Adjunctive Right Atrial Ablation for Persistent Atrial Fibrillation With Right Atrial Enlargement: A Pilot Study

BACKGROUND

Persistent atrial fibrillation (PerAF) is often associated with right atrial (RA) enlargement. We investigated the efficacy of RA intervention in patients with PerAF and RA enlargement.

METHODS

Patients with PerAF and RA enlargement were randomised (1:1) to receive adjunctive RA ablation (left atrial [LA] + RA group; n = 60) or to receive LA ablation alone (LA-only group; n = 60). In the LA + RA group, RA ablation was performed if LA ablation failed to terminate AF. The primary end point was freedom from AF/atrial tachycardia (AT) recurrence at 12 months after a single ablation procedure without antiarrhythmic drug therapy.

RESULTS

In the LA + RA group, 40 patients (67%) required RA ablation. The LA + RA group had a higher rate of acute AF termination than the LA-only group (63.3% vs 36.7%; P = 0.003). At the end of 12-month follow-up, 42 patients (70%) in the LA + RA group were free of AF/AT recurrence, compared with 31 (51.7%) in the LA-only group (log rank P = 0.034; hazard ratio 0.549, 95% confidence interval 0.310-0.974). The rate of freedom from AF recurrence was also higher in the LA + RA group than in the LA-only group (81.7% vs 63.3%; log rank P = 0.019). The 2 groups had similar rates of adverse events (5% vs 3.3%; P = 0.648).

CONCLUSIONS

Adjunctive RA ablation increased the success rate of a single ablation in patients with PerAF and RA enlargement.

CHINESE CLINICAL TRIAL REGISTRATION

ChiCTR220056844.

Prospective Longitudinal Assessment of Quality of Life After Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-based SABR-5 Phase II Trial

AIMS

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases, conducted in six regional cancer centres in British Columbia, Canada from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and at 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and the baseline score of individual patients. The mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with 'stable', 'improved' or 'worsened' QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI functional interference score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least one follow-up assessment were analysed (n = 133). On equivalence testing, the patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% confidence interval 1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% confidence interval 1.15 to 2.21; FACIT-AD TOI mean difference: -8.76, 90% confidence interval -11.29 to -6.24; POSI mean difference: -4.61, 90% confidence interval -6.09 to -3.14). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). Most patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSIONS

Transient decreases in QoL that met MCID were seen between patients' worst QoL scores and baseline scores. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterise patients at greatest risk for decreased QoL.

Predictors of Quality of Life Decline in Patients with Oligometastases treated with Stereotactic Ablative Radiotherapy: Analysis of the Population-Based SABR-5 Phase II Trial

AIMS

Most patients experience stable quality of life (QoL) after stereotactic ablative radiotherapy (SABR) treatment for oligometastases. However, a subset of patients experience clinically relevant declines in QoL on post-treatment follow-up. This study aimed to identify risk factors for QoL decline.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases. Prospective QoL was measured using treatment site-specific tools at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. The time to persistent QoL decline was calculated as the time from SABR to the first decline in QoL score meeting minimum clinically important difference with no improvement to baseline score on subsequent assessments. Univariable and multivariable logistic regression analyses were carried out to determine factors associated with QoL decline.

RESULTS

One hundred and thirty-three patients were included with a median follow-up of 32 months (interquartile range 25-43). Thirty-five patients (26%) experienced a persistent decline in QoL. The median time until persistent QoL decline was not reached. The cumulative incidence of QoL decline at 2 and 3 years were 22% (95% confidence interval 14.0-29.6) and 40% (95% confidence interval 28.0-51.2), respectively. In multivariable analysis, disease progression (odds ratio 5.23, 95% confidence interval 1.59-17.47, P = 0.007) and adrenal metastases (odds ratio 9.70, 95% confidence interval 1.41-66.93, P = 0.021) were associated with a higher risk of QoL decline. Grade 3 or higher (odds ratio 3.88, 95% confidence interval 0.92-16.31, P = 0.064) and grade 2 or higher SABR-associated toxicity (odds ratio 2.24, 95% confidence interval 0.85-5.91, P = 0.10) were associated with an increased risk of QoL decline but did not reach statistical significance.

CONCLUSIONS

Disease progression and adrenal lesion site were associated with persistent QoL decline following SABR. The development of grade 3 or higher toxicities was also associated with an increased risk, albeit not statistically significant. Further studies are needed, focusing on the QoL impact of metastasis-directed therapies.

Elevated MIF identified by multiple cytokine analyses facilitates macrophage M2 polarization contributing to postoperative recurrence in chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by tissue heterogeneity and high postoperative recurrence risk. This study aims to employ cytokine analyses to identify serum biomarkers associated with postoperative CRSwNP recurrence and elucidate underlying recurrent mechanisms.

METHODS

A prospective cohort study was conducted on CRSwNP patients undergoing functional endoscopic sinus surgery. Serum and tissue samples were collected and analyzed for multiple cytokines. Participants were followed for 3 years and categorized into recurrent and non-recurrent groups. Cytokine profiles were compared, and potential markers for recurrence were further assessed. Macrophage migration inhibitory factor (MIF) expression in macrophages was modulated, and their polarization and cytokine secretion were assessed.

RESULTS

In the discovery cohort (21 recurrent and 40 non-recurrent patients), circulating cytokine profiles differed significantly, with 8 cytokines showing differential expression between the two groups. Among them, serum eotaxin, MIF, RANTES, and TRAIL exhibited promise in predicting recurrence. In the validation cohort (24 recurrent and 44 non-recurrent patients), serum eotaxin, MIF, and TRAIL levels were higher in recurrent cases. Tissue MIF was elevated in recurrent cases and had a strong predictive value for recurrence. Moreover, tissue MIF was co-expressed with CD206 in recurrent cases. Mechanistically, MIF overexpression promoted macrophage M2 polarization and TGF-β1, CCL-24, and MIF secretion, and MIF recombinant protein facilitated M2 polarization, and TGF-β1 and CCL-24 production, contributing to CRSwNP recurrence.

CONCLUSIONS

Serum-specific cytokine signatures were associated with postoperative recurrence risk in CRSwNP. Elevated MIF enhanced macrophage M2 polarization and cytokine secretion, contributing to the recurrent mechanisms of CRSwNP.

The nonlinear association between HbA1c and cognitive impairment in patients with alcohol use disorder

Background: Extensive research has indicated that higher levels of glycated hemoglobin (HbA1c) are associated with poor cognitive performance regardless of the presence of diabetes. To our knowledge, the association between HbA1c levels and cognitive decline in patients with alcohol use disorder is not well understood. This study aimed to investigate whether HbA1c was associated with cognitive impairment in patients with alcohol use disorder. Methods: Patients admitted to the Psychiatry Department of the Third Hospital of Quzhou with a confirmed diagnosis of alcohol-related cognitive impairment were recruited between January 2019 and February 2022. Their HbA1c levels were measured, and they completed the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) after at least one week of monitored abstinence from alcohol. Univariate linear regression, multivariate linear regression and generalized additive models (GAMs) were used to investigate the association of HbA1c with MMSE and MoCA scores. Results: In total, 227 patients were included. Univariate and multivariate regression analyses suggested that HbA1c was negatively associated with MMSE and MoCA scores after adjustment for potential confounders (P < 0.05). The GAM analysis revealed that the relationships between the HbA1c level and the MMSE and MoCA scores were bell-shaped. The inflection points were 5.3% and 5.2% for the MMSE and MoCA respectively. Conclusion: The results of this study suggest that HbA1c levels are significantly related to cognitive impairment in patients with alcohol use disorder. Future studies are required to determine the effects of optimal glucose control in people with alcohol use disorder.

Red cell distribution in critically ill patients with chronic obstructive pulmonary disease

BACKGROUND

Red blood cell distribution width (RDW) is associated with increased mortality risk in patients with chronic obstructive pulmonary disease (COPD). However, limited data are available for critically ill patients with COPD.

METHODS

Data from the Medical Information Mart for Intensive Care III V1.4 database were analyzed in this retrospective cohort research. The International Classification of Diseases codes were used to identify critically ill patients with COPD. The first value of RDW was extracted within the first 24 h after intensive care unit admission. The endpoint was 28-day all-cause mortality. Multivariable logistic regression analysis was performed to examine the relationship between RDW and 28-day mortality. Age, sex, ethnicity, anemia status, comorbidities, clinical therapy, and disease severity score were considered for subgroup analysis.

RESULTS

A total of 2,344 patients were included with mean (standard deviation) age of 72.3 (11.3) years, in which 1,739 (53.6%) patients were men. The increase in RDW was correlated with an increased risk of 28-day mortality in the multivariate logistic regression model (odds ratio [OR] 1.15; 95% confidence interval [CI] 1.09-1.21). In comparison with the low-RDW group, the middle and high-RDW groups tended to have higher risks of 28-day all-cause mortality (OR [95% CI] 1.03 [0.78-1.34]; OR [95% CI] 1.70 [1.29-2.22]; P trend < 0.0001). Subgroup analyses show no evidence of effect modifications on the correlation of RDW and 28-day all-cause mortality.

CONCLUSION

An increase in RDW was associated with an increased risk of 28-day all-cause mortality in critically ill patients with COPD. Further studies are required to investigate this association.

Value of micro-flow imaging and high-definition micro-flow imaging in differentiating malignant and benign breast lesions

AIM

To evaluate the value of non-contrast micro-flow imaging (MFI) and high-definition micro-flow imaging (HD-MFI) in differentiating malignant and benign breast lesions.

MATERIALS AND METHODS

One hundred and thirty-three patients with 138 breast lesions (80 benign and 58 malignant lesions) were examined using colour Doppler flow imaging (CDFI), MFI, and HD-MFI before biopsy, with blood flow signals graded into four types (grade 0, 1, 2, and 3) and penetrating vessels evaluated. The micro-vascular patterns of MFI and HD-MFI were evaluated and classified into five patterns: avascular, line-like, tree-like, root hair-like, and crab claw-like pattern. The diagnostic efficiency of micro-vascular patterns was analysed. Moreover, ultrasound Breast Imaging Reporting and Data System (BI-RADS) 4A lesions were also re-assessed according to the micro-vascular patterns of MFI or HD-MFI.

RESULTS

The capability of detecting blood flow and penetrating vessels from high to low was HD-MFI, MFI, and CDFI, respectively (p<0.05). Rich blood flow signals, penetrating vessels, and root hair-like or crab claw-like pattern were more likely in malignant breast lesions, while few blood flow signals, tree-like pattern were mostly in benign lesions (p<0.05). The diagnostic efficiency of HD-MFI and MFI were higher than CDFI (p>0.05). MFI could reduce unnecessary biopsy of 52 US BI-RADS 4A lesions but with two malignancies missed, while 56 ultrasound BI-RADS 4A lesions could be downgraded by HD-MFI with none malignancies missed.

CONCLUSIONS

MFI and HD-MFI can detect more blood flow in breast lesions than CDFI, and could help distinguish benign and malignant breast lesions. HD-MFI could reduce the unnecessary biopsy of US BI-RADS 4A lesions without missed malignancy.

