Analyzing prehospital delays in recurrent acute ischemic stroke: Insights from interpretable machine learning

OBJECTIVE

This study investigates prehospital delays in recurrent Acute Ischemic Stroke (AIS) patients, aiming to identify key factors contributing to these delays to inform effective interventions.

METHODS

A retrospective cohort analysis of 1419 AIS patients in Shenzhen from December 2021 to August 2023 was performed. The study applied the Extreme Gradient Boosting (XGBoost) algorithm and SHapley Additive exPlanations (SHAP) for identifying determinants of delay.

RESULTS

Living with others and lack of stroke knowledge emerged as significant risk factors for delayed hospital presentation in recurrent AIS patients. Key features impacting delay times included residential status, awareness of stroke symptoms, presence of conscious disturbance, diabetes mellitus awareness, physical weakness, mode of hospital presentation, type of stroke, and presence of coronary artery disease.

CONCLUSION

Prehospital delays are similarly prevalent among both recurrent and first-time AIS patients, highlighting a pronounced knowledge gap in the former group. This discovery underscores the urgent need for enhanced stroke education and management.

PRACTICE IMPLICATION

The similarity in prehospital delay patterns between recurrent and first-time AIS patients emphasizes the necessity for public health initiatives and tailored educational programs. These strategies aim to improve stroke response times and outcomes for all patients.

Record high external quantum efficiency of 20% achieved in fully solution-processed quantum dot light-emitting diodes based on hole-conductive metal oxides

Poly(3,4-ethylenedioxythiophene):poly(styrenesulfonate) (PEDOT:PSS) has been widely used as a hole injection material in quantum dot (QD) light-emitting diodes (QLEDs). However, it degrades the organic materials and electrodes in QLEDs due to its strong hydroscopicity and acidity. Although hole-conductive metal oxides have a great potential to solve this disadvantage, it is still a challenge to achieve efficient and stable QLEDs by using these solution-processed metal oxides. Herein, the state-of-the-art QLEDs fabricated by using hole-conductive MoOx QDs are achieved. The α-phase MoOx QDs exhibit a monodispersed size distribution with clear and regular crystal lattices, corresponding to high-quality nanocrystals. Meanwhile, the MoOx film owns an excellent transmittance, suitable valence band, good morphology and impressive hole-conductivity, demonstrating that the MoOx film could be used as a hole injection layer in QLEDs. Moreover, the rigid and flexible red QLEDs made by MoOx exhibit peak external quantum efficiencies of over 20%, representing a new record for the hole-conductive metal oxide based QLEDs. Most importantly, the MoOx QDs afford their QLEDs with a longer T95 lifetime than these devices made by PEDOT:PSS. As a result, we believe that the MoOx QDs could be used as efficient and stable hole injection materials used in QLEDs.

[The long-term efficacy of metformin in megestrol acetate-based fertility-sparing treatment for patients with endometrial atypical hyperplasia and endometrioid endometrial cancer]

Objective: To assess the long-term efficacy of metformin in megestrol acetate (MA)-based fertility-sparing treatment for patients with endometrial atypical hyperplasia (EAH) and endometrioid endometrial cancer (EEC). Methods: The randomized controlled trail study was conducted from October 2013 to October 2017 in the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China. Patients with EAH or EEC were firstly stratified according to pathology, and randomized to receive MA (160 mg orally, daily) plus metformin (500 mg orally, three times a day) or MA (160 mg orally, daily). Baseline data between two groups of patients were compared. Estimates of time to complete remission (CR) and recurrence-free survival (RFS) were calculated using the Kaplan-Meier method. Cox proportional-hazards regression model was used to estimate hazard ratios (HR) of related factors for recurrence-free survival. Quantitative data were represented by M (Q1, Q3). Results: A total of 150 patients were included, and 76 patients were allocated to receive MA plus metformin with the age of 32.5 (28.0, 36.0), while 74 patients received MA alone with the age of 32.0 (28.0, 36.0). By the end of follow-up period, 96.7% (n=145) of patients achieved complete remission, with a median follow-up time of 57.7 (26.7, 70.5) months. The median CR time for the MA plus metformin group and the MA alone group were 6.3 (3.5, 8.3) months and 6.8 (4.0, 9.3) months, respectively (P=0.193), with 2-year cumulative CR rate of 98.6% and 98.5%, respectively (P=0.879). The median time of RFS was 28.1 (12.5, 57.3) months for the MA plus metformin group and 33.3 (14.1, 62.5) months for the MA alone group (P=0.213), with a cumulative RFS rate of 61.9% and 65.8%, respectively (P=0.560). In the subgroup of non-obese (body mass index<28 kg/m2) patients with EAH, the median RFS times were 25.7 (7.6, 60.3) months and 47.3 (17.5, 64.8) months for the MA plus metformin group and the MA alone group, respectively (P=0.033), with a cumulative RFS rate of 57.5% and 80.6%, respectively (P=0.029). According to Cox proportional hazards regression analysis, undergoing assisted reproductive treatment (HR=2.358, 95%CI: 1.069-5.204, P=0.034) was identified as an independent risk factor for recurrence-free survival after complete remission of endometrial lesions. Conclusion: The long-term follow-up outcome indicates that there is no significant difference in CR time and RFS time between MA plus metformin therapy and MA alone therapy for patients with EAH or EEC.

[Evaluation of the efficacy and safety of intravenous infusion of ferric derisomaltose in the treatment of iron deficiency anemia: a single-center retrospective analysis]

Objective: To investigate the clinical efficacy and safety of ferric derisomaltose injection versus iron sucrose injection in the treatment of iron deficiency anemia (IDA) . Methods: A total of 120 patients with iron deficiency anemia admitted from June 2021 to March 2023 were given intravenous iron supplementation with ferric derisomaltose to assess the efficacy and safety of hemoglobin (HGB) elevation before and after treatment. Simultaneously, the clinical effects of iron supplementation with iron sucrose were compared to those of inpatient patients during the same period. Results: Baseline values were comparable in both groups. Within 12 weeks of treatment, the elevated HGB level in the ferric derisomaltose group was higher than that of the iron sucrose group, with a statistical difference at all time points, and the proportion of HGB increased over 20 g/L in the patients treated for 4 weeks was higher (98.7%, 75.9% ). During the treatment with ferric derisomaltose and iron sucrose, the proportion of mild adverse reactions in the ferric derisomaltose group was slightly lower than that of the iron sucrose group, and neither group experienced any serious adverse reactions. The patients responded well to the infusion treatment, with no reports of pain or pigmentation at the injection site. Conclusion: The treatment of IDA patients with ferric derisomaltose has a satisfactory curative effect, with the advantages of rapidity, accuracy, and safety. Therefore, it is worthy of widespread clinical use.

[Advances in chest imaging in early chronic obstructive pulmonary disease]

Chronic obstructive pulmonary disease(COPD)is a heterogeneous and complex disease, and is characterized by exertional dyspnea and chronic cough. For many years, lung function testing have been used to diagnose COPD, but the sensitivity of lung function testing is low, so there is an urgent need for more sensitive diagnostic methods that show early changes in pathology. In recent years, with the rapid development of HRCT, quantitative CT, new magnetic resonance imaging technology, optical coherence tomography (OCT), artificial intelligence, electrical impedance tomography, etc, it provides a basis for the early diagnosis of COPD. This article reviewed the progress in imaging studies of early COPD in recent years.

