An autologous duraplasty in situ technique in the treatment of Chiari malformation Type I: a prospective study

OBJECTIVE

Our study aims to prospectively compare an autologous duraplasty in situ technique (IS group) with the synthetic dural graft duraplasty (SDG group) to clarify the effectiveness and superiority of the former in the treatment of patients with Chiari malformation type 1 (CM-I).

METHOD

29 patients with CM-I were randomly assigned to either IS or SDG group. In both groups, a dissection from the occipital bone was performed. All procedures were performed by the same surgeon. The two duraplasty methods were compared in terms of surgical factors and complications. Data analysis was done for the baseline material, the neurological outcome and MRI-documented syrinx size at the 6 month follow-up.

RESULT

29 patients were enrolled in this study, 14 in the IS group and 15 in the SDG group. The results showed no significant difference in operation time (P = 0.916), amount of bleeding (P = 0.120), operation complications, hospitalization time (P = 0.854) and prognosis between the two groups. The hospitalization cost of IS group was 15,125 yuan less than that of SDG group (P < 0.05).

CONCLUSION

The autogenous duraplasty in situ technique is a novel, simple, effective and economical surgical management for patients with CM-I.

The value of T2-weighted MRI contrast ratio combined with DWI in evaluating the pathological grade of solid lung adenocarcinoma

AIM

To assess the predictive value of T2-weighted (T2W) magnetic resonance imaging (MRI) in combination with diffusion-weighted imaging (DWI) for determining the pathological grading of solid lung adenocarcinoma.

MATERIALS AND METHODS

The clinical and imaging data from 153 cases of solid lung adenocarcinoma (82 men, 71 women, mean age 63.2 years) confirmed at histopathology in The First Affiliated Hospital of Xi'an Jiaotong University from January 2017 to May 2022 were analysed retrospectively. Adenocarcinomas were classified into low-grade (G1 and G2) and high-grade (G3) groups following the 2020 pathological grading system proposed by the International Association for the Study of Lung Cancer. The T2-weighted contrast ratio (T2CR), calculated as the T2 signal intensity of the lung mass/nodule divided by the T2 signal intensity of the right rhomboid muscle was utilised. Two experienced radiologists reviewed the MRI images independently, measured the T2CR, and obtained apparent diffusion coefficient (ADC) values. The Mann-Whitney U-test was used to compare general characteristics (sex, age, maximum diameter), T2CR, and ADC values between the low-grade and high-grade groups. The non-parametric Kruskal-Wallis test determined differences in T2CR and ADC values among the five adenocarcinoma subtypes. Receiver characteristic curve (ROC) analysis, along with area under the curve (AUC) calculation, assessed the effectiveness of each parameter in distinguishing the pathological grade of lung adenocarcinoma. A Z-test was used to compare the AUC values.

RESULTS

Among the 153 patients with adenocarcinoma, 103 had low-grade adenocarcinoma, and 50 had high-grade adenocarcinoma. The agreement between T2CR and ADC observers was good (0.948 and 0.929, respectively). None of the parameters followed a normal distribution (p<0.05). The ADC value was lower in the high-grade adenocarcinoma group compared to the low-grade adenocarcinoma group (p=0.004), while the T2CR value was higher in the high-grade group (p=0.011). Statistically significant differences were observed in maximum diameter and gender between the two groups (p<0.001 and p=0.005, respectively), while no significant differences were noted in age (p=0.980). Among the five adenocarcinoma subtypes, only the lepidic and micropapillary subtypes displayed statistical differences in ADC values (p=0.047), with the remaining subtypes showing no statistical differences (p>0.05). The AUC values for distinguishing high-grade adenocarcinoma from low-grade adenocarcinoma were 0.645 for ADC and 0.627 for T2CR. Combining T2CR, ADC, sex, and maximum diameter resulted in an AUC of 0.778, sensitivity of 70%, and specificity of 75%. This combination significantly improved diagnostic efficiency compared to T2CR and ADC alone (p=0.008, z = 2.624; p=0.007, z = 2.679).

CONCLUSION

The MRI quantitative parameters are useful for distinguishing the pathological grades of solid lung adenocarcinoma, offering valuable insights for precise lung cancer treatment.

Longitudinal evaluation of cervical length and shear wave elastography in women with spontaneous preterm birth

OBJECTIVES

To compare longitudinal changes in cervical length (CL) and mean cervical shear wave elastography (CSWE) scores between women with singleton and twin pregnancies who experience spontaneous preterm birth (sPTB) and those who have term births (TB).

METHODS

This was a prospective longitudinal study of 1264 unselected women with singleton (n=1143) and twin (n=121) pregnancy attending a dedicated research clinic for screening of sPTB at 4 timepoints during pregnancy including 11-15+6 (visit 1), 16-20+6 (visit 2), 21-24+6 (visit 3) and 28-32+6 (visit 4) weeks of gestation. At each visit, a transvaginal ultrasound scan was conducted to measure the CL and the CSWE scores from six regions of interest (ROI) (inner, middle, and external parts of anterior and posterior lips) in the cervix. The mean of CSWE scores from the six ROIs were calculated for data analysis. Log10 transformation was applied to make the data Gaussian prior to statistical analysis. A multilevel mixed-effects analysis was performed to compare CL and CSWE longitudinally between sPTB and TB groups.

RESULTS

A total of 57 (4.99%) singleton pregnancies and 33 (27.27%) twin pregnancies were complicated with sPTB. Women with sPTB had shorter CL across gestation when controlling for history of cervical surgery, number of fetuses, gestational age at cervical assessment (GA), and the interaction between GA and sPTB. CL in the sPTB group was significantly lower than that of the TB group at 21-24+6 weeks (p=0.039) and 28-32+6 weeks (p<0.001). Twin pregnancies had significantly longer CL throughout pregnancy, compared to singleton pregnancies (coefficient=0.01864, p<0.001). Furthermore, after adjusting for maternal age, weight, height, body mass index (BMI), and GA, CSWE scores in sPTB group were significantly lower in the sPTB group across gestation, compared to the TB group (1.28265 vs 1.32832; p=0.013). However, in the individual visit analysis, CSWE scores in the sPTB group were significantly lower than that of the TB group only at 11-15+6 weeks (p=0.013). There was no difference in CSWE scores between singleton and twin pregnancies throughout pregnancy (coefficient=-0.00128, p=0.937).

CONCLUSION

Women with sPTB have shorter CL and softer cervix across gestation when compared to those with TB. In the individual visit analysis, the reduction in CL in the sPTB group occurs from late second trimester onwards, while the reduction in cervical stiffness in the sPTB group is observed primarily in the first trimester. Additionally, our study has found that CL is significantly shorter in singleton pregnancies compared to twin pregnancies, while cervical stiffness does not differ between the two types of pregnancy. Our findings indicate that the cervix tends to undergo a softening process prior to shortening in the sPTB cases This article is protected by copyright. All rights reserved.

Critical Values of Daily Sedentary Time and Its Longitudinal Association with Mild Cognitive Impairment Considering APOE ε4: A Prospective Cohort Study

BACKGROUND

Long sedentary time and physical inactivity are negatively related to cognition, but the cut-off value remains unclear, and apolipoprotein E polymorphism ε4 (APOE ε4) is a known genetic risk factor of mild cognitive impairment (MCI).

OBJECTIVES

To explore longitudinal association of sedentary time and MCI, and to identify a cutoff value that increases the risk of developing MCI, taking into account APOE ε4 stratification and its interactions.

DESIGN

A prospective cohort study.

SETTING

Population-based study.

PARTICIPANTS

We included 4932 older adults from Tianjin Elderly Nutrition and Cognition (TENC) cohort study recruited from March 2018 to June 2021 with 3.11 years of median follow-up time.

MEASUREMENTS

The primary outcome was newly diagnosed MCI, which was diagnosed by a modified version of the Petersen's criteria. The information of sedentary time (hours/day) and physical activity (MET-h/week) were obtained by questionnaire. Cox proportional hazard regression models and restricted spline curve were conducted.

