[Current status and prospects of neoadjuvant therapy for resectable pancreatic cancer]

Pancreatic cancer is a highly malignant tumor. About 75% of patients with pancreatic cancer who underwent radical surgical resection will still experience postoperative recurrence. Neoadjuvant therapy could improve outcomes in patients with borderline resectable pancreatic cancer,has become a consensus;however it is still controversial in resectable pancreatic cancer. Limited high-quality randomized controlled trial studies support the routine initiation of neoadjuvant therapy in resectable pancreatic cancer. With the development of new technologies, such as next-generation sequencing, liquid biopsy, imaging omics, and organoids, patients are expected to benefit from the precision screening of potential candidates for neoadjuvant therapy and individualized treatment strategy.

[Current surgical concepts and future perspectives in the treatment of pancreatic cancer]

Over the past 20 years, the concept of pancreatic surgery has been updated and surgical skills has improved dramatically. With the significant improvement of surgical safety and increase of resection rate for pancreatic cancer, some traditional surgical issues such as surgical indications, timing and extent of resection are being re-evaluated. The improvement of patients' prognosis is the gold standard for judging the surgical indications. The traditional criteria of "unresectable" based on morphology will be constantly broken through, and the estimation of resectability will transition from "what can we resect" to "what should we resect". Except for clinical research, standard extent of lymph node dissection is recommended. However, for borderline resectable and locally advanced pancreatic cancer after neoadjuvant treatment, extended lymph node dissection is recommended. All kinds of surgical approaches are feasible. The approach is subject to the needs of anatomy, anatomy is subject to the needs of radical treatment, and radical treatment is subject to the needs of improving prognosis. For some patients with locally advanced pancreatic cancer, sub-adventitial divestment of superior mesenteric artery and "Heidelberg triangle" cleaning are helpful to improve the resection rate and reduce the local recurrence rate,however, the impact on the long-term prognosis still needs to be further observed clinically. The quality of pancreaticojejunostomy has more influence on the incidence of pancreatic fistula than the type of pancreaticojejunostomy. For the centers with high volume patients and the surgeons with rich personal experience, laparoscopic or robot assisted surgery has the advantages of minimally invasive, but for pancreatic head carcinoma, it is not enough evidence to prove the oncological advantages of laparoscopic pancreaticoduodenectomy and robotic-assistant pancreaticoduodenectomy.

[How to standardize the enhanced recovery after surgery in clinical practice?]

The enhanced recovery after surgery (ERAS) protocol is an evidence-based perioperative care pathway, which is to reduce the perioperative stress and metabolic variation, with the ultimate goal of improving patient recovery and outcomes. This article reviews some hot issues in the clinical practice of ERAS in China. Currently, the concept and pathways of ERAS are very consistent with China's medical reform, and the basic principle of "safety first, efficiency second" should be adhered to. In specific clinical practice, multidisciplinary cooperation, the improvement of surgical quality and the implementation of prehabilitation pathway should be advocated. In addition, the ERAS approaches should be implemented individually to avoid mechanical understanding and dogmatic implementation. The implementation of ERAS and its clinical outcome should be audited to accumulate experience, and a feedback mechanism should be established to improve the outcome continuously. In clinical practice, "fast recovery" should not be the sole purpose. For patients, the decrease in the risk of readmission rate is more important as compared to discharge rate. Additionally, the disparities between the development of ERAS clinical research in China and that in the world are also analyzed in this review. A national ERAS database should be established on the basic platform of academic groups to ensure the development of high-quality clinical research in China.

[The criteria of resectability for pancreatic ductal adenocarcinoma:tumor anatomy or tumor biology?]

Anatomical resectability criteria based on radiologic findings for pancreatic ductal adenocarcinoma has been the main or even the only criterion in practice for a long time. The anatomical criteria has played a very positive role in standardizing surgical indication and restricting medical behavior. However,in the current era of systematic treatment,the limitations of anatomical criteria are becoming increasingly prominent. Although the biological criteria which can be used to evaluate the resectability of pancreatic cancer is still very limited,the comprehensive benefit of CA19-9,PET-CT,neoadjuvant therapy,gene detection and so on can still provide a reference for the evaluation of the resectability of pancreatic cancer. At present,the evaluation of resectability of pancreatic cancer should still adhere to the basic principle of taking anatomical criteria as the basis,biological criteria as the guide,and improving the prognosis of patients as the goal.

[The predictive value of the CHA2DS2-VASc score for in-hospital outcomes in patients with acute myocardial infarction: China PEACE-retrospective acute myocardial infarction study]

Objectives: This study aimed to evaluate the predictive value of the CHA₂DS₂-VASc score for in-hospital outcomes of patients with acute myocardial infarction (AMI). Methods: Data of 23 728 patients from the China patient-centered Evaluative Assessment of cardiac Events (China PEACE)Retrospective Acute Myocardial Infarction Study were analyzed retrospectively. The patients were categorized into 3 groups according to the CHA₂DS₂-VASc scores: the low score group (score 1-3), the middle score group (score 4-6) and the high score group (score 7-9). The in-hospital outcomes included major adverse cardiovascular events (MACE), death, death or withdrawal from treatment, reinfarction, ischemic stroke,etc. The CHA₂DS₂-VASc score was incorporated into multivariate Cox regression analyses to determine its independent impact on in-hospital outcomes. Receiver operating Characteristic (ROC) curves were constructed, and the area under the curve (AUC) was used to evaluate the predictive value of the CHA₂DS₂-VASc score for in-hospital mortality and death or withdrawal from treatment, respectively. Results: The patients had a median age of 66 (56,75) years, and 30.7% of them were females. Patients with higher CHA₂DS₂-VASc scores had a higher in-hospital mortality and more in-hospital complications (all P<0.001). After adjustment of baseline covariates, the subjects in the high score group were associated with high risks of in-hospital mortality (OR=6.13, 95%CI 4.77-7.87, P<0.001), death or treatment withdrawal (OR=6.43, 95%CI 5.16-8.00, P<0.001) and MACE (OR=4.94, 95%CI 4.06-6.01, P<0.001). The AUCs of the CHA₂DS₂-VASc score were comparable with those of the mini-global registry of acute coronary events(mini-GRACE)score in evaluation of in-hospital mortality (0.699 vs. 0.696, P=0.752) and the death or treatment withdrawal risk (0.708 vs. 0.713, P=0.489). Conclusions: The CHA₂DS₂-VASc score is an independent predictor of in-hospital outcomes for patients with AMI. Its predictive value was comparable with the mini-GRACE score, which could be used as a simple tool for early and rapid outcome evaluation for AMI patients.

5-hydroxymethylcytosine profiles in circulating cell-free DNA as candidate diagnostic and predictive biomarkers for coronary artery disease

Background

DNA 5-hydroxymethylcytosine (5hmC) modification is an epigenetic marker involved in a range of biological processes. However, little information is available about its role in coronary artery disease (CAD), particularly in the acute phase of acute coronary syndrome (ACS).

Aims

To investigate whether 5hmC modification correlates with the pathogenesis and progression of CAD and whether 5hmC in cfDNA can be used as biomarkers.

Methods

We utilized 5hmC-Seal to generate genome-wide 5hmC profiles in plasma cell-free DNA (cfDNA) of normal coronary artery (NCA, n=200) controls and CAD patients, including stable coronary artery disease (sCAD, n=200) patients and ACS patients (n=371). To investigate the correlation between 5hmC modifications and CAD subtypes, we separated samples into training and validation cohorts and developed a 5hmC-based logistic regression model from the training cohort to predict the progression of CAD in the validation cohort.

Results

We detected a significant difference of 5hmC enrichment in gene bodies from CAD patients compared with NCA individuals. Particularly, our results showed that patients of CAD subgroups can be well separated from NCA individuals by 5hmC markers. The prediction performance of the model established by differentially regulated 5hmC modified genes achieved an AUC of 0.81 (sCAD vs. NCA) and 0.74 (ACS vs. NCA) in validation cohorts.

