Effect of extracorporeal shockwave therapy for rotator cuff tendinopathy: a systematic review and meta-analysis

BACKGROUND

Rotator cuff tendinopathy (RCT) is a widespread musculoskeletal disorder and a primary cause of shoulder pain and limited function. The resulting pain and limited functionality have a detrimental impact on the overall quality of life. The purpose of this study was to perform a systematic review of the effects of extracorporeal shock wave therapy (ESWT) for RCT.

METHODS

The literature search was conducted on the following databases from inception to February 20, 2024: PubMed, Web of Science, the Cochrane Library, Scopus, MEDLINE, EMBASE, EBSCO, and China National Knowledge Infrastructure (CNKI) were checked to identify the potential studies exploring the effect of ESWT for the treatment of Rotator cuff tendinopathy (Calcification or non-calcification), control group for sham, other treatments (including placebo), without restriction of date, language. Two researchers independently screened literature, extracted data, evaluated the risk of bias in the included studies, and performed meta-analysis using RevMan 5.3 software.

RESULTS

A total of 16 RCTs with 1093 patients were included. The results showed that compared with the control group, ESWT for pain score Visual Analogue Scale/Score (VAS) (SMD = -1.95, 95% CI -2.47, -1.41, P < 0.00001), function score Constant-Murley score (CMS) (SMD = 1.30, 95% CI 0.67, 1.92, P < 0.00001), University of California Los Angeles score (UCLA) (SMD = 2.69, 95% CI 1.64, 3.74, P < 0.00001), American Shoulder and Elbow Surgeons form (ASES) (SMD = 1.29, 95% CI 0.93, 1.65, P < 0.00001), Range of motion (ROM) External rotation (SMD = 1.00, 95% CI 0.29, 1.72, P = 0.02), Total effective rate (TER) (OR = 3.64, 95% CI 1.85, 7.14, P = 0.0002), the differences in the above results were statistically significant. But ROM-Abduction (SMD = 0.72, 95% CI -0.22, 1.66, P = 0.13), the difference was not statistically significant.

CONCLUSION

Currently limited evidence suggests that, compared with the control group, ESWT can provide better pain relief, functional recovery, and maintenance of function in patients with RCT.

Arthroscopic Surgery Combined With Platelet-Rich Plasma Does Not Significantly Improve Pain, Function, Complications, and Retear Rate Compared With Arthroscopic Surgery Alone for Full-Thickness Rotator Cuff Tears: A Systematic Review and Meta-analysis

PURPOSE

To evaluate the effectiveness and safety of arthroscopic surgery combined with platelet-rich plasma (PRP) compared with arthroscopic surgery alone in the treatment of patients with full-thickness rotator cuff tears.

METHODS

The Cochrane Library, PubMed, Embase, Scopus, EBSCO, Web of Science, China National Knowledge Infrastructure, and Wanfang Database were systematically searched from inception to November 2023. Subject words combined with free words were used to collect randomized controlled trials focusing on arthroscopic surgery combined with PRP in the treatment of full-thickness rotator cuff tears. The assessment of evidence quality employed the Cochrane Collaboration risk of bias tool, and data analysis was performed using RevMan 5.3 software.

RESULTS

A total of 9 studies with 537 patients were included. The meta-analysis revealed that compared with the arthroscopic surgery alone group, the summary result of University of California Los Angeles score scores in the arthroscopic combined with PRP group was (mean difference [MD] = 1.08, 95% confidence interval [CI] 0.19∼1.97, P = .02), subgroup analysis of surgical suture method visual analog scale (VAS) single-row (MD = -1.00, 95% CI -1.50 to -0.50, P < .0001), VAS double-row (MD = -0.10, 95% CI -0.17 to -0.02, P = .02), and Constant-Murley score single-row (MD = 3.49, 95% CI 0.32∼6.66, P = .03), the difference was statistically significant, and the differences in VAS, Constant-Murley score, and Quick Disabilities of the Arm, Shoulder and Hand, complications, and retear rate were not statistically significant.

CONCLUSIONS

Patients undergoing arthroscopic repair combined with PRP treatment showed no difference in pain, function, complications, and retear rate compared with those treated with arthroscopic surgery alone.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of Level I and II evidence.

Inlay structure can improve bone graft stability in the Bristow procedure

BACKGROUND

Compared with the Latarjet procedure, the Bristow procedure has a lower screw-related complication rate but poor bone healing. A modified Inlay Bristow procedure has been reported to significantly improve the bone healing rate, but the biomechanical mechanism is unclear. The aim of this study was to evaluate the biomechanical stability of the bone graft between a modified Inlay Bristow procedure and the classic Bristow procedure.

METHODS

Sixteen left scapula models (Sawbones, Composite Scapula, and fourth generation) were randomly divided into 2 groups (8:8). The bone graft in the first group was fixed with a 3.5 mm screw using the Inlay structure. The bone graft in the second group was fixed with a 3.5 mm screw via the traditional method. The maximum cyclic displacement, ultimate failure load and stiffness were evaluated biomechanically. The failure type was recorded for each model.

RESULTS

Cyclic loading tests demonstrated that the maximum cyclic displacement of the Inlay procedure was significantly smaller (P = .001) than that of the classic procedure. The Inlay Bristow technique resulted in a significantly higher (P = .024) ultimate failure load than the classic Bristow technique. The stiffness of the classic group was 19.17 ± 4.01 N/mm and that of the inlay group was 22.34 ± 5.35 N/mm (P = .232). Failure was mainly due to bone graft fractures through the drill hole or glenoid bone fractures.

CONCLUSION

Inlay Bristow fixation of the bone graft in a Sawbones model provides significantly stronger fixation and better time point zero stability than classic Bristow fixation, suggesting a higher likelihood of graft union.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

PURPOSE

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure.

METHODS

Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up.

RESULTS

No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P = .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P = .030 and P = .034, respectively).

CONCLUSIONS

Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of return to sports after coracoid transfer

PURPOSE

This study aims to determine the rate of different levels of return to sports (RTS) in athletes undergoing the modified arthroscopic Bristow procedure and the factors associated with the level of RTS.

METHODS

The study was performed retrospectively on patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow procedure with a minimum follow-up of 2 years. The RTS rate, the level of return and the timing of return were assessed. Additionally, factors such as preoperative basic information, clinical outcomes, graft position, graft healing and graft absorption were analysed to investigate their correlation with the level of RTS. Multivariate regression models were used to evaluate the factors affecting the level of RTS.

RESULTS

In total, this study included 182 shoulders of 177 athletes undergoing the modified arthroscopic Bristow procedure. Of these patients, 142 (78.0%) shoulders of 137 athletes were enrolled, with a mean of 3.3-year follow-up. At the final follow-up, 134 (94.4%) shoulders were able to RTS, 123 (86.6%) shoulders were able to RTS to the pre-injury level, 52 (36.6%) shoulders could be completely "forgotten" without any psychological barrier during exercise. The multivariate logistic regression analysis identified the variable associated with RTS at the pre-injury level as previously failed arthroscopic Bankart repair (p < 0.001). As for the "forgetting" operated shoulder, the duration from first dislocation to surgery was a significant independent predictor (p = 0.034).

CONCLUSION

Although a large majority of athletes were able to RTS at the pre-injury level after the modified arthroscopic Bristow procedure, about two-thirds of the athletes felt difference in shoulders on both sides and could not completely "forget" the operated shoulder during exercise. Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of RTS after the modified arthroscopic Bristow procedure.

LEVEL OF EVIDENCE

IV.

The role of insect intestinal microbes in controlling of Empoasca onukii Matsuda (Hemiptera: Cicadellidae) pest infestations in the production of tea garden: a review

Pests like the phytophagous bug Empoasca onukii Matsuda frequently harm tea plants. The harm this insect does to agricultural and environmentally sensitive places is extremely harmful since physical and chemical prevention and control are still the primary methods of handling it. Therefore, it is important to develop pest management strategies. Recent research has demonstrated that pathogenic fungus and the gut microbiota interact to induce host and death, and that the gut microbiota, which has a dramatic effect on the host, can engage in pest control. The advancement of genome editing technologies is also new to the field of pest management. The diversity, function, and research methodologies of insect gut microbiota are summarized in this work, and discusses E. onukii Matsuda control options as well as the importance of insect gut microbiome in pest management. In comparison to traditional pesticides and physical prevention and control, the interaction between pathogenic fungi represented by Beauveria bassiana and intestinal microorganisms, as well as their participation in pest management, causes physiological stress on the host, which meets the new requirements of modern agricultural green development and has a protective effect on habitat fragmentation areas (Karst region). Exploring additional harmful fungus for pest management and fully using the specific traits of insect gut microbiota to achieve "killing insects with bacteria" would be a promising technique from this standpoint.