Lymphocyte to Monocyte Ratio is Independently Associated with Futile Recanalization in Acute Ischemic Stroke After Endovascular Therapy

Background and Purpose

Acute ischemic stroke (AIS) caused by large artery occlusion (LAO) poses considerable risks in terms of mortality and disability. Endovascular treatment (EVT) has emerged as a primary intervention for this condition. However, the occurrence of futile recanalization (FR) following EVT remains common, necessitating the identification of predictive markers for treatment outcomes. Although the lymphocyte to monocyte ratio (LMR) has been linked to various diseases, its association with FR after EVT in AIS patients has not been investigated.

Methods

An analysis was conducted on patients with AIS who underwent EVT within 24 hours of symptom onset. The success of reperfusion was evaluated using the modified Thrombolysis in Cerebral Infarction (mTICI) scale, with patients achieving an mTICI score of ≥2b being included in the study. Various clinical, radiological, and laboratory variables, including lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), were collected. Logistic regression analysis was used to determine factors associated with FR, and receiver operating characteristic (ROC) analysis was performed to assess the predictive value of LMR.

Results

Among the cohort of 101 patients, it was observed that 52.4% experienced FR. Upon admission, lower levels of lymphocyte-to-monocyte ratio (LMR) were found to be associated with older age, higher baseline NIHSS scores, lower ASPECTS, and poorer mRS scores at 90 days. Both univariate and multivariate logistic regression analyses indicated that low LMR independently predicted FR, with an adjusted odds ratio of 0.64 (95% CI = 0.412-0.984, p = 0.042). ROC analysis further demonstrated that LMR had an area under the curve (AUC) of 0.789 for predicting FR.

Conclusion

This study establishes the potential value of the lymphocyte-to-monocyte ratio (LMR) as a prognostic marker for predicting FR in patients with AIS undergoing EVT. Decreased LMR levels are associated with unfavorable clinical outcomes.

[Role and clinical significance of MUC4 gene mutations in thrombotic events in patients with classic paroxysmal nocturnal hemoglobinuria]

Objective: This study aimed to investigate the role and clinical significance of MUC4 gene mutations in thrombotic events in patients with classic paroxysmal nocturnal hemoglobinuria (PNH) patients. Methods: A retrospective analysis was conducted on the clinical data and gene sequencing results of 45 patients with classic PNH admitted to the Department of Hematology, Tianjin Medical University General Hospital, from June 2018 to February 2022. MUC4 gene mutations in patients with classic PNH were summarized, and the risk factors for thrombotic events in these patients were analyzed. Additionally, the effects of MUC4 gene mutations on the cumulative incidence and survival of thrombotic events in patients with classic PNH were determined. Results: The detection rate of MUC4 gene mutations in patients with classic PNH who experienced thrombotic events (thrombotic group) was 68.8% (11/16), which was significantly higher than that in the non-thrombotic group [10.3% (3/29) ] (P<0.001). All mutations occurred in exon 2. MUC4 mutation (OR=20.815, P=0.010) was identified as an independent risk factor for thrombotic events in patients with classic PNH. The cumulative incidence of thrombotic events was 78.6% (11/14) in the MUC4 gene mutation group (mutation group) and 16.1% (5/31) in the non-mutation group, showing a statistically significant difference between the two groups (P<0.001). Survival analysis showed a lower overall survival (OS) rate in the thrombotic group compared with that in the non-thrombotic group [ (34.4±25.2) % vs. (62.7±19.3) % ] (P=0.045). The OS rate of patients was (41.7±29.9) % in the mutation group and (59.1±18.3) % in the non-mutation group (P=0.487) . Conclusion: MUC4 gene mutations are associated with an increased incidence of thrombotic events in classic PNH patients, highlighting their role as independent risk factors for thrombosis in this population. These mutations can be considered a novel predictive factor that aids in evaluating the risk of thrombosis in patients with classic PNH.

[A new form of familial platelet disorder caused by germline mutations in RUNX1 in a pedigree]

Objective: To investigate the clinical and biological characteristics of familial platelet disorder (FPD) with germline Runt-related transcription factor (RUNX) 1 mutations. Methods: Patients diagnosed with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) with RUNX1 mutations from February 2016 to December 2021 in Wuhan No.1 Hospital underwent pedigree analysis and were screened for gene mutations (somatic and germline). Patients diagnosed with FPD with germline RUNX1 mutations were enrolled and evaluated in terms of clinical characteristics and biological evolution. Bioinformatics analysis was used to assess the pathogenicity of mutations and to analyze the effect of mutated genes on the function of the corresponding protein. Results: Germline RUNX1 mutations were detected in three out of 34 patients suffering from MDS/AML who had RUNX1 mutations. A pedigree of FPD with RUNX1 (RUNX1-FPD) c.562A>C and RUNX1 c.1415T>C mutations was diagnosed, and the mutations were of patrilineal origin. Bioinformatics analysis indicated that the locus at positions 188 and 472 in the AML-1G type of RUNX1 was highly conserved across different species, and that variations might influence functions of the proteins. The mutations were evaluated to be highly pathogenic. Of the nine cases with germline RUNX1 mutations: two patients died due AML progression; one case with AML survived without leukemia after transplantation of hemopoietic stem cells; four patients showed mild-to-moderate thrombocytopenia; two cases had no thrombocytopenia. During the disease course of the proband and her son, mutations in RUNX1, NRAS and/or CEBPA and KIT appeared in succession, and expression of cluster of differentiation-7 on tumor cells was enhanced gradually. None of the gene mutations correlated with the tumor were detected in the four cases not suffering from MDS/AML, and they survived until the end of follow-up. Conclusions: RUNX1-FPD was rare. The mutations c.562A>C and c.1415T>C of RUNX1 could be the disease-causing genes for the family with RUNX1-FPD, and these mutations could promote malignant transformation. Biological monitoring should be carried out regularly to aid early intervention for family members with RUNX1-FPD.

A182 PREDICTING HIGH DIRECT HEALTHCARE COSTS IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN THE FIRST YEAR FOLLOWING DIAGNOSIS

Background

The incidence of inflammatory bowel disease (IBD) continues to rise rapidly among Canadian children. The care of children results in higher direct healthcare costs than adults with IBD. It is imperative that we identify individuals who will become the highest-cost users of the health system in order to intervene early and decrease the individual- and system-level burden of IBD.

Purpose

To develop a predictive-model for high-cost health system users and (2) identify factors associated with high-cost healthcare use.

Method

Incident cases of IBD diagnosed ≤17y residing in Ontario and enrolled in the Canadian Children IBD Network (CIDsCaNN) between Dec 31 2013 and Jan 31 2019 were linked deterministically using health card number to health administrative data. Using a validated algorithm, direct healthcare costs accumulated between the 31^st and 365^th day after diagnosis were calculated using data from CIDsCaNN (medications) and health administrative data (health system encounters, including surgery). A predictive model was created to determine high-cost (≤25^th percentile) and medium-cost (26^th to 75^th) users, compared to low-cost users (>75th) using ordinal logistic regression. Potential predictive variables were determined a priori based on clinical significance and magnitude of univariable association, based on sample size-informed degrees of freedom. Variables from CIDsCaNN data included: IBD type, age at diagnosis, sex, first line of therapy (steroids, aminosalicylates, exclusive enteral nutrition; yes or no, not mutually exclusive), disease activity (severe vs. moderate vs. none/mild based on PUCAI [UC] or wPCDAI [Crohn’s]). Predictive variables from the health administrative data included: rural/urban residence, hospitalization at diagnosis, intestinal resection or colectomy within 3 months of diagnosis, emergency department visit ±1 month of diagnosis, and a mental health encounter within the first year following diagnosis. Anti-TNF treatment was excluded from models due to the strong correlation with the outcome (direct costs). Overall model fit was estimated with a c-statistic.

