A case of hypertrophic cardiomyopathy with previous aortic valve replacement

We describe a 45-year-old patient who was diagnosed with hypertrophic obstructive cardiomyopathy (HOCM) after the aortic valve replacement surgery. Enlarged left atria, thickened ventricular septum, left ventricular outflow tract stenosis, moderate mitral regurgitation and mild tricuspid regurgitation in the echocardiography were found. We offered the patient the new minimally invasive treatment modality: percutaneous intra-myocardial septal radiofrequency ablation (PIMSRA). We demonstrate the safety and efficacy with pictures. One month after surgery, the patient recovered well with improved symptoms of chest tightness, and no LVOT obstruction or arrhythmia.

Protective Effects of Aspirin Supplemented With Quercetin in L-NAME-Induced Preeclampsia-Like Rats

Aspirin supplemented with quercetin was reported to enhance the therapeutic effects of aspirin in a rat model of preeclampsia. In this study, the underlying mechanisms were further explored. Preeclampsia was induced by L-NAME (50 mg/kg/day) via oral gavage from gestation day (GD)14 to GD19. Aspirin (1.5 mg/kg/day) administration was performed using aspirin mixed with rodent dough from GD0 to GD19. The administration of quercetin (2 mg/kg/day) was performed by intraperitoneal infusion from GD0 to GD19. Protein levels were evaluated using ELISA or Western blot, and microRNA (miRNA) level was evaluated by RT-PCR. Aspirin supplemented with quercetin ameliorated the increase of systolic blood pressure (SBP), proteinuria, tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) levels, and improved the pregnancy outcomes in preeclampsia rats. Aspirin supplemented with quercetin inhibited miR-155 expression in preeclampsia rats. The decreased miR-155 level in placenta further increased the protein level of SOCS1 and inhibited the phosphorylation of p65. In this study, we demonstrated that aspirin supplemented with quercetin enhanced the effects of aspirin for the treatment of preeclampsia.

The TTN p. Tyr4418Ter mutation causes cardiomyopathy in human and mice

OBJECTIVE

To generate a mouse model carrying TTNtv Y4370* simulating the newly discovered human heterozygous nonsense TTNtv c.13254T>G (p.Tyr4418Ter) to supplement and improve the functional evidence of pathogenic mutation TTNtv c.13254T>G on the pathogenic type of dilated cardiomyopathy.

METHODS

We generated 4 mice carrying TTNtv p. Y4370* through CRISPR/Cas-mediated genome engineering. Monthly serological detection, bimonthly echocardiography, and histology evaluation were carried out to observe and compare alterations of cardiac structure and function between 4 TTN+/- mice and 4 wild-type (WT) mice.

RESULTS

For the two-month-old TTN+/- mice, serum glutamic-oxalacetic transaminase (AST), lactic dehydrogenase (LDH), and creatine kinase (CK) were significantly increased, the diastolic Left Ventricular Systolic Anterior Wall (LVAW), and the LV mass markedly rose, with the left ventricular volume displaying an increasing trend and Ejection Fraction (EF) and Fractional Shortening (FS) showing a decreasing trend. Besides, the histological evaluation showed that cardiac fibrosis level and positive rate of cardiac mast cell of TTN+/- mice were obviously increased compared with WT mice.

CONCLUSIONS

TTNtv Y4370* could lead to cardiac structure and function alterations in mice, supplementing the evidence of TTNtv c.13254T>G pathogenicity in human.

[Etiological diagnostic methods and research progress of forest encephalitis]

Forest encephalitis is a natural focal disease transmitted through the bite of hard ticks, and its pathogen is the tick-borne encephalitis virus from the Flaviviridae family. The mortality rate of forest encephalitis is relatively high, making laboratory testing significant in diagnosing this disease. This article elaborates on the etiological diagnostic methods and recent research progress in forest encephalitis. Laboratory tests for forest encephalitis mainly include routine examinations, serological tests, virus isolation, and molecular biological testing. The detection of serum-specific IgM antibodies against the forest encephalitis virus is of great importance for early diagnosis, and specific IgG antibodies serve as a "gold standard" for differentiation from other diseases. Techniques such as enzyme-linked immunosorbent assay (ELISA) or indirect immunofluorescence assay for detecting specific IgM antibodies in serum and/or cerebrospinal fluid, the serum hemagglutination inhibition test or serum complement fixation test, and the double serum hemagglutination inhibition test or complement fixation test all contribute to the early diagnosis. The development of molecular testing methods is rapid, and techniques such as metabolomics, digital PCR, and matrix metalloproteinases are also applied in the early diagnosis of forest encephalitis.

A case report of adolescent myofibrillar myopathy due to a de novo R406W pathogenic variant in desmin with symptoms of "hypertrophic cardiomyopathy"

Objective

Myofibrillar myopathies (MFM) are a group of sporadic and inherited progressive skeletal muscle disorders that can lead to physical disability and premature death. To date, pathogenic variants in different genes are associated with MFM. MFM induced by variants in the Desmin (DES) gene is the most common subtype of MFM.

Case presentation

A 15-year-old boy with MFM was described, whose symptoms first presented as cardiac symptoms. Enlarged right and left atria, thickened ventricular septal (IVS) and mild mitral (MR) and tricuspid regurgitation (TR) in the echocardiography were found. Atrial fibrillation, intermittent atrioventricular (AV) block, ST-T changes in the dynamic electrocardiogram (ECG) were shown. Mild myopathic changes in the electromyographic exam were detected. Ultrastructural analysis found slight Z-line changes and a few small myolysis lesions, but no abnormal inclusion bodies. Genetic testing detected a heterozygous missense variant (c.1216C > T) of DES, and 2 rare variants: TNNI3K (c.1102C > G) and PRDM16 (c.3074G > A). The patient's parents didn't show skeletal and cardiac muscle disorders. DNA sequencing analysis showed no variant of DES was carried by them. Thus, we detected a case of MFM caused by de novo DES variant c.1216C > T/p.Arg406Trp with predominantly myocardial alterations.