RESULTS

A total of 4932 participants were included (mean [SD] age, 67.85 [4.96] years; 2627 female [53.3%] and 2305 male [46.7%]), 740 newly onset MCI patients were identified. Longer sedentary time was associated with higher risk of MCI for all participants (HR:1.069, 95%CI: 1.034, 1.105), especially in APOE ε4 non-carriers (HR:1.083, 95%CI: 1.045, 1.123) whether adjusted potential confounders. Sedentary time had synergistic interactions with APOE ε4 (β:1.503, 95%CI: 1.163, 1.942) and physical activities (β: 1.495, 95%CI: 1.210, 1.846). Restricted spline curve showed a cut-off value of 3.03 hours/day.

CONCLUSIONS

Long sedentary time (≥3.03 hours/day) could increase MCI risk, especially in APOE ε4 non-carriers, people with higher PA, aged 65 and above.

Recent advances in the management of postmenopausal women with non-atypical endometrial hyperplasia

Non-atypical endometrial hyperplasia is a benign disease without significant somatic genetic changes. Postmenopausal women with non-atypical endometrial hyperplasia have a significant risk of progression to endometrial cancer and persistent endometrial hyperplasia. Most cases of atypical endometrial hyperplasia in postmenopausal women are treated surgically, including hysterectomy. At present, the treatment of postmenopausal women with non-atypical endometrial hyperplasia is still controversial. Correct and timely diagnosis and treatment are of great significance to prevent progression of the lesion. This study mainly provides an updated synthesis of the literature that investigates the etiology, diagnosis and treatment of postmenopausal women with non-atypical endometrial hyperplasia. As of December 2022, a literature search related to postmenopausal non-atypical endometrial hyperplasia was conducted on the PubMed database. For most postmenopausal patients with non-atypical endometrial hyperplasia, regular re-examination should be performed during conservative treatment. For postmenopausal patients with endometrial cancer risk factors, persistent non-atypical endometrial hyperplasia or progesterone contraindications, hysterectomy and bilateral salpingo-oophorectomy should be the first choice.

[Evaluation of the efficacy and safety of Nocardia rubra cell wall skeleton immunotherapy for cervical high-risk HPV persistent infection]

Objective: To evaluate the efficacy and safety of Nocardia rubra cell wall skeleton (Nr-CWS) in the treatment of persistent cervical high-risk human papillomavirus (HR-HPV) infection. Methods: A randomized, double blind, multi-center trial was conducted. A total of 688 patients with clinically and pathologically confirmed HR-HPV infection of the cervix diagnosed in 13 hispital nationwide were recruited and divided into: (1) patients with simple HR-HPV infection lasting for 12 months or more; (2) patients with cervical intraepithelial neoplasia (CIN) Ⅰ and HR-HPV infection lasting for 12 months or more; (3) patients with the same HR-HPV subtype with no CINⅡ and more lesions after treatment with CINⅡ or CIN Ⅲ (CINⅡ/CIN Ⅲ). All participants were randomly divided into the test group and the control group at a ratio of 2∶1. The test group was locally treated with Nr-CWS freeze-dried powder and the control group was treated with freeze-dried powder without Nr-CWS. The efficacy and negative conversion rate of various subtypes of HR-HPV were evaluated at 1, 4, 8, and 12 months after treatment. The safety indicators of initial diagnosis and treatment were observed. Results: (1) This study included 555 patients with HR-HPV infection in the cervix (included 368 in the test group and 187 in the control group), with an age of (44.1±10.0) years. The baseline characteristics of the two groups of subjects, including age, proportion of Han people, weight, composition of HR-HPV subtypes, and proportion of each subgroup, were compared with no statistically significant differences (all P>0.05). (2) After 12 months of treatment, the effective rates of the test group and the control group were 91.0% (335/368) and 44.9% (84/187), respectively. The difference between the two groups was statistically significant (χ²=142.520, P<0.001). After 12 months of treatment, the negative conversion rates of HPV 16, 18, 52, and 58 infection in the test group were 79.2% (84/106), 73.3% (22/30), 83.1% (54/65), and 77.4% (48/62), respectively. The control group were 21.6% (11/51), 1/9, 35.1% (13/37), and 20.0% (8/40), respectively. The differences between the two groups were statistically significant (all P<0.001). (3) There were no statistically significant differences in vital signs (body weight, body temperature, respiration, pulse rate, systolic blood pressure, diastolic blood pressure, etc.) and laboratory routine indicators (blood cell analysis, urine routine examination) between the test group and the control group before treatment and at 1, 4, 8, and 12 months after treatment (all P>0.05); there was no statistically significant difference in the incidence of adverse reactions related to the investigational drug between the two groups of subjects [8.7% (32/368) vs 8.0% (15/187), respectively; χ²=0.073, P=0.787]. Conclusion: External use of Nr-CWS has good efficacy and safety in the treatment of high-risk HPV persistent infection in the cervix.

[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.

[Comparative analysis of clinical diagnosis application of two intrauterine adhesion scoring criteria]

Objective: To explore the similarities and differences of China Society of Gynecology Endoscopy (CSGE) and American Fertility Society (AFS) intrauterine adhesion (IUA) scoring criteria on IUA grading and their predictive value of reproductive prognosis. Methods: From January 2016 to January 2019, a total of 1 249 patients were diagnosed with IUA by hysteroscopy at Beijing Obstetrics and Gynecology Hospital. Totally, 378 patients with complete clinical data were enrolled, and the results diagnosed by CSGT and AFS scoring criteria were compared and analyzed.And follow-up for 2 years, the pregnancy rate and live birth rate were statistical analysis. Results: (1) The grade of IUA according to AFS and CSGE scoring criteria was less consistent (κ=0.295, P<0.001). Compared with AFS, the proportion of severe IUA cases diagnosed by CSGE was significantly lower [45.8% (173/378) vs 15.1% (57/378); RR=0.22, 95%CI: 0.15-0.30, P<0.01); the proportions of both mild and moderate IUA cases were significantly higher (RR=4.16, 95%CI: 2.38-7.14; RR=2.38, 95%CI: 1.75-3.23; both P<0.01). (2) The pregnancy rates of mild, moderate and severe IUA diagnosed according to CSGE were 11/13, 64.5% (147/228), 31.8% (7/22), live birth rates were 11/13, 54.8% (125/228) and 22.7% (5/22), respectively; there were statistically significant differences between the groups (all P<0.01). The pregnancy rates of mild, moderate and severe IUA diagnosed based on AFS were 3/3, 66.9% (97/145) and 56.5% (65/115), respectively, with no statistically significant difference between the groups (P>0.05). (3) IUA grades based on both CSGE and AFS criteria were significantly negatively correlated with pregnancy rates and live birth rates (CSGE: r=-0.210, r=-0.226; AFS: r=-0.130, r=-0.147; all P<0.05). Univariate logistic regression analysis showed that CSGE had higher OR for both pregnancy rates and live birth rates compared to AFS (3.889 vs 1.657, 3.983 vs 1.554, respectrvely). Conclusions: Compared with AFS, the IUA grade based on CSGE is better related with reproductive prognosis, suggesting that the CSGE standard might be more objective and comprehensive and has better predictive value for reproductive prognosis, thus avoiding overdiagnosis and overtreatment.

DNA methylation and waist-to-hip ratio: an epigenome-wide association study in Chinese monozygotic twins

PURPOSE

Epigenetic signatures such as DNA methylation may be associated with specific obesity traits. We performed an epigenome-wide association study (EWAS) by combining with the waist-to-hip ratio (WHR)-discordant monozygotic (MZ) twin design in an attempt to identify genetically independent DNA methylation marks associated with abdominal obesity in Northern Han Chinese and to determine the causation underlying.

METHODS

A total of 60 WHR discordant MZ twin pairs were selected from the Qingdao Twin Registry, China. Generalized estimated equation (GEE) model was used to regress the methylation level of CpG sites on WHR. The Inference about Causation through Examination of FAmiliaL CONfounding (ICE FALCON) was used to assess the temporal relationship between methylation and WHR. Gene expression analysis was conducted to validate the results of differentially methylated analyses.

