Multi-disciplinary diabetic limb salvage programme in octogenarians with diabetic foot ulcers is not futile: An observational study with historical controls

This study evaluated the effectiveness of a multi-disciplinary diabetic limb salvage programme in improving clinical outcomes and optimising healthcare utilisation in 406 patients aged ≥80 years with diabetic foot ulcers (DFUs), compared to 2392 younger patients enrolled from June 2020 to June 2021 and against 1716 historical controls using one-to-one propensity score matching. Results showed that elderly programme patients had lower odds of amputation-free survival (odds ratio: 0.64, 95% CI: 0.47, 0.88) and shorter cumulative length of stay (LOS) compared to younger programme patients (incidence rate ratio: 0.45, 95% CI: 0.29, 0.69). Compared to the matched controls, participating in the programme was associated with 5% higher probability of minor lower extremity amputation, reduced inpatient admissions and emergency visits, shorter LOS but increased specialist and primary care visits (all p-values <0.05). The findings suggest that the programme yielded favourable impacts on the clinical outcomes of patients aged≥80 years with DFUs. Further research is needed to develop specific interventions tailoring to the needs of the elderly population and to determine their effectiveness on patient outcomes while accounting for potential confounding factors.

A Systematic Review and Classification of Factors Influencing Diabetic Foot Ulcer Treatment Adherence, in Accordance With the WHO Dimensions of Adherence to Long-Term Therapies

PURPOSE

Effective treatment of diabetic foot ulcers (DFUs) involves a multidisciplinary treatment plan to promote wound healing and prevent complications. Given the lack of consensus data on the factors affecting patient adherence, a systematic review was performed to identify and classify factors according to the WHO Dimensions of Adherence to Long-Term Therapies.

METHODS

Six hundred and forty-three articles from PubMed, Embase, and Scopus were reviewed. The inclusion criteria included qualitative and quantitative studies which discussed factors affecting patient adherence to DFU treatment, had study populations that comprised patients with either prior history of or existing DFU, and had either prior history of DFU treatment or were currently receiving treatment. Factors, and associated measures of adherence, were extracted and organized according to the WHO Dimensions of Adherence to Long-Term Therapies.

RESULTS

Seven quantitative and eight qualitative studies were included. Eleven patient-related factors, seven condition-related factors, three therapy-related factors, five socioeconomic factors, and five health system-related factors were investigated by the included studies. The largest proportion of factors studied was patient-related, such as patient insight on DFU treatment, patient motivation, and patient perception of DFU treatment. There was notable overlap in the range of discussed factors across various domains, in the socioeconomic (including social support, income, social and cultural acceptability of DFU therapy, cost) and therapy-related domains (including duration of treatment, offloading footwear, and reminder devices). Different studies found that specific factors, such as gender and patients having a low internal locus of control, had differing effects on adherence on different cohorts.

CONCLUSION

Current literature presents heterogeneous findings regarding factors affecting patient adherence. It would be useful for future studies to categorize factors as such to provide more comprehensive understanding and personalized care to patients. Further research can be done to explore how significant factors can be addressed universally across different cohort populations in different cultural and socioeconomic contexts.

[Species and population density of malaria vector Anopheles in Sichuan Province from 2011 to 2021]

OBJECTIVE

To investigate the distribution of malaria vector Anopheles in Sichuan Province from 2011 to 2021, so as to provide the scientific evidence for improving the surveillance of malaria vector Anopheles and preventing re-establishment of imported malaria in Sichuan Province.

METHODS

The density and species of Anopheles mosquitoes were investigated using human-bait trapping and light trapping techniques in malaria vector surveillance sites of Sichuan Province from 2011 to 2021. The number, population and density of captured Anopheles mosquitoes were collected and descriptively analyzed, and the geographical distribution map of malaria vectors was plotted using the software ArcGIS 10.7 in Sichuan Province.

RESULTS

A total of 152 243 Anopheles mosquitoes were captured in malaria vector surveillance sites of Sichuan Province from 2011 to 2021, including 150 987 An. sinensis (99.18%) and 1 256 An. anthropophagus (0.82%), and no other Anopheles species were captured. The annual densities of An. sinensis and An. anthropophagus were 0.64 to 1.27 mosquitoes/(person-hour) and 0 to 0.07 mosquitoes/(person-hour) by the human-bait trapping technique, and 6.46 to 26.50 mosquitoes/(light-night) and 0 to 0.82 mosquitoes/(light-night) by the light trapping technique in malaria vector surveillance sites of Sichuan Province from 2011 to 2021. A relatively higher density of An. anthropophagus was seen in Renshou County, Jianyang City, Weiyuan County and Mabian Yi Autonomous County [> 0.40 mosquitoes/(person-hour)] by the human-bait trapping technique, and in Cuiping District and Gaoxian County in Yibin City [> 1.00 mosquito/(light-night)] by the light trapping technique in Sichuan Province from 2011 to 2018, with no An. anthropophagus captured from 2019 to 2021, and a relatively higher density of An. sinensis was detected in Emeishan City, Lushan County, Luojiang District, Tongchuan District and Zhaohua District [> 4.00 mosquitoes/(person-hour)] by the human-bait trapping technique, and in Huili County, Yuexi County, Dechang County, Langzhong City, Pingchang County and Xuanhan County [> 40.00 mosquitoes/(light-night)] by the light trapping technique in Sichuan Province from 2011 to 2021.

CONCLUSIONS

Malaria vectors were still widespread in Sichuan Province from 2011 to 2021, and An. sinensis was the dominant species of malaria vectors. There is still a risk of local re-establishment of imported malaria in Sichuan Province, and it is needed to continue to improve the surveillance of imported malaria cases and malaria vectors.

[Analysis on the use of HIV post-exposure prophylaxis and related factors in men who have sex with men in Qingdao]

Objective: To understand the use of post-exposure prophylaxis (PEP) and analyze related factors among men who have sex with men (MSM) in Qingdao, and provide a reference for the AIDS prevention and control in this population. Methods: A cross-sectional survey conducted from April 2022 to February 2023. Relying on MSM social groups in Qingdao, a snowball sampling method was applied to recruit research subjects who met the inclusion criteria of age ≥18 years old, having had homosexual anal or oral sex in the past six months, and HIV-negative or infection status unknown. The sample size was estimated at 566. Data on demographic characteristics, sexual behavior characteristics, PEP use, and others of the research subjects was collected through on-site questionnaires. The logistic regression model was used to analyze the factors associated with using PEP. Results: A total of 811 participants were recruited, mainly aged 25-34 (53.6%, 435/811), unmarried (74.7%, 606/811), with an average monthly income of ≥5 000 yuan (52.2%, 423/811), and having lived in Qingdao for ≥10 years (75.6%, 613/811). The proportion of those who knew the HIV status of their sexual partners in the last six months was 67.1% (544/811), and those with HIV-positive partners were 3.6% (29/811). In the last six months, the proportion of participants who had group sex (86.4%, 701/811), unprotected anal sex (98.2%, 796/811), and use of club drugs (80.3%, 651/811) was high. Moreover, 28.4% (230/811) had used PEP. The multivariate logistic regression analysis showed that the factors related to the use of PEP included divorced or widowed (aOR=5.46,95%CI:1.96-15.17), average monthly income ≥5 000 yuan (aOR=2.04,95%CI:1.44-2.89), same-sex sexual orientation (aOR=0.40,95%CI:0.22-0.71), having HIV-positive sexual partners in the last six months (aOR=2.54,95%CI:1.13-5.71) and having been tested for HIV ≥3 times in the last six months (aOR=1.46,95%CI:1.04-2.06). Conclusions: The prevalence of risk behaviors among MSM in Qingdao was high, and the use of PEP was low. In the future, it is essential to increase HIV/AIDS prevention education among MSM, promote MSM to know the HIV status of their sexual partners, and reduce the prevalence of risk behaviors among this population. Additionally, explore medical insurance reimbursement plans for PEP to reduce utilization costs and promote the use of PEP by MSM after HIV exposure occurs as soon as possible.

The global burden of lymphoma: estimates from the Global Burden of Disease 2019 study

OBJECTIVES

The aim of this study was to describe the global trends in the burden of lymphoma from 1990 to 2019.

STUDY DESIGN

The data used in this study were from the Global Burden of Disease 2019 study.

METHODS

This study described the age-standardised rates of incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) of lymphoma (non-Hodgkin and Hodgkin's lymphoma, NHL and HL, respectively) annually from 1990 to 2019, stratified by sociodemographic index (SDI) and 21 world regions. The estimated annual percentage changes in these indexes were calculated.

RESULTS

In 2019, the age-standardised rates of HL per 100,000 population were lower than those of NHL in terms of incidence (1.1 vs 6.7 per 100,000 person-years, respectively) and prevalence (0.3 vs 5.7 per 100,000 person-years, respectively) but not mortality (21.6 vs 3.2 per 100,000 person-years, respectively). From 1999 to 2019, the global incidence of HL decreased and the incidence of NHL increased, and the prevalence of both HL and NHL increased, but the mortality rates decreased. When stratified by SDI, the incidence of HL decreased in all but middle-SDI regions, the mortality rate of HL decreased in all regions, and both the incidence and mortality rate of NHL increased in all but high-SDI regions. The prevalence of HL and NHL increased in all SDI regions, especially in middle-SDI regions. YLLs and DALYs of HL in all SDI regions and those of NHL in high-SDI regions decreased. YLDs slightly increased in middle- to high-SDI regions.

CONCLUSIONS

Lymphoma remains a major public health issue, and better prevention, precise identification, and promising treatments are vitally important.

