Comparison of conservative management, microsurgery only, and microsurgery with preoperative embolization for unruptured arteriovenous malformations: A propensity score weighted prospective cohort study

AIMS

To compare the efficacy and deficiency of conservative management (CM), microsurgery (MS) only, and microsurgery with preoperative embolization (E + MS) for unruptured arteriovenous malformations (AVMs).

METHODS

We prospectively included unruptured AVMs undergoing CM, MS, and E + MS from our institution between August 2011 and August 2021. The primary outcomes were long-term neurofunctional outcomes and hemorrhagic stroke and death. In addition to the comparisons among CM, MS, and E + MS, E + MS was divided into single-staged hybrid and multi-staged E + MS for further analysis. Stabilized inverse probability of treatment weighting using propensity scores was applied to control for confounders by treatment indication across the three groups.

RESULTS

Of 3758 consecutive AVMs admitted, 718 patients were included finally (266 CM, 364 MS, and 88 E + MS). The median follow-up duration was 5.4 years. Compared with CM, interventions (MS and E + MS) were associated with neurological deterioration. MS could lower the risk of hemorrhagic stroke and death. Multi-staged E + MS was associated with neurological deterioration and higher hemorrhagic risks compared with MS, but the hybrid E + MS operation significantly reduced the hemorrhage risk.

CONCLUSION

In this study, unruptured AVMs receiving CM would expect better neurofunctional outcomes but bear higher risks of hemorrhage than MS or E + MS. The single-staged hybrid E + MS might be promising in reducing inter-procedural and subsequent hemorrhage.

IDH-mutant grade 4 astrocytoma: a comparison integrating the clinical, pathological, and survival features between primary and secondary patients

OBJECTIVE

IDH-mutant grade 4 astrocytomas (AIDHmut/G4) are divided into primary de novo (pAIDHmut/G4) and secondary with a history of prior lower-grade gliomas (LGGs; sAIDHmut/G4). The mutational spectrum and DNA methylation patterns are homogeneous within de novo pAIDHmut/G4 and evolved sAIDHmut/G4, but the two groups have different diagnoses, management, and outcomes. This study sought to systematically compare the clinical, pathological, and survival characteristics between them.

METHODS

Of the 871 grade 4 astrocytomas with data for IDH mutation, 698 (80.1%) were primary and 173 (19.9%) were secondary. Of the 698 primary tumors, 103 (14.8%) were pAIDHmut/G4, and of the 173 secondary tumors, 108 (62.4%) were sAIDHmut/G4. Clinical, pathological, and survival features were compared between pAIDHmut/G4 and sAIDHmut/G4. Multivariate analyses were performed to identify prognostic factors.

RESULTS

Patients with sAIDHmut/G4 had significantly shorter median overall survival (OS; 11.8 vs 34.2 months, hazard ratio [HR] 2.69, 95% confidence interval [CI] 1.367-5.306, p = 0.004) and progression-free survival (PFS; 8.5 vs 24.3 months, HR 2.83, 95% CI 1.532-5.235, p = 0.001) than patients with pAIDHmut/G4. In patients with sAIDHmut/G4, resection status and chemotherapy were independent prognostic factors for OS and PFS; in patients with pAIDHmut/G4, LGG component, resection status, and O6-methylguanine DNA methyltransferase promoter methylation were independent prognostic factors. The therapeutic strategies of LGGs did not influence survival of patients with sAIDHmut/G4, but patients who had not received radiotherapy or chemotherapy when they were diagnosed with LGGs were found to benefit from radiotherapy or chemotherapy when they progressed to sAIDHmut/G4.

CONCLUSIONS

The different clinical characteristics, survival, and risk factors between sAIDHmut/G4 and pAIDHmut/G4 provide a reference to guide treatment decisions in AIDHmut/G4.

Timing of microsurgical resection for ruptured brain arteriovenous malformations: a propensity score-matched analysis using prospective single-center registry data

OBJECTIVE

The optimal microsurgical timing in ruptured brain arteriovenous malformations (AVMs) is not well understood and is surrounded by controversy. This study aimed to elucidate the impacts of microsurgical resection timing on clinical outcomes.

METHODS

The authors retrieved and reviewed the records on all ruptured AVMs treated at their institution and registered in a nationwide multicenter prospective collaboration registry between August 2011 and August 2021. Patients were dichotomized into an early resection group (≤ 30 days from the last hemorrhagic stroke) and a delayed resection group (> 30 days after the last hemorrhagic stroke). Propensity score-matched analysis was used to compare long-term outcomes. The primary outcome was neurological status as assessed using the modified Rankin Scale (mRS). The secondary outcomes were complete obliteration rate, postoperative seizure, and postoperative hemorrhage.

RESULTS

Of the 3649 consecutive AVMs treated at the authors' institution, a total of 558 ruptured AVMs were microsurgically resected and had long-term follow-up. After propensity score matching, 390 ruptured AVMs (195 pairs) were included in the comparison of outcomes. The mean (± standard deviation) clinical follow-up duration was 4.93 ± 2.94 years in the early resection group and 5.61 ± 2.56 years in the delayed resection group. Finally, as regards the distribution of mRS scores, short-term neurological outcomes were better in the delayed resection group (risk difference [RD] 0.3%, 95% CI -0.1% to 0.6%, p = 0.010), whereas long-term neurological outcomes were similar between the two groups (RD 0.0%, 95% CI -0.2% to 0.2%, p = 0.906). Long-term favorable neurological outcomes (early vs delayed: 90.8% vs 90.3%, p > 0.999; RD 0.5%, 95% CI -5.8% to 6.9%; RR 1.01, 95% CI 0.94-1.07) and long-term disability (9.2% vs 9.7%, p > 0.999; RD -0.5%, 95% CI -6.9% to 5.8%; RR 0.95, 95% CI 0.51-1.75) were also similar between these groups. In terms of secondary outcomes, postoperative seizure (early vs delayed: 8.7% vs 5.6%, p = 0.239; RD 3.1%, 95% CI -2.6% to 8.8%; RR 1.55, 95% CI 0.74-3.22), postoperative hemorrhage (1.0% vs 1.0%, p > 0.999; RD 0.0%, 95% CI -3.1% to 3.1%; RR 1.00, 95% CI 0.14-7.04), and hospitalization time (16.4 ± 8.5 vs 19.1 ± 7.9 days, p = 0.793) were similar between the two groups, whereas early resection had a lower complete obliteration rate (91.3% vs 99.0%, p = 0.001; RD -7.7%, 95% CI -12.9% to 3.1%; RR 0.92, 95% CI 0.88-0.97).

CONCLUSIONS

Early and delayed resection of ruptured AVMs had similar long-term neurological outcomes. Delayed resection can lead to a higher complete obliteration rate, although the risk of rerupture during the resection waiting period should be vigilantly monitored.

Long-term outcomes of microsurgery and stereotactic radiosurgery as the first-line treatment for arteriovenous malformations: a propensity score-matched analysis using nationwide multicenter prospective registry data

BACKGROUND

This study aimed to compare the risk and benefit profile of microsurgery (MS) and stereotactic radiosurgery (SRS) as the first-line treatment for unruptured and ruptured arteriovenous malformations (AVMs).

MATERIALS AND METHODS

The authors included AVMs underwent MS or SRS as the first-line treatment from a nationwide prospective multicenter registry in mainland China. The authors used propensity score-matched methods to balance baseline characteristics between the MS and SRS groups. The primary outcomes were long-term hemorrhagic stroke or death, and the secondary outcomes were long-term obliteration and neurological outcomes. Subgroup analyses and sensitivity analyses with different study designs were performed to confirm the stability of our findings.

RESULTS

Of the 4286 consecutive AVMs in the registry from August 2011 to December 2021; 1604 patients were eligible. After matching, 244 unruptured and 442 ruptured AVMs remained for the final analysis. The mean follow-up duration was 7.0 years in the unruptured group and 6.1 years in the ruptured group. In the comparison of primary outcomes, SRS was associated with a higher risk of hemorrhagic stroke or death both in the unruptured and ruptured AVMs (unruptured: hazard ratio 4.06, 95% CI: 1.15-14.41; ruptured: hazard ratio 4.19, 95% CI: 1.58-11.15). In terms of the secondary outcomes, SRS was also observed to have a significant disadvantage in long-term obliteration [unruptured: odds ratio (OR) 0.01, 95% CI: 0.00-0.04; ruptured: OR 0.09, 95% CI: 0.05-0.15]. However, it should be noted that SRS may have advantages in preventing neurofunctional decline (unruptured: OR 0.56, 95% CI: 0.27-1.14; ruptured: OR 0.41, 95% CI: 0.23-0.76). The results of subgroup analyses and sensitivity analyses were consistent in trend but with slightly varied powers.

CONCLUSIONS

This clinical practice-based real-world study comprehensively compared MS and SRS for AVMs with long-term outcomes. MS is more effective in preventing future hemorrhage or death and achieving obliteration, while the risk of neurofunctional decline should not be ignored.

Recurrence of Cerebral Arteriovenous Malformation Following Complete Obliteration Through Endovascular Embolization

Arteriovenous malformation (AVM) recurrence after embolization was rarely reported. This study aimed to explore the potential risk factors of recurrence in angiographically obliterated AVMs treated with endovascular embolization. This study reviewed AVMs treated with embolization only in a prospective multicenter registry from August 2011 to December 2021, and ultimately included 92 AVMs who had achieved angiographic obliteration. Recurrence was assessed by follow-up digital subtraction angiography (DSA) or magnetic resonance imaging (MRI). Hazard ratios (HRs) with 95% confidence intervals were calculated using Cox proportional hazards regression models. Nineteen AVMs exhibited recurrence on follow-up imaging. The recurrence rates after complete obliteration at 6 months, 1 year, and 2 years were 4.35%, 9.78%, and 13.0%, respectively. Multivariate Cox regression analysis identified diffuse nidus (HR 3.208, 95% CI 1.030-9.997, p=0.044) as an independent risk factor for recurrence. Kaplan-Meier analysis confirmed a higher cumulative risk of recurrence with diffuse nidus (log-rank, p=0.016). Further, in the exploratory analysis of the effect of embolization timing after AVM rupture on recurrence after the complete obliteration, embolization within 7 days of the hemorrhage was found as an independent risk factor (HR 4.797, 95% CI 1.379-16.689, p=0.014). Kaplan-Meier analysis confirmed that embolization within 7 days of the hemorrhage was associated with a higher cumulative risk of recurrence in ruptured AVMs (log-rank, p<0.0001). This study highlights the significance of diffuse nidus as an independent risk factor for recurrence after complete embolization of AVMs. In addition, we identified a potential recurrent risk associated with early embolization in ruptured AVMs.

