Inverted U-shaped associations between serum uric acid and fasting - plasma glucose level in non-diabetic, pre-diabetic, and diabetic adults: A population-based study in China

OBJECTIVE

This study was designed to examine the correlation between serum uric acid (SUA) and fasting plasma glucose (FPG) levels across non-diabetic, pre-diabetic, and diabetic adults from Northwest China.

MATERIALS AND METHODS

This study utilized data from a cross-sectional survey conducted in Ningxia Hui Autonomous Region, which investigated the prevalence and risk factors of cardiovascular disease. All subjects underwent tests for SUA and FPG levels. Generalized additive models and two-piecewise linear regression models were applied to explore the relationships between SUA and FPG level. The triglyceride-glucose (TyG) index was examined as a measure of insulin resistance, with an analysis of its mediating effects on the association between SUA and FPG level.

RESULTS

A total of 10,217 individuals aged 18 and over were included. Generalized additive models verified the inverted U-shaped association between SUA and FPG levels, and the inflection points of FPG levels in the curves were 6.5 mmol/L in males and 8.8 mmol/L in females. The TyG index is an intermediate variable in the relationship between SUA levels and elevated FPG levels, with mediating effects of 12.82% (P < 0.001) for males and 34.02% (P < 0.001) for females.

CONCLUSIONS

An inverted U-shaped association between FPG and SUA levels was observed in both genders. The threshold of FPG level was lower in males than in females. The relationship between these variables seems to be partially mediated by serum insulin levels.

[Incidence of postoperative complications in Chinese patients with gastric or colorectal cancer based on a national, multicenter, prospective, cohort study]

Objective: To investigate the incidence of postoperative complications in Chinese patients with gastric or colorectal cancer, and to evaluate the risk factors for postoperative complications. Methods: This was a national, multicenter, prospective, registry-based, cohort study of data obtained from the database of the Prevalence of Abdominal Complications After Gastro- enterological Surgery (PACAGE) study sponsored by the China Gastrointestinal Cancer Surgical Union. The PACAGE database prospectively collected general demographic characteristics, protocols for perioperative treatment, and variables associated with postoperative complications in patients treated for gastric or colorectal cancer in 20 medical centers from December 2018 to December 2020. The patients were grouped according to the presence or absence of postoperative complications. Postoperative complications were categorized and graded in accordance with the expert consensus on postoperative complications in gastrointestinal oncology surgery and Clavien-Dindo grading criteria. The incidence of postoperative complications of different grades are presented as bar charts. Independent risk factors for occurrence of postoperative complications were identified by multifactorial unconditional logistic regression. Results: The study cohort comprised 3926 patients with gastric or colorectal cancer, 657 (16.7%) of whom had a total of 876 postoperative complications. Serious complications (Grade III and above) occurred in 4.0% of patients (156/3926). The rate of Grade V complications was 0.2% (7/3926). The cohort included 2271 patients with gastric cancer with a postoperative complication rate of 18.1% (412/2271) and serious complication rate of 4.7% (106/2271); and 1655 with colorectal cancer, with a postoperative complication rate of 14.8% (245/1655) and serious complication rate of 3.0% (50/1655). The incidences of anastomotic leakage in patients with gastric and colorectal cancer were 3.3% (74/2271) and 3.4% (56/1655), respectively. Abdominal infection was the most frequently occurring complication, accounting for 28.7% (164/572) and 39.5% (120/304) of postoperative complications in patients with gastric and colorectal cancer, respectively. The most frequently occurring grade of postoperative complication was Grade II, accounting for 65.4% (374/572) and 56.6% (172/304) of complications in patients with gastric and colorectal cancers, respectively. Multifactorial analysis identified (1) the following independent risk factors for postoperative complications in patients in the gastric cancer group: preoperative comorbidities (OR=2.54, 95%CI: 1.51-4.28, P<0.001), neoadjuvant therapy (OR=1.42, 95%CI:1.06-1.89, P=0.020), high American Society of Anesthesiologists (ASA) scores (ASA score 2 points:OR=1.60, 95% CI: 1.23-2.07, P<0.001, ASA score ≥3 points:OR=0.43, 95% CI: 0.25-0.73, P=0.002), operative time >180 minutes (OR=1.81, 95% CI: 1.42-2.31, P<0.001), intraoperative bleeding >50 mL (OR=1.29,95%CI: 1.01-1.63, P=0.038), and distal gastrectomy compared with total gastrectomy (OR=0.65,95%CI: 0.51-0.83, P<0.001); and (2) the following independent risk factors for postoperative complications in patients in the colorectal cancer group: female (OR=0.60, 95%CI: 0.44-0.80, P<0.001), preoperative comorbidities (OR=2.73, 95%CI: 1.25-5.99, P=0.030), neoadjuvant therapy (OR=1.83, 95%CI:1.23-2.72, P=0.008), laparoscopic surgery (OR=0.47, 95%CI: 0.30-0.72, P=0.022), and abdominoperineal resection compared with low anterior resection (OR=2.74, 95%CI: 1.71-4.41, P<0.001). Conclusion: Postoperative complications associated with various types of infection were the most frequent complications in patients with gastric or colorectal cancer. Although the risk factors for postoperative complications differed between patients with gastric cancer and those with colorectal cancer, the presence of preoperative comorbidities, administration of neoadjuvant therapy, and extent of surgical resection, were the commonest factors associated with postoperative complications in patients of both categories.

[Mid-term analysis of prospective cohort study of rivaroxaban in preventing CRT in breast cancer]

Objective: To explore the efficacy and safety of Rivaroxaban in preventing catheter related thrombosis (CRT) in patients with breast cancer who are undergoing central venous catheter chemotherapy, and provide basis for making standardized prevention and treatment strategies. Methods: In this research, a prospective cohort study was adopted, and breast cancer patients who received central venous catheter chemotherapy in Sanhuan Cancer Hospital during September 2020 to March 2022 were selected as a treatment group to take the rivaroxaban anticoagulation therapy with 10 mg.po.qd for one month. The control group got no preventive anticoagulation therapy. Vascular ultrasound examination was taken to confirm the occurrence of CRT, and a chi-square test was done for comparison the disparity between the groups. Logistic regression was applied to analyze the univariate and multivariate factors for the formation of CRT. Results: In the research, a total of 235 patients were selected, and there were a total of 19 035 days of catheterization with 81 days of catheterization on average. While in the control group, the incidence of CRT was 28.0% (33/118), the incidence of CRT in the treatment group was 20.5% (24/117), the difference was no significant (P=0.183). Subgroup analysis results showed that the peripherally inserted central catheter (PICC) was performed in 165 cases with the CRT incidence of 18.2% (30/165) and thrombosis was mostly seen around axillary vein, accounting for 63.3%. Subclavian vein catheterization was performed in 63 cases with the CRT incidence of 39.7% (25/63), and thrombosis was mostly seen around subclavian vein, accounting for 88.0% (22/25). Implantable venous access port was implanted in 7 cases around subclavian vein and internal jugular vein with the CRT incidence of 28.6% (2/7). The patients who developed CRT within 30 days after catheterization accounted for 54.4% (31/57), 22.8% (13/57) in a period during 30 days and 60 days) and 22.8% (13/57) in a period during 60 days and 180 days). The diagnosed CRT patients had been treated with rivaroxaban 15 mg.bid.po for 3 months. During the 3 months, 100.0% of the thrombosis waned, 71.9% (41/57) of the thrombosis waned within 30 days, 19.3% (11/57) in a period during 30 and 60days and 8.8% (5/57) in a period during 60 days and 90 days. Univariate and multivariate analysis indicated that the risk of CRT in subclavian vein catheterization was higher than that in PICC, respectively (OR=2.898, 95% CI:1.386-6.056 P=0.005), and the type of catheterization was an independent factor for the formation of thrombosis. Safety analysis result showed that in the prevention of CRT, rivaroxaban treatment did not induce drug-related bleeding, liver function damage, bone marrow suppression or any other side effects. While CRT diagnosed patients were treated with anticoagulation, they kept the central venous catheter, and the infusion was smooth. These patients all finished the anti-tumor treatment as planned, and no abnormalities like new thrombosis or pulmonary embolism were observed. Conclusions: In the mid-term analysis, the proportion of Rivaroxaban in preventing anticoagulant CRT decreases, but it don't reach statistical significance. The sample size should be further increased for observation. Rivaroxaban is proved effective and very safe in the treatment of CRT, and does not affect the concurrent chemotherapy. Medical personnel should carry out the policy of "early prevention, early detection and early treatment" for CRT so as to improve the patients' quality of life.