Early and Mid-Term Outcomes of Using the Chimney Technique in Redo Mitral Valve Replacement in Patients with a Small Mitral Annulus

The outcomes of redo mitral valve replacement (Re-MVR) in a small mitral annulus with the use of the chimney technique are not well documented. The purpose of this study is to present our early experience with this group of patients, illustrating the periop-erative complications and mortality outcomes. From 2019 to 2020, 77 consecutive patients underwent Re-MVR with the use of the chimney technique because of a small mitral annulus. To evaluate heart structural integrity and clinical outcomes, postoperative clinical data and echocardiograms were examined. The mean age was 56.7 ± 15.98 years. All patients underwent mitral valve surgery, of which 62 were mitral valve replacements, 7 mitral valve repairs, and 8 double valve replacements. The preoperative mitral valve mean gradient was 18.07 ± 9.40 mmHg, and the postoperative mitral prosthesis size was 28.51 ± 1.22 mm. The median increment of mitral size enlargement was 4 (0, 6) valve sizes. The mean mitral gradient coming out of the operating room was 10.34 ± 2.12 mmHg, and at the follow-up echocardiogram performed at 3 years after the procedure, it was 10.36 ± 1.70 mmHg. One-year survival was 93.3%, while the 4-year survival rate was 89.3%, with no reoperation. The use of the chimney technique in small mitral valve re-mitral valve replacement results in larger valve sizes. Moreover, the mean gradients over the mitral valve are acceptable both intraoperatively and over time.

The relationship between uric acid and in-hospital mortality in patients with type A acute aortic dissection: A retrospective single-center study

OBJECTIVE

To measure the preoperative uric acid (UA) concentration in patients with type A aortic dissection (TAAD), and to assess its value in predicting in-hospital mortality.

METHODS

A total of 747 patients with TAAD between January 2016 and December 2022 were enrolled. The patients were divided into a survivor group and a non-survivor group. The clinical data of the two groups were compared. Univariate and multiple logistic regression analyses were performed to determine risk factors related to in-hospital mortality.

RESULTS

Compared with survivors, non-survivors had significantly higher serum uric acid levels (486.84 ± 127.59 vs 419.49 ± 141.02, P = 0.040). The incidence of in-hospital death increased along with higher UA levels (3.8% vs 0.7%, P = 0.007). Serum UA ≥ 373.5 μmol/L had 89.5% sensitivity and 41.3% specificity for predicting in-hospital death (area under the curve = 0.659, 95% CI: 0.554-0.765, P < 0.05). In the multivariable logistic model, Serum UA ≥ 373.5 μmol/L was independently associated with in-hospital mortality (OR = 1.022, 95% CI: 1.000-1.044, P = 0.048).

CONCLUSION

Serum UA resulted as an independent predictor of adverse prognosis in patients with TAAD, and thus could be used as an effective tool for the risk-stratification of patients with TAAD.

Deep learning for the early identification of periodontitis: a retrospective, multicentre study

AIM

To develop a deep-learning model to help general dental practitioners diagnose periodontitis accurately and at an early stage.

MATERIALS AND METHODS

First, the panoramic radiographs (PARs) from the Second Affiliated Hospital of Nanchang University were input into the convolutional neural network (CNN) architecture to establish the PAR-CNN model for healthy controls and periodontitis patients. Then, the PARs from the Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine were included in the second testing set to validate the effectiveness of the model with data from two centres. Heat maps were produced using a gradient-weighted class activation mapping method to visualise the regions of interest of the model. The accuracy and time required to read the PARs were compared between the model, periodontal experts, and general dental practitioners. Areas under the receiver operating characteristic curve (AUCs) were used to evaluate the performance of the model.

RESULTS

The AUC of the PAR-CNN model was 0.843, and the AUC of the second test set was 0.793. The heat map showed that the regions of interest predicted by the model were periodontitis bone lesions. The accuracy of the model, periodontal experts, and general dental practitioners was 0.800, 0.813, and 0.693, respectively. The time required to read each PAR by periodontal experts (6.042 ± 1.148 seconds) and general dental practitioners (13.105 ± 3.153 seconds), which was significantly longer than the time required by the model (0.027 ± 0.002 seconds).

CONCLUSION

The ability of the CNN model to diagnose periodontitis approached the level of periodontal experts. Deep-learning methods can assist general dental practitioners to diagnose periodontitis quickly and accurately.

[Observation on the efficacy of different targets low-frequency repetitive transcranial magnetic stimulation for the treatment of tremor-dominant subtypes of Parkinson's disease]

Objective: To analyze the efficacy of different targets low-frequency repetitive transcranial magnetic stimulation (rTMS) for the treatment of tremor Parkinson's disease(PD). Method: A total of 82 patients with primary PD who were admitted to the Department of Neurology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from April 1, 2020 to March 31, 2021 were prospectively collected. According to the clinical characteristics of major movement disorders, 82 patients with tremor type (TD) were selected to enroll.The patients were randomly divided into 3 groups at a 1∶1∶1 ratio according to the randomized coding sequence of the trial: the primary motor cortex (M1) group with 26 cases, the cerebellum group with 26 cases and the dual-site (M1, cerebellum) group with 30 cases. All patients were treated with 1 Hz low-frequency stimulation of the corresponding target once a day for 5 days a week for 2 weeks, a total of 10 times; The dosage remained unchanged during the treatment for all groups. Before and after 2 weeks' treatment, the patients were assessed with the Unified PD Rating Scale (UPDRS) and PD Quality of Life Questionnaire-39 (PDQ-39) without medication. Cortical excitability, namely transcranial magnetic stimulation motor evoked potential (TMS-MEP), [including resting motor threshold (rMT) and active motor threshold (aMT) examinations], timed up and go (TUG) and electromyographic tremor were conducted. Result: There were 82 patients, 39 males and 43 females, with an average age of (67±8) years. Before the treatment, there was no statistically significant difference in the evaluation indicators among the three groups (all P>0.05). After the treatment, the differences of the UPDRS-Ⅲ score [(38.9±2.5) vs (29.2±3.6) ], UPDRS tremor score [(23.7±2.1) vs (14.6±3.1) ], TUG time [(44.8±3.1) s vs (33.7±4.1) s], tremor amplitude [(480±126) μV vs (276±94) μV], PDQ-39 score [(51±13) vs (45±13) ], rMT [(36±17)% vs (43±13)%], and aMT [(26±16)% vs (31±12)%] were statistically significant (all P<0.01) from those before the treatment. There was no statistical difference in the above factors between the M1 group and cerebellum group (all P>0.05). There was no statistically significant difference in tremor peak frequency among the three groups before and after the treatment (all P>0.05). Conclusions: Dual-site low-frequency rTMS can improve PD tremor, while M1 or cerebellar low-frequency rTMS does not significantly improve PD tremor. Its mechanism may be to improve PD tremor symptoms by regulating cortical excitability.