Re-rupture in ruptured brain arteriovenous malformations: a retrospective cohort study based on a nationwide multicenter prospective registry

BACKGROUND

This study aimed to investigate the natural history of re-rupture in ruptured brain arteriovenous malformations (AVMs) and to provide comprehensive insights into its associated factors and prevention.

METHODS

This study included 1712 eligible ruptured AVMs from a nationwide multicenter prospective collaboration registry between August 2011 and September 2021. The natural rupture risk before intervention and the annual rupture risk after intervention were both assessed. Cox proportional hazard regression models and Kaplan-Meier survival curves were used to explore independent factors associated with AVM re-rupture. The correlation between these factors and AVM re-rupture was verified in multiple independent cohorts, and the prevention effect of intervention timing and intervention strategies on AVM re-rupture was further analyzed.

RESULTS

The annual re-rupture risk in ruptured AVMs was 7.6%, and the cumulative re-rupture risk in the first 1, 3, 5, and 10 years following the initial rupture were 10%, 25%, 37.5%, and 50%, respectively. Cox proportional hazard regression analysis confirmed adult patients, ventricular system involvement, and any deep venous drainage as independent factors associated with AVM re-rupture. The intervention was found to significantly reduce the risk of AVM re-rupture (annual rupture risk 11.34% vs 1.70%, p<0.001), especially in those who underwent surgical resection (annual rupture risk 0.13%).

CONCLUSIONS

The risk of re-rupture in ruptured AVMs is high. Adult patients, ventricular system involvement, and any deep venous drainage are independent risk factors for re-rupture. Applying the results universally to all ruptured AVM cases may be biased. Intervention could effectively reduce the risk of re-rupture.

Comparison of Long-Term Outcomes in Ruptured Diffuse Brain Arteriovenous Malformations Between Interventional Therapy and Conservative Management

Brain arteriovenous malformations (AVMs) with a diffuse nidus structure present a therapeutic challenge due to their complexity and elevated risk of hemorrhagic events. This study examines the long-term effectiveness of interventional therapy versus conservative management in reducing hemorrhagic stroke or death in patients with ruptured diffuse AVMs. The analysis was conducted based on a multi-institutional database in China. Patients were divided into two groups: conservative management and interventional therapy. Using propensity score matching, patients were compared for the primary outcome of hemorrhagic stroke or death and the secondary outcomes of disability and neurofunctional decline. Out of 4286 consecutive AVMs in the registry, 901 patients were eligible. After matching, 70 pairs of patients remained with a median follow-up of 4.0 years. The conservative management group showed a trend toward higher rates of the primary outcome compared to the interventional group (4.15 vs. 1.87 per 100 patient-years, P = 0.090). While not statistically significant, intervention reduced the risk of hemorrhagic stroke or death by 55% (HR, 0.45 [95% CI 0.18-1.14], P = 0.094). No significant differences were observed in secondary outcomes of disability (OR, 0.89 [95% CI 0.35-2.26], P = 0.813) and neurofunctional decline (OR, 0.65 [95% CI 0.26 -1.63], P = 0.355). Subgroup analysis revealed particular benefits in interventional therapy for AVMs with a supplemented S-M grade of II-VI (HR, 0.10 [95% CI 0.01-0.79], P = 0.029). This study suggests a trend toward lower long-term hemorrhagic risks with intervention when compared to conservative management in ruptured diffuse AVMs, especially within supplemented S-M grade II-VI subgroups. No evidence indicated that interventional approaches worsen neurofunctional outcomes.

Expression of TMEM59L associated with radiosensitive in glioblastoma

Radiotherapy is one of the cornerstone of the glioblastoma treatment paradigm. However, the resistance of tumor cells to radiation results in poor survival. The mechanism of radioresistance has not been fully elucidated. This study aimed to screen the differential expressed genes related with radiosensitivity. The differentially expressed genes were screened based on RNA sequencing in 15 pairs of primary and recurrent glioblastoma that have undergone radiotherapy. Candidate genes were validated in 226 primary and 134 recurrent glioblastoma (GBM) obtained from the Chinese Glioma Genome Atlas (CGGA) database. RNA and protein expression were verified by Quantitative Real-time PCR (qPCR) and western blot in irradiated GBM cell lines. The candidate gene was investigated to explore the relationship between mRNA levels and clinical characteristics in the CGGA and The Cancer Genome Atlas dataset. Kaplan-Meier survival analysis and Cox regression analysis were used for survival analysis. Gene ontology and KEGG pathway analysis were used for bioinformatics analysis. Four genes (TMEM59L, Gelsolin, ZBTB7A and ATX) were screened. TMEM59L expression was significantly elevated in recurrent glioblastoma and lower in normal brain tissue. We selected TMEM59L as the target gene for further study. The increasing of TMEM59L expression induced by radiation was confirmed by mRNA and western blot in irradiated GBM cell. Further investigation revealed that high expression of TMEM59L was enriched in IDH mutant and MGMT methylated gliomas and associated with a better prognosis. Gene ontology and KEGG pathway analysis revealed that TMEM59L was closely related to the DNA damage repair and oxidative stress respond process. We speculated that the high expression of TMEM59L might enhance radiotherapy sensitivity by increasing ROS-induced DNA damage and inhibiting DNA damage repair process.

Association of the combined stereotactic radiosurgery and embolization strategy and long-term outcomes in brain arteriovenous malformations with a volume ≤10 mL: a nationwide multicenter observational prospective cohort study

BACKGROUND

To compare the long-term outcomes of stereotactic radiosurgery (SRS) with or without prior embolization in brain arteriovenous malformations (AVMs) (volume ≤10 mL) for which SRS is indicated.

METHODS

Patients were recruited from a nationwide multicenter prospective collaboration registry (the MATCH study) between August 2011 and August 2021, and categorized into combined embolization and SRS (E+SRS) and SRS alone cohorts. We performed propensity score-matched survival analysis to compare the long-term risk of non-fatal hemorrhagic stroke and death (primary outcomes). The long-term obliteration rate, favorable neurological outcomes, seizure, worsened mRS score, radiation-induced changes, and embolization complications were also evaluated (secondary outcomes). Hazard ratios (HRs) were calculated using Cox proportional hazards models.

RESULTS

After study exclusions and propensity score matching, 486 patients (243 pairs) were included. The median (IQR) follow-up duration for the primary outcomes was 5.7 (3.1-8.2) years. Overall, E+SRS and SRS alone were similar in preventing long-term non-fatal hemorrhagic stroke and death (0.68 vs 0.45 per 100 patient-years; HR=1.46 (95% CI 0.56 to 3.84)), as well as in facilitating AVM obliteration (10.02 vs 9.48 per 100 patient-years; HR=1.10 (95% CI 0.87 to 1.38)). However, the E+SRS strategy was significantly inferior to the SRS alone strategy in terms of neurological deterioration (worsened mRS score: 16.0% vs 9.1%; HR=2.00 (95% CI 1.18 to 3.38)).

CONCLUSIONS

In this observational prospective cohort study, the combined strategy of E+SRS does not show substantial advantages over SRS alone. The findings do not support pre-SRS embolization for AVMs with a volume ≤10 mL.

Association of embolization with long-term outcomes in brain arteriovenous malformations: a propensity score-matched analysis using nationwide multicenter prospective registry data

BACKGROUND

Brain arteriovenous malformations (AVMs) account for 25% of hemorrhagic strokes in young adults. Although embolization has been widely performed as a stand-alone procedure to cure brain AVM, it is undermined whether patients benefit from this treatment. This study aimed to compare the long-term outcome of hemorrhagic stroke or death in patients with either conservative management or stand-alone embolization for AVM.

METHODS

The study population was derived from a nationwide multicenter prospective collaboration registry (the *BLINDED* registry) between 2011.08 and 2021.08. The propensity score-matched survival analysis was performed in the overall and stratified AVM cases (unruptured and ruptured) respectively, to compare the long-term outcome of hemorrhagic stroke or death, and neurological status. The efficacy of distinct embolization strategies was also evaluated. Hazard ratios (HRs) with 95% confidence intervals were calculated using Fine-Gray competing risk models.

RESULTS

Of the 3,682 consecutive AVMs, 906 underwent either conservative management or embolization as the stand-alone management strategy. After propensity score matching, a total of 622 (311 pairs) patients constituted an overall cohort. The unruptured and ruptured subgroups were composed of 288 cases (144 pairs) and 252 cases (126 pairs), respectively. In the overall cohort, embolization did not prevent long-term hemorrhagic stroke or death compared with conservative management (2.07 vs. 1.57 per 100 patient-years; HR, 1.28 [95%CI, 0.81-2.04]). Similar results maintained in both unruptured AVMs (1.97 vs. 0.93 per 100 patient-years; HR, 2.09 [95%CI, 0.99-4.41]) and ruptured AVMs (2.36 vs. 2.57 per 100 patient-years; HR, 0.76 [95%CI, 0.39-1.48]). Stratified analysis showed that the target embolization might be beneficial for unruptured AVMs (HR, 0.42 [95%CI, 0.08-2.29]), while the curative embolization improved the outcome of ruptured AVMs (HR, 0.29 [95%CI, 0.10-0.87]). The long-term neurological status was similar between these two strategies.

CONCLUSIONS

This prospective cohort study did not support a substantial superiority of embolization over conservative management for AVMs in preventing long-term hemorrhagic stroke or death.

