[Clinical application of split liver transplantation: a single center report of 203 cases]

Objective: To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application. Methods: This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis. Results: The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group (χ2=5.560,P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group (χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion: SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Insights for the Captive Management of South China Tigers Based on a Large-Scale Genetic Survey

There is an urgent need to find a way to improve the genetic diversity of captive South China tiger (SCT, Panthera tigris amoyensis), the most critically endangered taxon of living tigers, facing inbreeding depression. The genomes showed that 13 hybrid SCTs from Meihuashan were divided into two groups; one group included three individuals who had a closer relationship with pureblood SCTs than another group. The three individuals shared more that 40% of their genome with pureblood SCTs and might be potential individuals for genetic rescuing in SCTs. A large-scale genetic survey based on 319 pureblood SCTs showed that the mean microsatellite inbreeding coefficient of pureblood SCTs decreased significantly from 0.1789 to 0.0600 (p = 0.000009) and the ratio of heterozygous loci increased significantly from 38.5% to 43.2% (p = 0.02) after one individual of the Chongqing line joined the Suzhou line and began to breed in the mid-1980s, which is a reason why the current SCTs keep a moderate level of microsatellite heterozygosity and nucleotide diversity. However, it is important to establish a back-up population based on the three individuals through introducing one pureblood SCT into the back-up population every year. The back-up population should be an important reserve in case the pureblood SCTs are in danger in the future.

Neurosonographic evaluation of corpus callosum-fastigium and tectal length in late-onset small fetuses

Linked article: This Correspondence comments on Lip‐Sosa et al. Click here to view the article.

[Serum hepatitis B virus pregenomic RNA profiles in patients with chronic hepatitis B on long-term antiviral therapy]

Objective: To explore the clinical changes in levels of the new clinical marker serum hepatitis B virus (HBV) pregenomic RNA (pgRNA) in patients with chronic hepatitis B (CHB) with long-term antiviral therapy. Methods: 100 CHB cases who were initially treated with nucleos(t)ide analogues (NAs) at Peking University First Hospital were included. The levels of alanine aminotransferase (ALT), HBV DNA, hepatitis B e-antigen (HBeAg), and hepatitis B surface antigen (HBsAg) during the follow-up period were measured. The TaqMan-based real-time quantitative PCR method was used to detect serum HBV pgRNA levels. The independent sample t-test and Mann-Whitney U test were used to compare continuous variables between groups, while Pearson's χ (2) test and Fisher's exact test were used to compare categorical variables. Results: HBV pgRNA levels decreased significantly in patients who developed virological responses at 48 weeks (n = 54) during subsequent treatment compared to those who did not (n = 46). The HBV pgRNA level was lower in HBeAg-positive patients than in HBeAg-negative patients (P < 0.05 or P < 0.01). Patients with higher HBV DNA and HBeAg-positivity levels at baseline had a higher HBV pgRNA level following antiviral therapy. There was no statistically significant difference in HBV pgRNA levels in patients with different HBV pgRNA levels at baseline after antiviral therapy. There was no correlation between serum HBV pgRNA and HBsAg at baseline, but there was a correlation after long-term antiviral therapy, while there was a weak correlation between HBV pgRNA and HBsAg at the fifth and ninth years of antiviral therapy (r = 0.262, P = 0.031; r = 0.288, P = 0.008). Conclusion: HBV pgRNA levels were higher with higher HBV activity in CHB patients with long-term antiviral therapy.

Integrative analysis reveals the recurrent genetic etiologies in idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is increasingly recognized as a chronic, progressive and fatal lung disease with an unknown etiology. Current studies focus on revealing the genetic factors in the risk of IPF, making the integrative analysis of genetic variations and transcriptomic alterations of substantial value.

AIM

This study aimed to improve the understanding of the molecular basis of IPF through an integrative analysis of whole-exome sequencing (WES), bulk RNA sequencing (RNA-seq) and single-cell RNA sequencing (scRNA-seq) data.

METHODS

WES is a powerful tool for studying the genetic basis of IPF, allowing for the identification of genetic variants that may be associated with the development of the disease. RNA-seq data provide a comprehensive view of the transcriptional changes in IPF patients, while scRNA-seq data offer a more granule view of cell-type-specific alterations.

RESULTS

In this study, we identified a comprehensive mutational landscape of recurrent genomic and transcriptomic variations, including single-nucleotide polymorphisms, CNVs and differentially expressed genes, in IPF populations, which may play a significant role in the development and progression of IPF.

CONCLUSIONS

Our study provided valuable insights into the genetic and transcriptomic variations associated with IPF, revealing changes in gene expression that may contribute to disease development and progression. These findings highlight the importance of an integrative approach to understanding the molecular mechanisms underlying IPF and may pave the way for identifying potential therapeutic targets.

The feasibility and safety of laparoscopic inguinal hernia repair as a 24-h day surgery for patients aged 80 years and older: a retrospective cohort study

INTRODUCTION

As the proportion of aging adults increases and inguinal hernia repair becomes increasingly popular as a day surgery, the demand for laparoscopic inguinal hernia repair as a day surgery is increasing among patients aged 80 years and older. Relevant research needs to be completed, so we aimed to evaluate laparoscopic inguinal hernia repair as a 24-h day surgery for this group of patients.

METHODS

In this retrospective cohort study, we utilized propensity score matching to analyze the data of patients who underwent laparoscopic inguinal hernia repair at a day surgery center between January 1, 2019, and March 1, 2022. Patients were divided into ≥ 80 years old and < 80 years old groups. We compared the perioperative laboratory results, perioperative outcomes, and 1-year complications between the two groups.

RESULT

A total of 554 patients were included in the study. After propensity score matching, 292 patients were included in the matched cohort (98 patients in the ≥ 80 years old group and 194 patients in the < 80 years old group). During hospitalization, there were significant differences in ASA classification, Caprini score, length of hospital stays, risk of thrombosis, and delayed discharge rate. No significant difference was found in the incidence of total postoperative complications between the two groups at the 1-year follow-up (HR: 0.96, 95% CI 0.36-2.54, P = 0.96).

CONCLUSION

In our study, LIHR as a 24-h day surgery was safe and effective for patients over 80 years old. However, to reduce the rate of delayed discharge, cautious perioperative evaluation is necessary.

Design and experiments of a compact electrostatic low energy beam transport with a double Einzel-lens for a transportable neutron source

A transportable, compact, accelerator-based neutron source is under development at Xian Jiaotong University. An electrostatic low energy beam transport (LEBT) structure with a double Einzel-lens setup was adopted due to its short length and low power consumption. It can transport a pulsed proton beam to the radio frequency quadrupole with a required beam current of 15 mA and an energy of 30 keV. We performed detailed structure optimization and beam tracking to achieve beam matching and small emittance growth. In addition, the fast chopper, beam steering, and diagnostic devices are integrated into the LEBT. The fabrication and assembly of the proton injector have been completed, and beam commissioning was carried out to measure the beam current and Twiss parameters. The design strategy, beam simulation, and experimental results are presented and discussed in this paper.

Characterization of adnexal lesions using photoacoustic imaging to improve sonographic O-RADS risk assessment

OBJECTIVE

To assess the impact of photoacoustic imaging (PAI) on the assessment of ovarian/adnexal lesion(s) of different risk categories using the sonographic ovarian-adnexal imaging-reporting-data system (O-RADS) in women undergoing planned oophorectomy.

METHOD

This prospective study enrolled women with ovarian/adnexal lesion(s) suggestive of malignancy referred for oophorectomy. Participants underwent clinical ultrasound (US) examination followed by coregistered US and PAI prior to oophorectomy. Each ovarian/adnexal lesion was graded by two radiologists using the US O-RADS scale. PAI was used to compute relative total hemoglobin concentration (rHbT) and blood oxygenation saturation (%sO2 ) colormaps in the region of interest. Lesions were categorized by histopathology into malignant ovarian/adnexal lesion, malignant Fallopian tube only and several benign categories, in order to assess the impact of incorporating PAI in the assessment of risk of malignancy with O-RADS. Malignant and benign histologic groups were compared with respect to rHbT and %sO2 and logistic regression models were developed based on tumor marker CA125 alone, US-based O-RADS alone, PAI-based rHbT with %sO2 , and the combination of CA125, O-RADS, rHbT and %sO2. Areas under the receiver-operating-characteristics curve (AUC) were used to compare the diagnostic performance of the models.