Conclusions

Our results demonstrated that patients of CAD subtypes and NCA individuals had distinct differences in 5hmC enrichment. 5hmC markers derived from plasma cfDNA may potentially serve as a clinical-applicable, minimally invasive, and liquid biopsy-based approach to diagnose CAD, particularly used to predict the occurrence of fetal ACS.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Chinese Academy of Medical Science (CAMS) Innovation Fund for Medical Sciences Figure 1Figure 2

[The comparison of prognosis and risk factors after radical resection for pancreatic ductal adenocarcinoma between China Pancreas Data Center and SEER]

Objectives: To compare the prognosis of patients underwent radical resection for pancreatic ductal adenocarcinoma(PDAC) in Surveillance, Epidemiology, and End Results(SEER) and China Pancreas Data Center(CPDC), and to compare the prognostic factors for PDAC in both databases. Methods: The data of patients underwent radical resection for PDAC in CPDC database from January 2016 to December 2017 and SEER database from January 2014 to December 2015 were retrospectively analyzed. The prognosis of patients in both databases was analyzed by the Kaplan-Meier method, Log-rank method, and propensity score matching, and the Cox proportional hazard regression was used to analyze the independent prognosis factors for PDAC. Results: There were 1 977 cases and 2 220 cases of pancreatic cancer that underwent radical resection from CPDC and SEER, respectively. There were more male patients(60.90%,1 204/1 977) than female patients(39.10%,773/1 977) in CPDC, while nearly 1∶1 ratio(male:1 112 cases,female:1108)was observed between male and female in SEER(χ²=48.977,P<0.01). The proportion of patients under 45 years old was the smallest in both databases, and the age group with the most significant proportion was 60 to 74 years old. The ratio of patients over 75 years old in the SEER(24.28%,539/2 220) was higher than that of CPDC(7.89%,156/1 977)(χ²=202.090,P<0.01), while the proportion of patients between 45 and 59 years old in CPDC(33.69%,666/1 977) was higher than that in SEER(19.77%,439/2 220)(χ²=103.640,P<0.01). There were more pancreatic head cancers than body and tail cancers in both databases, and no statistical difference was found in tumor size between the two databases (W=2 181 502,P=0.740). More positive and examined lymph nodes were found in SEER patients (W=3 265 131,W=2 954 363,all P<0.01); and the proportion of patients who had at least 15 lymph nodes dissected was higher in SEER(63.24%,1 404/2 220)(χ²=532.130,P<0.01). There were more patients without neoadjuvant or adjuvant therapy in CPDC(57.16%,1 130/1 977) than that in SEER(24.91%,553/2 220)(χ²=451.390,P<0.01). After propensity score matching, the overall survival for CPDC was better than that for SEER(Log-rank test:χ²=4.500,P=0.034), and the median overall survival was 24 months and 23 months respectively. Cox regressional analysis showed the common independent prognosis factors in both databases were ≥75 years old, pancreatic head cancer, poorly differentiated and undifferentiated tumors, T stage, N stage(All P<0.05). Neoadjuvant or adjuvant therapy was a protective factor in both databases(CPDC:Wald=27.082;SEER:Wald=212.285, all P<0.01) and 45 to 59 years old was protective factor in the SEER database(Wald=5.212,P=0.020). Conclusions: The data in both databases have a good consistency. However, in terms of data quality, examined lymph nodes count, and neoadjuvant/adjuvant therapy rate, the CPDC differs greatly from the SEER.

[Prevalence of human soil-borne nematode infections in Yunnan Province: a cross-sectional study in 2015]

OBJECTIVE

To investigate the current prevalence of human soil-borne nematode infections in Yunnan province, so as to provide the scientific evidence for formulating the soil-borne nematodiasis control strategy in the province.

METHODS

In 2015, a total of 20 survey sites were sampled in 10 counties (cities) of Yunnan Province using the stratified cluster random sampling method. Stool samples were collected from all local permanent residents at ages of one year and older in each survey site, and the soil-borne nematode eggs were identified using the modified Kato-Katz technique and the egg number was counted. In addition, the hookworm species was identified using the filter-paperculture method, and Enterobius vermicularis eggs were detected using the cellophane tape method in children at ages of 3 to 6 years.

RESULTS

A total of 5 067 residents received stool examinations, and 950 residents were detected with soil-borne nematode infections, with an overall prevalence rate of 18.75%. The prevalence of Ascaris lumbricoides, Trichuris trichura and hookworm was 7.52%, 8.47% and 9.02%, respectively. Among 446 children detected using the cellophane tape method, 5 children were detected with E. vermicularis infections. Among the 160 residents with hookworm infections, there were 139 residents with Necator americanus infections (86.88%), 16 with A. duodenale infections (10.00%) and 5 with mixed infections (3.12%). Mild A. lumbricoides (67.98%, 259/381), T. trichura (88.58%, 380/429) and hookworm infections (94.53%, 432/457) were predominant. Among the four ecological zones, the highest prevalence of human soilborne nematode infections was found in the East Tibet-South Sichuan Ecological Zone (31.79%), and among the 10 survey counties (cities), the greatest prevalence was seen in Gongshan Derung and Nu Autonomous County (50.13%), while the lowest prevalence was found in Ninglang Yi Autonomous County (0.40%). The prevalence of human soil-borne nematode infections was 5.67% (43/759), 26.67% (610/2 287) and 14.70% (297/2 021) in high-, moderate- and low-economic-level regions, respectively. There were no significant differences in the prevalence of human soil-borne nematode infections in terms of ecological regions, survey counties (cities) or economic development levels (χ² = 342.20, 814.60 and 201.34, all P < 0.05). There was no significantdifference in the prevalence of human soil-borne nematode infections between male (18.21%, 441/2 422) and female residents (19.24%, 509/2 645) (χ² = 0.89, P > 0.05), and soil-borne nematode infections were detected in residents at all age groups, with the greatest prevalence found in residents at ages of 1 to 9 years (25.88%). In addition, the highest prevalence of soil-borne nematode infections was seen in residents with the Dulong Ethnic Minority (82.09%), in preschool children (25.06%) and in illiterate residents (24.80%), and there was no age-, ethnicity-, occupation- or education level-specific prevalence of soil-borne nematode infections detected (χ² = 46.50, 1 016.96, 36.33 and 52.43, all P < 0.05).

CONCLUSIONS

The prevalence of human soil-borne nematode infections remains high in Yunnan Province. The management of soil-borne nematodiasis requires to be reinforced among low-age children, farmers, old people and residents with low educations levels or ethnic groups.

O18 Activated leukocyte cell adhesion molecule (ALCAM) and its intracellular linkers in assessing the outcome of patients with breast cancer

Introduction

ALCAM (also known as CD166) is a membrane integral protein and said to have a role in predicting the clinical outcome of patients with breast cancer, but the pattern of the prediction value is inconsistent. ALCAM confers cell-cell adhesion via heterotypic and homotypic interactions and linked to cytoskeleton via the ERM protein family (Ezrin, Moesin, Radixin and EHM2), particularly ezrin. The present study explored if the ALCAM and its ERM linkers may assist in refining the prognostic value of ALCAM.

Method

Gene transcripts of ACLAM and the ERM family members were quantitatively analysed in an existing breast cancer cohort collected freshly after surgery. The relationship between ALCAM and patient’s survival (follow-up 10 years) were stratified by the ALCAM linkers. Statistical methods were Kaplan-Meier’s survival method, ROC and logistic regression.

Result

ALCAM significantly correlated with four ERM family members (P &lt; 0.005). Patients with high levels of ALCAM transcripts had significantly long overall survival. Further stratification by the epithelial rich Ezrin and endothelial rich Moesin identified subgroup of patients with good prognosis. Multivariant analysis indicates that the combined power of ALCAM and ERM family serves as an independent prognostic factor (P = 0.003) together with the other two factors, namely the Nottingham Prognostic Index and Nodal status (P = 0.02). A similar prediction power for disease free survival was seen with ALCAM and ERM combination.