[A cohort study of HIV infection in club drug abusers among men who have sex with men in Qingdao]

Objective: To understand and analyze the incidence of HIV infection in club drug abusers among men who have sex with men (MSM) in Qingdao and provide a reference for the prevention and intervention of this population. Methods: From March 2017 to July 2022, club drug abusers among MSM who are HIV-negative were recruited by snowball sampling of MSM social organizations in Qingdao, a prospective cohort was established, and a follow-up survey was conducted every six months, with the sample size estimated to be 436. The survey contents included demographic characteristics, sexual characteristics, AIDS knowledge awareness, club drug abuse, HIV testing, and other information. HIV infection was the outcome-dependent variable, and the interval between the recruitment into the cohort and the HIV infection was the time-dependent variable. Cox proportional hazards regression analysis was conducted to identify the related factors for HIV infection. Results: A total of 987 participants of club drug abusers among MSM were recruited during the baseline survey and 826 eligible participants were enrolled in this cohort. A total of 46 HIV infection cases were found, and the cumulative follow-up time was 1 960.68 person-years. The incidence of HIV infection was 2.35/100 person-years. The multivariate Cox regression analysis showed that <30 (aHR=3.04, 95%CI: 1.62-5.71) non-Shandong residents (aHR=2.29,95%CI:1.20-4.39) found their partners through offline (aHR=4.62,95%CI:2.05-10.41), homosexual sexual partners >4 (aHR=3.06,95%CI:1.59-5.88), condom broken during sex (aHR=2.24,95%CI:1.21-4.17) and hemorrhage sexual intercourse (aHR=2.56,95%CI:1.31-5.03) were significantly associated with HIV infection in this cohort. Conclusions: The incidence of HIV infection in club drug abusers among MSM in Qingdao is generally low, but knowledge and practice have separated, and the risk of HIV infection is high. The related factors of HIV infection included younger age, non-Shandong residents, finding their partners offline, multiple sexual partners, condom break during sex, and hemorrhage sexual intercourse; HIV-related behavioral intervention should be strengthened.

Ascending thoracic aortic aneurysm size at presentation and growth by diameter

AIM

To investigate the hypothesis that lung cancer screening allows for earlier identification of ascending thoracic aortic aneurysms (aTAAs) and that growth rates for aTAAs are greatest at larger sizes.

MATERIALS AND METHODS

This single referral centre retrospective study manually gathered computed tomography (CT) data from 732 patients presenting from July 2002 to August 2022. Five hundred and seventeen patients with aTAA >39 mm were identified to compare presenting diameter by year of presentation. Four hundred and thirty-two patients had CT examinations >3 months apart, allowing for growth analysis. Patients were separated by initial examination date (before or after 12/31/2013) for presenting size comparison. Patients were then divided into five groups based on aTAA diameter for growth rate analysis.

RESULTS

At identification, patients had a median aTAA diameter of 44 mm (IQR 41-47 mm). Patients with aTAAs identified prior to December 2013 (n=129) had an average aTAA diameter 1.7 mm larger than those identified later (n=388; p=0.003). The growth analysis showed an average growth rate of 0.1 mm/year (p<0.001) across the entire cohort. Patients with an aTAA diameter of ≥55 mm (n=12) grew the fastest at 1.9 mm/year (p<0.001). In the <40 mm group (n=43), the aTAAs expanded at 0.2 mm/year, faster than the 0.1 mm/year of the slowest expanding 45-49 mm group (n=130; p=0.04).

CONCLUSION

aTAA size at discovery was larger before lung cancer screening guidelines took effect in December 2013. The largest aTAAs expanded fastest, but growth rates were slowest in the medium-sized 45-49 mm diameter group.

Perceived Roles and Barriers in Delivering Community-Based Care: A Qualitative Study of Health and Social Care Professionals

Introduction

As healthcare systems increasingly embrace population health management, the integration of health and social care to improve the health and well-being of individuals is crucial. Thus, we conducted a qualitative study in Singapore to understand health and social care professionals' (HCPs and SCPs) perception of the roles they played in delivering community-based care.

Methods

A descriptive phenomenological research design was adopted. HCPs and SCPs (n = 53) providing services in community settings were recruited purposefully and interviewed through eleven focus group discussions. Each session was recorded and transcribed. Thematic analysis was applied.

Results

Our results revealed eight themes in three main categories describing the roles played by HCPs and SCPs, including: (1) delivering needs-based care in community settings; (2) activating and empowering clients in health care, and (3) fostering community-based sustainable support networks. Six barriers encountered while performing these roles were also identified.

Discussion and Conclusion

Our results highlight that the roles of HCPs and SCPs go beyond the provision of direct medical and social care. They were involved in activating and empowering clients to take care of their health, and importantly, fostering community-based sustainable support networks to better empower individuals in coping with health challenges. The identified barriers shed light on areas for potential improvements for integrated community care.

Understanding reasons and determinants of medication non-adherence in community-dwelling adults: a cross-sectional study comparing young and older age groups

BACKGROUND

Medication non-adherence has become a striking problem among patients with chronic diseases worldwide. However, literature on prevalence, reasons and factors associated with medication non-adherence in Singapore general population is still lacking. This study aimed to (1) estimate the prevalence of intentional and unintentional medication non-adherence in young (aged 21-64 years) and older adults (aged ≥ 65 years), respectively; (2) identify and compare the main reasons for non-adherence; and (3) examine the association between potential factors and non-adherence in each group.

METHODS

This study sampled 1,528 community-dwelling adults on medications (young adults:766, older adults: 762) from a cross-sectional population health survey conducted in the northern and central regions of Singapore in 2018/2019. Self-reported medication non-adherence and its reasons were collected using a modified questionnaire and compared between the two groups. Multiple logistic regressions were conducted to examine the association between potential factors (e.g., social-demographic factors, smoking and drinking status, presence of diabetes, hypertension, or dyslipidaemia, and presence of depressive symptoms) and medication non-adherence in each group.

RESULTS

The prevalence of non-adherence was 38.4% and 22.3% in young and older adults, respectively, with young adults reporting higher unintentional and intentional non-adherence rates than older adults. "Afraid of developing drug dependence" was the most common reason in both groups (young:74.8% vs. old:73.5%). Compared to young adults (3.7%), "Not understanding medication labels" was more prevalent in older adults (8.8%). Presence of depressive symptoms was associated with non-adherence in both young (odds ratio [95% confidence interval]: 3.00 [1.79, 5.05]) and older adults (4.16 [2.31, 7.51]). Being employed (2.92 [1.76, 4.84]) and taking ≥ 2 medications (1.42 [1.04, 1.95]) had positive association while personal income of SGD1,000-4,000 (0.53 [0.36, 0.77]) and current smoking (0.61 [0.39, 0.95]) had inverse association with non-compliance in young adults. Diagnosis of diabetes, hypertension, or dyslipidaemia (2.63 [1.25, 5.53]) was associated with higher odds of non-compliance in older adults.

CONCLUSIONS

Young adults had higher prevalence of medication non-adherence than older adults. The main reasons for non-adherence reported by young and older adults were generally comparable. Presence of depressive symptoms was a risk factor of medication non-adherence in both groups.

[Clinical characteristics and short-term prognosis of 22 cases with SARS-CoV-2 infection associated acute encephalopathy]

Objective: To investigate the clinical features and short-term prognosis of patients with SARS-CoV-2 infection associated acute encephalopathy (AE). Methods: Retrospective cohort study. The clinical data, radiological features and short-term follow-up of 22 cases diagnosed with SARS-CoV-2 infection associated AE in the Department of Neurology, Beijing Children's Hospital from December 2022 to January 2023 were retrospectively analyzed. The patients were divided into cytokine storm group, excitotoxic brain damage group and unclassified encephalopathy group according to the the clinicopathological features and the imaging features. The clinical characteristics of each group were analyzed descriptively. Patients were divided into good prognosis group (≤2 scores) and poor prognosis group (>2 scores) based on the modified Rankin scale (mRS) score of the last follow-up. Fisher exact test or Mann-Whitney U test was used to compare the two groups. Results: A total of 22 cases (12 females, 10 males) were included. The age of onset was 3.3 (1.7, 8.6) years. There were 11 cases (50%) with abnormal medical history, and 4 cases with abnormal family history. All the enrolled patients had fever as the initial clinical symptom, and 21 cases (95%) developed neurological symptoms within 24 hours after fever. The onset of neurological symptoms included convulsions (17 cases) and disturbance of consciousness (5 cases). There were 22 cases of encephalopathy, 20 cases of convulsions, 14 cases of speech disorders, 8 cases of involuntary movements and 3 cases of ataxia during the course of the disease. Clinical classification included 3 cases in the cytokine storm group, all with acute necrotizing encephalopathy (ANE); 9 cases in the excitotoxicity group, 8 cases with acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) and 1 case with hemiconvulsion-hemiplegia syndrome; and 10 cases of unclassified encephalopathy. Laboratory studies revealed elevated glutathione transaminase in 9 cases, elevated glutamic alanine transaminase in 4 cases, elevated blood glucose in 3 cases, and elevated D-dimer in 3 cases. Serum ferritin was elevated in 3 of 5 cases, serum and cerebrospinal fluid (CSF) neurofilament light chain protein was elevated in 5 of 9 cases, serum cytokines were elevated in 7 of 18 cases, and CSF cytokines were elevated in 7 of 8 cases. Cranial imaging abnormalities were noted in 18 cases, including bilateral symmetric lesions in 3 ANE cases and "bright tree appearance" in 8 AESD cases. All 22 cases received symptomatic treatment and immunotherapy (intravenous immunoglobulin or glucocorticosteroids), and 1 ANE patient received tocilizumab. The follow-up time was 50 (43, 53) d, and 10 patients had a good prognosis and 12 patients had a poor prognosis. No statistically significant differences were found between the two groups in terms of epidemiology, clinical manifestations, biochemical indices, and duration of illness to initiate immunotherapy (all P>0.05). Conclusions: SARS-CoV-2 infection is also a major cause of AE. AESD and ANE are the common AE syndromes. Therefore, it is crucial to identify AE patients with fever, convulsions, and impaired consciousness, and apply aggressive therapy as early as possible.