RESULTS

EWAS identified 92 CpG sites with the level of P < 10^- 4 which were annotated to 32 genes, especially CADPS2, TUSC5, ZCCHC14, CORO7, COL23A1, CACNA1C, CYP26B1, and BCAT1. ICE FALCON showed significant causality between DNA methylation of several genes and WHR (P < 0.05). In region-based analysis, 14 differentially methylated regions (DMRs) located at 15 genes (slk-corrected P < 0.05) were detected. The gene expression analysis identified the significant correlation between expression levels of 5 differentially methylated genes and WHR (P < 0.05).

CONCLUSIONS

Our study identifies the associations between specific epigenetic variations and WHR in Northern Han Chinese. These DNA methylation signatures may have value as diagnostic biomarkers and provide novel insights into the molecular mechanisms of pathogenesis.

P11.75.B Survival benefit of radiotherapy and surgery in patients with lung cancer brain metastases with poor prognosis factors

Background

Radiotherapy and surgery are the standard treatments for lung cancer brain metastases (BMs). However, limitted studies focused on the treatments for patients with lung cancer BMs with poor prognosis factors. The purpose of this study was to investigate the effects of radiotherapy and surgery in patients with lung cancer BMs with poor prognosis factors, providing reference for clinical strategies.

Material and Methods

We analyzed retrospectively 714 patients with lung cancer BMs. A 1:1 propensity score matching (PSM) was performed to balance potential confounders. Analyses of overall survival (OS) and risk factors for OS were assessed by log-rank test and Cox proportional hazard model.

Results

Age ≥65 years, Karnofsky Performance Scale (KPS) score ≤70, anaplastic large-cell lymphoma kinase (ALK)/epidermal growth factor receptor (EGFR) wild type, extracranial metastases, non-surgery and non-radiotherapy led to poor prognosis. Patients were stratified according to these factors. Radiotherapy and surgery showed no survival benefit in patients with aged ≥65 years or pretreatment KPS score ≤70 before and after PSM. Before PSM, whole brain radiotherapy (WBRT) improved the OS and predicted good prognosis in patients with ALK/EGFR wild type or extracranial metastases. WBRT also predicted good prognosis in patients with non-surgery. Stereotactic radiosurgery (SRS) improved the OS and predicted good prognosis in patients with ALK/EGFR wild type or non-surgery. WBRT plus SRS improved the OS and predicted good prognosis in patients with extracranial metastases or non-surgery. WBRT plus SRS also predicted good prognosis in patients with ALK/EGFR wild type. Surgery improved the OS and predicted good prognosis in patients with non-radiotherapy. After PSM, SRS improved the OS and predicted good prognosis in patients with non-surgery. WBRT plus SRS improved the OS and predicted good prognosis in patients with non-surgery or extracranial metastases. WBRT plus SRS also predicted good prognosis in patients with ALK/EGFR wild type. Surgery improved the OS of patients with non-radiotherapy. We defined that the treatment would provide significant survival benefit if it both prolonged the OS and predicted good prognosis. Meanwhile, the results after PSM were more convincing than the results before PSM.

Conclusion

Radiotherapy has significant survival benefit in patients with lung cancer BMs with poor prognosis factors, including patients with ALK/EGFR wild type or extracranial metastases or non-surgery. Surgery only has significant survival benefit in patients with non-radiotherapy.

MRI-based radiomics analysis in differentiating solid non-small-cell from small-cell lung carcinoma: a pilot study

AIM

To investigate the ability of a T2-weighted (W) magnetic resonance imaging (MRI)-based radiomics signature to differentiate solid non-small-cell lung carcinoma (NSCLC) from small-cell lung carcinoma (SCLC).

MATERIALS AND METHODS

The present retrospective study enrolled 152 eligible patients (NSCLC = 125, SCLC = 27). All patients underwent MRI using a 3 T scanner and radiomics features were extracted from T2W MRI. The least absolute shrinkage and selection operator (LASSO) logistic regression model was used to identify the optimal radiomics features for the construction of a radiomics model to differentiate solid NSCLC from SCLC. Threefold cross validation repeated 10 times was used for model training and evaluation. The conventional MRI morphology features of the lesions were also evaluated. The performance of the conventional MRI morphological features, and the radiomics signature model and nomogram model (combining radiomics signature with conventional MRI morphological features) was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Five optimal features were chosen to build a radiomics signature. There was no significant difference in age, gender, and the largest diameter. The radiomics signature and conventional MRI morphological features (only pleural indentation and lymph node enlargement) were independent predictive factors for differentiating solid NSCLC from SCLC. The area under the ROC curves (AUCs) for MRI morphological features, and the radiomics model, and nomogram model was 0.69, 0.85, and 0.90 (ROC), respectively.

CONCLUSIONS

The T2W MRI-based radiomics signature is a potential non-invasive approach for distinguishing solid NSCLC from SCLC.

The Etiology of Chest Pain in Children Admitted to Cardiology Clinics and the Use Echocardiography to Screen for Cardiac Chest Pain in Children

AIMS

Chest pain is a common disease in children. Most cardiac specialists use echocardiography to evaluate the etiology of and screen for children's cardiac chest pain. We analyzed the etiology and echocardiography results of children with chest pain in pediatric cardiology clinics, clarified the disease spectrum and evaluated the diagnostic value of echocardiography in screening cardiac chest pain in children.

METHODS AND RESULTS

The clinical data of children with chest pain aged younger than 18 years who admitted to the pediatric cardiology clinic of Beijing Anzhen Hospital between 2005 and 2019 were analyzed. The patients were divided into three groups, including the preschool group, the school-age group and the adolescent group. Total 3,477 children were enrolled in this study. 232 (6.7%) patients were caused by cardiac diseases and chest pain was of non-cardiac origin in 3,245 patients (93.3%). The incidence of non-cardiac chest pain in the adolescent group was significantly lower than the other two groups, respectively (91.4 vs. 94.9 vs. 94.3%, P < 0.05). In the preschool group, most of the patients were girls (51.4%), while in the school-age group and the adolescent group, most of the patients were boys (P < 0.05). Among the children (n = 3,205) who underwent echocardiography, 108 children had positive results, and 3,097 children had negative results. Among the 108 positive results, 10 cases of cardiac diseases were related to chest pain. The sensitivity, specificity of echocardiography in the diagnosis of cardiac chest pain were 6.7, and 96.9%, while the positive predictive value and negative predictive value was 12.96 and 93.67%, respectively.

CONCLUSION

In children with chest pain who are admitted to pediatric cardiology clinics, chest pain is mostly benign and rarely due to cardiac diseases. The use of echocardiography in evaluating cardiac chest pain in children is of little diagnostic value and leads to excess costs for patients and the health care system.

Myocardial Infarction Is Associated With Increased Stroke Severity, In-Hospital Mortality, and Complications: Insights From China Stroke Center Alliance Registries

Background

Prior studies have shown an increased risk of ischemic stroke (IS) after myocardial infarction (MI); however, there are limited studies concerning the characteristics, in‐hospital mortality, and complications of patients with IS with a medical history of MI. We hypothesized that patients with IS with a medical history of MI may experience more severe strokes and have a higher risk of in‐hospital mortality and complications than patients with IS without a medical history of MI.