Transitional Dynamics of Sarcopenia and Associations of Nutritional Indices with State Transitions in Chinese aged ≥ 50

OBJECTIVES

Sarcopenia's temporal profile can be regarded as a dynamic process with distinct states, in which malnutrition plays an important role. This study aimed to address two research gaps: sarcopenia's transitional dynamics and associations of nutritional indices with state transitions in community-dwelling Chinese adults aged 50 and older.

DESIGN

A prospective population-based cohort study.

SETTING

Community-based setting in western China.

PARTICIPANTS

The analytic sample included data from 1910 participants aged ≥ 50 in the West China Health and Aging Trend study between 2018-2022.

MEASUREMENTS

We defined three states: the initial normal state (normal muscle strength, physical performance and muscle mass), the worst sarcopenia state (low muscle mass plus low muscle strength and/or low physical performance) and the intermediate subclinical state (the other scenarios). The relevant measurement methods and cut-off points were based on the 2019 AWGS consensus. Using a continuous-time multistate Markov model, we calculated probabilities of transitions between different states over 1, 2 and 4 years; we also examined associations between nutritional indices and transitions, including body mass index (BMI), calf circumference (CC), mid-arm circumference (MAC), triceps skinfold thickness (TST), albumin (ALB), geriatric nutrition risk index (GNRI), vitamin D (VitD) and prealbumin (PA).

RESULTS

For individuals in the normal state, their probabilities of remaining stable versus progressing to a subclinical state were 53.4% versus 42.1% at 2 years, and 40.6% versus 49.0% at 4 years. In the subclinical population, their 2- and 4-year chances were 60.2% and 51.2% for maintaining this state, 11.8% and 16.2% for developing sarcopenia, 28.0% and 32.6% for reverting to normal. For sarcopenic individuals, the likelihood of staying stable versus retrogressing to the subclinical state were 67.0% versus 26.3% at 2 years, and 48.3% versus 36.3% at 4 years. Increased BMI, CC, MAC, TST, ALB, GNRI and PA correlated with reversion from the subclinical state, among which increased TST, ALB and PA were also paralleled with reversion from sarcopenia, while decreased BMI, CC, MAC, TST and GNRI were associated with progression to sarcopenia. VitD was not significantly associated with any transitions.

CONCLUSION

This study reveals how sarcopenia changes over time in a Chinese population. It also highlights the usefulness of simple and cost-effective nutritional status indices for indicating state transitions, which can help identify individuals at risk of sarcopenia and guide targeted interventions within the optimal time window.

[Activation of cannabinoid receptor 2 alleviates acute lung injury in rats with lipopolysaccharide-induced sepsis]

OBJECTIVE

To investigate the protective effect of cannabinoid receptor 2 (CB2) activation against acute lung injury in rats with lipopolysaccharide (LPS)-induced sepsis and explore the underlying mechanism.

METHODS

Forty-eight SD rats were randomly assigned into control group, model group, CB2 agonist group and P38 MAPK inhibitor group (n=12). In the latter 3 groups, the rats received intraperitoneal injection of LPS to induce sepsis, and the control rats were given saline injection. In CB2 agonist group, JWH133 (3 mg/kg) was injected intraperitoneally 30 min before LPS injection; in P38 MAPK inhibitor group, the rats received intraperitoneal injection of SB203580 (5 mg/kg) 30 min prior to JWH133 injection. The changes in lung histopathology, water content, fluid clearance rate, inflammatory factors, pulmonary expressions of CB2 and tight junctionrelated genes, and phosphorylation of P38 MAPK in the lung tissues were examined.

RESULTS

The rat models of sepsis showed severe damage of alveolar structures with significantly decreased fluid clearance rate, lowered pulmonary expressions of CB2, occludin and ZO-1 mRNA and proteins, increased water content in the lung tissue, and increased phosphorylation level of P38 MAPK and TNF-α and IL-1β levels in lung lavage fluid (all P < 0.05). Treatment with JWH133 improved alveolar pathology in the septic rats, but there was still inflammatory infiltration; lung tissue water content, phosphorylation of P38 MAPK, and TNF-α and IL-1β levels in lung lavage fluid were all significantly decreased, and the fluid clearance rate, pulmonary expressions of CB2, occludin and ZO-1 were significantly increased (all P < 0.05). Additional treatment with SB203580 resulted in further improvements of alveolar pathologies, lowered phosphorylation levels of P38 MAPK in the lung tissue and TNF-α and IL-1β levels in lung lavage fluid, and increased the protein expressions of occludin and ZO-1 (P < 0.05) without causing significant changes in mRNA and protein expression of CB2 (P > 0.05).

CONCLUSION

In rats with LPS-induced sepsis, activation of CB2 can inhibit the p38 MAPK signaling pathway, reduce the release of inflammatory factors in the lung tissues, promote tight junction protein expressions, and thus offer protection against acute lung injury.

Clinical and Radiologic Outcomes of All-Arthroscopic Latarjet Procedure With Modified Suture Button Fixation: Excellent Bone Healing With a Low Complication Rate

PURPOSE

To investigate the clinical outcomes and radiologic evaluation of an all-arthroscopic Latarjet procedure with modified button fixation.

METHODS

Patients who received all-arthroscopic Latarjet procedure with modified suture button fixation between September 2015 to September 2016 were retrospectively reviewed. Indications for surgery were recurrent anterior shoulder dislocation with any 1 of these 3 conditions: glenoid defect >15%, contact-sport athlete, or failure after Bankart repair. Inclusion criteria included cases who received this surgery. Clinical outcomes were evaluated by University of California Los Angeles, ASES and Rowe score with a minimal follow-up of 3 years. Radiologic assessment on 3D computed tomography scan was performed preoperatively and postoperatively at different time points. Complications were also recorded.

RESULTS

A total of 30 patients were eventually included in this study. The mean follow-up time was 38.0 ± 2.5 months. There were 25 patients who performed contact sports. Of them, 10 patients were without glenoid defect >15% or failed Bankart repair. The remaining 20 patients had glenoid defect >15%, including 2 failed Bankart cases. Ten patients had glenoid defect < 13.5%, and the rest 20 patients had > 13.5%. UCLA, American Shoulder and Elbow Surgeons, and Rowe score significantly improved during follow-up, and the improvement exceeded MCID for all patients. No severe complications were noted. In total, 86.7% of the graft positioning was measured as flush and 13.3% as medial. The bone union rate was 96.7% at 3 months postoperatively and at final follow-up. The remodeling process for the restoration of the normal anatomy of the lower part of glenoid was noted.

CONCLUSIONS

All-arthroscopic Latarjet with modified suture button fixation can achieve stable fixation of the coracoid, good clinical outcomes (all patients with improvement exceeding MCID), low complications rate. Furthermore, the bone remodeling process contributes to the recovery of the normal anatomy of anteroinferior glenoid.

STUDY DESIGN

Case series; Level of evidence, 4.

POS0969 GENETIC AND MOLECULAR DISTINCTIONS BETWEEN AXIAL PSORIATIC ARTHRITIS AND ANKYLOSING SPONDYLITIS

Background

Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) represent the prototypical spondyloarthritides. PsA patients may also suffer from axial disease (axPsA). Despite overlapping symptoms, axPsA and AS may be distinct disorders with differing clinical manifestations, genetic associations, and radiographic findings.1 These disorders also respond differently to immunomodulatory therapies such as anti-interleukin (IL)-23 inhibitors. While guselkumab, a human monoclonal antibody targeting the IL-23p19 subunit, improved symptoms of axPsA,2 risankizumab, a humanized monoclonal antibody targeting the IL-23p19 subunit, did not show improvement in the primary endpoint of proportion of AS patients achieving an Assessment of SpondyloArthritis International Society 40% (ASAS40) response at week (W) 12.3

Objectives

To understand molecular distinctions between axPsA and AS to differentiate these diseases and guide treatment choice.

Methods

Whole blood and serum samples were collected from consenting patients in the NCT03162796/NCT0315828 studies of guselkumab in PsA and the NCT02437162/NCT02438787 studies of ustekinumab in AS. axPsA patients were investigator-verified as having magnetic resonance imaging- or pelvic x-ray-confirmed sacroiliitis at screening (locally read). Human leukocyte antigen (HLA) genotypes were determined by RNA sequencing, limited to Caucasian patients to reduce genetic variability,4 and select serum cytokine levels were analyzed alongside samples from healthy individuals. Differential prevalence of HLA alleles in axPsA versus AS was determined using a Fisher’s Exact test. Statistical significance of differential baseline serum cytokine expression among axPsA versus non-axPsA versus AS patients, and of guselkumab effect on serum cytokine reduction versus placebo among axPsA and non-axPsA patients, were determined with a generalized linear model performed on log2-transformed data. Biomarker data from guselkumab every-4-weeks and every-8-weeks treatment arms were pooled.