[Spatial distribution pattern of local tumor progression analysis after microwave ablation of hepatocellular carcinoma based on three-dimensional magnetic resonance imaging]

Objective: To investigate the spatial distribution pattern of local tumor progression (LTP) for hepatocellular carcinoma (HCC) ≤5 cm after microwave ablation. Methods: A retrospective analysis was performed on 169 HCCs with matched MRI before and after ablation from December 2009 to December 2019. A tumor MRI was reconstructed using three-dimensional visualization technology. LTP was classified as contact or non-contact, early or late stage, according to whether LTP was in contact with the edge of the ablation zone and the occurrence time (24 months). The tumor-surrounded area was divided into eight quadrants by using the eight-quadrant map method. An analysis was conducted on the spatial correlation between the quadrant where the ablative margin (AM) safety boundary was located and the quadrant where different types of LTP occurred. The t-test, or rank-sum test, was used for the measurement data. 2-test for count data was used to compare the difference between the two groups. Results: The AM quadrant had a distribution of 54.4% LTP, 64.2% early LTP stage, and 69.1% contact LTP, suggesting this quadrant was much more concentrated than the other quadrants (P < 0.001). Additionally, the AM quadrant had only 15.2% of non-contact type LTP and 17.1% of late LTP, which was not significantly different from the average distribution probability of 12.5% (100/8%) among the eight quadrants (P = 0.667, 0.743). 46.6% of early contact type LTP was located at the ablation needle tip, 25.2% at the body, and 28.1% at the caudal, while the location distribution probabilities of non-early contact LTP were 34.8%, 31.8%, and 33.3%, respectively. Conclusion: LTP mostly occurs in areas where the ablation safety boundary is the shortest. However, non-contact LTP and late LTP stages exhibit the feature of uniform distribution. Thus, this type of LPT may result from an inadequate non-ablation safety boundary.

Dementia increases the risk of death in stroke patients: A retrospective cohort-based risk score model study

BACKGROUND

The relationship between dementia and the mortality of stroke is a significant concern for patients and careers. However, there are few research about it in China and a lack of reliable data on the risk of dementia. We aim to analyze and compare the risk of death in stroke patients with and without dementia. Further investigation into the predictive value of dementia for stroke death.

METHODS

All patients with stroke who were identified among residents of Ningxia, between January 1, 2014 to December 31, 2021, set death or May 22, 2022 as the observation endpoint. All patients were screened by 1:4 propensity score matching (PSM). The association between dementia and all-cause mortality was evaluated using Cox regression with survival time. Evaluation of the predictive value of dementia using decision curve analysis (DCA) and clinical impact curve (CIC) curves.

RESULT

Mortality of stroke with dementia is 45.4% and without dementia is 13.8%, further calculated one-year mortality is higher in the patients with dementia than without dementia (17.3%vs. 5.4%, p < 0.001). Stroke patients with dementia had a 3.74 times higher risk of death (95% CI = 3.29,4.26) and had a shorter survival time than those without dementia. Dementia was an independent predictor of death in all models (hazard ratio [HR]=3.77,95%CI: 3.31-4.30, p < 0.001). DCA and CIC curves indicated that dementia has a high value in predicting the risk of death in stroke patients.

CONCLUSION

Dementia is an independent risk factor for death and reduces survival time in stroke patients.

Trends of hospitalisation for patients with liver cirrhosis in Ningxia, China: a cross-sectional study

OBJECTIVE

To evaluate the changing trends of hospitalisation for patients with liver cirrhosis between 2015 and 2019 by using hospitalisation summary records in Ningxia Hui Autonomous Region (NHAR), China.

DESIGN

A cross-sectional study.

SETTING

Hospitalisation summary records between 1 January 2015 and 31 December 2019 from 28 top-ranking hospitals in NHAR were extracted and rigorously analysed.

PARTICIPANTS

During the study period, hospitalisation records referring to liver cirrhosis were included. Records with missing data were excluded. A total of 16 566 patients with liver cirrhosis were included in this study.

OUTCOME MEASURES

International Classification of Diseases codes, tenth version (ICD-10) and text-diagnoses were used to identify hospitalisation records referring to liver cirrhosis.

RESULTS

Between 2015 and 2019, hospitalisation rates for liver cirrhosis declined from 8.38% to 5.57%. Chronic viral hepatitis accounted for almost 70% of all liver cirrhosis admissions; the remaining 30% of patients were admitted due to non-viral hepatitis cirrhosis (28.06%) and alcoholic cirrhosis (2.05%). The male-to-female hospitalisation rate ratio for liver cirrhosis was 2.57. The hospitalisation rate for workers with hepatitis cirrhosis was significantly higher than farmers (hospitalisation rate ratio (RR)=1.06, 95% CI 1.01 to 1.15, p<0.001); this was also the case for alcoholic cirrhosis (RR=5.23, 95% CI 3.34 to 8.20). However, the hospitalisation rate for workers with non-viral hepatitis cirrhosis was significantly lower than for farmers (RR=5.23, 95% CI 3.34 to 8.20, p<0.001). The hospitalisation rate increased in patients over the age of 30 years and reached a peak at the age of 45-50 years.

CONCLUSIONS

The hospitalisation rate for liver cirrhosis has declined over recent years and chronic viral hepatitis remains the major cause of liver cirrhosis in NHAR. Hospitalisation summary records can efficiently reflect the local changing trends of hospitalisation for liver cirrhosis and represent an efficient strategy for the surveillance of chronic disease.

[Puerarin alleviates lipopolysaccharide-induced acute kidney injury in mice by modulating the SIRT1/NF-κB pathway]

OBJECTIVE

To investigate the role of the SIRT1/NF-κB pathway in mediating the effect of puerarin against lipopolysaccharide (LPS)-induced acute kidney injury (AKI).

METHODS

Fifteen BALB/C mice were randomized into control group, LPS group and puerarin treatment group, and in the latter two groups, the mice were given an intraperitoneal injection of LPS (5 mg/kg), followed by daily injection of normal saline for 3 days or injection of puerarin (25 mg/kg) given 1 h later and then on a daily basis for 3 days. On day 5 after modeling, the kidney tissues were taken for histological observation and detection of cell apoptosis. The renal function indexes including urea nitrogen (BUN), serum creatinine (Scr) and kidney injury molecule 1 (KIM-1) and the levels of tumor necrosis factor (TNF-α) and interleukin 1β (IL-1β) were measured, and the expressions of SIRT1 and NF-κB-p65(acetyl K310) in the renal tissues were detected.

RESULTS

Intraperitoneal injection of LPS caused obvious glomerular capillary dilatation, hyperemia, renal interstitial edema, and renal tubular epithelial cell swelling and deformation in the mice. The mouse models of LPS-induced AKI also showed significantly increased renal tubular injury score and renal cell apoptosis (P < 0.01) with increased serum levels of BUN, Scr, KIM-1, TNF-α and IL-1β (P < 0.01), enhanced renal expressions of TNF-α, IL-1β and NF-κB p65(acetyl K310) (P < 0.01) and lowered renal expression of SIRT1 (P < 0.05). Treatment with puerarin effectively alleviated LPS-induced renal interstitial edema and renal tubular epithelial cell shedding, lowered renal tubular injury score (P < 0.01) and renal cell apoptosis rate (P < 0.01), and decreased serum levels of BUN, Scr, KIM, TNF-α and IL-1β (P < 0.01). Puerarin treatment significantly reduced TNF-α, IL-1β and NF-κB p65 (acetyl K310) expression in the renal tissue (P < 0.05) and increased SIRT1 expression by 17% (P < 0.05) in the mouse models.

CONCLUSION

Puerarin can effectively alleviate LPS-induced AKI in mice possibly by modulating the SIRT1/NF-κB signaling pathway.

Increased Incidence and Risk Factors of Infections by Extended-Spectrum β-Lactamase-Producing Enterobacterales During the COVID-19 Pandemic: A Retrospective Case-Control Study

Purpose

To investigate changes in the incidence of infections by extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) and analyzed whether there was an association between endogenous changes in the organism due to COVID-19 infection and the infections by ESBL-E.

Patients and Methods

The study was a single-center retrospective case-control design. A total of 107 patients infected by ESBL-E during the COVID-19 pandemic were selected as the case group, while 214 uninfected patients selected by 1:2 propensity score matching (PSM) acted as the control group. Univariate analysis, LASSO logistic regression, and multivariate logistic regression were used to determine the risk factors for ESBL-E infection. An interrupted time series was used to analyze the changes in the incidence of ESBL-E infections in hospitalized patients during the COVID-19 pandemic.

Results

The incidence of infection with ESBL-E showed a significant increase during COVID-19 (3.42 vs 4.92 per 1000 patients, p = 0.003). The incidence of ESBL-E infections increased at an average rate of 0.45 per 1000 patients per week compared to the pre-pandemic period (p = 0.022). Multivariate logistic regression analysis showed that a length of hospitalization ≥ 15 days (OR: 2.98 (1.07-8.28), chronic kidney disease (OR: 4.25 (1.32-13.70), white blood cell (WBC) > 9.5×10^9/L (OR: 3.04 (1.54-6.01), use of hormonal drugs (OR: 2.38 (1.04-5.43), antibacterial drug use 1 type (OR: 5.38 (2.04-14.21), antibacterial drug use 2 types (OR: 23.05 (6.71-79.25) and antibacterial drug use ≥ 3 types (OR: 88.35 (8.55-912.63) were independent risk factors for infection with ESBL-E, while chronic obstructive pulmonary disease (COPD) was a protective factor (OR: 0.14 (0.03-0.66). COVID-19 was not an independent risk factor for infection by ESBL-E.

Conclusion

During the COVID-19 pandemic, the incidence of infections by ESBL-E increased significantly. Increased exposure to traditional risk factors were the main reasons, however, COVID-19 was not an independent risk factor for ESBL-E infection.