[A cohort study of incidence of club drug abuse in men who have sex with men in Qingdao]

Objective: To understand and analyze the incidence of club drug abuse and influencing factors in men who have sex with men (MSM) in Qingdao, and provide reference for the AIDS prevention and intervention in this population. Methods: From March 2017 to July 31, 2022, MSM who did not abuse club drug were recruited by snowball sampling of MSM social organizations in Qingdao, a prospective cohort was established, and a follow-up survey was conducted every 6 months. The survey collected the information about the MSM's demographic characteristics, sexual characteristics, club drug abuse and others. The incidence of club drug abuse was the outcome dependent variable and the interval between the recruitment into the cohort and the incidence of club drug abuse was the time dependent variable. Cox regression analysis was conducted to identify the influencing factors for club drug abuse. Results: A total of 509 MSM were recruited at baseline survey, and 369 eligible MSM were enrolled in this cohort. A total of 62 MSM began to abuse club drug during the study period, and the cumulative follow-up time was 911.54 person-years, the incidence of club drug abuse was 6.80/100 person-years. All the club drug abusers shared drugs with others in the first club drug abuse, and 16.13% (10/62) had mix-use of club drugs. The multivariate Cox proportional risk regression analysis showed that being students (aHR=2.17, 95%CI: 1.15-4.10), receiving no HIV testing or receiving 1 HIV testing during past 6 months (aHR=4.57, 95%CI:1.80-11.60; aHR=5.15, 95%CI: 2.83-9.36), having sex only with regular sexual partners during past 6 months (aHR=4.75,95%CI:2.32-9.75), having more than 4 homosexual partners (aHR=1.70, 95%CI:1.01-2.87) and abuse of club drug of sexual partners during past 6 months (aHR=12.78, 95%CI:3.06-53.35) were significantly associated with club drug abuse in the MSM. Conclusions: The incidence of club drug abuse was at a high level in the MSM cohort in Qingdao, indicating a high risk for HIV infection. Being student, receiving less HIV testing, having sex only with regular sexual partners, having more homosexual partners and abuse of club drug of sexual partners during past 6 months were risk factors for the incidence of club drug abuse in the MSM. Targeted surveillance and intervention measures should be strengthened to reduce the risk of club drug abuse in MSM.

[HIV self-testing and related factors in men who have sex with men in Shijiazhuang]

Objective: To understand HIV self-testing and related factors in men who have sex with men (MSM) in Shijiazhuang. Methods: From August to September 2020, convenient sampling was used to recruit MSM in Shijiazhuang. Online questionnaires were used to collect information about their demographic characteristics, sexual behaviors and HIV self-testing. logistic regression model was used to analyze the related factors associated with HIV self-testing. Results: In the 304 MSM respondents, 52.3% (159/304) had HIV self-testing in the past 6 months, and 95.0% (151/159) used fingertip blood HIV detection reagent. Self-purchase was the main way to obtain HIV testing reagents (45.9%, 73/159), followed by supply from MSM social organization (44.7%, 71/159). The reasons for having HIV self-testing were non-specific testing time (67.9%, 108/159) and privacy protection (62.9%,100/159), the reasons for having no HIV self-testing included inability of using (32.4%, 47/145), being unaware of HIV self-testing reagent (24.1%, 35/145), and worry about inaccurate self-testing results (19.3%, 28/145). Multivariate logistic regression analysis showed that being 18-29 years old (aOR=2.68, 95%CI: 1.20-5.94), obtaining free HIV self-testing kits in recent 6 months (aOR=8.61, 95%CI: 4.09-18.11) and making friends through Internet and social software (aOR=2.68, 95%CI: 1.48-4.88) were positive factors for having HIV self-testing. Conclusion: HIV self-testing is a more flexible and convenient way to detect HIV in MSM, and the promotion of HIV self-testing in MSM should be strengthened to further increase the HIV detection rate in this population.

Association Between Domain-Specific Physical Activity and Cardiometabolic Factors in a Multiethnic Asian Population: A Longitudinal Study

AIMS

To examine the association between domain-specific physical activity (PA) and cardiometabolic factors with longitudinal data, which is limited in current literature.

METHODS

Participants who attended the Singapore Multi-Ethnic Cohort and follow-up surveys were included in this study (N = 3950, mean age: 44.7 y, female: 57.9%). Self-reported moderate- to vigorous-intensity PA (MVPA) for each domain (leisure-time, transportation, occupation, and household) was categorized into 4 levels: no, low, middle, and high MVPA. The longitudinal associations of domain-specific MVPA with cardiometabolic factors including systolic and diastolic blood pressures, low-density and high-density lipoprotein cholesterols, triglycerides, and body mass index were examined using Generalized Estimating Equations, accounting for confounding factors and repeated measurements.

RESULTS

There were 5.2% participants who had no MVPA. For each domain, this rate ranged from 22.6% (household) to 83.3% (occupation). Leisure-time and occupation MVPAs had positive and linear associations with high-density lipoprotein cholesterols, corresponding to 0.030 (95% confidence interval, 0.015 to 0.045) mmol/L (leisure-time) and 0.063 (95% confidence interval, 0.043 to 0.083) mmol/L (occupation), when compared high with no respective MVPA. Occupation and household MVPAs were associated with low-density lipoprotein cholesterol. Transportation and occupation exhibited a positive and linear relationship with diastolic blood pressure. None of the domains were associated with body mass index, systolic blood pressures, or triglycerides.

CONCLUSIONS

This study showed that each domain had differential association with individual cardiometabolic risk factors. As occupation, transportation, or household PA had unfavorable associations with low-density lipoprotein cholesterol or diastolic blood pressure, the overall beneficial impact of higher PA levels may not necessarily hold in the context of domain-specific PA and cardiovascular health. Further investigation is needed to corroborate our findings.

Risk factors for incident falls in Singaporean community-dwelling adult men and women: a prospective cohort study

OBJECTIVES

Our study aimed to identify the risk factors of incident falls between men and women.

DESIGN

Prospective cohort study.

SETTING

The study recruited participants from the Central region of Singapore. Baseline and follow-up data were collected via a face-to-face survey.

PARTICIPANTS

Community-dwelling adults aged 40 years and above from the Population Health Index Survey.

OUTCOME MEASURE

Incident falls were defined as the experience of a fall between the baseline and 1-year follow-up but having no falls 1 year prior to baseline. Multiple logistic regressions were performed to determine the association of sociodemographic factors, medical history and lifestyle with incident falls. Sex subgroup analyses were conducted to examine sex-specific risk factors for incident falls.

RESULTS

1056 participants were included in the analysis. At 1-year follow-up, 9.6% of the participants experienced an incident fall. Incidence of falls in women was 9.8% compared with 7.4% in men. In the multivariable analysis for the overall sample, older age (OR: 1.88, 95% CI: 1.10 to 2.86), being pre-frail (OR: 2.13, 95% CI: 1.12 to 4.00) and having depression or feeling depressed/anxious (OR: 2.35, 95% CI: 1.10 to 4.99) were associated with higher odds for incident falls. In subgroup analyses, older age was a risk factor for incident falls in men (OR: 2.68, 95% CI: 1.21 to 5.90) and pre-frail was a risk factor for incident falls in women (OR: 2.82, 95% CI: 1.28 to 6.20). There was no significant interaction effect between sex and age group (p value=0.341) and sex and frailty status (p value=0.181).

CONCLUSION

Older age, presence of pre-frailty and having depression or feeling depressed/anxious were associated with higher odds of incident falls. In our subgroup analyses, older age was a risk factor for incident falls in men and being pre-frail was a risk factor for incident falls in women. These findings provide useful information for community health services in designing falls prevention programmes for community-dwelling adults in a multi-ethnic Asian population.

Treatments for Burning Mouth Syndrome: A Network Meta-analysis

The aim of this systematic review and network meta-analysis (NMA) of randomized controlled trials was to evaluate the effectiveness of treatments for pain relief of burning mouth syndrome (BMS). Five databases and gray literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. The primary outcome was pain relief or burning sensation, and the secondary outcomes were side effects, quality of life, salivary flow, and TNF-α and interleukin 6 levels. Four comparable interventions were grouped into different network geometries to ensure the transitivity assumption for pain: photobiomodulation therapy, alpha-lipoic acid, phytotherapics, and anxiolytics/antidepressants. Mean difference (MD) and 95% CI were calculated for continuous outcomes. The minimal important difference to consider a therapy beneficial against placebo was an MD of at least -1 for relief of pain. To interpret the results, the GRADE approach for NMA was used with a minimally contextualized framework and the magnitude of the effect. Forty-four trials were included (24 in the NMA). The anxiolytic (clonazepam) probably reduces the pain of BMS when compared with placebo (MD, -1.88; 95% CI, -2.61 to -1.16; moderate certainty). Photobiomodulation therapy (MD, -1.90; 95% CI, -3.58 to -0.21) and pregabalin (MD, -2.40; 95% CI, -3.49 to -1.32) achieved the minimal important difference of a beneficial effect with low or very low certainty. Among all tested treatments, only clonazepam is likely to reduce the pain of BMS when compared with placebo. The majority of the other treatments had low and very low certainty, mainly due to imprecision, indirectness, and intransitivity. More randomized controlled trials comparing treatments against placebo are encouraged to confirm the evidence and test possible alternative treatments (PROSPERO CRD42021255039).