[Current status of diagnosis and treatment of chronic lymphocytic leukemia in China: A national multicenter survey research]

Objective: To understand the current status of diagnosis and treatment of chronic lymphocytic leukemia (CLL) /small lymphocytic lymphoma (SLL) among hematologists, oncologists, and lymphoma physicians from hospitals of different levels in China. Methods: This multicenter questionnaire survey was conducted from March 2021 to July 2021 and included 1,000 eligible physicians. A combination of face-to-face interviews and online questionnaire surveys was used. A standardized questionnaire regarding the composition of patients treated for CLL/SLL, disease diagnosis and prognosis evaluation, concomitant diseases, organ function evaluation, treatment selection, and Bruton tyrosine kinase (BTK) inhibitor was used. Results: ①The interviewed physicians stated that the proportion of male patients treated for CLL/SLL is higher than that of females, and the age is mainly concentrated in 61-70 years old. ②Most of the interviewed physicians conducted tests, such as bone marrow biopsies and immunohistochemistry, for patient diagnosis, in addition to the blood test. ③Only 13.7% of the interviewed physicians fully grasped the initial treatment indications recommended by the existing guidelines. ④In terms of cognition of high-risk prognostic factors, physicians' knowledge of unmutated immunoglobulin heavy-chain variable and 11q- is far inferior to that of TP53 mutation and complex karyotype, which are two high-risk prognostic factors, and only 17.1% of the interviewed physicians fully mastered CLL International Prognostic Index scoring system. ⑤Among the first-line treatment strategy, BTK inhibitors are used for different types of patients, and physicians have formed a certain understanding that BTK inhibitors should be preferentially used in patients with high-risk factors and elderly patients, but the actual use of BTK inhibitors in different types of patients is not high (31.6%-46.0%). ⑥BTK inhibitors at a reduced dose in actual clinical treatment were used by 69.0% of the physicians, and 66.8% of the physicians had interrupted the BTK inhibitor for >12 days in actual clinical treatment. The use of BTK inhibitors is reduced or interrupted mainly because of adverse reactions, such as atrial fibrillation, severe bone marrow suppression, hemorrhage, and pulmonary infection, as well as patients' payment capacity and effective disease progression control. ⑦Some differences were found in the perceptions and behaviors of hematologists and oncologists regarding the prognostic assessment of CLL/SLL, the choice of treatment options, the clinical use of BTK inhibitors, etc. Conclusion: At present, a gap remains between the diagnosis and treatment of CLL/SLL among Chinese physicians compared with the recommendations in the guidelines regarding the diagnostic criteria, treatment indications, prognosis assessment, accompanying disease assessment, treatment strategy selection, and rational BTK inhibitor use, especially the proportion of dose reduction or BTK inhibitor discontinuation due to high adverse events.

Development and Validation of a Scoring System for Hemorrhage Risk in Brain Arteriovenous Malformations

IMPORTANCE

The dilemma between natural rupture risk and adverse outcomes of intervention is of major concern for patients with unruptured arteriovenous malformations (AVMs). The existing risk score for AVM rupture includes factors that are controversial and lacks prospective validation.

OBJECTIVE

To develop and robustly validate a reliable scoring system to predict the rupture risk of AVMs.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study developed a prediction model derived from a single-center cohort (derivation cohort) and validated in a multicenter external cohort (multicenter external validation cohort) and a cohort of patients receiving conservative treatment management (conservative treatment validation cohort). Patients were recruited from a nationwide multicenter prospective collaboration registry in China. A total of 4135 patients were enrolled in the registry between August 1, 2011, and September 1, 2021. Of those, 3962 patients were included in the study (3585 in the derivation cohort and 377 in the multicenter external validation cohort); 1028 patients from the derivation cohort who had time-to-event data and prerupture imaging results were included in the conservative treatment validation cohort. Data were analyzed from March 10 to June 21, 2022.

MAIN OUTCOMES AND MEASURES

A scoring system was developed based on risk factors identified from a literature review and a robust selection process. Patients were stratified into different risk groups based on scores to calculate hemorrhage-free probability in future years, and Kaplan-Meier curves were plotted to visualize risk stratification. Receiver operating characteristic curves were used to assess the discrimination of models. Univariable analyses (logistic regression analysis for descriptive data and Cox regression analysis for survival data) were used to compare baseline information and assess bias.

RESULTS

Among 3962 patients (2311 men [58.3%]; median [IQR] age, 26.1 [14.6-35.5] years), 3585 patients (2100 men [58.6%]; median [IQR] age, 25.9 [14.6-35.0] years) were included in the derivation cohort, and 377 patients (211 men [56.0%]; median [IQR] age, 26.4 [14.5-39.2] years) were included in the multicenter external validation cohort. Thirty-six hemorrhages occurred over a median (IQR) follow-up of 4.2 (0.3-6.0) years among 1028 patients in the conservative treatment validation cohort. Four risk factors were used to develop the scoring system: ventricular system involvement, venous aneurysm, deep location, and exclusively deep drainage (VALE). The VALE scoring system performed well in all 3 cohorts, with areas under the receiver operating characteristic curve of 0.77 (95% CI, 0.75-0.78) in the derivation cohort, 0.85 (95% CI, 0.81-0.89) in the multicenter external validation cohort, and 0.73 (95% CI, 0.65-0.81) in the conservative treatment validation cohort. The 10-year hemorrhage-free rate was 95.5% (95% CI, 87.1%-100%) in the low-risk group, 92.8% (95% CI, 88.8%-97.0%) in the moderate-risk group, and 75.8% (95% CI, 65.1%-88.3%) in the high-risk group; the model discrimination was significant when comparing these rates between the high-risk group and the low- and moderate-risk groups (P < .001 for both comparisons).

CONCLUSIONS AND RELEVANCE

In this prognostic study, the VALE scoring system was developed to distinguish rupture risk among patients with AVMs. The stratification of unruptured AVMs may enable patients with low risk of rupture to avoid unnecessary interventions. These findings suggest that the scoring system is a reliable and applicable tool that can be used to facilitate patient and physician decision-making and reduce unnecessary interventions or unexpected AVM ruptures.

[Correlation between polycyclic aromatic hydrocarbons component phenanthrene and clinical indicators in patients on peritoneal dialysis]

Objective: To explore the correlation between polycyclic aromatic hydrocarbons (PAHs) component phenanthrene and clinical indicators in patients on continuous ambulatory peritoneal dialysis (CAPD). Methods: A total of 22 patients who underwent peritoneal dialysis catheterization and regular dialysis in the First Affiliated Hospital of Zhengzhou University from June to August 2018 were selected. Meanwhile, 18 healthy adults who underwent physical examination were also selected as the control group. Fasting blood samples were taken to detect the concentration of PAHs components for comparison, and the correlation between PAHs components and clinical indicators was further analyzed. Results: There were 22 cases in CAPD group (13 males and 9 females), and aged (45±13) years, while there were 18 cases in control group (6 males and 12 females), and aged (41±13) years. The concentration of blood phenanthrene (PHE) was the highest in CAPD group [0.449 (0.254, 0.581) mg/L], and it was only lower than acenaphthene in the control group [0.081 (0.050, 0.444) mg/L], with a statistically significant difference between the two groups (P=0.008). The analysis of PHE and clinical indicators showed that the concentration of PHE in CAPD patients was negatively correlated with weekly urea clearance index (Kt/V), weekly creatinine clearance (Ccr) and leukocyte level, but positively correlated with triglyceride level (r=-0.743, -0.749, -0.655 and 0.610, respectively, all P<0.05). Simple linear regression analysis demonstrated that for every 0.1 mg/L increase in PHE concentration, weekly Kt/V, weekly Ccr and white blood cell count decreased by 0.226, 3.050 L/1.73 m² and 0.512×10⁹/L, respectively, but triglyceride level increased by 0.152 mmol/L (all P<0.05). Multiple linear regression analysis revealed that the blood PHE concentration of CAPD patients was negatively correlated with weekly Kt/V and Ccr levels (t=-2.402 and -2.368, respectively, both P<0.05). All CAPD patients were followed up for 3 years, during which 8 patients (36.4%) withdrew from peritoneal dialysis due to technical failure, and the baseline PHE concentration was higher than that of patients who did not quit peritoneal dialysis [0.572 (0.416, 0.662) vs 0.268 (0.120, 0.475) mg/L, P=0.003]. Eight patients (36.4%) had cardiovascular events, and the baseline blood PHE concentration was higher than that of patients without cardiovascular events [0.542 (0.389, 0.741) vs 0.373 (0.157, 0.545) mg/L, P=0.045]. Conclusion: PHE correlates with clinical indicators of CAPD patients, including Kt/v, Ccr, leukocyte and triglyceride.

The role of Gamma Knife radiosurgery in the management of skull base chordoma

Objective

Chordoma is a slow-growing and locally aggressive cancer, which arises from the remnants of the primitive notochord. The first line treatment for the skull base chordoma is neurosurgery. Gamma Knife radiosurgery (GKS) is often be chosen especially in the setting of residual or recurrent chordomas. The purpose of this study is to evaluate the prognosis of patients with skull base chordoma who underwent GKS.

Methods

The present study was a retrospective analysis of 53 patients with skull base chordomas who underwent GKS. Univariate Cox and Kaplan-Meier survival analysis were performed to analyze the relationship between the tumor control time and the clinical characteristics.

Results

The 1-, 2-, 3-, and 5-year progression free survival (PFS) rates were 87, 71, 51, and 18%, respectively. After performing the univariate analysis, the clinical characteristics were not found to be significantly associated with the time of PFS; however, surgical history, peripheral dose, and tumor volume did have tendencies to predict the prognosis.

Conclusion

GKS provided a safe and relatively effective treatment for residual or recurrent chordomas after surgical resection. A higher tumor control rate depends on two approaches, an appropriate dose of radiation for the tumor and the accurate identification of the tumor margins.

[Associations between early onset of puberty and obesity types in children: Based on both the cross-sectional study and cohort study]

OBJECTIVE

To explore and analyze the relationship between early onset of puberty and different types of obesity in children, by combining large sample cross-sectional survey data with long-term longitudinal cohort data, so as to provide clues for further clarifying the health hazards of early onset of puberty and obesity prevention and control.

METHODS

The research data were from the cross-sectional survey data of seven provinces(autonomous regions, municipalities) in China and the cohort data of adolescent development in Xiamen. The study first found the association between early onset of puberty and obesity by Logistic regression on the cross-sectional data, and then used Poisson regression to analyze the association between early puberty initiation and various types of obesity risk.

RESULTS

In the study, 43 137 and 1 266 children were included in the cross-sectional survey and cohort survey respectively. The cross-sectional study found that among the girls aged 10-13 years, compared with the girls of the same age who did not start puberty, the body mass index (BMI)-Z score of the girls in the puberty start group was 0.5-0.8 higher, and the waist circumference Z score was 0.4-0.7 higher, and the risk of various types of obesity was higher. At the same time, the early onset of puberty was positively correlated with simple obesity, central obesity and compound obesity, the OR (95%CI) were 1.86 (1.42-2.44), 1.95 (1.65-2.32) and 1.86 (1.41-2.45), respectively. No significant association was found in boys. According to the cohort data, in girls, the risk of simple obesity was 6.00 times [RR (95%CI): 6.00 (1.07-33.60)], the risk of central obesity was 3.30 times [RR (95%CI): 3.30 (1.22-8.92)], and the risk of compound obesity was 5.76 times [RR (95%CI): 5.76 (1.03-32.30)], compared with the group without early puberty initiation, while no association between early puberty initiation and obesity was found in boys.

CONCLUSION

Based on the cross-sectional survey and longitudinal cohort survey, it is confirmed that the early onset of puberty in girls may increase the risk of simple obesity, central obesity and compound obesity, while there is no significant correlation between puberty onset and obesity in boys.