Multiple Mechanisms in Proton-Induced Nucleon Removal at ∼100 MeV/Nucleon

We report on the first proton-induced single proton- and neutron-removal reactions from the neutron-deficient ^{14}O nucleus with large Fermi-surface asymmetry S_{n}-S_{p}=18.6  MeV at ∼100  MeV/nucleon, a widely used energy regime for rare-isotope studies. The measured inclusive cross sections and parallel momentum distributions of the ^{13}N and ^{13}O residues are compared to the state-of-the-art reaction models, with nuclear structure inputs from many-body shell-model calculations. Our results provide the first quantitative contributions of multiple reaction mechanisms including the quasifree knockout, inelastic scattering, and nucleon transfer processes. It is shown that the inelastic scattering and nucleon transfer, usually neglected at such energy regime, contribute about 50% and 30% to the loosely bound proton and deeply bound neutron removal, respectively. These multiple reaction mechanisms should be considered in analyses of inclusive one-nucleon removal cross sections measured at intermediate energies for quantitative investigation of single-particle strengths and correlations in atomic nuclei.

Magnetic-field-synchronized wireless modulation of neural activity by magnetoelectric nanoparticles

The in vitro study demonstrates wirelessly controlled modulation of neural activity using magnetoelectric nanoparticles (MENPs), synchronized to magnetic field application with a sub-25-msec temporal response. Herein, MENPs are sub-30-nm CoFe₂O₄@BaTiO₃ core-shell nanostructures. MENPs were added to E18 rat hippocampal cell cultures (0.5 μg of MENPs per 100,000 neurons) tagged with fluorescent Ca²⁺ sensitive indicator cal520. MENPs were shown to wirelessly induce calcium transients which were synchronized with application of 1200-Oe bipolar 25-msec magnetic pulses at a rate of 20 pulses/sec. The observed calcium transients were similar, in shape and magnitude, to those generated through the control electric field stimulation with a 50-μA current, and they were inhibited by the sodium channel blocker tetrodotoxin. The observed MENP-based magnetic excitation of neural activity is in agreement with the non-linear M - H hysteresis loop of the MENPs, wherein the MENPs' coercivity value sets the threshold for the externally applied magnetic field.

The direct and indirect effects of length of hospital stay on the costs of inpatients with stroke in Ningxia, China, between 2015 and 2020: A retrospective study using quantile regression and structural equation models

Importance

Length of hospital stay (LOHS) is the main cost-determining factor of hospitalization for stroke patients. However, previous analyses involving LOHS did not consider confounding or indirect factors, or the effects of other factors on LOHS and inpatient costs.

Objective

To investigate the direct and indirect effects of LOHS on the hospitalization costs of inpatients with ischemic and hemorrhagic stroke.

Design setting and participants

This was a population-based, retrospective, and observational study that analyzed data acquired from the Nationwide Inpatient Sample between 2015 and 2020 relating to ischemic and hemorrhagic stroke in Ningxia, China.

Main outcomes and measures

Hospitalizations were identified by the International Classification of Diseases 10th Revision (ICD-10). Inpatient costs were described by the median M (P25, P75). We used a quantile regression model to estimate the linear relationships between a group of independent variables X and the quantile of the explained variable hospitalization cost (Y). A structural equation model (SEM) was then used to investigate the direct and indirect effects of LOHS on inpatient costs.

Results

The study included 129,444 patients with ischemic stroke and 15,525 patients with hemorrhagic stroke. The median LOHS was 10 (8-13) days for ischemic stroke and 15 (10-22) days for hemorrhagic stroke. The median M (P₂₅, P₇₅) of inpatient costs was $1020 (742-1545) for ischemic stroke and 2813 (1576-6191) for hemorrhagic stroke. The total effect of LOHS on inpatient costs was 0.795 in patients with ischemic stroke. The effect of yearof discharge (X4) and CCI (X8) on inpatient costs was dominated by an indirect effect through the LOHS. The indirect effect was -0.071 (84.52% of the total effect value) and 0.034 (69.39% of the total effect value), respectively. The total effect of LOHS on inpatient costs in patients with hemorrhagic stroke was 0.754. The influence of CCI on inpatient costs was dominated by an indirect effect through LOHS; the indirect effect value was -0.028 (77.78% of the total effect value). The payment type, surgery, method of discharge, and hospital level also exerted an impact on inpatient costs by direct and indirect effects through the LOHS.

Conclusions and relevance

Length of hospital stay (LOHS) was identified as the main factor influencing hospitalization costs. However, other social factors were shown to indirectly influence hospitalization costs through the LOHS. Taking effective measures to further reduce hospitalization costs remains an effective way to control hospitalization costs for stroke patients.

Effects of Ce, Sm and Yb on cavitation erosion of NAB alloy in 3.5% NaCl solution

The influences of Ce, Sm and Yb on cavitation erosion of NAB alloy in 3.5% NaCl solution are evaluated using mass loss, SEM, 3D morphology and Tafel plot, respectively. The results show that the addition of Ce or Sm or Yb enhances the mechanical property of NAB alloy, and the sizes of κ_Ⅰ and κ_Ⅱ phases within NAB alloy decrease with adding Ce or Sm or Yb, resulting in the prevention of the propagation of the cracks caused by cavitation erosion initially originated at the phase boundaries between α and κ phases, and finally the cavitation erosion damage significantly decreases with adding Ce or Sm or Yb. The corrosion of NAB alloy in 3.5% NaCl solution can promote the cavitation erosion of NAB alloy, while the corrosion resistance of NAB alloy increases with the addition of Ce or Sm or Yb, and then the cavitation erosion resistance is accordingly improved with the addition of rare earth element.

Improving the communication skills of medical students --A survey of simulated patient-based learning in Chinese medical universities

BACKGROUND

It is useful to advance simulated patient (SP) participation in teaching to improve the communication skills of medical students, so this study aims to explore the current state of Chinese mainland SP education.

METHODS

A cross sectional survey was designed utilizing well defined quantitative research methods and descriptive statistics. The questionnaire sought information which elucidated the current status of SP-based education, the origin of SP-based learning, SP training, challenges of this learning strategy and future developments. Questionnaires were distributed to 79 medical colleges in mainland China, and 68 were returned. Of these, 64 constituted valid responses (81%).

RESULTS

The number of SP-based education activities in medical colleges offering 5-year、7-year and 8-year clinical medicine programs was significantly higher than that in medical colleges which offered only a single 5-year program (p < 0.01). Communication skills training accounted for 73% of the content of SP-based learning activities, and was expected to rise in the future to 90%, in response to a need to improve doctor-patient relationships. Persons recruited as 'simulated patients' included students (21% of the total), residents (49%), medical staff (15%) and teaching staff (14%). Colleges, planning a SP-based education program, preferred teachers (80%) and students (55%) to assume 'simulated patient' roles. In objective structured clinical education (OSCE) scenarios, co-scoring by both SPs and teachers featured more highly in the 'consultation' station and 'doctor-patient communication' station. A number of factors were identified as hindering future development and implementation of SP-based learning including budget restraints, SP selection and training.

CONCLUSIONS

SP-based learning programs offer clear benefits for improving the clinical education of medical students and their communication skills. The main obstacles to achieving more widespread and higher quality SP-based education are insufficient funding and the lack of standardized training and performance evaluation processes for simulated patients. Medical colleges should consider reducing the proportion of students and teachers acting as SPs, and attract more citizens to participate in SP-based learning activities. Formalised training and evaluation of SPs performance are necessary to establish a 'standard simulated patient' for a particular medical discipline, thus improving SP-based activities and student learning.

AB0392 EFFICACY AND SAFETY OF UPADACITINIB IN A CHINESE SUBGROUP OF PATIENTS WITH RHEUMATOID ARTHRITIS AND INADEQUATE RESPONSE TO CONVENTIONAL SYNTHETIC DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS

Background

Upadacitinib (UPA) was effective in global Phase 3 trials in rheumatoid arthritis (RA) patients (pts) with inadequate response (IR) to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

Objectives

To assess the efficacy and safety of UPA in csDMARD-IR pts with RA in Chinese subgroup from a Phase 3, randomized, double-blind, placebo (PBO)-controlled study (NCT02955212) 1.

Methods

Pts were randomized to 12 weeks of blinded treatment with UPA 15 mg once daily (QD) or PBO, in combination with csDMARDs. Primary and secondary endpoints were analyzed in a Chinese subgroup, including American College of Rheumatology criteria (ACR) responses, remission and low disease activity measures. Safety was analyzed for pts who received ≥1 dose of study drug.

Results

228 Chinese pts (67.5% of overall trial population) were randomized and took at least one dose of study drug. Baseline characteristics were generally balanced between UPA and PBO. 46% and 35.1% used methotrexate (MTX) alone as concomitant csDMARD in UPA and PBO group, respectively. 38.9% in UPA and 43.0% in PBO group used concomitant csDMARDs other than MTX and 15.0% and 21.9% respectively used a combination. At week 12, more Chinese pts receiving UPA achieved the primary endpoint of ACR20 compared with PBO (71.9% vs 31.6%, nominal p<0.001). UPA also showed greater improvements in all secondary endpoints vs PBO at Week 12 (Table 1), including ACR50 and ACR70, mean change in Disease Activity Score in 28 joints using C-reactive protein (DAS28-CRP), Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form 36-item Health Survey-Physical Component Summary (SF-36 PCS), as well as proportion of pts achieving low disease activity based on DAS28-CRP ≤3.2 and Clinical Disease Activity Index (CDAI) ≤10, and clinical remission based on DAS28-CRP <2.6. Onset of response was rapid with more pts receiving UPA achieving ACR20 by Week 1 versus PBO (25.4% vs 5.3%, nominal p<0.001). Through Week 12 treatment-emergent adverse events (TEAEs) occurred in 57.9% of pts on UPA and 49.1% on PBO. The rate of pts with serious AEs (SAEs) was numerically higher with UPA than with PBO (6.1% vs 4.4%). TEAEs reported in ≥ 3% of subjects and with a higher rate on UPA vs. PBO were: upper respiratory tract infection, alanine aminotransferase increased, aspartate aminotransferase increased, hypertension, diarrhea, and leukopenia. Overall safety was consistent with the trial population1 and similar with the reported safety profile of the global clinical program2.