Results

Among the 186/234 Caucasian axPsA/AS patients with available data, 34%/15% were female, 70%/14% used methotrexate at baseline, mean serum C-reactive protein (CRP) levels were 2.8/2.4 mg/dL and mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores were 6.4/7.5, respectively. Aside from race, baseline demographics and disease characteristics were representative of the overall population. The prevalence of class I HLA allele -B27, -C01, and -C02 carriers was significantly lower in axPsA than AS patients (30.7% versus 92.3%, p<0.001; 5.9% versus 31.6%, p<0.001; and 28.0% versus 62.0%, p<0.001, respectively), while the prevalence of HLA-C06 was significantly higher in axPsA than AS populations (36.0% versus 8.6%, p<0.001). Baseline serum levels of IL-17A and IL-17F were significantly higher in axPsA (N=71) than in AS (N=58) patients (p<0.01 and p<0.001, respectively). Comparable IL-17A/F expression was seen for axPsA and non-axPsA (N=229) patients (both p=not significant). Significant and comparable reductions from baseline in serum IL-17A/F in axPsA and non-axPsA patients were seen with guselkumab treatment (axPsA N=41, non-axPsA N=160) versus placebo (axPsA N=30, non-axPsA N=69) at W4/24 (all p<0.05).

Conclusion

Adults with axPsA and AS exhibit different genetic risk factors and serum IL-17 levels, supporting the concept of distinct disorders. Guselkumab demonstrated significant pharmacodynamic effects in axPsA patients that aligned with such effects in non-axPsA patients, consistent with observed clinical improvement.2

References

[1]Feld et al. Nat Rev Rheumatol. 2018;14(6):363-371.

[2]Mease et al. Lancet Rheumatol. 2021;3(10)E715-E723.

[3]Baeten et al. Ann Rheum Dis. 2018;77(9):1295-1302.

[4]Buchkovich et al. Genome Med. 2017;9(86).

Disclosure of Interests

Arthur Kavanaugh Consultant of: AbbVie, Amgen, BMS, Genentech, Janssen, Eli Lilly, Merck, Novartis, Pfizer and UCB, Xenofon Baraliakos Consultant of: AbbVie, Chugai, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, MSD, and Novartis, Sheng Gao Employee of: Janssen Research & Development, LLC, and may own stock or stock options in Johnson & Johnson, Warner Chen Employee of: Janssen Research & Development, LLC, and may own stock or stock options in Johnson & Johnson, Kristen Sweet Employee of: Janssen Research & Development, LLC, and may own stock or stock options in Johnson & Johnson, Soumya D Chakravarty Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Qingxuan Song Employee of: Janssen Research & Development, LLC, and may own stock or stock options in Johnson & Johnson, May Shawi Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Frank Behrens Speakers bureau: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Chugai, Eli Lilly, Galapagos, Genzyme, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Chugai, Eli Lilly, Galapagos, Genzyme, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Grant/research support from: Celgene, Chugai, Janssen, Pfizer, and Roche, Proton Rahman Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: Janssen, research grants from Janssen and Novartis

Effects of residual feed intake divergence on growth performance, carcass traits, meat quality, and blood biochemical parameters in small-sized meat ducks

Feed efficiency (FE) is a major economic trait of meat duck. This study aimed to evaluate the effects of residual feed intake (RFI) divergence on growth performance, carcass traits, meat quality, and blood biochemical parameters in small-sized meat ducks. A total of 500 healthy 21-day-old male ducks were housed in individual cages until slaughter at 63 d of age. The growth performance was determined for all the ducks. The carcass yield, meat quality, and blood biochemical parameters were determined for the selected 30 high-RFI (HRFI) and 30 low-RFI (LRFI) ducks. In terms of growth performance, the RFI, feed conversion ratio (FCR), and average daily feed intake (ADFI) were found to be significantly lower in the LRFI group (P < 0.01), whereas no differences were observed in the BW and body weight gain (P > 0.05). For slaughter performance, no differences were observed in the carcass traits between the LRFI and HRFI groups (P > 0.05). For meat quality, the shear force of breast muscle was significantly lower in the LRFI group (P < 0.05), while the other meat quality traits of breast and thigh muscles demonstrated no differences (P > 0.05). For blood biochemical parameters, the serum concentrations of triglycerides (TG) and glucose (GLU) were significantly lower in the LRFI group (P < 0.05), while the other parameters showed no differences (P > 0.05). The correlation analysis demonstrated a high positive correlation between RFI, FCR, and ADFI (P < 0.01). The RFI demonstrated a negative effect on the breast muscle and lean meat yields, but a positive effect on the shear force of breast muscle (P < 0.05). Further, the RFI demonstrated a positive effect on the TG and GLU levels (P < 0.05). These results indicate that the selection for low RFI could improve the FE of small-sized meat ducks without affecting the production performance. This study provides valuable insight into the biological processes underlying the variations in FE in small-sized meat ducks.

OP0013 LOSS OF SYNOVIAL TISSUE MACROPHAGE HOMEOSTASIS PRECEDES RHEUMATOID ARTHRITIS CLINICAL ONSET

Background

Synovial tissue macrophages significantly contribute to Rheumatoid Arthritis, yet the precise nature/function of macrophage subsets within the inflamed joint remains unexplored.

Objectives

To fully explore the spectrum of distinct macrophage activation states residing within the synovium of RA, at risk and healthy individuals.

Methods

Single-cell synovial tissue suspensions from RA (n=44), IAR (n=5), HC (n=11), PsA (n=11) and OA (n=4) were obtained, and synovial macrophage subsets examined by advanced multiparameter flow cytometric analysis, bulk RNA-sequencing, metabolic and functional assays.

Results

Multidimensional analysis identifies enrichment of CD206+CD163+ synovial-tissue macrophages co-expressing CD40 in the RA joint compared to healthy synovial-tissue, with frequency of CD206+CD163+CD40+ macrophages associated with increased disease activity and treatment response. In contrast, CX3CR1-expressing macrophages which form a protective barrier in healthy synovium are significantly depleted in RA. Importantly this signature of enriched CD40 expression coupled with depleted CX3CR1 expression is an early phenomenon, occurring prior to clinical manifestation of disease in individuals ‘at-risk’ of RA (IAR). RNAseq and metabolic profiling of sorted RA synovial-macrophages identified that this population is transcriptionally distinct, displaying unique inflammatory, phagocytic and tissue-resident gene signatures, paralleled by a bioenergetically stable profile as indicated by NAD(P)H emission. Functionally CD206+CD163+ RA macrophages are potent producers of pro-inflammatory mediators (reversed by CD40-signalling inhibition) and induce an invasive phenotype in healthy synovial-fibroblasts. These findings identify a distinct pathogenic population of synovial-tissue macrophage involved in shaping the immune response in RA. Crucially, this signature is present pre-disease representing a unique opportunity for early diagnosis and therapeutic intervention.

Conclusion

We have identified a novel population of tissue-resident macrophages in the RA synovium which are transcriptionally/metabolically distinct and capable of contributing to disease pathology. Uncovering the molecular patterns and cues that transform this immunoregulatory macrophage population into a dysfunctional inflammatory activation state may provide opportunities to reinstate joint homeostasis in RA patients.

Disclosure of Interests

Megan Hanlon: None declared, Mary Canavan: None declared, Nuno Neto: None declared, Qingxuan Song Employee of: Employee of Janssen Pharmaceuticals, Phil Gallagher: None declared, Ronan Mullan: None declared, Conor Hurson: None declared, Barry Moran: None declared, Michael Monaghan: None declared, Sunil Nagpal Employee of: Employee of Janssen Pharmaceuticals, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer

[Status of vaccination and related influencing factors in patients with chronic obstructive pulmonary disease: a real-world cross-sectional study]

Objective: To investigate the influenza and pneumonia vaccination rates in patients with chronic obstructive pulmonary disease (COPD), and analyze the factors affecting vaccination. Methods: Totally 4 016 COPD patients at the initial visit were included in the Respiratory Department of Xiangya Second Hospital of Central South University from December, 2016 to December, 2019. Each patient's vaccination status after the visit for 1 year was reviewed, and finally 3 177 patients were included in the analysis. Relevant factors affecting vaccination were analyzed with logistic regression. Results: The overall vaccination rates of COPD patients with influenza vaccine, pneumonia vaccine and influenza combined pneumonia vaccine were 2.3% (72/3 177), 1.1% (34/3 177) and 1.1% (34/3 177), respectively. The influenza vaccination rate of urban patients (3.3%, 41/1 252) was higher than that of rural patients (1.6%, 31/1 925,P=0.002). The rates of influenza vaccine, pneumonia vaccine and influenza combined pneumonia vaccine in ex-smokers with COPD were 3.3% (33/993), 2.1% (21/993), 2.1% (21/993), respectively and 1.7% (25/1 467), 0.7% (11/1 467), 0.7% (11/1 467), in current smokers with COPD, respectively (P=0.034, P=0.015, P=0.015, respectively). The influenza vaccination rate was higher in patients with COPD assessment test (CAT) scored less than 10 (4%, 27/673) than patients with CAT scored more than 10 (1.8%, 45/2 504,P=0.002). In a multifactor analysis, patients who lived in country side, were current smokers, and had more symptoms were less likely to be vaccinated, with an aOR 1.73(95%CI 1.02-2.93), 2.10(95%CI 1.18-3.76), 2.06(95%CI 1.24-3.43), respectively. 81.2% of COPD patients did not receive the vaccine because they did not know the vaccine. Conclusions: Vaccination rates for influenza vaccine, pneumonia vaccine and both of them in COPD patients were low and the patients lacked knowledge of vaccine. The residence, smoking status and symptoms were related to the vaccination of COPD patients, and these should be taken into account in the vaccination health education.