Result(s)

Among the 487 (57% Crohn’s) children included in the study, the mean (sd) direct costs accumulated between the 31^st and 365^th days following IBD diagnosis was $14,451 (14,665). The mean cost among high-cost users was $33,533 (16,530); medium-cost users, $11,038 (5322); low-cost users, $2530 (831). The predictive model identified high-cost users of the health system with acceptable model fit (c-statistic 0.69). The relative contribution of individual variables, as measured by odds ratio (OR), is reported in the Table.

Image

Conclusion(s)

The direct healthcare costs of pediatric IBD are substantial. Children with IBD who become high-cost users of the health system were identifiable using characteristics at diagnosis (e.g., need for mental health care, emergency visits, older age). Further research should assess whether interventions in patients at-risk for becoming high-cost users may help to reduce costs.

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Ontario Academic Health Sciences Centres Alternate Funding Plan Innovation Fund

Disclosure of Interest

E. Kuenzig: None Declared, R. Duchen: None Declared, T. Walters Grant / Research support from: Janssen, Abbvie, Psfizer, Ferring, Amgen, Consultant of: Janssen, Abbvie, Psfizer, Ferring, Amgen, D. Mack: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, C. Bernstein Grant / Research support from: Research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, Takeda, Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, W. Yu: None Declared, X. Wang: None Declared, J. Guan: None Declared, S. Fung: None Declared, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)

Nomogram-Based Prediction of the Futile Recanalization Risk Among Acute Ischemic Stroke Patients Before and After Endovascular Therapy: A Retrospective Study

Background and Purpose

Futile recanalization (FRC) is common among large artery occlusion (LAO) patients after endovascular therapy (EVT). We developed nomogram models to identify LAO patients at a high risk of FRC pre- and post-EVT to help neurologists select the optimal candidates for EVT.

Methods

From April 2020 to July 2022, EVT and mTICI score ≥2b LAO patients were recruited. Nomogram models was developed by two-step approach for predicting the outcomes of LAO patients. First, the least absolute shrinkage and selection operator (LASSO) regression analysis was to optimize variable selection. Then, a multivariable analysis was to construct an estimation model with significant indicators from the LASSO. The accuracy of the model was verified using receiver operating characteristic (ROC), calibration curve, and decision curve analyses (DCA), along with validation cohort (VC).

Results

Using LASSO, age, sex, hypertension history, baseline NIHSS, ASPECTS and baseline SBP upon admission were identified from the pre-EVT variables. Model 1 (pre-EVT) showed good predictive performance, with an area under the ROC curve (AUC) of 0.815 in the training cohort (TrC) and 0.904 in VC. Under the DCA, the generated nomogram was clinically applicable where risk cut-off was between 15%-85% in the TrC and 5%-100% in the VC. Moreover, age, ASPECTS upon admission, onset duration, puncture-to-recanalization (PTR) duration, and lymphocyte-to-monocyte ratio (LMR) were screened by LASSO. Model 2 (post-EVT) also demonstrated good predictive performance with AUCs of 0.888 and 0.814 for TrC and VC, respectively. Under the DCA, the generated nomogram was clinically applicable if the risk cut-off was between 13-100% in the TrC and 22-85% of VC.

Conclusion

In this study, two nomogram models were generated that showed good discriminative performance, improved calibration, and clinical benefits. These nomograms can potentially accurately predict the risk of FRC in LAO patients pre- and post-EVT and help to select appropriate candidates for EVT.

[Posterior atlanto-axial intraarticular distraction technique as revision surgery to treat atlanto-axial dislocation associated with basilar invagination]

Objective: To examine the effect of posterior atlanto-axial intraarticular distraction technique as revision surgery for failed posterior fossa decompression in patients with basilar invagination(BI) and atlanto-axial dislocation(AAD). Methods: The clinical data of 13 cases of AAD accompanied with BI treated at Department of Neurosurgery, Xuanwu Hospital, Capital Medical University were retrospectively analyzed. There were 3 males and 10 females,aged (42.6±9.5) years (range:30 to 63 years). All cases had assimilation of atlas and once underwent posterior fossa decompression. Anterior tissue was released through posterior approach followed by cage implantation into facet joint and occipital-cervical fixation with cantilever technique. The clinical results were evaluated using Japanese Orthopedic Association scale(JOA) and the main radiological measurements including atlantodental interval (ADI), the distance of odontoid tip above Chamberlain line(DCL),clivus-canal angle(CCA) and the length of syrinx were collected. Paired sample t test was used to compared the data before and after operation. Results: All patients underwent surgery successfully, the mean surgical time was (187.7±47.4) minutes (range from 116 to 261 minutes). Twenty occipital condyle screws, 26 C2 pedicle screws and 3 occipital plates were implanted. Clinical symptoms improved in all patients. Twelve patients had complete reduction of basilar invagination and atlanto-axial dislocation, 1 achieved near completely reduction of basilar invagination. The postoperative ADI, DCL and CCA significantly improved((4.3±1.1) mm vs. (1.8±0.8) mm, (11.7±5.0) mm vs. (6.4±2.8) mm, (142.4±7.9)° vs. (133.3±7.9)°, all P<0.01).There were 5 cases with syringomyelia before surgery, and shrinkage of syrinx was observed 1 week after surgery in all cases. Eight patients achieved bone fusion 3 months after surgery, all patients achieved bone fusion 6 months after surgery. The JOA score increased from 12.8±2.3 before surgery to 14.8±1.3 one year after surgery, with statistically significant difference (t=4.416, P<0.01).No implant failure, spacer subsidence and infection were observed. Conclusion: In cases of failure posterior fossa decompression of basilar invagination and atlanto-axial dislocation, using posterior atlanto-axial intraarticular distraction and cantilever technique with cage implantation could achieve complete reduction and symptomatic relief.

Use of a urinary catheter as a guidewire to facilitate safe nasotracheal intubation following iatrogenic retropharyngeal perforation

Nasotracheal intubation facilitates adequate access for surgical procedures in the oral cavity, is not limited by mouth opening and can be better tolerated by patients in intensive care. Complications of nasotracheal intubation can include epistaxis, turbinate injury and sinusitis. Retropharyngeal submucosal perforation by the tracheal tube has also been infrequently reported. Here, we report a case of difficult nasotracheal intubation resulting in retropharyngeal submucosal perforation in a patient with a history of obstructive sleep apnoea listed for uvulopalatopharyngoplasty. To facilitate successful tracheal re-intubation, we used a soft urinary catheter via the other nostril. In this report, we discuss the reasons why this complication may have occurred, how submucosal perforation could be avoided, and reflect on our management of this rare complication. Difficult nasotracheal intubation can present unique challenges, and airway management plans should be made accordingly.