Table 1.

Summary of Efficacy Endpoint Results at Week 12 in Chinese Subgroup

Endpoint aUPA 15mg (N=114)PBO (N=114)Primary endpointACR20, %71.9***31.6Secondary endpointsΔ DAS28-CRP-2.42***-0.75Δ HAQ-DI-0.55***-0.11Δ SF-36 PCS7.63 b***2.94 cDAS28-CRP ≤3.2, %46.5***9.6DAS28-CRP <2.6, %28.1***1.8CDAI ≤10, %33.3***7.0ACR50, %39.5***7.0ACR70, %16.7***2.6ACR20 at Week 1, %25.4***5.3

***Nominal p<0.001 vs PBO

aNon-responder imputation for binary endpoints; ANCOVA with multiple imputation for DAS28(CRP) and HAQ-DI; mixed model repeated measures for other continuous endpoints. Δ: mean change from baseline

bN=106

cN=104

Conclusion

UPA demonstrated clinical and functional improvement in Chinese csDMARD-IR RA pts. The safety of UPA was comparable with the overall study population and with the safety seen in the global Phase 3 program.

References

[1]Zeng X, Zhao D, Radominski SC, et al. Int J Rheum Dis. 2021;24:1530–1539.

[2]Cohen SB, van Vollenhoven RF, Winthrop KL, et al. Ann Rheum Dis 2021;80:304–311.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship.

Disclosure of Interests

Xiaofeng Zeng: None declared, Yi Liu: None declared, Jiankang Hu: None declared, Jingyang Li: None declared, Yongfu Wang: None declared, Dongbao Zhao: None declared, Lijun Wu: None declared, Zhengyu Xiao: None declared, ZHIJUN LI: None declared, Jian Xu: None declared, Sebastian Meerwein Shareholder of: may own AbbVie stock or options, Employee of: AbbVie employee, Yunxia Xie Shareholder of: may own AbbVie stock or options, Employee of: AbbVie employee, Peiwen Liang Employee of: AbbVie

[Comparative study of CT relative enhancement value and subjective visual evaluation for intestinal ischemia in patients with closed loop obstruction]

Objective: To compare and evaluate the diagnostic performance of visual evaluation and CT maximal density relative enhancement value in the diagnosis of intestinal ischemia complication in patients with closed loop obstruction and to explore the feasibility of CT maximal density relative enhancement value in quantifying the degrees of intestinal ischemia. Methods: The clinical and CT imaging data of 82 patients, 46 males and 36 females, aged from 19 to 78(52±18) years, with closed loop obstruction were retrospectively analyzed in the First Affiliated Hospital of Zhengzhou University from July 2017 to July 2019. All patients were classified into three groups: necrosis group (28 cases), ischemia group (22 cases), non-ischemia group(32 cases) using clinicopathologic results as reference standard. CT visual evaluation was performed by two experienced radiologists. The sensitivity, specificity, positive and negative predictive values and accuracy of the two observers were calculated respectively. The inter-observer agreement was analyzed by kappa analysis. Maximal density relative enhancement value was defined as the difference CT value of an ROI at dilated obstructed loops between contrast-enhanced and unenhanced CT images. The differences among groups were compared by one-way analysis of variance. Diagnostic performances were evaluated by receiver operating characteristic (ROC) curve analysis. Results: The sensitivity, specificity, positive and negative predictive values and accuracy of observer1 were 62.0%, 87.5%, 88.6%, 59.6%, 72.0%, and 58.0%, 93.8%, 93.5%, 58.8%, 72.0%for observer2, respectively. The kappa value of inter-observer agreement was 0.747. The unenhanced CT value of necrosis group, ischemia group and non-ischemia group was (53.7±9.7), (45.7±7.2) and (44.7±7.0) HU, enhanced CT value was (60.5±10.1), (65.0±11.6) and (87.0±15.8) HU, relative enhancement value was(6.8±8.4), (19.2±12.4) and(44.7±16.2)HU, respectively. All had a statistical difference among three groups (all P<0.05). The unenhanced CT value of necrosis group was higher than that of ischemia group and un-ischemia group (both P<0.05). The enhanced CT value of non-ischemia group was higher than that of ischemia group and necrosis (both P<0.05). The relative enhancement value all had a significant difference between groups (all P<0.05). Taking maximal density relative enhancement value below 19.5 HU as diagnosis threshold, the sensitivity, specificity and area under curve(AUC) were 96.9%, 74.0% and 0.947, respectively. Taking enhanced CT value below 66.5 HU as diagnosis threshold, the sensitivity, specificity and AUC were 93.8%, 60.0% and 0.903, respectively; the sensitivity was higher than that of objective visual evaluation. Conclusion: Maximal density relative enhancement value can quantize the bowel wall enhancement, and is a more reliable way in the diagnosis of intestinal ischemia than visual evaluation.

[Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy for gastric cancer]

Objective: To investigate the safety and feasibility of Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy for gastric cancer. Methods: In this study, descriptive case series method was used to retrospectively analyze the data of 3 patients with gastric cancer who underwent Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy in the First Affiliated Hospital of Dalian Medical University from December 2020 to February 2021. The linear layout was adopted for the setting of trocar, and the co-axial direction was the line connecting the umbilicus and splenic hilum. The inferior pyloric arteries and veins need to be preserved. The center was the bifurcation of the right gastroepiploic vessel and the inferior pyloric vessel. Dissection and exposure were performed from the upper, lower, right and left sides, and ventral and dorsal sides to complete the dissection of the inferior pyloric lymph nodes. The superior border of the pancreas was treated by the right diaphragmatic crus approach, the left retroperitoneal approach and the esophageal approach to determine the distribution of the posterior vagal trunk and its branches, and to determine the anatomical relationship with the left gastric artery. The left gastric artery was cut off while the celiac branch of vagus nerve and cardia branch of left gastric artery were preserved. Lymph node dissection was performed on the lateral side of nerve fibers around the blood vessels. Result: All the 3 patients successfully completed the robotic surgery without conversion to laparoscopy or laparotomy. The operation time was (340.0±26.4) (300-390) minutes, the intraoperative blood loss was (13.3±3.3) (10-20) ml, the number of dissected lymph nodes was 26.7±3.9 (19-32), the length of pylorus canal preserved was (3.3±0.3) (3-4) cm, the distal margin was (2.3±0.3) (2-3) cm, and the proximal margin was (3.0±0.6) (2-4) cm. No postoperative complications occurred in all the 3 patients. The first flatus time was 2-3 days after operation, and the postoperative hospital stay was 6-7 days. The operation cost of the 3 patients was (40±7) (33-53) thousand yuan. Conclusion: Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy is safe and feasible.

[Diagnostic efficacy of a combined diagnostic model based on extreme gradient boosting algorithm in differentiating the pathological grading of gastric neuroendocrine neoplasms]

Objective: To evaluate the diagnostic efficacy of combined diagnostic model based on extreme gradient boosting (XGBoost) algorithm to determine the pathological grading of gastric neuroendocrine neoplasms (NENs). Methods: A total of 81 gastric NENs patients in the First Affiliated Hospital of Zhengzhou University confirmed by definite pathological grading from August 2012 to December 2019 were enrolled. The data of clinical and CT findings were collected. The number of lesions, tumor location, shape, lymph node metastasis, thickness, longitude of tumor and CT values in arterial and venous phase were analyzed. ITK-SNAP software and Python 2.1.0 PyRadiomics software were used to perform the image preprocessing and radiomics features extraction from segmented images. XGBoost algorithm was used to build the CT findings model, radiomics model in arterial phase, radiomics model in venous phase and combined diagnostic model. The diagnostic efficacy of CT imaging model, radiomics model in arterial phase, radiomics model in venous phase and combined diagnostic model were evaluated by accuracy, mean squared error (MSE) and mean absolute error (MAE). Results: The subjects were 28.0 to 78.0 (58.6+10.7) years old, including 56 males (69.1%). The number of lesions, tumor location, shape, lymph node metastasis, thickness and longitude of tumor between G1/G2 and G3 patients showed statistic significances (all P values<0.05), while there were no differences in CT values in arterial and venous phase (both P values>0.05). Six most important features in the combined diagnostic model were A_logarithm_glcm_Imc1, P_squareroot_glcm_Maximum Probability, thickness, longitude, A_wavelet-HHL_glrlm_GrayLevelNonUniformity and P_wavelet-LLL_ngtdm_Contrast, respectively. The accuracy of CT findings model, radiomics model in arterial phase, radiomics model in venous phase and combined diagnostic model were 81.8%, 86.0%, 87.8% and 91.0%, respectively; with MSE were 539.41, 490.08, 429.99 and 371.92, respectively; and MAE were 16.72, 15.25, 14.23 and 12.33, respectively. The MAE value of the combined diagnostic model was lower than those of CT findings model and radiomics model in arterial phase (P<0.001 and 0.004, respectively), while no statistically difference was detected compared to radiomics model in venous phase (P=0.111). Conclusion: The combined diagnostic model based on XGBoost algorithm have a good diagnostic efficiency for the pathological grading of gastric NENs.