Multimodality treatment for brain arteriovenous malformation in Mainland China: design, rationale, and baseline patient characteristics of a nationwide multicenter prospective registry

BACKGROUND

Brain arteriovenous malformation (AVM) is an important cause of hemorrhagic stroke in young adults, which can lead to severe neurological impairment. The registry of Multimodality treatment for brain ArTeriovenous malformation in mainland CHina (MATCH) is a national prospective registry to identify the natural history of AVMs in Asian population; to investigate traditional and emerging hemorrhagic predictors; and to explore the superiority of the multidisciplinary assessment in improving the long-term outcomes.  METHODS: Consecutive AVM patients will be enrolled from 52 participating hospitals in mainland China. Baseline demographic, clinical and imaging data will be collected prospectively. Conservation, microsurgery, embolization, stereotactic radiosurgery (SRS), and multimodal strategies are all included in this study. Patients will be divided into experimental and control group according to whether the treatment protocols are formulated by multidisciplinary team. Neurofunctional status, subsequent hemorrhage, seizure, and novel neurofunctional deficit will be queried at 3 months, annually (1 and 2 years), 3 years, and 10 years follow-up.

RESULTS

Between August 2011 and April 2021, 3241 AVMs were enrolled in 11 participating sites. Among them, 59.0% were male with an average age of 28.4 ± 14.6 years, 61.2% had rupture history and 2268 hemorrhagic events occurred before admission. The median Spetzler-Martin grade and Lawton-Young grade was 3 and 5, respectively. Microsurgery is the dominant strategy (35.7%), with a similar proportion of embolization, SRS, and a combination of both (12.7%; 14.8%; 11.8%; respectively). Among them, 15.43% underwent multidisciplinary assessment and received standardized treatment. At the most recent follow-up, 7.8% were lost and the median follow-up duration was 5.6 years.

CONCLUSIONS

The MATCH study is a large-sample nationwide prospective registry to investigate multimodality management strategy for AVMs. Data from this registry may also provide the opportunity for individualized risk assessment and the development of optimal individual management strategies.

TRIAL REGISTRATION

ClinicalTrials.gov Registry ( NCT04572568 ).

Assessment of gamma knife radiosurgery for unruptured cerebral arterioveneus malformations based on multi-parameter radiomics of MRI

OBJECTIVE

The treatment of Gamma knife radiosurgery (GKS) for unruptured Arteriovenous Malformations (AVM) remains controversial. A safe, effective and non-invasive method to predict outcome seems attractive for GKS. The purpose of this study was to develop and validate a MRI based multi-parameter radiomics model predicting the outcome of GKS for unruptured AVM.

METHODS

Eighty-eight unruptured AVM patients who initial underwent GKS between January 2011 and December 2016 in our hospital were included in this retrospective study. Patients were divided into two groups named as favourable and unfavourable outcome, according to the clinical outcome. Favourable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC). Multivariate logistic regression analysis was used to select appropriate clinical features and construct a clinical predicting model. In terms of radiomic model, manually segmentation and radiomics extracted were performed on each AVM lesions. Finally, 1684 radiomics features were extracted and Recursive Feature Elimination (RFE) method combined with Random forest classifier were used for feature selection and model construction. The performance of the radiomics model was evaluated by the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). In addition, the favourable group was further divided into early and late respond subgroup according to the time of obliteration evaluated by 2 years. The selected features were further compared according the respond time.

RESULTS

The median duration of neuroimaging follow-up was 65 months, 56 patients showed favourable outcome and 17 patients were observed obliteration within 2 years. The radiomics model constructed by 12 selected features achieved significant higher AUC of 0.88 (95% confidence interval 0.87-0.90) than traditional scoring system for predicting AVM outcome. Two selected radiomics features named "Dependence Variance" and "firstorder-Skewness" were found significant difference between the patients with early or late-respond.

CONCLUSIONS

The results suggest that the radiomics features could be successfully used for the pretreatment prediction of outcome for GKS in unruptured AVMs, which is helpful for decision-making process on unruptured AVM patients.

POS0599 IMPACT OF TREAT-TO-TARGET THERAPY ON BONE MINERAL DENSITY LOSS IN PATIENTS WITH RHEUMATOID ARTHRITIS: A PROSPECTIVE COHORT STUDY

Background

Osteoporosis is a common comorbidity of rheumatoid arthritis (RA). Although RA disease activity has been demonstrated to be associated with bone loss in previous studies, most of them were cross-sectional studies and not in the context of treat-to-target (T2T) strategies.

Objectives

To evaluate the association of disease activity with bone mineral density (BMD) changes in the context of T2T strategies in a prospective RA cohort.

Methods

RA patients were enrolled from a prospective CENTRA cohort of Peking University First Hospital. BMD was repeated at baseline, 1-year and then every other year. Time-adjusted mean disease activity scores were adopted to reflect the overall disease activity during follow-up. The influence of univariable associations between predictors and BMD was investigated using linear regression.

Results

A total of 268 patients were included in our analysis. Their mean age was 50 (12.9) years old. At enrollment, the mean (SD) DAS28-ESR was 3.70 (1.17), and the median (IQR) CDAI and SDIA was 10 (14.45) and 10.30 (16.53), respectively. Osteoporosis at lumbar spine was observed in 23.1% patients and 9.3% at femoral neck at enrollment. Older age, higher SDAI score and lower BMI were found to be associated with osteoporosis at baseline. Reevaluations of BMD at 1 year was applied in 144 patients. Mean decreases of BMDs were 1.75 % at the lumbar spine and 1.40 % at femoral neck at 1 year form baseline, respectively. Patients who achieved remission had less yearly bone loss at lumbar spine (p=0.036). Female gender was identified as a risk factor in the multiple linear regression analyses, and lower disease activity and bisphosphonates were protective factors of continuous bone loss.

Conclusion

Disease activity is associated with bone loss in RA patients in the context of T2T strategies, and those who achieved remission had less yearly bone loss.

Disclosure of Interests

None declared

POS0720 LOW-DOSE GLUCOCORTICOIDS WITHDRAWN IN SYSTEMIC LUPUS ERYTHEMATOSUS: A DESIRABLE AND ATTAINABLE GOAL

Background

Prolonged use of GC may cause irreversible organ damage, leading to impaired quality of life and even increased mortality. However, many physicians are worried about severe flares after GC withdrawal in daily practice.

Objectives

To assess the risk of flare in systemic lupus erythematosus (SLE) patients after low dose glucocorticoids (GC) discontinuation and evaluate the risk factors of flare.

Methods

SLE patients who ever discontinued GC were identified from PKUFHS cohort. The disease flare profile after GC discontinuation were analyzed. Flare rate was analyzed using Kaplan-Meier analysis. COX regression was used to determine the effect of variables on SLE flare. A prognostic nomogram using Cox proportional hazards regression modeling were developed.

Results

132 SLE patients were eligible for the final analysis. They were followed up for a median (IQR) period of 21.8 (9.01, 36.7) months. The cumulative probability of flare after GC discontinuation was 8.3 % at 6 months, 16.8% at year 1 and 27.5% at year 2 (Figure 1A). In multivariate COX analysis, hypocomplementemia and serologically active clinically quiescent (SACQ) were independent risk factors of flare [HR 2.53, 95% CI (1.32, 4.88); HR 3.17, 95% CI (1.44, 6.97), respectively]. Age ≥ 40y at GC withdrawal and hydroxychloroquine usage were independent protective factors of flare [HR 0.53, 95% CI (0.29, 0.99); HR 0.32, 95% CI (0.17, 0.62), respectively] (Table 1). The protective effect of hydroxychloroquine was dosage related. From the prospective of different tapering strategies embodied as duration from prednisone 5mg/d to complete discontinuation, slower tapering strategy (12-24 months) significantly reduced the risk of flare compared to faster tapering strategy (< 3 months) [HR 0.30, 95% CI (0.11, 0.82), p=0.019]. The prognostic nomogram including aforementioned factors effectively predicted 1- and 2-year probability of flare-free (Figure 1B).

Table 1.

Predictors of flare by univariate and multivariate COX analysis.

UnivariatepMultivariatepMultivariatepModel 1Model 2age≥40y at GC withdrawal0.59 (0.33,1.07)0.0840.53 (0.29, 0.99)0.0490.63 (0.33, 1.18)0.147Age at onset ≥18y2.03 (0.62, 6.66)0.2442.75 (0.77, 9.85)0.1212.88 (0.81, 10.2)0.103Remission duration≥60 months since the last flare0.66 (0.35, 1.27)0.2170.81 (0.41, 1.57)0.5260.73 (0.38, 1.41)0.346history of thrombocytopenia1.73 (0.94, 3.18)0.0771.36 (0.70, 2.65)0.3591.45 (0.74, 2.83)0.278history of lupus nephritis0.86 (0.47, 1.55)0.610////Hypocomplementemia1.97 (1.06, 3.66)0.0312.53 (1.32, 4.88)0.005//anti-dsDNA positive1.25 (0.70, 2.23)0.456////SACQ (both)2.91 (1.38, 6.15)0.005//3.17 (1.44, 6.97)0.004SACQ (or)1.29 (0.73, 2.30)0.380////Hydroxychloroquine or not0.29 (0.16, 0.53)<0.0010.29 (0.15, 0.56)<0.0010.32 (0.17, 0.62)0.001Immunosuppressant or not0.77 (0.40, 1.48)0.426////

There was strong collinearity between hypocomplementemia and SACQ, so the two parameters were separated into two models. SACQ (both): anti-dsDNA positive and hypocomplementemia; SACQ (or): anti-dsDNA positive or hypocomplementemia; GC: glucocorticoids. Data were shown as HR (95% CI).

Figure 1.

Conclusion

Low-dose GC is feasibly discontinued with infrequent flare in real-life setting. SACQ and younger age are potential risk factors of SLE flare, while hydroxychloroquine usage and slow GC tapering to withdrawal can reduce relapse. The visualized model we developed may help to predict risk of flare among SLE patients who discontinued GC.

Disclosure of Interests

None declared

AB0030 THE BIOLOGICAL FUNCTION AND MECHANISM EXPLORATION OF TACI IN SJOGREN’S SYNDROME

Background

primary Sjogren’s syndrome (pSS) is a chronic autoimmune disease that affects the lacrimal, salivary and other exocrine glands. More and more studies have shown that B cells play a central role in the pathogenesis of SS.

Objectives

We intended to explore the expression of the transmembrane activator, calcium modulator and cyclophilin ligand interactor (TACI) on the B cells, its role in pSS, and possible signal transduction pathways.