Longitudinal Study Comparing Mental Health Outcomes in Frontline Emergency Department Healthcare Workers through the Different Waves of the COVID-19 Pandemic

As countries transition from the COVID-19 pandemic to endemic status, healthcare systems continue to be under pressure. We aimed to quantify changes in depression, anxiety, stress and post-traumatic stress disorder (PTSD) between 3 cohorts (2020, 2021 and 2022) of our Emergency Department (ED) healthcare workers (HCWs) and those who had worked through all 3 phases of the pandemic; and identify factors associated with poorer mental health outcomes (MHOs). In this longitudinal single-centre study in Singapore, three surveys were carried out yearly (2020, 2021 and 2022) since the COVID-19 outbreak. Depression, anxiety and stress were measured using DASS-21, and PTSD was measured using IES-R. A total of 327 HCWs (90.1%) participated in 2020, 279 (71.5%) in 2021 and 397 (92.8%) in 2022. In 2022, ED HCWs had greater concerns about workload (Mean score ± SD: 2022: 4.81 ± 0.86, vs. 2021: 4.37 ± 0.89, vs. 2020: 4.04 ± 0.97) and perceived to have less workplace support (2022: 4.48 ± 0.76, vs. 2021: 4.66 ± 0.70, vs. 2020: 4.80 ± 0.69). There was overall worsening depression (27.5% in 2020, 29.7% in 2021 and 32.2% in 2022) and stress (12.2% in 2020, 14.0% in 2021 and 17.4% in 2022). Healthcare assistants as a subgroup had improving MHOs. ED HCWs who were female and had psychiatric history, were living with the elderly, and had concerns about their working environment, workload and infection had poorer MHOs. This study will guide us in refining existing and devising more focused interventions to further support our ED HCWs' wellbeing.

Chronic low back pain and its impact on physical function, mental health, and health-related quality of life: a cross-sectional study in Singapore

Chronic low back pain, defined as low back pain lasting more than 3 months, is a globally prevalent health problem with significantly high medical and economic burden on individuals and the society. This study aimed to estimate the prevalence of chronic low back pain and examine its association with health outcomes including physical function, mental health, and quality of life among adult population in Singapore. Cross-sectional secondary data analysis was performed using baseline data of the 1941 adults (mean age: 52.6 years, range: 21-97 years) from a representative population health survey conducted in the Central region of Singapore. Those with self-reported chronic low back pain in past six months were identified. The Late-Life Function and Disability Instrument, Patient Health Questionnaire-9, and EQ-5D-5L were used to measure physical function and limitation, mental health, and health-related quality of life, respectively. Generalized Linear Regressions were used to examine the association of chronic low back pain with physical function, limitation, depressive symptoms, and health-related quality of life. There were 8.1% (n = 180) participants reporting having chronic low back pain in past six months, among whom 80.5% sought treatments at either primary care, specialist outpatient, or Traditional Chinese Medicine clinics. Individuals with chronic low back pain reported poorer physical function, more limitations in performing major life tasks and social activities, more depressive symptoms, and lower health-related quality of life (all p < 0.01), even after adjusting for socio-demographics, lifestyle factors, and number of morbidities. The prevalence of chronic low back pain was 8.1% among the study population. Chronic low back pain was associated with poorer physical function, more limitations and depressive symptoms, and lower health-related quality of life. The findings highlight the significant impact of chronic low back pain on physical function and limitation, mental health, and health-related quality of life in a general population. Increased awareness on prevention, early and proper management of low back pain, and rehabilitation policies are required to better tackle the burden of low back pain at the population level.

P-065 Phenotype, genetic analysis and treatment strategy of acephalic spermatozoa

Study question

Do severe acephalic spermatozoa syndrome (ASS) patients with different genes variants obtain good fertilization rate after intracytoplasmic sperm injection (ICSI)?

Summary answer

Despite highly abnormal sperm morphology, severe ASS patients with SUN5, TSGA10 and PMFBP1 different variations have a favorable pregnancy outcome following ICSI.

What is known already

ASS is a rare cause of infertility characterized by the production of two main subtypes: one type has small “pin-head” ends devoid of any nuclear material, and the other comprises spermatozoa with misaligned head-midpiece junctions. Many researchers have suggested that variants in TSGA10 without a proximal centriole might influence early embryonic development. Some case reports studies with very few cases showed that ICSI could help patients with ASS father children.

Study design, size, duration

This retrospective cohort study included 14 infertile men with severe ASS and 100 fertile men in Reproductive and Genetic Hospital of CITIC-Xiangya in China, from January 2020 to December 2021.

Participants/materials, setting, methods

Patients and fertile men were recruited respectively from Outpatient Department and Sperm bank of our hospital in China. 14 severe ASS were analyzed by whole exome sequencing. Mutational analysis in the 14 severe ASS and 100 fertile men were performed. Identified SUN5, TSGA10 and PMFBP1 variations were further investigated using bioinformatics, RT-PCR, Western Blot, indirect immunofluorescence assay, papanicolaou staining, CASA, transmission electron microscopy and ICSI treatments. Clinical data were collected from the fertility center.

Main results and the role of chance

In 14 patients with severe acephalic spermatozoa,16 homozygous or heterozygous variants were identified from SUN5,TSGA10 and PMFBP1. We performed deep phenotyping in acephalic spermatozoa with different variants, and found that, other than the two major subtypes, multiple variations in different genes that affect sperm heads in humans produce diverse phenotypes with subtle differences. Our findings were supported by Papanicolaou staining, SEM and TEM analyses. The rates of fertilization, good-quality embryos and pregnancy for 13 patients following ICSI were 85.71% (174/203), 55.17% (96 /174) and 69.23% (9/13), respectively. There were no differences in ICSI results between ASS patients with different genes mutations. The defects of acephalic spermatozoa caused by different genetic variations may only affect the morphology of sperm. ICSI can be used in the treatment of acephalic spermatozoa and obtain favorable fertilization rate without affecting the quality of early embryos and clinical pregnancy outcome. For individuals with ASS, ICSI using intact spermatozoa (or separated heads and tails) is suggested. If no sperm heads in their ejaculate, the spermatozoa can be collected from the testes. Very few intact spermatozoa or loose sperm heads will be available, even if normal morphology of spermatozoa is 0% and 100% spermatozoa are acephalic.

Limitations, reasons for caution

Only a small number ASS patients was available because of its rare incidence. Patients with ASS can be effectively treated with ICSI. However, the results in this study should be treated with caution, which involves the TSGA10, SUN5 and PMFBP1 genes and cannot be extrapolated to other genes.

Wider implications of the findings

The identification of novel variants in SUN5, TSGA10 and PMFBP1 broadens the spectrum of ASS genetic causes. Our study is the first to thoroughly evaluate the phenotypes and pathogenic genotypes of patients with severe ASS in China. SUN5, TSGA10 and PMFBP1 mutation-associated male infertility can be overcome by ICSI.

Trial registration number

kq2014032

[Development of a Ranking Tool for Scientificity, Transparency and Applicability of Clinical Practice Guidelines]

Objective: To address the limitations of existing methods and tools for evaluating clinical practice guidelines, we aimed to develop a comprehensive instrument focusing on the three main dimensions of guideline development: scientificity, transparency, applicability. We will use it to rank the guidelines according to the scores. We abbreviated it as STAR, and its reliability, validity and usability were also tested. Methods: A multidisciplinary expert working group was set up, including methodologists, statisticians, journal editors, medical professionals, and others. Scoping review, Delphi methods and hierarchical analysis were used to determine the final checklist of STAR. Results: The new instrument contained 11 domains and 39 items. Intrinsic reliability of each domain was indicated by Cronbach's α coefficient, with a average value of 0.646. The Cohen's kappa coefficients for methodological evaluators and clinical evaluators were 0.783 and 0.618. The overall content validity index was 0.905. The R2 for the criterion validity analysis was 0.76. The average score for usability of the items was 4.6, and the mean time spent to evaluate each guideline was 20 minutes. Conclusion: The instrument has good reliability, validity and evaluating efficiency, and can be used for evaluating and ranking guidelines more comprehensively.

Tumor microenvironment and its clinicopathological and prognostic associations in surgically resected cutaneous angiosarcoma

PURPOSE

Cutaneous angiosarcoma (CAS) is a rare but typically aggressive malignant vascular neoplasm of the skin. Tumor microenvironment (TME) of CAS and its associations with baseline clinicopathological features and patient outcomes are very important, especially when considering the recent advances in understanding of the tumor biology.

METHODS/PATIENTS

We retrospectively reviewed medical records of patients who underwent surgical resection for CAS at a tertiary Hospital. The pretreated specimens were evaluated by immunohistochemistry for programmed cell death protein 1 (PD-1) and its ligand (PD-L1), densities of tumor infiltrative lymphocytes (TILs) (CD3+, CD4+, CD8+, CD45RO+, FoxP3+), as well as c-MYC and Ki-67 expressions. Overall survival (OS) was estimated by Kaplan-Meier method and compared with Log-rank test.

RESULTS

A total of 21 CAS patients were identified. Median age was 67 (ranges: 20-81) years, 14 (66.7%) were male, and over 50% had lesions of scalp. Histopathological examination showed a predominantly spindle cell type (57.1%). All patients underwent surgery, 16 (76.2%) were treated further. PD-L1 was positively stained (> 1%) in tumor cells (42.9%) and TILs (23.8%). PD-1 expression (> 1%) was identified in TILs of 11 (52.4%) cases. PD-1/PD-L1 expressions were significantly associated with the higher densities of CD3+, CD4+, CD8+, CD45RO+, and Foxp3+ TILs, but not with patient characteristics or c-MYC or Ki-67 expression. Median OS was 18.5 months (95% CI 6.0-35.9), although no prognostic significance was observed with respect to any clinicopathological features.

CONCLUSION

We characterized TME and its clinical and prognostic association in CAS. PD-1/PD-L1 expressions were significantly associated with TILs subtypes but not with OS.

Associations of social isolation, social participation, and loneliness with frailty in older adults in Singapore: a panel data analysis

BACKGROUND

There is a shortage of research evidence about how social isolation, social participation, and loneliness were longitudinally associated with frailty. This study was to 1) examine the associations of social isolation, social participation, and loneliness with level of frailty among community-dwelling older adults using panel data, and 2) explore the moderating effect of gender on the association of social isolation, social participation and loneliness with frailty.