A Neural Network-based Method for Predicting Dose to Organs at Risk in Intensity-modulated Radiotherapy for Nasopharyngeal Carcinoma

OBJECTIVE

A neural network method was used to establish a dose prediction model for organs at risk (OARs) during intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

In total, 103 patients with NPC were randomly selected for IMRT. Suborgans were automatically generated for OARs using ring structures based on distance to the target using a MATLAB program and the corresponding volume of each suborgan was determined. The correlation between the volume of each suborgan and the dose to each OAR was analysed and neural network prediction models of the OAR dose were established using the MATLAB Neural Net Fitting application. The R-value and mean square error in the regression analysis were used to evaluate the prediction model.

RESULTS

The OAR dose was related to the volume of the corresponding sub-OAR. The average R-values for the normalised mean dose (Dnmean) to parallel organs and serial organs and the normalised maximum dose (Dn0) to serial organs in the training set were 0.880, 0.927 and 0.905, respectively. The mean square error for each OAR in the prediction model was low (ranging from 1.72 × 10-4 to 7.06 × 10-3).

CONCLUSION

The neural network-based model for predicting OAR dose during IMRT for NPC is simple, reliable and worth further investigation and application.

[Effectiveness of 13-valent pneumococcal conjugate vaccine against invasive disease caused by serotype 19A in children: a meta-analysis]

Objective: Using Meta-analysis to evaluate the vaccine effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) against invasive Streptococcus pneumoniae disease (IPD) caused by serotype 19A in children <5 years old. Methods: "Streptococcus pneumoniae infection""invasive pneumococcal disease""13-valent pneumococcal polysaccharide conjugate vaccine""PCV13""effectiveness""infant""child" and related terms were searched from China National Knowledge Infrastructure (CNKI), WANFANG DATA, PubMed, SCOPUS and Web of science with no limited on language, region and research institution. The retrieval time was limited from January 2010 to February 2023 and cohort study, case-control study and randomized controlled trial were included. Data were extracted from eligible studies by two independent reviewers, and after study quality assessment by NOS scale, Meta-analysis was completed using Stata 16.0 software. Results: A total of 2 340 related literatures were searched, and 10 literatures were finally included, including 5 case-control studies and 5 indirect cohort studies, which showed good literature quality. The vaccine effectiveness against serotype 19A IPD of PCV13 in children was 83.91% (95%CI: 78.92%-88.89%), and the subgroup analysis (P=0.240) showed there was no significant difference among the case-control study (VE=87.34%, 95%CI:79.74%-94.94%) and the indirect cohort study (VE=81.30%, 95%CI:74.69%-87.92%). The funnel plot and Egger test suggested that the possibility of publication bias was small. Conclusion: The present evidence indicates that PCV13 has a good vaccine effectiveness against serotype 19A IPD in children, and it is recommended to further increase the vaccination rate of PCV13 to reduce the disease burden of IPD in children <5 years old.

Serum metabolomics identifies uric acid as a possible novel biomarker for predicting recurrence of chronic rhinosinusitis with nasal polyps

BACKGROUND

Metabolomics has proven to be a valuable tool in gaining new insights into disease progression and prognosis, the specific metabolic alterations in the serum of recurrent chronic rhinosinusitis with nasal polyps (CRSwNP) patients remain unknown. This study aims to explore the serum metabolomic profiles of recurrent CRSwNP and identify potential predictive biomarkers.

METHODS

A prospective, single-center study was conducted on CRSwNP patients prior to endoscopic sinus surgery. Serum samples were subjected to untargeted metabolomic profiling. Patients were followed up for over 2 years and categorized into recurrence and non-recurrence groups. Metabolite differences between the two groups were compared, and the identified differentially regulated metabolites were subsequently validated in a large clinical cohort.

RESULTS

67 CRSwNP patients completed the follow-up schedule, with 47 classified into the non-recurrent group and 20 into the recurrent group. Significant differences were found in the metabolomic profiles between both groups, and serum uric acid (SUA) showed promising predictive potential for postoperative recurrence in both positive and negative ion models. A validation cohort comprising 398 non-recurrent and 142 recurrent CRSwNP patients was recruited, and a significant elevation in SUA levels was observed in recurrent cases. Patients were stratified into tertiles based on the distribution of baseline SUA levels. Multivariate Cox regression analysis showed that higher tertiles of SUA were associated with an increased risk of CRSwNP recurrence compared to lower tertiles, even after adjusting for potential confounding factors. The receiver operating characteristic curve and Kaplan-Meier survival analysis highlighted that elevated SUA levels exhibited potential predictive values for postoperative recurrence.

CONCLUSION

Serum metabolic signatures might predict postoperative recurrence in CRSwNP patients. Increased SUA concentrations were found to be associated with a higher risk of future postoperative recurrence in CRSwNP, independent of traditional risk factors.

Health inequalities of global protein-energy malnutrition from 1990 to 2019 and forecast prevalence for 2044: data from the Global Burden of Disease Study 2019

OBJECTIVES

Protein-energy malnutrition poses a serious medical problem worldwide. This study aims to describe the global burden, trends, and health inequalities of protein-energy malnutrition and forecasts for future prevalence.

STUDY DESIGN

This was a comprehensive analysis based on data provided by the Global Burden of Disease Study 2019.

METHODS

Data were obtained from the Global Health Data Exchange query tool, including prevalence, deaths, disability-adjusted life years (DALYs) and sociodemographic index (SDI). The estimated annual percentage changes were calculated to evaluate temporal trends. We quantified cross-country inequalities in protein-energy malnutrition burden and predicted the prevalence number and rate to 2044.

RESULTS

Globally, there were 147,672,757 (130,405,923 to 167,471,359) cases of protein-energy malnutrition in 2019, with 212,242 (185,403 to 246,217) deaths. Eastern Sub-Saharan Africa had the highest age-standardised death and DALY rates in 2019. From 1990 to 2019, the global age-standardised prevalence rate of protein-energy malnutrition showed an upward trend, while the age-standardised death rate showed a downward trend. A significant decline occurred in SDI-related health inequality, from 2126.1 DALYs per 100,000 persons between the poorest and richest countries in 1990 to 357.9 DALYs per 100,000 persons in 2019. There was a trend of decreasing age-standardised death and DALY rates along with increases in the SDI. Frontier analyses showed that there is much room for improving the current situation of protein-energy malnutrition in some countries. In the next 35 years, the prevalence of protein-energy malnutrition will continue to increase.

CONCLUSION

Although the disease burden of protein-energy malnutrition has greatly decreased since 1990 and health inequalities between countries are shrinking, the prevalence in Asian and African countries may continue to increase. Focussing on regional differences and strengthening the nutritional intake of people in underdeveloped areas are necessary to reduce future burdens.

Quercetin improves cerebral ischemia/reperfusion injury by promoting microglia/macrophages M2 polarization via regulating PI3K/Akt/NF-κB signaling pathway

The modulation of microglial polarization from the pro-inflammatory M1 to the anti-inflammatory M2 phenotype shows promise as a therapeutic strategy for ischemic stroke. Quercetin, a natural flavonoid abundant in various plants, possesses anti-inflammatory, anti-apoptotic, and antioxidant properties. Nevertheless, its effect and underlying mechanism on microglia/macrophages M1/M2 polarization in the treatment of cerebral ischemia/reperfusion injury (CI/RI) remain poorly explored. In the current study, we observed that quercetin ameliorated neurological deficits, reduced infarct volume, decreased the number of M1 microglia/macrophages (CD16/32+/Iba1+), and enhanced the number of M2 microglia/macrophages (CD206+/Iba1+) after establishing the CI/RI model in rats. Subsequent in vivo and in vitro experiments indicated that quercetin downregulated M1 markers (CD86, iNOS, TNF-α, IL-1β, and IL-6) and upregulated M2 markers (CD206, Arg-1, IL-10, and TGF-β). Network pharmacology analysis and molecular docking revealed that the PI3K/Akt/NF-κB signaling pathway emerged as the core pathway. Western blot confirmed that quercetin upregulated the phosphorylation of PI3K and Akt, while alleviating the phosphorylation of IκBα and NF-κB both in vivo and in vitro. However, the PI3K inhibitor LY294002 reversed the effects of quercetin on M2 polarization and the expression of key proteins in the PI3K/Akt/NF-κB pathway in primary microglia after oxygen-glucose deprivation/reoxygenation (OGD/R) in vitro. Collectively, our findings demonstrate that quercetin facilitates microglia/macrophages M2 polarization by modulating the PI3K/Akt/NF-κB signaling pathway in the treatment of CI/RI. These findings provide novel insights into the therapeutic mechanisms of quercetin in ischemic stroke.

The Global Bioequivalence Harmonisation Initiative (GBHI): Report of the fifth international EUFEPS/AAPS conference

The series of conferences of the Global Bioequivalence Harmonisation Initiative (GBHI) was started in 2015 by the European Federation for Pharmaceutical Sciences (EUFEPS). All GBHI meetings so far were co-organised together with the American Association of Pharmaceutical Scientists (AAPS). Beginning with the 3rd workshop US-FDA joined as co-sponsor - to support global harmonisation of regulatory recommendations for bioequivalence (BE) assessment. At the 5th GBHI conference, the following BE topics were intensively discussed, and the following main conclusions were drawn: (1) Statistical considerations for BE assessment in specific situations covering scaling approaches for highly variable drug (HVD) products, two-stage adaptive design and opportunities of modelling and simulation to support BE: even though special BE study concepts like adaptive designs are not often used in practise so far, a majority of the workshop participants were in favour of a more frequent application of such approaches. The regulatory conditions relevant in this context need further concretisation and harmonisation between the regions. Moreover, modelling and simulation were considered as a promising and evolving approach, also for BE development programmes. (2) Fed versus fasting conditions in BE trials: Findings that BE between generic products could be confirmed only after fasted administration but failed under fed conditions seem more an exception than the rule. Obviously, BCS class IV compounds are most problematic in this context. Differences in critical excipients such as surfactants or pH-modifiers may be relevant reasons for different sensitivity for interactions in fasted versus fed conditions. Consequently, such deviations in composition of generic preparations should be avoided. Moreover, confirmation of BE may be generally difficult comparing different dosage forms, such like capsules versus tablets, especially in fed state. (3) BE assessment of locally acting drug products applied topically to the skin: Appropriateness and potential benefit of in-vitro tests as alternatives to clinical efficacy studies have been comprehensively discussed. In addition to the already well-established in-vitro release and permeation tests, other techniques were suggested, e.g., Raman spectroscopy or dermal open flow microperfusion. Validation of those methods is challenging and, despite significant progress already achieved during previous years, more research is needed before they may be fully accepted for regulatory purposes. (4) BE evaluation of narrow therapeutic index (NTI) drugs: The discrepancies amongst regulatory agencies in necessity of tighter BE acceptance ranges, the recommendations for inclusion of peak and total drug exposure into BE assessment with more restrictive criteria and the importance of comparison of the product-related within-subject variability for NTI drugs were debated. Arguments in favour and against the different approaches were presented and discussed but need further consideration before harmonisation can be achieved. The highly interactive meeting and extensive exchange between regulators and scientists from industry and academia resulted in useful progress in open BE issues and supported the goal of science-driven harmonisation.

Complete mesocolic excision versus standard resection for colon cancer: a systematic review and meta-analysis of perioperative safety and an evaluation of the use of a robotic approach

PURPOSE

Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly because of the technical complexity and perceived risks of the approach. The aim of out study was to evaluate the safety of CME compared to standard resection and to compare robotic versus laparoscopic approaches.