Methods and Results

Consecutive in‐hospital data were extracted from the China Stroke Center Alliance database from August 2015 to July 2019. Patient characteristics, hospital tests, in‐hospital mortality, and complications were analyzed and compared in patients with IS with or without a history of MI. Of 893 429 patients with IS, we identified 81 646 (9.1%) patients with a history of MI (MI group). Compared with patients with IS without MI, MI group patients were older, had a lower prevalence of current smoking, had a higher prevalence of a relative medical history, and took more medications before admission. Compared with the group with IS without MI, the MI group had a higher National Institute of Health Stroke Scale score after onset (4.0 versus 3.0; Hodges‐Lehmann estimator, 22.5) and a higher proportion of severe strokes (National Institute of Health Stroke Scale score ≥15) (7.1% versus 4.4%; absolute standardized difference=11.6%). In the fully adjusted models, the risk of in‐hospital mortality was higher in the MI group (odds ratio [OR], 1.74; 95% CI, 1.57–1.92; P<0.0001). MI group patients also had a higher risk of complications, including urinary tract infection (OR, 1.28; 95% CI, 1.2–1.36; P<0.0001), gastrointestinal bleeding (OR, 1.29; 95% CI, 1.19–1.39; P<0.0001), pneumonia (OR, 1.24; 95% CI, 1.21–1.28; P<0.0001), depression (OR, 1.33; 95% CI, 1.24–1.42; P<0.0001), seizure (OR, 1.35; 95% CI, 1.22–1.49; P<0.0001), atrial fibrillation (OR, 1.78; 95% CI, 1.71–1.86; P<0.0001), and cardiac or respiratory arrest (OR, 1.98; 95% CI, 1.78–2.2; P<0.0001).

Conclusions

Patients with IS with a medical history of MI have an increased risk of severe stroke, in‐hospital mortality, and complications. Studies exploring the underlying mechanisms are needed to improve and tailor stroke treatment strategies.

Primary central nervous system ALK-negative anaplastic large cell lymphoma: a case report and literature review

Primary central nervous system anaplastic lymphoma kinase (ALK)-negative anaplastic large cell lymphoma (ALCL) is an extremely rare type of primary central nervous system lymphoma (PCNSL). There are only nine cases reported in the literature to date, most of which have an overall survival time of no more than 8 months. Herein, we report such a rare case who has a good outcome with the longest survival time and perform a review of the literature. A 19-year-old male patient was admitted to the hospital complaining of dizziness. CT and MRI imaging showed a heterogeneous enhanced lesion in the left parieto-occipital lobe and the leptomeninges of the occipital lobe and the cerebellum. The lesion was resected and confirmed to be ALK-negative ALCL by pathological examination. Then, the patient received 10 cycles of chemotherapy with high-dose methotrexate (HD-MTX) and whole-brain radiotherapy. The patient recovered well and was regularly followed up. He was free of symptoms without recurrence on imaging examination 3 years later. ALCL is a rare type of PCNSL. HD-MTX combined with radiation is an effective therapeutic approach. However, further prospective studies with a large number of patients are needed to identify the biological characteristics of this rare type of PCNSL.

Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage

Background: The ideal treatment for patients who survive from acute vertebrobasilar artery occlusion but develop aggressive ischemic events despite maximal medical therapy in the early non-acute stage is unknown. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion.

Methods: Ten consecutive patients who presented with aggressive ischemic events in the early non-acute stage of intracranial vertebral artery occlusion from Jan 2015 to Nov 2020 were retrospectively reviewed. Among them, eight male and two female patients with a mean age of 66.7 years developed aggressive ischemic events, and the NIHSS score was elevated by a median of 7 points despite medical therapy. All patients received staged endovascular treatment 4–21 days from onset, at an average of 11 days. The strategy of staged treatment was as follows: first, a microwire was passed through the portion of the occlusion, which was then dilated with balloon inflation to maintain the perfusion above TICI grade 2b. Then, with the use of antiplatelet drugs, the residual intravascular thrombus was gradually eliminated by the continuous perfusion and an activated fibrinolytic system, leaving the residual stenosis. A second stage of angioplasty with stent implantation was subsequently performed if residual stenosis was ≥50%. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period.

Results: Technical success was achieved in 9 patients who received staged endovascular treatment (perforation occurred in one patient during the first stage). The NIHSS scores were significantly improved, with a median score 7 points lower on discharge compared with the scores for the most severe status. Favorable outcomes with mRS score ≤ 2 were achieved in 7 and 9 patients at the 3-month follow-up and the latest follow-up, respectively, which was better than the preoperative status.

Conclusion: Staged endovascular treatment might be a safe, efficient, and viable option in carefully selected patients with symptomatic intracranial vertebral artery occlusion in the early non-acute stage. However, this needs to be confirmed by further investigation, preferably in a large, controlled setting.

Thirty-Day and One-Year Outcomes of Endovascular Treatments for Severe Atherosclerotic Stenosis of Intracranial ICA: Results From a Single Center

Background: Endovascular treatment for intracranial atherosclerotic stenosis (ICAS) has been developed. However, the intracranial internal carotid artery (ICA) presents a particular challenge due to the location and tortuous route, and the outcomes of endovascular treatment in patients with stenosis of the intracranial ICA still have not been reported. This article retrospectively investigated the 30-day and 1-year outcomes of tailored endovascular treatment for patients with severe intracranial ICA stenosis from a single center. Methods: Between June 2014 and December 2017, 96 consecutive patients with severe atherosclerotic stenosis (70-99%) of the intracranial ICA were managed with endovascular treatment in Beijing Tiantan Hospital. Three different kinds of treatments [angioplasty with balloon dilatation alone (BD group), balloon-mounted stent (BMS group), and self-expanding stent (SES group)] were performed according to the characteristics of the lesions. The primary endpoints included any stroke or death within 30 days and ipsilateral ischemic stroke afterwards within 1 year. Secondary endpoints included the revascularization success rate (residual stenosis <30%) and the restenosis rate (stenosis ≥ 50%) within 1 year. Results: The 30-day death rate was 0, and the stroke rate of all patients was 7.3% (7/96). The stroke rate was higher in the BD group (15.8%) and SES group (9.8%) than in the BMS group (0%) (p = 0.047). Thirteen (13.5%) patients suffered at least one onset of ischemic stroke in the ipsilateral ICA territory within 1 year, and there was no significant difference among the three groups (p = 0.165). The overall revascularization success rate was 93.8%, and the revascularization success rate was significantly higher in the SES group (100%) than in the BD group (78.9%) (p = 0.006). The restenosis rate of all patients within 12 months was 20.8%, and there was no significant difference among the three groups. Patients with Mori type C target lesions were more likely to suffer stroke within 30 days (25%) and restenosis within 1 year (31.3%). Conclusions: Both the 30-day and 1-year outcomes of tailored endovascular treatments seemed to be acceptable in the treatment of symptomatic atherosclerotic stenosis of the intracranial ICA. However, this needs to be confirmed by further investigation, preferably in large multicenter randomized controlled clinical trials.

Dural arteriovenous fistula, a rare cause of rapidly progressive dementia in a patient with bilateral thalamic lesions: a case report

There are many causes of bilateral thalamic lesions, but few cases of dural arteriovenous fistula (DAVF) associated with such lesions have been reported previously. Here, we describe an adult man with reversible rapid progressive dementia (RPD) in whom bilateral thalamic lesions were caused by a DAVF that had six supply arteries and drained into both the venous sinus and cortical veins. A 53-year-old man presented with memory decline and abnormal behavior. Head computed tomography (CT) revealed insignificant low density in the bilateral thalami and high density in the right occipital lobe. Brain magnetic resonance imaging showed hyperintensities in the thalami on T2-weighted images. Magnetic resonance venogram revealed no sign of the straight sinus, but multiple tortuous vessels in the cistern of the vein of Galen. Digital subtraction angiography revealed DAVFs near the tentorium cerebelli draining into the vein of Galen, which caused the vasogenic oedema of the thalami. The patient was then treated by transarterial embolization of the feeders. He gradually recovered after the surgery. RPD with bithalamic lesions caused by DAVF is rare but reversible. Therefore, the early recognition and intervention of DAVFs is crucial for the good prognosis of patients so that fistulas can be embolized in time.

Superficial siderosis of the central nervous system with epilepsy originating from traumatic cervical injury: illustrative case

BACKGROUND

Superficial siderosis of the central nervous system (SSCNS) is a rare condition that results from hemosiderin deposition in the brain, brainstem, cerebellum, and spinal cord as a result of chronic, repeated, and recurrent subarachnoid hemorrhage. SSCNS that originates in the spinal cord is rarely reported, and epilepsy as a manifestation of such a case has not been reported before.