RESULTS

There were 93 lesions identified on imaging among 68 women (mean age, 52 (range, 21-79) years). Surgical pathology revealed 14 patients with malignant ovarian/adnexal lesion, two with malignant Fallopian tube only and 52 with benign findings. rHbT was significantly higher in malignant compared with benign lesions. %sO2 was lower in malignant lesions, but the difference was not statistically significant for all benign categories. Feature analysis revealed that rHbT, CA125, O-RADS and %sO2 were the most important predictors of malignancy. Logistic regression models revealed an AUC of 0.789 (95% CI, 0.626-0.953) for CA125 alone, AUC of 0.857 (95% CI, 0.733-0.981) for O-RADS only, AUC of 0.883 (95% CI, 0.760-1) for CA125 and O-RADS and an AUC of 0.900 (95% CI, 0.815-0.985) for rHbT and %sO2 in the prediction of malignancy. A model utilizing all four predictors (CA125, O-RADS, rHbT and %sO2 ) achieved superior performance, with an AUC of 0.970 (95% CI, 0.932-1), sensitivity of 100% and specificity of 82%.

CONCLUSIONS

Incorporating the additional information provided by PAI-derived rHbT and %sO2 improves significantly the performance of US-based O-RADS in the diagnosis of adnexal lesions. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of efficacy and safety of flexible ureteroscopy and mini-percutaneous nephrolithotomy for 2-3 cm renal calculi in women: a single-center study

OBJECTIVE

This study aimed to compare the efficacy and safety of flexible ureteroscopic lithotripsy (FURSL) and mini-percutaneous nephrolithotomy (mPCNL) in the treatment of 2-3 cm renal calculi in women.

PATIENTS AND METHODS

Clinical data of 186 patients who underwent mPCNL (n=96) and FURSL (n=90) surgery in our hospital from June 2018 to February 2023 were collected. Several parameters were assessed and compared between the two groups, including operation duration, length of hospital stay, cost of hospitalization, pain intensity measured by the visual analogue scale (VAS), patient comfort assessed using the Bruggrmann Comfort Scale (BCS), decrease in hemoglobin levels, changes in blood urea nitrogen (BUN), fluctuations in serum creatinine (Scr), hypersensitive C-reactive protein (hs-CRP) levels, complication rates, immediate post-operative stone-free rate (RSFR), and long-term stone-free rate (LSFR).

RESULTS

The comparative analysis of patient age, body mass index (BMI), stone size, computed X-ray tomography (CT) value of stones, number of stones, and comorbidities revealed no statistically significant differences between the mPCNL and FURSL groups (p>0.05). The mPCNL cohort exhibited a markedly lower duration of operation (p<0.001) and BCS score (p<0.001) compared to the FURSL cohort. Nonetheless, the mPCNL cohort demonstrated significantly higher hospitalization expenses (p<0.001), length of hospital stay (p<0.001), VAS score for pain (p<0.001), and level of hemoglobin decrease (p<0.001) in comparison to the FURSL cohort. Moreover, the immediate post-operative stone-free rate (RSFR) was significantly higher in the mPCNL group (p=0.007). The long-term stone-free rate (LSFR), however, showed no significant difference between the two groups (p=0.160). Furthermore, the FURSL group exhibited significantly fewer overall complications in contrast to the mPCNL group (p=0.006).

CONCLUSIONS

mPCNL and FURSL are both safe and effective surgical methods for treating 2-3 cm renal calculi in women. However, FURSL holds distinct advantages, including minimally invasive procedure, accelerated recovery, reduced cost, and lower incidence of complications.

The Potential Ability of Plan Complexity Metrics on the Dose Calculation and Plans Delivery in Intensity Modulated Radiotherapy

PURPOSE/OBJECTIVE(S)

The excessive modulation of treatment plan during radiotherapy (RT) increases the complexity. Evaluation of the multidimensional relationship between program complexity metrics, computation-based patient-specific quality assurance (PSQA), and conventional measurement-based PSQA could assist in enhancing the robustness of treatment planning, guide the allocation of clinical QA resources, and ultimately lessen QA workload.

MATERIALS/METHODS

The fifty-five metrics affecting RT planning and delivery accuracy were calculated by a house-built program to describe the complexity of 404 dynamic IMRT plans, with sensitivity to the small field, aperture position, MLC edge, low MUs, MLC leaf motion, leaf speed/acceleration, etc. The calculation-based PSQA was performed using Monte Carlo (MC) method and Collapsed Cone Convolution (CCC) algorithm, implemented in SciMoCa and Mobius 3D, respectively. The measurement-based PSQA was performed using 3D diode arrays with different geometries covering "O", "+" and " × " shapes which exist in ArcCheck, Delta4 phantom+ (Delta4) and Delta4PT phantom (Delta4PT), respectively. Gamma passing rates (GPRs) were recorded to measure the results of each QA system. This multidimensional relationship was evaluated using correlation analysis and principal component linear regression (PCR) analysis.

RESULTS

A total of 4448 GPRs for various QA systems corresponding to two Linacs were counted. The modulation index for speed (MIs) and modulation index for acceleration (MIa) were consistently located at the high points of the radarplots of the Spearman correlation coefficient |rs| between metrics and GPRs of the four QA systems, just except Delta4. Besides, the rs between SciMoCa and ArcCheck were 0.275-0.531 (P ≤ 0.001), SciMoCa and Delta4 were 0.32-0.418 (P ≤ 0.001), and Mobius 3Dand Delta4PT were 0.124-0.226 (P ≤ 0.05). The PCR model's coefficients determination (R2) for SciMoCa were 0.461-0.756 (P ≤ 0.001), ArcCheck were 0.243-0.440 (P ≤ 0.001), Delta4 were 0.268-0.402 (P ≤ 0.001), Mobius 3D were 0.299-0.407 (P ≤ 0.001), and Delta4PT were 0.087-0.141 (P ≤ 0.05).

CONCLUSION

This study is the first overall assessment of the impact of various complexity metrics on the accuracy of TPS calculation and Linac delivery. Of the metrics studied, MIs and MIa metrics have a standout impact on the ability of the TPS calculation and delivery system, extra attention should be paid during the planning process. It is inappropriate to utilize calculation-based QA to predict the results of measurement-based QA since there is a poor correlation between the two. Furthermore, calculation-based QA outperforms measurement-based QA in identifying highly complex plans, which can further guide clinical QA process optimization and save limited clinical resources.

Optimal Fractionation and Timing of Weekly Cone-Beam CT in Daily Surface-Guided Radiotherapy for Breast Cancer

PURPOSE/OBJECTIVE(S)

SGRT has been demonstrated as a promising supplement to CBCT in adjuvant breast cancer radiotherapy, but a rational combination mode is lacking in clinical practice. The aim of this study was to explore this mode and investigate its impact on setup and dose accuracy.

MATERIALS/METHODS

Both daily SGRT and weekly CBCT images were acquired for 23 breast cancer patients receiving conventional fractionated radiotherapy after lumpectomy. Based on the scanning frequencies and time intervals of CBCT, sixteen modes were acquired by randomly selecting one (CBCT1), two (CBCTij), three (CBCTijk), four (CBCTijkl), and five (CBCT12345) images from the patient's off-line CBCT images for fusion with SGRT. Due to TPS system limitations, the 6D SGRT setup errors were transformed into 3D deviations in the translational directions, and the CTV-PTV margins, the dose coverage (V95%) of PTV and CTV, and the OAR doses (the ipsilateral lung's V5, V10, V20, and Dmean, the contralateral breast's V3 and Dmean, and the heart's Dmean and Dmax) were calculated based on the 3D deviations with different regions of interest (ROIs). Dose correlations between these modalities were investigated using Pearson and Spearman's methods.

RESULTS

For the ipsilateral breast ROI, the larger SGRT errors in the AP direction and higher target doses were found in all modes compared to the whole breast ROI (P < 0.05). In the ipsilateral ROI, the CTV-PTV margins decreased as CBCT frequencies increased, reaching approximately 5 mm for CBCTijkl and CBCT12345. The decline of Σ (systematic errors) was greater than the decline of σ (random errors), and it contributed more to the decline of margins. For the same frequency, the CBCT time intervals had essentially little influence on the errors and margins. Compared with other directions, the margins in the SI direction were the largest for all modes except for CBCT124 and CBCT125. The target dose correlations between all modes increased with increasing CBCT time intervals, decreased and then increased with increasing CBCT frequencies, with the turning point observed at week 5 of CBCT participation. The dose deviations in CBCT123, CBCT124, CBCT125, CBCTijkl, and CBCT12345 were minimal and not significantly different (P > 0.05). There was excellent agreement in CBCT124 vs. CBCT1234, and (CBCTijkl, CBCT12345) vs. CBCT125 in determining the classification for the percentage of PTV deviation (Kappa = 0.775-0.901). The frequencies and time intervals of CBCT had little effect on the OAR doses. For all modes, there were strong correlations (R > 0.9) in the OAR doses between different modes, except for the ipsilateral lung's V20 and Dmean (R = 0.734-0.987).

CONCLUSION

Based on weekly CBCT, these modes with the ipsilateral breast ROI and a combination of daily SGRT and CBCT frequencies of ≥ 3 were recommended, and the CBCT was required at weeks 1 and 2. Considering the additional radiation, time consumption, and expensive cost of CBCT, modes CBCT124 and CBCT125 could replace the modes with higher CBCT frequencies.