[Sleep quality and sleep disturbances in Chinese pregnant women: a multicenter cross-sectional study]

Objective: This study aims to investigate the sleep quality of pregnant women in Xuhui District, Shanghai, and the related factors of sleep disturbances during pregnancy. Methods: From February 2019 to February 2021, we used online integrated sleep questionnaire (including PSQI, BQ, ESS, AIS) in Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, The International Peace Maternity and Child Health Hospitals of China Welfare Institution, and Shanghai Eighth People's Hospital, to investigate the sleep quality across pregnancy. We also collected maternal physical examination results, childbearing history, sociodemographic, and other clinical data. The prevalences and related factors of various sleep disturbances in pregnant women were analyzed, including insufficient/excessive nighttime sleep, low sleep efficiency, difficulty falling asleep, poor sleep quality, insomnia, daytime sleepiness, and high risk of sleep-disordered breathing (SDB). Results: This study includes 1 898 cases in the first trimester (T1), 3 099 cases in the second trimester (T2), and 1 539 cases in the third trimester (T3). Poor sleep quality (38.6%), daytime sleepiness (mild 41.9%, moderate 17.7%, severe 2.1%), and suspicious insomnia (32.3%) are most prevalent among women in T1 (P<0.01). In comparison, short sleep time (2.7%), long sleep time (8.6%), difficulty falling asleep (12.2%), poor sleep efficiency (35.4%), very poor sleep quality (6.7%), clinical insomnia (21.8%), and high-risk SDB (6.4%) are most prevalent among women in T3 (P<0.05). During pregnancy, late gestation (OR=1.016, 95%CI: 1.006-1.025) and multiple induced/drug abortions (OR=1.329, 95%CI: 1.043-1.692) are risk factors for poor sleep quality (PSQI>5), while multiple full-term deliveries (OR=0.800, 95%CI: 0.675-0.949) is its protective factor. Advanced maternal age (OR=0.976, 95%CI: 0.956-0.997), multiple full-term deliveries (OR=0.808, 95%CI: 0.680-0.959), late gestation (OR=0.983, 95%CI: 0.974-0.992) and hypertension (OR=0.572, 95%CI: 0.401-0.814) are protective factors for daytime sleepiness (ESS>6). The high-risk pregnancy category (OR=9.312, 95%CI: 1.156-74.978) is a risk factor for insomnia (AIS≥4), while multiple full-term deliveries (OR=0.815, 95%CI: 0.691-0.961) is its protective factor. High BMI (OR=1.334, 95%CI: 1.270-1.402) and hypertension (OR=4.427, 95%CI: 2.539-7.719) are risk factors for high-risk SDB in pregnant women. Conclusions: The prevalences of various sleep disturbances are high throughout pregnancy. Noticeably, symptoms of maternal SDB develop along with pregnancy. Different types of sleep disturbances are associated with different factors. Women of high-risk pregnancy category, in late gestation, with high BMI, hypertension, a history of induced/drug abortion, or without a history of full-term delivery can be at high risk of sleep disturbances during pregnancy.

[Clinical and genetic spectrum of SCN2A gene associated epilepsy and episodic ataxia]

Objective: To explore the clinical manifestations and genetic characteristics of patients with epilepsy and episodic ataxia caused by SCN2A gene variation. Methods: The clinical data of seizure manifestation, imaging examination and genetic results of 5 patients with epilepsy and (or) episodic ataxia because of SCN2A gene variation admitted to the Department of Pediatrics, the Third Affiliated Hospital of Zhengzhou University from July 2017 to January 2021 were analyzed retrospectively. Results: Among 5 patients, 4 were female and 1 was male. The onset age of epilepsy ranged from 4 days to 8 months. There were 2 cases of benign neonatal or infantile epilepsy and 3 cases of epileptic encephalopathy, in whom 1 case had development retardation,1 case transformed from West syndrome to infantile spasm and another one transformed from infantile spasm to Lennox-Gastaut syndrome. One case of benign neonatal-infantile epilepsy was characterized by neonatal onset seizures and episodic ataxia developed at the age of 78 months. Electroencephalograms at first visit of 5 cases showed that 2 cases were normal, 1 case had focal epileptic discharge, and 2 cases had multi-focal abnormal discharge with peak arrhythmia. The brain magnetic resonance imaging (MRI) of 3 cases were nomal, 1 case was abnormal (brain atrophy with decreased white matter) and the results of 1 case was unknown. The follow-up time ranged from 17 months to 89 months. Four cases of epilepsy were controlled and 1 case died at 2 years of age. Two cases had normal intelligence and motor development, 2 had moderate to severe intelligence retardation and motor critical state, and 1 had moderate to severe intelligence and motor development retardation. SCN2A gene variations were identified in all cases. There were 4 missense variations and 1 frameshift variation. Three variations had not been reported so far, including c.4906A>G,c.3643G>T,c.638delT. Conclusions: Variations in SCN2A gene can cause benign neonatal or infantile epilepsy and epileptic encephalopathy. Some children develop episodic ataxia with growing age. The variation of SCN2A gene is mainly missense variation.

[Obstructive sleep apnea and metabolic syndrome: an association study based on a large sample clinical database]

Objective: To investigate the prevalence and associated risk factors of metabolic syndrome (MS) in patients with obstructive sleep apnea (OSA). Methods: From July 2007 to June 2017, a total of 8 155 adult subjects, including 6 484 males and 1 671 females, aged 18-90 (43.13±12.28), body mass index 14.61~59.56 (25.59±3.98) kg/m²,who were admitted to the Department of Otorhinolaryngology head and Neck surgery of The Sixth People's Hospital affiliated to Shanghai Jiao Tong University, were retrospectively analyzed. All patients underwent polysomnography and biochemical tests. Subjects were divided into four groups (non-OSA, mild OSA, moderate OSA, and severe OSA) according to OSA severity. The prevalence of MS was expressed as percentage, and the correlation between OSA and MS and its characteristic pathophysiological indicators was evaluated by logistic regression model after adjusting for factors such as gender, age, BMI, neck circumference, hip circumference, smoking and alcohol consumption, and was expressed by odds ratio (OR). SPSS 25.0 software was used for statistical analysis. Results: The overall prevalence of MS was 43.6%, and that of non-/mild/moderate/severe OSA group was 18.6%, 30.4%, 43.8%, 57.1%.Logistic regression showed that patients with mild/moderate/severe OSA had an increased risk of MS compared with non-OSA patients, with adjusted OR values and confidence intervals of 1.27 (1.05-1.54), 1.84 (1.53-2.22), and 2.08 (1.76-2.46), respectively (P<0.01).In addition, indicators of OSA anoxic burden [oxygen drop index(T_oxygen=7.1), minimum blood oxygen(T_minimum=56.3), blood oxygen saturation below 90% cumulative time ratio (T_CT90=10.6) ]were closely associated with MS disease(P<0.01), but sleep fragmentation index (arousals index) was not significantly associated with MS disease. Conclusion: The risk of MS gradually increases with the severity of OSA, and the indicators reflecting OSA hypoxia burden are closely related to MS disease.

[The effect of diallyl sulfide on the lung tissue of rats poisoned by paraquat]

Objective: To investigate the mechanism of diallyl sulfide (DAS) on paraquat (PQ) - induced acute lung injury in rats. Methods: In May 2016, 32 adult male Wistar rats were randomly divided into control group, model (PQ) group, DAS treatment group and dexamethasone (DXM) treatment group, with 8 rats in each group. PQ poisoning model was established by intragastric administration of PQ solution (70 mg/kg) . 100 mg/kg DAS (DAS treatment group) , normal saline (control group and PQ group) and 1 mg/kg DXM (DXM treatment group) were injected intraperitoneally before and after modeling. After 24 hours, the rats were killed and the degree of lung injury was observed. The expression of inducible nitric oxide synthase (iNOS) in lung tissue was measured. Alveolar macrophages were isolated and cultured. The supernatant was taken to determine the content of NO, and the expressions of iNOS mRNA in alveolar macrophages were detected. Results: Compared with the control group, the pathological injury score and the expression of iNOS in the lung tissue of PQ group were significantly increased, and the content of NO secreted by alveolar macrophages and the expression of iNOS mRNA were significantly increased (P<0.05) . Compared with PQ group, the pathological injury scores and the expressions of iNOS in lung tissue of rats in DAS treatment group and DXM treatment group were significantly decreased, and the contents of NO secreted by alveolar macrophages and the expressions of iNOS mRNA were significantly decreased (P<0.05) . There was no significant difference between DXM group and DAS group (P>0.05) . Conclusion: DAS may have protective effect on acute lung injury induced by PQ in rats.

DEVELOPING twin-specific 75-g oral glucose tolerance test diagnostic thresholds for gestational diabetes based on the risk of future maternal diabetes: a population-based cohort study

OBJECTIVE

To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes.