METHODS

The study included 606 participants aged 60 years and above from the longitudinal Population Health Index Survey conducted in Singapore. At each timepoint, level of frailty was determined using the Clinical Frailty Scale. Social isolation was assessed by the Lubben Social Network Scale-6, and loneliness was assessed using the three-item UCLA Loneliness Scale. Fixed-effects ordinal logistic regressions were conducted with level of frailty as the dependent variable and social isolation and loneliness as the independent variables, adjusting for time-varying socio-demographic, lifestyle, and health-related factors.

RESULTS

Increase in social participation was associated with lower level of frailty (odds ratio: 0.96, 95% confidence interval: 0.93-0.99) and feeling lonely was associated with higher level of frailty (odds ratio: 2.90, 95% confidence interval: 1.44-5.84). Social isolation was not associated with frailty. Gender did not have moderating effect on these associations.

CONCLUSIONS

This study observed that social isolation and loneliness had differential longitudinal association with level of frailty among community-dwelling older adults and suggested that loneliness and frailty should be measured and addressed concurrently among community-dwelling older adults.

Tuning the Ni site location of bifunctional Ni-based catalysts for improving the performance on ethylene oligomerization

The location of Ni sites in the catalyst is very important on the Ni-based catalyst for the ethylene oligomerization. In this work, a series of bifunctional Ni/Al-MCM-41 samples with carefully...

Psychometric Properties of the Patient Activation Measure in Community-Dwelling Adults in Singapore

Introduction

Measuring health activation in general population using valid instruments is needed to facilitate the evaluation of health education and behavioral programs in community. The 13-item Patient Activation Measure was well validated in patients with different chronic diseases but rarely validated in general population. The objective of this study was to assess the psychometric properties of the Patient Activation Measure among community-dwelling adults in Singapore.

Methods

Data of participants having valid responses to the English-version measure (N = 824) were analyzed. The psychometric properties were assessed by demonstrating evidence for uni-dimensionality using Rasch Principal Component Analysis of Residuals, known-group validity, convergent and divergent validity, and internal consistency reliability using Cronbach’s alpha.

Results

The uni-dimensionality of the Patient Activation Measure was supported by the Rasch Principal Component Analysis of Residuals results. Participants having multimorbidity or polypharmacy and being inactive in physical activity had significantly lower activation scores. The activation score was positively and moderately correlated with health confidence measured by the Health Confidence Measure (r = .38, P < .001), and negatively and weakly correlated with depressive symptoms measured by the Patient Health Questionnaire (r = − .13, P < .001). The internal reliability was good with a Cronbach’s alpha of .82.

Conclusion

The 13-item Patient Activation Measure has acceptable construct validity and good internal consistency among community-dwelling adults. It is a potential instrument to measure health activation in this population. Further research is required to investigate the expansion of response options, validate the cut-off scores for the activation levels and examine the test-retest reliability and responsiveness.

Psychometric evaluation of the 8-item Altarum Consumer Engagement (ACE) Measure™ in community-dwelling adults in Singapore

BACKGROUND

A valid and reliable measure is essential to assess patient engagement and its impact on health outcomes. This study aimed to examine the psychometric properties of the 8-item Altarum Consumer Engagement Measure™ (ACE Measure) among English-speaking community-dwelling adults in Singapore.

METHODS

This cross-sectional study involved 400 randomly selected community-dwelling adults (mean age: 49.7 years, 50.0% were female, 72.3% were Chinese) who completed the English version of the 8-item ACE Measure independently. The item-level statistics were described. The internal consistency of the measure was measured by Cronbach alpha and item-rest correlations. Validity of the tool was assessed by 1) factorial validity using confirmatory factor analysis (CFA), 2) hypothesis-testing validity by correlating ACE subscales (Commitment and Navigation) with health-related outcomes, and 3) criterion validity against the Patient Activation Measure and Health Confidence Measure.

RESULTS

There was no floor or ceiling effect for Commitment and Navigation subscales, and the Cronbach alpha for each subscale was 0.76 and 0.54, respectively. The two-factor structure was confirmed by CFA. In general, Commitment and Navigation subscales were positively correlated with frequency of activity participation (rho = 0.30 - 0.33) and EQ-5D visual analog scale (rho = 0.15 - 0.30). Individuals who perceived better health than peers had higher subscale scores (p < 0.01). Each subscale score had moderate and positive correlations with activation score (rho = 0.48 - 0.55) and health confidence score (rho = 0.35 - 0.47).

CONCLUSIONS

The two-subscale ACE Measure demonstrated good construct validity in English-speaking Singapore community-dwelling adults. Evidence in internal consistency was mixed, indicating further investigation.

[Analysis of laboratory re-examination results in Sichuan Provincial Malaria Diagnostic Reference Laboratory from 2014 to 2020]

OBJECTIVE

To re-examine the diagnosis results of reported malaria cases in Sichuan Province from 2014 to 2020, so as to assess the malaria diagnostic capability of Sichuan Provincial Malaria Diagnostic Reference Laboratory.

METHODS

The blood and blood smear samples from reported malaria cases were collected by Sichuan Provincial Malaria Diagnostic Reference Laboratory from 2014 to 2020, and subjected to re-examinations using microscopy and nested PCR assay. The re-examination results were compared.

RESULTS

A total of 1 710 samples from reported malaria cases were re-examined by Sichuan Provincial Malaria Diagnostic Reference Laboratory from 2014 to 2020, and 1 634 samples were identified positive, with a positive coincidence rate of 95.56% (1 634/1 710) and a 92.29% (1 508/1 634) total coincidence rate of the Plasmodium species. The coincidence rates with P. falciparum, P. vivax, P. malariae and P. ovale were 99.48% (961/966), 97.07% (430/443), 83.05% (98/118) and 67.86% (19/28), respectively, and the coincidence rate was 91.81% (1 513/1 648) between microscopic and nested-PCR results.

CONCLUSIONS

The capability of microscopists remains weak at grassroot medical institutions in Sichuan Province. Further training is required among microscopists to improve the malaria surveillance capability in Sichuan Province during the post-elimination stage.

A One-Year Longitudinal Study: Changes in Depression and Anxiety in Frontline Emergency Department Healthcare Workers in the COVID-19 Pandemic

Frontline healthcare workers (HCWs) fighting COVID-19 have been associated with depression and anxiety, but there is limited data to illustrate these changes over time. We aim to quantify the changes in depression and anxiety amongst Emergency Department (ED) HCWs over one year and examine the factors associated with these changes. In this longitudinal single-centre study in Singapore, all ED HCWs were prospectively recruited face-to-face. Paper-based surveys were administered in June 2020 and June 2021. Depression and anxiety were measured using DASS-21. The results of 241 HCWs who had completed both surveys were matched. There was significant improvement in anxiety amongst all HCWs (Mean: 2020: 2.85 (±3.19) vs. 2021: 2.54 (±3.11); Median: 2020: 2 (0–4) vs. 2021: 2 (0–4), p = 0.045). HCWs living with elderly and with concerns about infection risk had higher odds of anxiety; those living with young children had lower odds of anxiety. There was significant worsening depression amongst doctors (Mean: 2020: 2.71 (±4.18) vs. 2021: 3.60 (±4.50); Median: 2020: 1 (0–3) vs. 2021: 3 (0–5), p = 0.018). HCWs ≥ 41 years, living with elderly and with greater concerns about workload had higher odds of depression. HCWs who perceived better workplace support and better social connectedness had lower odds of depression. In summary, our study showed significant improvement in anxiety amongst ED HCWs and significant worsening depression amongst ED doctors over one year. Age, living with elderly, and concerns about workload and infection risk were associated with higher odds of depression and anxiety.

O-206 Meiotic segregation analysis for reciprocal translocation carriers: Assessment of factors influencing meiotic segregation patterns

Study question

To analyze factors that could influence meiotic segregation patterns for reciprocal translocation carriers.

Summary answer

Involvement of an Acr-ch, female gender, and lower TAR1 (ratio of translocated segment 1 over the chromosome arm) were independent risk factors for alternate segregation.

What is known already

Reciprocal translocation is one of the more common structural rearrangements of chromosomes, which is associated with reproductive risks, such as infertility, spontaneous abortion and the delivery of babies with mental retardation or developmental delay. Extensive studies on meiotic segregation patterns of sperm, blastomere, and blastocysts have identified several factors that may influence the generation of unbalanced rearrangement of reciprocal translocations, including carrier’s gender and age, location of breakpoints, chromosome type, and the quadrivalent structure. However, some results are controversial.

Study design, size, duration

A retrospective study from October 2013 to December 2019, a total of 10846 blastocysts originating from 2871 oocyte retrieval cycles from 2253 couples with one of the partners carrying reciprocal were investigated. The mean maternal age was 29.97±4 years (20 –47years).

Participants/materials, setting, methods

Trophectoderm biopsy of blastocysts was performed on the 5th or 6th day of development. Whole genome amplification (WGA) was performed on all samples, and the WGA was analyzed with SNP array or NGS. Segregation patterns of quadrivalent in 10846 blastocysts were analyzed. Risk factors for segregation patterns were explored through analyzing carriers’ demographic and cytogenetic characteristics using multivariate generalized linear mixed models (GLMMs).

Main results and the role of chance

The percentage of normal/balanced blastocysts was 34.3%, and 2:2 segregation was observed in 90.0% of blastocysts. Increased TAR1 (the ratio of translocated segment 1 over the chromosome arm) was noted as an independent protective factor for the proportion of alternate segregation (P = 0.004). The female gender and involvement of an Acr-ch were found independent risk factors for alternate segregation (P &lt; 0.001). A higher TAR1 reduced the risk of adjacent-1 segregation; longer translocated segment and female gender increased the risk of adjacent-2 segregation (P = 0.009 and P &lt; 0.001, respectively). Female gender and involvement of an Acr-ch enhanced the risk of 3:1 segregation (P &lt; 0.001 and P = 0.012, respectively).