Complexity Metrics and Planning Dose-Based Pretreatment Patient-Specific Quality Assurance Prediction: Classification, Gamma Passing Rates, and DVH Deviation

PURPOSE/OBJECTIVE(S)

Patient-specific quality assurance (QA) prediction before treatment is beneficial to the clinical resource allocation and the dosimetric monitoring of the patient plans. The aim of this study is to investigate the potential of complexity metrics of radiotherapy plan and patient planning dose to predict QA result, gamma passing rates and dose-volume indices deviation.

MATERIALS/METHODS

Planning dose from treatment planning system (TPS), reconstructed dose from a vendor provided QA phantom and complexity metrics of the 499 radiotherapy plans of patients in our institution from March 2022 to September 2022 were used for methodology verification. Gamma passing rate (3%/2mm,10% threshold) 90% was regarded as criterion of QA pass or fail. A deep learning model ResNet-50 was modified to 3D dose processing and a multilayer perceptron (MLP) with three layers were adopted to extract features from 3D dose and 1D metrics in two parallel ways, then, the features were concatenate together to predict QA results. The dataset was split into 349 for train, 50 for validation and 100 for testing. Evaluation of predictions was based on absolute value deviation and area under the curves (AUC) of receiver operator characteristic (ROC) curve.

RESULTS

In this dataset, 71% (355/499) plans pass the pretreatment QA test. For QA passing prediction in 100 testing cases, the AUC of ROC could achieve 0.92. For gamma passing rates prediction, a mean absolute error (MAE) of 1.8% could be observed for cases with gamma passing rates bigger than 90%, and a MAE of 4.5% deviation could be observed for cases with gamma passing rates from 80% to 90%. For PTV ΔD95 (%) and PTV ΔHI (%), the MAE of prediction and ground truth is 1%. The model with only complexity metrics and only 3D dose could achieve the AUC of ROC 0.91 and 0.84, respectively.

CONCLUSION

The complexity metrics and 3D planning dose-based model could predict pretreatment patient specific QA results with high accuracy and the complexity metrics play a leading role in the model. Dose-volume metrics deviations of PTV could be predicted and more clinically useful information could be provided.

Feasibility of Using Pseudo-CT for Dosimetry, Radiomics, and Efficacy Assessment in IMRT/VMAT of Brain Tumors: A Multi-Omics Analysis

PURPOSE/OBJECTIVE(S)

Pseudo-CT generated by convolutional neural networks (CNN) and planning MRI has facilitated the promotion of MRI-Only. The technology not only reduces the time and money spent on CT scans, but also eliminates the cumbersome CT-MR registration. The feasibility in Stereotactic Brain Radiotherapy has been analyzed in previous studies by our team. However, when the prescribed requirements are not met, IMRT/VMAT are still selected. The study aims to evaluate the feasibility of pseudo-CT in IMRT/VMAT for brain cancer via the following 5 aspects: (1) image difference, (2) dose accuracy, (3) radiomics feature, (4) efficacy assessment, and (5) correlation analysis.

MATERIALS/METHODS

Brain tumor patients who had received radiotherapy at our institution and had planning MRI and CT were included in the study. Redesign of IMRT and VMAT radiotherapy plans according to 3 × 15Gy for each patient. Hounsfield unit (HU) values for PTV and OARs were used to assess image differences. And dose accuracy analysis contained a 2D dose volume histogram (DVH) metrics (Dmax, Dmean, D2%, D50%, D98%, HI, CI) and 3D gamma metrics (criteria: 1-3%/2mm, 1%/1mm, 10% threshold). Then 107 original image features of PTV and OARs were extracted for radiometry analysis. And tumor control probability (TCP) of PTV (Poisson model) and normal tissue complication probability (NTCP) of OARs (Lyman-Kutcher-Burman model) were used for the variance analysis of efficacy assessment. Wilcox-test was used for significance of differences test (0.05), and spearman correlation analysis was used to explore the key features of the dose bias.

RESULTS

A total of 42 patients were included, with 42 planning CTs and pseudo-CTs (mDixon-T1), and 38 pseudo-CTs (mDixon-T1-CE). The median volume of PTV was 4.1 cc (range 0.5-27.3), with no significant differences in HU, DVH, 3D gamma, and NTCP/TCP metrics. The median local gamma passing rates (1%/1mm) between planning CTs and pseudo-CTs (mDixon-T1) were 93.1% (range 65.5%-99.7%, IMRT) and 93.3% (range 63.9%-99.6%, VMAT). And more than 85% original radiomics features have significant difference. Further, the feature HU-Min was found to be more correlated with dose metrics in the correlation analysis. We speculate that it may be caused by the smoothing of the low frequency signal before outputting image. And since Shape_MeshVolume, Shape_VoxelVolume and PTV volume difference are highly correlated with dose deviation, it indicates that dose deviation affected by CT-MR registration.

CONCLUSION

This study has the potential to provide guidance for the clinical application of pseudo-CT in the MRI-Only workflow with IMRT/VMAT for brain tumors. These quantitative results strongly indicate pseudo-CT can be used as a substitute for the initial CT in IMRT/VMAT for small brain lesions (size <5 cm, numbers <5), but not for radiomics analysis. Additionally, the impact of inter-image differences on dose accuracy is less significant compared to the deviation caused by image registration.

Incidence and Risk Factors for Brain Metastases in Patients with Lung Cancer: A Systematic Review and Meta-Analysis

PURPOSE/OBJECTIVE(S)

Brain metastases (BM) are a very common metastatic site in lung cancer, but the exact rate of metastasis is still controversial. Risk factors for BM development are also largely lacking, hampering personalized treatment strategies. This study aimed to identify the incidence and possible risk factors for BM in lung cancer.

MATERIALS/METHODS

A systematic review, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide-lines, was conducted using PubMed, Medline databases and Cochrane Library databases from inception until February 2023. Two investigators independently searched and selected literature, included in randomized controlled trials and cohort studies. Heterogeneity was assessed using the χ2 test and the I2 statistic. Significant heterogeneity was indicated by P <0.05 in Cochrane Q tests and a ratio greater than 40% in I2 statistics. The review is registered on PROSPERO, number: CRD42022370173.

RESULTS

Forty-nine studies were included in the meta-analysis. The results showed that the incidence rate of BM in non-small cell lung cancer (NSCLC) was 0.24 (95% confidence interval [CI]: 0.23-0.25; I2 = 97.1%). The incidence rate in early NSCLC was 0.11 (95% CI: 0.10-0.13), locally advanced NSCLC was 0.32 (95% CI: 0.29-0.34), and advanced NSCLC was 0.37 (95% CI: 0.35-0.38). Lung adenocarcinoma was more prone to BM in NSCLC (risk ratio [RR] = 3.59, 95% CI: 1.97-6.54; P<0.001). The BM rate of NSCLC with EGFR mutation was also higher (hazard ratio [HR] = 1.49, 95% CI: 1.14-1.94; P = 0.004). Sex and smoking had no significant effect on the incidence of BM in NSCLC. Prophylactic Cranial Irradiation (PCI) could significantly reduce BM in NSCLC (HR = 0.36, 95% CI: 0.23-0.56; P<0.001), but chemotherapy had no obvious effect on decreasing the rate of BM (HR = 0.91, 95% CI: 0.54-1.54; P = 0.73). The incidence rate of BM in small cell lung cancer (SCLC) was 0.28 (95% CI: 0.27-0.30; I2 = 95.9%), and 0.23 (95% CI: 0.20-0.25) in the limited-stage SCLC. Older age (≥65) (HR = 0.70, 95% CI: 0.54-0.92; P = 0.01) were associated with less BM in SCLC. A higher T stage (≥T3) (HR = 1.72, 95% CI: 1.16-2.56; P = 0.007) was a significant risk factor for BM, while sex, smoking dose were not. PCI could also significantly decreased BM in SCLC (HR = 0.47, 95% CI: 0.38-0.58; P<0.001).

CONCLUSION

This study is the first meta-analysis of BM incidence rate in lung cancer, and further explores the factors affecting BM, providing some suggestions for clinical decision-making of BM prevention in patients with lung cancer.

Prediction Analysis of Dose Verification Based on Plan Complexity Metrics during Radiotherapy

PURPOSE/OBJECTIVE(S)

Plan validation in radiotherapy includes pre-treatment and in-treatment validation. It is feasible to leverage plan complexity to optimize validation processes, because some research reports that the consistency between planning and measurement or execution decreases as plan complexity increases. Therefore, starting from the plan complexity, this study comprehensively and systematically explores these factors affecting whether the plan verification is passed or not and the strength of their correlations, so as to establish a regression model and optimize the verification process.