DESIGN

A population-based retrospective cohort study (2007-2017).

SETTING

Ontario, Canada.

METHODS

Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies.

RESULTS

For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively.

CONCLUSIONS

We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds.

TWEETABLE ABSTRACT

Potential twin-specific OGTT thresholds for GDM were identified.

Therapeutic efficacy of zoledronic acid combined with calcitriol in elderly patients receiving total hip arthroplasty or hemiarthroplasty for osteoporotic femoral neck fracture

Zoledronic acid could improve the clinical outcome in elderly patients receiving total hip arthroplasty or hemiarthroplasty for osteoporotic femoral neck fracture in the 1-year prospective study.

INTRODUCTION

To validate the therapeutic efficacy of zoledronic acid (ZOL) in elderly patients with femoral neck fracture who received total hip arthroplasty (THA) or hemiarthroplasty (HA).

METHODS

Included in this study were 95 elderly patients with femoral neck fractures who received THA/HA between August 2015 and June 2018. They were randomized into a ZOL group and a control group. Patients in ZOL group received a yearly single dose of 5 mg ZOL intravenous injection plus 0.5 μg/day calcitriol and 1000 mg/day calcium carbonate 2 days before THA or HA. Patients in the control group were treated with the same dose of calcitriol and calcium carbonate only without ZOL. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Bone metabolism markers including the total extension of the peptide type I collagen amino end (P1NP) and beta collagen degradation product (β-CTX) were obtained by serum examination. The postoperative functional outcome was assessed using Harris Hip Score (HHS).

RESULTS

During the follow-up period, BMD in the ZOL group was improved and significantly higher than that in the control group at 6 and 12 months post-operation. Bone metabolism markers P1NP and β-CTX in ZOL group remained at a relatively low level as compared with that in the control group at 6 months after treatment. No significant difference in the mean HHS and the excellent/good rate of joint function was observed during the follow-up period between the two groups. The occurrence of adverse events in the ZOL group was significantly higher than that in the control group.

CONCLUSIONS

A single infusion of ZOL shows promise in improving BMD of the healthy side of the femoral neck, lumbar spine, and total hip and decreasing the level of bone markers, which may improve the clinical outcome of patients with osteoporotic femoral neck fractures receiving THA/HA.

[Identification of a novel mutation of SOX10 gene and analysis of the phenotype]

Objective: To explore the clinical features and pathogenic mechanisms of a special syndrome with congenital sensorineural hearing loss, albinism, heterochromia iridis, nystagmus and myelin dysplasia. Methods: Detailed medical history, systematic audiology tests, ophthalmic and neurological examinations were carried out to analyze the clinical features of the child, and further molecular genetic tests including chromosome karyotype analysis, and deafness gene screening were conducted. Results: A new de novo heterozygous mutation (c.336G>T/p.Met112Ile) was detected in the child, while both his parents were demonstrated to be wild-type and symptom free. The analysis of clinical features indicated the diagnosis of PCW syndrome. Conclusion: This study identified a new mutation of SOX10 gene, which enriched the mutation spectrum of this gene. And the analysis of clinical characteristics of this patient also expanded the phenotype of this gene. This study provided a reference for clinical diagnosis and genetic diagnosis of PCW syndrome.

Generation and propagation of hyperbolic secant solitons, Peregrine solitons, and breathers in a coherently prepared atomic system

We study the generation and propagation of hyperbolic secant solitons, Peregrine solitons, and various breathers in a coherently prepared three-level atomic system, where two lower states are coherently prepared prior to the injection of a strong pump field and a weak probe field. We show that a flat dispersion without gain and loss along with a large Kerr nonlinearity can be achieved in a broad range of probe field frequency. Moreover, optical hyperbolic secant solitons can be easily achieved in such a broad range at a very low light intensity and propagate stably. Due to the enhanced Kerr nonlinearity, we also show that it is possible to generate optical rogue waves and breathers with very weak light stimulus, which is three orders of magnitude smaller than that used in nonlinear fibers. Because the gain/absorption is negligible and the quantum noise of the probe field can be significantly suppressed, our work may pave the way for realizing solitons, rogue waves, and breathers at the quantum level.

Association between indoor air pollution, tobacco smoke and tuberculosis: an updated systematic review and meta-analysis

OBJECTIVE

This study aims to further quantify evidence of the association between exposure to indoor air pollution (IAP), tobacco smoke etc., on the one hand and the risk of contracting tuberculosis (TB) on the other.

STUDY DESIGN

This was a systematic review and meta-analysis of articles published between June 2014 and February 2020 in PubMed, Web of Science, among others.

METHODS

We only included studies that controlled for confounders, screened both the exposed and unexposed study participants, and passive smoking studies that limited the study population to non-smokers. Quality of studies was assessed using the Newcastle-Ottawa scale. The analysis was conducted using STATA, and pooled effect sizes were calculated using the random-effects model, and heterogeneity was tested for using the Cochran Q test and I2 statistic.

RESULTS

A total of 26 articles were included in the final analysis. There was an increased risk of contracting TB among people exposed to IAP (risk ratio [RR] = 1.68, 95% confidence interval [CI] 1.108-2.542). We also observed a two-fold increase in the risk of contracting TB from exposure to secondhand tobacco smoke (RR = 2.15, 95%CI 1.419-3.242). Tobacco smoking doubled the risk of contracting TB (RR = 2.67, 95%CI 2.017-3.527). Furthermore, studies that used microbiological tests showed a higher RR compared to those that used other TB diagnostic methods.

CONCLUSION

Exposure to IAP and secondhand tobacco smoke increases the risk of contracting TB. Various disease prevention campaigns should include IAP awareness and encourage a shift to cleaner sources of energy.

FRI0194 IDENTIFYING PHENOTYPES OF PATIENTS WITH BEHÇET’S SYNDROME BY A CLUSTER ANALYSIS IN A LARGE COHORT

Background:

Behçet’s syndrome (BS) is a clinical entity with heterogeneous clinical manifestations (1). The symptoms and major organ involvement of BS tend to vary among gender and age (2).

Objectives:

To investigate the gender associated clinical features and aggregate of patients with BS based on phenotypes and organ involvement in a well-defined large cohort of patients with BS.

Methods:

This was a single-center study of 1,596 consecutive BS patients in Shanghai, China from 2012 September to 2019 December. We compared clinical variables and conducted a hierarchical cluster analysis applied according to twenty-five clinical variables to determine subgroups of patients.

Results:

A total of 850 BS patients were included. Male gender was associated with ocular involvement (RR 2.33), vascular involvement (RR 2.05) and cardiac lesions (RR 5.52). Female gender associated with genital ulcers (RR 0.85). Four clusters (C1–C4) were yielded. Cluster C1 (n=165, 19.9%), merely oral and genital ulcer type: consisted predominantly of older females. Disease severity was relatively low, Krause score = 2.32. In C2 (n=365, 43.9%), mix type: was an equal gender distribution with older onset age. Most patients had erythematous nodosum (64.1%) and genital ulcers (82.2%). Cardiac and vascular involvement were observed in 9.3% and 12.1%, which were the highest frequencies among the four clusters. C3 (n=160, 19.3%), intestinal type: was an equal sex ratio with older onset age. All patients presented with intestinal ulcer, while fewer patients had erythematous nodosum and pseudofolliculitis, 20.0% and 25.0% respectively. In C4 (n=141, 17.0%), uveitis type: was predominantly male with younger onset age. Intestinal involvement was negatively associated with uveitis [0.24, (0.13, 0.46), P < 0.0001]. No patients had cardiac involvement in C3 or C4. Regarding the sensitivity of classification criteria, Cheng and Zhang (China) remain the highest in all clusters compared with Japan revised criteria, ICBD, ISG.