METHODS

Two parallel searches were undertaken in MEDLINE, Embase and Web of Science databases 12 December 2021. The first was to evaluate IDEAL stage 3 evidence to compare complication rates as a surrogate marker of perioperative safety between CME and standard resection. The second independent search compared lymph node yield and survival outcomes between minimally invasive approaches.

RESULTS

There were four randomized control trials (n = 1422) comparing CME to standard resection, and three studies comparing laparoscopic (n = 164) to robotic (n = 161) approaches. Compared to standard resection, CME was associated with a reduction in Clavien-Dindo grade 3 or higher complication rates (3.56% vs. 7.24%, p = 0.002), reduced blood loss (113.1 ml vs. 137.6 ml, p < 0.0001) and greater mean lymph node harvest (25.6 vs. 20.9 nodes, p = 0.001). Between the robotic and laparoscopic groups, there were no significant differences in complication rates, blood loss, lymph node yield, 5-year disease-free survival (OR 1.05, p = 0.87) and overall survival (OR 0.83, p = 0.54).

CONCLUSIONS

Our study demonstrated improved safety with CME. There was no difference in safety or survival outcomes between robotic and laparoscopic CME. The advantage of a robotic approach may lie in the reduced learning curve and an increased penetration of minimally invasive approach to CME. Further studies are required to explore this.

PROSPERO ID

CRD42021287065.

Listeriolysin O Drives Innate and Adaptive Immune Responses to CD47 Immunotherapy

PURPOSE/OBJECTIVE(S)

Radioimmunotherapies that combine radiation with antibodies against the "don't eat me" signal CD47 show increasing promise. One opportunity to synergize RT with anti-CD47 is via the Stimulator of Interferon Genes (STING) pathway which facilitates potent immune responses to cytoplasmic DNA. Anti-CD47 should activate STING by increasing macrophage consumption of tumor DNA. However, tumor contents are destroyed in phagolysosomes. Listeria (L.) monocytogenes escape lysosomes by secreting a pore-forming protein Listeriolysin O (LLO). We recently engineered a protein-antibody conjugate linking anti-CD47 to LLO. Here, we demonstrate that LLO-CD47 enhances macrophage STING signaling, tumor cell phagocytosis, and tumor antigen presentation. At doses compatible with minimal toxicity in mice, LLO-CD47 delays the growth of orthotopic breast tumors. By contrast, anti-CD47 fails to activate STING in macrophages or inhibit tumor growth. We further hypothesize that LLO-CD47 requires innate and adaptive immune cells for antitumor immunity.

MATERIALS/METHODS

Anti-CD47 was conjugated to LLO using a water-soluble SPDP crosslinker and purified by affinity chromatography. Transmission electron microscopy (TEM) was used to visualize the integrity of macrophage phagolysosomes following treatment. C57B6 mouse bone marrow-derived macrophages (BMDMs) were used to study the impact of LLO-CD47 on M2-to-M1 polarization, tumor cell phagocytosis, STING activation, and antigen presentation. CD8+ T cells or tumor-associated macrophages (TAMs) were depleted from tumor-bearing mice using an anti-CD8 antibody or anti-CSF-1R antibody prior to LLO-CD47 treatment.

RESULTS

(1) LLO-CD47 skews BMDMs from M2-to-M1 inflammatory phenotypes and enhances the phagocytosis of E0771 tumor cells. (2) BMDMs visualized by TEM show breaches in phagosome membranes following LLO-CD47, but not anti-CD47, treatment. (3) LLO-CD47 increases levels of phosphorylated STING, IFN, and TNFα relative to cells treated with anti-CD47. (4) LLO-CD47 significantly inhibits the growth of orthotopically implanted E0771 murine breast tumors relative to anti-CD47. (5) The elimination of CD8+ T cells or TAMs abrogates the antitumor effect of LLO-CD47.

CONCLUSION

LLO-CD47 is a de novo protein-antibody conjugate engineered for cGAS-STING pathway activation in innate immune cells. CD8+ T cells and TAMs are required for the antitumor activity LLO-CD47 in orthotopic models of breast cancer. This novel immunotherapy builds on clinical interest in myeloid checkpoint inhibitors and may be studied as a supplemental therapy for patients with metastatic breast cancer.

Role and Modality of Combining Radiotherapy with Immunotherapy in Stage III-IV Unresectable Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

The combination of radiotherapy and immunotherapy was rarely reported in the management of small cell lung cancer (SCLC). We retrospectively assessed the role and modality of this combination in Stage III-IV unresectable SCLC.

MATERIALS/METHODS

Patients with stage III and IV SCLC were enrolled according to AJCC 8th edition. Both efficacy and safety of immunotherapy combined with radiotherapy were evaluated. Thereinto, patients received first-line chemo-immunotherapy and sequential thoracic consolidation radiotherapy (TCRT) were further evaluated. Survival and descriptive analyses were performed.

RESULTS

Between January 1, 2019 and December 31, 2021, 51 patients were included in our analysis. Median follow-up was 28.0 months (95% CI 22.8-33.2). Patients received radiotherapy in treatment course had a prolonged 2-year overall survival (OS). And in the first-line immunotherapy cohort of 27 patients, the addition of TCRT significantly improved 2y-OS (72.22% vs. 13.89%, p = 0.0048), 2y-locoregional recurrence free survival (LRRFS) (90.00% vs 48.00%, p = 0.011), and 2y-distance progression free survival (DPFS) (66.67% vs. 16.67%, p = 0.039). Subgroup analyses showed that TCRT rendered superior outcomes regardless of brain metastases. Dose-escalation (45 Gy/15f) and earlier radiotherapy seemed to improve the benefit. Of 70.37% (19/27) patients experienced disease progression in the TCRT evaluation cohort, 63.16% (12/19) patients failed in brain. A tendency toward better OS and superior brain metastases free survival (BMFS) were observed after receiving prophylactic cranial irradiation (PCI). Finally, the most common grade 2 or higher toxic effects were pneumonitis in all patients (11.76% of immune-related vs. 7.84% of radiation related).

CONCLUSION

Earlier addition of TCRT to immunotherapy could significantly improve survival and extracranial control for stage IIIA-IVB unresectable SCLC patients, with no increased risk of adverse events. In the era of immunotherapy, PCI may still be a recommended strategy. Further investigation is warranted.

Dosimetric Analysis of Proton Beam Therapy vs. Photon Radiotherapy for Cardiac Tumors with or without Deep Inspiratory Breath Holding: A Case Report

PURPOSE/OBJECTIVE(S)

Proton beam therapy (PBT) has been demonstrated to deliver equivalent dosimetric radiation with the benefit of improved sparing of organs at risk (OAR). Deep inspiration breath holding (DIBH) is a commonly used method for reducing the radiation dose to the heart and lungs. However, few studies have ever reported the usage of DIBH combined with proton beam therapy in cardiac tumors. The purpose of this case report is to compare the dosimetric differences between photon radiotherapy and proton radiation therapy (PBT) with or without deep inspiration breath holding.

MATERIALS/METHODS

A 66-year-old female patient with cardiac tumors was recruited, and the prescribed dose of radiotherapy for cardiac tumors was 95%PGTV 50Gy/2.5Gy/20f. Two simulation CT scans were collected during free breath (FB) and DIBH. And the target area was delineated on deep inspiratory breath holding image (DIBH-CT) and free breathing image (FB-CT). The target area of FB-CT was modified by referring to the ten-time phases of 4D-CT. Finally, IMRT, VMAT and PBT plans (DIBH-IMRT, DIBH-VAMT, DIBH-PBT, FB-IMRT, FB-VAMT, FB-PBT) were generated on the above images, and the organs at risk were limited as follows: lungs V20 ≤20%, lungs mean ≤11 Gy, heart V30 ≤40%, coronary artery mean ≤26 Gy, spinal cord ≤30 Gy, and left breast mean ≤5 Gy.

RESULTS

All of the six plans satisfied most of the treatment planning goals. DIBH resulted in a dose reduction in all organs at risk including the heart, lungs, coronary artery (CA), spinal cord and breasts, when compared with FB using IMRT, VMAT, or PBT. Compared with the FB, DIBH provided a significant reduction in the mean dose of coronary artery (CA mean for DIBH-IMRT vs FB-IMRT = 28.32 Gy vs 42.66 Gy, CA mean for DIBH-VMAT vs FB-VAMT = 26.44Gy vs 40.85Gy, CA mean for DIBH-PBT vs FB-PBT = 27.71Gy vs 39.51Gy). Similarly, when compared with IMRT or VMAT in either FB or DIBH, PBT reduced radiation doses for all of the OAR. In comparison, the difference was less significant between IMRT and VMAT technique. Pitmen compared with IMRT and VMAT, reduced significantly the max dose of spinal cord, lungs V5, breast-L/R mean. Totally, DIBH-PBT was observed sufficient dose coverage and better sparing of organs at risk.

CONCLUSION

PBT combined with DIBH technique gained an advantage in the sparing of OAR for cardiac tumors, especially in coronary protection. The possibility of broader application of PBT with DIBH in clinical practice is currently being evaluated and further studies are needed.

Polymetastatic Recurrence-Free Survival in Patients with Repeat Oligometastases on the SABR-5 Trial

PURPOSE/OBJECTIVE(S)

To determine polymetastatic recurrence-free survival (PMRFS) in patients with repeat oligometastases (OM) on the SABR-5 trial.

MATERIALS/METHODS

SABR-5 is a prospective, multi-center trial that evaluated the safety of stereotactic ablative radiotherapy (SABR) in patients with 1-5 OM or oligoprogressive lesions. On SABR-5, patients were followed post-SABR according to standardized protocols. Patients with repeat extra-cranial OM after metastasis-directed therapy (MDT; SABR, surgery, or thermoablation) to all initial OM (including those treated before enrolment on SABR-5) were identified. Exclusion criteria included history of multiple primary malignancies and incomplete re-staging. PMRFS was defined as time from presentation of repeat oligometastases to death or presentation of 6 or more progressing metastases, leptomeningeal metastases, lymphangitic carcinomatosis, malignant ascites, or malignant pleural effusion. PMRFS, overall survival (OS), and progression-free survival (PFS) were calculated using the Kaplan-Meier method.

RESULTS

Seventy-six patients with repeat OM were included, of which 44 (58%) received second MDT to all OM. The most common histology in patients who received second MDT was colorectal cancer (10/44 [23%]) and in those who did not was prostate cancer (17/32 [53%]). Patients who did vs. did not receive second MDT had fewer metastases at repeat OM (mean 1.3 vs 2.2; p<0.001) and no difference in time between initial OM and repeat OM (16 vs. 17 months; p = 0.74). For patients who received second MDT, median follow-up from presentation of repeat OM was 2.6 years. Median PFS after first and second MDT were 15 months (95% CI 11-18) and 11 months (95% CI 7-17), respectively. At last follow-up, 22/44 patients (50%) were alive without polymetastatic recurrence. 3-year PMRFS and OS from presentation of repeat OM were 51% (95% CI 33-66%) and 66% (95% CI 47-79%), respectively.

CONCLUSION

Patients presenting with repeat OM after MDT may still have favorable 3-year PMRFS and OS, which may justify exploring aggressive local treatments in this subpopulation. Further randomized trials in this space are needed.