MATERIALS/METHODS

The IMRT and model-based validation information were retrospectively collected for patients who received tumor radiotherapy at our institution from January 2020 to May 2022. The seventy-eight metrics characterizing the plan complexity were calculated and checked for each plan by an in-house developed computing platform. The comparisons of plan verification results under different tumor species and different verification methods were carried out, and the plan complexity metrics was also compared. Subsequently, Spearman correlation analysis between plan complexity and plan validation under different tumor species, different verification methods and different evaluation indexes was analyzed to provide the basis for regression analysis.

RESULTS

One thousand two hundred twenty-six patients were enrolled in the study. The plans in Eclipse TPS were performed by Varian Edge and iX linear accelerators and their verification were executed by EPID, Delat4, and ArcCheck. The gamma index under evaluation index of 3%/3mm, 3%/2mm, 2%/2mm, 1%/1mm were respectively 97.4% (7.1%), 94.8% (10.9%), 86.1% (20.1%), 50.7% (22.6%). The γ and DD of EPID and Detla4 decreased with the increase of TH, and the change of DD was the most significant, while the DTA of Detla4 did not change significantly with TH, and the passing rate of DTA and γ in thoracic and abdominal was the highest in ArcCheck group. Contrast and Variance were the most different between tumor types. The pelvic MIs and MIa were larger than those planned for the other three sites. Except for head and neck CLS and MD, other metrics did not vary significantly among tumor species. The correlation between the metrics characterizing the static characteristics of leaves was more significant for head and neck tumors; the correlation between metrics characterizing the flux complexity were significantly different in pelvic. There was a correlation between plan complexity and γ indicators, and the overall strength was ArcCheck > EPID > Delta4 for head and neck, Delta4 > EPID and ArcCheck for thorax-abdomen, Delta4 and EPID > ArcCheck for pelvic, Delta4 > ArcCheck > EPID for arms and legs.

CONCLUSION

There was a correlation between different plan complexity metrics. Based on this study, it is feasible to predict the verification results based on these complexity metrics, but the regression models were respectively established according to tumor types and validation methods.

[Construction of a schistosomiasis transmission risk assessment system in Wuhan City based on analytic hierarchy process]

OBJECTIVE

To construct a schistosomiasis transmission risk assessment system in Wuhan City and preliminary evaluate its application effect, so as to promote the rational allocation of schistosomiasis control resources and accelerate the progress towards schistosomiasis elimination.

METHODS

The schistosomiasis risk assessment indicators were collected through referring schistosomiasis surveillance data of Wuhan City from 2014 to 2020, literature review and expert interviews. Indicators within each criterion and sub-criterion were screened using the Delphi method, and a hierarchical structure model was created based on analytic hierarchy process. Quantitative assignment of each indicator was conducted according to relative importance, and the weight and combination weight of each criterion were calculated in each analytic hierarchy framework to create a schistosomiasis transmission risk assessment system, which was used for the schistosomiasis transmission risk assessment in 12 national schistosomiasis surveillance sites in Wuhan City.

RESULTS

A three-level schistosomiasis transmission risk assessment system was preliminarily constructed, which included a target layer, 5 criterion layers and 21 sub-criterion layers. Of all indicators in the criterion layer, transmission route had the highest weight (0.433), followed by source of Schistosoma japonicum infection (0.294); and among all indicators in the sub-criterion layer, S. japonicum infection in Oncomelania hupensis and sentinel mice had the highest combination weight (0.125), followed by prevalence of S. japonicum infection in humans (0.091) and bovines (0.053), snail control by chemical treatment (0.049), positive rate of inquiry examinations (0.048), allocation of schistosomiasis control professionals (0.045), and areas of submerged snail-infested settings (0.041). Of the 12 national schistosomiasis surveillance sites in Wuhan City, there were 5 sites with weights of > 0.8, 4 sites with weights of 0.6 to 0.8, and 3 sites with weights of < 0.6 in 2020.

CONCLUSIONS

A schistosomiasis transmission risk assessment system has been constructed based on analytic hierarchy process in Wuhan City, which may provide a evidence-based basis for health resource allocation and decision-making for schistosomiasis control.

Machine learning-powered, device-embedded heart sound measurement can optimize AV delay in patients with CRT

BACKGROUND

Continuous optimization of atrioventricular (AV) delay for cardiac resynchronization therapy (CRT) is mainly performed by electrical means.

OBJECTIVE

The purpose of this study was to develop an estimation model of cardiac function that uses a piezoelectric microphone embedded in a pulse generator to guide CRT optimization.

METHODS

Electrocardiogram, left ventricular pressure (LVP), and heart sounds were simultaneously collected during CRT device implantation procedures. A piezoelectric alarm transducer embedded in a modified CRT device facilitated recording of heart sounds in patients undergoing a pacing protocol with different AV delays. Machine learning (ML) was used to produce a decision-tree ensemble model capable of estimating absolute maximal LVP (LVPmax) and maximal rise of LVP (LVdP/dtmax) using 3 heart sound-based features. To gauge the applicability of ML in AV delay optimization, polynomial curves were fitted to measured and estimated values.

RESULTS

In the data set of ∼30,000 heartbeats, ML indicated S1 amplitude, S2 amplitude, and S1 integral (S1 energy for LVdP/dtmax) as most prominent features for AV delay optimization. ML resulted in single-beat estimation precision for absolute values of LVPmax and LVdP/dtmax of 67% and 64%, respectively. For 20-30 beat averages, cross-correlation between measured and estimated LVPmax and LVdP/dtmax was 0.999 for both. The estimated optimal AV delays were not significantly different from those measured using invasive LVP (difference -5.6 ± 17.1 ms for LVPmax and +5.1 ± 6.7 ms for LVdP/dtmax). The difference in function at estimated and measured optimal AV delays was not statiscally significant (1 ± 3 mm Hg for LVPmax and 9 ± 57 mm Hg/s for LVdP/dtmax).

CONCLUSION

Heart sound sensors embedded in a CRT device, powered by a ML algorithm, provide a reliable assessment of optimal AV delays and absolute LVPmax and LVdP/dtmax.

[Clinical characteristics of patients with rheumatic diseases and abnormal liver function]

Objective: To investigate the clinical characteristics of patients with rheumatic diseases and abnormal liver function, as well as determine the proportion and severity of liver function abnormalities. Methods: Cross-sectional study. Data were collected from patients registered in the Chinese Rheumatism Date Center from 2011 to 2021. The rheumatic diseases analyzed in this study were rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren syndrome (SS), ankylosing spondylitis (AS), and gout. Patient data, including demographic characteristics [ such as age, sex, body mass index,(BMI), and smoking history], liver function test results [including alanine aminotransferase (ALT), aspartate aminotransferase, alkaline phosphatase(ALP), and total bilirubin], and use of anti-rheumatic immune drugs and liver-protective drugs, were collected and compared between groups with normal and abnormal liver functions. In addition, the proportions of abnormal liver function were compared between sex and age groups. Results: A total of 116 308 patients were included in this study, including 49 659 with RA, 17 597 with SLE, 9 039 with SS, 11 321 with AS, and 28 692 with gout. The lowest proportion of liver function abnormalities was observed in patients with RA[11.02% (5 470/49 659)], followed by those with SS[17.97% (1 624/9 039)] and AS [18.22% (2 063/11 321) ], whereas patients with SLE [21.14% (3 720/17 597) ] and gout [28.73% (8 242/28 692)] exhibited the highest proportion of these abnormalities. Elevated ALT, mostly classified as grade 1, was the most commonly noted liver function abnormality, whereas elevated ALP was the least common. Some patients who took liver-protective drugs had normal liver function, with the lowest percentage observed in patients with gout [7.45% (36/483) ] and ranging from 21.7% to 30.34% in patients with RA, SLE, SS, and AS. The proportion of liver function abnormalities was higher in males than in females for all disease types [RA: 13.8%(1 368/9 906) vs. 10.3%(4 102/39 753); SLE: 33.6% (479/1 424) vs. 20.0% (3 241/16 173); SS: 25.4%(111/437) vs. 17.6%(1 513/8 602); AS: 20.1%(1 629/8 119) vs. 13.6% (434/3 202); and gout: 29.3% (8 033/27 394) vs. 16.1% (209/1 298)]. In RA, SLE, and AS, the proportions of liver function abnormalities were similar across all age groups. In SS, the proportion of liver function abnormalities increased with age [<40 years: 14.9%(294/1 979); 40-59 years: 18.1%(858/4 741); ≥60 years: 20.4%(472/2 319)], whereas a reversal of this trend was observed in gout [<40 years: 34.9%(4 294/12 320); 40-59 years: 25.5%(2 905/11 398);≥60 years: 21.0%(1 042/4 971)]. Conclusions: The proportions of combined liver function abnormalities in patients with rheumatologic diseases were high, and the utilization rates of liver-protective drugs were low. It is necessary to pay more attention to monitoring patients' liver function, timely administer liver-protective drugs, and optimize liver-protective regimens during the treatment of rheumatic diseases.