Methods

We included 34 naive pSS patients who visited the rheumatology department of Peking University First Hospital, and 37 gender- and age-distribution matched healthy controls (HCs). (1) To compare the B cell subsets, expression of TACI and relevant receptors in pSS patients, peripheral blood mononuclear cells were separated to analyze the ratio of B subsets, TACI, and BAFF-R by flow cytometry; ELISA was applied to detect the serum BAFF and soluble TACI (sTACI) concentration. (2) As for functional research of TACI, CD19+ B cells separated by magnetic sorting were treated under in vitro culture circumstances with raw TACI, TACI knocked down by siRNA, and sTACI analog (telitacicept) intervention with varing doses. The apoptosis, proliferation, differentiation and regulatory capacity on T cells were analyzed by flow cytometry, inflammatory cytokines and immunoglobulin levels in the culture supernatants were detected by CBA. (3) As for TACI-associated signaling pathway exploration, based on our previous miRNA data and relevant report of high quality, miRNA associated with TACI with significantly biased expression was confirmed by RT-qPCR. Screening the target gene of the candidate miRNA, and miRNA overexpression and inhibition experiments were conducted to validate the targeted relationship in B cells. And TACI-associated signaling pathway was explored via overexpressing and inhibiting the target gene.

Results

(1) Compared to HC, peripheral blood B subsets of pSS patients exhibited a significant bias, manifesting as increased proportion of CD19+CD24hiCD38hi Breg and decreased ratio of CD19+CD24+CD38- memory B cells. The expression of TACI in all B subsets was down-regulated, while that of BAFF-R was up-regulated. Both the serum concentration of BAFF and sTACI in pSS patients increased significantly. (2) As for functional research of TACI, in the setting of raw TACI, B cells in the pSS group showed higher apoptosis rate than HC under culture in vitro, where the ligand of TACI (APRIL or BAFF) addition turned the rate comparable; more active proliferation, and impaired capacity of inducing Treg cells to secrete IL-10. When TACI was knocked down by 50%, B cells performed less late apoptosis, significantly increased proliferation, impaired differentiation, significant dysfunction of Breg itself and impaired induction of Treg cells to secrete IL-10. While telitacicept intervention increased early apoptosis rate of B cells, significantly inhibited proliferation in 500ng/mL group and impaired ability of Breg and Treg cells to secrete IL-10. Besides, increased TACI on B cells treated with telitacicept, decreased IgG and increased IgA in the culture supernatants were observed. (3) As for TACI-associated signaling pathway exploration, hsa-miR-30b-5p showed satisfactory correlation between both transmembrane and sTACI. Besides, the expression of hsa-miR-30b-5p was significantly down-regulated, and inhibition its expression in vitro could lead to differentiation retard, impaired secretion of IL-10 by Breg cells. SMAD1 was screened based on database and validated as its target gene by overexpressing and inhibiting hsa-miR-30b-5p in B cell. After targeted up- or down-regulating the transcription of SMAD1 further, the transcription of ID2 downstream the TGF-β/Hippo signaling pathway changed accordingly.

Conclusion

The expression of TACI on peripheral blood B cells was deficient in pSS patients. TACI deficiency was closely associated with the downregulation of hsa-miR-30b-5p, activating TGF-β/Hippo pathway mediated by its target gene SMAD1 and taking part in the pathogenesis of pSS.

Disclosure of Interests

None declared

A Machine Learning Model Predicts the Outcome of SRS for Residual Arteriovenous malformations after partial embolization- A Real-World Clinical Obstacle

PURPOSE

To propose a machine learning (ML) model predicting the favorable outcome of stereotactic radiosurgery (SRS) for residual brain arteriovenous malformation (bAVM) after partial embolization.

MATERIALS AND METHODS

One hundred and thirty bAVM patients who underwent partial embolization followed by SRS were retrospectively reviewed. Patients were randomly split into training datasets (n=100) and testing datasets (n=30). Radiomics and dosimetric features were extracted from pre-SRS treatment images. Feature selection was performed to select appropriate radiomics and dosimetric features. Three ML algorithms were applied to construct models using selected features respectively. A total of 9 models were trained to predict favorable outcomes (obliteration without complication) of bAVMs. The efficacy of these models was evaluated on the testing dataset using mean accuracy (ACC) and area under the receiver operating characteristic curve (AUROC).

RESULTS

The obliteration rate of this cohort was 70.77% (92/130) with a mean follow-up period of 43.8 (Range 12-108 months) months. Favorable outcomes were achieved in 89 (68.46%) patients. Four radiomics features and 7 dosimetric features were selected for ML model construction. The dosimetric SVM showed the best performance on the training dataset, with an ACC and AUC of 0.74 and 0.78 respectively. The dosimetric SVM model also showed the best performance on the testing dataset where the ACC and AUC were 0.83 and 0.77 respectively.

CONCLUSION

Dosimetric features are good predictors of prognosis for patients with partially embolized bAVM followed by SRS therapy. The use of ML models is an innovative method for predicting favorable outcomes of partially embolized bAVM followed by SRS therapy.

Factors Affecting Volume Reduction Velocity for Arteriovenous Malformations After Treatment With Dose-Stage Stereotactic Radiosurgery

Background and Purpose

The purpose of this study was to identify morphologic and dosimetric features associated with volume reduction velocity for arteriovenous malformation (AVM) after dose-stage stereotactic radiosurgery (DS-SRS).

Methods

Thirty patients with intracranial AVM were treated with DS fractionated SRS at Beijing Tiantan Hospital from 2011 to 2019. The AVM nidus was automatically segmented from DICOMRT files using the 3D Slicer software. The change in lesion volume was obtained from the decrease in the planning target volume (PTV) between the two treatment sessions. The volume reduction velocity was measured by the change in volume divided by the time interval between treatments. Fourteen morphologic features of AVM prior to treatment were extracted from the PTV using ‘Pyradiomics’ implemented in Python. Along with other dosimetric features, univariate and multivariate analyses were performed to explore predictors of the volume reduction velocity.

Results

Among the 15 male (50.0%) and 15 female (50.0%) patients enrolled in this study, 17 patients (56.7%) initially presented with hemorrhage. The mean treatment interval between the initial and second SRS was 35.73 months. In multivariate analysis, the SurfaceVolumeRatio was the only independent factor associated with the volume reduction velocity (p=0.010, odds ratio=0.720, 95% confidence interval: 0.560–0.925). The area under the curve of this feature for predicting the volume reduction velocity after the initial treatment of DS-SRS was 0.83. (p=0.0018).

Conclusions

The morphologic features correlated well with the volume reduction velocity in patients with intracranial AVM who underwent DS-SRS treatment. The SurfaceVolumeRatio could predict the rate of volume reduction of AVMs after DS-SRS.

[The impact of occupational aluminum exposure on workers' overall cognitive function and various cognitive fields]

Objective: To evaluate the effects of occupational aluminum exposure on workers' overall cognitive function and cognitive fields. Methods: From July to August 2019, using the method of cluster sampling, 101 and 117 workers were selected from the electrolytic aluminum workshop of an aluminum plant in a region and the maintenance workshop of a plant in the same region. The venous blood of the subjects was collected, the plasma was extracted, and the blood aluminum concentration was measured by ICP-MS. According to the blood aluminum concentration and type of work, 93 workers who were lower than the median blood aluminum concentration and in the maintenance workshop of a factory were divided into low aluminum exposure group, and 85 workers who were higher than the median blood aluminum concentration and in the electrolytic aluminum workshop of an aluminum factory were divided into high aluminum exposure group. The basic information of the respondents, was collected through the employee physical examination form. The overall cognitive function of workers was evaluated by Beijing Montreal Cognitive Assessment Scale (MoCA) . Multiple linear regression analysis and logistic regression analysis were used for multiple statistical analysis. Results: Compared with the low aluminum exposure group (25.42±1.808) , the total score of MoCA in the high aluminum exposure group (23.84±2.919) was significantly lower, and the scores of visual space, executive function, abstract and delayed recall were significantly lower (P<0.05) . Linear regression analysis showed that the total score of MoCA, visual space and executive function, naming and delayed recall were negatively correlated with blood aluminum concentration (β=-0.018、-0.008、-0.003、-0.008, P<0.05) .MOCA total score, visual space and executive function, attention, language, abstraction, orientation were positively correlated with educational level (β=0.853、0.310、0.216、0.171、0.412、0.122, P<0.05) . Logistic regression analysis showed that adjusting for age, smoking, drinking and education, blood aluminum was a risk factor for mild cognitive impairment (OR=1.017, P<0.05) ; Education level was the protective factor of mild cognitive impairment (OR=0.419, P<0.05) . Conclusion: Occupational aluminum exposure can affect the overall cognitive function of workers, and occupational aluminum exposure increases the risk of MCI.

[Application of traction metal clip with fishhook-like device in endoscopic resection]

From July 2020 to June 2021, patients in Jiangyin Hospital Affiliated to Nantong University who met the enrollment criteria were treated with the fishhook-like device during the operation to suture the postoperative wound (group A). Patients with similar conditions and similar size wounds who were treated with a "purse-string suture" to suture the wounds were retrospectively analyzed as the control group (group B). Difference in the suture rate, adverse events, time required for suturing, and number of metal clips were compared between the two groups. The time required for suturing was (7.83±2.41) min in group A and (11.00±3.31) min in group B. The difference was statistically significant (P=0.002). The number of metal clamps used in group A averaged 7.17 pieces/case, and the number of metal clamps used in group B averaged 7.06 pieces/case. The difference was not statistically significant (P>0.05).The traction metal clip with the fishhook-like device is ingeniously designed and easy to operate. It has a good suture effect on the wound after endoscopic resection and effectively prevents postoperative adverse events.

Stereotactic Radiosurgery With vs. Without Prior Embolization for Brain Arteriovenous Malformations: A Propensity Score Matching Analysis

Objective: Whether partial embolization could facilitate the post-stereotactic radiosurgery (SRS) obliteration for brain arteriovenous malformations (bAVMs) remains controversial. We performed this study to compare the outcomes of SRS with and without prior embolization for bAVMs.

Methods: We retrospectively reviewed the Beijing Tiantan AVMs prospective registration research database from September 2011 to October 2014. Patients were categorized into two groups, combined upfront embolization and SRS (Em+SRS group) and SRS alone (SRS group), and we performed a propensity score matching analysis based on pre-embolization baseline characteristics; the matched groups each comprised 76 patients.

Results: The obliteration rate was similar between SRS and Em+SRS (44.7 vs. 31.6%; OR, 1.754; 95% CI, 0.905–3.401; p = 0.096). However, the SRS group was superior to the Em+SRS group in terms of cumulative obliteration rate at a follow-up of 5 years (HR,1.778; 95% CI, 1.017–3.110; p = 0.033). The secondary outcomes, including functional state, post-SRS hemorrhage, all-cause mortality, and edema or cyst formation were similar between the matched cohorts. In the ruptured subgroup, the SRS group could achieve higher obliteration rate than Em+SRS group (56.5 vs. 31.9%; OR, 2.773; 95% CI, 1.190–6.464; p = 0.018). The cumulative obliteration rate at 5 years was also higher in the SRS group (64.5 vs. 41.3%; HR, 2.012; 95% CI, 1.037–3.903; p = 0.038), and the secondary outcomes were also similar between the matched cohorts.