[Effect of PCSK9 inhibitors on early neurological deterioration in patients with branch atheromatous disease]

Objective: To investigate the effect of Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors on the incidence of early neurological deterioration during the treatment of branch atheromatous disease (BAD). Methods: A retrospective analysis of 297 BAD patients admitted to the Department of Neurology in Zhengzhou People's Hospital from January 2020 to April 2023 was made. According to whether to use PCSK9 inhibitor treatment, they were divided into PCSK9 inhibitor group (81 cases) and control group (216 cases). Propensity score matching (PSM) method was used to eliminate the general situation difference between PCSK9 inhibitor group and control group. Seventy-two cases were successfully matched in each group. The early neurological deterioration (END) and low-density lipoprotein cholesterol (LDL-C) were compared. END was defined as the National Institutes of Health Stroke Scale (NIHSS) score increase≥2 points within 72 hours after stroke. Suspicious influencing factors leading to END were screened for multivariate logistic regression model analysis. Results: After PSM matching, among the 144 patients, 90 were male and 54 were female, aged (61.2±9.6) years. After matching, The hospital stay[M(Q1, Q3)] [9(7, 11)d vs 10(8, 13)d] in PCSK9 and NIHSS score at discharge [2(1, 3) vs 3(1, 4) points] were significantly different from those in the control group (all P<0.05). In addition, the incidence of END was reduced in the PCSK9 inhibitor group [12.5%(9/72) vs 31.9%(23/72),P<0.05]. Multivariate logistic regression analysis found that C-reactive protein (CRP)(OR=1.119,95%CI: 1.010-1.240, P<0.05) and PCSK9 inhibitor (OR=0.298, 95%CI: 0.117-0.755, P<0.05) were factors associated with the development of END. Conclusion: The use of PCSK9 inhibitors in the treatment of patients with BAD can reduce the incidence of END.

Disentangling the roles of chance, abiotic factors and biotic interactions among epiphytic bryophyte communities in a tropical rainforest (Yunnan, China)

Epiphytes offer an appealing framework to disentangle the contributions of chance, biotic and abiotic drivers of species distributions. In the context of the stress-gradient theory, we test the hypotheses that (i) deterministic (i.e., non-random) factors play an increasing role in communities from young to old trees, (ii) negative biotic interactions increase on older trees and towards the tree base, and (iii) positive interactions show the reverse pattern. Bryophyte species distributions and abiotic conditions were recorded on a 1.1 ha tropical rainforest canopy crane site. We analysed co-occurrence patterns in a niche modelling framework to disentangle the roles of chance, abiotic factors and putative biotic interactions among species pairs. 76% of species pairs resulted from chance. Abiotic factors explained 78% of non-randomly associated species pairs, and co-occurrences prevailed over non-coincidences in the remaining species pairs. Positive and negative interactions mostly involved species pairs from the same versus different communities (mosses versus liverworts) and life forms, respectively. There was an increase in randomly associated pairs from large to small trees. No increase in negative interactions from young to old trees or from the canopy to the base was observed. Our results suggest that epiphytic bryophyte community composition is primarily driven by environmental filtering, whose importance increases with niche complexity and diversity. Biotic interactions play a secondary role, with a very marginal contribution of competitive exclusion. Biotic interactions vary among communities (mosses versus liverworts) and life forms, facilitation prevailing among species from the same community and life form, and competition among species from different communities and life forms.

[Perspectives on molecular diagnosis and targeted therapy for complex vascular malformations in pediatrics]

Vascular malformations are due to abnormal development of blood and/or lymphatic vessels during embryonic life without endothelial cell proliferation. Most of the previous treatments were symptomatic methods as surgery and sclerotherapy because the pathogenic mechanism was not clearly understood. With advances in molecular biology, the pathogenesis of vascular malformations is thought to be related to inherited and/or somatic mutations that eventually activate the PI3K/ATK/mTOR, Ras/Raf/MEK/ERK pathways. Also, related studies have promoted the use of targeted inhibitors. This article provides a review of current causative genes and targeted drugs for pediatric vascular malformations, aiming to provide a basis for promoting accurate molecular diagnosis and precision targeted therapy for these diseases.

Early outcomes of the "Chimney" commando procedure in the small aortic and mitral annuli

BACKGROUND

Commando procedure, the surgical replacement of the mitral and aortic valves combined with reconstruction of the fibrosa fibrous body, is a technical challenge in patients with small aortic and mitral annuli. In this study, we evaluated the safety and early outcomes of the "Chimney" modality of the Commando procedure, in patients with small aortic and mitral annuli, after prior valve surgery, using a self-assembled valved conduit.

METHODS

From April 2021 to April 2022, 30 consecutive cases of the "Chimney" Commando procedure, with a self-assembled valved conduit and other combined cardiac procedures, were fully performed for re-operative patients with small aortic roots. Data were obtained through a medical record review, at the Asian Heart Hospital in Wuhan, China.

RESULTS

The patient's mean age was 52.7 ± 13.53 years, with 93.3% females. All patients had a previous heart valve surgery, 90% of which had double valve replacement (DVR). Hospital death occurred in 3.3% (n = 1) of the patients, due to malignant arrhythmias and multiorgan failure. Postoperative echocardiogram exams showed that the sizes of the aortic and mitral valve prostheses were 24.23 ± 1.60 mm and 28.33 ± 1.21 mm, respectively. All patients had intact intervalvular fibrosa (IVF) repair and no patient had any aberration in the left heart chamber communication. With the exception of one postoperative sick sinus syndrome and one re-sternotomy for bleeding, there were no significant postoperative complications, such as mortality, renal failure requiring ongoing dialysis, or mediastinitis. Echocardiography exams in the sixth postoperative month showed that the mean gradients of the aortic and mitral valves were 16.26 ± 6.44 mmHg and 11.24 ± 4.90 mmHg, respectively.

CONCLUSIONS

In comparison with the standard Commando operation, the early outcomes and safety of the "Chimney" Commando procedure proved to be a feasible therapeutic option for patients with small aortic and mitral annuli, after prior valve operations. This approach enables the enlargement of the aortic and mitral annuli and the implantation of the necessary valve prosthesis.

Suvemcitug as second-line treatment of advanced or metastatic solid tumors and with FOLFIRI for pretreated metastatic colorectal cancer: phase Ia/Ib open label, dose-escalation trials

BACKGROUND

Suvemcitug (BD0801), a novel humanized rabbit monoclonal antibody against vascular endothelial growth factor, has demonstrated promising antitumor activities in preclinical studies.

PATIENTS AND METHODS

The phase Ia/b trials investigated the safety and tolerability and antitumor activities of suvemcitug for pretreated advanced solid tumors and in combination with FOLFIRI (leucovorin and fluorouracil plus irinotecan) in second-line treatment of metastatic colorectal cancer using a 3 + 3 dose-escalation design. Patients received escalating doses of suvemcitug (phase Ia: 2, 4, 5, 6, and 7.5 mg/kg; phase Ib: 1, 2, 3, 4, and 5 mg/kg plus FOLFIRI). The primary endpoint was safety and tolerability in both trials.