[Hereditary pulmonary hypertension family with BMPR2 gene variation: a case report and literature review]

Objective: To describe the clinical characteristics, diagnosis, genetic features and treatment of hereditary pulmonary hypertension complicated with suspected hereditary hemorrhagic telangiectasia (HHT). Methods: Firstly, we summarized and analyzed the clinical data of two cases of suspected HHT admitted to the Department of Pulmonary and Critical Care Medicine, the Second Xiangya Hospital, Central South University. Secondly, the genes of peripheral blood of patients and their families were completely sequenced and sanger sequencing was performed to verify the variation sites, and then the mRNA deletion caused by the variation was further verified. Thirdly, "HHT" "FPAH" and "BMPR2 gene variation" were used as keywords,and the related literatures of Wanfang database and PubMed database from January 2000 to November 2021 were searched and reviewed. Results: We found two patients in a family from Yiyang, Hunan province, who had symptoms of hemoptysis or pulmonary hypertension without epistaxis or other clinical features of HHT. However, both patients had pulmonary vascular abnormalities and pulmonary hypertension in their lungs. We found that BMPR2 gene variation (NM_001204.7:c.1128+1G>T) was positive and ENG, ACVRL1 and SMAD4 genes were negative. Family analysis and Sanger verification were carried out on 16 individuals in 4 generations of the family (7 of whom were found to carry the mutant gene), and then transcriptional level mRNA sequencing further confirmed that the variation resulted in the deletion of exon 8 and exon 9, and amino acid sequence estimation revealed that the amino acids of the protein from 323 to 425 were deleted. We thought that the incomplete translation of BMPR2 gene could lead to BMPRⅡ dysfunction. Therefore, it was diagnosed as hereditary pulmonary hypertension with suspected HHT. Both patients were suggested to reduce the pulmonary artery pressure, and at the same time, the whole-body imaging examination should be performed to screen other arteriovenous malformations, and the annual cardiac color Doppler ultrasound should be reviewed to evaluate the changes of pulmonary artery pressure. Conclusions: Hereditary pulmonary hypertension (HPAH) is a group of diseases with increasing pulmonary vascular resistance caused by genetic factors, including familial PAH and simple PAH. Variation in the BMPR2 gene is an important pathogenic factor of HPAH. Therefore, we should pay attention to the inquiry of family history when we clinically encounter young patients with pulmonary hypertension. If the cause is unknown, genetic testing is recommended. HHT is a rare autosomal dominant genetic disease. The possibility of this disease should be considered in clinical manifestations such as familial pulmonary vascular abnormality, pulmonary hypertension and recurrent epistaxis. There is no effective specific treatment for HPAH and HHT, which are treated symptomatically (including blood pressure reduction and hemostasis, etc.). It is suggested for these patients that pulmonary artery pressure should be dynamically monitored and have genetic counseling before giving birth.

[Development and validation of prognostic nomogram for malignant pleural mesothelioma]

Objective: To development the prognostic nomogram for malignant pleural mesothelioma (MPM). Methods: Two hundred and ten patients pathologically confirmed as MPM were enrolled in this retrospective study from 2007 to 2020 in the People's Hospital of Chuxiong Yi Autonomous Prefecture, the First and Third Affiliated Hospital of Kunming Medical University, and divided into training (n=112) and test (n=98) sets according to the admission time. The observation factors included demography, symptoms, history, clinical score and stage, blood cell and biochemistry, tumor markers, pathology and treatment. The Cox proportional risk model was used to analyze the prognostic factors of 112 patients in the training set. According to the results of multivariate Cox regression analysis, the prognostic prediction nomogram was established. C-Index and calibration curve were used to evaluate the model's discrimination and consistency in raining and test sets, respectively. Patients were stratified according to the median risk score of nomogram in the training set. Log rank test was performed to compare the survival differences between the high and low risk groups in the two sets. Results: The median overall survival (OS) of 210 MPM patients was 384 days (IQR=472 days), and the 6-month, 1-year, 2-year, and 3-year survival rates were 75.7%, 52.6%, 19.7%, and 13.0%, respectively. Cox multivariate regression analysis showed that residence (HR=2.127, 95% CI: 1.154-3.920), serum albumin (HR=1.583, 95% CI: 1.017-2.464), clinical stage (stage Ⅳ: HR=3.073, 95% CI: 1.366-6.910) and the chemotherapy (HR=0.476, 95% CI: 0.292-0.777) were independent prognostic factors for MPM patients. The C-index of the nomogram established based on the results of Cox multivariate regression analysis in the training and test sets were 0.662 and 0.613, respectively. Calibration curves for both the training and test sets showed moderate consistency between the predicted and actual survival probabilities of MPM patients at 6 months, 1 year, and 2 years. The low-risk group had better outcomes than the high-risk group in both training (P=0.001) and test (P=0.003) sets. Conclusion: The survival prediction nomogram established based on routine clinical indicators of MPM patients provides a reliable tool for prognostic prediction and risk stratification.

[Influence of muscle energy technology combined with Maitland joint mobilization surgery on the elbow joint flexion function in patients with deep burn of elbow joint]

Objective: To investigate the influence of muscle energy technology (MET) combined with Maitland joint mobilization surgery on the elbow joint flexion function in patients with deep burn of elbow joint. Methods: A retrospective controlled clinical trial was conducted. From January 2020 to January 2022, 53 patients with elbow joint flexion dysfunction after deep burns who met the inclusion criteria were treated in Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 32 males and 21 females, aged (37±12) years. According to the treatment method used, the patients were divided into conventional treatment alone group (15 cases), conventional treatment+joint mobilization surgery group (18 cases), and conventional treatment+joint mobilization surgery+MET group (20 cases). Before treatment and 2 months after treatment, the patient's elbow joint range of motion was measured using a protractor, the Mayo elbow joint function score was used to evaluate elbow joint function, a portable muscle strength tester was used to measure elbow extensor muscle strength, and visual analogue scale was used to evaluate pain degree. Data were statistically analyzed with one-way analysis of variance, least significant difference test, paired sample t test, Kruskal-Wallis H test, Wilcoxon signed rank-sum test, chi-square test, Fisher's exact probability test, and Bonferroni correction. Results: After two months of treatment, the elbow joint range of motion and elbow joint function scores of patients in conventional treatment+joint mobilization surgery group and conventional treatment+joint mobilization surgery+MET group ((103±12)° and 60 (50, 66), (131±14)° and 73 (65, 80)) were significantly larger and higher than those in conventional treatment alone group ((77±15)° and 45 (35, 50), P values all <0.05), respectively. The elbow joint range of motion and elbow joint function scores of patients in conventional treatment+joint mobilization surgery+MET group were significantly larger and higher than those in conventional treatment+joint mobilization surgery group (P values all <0.05), respectively. After two months of treatment, the elbow extensor muscle strength and pain score of patients in conventional treatment+joint mobilization surgery+MET group were respectively significantly larger and lower than those in conventional treatment alone group and conventional treatment+joint mobilization surgery group (P values all <0.05). The elbow extensor muscle strength and pain score of patients in conventional treatment+joint mobilization surgery group were similar to those in conventional treatment alone group (P>0.05). The elbow joint range of motion and elbow extensor muscle strength (with t values of 9.37, 25.54, 28.71, 6.70, 7.20, and 7.01, respectively, P<0.05), elbow joint function scores and pain scores (with Z values of 3.15, 3.63, 3.93, 3.30, 3.52, and 3.84, respectively, P<0.05) of patients in conventional treatment alone group, conventional treatment+joint mobilization surgery group, and conventional treatment+joint mobilization surgery+MET group after two months of treatment were significantly improved compared with those before treatment. Conclusions: The combination of MET and Maitland joint mobilization surgery can effectively improve elbow joint range of motion, elbow joint function, elbow extensor muscle strength, and pain of patients with deep elbow joint burns, therefore it is worthy of promotion.

Development and validation of a prediction model for unsuccessful treatment outcomes in patients with multi-drug resistance tuberculosis

BACKGROUND

The World Health Organization has reported that the treatment success rate of multi-drug resistance tuberculosis is approximately 57% globally. Although new drugs such as bedaquiline and linezolid is likely improve the treatment outcome, there are other factors associated with unsuccessful treatment outcome. The factors associated with unsuccessful treatment outcomes have been widely examined, but only a few studies have developed prediction models. We aimed to develop and validate a simple clinical prediction model for unsuccessful treatment outcomes in patients with multi-drug resistance pulmonary tuberculosis (MDR-PTB).