P13.15 Pre-clinical trial of T601 oncolytic virus for high grade glima via intra-tumoral injection

BACKGROUND

An effective therapeutic method still hasn’t been devised for lethal high grade glioma. Thus, a method with high anti-tumoral efficiency, tumoral targeting, and acceptable side effect needs to be designed. Oncolytic virotherapy which can specifically lyse tumor cells via mass replication and deleting nucleotide metabolism related gene, like TK, required in viral replication and overexpressed in tumor cells, provides hope for patients. However, the virus only contained TK deletion is unable to show sufficient specificity of anti-tumoral response in tumor cells. Here, the adapted strain of vaccinia virus with high tumoral specificity due to TK and RR deletion and FUC1 insertion, named T601, is chosen in this project. In clinical application, intra-tumoral injection showed improved anti-tumoral efficiency and acceptable side effect. However, intra-tumoral viral injection in orthotropic glioma model is rare. In this project, various biosafety and antitumoral efficiency parameter would be tested for confirming the biosafety and reliability of intra-tumoral T601 viral injection for future clinical trials.

MATERIAL AND METHODS

For measuring the IC50 of T601, 10 different amounts of virus was tested in vitro via calculating cell viability with CCK-8(cell counting kit-8). For measuring the further antitumoral response of FCU1, different concentration of the 5-FC was added into the medium with IC50 viral amount. To ensure the biosafety of T601, MTD (maximum tolerance dose) was measured. Based on the MTD result, for evaluating the anti-tumoral efficiency, 106 pfu,105 pfu,104 pfu of virus was intra-tumoral injected in orthotopic GBM bearing mice. Tumor size was measured once a week through in vivo bioimaging system.

RESULTS

0.022 MOI, the IC50 of T601, showed high cytotoxicity of T601. Moreover, the significantly decreased cell viability under the combined treatment of 5-FC and 0.22MOI T601 showed intact anti-tumoral function. In MTD assay, except for 107 group, no significant weight loss was found. However, in 107 pfu group, mean body weight decreased around 10% and animal fatality happened on day 9. According to the MTD result, certain amount of virus was intra-tumorally injected. In all treatment group, the tumor size was significantly shrined. At the same time, the survival rate of mice under viral treatment was significantly extended.

CONCLUSION

In summary, T601 exhibited efficient anti-tumoral function and acceptable side effect. T601 treatment prolonged the survival period of GBM mice with acceptable neurotoxicity, demonstrating that T601 contains necessary criterial for intra-tumoral injection. Ultimately, this project provided basic reference information of dose for future clinical trial.

[Practical on primary trauma care training mode in public cardiopulmonary resuscitation training]

OBJECTIVE

To envaluate the effect of public cardiopulmonary resuscitation (CPR) training in Ningnan Mountain area.

METHODS

Using the method of convenient sampling, 775 people in Ningnan Mountain area were investigated about CPR and first aid knowledge by questionnaire from January to December 2019. The awareness rate of CPR, operation score, and operation qualification rate of the public before and after CPR training in the primary trauma treatment (PTC) mode were observed.

RESULTS

After PTC training, the public's CPR knowledge score, operation score and operation qualification rate, in terms of first aid telephone, consciousness judgment method, identification of respiratory arrest, artificial respiration implementation method, effective CPR indication and extrathoracic cardiac compression position were significantly improved [first aid telephone score: 82.68±8.54 vs. 60.25±10.38, consciousness judgment method score: 79.46±10.82 vs. 58.35±9.26, identification of respiratory arrest score: 80.85±9.64 vs. 59.26±11.45, artificial respiration implementation method score: 81.54±9.48 vs. 56.47±10.54, extrathoracic cardiac compression site score: 80.35±10.48 vs. 59.56±9.85, effective indication of CPR score: 81.02±9.45 vs. 58.21±8.69, operation assessment score: 60.25±10.45 vs. 50.38±9.68, operation assessment qualified rate: 60.39% (468/775) vs. 12.13% (94/775), all P < 0.05].

CONCLUSIONS

PTC mode is helpful to improve the effect of public CPR training, which is worthy of clinical promotion.

Combined Fracture of Carpal and Volar Divergent Dislocation of the Second to Fifth Carpometacarpal Joints

The volar divergent dislocation of the second to fifth carpometacarpal joints and involving fracture of carpal is an extremely rare injury. We reported a case of 55-year-old man, victim of a motorbike, who was struck by a car, admitted at the emergency department unable to move his left hand with severe swelling. X-rays and CT scan showed a volar divergent dislocation of second to fifth carpometacarpal joints and involving fracture of carpal. Patient underwent closed reduction and plaster fixation right way, after one week, he received open reduction internal fixation with K-wire and plaster. Functional exercise was started progressively once K-wire and plaster were removed after six weeks. At six months follow-up, results were excellent and patient has regained all of his range of motion and hand activities. Key words: carpometacarpal joint, palmar, divergent, dislocation, hand, wrist.

[Application effect of primary trauma treatment teaching mode in cardiopulmonary resuscitation training of special occupation in mountainous area of Southern Ningxia]

OBJECTIVE

To explore the application value of primary trauma treatment (PTC) teaching mode in special professional cardiopulmonary resuscitation (CPR) guide training.

METHODS

Cluster sampling method was adopted, and the residents' committee selected special occupation population from every town/sub-district office in the southern mountainous area of Ningxia Hui Autonomous Region for CPR training. A monthly session was held from January to December 2019, with personnel trained by traditional operation teaching and individual practice method from January to June 2019 as the control group and personnel trained by PTC teaching mode from July to December 2019 as the observation group. The two groups of trainers, training objectives and assessment standards were consistent. Questionnaire survey was conducted at the beginning and end of each training period, including the degree of mastery of first-aid knowledge and skills and the level of self-efficacy, etc., to evaluate the training effect.

RESULTS

There were 503 trainees in each group, and there was no significant difference in gender, age, education and occupation distribution between the two groups. There was no significant difference in the first aid principles, CPR skill level and self-efficacy between the two groups before the training. The first aid principle, CPR skills level and self-efficacy of the two groups after training were all improved, and the principle of first aid and CPR skills level in the observation group was obviously higher than that in the control group (first aid related concepts: 4.39±0.76 vs. 3.87±0.89, gold life-saving time: 5.71±0.49 vs. 4.53±0.62, the meaning of the first witnesses: 5.33±0.82 vs. 4.18±0.78, cardiac, respiratory cardiac arrest in the judgment: 5.12±0.73 vs. 4.07±0.73, CPR skills: 5.29±0.64 vs. 4.15±0.71, all P < 0.05). The self-efficacy score of the observation group was significantly higher than that of the control group (emergency attitude: 18.17±1.24 vs. 17.35±1.25, self-efficacy: 13.56±1.54 vs. 11.35±1.26, behavioral intention: 9.56±0.84 vs. 8.92±0.95, all P < 0.05).

CONCLUSIONS

The application of PTC teaching mode in the training of CPR guidelines for special professions has significant effects, which can effectively help special professions to master CPR knowledge and skills, and has promotion value.

[Significance of celiac branch of the vagal nerve in function-preserving gastrectomy]

Function-preserving gastrectomy, especially pylorus-preserving gastrectomy (PPG), can improve the quality of life and has been widely recognized. With the development of surgical techniques and equipment, nerve preservation has become a new requirement in the era of "precision medicine", but the preservation of celiac branch of the vagal nerve remains controversial in gastric cancer surgery. Current researches have shown that the preservation of celiac branch of the vagal nerve is safe and feasible in patients with early gastric cancer. Although controversial, nerve preservation may play a role in preventing gallstones, regulating gastric emptying, reducing dumping syndrome, alleviating chronic diarrhea, reducing gastroesophageal reflux, and inhibiting bile reflux. The significance of the celiac branch of the vagal nerve in gastric cancer surgery is worth further attention and exploration to promote the development of function-preserving gastrectomy and improve the quality of life of patients.