30 Gy vs. 45 Gy Consolidative Thoracic Radiation (cTRT) for Extensive Stage Small Cell Lung Cancer (ES-SCLC): A Multicenter, Randomized, Phase 3 Trial

PURPOSE/OBJECTIVE(S)

Consolidative thoracic radiotherapy (cTRT) showed potential benefit to extensive stage small cell lung cancer (ES-SCLC). However, the optimum dose of cTRT is unknown. The purpose of this randomized trial was to compare the effect of 45 Gy in 15 fractions with 30 Gy in 10 fractions cTRT in ES-SCLC.

MATERIALS/METHODS

This phase III, randomized trial was conducted in 12 public hospitals in China. Eligible patients with pathologically confirmed ES-SCLC who responded to 4-6 cycles of etoposide plus cisplatin (EP) or carboplatin (EC) chemotherapy were randomized 1:1 to receive either 30 Gy in 10 fractions or 45 Gy in 15 fractions cTRT. The primary outcome was 2-year overall survival (OS). Secondary outcomes included 2-year progression-free survival (PFS), 2-year local control (LC) and radiation treatment related toxicity. The primary objective was to detect an OS improvement in 45 Gy cTRT group at 2 years from 13% to 26% assuming a two-sided a = 0.05 and power of 85%, with a planned sample size of 186 patients. This trial was registered with Clinical Trials.gov, number NCT02675088.

RESULTS

Between January 15, 2016, and September 20, 2022, 90 patients were randomly assigned either 30 Gy in 10 fractions (n = 50) or 45 Gy in 15 fractions (n = 40) cTRT group. Recruitment to the trial closed early due to slow accrual since first-line chemoimmunotherapy has become the new standard of care for ES-SCLC. The median age of patients was 58 years, 87.8% were male, 76.7% had a smoking history, 95.6% received IMRT, and 58.9% received prophylactic cranial irradiation. At a median follow-up of 39.9 months (IQR 27.2-59.2), there was no significant difference in the 2-year OS between the 45 Gy group and the 30 Gy group, at 43.4% (95% CI 29.3%-64.3%) and 40.0% (95% CI 27.9%-59.1%), respectively (log-rank p = 0.62; HR 1.13 [95% CI 0.69-1.84]). The 2-year PFS was 12.1% (95% CI 4.3%-33.8%) in the 45 Gy group and 9.0% (95% CI 3.2%-25.2%) in the 30 Gy group (log-rank p = 0.25, HR 0.76(95% CI [0.478-1.22]). There were also no significant differences in locoregional recurrence free survival (log-rank p = 0.75; HR 0.888 [95% CI 0.423-1.863]) and distant metastasis free survival (log-rank p = 0.95; HR 1.015 [95% CI 0.624-1.651]) between two groups. No grade 5 toxicity was observed in both groups. Patients treated with higher cTRT dose presented with increased incidence of grade 3+ radiation pneumonitis (10% vs 2%) and hematological toxicity (20% vs 12.5%).

CONCLUSION

This randomized trial did not find a higher probability of survival improvement in patients with ES-SCLC receiving cTRT of 45 Gy in 15 fractions compared with 30 Gy in 10 fractions. In contrast, there was an increase in toxicity, especially radiation pneumonitis. Additional randomized studies investigating the role of cTRT in ES-SCLC after a response to chemoimmunotherapy are warranted.

Feature Selection Based on Unsupervised Clustering Mechanism on Multiple-Sequence MRIs for Predicting Neoadjuvant Chemoradiation Response in Locally Advanced Rectal Cancer

PURPOSE/OBJECTIVE(S)

Accurate response prediction allows for personalized cancer management. We developed an unsupervised clustering mechanism to improve effectiveness and efficiency in feature selection operation for accurate patient stratification.

MATERIALS/METHODS

Forty-three locally advanced rectal cancer (LARC) patients underwent neoadjuvant chemoradiation were included, pre-treatment T2 and ADC MRIs were acquired for each patient. An initial feature space consisting of 200 radiomic features extracted from manually delineated GTVs from two sequences of MR images. Additional 960 high-order radiomic features extracted from a 3D convolutional neural network (CNN). To remove redundant and irrelevant features, we developed an unsupervised clustering-based feature selection operation to determine the combination of features with potential best performance. The normal process of feature selection involves searching new feature combinations and training new classifiers for evaluating their performance via an iterative process based on selected feature set, the overall time cost is tremendous. To balance the computational cost and search efficiency, firstly, we proposed an unsupervised clustering analysis metric- Comprehensive Cluster Analysis Index (CCAI) through the K-means algorithm, where the average distances between the sample points and the cluster centroids and so on, to construct a multiple linear regression model. Secondly, we extracted sample points by varying the number of features and feature ratios between radiomic features and 3D-CNN features in the output of feature selection. Thirdly, we optimized the model using the sampling points to calculate the CCAI. Two typical feature combination search algorithms, the random forest recursive feature elimination (RF-RFE) and the differential evolution (DE), were used to perform feature selection with CCAI.

RESULTS

The accuracy, area-under-curve (AUC) and specificity, based on combined 3D-CNN and radiomic features extracted from combined T2 and ADC images, were 0.852, 0.871, and 0.735, respectively. Our experiments illustrated higher predictive power (AUC = 0.846) based on high-order abstract features extracted from the CNN on ADC and T2 images, compared to the traditional radiomic model (AUC = 0.714). Additionally, the predictive models constructed based on radiomics and CNN features extracted from ADC images were more predictable in terms of treatment responses than the radiomic and CNN imaging features extracted from T2 images. The average computational time of DE and RF-RFE were 50.5s and 128.6s in one single computation, the average computational time were 24.2s and 91.3s with CCAI, respectively.

CONCLUSION

We proposed an unsupervised clustering analysis mechanism to improve the effectiveness of feature selection while decreasing its time cost markedly, which highlight the correlation and complementarity between low- and high-level imaging features, achieving better predictive accuracy.

The Causes of Death and Conditional Survival for Long-Term Survivors of Thymoma

PURPOSE/OBJECTIVE(S)

Data on the morality cause for long-time survival of thymoma is limited. The previous study hinted that thymoma may be a chronic disease rather than a curable cancer. we performed a large-scale retrospective analysis to assess long-term cause of death in patients with thymoma.

MATERIALS/METHODS

This study reviewed thymoma patients from the Surveillance, Epidemiology, and End Results (SEER) database between January1975 and December 2016.Conditional survival and annual hazard rates was calculated with Kaplan-Meier, and cause-specific mortality was performed using Fine-Gray competing risks analysis.

RESULTS

Of 3105 patients were identified (median [range] age,58 (18-93), years), 1615 (52.0%) were male,1028(33.1%) were 65 years or older and 1360(43.8%)patients was at locally advanced (IIB-III) disease. The 10-year overall survival (OS) and cancer-specific survival (CSS) rates were 55.5% (95% CI, 53.4-57.6%) and 74.4% (95% CI, 72.4-76.3%) respectively. Smoothed hazard showed that the annual overall death hazard of death increased steadily, but the hazard of thymoma-related death began to decline at about 4 years and is exceeded by other causes at death. However, the annual risk of death by thymoma remain about 1-2% at 5-25 years. Similarly, the conditional OS increased slowly with increased survival time however the cancer-specific survival based decreased slowly. The cumulative incidence of the most common causes of death was 23.1% for thymoma, 5.4% for heart of disease, and 3.9% for the second cancer in 10 years, 28.5%,8.3 and 7.0% in 15 years, and 31.8%,11.8% and 10.8% in 25 years. After 5 years of survival, the death of heart was the main cause of non-thymoma death. The 10-years survivors' older patients (≥65 years) or with radiotherapy suffered more heart specific death (adjust P< 0.001, P = 0.015, respectively).

CONCLUSION

The risk of cancer-specific death and other causes of death shift over time for patients with thymoma. The non-cancer cause, especially heart diseases which may be the vital competing cause of death, increased with prolongation of survival time.

MD Anderson Phase III Randomized Preoperative Stereotactic Radiosurgery (SRS) vs. Postoperative SRS for Brain Metastases Trial

PURPOSE/OBJECTIVE(S)

Postoperative stereotactic radiation therapy/radiosurgery (SRT/SRS) is being evaluated in comparison to Preoperative SRT for brain metastases (mets) in a limited number of prospective clinical trials. Our objective is to address the significant knowledge gap concerning the logistics of preoperative SRT in comparison to postoperative SRT in a randomized controlled study.

MATERIALS/METHODS

Patients with brain mets with at least 1 surgically operable met were randomized (1:1) to Preop vs Postop SRT. In this abstract, we present non-primary endpoint data on the trial concept and logistics of treatment for this data safety monitoring board reviewed study. Patients enrolled had 1-2 lesions resected and <15 lesions treated at time of SRT to best reflect the standard population that receive SRT and surgery at our institution.

RESULTS

From 12/2018 to 12/2022, 99 patients with 1-2 operable brain mets were enrolled and randomized to Preop (n = 49) or Postop (n = 50) SRT. Males represented 56% of the cohort compared to females, and <25% were age 18-49 years, while 27%, 29, and 19% respectively were 50-59, 60-69, and > = 70. The most frequent histologies enrolled were lung (29%), renal cell (15%), melanoma (14%), and breast (11%) cancers. The majority of patients (83%) had 1-4 brain mets on their baseline MRI and 91% subsequently had a single lesion resected. Seventy-nine patients completed both SRT and surgery, while 9% received no therapy due to drop out before study therapy initiation. Among patients receiving both therapies in the combined cohort, 68% received a non-invasive stereotactic radiosurgery instrument to the randomized cavity lesion compared to 32% receiving LINAC based SRT. Treatment of the lesion or cavity with single fraction SRT was 51% in the Preop arm vs 31% in the Postop arm. Multi-fraction (3-5 SRT) was 67% in the Postop cohort in contrast to 47% in the Preop cohort. Time from randomization to RT was 5.6 days and 33.7 days in the Preop and Postop cohorts respectively, and for surgery was 10.2 days vs 12.9 days in the Postop vs Preop cohorts. The average time from RT to surgery was 7.3 days in the Preop arm and 23.5 days in the Postop arm (to allow for incisional healing time).

CONCLUSION

In one of the early initiated randomized prospective cohorts of Preop vs Postop SRT, we demonstrated logistical feasibility with an efficient clinical trial workflow for study treatment. Differences in Preop vs Postop logistics reflect clinical practice differences in time-to-treatment. Therapy with various modalities reflected real-world practice and possibly provider preferences in technique when addressing the nature of delineating cavities and changes in cavity volume with regard to fractionation. Independent of the primary outcomes, our data provides insights in the practical management of patients receiving these two modalities of therapy, and further data at the completion of trial will address relevant primary outcomes.

Prospective Longitudinal Assessment of Quality of Life after Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-Based SABR-5 Phase II Trial

PURPOSE/OBJECTIVE(S)

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS/METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to 5 sites of oligometastases, conducted in 6 regional cancer centers in British Columbia from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30, and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal, and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and baseline score of individual patients. Mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with "stable," "improved," or "worsened" QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI Functional Interference Score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least 1 follow-up assessment were analyzed (n = 135). On equivalence testing, patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% CI [1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% CI [1.15 to 2.21]; FACIT-AD TOI mean difference: -8.76, 90% CI [-11.29 to -6.24]; POSI mean difference: -4.61, 90% CI [-6.09 to -3.14]). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). The majority of patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening, and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSION

SABR in the oligometastatic setting can lead to transient decreases in QoL. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterize patients at greatest risk for decreased QoL.