Clinical and Radiographic Outcomes After Arthroscopic Inlay Bristow Surgery With Screw Versus Suture Button Fixation: A Comparative Study of 117 Patients With 3.3-Year Follow-up

Background:

Some studies have advocated the use of suture button fixation during Bristow-Latarjet surgery to reduce complications associated with screw fixation. However, data comparing these fixation methods are relatively incomplete.

Purpose:

To investigate the efficacy of modified arthroscopic Bristow-Latarjet surgery and compare the clinical and radiographic outcomes using screw versus suture button fixation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 136 patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow-Latarjet surgery between June 2015 and February 2018. Of these patients, 117 who met the inclusion criteria were enrolled at a mean follow-up of 3.3 ± 0.7 years. Shoulders were separated into 2 groups based on fixation technique: screw fixation (group A; n = 63) or suture button fixation (group B; n = 54). Computed tomography imaging findings and clinical results were assessed preoperatively; immediately after operation; and postoperatively at 3 months, 6 months, 1 year, and final follow-up.

Results:

There were no significant differences between the groups in terms of postoperative clinical scores, the level of return to sports, range of motion, graft position, or reoperation rates. Bone healing was observed in 97.4% of the cases overall (114/117), with 98.4% bone union in group A and 96.3% in group B at final follow-up. Bone absorption was more common in group A (n = 30; 47.6%) compared with group B (n = 10; 18.5%) (P = .003). There were no hardware-related complications in group B, compared with 7.9% of patients in group A (P = .034). One patient in group B had a recurrent dislocation due to an unexpected event, and there were no recurrent dislocations in group A.

Conclusion:

After the modified arthroscopic Bristow-Latarjet procedure, both suture button and screw fixation methods demonstrated high bony healing rates and low risk of recurrence. Less coracoid graft resorption and no hardware-related complications were seen with suture button fixation.

Acceleration of Brain Susceptibility-Weighted Imaging with Compressed Sensitivity Encoding: A Prospective Multicenter Study

BACKGROUND AND PURPOSE

While three-dimensional susceptibility-weighted imaging has been widely suggested for intracranial vessel imaging, hemorrhage detection, and other neuro-diseases, its relatively long scan time has necessitated the clinical verification of recent progresses of fast imaging techniques. Our aim was to evaluate the effectiveness of brain SWI accelerated by compressed sensitivity encoding to identify the optimal acceleration factors for clinical practice.

MATERIALS AND METHODS

Ninety-nine subjects, prospectively enrolled from 5 centers, underwent 8 brain SWI sequences: 5 different folds of compressed sensitivity encoding acceleration (CS2, CS4, CS6, CS8, and CS10), 2 different folds of sensitivity encoding acceleration (SF2 and SF4), and 1 without acceleration. Images were assessed quantitatively on both the SNR of the red nucleus and its contrast ratio to the CSF and, subjectively, with scoring on overall image quality; visibility of the substantia nigra-red nucleus, basilar artery, and internal cerebral vein; and diagnostic confidence of the cerebral microbleeds and other intracranial diseases.

RESULTS

Compressed sensitivity encoding showed a promising ability to reduce the acquisition time (from 202 to 41 seconds) of SWI while increasing the acceleration factor from 2 to 10, though at the cost of decreasing the SNR, contrast ratio, and the scores of visual assessments. The visibility of the substantia nigra-red nucleus and internal cerebral vein became unacceptable in CS6 to CS10. The basilar artery was well-distinguished, and diseases including cerebral microbleeds, cavernous angiomas, intracranial gliomas, venous malformations, and subacute hemorrhage were well-diagnosed in all compressed sensitivity encoding sequences.

CONCLUSIONS

Compressed sensitivity encoding factor 4 is recommended in routine practice. Compressed sensitivity encoding factor 10 is potentially a fast surrogate for distinguishing the basilar artery and detecting susceptibility-related abnormalities (eg, cerebral microbleeds, cavernous angiomas, gliomas, and venous malformation) at the sacrifice of visualization of the substantia nigra-red nucleus and internal cerebral vein.

Two new species of the leafhopper genus Mitjaevia Dworakowska from China (Hemiptera, Cicadellidae, Typhlocybinae)

Background

The leafhopper genus Mitjaevia Dworakowska,1970 includes 19 species worldwide, nine species are known in China and is widely distributed in Palaearctic and Oriental Regions

New information

Two new species from Guizhou Province, China are described within the genus Mitjaevia Dworakowska, 1970 (Hemiptera: Cicadellidae: Typhlocybinae). A key to the species of the genus is provided and the female valvulae are described and figured.

JS01.3.A Oncogenic chaperoning of Hsp90 in glioma with FGFR3-TACC3

BACKGROUND

Fusion genes are chromosomal aberrations in malignancies that can be used as prognostic markers as well as therapeutic targets. The FGFR3-TACC3 (F3-T3) was initially discovered as an oncogenic molecule in glioblastoma and bladder cancer and subsequently found in many other cancer types. Based on clinical evidence, F3-T3 was found in glioblastoma patients before and after TMZ and radiotherapy treatment, suggesting that targeting F3-T3 is a valid strategy for glioblastoma treatment.

MATERIAL AND METHODS

We profiled the proteins that interacted with F3-T3 fusion protein in U-251 MG cells with F3-T3 through 2-D liquid chromatography-tandem mass spectrometry. To validate the result of proteomic analysis, we performed reverse immunoprecipitation by pulling down Hsp90 or Cdc37 in U-251 MG cells stably expressing F3-T3. To inhibit the association between F3-T3 and the Hsp90-Cdc37 complex, we treated U-251 MG and LN-229 cells stably expressing F3-T3 with Hsp90 inhibitors or siRNA of Cdc37. We applied the CCK8 assay to evaluate the sensitivity of glioblastoma cells stably expressing F3-T3, wild-type FGFR3, kinase-dead F3-T3 (K508R), and empty vectors to TMZ. Immunoblot and immunofluorescence staining were used to detect DNA damage marker pH2AX. The drug combination effect index was analyzed using software CalcuSyn. U-251 MG cells stably expressing F3-T3 infected with luciferase virus were intracranially injected in nude mice. The experimental group was administered with temozolomide (5mg/kg/day) by oral gavage, Hsp90 inhibitor Onalespib (30mg/kg/day) by tail vein injection or the combination of the two for indicated days.

RESULTS

We identified the proteins that showed increased binding ratios to F3-T3 over full-length FGFR3, the molecular chaperone proteins encoded by the genes HSP90AB1, HSP90AA1, and CDC37 emerged as 5th, 6th, and 7th on the top ten list, showing an approximately 4-fold increase in normalized spectral counts. Using Hsp90 inhibitors or Cdc37 siRNA disrupted the formation of the F3-T3/Hsp90/Cdc37 complex. Disruption of Hsp90-Cdc37 chaperoning caused a ubiquitination-mediated degradation of the glycosylated form of F3-T3 and abrogated the maturation of nascent F3-T3, resulting in suppression of F3-T3 signaling pathways. Additionally, our results provide evidence that the F3-T3 signaling pathway confers drug resistance to TMZ induced DNA damage. However, the resistance of TMZ was disrupted in glioblastoma cells harboring kinase-dead F3-T3 (K508R). We also demonstrated Hsp90 inhibitor significantly sensitized glioblastoma cells harboring the F3-T3 fusion gene to TMZ treatment and improved survival of xenograft model bearing F3-T3 tumor in vivo.

CONCLUSION

F3-T3 is a strong Hsp90 client that shows strong addiction to the Hsp90-Cdc37 chaperone system. Combination therapy with Hsp90 inhibitor overcomes the TMZ resistance conferred by F3-T3.