Limitations, reasons for caution

About 1400 blastocysts were not diagnosed in the 2871 cycles, which might cause bias in the results. Secondly, the interchromosomal effect of reciprocal translocations was not analyzed in this study.

Wider implications of the findings

In conclusion, a carrier’s gender, involvement of an Acr-ch, and location of breakpoints may influence the segregation patterns. Besides, involvement of an Acr-ch, female gender, and lower TAR1 are independent risk factors for alternate segregation. These results may provide more appropriate genetic counseling for couples with balanced translocation.

Trial registration number

no

P–554 Reproductive risks and preimplantation genetic testing intervention for X-autosome translocation carriers

Study question

For X-autosome translocation [t(X-A)] carriers, is it a more applicable preimplantation genetic testing (PGT) strategy, that distinguishing noncarrier from euploid/ balanced embryos and prioritized transfer?

Summary answer

Noncarrier and carrier embryos discrimination in PGT is an applicable strategy to avoid transferring genetic and reproductive risks to the offspring of t(X-A) carriers.

What is known already

Balanced t(X-A) is a specific reciprocal translocation, with a higher risk of detrimental phenotype and fertility issues compared to individuals with autosomal translocation. Alternative X-chromosome inactivation (XCI) is a specific pathogenic mechanism in this population. For carrier offspring of couples with t(X-A), the genetic counseling is challenged in both the prenatal and postpartum stages, because of the complexity and severity of phenotype outcomes that are unpredictable and associated with the complex XCI mechanism. Therefore, caution is necessary when designing a PGT strategy for couples with t(X-A).

Study design, size, duration

A retrospective study. We collected a 3-year-old girl with maternal translocation 46,X,t(X;1)(q28;p31.1) presenting with multiple congenital disabilities. Three couples with female t(X-A) carrier requesting for PGT.

Participants/materials, setting, methods

Karyotype analysis, whole-exome sequencing (WES), and X inactivation analysis were performed for the girl with congenital cardiac anomaly, language defect, and mild neurodevelopmental delay. PGT based on next-generation sequencing following the microdissecting junction region to distinguish noncarrier and carrier embryos were used in three couples with female t(X-A) carrier (Cases 1–3).

Main results and the role of chance

The girl carried a maternal balanced translocation 46,X,t(X;1)(q28;p31.1). WES revealed none monogenic mutation related to her phenotype, but she carried a rare skewed inactivation of the translocation X chromosome and spread to the adjacent interstitial 1p segment, contrary to her mother. All translocation breakpoints of Cases 1–3 were successfully identified and each couple underwent one PGT cycle. Thirty oocytes were retrieved, and 13 blastocysts were eligible for biopsy, of which 6 (46.15%) embryos were balanced and only 4 were noncarriers. Three frozen embryo transfers with noncarrier embryos resulted in the birth of two healthy children (one girl and one boy), who were subsequently confirmed to have normal karyotypes. We reported a girl with multiple congenital disabilities resulting from maternally balanced t(X-A) and validated that noncarrier and carrier embryo discrimination is an effective and applicable strategy for avoiding transferring genetic and reproductive risks to the offspring from t(X-A) carriers.

Limitations, reasons for caution

Here, we reported a girl with multiple congenital disabilities resulting from maternally balanced t(X-A) found different XCI patterns, while we did not further determine the mechanism causing the different XCI patterns between the girl and her mother.

Wider implications of the findings: We demonstrated passing on a balanced t(X-A) may result in clinical manifestations associated with the X-inactivation, and verified the PGT strategy, that distinguishing normal and carrier embryos in can widely applied in t(X-A) carrier couples to avoid the genetic and reproductive risk of transferring t(X-A) to the next generation.

Trial registration number

the National Key Research & Developmental Program of China (2018YFC1004900), the National Natural Science Foundation of China (81771645 and 81971447), the Key Grant of Prevention and Treatment of Birth Defect from Hunan Province (2019SK1012), Hunan Provincial Grant for Innovative Province Construction (2019SK4012) and the Research Grant of CITIC-Xiangya (YNXM–201916).

[Application of indocyanine green fluorescence imaging technique in evaluation of intestinal perfusion in totally laparoscopic left hemicolectomy]

Objective: To examine the safety and feasibility of using fusion indocyanine green fluorescence imaging (FIGFI) technique for intraoperative evaluation of colorectal perfusion in the totally laparoscopic left colectomy. Methods: A retrospective cohort study was conducted to collect the clinical data of 58 patients with left colon cancer who underwent totally laparoscopic surgery at the Colorectal Surgery Department, Cancer Hospital, Chinese Academy of Medical Sciences from October 2016 to December 2019. There were 39 males and 19 females, aging (57.0±10.1)years(range:28 to 75 years). According to whether the FIGFI was used during the operation, they were divided into 36 cases in the study group and 22 cases in the control group. The clinical pathological characteristics, operative and postoperative recovery of the two groups were compared by t test, χ² test, and Fisher exact test. Results: All the 58 patients underwent R0 resection with totally laparoscopic surgery. In the study group, due to poor bowel blood flow after cutting the mesentery (Sherwinter score = 1), 1 patient had to be expanded the resection range until the blood flow was rich(Sherwinter score≥3), and 1 patient in the control group had the complication of postoperative anastomotic leakage of grade A. Compared with the control group, the operation time in the study group was shorter ((156.3±43.5) minutes vs. (180.4±41.3) minutes, t=-2.083, P=0.042). However, there were no significant differences in the amount of blood loss, postoperative hospital stay, postoperative time of anal exhaust, length of bowel resection, number of lymph nodes dissected, and in the incidence of postoperative complications between the two groups. Median follow-up period was 23 months (range: 18 to 37 months). There were no long-term postoperative complications such as ischemic enteritis and anastomotic stenosis in both groups. Conclusions: The FIGFI is safe and feasible to assess the blood supply of intestinal segment and anastomosis during totally laparoscopic left hemicolectomy, and is easy to operate. It is expected to reduce the incidence of anastomotic leakage.

[Clinical efficacy of stent-assisted coil embolization for recurrent intracranial bifurcation aneurysms]

Objective: To evaluate the safety and efficacy of stent-assisted coil embolization in patients with recurrent intracranial bifurcation aneurysms,after initial simple coiling or microsurgical clipping. Methods: Clinical data of 20 patients with recurrent intracranial bifurcation aneurysms who initially underwent simple coiling or surgical clipping and subsequently re-treated by stent-assisted coiling embolization at the Radiology Intervention Department of Huashan Hospital between March 2009 and November 2019 were collected and analyzed retrospectively.There were 9 males and 11 females,with a median age of 55.5 years (range:33 to 71 years),including 17 aneurysms initially treated with simple coiling and 3 treated with surgical clipping.All cases were re-treated with stent-assisted coiling,15 using a single stent and 5 employing two stents in a Y-configuration.Peri-and post-operative complications and outcomes were evaluated.Mann-Whitney U tests were performed to compare the follow-up duration between initial treatment and re-treatment.Student's t tests were used to compare the parent artery angles before re-treatment, after re-treatment and at the last follow-up. The parent artery angle was defined using the proximal main trunk and the stented branch. Results: Immediate complete occlusion (Raymond Ⅰ) was achieved in 18 aneurysms (90.0%) while 2 aneurysms (10.0%) had a residual neck (Raymond Ⅱ).The median follow-up time(M(Q_R)) was 8.5(16.3)months,which had no significantly different from the initial treatment follow-up duration (15.5(27.0)months)(U=157.7,P=0.25). During the follow-up period,2 aneurysms (10.0%) with immediate post-operative residual necks recanalized again,including 1 aneurysm re-treated with the Y-configuration stent.Symptomatic thromboembolic complications occurred in 6 patients,including 4 re-treated with the Y-configuration stent.No peri-operative hemorrhagic complications occurred,along with no operation-related permanent disability or death. The parent artery angle increased significantly from pre-operative(90.1±21.1)°to post-operative and the last follow-up ((115.4±28.9)° and (132.6±26.8)°);t=5.14,P<0.01;t=7.78,P<0.01). Conclusion: For recurrent intracranial bifurcation aneurysms after initial surgical clipping or simple coiling,stent assisted coil embolization is proved to be safe and can decrease recurrence rate.

[Tends on HIV and syphilis prevalence and sexual behaviors among young students in China, 2015-2019]

Objective: To analyze the tends on HIV/syphilis prevalence and sexual behaviors using the HIV/AIDS sentinel surveillance data of young students in China from 2015 to 2019 and provide evidence for the formulation of HIV/AIDS prevention and control measures among young students. Methods: From 2015 to 2019, a nationwide continuous cross-sectional survey was conducted in cities where colleges and technical schools were concentrated in each province. Multi-stage cluster sampling with the simple size 800, anonymous questionnaire, and blood sample collection were implemented to achieve general demographic information, sexual behavior, and serological information, analyze the trends and influence on HIV/syphilis infection and behaviors. Results: During 2015-2019, there was no linear trend on the antibody-positive rate of HIV[2019, 0.03% (17/54 110)], and there was a weak correlation on the antibody-positive rate of syphilis [2019, 0.08%(41/54 110)]. In 2019, the proportion of the respondents ever had sex was 8.71%(4 731/54 339), of those having regular sex partner in the last year was 3.96% (2 153/54 339), of those having a temporary partner was 1.81%(984/54 339), of a commercial sex partner was 0.19% (101/54 339), and of homosexual partners was 0.19% (101/54 339), who they were all stable. Multivariate logistic regression analysis showed that the young students who had male homosexual partners were most likely to be infected by HIV. The young students who had multiple sexual partners, including homosexual partners, were foreigners or minorities were most likely to be infected by syphilis (all P<0.05). Conclusions: The antibody-positive rates of HIV and syphilis remained low and stable among young students from 2015 to 2019 in China. However, the risk of sexual transmission of HIV and syphilis still remains among young students.