Conclusion

ALCAM and its intracellular cytoskeletal linker molecules, the ERM family, together forms a significant prognostic factor to the clinical outcome of patients with breast cancer.

Take-home Message

ALCAM stratified by the ERM family have prognostic value in breast cancer

[Implementation and controversies of enhanced recovery after surgery in pancreaticoduodenectomy]

The concept of enhanced recovery after surgery(ERAS) has been widely accepted and applied in clinical practice.However,as one of the most complex surgical procedures in abdominal surgery,pancreaticoduodenectomy is characterized by long operation time,high incidence rate of postoperative complications and delayed recovery,there still remain some controversies about application of ERAS approaches in perioperative managements of pancreaticoduodenectomy.Although more and more studies has revealed the safety and efficacy of ERAS approaches in pancreaticoduodenectomy,the implementation of ERAS approaches should be still individualized in clinical practice to ensure safety of the patients.

Toroidal soft x-ray array on the EXL-50 spherical tokamak

A toroidal soft x-ray array system for spectrum and intensity measurements on the EXL-50 spherical tokamak is described. Silicon drift detectors and digital multichannel analyzers are adopted for all 21 channels of the array, and an average energy resolution of 147 eV at 5.89 keV has been achieved at count rates over 500 kcps. In total, 20 channels of the array are symmetrically observed in both co- and counter-current directions on the EXL-50 mid-plane with a spatial resolution of around 10 cm, and the remaining one serves as a background reference channel. Tungsten emissions from tungsten coating of the limiters on the central post are observed. The influence of hard x rays on measured soft x-ray spectra and system operation is discussed.

[Clinical analysis of 11 cases of sub-acute arsenic poisoning]

Objective: To investigate the clinical manifestations, treatments and prognosis of subacute arsenic poisoning. Methods: In January 2020, a retrospective analysis was carried out on 11 patients hospitalized with subacute arsenic poisoning caused by arsenic contaminated drinking water. We observed manifestations, treatments and prognosis. Results: The main clinical presentations of subacute arsenic poisoningin were gastroenteritis in early phase, some of them had other organ damage, such as skin, blood, liver, kidney, cardiovascular and so on. The later phase was mainly peripheral nervous system damage. The treatment was mainly to chelate arsenic, protect target organs and treat toxic peripheral neuropathy. Most were significantly recoveried, but the recovery of severe toxic peripheral neuropathy was tardy. Conclusion: Acute gastroenteritis is the mainly early manifestation of subacute arsenic poisoning caused by digestive tract, and toxic peripheral neuropathy in the later phase. The prognosis is good, but the recovery of severe toxic peripheral neuropathy is tardy.

[Manual suture or stapler closure: management of pancreatic stump during distal pancreatectomy]

Postoperative pancreatic fistula is the most common complication after distal pancreatectomy.With the update of the domestic and international guidelines or consensuses, the definition of pancreatic fistula has become more standardized.And the classification of pancreatic fistula is able to represent the severity of clinical outcomes more accurately.Currently, the determination of risk factors of pancreatic fistula after distal pancreatectomy, the establishment of prediction model, and the surgical closure mode of pancreatic stump still remain the major topics.With the rapid development of laparoscopic and robotic surgery in pancreatectomy, there are more and more selectionsin transection and managing the pancreatic stump after distal pancreatectomy for prevention of pancreatic fistula.However, there has not been a uniform fashion in terms of manual suture or stapler use to close the pancreatic stump.Herein the current status and development of pancreatic fistula after distal pancreatectomy are reviewed.The strategy of managing the pancreatic stump after distal pancreatectomy should be adopted individually according to the texture and thickness of pancreatic parenchyma.

[Associations between postprocedural D-dimer, hs-CRP, LDL-C levels and prognosis of acute myocardial infarction patients treated by percutaneous coronary intervention]

Objective: To investigate the association between postprocedural D-dimer, high sensitivity C-reactive protein(hs-CRP) and low-density lipoprotein-cholesterol(LDL-C) and outcomes of acute myocardial infarction (AMI) patients treated by percutaneous coronary intervention(PCI), in order to clarify the impacts of thrombotic, inflammatory and cholesterol risks on long-term prognosis. Methods: Patients with AMI who underwent emergency PCI from January 2010 to June 2017 in Fuwai Hospital with complete baseline data were enrolled. Patients were stratified into four groups according to quartiles of D-dimer, hs-CRP and LCL-C. Cox regression was used to analyze the relationship between these biomarkers and prognosis. Restricted cubic spline (RCS) was used to characterize the continuous association between risk of all-cause death and biomarkers. The primary outcome was all-cause death. Results: A total of 3 614 patients were included in the analysis. The age was (59.2±12.0) years old, and 2 845 (78.7%) were male and 3 161 (87.5%) patients were diagnosed as ST-segment elevation myocardial infarction. The follow-up time was 652 (414, 1 880) days. Survival analysis showed that postprocedural D-dimer and hs-CRP were significantly associated with all-cause mortality (all P<0.05). Cox regression with multiple adjustments showed that patients with D-dimer≥580 μg/L presented higher risk of all-cause death (HR=2.03, 95%CI 1.22-3.38, P=0.006), compared to patients with D-dimer<220 μg/L. RCS analysis showed that risk of all-cause death was stably high when D-dimer reached 500 μg/L. Multivariable Cox regression also showed that patients with hs-CRP<2.74 mg/L (HR=1.86, 95%CI 1.10-3.15, P=0.020)or hs-CRP≥11.99 mg/L (HR=2.14, 95%CI 1.35-3.40, P=0.001) presented higher mortality compared to patients whose hs-CRP was 2.74-7.18 mg/L. RCS analysis indicated a J-shaped relation between hs-CRP and mortality, as greater risk of death was observed when hs-CRP was lower than 2 mg/L or higher than 10 mg/L. LDL-C was not associated with outcomes (all P>0.05). Conclusions: Postprocedural D-dimer is significantly associated with long-term prognosis of AMI patients treated by PCI. Patients with extremely high or low levels of hs-CRP presents worse outcomes. Intensive and tailored antithrombotic or anti-inflammatory therapies should be considered for patients with increased thrombotic risk and those with extremely high or low inflammatory risk.

[Current research status and progress in comprehensive diagnosis and treatment of pancreatic cancer in the era of targeted therapy]

The incidence of pancreatic cancer (PC) has continuously shown an upward trend all over the world. It remains one of the most challenging malignant tumors in clinical practice and is characterized by difficult diagnosis in early stages, low surgical resection rate and poor prognosis. Due to its significant genetic heterogeneity, there are notable individual differences in disease progression, clinical efficacy, sensitivity to chemoradiotherapy, and prognosis among PC patients. In-depth study is needed to reveal the molecular biological characteristics of different PC subtypes and their correlation with clinical manifestations and chemoradiotherapy sensitivity, which could contribute to develop corresponding targeted therapeutic strategies.It is not only the fundamental basis for the innovation of PC morphological classification to molecular subtyping, but also a prerequisite for achieving a shift in treatment mode from "standard therapeutic strategy for different diseases" to "treat the same disease with different strategies" .This article reviews several hot issues on the comprehensive diagnosis and treatment of PC in the era of targeted therapy and prospects its future development.