[Free rectus abdominis myocutaneous flap for the reconstruction of major and complex defects in the craniofacial regions after ablation of advanced sinonasal carcinomas]

Objective: To explore the method and plausibility of using free rectus abdominis flap (FRAF) to reconstruct the major and complex defects in the craniofacial regions after ablation of advanced sinonasal carcinoma. Methods: From 2007 to 2018 at No. 980 Hospital of Joint Logistic Supportive Force of People's Liberation Army of China, 13 patients with advanced carcinoma of nasal cavity and paranasal sinuses, including 11 males and 2 females, aged from 33 to 67 years, were treated with FRAF to repair the invasion of skull base, face and orbit. Based on adequate and meticulous preoperative evaluations on patients and tumors, complete resection of tumor bulks was performed. According to the sites, characters and extents of the defects, FRAF was introduced in different ways into reconstruction of major and complex defects in the craniofacial regions after resection of advanced sinonasal carcinomas, restoring the structure and contour of the craniofacial region. Results: Complete resection of tumors was achieved in all cases. For repairing the major and complex defects resulted from tumor ablation, FRAF graft was conducted in 13 patients with advanced sinonasal carcinomas. The recipient vessels were facial artery and vein in 9 cases, superficial temporal artery and vein in 4 cases. Vascular bridging with the external jugular vein was carried out in 2 cases who underwent submandibular neck dissections, in which facial artery and vein were used as recipient vessels. Free fibular flap was used along with FRAF in a case undergone bilateral maxillectomy. Pedicled galea capitis and periosteal flap were applied simultaneously in 3 cases with dura defects at the skullbase resulted from tumor resection. All flaps used in 13 cases survived uneventfully without major complications, with successful repair of defects, reconstruction of structures and restoration of contour of craniofacial regions. Conclusion: With adequate evaluation of resectability of tumors as well as nature and extent of defects after tumor removal, FRAF transplantation is an ideal method and strategy of choice for reconstructing the major and complex defects in craniofacial regions resulted from tumor ablation of advanced sinonasal carcinomas.

OP0028 CD206+CD163+ PATHOGENIC MACROPHAGES ENRICHED IN RHEUMATOID ARTHRITIS SYNOVIAL TISSUE WITH DISTINCT TRANSCRIPTIONAL SIGNATURES

Background:

Synovial tissue macrophages are an exquisitely plastic pool of innate cells that play a key role in RA disease progression. However, the precise nature, diversity, and function of macrophage subsets within the inflamed joint remains unexplored.

Objectives:

Therefore, the aims of this study are to phenotypically, transcriptionally and functionally characterise synovial tissue macrophages residing within the inflamed joint.

Methods:

Rheumatoid Arthritis, Psoriatic Arthritis, Osteoarthritis and healthy control synovial-tissue biopsies and synovial-fluid mononuclear cells were analysed using the following panel (CD40,-CD45,-CD64,-CD68,-CD163,-CD206,-CD253,-CCR4,-CCR7,-CXCR1,-CXCR3). CD206+CD163+ and CD206-CD163- macrophages were sorted from RA synovial-tissue by FACSAria sorter; RNAseq and FLIM analysis, autologous T-cell co-culture and heathy fibroblast experiments performed. Cytokine expression was measured by MSD immunoassay.

Results:

RA synovial tissue and fluid macrophages display markers typical of both M1 (CD40+CD253+) and M2 (CD206+CD163+) macrophages with a spectrum of macrophage activation states identified. Within this spectrum, significant enrichment of dominant CD206+CD163+ macrophage-subtype is present in synovial tissue versus fluid (p<0.05). CD206+CD163+ synovial tissue macrophages express significantly more CD40 than synovial fluid (p<0.0003), positively correlate with disease activity (r=0.6, p<0.01), with baseline levels predicting response to therapy (p<0.05). Moreover, CD206+CD163+CD40+ macrophages are enriched in RA synovial tissue compared to PsA and OA pathotypes (p<0.05). While the CD206+CD163+ subset is present in healthy synovial tissue, expression of CD40 is completely absent in healthy synovium (p<0.05) with dramatically decreased expression of CX3CR1 on RA macrophages. RNA-seq analysis indicates that CD206+CD163+ population is transcriptionally distinct from synovial tissue CD206-CD163-, synovial fluid CD206+CD163+, and RA monocyte-derived M1/M2 macrophages, with unique tissue-resident gene signatures. Moreover, differing metabolic demands between CD206+CD163+ and CD206-CD163- subsets was demonstrated by RNAseq and FLIM analysis. CD206+CD163+ macrophages enhance autologous T-cell responses, spontaneously secrete high levels of pro-inflammatory cytokines and activate healthy fibroblasts towards pro-inflammatory mechanisms thus further contributing to the local inflammatory response. Finally, inhibition of CD40 activity abrogates the expression of pro-inflammatory mediators (TNFa, IL-1B, IL-6, IFNy) and induces IL-10 expression in sorted CD206+CD163+ synovial tissue-macrophages suggesting a key role for CD40 in driving this pathogenic phenotype.

Conclusion:

This data identifies for the first-time enrichment of a previously undescribed dysfunctional dominant and transcriptionally distinct macrophage subtype in RA synovial tissue. Taken together, this data provides a greater understanding of the critical role tissue-resident macrophages play in perpetuating inflammation in RA. Further investigation of the molecular patterns and cues that shape specific synovial macrophage subsets may provide opportunities to reinstate RA joint homeostasis.

Disclosure of Interests:

Megan Hanlon: None declared, Mary Canavan: None declared, Qingxuan Song Employee of: Janssen Research & Development, Nuno Neto: None declared, Phil Gallagher: None declared, Ronan Mullan: None declared, Conor Hurson: None declared, Michael Monaghan: None declared, Sunil Nagpal Employee of: Janssen Research & Development, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0195 GUSELKUMAB TREATMENT MODULATES CORE PSORIATIC ARTHRITIS GENE EXPRESSION IN TWO PHASE 3 CLINICAL TRIALS (DISCOVER-1 AND -2)

Background:

Guselkumab (GUS), an interleukin-23 p19-subunit monoclonal antibody, demonstrated efficacy compared with placebo (PBO) in reducing signs and symptoms of psoriatic arthritis (PsA) in the phase 3 DISCOVER-1 & 2 studies.1,2

Objectives:

To evaluate gene expression in the blood of PsA patients (pts) in the DISCOVER-1 & -2 studies and the impact of GUS on the expression of these genes.

Methods:

Pts were treated with GUS 100 mg every 4 weeks (Q4W); GUS 100 mg at W0, W4, then Q8W; or matching PBO. Whole transcriptome profiling by RNA-sequencing was performed using the Novaseq platform on blood samples obtained from a subset of 673 pts with PsA at baseline across the 2 DISCOVER studies, as well as from 21 demographically (age, sex, and ethnicity) matched healthy controls procured independently of the clinical program. A subgroup (N=227) also had serial blood samples (W0/W4/W24) evaluated; the subgroup pts were selected based on having baseline characteristics (demographics, disease activity, medication use) representative of the overall cross-study PsA population. Significance of differentially expressed genes (DEGs) between PsA and healthy controls was defined by a false discovery rate (FDR) <0.05 based on a log-linear model using edgeR. Top genes were defined by significance and |logFC| >1. For cell type analysis, genes that changed with GUS treatment were tested for enrichment using Cibersort. Gene enrichment scores were calculated using Gene Set Variation Analysis (GSVA).

Results:

To define disease genes, we compared genes at baseline in pts with active PsA vs. healthy control whole blood transcriptomes and detected 355 upregulated and 314 downregulated (top genes shown in Table 1), defined here as core disease genes. Upregulated genes were largely related to neutrophils, monocytes, macrophages, and extracellular matrix, whereas downregulated genes were related to T cells. The upregulated disease genes were significantly decreased and the downregulated disease genes were significantly increased by GUS treatment vs. PBO at W4 and W24 (Fig 1). Upon stratification by Psoriasis Area and Severity Index 75% response and American College of Rheumatology 20% response, changes in core disease gene expression from W0 were statistically significant among responders, but not in non-responders, at W4 and W24 (data not shown). We then performed the second differential expression analysis comparing baseline to W4 and W24 for both PBO and GUS treatment arms to define genes that change with treatment arm over time. At W4 and W24 we found many DEGs from baseline with GUS treatment and none with PBO. These included genes related to B-, T-, NK-, and plasma cells (increased by GUS) and neutrophils, monocytes, eosinophils, and macrophages (decreased by GUS), suggestive of a partial normalization of immune cell composition in whole blood.