Conclusion: Although there was no significant difference in the overall obliteration rate between the two strategies, this study suggested that pre-SRS embolization may have a negative effect on post-SRS obliteration. Furthermore, the obliteration rates of the SRS only strategy was significantly higher than that of the Em+SRS strategy in the ruptured cohort, while no such phenomenon was found in the unruptured cohort.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

AB0280 THE INFLUENCE OF TARGET THERAPY AS WELL AS GLUCOCORTICOIDS TAPERING ON DISEASE FLARE IN SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM A PROSPECTIVE CHINESE COHORT

Background:

Treat-to-target in systemic lupus erythematosus (SLE) has been proposed for 7 years and several recommendations were developed [1]. In these recommendations, prevention of flares should be a realistic target. Meanwhile, ‘remission’ or ‘low disease activity’ was recommended as the treatment target and minimizing glucocorticoids (GC) dose or withdrawal if possible was suggested in the maintenance treatment. However, would target therapy and GC tapering/withdrawal influence disease flare?

Objectives:

To investigate the frequency and determinants of disease flare, especially the influence of target therapy as well as GC tapering on flare in Chinese lupus patients.

Methods:

The baseline and follow-up data of all consecutive patients in a prospective longitudinal lupus cohort from January 2017 to June 2020 were collected. The lupus low disease activity state (LLDAS) was defined as in Golder et al., 2019[2]. The criteria for remission were from DORIS definitions [3]. Flare was assessed using the SELENA-SLEDAI flare index [4].

Results:

We enrolled 185 patients with disease duration at recruitment of 2.3 (0.8–7.7) years. During the 26.2 (12.5-34.5) months of follow-up, 73 (39.5%) patients experienced 95 flares, including 70 mild/moderate and 25 severe flares. The incidence of flare per patient-year was 0.27. Kaplan-Meier analyses showed that compared with those who never achieved LLDAS or DORIS, the patients who achieved the target at least once had a higher flare free survival rate; meanwhile, the patients with prednisone withdrawn had significantly lower flare free rate compared with those with small dose of GC maintained (≤7.5mg/d) (Figure 1A), but among the patients with different prednisone maintain doses (7.5~5mg, 5~2.5mg, and ≤2.5mg) there was not significant difference (Figure 1B). Cox regression analysis showed that younger age at disease onset and lower Complement 3 (C3) level at recruitment were independent risk factors for flare and achieving LLDAS or DORIS ≥50% of visits was independent protective factor (Table 1).

Conclusion:

In this Chinese prospective SLE cohort, age at disease onset, C3 level at recruitment and therapeutic target achieving influenced disease flare independently and significantly. GC tapering in appropriate patients and with appropriate pace did not increase the flare rate, but prednisone withdrawal may induce more disease exacerbation, which needs to be confirmed by large prospective studies.

References:

[1]Van Vollenhoven R F, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis, 2014. 73(6): 958-967

[2]Golder, V., et al. Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.

[3]van Vollenhoven R, et al. A framework for remission in SLE: consensus findings from a large international task force on definitions of remission in SLE (DORIS). Ann Rheum Dis. 2017. 76(3): 554–561.

[4]Petri M, et al. Classification and definition of major flares in SLE clinical trials. Lupus. 1999. 8(8): 685-691.

Table 1.

Determinants of disease flare by multivariate Cox regression analyses

Model 1(LLDAS) ΔModel 2(RONT) ΔModel 3(Complete RONT) ΔHR95%CIP valueHR95%CIP valueHR95%CIP valueAge at disease onset (years)†0.970.95-0.990.0040.970.95-0.990.0030.970.95-0.990.003Anti-dsDNA positive at recruitment1.340.82-2.180.2171.120.68-1.850.6491.190.73-1.960.486C3 (mg/L) at recruitment0.9980.997-0.9990.0040.9980.997-0.9990.0070.9980.997-1.0000.010Minimum prednisone dose during follow- up (mg/d)0.980.90-1.080.7161.010.94-1.080.7471.040.97-1.110.243Therapeutic target achieved≥50% of observationsΔ0.600.39-0.940.0010.540.34-0.870.0110.680.51-0.920.011

Δ In the three hazard models, the different target achievement status were included respectively.

RONT: Clinical remission on treatment; Complete RONT: Complete remission on treatment.

Disclosure of Interests:

None declared

POS1481-HPR SEXUAL EXPERIENCE IN MALE PATIENTS WITH ANKYLOSING SPONDYLITIS: RESULTS FROM A CROSS-SECTIONAL STUDY OF 113 PATIENTS

Background:

The expression and experience of sexuality is a key part of an individual self-identity1, so it is essential for both healthy individuals and patients. Patients with ankylosing spondylitis (AS) may be susceptible to sexual issues due to disease activity, dysfunction and comorbid emotional problems. However, sexuality, especially sexual experience, are rarely paid attention in patients with AS.

Objectives:

Our study aims to assess sexual experience in male patients with AS, and analyze the factors affecting sexual experience.

Methods:

This is a cross-sectional study. A total of 113 patients with AS and 46 healthy people were investigated, matched according to age and body mass index. The Sexual Experience Questionnaire is used to assess male sexual experience. Linear regression analysis is used to explore the contributions of clinical variables to worse sexual experience.

Results:

There is a significant difference in the total sexual experience score between AS patients and healthy controls (41.92±8.83 vs 46.98±8.10, P=0.0013). Also, patients with AS have a worse score in all dimensions of sexual experience, including erectile function, individual satisfaction and couple satisfaction, comparing to healthy people. In the regression model after controlling for the effects of age, disease duration and body mass index, disease activity (BASDAI), function (BASFI), mobility (BASMI, chest expansion and finger-floor distance), health index (ASAS HI), sleep quality (PSQI) and psychological status (HADS, HADS-A and HADS-D) are significant determinants of sexual experience, including erectile function (except for chest expansion), individual satisfaction (except for BASMI) and couple satisfaction (except for BASMI). See Table 1 for details.

Table 1.

Multivariable regression analysis of association between sexual experience and clinical outcomes

IndependentSexual experience total scoreErectile functionIndividual satisfactionCouple satisfactionβ (95%CI)Pβ (95%CI)Pβ (95%CI)Pβ (95%CI)PPain total-0.09 (-0.25, 0.07)0.28-0.27 (-0.58, 0.03)0.073-0.51 (-0.91, -0.100.014-0.15 (-0.32, 0.02)0.077BASDAI1.35 (-2.24, -0.45)0.003-0.42 (-0.75, -0.09)0.014-0.72 (-1.16, -0.28)0.001-0.21 (-0.40, -0.02)0.028BASFI-1.80 (-2.59, -1.01)<0.001-0.62 (-0.91, -0.32)<0.001-0.89 (-1.28, -0.50)<0.001-0.30 (-0.47, -0.13)0.001BASMI-1.04 (-2.01, -0.07)0.036-0.47 (-0.82, -0.12)0.008-0.48 (-0.96, 0.001)0.051-0.09 (-0.29, 0.12)0.413Chest expansion1.60 (0.24, 2.96)0.0210.50 (-0.004, 0.99)0.0520.74 (0.07, 1.42)0.0320.36 (0.08, 0.64)0.011Finger-floor distance-0.20 (-0.33, -0.07)0.003-0.07 (-0.11, -0.02)0.009-0.10 (-0.17, -0.03)0.003-0.04 (-0.06, -0.01)0.011ASAS HI-1.27 (-1.64, -0.91)<0.001-0.42 (-0.55, -0.28)<0.001-0.62 (-0.80, -0.43)<0.001-0.24 (-0.32, -0.16)<0.001PSQI-0.60 (-1.11, -0.09)0.021-0.19 (-0.38, -0.004)0.045-0.28 (-0.54, -0.03)0.03-0.13 (-0.23, -0.02)0.019HADS-0.53 (-0.76, -0.29)<0.001-0.18 (-0.27, -0.09)<0.001-0.24 (-0.36, -0.13)<0.001-0.10 (-0.15, -0.05)<0.001HADS-A-0.86 (-1.30, -0.42)<0.001-0.28 (-0.44, -0.12)0.001-0.42 (-0.63, -0.20)<0.001-0.17 (-0.26, -0.07)<0.001HADS-D-0.99 (-1.45, -0.53)<0.001-0.35 (-0.52, -0.19)<0.001-0.44 (-0.67, -0.21)<0.001-0.20 (-0.29, -0.10)<0.001

Conclusion:

Worse sexual experience is associated with increased disease activity, decreased function, poor mobility, decreased health index, poor sleep quality and psychological status. Therefore, special attention to worse sexual experience in patients with AS is essential to assess disease-related suffering and develop new patient management strategies.

References:

[1]Hill J, Bird H, Thorpe R. Effects of rheumatoid arthritis on sexual activity and relationships. Rheumatology (Oxford), 2003. 42(2):280-6.

Disclosure of Interests:

None declared

Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations

Background and purpose: To evaluate whether a radiosurgery-based arteriovenous malformation (AVM) scale (RBAS) could be used to predict obliteration of brain arteriovenous malformations (bAVMs) supposed for combined endovascular embolization (EMB) and gamma knife surgery (GKS) treatment. Methods: bAVM patients who underwent GKS with or without previous EMB from January 2011 to December 2016 at our institution were retrospectively reviewed. The patients were categorized into a combined treatment group and a GKS group. A 1:1 propensity score matching (PSM) was used to match the two groups. Pre-EMB and pre-GKS RBAS were assessed for every patient. Multivariate analysis was performed to find factors associated with complete obliteration in the combined treatment group. Survival analysis based on sub-groups according to RBAS was performed to compare obliteration rate and find cutoffs for appropriate treatment modalities. Results: A total of 96 patients were involved, and each group comprised 48 patients. There was no difference between the two groups in terms of obliteration rate (75.0 vs. 83.3%, p = 0.174). Pre-EMB RBAS (p = 0.010) and the number of feeding arteries (p = 0.014) were independent factors associated with obliteration rate in the combined treatment group. For the combined treatment patients, sub-group analysis according to pre-EMB RBAS (score <1.0, 1.0-1.5, and >1.5) showed statistical difference in obliteration rate (p = 0.002). Sub-group analysis according to RBAS between the two groups showed that the obliteration rate of the GKS group is significantly higher than the combined group when RBAS >1.5 (47.4 vs. 66.7%, p = 0.036). Conclusions: The RBAS is proposed to be efficient in predicting obliteration of bAVMs supposed to receive combined EMB and GKS treatment. Patients with RBAS >1.5 are inclined to be more suitable for GKS instead of the combined treatment.