Assessing the feasibility of SUVindex (a metric derived from FDG PET/CT) for the diagnosis of polymyalgia rheumatica

AIM

To evaluate the feasibility of standard uptake value (SUV) index (ratio lesional maximum SUV [SUVmax] to liver mean SUV [SUVmean]) as a metabolic parameter for diagnosing polymyalgia rheumatica (PMR).

MATERIALS AND METHODS

A retrospective group of patients with PMR and controls with symptoms similar to PMR but diagnosed with other diseases. Semiquantitative and qualitative analysis of 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) uptake at 18 sites was undertaken for all patients. The diagnostic value of positron-emission tomography/computed tomography (PET/CT) for PMR was assessed by R software using logistic regression and a generalised additive model (GAM). All images were examined independently by two nuclear medicine physicians with extensive work experience.

RESULTS

The characteristic sites of PMR were the ischial tuberosity, interspinous bursa, periarticular hip, and symphysis pubis enthesis. The area under the curve (AUC) of the characteristic site SUV index was 0.930, and the best cut-off value was 1.685 with a sensitivity of 84.6% and a specificity of 92.6%. After adjusting for potential confounders, the probability of PMR diagnosis increased as the characteristic site SUV index increased and there was a nonlinear correlation between the two. When the characteristic site SUV index was ≥2.56, the probability of PMR gradually reached the threshold effect, which was as high as 90% or more.

CONCLUSION

The characteristic site SUV index is an independent factor for diagnosing PMR, and PMR should be highly suspected when it is ≥ 1.685. Nonetheless, it is important to note that these findings are based on an initial retrospective single-centre study and require external validation and further prospective evaluation before being translated into clinical practice.

Design and experimental demonstration of a silicon five-mode (de)multiplexer based on multi-phase matching condition

A compact 5-mode (de)multiplexer [(De)MUX] is proposed and experimentally demonstrated based on the principle of multi-phase matching. The proposed device comprises a cascaded asymmetric directional coupler (ADC) based on 3-mode phase-matching, a polarization beam combiner, and a taper waveguide connecting them. The multiple modes in the access waveguides are matched to different modes in the same bus waveguide, which eliminates the need for additional taper structures and results in a total coupling length of only 18.9 µm. Experimental results exhibit that the insertion losses of the five modes are below 3.4 dB, and the mode crosstalks are below -15 dB at the central wavelength. The 3-dB bandwidths of TM0, TM1, TE0, TE1, and TE2 modes are greater than 100 nm, 46 nm, 100 nm, 28 nm, and 37 nm, respectively. The proposed device can serve as a key functional component in highly integrated on-chip mode-division multiplexing systems.

Inverse-designed counter-tapered coupler based broadband and compact silicon mode multiplexer/demultiplexer

A mode multiplexer/demultiplexer (MUX/DeMUX) is a crucial component for constructing mode-division multiplexing (MDM) systems. In this paper, we propose and experimentally demonstrate a wide-bandwidth and highly-integrated mode MUX/DeMUX based on an inverse-designed counter-tapered coupler. By introducing a functional region composed of subunits, efficient mode conversion and evolution can be achieved, greatly improving the mode conversion efficiency. The optimized mode MUX/DeMUX has a size of only 4 µm × 2.2 µm. An MDM-link consisting of a mode MUX and a mode DeMUX was fabricated on the silicon-on-insulator (SOI) platform. The experimental results show that the 3-dB bandwidth of the TE fundamental mode and first-order mode can reach 116 nm and 138 nm, respectively. The proposed mode MUX/DeMUX is scalable and could provide a feasible solution for constructing high-performance MDM systems.

Use of thermal imaging to measure the quality of hand hygiene

OBJECTIVES

Hand hygiene has long been promoted as the most effective way to prevent the transmission of infection. However, due to low compliance and low quality of hand hygiene reported in previous studies, constant monitoring of hand hygiene compliance and quality among healthcare workers is crucial. This study investigated the feasibility of using a thermal camera with an RGB camera to detect hand coverage of alcohol-based formulation, thereby monitoring the quality of hand rubbing.

METHODS

In total, 32 participants were recruited to participate in this study. Participants were required to perform four types of hand rubbing to achieve different coverage of the alcohol-based formulation. After each task, participants' hands were photographed under a thermal camera and an RGB camera, while an ultraviolet (UV) test was used to provide the ground truth of hand coverage of alcohol-based formulation. U-Net was used to segment areas exposed to alcohol-based formulation from thermal images, and system performance was evaluated by comparing differences in coverage between thermal images and UV images in terms of accuracy and Dice coefficient.

RESULTS

This system found promising results in terms of accuracy (93.5%) and Dice coefficient (87.1%) when observations took place 10 s after hand rubbing. At 60 s after hand rubbing, accuracy and Dice coefficient were 92.4% and 85.7%.

CONCLUSIONS

Thermal imaging has potential for accurate, constant and systematic monitoring of the quality of hand hygiene.

[Evaluation of right ventricular function using two-dimensional speckle tracking echocardiography and analysis of the risk factors for right ventricular dysfunction in patients with silicosis]

Objective: To evaluate the right ventricular function using two-dimensional speckle tracking echocardiography (2-D STE) and analyze the associated risk factors of right ventricular dysfunction in patients with silicosis. Methods: All 104 patients with silicosis treated in the Department of Occupational Medicine and Toxicology in Beijing Chao-Yang Hospital, Capital Medical University from May 2021 to September 2022 were enrolled in this study in October 2022. The clinical information of patients such as general data, arterial blood gas analysis and pulmonary function test were collected. The right ventricular function of patients was evaluated by 2-D STE-derived right ventricular free wall longitudinal strain (RVFWLS) and conventional echocardiographic-derived parameters, including right ventricular fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and doppler tissue imaging-derived tricuspid lateral annular systolic velocity (S'), respectively. Based on their RVFWLS, the patients were divided into right ventricular dysfunction group and normal right ventricular function group. Risk factors for right ventricular dysfunction in patients with silicosis were analyzed using binary logistic regression analysis. Results: A total of 104 silicosis patients were enrolled, with aneverage age (65.52±11.18) years old, among whom including 57 cases diagnosed with stage Ⅰ/Ⅱ silicosis and 47 cases diagnosed with stage Ⅲ silicosis. 26 (25.00%) patients concurrent right ventricular dysfunction. The abnormal rates of RVFAC, TAPSE and S' in patients were 16.35% (17 cases), 21.15% (22 cases) and 6.73% (7 cases), respectively. The RVFAC and TAPSE in right ventricular dysfunction group were lower than those in normal right ventricular function group, and the incidence of pulmonary arterial systolic pressure ≥36 mmHg was higher than that in normal right ventricular function group (P<0.05). Logistic regression analysis showed that arterial partial pressure of oxygen (OR=0.932, 95%CI: 0.885-0.981, P=0.007) was the protective factor, and the forced expiratory volume in 1 second (FEV(1)) /forced vital capacity (FVC) ratio<70% (OR=5.484, 95%CI: 1.049-28.662, P=0.044) and stage Ⅲ silicosis (OR=6.343, 95%CI: 1.698-23.697, P=0.007) were the risk factors for silicosis patients concurrent right ventricular dysfunction. Conclusion: The incidence of right ventricular dysfunction is higher in patients with stage Ⅲ silicosis than that in patients with stage Ⅰ/Ⅱ silicosis. Using 2-D STE can help the early detection of silicosis with right ventricular dysfunction. Hypoxemia, airflow limitation and the stage Ⅲ silicosis are the risk factors for silicosis patients concurrent right ventricular dysfunction.

[Effect of the varicella vaccination on the clinical characteristics of herpes zoster cases aged 20 years and under]

To discuss the effect of varicella vaccination on the clinical characteristics of herpes zoster (shingles) cases aged 20 years and under, and analyze its clinical features. Based on the Yichang Health Big Data Platform, a descriptive study was conducted to collect the information of cases aged 20 years and under in three medical institutions of Yichang Central People's Hospital, Yichang First People's Hospital and Yichang Second People's Hospital from March 2019 to September 2020. According to the history of varicella vaccine, cases were divided into vaccination group and non-vaccination group, and their clinical features and outcomes were compared. The results showed that 46 shingles cases, aged from 7 to 20 years old, were included in this study. 26 males (56.5%), 20 females (43.5%), 15 cases in vaccination group (32.6%) and 31 cases in non-vaccination group (67.4%). 28 cases had thoracic involvement, followed by lumbar (n=8), cranial (n=7) involvements and extremities (n=7). The spread of herpes skin area: 2 cases involved too large area, 21 cases of 10 cm×10 cm, 14 cases of 5 cm×5 cm, 9 cases of 1 cm×1 cm. Herpes number: 26 cases had 10-49 herpes, followed by <10 herpes (n=9), uncountable herpes (n=7) and 50-99 herpes (n=4). The clinical course[M(Q₁,Q₃)] lasted 20.5 (13.5,24.8) d averagely, 5 cases had postherpetic neuralgia (PHN) and 1 case had respiratory complications. Shingles decrustation time was significantly shorter in vaccination group (Z=-2.01, P<0.05), and there was no significant difference in other characteristics by vaccination. In conclusion, the number and spread of shingles in most children and adolescents are less, and the complications such as PHN are less. Varicella vaccination can reduce the decrustation time and relieve shingles cases with some clinical symptoms.

[Mechanism of podocyte pyroptosis aggravated by up-regulation of phospholipase A2 receptor by hepatitis B virus X protein]

Objective: To explore the effect and underlying mechanism of increased expression of M-type phospholipase A₂ receptor (PLA₂R) on podocyte membrane induced by hepatitis B virus X protein (HBx) on podocyte pyroptosis in hepatitis B virus-associated glomerulonephritis (HBV-GN). Methods: Transfection of the HBx gene into human kidney podocytes was used to mimic the HBV-GN pathogenesis process. Subsequently, podocytes were divided into the following eight groups: normal control plus secretory phospholipase A₂-ⅠB (sPLA₂-ⅠB) group, empty plasmid plus sPLA₂-ⅠB group, HBx group, HBx plus sPLA₂-ⅠB group, HBx plus sPLA₂-ⅠB plus PLA₂R control siRNA group, HBx plus sPLA₂-ⅠB plus PLA₂R-siRNA group, HBx plus sPLA₂-ⅠB plus ROS control siRNA group, and HBx plus sPLA₂-ⅠB plus ROS-siRNA group. Podocyte morphology was observed under a transmission electron microscope, and PLA₂R expression was detected under a fluorescence microscope. Podocyte pyroptosis and reactive oxygen species (ROS) expression were analyzed by flow cytometry, and the mRNA and protein expression of PLA₂R, nucleotide-binding oligomerization domain-like receptor 3 (NLRP3), apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC), caspase-1, interleukin (IL)-1β and IL-18 were determined by real-time fluorescence quantitative PCR and Western blot. Results: Compared with the control group, the expression of PLA₂R on podocyte membrane significantly increased after transfection with HBx plasmid in vitro (4.07±0.41 vs 1.01±0.17, P<0.001). Transmission electron microscope and fluorochrome-labeled inhibitor of caspases/propidium iodide (FLICA/PI) double staining suggested that overexpressed PLA₂R combined with sPLA₂-ⅠB caused aggravated podocyte injury and increased pyroptosis (20.22%±0.36% vs 7.86%±0.28%, P<0.001). Moreover, the expression levels of ROS (4 324 515±222 764 vs 12 920±46, P<0.001), NLRP3 (48.30±2.73 vs 1.00±0.11, P<0.001), ASC (4.02±0.84 vs 1.01±0.15, P<0.001), caspase-1 (3.99±0.42 vs 1.00±0.11, P<0.001), IL-1β (9.08±0.75 vs 1.00±0.09, P<0.001) and IL-18 (19.20±0.70 vs 1.00±0.02, P<0.001) increased when PLA₂R was overexpressed. In contrast, with the addition of PLA₂R-siRNA or ROS-siRNA to knockdown the expression of related substances, podocyte injury was alleviated and the degree of pyroptosis decreased, and the expressions of genes related to the downstream signaling pathway (NLRP3, ASC, caspase-1, IL-1β and IL-18) decreased (all P<0.01). Conclusion: HBx may promote podocyte pyroptosis in HBV-GN by targeting the ROS-NLRP3 signaling pathway via the upregulation of PLA₂R.