Conclusion:

Using whole transcriptome profiling, we detected DEGs in blood samples obtained from PsA pts vs. healthy controls, suggesting a dysregulation of immune cell profiles in PsA. The majority of these disease-associated genes were modulated by GUS, with directionality toward a normalization of whole blood transcriptomic signatures.

References:

[1]Deodhar A et al. Lancet. 2020;395:1115.

[2]Mease P et al. Lancet. 2020;395:1126.

Table 1.

Top DEGs derived from PsA vs. healthy whole blood transcriptomes.

Upregulated in PsADownregulated in PsAGenelogFClogCPMFDRGenelogFClogCPMFDRADGRG75.92-0.900.02101AK8-1.36-1.061.61E-07ADAMTS24.060.820.006466FTCD-1.48-1.741.67E-05PGF3.21-0.680.006466GPR15-1.541.811.67E-05PCSK93.21-2.960.023872CHRM3-1.54-2.629.6E-08OLAH2.760.750.004539RFPL4AL1-1.69-3.340.009738MAOA2.55-0.260.005463SPACA3-1.85-3.230.000216SLC2A142.300.590.022594VANGL2-1.95-1.799.6E-08MMP12.25-1.160.004745RFPL4A-2.04-1.280.004539DAAM22.124.310.024628GLYATL2-2.77-2.781.93E-15BCAR1-3.13-2.586.24E-26

Bold indicates positive change. CPM = counts per million.

Disclosure of Interests:

Stefan Siebert Consultant of: AbbVie, Janssen, Novartis, UCB, Grant/research support from: AbbVie, Amgen (previously Celgene), Bristol Myers Squibb, Boehringer Ingelheim, GSK, Janssen, Novartis, UCB, Kristen Sweet Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development LLC, Christopher T. Ritchlin Consultant of: AbbVie, Amgen, Gilead, Janssen, Eli Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, and UCB, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development LLC, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development LLC, Xie L Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development LLC, Qingxuan Song Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development LLC, Michelle Miron Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development LLC

Acceleration of Brain TOF-MRA with Compressed Sensitivity Encoding: A Multicenter Clinical Study

BACKGROUND AND PURPOSE

The clinical practice of three-dimensional TOF-MRA, despite its capability in brain artery assessment, has been hampered by the relatively long scan time, while recent developments in fast imaging techniques with random undersampling has shed light on an improved balance between image quality and imaging speed. Our aim was to evaluate the effectiveness of TOF-MRA accelerated by compressed sensitivity encoding and to identify the optimal acceleration factors for routine clinical use.

MATERIALS AND METHODS

One hundred subjects, enrolled at 5 centers, underwent 8 brain TOF-MRA sequences: 5 sequences using compressed sensitivity encoding with acceleration factors of 2, 4, 6, 8, and 10 (CS2, CS4, CS6, CS8, and CS10), 2 using sensitivity encoding with factors of 2 and 4 (SF2 and SF4), and 1 without acceleration as a reference sequence (RS). Five large arteries, 6 medium arteries, and 6 small arteries were evaluated quantitatively (reconstructed signal intensity, structural similarity, contrast ratio) and qualitatively (scores on arteries, artifacts, overall image quality, and diagnostic confidence for aneurysm and stenosis). Comparisons were performed among the 8 sequences.

RESULTS

The quantitative measurements showed that the reconstructed signal intensities of the assessed arteries and the structural similarity consistently decreased as the compressed sensitivity encoding acceleration factor increased, and no significant difference was found for the contrast ratios in pair-wise comparisons among SF2, CS2, and CS4. Qualitative evaluations showed no significant difference in pair-wise comparisons among RS, SF2, and CS2 (P > .05). The visualization of all the assessed arteries was acceptable for CS2 and CS4, while 2 small arteries in images of CS6 were not reliably displayed, and the visualization of large arteries was acceptable in images of CS8 and CS10.

CONCLUSIONS

CS4 is recommended for routine brain TOF-MRA with balanced image quality and acquisition time; CS6, for examinations when small arteries are not evaluated; and CS10, for fast visualization of large arteries.

Inhibition of connexin 43 induces hearing loss in postnatal mice

BACKGROUND

Connexin 43 (Cx43) is the most ubiquitously expressed member of the family of connexins, constituting gap junctions and mediating cell communication, still its role in hearing loss has been little studied.

METHODS

Immunohistochemistry was used to detect the expression pattern of Cx43. Spiral ganglia neurons (SGNs) and Corti co-culture were utilized to assay the re-innervation of hair cells by newborn SGNs. Gap19 was utilized to inhibit Cx43 hemichannels. Auditory brainstem responses (ABR) and endocochlear potential (E.P.) were measured to confirm the hearing loss.

RESULTS

The expression of Cx43 in P14 mice was higher than in P0 and P28 (adult) mice, the earlier time point coinciding with the early inner ear development. Additionally, the growth and synapse generation of fibers were inhibited after Gap 19 treatment of the co-cultures of the Corti and SGNs from newborn mice. Furthermore, the inhibition of Cx43 could increase the ABR threshold and decrease E.P. level in postnatal mice, whereas such an effect was not observed in adult mice.

CONCLUSION

The function of Cx43 is critical during the early development of mouse cochlea but is dispensable in adult mice.

Cuistow: Chinese Unique Inlay Bristow: A Novel Arthroscopic Surgical Procedure for Treatment of Recurrent Anterior Shoulder Instability with a Minimum 3-Year Follow-Up

BACKGROUND

The prevalence of nonunion after the Latarjet procedure remains high. The purpose of the present study was to investigate healing and clinical outcomes after a novel arthroscopic coracoid process transfer procedure.

METHODS

Sixty-three patients who underwent the arthroscopic inlay Bristow procedure combined with Bankart repair were identified, and 51 patients who met the inclusion criteria were enrolled in this study. The key feature of this technique was that the coracoid process was trimmed and fixed into a trough (5 to 10 mm deep) in the glenoid neck with a metal screw. Bone graft union and positioning accuracy were assessed with use of postoperative computed tomography (CT) imaging. Clinical examinations, return to sport, and functional scores (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) were recorded.

RESULTS

The mean duration of follow-up (and standard deviation) was 41.5 ± 7.7 months (range, 36 to 48 months). Postoperative CT scans showed that the position of coracoid graft was at 4:10 (from 3:50 to 5:00) (referencing the right shoulder) in the sagittal view. The α angle was 16.4° ± 9.5°, with 4 (7.8%) of 51 screws being over-angulated (α > 25°). On the axial view, the graft position was considered to be flush in 33 patients (64.7%), medial in 11 (21.6%), congruent in 7 (13.7%), and lateral or too medial in none. At 1 year, the coracoid graft had healed in 49 patients (96.1%) and had failed to unite in 2 patients. CT scanning, performed for 47 patients, showed grade-0 osteolysis in 9 patients, grade-1 osteolysis in 21 patients, and grade-2 osteolysis in 17 patients. At the time of the latest follow-up, there was a significant increase in the Rowe score (from 35.5 ± 8.3 to 95.7 ± 7.2) and the ASES score (from 71.2 ± 9.7 to 91.5 ± 4.4), and 87.0% of patients were able to return to sport. No arthropathy was observed in any patient.

CONCLUSIONS

After a minimum 3-year follow-up, the arthroscopic inlay Bristow procedure resulted in a high rate of graft healing, excellent clinical outcomes, and a high rate of return to sports.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bandwidth-unlimited polarization-maintaining metasurfaces

Any arbitrary state of polarization of light beam can be decomposed into a linear superposition of two orthogonal oscillations, each of which has a specific amplitude of the electric field. The dispersive nature of diffractive and refractive optical components generally affects these amplitude responses over a small wavelength range, tumbling the light polarization properties. Although recent works suggest the realization of broadband nanophotonic interfaces that can mitigate frequency dispersion, their usage for arbitrary polarization control remains elusively chromatic. Here, we present a general method to address broadband full-polarization properties of diffracted fields using an original superposition of circular polarization beams transmitted through metasurfaces. The polarization-maintaining metasurfaces are applied for complex broadband wavefront shaping, including beam deflectors and white-light holograms. Eliminating chromatic dispersion and dispersive polarization response of conventional diffractive elements lead to broadband polarization-maintaining devices of interest for applications in polarization imaging, broadband-polarimetry, augmented/virtual reality imaging, full color display, etc.

Diffusion-tensor imaging for differentiating uterine sarcoma from degenerative uterine fibroids

AIM

To explore the applicability of diffusion-tensor imaging (DTI) sequence quantitative parameters in differentiating uterine sarcoma (USr) from degenerative uterine fibroids (DUF).