Conclusion:

From our large cohort, the gender-phenotypes analyses suggest that male is a risk factor for ocular and cardiovascular in BS patients. We identify four unique subphenotypes representing different clinical features, intestinal and ocular phenotype clusters represent the two most common manifestations of major organ involvement in BS.

References:

[1]Bettiol A, Hatemi G, Vannozzi L, et al. Treating the Different Phenotypes of Behcet’s Syndrome. Front Immunol 2019;10:2830.

[2]Ishido T, Horita N, Takeuchi M, et al. Clinical manifestations of Behcet’s disease depending on sex and age: results from Japanese nationwide registration. Rheumatology (Oxford). 2017;56:1918-27.

TABLE 1.

Characteristics of patients with Behçet’s syndrome after clustering on clinical manifestations

CharacteristicsC1 (n=165)C2 (n=356)C3 (n=160)C4 (n=141)Age at onset (IQR), years29 (20-40)28 (20-35)27 (20-38)25 (19-32)Disease duration (IQR), years5 (3-10)8 (3-10)6 (3-10)7 (4-10)Male gender (%)38.952.351.275.2Classification criteriaJPN (%)069.625.083.7CHN (%)98.896.797.599.3ICBD (%)98.889.965.699.3ISG (%)0.672.125.081.6Oral ulceration (%)10010098.199.3Genital ulceration (%)98.282.263.158.9Erythema nodosum (%)064.120.048.9Pseudofolliculitis (%)034.525.027.0Arthritis/Arthralgia (%)036.211.614.2Uveitis (%)0.60.81.9100Gastrointestinal involvement (%)01.11002.7Vascular involvement (%)2.412.11.24.3Cardiac lesion3.69.300Central nerve system involvement (%)4.23.82.53.5

JPN: Japan revised criteria; CHN: Cheng and Zhang (China) criteria; ICBD: International Criteria for Behçet’s disease; ISG: International Study Group for Behçet’s disease.

Disclosure of Interests:

None declared

0559 Association of Rapid Eye Movement Sleep with Insulin Resistance in Han Chinese Patients With Obstructive Sleep Apnea

Introduction

Obstructive sleep apnea (OSA) is increasingly associated with insulin resistance. The underlying pathophysiology remains unclear but rapid eye movement (REM) sleep has been hypothesized to play a key role. To investigate the associations of insulin resistance with respiratory events and sleep duration during REM sleep, 4,062 Han Chinese individuals with suspected OSA were screened and 2,899 were analyzed.

Methods

We screened 4,062 participants with suspected OSA who underwent polysomnography in our sleep center from 2009 to 2016. Polysomnographic variables, biochemical indicators, and physical measurements were collected. Logistic regression analyses were conducted to determine the odds ratios (ORs) and 95% confidence intervals (95% CIs) for insulin resistance as assessed by hyperinsulinemia, the homeostasis model assessment of insulin resistance (HOMA-IR), fasting insulin resistance index (FIRI), and Bennet’s insulin sensitivity index (ISI).

Results

The final analyses included 2,899 participants. After adjusting for age, gender, body mass index, waist circumference, mean arterial pressure, smoking status, alcohol consumption, and the apnea and hypopnea index during non-REM sleep (AHINREM), the results revealed that AHI during REM sleep (AHIREM) was independently associated with insulin resistance; across higher AHIREM quartiles, the ORs (95% CIs) for hyperinsulinemia were 1.340 (1.022, 1.757), 1.210 (0.882, 1.660), and 1.632 (1.103, 2.416); those for abnormal HOMA-IR were 1.287 (0.998, 1.661), 1.263 (0.933, 1.711), and 1.556 (1.056, 2.293); those for abnormal FIRI were 1.386 (1.048, 1.835), 1.317 (0.954, 1.818), and 1.888 (1.269, 2.807); and those for abnormal Bennet’s ISI were 1.297 (1.003, 1.678), 1.287 (0.949, 1.747), and 1.663 (1.127, 2.452) (P &lt; 0.01 for all linear trends). Additionally, the results showed that for every 1-h increase in REM duration, the risk of hyperinsulinemia decreased by 22.3% (P &lt; 0.05).

Conclusion

The present study demonstrated that AHIREM was independently associated with hyperinsulinemia and abnormal HOMA-IR, FIRI, and Bennet’s ISI. Additionally, REM sleep duration was independently associated with hyperinsulinemia.

Support

This study was supported by Grants-in-aid from Shanghai Municipal Commission of Science and Technology (No.18DZ2260200).

0713 Association Between Obesity Indices And Obstructive Sleep Apnea Is Modified By Age In A Sex-specific Manner

Introduction

The beneficial effects of weight loss on obstructive sleep apnea (OSA) are highly variable. Whether the variability is associated with the effects of age and sex remains unclear. This study examined this issue with large cross-sectional data.

Methods

A total of 4600 adult males and 1156 females with suspected OSA were included in the study. Anthropometric measurements, polysomnographic variables, biochemical indicators, and medical history were collected for each subject. Multivariable linear regression with interaction terms was used to estimate the modification effect of age on the associations between OSA severity (assessed by apnea-hypopnea index, AHI) with obesity indices (body mass index, BMI; neck circumference, NC; waist circumference, WC) in a sex-specific manner, and vice versa.

Results

BMI, NC, and WC were all positively correlated with AHI after adjusting for potential confounders in all populations. In males, these associations were much stronger and more significant in younger than older individuals (P for interaction &lt; 0.001). For example, a 10% increase in BMI was independently associated with a 31.6% increase in AHI for males &lt; 40 years old, whereas the corresponding increases were 20.8% and 16.7% for males 40-60 and &gt;60 years old, respectively. By contrast, no modification effect of age was observed in females (P for interaction &gt; 0.05). A 10% increase in BMI was associated with 25.6%, 26.8%, and 23.8% increases in AHI for females &lt; 40, 40-60, and &gt;60 years old, respectively.

Conclusion

Age modifies the associations between obesity indices and OSA severity in a sex-specific manner, and vice versa. These findings may broaden the understanding of age- and sex-related heterogeneities in the pathogenic role of obesity in OSA, and may be beneficial for individualized risk evaluation and treatment management for patients with OSA.

Support

This study was funded by Shanghai Municipal Commission of Science and Technology (grant number.18DZ2260200); the National Key R&D Program of China (grant number: 2017YFC0112500); Multi-Center Clinical Research Project from the School of Medicine, Shanghai Jiao Tong University (grant number: DLY201502); and the Shanghai Shen-Kang Hospital Management Center Project (grant number: SHDC12015101 and 16CR3103B).

0601 Use of The Epworth Sleepiness Scale, the NoSAS, and the STOP-BANG Questionnaire to Identify Patients with Moderate-to-Severe Obstructive Sleep Apnea

Introduction

A variety of scales and questionnaires regarding sleep and sleep-related disorders have been widely used in scientific research and clinical practice, as important tools for differential diagnosis and rapid screening of complex sleep disorders, especially obstructive sleep apnea (OSA). However, the diagnostic efficacy of different scales and questionnaires for patients with different severity of OSA and of different demographic characteristics has not been clearly described. In this study, we evaluated the ability of the most popular scales, including the Epworth Sleepiness Scale (ESS), the NoSAS, and the STOP-BANG questionnaire in predicting moderate-to-severe obstructive sleep apnea (OSA) by gender.

Methods

This cross-sectional study screened 2,031 consecutive subjects referred with suspected OSA from 2012 to 2016. Anthropometric measurements, polysomnographic data, ESS, NoSAS scores and STOP-BANG scores were recorded. Receiver operating characteristic curve analyses were performed, and the final predictive models were verified in a validation cohort.