[The value of spectral CT-based radiomics in preoperative prediction of lymph node metastasis of advanced gastric cancer]

Objective: To investigate the spectral CT-based radiomics in predicting preoperatively the lymph node metastasis (LNM) of advanced gastric cancer. Methods: From January 2014 to October 2018, the spectral CT imaging and clinical data of 196 gastric adenocarcinoma patients confirmed by pathology in the First Affiliated Hospital of Zhengzhou University were retrospectively enrolled (training set and test set were randomly divided according to the ratio of 1∶1). These 196 patients include143 males and 53 females, aged from 28 to 81 years, with an average age of (59±11) years, and were divided into nodular metastasis group and non-metastasis group according to clinicopathological data. The spectral parameters were measured and calculated, and the CT-reported lymph node (LN) status from CT images were obtained. 273 radiomics features were extracted from the dual-phases CT images in different energy level (40, 65 and 100 keV) to build the radiomics signature respectively. Univariate analysis was used to compare the differences of spectral parameters and radiomics features between two groups, and then the significant indicators were put into multivariable logistic regression analysis to construct combined prediction model and radiomics nomogram. In addition, the performance of prediction model in training and test set were measured using the receiver operating characteristics (ROC) curves and were compared using DeLong test. Results: Both in training set and in test set, the iodine concentration (IC) of tumor in venous phase (VP) in nodular metastasis group were higher than that in non-metastasis group [training set: 22.98 (100 mg/L)>20.31 (100 mg/L), P=0.086; test set: 25.14 (100 mg/L)>21.07 (100 mg/L), P=0.009]. The CT-reported LN status showed significant differences between the two group (P<0.001, P=0.001). The radiomics signatures 40 keV-arterial phase, 65 keV-venous phase, IC-VP of tumor and CT-reported LN status were independent indicators for prediction of preoperative LNM of advanced gastric cancer in combined prediction model (P<0.05). The radiomics nomogram predicated LNM with an area under curve (AUC) and 95% confidence interval (CI) of 0.822 (0.739-0.906) in training set and 0.819(0.732-0.906) in test set, and there were no significant differences in AUC between two sets (P>0.05). Conclusions: The spectral CT-based radiomics can be used to quantitatively predict the LNM of advanced gastric cancer preoperatively.

FRI0031 OBSERVATIONS ON BIOMARKERS IN VERY EARLY RHEUMATOID ARTHRITIS CONSECUTIVELY RECRUITED OVER 20 YEARS, FROM BASELINE PRESENTATION TO FIVE-YEAR OUTCOMES

Background:

Since July 1998, the Early Undifferentiated PolyArthritis (EUPA) cohort recruited consecutive adults with recent-onset immune-mediated polyarthritis1,2. Patients were treated aiming at 0 swollen joint.

Objectives:

To analyze the impact of biomarkers over 20 years on baseline variables, treatments, comorbidities and outcomes over the first 5 years of follow up.

Methods:

Variables and Outcomes were collected over 5 years in consecutive patients fulfilling RA criteria, grouped according to date of inclusion (Period 1: 1998-2004; Period 2: 2005-2010; Period 3: 2011-2018). Comparisons of baseline characteristics, treatment, and outcomes over 5 years between the 3 Periods were previously presented (ACR 2018 and 2019). Erosive damage was scored according to Sharp/van der Heijde; erosive status was defined as ≥5 Erosion units. We now present observed associations between the presence of baseline prognostic biomarkers (anti-CCP2 (ACPA), RF, anti-Sa, and erosive status) with concomitant and subsequent disease activity levels, radiographic scores, comorbidities and impact of treatment. False discovery rate correction was used to adjust p-values for multiple comparisons.

Results:

753 patients were included: 247, 263 and 243 in Periods 1, 2 and 3, respectively. Variables at baseline. No biomarkers, including erosive status, were associated with demographics or disease activity. Erosive disease was more prevalent in ACPA+ (19.9% vs 13.9%, p=0.0417). Current smoking decreased by period (20.6, 17.2, 8.6%; p=0.02) in ACPA negatives only, remaining stable among ACPA+ (25.3, 20.9, 18.8%, NS). All comorbidities were significantly more present in ACPA negatives vs positives (RR between 1.55 and 1.99). Prevalence of cardiovascular (CV; 44.8, 55.0, 60.0%; p=0.036) and cancer (4.1, 7.1, 13.1%; p=0.02) comorbidities increased over time in ACPA negatives and remained stable in ACPA+ (CV: 33.0, 30.8, 40.7, NS; cancer: 3.0, 4.4, 6.2, NS). RF positivity decreased by period (47.8, 36.9, 36.7%, p=0.03), but ACPA+ remained stable (40.8, 35, 35.4% NS).

Outcomes over 5 years of follow up.

There was no link between the presence of any biomarker and subsequent disease activity scores. Positive ACPA, RF and anti-Sa at baseline predicted development of more erosive status (RR = 1.50; 1.37 and 1.52, all p<0.001). 68% reached DAS28 remission overall (70.3% in ACPA negatives, 65.2% in ACPA+). Independent of ACPA status, remission rates increased between Periods 1 vs 2 (RR = 1.14, p=0.04) and 1 vs 3 (RR=1.13, p=0.055), but not between 2 vs 3. CV comorbidities among ACPA+ increased significantly more over time vs ACPA negatives (+8.9% vs +4.1%; RR = 1.18, p=0.03). Erosion scores increased significantly more in ACPA+ treated with DMARDs only vs receiving a biologic (ΔSharp: 3.98 vs 3.11, p= 0.026; ΔErosions: 2.58 vs 1.83, p= 0.02). By period, erosive status decreased significantly (Periods 2 vs 1: RR= 0.65, p=0.002; 3 vs 1: RR=0.42, p=0.002; 3 vs 2: RR=0.64, p=0.007), both in ACPA+ and negatives.

Conclusion:

In this cohort of recent onset RA recruited over 20 years, we observed a constant drift towards RF-negative arthritis at baseline with decreasing smoking rates and increasing comorbidities in seronegative patients. Positive antibodies were associated more cardiovascular comorbidities accrual. Autoantibody positive (especially ACPA+) patients developed more erosive disease and had better erosion outcomes with biologic treatments. Irrespective of the presence or absence of biomarkers, marked improvements in control of disease activity and in remission rates occured over each period.

References:

[1]Boire G, et al.Arthritis Res Ther2005;7:R592-R603;

[2]Carrier N, et al. Arthritis Res Ther2016;18:37

Disclosure of Interests:

Nathalie Carrier: None declared, Sophie Roux: None declared, Ariel Masetto: None declared, Artur J. deBrum Fernandes: None declared, Patrick Liang: None declared, Meryem Maoui Employee of: Bristol Myers Squibb Canada, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer

The spatiotemporal distribution of human brucellosis in mainland China from 2007-2016

Background

Despite the considerable efforts made to address the issue of brucellosis worldwide, its prevalence in dairy products continues to be difficult to estimate and represents a key public health issue around the world today. The aim of the present study was to better understand the epidemiology of this disease in mainland China. We set out to investigate the yearly spatial distribution and possible hotspots of the disease.

Methods

Human brucellosis data from mainland China between 2007 and 2016 were collected from the China Information System for Disease Control and Prevention. A geographic information system ArcGIS10.3 (ESRI, Redlands) was used to identify potential changes in the spatial and temporal distribution of human brucellosis in mainland China during the study period. These distributions were evaluated using three-dimensional trend analysis and spatial autocorrelation analyse. A gravity-center was used to analyse the migration track of human brucellosis.

Results

A total of 399,578 cases of human brucellosis were reported during the 10-year study period. The monthly incidence of brucellosis in China demonstrates clear seasonality. Spring and summer are the peak seasons, while May is the peak month for brucellosis. Three-dimensional trend analysis suggests that brucellosis is on the rise from south to north, and that the epidemic situation in northern China is more severe. Between 2007 and 2016, the overall migration distance of the brucellosis incidence gravity-center was 906.43 km, and the direction was southwest. However, the overall gravity center of brucellosis was still in the northern part of China. In the global autocorrelation analysis, brucellosis in China demonstrated a non-random distribution between 2013 and 2014, with spatial autocorrelation (Z > 1.96, P < 0.05) and a clustering trend, while no clustering trend was found from 2007 to 2012 or from 2015 to 2016. In the local autocorrelation analysis, a Low-Low cluster phenomenon was found in the south of China in 2013 and 2014.

Conclusion

Human brucellosis remains a widespread challenge, particularly in northern China. The hotspots highlight potential high-risk areas which may require special plans and resources for monitoring and controlling the disease.

Tenofovir prophylaxis for preventing mother-to-child hepatitis B virus transmission in China: A cost-effectiveness analysis

OBJECTIVES

This study aimed to evaluate whether tenofovir prophylaxis for mothers with high viral loads in late pregnancy is a cost-effective way to prevent mother-to-child hepatitis B virus (HBV) transmission in China.

METHODS

A decision tree Markov model was constructed for a cohort of infants born to HBV surface antigen-positive mothers in China, 2016. The expected cost and effectiveness were compared between the current active-passive immunoprophylaxis strategy and the tenofovir prophylaxis strategy, and the incremental cost-effectiveness ratio was calculated. One-way and multi-way probabilistic sensitivity analyses were performed.

RESULTS

For 100,000 babies born to mothers positive for hepatitis B surface antigen, tenofovir prophylaxis strategy will prevent 2213 perinatal HBV infections and will gain 931 quality-adjusted life years when compared with the current active-passive immunoprophylaxis strategy. The incremental cost-effectiveness ratio was ￥59,973 ($9087) per quality-adjusted life years gained. This result was robust over a wide range of assumptions.

CONCLUSIONS

Tenofovir prophylaxis for mothers with high viral loads in late pregnancy was found to be more cost-effective than the current active-passive immunoprophylaxis alone. Embedding tenofovir prophylaxis for mothers with high virus loads into the present hepatitis B prevention strategies should be considered to further prevent mother-to-child hepatitis B transmission in China.