MATERIALS AND METHODS

Fourteen cases of USr and 30 cases of DUF were analysed retrospectively. The diffusion-weighted imaging (DWI) and DTI images were analysed by two observers using Functool software on a ADW4.6 workstation. The images were post-processed to generate an apparent diffusion coefficient (ADC) map of DWI, ADC map of DTI (ADC^T map), and fractional anisotropy (FA) map. Three regions of interest (ROI) were selected from the ADC, ADC^T, and FA maps to obtain the ADC, ADC^T, and FA values. The receiver operating characteristic (ROC) curves of all parameters were used to analyse and compare the diagnostic value of USr and DUF.

RESULTS

The ADC value, ADC^T value, and FA value of USr (1.190 ± 0.262 × 10^-3mm²/s, 1.165 ± 0.270 × 10^-9mm²/s, 0.168 ± 0.063) were significantly lower compared to the values for DUF (1.525 ± 0.314 × 10^-3mm²/s, 1.650 ± 0.332 × 10^-9mm²/s, 0.254 ± 0.111; all p<0.001). The diagnostic threshold values for USr were: ADC ≤1.290 × 10^-3mm²/s, ADC^T ≤1.322 × 10^-9mm²/s and FA ≤0.192. The corresponding sensitivities and specificities were 78.6%/90%, 96.7%/92.9%, and 86.7%/85.7%, respectively. The areas under the curve (AUC) were 0.875, 0.974, and 0.831, respectively.

CONCLUSIONS

DTI quantitative parameters can be used to differentiate USr from DUF. The ADC^T value had the highest diagnostic efficacy.

Comparison of overfeeding effects on gut physiology and microbiota in two goose breeds

To have a better understanding of how the “gut–liver axis” mediates the lipid deposition in the liver, a comparison of overfeeding influence on intestine physiology and microbiota between Gang Goose and Tianfu Meat Goose was performed in this study. After force-feeding, compared with Gang Goose, Tianfu Meat Goose had better fat storage capacity in liver (397.94 vs. 166.54 for foie gras weight (g), P < 0.05; 6.37 vs. 2.92% for the ratio of liver to body, P < 0.05; 60.01 vs. 46.64% for fat content, P < 0.05) and the less subcutaneous adipose tissue weight (1240.96 g vs. 1440.46 g, P < 0.05). After force-feeding, the digestion–absorption capacity of Tianfu Meat Goose was higher than that of Gang Goose (5.56 vs. 3.64 and 4.63 vs. 3.68 for the ratio of villus height to crypt depth in duodenum and ileum, respectively, P < 0.05; 1394.96 vs. 782.59 and 1314.76 vs. 766.17 for the invertase activity (U/mg-prot), in duodenum and ileum, respectively, P < 0.05; 6038.36 vs. 3088.29 and 4645.29 vs. 3927.61 for the activity of maltase (U/mg-prot), in duodenum and ileum, respectively, P < 0.05). Force-feeding decreased the gene expression of Escherichia coli in the ileum of Tianfu Meat Goose; force-feeding increased the number of gut microbiota Enterobacterial Repetitive Intergenic Consensus-Polymerase Chain Reaction band in Tianfu Meat Goose and decreased the number in Gang Goose. In conclusion, compared with Gang Goose, the lipid deposition in the liver and the intestine digestion–absorption capacity and stability were higher in Tianfu Meat Goose. Thereby, Tianfu Meat Goose is the better breed for foie gras production for prolonged force-feeding; Gang Goose possesses better fat storage capacity in subcutaneous adipose tissue. However, Gang Goose has lower gut stability responding to force-feeding, so Gang Goose is suited to force-feeding in a short time to gain the body weight and subcutaneous fat as an overfed duck for roast duck.

[Radiomics nomogram of MR: a prediction of cervical lymph node metastasis in laryngeal cancer]

Objective: To establish and validate a radiomics nomogram based on MR for predicting cervical lymph node metastasis in laryngeal cancer. Methods: One hundred and seventeen patients with laryngeal cancer who underwent MR examinations and received open surgery and neck dissection between January 2016 and December 2019 were included in this study. All patients were randomly divided into a training cohort (n=89) and test cohort (n=28) using computer-generated random numbers. Clinical characteristics and MR were collected. Radiological features were extracted from the MR images. Enhanced T1 and T2WI were selected for radiomics analysis, and the volume of interest was manually segmented from the Huiyihuiying radiomics cloud platform. The variance analysis (ANOVA) and the least absolute shrinkage and selection operator (LASSO) algorithm were used to reduce the dimensionality of the radiomics features in the training cohort. Then, a radiomic signature was established. The clinical risk factors were screened by using ANOVA and multivariate logistic regression. A nomogram was generated using clinical risk factors and the radiomic signature. The calibration curve and receiver operator characteristic (ROC) curve were used to confirm the nomogram's performance in the training and test sets. The clinical usefulness of the nomogram was evaluated by decision curve analysis (DCA). Furthermore, a testing cohort was used to validate the model. Results: The radiomics signature consisted of 21 features, and the nomogram model included the radiomics signature and the MR-reported lymph node status. The model showed good calibration and discrimination. The model yielded areas under the ROC curve (AUC) in the training cohort, specificity, and sensitivity of 0.930, 0.930 and 0.875. In the test cohort, the model yielded AUC, specificity and sensitivity of 0.883, 0.889 and 0.800. DCA indicated that the nomogram model was clinically useful. Conclusion: The MR-based radiomics nomogram model may be used to predict cervical lymph node metastasis of laryngeal cancer preoperatively. MR-based radiomics could serve as a potential tool to help clinicians make an optimal clinical decision.

Association of iodine-related knowledge, attitudes and behaviours with urinary iodine excretion in pregnant women with mild iodine deficiency

BACKGROUND

Subsequent to the implementation of the universal salt iodisation policy, China has all but eliminated the iodine deficiency disorders. However, pregnant women are still experiencing mild iodine deficiency. The present study explored factors that could relate to mild iodine deficiency in pregnant women.

METHODS

In total, 2400 pregnant women were enrolled using a multistage, stratified, random sampling method in Shanghai. Data were collected via a standardised questionnaire. The urine samples and household cooking salt samples were collected for the detection of urinary iodine and salt iodine concentrations.

RESULTS

The median urinary iodine concentration (MUIC) was 148.0 μg L^-1 for all participants, and 155.0 μg L^-1 , 151.0 μg L^-1 and 139.6 μg L^-1 in the first, second and third trimesters. The MUIC in the third trimester was significantly lower than that of the first trimester (P < 0.05). The usage rates of iodised salt and qualified-iodised salt were 71.5% and 59.4%, respectively. Iodine-related knowledge score composition ratio was significantly different between the high and low UIC groups (P < 0.05). Participants' MUIC increased significantly with the increases in iodine-related knowledge score (P < 0.001). The third trimester was a significant risk factor for high UIC, whereas high iodine-related knowledge score, actively learning dietary knowledge and having a habit of consuming iodine-rich food were significant protective factors for high UIC (P < 0.05).

CONCLUSIONS

Iodine level is adequate among pregnant women in Shanghai during the first and the second trimesters, although it is is insufficient in the third trimester. Good iodine-related knowledge, attitudes and behaviours are important for pregnant women with respect to maintaining adequate urinary iodine.

A WRKY transcription factor, TaWRKY40-D, promotes leaf senescence associated with jasmonic acid and abscisic acid pathways in wheat

Leaf senescence is a complex and precise regulatory process that is correlated with numerous internal and environmental factors. Leaf senescence is tightly related to the redistribution of nutrients, which significantly affects productivity and quality, especially in crops. Evidence shows that the mediation of transcriptional regulation by WRKY transcription factors is vital for the fine-tuning of leaf senescence. However, the underlying mechanisms of the involvement of WRKY in leaf senescence are still unclear in wheat. Using RNA sequencing data, we isolated a novel WRKY transcription factor, TaWRKY40-D, which localizes in the nucleus and is basically induced by the progression of leaf senescence. TaWRKY40-D is a promoter of natural and dark-induced leaf senescence in transgenic Arabidopsis thaliana and wheat. We also demonstrated a positive response of TaWRKY40-D in wheat upon jasmonic acid (JA) and abscisic acid (ABA) treatment. Consistent with this, the detached leaves of TaWRKY40-D VIGS (virus-induced gene silencing) wheat plants showed a stay-green phenotype, while TaWRKY40-D overexpressing Arabidopsis plants showed premature leaf senescence after JA and ABA treatment. Moreover, our results revealed that TaWRKY40-D positively regulates leaf senescence, possibly by altering the biosynthesis and signalling of JA and ABA pathway genes. Together, our results suggest a new regulator of JA- and ABA-related leaf senescence, as well as a new candidate gene that can be used for molecular breeding in wheat.