OBSERVATIONS

The authors reported a rare case of SSCNS with epilepsy originating from traumatic cervical injury and presented a literature review of all reported SSCNS cases that originated in the spine. The patient was a 29-year-old man with a 16-year history of progressive headache accompanied by seizures, ataxia, and sensorineural hearing loss. He had experienced a traumatic cervical injury at age 7. Magnetic resonance imaging revealed a characteristic hypointense rim around the pons and cervical spinal cord on susceptibility-weighted imaging scans. Cerebrospinal fluid examination during a headache episode confirmed subarachnoid hemorrhage and increased intracranial pressure. Surgical exploration revealed a C6 dural defect with bone spurs inserted into the dura mater. After the patient underwent dura mater repair and shunt implantation, his symptoms disappeared completely except for hearing loss.

LESSONS

This rare case indicated that symptomatic epilepsy followed by SSCNS can be eliminated by complete repair of the cervical dura mater.

Case Report: Multi-Orifices Vertebral Arteriovenous Fistula With Severe Scoliosis in Neurofibromatosis Type 1: Might Be a Congenital Disease With Mesodermal Dysplasia

Background: Vertebral arteriovenous fistula (AVF) associated with neurofibromatosis type 1 (NF-1) is a rare condition in the previous reports. However, whether vertebral AVF in NF-1 is congenital or NF-1 disease progression hasn't been clarified. Case Description: We reported a 48-year-old male case of vertebral AVF simultaneously combined with thoracic scoliosis and NF-1. Preoperative CT angiography showed the AVF with multiple orifices located on the vessel wall of the vertebral artery, which was proved during the procedure of endovascular treatment. By occluding the parent vertebral artery, the AVF was finally cured. Further whole-exome sequencing identified a novel germline heterozygous point nonsense mutation, c.G397T(p.E133X), in the NF1(NM_000267) gene exon4. Conclusions: From this patient, we speculate that vertebral AVF associated with NF-1 might be a congenital disease as a manifestation of mesodermal dysplasia.

Whether Intracranial Aneurysm Could Be Well Treated by Flow Diversion: A Comprehensive Meta-Analysis of Large-Sample Studies including Anterior and Posterior Circulation

BACKGROUND

Flow diversion (FD) has become a widely adopted treatment method for intracranial aneurysms in the clinic, but a comprehensive meta-analysis of large-sample studies including anterior and posterior circulation is still lacking.

METHODS

The PubMed, Embase, Web of Science, and Cochrane databases were searched between January 1, 2008, and December 1, 2019. A random-effect model was used to calculate the efficacy and safety data as well as 95% confidence intervals (CIs).

RESULTS

The pooled sample size of all included studies was 6695 patients; the mean age was 55.5 years old, with a total of 7406 aneurysms. For efficacy, the complete occlusion rate in angiographic follow-up (AFU) at 6 months was 78% (95% CI, 0.77, 0.80), and the AFU rate at 6-12 months was 90% (95% CI, 0.88, 0.92). For safety, the hemorrhagic event rate was 2%, the ischemic event rate was 5%, and the mortality rate was 3%.

CONCLUSION

FD is an effective and safe treatment for intracranial aneurysm with high complete occlusion rate and acceptable complication rate.

The Causes of Chest Pain in Children and the Criteria for Targeted Myocardial Enzyme Testing in Identifying the Causes of Chest Pain in Children

Aims: Chest pain is a common complaint at pediatric cardiology clinics and often leads to an extensive cardiac evaluation. In this study, we analyzed the causes of chest pain in Chinese children and developed diagnostic procedures and criteria for targeted myocardial enzyme testing. Methods and Results: We retrospectively analyzed the clinical data of patients aged below 18 years visiting our hospital for chest pain between 2005 and 2019. Based on auxiliary exams and clinical diagnosis, we developed diagnostic procedures and criteria for targeted myocardial enzyme testing in children with chest pain. A total of 7,251 children were included in this study. The chest pain was of cardiac origin in 581 patients (8.0%). The incidence of non-cardiac chest pain was significantly higher in the preschool group and the school-age group than in the adolescent group (93.5 vs. 93.8 vs. 90.3%, P < 0.05). Among children with cardiac chest pain, the most common concomitant symptom was chest tightness (67.0%). Myocardial enzyme testing was performed in 5,408 patients and was abnormal in 453 patients. We developed a diagnostic procedure and criteria for targeted myocardial enzyme testing using pertinent history, physical examination, and ECG findings or UCG finding. Applying the diagnostic procedure and criteria could lead to the reduction in myocardial enzyme testing while still capturing all cardiac diagnoses. Conclusion: In children, chest pain is mostly benign and rarely cardiac. During diagnosis, targeted myocardial enzyme testing based on medical history and physical examination can effectively reduce resource use.

[Expression and significance of chemokine CXCL12 and receptor CXCR4 in adenomyosis]

Objective: To observe the expression, correlation and significance of chemokine (C-X-C motif) ligand 12 (CXCL12) and chemokine (C-X-C motif) receptor 4 (CXCR4) in endometrium and myometrium of adenomyosis. Methods: Totally 38 patients were selected in this study, who underwent hysterectomy for adenomyosis at Beijing Obstetrics and Gynecology Hospital from October 2017 to December 2018 as the adenomyosis group, and, in the same period, selected 31 patients with cervical intraepithelial neoplasia Ⅲ or cervical cancer undergoing hysterectomy served as control group. The expression levels of mRNA and protein for CXCL12, CXCR4 in the endometrium and myometrium of the two groups were detected by immunohistochemistry and real-time PCR. Results: (1) The protein levels of CXCL12 and CXCR4 in endometrium in uterus with adenomyosis (0.229±0.025 and 0.226±0.016) were significantly higher than those in endometrium in uterus without adenomyosis (0.153±0.018 and 0.178±0.026); compared with each other, the differences were statistically significant (all P<0.05). And the expressions of CXCL12 and CXCR4 proteins in uterine myometrium of adenomyosis were 0.222±0.045 and 0.126±0.058, respectively, which were higher than those in the control group (0.091±0.029 and 0.099±0.020); compared with each other, the differences were statistically significant (all P<0.05). (2) The expression levels of CXCL12 and CXCR4 mRNA in endometrium of patients with adenomyosis were 6.31±0.12 and 8.49±0.21, respectively, which were higher than those in the control group (1.23±0.10 and 1.36±0.13); compared with each other, the differences were statistically significant (all P<0.05). Moreover, the expression levels of CXCL12 and CXCR4 mRNA in myometrium of patients with adenomyosis were 9.11±0.12 and 8.45±0.16, respectively, which were higher than those in the control group (1.18±0.08 and 1.46±0.13); compared with each other, the differences were statistically significant (all P<0.05). (3) In endometrium and myometrium of uterus with adenomyosis, CXCL12 and CXCR4 mRNA expression levels were positively associated (r=0.478, 0.542, all P<0.05). Conclusions: The levels of CXCL12 and CXCR4 in the endometrium and myometrium of adenomyosis are increased and positively correlated. The two chemokine may be involved in the development of adenomyosis.

Ependymomas of Filum Terminale: Clinical Characteristics and Surgical Management of 5 Patients

OBJECTIVE

To retrospective review a series of patients with ependymomas of filum terminale (FTEs) who underwent microsurgical resection and had long-term follow-up.

METHODS

Five adults with FTEs were surgically treated and enrolled in the study. Clinical manifestations, imaging data, intraoperative findings, and postoperative outcome were recorded.

RESULTS

Six FTEs were discovered on preoperative lumbar magnetic resonance imaging, with 1 rare case of a single FTE accompanied by a neurofibroma. Gross total resection was achieved in all patients; en bloc excision was carried out in 2 patients for 2 FTEs and 1 neurofibroma, while piecemeal resection was done in 3 patients for 4 FTEs. Most preoperative symptoms were relieved soon after surgery; 1 patient with urination difficulty achieved complete recovery 1 year postoperatively. Tumor recurrence was found in 1 patient 54 months after her first surgery.