Discovery of an Aedes (Stegomyia) albopictus population and first records of Aedes (Stegomyia) aegypti in Canada

A population of Aedes (Stegomyia) albopictus (Skuse) (Diptera: Culicidae), a vector of chikungunya, dengue, yellow fever, and Zika and West Nile viruses, has been detected in Windsor, Ontario, Canada from 2016 onwards. Here, we describe its seasonal distribution, as well as the various aquatic habitats from which this species was collected and its larval co-habitation. We collected immatures from tires, treeholes, extruded polystyrene foam containers, discarded plastic cups, old recycling bins and oviposition traps. Aedes albopictus larvae were collected with Aedes japonicus (Theobald), Anopheles punctipennis (Say), Culex pipiens Linnaeus, Ochlerotatus hendersoni (Cockerell), Ochlerotatus triseriatus (Say) and Orthopodomyia signifera (Coquillett). Adult female and male specimens were collected from Biogents sentinel traps (Biogents AG, Regensburg, Germany), as well as Centers for Disease Control and Prevention miniature light traps (CDC, Atlanta, GA, U.S.A.), and also as they alighted on the investigators. Peak adult collections occurred in September during epidemiological week 37. We also collected Aedes (Stegomyia) aegypti (Linnaeus), a new record for Canada, in 2016 and from two new collection sites in 2017. The 2017 collections were 3.5 km north and 19.4 km south of the index site. The present study adds to the increasing number of studies reporting range expansions of these mosquito species.

[A functional magnetic resonance imaging study of exercise addiction]

Objective: To investigate the brain activities of exercise addiction (EA) group people with the task-functional magnetic resonance image (task-fMRI). Methods: A total of 29 exercise addicts (addiction group, average age 46±4 years) and 26 non-exercise addicts (control group, average age 46±6 years) matched by sex, age, average education level and sports dependence degree were selected by using exercise addiction index (EAI) through questionnaires to members of Jiangsu Local Fitness and Long-distance Running Association between January 2018 and June 2018. The participants were scanned with fMRI while watching sports pictures or non-sports pictures. The brain responses of the two groups under two stimulation tasks were analyzed and compared. Results: Compared with the control group, while watching sports pictures, the right fusiform gyrus (MNI:x=30, y=-87, z=0), left posterior central gyrus (MNI:x=-51, y=-21, z=54), left medial superior frontal gyrus (MNI:x=-9, y=54, z=30), and right middle occipital gyrus (MNI:x=42, y=-72, z=36) were significantly inhibited in the addiction group (t-test, all P<0.05). When watching non-sports pictures, the addictive group showed the left superior frontal gyrus (MNI:x=-12, y=54, z=30), left middle frontal gyrus (MNI:x=-30, y=18, z=45), right inferior frontal gyrus (MNI:x=42, y=33, z=-12), right occipital gyrus (MNI:x=42, y=-72, z=36), and they were more significantly inhibited than the control group (t-test, all P<0.05). Conclusion: Compared to the control group, the EA group shows significant brain inhibition with visual stimulation, particularly with non-sports pictures.

P12.01 Local implantation of thermoresponsive interferon alpha-polypeptide conjugate combined with temozolomide for post-surgical glioblastoma chemoimmunotherapy

BACKGROUND

Glioblastoma(GBM) is associated with gloomy prognosis despite maximal safe resection and following chemoradiation. In recent years, significant progress has been made in cancer immunotherapy except for GBM, which is largerly due to its local immunosuppressive microenvironment. Some research has demonstrated that local immunotherapy may be more efficient than systematic administrators. IFNα has been investigated as antitumor agent for some cancers, including glioma. Nevertheless, the short circulating half-life greatly limits its clinical application. Hence, a thermoresponsive IFNα-elastin-like polypeptide (IFNα-ELP) was genetically engineered for the earliest local intervention post-surgery.

MATERIAL AND METHODS

Firstly, IFNα-ELP(V) was constructed, expressed and purified, then, its physicochemical characterization was verified. The tumor was resected 10 days after U87MG-mCherry-luc cells orthotopic implantation, and IFNα-ELP(V) was injected into the resection cavity. Two days later, temozolomide(TMZ) was intraperitoneally injected. Using in vivo imaging technique, we could monitor the trends in tumor size. The survival time of mice was counted. Biosafety was evaluated by peripheral blood biochemistry analysis and pathology of the organs.

RESULTS

In this study, the bioconjugate not only in situ deposited in the resection cavity because of the thermoresponsive characteristic, but also showed zero-order release kinetics from the depot and dramatically improved pharmacokinetics and biodistribution of IFNα. Consequently, it showed the inhibition of tumor relapse in GBM orthotopic resection mice models. When followed by TMZ intraperitoneal injection, IFNα-ELP(V) could significantly prevent the tumor recurrence than itself or TMZ alone. Biosafety results indicated that the systemic toxicity of IFNα-ELP(V) in mice can be reduced to safe levels.

CONCLUSION

The results reveal that local implantation of thermoresponsive IFNα-ELP(V) combined with TMZ exhibits the synergy of post-surgical GBM chemoimmunotherapy.

P04.13 Prognostic role of single stranded DNA binding protein 2 in IDH wild type lower grade glioma

Comprehensive and integrative characterizations of genomic analysis including somatic alterations and molecular subtypes of glioma have been established. However, diffuse gliomas (World Health Organization grades II and III, hereafter referred to collectively as lower-grade gliomas,LGG) consist of highly variable clinical behaviors, leading to emerging studies to identify prognostic factors. Through comparative analyses of 516 cases of primary LGG patients from The Cancer Genome Atlas (TCGA) dataset, we reported that the expression level and methylation level of SSBP2 (encoding single stranded DNA-binding protein 2) gene vary among LGG patients and SSBP2 expression or gene body methylation can be served as prognostic biomarkers for LGG survival. Cox regression results confirmed that SSBP2 as an independent predictor of survival in LGG, with a cox coefficient of 0.534 indicating a worse prognosis. Furthermore, lower-grade glioma was statistically ranked first among 21 different cancer types according to the FDR correction. We further investigated the combination of SSBP2 with other known genetic prognostic factors(IDH mutation and 1p19q co-deletion) of LGG. By matching gene expression profile of LGG patients, IDH-mutant gliomas had decreased expression of SSBP2 compared with IDH-wildtype gliomas and 1p19q intact gliomas had increased expression of SSBP2 compared with 1p19q codeletion gliomas. Moreover, we found that the combination of IDH or 1p19q status with SSBP2 identified LGG subsets with significantly diverse survival effects. Patients with low SSBP2 expression had significantly better 5-, 10-, and 15-year OS in IDH wild type, but not in the cohorts of IDH mutant. Our findings offer an explanation for the specificity of SSBP2 effect on survival rate in IDH wild type LGG patients.

[Relationship between one-stop CT spectral perfusion imaging parameters and expression of lymphatic microvessel density and vascular endothelial growth factor-C in axillary lymph nodes of rabbit VX2 breast cancer]

Objective: To analyze the correlation between quantitative parameters of one-stop spectral perfusion computed tomography imaging and the expression level of vascular endothelial growth factor-C(VEGF-C) and MLVD in metastatic lymph nodes of rabbit VX2 breast cancer. Methods: Thirty New Zealand purebred female rabbits were used to establish the lymph node metastasis model of rabbit VX2 breast cancer, one-stop spectral and perfusion CT imaging protocol was performed.The axillary lymph nodes were selected for corresponding image markers. The observed morphology of conventional HE staining and the EnVision method were used to quantitatively analyze VEGF-C expression and calculate MLVD.Pearson linear correlation was used to analyze the perfusion parameters of metastatic lymph node energy spectrum and the correlation of MLVD and VEGF-C expression. Results: Twenty-four experimental rabbits were successfully modeled and performed a one-stop CT scan on the 28th day. A total of 39 metastatic lymph nodes were included. The VEGF-C of metastatic lymph node was 20.0%±2.8%,and the MLVD was 12.5±3.5. There was a positive correlation between BF, AP(λHU), IC(VP), NIC(VP), VP(λHU) of metastatic lymph node and VEGF-C and MLVD (P<0.05). There was a positive correlation between lymph node IC(AP) and MLVD (P=0.027) and no correlation with VEGF-C expression (P=0.386).There was no correlation between BV, NIC(A)P and VEGF-C, MLVD(P>0.05). The correlation between VP(λHU) and MLVD was higher (r=0.448, P=0.001). Conclusions: One-stop CT spectral perfusion imaging quantitative parameters and pathological indicators have a good correlation, and it can reflect lymphatic vessel metastasis in lymph nodes.