[The effect of standardized lymphectomy and sampling of resected lymph nodes on TNM staging of resectable pancreatic head cancer]

Objective: To examine the effect of standardized lymphectomy and sampling of resected lymph nodes (LN) on TNM staging of resectable pancreatic head cancer. Methods: Consecutive patients with resectable pancreatic head cancer who received standard pancreatoduodenctomy at Department of General Surgery in Beijing Hospital from December 2017 to November 2018 were recruited as study group. After operation, the surgeon sampled lymph nodes from the fresh specimen following the Japanese Gastric Cancer Guidelines.Thirty-three cases were recruited in the study group and the mean age was (59.8±15.2) years.Pathologic reports from December 2015 to November 2016 were taken as control group, containing 29 cases with age of (57.0±13.0) years. Number of lymph nodes, standard-reaching ratio and positive nodes ratio were compared between two groups. According to the seventh edition and eighth edition of TNM staging, the changes of N staging and TNM staging were analysed. The quantitative data conforming to normal distribution were tested by independent sample t test, the quantitative data not conforming to normal distribution were tested by rank sum test, and the enumeration data were analysed by χ(2) test. Results: The basal data of the two groups were comparable (all P>0.05) . The number of lymph nodes sampled in the study group was 23.27±8.87, significantly more than in control group (12.86±5.90, t=0.653, P=0.000) .Ratio of cases with more than 15 nodes was 81.8% (27/33) in the study group and 34.5% (10/29) in the control group with statistical significance (χ(2)=14.373, P=0.000) . In the study group, the positive lymph node ratios of No. 17a+17b, 14a+14b, 8a+8p LN were 36.4% (12/33) , 30.3% (10/33) and 9.1% (3/33) respectively. The positive lymph node ratio in No.14a+14b LN was higher than in No.8 LN (χ(2)=4.694, P=0.030) . According to the change in N staging system in the AJCC eighth edition, 2 cases (6.1%, 2/33) changed from ⅠB to ⅡA, 7 cases (21.2%, 7/33) from ⅡA to ⅠB and 5 cases (15.2%, 5/33) changed from ⅡB to Ⅲ (25.0%, 5/20) . Conclusions: No.14 LN should be treated as the first station rather than second station because of the anatomic character and higher metastatic ratio. Standardised lymphectomy and sampling may increase the number of LN resected and improve the TNM staging of resectable pancreatic head cancer.

[Circulating tumor cells in pancreatic cancer patients: progression in the detection methods and clinical application]

Circulating tumor cells (CTC) disseminate from primary tumors by undergoing epithelial mesenchymal transition that allow their entry into the circulation to drive metastatic formation in pancreatic cancer patients.Technological advances in detection and characterization of CTC are conducive to the early diagnosis, differential diagnosis, monitoring disease progression and predicating the probability of canceration or the chemotherapeutic efficacy. Nowadays, detection methods of CTC can be based on immunomagnetic beads technique, cell filtration or microfluidic chips technology, but there are great differences in the sample throughput, CTC recovery rate, purity, and CTC viability among them.Owing to the dilemma in detection methods, the intrinsic relevance between the biological characteristics of CTC and clinical manifestations is still not exactly elucidated. By the improved methodology, next generation sequencing technology and exploring the technique for culturing CTC in vitro and establishing xenotransplanted tumor model in nude mice, more and more biological information will be revealed, and finally, individualized treatment is achieved.

[Results of microscopic examinations and blood slide re-examinations of malaria elimination evaluation in ten prefectures of Yunnan Province]

OBJECTIVE

To understand the laboratory technicians' abilities in blood slide making and reading in 10 prefectures of Yunnan Province which have passed the provincial malaria elimination evaluation, so as to provide the evidence for improving the malaria elimination surveillance and parasite examination.

METHODS

Thirty negative blood slides were randomly sampled to evaluate coating, dyeing and clean quality and reading results, and 4 laboratory technicians were sampled to evaluate their reading abilities from each prefecture level and its 2 subordinate counties (districts) respectively, and then the results were analyzed.

RESULTS

A total of 869 negative blood samples were evaluated. The coincidence rate was 100%. The proportions of good coating, dyeing and clean quality were 96.09%, 91.71% and 96.89%, respectively. Totally 576 blood slides were used to evaluate the reading ability. The number of correct reading was 505, and the correct rate was 87.67%. Among them, the Plasmodium vivax correct reading rate was 87.76%, the P. falciparum correct reading rate was 87.50%, and the correct reading rate of mixed infections was 47.62%. The laboratory technicians' ability to the mixed infections was significantly lower than the ability to the others (χ² = 37.169, P < 0.05), however, in the laboratory technicians' abilities, there was no significant difference among the center (s) for disease control and prevention, general hospitals and township hospitals (χ² = 2.782, P > 0.05), and the prefecture, county and township levels (χ² = 0.358, P > 0.05) .

CONCLUSIONS

The 10 prefectures have passed the provincial evaluation in blood slide making and microscopic examination skill indicators requested, but the medical and public health institutions at all levels still should further improve their laboratory technicians' abilities in blood slide making and microscopic examination skills.

[Network correlation of circRNA-miRNA and the possible regulatory mechanism in acute myocardial infarction]

Objective: Using microarray technology, to research characteristic circRNA and miRNA expression profile of acute myocardial infarction (AMI), and then explore the role of these circRNA and miRNA in gene regulation. The aim is to explore the mechanism of development of AMI. Methods: The patients hospitalized in the Cardiovascular Research Center of the First Affiliated Hospital of Xinxiang Medical University between November 2016 and January 2017 were included and divided into control group and AMI group according to diagnostic criteria. We collected their whole blood and extracted the total RNA, and the expression profiles of circRNA and microRNA genes in peripheral blood of AMI were analyzed by gene chip. We predicted circRNA which was possible to combine with miRNA, and drew a network diagram, and the differentially expressed circRNA was analyzed by GO and Pathway. Results: There was difference in circRNA expression profile between the control group and the AMI group. The results showed: (1) a total of 1 670 circRNA had differential expressions, and in the analysis of miRNA expression, 13 miRNA had differential expressions (P<0.05, fc≥2); (2) multiple circRNAs-miRNAs were involved in the occurrence of AMI; (3) the analysis of GO and Pathway for differentially expressed circRNAs showed that many pathways, disease and function participated in it. Conclusion: CircRNA, as an important post transcriptional regulator, is closely related to the development of AMI with miRNA.

[Diagnosis and treatment of pancreatic neuroendocrine neoplasmas in Von Hippel-Lindau syndrome]

Von Hippel-Lindau(VHL) syndrome is a rare autosomal dominant hereditary disease, and pancreas is one of the frequently involved intra-abdominal organs, including simple pancreatic cysts, pancreatic serous cystadenomas and neuroendocrine neoplasmas. Most of the VHL-related pancreatic neuroendocrine neoplasmas (VHL-pNEN)were non-functional, but they still have a tendency to be malignant. Treatment options for VHL-pNEN include regular follow-up, surgical resection, and medication therapy. When compared with sporadic pNEN, the malignant degree of VHL-pNEN is lower, with a better prognosis, so the surgical treatment should be carefully considered. The indications of surgery for VHL-pNEN include big primary lesions (≥3 cm), fast tumor doubling time (<500 days), VHL gene mutation on exon 3, malignant manifestations on imaging findings, and functional pNEN lesions. The function-preserving approach should be performed to keep the functional pancreatic parenchyma as much as possible. Even for patients with a late stage malignancy that cannot be radically resected, active medication therapy may still lead to a long-term survival.