METHODS

This retrospective cohort study was performed between January 2017 and December 2019 at a special hospital in Xi'an, China. A total of 446 patients with MDR-PTB were included. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were used to select prognostic factors for unsuccessful treatment outcomes. A nomogram was built based on four prognostic factors. Internal validation and leave-one-out cross-validation was used to assess the model.

RESULTS

Of the 446 patients with MDR-PTB, 32.9% (147/446) cases had unsuccessful treatment outcomes, and 67.1% had successful outcomes. After LASSO regression and multivariate logistic analyses, no health education, advanced age, being male, and larger extent lung involvement were identified as prognostic factors. These four prognostic factors were used to build the prediction nomograms. The area under the curve of the model was 0.757 (95%CI 0.711 to 0.804), and the concordance index (C-index) was 0.75. For the bootstrap sampling validation, the corrected C-index was 0.747. In the leave-one-out cross-validation, the C-index was 0.765. The slope of the calibration curve was 0.968, which was approximately 1.0. This indicated that the model was accurate in predicting unsuccessful treatment outcomes.

CONCLUSIONS

We built a predictive model and established a nomogram for unsuccessful treatment outcomes of multi-drug resistance pulmonary tuberculosis based on baseline characteristics. This predictive model showed good performance and could be used as a tool by clinicians to predict who among their patients will have an unsuccessful treatment outcome.

Diabetes, Edentulism, and Cognitive Decline: A 12-Year Prospective Analysis

Diabetes mellitus (DM) is a recognized risk factor for dementia, and increasing evidence shows that tooth loss is associated with cognitive impairment and dementia. However, the effect of the co-occurrence of DM and edentulism on cognitive decline is understudied. This 12-y cohort study aimed to assess the effect of the co-occurrence of DM and edentulism on cognitive decline and examine whether the effect differs by age group. Data were drawn from the 2006 to 2018 Health and Retirement Study. The study sample included 5,440 older adults aged 65 to 74 y, 3,300 aged 75 to 84 y, and 1,208 aged 85 y or older. Linear mixed-effect regression was employed to model the rates of cognitive decline stratified by age cohorts. Compared with their counterparts with neither DM nor edentulism at baseline, older adults aged 65 to 74 y (β = -1.12; 95% confidence interval [CI], -1.56 to -0.65; P < 0.001) and those aged 75 to 84 y with both conditions (β = -1.35; 95% CI, -2.09 to -0.61; P < 0.001) had a worse cognitive function. For the rate of cognitive decline, compared to those with neither condition from the same age cohort, older adults aged 65 to 74 y with both conditions declined at a higher rate (β = -0.15; 95% CI, -0.20 to -0.10; P < 0.001). Having DM alone led to an accelerated cognitive decline in older adults aged 65 to 74 y (β = -0.09; 95% CI, -0.13 to -0.05; P < 0.001); having edentulism alone led to an accelerated decline in older adults aged 65 to 74 y (β = -0.13; 95% CI, -0.17 to -0.08; P < 0.001) and older adults aged 75 to 84 (β = -0.10; 95% CI, -0.17 to -0.03; P < 0.01). Our study finds the co-occurrence of DM and edentulism led to a worse cognitive function and a faster cognitive decline in older adults aged 65 to 74 y.

Dexmedetomidine for adult cardiac surgery: a systematic review, meta-analysis and trial sequential analysis

The effects of dexmedetomidine in adults undergoing cardiac surgery are inconsistent. We conducted a systematic review and meta-analysis to analyse the effects of peri-operative dexmedetomidine in adults undergoing cardiac surgery. We searched MEDLINE via Pubmed, EMBASE, Scopus and Cochrane for relevant randomised controlled trials between 1 January 1990 and 1 March 2022. We used the Joanna Briggs Institute methodology checklist to assess study quality and the GRADE approach to certainty of evidence. We assessed the sensitivity of results to false data. We used random-effects meta-analyses to analyse the primary outcomes: durations of intensive care and tracheal intubation. We included 48 trials of 6273 participants. Dexmedetomidine reduced the mean (95%CI) duration of intensive care by 5.0 (2.2-7.7) h, p = 0.001, and tracheal intubation by 1.6 (0.6-2.7) h, p = 0.003. The relative risk (95%CI) for postoperative delirium was 0.58 (0.43-0.78), p = 0.001; 0.76 (0.61-0.95) for atrial fibrillation, p = 0.015; and 0.49 (0.25-0.97) for short-term mortality, p = 0.041. Bradycardia and hypotension were not significantly affected. Trial sequential analysis was consistent with the primary meta-analysis. Adjustments for possible false data reduced the mean (95%CI) reduction in duration of intensive care and tracheal intubation by dexmedetomidine to 3.6 (1.8-5.4) h and 0.8 (0.2-1.4) h, respectively. Binary adjustment for methodological quality at a Joanna Briggs Institute score threshold of 10 did not alter the results significantly. In summary, peri-operative dexmedetomidine reduced the durations of intensive care and tracheal intubation and the incidence of short-term mortality after adult cardiac surgery. The reductions in intensive care stay and tracheal intubation may or may not be considered clinically useful, particularly after adjustment for possible false data.

Association between Elevated Magnesium Intake and Reduced Risk of Recurrent Falls and Frailty in Osteoarthritis: Data from the Osteoarthritis Initiative

OBJECTIVES

The objective of this 8-year follow-up study was to investigate the relationship between magnesium intake and frailty, as well as recurrent falls, in individuals diagnosed with Osteoarthritis (OA) or those at a heightened risk for developing the condition.

METHODS

This study utilized data from the Osteoarthritis Initiative (OAI) database and conducted a prospective cohort study with a 8-year follow-up period. Total magnesium intake from both food sources and supplements was assessed using a food frequency questionnaire (FFQ), while frailty and recurrent falls were evaluated through established criteria and self-report, respectively. To account for potential confounding factors, various covariates were considered, and statistical analyses, including generalized additive mixed models (GAMMs), were employed to examine the associations.

RESULTS

Among the 4,667 participants with OA, those with lower total magnesium intake were characterized by younger age, a higher proportion of African American individuals, higher body mass index (BMI), and lower dietary fiber intake (P<0.001). Notably, this group exhibited higher odds of experiencing recurrent falls and frailty (P = 0.034 and 0.006, respectively). Controlling for various factors, the GAMMs consistently revealed negative correlations between magnesium intake and the likelihood of frailty and recurrent falls, with each 1 mg/1000 kcal increase in magnesium intake associated with a 0.5% reduced frailty risk (p < 0.001) and a 0.2% decreased risk of recurrent falls (p = 0.001). Subgroup analyses suggested that increased total magnesium intake from both food sources and supplements may exert a more pronounced preventive effect on recurrent falls and frailty in men, older adults, individuals with normal BMI, and those with higher dietary fiber intake.

CONCLUSIONS

Elevated total magnesium intake from both food sources and supplements was found to be associated with a decreased risk of recurrent falls and frailty in individuals diagnosed with OA or those at risk of developing the condition. These findings imply that increased total magnesium intake might be beneficial in managing the risk of these outcomes, particularly within specific subgroups, including men, older adults, those with a normal BMI, and those with higher dietary fiber intake.

Heart sound-derived systolic time intervals for atrioventricular delay optimization in cardiac resynchronization therapy

BACKGROUND

Phonocardiography (PCG) can be used to determine systolic time intervals (STIs) from ventricular pacing spike to the first heart sound (VS1) and from the first to the second heart sound (S1S2).

OBJECTIVE

The purpose of this study was to investigate the relations between STIs and hemodynamics during atrioventricular (AV) delay optimization of biventricular pacing (BiVP) in animals and patients.

METHODS

Five pigs with AV block underwent BiVP, while PCG was collected from an epicardial accelerometer. In 21 patients undergoing cardiac resynchronization therapy device implantation, PCG was recorded with a pulse generator-embedded microphone. Optimal AV delays derived from shortest VS1 and longest S1S2 were compared with AV delays derived from highest left ventricular pressure (LVP), maximal rate of rise in LVP, and stroke work.

RESULTS

In pigs, VS1 and S1S2 predicted the AV delays with optimal hemodynamics (highest LVP, maximal rate of rise in LVP, and stroke work) by a median error of 2-28 ms, resulting in a median loss of <2% of pump function. In patients, VS1 and S1S2 predicted the optimal AV delay by errors of 32.5 and 37.5 ms, respectively, resulting in 0.2%-0.9% lower LVP and stroke work, which were reduced to 21 and 24 ms in 8 patients with a full-capture AV delay of >180 ms.

CONCLUSION

During BiVP with varying AV delays, close relations exist between PCG-derived STIs and hemodynamic parameters. AV delays advised by PCG-derived STIs cause only a minimal loss of pump function compared with those based on invasive hemodynamic measurements.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01832493.