CONCLUSIONS

FTEs are rare subdural extramedullary tumors. Patients usually present initially with back and leg pain. Elaborate microsurgical manipulations and intraoperative electrophysiologic monitoring are helpful in ensuring satisfactory excision and neurological prognosis. Regular long-term follow-up is recommended for all postoperative patients.

Biological and clinical impact of central nervous system hemangioblastomas in Chinese patients with von Hippel-Lindau disease: implications for treatment

Objective

Central nervous system (CNS) hemangioblastomas (HGBs) are the most frequent cause of mortality in patients with von Hippel-Lindau (VHL) genetic syndrome. However, there is a lack of large studies on the clinical features and optimal management of HGBs in Chinese patients.

Methods

VHL-related HGB cases treated surgically at our hospital from 2012 to 2019 were evaluated. Patients and family members meeting the clinical diagnostic criteria underwent genetic testing. Clinical, genetic and relevant imaging data were analyzed.

Results

Eighty-five VHL patients from 34 pedigrees in 16 Chinese provinces who underwent 121 operations for CNS HGBs were enrolled. Multiple operations were associated with a younger age at first operation (OR = 0.926, 95% CI = 0.871–0.985, P = 0.014, threshold: 27.5, sensitivity: 72.2%, specificity: 71.2%) and a longer postoperative period (OR = 1.096, 95% CI = 1.015–1.184, P = 0.019, threshold: 10.5, sensitivity: 66.7%, specificity: 76.3%). The age at first operation was younger in children than in their parents (23 pairs, P < 0.001). The age at first operation was younger in siblings born later than in those born earlier (10 pairs, P = 0.01). Most untreated tumors (98.2%) remained relatively stable during follow-up (range, 0.5–7; median, 2). However, new tumors continued to emerge (0.14 tumor/year).

Conclusion

VHL-associated CNS HGB is a long-term chronic disease with repeated attacks, likely with genetic anticipation in Chinese pedigrees. When the age at first operation is under 27.5 years, or the postoperative period is longer than 10.5 years, the risk of multiple operations is increased. While most unresected HGBs remain stable after surgery, new tumors may still slowly emerge; hence, scheduled follow-ups are necessary.

Incidence, Prognostic Factors and Survival for Hemangioblastoma of the Central Nervous System: Analysis Based on the Surveillance, Epidemiology, and End Results Database

Background

Hemangioblastomas are uncommon, benign neoplasms of the central nervous system (CNS). This study aims to evaluate the incidence, demographics, clinical characteristics, and prognosis of CNS hemangioblastomas using the data from the Surveillance, Epidemiology, and End Results (SEER) Program.

Methods

Univariate and multivariate analyses using the Cox proportional hazards model were employed to identify prognostic factors of overall survival. The Kaplan-Meier method was utilized to evaluate overall survival distribution by treatment modality. A nomogram was further built to predict survival at 3 and 5 years.

Results

The overall incidence rate of CNS hemangioblastomas was 0.141 per 100,000 person-years. Through univariate analysis and multivariate analyses, age between 60 and 79 years (HR = 3.697, p < 0.001), age greater than 80 years (HR = 12.318, p < 0.001), African American race (HR = 1.857, p = 0.003), multiple tumors (HR = 1.715, p < 0.001), and prior surgery (HR = 0.638, p = 0.013) were significantly associated with overall survival. Patients receiving surgery alone had better overall survival compared with patients receiving no treatment (p = 0.008) and patients receiving both surgery and radiotherapy (p = 0.002). The calibration plots demonstrated an excellent agreement between nomogram-predicted and actual survival.

Conclusion

In conclusion, age, race, tumor location, number of tumors, and prior surgery are prognostic factors for survival. Surgery was the most common modality and was suggested as an effective and optimal treatment. The proposed nomogram can predict the prognosis of patients with CNS hemangioblastomas and help clinicians in making decisions.

Diagnostic value of combined nucleic acid and antibody detection in suspected COVID-19 cases

OBJECTIVES

Nucleic acid testing is the gold standard method for the diagnosis of coronavirus disease 2019 (COVID-19); however, large numbers of false-negative results have been reported. In this study, nucleic acid detection and antibody detection (IgG and IgM) were combined to improve the testing accuracy of patients with suspected COVID-19.

STUDY DESIGN

The positive rate of nucleic acid detection and antibody detection (IgG and IgM) were compared in suspected COVID-19 patients.

METHODS

A total of 71 patients with suspected COVID-19 were selected to participate in this study, which included a retrospective analysis of clinical features, imaging examination, laboratory biochemical examination and nucleic acid detection and specific antibody (IgM and IgG) detection.

RESULTS

The majority of participants with suspected COVID-19 presented with fever (67.61%) and cough (54.93%), and the imaging results showed multiple small patches and ground-glass opacity in both lungs, with less common infiltration and consolidation opacity (23.94%). Routine blood tests were mostly normal (69.01%), although only a few patients had lymphopenia (4.23%) or leucopenia (12.68%). There was no statistical difference in the double-positive rate between nucleic acid detection (46.48%) and specific antibody (IgG and IgM) detection (42.25%) (P = 0.612), both of which were also poorly consistent with each other (kappa = 0.231). The positive rate of combined nucleic acid detection and antibody detection (63.38%) was significantly increased, compared with that of nucleic acid detection (46.48%) and that of specific antibody (IgG and IgM) detection (42.25%), and the differences were statistically significant (P = 0.043 and P = 0.012, respectively).

CONCLUSIONS

Nucleic acid detection and specific antibody (IgG and IgM) detection had similar positive rates, and their combination could improve the positive rate of COVID-19 detection, which is of great significance for diagnosis and epidemic control.

Assessment of knee extensor and flexor function using isokinetic test in COPD: impact on exercise capacity

OBJECTIVE: To quantify the relationship between strength and endurance of knee extensor and flexor and exercise capacity in patients with chronic obstructive pulmonary disease (COPD).METHODS: A total of 108 patients with stable COPD (age: 65 years, IQR25-75: 59-72) were enrolled in this cross-sectional study. Knee extensor and flexor function was evaluated using the isokinetic test, and the parameters attained were considered as independent variables. Exercise capacity was evaluated using 6-minute walking test (6MWT) and 30-second sit-to-stand test (30s SST), and the results were considered as dependent variables. The association between lower-limb muscle function and exercise capacity was assessed using multiple regression analysis.RESULTS: The patients mostly had moderate-to-severe airflow obstruction with a post-bronchodilator forced expiratory volume in 1 second (FEV₁) of 57.87 ± 17.71% predicted. In multiple regression analysis, flexor total work (TW), extensor endurance ratio (ER), age and FEV₁%pred were significantly associated with 6MWT (adjusted R² = 0.455, P < 0.001). Flexor TW and age were significantly associated with 30s SST (adjusted R² = 0.355, P < 0.001).CONCLUSION: Knee endurance has a significant relationship with exercise capacity, and knee flexor endurance seems to be an important factor contributing to exercise capacity in COPD patients.

Hydrogen Sulfide Reduces Cognitive Impairment in Rats After Subarachnoid Hemorrhage by Ameliorating Neuroinflammation Mediated by the TLR4/NF-κB Pathway in Microglia

Background and Aims: Cognitive impairment is one of the major complications of subarachnoid hemorrhage (SAH) and is closely associated with neuroinflammation. Hydrogen sulfide (H₂S) has been shown to have an anti-inflammatory effect and reduce cognitive impairment in neurodegenerative diseases, but its effects in SAH have been little studied. This study aimed to investigate the effects of H₂S on cognitive impairment after SAH and the possible underlying mechanisms.