[Factors affecting BK polyomavirus infection after kidney transplantation in post-school children and a predictive infection model]

Objective: To analyze high-risk factors affecting BK polyomavirus (BKPyV) infection and to construct a prediction model for BKPyV infection in children after renal transplantation. Methods: The clinical data of 332 children who received allogeneic kidney transplantation in the First Affiliated Hospital of Zhengzhou University from January 2014 to March 2022 were retrospectively collected. According to the BKPyV load level, the dynamic change process of lymphocytes at different time points were analyzed. The factors that have potential influence on BKPyV infection were screened by Cox regression analysis, and the receiver operating characteristic curve (ROC) was used to evaluate the sensitivity and specificity of the predictive model of infection. Results: Among the 332 children, there were 215 males and 117 females; the age of transplantation was (12.2±3.9) years old; 37 cases were preschool (1-5 years old), and 295 cases were post-school age (6-18 years old). BKPyV load in 224 urine samples and 30 blood samples of children were detected. There were 9 cases of BKPyV-associated viruria and 3 cases of BKPyV associated viremia in pre-school children, 76 cases BKPyV associated viruria and 14 cases of BKPyV associated viremia in post-school children. Multivariate Cox regression analysis showed that higher body mass index (BMI) (HR=1.105, 95%CI: 1.020-1.197), antithyroglobulin (ATG) application (HR=2.196, 95%CI: 1.335-3.613), and higher tacrolimus concentration (HR=2.484, 95%CI: 1.298-4.753), higher natural killer (NK) lymphocyte count (HR=1.193, 95%CI: 1.009-1.411), higher CD14⁺⁺CD16^-cell count (HR=1.096, 95%CI: 1.024-1.173) were independent risk factors for BKPyV associated viruria in post-school children. Delayed graft function (DGF) (HR=4.993, 95%CI: 1.555-16.038), Acute rejection (AR) (HR=6.021, 95%CI: 1.930-18.787), higher CD14⁺⁺CD16^-cell count (HR=1.227, 95%CI: 1.081-1.392) were independent risk factors for BKPyV associated viremia in post-school children. The results of ROC curve analysis showed that combined BMI, immune induction drugs, tacrolimus concentration, NK cell count, and CD14⁺⁺CD16^-cell count predicted the occurrence of BKPyV associated viruria in post-school children after kidney transplantation at 0.5, 1, 2, and 5 years with area under curve (AUC) of 0.712 (95%CI: 0.626-0.798), 0.708 (95%CI: 0.612-0.804), 0.754 (95%CI: 0.668-0.840) and 0.767 (95%CI: 0.685-0.849). The sensitivity and specificity of the model were 64.9%, 61.4%, 61.6%, 55.8% and 70.9%, 72.4%, 76.0%, 84.0%, respectively. Combined with DGF, AR, and CD14⁺⁺CD16^-cell counts predicted the occurrence of BKPyV-associated viremia at 0.5, 1, 2, and 5 years after renal transplantation in post-school children with AUC of 0.791 (95%CI: 0.631-0.951), 0.744 (95%CI: 0.547-0.936), 0.786 (95%CI: 0.629-0.946) and 0.812 (95%CI: 0.672-0.948). The sensitivity and specificity of the model were 76.1%, 67.1%, 75.0%, 77.9% and 88.9%, 89.0%, 89.9%, 88.0%, respectively. Conclusions: The postoperative CD14⁺⁺CD16^-cell level can be used as an independent predictor of BKPyV infection in post-school children after renal transplantation. Combined BMI, immune induction drugs, tacrolimus concentration, NK cell count, CD14⁺⁺CD16^-cell count and combined DGF, AR, CD14⁺⁺CD16^-cell count show good fitting effect in predicting the occurrence of BKPyV-associated viruria and viremia after transplantation in post-school children respectively.

Multi-centre, prospective randomized comparison of three different substrate ablation strategies for persistent atrial fibrillation

AIMS

The optimal strategy for persistent atrial fibrillation (PerAF) is poorly defined. We conducted a multicentre, randomized, prospective trial to compare the outcomes of different ablation strategies for PerAF.

METHODS AND RESULTS

We enrolled 450 patients and randomly assigned them in a 1:1:1 ratio to undergo pulmonary vein isolation and subsequently undergo the following three different ablation strategies: anatomical guided ablation (ANAT group, n = 150), electrogram guided ablation (EGM group, n = 150), and extensive electro-anatomical guided ablation (EXT group, n = 150). The primary endpoint was freedom from atrial fibrillation (AF) lasting longer than 30 s at 12 months after a single ablation procedure. After 12 months of follow-up, 72% (108) of patients in the EXT group were free from AF recurrence, as compared with the 64% (96) in the EGM group (P = 0.116), and 54% (81) in the ANAT group (P = 0.002). The EXT group showed less AF/atrial tachycardia recurrence than the EGM group (60% vs. 50%, P = 0.064) and the ANAT group (60% vs. 37.3%, P < 0.001). The EXT group showed the highest rate of AF termination (66.7%), followed by 56.7% in the EGM group, and 20.7% in the ANAT group. The AF termination signified less AF recurrence at 12 months compared to patients without AF termination (30.1% vs. 42.7%, P = 0.008). Safety endpoints did not differ significantly between the three groups (P = 0.924).

CONCLUSIONS

Electro-anatomical guided ablation achieved the most favourable outcomes among the three ablation strategies. The AF termination is a reliable ablation endpoint.

[Correction of the pathogenic mutation in the G6PC3 gene by adenine base editing in mutant embryos]

Objective: To determine whether the adenine base editor (ABE7.10) can be used to fix harmful mutations in the human G6PC3 gene. Methods: To investigate the safety of base-edited embryos, off-target analysis by deep sequencing was used to examine the feasibility and editing efficiency of various sgRNA expression vectors. The human HEK293T mutation models and human embryos were also used to test the feasibility and editing efficiency of correction. Results: ①The G6PC3(C295T) mutant cell model was successfully created. ②In the G6PC3(C295T) mutant cell model, three distinct Re-sgRNAs were created and corrected, with base correction efficiency ranging from 8.79% to 19.56% . ③ ABE7.10 could successfully fix mutant bases in the human pathogenic embryo test; however, base editing events had also happened in other locations. ④ With the exception of one noncoding site, which had a high safety rate, deep sequencing analysis revealed that the detection of 32 probable off-target sites was <0.5% . Conclusion: This study proposes a new base correction strategy based on human pathogenic embryos; however, it also produces a certain nontarget site editing, which needs to be further analyzed on the PAM site or editor window.

[Analysis of the core knowledge level of chronic diseases in Chinese adults and related factors]

Objective: To understand the core knowledge level and influencing factors of chronic disease prevention and control in Adults in China, and to provide a scientific basis for formulating chronic disease prevention and control measures. Methods: In this study, cross-sectional survey and quota sampling were used to recruit 173 819 permanent residents aged 18 and above from 302 counties of adult chronic diseases and nutrition surveillance in China to conduct an online questionnaire survey, including basic information and core knowledge of chronic diseases. The scores of the core knowledge of chronic disease prevention and control were described by median and interquartile range, the Wilcoxon rank sum test or the Kruskal Wallis test was used for the inter-group comparison, and the correlation factors of the total score were analyzed by the multilinear regression model. Results: A total of 172 808 participants were surveyed in 302 counties and districts, of which 42.60%(73 623) were male and 57.40%(99 185) were female; The proportion of respondents aged 18-44, 45-59, and 60 years old and above was 54.74% (94 594), 30.91% (53 423) and 14.35% (24 791), respectively. The total score of the core knowledge of chronic prevention and control in the total population was 66(13), and the scores of different characteristic groups were different, and the differences were statistically significant: the eastern region had the highest score at 67(11) (H=840.66, P<0.01), the urban 66(12) was higher than the rural 65(14) (Z=-31.35, P<0.01), and the male 66(14) was lower than female 66(12) (Z=-11.66, P<0.01), 18-24 years old 64(13) was lower than other age groups(H=115.80, P<0.01), and undergraduate degree and above had the highest score compared to other academic qualifications, with 68(9) points(H=2 547.25, P<0.01). Multivariate analysis showed that eastern (t=27.42, P<0.01), central (t=17.33, P<0.01), urban (t=5.69, P<0.01), female (t=17.81, P<0.01), high age (t=46.04, P<0.01) and high education (t=57.77, P<0.01) had higher scores of core knowledge of chronic disease prevention and control than other groups, the scores of core knowledge of chronic disease prevention and control of professional and technical personnel (t=8.63, P<0.01), state enterprises and institutions (t=38.67, P<0.01), agriculture, forestry, animal husbandry, fishery and water conservancy production (t=5.30, P<0.01), production, transportation and commercial personnel (t=24.87, P<0.01), and other workers (t=8.89, P<0.01) were higher than those of non-employed people. Conclusion: There are differences in the total scores of the core knowledge of chronic disease prevention and control in different characteristics of people in China, and in the future, health education on the prevention and treatment of chronic diseases should be strengthened for specific groups to improve the knowledge level of residents.

Human amniotic membrane graft for refractory macular hole: A single-arm meta-analysis and systematic review

PURPOSE

The treatment of refractory macular holes is controversial, with human amniotic membrane grafts emerging recently as an attractive option. We performed a meta-analysis and systematic review in this paper to assess the results of human amniotic membrane (hAM) in the treatment of refractory macular hole (MH).

METHODS

We searched the Cochrane Database of Systematic Reviews, Web of Science, PubMed, Embase, China National Knowledge Infrastructure databases, VIP database, Wanfang Data Knowledge Service Platform, Sinomed, Chinese Clinical Trial Registry, and Clinical Trials.gov. Studies reporting hAM for the treatment of refractory MH were included. The outcomes are MH closure rate, visual acuity (VA) improvement rate, and graft dislocation/contracture rate.