[Trend of clinical features in patients with acute coronary syndrome undergoing emergent percutaneous coronary intervention]

Objective: To investigate the clinical features and change trend of patients with acute coronary syndrome(ACS) undergoing emergent percutaneous coronary intervention(PCI). Methods: In this retrospective study, we retrieved all medical records of 4 907 ACS patients who underwent emergent PCI in Fuwai hospital from January 1,2010 to December 31,2016. We analyzed the clinical features and change trend in these patients. According to clinical diagnosis, patients were grouped as ST-elevated myocardial infarction(STEMI) group (3 719 cases) and NSTE-ACS group (patients with non-STEMI and unstable angina, 1 188 cases). Results: The ACS patients were aged (59.5±11.8) years old. There were 3 772 males and 1 135 females. The annual number of ACS patients underwent emergent PCI increased from 412 patients in 2010 to 1 067 patients in 2016. The number of NSTE-ACS patients increased from 11.4% (47/412) in 2010 to 26.5% (283/1 067) in 2016. Compared with STEMI group, patients in NSTE-ACS group were significantly older ((61.2±10.9) years old vs. (58.9±12.1) years old,P<0.01).The percent of female patients (30.1% (358/1 188) vs. 20.9% (777/3 719), P < 0.01), history of hypertension (69.1% (821/1 188) vs. 60.4% (2 248/3 719,P <0.01), previous PCI (25.8% (307/1 188) vs. 12.4% (461/3 719), P <0.01), and previous coronary artery bypass grafting (3.0% (36/1 188) vs. 1.0% (37/3 719), P <0.01) were all significantly higher in NSTE-ACS group than in STEMI group. On the other hand, NSTE-ACS patients presented less chronic renal failure (2.9% (35/1 188) vs. 4.3% (173/3 719), P <0.05) and hepatic dysfunction (8.5% (101/1 188) vs. 13.3% (495/3 719), P<0.01) as compared to ACS patients. In coronary angiography, NSTE-ACS patients had a higher prevalence of left-main disease (14.0% (166/1 188) vs. 7.8% (291/3 719), P<0.012 5) and triple vessel disease (47.8% (568/1 188) vs. 43.5% (1 619/3 719), P<0.012 5). There were no differences in prevalence of diabetes mellitus (31.9% (1 187/3 719) vs. 34.8% (414/1 188),P>0.05) and acute renal failure (0.1% (38/3 719) vs. 0.6% (7/1 188),P>0.05) between STEMI group and NSTE-ACS group. Conclusions: This single center retrospective analysis reveals that there is an increasing trend of NSTE-ACS patients from 2010 to 2016. Furthermore, there are more high-risk clinical characteristics in NSTE-ACS patients than in STEMI patients.

[Contemporary use of ticagrelor in patients with acute coronary syndrome after discharge]

Objective: To investigate the degree and determinants of using ticagrelor among discharged patients with acute coronary syndrome (ACS). Methods: Patients with ACS in Fuwai hospital who were given ticagrelor after discharge between Jan. 2015 to Jun. 2015 were analyzed.The clinical characteristics and adherence to ticagrelor of these patients were collected by reviewing the electronic medical records and telephone interview.Date were statistically-analyzed. Results: Among all screened 404 patients, 158 (39.1%) patients prematurely stopped ticagrelor within 12 months, while 119(29.5%) patients switched from ticagrelor to clopidogrel.Unavailable locally (34.8%), economic reasons (17.7%) and hemorrhagic events (18.4%) were the main causes of the premature discontinuation of ticagrelor.Univariate analysis showed left main disease (P=0.04) and the frequency of outpatient follow-up (P<0.01) as relative factors for prematurely stopping ticagrelor outside hospital after discharge.Multivariate analysis revealed medical insurance payment (OR 1.79, 95%CI 1.03-3.11) and the frequency of outpatient follow-up (OR 0.61, 95%CI 0.43-0.86) as independent predictors of prematurely stopping ticagrelor outside hospital.Prematurely stopping ticagrelor has no significant effect on the ischemic events (myocardial infaction or stroke) (P=0.76). Conclusion: Social cinditions is the main factor for the persistence to ticagrelor among ACS patients after dischcrge.Medical insurance payment and low frequency of outpatient follow-up were independent predictors of prematurely stopping ticagrelor and it may not have impact on ischemic events.

[Reliability and validity of Driving Anger Scale in professional drivers in China]

Objective: To assess the reliability and validity of the Chinese version of Driving Anger Scale (DAS) in professional drivers in China and provide a scientific basis for the application of the scale in drivers in China. Methods: Professional drivers, including taxi drivers, bus drivers, truck drivers and school bus drivers, were selected to complete the questionnaire. Cronbach's α and split-half reliability were calculated to evaluate the reliability of DAS, and content, contract, discriminant and convergent validity were performed to measure the validity of the scale. Results: The overall Cronbach's α of DAS was 0.934 and the split-half reliability was 0.874. The correlation coefficient of each subscale with the total scale was 0.639-0.922. The simplified version of DAS supported a presupposed six-factor structure, explaining 56.371% of the total variance revealed by exploratory factor analysis. The DAS had good convergent and discriminant validity, with the success rate of calibration experiment of 100%. Conclusion: DAS has a good reliability and validity in professional drivers in China, and the use of DAS is worth promoting in divers.

Reversed aqueductal cerebrospinal fluid net flow in idiopathic normal pressure hydrocephalus

OBJECTIVES

The changes of CSF flow dynamics in idiopathic normal pressure hydrocephalus (iNPH) are not fully elucidated. Most previous studies took the whole cardiac cycle as a unit. In this work, it is divided into systole and diastole phase and compared between iNPH patients and normal elderly and paid special attention to the change of netflow direction.

MATERIALS AND METHODS

Twenty iNPH patients according to international guideline and twenty healthy volunteers were included in this study and examined by MRI. Three categories of CSF flow parameters were measured: peak velocity (V_peak ), stroke volume (SV), and minute flow volume (MinV) covering the whole cycle; peak velocity (V_peak-s , V_peak-d ) and flow volume (Vol_s , Vol_d ) of the systole and diastole, respectively; net flow. Evans index (EI) was also measured and compared statistically between the two groups.

RESULTS

EI, V_peak , SV, MinV, Vol_s , Vol_d , and V_peak-d significantly increased in iNPH group (P<0.05). V_peak-s of the two groups were not significantly different (P>0.05). The net flow of 16 iNPH patients (16/20) was in the caudo-cranial direction, while 15 volunteers (15/20) were in the opposite direction, which showed statistically significant differences (P=.001).

CONCLUSIONS

INPH patients present hyperdynamic flow with increased velocity and volume both in systole and diastole phase. Degree of rising in diastole phase exceeds that of systole phase. The resulting reversal of netflow direction may play a key role in the occurrence of ventriculomegaly in iNPH patients.

[Dabigatran versus warfarin for the prevention of stroke in Chinese patients with nonvalvular atrial fibrillation: Chinese subpopulation analysis of RE-LY]

Objective: This analysis was performed to evaluate the efficacy in stroke prevention and safety of dabigatran in Chinese nonvalvular atrial fibrillation(NVAF) patients enrolled in RE-LY trial. Methods: RE-LY was an prospective, open-label, randomized, multicenter study. From March 2006 to March 2009, 541 atrial fibrillation patients at risk of stroke were recruited from 13 medical centers in China. Patients randomly received, in a blinded fashion, fixed doses of dabigatran-110 mg or 150 mg twice daily or, in an unblinded fashion, adjusted-dose warfarin. The primary efficacy endpoint was stroke or systemic embolism. The primary safety endpoint was major bleeding. Results: The incidence of stroke in the Chinese subpopulation was 1.94% per year(7 cases) in the group that received 110 mg of dabigatran (dabigatran 110) and 1.10% per year(4 cases) in the group that received 150 mg of dabigatran (dabigatran 150), as compared with 2.87% per year (10 cases) in warfarin group . Incidence of ischemic stroke was 1.11% per year(4 patients) in dabigatran 110 group, 0.82% per year(3 cases) in dabigatran 150 group and 2.01% per year(7 patients) in warfarin group. Incidence of hemorrhagic stroke was 0.28% per year(1 case) in dabigatran 110 group, 0.27% per year(1 case) in dabigatran 150 group and 0.57% per year(2 cases) in warfarin group. All-cause mortality was similar among the three treatment groups: 3.33% per year(12 cases) in dabigatran 110, 2.19% per year(8 cases) in dabigatran 150 and 2.58% per year(9 cases) in warfarin group. Incidence of major bleeding event was 0.56% per year(2 cases) in both dabigatran groups, as compared with 1.43% per year(5 cases) in warfarin group. Gastrointestinal disorders such as dyspepsia occurred in 12.8% patients of both dabigatran groups, and in 5.6% patients of warfarin group. Conclusions: Despite the descriptive statistical analysis in nature of present study due to the limited number of subjects, our subgroup analysis implies that like warfarin, dabigatran is efficacious and safe for thromboembolism prevention in Chinese patients with atrial fibrillation at risk of stroke. Clinical Trail Registry National Institutes of Health(http: //www.clinicaltrials.gov), CT00262600.