An Arthroscopic "Inlay" Bristow Procedure With Suture Button Fixation for the Treatment of Recurrent Anterior Glenohumeral Instability: 3-Year Follow-up

BACKGROUND

Coracoid graft positioning, fixation, and bone union are key factors affecting the clinical outcomes of Bristow and Latarjet procedures. We developed an arthroscopic "inlay" Bristow procedure based on the "mortise-tenon" joint structure concept using suture button fixation to achieve more stable fixation and better bone union of the graft.

PURPOSE

To evaluate the positioning of the coracoid graft, bone union rate, and clinical outcomes of this arthroscopic inlay Bristow procedure with suture button fixation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 62 patients who received the arthroscopic inlay Bristow procedure with suture button fixation between June 2015 to June 2016 were eligible for inclusion, and 56 patients who met the inclusion criteria were enrolled in this study. Radiological assessment on 3-dimensional computed tomography scan was performed preoperatively, immediately after the operation, and postoperatively at 3 months, 6 months, 1 year, and the final follow-up. Pre- and postoperative clinical results were also assessed.

RESULTS

A total of 56 patients were included in this study. The mean ± SD follow-up time was 36.1 ± 3.7 months. Coracoid grafts (middle point) were positioned at 4 o'clock (range, 123.8°± 12.3°) in the sagittal view. In the axial view, 94.6% (53/56) of the graft positioning was measured as flush and 5.4% (3/56) as medial. Neither lateral nor too medial positioning was noted. The bone union rate was 96.4% at final follow-up. The mean visual analog scale score for pain during motion, American Shoulder and Elbow Surgeons score, and Rowe score all improved significantly after surgery-from 4.8 ± 2.6 to 1.1 ± 1.0, 69.2 ± 12.5 to 92.5 ± 7.0, and 33.5 ± 12.1 to 96.0 ± 4.9 at last follow-up, respectively. Almost all patients (98%; 55/56) returned to sports within 1 year after surgery at the same or higher level as compared with their preinjury performance. The mean subjective value for sports participation was 90.3% ± 7.1% (range, 70%-100%) as compared with the normal shoulder. The overall complication rate was 3.6%. No degenerative changes were noted in any patients.

CONCLUSION

This study reported the first series of an inlay Bristow procedure with suture button fixation for recurrent shoulder dislocation, providing a satisfactory union rate and excellent graft positioning with a low complication rate. The mortise-tenon joint structure can provide excellent graft fixation and healing, while using suture button fixation instead of screw fixation could reduce osteolysis and complications related to hardware implantation.

New Andean source of resistance to anthracnose and angular leaf spot: Fine-mapping of disease-resistance genes in California Dark Red Kidney common bean cultivar

Anthracnose (ANT) and angular leaf spot (ALS) caused by Colletotrichum lindemuthianum and Pseudocercospora griseola, respectively, are devastating diseases of common bean around the world. Therefore, breeders are constantly searching for new genes with broad-spectrum resistance against ANT and ALS. This study aimed to characterize the genetic resistance of California Dark Red Kidney (CDRK) to C. lindemuthianum races 73, 2047, and 3481 and P. griseola race 63-39 through inheritance, allelism testing, and molecular analyses. Genetic analysis of response to ANT and ALS in recombinant inbred lines (RILs) from a CDRK × Yolano cross (CY) showed that the resistance of CDRK cultivar is conferred by a single dominant loci, which we named CoPv01CDRK/PhgPv01CDRK. Allelism tests performed with race 3481showed that the resistance gene in CDRK is independent of the Co-1 and Co-AC. We conducted co-segregation analysis in genotypes of 110 CY RILs and phenotypes of the RILs in response to different races of the ANT and ALS pathogens. The results revealed that CoPv01CDRK and PhgPv01CDRK are coinherited, conferring resistance to all races. Genetic mapping of the CY population placed the CoPv01CDRK/PhgPv01CDRK loci in a 245 Kb genomic region at the end of Pv01. By genotyping 19 RILs from the CY population using three additional markers, we fine-mapped the CoPv01CDRK/PhgPv01CDRK loci to a smaller genomic region of 33 Kb. This 33 Kb region harbors five predicted genes based on the common bean reference genome. These results can be applied in breeding programs to develop bean cultivars with ANT and ALS resistance using marker-assisted selection.

Rhythmic change of adipokinetic hormones diurnally regulates locust vitellogenesis and egg development

Adipokinetic hormones (AKHs), the neurohormones synthesized in the insect corpora cardiaca are known to mobilize lipids and carbohydrates for energy-consuming activities including reproduction. However, both inhibitory and stimulatory effects of AKHs on insect reproduction have been reported, and the underlying mechanisms remain elusive. Using the migratory locust, Locusta migratoria, as a model system, we report here that AKHs are expressed in response to rhythmic diel change, and AKH III expression increases markedly at photophase. Diurnal injection of AKH III but not AKH I or AKH II in adult females stimulates vitellogenesis and egg development. In contrast, AKH treatment at scotophase represses female reproduction. RNA interference-mediated knockdown of AKH receptor (AKHR) results in significantly reduced vitellogenin (Vg) expression in the fat body at photophase along with reduced Vg deposition in the ovary. AKHR knockdown also leads to decreased expression of Brummer, triacylglycerol lipase and trehalose transporter, accompanied by suppressed mobilization of triacylglycerol and trehalose. We propose that in addition to stimulating Vg expression at photophase, AKH/AKHR signalling is likely to regulate ovarian uptake of Vg via triacylglycerol mobilization and trehalose homeostasis. This study provides new insights into the understanding of AKH/AKHR signalling in the regulation of insect reproduction.

AB0037 EXPRESSION OF NEGATIVE CHECKPOINT MOLECULES BTLA AND HVEM IS DYSREGULATED IN AUTOIMMUNE DISEASES

Background:

Immune checkpoint blockade with agents targeting CTLA4 and PD-1/PD-L1 alone or in combination has demonstrated exceptional efficacy in multiple cancer types by “unleashing” the cytotoxic action of quiescent, tumor-infiltrating T cells. However, the therapeutic action of these immunotherapies goes hand in hand with the loss of immune tolerance and appearance of immune-related adverse events such as colitis, arthralgia and inflammatory arthritis in responsive patients. Therefore, immune checkpoint molecules have been proposed as targets for the treatment of autoimmune diseases.

Objectives:

Herein, we interrogate the potential of BTLA/HVEM axis as a target for restoring immune homeostasis in rheumatoid arthritis (RA), Systemic Lupus Erythematosus (SLE) and Sjogren’s Syndrome (SjS) by examining their expression patterns in autoimmune disease tissues.

Methods:

Message and protein expression of BTLA and HVEM were examined in RA and SLE synovial tissues, SLE cutaneous lesions, SjS salivary glands and peripheral blood samples of autoimmune disease by RNA sequencing and flow cytometry.

Results:

Tissue dysregulation of the BTLA-HVEM axis was observed: Increased BTLA RNA level in RA synovium, SLE-affected skin, and SjS salivary gland samples, whereas HVEM level was affected only in the RA synovium when compared to unaffected tissues. Detailed immunophenotyping of B, T, and myeloid cell populations in RA, SLE, SjS and healthy control PBMCs revealed differential modulation of the BTLA+ or HVEM+ immune cell subsets in a disease-context dependent manner. SjS patients showed an overall decrease in memory B cells and most of the BTLA+ B cell subsets while a decrease in HVEM+ B cells was observed only in SLE PBMC samples and not RA and SLE samples. Immunophenotyping with a T cell panel exhibited decreased BTLA and HVEM expression on T cell subsets in SjS and SLE but not in RA patients. In addition, protein levels of HVEM were differentially decreased in SLE myeloid cell subsets. Finally, we demonstrate tissue-specific surface expression patterns of BTLA in RA and SLE samples: higher surface BTLA levels on RA and SLE PBMC B cells than matched tissue-derived B cells.

Conclusion:

Our results demonstrate a dysregulation of the BTLA/HVEM axis in either lesional tissue or peripheral blood in an autoimmune disease context-dependent manner. These results also indicate the potential of targeting BTLA-HVEM axis for the treatment of multiple autoimmune diseases.

Disclosure of Interests:

Sunil Nagpal Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Suzanne Cole Shareholder of: Janssen Research & Development employee, Employee of: Janssen Research & Development employee, Achilleas Floudas: None declared, Mihir Wechalekar Grant/research support from: Grant from Janssen Research & Development, Qingxuan Song Shareholder of: Employee of Janssen Research, Employee of: Employee of Janssen Research, Tom Gordon: None declared, Roberto Caricchio Grant/research support from: Financial grant from Janssen Research & Development, Douglas Veale: None declared, Ursula Fearon: None declared, Navin Rao Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Ling-Yang Hao Shareholder of: Employee of Janssen Research, Employee of: Employee of Janssen Research

Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach

BACKGROUND

Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation.

METHODS

This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN.

RESULTS

Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths).

CONCLUSION

A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.