[Application of a multi-material artifact reduction algorithm in a wide-detector CT in the evaluation of the portal venous angiography of postoperative TIPS and embolization]

Objective: To assess the effect of monochromatic images and metal artifact reduction (MAR) on the image quality of spectral CT portal venous angiography in patients with operation of after the performing transjugular intrahepatic portosystemic stent shunt(TIPS) and embolization. Methods: From December 2017 to April 2018, the examination data of 28 patients with portal hypertension due to cirrhosis who underwent portal vein angiography 1 month after TIPS and embolization were prospectively collected. After spectral CT scanning in revolution CT, the monochromatic energy levels(60 keV, 120 keV), 60 keV + 120 keV, 120kV-like + 120 keV fused images combined with MAR algorithm were reconstructed. Quantitative parameters such as image artifact index (AI) and qualitative visual evaluation scores were recorded and compared. Results: The 120 keV monochromatic images showed the lowest AI value(30.8±8.5, 18.2±4.3) and highest metal artifacts reduction effect. The 60 keV monochromatic images showed the highest AI value (57.3±15.7, 32.1±7.9) and the lowest metal artifacts reduction effect. The AI value of 60 keV + 120 keV fused images was lower than that of 60 keV images(26.2%, 24.7%). The difference of AI value between each group was statistically significant(all P<0.05). The interobserver agreement in the subjective image scores was moderate with kappa value of 0.824. The overall image quality score of 60 keV + 120 keV fused image and the noise score of 120 kV-like+120 keV were higher than the remaining groups. The differences of the subjective scores among each group were statistically significant(all P<0.05). Conclusion: The spectral CT with MAR algorithm can effectively improve the image quality of portal vein angiography after the TIPS and embolization therapy and the 60 keV + 120 keV fused images can eliminate artifacts and ensure a clear display of blood vessels.

[Thoracic paravertebral block in the PACU for immediate postoperative pain relief after video-assisted thoracoscopic surgery]

Objective: To investigate the effectiveness and safety of the thoracic paravertebral block(TPVB) in the post postanesthesia care unit(PACU) for patients suffered moderate to severe pain after Video-Assisted Thoracoscopic Surgery(VATS). Methods: 78 atients who complained moderate to severe pain on arrival to PACU after VATS were randomly assigned into two groups: thoracic paravertebral block treatment group(P group) and sufentanil treatment group(S group). The VAS Pain score at rest and movement, heart rate, blood pressure, and pulse oximetry 1 hour after treatment and duration of patients staying in the PACU after treatment were recorded. VAS Pain score at rest and on coughing at 8, 24 and 48 hours after treatment were closely monitored. Sufentanil comsumption, patient satisfaction and related complications were also recorded. Results: A successful TPVB was achieved in all patients in P group without puncture related complications. The VAS pain scores at rest and on coughing 1 hour, 8 hours, 24 hours and 48 hours after treatment in P group were significantly lower than the patients in S group. Systolic blood pressure 1 hour after treatment in P group was also lower than the patients in S group(118mmHg±14mmHg vs 128 mmHg±14 mmHg, P=0.021). SPO2 1 hour after treatment in P group was much higher than the patients in S group(95%±3% vs 92%±4%, P=0.015). The duration of patients staying in the PACU after treatment in both groups were similar. Sufentanil comsumption, rate of vomiting and nausea was significantly less and satisfaction was better in P group than thoses in S group. Conclusion: In the postanesthesia care unit, TPVB could provide effective and safe analgesia therapy for patients suffered from moderate to severe pain after VATS.

Mapping the Brain's electric fields with Magnetoelectric nanoparticles

Background

Neurodegenerative diseases are devastating diagnoses. Examining local electric fields in response to neural activity in real time could shed light on understanding the origins of these diseases. To date, there has not been found a way to directly map these fields without interfering with the electric circuitry of the brain. This theoretical study is focused on a nanotechnology concept to overcome the challenge of brain electric field mapping in real time. The paper shows that coupling the magnetoelectric effect of multiferroic nanoparticles, known as magnetoelectric nanoparticles (MENs), with the ultra-fast and high-sensitivity imaging capability of the recently emerged magnetic particle imaging (MPI) can enable wirelessly conducted electric-field mapping with specifications to meet the requirements for monitoring neural activity in real time.

Methods

The MPI signal is numerically simulated on a realistic human brain template obtained from BrainWeb, while brain segmentation was performed with BrainSuite software. The finite element mesh is generated with Computer Geometry Algorithm Library. The effect of MENs is modeled through local point magnetization changes according to the magnetoelectric effect.

Results

It is shown that, unlike traditional magnetic nanoparticles, MENs, when coupled with MPI, provide information containing electric field's spatial and temporal patterns due to local neural activity with signal sensitivities adequate for detection of minute changes at the sub-cellular level corresponding to early stage disease processes.

Conclusions

Like no other nanoparticles known to date, MENs coupled with MPI can be used for mapping electric field activity of the brain at the sub-neuronal level in real time. The potential applications span from prevention and treatment of neurodegenerative diseases to paving the way to fundamental understanding and reverse engineering the brain.

Risk factors of haemoglobinuria after microwave ablation of liver tumours

AIM

To explore the risk factors predicting haemoglobinuria after ultrasound-guided percutaneous microwave ablation (MWA) of liver tumours and discuss the treatments and outcomes.

MATERIALS AND METHODS

The present study comprised 2,829 patients admitted for liver tumours treated with MWA from Jan 2011 to April 2017. Ethics committee approval was waived and informed consent for treatment procedures were obtained from the patients. Haemoglobinuria after MWA was found in 149 patients. The influence of 19 risk factors was assessed. Binary logistic regression and receiver operating characteristic (ROC) curve analysis were used for statistical analysis. The treatments and outcomes of patients with haemoglobinuria were summarised.

RESULTS

By univariate analysis, histopathology, liver cirrhosis, MWA volume, MWA energy, and MWA duration were significant risk factors. By multivariate analysis and ROC curve, MWA energy, duration, and volume were identified as predictors of haemoglobinuria after MWA. Drug treatments including kidney protection, adequate hydration, alkalisation of urine, and diuresis were administrated to the patients with haemoglobinuria. One patient progressed to acute kidney injury (AKI) while others had good clinical outcomes.

CONCLUSION

Haemoglobinuria is a controllable side effect after MWA of liver tumours, which is related to high MWA energy, long MWA duration, and great MWA volume. It usually caused few side effects on renal function with correct treatment.

Treatment of hepatocellular carcinoma in the caudate lobe: US-guided percutaneous radiofrequency ablation combined with ethanol ablation

AIM

To evaluate the technical feasibility and treatment results of ultrasound (US)-guided percutaneous radiofrequency ablation (RFA) combined with ethanol ablation (EA) for hepatocellular carcinoma (HCC) in the caudate lobe.

MATERIALS AND METHODS

The institutional review board approved this retrospective study and the requirement for informed consent was waived. From October 2009 to June 2016, there were 49 patients with HCC in the caudate lobe underwent ablation. Among them, 14 patients (12 men and two women, mean age: 49.9±14.9 years) with 16 caudate lobe HCCs (mean size: 3±1.1 cm) who underwent US-guided RFA-EA were identified. These patients were compared with patients who underwent RFA alone (n=17) and EA alone (n=18).

RESULTS

HCCs in the RFA-EA group were larger than those in the EA-alone group (3±1.1 versus 2.1±0.7 cm, p=0.028). In the RFA-EA group, all the patients achieved treatment success (14/14) and entered follow-up. After a follow-up period of 17.1±10.6 months (range, 5-36 months), local tumour progression (LTP) was detected in four tumours. The 1- and 2-year LTP rates after RFA-EA were 18.8% and 27.8%, respectively. The 1- and 2-year disease-free survival (DFS) rates were 35.7% and 13.4%. Six patients died, with the 1-, 2-, and 3-year overall survival (OS) rates of 85.1%, 63.1%, and 21%, respectively. There were no significant differences in the LTP, DFS, and OS rates between the RFA-EA group and RFA-alone or EA groups (p=0.363-0.733).

CONCLUSION

US-guided percutaneous RFA-EA appears to be a feasible and effective treatment for HCC in the caudate lobe.

Estimating the impact of test-and-treat strategies on hepatitis B virus infection in China by using an age-structured mathematical model

The potential impact of increasing test-and-treat coverage on hepatitis B virus (HBV) infection remains unclear in China. The objective of this study was to develop a dynamic compartmental model at a population level to estimate the long-term effect of this strategy.Based on the natural history of HBV infection and 3 serosurvey data of hepatitis B in China, we proposed an age- and time-dependent discrete model to predict the number of new HBV infection, the number of chronic HBV infection, and the number of HBV-related deaths for the time from 2018 to 2050 under 5 different test-and-treat coverage and compared them with current intervention policy.Compared with current policy, if the test-and-treat coverage was increased to 100% since 2018, the numbers of chronic HBV infection, new HBV infection, and HBV-related deaths in 2035 would be reduced by 26.60%, 24.88%, 26.55%, respectively, and in 2050 it would be reduced by 44.93%, 43.29%, 43.67%, respectively. In contrast, if the test-and-treat coverage was increased by 10% every year since 2018, then the numbers of chronic HBV infection, new HBV infection, and HBV-related deaths in 2035 would be reduced by 21.81%, 20.10%, 21.40%, respectively, and in 2050 it would be reduced by 41.53%, 39.89%, 40.32%, respectively. In particular, if the test-and-treat coverage was increased to 75% since 2018, then the annual number of HBV-related deaths would begin to decrease from 2018. If the test-and-treat coverage was increased to above 25% since 2018, then the hepatitis B surface antigen (HBsAg) prevalence for population aged 1 to 59 years in China would be reduced to below 2% in 2035. Our model also showed that in 2035, the numbers of chronic HBV infection and HBV-related deaths in 65 to 69 age group would be reduced the most (about 1.6 million and 13 thousand, respectively).Increasing test-and-treat coverage would significantly reduce HBV infection in China, especially in the middle-aged people and older people. The earlier the treatment and the longer the time, the more significant the reduction. Implementation of test-and-treat strategy is highly effective in controlling hepatitis B in China.