[Comparison of the effects of self-made three-dimensional printed assistant tableware and traditional universal cuff assistant tableware in patients with upper limb dysfunction after burn injury]

Objective: To compare the effects of self-made three-dimensional (3D) printed assistant tableware (hereinafter referred to as 3D assistive device) and traditional universal cuff assistant tableware (hereinafter referred to as universal cuff) on the voluntary eating function of patients with upper limb dysfunction after burns. Methods: The prospective self-control study was conducted. From March 2020 to June 2021, 18 patients with upper limb dysfunction after moderate to severe burns who met the inclusion criteria were admitted to Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 15 males and 3 females, aged 21-58 (42±11) years. After using the 3D software and 3D printer to customize 3D assistive devices for patients, the patients were instructed to eat with the 3D assistive devices and the universal cuff on alternate days for 14 consecutive days, each for 7 days. During this time, the patients could also be fed by someone else without using the assistive device. The number of times the patients ate regular meals with each assistive device and the proportion of them to the total number of regular meals ate during the 7 days to which they belonged were counted. After the total use of two assistive devices for 14 days (hereinafter referred to as after use of 14 days), the amount and time of transferring liquid using the two assistive devices of patients were measured; the patients' feeding items in the modified Barthel index (MBI) were scored respectively when eating without the assistive device, with the 3D assistive device, or with the universal cuff; the satisfaction degree of feeding when eating without the assistive device, with the 3D assistive device, or with the universal cuff was evaluated using the 5-grade Likert scale. Data were statistically analyzed with paired sample t test, Wilcoxon signed rank sum test, and chi-square test. Results: The number of the patients ate regular meals with the 3D assistive device during the 7 days was (18.1±2.0) times, which was significantly more than (4.0±2.0) times with the universal cuff (t=53.72, P<0.01). The proportion of the number of the patients ate regular meals with the 3D assistive device to the total number of regular meals ate during the 7 days to which it belonged was 72.4% (325/449), which was significantly higher than 16.7% (72/431) with the universal cuff (χ2=257.36, P<0.01). After use of 14 days, the patients' time and amount of transferring liquid using the 3D assistive device were respectively significantly shorter and more than using the universal cuff (with t values of 2.49 and 7.52, respectively, P<0.05 or P<0.01). The patients' MBI feeding scores when eating with the 3D assistive device and with the universal cuff were close (P>0.05), which were both significantly higher than the score when eating without the assistive device (with Z values of 3.90 and 3.86, respectively, P<0.01).The patients' satisfaction scores of feeding when eating with the 3D assistive device and with the universal cuff were close (P>0.05), which were both significantly higher than the score when eating without the assistive device (with Z values of 3.61 and 3.00, respectively, P<0.01). Conclusions: Both the 3D assistive device and the universal cuff can compensate the limb function of patients with upper limb dysfunction after burns and improve their self-feeding ability, but the 3D assistive device has more advantages in improving patients' willingness to eat and the efficiency of food transfer.

Experimental evaluation and structure-activity relationship analysis of bridged-ring terpenoid derivatives as novel Blattella germanica repellent

Cockroaches are urban pests that are very difficult to control. Using repellents is a green, safe and effective strategy for their control. In order to find novel cockroach repellents, the repellent activity of 45 bridged-ring terpenoid derivatives synthesized from β-pinene against Blattella germanica was tested. The relationship between the molecular structure of these bridged-ring terpenoid derivatives and their repellent activity against Blattella germanica was also analysed. The results show that some of the bridged-ring terpenoid derivatives exhibit good repellent activity against Blattella germanica, and six compounds (RR = 60.44-87.32%) show higher repellent activity against Blattella germanica than DEET (RR = 54.77%), making them promising for development as new cockroach repellents. Quantitative structure-activity relationship (QSAR) analysis revealed that the HOMO-1 energy, Kier and Hall index (order 2), Balaban index, and relative positive charged surface area of bridged-ring terpenoid derivatives have effects on repellent activity against Blattella germanica. The present study may provide a theoretical basis for the high-value use of β-pinene and can be helpful to the development of novel repellents against Blattella germanica.

Association between phonocardiography and echocardiography in heart failure patients with preserved ejection fraction

Aims

Heart failure with preserved ejection fraction (HFpEF) is associated with stiffened myocardium and elevated filling pressure that may be captured by heart sound (HS). We investigated the relationship between phonocardiography (PCG) and echocardiography in symptomatic patients suspected of HFpEF.

Methods and results

Consecutive symptomatic patients with sinus rhythm and left ventricular ejection fraction >45% were enrolled. Echocardiography was performed to evaluate the patients' diastolic function, accompanied by PCG measurements. Phonocardiography features including HS amplitude, frequency, and timing intervals were calculated, and their abilities to differentiate the ratio between early mitral inflow velocity and early diastolic mitral annular velocity (E/e') were investigated. Of 45 patients, variable ratio matching was applied to obtain two groups of patients with similar characteristics but different E/e'. Patients with a higher E/e' showed higher first and second HS frequencies and more fourth HS and longer systolic time intervals. The interval from QRS onset to first HS was the best feature for the prediction of E/e' > 9 [area under the curve (AUC): 0.72 (0.51-0.88)] in the matched patients. In comparison, N-terminal pro-brain natriuretic peptide (NT-proBNP) showed an AUC of 0.67 (0.46-0.85), a value not better than any PCG feature (P > 0.05).

Conclusion

Phonocardiography features stratify E/e' in symptomatic patients suspected of HFpEF with a diagnostic performance similar to NT-proBNP. Heart sound may serve as a simple non-invasive tool for evaluating HFpEF patients.

[Effects of p16/pRb and JNK signaling pathways in hydroquinone-induced malignant transformation of TK6 cells]

Objective: To investigate the cell cycle and apoptosis in hydroquinone (HQ) -induced malignant transformation of TK6 cells and its related regulatory mechanisms. Methods: TK6 cells were exposed to 20 μmol/L HQ, 24 h/time, once a week, for 19 weeks as experimental group and TK6 cells treated with phosphate buffer (PBS) for 19 weeks was used as control group from March 2014. In regulatory mechanism research, the cells were divided into four groups: control group, experimental group, control inhibitor group and experimental inhibitor group (inhibitor groups were added 10 μmol/L P600125) . Cell cycle and apoptosis were detected by flow cytometry. The protein expression of cell cycle-related proteins and JNK signaling pathway proteins were detected by Western blot. Results: Flow cytometry showed that compared with control group, the ratio of cells in the G0/G1 phase of the experimental group was significantly decreased (P=0.001) , and the ratio of cells in the S phase was significantly increased (P=0.002) . Western blotting demonstrated that the protein expressions of p-Rb (Ser780) , E2F1, Cyclin D1, p-p16 (Ser152) , JNK1, p-JNK1 (Thr183/Tyr185) , c-jun, p-c-jun (Ser63) (P=0.015, 0.021, 0.001, 0.001, 0.005, 0.001, 0.039, 0.003) were up-regulated, while the protein expressions of Rb (P=0.048) and p16 (P=0.002) were significantly down-regulated. After exposed to SP600125, compared with experimental group, there were no significant changes in cell cycle distribution (P=0.946) and apoptosis rate (P=0.923) in experimental inhibitor group. The expression of c-jun (P=0.040) protein was down-regulated, while the expression of Rb (P=0.027) protein was up-regulated in experimental inhibitor group. Conclusion: In HQ-induced TK6 cells malignant transformation, the cell cycle is arrested in the S phase, and the p16/pRb signaling pathway is inhibited, while the JNK signaling pathway is activated. However, the activated JNK signaling pathway may not be involved in the regulation of cell cycle.

Hemodynamics-driven mathematical model of third heart sound generation

The proto-diastolic third heart sound (S3) is observed in various hemodynamic conditions in both normal and diseased hearts. We propose a novel, one-degree of freedom mathematical model of mechanical vibrations of heart and blood that generates the third heart sound, implemented in a real-time model of the cardiovascular system (CircAdapt). To examine model functionality, S3 simulations were performed for conditions mimicking the normal heart as well as heart failure with preserved ejection fraction (HFpEF), atrioventricular valve regurgitation (AVR), atrioventricular valve stenosis (AVS) and septal shunts (SS). Simulated S3 showed both qualitative and quantitative agreements with measured S3 in terms of morphology, frequency, and timing. It was shown that ventricular mass, ventricular viscoelastic properties as well as inflow momentum play a key role in the generation of S3. The model indicated that irrespective of cardiac conditions, S3 vibrations are always generated, in both the left and right sides of the heart, albeit at different levels of audibility. S3 intensities increased in HFpEF, AVR and SS, but the changes of acoustic S3 features in AVS were not significant, as compared with the reference simulation. S3 loudness in all simulated conditions was proportional to the level of cardiac output and severity of cardiac conditions. In conclusion, our hemodynamics-driven mathematical model provides a fast and realistic simulation of S3 under various conditions which may be helpful to find new indicators for diagnosis and prognosis of cardiac diseases.