RESULTS

A total of 8 studies on 103 eyes were included, all of which had undergone failed vitrectomy and internal limiting membrane (ILM) peeling. In all studies, the VA improvement rate was 66% (95%CI: 45 to 84%), the MH closure rate was 94% (95%CI: 84 to 100%) and the hAM graft dislocation/contracture rate was 6% (95%CI: 0 to 15%). In the studies using cryopreserved hAM grafts, the MH closure rate was 99% (95%CI: 94 to 100%) and the hAM graft dislocation/contracture rate was 3% (0%, 10%). The VA improvement rates were 94% (95%CI: 79 to 100%) in the retinal detachment subgroup, 37% (95%CI: 20 to 56%) in the pathologic myopia subgroup, and 62% (95%CI: 14 to 100%) in the idiopathic MH subgroup.

CONCLUSION

Human amniotic membrane in the treatment of refractory MH results in visual improvement. It has a high macular hole closure rate and low dislocation/contracture rate. Cryopreserved hAM grafts might have better outcomes than dehydrated grafts.

Single-Cell Analyses of the Oral Mucosa Reveal Immune Cell Signatures

Inflammatory bowel disease (IBD) is a common immune-related disease of the gastrointestinal tract that affects many people around the world. Extraintestinal manifestations of IBD have been frequently observed in recent years; one of these, periodontitis, has gained increasing attention. Periodontitis is a chronic inflammatory disease characterized by inflammation and destruction of periodontal tissues due to the disruption of host immune homeostasis. Clinical studies have revealed that periodontal inflammation is associated with IBD. However, the detailed heterogeneity of immune cells and their developmental relationships remain poorly understood at the single-cell level. In this study, we performed single-cell RNA (scRNA) sequencing to assess the transcriptome heterogeneity in periodontal tissues. We found the cellular composition and subclusters with specific gene expression profiles by uniform manifold approximation and projection. Pseudo-time analysis combined with gene enrichment analysis was performed to reveal cell states and key pathways. Ligand-receptor pairs revealed cell-cell communication among the immune cell types in periodontal tissues. Based on our analysis, we identified an essential role for Tcr⁺ macrophage, Prdx1⁺ neutrophil, and Mif⁺ T subpopulations with proinflammatory phenotype infiltration. Moreover, we examined the heterogeneity of monocytic cells and B cells. Collectively, the mapping of scRNA revealed the complex cellular landscape of oral mucosa immune cells and highlighted these immune cells as a previously unrecognized factor that may aggravate inflammation. Our analysis proves that periodontitis could exacerbate colitis and provides novel ideas for controlling and preventing IBD exacerbations.

Residence times of groundwater along a flow path in the Great Artesian Basin determined by 81Kr, 36Cl and 4He: Implications for palaeo hydrogeology

Understanding the age distribution of groundwater can provide information on both the recharge history as well as the geochemical evolution of groundwater flow systems. Of the few candidates available that can be used to date old groundwater, ⁸¹Kr shows the most promise because its input function is constant through time and there are less sources and sinks to complicate the dating procedure in comparison to traditional tracers such as ³⁶Cl and ⁴He. In this paper we use ⁸¹Kr in a large groundwater basin to obtain a better understanding of the residence time distribution of an unconfined-confined aquifer system. A suite of environmental tracers along a groundwater flow path in the south-west Great Artesian Basin of Australia have been sampled. All age tracers (⁸⁵Kr, ³⁹Ar ¹⁴C, ⁸¹Kr, ³⁶Cl and ⁴He) display a consistent increase in groundwater age with distance from the recharge area indicating the presence of a connected flow path. Assuming that ⁸¹Kr is the most accurate dating technique the ³⁶Cl/Cl systematics was unravelled to reveal information on recharge mechanism and chloride concentration at the time of recharge. Current-day recharge occurs via ephemeral river recharge beneath the Finke River, while diffuse recharge is minor in the young groundwaters. Towards the end of the transect the influence of ephemeral recharge is less while diffuse recharge and the initial chloride concentration at recharge were higher.

Phase transitions study of the liquid crystal DIO with a ferroelectric nematic, a nematic, and an intermediate phase and of mixtures with the ferroelectric nematic compound RM734 by adiabatic scanning calorimetry

High-resolution calorimetry has played a significant role in providing detailed information on phase transitions in liquid crystals. In particular, adiabatic scanning calorimetry (ASC), capable of providing simultaneous information on the temperature dependence of the specific enthalpy h(T) and on the specific heat capacity c_{p}(T), has proven to be an important tool to determine the order of transitions and render high-resolution information on pretransitional thermal behavior. Here we report on ASC results on the compound 2,3',4',5'-tetrafluoro[1,1'-biphenyl]-4-yl 2,6-difluoro-4-(5-propyl-1,3-dioxan-2-yl) benzoate (DIO) and on mixtures with 4-[(4-nitrophenoxy)carbonyl]phenyl 2,4-dimethoxybenzoate (RM734). Both compounds exhibit a low-temperature ferroelectric nematic phase (N_{F}) and a high-temperature paraelectric nematic phase (N). However, in DIO these two phases are separated by an intermediate phase (N_{x}). From the detailed data of h(T) and c_{p}(T), we found that the intermediate phase was present in all the mixtures over the complete composition range, albeit with strongly decreasing temperature width for that phase with decreasing mole fraction of DIO (x_{DIO}). The x_{DIO} dependence on the transition temperatures for both transitions could be well described by a quadratic function. Both these transitions were weakly first order. The true latent heat of the N_{x}-N transition of DIO was as low as L=0.0075±0.0005J/g and L=0.23±0.03J/g for the N_{F}-N_{x} transition, which is about twice the previously reported value of 0.115 J/g for the N_{F}-N transition in RM734. In the mixtures both transition latent heats decrease gradually with decreasing x_{DIO}. At all the N_{x}-N transitions pretransition fluctuation effects are absent and these transitions are purely but very weakly first order. As in RM734 the transition from the N_{F} to the higher-temperature phase exhibits substantial pretransitional behavior, in particular, in the high-temperature phase. Power-law analysis of c_{p}(T) resulted in an effective critical exponent α=0.88±0.1 for DIO and this value decreased in the mixtures with decreasing x_{DIO} toward α=0.50±0.05 reported for RM734. Ideal mixture analysis of the phase diagram was consistent with ideal mixture behavior provided the total transition enthalpy change was used in the analysis.

Effects of Beta-Hydroxy-Beta-Methylbutyrate Supplementation on Older Adults with Sarcopenia: A Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVES

Sarcopenia is recognized as a major public health concern because of its association with several adverse health events. Beta-hydroxy-beta-methylbutyrate (HMB) supplementation reportedly delays the loss of muscle mass and function; however, the effect of HMB on sarcopenia remains inconclusive. We aimed to evaluate the impact of HMB intervention on muscle strength, physical performance, body compositions, and inflammatory factors in older adults with sarcopenia.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING AND PARTICIPANTS

This study included subjects aged ≥60 years with sarcopenia which were assigned to the HMB group (HMBG, n=18) and the placebo group (PG, n=16).

INTERVENTION

The HMBG and PG were supplied with HMB and placebo products twice daily for 12 weeks, and both received resistance exercise training twice a week in 12 weeks.

MEASUREMENTS

Hand grip strength was selected as the primary outcome; gait speed, five-time chair stand test, body composition and inflammatory indicators were selected as the secondary outcomes. The differences in changes from baseline between the two groups were analyzed using the analysis of covariance(ANCOVA).

RESULTS

After the 12-week intervention, the HMBG demonstrated significantly greater improvements in handgrip strength (4.61(95%CI:2.93,6.28) kg, P<0.001), gait speed (0.11(95%CI:0.02,0.20)m/s, P=0.014), five-time chair stand test (-3.65 (95%CI:-5.72, -1.58)s, P=0.001), muscle quality (2.47(95%CI:1.15,3.80),kg.kg-1 P=0.001) and tumor necrosis factor-like weak inducer of apoptosis (-15.23(95%CI:-29.80,-0.66)pmol/mL, P=0.041) compared with the PG; no significant differences in skeletal muscle mass, skeletal muscle index, and other body composition parameters were found between the two groups.

CONCLUSION

In older adults with sarcopenia, HMB significantly enhance the effect of resistance exercise training on muscle strength, physical performance, muscle quality, and reduced inflammatory factors. Therefore, HMB supplementation could be an effective treatment for sarcorpenia. The trial protocol was registered at http://www.chictr.org.cn/showproj.aspx?proj=47571 as ChiCTR2000028778.

[Impact of regional positive lymph node ratio of gallbladder carcinoma on prognosis]

Objective: To study the impact of regional positive lymph node ratio (LNR) on prognosis of patients with gallbladder carcinoma. Methods: The clinicopathological and survival data of 53 patients with gallbladder carcinoma who underwent radical resection with regional lymph node metastasis in Ningbo University Affiliated Lihuili Hospital from May 2012 to December 2020 were collected, and receiver operating characteristic curve (ROC) was used to determine the optimal cut-off value of LNR for predicting postoperative survival status in patients with gallbladder carcinoma. According to the critical value, the patients were divided into low LNR group and high LNR group. The clinicopathological features and prognosis of the two groups were compared. Log rank test was used for univariate analysis of prognostic factors in patients with gallbladder carcinoma, and Cox proportional hazards model was used for multivariate analysis. Results: A total of 417 regional lymph nodes were dissected in 53 patients, of which 144 lymph nodes were positive, with a positive rate of 34.5%. The optimal cut-off value of LNR for predicting postoperative survival status of patients with gallbladder carcinoma was 0.33. According to this cut-off value, patients were divided into low LNR group (LNR≤0.33, 28 cases) and high LNR group (LNR>0.33, 25 cases). The recurrence rates were 64.3% (18/28) and 88.0 % (22/25) in low LNR group and high LNR group, respectively. The median recurrence-free survival (RFS) was 8 and 7 months, respectively (P=0.032). In the low LNR group, the 1-, 3-, and 5-year survival rates were 56.2%, 38.4%, and 32.0%, respectively, and the median overall survival (OS) was 16 months. In the high LNR group, the 1-, 3-, and 5-year survival rates were 37.9%, 5.4%, and 0, respectively, and the median OS was 9 months. The postoperative survival rate of patients in the low LNR group was better than that in the high LNR group (P=0.008). Univariate analysis showed that LNR was even associated with RFS and OS in patients with gallbladder carcinoma (P<0.05). Multivariate analysis showed that LNR>0.33 was an independent risk factor for postoperative RFS (HR=1.977, 95% CI: 1.045-3.740), but not for OS (HR=1.561, 95% CI: 0.685-3.553). Conclusion: On the basis of clearing a sufficient number of regional lymph nodes, patients with gallbladder carcinoma with regional LNR>0.33 are more likely to relapse after operation, but the predictive value of LNR>0.33 OS is insufficient.

