. The protein expression of nuclear factor-kappa B (NF-κB) of cells was determined with Western blotting in experiment 3. (2) In experiment 4, cells were divided into normoxia group, hypoxia group, and hypoxia+ pyrrolidine dithiocarbamate (PDTC) group according to the random number table, with 5 dishes in each group. Cells in the former two groups were treated the same as those in experiment 1. Cells in hypoxia+ PDTC group were treated the same as those in hypoxia group plus adding 4 mL PDTC with a final molarity of 10 μmol/L in the culture medium. At PCH 48, the protein expression of NF-κB of cells was determined with Western blotting. (3) In experiment 5, cells were divided into normoxia group, hypoxia group, hypoxia+ PDTC group, and normoxia+ PDTC group according to the random number table, with 5 dishes in each group. Cells in the former three groups were treated the same as those in experiment 4. Cells in normoxia+ PDTC group were treated the same as those in normoxia group plus adding 4 mL PDTC with a final molarity of 10 μmol/L in the culture medium. At PCH 48, protein expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen of cells were determined with Western blotting. Data were processed with analysis of variance of factorial design, one-way analysis of variance, and LSD-t test. Results: (1) Compared with those of normoxia group at corresponding time point, mRNA expressions and protein expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen and the protein expression of NF-κB in fibroblasts of hypoxia group were not changed obviously at PCH 0 (with t values from -1.21 to 2.04, P values above 0.05), while mRNA expressions and protein expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen and the protein expression of NF-κB significantly increased at PCH 48 (with t values from -12.57 to -3.44, P values below 0.01). (2) At PCH 48, the protein expression of NF-κB in fibroblasts of hypoxia group was 0.83±0.12, significantly higher than that of normoxia group (0.17±0.06, t=-16.96, P<0.001). The protein expression of NF-κB in fibroblasts of hypoxia+ PDTC group was 0.31±0.08, significantly lower than that of hypoxia group (t=12.73, P<0.001). (3) At PCH 48, protein expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen in fibroblasts of hypoxia group were 0.73±0.09, 1.25±0.10, and 1.16±0.07, respectively, significantly higher than those of normoxia group (0.14±0.06, 0.87±0.08, and 0.77±0.13, respectively, with t values from 9.24 to 11.24, P values below 0.001). The protein expression of α-SMA in fibroblasts of normoxia+ PDTC group was 0.24±0.07, significantly higher than that of normoxia group (t=4.22, P<0.01). Protein expressions of type Ⅰ collagen and type Ⅲ collagen in fibroblasts of normoxia+ PDTC group were 0.25±0.06 and 0.32±0.11, respectively, significantly lower than those of normoxia group (with t values respectively -4.31 and -3.88, P values below 0.01). Protein expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen in fibroblasts of hypoxia+ PDTC group were 0.09±0.08, 0.38±0.12, and 0.47±0.08, respectively, significantly lower than those of hypoxia group (with t values from 11.78 to 22.98, P values below 0.001). Conclusions: Hypoxia can significantly up-regulate the expressions of α-SMA, type Ⅰ collagen, and type Ⅲ collagen in human dermal fibroblasts, which may promote the phenotype transformation of fibroblasts to myofibroblasts, and this is likely to be associated with the activation of NF-κB signal pathway.

[Clinical application and recent advance in BAHA]

There are many deafness patients at present in the world. Bone-anchored hearing aids are well-established solutions for treatment of hearing-impaired patients,such as conductive deafness,mixed deafness and single side deafness. The article aimed to review the basic structure,clinical indications,surgical method and complications of bone anchored hearing aids,and for a new BAHA attract system,we also have a brief discussion. To conclude,the BAHA attract system is an aesthetic,easy,safe and effective hearing aid,and become the patient's preference.

[The application value of contrast-enhanced ultrasound in the surgery of renal masses]

Objective: To investigate the clinical value of contrast-enhanced ultrasound in the diagnosis of renal masses. Methods: A total of 50 patients with renal masses who underwent partial nephrectomy were analyzed from January 2014 to October 2016 in the Department of Urology of China-Japan Union Hospital of Jilin University.In the intraoperative contrast-enhanced ultrasound, the characteristics of ultrasound imaging were recorded including location, size, boundary, echo, real-time internal and peripheral blood and renal pelvis distance, artery, guidance on the selection of surgical methods, intraoperative real-time estimation of the extent of tumor resection. Results: In the 50 patients, there were 49 cases enhancement in the imaging of the cystic masses, 1 case had no enhancement.Contrast-enhanced ultrasound assisted clinical accurate positioning 34 masses which were in the renal contour and not convex.And 15 patients were found main arteries of renal occupied lesions.There were 38 cases whose distance from occupying to pelvis was more than 0.5 cm, and maintained the original operation scheme for partial nephrectomy.There were 12 cases whose distance from occupying to pelvis was less than 0.5 cm, and proceeded radical resection. Conclusions: Intraoperative contrast-enhanced ultrasound can provide a more accurate imaging basis for the surgeon in partial nephrectomy.It's of great significance for the correct choice of surgical procedures, and can reduce or avoid the occurrence of postoperative complications.

Efficacy and safety of fosaprepitant in the prevention of nausea and vomiting following highly emetogenic chemotherapy in Chinese people: A randomized, double-blind, phase III study

The prevention of chemotherapy‐induced nausea and vomiting was one of the most challenging supportive care issues in oncology, especially to highly emetogenic chemotherapy (HEC). A total of 645 patients were randomized into fosaprepitant group (fosaprepitant/placebo 150 mg d1 in combination with granisetron and dexamethasone) or aprepitant group (aprepitant/placebo 125 mg d1; 80 mg d2‐d3 plus granisetron and dexamethasone).The primary endpoint was the percentage of patients who had a complete response (CR) over the entire treatment course (0–120 hr, overall phase [OP]). It was assessed by using a non‐inferiority model, with a non‐inferiority margin of 10%. The difference of the CR rate was compared between two groups with chi‐square analysis. Six hundred and twenty‐six patients were included in the per protocol analysis. The percentage of patients with a CR in the fosaprepitant group was not inferior to that in the aprepitant group (90.85% versus 94.17%, p = .1302) during OP. Whether the cisplatin‐based chemotherapy or not, the CR rate of the fosaprepitant group was not inferior to that of the aprepitant group. Both regimens were well tolerated. The most common adverse event was constipation. Fosaprepitant provided effective and well‐tolerated control of nausea and vomiting associated with HEC in Chinese patients.