Long-Term Outcomes of Elderly Brain Arteriovenous Malformations After Different Management Modalities: A Multicenter Retrospective Study

Background: More and more elderly patients are being diagnosed with arteriovenous malformation (AVM) in this global aging society, while the treatment strategy remains controversial among these aging population. This study aimed to clarify the long-term outcomes of elderly AVMs after different management modalities.

Methods: The authors retrospectively reviewed 71 elderly AVMs (>60 years) in two tertiary neurosurgery centers between 2011 and 2019. Patients were divided into four groups: conservation, microsurgery, embolization, and stereotactic radiosurgery (SRS). The perioperative complications, short-term and long-term neurological outcomes, obliteration rates, annualized rupture risk, and mortality rates were compared among different management modalities in the ruptured and unruptured subgroups. Kaplan-Meier survival analysis was employed to compare the death-free survival rates among different management modalities. Logistic regression analyses were conducted to calculate the odds ratios (ORs) and 95% confidence intervals (CI) for predictors of long-term unfavorable outcomes (mRS > 2).

Results: A total of 71 elderly AVMs were followed up for an average of 4.2 ± 2.3 years. Fifty-four (76.1%) presented with hemorrhage, and the preoperative annualized rupture risk was 9.4%. Among these patients, 21 cases (29.6%) received conservative treatment, 30 (42.3%) underwent microsurgical resection, 13 (18.3%) received embolization, and 7 (9.9%) underwent SRS. In the prognostic comparison, the short-term and long-term neurological outcomes were similar between conservation and intervention both in the ruptured and unruptured subgroups (ruptured: p = 0.096, p = 0.904, respectively; unruptured: p = 0.568, p = 0.306, respectively). In the ruptured subgroup, the intervention cannot reduce long-term mortality (p = 0.654) despite the significant reduction of subsequent hemorrhage than conservation (p = 0.014), and the main cause of death in the intervention group was treatment-related complications (five of seven, 71.4%). In the logistic regression analysis, higher admission mRS score (OR 3.070, 95% CI 1.559–6.043, p = 0.001) was the independent predictor of long-term unfavorable outcomes (mRS>2) in the intervention group, while complete obliteration (OR 0.146, 95% CI 0.026–0.828, p = 0.030) was the protective factor.

Conclusions: The long-term outcomes of elderly AVMs after different management modalities were similar. Intervention for unruptured elderly AVMs was not recommended. For those ruptured, we should carefully weigh the risk of subsequent hemorrhage and treatment-related complications. Besides, complete obliteration should be pursued once the intervention was initiated.

Clinical Trial Registration:http://www.clinicaltrials.gov. Unique identifier: NCT04136860

[Sex Estimation of Typical Adult Vertebrae Morphology in Central China Based on CT Technique]

Abstract

Objective The morphological data of the second thoracic vertebra and the third lumbar vertebra were measured by computerized tomography （CT）. The sex differences were analyzed and the discrimination equation was obtained. Methods The data of 274 adults （203 cases from experimental group and 69 cases from validation group） from central China were collected. Four linear data （maximum transverse length of vertebral body, maximum longitudinal length of vertebral body, maximum transverse length of vertebral foramen, maximum longitudinal length of vertebral foramen）, one angle data （angle between spinous processes） and two area （vertebral foramen area, total cross-sectional area of vertebral body） data of the second thoracic vertebra and the third lumbar vertebra were collected, respectively. Then three ratios ［maximum transverse length/　maximum longitudinal length of vertebral body, maximum transverse length/ maximum longitudinal length of vertebral foramen, vertebral foramen area/ （total cross-sectional area of vertebral body-vertebral foramen area）］ and one angle （angle between spinous processes） were obtained. The discriminant equation was established for sexual discriminant analysis. Results The morphology of the second thoracic vertebra and the third lumbar vertebra was related with gender. Four single index discriminant formulae and eleven multi-index discriminant formulae were established. The 69 validation group samples were substituted into the formula for testing, and the maximum discriminant accuracy rate of the single-index discriminant formula was 75%. The maximum discriminant accuracy rate of multi-index discriminant formula was 83%. Conclusion It is feasible to conduct individual sex analysis by the morphological indexes of second thoracic vertebra and the third lumbar vertebra. The indexes have important application values in practice.

Effects of IL-1β and IL-18 induced by NLRP3 inflammasome activation on myocardial reperfusion injury after PCI

OBJECTIVE

To investigate the effect of nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) inflammasome in the serum levels of interleukin-1β (IL-1β) and interleukin-18 (IL-18) in patients with myocardial reperfusion injury after the percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

Twenty healthy controls (control group) and forty patients (treatment group) were recruited in this study. The enzyme-linked immunosorbent assay (ELISA) was used to measure the serum levels of IL-1β and IL-18 at various time points in both the control and treatment groups. Data processing and analysis were performed using the Statistical Product and Service Solution (SPSS) 22.0 software (IBM Corp, Armonk, NY, USA). Pearson's correlation coefficient test was applied in all data analyses. A difference was statistically significant when p<0.05.

RESULTS

The levels of IL-1β and IL-18 in the treatment group were significantly higher than those in the control group (p<0.05). The IL-1β level in the treatment group peaked at 0.5 h after PCI and then, gradually decreased. The multiple regression analysis showed that IL-1β level was positively correlated with levels of LDL-C and IL-18 (p<0.05, r=0.527 and 0.955 respectively), and negatively correlated with the HDL-C level (p<0.05, r=-0.34).

CONCLUSIONS

The levels of IL-1β and IL-18 significantly rose in patients with myocardial ischemia-reperfusion injury after PCI.

Effect of Lonicera japonica extract on lactation performance, antioxidant status, and endocrine and immune function in heat-stressed mid-lactation dairy cows

Here, we examined the effects of Lonicera japonica extract (LJE) on lactation performance, antioxidant status, and endocrine and immune function in heat-stressed mid-lactation dairy cows. Twenty-four healthy Chinese Holstein mid-lactation dairy cows, all with similar milk yield (30.0 ± 1.0 kg/d), parity (2.5 ± 0.3), and days in milk (105 ± 5 d) were allocated to 4 groups using a randomized complete block design: a negative control group (without LJE supplementation; CON) and groups that received LJE at 14, 28, and 56 g/d. The experiment lasted 10 wk over a hot summer, with a pre-feeding period of 2 wk. Cows were exposed to heat stress, as the average temperature-humidity index was greater than 72. The results showed that LJE had no effect on respiration rate; however, it reduced the rectal temperature of dairy cows experiencing heat stress in both a linear and quadratic manner; the lowest (39.03°C) was recorded for the LJE-28 group, lower than the CON group. Supplementation with LJE did not affect dry matter intake, milk yield, or milk composition. The majority of biochemical parameters in serum were unaffected by supplementation with different amounts of LJE; the exception was creatinine, which was reduced quadratically. Compared with the CON group, serum triiodothyronine concentrations increased significantly in the LJE-28 group. Addition of LJE to the diet increased thyroxine concentrations quadratically; values peaked at 18.62 ng/mL in the LJE-28 group. Furthermore, supplementation with increasing amounts of LJE quadratically increased the activity of glutathione peroxidase and total antioxidant capacity in serum but decreased concentration of malondialdehyde. Although we detected no differences in the concentrations of IgA, IgM, or cytokines, dairy cows in the LJE-28 group had higher IgG and IL-4 concentrations than did cows in the CON group. Supplementation with LJE increased concentrations of IgG and IL-4 in the serum quadratically but decreased that of IL-2. Finally, heat shock protein 72 concentrations in the serum tended to fall quadratically as the amount of LJE increased. In summary, LJE had no negative effects on lactation performance but helped to alleviate heat stress by improving antioxidant status and promoting endocrine and immune functions. Supplementation with LJE at 28 g/d is recommended for lactating dairy cows experiencing heat stress during hot summers.

Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience

OBJECTIVE

The aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations (AVMs) after different management modalities.

METHODS

The authors retrospectively reviewed 61 brainstem AVMs in their institution between 2011 and 2017. The rupture risk was represented by annualised haemorrhagic rate. Patients were divided into five groups: conservation, microsurgery, embolisation, stereotactic radiosurgery (SRS) and embolisation+SRS. Neurofunctional outcomes were evaluated by the modified Rankin Scale (mRS). Subgroup analysis was conducted between different management modalities to compare the long-term outcomes in rupture or unruptured cohorts.

RESULTS

All of 61 brainstem AVMs (12 unruptured and 49 ruptured) were followed up for an average of 4.5 years. The natural annualised rupture risk was 7.3%, and the natural annualised reruptured risk in the ruptured cohort was 8.9%. 13 cases were conservative managed and 48 cases underwent intervention (including 6 microsurgery, 12 embolisation, 21 SRS and 9 embolisation+SRS). In the selection of interventional indication, diffuse nidus were often suggested conservative management (p=0.004) and nidus involving the midbrain were more likely to be recommended for intervention (p=0.034). The risk of subsequent haemorrhage was significantly increased in partial occlusion compared with complete occlusion and conservative management (p<0.001, p=0.036, respectively). In the subgroup analysis, the follow-up mRS scores of different management modalities were similar whether in the rupture cohort (p=0.064) or the unruptured cohort (p=0.391), as well as the haemorrhage-free survival (p=0.145). In the adjusted Bonferroni correction analysis of the ruptured cohort, microsurgery and SRS could significantly improve the obliteration rate compared with conservation (p<0.001, p=0.001, respectively) and SRS may have positive effect on avoiding new-onset neurofunctional deficit compared with microsurgery and embolisation (p=0.003, p=0.003, respectively).

CONCLUSIONS

Intervention has similar neurofunctional outcomes as conservation in these brainstem AVM cohorts. If intervention is adopted, partial obliteration should be avoided because of the high subsequent rupture risk.

TRIAL REGISTRATION NUMBER

NCT04136860.

[Interpretation for the group standards in guidelines for personal protection against coronavirus disease 2019 for diseases control person]

As an emerging infectious disease, the COVID-19 threatened the safety of personnel in the prevention and control during the COVID-19 pandemic. Beijing Association of Preventive Medicine organizes the Beijing CDC and other organizations drafted the group standard entitled "Guidelines for personal protection against coronavirus disease 2019 for diseases control person (T/BPMA 0002-2020)" , according to years of scientific research on personal protection. Based on the principles of emphasizing the scientific, normative and safe nature, the standard was drafted to put forward the reasonable selection and correct use of personal protective equipment for disease control personnel, as well as the procedures for personal protective equipment. The standard provided a standardized basis for ensuring the safety of disease control personnel in contacting and handling of the new coronary pneumonia outbreaks with high risks.