Smartphone as an electronic stethoscope: factors influencing heart sound quality. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022;3:473-480. [PMID: 36712168 PMCID: PMC9708017 DOI: 10.1093/ehjdh/ztac044]

Aims

Smartphones are equipped with a high-quality microphone which may be used as an electronic stethoscope. We aim to investigate the factors influencing quality of heart sound recorded using a smartphone by non-medical users.

Methods and results

An app named Echoes was developed for recording heart sounds using iPhone. Information on phone version and users' characteristics including sex, age, and body mass index (BMI) was collected. Heart sound quality was visually assessed and its relation to phone version and users' characteristics was analysed. A total of 1148 users contributed to 7597 heart sound recordings. Over 80% of users were able to make at least one good-quality recording. Good-, unsure- and bad-quality recordings amounted to 5647 (74.6%), 466 (6.2%) and 1457 (19.2%), respectively. Most good recordings were collected in the first three attempts of the users. Phone version did not significantly change the users' success rate of making a good recording, neither was sex in the first attempt (P = 0.41) or the first three attempts (P = 0.21). Success rate tended to decrease with age in the first attempt (P = 0.06) but not the first three attempts (P = 0.70). BMI did not significantly affect the heart sound quality in a single attempt (P = 0.73) or in three attempts (P = 0.14).

Conclusion

Smartphone can be used by non-medical users to record heart sounds in good quality. Age may affect heart sound recording, but hardware, sex, and BMI do not alter the recording.

[Comparison of the anesthetic effects of mivacurium and cisatracurium besylate in laser laryngeal microsurgery]

Objective: To compare the anesthetic effects of mivacurium and cisatracurium besylate in laser laryngeal microsurgery, and to provide clinical evidence and reference for further optimization of muscle relaxation application. Methods: From October 2021 to January 2022, fifty-six patients of Beijing Tongren Hospital, Capital Medical University, scheduled for laser laryngeal microsurgery with general anesthesia, were enrolled. These patients, aged 18-65 years old, 25 males and 31 females, were divided into two groups (n=28) by random number table method. Cisatracurium besylate group (group C): cisatracurium besylate was injected at 0.1 mg/kg. Normal saline was continuously infused during operation. Mivacurium group (group M):Mivacurium was injected at 0.25 mg/kg and continuously infused at 0.3 mg·kg^-1·h^-1 during operation.The intubation time, the extubation time, recovery index, Cooper's score, Cormack-Lehane grade, surgical condition grade, postoperative residual neuromuscular block and allergic related adverse events were compared between the two groups. Results: The intubation time and the extubation time of group M were (3.7±1.1) and (16.2±5.0) min, which were statistically significant shorter than those of group C (4.9±0.7) and (26.4±8.6) min (all P<0.05). The recovery indexes of the patients in group M and group C were (4.5±3.4) and (6.2±5.0) min. The Cooper's scores of the two groups were both 9(9, 9). The Cormack-Lehane grades of the two groups were all grade Ⅰ. The number of cases with good/excellent surgical condition grades in group M and group C were 5/23 and 0/28. There were no significant differences in recovery index, Cooper's score, Cormack-Lehane grades and surgical condition grades between the two groups (all P>0.05). The TOF ratio of group M in the post anesthesia care unit (PACU) was (95.7±2.6) %, which was significantly higher than (92.9±3.9) % of group C(P=0.015). There were no significant differences in MAP and HR between the two groups at different time points (all P>0.05). The incidence of skin flushing in group M and group C was 10.7% (3/28) and 0, and the difference was not statistically significant (P=0.074). There were no cases of severe hypotension, significantly elevated airway pressure or airway spasm in both groups. Conclusion: In laser laryngeal microsurgery, compared with cisatracurium besylate, mivacurium has shorter intubation time and extubation time, stable hemodynamics, no significant increase in allergic related adverse events. mivacurium is safe and effective.

Left Ventricular Pressure Estimation Using Machine Learning-Based Heart Sound Classification

Objective

A method to estimate absolute left ventricular (LV) pressure and its maximum rate of rise (LV dP/dtmax) from epicardial accelerometer data and machine learning is proposed.

Methods

Five acute experiments were performed on pigs. Custom-made accelerometers were sutured epicardially onto the right ventricle, LV, and right atrium. Different pacing configurations and contractility modulations, using isoflurane and dobutamine infusions, were performed to create a wide variety of hemodynamic conditions. Automated beat-by-beat analysis was performed on the acceleration signals to evaluate amplitude, time, and energy-based features. For each sensing location, bootstrap aggregated classification tree ensembles were trained to estimate absolute maximum LV pressure (LVPmax) and LV dP/dtmax using amplitude, time, and energy-based features. After extraction of acceleration and pressure-based features, location specific, bootstrap aggregated classification ensembles were trained to estimate absolute values of LVPmax and its maximum rate of rise (LV dP/dtmax) from acceleration data.

Results

With a dataset of over 6,000 beats, the algorithm narrowed the selection of 17 predefined features to the most suitable 3 for each sensor location. Validation tests showed the minimal estimation accuracies to be 93% and 86% for LVPmax at estimation intervals of 20 and 10 mmHg, respectively. Models estimating LV dP/dtmax achieved an accuracy of minimal 93 and 87% at estimation intervals of 100 and 200 mmHg/s, respectively. Accuracies were similar for all sensor locations used.

Conclusion

Under pre-clinical conditions, the developed estimation method, employing epicardial accelerometers in conjunction with machine learning, can reliably estimate absolute LV pressure and its first derivative.

[A prospective randomized controlled study on the effects of bicycle ergometer rehabilitation training on quadriceps and walking ability of patients with lower limb dysfunction caused by extensive burns]

Objective: To explore the effects of bicycle ergometer rehabilitation training on quadriceps and walking ability of patients with lower limb dysfunction caused by extensive burns. Methods: A prospective randomized controlled study was conducted. A total of 40 patients with extensive burns who met the inclusion criteria and were admitted to Tongren Hospital of Wuhan University＆Wuhan Third Hospital from December 2017 to December 2020 were selected. According to the random number table, the patients were divided into conventional training group (16 males, 4 females, aged (45±10) years) and combined training group (13 males, 7 females, aged (39±8) years). Patients in conventional training group were given conventional rehabilitation therapy such as joint loosening, lower limb strength training, walking training, and pressure therapy, while patients in combined training group were given additional bicycle ergometer rehabilitation training on the basis of conventional rehabilitation. For patients in the 2 groups before and after a 2-month's treatment, the thickness of quadriceps was measured by ultrasonic diagnostic instrument, the muscle strength of quadriceps was measured by portable muscle strength tester, the walking ability was tested with a 6-min and a 10-meter walk tests, and the patients' satisfaction for treatment effects was assessed using the modified Likert scale. Data were statistically analyzed with independent or paired sample t test, Mann-Whitney U test, Wilcoxon signed rank test, or chi-square test. Results: After 2-month's treatment, the quadriceps thickness of patients in combined training group was (3.76±0.39) cm, which was significantly thicker than (3.45±0.35) cm in conventional training group (t=2.67, P<0.05); quadriceps thickness of patients in conventional training group and combined training group after 2-month's treatment was significantly thicker than that before treatment (with t values of 5.99 and 8.62, respectively, P<0.01). After 2-month's treatment, the quadriceps muscle strength of patients in combined training group was significantly greater than that in conventional training group (Z=2.69, P<0.01); quadriceps muscle strength of patients in conventional training group and combined training group after 2-month's treatment was significantly greater than that before treatment (with Z values of 3.92 and 3.92, respectively, P<0.01). After 2-month's treatment, the 6-min walking distance of patients in combined training group was (488±39) m, which was significantly longer than (429±25) m in conventional training group (t=5.66, P<0.01); the 6-min walking distance of patients after 2-month's treatment in conventional training group and combined training group was significantly longer than that before treatment (with t values of 13.16 and 17.92, respectively, P<0.01). After 2-month's treatment, the 10-meter walking time of patients in combined training group was significantly shorter than that in conventional training group (t=3.20, P<0.01); and the 10-meter walking time in conventional training group and combined training group was significantly shorter than that before treatment (with t values of 7.21 and 13.13, respectively, P<0.01). The patients' satisfaction score for treatment effects in combined training group was significantly higher than that in conventional training group (Z=3.14, P<0.01), and the patients' satisfaction scores for treatment effects in conventional training group and combined training group after 2-month's treatment were significantly greater than those before treatment (with Z values of 3.98 and 4.04, respectively, P<0.01). Conclusions: Bicycle ergometer rehabilitation training can be used to improve quadriceps thickness, muscle strength, and walking ability of patients with lower limb dysfunction caused by extensive burns. It can also improve the satisfaction of patients with the treatment outcome, and therefore is worthy of promotion.