Methods: Forty-eight male Sprague–Dawley (SD) rats were randomly divided into three groups: a sham group, a SAH group, and a SAH + NaHS (an H₂S donor) group. The endovascular perforation technique was used to establish the experimental SAH model. NaHS was administered intraperitoneally. An active avoidance test (AAT) was performed to investigate cognitive function. The expression of TNF-α, toll-like receptor 4 (TLR4), and NF-κB p65 in the hippocampus was measured by Western blot and immunohistochemistry. The types of cells expressing TNF-α were detected by double immunofluorescence staining.

Results: Compared to that in the sham group, the learning and memory ability of rats in the SAH group was damaged. Furthermore, the expression of TNF-α, TLR4, and NF-κB p65 in the hippocampus was elevated in the SAH group (p < 0.05). TNF-α was mainly expressed in activated microglia, which was consistent with the expression of TLR4. Treatment with NaHS significantly decreased the cognitive impairment of rats after SAH and simultaneously reduced the expression of TNF-α, TLR4, and NF-κB p65 and alleviated the nuclear translocation of NF-κB p65 (p < 0.05).

Conclusions: The neuroinflammation reaction in microglia contributes to cognitive impairment after SAH. H₂S reduced the cognitive impairment of rats after SAH by ameliorating neuroinflammation in microglia, potentially via the TLR4/NF-κB pathway.

Cerebellar Neurocytoma with Excellent Response to Radiotherapy

BACKGROUND

Extraventricular neurocytoma (EVN) is a rare neurocytoma occurring in the brain parenchyma outside the ventricular system that shares similar biological behaviors and histopathologic characteristics with central neurocytoma. Reports of EVN localized in the brainstem and cerebellum are relatively uncommon. In addition, few cases with radiotherapy as the only treatment have been reported and their outcomes were unclear.

CASE DESCRIPTION

We report a case of pathologically confirmed EVN of the brainstem and cerebellum in a 43-year-old male who presented with unprovoked nausea and dizziness. The patient received radiotherapy only and showed a favorable outcome during the 2-year follow-up period.

CONCLUSIONS

These results suggest that patients with EVN who are treated with radiotherapy without surgery may have a favorable prognosis.

Overexpression of EGFR and TGFα in von Hippel-Lindau-Related Central Nervous System Hemangioblastomas

Background: Central nervous system (CNS) hemangioblastomas (HGBs) are the most frequent cause of mortality in patients with von Hippel–Lindau (VHL) disease. Characteristics of multiple and recurrent disease cause certain difficulties in the treatment of CNS HGBs.

Methods: VHL-related HGB cases treated surgically at our hospital from September 2015 to February 2019 were analyzed. Patients meeting the clinical diagnostic criteria underwent genetic testing. Real-time PCR and immunohistochemistry were used in HGBs to verify differential expression of mRNAs and proteins, respectively. Furthermore, correlations between the differentially expressed proteins and the histological grading, genetic mutations, and tumor burden were also analyzed.

Results: A total of 21 patients with VHL syndrome confirmed by genetic testing (missense group, 9; partial deletion group, 12) were enrolled, and 30 CNS HGBs from these patients were studied. Clinical data showed that men at first operation were significantly younger than females (p = 0.005). Real-time PCR demonstrated that EGFR (p = 0.017) and TGFα (p = 0.017) mRNA expression in VHL-related HGBs was significantly higher than that in the control group. Immunohistochemistry showed that the mean optical density in VHL-related HGBs was significantly higher than that in controls (EGFR, p = 0.007; TGFα, p = 0.021). Finally, the cyst volume was related to the upregulation of EGFR (r = 0.782, p < 0.01).

Conclusion: Overexpression of EGFR and TGFα may contribute to tumor growth in VHL-related CNS HGBs. The cyst volume was associated with EGFR overexpression. These results provide information for the management of VHL-related HGBs in the era of targeted therapeutics.

Safety and efficacy of surgical treatment for brainstem hemangioblastoma: a meta-analysis

Brainstem hemangioblastomas are benign, highly vascular tumors located in the mesencephalon, pons, and medulla oblongata. Although surgical resection is currently considered the main therapeutic option for symptomatic lesions, evidence supporting the application of microsurgery has not been systematically assessed. This meta-analysis aims to evaluate the safety and efficacy of surgical treatment for brainstem hemangioblastomas. A comprehensive search of the PubMed, Embase, and Web of Science databases was performed to identify all English language publications reporting the outcomes of surgical treatment for brainstem hemangioblastomas. Studies from January 1990 to July 2019 with ≥ 10 cases were included. We analyzed the surgical outcomes, including gross total resection, mortality, neurological morbidity, and functional outcome according to the McCormick Scale or Karnofsky Performance Scale. Thirteen studies with 473 cases were included. The pooled proportion of gross total resection was 98% (95% confidence interval (CI), 94-100%). Overall mortality and neurological morbidity were 4 (95% CI, 2-6%) and 13% (95% CI, 7-20%), respectively. Favorable functional outcomes at the last follow-up were achieved in 85% (95% CI, 78-92%) of all patients. Improved or stable functional outcomes at long-term follow-up were achieved in 94% (95% CI, 89-97%) of patients. This meta-analysis revealed that surgical treatment for brainstem hemangioblastomas is technically feasible and effective with lasting patient benefits and cure.

Carotid-vertebral artery bypass with saphenous vein graft for symptomatic vertebrobasilar insufficiency

OBJECTIVESymptomatic steno-occlusion of the proximal vertebral artery (VA) or subclavian artery (ScA) heralds a poor prognosis and high risk of stroke recurrence despite medical therapy, including antiplatelet or anticoagulant drugs. In some cases, the V2 segment of the cervical VA is patent and perfused via collateral vessels. The authors describe 7 patients who were successfully treated by external carotid artery (ECA)-saphenous vein (SV)-VA bypass.METHODSSeven cases involving symptomatic patients were retrospectively studied: 3 cases of V1 segment occlusion, 2 cases of severe in-stent restenosis in the V1 segment, and 2 cases of occlusion of the proximal ScA. All patients underwent ECA-SV-VA bypass. The ECA was isolated and retracted, and the anterior wall of the transverse foramen was unroofed. The VA was exposed, and then the 2 ends of the SV were anastomosed to the VA and ECA in an end-to-side fashion.RESULTSSurgical procedures were all performed as planned, with no intraoperative complications. There were 2 postoperative complications (severe laryngeal edema in one case and shoulder weakness in another), but both patients recovered fully and measures were taken to minimize laryngeal edema and its effects in subsequent cases. All patients experienced improvement of their symptoms. No new neurological deficits were reported. Postoperative angiography demonstrated that the anastomoses were all patent, and analysis of follow-up data (range of follow-up 12-78 months) revealed no further ischemic events in the vertebrobasilar territory.CONCLUSIONSThe ECA-SV-VA bypass is a useful treatment for patients who suffer medically refractory ischemic events in the vertebrobasilar territory when the proximal part of the VA or ScA is severely stenosed or occluded but the V2 segment of the cervical VA is patent.

Transcriptomic changes in the nasal epithelium associated with diesel engine exhaust exposure

BACKGROUND

Diesel engine exhaust (DEE) exposure causes lung cancer, but the molecular mechanisms by which this occurs are not well understood.

OBJECTIVES

To assess transcriptomic alterations in nasal epithelium of DEE-exposed factory workers to better understand the cellular and molecular effects of DEE.

METHODS

Nasal epithelial brushings were obtained from 41 diesel engine factory workers exposed to relatively high levels of DEE (17.2-105.4 μg/m3), and 38 unexposed workers from factories without DEE exposure. mRNA was profiled for gene expression using Affymetrix microarrays. Linear modeling was used to identify differentially expressed genes associated with DEE exposure and interaction effects with current smoking status. Pathway enrichment among differentially expressed genes was assessed using EnrichR. Gene Set Enrichment Analysis (GSEA) was used to compare gene expression patterns between datasets.