Contemporary management of brain arteriovenous malformations in mainland China: a web-based nationwide questionnaire survey

BACKGROUND

In the benefit of the large population and rapid economic growth, the interventional techniques and equipment for brain arteriovenous malformations (bAVMs) in mainland China have been rapidly improved. Chinese neurosurgical cerebrovascular physicians have accumulated rich experience and made pioneering explorations. This study aims to summarize the experience and treatment progress of bAVMs in mainland China.

METHODS

We performed a web-based nationwide questionnaire survey among 67 tertiary neurosurgical institutions that had acknowledged treating bAVMs in the primary survey. Our questionnaire included clinical characteristics, radiological findings, intervention indications/contraindications, intervention timing, and intraoperative management of different treatment modalities.

RESULTS

A total of 63 participants from 49 (73.1%) tertiary neurosurgical institutions responded to our questionnaire. Forty-two (66.7%) were neurosurgeons, 13 (20.6%) were neurointerventionists, and 8 (12.7%) were radiosurgeons. Approximately 3500 to 4000 cases of bAVMs were treated annually in these 49 departments. All participants agreed that the conclusions of ARUBA are debatable. Flow-related aneurysms, deep venous drainage, and arteriovenous fistula were considered as common hemorrhagic risk factors. Unruptured SM IV-V bAVMs, giant bAVMs, pediatric bAVMs, elderly bAVMs, and eloquent bAVMs were not absolute contraindications to intervention. Maximum lesion occlusion and minimal functional impairment were the principles of intervention management. Most of the neurosurgeons and neurointerventionists recommended early intervention (< 30 days) for ruptured bAVMs, and the radiosurgeons suggested intervention in the chronic phase or recovery phase (P < 0.01) and preferably 3 months after bleeding. Multi-modality strategies were thought effective for complex bAVMs, and more exploration of individualized intraoperative management was necessary.

CONCLUSIONS

Intervention was acceptable for specific selected unruptured bAVMs in mainland China, especially in patients with hemorrhagic risk factors. The application of multidisciplinary cerebrovascular team and multicenter large-sample international registry study might be the next work for Chinese neurosurgical cerebrovascular physicians.

[A study on the relationship between insufficient sleep and obesity among children and adolescents in China]

Objective: To analyze the relationship between insufficient sleep and obesity or central obesity in Chinese Han children and adolescents aged 9-18 years. Methods: A total of 172 710 students who participated in the 2014 Chinese National Survey on Students Constitution and Health with complete data of sleep duration and physical examination, were selected as study subjects. Insufficient sleep was defined, according to the amount of sleep for pediatric populations recommended by the American Academy of Sleep Medicine. Obesity and central obesity of children and adolescents were judged by experts from the Group of China Obesity Task Force and Health Industry Standards in China. Differences between groups were compared by using the t test or χ(2) test. Logistic regression method was applied to assess the relationship between insufficient sleep and obesity or central obesity. Results: In 2014, numbers of students with insufficient sleep, obesity and central obesity among Chinese Han children and adolescents aged 9-18 years appeared as 133 410 (77.2%), 11 145 (6.5%), and 12 603 (17.8%), respectively. Among the students with insufficient sleep, 8 358 (6.3%) were with obesity and 12 244 (17.9%) were with central obesity. The prevalence of obesity and central obesity among boys with insufficient sleep was higher than that in girls. Pupils with insufficient sleep showed the highest prevalence of obesity and central obesity. After controlling for potential confounders, the risk of obesity appeared an increase of 14.5% (OR=1.145, 95%CI: 1.092-1.200) and the risk of central obesity increased by 12.7% (OR=1.127, 95%CI: 1.078-1.178) in students with insufficient sleep, when compared with those with adequate sleep. Compared with those whose daily sleep duration was less than 6 hours, the ones who slept 7-10 hours per day showed significantly reduction on the risk of obesity and central obesity in students. Conclusions: Insufficient sleep significantly increase the risk of obesity and central obesity in children and adolescents while adequate sleep of 7-10 hours per day would reduce the risk of obesity and central obesity in students.

AB0148 ANALYSIS OF DIFFERENTIALLY EXPRESSED GENES AND MICRORNAS OF B CELLS IN PRIMARY SJOGREN’S SYNDROME BY RNA SEQUENCING

Background:

Primary Sjogren’s syndrome (pSS) is a chronic autimmune disease mainly characterized by the inflammation of exocrine glands. There two key insights into pSS pathogenesis, which included “IFN signature” and hyperactivity of B cells. mRNA and microRNA (miRNA) are very important to control the gene expression.

Objectives:

In this research, we analyzed the differentially expressed genes (DEG) and miRNA of B cells in pSS patients by RNA-sequencing. And we aim to preliminarily screen out some special miRNAs and target gene loci that may be involved in transcription regulation of B cells of pSS.

Methods:

Peripheral blood samples from 3 pSS patients and 3 age-matched healthy controls (HC) were collected. CD19+B cells were sorted by Magnetic cell sorting method. Total RNA was extracted and cDNA of transcriptome or miRNA analysis were prepared and RNA-sequencing was performed to screen the DEG and miRNA. The GO Terms was used to uncover the biological function of DEGs, and the KEGG pathway enrichment was used to find out the related signal pathway. The mRNA-miRNA conjoint analysis was also performed.

Results:

There were a total of 73 significantly DEGs in B cells of pSS patients compared to HC, including 51 upregulated DEGs (such asIFI44L,IFI44,IFIT1,IFITM1,IFIT3,IFIT2,IRF7,IFI6andISG15)and 22 downregulated DEGs (such asESR2andEGR1). GO Terms and KEGG pathway analyses showed that most of the upregulated DEGs were enriched in IFN signaling and IFN regulatory pathway, and also showed the relationship with microbial infection, such as influenza A virus, hepatitis C virus, measles and herpes simplex virus.

There were five significantly differentially expressed miRNAs, including hsa-miR-4485-3p, hsa-miR-144-5p, hsa-miR-144-3p, hsa-miR-451a, hsa-miR-4732-3p. GO Terms and KEGG pathway analyses showed that most of the target genes which regulated by those miRNAs were enrichment on herpes simplex virus and TGF-β signaling pathway.

DEG and differentially expressed miRNAs conjoint analysis showed that the target DEGs which regulated by those miRNAs participated in cytoskeleton formation and modification of DNA or RNA, such asRASD2,CKAP4,SPARS2L METTL.

Conclusion:

There were 51 upregulated DEGs and 22 downregulated DEGs in B cells of pSS patients. GO Terms and KEGG pathway analyses showed that most of the upregulated DEGs were enriched in IFN related signaling pathway, and also showed the significant relationship with microbial infection.

Conjoint analysis showed that the target DEGs which regulated by differentially expressed miRNAs participated in cytoskeleton formation and modification of DNA or RNA. There maybe more than one regulatory methods lead to DEGs in B cells of pSS patients.

Disclosure of Interests:

None declared

OP0093 FREQUENCIES AND PREDICTORS OF THE LUPUS LOW DISEASE ACTIVITY STATE AND REMISSION IN TREATMENT-NAÏVE PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS -- A REAL-WORLD COHORT STUDY

Background:

After the introduction of treat-to-target strategy in systemic lupus erythematosus (SLE), Lupus Low Disease Activity State (LLDAS) and definitions of remission in SLE (DORIS) were developed and validated. Several studies had demonstrated that the achievement and maintenance of LLDAS or DORIS was associated with good prognosis.

Objectives:

To evaluate the attainability of LLDAS and DORIS in a treatment-naïve cohort of SLE.

Methods:

LDAS5 was defined as LLDAS with a prednisone dose ≤5 mg/d. There were 4 definitions in DORIS: clinical remission on treatment (RONT), complete RONT, clinical remission off treatment (ROFT) and complete ROFT. The treatment-naïve patients from Peking University First Hospital SLE cohort were enrolled. The time to each state and their annual cumulative probabilities were estimated by Kaplan-Meier approach. The frequencies of patients who achieved each component of LLDAS or DORIS during follow-up were determined.

Results:

A total of 218 treatment-naïve patients were included, with a median follow-up of 4.48 years. Respectively, 190 (87.2%), 160 (73.4%), 148 (67.9%), 94 (43.1%), 23 (10.6%) and 18 (8.3%) patients achieved LLDAS, LLDAS5, clinical RONT, complete RONT, clinical ROFT and complete ROFT at least once during the follow-up time. The median time to LLDAS, LLDAS5, clinical RONT and complete RONT were 1.4, 2.3, 2.6 and 4.7 years, respectively.

Table 1.

Frequencies, time to achieve and annual cumulative probabilities of each state by Kaplan-Meier approach

StatesAchieved patientsNumber (%)Time to achieve(years)Cumulative probabilities of achievement (%)Year 1Year 2Year 3Year 4Year 5LLDAS190 (87.2)1.418.869.786.789.192.6LLDAS5160 (73.4)2.36.940.763.376.082.3Clinical RONT148 (67.9)2.65.536.156.168.876.6Complete RONT94 (43.1)4.74.122.637.545.350.4Clinical ROFT23 (10.6)NA1.42.95.46.710.6Complete ROFT18 (8.3)NA0.92.54.84.88.8Table 2.

Patients who achieved each component of LLDAS or DORIS during follow-up

ComponentsNumber (%)SLEDAI-2K ≤4, with no activity in major organ systems (renal, central nervous system, cardiopulmonary, vasculitis, fever), and no haemolytic anaemia or gastrointestinal active213 (97.7)Clinical SLEDAI-2K =0210 (96.3)PGA ≤1217 (99.5)PGA <0.5199 (91.3)Serology (anti-dsDNA and complement) negative148 (67.9)Prednisone dose ≤7.5 mg/day201 (92.2)Prednisone dose ≤5 mg/day171 (78.4)No prednisone dose40 (18.3)No prednisone dose and Immunosuppressants32 (14.7)

Conclusion:

Our data confirmed that LLDAS is an attainable early treatment target for SLE. Though with more difficulty, RONT can be achieved in two-thirds of our patients. ROFT may not be an ideal treatment target at present as it is only attained in few patients.

References:

[1]Franklyn, K. et al. Ann Rheum Dis. 2016 Sep;75(9):1615-21.

[2]van Vollenhoven, R. et al. Ann Rheum Dis. 2017 Mar;76(3):554-561.

Disclosure of Interests:

None declared