Association between patient-reported functional measures and incident falls

Lower extremity muscle strength, and functional limitations are important modifiable predictors of falls, but are often examined using performance based measures. We examined the association between self-reported physical function limitations, determined using Late-Life Function and Disability Instrument(LLFDI) and incident falls in community-dwelling elderly individuals. 283 older adults participants were included in this analysis. Physical function limitations were defined as a person's difficulty in completing items of the lower extremity function domain and composite scores of the LLFDI. Information on falls was obtained through a standardised questionnaire. At one-year follow-up, 15.2% (43) of the participants experienced their first fall. In the multivariable analysis, individuals who reported difficulties in items of lower extremity function domain were more likely to experience a fall (incidence rate ratio[IRR]: ranging between 2.43 and 7.01; all P ≤ 0.046). In addition, decreasing advanced lower extremity function scores (IRR: 1.70, 95% confidence interval[CI]): 1.04, 2.78) and overall function component score (IRR: 2.05, 95% CI: 1.22, 3.44) were associated with higher risk of incident falls. Physical function limitations, determined using LLFDI, were associated with incident falls. Our findings provide further evidence that the LLFDI function component has the potential to be used as a self-assessment tool for fall risk.

[Estimation of newly HIV infection trend by using the back-calculation method in Honghe Hani and Yi autonomous prefecture]

Objective: Using the changing patterns of CD(4)(+) lymphocytes (CD(4)) counts of HIV/AIDS cases, we tried to estimate the number of newly infected HIV in Honghe Hani and Yi autonomous prefecture (Honghe prefecture) Yunnan province, and to provide reference for evaluating the trend of local HIV epidemic. Methods: Among diagnosed HIV infections, those who were at ≥15 years old, having available initial CD(4) records of testing, initiating antiviral therapy before the end of 2018, were selected from the case reporting system of Honghe prefecture, Yunnan province. Both Depletion model of the square root on CD(4) and the time of infection were used to back-calculate the seroconversion time of each individual. Both direct probability distribution method and life table method were used to calculate the distribution rates of diagnosis and the weight of delay. The number of diagnoses over the years was used to reversely estimate the total number of newly HIV infections. Results: At the end of 2018, the total number of HIV infections was estimated 35 977 with the rate of diagnosis as 77.50% in Honghe prefecture of Yunnan province. The number of new HIV infections appeared as 23 792 in 2008-2018. Cumulatively, the number of new HIV infections was 12 185 up to 2007. The estimated number of new HIV infections decreased from 2 602 in 2008 to 1 480 in 2018. The weight of diagnostic delay decreased from 5.49 in one year to 1.00 in 20 years, and the diagnosis rate increased from 18.2% to 100.0% during 20 years. Conclusion: In Honghe prefecture of Yunnan province, the number of newly infection showed a declining trend but the diagnostic rate was still far from reaching the "first 90% target" . It is expected to expand the timeliness on detection and case-finding so as to reduce the risk of HIV transmission.

Psychosocial impact of skin diseases: A population-based study

Background

While it is well established that skin disease places significant psychosocial burden on a patient’s wellbeing, its effects have rarely been examined in Asian populations.

Objective

Evaluate the psychosocial burden of skin disease among community-dwelling adults in Singapore.

Methods

This cross-sectional study included 1510 participants interviewed on their history of thirteen skin diseases. The Patient Health Questionnaire (PHQ-9), Lubben Social Network Scale-6 (LSNS-6), University of California Los Angeles (UCLA) Loneliness Scale, and European Quality of Life-5 Dimensions- 5 Level (EQ-5D-5L) were used as measures for depressive symptoms, social isolation, loneliness and quality of life respectively. Multiple linear regression analysis was used to examine the association of skin diseases with each of the four measured outcomes.

Results

Participants with skin diseases reported significantly higher PHQ-9 and UCLA Loneliness scale scores, and lower LSNS-6 and EQ-5D-5L scores when compared to their healthy counterparts. The presence of skin disease was positively associated with depressive symptoms (B = 0.40, SE = 0.11), and negatively associated with quality of life (B = -0.03, SE = 0.01). As disease severity was not evaluated in this study, we were unable to ascertain the associations between disease severity and measured outcomes.

Conclusion

Participants with skin diseases were more likely to have depressive symptoms, social isolation, loneliness and lower quality of life. Unemployed, single and elderly patients were at higher risk of developing depressive symptoms. More emphasis should be placed on the psychosocial aspect of care to reduce the burden of skin disease. Some considerations include monitoring patients for mood-related changes and implementing early psychosocial interventions.

[Short-term efficacy of preservation versus non-preservation of inferior mesenteric artery in laparoscopic-assisted radical resection for left hemicolon cancer]

Objective: In laparoscopic-assisted left hemicolectomy, previous studies have suggested that preserving the inferior mesenteric artery (IMA) may improve intestinal blood flow and reduce the incidence of anastomotic leakage. However, whether IMA should be retained is controversial currently. This study aims to investigate the short-term efficacy of the inferior mesenteric artery preservation (IMAP) and the inferior mesenteric artery resection (IMAR) on the laparoscopic-assisted radical resection of left hemicolon cancer. Methods: A retrospective cohort study was conducted to collect the clinical data of 195 patients with left colon cancer who underwent laparoscopic surgery in the Colorectal Surgery Department of Cancer Hospital of Chinese Academy of Medical Sciences from October 2012 to February 2019. After D3 radical resection for left semicolon cancer, they were divided into the IMAR group (91 cases), and the IMAP group (104 cases). In IMAR group, the left colon artery (LCA) and 1-2 branches of sigmoid artery (SA) were identified about 5 cm away from the root of the IMA, then the main IMA trunk was transected at the distal end. In IMAP group, the main trunk of IMA was dissected and the lymph nodes around IMA were cleaned. After the LCA and the first branch of SA (SA1) were separated, the LCA and SA1 were closed and cut off at the root. The intraoperative and postoperative data were compared between two groups, including the morbidity of complications within 30 days after operation, postoperative follow-up recovery, operation time, intraoperative blood loss, number of harvested lymph nodes, length of specimens, postoperative passage of gas and hospital stay. Results: The operation was successfully completed in all the cases without any death related to the operation. Compared with the IMAP group, the operation time was shorter [(161.8±48.0) minutes vs. (182.9±49.4) minutes, t=2.985, P=0.003], the intraoperative blood loss was less [(38.5±30.8) ml vs.(52.9±32.2) ml, t=2.088, P=0.038], the length of the resected bowel was longer [(19.2±6.0) cm vs.(17.2±5.4) cm, t=-2.447, P=0.015] in the IMAR group, whose differences were statistically significant (all P<0.05). There were no significant differences in the number of harvested lymph nodes, time of postoperative passage of gas and postoperative hospital stay between two groups (all P>0.05). There was no significant difference in overall morbidity of postoperative complications between the two group [6/91 (6.6%) vs. 7/104 (6.7%), χ(2)=0.001, P=0.969]. In the IMAR group, one case developed postoperative abdominal infection, two cases developed incision infection, one case developed lung infection, two cases developed intestinal obstruction, and no anastomotic bleeding occurred. In IMAP group, one case developed postoperative lung infection, one case developed incision infection, one case developed abdominal bleeding, two cases developed intestinal obstruction and two cases developed anastomotic bleeding. There was no anastomotic leakage in either group. All complications were treated by conservative treatment successfully. After a median follow-up of 12 (range 3-24) months, patients in the two groups had good intestinal blood supply after surgery, and there was no clear manifestation of congestive or ischemic enteritis under colonoscopy. Conclusion: Laparoscopic-assisted left hemicolectomy with IMA resection in patients with left hemicolon cancer provides better short-term efficacy safely and feasibly, including shorter operative time, less intraoperative bleeding and without increasing postoperative complications.

Frailty and healthcare utilisation across care settings among community-dwelling older adults in Singapore

Background

Frailty is frequently found to be associated with increased healthcare utilisation in western countries, but little is known in Asian population. This study was conducted to investigate the association between frailty and healthcare utilisation in different care settings among community-dwelling older adults in Singapore.

Methods

Data from a population health survey among community-dwelling adults were linked with an administrative database to retrieve data of healthcare utilisation (including government primary care clinic visits, specialised outpatient clinic visits, emergency department visits, day surgery and hospitalisations) occurred during a six-month look-back period and six-month post-baseline respectively. Baseline frailty status was measured using the five-item FRAIL scale, which was categorised into three groups: robust (0), pre-frail (1–2), and frail (3–5). Negative binomial regression was applied to examine the association between frailty with respective healthcare utilisation (dependent variables), controlling for other confounding variables.

Results

In our sample of 701 older adults, 64.8% were of robust health, 27.7% were pre-frail, and 7.6% were frail. Compared to the robust group, frail individuals had a higher rate of specialised outpatient clinic visits (incidence rate ratio (IRR): 2.8, 95% confidence interval (CI): 1.2–6.5), emergency department visits (IRR: 3.1, 95%CI: 1.1–8.1), day surgery attendances (IRR: 6.4, 95%CI: 1.3–30.9), and hospitalisations (IRR: 6.7, 95%CI: 2.1–21.1) in the six-month period prior to the baseline and in subsequent 6 months (IRR: 3.3, 95%CI: 1.6–7.1; 6.4, 2.4–17.2; 5.8, 1.3–25.8; 13.1, 4.9–35.0; respectively), controlling for covariates.

Conclusions

Frailty was positively associated with the number of specialised outpatient clinic visits, emergency department visits, day surgeries and hospitalisations occurred during 6 months prior to and after the baseline. As frailty is a potentially reversible health state with early screening and intervention, providing preventive activities that delay the onset or progression of frailty should have potential effect on delaying secondary and tertiary care utilisation.