[Efficacy of in-situ full-left/full-right split liver transplantation for adult recipients using the living donor liver transplantation technique:a single-center report of 25 cases]

Objective: To evaluate the efficacy of in-situ full size split liver transplantation(fSLT) for adult recipients using the living donor liver transplantation(LDLT) technique and to compare the characteristics of the left hemiliver graft (LHG) and the right hemiliver graft(RHG)transplantation. Methods: Deceased donor and recipient data of 25 consecutive cases of fSLT at Department of Hepatopancreatobiliary Surgery, Ningbo Medical Center Lihuili Hospital from March to December 2021 was retrieved and the patients divided into two groups:LHG group and RHG group. Among the 13 donors,11 were male and 2 were female,aged (M(IQR))38(19) years(range: 25 to 56 years),with height of 168(5) cm(range:160 to 175 cm) and weight of 65(9) kg(range: 50 to 75 kg). The median age of the 25 recipients was 52(14) years(range:35 to 71 years),17 were male and 8 were female,15 had primary liver cancer and 10 had benign end-stage liver disease,model for end-stage liver disease score was 10(9) points(range:7 to 23 points). Of the 25 recipients,10 recipients had previously undergone hepatobiliary surgery. The follow-up period was to January 2022. Demographic,clinicopathological,surgical outcomes and postoperative complications were evaluated and compared between the two groups. Continuous quantitative data were compared using Mann-Whitney U test. Classification data were expressed as frequencies,and were compared between groups using χ² test or Fisher exact probability method. Results: Using LDLT technique,in-situ full-left/full-right liver splitting was performed and 13 viable pairs of hemiliver grafts were harvested with acquisition time of 230(53) minutes(range:125 to 352 minutes) and blood loss of 250(100) ml(range:150 to 1 000 ml). A total of 25 hemiliver grafts(13 LHG and 12 RHG) were allocated to patients listed for liver transplantation in our center by China Organ Transplant Response System. In the LHG group(13 cases),there were more females and more patients with benign end-stage liver disease than in the RHG group(12 cases)(P<0.05). The body weight and graft weight of recipients in the LHG group were lower than that in RHG group(both P<0.05). There were no significant differences in other baseline data between the two groups(all P>0.05). The graft to recipient weight ratio(GRWR) was 1.2(0.4)%(range:0.7% to 1.9%) for 25 recipients,1.1(0.5)%(range:0.7% to 1.6%)for the LHG group and 1.3(0.5)%(range:0.9% to 1.9%)for the RHG group. There was no significant difference between the two groups (P>0.05). Sharing patterns of hepatic vessels and the common bile duct are as follows:all the trunk of middle hepatic vein were allocated to the LHG group. The proportion of celiac trunk,main portal vein and common bile duct assigned to LHG and RHG was 10∶3 (P=0.009), 9∶4 (P>0.05) and 4∶9 (P=0.027),respectively. The vena cava of 12 donors in early stage retained in LHG and that of last one was shared between LHG and RHG (P<0.01). The median cold ischemia time of 25 hemiliver grafts was 240(90) minutes(range:138 to 420 minutes). For the total of 25 fSLT,the median anhepatic phase was 50(16) minutes(range:31 to 98 minutes) and the operation time was 474(138)minutes(range:294 to 680 minutes) with blood loss of 800(640) ml(range:200 to 5 000 ml). There were no significant differences in all of operation data between two groups. In the LHG group,3 patients with GRWR≤0.8% had postoperative small-for-size syndrome which improved after treatment. Postoperative Clavien-Dindo grade≥Ⅲ complications were observed in 6 cases(24.0%),4 cases(4/13) in the LHG group and 2 cases(2/12) in the RHG group,respectively. The difference was not statistically significant. Among them,5 cases improved after re-operation and intervention,1 case in LHG group died of secondary infection 2 weeks after operation,and the mortality was 4.0%. Analysis of serious postoperative complications and death has suggested that conventional caval interposition should not be used for LHG transplantation. Conclusion: Relying on accurate donor-recipient evaluation and the apply of LDLT technique,the morbidity and mortality of in-situ fSLT in adults is acceptable.

[Comparison of a new thermosensitive rhAm carrier versus traditional PGA carrier for in vitro antibacterial activity and biocompatibility]

OBJECTIVE

To compare a new thermosensitive recombinant human amelogenin (rhAm) carrier and traditional propylene glycol alginate (PGA) carrier for their characteristics, antibacterial activity, and biocompatibility with human periodontal membrane fibroblasts.

METHODS

PGA-rhAm was prepared by mixing 3.3% PGA and rhAm, and CS-βGP-rhAm was prepared by mixing 2% chitosan (CS) with rhAm and then with 60% β-sodium glycerophosphate solution (βGP) as the crosslinking agent. The biophysical properties of the prepared carriers were characterized, and their antibacterial activity was assessed by observing Staphylococcus aureus growth. The biocompatibility of the carriers was evaluated in human periodontal membrane fibroblasts (hPDLFs) using CCK8 assay and scratch test, and mRNA and protein expressions of osteogenic genes of the cells incubated with the carriers were detected using RT-qPCR and Western blotting; osteogenic differentiation of the cells was detected using alkaline phosphatase staining.

RESULTS

PGA-rhAm had a viscosity value of 3.262±0.055 Pa.s. CS-βGP-rhAm had a solidification capacity of 6 min at 37 ℃ with a pH value close to that of the oral cavity and a swelling rate of about 90%. CS-β GP-rhAm maintained sustained release of rhAm for over 2 weeks with a self-degradation time over 3 weeks. CS-βGPrhAm more effectively inhibited the growth of S. aureus than rhAm-loaded PGA. While PGA did not obviously affect the proliferation of hPDLFs, both CS-βGP and CS-βGP-rhAm significantly promoted the cell proliferation(P < 0.001). Scratch test showed that after rhAm loading, both CS-βGP and PGA promoted cell migration (P < 0.01). CS-βGP-rhAm significantly enhanced the mRNA expressions of RUNX2 and OCN mRNA level and the protein expressions of Ki67, RUNX2, collagen I, and β-catenin (P < 0.05); PGA-rhAm only enhanced RUNX2 (P < 0.05) and OCN (P < 0.01) mRNA expressions without significant effects on the protein expressions. Alkaline phosphatase staining results showed that CS-βGP, but not PGA, promoted osteogenic differentiation of hPDLFs.

CONCLUSION

CS-βGP carrier is capable of sustained release of rhAm, inhibiting the growth of S. aureus, and improving the biological activity of hPDLFs without affecting the bioactivity of rhAm after drug loading.

HIF-2α Inhibits Ameloblast Differentiation via Hey2 in Tooth Development

Enamel is the highly mineralized outer layer of teeth; the cells responsible for enamel formation are ameloblasts. Local hypoxia and hypoxia inducible factor (HIF) in embryonic tissues are important to promote normal organogenesis. However, hypoxic state in tooth germs and the roles of HIF in ameloblast differentiation have not been understood. The aim of this study is to clarify the role of HIF in ameloblast differentiation during tooth germ development. We found that tooth germs were under hypoxia and HIF-1α and HIF-2α were expressed in tooth germs in embryonic mice. Then, we used HIF inhibitors to evaluate the function of HIF during tooth germ development. The HIF-2α inhibitor significantly decreased the size of tooth germs in organ culture, while the HIF-1α inhibitor did not apparently affect the size of tooth germs. The HIF-2α inhibitor enhanced the expression of amelogenin, a marker of ameloblast differentiation, in the tooth germs in organ culture and rat dental epithelial SF2 cells. Moreover, we found that the HIF-2α inhibitor-stimulating amelogenin expression was regulated by hes-related family basic helix-loop-helix transcription factor with YRPW motif 2(Hey2) in SF2 cells. These findings suggest that the HIF-2α-Hey2 axis plays an important role in ameloblast differentiation during tooth germ development.

Predictors of early polymetastatic relapse following stereotactic ablative radiotherapy for up to 5 oligometastases: a secondary analysis of the phase II SABR-5 trial

PURPOSE

A subset of patients with oligometastatic cancer experience early widespread cancer dissemination and do not benefit from metastasis-directed therapy such as stereotactic ablative radiotherapy (SABR). This study aimed to identify factors associated with early polymetastatic relapse (PMR).

METHODS AND MATERIALS

The XXX trial was a single arm phase II study conducted at all 6 regional cancer centres across XXX. SABR for oligometastases was only offered on trial. Patients with up to 5 oligometastatic lesions (total, progressing or induced) received SABR to all lesions. Patients were 18 years of age or older, ECOG 0-2 and life expectancy ≥ 6 months. This secondary analysis evaluated factors associated with early PMR, defined as disease recurrence within 6 months of SABR which is not amenable to further local treatment. Univariable and multivariable analyses were performed using binary logistic regression. The Kaplan Meier method and log-rank tests assessed PMR-free survival and differences between risk groups, respectively.

RESULTS

Between November 2016 and July 2020, 381 patients underwent treatment on XXX. A total of 16% of patients experienced PMR. Worse performance status (ECOG 1-2 vs 0; HR=2.01, p=0.018), non-prostate/breast histology (HR=3.64, p<0.001) and oligoprogression (HR=3.84, p<0.001) were independent predictors for early PMR. Risk groups were identified with median PMR-free survival ranging from 5 months to not yet reached at the time of analysis. Rates of 3-year OS were 0%, 53% (95% confidence interval [CI] 48 - 58), 77% (95% CI 73 - 81) and 93% (95% CI 90 - 96) in groups 1-4, respectively (p<0.001).

CONCLUSION

Four distinct risk groups for early PMR are identified, which differ significantly in PMR-free survival and overall survival. The group with all three risk factors had a median PMR-free survival of 5 months and may not benefit from local ablative therapy alone. This model should be externally validated with data from other prospective trials.

Progression-free survival and local control following stereotactic ablative radiotherapy for up to 5 oligometastases: an analysis from the population-based phase II SABR-5 trial

PURPOSE

Despite increasing utilization of stereotactic ablative therapy (SABR) for oligometastatic cancer, prospective outcomes are lacking. The purpose of this study was to determine progression-free survival (PFS), local control (LC) and prognostic factors from the population-based phase II XXX trial.

METHODS AND MATERIALS

The XXX trial was a single arm phase II study with the primary endpoint of toxicity, conducted at the 6 regional cancer centres across XXX, during which time SABR for oligometastases was only offered on trial. Patients with up to 5 oligometastases (total or not controlled by prior treatment, and including induced oligometastatic disease) underwent SABR to all lesions. Patients were 18 years of age or older, ECOG 0-2 and had life expectancy ≥ 6 months. The secondary outcomes of PFS and LC are presented here.

RESULTS

Between November 2016 and July 2020, 381 patients underwent SABR on trial. Median follow-up was 27 months (IQR 18-36). Median PFS was 15 months (95% CI 12-18). LC at 1 and 3 years were 93% (95% CI 91 - 95) and 87% (95% CI 84 - 90), respectively. On multivariable analysis, increasing tumor diameter (HR=1.09, p<0.001), declining performance status (HR=2.13, p<0.001), disease-free interval < 18 months (HR=1.52, p=0.003), four or more metastases at SABR (HR=1.48, p=0.048), initiation or change in systemic treatment (HR=0.50, p<0.001) and oligoprogression (HR=1.56, p=0.008) were significant independent predictors of PFS. Tumor diameter (SHR=1.28, p<0.001), colorectal histology (SHR=4.33, p=0.002) and "other" histology (SHR=3.90, p<0.001) were associated with worse local control.

CONCLUSIONS

In this population-based cohort including patients with genuine oligometastatic, oligoprogressive, and induced oligometastatic disease, the median PFS was 15 months and LC at 3 years was 87%. This supports ongoing efforts to randomize patients on phase III trials, even outside the original 1-5 metachronous oligometastatic paradigm.