[Sinus pericranii in adults: clinical features and therapeutic management (13 cases report)]

Objective: To study the character of sinus pericranii in the adults and enhance the levels of the diagnosis and treatment of sinus pericranii. Methods: The clinical data of 13 adult patients with sinuses pericranii undergoing surgery in Beijing Hospital from 1992 to 2016 were analyzed retrospectively, including clinical manifestations, imaging data, surgical results. Results: Each of the patients presented with a nonpulsatile and soft tissue mass in their heads.Their ages ranged from 18 to 48 years (mean, 26 years). The diagnosis of the sinus pericranii was made by the clinical manifestations combined with CT and/or MRI examinations.The sinus pericranii did not play the main role in the drainage of the cerebral vein blood.All the patients were cured.The follow up time was from 6 months to 20 years with no sinus pericranii recurrence in all the patients. Conclusions: The analysis of the drainage pattern of sinus pericranii was necessary before surgery in order to get a safe and good operation.The curative effect of the surgery on the sinus pericranii in adult was reliable.

[Anatomic study and clinical practice of mesopancreas and total mesopancreatic excision]

Objective: To explore the anatomical characteristics of the mesopancreas, to define the range of the total mesopancreas excision and to evaluate the feasibility, safety and effectiveness in the treatment of pancreatic cancer. Methods: A regional anatomical and pathological study was performed on 14 cadavers with large slices and paraffin sections. The clinical and pathological data of 58 consecutive patients underwent total mesopancreas excision for pancreatic head carcinoma from January 2013 to December 2015 were prospectively collected and analysed. The perioperative morbidity, mortality and clinical outcomes of patients underwent total mesopancreas excision were compared with the patients underwent conventional pancreaticoduodenectomy from January 2010 to December 2012. Results: The mesopancreas located in the retropancreatic area, extending from the head, neck, and uncinated process of pancreas to the aorto-caval groove, in which there were loose areolar tissue, adipose tissue, nerve plexus, lymphatic and capillaries. Although no fibrous sheath or fascia like mesocolorectum was found around the structures, a relatively fixed extent could be defined according to its embryologic and anatomic characters. In clinical practice, total mesopancreas excision was classified into two levels according to the extent of resection in this series: level Ⅰ was a"standard total mesopancreas excision" or"total mesopancreas excision in a narrow sense" , which was similar to the extent of standard resection from consensus statement of ISGPS. Level Ⅱ was defined as any procedure extending the range of level Ⅰ, called the"extended total mesopancreas excision" or"total mesopancreas excision in a broad sense". In TMpE group, the intraoperative blood loss( (461.4±184.5)ml vs. (532.2±319.8)ml, P=0.301), operation time( (368.6±92.5)minutes vs. (397.1±112.7)minutes, P=0.559), total complication rate (39.7% vs. 51.2%, P=0.250), fistula mortality (25.9% vs. 30.2%, P=0.628) were all reduced. There were significantly higher R0 rate (91.4% vs.76.7%, P=0.041) and more harvested lymph nodes (16.2 vs. 11.4, P=0.000) and lower total and local recurrence: rate (half-year local recurrence rate: 7.8% vs. 23.7%, P=0.036; one-year local recurrence rate: 18.2% vs. 39.5%, P=0.018) and longer disease-free survival (16.9 months vs. 13.4 months, P=0.044) and overall survival(22.5 months vs. 19.9 months, P>0.05) were also found in the study group. Conclusions: Mesopancreas is different from mesorectum since it has no fascial envelop, which should be regarded as a surgical concept, rather than an anatomical structure. Total mesopancreas excision is safe and feasible for pancreatic head cancer and probably helps to increase the R0 resection rate and improve the clinical outcomes.

[Anatomy and management of superior petrosal vein in microvascular decompression for trigeminal neuralgia]

Objective: To investigate the characteristics of superior petrosal vein (SPV) and its influence on the surgical field in microvascular decompression (MVD) for trigeminal neuralgia (TN), and to analyze the effect of the surgical treatment of SPV on the surgical approach, indication and prognosis. Methods: The clinical data of 280 patients with trigeminal neuralgia between Jan. 2013 and Jun. 2016 were collected, including the trunks and the branches of SPV, intraoperative electrocoagulation status, the surgery outcome and complications. Results: The petrosal vein during the operation was fully preserved in 152 cases (54.29%). The SPV were completely sectioned in 25 cases (8.92%), while some branches of SPV were sectioned in 103 cases (36.79%). We found that SPV have 1 to 3 trunks, accounted for 67 cases (23.90%), 168 cases (60%), and 45 cases (16.10%), while the SPV with 1 to 4 branches accounted for 17 cases (6.07%), 112 cases (40%), 136 cases (48.57%), and 15 cases (5.36%). The SPV was identified as offending vessel in 17 cases (6.07%). One patient with cutoff SPV trunk encountered cerebellar infarction and recovered completely at 2 weeks after MVD by using intravenous medication. Conclusions: MVD is the recommended treatment method for PTN, mostly SPV is unnecessary to be sectioned completely and small branches of SPV could be sacrificed. Very few patients may develop cerebellar infarction or hematoma.

[Evaluation of American Joint Commission on Cancer(8th edition) and Japanese Pancreas Society(7th edition)changes for T and N staging in patients with pancreatic adenocarcinoma]

Accurate staging for cancer is the basis for clinical practice, individualized treatment strategy, and prognosis determination.Recently, the T and N staging systems for pancreatic adenocarcinoma were updated by both American Joint Commission on Cancer(AJCC)8th edition and Japanese Pancreas Society 7th edition, in which more objective parameters were applied.When a large number of patients within the test set were staged, AJCC 8th edition has showed more reproducible and helped to predict the patient prognosis more accurately.

Impact of Age on the Association Between Body Mass Index and All-Cause Mortality in Patients with Atrial Fibrillation

OBJECTIVES

To explore the impact of age on the association between body mass index (BMI) and all-cause mortality in patients with atrial fibrillation (AF).

METHODS

A total of 1991 patients with AF (69 ± 13 years, 54.9% female) were divided into three age groups: < 65 years, 65-75 years, and > 75 years, and followed for one year. The primary outcome was defined as all-cause mortality, with secondary outcomes including thromboembolism and major bleeding. Cox regression models were utilized to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Compared to patients aged < 65 years, elder groups had much lower BMI and more comorbidities other than a lower prevalence of valvular heart disease. During one-year follow-up, 277 (13.9%) patients died, 158 (7.9%) underwent thromboembolism events and 26 (1.3%) had major bleeding. Mortality and thromboembolism risk were both notably higher in patients with advanced age (all P values < 0.001). Using normal weight patients as reference, mortality risk was significantly lower in overweight (HR 0.548; 95% CI 0.404-0.744) and obese patients (HR 0.536; 95% CI 0.325-0.883) for the entire cohort, with reduced death risk mainly observed in overweight patients aged 65-75 years (HR 0.285; 95% CI 0.131-0.621) and aged > 75 years (HR 0.686; 95% CI 0.473-0.993), but not in patients aged < 65 years. Continuous analyses of BMI indicated consistent results.

CONCLUSION

High BMI is associated with reduced mortality rate in patients with AF, and this association is affected by age, with the so-called "obesity paradox" confined to those with advanced age rather than young patients.