RESULTS

All patients in the phase Ia trial had at least one adverse event (AE). Dose-limiting toxicities included grade 3 hyperbilirubinemia (one patient), hypertension and proteinuria (one patient), and proteinuria (one patient). The maximum tolerated dose was 5 mg/kg. The most common grade 3 and above AEs were proteinuria (9/25, 36%) and hypertension (8/25, 32%). Forty-eight patients (85.7%) in phase Ib had grade 3 and above AEs, including neutropenia (25/56, 44.6%), reduced leucocyte count (12/56, 21.4%), proteinuria (10/56, 17.9%), and elevated blood pressure (9/56, 16.1%). Only 1 patient in the phase Ia trial showed partial response, [objective response rate 4.0%, 95% confidence interval (CI) 0.1% to 20.4%] whereas 18/53 patients in the phase Ib trial exhibited partial response (objective response rate 34.0%, 95% CI 21.5% to 48.3%). The median progression-free survival was 7.2 months (95% CI 5.1-8.7 months).

CONCLUSIONS

Suvemcitug has an acceptable toxicity profile and exhibits antitumor activities in pretreated patients with advanced solid tumors or metastatic colorectal cancer.

[The characteristics and correlations of vaginal flora in women with cervical lesions]

Objective: To explore the characteristics and correlations of vaginal flora in women with cervical lesions. Methods: A total of 132 women, including 41 women diagnosed with normal cervical (NC), 39 patients with low-grade cervical intraepithelial neoplasia (CIN 1), 37 patients with high-grade cervical intraepithelial neoplasia (CIN 2/3) and 15 patients with cervical squamous cell carcinoma (SCC), who came from the gynecological clinic of Second Hospital of Shanxi Medical University during January 2018 to June 2018, were enrolled in this study according to the inclusive and exclusive criteria strictly. The vaginal flora was detected by 16S rDNA sequencing technology. Co-occurrence network analysis was used to investigate the Spearman correlations between different genera of bacteria. Results: The dominant bacteria in NC, CIN 1 and CIN 2/3 groups were Lactobacillus [constituent ratios 79.4% (1 869 598/2 354 098), 63.6% (1 536 466/2 415 100) and 58.3% (1 342 896/2 301 536), respectively], while Peptophilus [20.4% (246 072/1 205 154) ] was the dominant bacteria in SCC group. With the aggravation of cervical lesions, the diversity of vaginal flora gradually increased (Shannon index: F=6.39, P=0.001; Simpson index: F=3.95, P=0.012). During the cervical lesion progress, the ratio of Lactobacillus gradually decreased, the ratio of other anaerobes such as Peptophilus, Sneathia, Prevotella and etc. gradually increased, and the differential bacteria (LDA score >3.5) gradually evolved from Lactobacillus to other anaerobes. The top 10 relative abundance bacteria, spearman correlation coefficient>0.4 and P<0.05 were selected. Co-occurrence network analysis showed that Prevotella, Peptophilus, Porphyrinomonas, Anaerococcus, Sneathia, Atopobium, Gardnerella and Streptococcus were positively correlated in different stages of cervical lesions, while Lactobacillus was negatively correlated with the above anaerobes. It was found that the relationship between vaginal floras in CIN 1 group was the most complex and only Peptophilus was significantly negatively correlated with Lactobacillus in SCC group. Conclusions: The increased diversity and changed correlations between vaginal floras are closely related to cervical lesions. Peptophilus is of great significance in the diagnosis, prediction and early warning of cervical carcinogenesis.

[Clinical features and long-term prognosis of diabetic patients with low or intermediate complexity coronary artery disease post percutaneous coronary intervention]

Objective: To investigate the clinical features and long-term prognostic factors of diabetic patients with low or intermediate complexity coronary artery disease (CAD) post percutaneous coronary intervention (PCI). Methods: This was a prospective, single-centre observational study. Consecutive diabetic patients with SYNTAX score (SS)≤32 undergoing PCI between January and December 2013 in Fuwai hospital were included in this analysis. The patients were divided into two groups based on SS, namely SS≤22 group and SS 23-32 group. Multivariate Cox regression analysis was performed to identify independent factors related to poor 5-year prognosis. The primary outcomes were cardiac death and recurrent myocardial infarction, the secondary outcomes were all cause death and revascularization. Results: Of the 3 899 patients included in the study, 2 888 were men (74.1%); mean age was 59.4±9.8 years. There were 3 450 patients in the SS≤22 group and 449 patients in the SS 23-32 group. Compared with SS≤22 group, the incidence of revascularization was higher in SS 23-32 group (18.9% (85/449) vs. 15.2% (524/3450), log-rank P=0.019). There was no significant difference in all-cause death, cardiac death and recurrent myocardial infarction between the two groups (log-rank P>0.05). Multivariate Cox regression analysis showed that age (HR=1.05, 95%CI 1.02-1.08, P<0.001), chronic obstructive pulmonary disease (HR=3.12, 95%CI 1.37-7.07, P=0.007) and creatinine clearance rate (CCr)<60 ml/min (HR=3.67, 95%CI 2.05-6.58, P<0.001) were independent risk factors for 5-year cardiac death, while left ventricular ejection fraction (HR=0.94, 95%CI 0.91-0.96, P<0.001) was a protective factor. Previous PCI (HR=2.04, 95%CI 1.38-3.00, P<0.001), blood glucose level≥11.1 mmol/L on admission (HR=2.49, 95%CI 1.32-4.70, P=0.005) and CCr<60 ml/min (HR=1.85, 95%CI 1.14-2.99, P=0.012) were independent risk factors for 5-year recurrent myocardial infarction. The SS of 23-32 was independently associated with risk of revascularization (HR=1.54, 95%CI 1.09-2.16, P=0.014), after adjusting for residual SS. Residual SS was not a risk factor for 5-year prognosis. Conclusions: In diabetic patients with low-or intermediate complexity CAD, SS 23-32 is associated with increased risk of 5-year revascularization; the clinical characteristics of the patients are associated with the long-term mortality and recurrent myocardial infarction, but not related to revascularization.

Right atrial myxoma after Amplatzer atrial septal defect closure device deployment

Right atrial (RA) myxoma is common; however, RA myxoma after the percutaneous atrial septal defect closure is very rare. To the best of our knowledge, this might be the first reported case of RA myxoma after Amplatzer closure of an atrial septal defect, leading to a pulmonary artery embolism. We removed all the RA mass, occluder and pulmonary embolus and reconstructed the atrial septum successfully. As a result of surgery, there were no other complications as following up.