RESULTS

225 genes had expression associated with DEE exposure after adjusting for smoking status (FDR q < 0.25) and were enriched for genes in pathways related to oxidative stress response, cell cycle pathways such as MAPK/ERK, protein modification, and transmembrane transport. Genes up-regulated in DEE-exposed individuals were enriched among the genes most up-regulated by cigarette smoking in a previously reported bronchial airway smoking dataset. We also found that the DEE signature was enriched among the genes most altered in two previous studies of the effects of acute DEE on PBMC gene expression. An exposure-response relationship was demonstrated between air levels of elemental carbon and the first principal component of the DEE signature.

CONCLUSIONS

A gene expression signature was identified for workers occupationally exposed to DEE that was altered in an exposure-dependent manner and had some overlap with the effects of smoking and the effects of acute DEE exposure. This is the first study of gene expression in nasal epithelial cells of workers heavily exposed to DEE and provides new insights into the molecular alterations that occur with DEE exposure.

Cell-free Mycobacterium tuberculosis DNA test in pleural effusion for tuberculous pleurisy: a diagnostic accuracy study

OBJECTIVES

Tuberculous pleurisy (TP) diagnosis remains difficult, with the sensitivity of Xpert MTB/RIF (Xpert) and mycobacterial culture (culture) only about 30-50%. We aimed to assess the diagnostic performance of a cell-free Mycobacterium tuberculosis DNA test (cf-TB) in pleural effusion for TP.

METHODS

Adults (≥18 years) with suspected TP presenting with pleural effusion were consecutively recruited, and pleural effusion specimens were prospectively collected in Beijing Chest Hospital, Beijing, China. After centrifuging pleural effusion, sediments were used for culture, Xpert and T-SPOT.TB assay, whereas supernatants were used for cf-TB and adenosine deaminase assay. The diagnostic performance was assessed against a composite reference standard.

RESULTS

From June 2015 to December 2018, we prospectively evaluated 286 adults with suspected TP. One hundred twenty-two participants were classified as definite TP based on the prespecified composite reference standard. The cf-TB produced a sensitivity of 79.5% (97/122, 95% confidence interval (CI) 72.4- 86.7) for definite TP, which was superior to Xpert (38.5% (29.9-47.2); 47/122; p < 0.001) and culture (27.1% (19.2-34.9); 33/122; p < 0.001). With pleural effusion Xpert and/or culture as the reference standard, cf-TB showed 96.6% (57/59, 95% CI 92.0-100.0) sensitivity, which was also significantly higher than Xpert (79.7%, 95% CI 69.4-89.9; 47/59; p 0.004) and culture (55.9%, 95% CI: 43.3-68.6; 33/59; p < 0.001).

CONCLUSIONS

The cf-TB clearly showed improved sensitivity compared with Xpert and culture. We recommend cf-TB as the first-line test for TP diagnosis.

Gonadotrophin-releasing hormone agonist combined with high-intensity focused ultrasound ablation for adenomyosis: a clinical study

OBJECTIVES

This study was to investigate the clinical efficacy of a gonadotrophin-releasing hormone agonist (GnRH-a) combined with high-intensity focused ultrasound (HIFU) ablation treatment for adenomyosis.

DESIGN

A non-randomized prospective study.

SETTING

Gynaecological Minimally Invasive Centre in a single hospital.

POPULATION

Patients with adenomyosis.

METHODS

Seventy-nine patients with adenomyosis were enrolled, including 55 patients in the control group treated with only HIFU and 24 patients in the study group treated with GnRH-a combined with HIFU. All the patients follow up 6 months after the HIFU procedure. The related parameters in the two groups were assessed before and 3 months as well as 6 months after treatment including serum levels of tumor marker and cytokine, volumes of uterine, adenomyotic lesion, and menstrual blood, as well as dysmenorrheal scores.

MAIN OUTCOME MEASURES

Differences between the group treated with HIFU alone and the group treated with GnRH-a combined with HIFU.

RESULTS

Before HIFU treatment, no significant difference was observed in serum levels of CA125, CA19-9, and interleukin-6 (IL-6), the volumes of uterine, adenomyotic lesion, and menstrual blood, as well as dysmenorrhea scores between the two groups. (P > 0.05). The serum CA125 levels significantly decreased in both groups after HIFU, but the serum CA125 levels in the study group were still significantly lower than those in the control group (P < 0.05). The volume of uterine and adenomyotic lesion significantly decreased in both groups after HIFU procedure, and decreased even more in the study group 3 and 6 months after treatment (P < 0.05). Dysmenorrhea scores and menstruation volumes significantly decreased in both groups after HIFU treatment. Moreover in the study group were significantly lower than those in the control group after 3 and 6 months (P < 0.05). No significant difference was observed in the rate of adverse effects between the two groups.

CONCLUSIONS

The short-term follow-up results indicate that the combination of GnRH-a and HIFU treatment significantly decreased serum CA125 levels, volumes of uterine, adenomyotic lesion and menstrual blood, as well as dysmenorrhea scores, and improved the clinical outcomes compared with the HIFU ablation alone in patients with adenomyosis. However, the further follow-up is needed to explore the long-term effects.

TWEETABLE ABSTRACT

A combination of GnRH-a with HIFU in the treatment of adenomyosis significantly decreased serum CA125 levels, uterine and adenomyotic lesion volumes, dysmenorrhea scores, and menstrual blood volumes.

Low frequency, weak MCP-1 secretion and exhausted immune status of peripheral monocytes were associated with progression of severe enterovirus A71-infected hand, foot and mouth disease

A minority of hand, foot and mouth disease (HFMD) caused by enterovirus A71 (EV-A71) results in severe neural complications. However, whether monocyte-mediated immunity is involved in the disease progression of HFMD remains unknown. One hundred and twenty mild and 103 severe HFMD patients were recruited and enzyme-linked immunosorbent assay (ELISA), flow cytometry and Transwell culture were performed in the study. Peripheral monocyte counts were lower in both absolute counts and frequencies in severe cases compared to mild cases. After screening 10 monocyte-related cytokines by ELISA, only monocyte chemoattractant protein-1 (MCP-1) was found at higher levels in sera of mild cases compared to those with severe symptoms. Monocytes purified from mild cases produced more MCP-1 than the cells from severe patients when stimulated in vitro. We observed that immune exhaustion markers programmed death 1 (PD-1) and programmed death ligand 1 (PD-L1) were highly regulated on the surface of monocytes from severe cases compared to mild cases. PD-L1 blockade induced a higher production of MCP-1 in the supernatant of a Transwell system. The production of MCP-1 also increased following PD-L1 blockade of purified monocytes activated by granulocyte-macrophage colony-stimulating factor (GM-CSF) combined with R848 or EV-A71 virus. Our results indicate that absolute count, frequency and levels of MCP-1 secretion of peripheral monocytes, together with their immune status, probably contribute to differential disease prognosis in EV-A71-associated HFMD.

Stenting for Middle Cerebral Artery Stenosis Associated with a Nonbifurcating Cervical Carotid Artery: Case Report and Naming Consideration

BACKGROUND

A nonbifurcating cervical carotid artery (NBCCA) is a rare anatomic variation of the carotid artery which directly arises from the common carotid artery without forming a bifurcation. A rare case of an NBCCA associated with middle cerebral artery (MCA) stenosis is reported herein.

CASE DESCRIPTION

A 70-year-old man was admitted to the hospital for fresh infarctions in the left frontoparietal lobe. The angiographic imaging showed severe atherosclerotic stenosis in the left MCA associated with an ipsilateral NBCCA. The origin of the left internal carotid artery (ICA) was occluded leaving a stump. A tortuous anastomotic vessel arose from the external carotid artery and continued as the cervical ICA. A stent was placed in the left MCA, and the patient recovered uneventfully and without further ischemia during follow-up. Embryogenesis and naming considerations are briefly discussed.

CONCLUSIONS

This is the first report of an NBCCA accompanied by ipsilateral MCA stenosis. The name hypogenesis/agenesis of the proximal ICA might describe the congenital anatomic variation of an NBCCA more accurately than NBCCA.