Genetic polymorphisms in extracellular superoxide dismutase Leu53Leu, Arg213Gly, and Ala40Thr and susceptibility to type 2 diabetes mellitus

The most common type of endocrine disease is type 2 diabetes mellitus (T2DM); genetic factors contribute to the development to T2DM. In this study, we investigated the role of the Leu53Leu, Arg213Gly, and Ala40Thr polymorphisms in extracellular superoxide dismutase (EC-SOD) gene in the development of T2DM in a Chinese population. DNA was extracted from peripheral blood samples obtained from 256 T2DM patients and 324 control subjects recruited from our hospital between January 2013 and March 2015. DNA was genotyped by polymerase chain reaction-restriction fragment length polymorphism. The obtained data was then statistically analyzed. The chi-square test revealed a statistically significant difference in the genotype frequencies of EC-SOD Ala40Thr (χ² = 13.26, P = 0.001) between the patients and controls. Unconditional regression analysis indicated that the GA and AA genotypes of EC-SOD Ala40Thr were associated with an increased risk of T2DM compared to the GG genotype {adjusted odds ratio (OR) [95% confidence interval (CI)] = 1.46 (1.01-2.11) and 2.67 (1.48-4.85), respectively}. In the dominant model, the GA+AA genotype of EC-SOD Ala40Thr was correlated with a higher risk of T2DM, in comparison with the GG genotype (OR = 1.64, 95%CI = 1.16-2.33). In the recessive model, AA of EC-SOD Ala40Thr showed a 2.19-fold higher risk of developing T2DM than the GG+GA genotype. In conclusion, people with the Ala40Thr polymorphism in EC-SOD are at a higher risk of developing T2DM; therefore, this may be utilized as a biomarker for early screening of T2DM in a Chinese population.

[Surgical treatment of pancreatic cystic neoplasms: follow-up or surgical intervention]

Pancreatic cystic neoplasm(PCN) are common and increasingly detected in recent years including serous cystic neoplasms, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary neoplasms and cystic pancreatic neuroendocrine tumors.Some of PCN have a low risk of malignancy while others have a high risk and need interventions, even in the same type of cystic neoplasms. The management of PCN requires risk stratification for malignant potential, and clinicians should have a systematic approach for establishing a diagnosis and determining which patients require surgical treatment. Under the guidance of minimally invasive surgery, some organ preserving procedures including tumor enucleation, segmental pancreatic resection, duodenum-preserving total or subtotal pancreatic head resection, and spleen-preserving pancreatic body and tail resection are recommended for treatment of PCN. The indications for follow-up or surgical intervention for treatment of PCN patients should be mastered strictly to avoid either insufficient- or over-treatment.

[Distribution characteristics of serotypes of invasive pneumococcal disease in Chinese mainland children]

OBJECTIVE

To systematically estimate the regional distributions of invasive pneumococcal disease (IPD)'s serotypes in children of Chinese mainland.

METHODS

The literatures which described at least 20 strains of streptococcus pneumonia samples isolated from children with IPD in Chinese mainland were included in this study. Finally, 39 literatures met the inclusion criteria and were reviewed in this study. The average frequency of each serotype of streptococcus pneumonia was calculated and the uncertainty of each serotype range was described by 95% CI.

RESULTS

This study analyzed a total of 7 391 strains of streptococcus pneumoniae samples which mainly came from north China, east China, central China, south China and southwest regions of China. The results showed that the most common streptococcus pneumonia serotype causing IPD was 19F[30.05% (28.16%-31.98%)], and the second serotype was 23F[12.16% (10.00%-14.28%)], and the others were 19A[9.19% (7.01%-11.37%)], 6B[7.30% (5.09%-9.50%)], 14[7.02% (4.82%-9.23%)], 6A[6.08% (3.87%-8.30%)]and 15B[6.53% (2.88%-7.34%)].

CONCLUSION

The most common streptococcus pneumoniae serotype is 19F, 23F, 19A, 6B, 14, 6A and 15B in Chinese Mainland.

[Analysis of clinical characteristics and risk of stroke and death within 1 year of patients with nonvalvular atrial fibrillation combined with diabetes mellitus]

OBJECTIVE

To explore the clinical characteristics and impact of diabetes mellitus (DM) on prognosis in patients with nonvalvular atrial fibrillation (AF).

METHODS

Data of nonvalvular AF patients in the Chinese Emergency Atrial Fibrillation Registry Study were retrospectively analyzed. The eligible patients were divided into the DM group and the non-DM group. Uni- and multi-variate Cox regression analysis were used to explore risk factors of 1-year outcomes.

RESULTS

A total of 1 644 patients were enrolled in the study with 227 patients combined with DM (16.8%). Compared with non-DM group, patients with DM were older and had higher body weight, had higher prevalence of myocardial infarction, coronary heart disease, hypertension and stroke, and were at higher risk of thromboembolism. The proportion of anticoagulant treatment was low in both groups (10.1% vs 7.4%, P=0.141). Compared with patients without DM, patients with DM had higher all-cause mortality (19.5% vs 12.7%, P=0.004), cardiovascular death (10.8% vs 7.02%, P=0.047) and combined end events (CEE, 26.4% vs 2.4%, P=0.023), while with comparable incidence of stroke (10.1% vs 7.4%, P=0.141). Multi-variate Cox regression analysis showed that DM was an independent risk factor for 1-year all-cause mortality (HR=1.558, 95% CI 1.126-2.156), cardiovascular death (HR=1.615, 95% CI 1.052-2.479) and CEE (HR=1.523, 95% CI 1.098-2.112), while not for stroke (HR=1.523, 95% CI 1.098-2.112).

CONCLUSION

DM is the independent risk factor for all-cause mortality, cardiovascular death and combined end events in patients with nonvalvular AF, while not a predictor for the occurrence of stroke.

Concurrent Monte Carlo transport and fluence optimization with fluence adjusting scalable transport Monte Carlo

PURPOSE

The future of radiation therapy will require advanced inverse planning solutions to support single-arc, multiple-arc, and "4π" delivery modes, which present unique challenges in finding an optimal treatment plan over a vast search space, while still preserving dosimetric accuracy. The successful clinical implementation of such methods would benefit from Monte Carlo (MC) based dose calculation methods, which can offer improvements in dosimetric accuracy when compared to deterministic methods. The standard method for MC based treatment planning optimization leverages the accuracy of the MC dose calculation and efficiency of well-developed optimization methods, by precalculating the fluence to dose relationship within a patient with MC methods and subsequently optimizing the fluence weights. However, the sequential nature of this implementation is computationally time consuming and memory intensive. Methods to reduce the overhead of the MC precalculation have been explored in the past, demonstrating promising reductions of computational time overhead, but with limited impact on the memory overhead due to the sequential nature of the dose calculation and fluence optimization. The authors propose an entirely new form of "concurrent" Monte Carlo treat plan optimization: a platform which optimizes the fluence during the dose calculation, reduces wasted computation time being spent on beamlets that weakly contribute to the final dose distribution, and requires only a low memory footprint to function. In this initial investigation, the authors explore the key theoretical and practical considerations of optimizing fluence in such a manner.

METHODS

The authors present a novel derivation and implementation of a gradient descent algorithm that allows for optimization during MC particle transport, based on highly stochastic information generated through particle transport of very few histories. A gradient rescaling and renormalization algorithm, and the concept of momentum from stochastic gradient descent were used to address obstacles unique to performing gradient descent fluence optimization during MC particle transport. The authors have applied their method to two simple geometrical phantoms, and one clinical patient geometry to examine the capability of this platform to generate conformal plans as well as assess its computational scaling and efficiency, respectively.

RESULTS

The authors obtain a reduction of at least 50% in total histories transported in their investigation compared to a theoretical unweighted beamlet calculation and subsequent fluence optimization method, and observe a roughly fixed optimization time overhead consisting of ∼10% of the total computation time in all cases. Finally, the authors demonstrate a negligible increase in memory overhead of ∼7-8 MB to allow for optimization of a clinical patient geometry surrounded by 36 beams using their platform.