Clinical characteristics of non-critically ill patients with novel coronavirus infection (COVID-19) in a Fangcang Hospital

OBJECTIVES

To describe the clinical characteristics of patients in a Fangcang Hospital.

METHODS

Non-critically ill individuals with positive SARS-CoV-2 RT-PCR tests admitted between 7 February and 12 February 2020 to Dongxihu Fangcang Hospital, which was promptly constructed because of the rapid, exponential increase in COVID-19 patients in Wuhan, China, were included; clinical course through to 22 February was recorded.

RESULTS

A total of 1012 non-critically ill individuals with positive SARS-CoV-2 RT-PCR tests were included in the study. Thirty (of 1012, 3.0%) individuals were asymptomatic on admission. During hospitalization, 16 of 30 (53.3%) asymptomatic individuals developed different symptoms. Fourteen of 1012 patients (1.4%) remained asymptomatic from exposure to the end of follow up, with a median duration of 24 days (interquartile range 22-27). Fever (761 of 1012, 75.2%) and cough (531 of 1012, 52.4%) were the most common symptoms. Small patchy opacities (355 of 917, 38.7%) and ground-glass opacities (508 of 917, 55.4%) were common imaging manifestations in chest CT scans. One hundred patients (9.9%) were transferred to designated hospitals due to aggravation of illness. Diarrhoea emerged in 152 of 1012 patients (15.0%). Male, older age, diabetes, cardiovascular diseases, chills, dyspnoea, So2 value of ≤93%, white blood cell counts of >10 × 109/L and large consolidated opacities on CT images were all risk factors for aggravation of illness.

CONCLUSIONS

Non-critically ill individuals had different clinical characteristics from critically ill individuals. Asymptomatic infections only accounted for a small proportion of COVID-19. Although with a low incidence, diarrhoea was observed in patients with COVID-19, indicating the possibility of faecal-oral transmission.

[Short-term efficacy of totally laparoscopic left colon cancer radical resection with overlapped delta-shaped anastomosis technique]

Objective: To evaluate the safety, feasibility and short-term efficacy of totally laparoscopic left colectomy for left colon cancer by using overlapped delta-shaped anastomosis technique for digestive tract reconstruction. Methods: A retrospective cohort study was conducted to collect the clinical data of 86 patients with left colon cancer who underwent laparoscopic surgery in Cancer Hospital of Chinese Academy of Medical Sciences from October, 2017 to February, 2019. The patients were divided into totally laparoscopic left-sided colectomy (TLLC) (treatment group, n=25 cases) and laparoscopic-assisted left-sided colectomy (LALC) (control group, n=61 cases). The intraoperative and postoperative data were compared between the two groups. Results: There were no surgical-related deaths in both groups. All the patients in the TLLC group underwent laparoscopic resection, while one patient in the LALC group transfer to open surgery. The operation time in TLLC group and LALC group were (164.5±42.3) min and (171.0±43.1) min, respectively, without statistically significant difference (P=0.516). However, the intraoperative blood loss of patients in the TLLC group was (36.4±22.7) ml, which was significantly less than (52.9±32.2) ml in the LALC group (P=0.026). The anastomosis time in the TLLC group was (39.1±6.5) min, which was significantly longer than (24.9±5.4) min in the LALC group (P<0.001). Postoperative exhaust time in the TLLC group was (2.6±0.5) days, which was significantly shorter than (3.3±0.8) days in the LALC group (P<0.001). The incision length in the TLLC group was (4.2±2.2) cm, significantly shorter than (7.0±2.5) cm in the LALC group (P<0.001). The length of the resected bowel was (21.0±7.3) cm in the TLLC group, which was significantly longer than (17.5±5.4) cm in the LALC group (P=0.037). The length of hospital stay in the TLLC group was (6.2±1.9) days, which was significantly shorter than (7.9±1.5) days in the LALC group (P<0.001). The incidences of postoperative complications in the TLLC group and LALC group were 0 and 4.9% (3/61), respectively, without statistically significant (P=0.553). No anastomotic complications occurred in both groups. During the follow-up period, neither group of patients was hospitalized again, and no tumor metastasis or recurrence occurred. Conclusions: It is safe and feasible to apply the TLLC with overlapped delta-shaped anastomosis in patients with left colon cancer. It has better short-term effects such as shorter incisions, faster recovery, and shorter postoperative hospital stays, and is worthy of further promotion.

Gamma-Ray Irradiation to Accelerate Crystallization of Mesoporous Zeolites

Gamma-ray (γ-ray) irradiation was introduced into zeolite synthesis. The crystallization process of zeolite NaA, NaY, Silicalite-1, and ZSM-5 were greatly accelerated. The crystallization time of NaA zeolite was significantly decreased to 18 h under γ-ray irradiation at 20 °C, while more than 102 h was needed for the conventional process. Unexpectedly, more mesopores were created during this process, and thus the adsorption capacity of CO₂ increased by 6-fold compared to the NaA prepared without γ-ray irradiation. Solid experimental evidence and density function theory (DFT) calculations demonstrated that hydroxyl free radicals (OH*) generated by γ-rays accelerated the crystallization of zeolite NaA. Besides NaA, mesoporous ZSM-5 with MFI topology was also successfully synthesized under γ-ray irradiation, which possessed excellent catalytic performance for methanol conversion, suggesting the universality of this new synthetic strategy for various zeolites.

[Clinical phenotype and genotype of early-onset facioscapulohumeral muscular dystrophy type 1]

Objective: To explore the clinical, pathological and genetic characteristics of early-onset facioscapulohumeral muscular dystrophy type 1 (FSHD1), in order to increase awareness of the disease. Methods: In this retrospective study, the history of 3 patients, who were diagnosed with early-onset FSHD1 by molecular genetic test in Pediatric Outpatient Department of Peking University First Hospital from 4(th) June 2012 to 4(th) June 2018, were collected. Their clinical data, genotypes, phenotypes and pathological features of muscle biopsy were analyzed. Results: All the three patients were males at the age of 14 years, 11 years and 9 years 11 months, respectively, whose onset age was between infancy and early childhood and they got confirmed diagnosis within 4 to 10 years after the onset of illness. Their molecular genetic testing indicated that the number of D4Z4 repeat arrays located in 4qA were 2, 3 and 4, which was consistent with the characteristics of early-onset FSHD1. Their common clinical manifestations were facial, scapular and proximal lower limb muscle progressively and asymmetrically weakness. All patients had different severity of spine deformity and high-frequency dominant sensorineural hearing loss, however, the phenotype of the third patient with 4 D4Z4 repeats was significantly the most severe. Conclusions: Early-onset FSHD1 usually concealed onset and is difficult to diagnose. Its precise diagnosis depends on molecular genetic techniques, but the genotypes of 3 patients here are not corresponding to phenotypes strictly and it is necessary to accumulate more cases for further analysis in order to provide a more reliable basis for the relationship of genotype-phenotype and prognosis evaluation of the disease.

Association of Nutritional Status with Physical Function and Disability in Community-Dwelling Older Adults: A Longitudinal Data Analysis

Objective: To investigate how change in nutritional status is associated with physical function and disability among community-dwelling older adults. Methods: Baseline and 1-year follow-up data of 593 community-dwelling older adults were obtained from the Population Health Index survey in Singapore. The Mini Nutritional Assessment was used to assess nutritional status; the Late-Life Function and Disability Instrument was used to measure physical function and disability. Multivariate linear regression was applied to examine the association of change in nutritional status with physical function and disability. Results: Compared to older adults with normal nutritional status at both baseline and 1-year follow-up, those who became undernourished or remained undernourished reported poorer physical function (B = -6.36 and -5.96, respectively; both P < 0.01), and had less frequent involvement (B = -3.95 and -2.84, respectively; both P < 0.01) and more limitation in performing life tasks (B = -13.24 and -16.02, respectively; both P < 0.01) at 1-year follow-up. However, older adults with improved nutritional status did not differ in physical function and frequency of involvement in life tasks compared to those with normal nutrition. Conclusion: Undernutrition is associated with poorer physical function and disability in community-dwelling older adults regardless of whether it developed or was persistent over one year. Improving nutritional status could be an effective strategy to improve physical function in older adults.

A comparison of open, laparoscopic and robotic total mesorectal excision: trial sequential analysis and network meta-analysis

AIM

Total mesorectal excision (TME) for rectal cancer can be achieved by employing open (OpTME), laparoscopic (LaTME) and robotic (RoTME) approaches but which of these has the best outcome? The aim of present study is to identify the most effective technique for rectal cancer by comparing all outcomes.

METHODS

Randomized controlled trials (RCTs) which compared at least two TME strategies were identified by literature search of electronic databases of articles published to June 2018. Network meta-analysis with trial sequential analysis was performed using a frequentist approach with random-effects meta-analysis. Data collection and analysis We conducted a systematic search of PubMed, EmBase, the Cochrane Library, CNKI, and Web of Science. Titles and abstracts of the retrieved publications were independently and blindly assessed by two authors.

RESULTS

Twenty-two RCTs with 4882 rectal cancer patients were included in this analysis. The trial sequential analysis demonstrated that the cumulative Z-curve crossed either the traditional boundary or the trial sequential monitoring boundaries, suggesting that OpTME resulted in a more complete TME specimen than LaTME (relative risk 1.05, 95% confidence interval 1.01-1.08). Network meta-analysis showed there was no significant difference in the other comparisons. Based on the P score of completeness of the TME specimen and circumferential resection margin positivity, the best technique was OpTME, followed by RoTME and then LaTME. However, this order was reversed when complications and mortality were considered. RoTME led to better lymph node harvest.

CONCLUSIONS

Although OpTME may give better pathological specimens, minimally invasive techniques may have advantages when considering lymph node harvest, complications and mortality. More RCTs are needed to determine which technique actually gives the best chance of survival.