Results

A total of 1,840 adults were finally included. The STOP-BANG questionnaire afforded a better diagnostic accuracy than did the ESS, with different cutoffs for the two genders: 3 in males and 1 in females. A predictive model based on STOP-BANG yielded an area under the curve (AUC) of 0.918 (0.897-0.935), a sensitivity of 79.89%, and a specificity of 89.19%, in males; and an AUC of 0.951 (0.914-0.975), a sensitivity of 80.52%, and a specificity of 95.92%, in females. In the validation cohort, the sensitivity and specificity were respectively 85.44 and 93.00% in males and respectively 83.02 and 87.60% in females.

Conclusion

The STOP-BANG questionnaire was moderately effective when used to screen for moderate-to-severe OSA. A STOP-BANG-based predictive model afforded excellent diagnostic efficacy, which could be applied in clinical practice. However, gender differences must be considered.

Support

This study was supported by Grants-in-aid from Shanghai Municipal Commission of Science and Technology (Grant No.18DZ2260200).

0565 Obstructive Sleep Apnea, But Not Short Sleep Duration, is Independently Associated with Insulin Resistance: A Large-Scale Cohort Study

Introduction

Both short sleep duration and obstructive sleep apnea (OSA) seem to be associated with insulin resistance. However, the majority of previous studies addressing the relationship between OSA and insulin resistance did not evaluate short sleep duration, and vice versa. In this study, we used a large-scale hospital-based cross-sectional dataset, including 5,447 participants, to examine 1) whether objectively measured short sleep duration and OSA are independently associated with insulin resistance, and 2) whether the presence of OSA modulates the association between sleep duration and insulin resistance.

Methods

Participants were consecutively enrolled from our sleep center during the period from 2007 to 2017. The index of homeostasis model assessment insulin resistance (HOMA-IR) was calculated from insulin and glucose. Sleep duration was determined by standard polysomnography. The associations between sleep duration and insulin resistance were estimated by logistic regression analyses.

Results

A total of 5,447 participants (4507 OSA and 940 primary snorers) were included in the study. In comparison to primary snorers, OSA combined with extremely short sleep duration (&lt; 5 hours) increased the risk of insulin resistance by 34% (OR, 1.34; 95% CI, 1.01-1.77) after adjusting for confounding factors that are frequently associated with insulin resistance and OSA. In subgroup analysis stratified by sleep duration, the risk of insulin resistance in patients with a short sleep duration (5-6 hours or &lt; 5 hours) was increased in those with OSA compared to primary snorers, but not in the other three sleep duration groups (6 - 7, 7 - 8, and &gt; 8 hours).

Conclusion

OSA, but not short sleep duration, was independently associated with insulin resistance. It is worth noting that OSA combined with extremely short sleep duration showed a greater detrimental effect than OSA itself with regard to insulin resistance.

Support

This study was supported by grants-in-aid from Shanghai Municipal Commission of Science and Technology (Grant No.18DZ2260200).

Romosozumab or alendronate for fracture prevention in East Asian patients: a subanalysis of the phase III, randomized ARCH study

Romosozumab, a sclerostin antibody, exerts dual effect to increase bone formation and decrease bone resorption. Among high-risk postmenopausal East Asian women, romosozumab followed by alendronate was associated with lower incidences of fractures vs alendronate alone. Romosozumab demonstrates potential to address an unmet need in osteoporosis management in Asia.

INTRODUCTION

Romosozumab, a sclerostin antibody, exerts dual effect to increase bone formation and decrease bone resorption. The global ARCH study demonstrated superiority of romosozumab followed by alendronate in reducing fracture risk in high-risk postmenopausal osteoporotic women vs alendronate alone. We report outcomes among ARCH East Asian patients.

METHODS

In ARCH, 4093 postmenopausal osteoporotic women with fragility fracture were randomized 1:1 to monthly romosozumab 210 mg or weekly alendronate 70 mg for 12 months, both followed by open-label alendronate. Primary endpoints were incidence of new vertebral fracture (VF) at 24 months and clinical fracture at primary analysis (confirmed fractures in ≥ 330 patients and all patients had opportunity to attend month 24 visit). This post hoc analysis was not powered to detect fracture-rate differences.

RESULTS

This analysis included 275 patients from Hong Kong, Korea, and Taiwan. Romosozumab followed by alendronate reduced risk of new VFs at 24 months by 60% (P = 0.11) and clinical fractures at primary analysis by 44% (P = 0.15) vs alendronate alone. Romosozumab followed by alendronate significantly increased mean bone mineral density at 24 months from baseline by a further 9.0%, 3.3%, and 3.0% at the lumbar spine, total hip, and femoral neck vs alendronate alone. Adverse event (AE) rates, including positively adjudicated serious cardiovascular AEs (1.6% vs 1.4% at 12 months for romosozumab vs alendronate), were similar across treatment groups.

CONCLUSIONS

Consistent with the global analysis, romosozumab followed by alendronate was associated with lower incidences of new vertebral, clinical, non-vertebral, and hip fractures vs alendronate alone among East Asian patients.

Metformin plus megestrol acetate compared with megestrol acetate alone as fertility-sparing treatment in patients with atypical endometrial hyperplasia and well-differentiated endometrial cancer: a randomised controlled trial

OBJECTIVE

To assess the efficacy of metformin in megestrol acetate (MA)-based fertility-sparing treatment for patients with atypical endometrial hyperplasia (AEH) and endometrioid endometrial cancer (EEC).

DESIGN

A randomised, single-centre, open-label, controlled trial conducted between October 2013 and December 2017.

SETTING

Shanghai OBGYN Hospital of Fudan University, China.

POPULATION

A total of 150 patients (18-45 years old) with primary AEH or well-differentiated EEC were randomised into an MA group (n = 74) and an MA plus metformin group (n = 76).

METHODS

Patients with AEH or EEC were firstly stratified, then randomised to receive MA (160 mg orally, daily) or MA (160 mg orally, daily) plus metformin (500 mg orally, three times a day).

MAIN OUTCOMES AND MEASURES

The primary efficacy parameter was the cumulate complete response (CR) rate within 16 weeks of treatment (16w-CR rate); the secondary efficacy parameters were 30w-CR rate and adverse events.

RESULTS

The 16w-CR rate was higher in the metformin plus MA group than in the MA-only group (34.3 versus 20.7%, odds ratio [OR] 2.0, 95% confidence interval [CI] 0.89-4.51, P = 0.09) but the difference was more significant in 102 AEH patients (39.6 versus 20.4%, OR 2.56, 95% CI 1.06-6.21, P = 0.04). This effect of metformin was also significant in non-obese (51.4 versus 24.3%, OR 3.28, 95% CI 1.22-8.84, P = 0.02) and insulin-sensitive (54.8 versus 28.6%, OR 3.04, 95% CI 1.03-8.97, P = 0.04) subgroups of AEH women. No significant result was found in secondary endpoints.

CONCLUSION

As a fertility-sparing treatment, metformin plus MA was associated with a higher early CR rate compared with MA alone in AEH patients.

TWEETABLE ABSTRACT

For AEH patients, metformin plus MA might be a better fertility-sparing treatment to achieve a higher early CR rate compared with MA alone.