CONCLUSIONS

This study demonstrates a fluence optimization approach, which could significantly improve the development of next generation radiation therapy solutions while incurring minimal additional computational overhead.

[Surgical treatment of pancreatic carcinoma: problems and recent advances]

Nowadays surgical technologies develop fast under the guidance of minimally invasive medicine, evidence-based medicine, multi-disciplinary team and other ideas. However, the long-term outcome of pancreatic cancer remains dismal. In addition to the improvement of surgical resection rate, more attention should be paid to improve the overall survival rate of the patients with pancreatic cancer after surgery. Clinical studies of neoadjuvant therapies for the treatment of borderline resectable pancreatic cancer are advocated. Various types of pancreaticojejunostmy should be applied individually to improve the anastomosis quality and to reduce the postoperative complications. In the system of precision medicine, standardized surgical treatment pattern remains important.

[Clinical characteristics and outcomes of patients with acute aortic dissection: impact of hypertension]

OBJECTIVE

To observe the clinical characteristics and outcomes of patients with acute aortic dissection (AAD) and explore the impact of hypertension.

METHODS

The present study enrolled 1 087 consecutive patients with AAD who were confirmed by computed tomographic scanning in Fuwai Hospital from January 2008 to December 2010. The major endpoints were in-hospital death and long-term mortality during follow up.

RESULTS

A total of 595 (54.7%) patients were Stanford type A and 492 (45.3%) patients were Stanford type B. The median length of follow-up was 24.2 months (interquartile range 10.9, 40.8 months). The prevalence of hypertension was 67.4%(733 cases), and was significantly higher in type B patients than in type A patients (71.3%(351/492) vs. 64.2%(382/595), P=0.01). Regardless of Stanford classification, patients complicating with hypertension were older, had higher comorbidities (coronary heart diseases or diabetes), and less likely to receive surgical treatment compared with those without hypertension (all P<0.05). In Stanford type A AAD group, patients with hypertension had higher levels of admission blood pressure, serum creatinine and inflammatory markers (including WBC count, D-dimer and CRP) than those without hypertension (all P<0.05). In-hospital death (9.9% (38/382)vs. 5.6%(12/213), P=0.07) and long-term mortality (9.0% (31/344) vs. 8.9% (18/201), P=0.98) were similar in hypertensive and normotensive AAD type A patients. In type B AAD group, the in-hospital death rate was significantly higher in patients with hypertension than those without hypertension (5.4%(19/351) vs. 0.7%(1/141), P=0.02), while the long-term mortality was similar (6.9%(23/332) vs. 7.9%(11/140), P=0.71) between patients with and without hypertension. Multiple logistic regression analysis showed that hypertension did not predict the increased risk of in-hospital death of type A or type B AAD patients. The main protective factor of in-hospital mortality was operation in patients with type A AAD. The independent predictors of in-hospital death were age and surgical treatment in patients with type B AAD.

CONCLUSIONS

Hypertension is a common co-morbidity in patients with AAD. AAD patients with hypertension are usually elder, have higher comorbidities of cardiovascular diseases, and less likely to receive surgical treatment compared with those without hypertension, but hypertension is not associated with increased risk of in-hospital and long-term mortality in both AAD type A and type B patients.

Monte Carlo simulations of patient dose perturbations in rotational-type radiotherapy due to a transverse magnetic field: a tomotherapy investigation

PURPOSE

Several groups are exploring the integration of magnetic resonance (MR) image guidance with radiotherapy to reduce tumor position uncertainty during photon radiotherapy. The therapeutic gain from reducing tumor position uncertainty using intrafraction MR imaging during radiotherapy could be partially offset if the negative effects of magnetic field-induced dose perturbations are not appreciated or accounted for. The authors hypothesize that a more rotationally symmetric modality such as helical tomotherapy will permit a systematic mediation of these dose perturbations. This investigation offers a unique look at the dose perturbations due to homogeneous transverse magnetic field during the delivery of Tomotherapy(®) Treatment System plans under varying degrees of rotational beamlet symmetry.

METHODS

The authors accurately reproduced treatment plan beamlet and patient configurations using the Monte Carlo code geant4. This code has a thoroughly benchmarked electromagnetic particle transport physics package well-suited for the radiotherapy energy regime. The three approved clinical treatment plans for this study were for a prostate, head and neck, and lung treatment. The dose heterogeneity index metric was used to quantify the effect of the dose perturbations to the target volumes.

RESULTS

The authors demonstrate the ability to reproduce the clinical dose-volume histograms (DVH) to within 4% dose agreement at each DVH point for the target volumes and most planning structures, and therefore, are able to confidently examine the effects of transverse magnetic fields on the plans. The authors investigated field strengths of 0.35, 0.7, 1, 1.5, and 3 T. Changes to the dose heterogeneity index of 0.1% were seen in the prostate and head and neck case, reflecting negligible dose perturbations to the target volumes, a change from 5.5% to 20.1% was observed with the lung case.

CONCLUSIONS

This study demonstrated that the effect of external magnetic fields can be mitigated by exploiting a more rotationally symmetric treatment modality.

Syntheses and luminescent properties of a copolymer of terbium-p-aminobenzoic acid-methacrylic acid and styrene

A reactive Tb(III) complex with p-aminobenzoic acid (p-ABA) and methacrylic acid (MAA) as ligands was synthesized. A novel copolymer was synthesized by free radical copolymerization of styrene and the reactive Tb(III) complex in dimethyl sulfoxide (DMSO) with 2,2'-azobis(2-methylpropionitrile) (AIBN) as the initiator. IR and UV/Vis spectra indicate that the copolymer exhibited absorption from polystyrene and the complex. Thermogravimetric analysis indicates that the copolymer remained stable up to 357°C and the thermal stability was significantly improved in comparison with polymer matrix and the Tb(III) complex. The luminescent intensity of the synthetic terbium macromolecular complexes increased with increasing complex monomer content. Moreover, concentration quenching was not observed.

Hypotonic stress induces RANKL via transient receptor potential melastatin 3 (TRPM3) and vaniloid 4 (TRPV4) in human PDL cells

Bone remodeling occurs in response to various types of mechanical stress. The periodontal ligament (PDL) plays an important role in mechanical stress-mediated alveolar bone remodeling. However, the underlying mechanism at the cellular level has not been extensively studied. In this study, we investigated the effect of shear stress on the expression of bone remodeling factors, including receptor activator of nuclear factor-kappa B (NF-κB) ligand (RANKL) and osteoprotegerin (OPG), as well as its upstream signaling pathway in primary human PDL cells. We applied hypotonic stress to reproduce shear stress to PDL cells. Hypotonic stress induced the messenger RNA (mRNA) and protein expression of RANKL but not OPG. It also increased intracellular Ca(2+) concentration ([Ca(2+)]i). Extracellular Ca(2+) depletion and nonspecific plasma membrane Ca(2+) channel blockers completely inhibited the increase in both [Ca(2+)]i and RANKL mRNA expression. We identified the expression and activation of transient receptor potential melastatin 3 (TRPM3) and vaniloid 4 (TRPV4) channels in PDL cells. Pregnenolone sulfate (PS) and 4α-phorbol 12, 13-didecanoate (4α-PDD), which are agonists of TRPM3 and TRPV4, augmented Ca(2+) influx and RANKL mRNA expression. Both pharmacological (2-aminoethoxydiphenyl borate [2-APB], ruthenium red [RR], ononetin [Ono], and HC 067047 [HC]) and genetic (small interfering RNA [siRNA]) inhibitors of TRPM3 and TRPV4 reduced the hypotonic stress-mediated increase in [Ca(2+)]i and RANKL mRNA expression. Our study shows that hypotonic stress induced RANKL mRNA expression via TRPM3- and TRPV4-mediated extracellular Ca(2+) influx and RANKL expression. This signaling pathway in PDL cells may play a critical role in mechanical stress-mediated alveolar bone remodeling.