Analysis of the Safety and Pregnancy Outcomes of Fertility-sparing Surgery in Ovarian Malignant Sex Cord-stromal Tumours: A Multicentre Retrospective Study

AIMS

To assess the difference in survival between fertility-sparing surgery (FSS) and radical surgery and explore pregnancy outcomes after FSS in stage I malignant sex cord-stromal tumours (MSCSTs).

MATERIALS AND METHODS

We carried out a multicentre retrospective cohort study on patients who were diagnosed with MSCSTs and the tumour was confined to one ovary. The patients were divided into FSS and radical surgery groups. Inverse probability of treatment weighting (IPTW) was used to balance variables between the two groups. Kaplan-Meier analysis was used to compare the difference in disease-free survival (DFS). Univariate and multivariate Cox regression analysis was used to find risk factors of DFS. Univariate logistic regression analysis was used to assess risk factors of pregnancy.

RESULTS

In total, 107 patients were included, of whom 54 (50.5%) women underwent FSS and 53 (49.5%) received radical surgery. After IPTW, a pseudo-population of 208 was determined and all of the covariates were well balanced. After a median follow-up time of 50 months (range 7-156 months), 10 patients experienced recurrence and two died. There was no significant difference in DFS between the two groups, both in unweighted (P = 0.969) or weighted cohorts (P = 0.792). In the weighted cohort, stage IC (P = 0.014), tumour diameter >8 cm (P = 0.003), incomplete staging surgery (P = 0.003) and no adjuvant chemotherapy (P < 0.001) were the four high-risk factors associated with a shorter DFS. Among 14 patients who had pregnancy desire, 11 (78.6%) women conceived successfully; the live birth rate was 76.9%. In univariate analysis, only adjuvant chemotherapy (P = 0.009) was associated with infertility.

CONCLUSIONS

On the premise of complete staging surgery, FSS is safe and feasible in early stage MSCSTs with satisfactory reproductive outcomes.

Vascular epiphyte populations with higher leaf nutrient concentrations showed weaker resilience to an extreme drought in a montane cloud forest

Leaf stoichiometry can characterize plant ecological strategies and correlate with plant responses to climate change. The role of vascular epiphytes in the ecosystem processes of tropical and subtropical forest ecosystems cannot be ignored. Vascular epiphytes are very vulnerable to climate change, however, the relationship between the response of epiphytes to climate change and leaf stoichiometry is not well understood. We present data for 19 vascular epiphyte species that were collected during four consecutive censuses (in 2005, 2010, 2015, and 2020) over 15 years in a subtropical montane cloud forest. We assessed the relationships between the population dynamics and leaf stoichiometry of these vascular epiphytes. Experiencing an extreme drought, 14 of the 19 epiphyte species showed an obvious decrease in the number of individuals, and all species showed negative growth in the number of populations. Subsequently, the total number of individuals gradually recovered, increasing from 7,195 in 2010 to 10,121 in 2015, then to 13,667 in 2020. The increase in the number of vascular epiphyte individuals from 2010 to 2015 was significantly negatively correlated with leaf nitrogen and phosphorus concentration, and was significantly positively correlated with the leaf carbon-nitrogen ratio. Vascular epiphyte populations with higher leaf nutrient concentrations exhibited weaker resilience to the extreme drought, which demonstrated that a resource-conservative strategy was advantageous for the recovery of epiphyte populations. Our findings suggest that ecological stoichiometry can be a useful framework for forecasting the dynamics of vascular epiphyte populations in response to climate change.

Insulin Resistance-Varying Associations of Adiposity Indices with Cerebral Perfusion in Older Adults: A Population-Based Study

OBJECTIVES

Excessive accumulation of adipose tissue may accelerate brain aging, but the underlying mechanisms are poorly understood. Several adiposity indices were proposed to assess obesity, while their linkage with brain health in older adults remained unclear. Here we aimed to examine the associations of adiposity indices with global and regional cerebral blood flow (CBF) in older adults, while considering insulin resistance.

DESIGN

This was a cross-sectional population-based study that included older adults derived from the baseline participants in the ongoing Multimodal Interventions to Delay Dementia and Disability in rural China (MIND-China) study.

SETTING AND PARTICIPANTS

The study included 103 Chinese rural-dwelling older adults (age≥60 years; 69.9% women) who underwent brain magnetic resonance imaging scans.

METHODS

We estimated eight adiposity indices based on anthropometric measures. We automatically quantified global and regional CBF using the arterial spin labeling scans. Insulin resistance was assessed using the triglyceride-glucose index and then dichotomized into high and low levels according to the median. Data were analyzed using general linear model and voxel-wise analysis.

RESULTS

Of the eight examined adiposity indices, only higher waist-to-height ratio (WHtR) and body roundness index (BRI) were associated with reduced global CBF (multivariable-adjusted β-coefficients and 95%CI: -1.76; -3.25, -0.27 and -1.77; -3.25, -0.30, respectively) and hypoperfusion in bilateral middle temporal gyri, angular gyri and superior temporal gyri, left middle cingulum and precuneus (P<0.05). There were statistical interactions of WHtR and BRI with levels of insulin resistance on CBF, such that the significant associations of higher WHtR and BRI with lower global and regional CBF existed only in people with high insulin resistance (P<0.05).

CONCLUSION

Higher WHtR and BRI are associated with cerebral hypoperfusion in older adults, especially in people with high insulin resistance. This may highlight the pathological role of visceral fat in vascular brain aging.

A Large Retrospective Cohort Study on the Risk of Alzheimer's Disease and Related Dementias in Association with Vascular Diseases and Cancer Therapy in Men with Prostate Cancer

BACKGROUND

No study was conducted on the long-term risk of Alzheimer's disease (AD) and related dementias (ADRD) in association with vascular diseases in men with prostate cancer.

OBJECTIVES

To determine the 26-year risk of ADRD in association with cardiovascular disease (CVD), stroke, hypertension, and diabetes in a nationwide cohort of men with prostate cancer.

DESIGN

Retrospective cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) areas of the United States.

PARTICIPANTS

351,571 men diagnosed with prostate cancer at age ≥65 years.

MEASUREMENTS

Main exposures were CVD, stroke, hypertension, and diabetes. Main outcome was the incidence of ADRD.