[Vaccine loss related to the expanded immunization program in Xinjiang Uygur Autonomous Region, 2016-2017]

Objective: To assess the vaccine loss related to the Expanded Program on Immunization (EPI) in Xinjiang Uygur Autonomous Region so as to improve the management of vaccines. Methods: A total of 135 vaccination clinics were randomly selected, using a stratified cluster sampling method. In each clinic, data on vaccination was collected between 2016 and 2017, including the number of doses in routine immunization program and supplementary immunization activities (i.e., vaccine doses in vials that were opened for use) on polio vaccine, number of doses administered to children and the number of doses discarded (e.g., expired vaccine or broken vials that had not been opened for use), etc. Coefficient on vaccine loss was calculated with the following equation: vaccine loss coefficient=(number of vaccine doses used)/(number of vaccine doses administered). The vaccine discard rate appeared as: number of vaccine doses discarded)/number of vaccine doses used. Results: For vaccines in single-dose vials [diphtheria-tetanus-pertussis vaccine (DTaP) and trivalent oral polio virus vaccine (tOPV)], the loss coefficients appeared as 1.00 and 1.02, respectively. For vaccines in multi-dose vials [bivalent oral polio vaccine (bOPV), group A meningococcal polysaccharide vaccine (MPV-A), diphtheria-tetanus combined vaccine (DT) and bacilli Calmette-Guérin (BCG) vaccine], the loss coefficients were 1.58, 1.67, 1.68, and 3.02, respectively. The coefficients of EPI vaccine loss in urban, rural, and pastoral area vaccination clinics ranged between 1.00-2.84, 1.00-3.71, and 1.00-2.27, respectively. Loss coefficients ranged between 1.00-3.00, 1.00- 4.41, and 1.00-1.94, respectively, were seen in township clinics, village clinics, and decentralized vaccination clinics. Coefficients on larger vaccine loss were associated with longer intervals between clinic sessions and with fewer vaccinations administrations per day. Conclusions: In Xinjiang, coefficients on the loss of multi-dose EPI vaccines were high. The coefficients on loss were different from the levels of region and types of clinics, and time interval between clinic sessions. Programs on refining the management and distribution of EPI vaccines, to minimize the vaccine loss were recommended.

Relationship of platelet microparticle CD62P and activated GP IIb/IIIa with hypercoagulable state after atrial fibrillation radiofrequency catheter ablation

OBJECTIVE

The morbidity of atrial fibrillation (AF) is 1%-2% in clinic. Radiofrequency catheter ablation (RFCA) is a type of radical interventional therapy for AF, whereas it may lead to a hypercoagulable state. This study evaluated platelet particle CD62P and platelet activation biomarker GP IIb/IIIa expressions in AF patients treated by RFCA, and aimed to analyze their relationships with the hypercoagulable state after RFCA.

PATIENTS AND METHODS

A total of 60 AF patients received RFCA in our hospital were enrolled. The patients were divided into group A as hypercoagulable state group and group B as non-hypercoagulable group. Healthy volunteers were selected as normal control. Serum D-Dimer, parathyroid activity index 1 (PAI-1), and tissue plasminogen activator (t-PA) content were tested by using enzyme-linked immunosorbent assay (ELISA), while peripheral CD62P and GP IIb/IIIa expressions were detected by using flow cytometry before, after, and seven days after RFCA.

RESULTS

D-Dimer and PAI-1 levels increased, while t-PA reduced in group A compared with that in group B and control (p<0.05). D-Dimer and t-PA contents gradually elevated, whereas t-PA level gradually declined in group A before, after, and seven days after RFCA (p<0.05). Serum CD62P and GP IIb/IIIa expressions in group A were significantly higher compared to that in group B and control (p<0.05). CD62P and GP IIb/IIIa levels were significantly higher seven days after RFCA compared with immediate after RFCA in group A (p<0.05). CD62P showed a positive correlation with GP IIb/IIIa in hypercoagulable state patients after RFCA (p<0.05).

CONCLUSIONS

AF patient may appear in hypercoagulable state after RFCA. CD62P and GP IIb/IIIa significantly increased and exhibited a positive correlation.

[Reduction of the atlantoaxial dislocation associated with basilar invagination through single-stage posterior approach: using Xuanwu occipital-cervical reduction surgical suite]

Objective: To examine the effect of posterior reduction in atlantoaxial dislocation (AAD) associated with basilar invagination(BI) using Xuanwu occipital-cervical fusion system in single stage. Methods: Thirty-seven AAD accompanied with BI cases treated at Department of Neurosurgery, Xuanwu Hospital, Capital Medical Universiy and the Second Hospital of Hebei Medical University were retrospective analyzed. There were 15 males and 22 females with age of (42.3±12.3)years (range: 18-69 yars). All the cases had congenital osseous abnormalities, such as assimilation of atlas and abnormal cervical fusion. Anterior tissue was released through posterior route followed by cage implantation into facet joint and occipital-cervical fixation with cantilever technique. The clinical results were evaluated using Japanese Orthopedic Association scale(JOA) and the main radiological measurements including anterior atlantodental interval (ADI),the distance of odontoid tip above Chamberlain line,clivus-canal angle (CCA) and the length of syrinx were collected.The preoperative and postoperative JOA score and radiological measurements were compared by paired t-test. Results: The mean JOA score of the patients increased from 10.5 to 14.4 at the one-year follow-up(t=14.3,P=0.00).Complete reduction of AAD and BI was achieved in 34 patients.The mean clivus-canal angle improved from 118.0 degrees preoperative to 143.7 degrees postoperative(t=6.2,P=0.00). Shrinkage of the syrinx was observed 1 week after surgery in 24 patients, and 6 months in 31 patients. Twenty-eight patients achieved bone fusion 6 months after surgery. All the patients achieved bone fusion 12 months after surgery. One-side vertebral artery occlusion was diagnosed in 1 case postoperatively for transient dizziness, and relieved in 2 weeks. Two patients developed moderate neck pain after surgery, and relieved in 1 month. No implant failure, spacer subsidence or infection was observed. Conclusions: The treatment of AAD associated with BI using Xuanwu occipital-cervical fusion system from posterior approach in single stage is effective and safe. Cage implantation intraarticularly and fixation with cantilever technique achieve complete reduction in most cases.

[Relationship between smoking and the severity of OSA]

Objective:To explore the relationship between smoking and the severity of OSA. Method:There were 719 patients included in the study, who were accompanied by snoring, daytime sleepiness and other symptoms. Laboratory-based polysomnographic variables （including AHI, oxygen desaturation index and microarousal index, etc.）, and anthropometric measurements （including weight, neck circumference, waist circumference, hip circumference etc.） were collected for all participants. The severity of OSA was determined by AHI. No OSA was defined as AHI<5, mild OSA as AHI of 5 to 15，moderate OSA as AHI of >15 to 30, and severe OSA as AHI of >30. Smoking severity was determined by the smoking index （SI）. Light smoke was defined as SI<200, moderate smoke was as SI 200 to 400, and severe smoke as SI>400. Result:There were 138 cases of non-OSA and 581 cases of OSA. There were 381 non-smokers, 279 smokers and 59 quit smokers. The smoking rate of OSA group was significantly higher than that of non-OSA group （41.5% vs. 27.5%,P<0.01）. After excluding 59 quit smokers, the remaining 660 subjects were divided into four groups according to the severity of smoking, then each group was further divided into four groups according to OSA severity. Unadjusted analysis showed that OSA severity positively correlated with smoking severity （r=0.203,P<0.01）. The positive correlation remained significant after further adjustment for age, BMI and waist-hip ratio. In addition, logistic regression analysis showed that compared to non-smokers, the odd ratios for OSA in moderate smokers were 1.72 （95%CI 1.08-2.75） and in severe smokers were 2.68 （95%CI 1.61-4.46）, after adjustment for age, BMI and waist-hip ratio. Conclusion:The severity of smoking significantly correlated with the severity of OSA. There was increased risk of OSA in patients with severe smoke. The correlation was independent of some confounders such as age and obesity.