RESULTS

The crude 26-year cumulative incidence of any ADRD was higher in those with versus without CVD (33.80% vs 29.11%), stroke (40.70% vs 28.03%), hypertension (30.88% vs 27.31%), and diabetes (32.23% vs 28.68%). Men with CVD (adjusted hazard ratio: 1.17, 95% CI: 1.15-1.20), stroke (1.59, 1.56-1.61), hypertension (1.13, 1.11-1.14), and diabetes (1.25, 1.23-1.27) were significantly more likely to develop ADRD than those without. Patients with 4 of these vascular diseases were 161% more likely to develop ADRD (2.61, 2.47-2.76) than those without. The risk of AD (0.89, 0.87-0.91) and ADRD (0.91, 0.90-0.93) became significantly lower in men with prostate cancer who received androgen deprivation therapy as compared to those who did not after considering death as a competing risk.

CONCLUSIONS

In men with prostate cancer, vascular diseases were associated with significantly higher risks of developing ADRD. Androgen deprivation therapy was associated with a significantly decreased risk of AD in men with prostate cancer.

[Impact of interventional therapy on top of standard drug therapy on left ventricular structure and function in HFrEF patients complicating with middle aortic syndrome caused by Takayasu arteritis]

Objective: To evaluate the impact of interventional therapy on top of drug therapy on cardiac function and structure in heart failure with reduced ejection fraction (HFrEF) patients complicating with middle aortic syndrome caused by Takayasu arteritis (TA-MAS). Methods: It was a retrospective longitudinal study. The data of patients with TA-MAS and HFrEF, who received interventional therapy on top of drug therapy in Fuwai Hospital from January 2010 to September 2020, were collected and analyzed. Baseline clinical data (including demographic data, basic treatment, etc.) were collected through the electronic medical record system. Changes of indexes such as New York Heart Association (NYHA) classification, N-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular end diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMI) before and after therapy were analyzed. Results: A total of 10 patients were collected. There were 8 females in this patient cohort, age was (18.4±5.0) years and onset age was (15.3±5.0) years. All 10 patients received standard heart failure medication therapy in addition to hormone and/or immunosuppressive anti-inflammatory therapy, but cardiac function was not improved, so aortic balloon dilatation and/or aortic stenting were performed in these patients. The median follow-up was 3.3(1.3, 5.6) years. On the third day after interventional therapy, the clinical symptoms of the 10 patients were significantly improved, NYHA classfication was restored from preoperative Ⅲ/Ⅳ to Ⅱ at 6 months post intervention(P<0.05). Compared with preoperation, NT-proBNP (P=0.028), LVEDD (P=0.011) and LVMI (P=0.019) were significantly decreased, LVEF was significantly increased (P<0.001) at 6 months after operation. Compared with preoperation, NT-proBNP (P=0.016), LVEDD (P=0.023) and LVMI (P=0.043) remained decreased, LVEF remained increased (P<0.001) at 1 year after operation. Conclusion: Results from short and medium term follow-up show that interventional therapy on top of heart failure drug therpay can effectively improve left cardiac function and attenuate cardiac remodeling in patients with TA-MAS comorbid with HFrEF.

[Analysis of 1153 Cases of Forest Encephalitis Reported by Domestic Documents]

Objective: To summarize the clinical characteristics, diagnosis and treatment of forest encephalitis, and provide basis for revising relevant diagnostic criteria. Methods: From January to December 2020, the clinical characteristics, diagnosis and treatment of forest encephalitis cases in the data of China National Knowledge Infrastructure (CNKI) and Wanfang Chinese journals from 2009 to 2020 were retrospectively analyzed. The measurement data are expressed in Mean±SD, numbers, and the counting data of gender, region and occupation are expressed in numbers and composition ratio. Descriptive analysis of relevant data is carried out. Results: There were 1 153 confirmed cases of forest encephalitis reported in domestic literature, including 910 males and 243 females. Age: 16-78 years old; Cases were mainly distributed in Jilin Province, Inner Mongolia Autonomous Region and Heilongjiang Province. The cases included forest rangers (112/518), freelancers (104/518) and loggers (88/518). The common symptoms and signs were fever 81.2% (936/1153), headache 70.3% (811/1153), meninges irritation 29.0% (334/1153), vomiting 25.3% (292/1153), nausea 21.8% (251/1153), etc. Only 48.1% (555/1153) of the patients obtained positive pathogenic test results from blood and/or cerebrospinal fluid specimens. 42.1% (485/1153) had definite diagnosis grade, 354 cases were mild, 58 cases were moderate, and 73 cases were severe. Among 730 patients with forest encephalitis who received complete treatment, 511 cases were cured, 148 cases were improved, 48 cases were not cured, and 23 cases died. Conclusion: The epidemic of forest encephalitis has strict regional, seasonal and occupational characteristics. Early diagnosis and treatment can reduce the mortality and disability rate.

[Evaluation of the implementation of Diagnostic Criteria of Occupational Acute Neurotoxic Diseases Caused by Chemicals (GBZ 76-2002)]

Objective: To investigate the implementation of Diagnostic Criteria of Occupational Acute Neurotoxic Diseases Caused by Chemicals (GBZ 76-2002) for accumulating basis of standard revision. Methods: In February 2020, 85 experts in occupational diseases and neurology from 39 medical and health institutions were selected as the respondents. The modified Delphi method was used to establish the standard evaluation index system and special group was organized for discussing the pre-survey and completing the questionnaire survey. Questionnaire survey was performed to investigate the grasp of the standards, application and modification suggestions of respondents. Results: The respondents' mastery of standard-related knowledge mainly came from work experience (84.7%, 72/85) , standard learning (81.2%, 69/85) and training (75.3%, 64/85) . Among the institutions in which the respondents worked, 98.8% (84/85) could carry out CT examinations, 96.5% (82/85) could carry out nerve conduction velocity and electromyography examinations, 89.4% (76/85) could carry out EEG examinations, 80% (68/85) could carry out evoked potential examinations and 72.9% (62/85) could carry out MRI examinations. Among the toxicants diagnosed as occupational acute toxic myelopathy, 10.6% (9/85) were organic phosphorus and 9.4% (8/85) were asphyxiating gas; Among the toxicants diagnosed as delayed peripheral neuropathy, pesticides accounted for 25.9% (22/85) and asphyxiating gases accounted for 12.9% (11/85) . 85.9% (73/85) of the respondents believed that the basis for the classification of acute toxic encephalopathy needed to supplement objective evidence; 80.0% (68/85) of the respondents thought that the diagnosis and classification of peripheral neuropathy should be refined according to the abnormal indexes of neuroelectromyography. Conclusion: The applicability of the criteria needs to be improved because the current criteria has a long application cycle without enough objective investigation bases in classification criteria index.

Symptom burden, psychological distress, and symptom management status in hospitalized patients with advanced cancer: a multicenter study in China

BACKGROUND

The management of physical symptoms and psychological distress of cancer patients is an important component of cancer care. The purpose of this study was to evaluate the symptom burden, psychological distress, and management status of hospitalized patients with advanced cancer in China and explore the potential influencing factors of undertreatment and non-treatment of symptoms.

PATIENTS AND METHODS

A total of 2930 hospitalized patients with advanced cancer (top six types of cancer in China) were recruited from 10 centers all over China. Patient-reported MD Anderson Symptom Inventory, Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9) scales and symptom management-related information were collected and linked with the patient's clinical data. The proportion of patients reporting moderate-to-severe (MS) symptoms and whether they were currently well managed were examined. Multivariable logistic regression models were applied to explore the factors correlated to undertreatment and non-treatment of symptoms.

RESULTS

About 27% of patients reported over three MS symptoms, 16% reported over five, and 9% reported over seven. Regarding psychological distress, the prevalence of HADS-anxiety was 29% and that of PHQ-9 depression was 11%. Sixty-one percent of patients have at least one MS symptom without any treatment. Sex [odds ratio (OR) = 2.238, 95% confidence interval (95% CI) 1.502-3.336], Eastern Cooperative Oncology Group (ECOG; OR = 0.404, 95% CI 0.241-0.676), and whether currently undergoing anticancer treatment (OR = 0.667, 95% CI 0.503-0.886) are the main factors correlated with the undertreatment of symptoms. Age (OR = 1.972, 95% CI 1.263-3.336), sex (OR = 0.626, 95% CI 0.414-0.948), ECOG (OR = 0.266, 95% CI 0.175-0.403), whether currently undergoing anticancer treatment (OR = 0.356, 95% CI 0.249-0.509), and comorbidity (OR = 0.713, 95% CI 0.526-0.966) are the main factors correlated with the non-treatment of symptoms.

CONCLUSIONS

This study shows that hospitalized patients with advanced cancer had a variety of physical and psychological symptoms but lacked adequate management and suggests that a complete symptom screening and management system is needed to deal with this complex problem.

Evaluation of right ventricular function in patients with pulmonary arterial hypertension by different right ventricular-pulmonary artery coupling methods

To compare the accuracy of end-systolic elasticity (Ees)/arterial elasticity (Ea) ratio measured by single beat estimation, pressure-volume loop and cardiac magnetic resonance (CMR) combined volume method in patients with pulmonary artery hypertension, and to find a feasible and reliable method to quantitatively evaluate the function of right ventricle in patients with pulmonary artery hypertension. Forty-nine pulmonary artery hypertension patients enrolled between May 2017 and May 2018 in our hospital were retrospectively analyzed. Firstly, measure Ees/Ea ratio by single beat estimation, pressure-volume loop and CMR combined volume method, then, compare Ees/Ea ratio with New York Heart Association (NYHA) classification and NT-proBNP value respectively to evaluate the accuracy of the 3 methods. Ees/Ea ratio measured by single beat estimation is 2.07 ± 1.01, correlation analysis is not statistically significant when compare with NYHA classification and NT-proBNP value (P > .05). Ees/Ea ratio measured by pressure-volume loop is 2.64 ± 1.48, correlation analysis is not statistically significant when compare with NYHA classification and NT-proBNP value (P > .05). Ees/Ea ratio measured by CMR combined volume method is 0.72 ± 0.43, correlation analysis is statistically significant when compare with NYHA classification and NT-proBNP with negative correlation (P < .05). Ees/Ea ratio decrease according to the increase of NT-proBNP value and the NYHA classification. There is linear regression equation between Ees/Ea ratio measured by CMR combined volume method and log (NT-proBNP) value: Y = -0.257X + 1.45, and the linear regression equation is statistically significant (P = .001). Ees/Ea ratio measured by CMR combined volume method is a feasible and reliable method to quantitatively evaluate the function of right ventricule in patients with pulmonary artery hypertension, which might be further verified in a larger patient population.

[Tuberculosis presenting as gastrointestinal perforation and large confluent pulmonary cavities: a case report]

We report an unusual case presented as acute gastrointestinal perforation and large confluent pulmonary cavities. A 23-year-old male was admitted to the emergency department with complaints of abdominal pain for 1 month, which exacerbated for 1 day. He also reported a 3-month history of diarrhea and productive cough. Computed tomography (CT) scan showed multiple large confluent cavities in the lung, along with massive free gas in the abdomen suggesting gastrointestinal perforation. Exploratory laparotomy was performed and affected bowel segment was resected. His sputum examination was positive for both acid-fast staining and Mycobacterium tuberculosis complex gene (Xpert) testing. Pathology of small intestine revealed micro-abscess formation and was positive for acid-fast bacilli. A final diagnosis of pulmonary tuberculosis and intestinal tuberculosis was made.

Giant primary cardiac alveolar rhabdomyosarcoma of the right atrium

Primary cardiac alveolar rhabdomyosarcoma (ARMS) is an extremely rare malignant tumor with dismal prognosis. We herein report a case of right atrial ARMS in a 63-year-old female with intermittent dizziness. Complete surgical resection of the mass was performed and the postoperative histopathologic examination confirmed ARMS. The patient received adjuvant therapy after surgery and was doing well at 1-year follow-up.

A rare pulmonary-to-systemic venous connection associated with the partially anomalous pulmonary venous connection

BACKGROUND

We report an extremely rare case of pulmonary-to-systemic venous connection associated with the partially anomalous pulmonary venous connection. Our case highlights that computed tomography angiography has a significant diagnostic and differential value for this rare anomaly.

METHODS AND RESULTS

A 32-year-old male presented with chest discomfort for 2 weeks. The electrocardiogram and laboratory were unremarkable abnormalities. Transthoracic echocardiography suggested an enlargement of the right atrium and right ventricle. Cardiac computed tomography angiography images showed partial anomalous drainage of the right superior pulmonary vein into the superior caval vein, and a large pulmonary-to-systemic venous connection from the right middle pulmonary vein into the superior vena cava resulting in left atrial to systemic venous shunt. The patient underwent a successful thoracoscopic correction of partially anomalous pulmonary venous connection. Post-procedural course was uneventful, and he was discharged after 7 days.

DISCUSSION

Pulmonary-to-systemic venous connection may also be called a levoatriocardinal vein. The embryological origin of this venous connection is an abnormal persistency of the splanchnic plexus connecting the pulmonary venous plexus and the cardinal system. The diagnosis of these rare types of the pulmonary to systemic communications has important clinical implications. We report an extremely rare case with pulmonary-to-systemic venous connection from the right middle pulmonary vein into the superior caval vein, although the connection might have been considered a levoatriocardinal vein, there is no separate formation of the right middle pulmonary vein at the time of existence of the splanchnic plexus, so it is inappropriate to explain the collateral channel encountered in our patient on the basis of an embryological remnant, a more appropriate term for these anomalies would be a "pulmonary-to-systemic collateral vein". Because the venous collateral pathway may be a source of the persistent left-to-right shunt and cause clinical manifestations of chronic right heart volume overload later in life. Therefore, we have performed successful thoracoscopic correction of partial anomalous pulmonary venous drainage. The Post-procedural course was uneventful.

CONCLUSION

The pulmonary-to-systemic venous connection associated with the partially anomalous pulmonary venous connection is a rare congenital malformation. Computed tomography angiography as a noninvasive imaging method plays an important diagnostic and differential value for this entity.

O-197 Predicting individualised risk of developing amenorrhoea in young breast cancer patients: an international multi-cohort study

Study question

What is the likelihood of developing amenorrhoea after breast cancer treatment in young women with early breast cancer?

Summary answer

We developed risk prediction model for a web-based tool to provide an individualized risk of developing amenorrhoea of young breast cancer patients at diagnosis.

What is known already

Young breast cancer survivors have an increased risk of developing premature ovarian insufficiency as a long-term adverse effect of chemotherapy. The potential for developing amenorrhoea is a high priority for these young patients, with some choosing less optimal cancer treatments to minimise the impact on fertility and/or unnecessarily taking on the physical and financial burden of fertility preservation. A key component in good-quality decision-making is understanding the likelihood of outcomes. Yet, current tools to predict individualised ovarian function after breast cancer treatments are imprecise with minimal applicability for clinical practice.

Study design, size, duration

The FoRECAsT (Fertility after Cancer Predictor) study is a multi-institutional study of 5-year survivors of breast cancer. A literature review addressing the impact of chemotherapy regimens for breast cancer on developing amenorrhoea was conducted. Authors of identified articles and known data registries were contacted and invited to contribute their data to the FoRECAsT database. The FoRECAsT database contains 7473 individuals sourced from Australia, UK, USA, Hong Kong, France, Denmark, Italy, Belgium and International Trial Groups.

Participants/materials, setting, methods

FoRECAsT cohort includes premenopausal women diagnosed with primary breast cancer, reported history of two or more predictors of developing amenorrhoea and menstrual history information after chemotherapy. Patients with bilateral salpingo-oophorectomy were excluded. Primary outcomes were likelihood of developing amenorrhea at 12 and 24 months. Cross imputation was used to manage missing values. Logistic regression was used to develop risk prediction models and prediction performance was evaluated internally using area under the receiver operating curve (AUC).

Main results and the role of chance

Out of 7473 individual records from FoRECAsT database, 2833 participants (37.91%) reported menstrual history information at 12 months and 2118 participants (28.34%) reported menstrual history information at 24 months and, thus were included in the analysis. In multivariate logistic regression analyses, common predictors for amenorrhea at 12 and 24 months were older age at diagnosis, lower body mass index, chemotherapy regimens, endocrine therapy and pre-treatment follicle stimulating hormone. In addition, history of smoking and alcohol consumption were also predictors for developing amenorrhea at 12-months. Receiver–operator characteristic analysis produced an estimated AUC of 0.88, sensitivity of 95.75% and specificity of 58.52% for amenorrhoea at 12 months and AUC of 0.92, sensitivity of 94.09% and specificity of 53.58% for amenorrhoea at 24 months. Internal validation with 1000 bootstrap resampling showed good discrimination for both models, C-index of 0·88 (95% CI 0·84–0·91) for amenorrhoea at 12 month and C-index of 0·93 (95% CI 0.90 − 0.94) amenorrhoea at 24 months. Based on these models, a web-based calculator that predicts individualised ovarian function is under development for implementing in clinical practice worldwide.

Limitations, reasons for caution

The limitations including reliance on self-reported menstrual history, heterogeneity in collecting data in different countries could result in bias and insufficiency. These models require external validation. However, excellent prediction performance of the models and good precision in the estimate of accuracy in internal validation provides reassurance.

Wider implications of the findings

The model and the associated web application could help clinical discussions and decision-making regarding fertility preservation before chemotherapy when appropriate and to optimise adjuvant endocrine therapy in young women with early breast cancer. Additionally, this tool could be adapted to newer breast cancer treatments and for other cancer treatments.

Trial registration number

N/A

Unusual case of a right atrial inflammatory myofibroblastic tumor presenting with an episodic cyanosis in an infant

Cardiac inflammatory myofibroblastic tumor (IMT) is a rare benign tumor that occurs mainly in infants and children. We report a case of right atrial IMT in a 1-month-old girl with episodic cyanosis. Both echocardiography and cardiac computed tomography revealed a right atrial mass. The patient underwent a complete surgical resection of the mass and the postoperative histological examination confirmed the diagnosis of cardiac IMT. The patient recovered well after the operation and further follow-up evaluation was uneventful.

[Impact of prolonging dual antiplatelet therapy on long-term prognosis of elderly patients with coronary heart disease complicated with diabetes mellitus undergoing drug-eluting stent implantation]

Objective: To explore and compare the effect of standard or prolonged dual antiplatelet therapy (DAPT) on the long-term prognosis of elderly patients with coronary heart disease complicated with diabetes mellitus after drug-eluting stent (DES) implantation. Methods: Consecutive patients with diabetes mellitus, ≥65 years old, underwent DES implantation, and had no adverse events within 1 year after operation underwent percutaneous coronary intervention (PCI) from January to December 2013 in Fuwai Hospital were enrolled in this prospective cohort study. These patients were divided into three groups according to DAPT duration: standard DAPT duration group (11 ≤ DAPT duration≤ 13 months) and prolonged DAPT duration group (13<DAPT duration≤ 24 months; DAPT duration>24 months). All the patients were followed up at 1, 6 months, 1, 2 and 5 years in order to collect the incidence of major adverse cardiovascular and cerebrovascular events (MACCE), and type 2 to 5 bleeding events defined by the Federation of Bleeding Academic Research (BARC). MACCE were consisted of all cause death, myocardial infarction, target vessel revascularization or stroke. The incidence of clinical adverse events were compared among 3 different DAPT duration groups, and Cox regression model were used to analyze the effect of different DAPT duration on 5-year long-term prognosis. Results: A total of 1 562 patients were enrolled, aged (70.8±4.5) years, with 398 female (25.5%). There were 467 cases in standard DAPT duration group, 684 cases in 13<DAPT duration≤ 24 months group and 411 cases in DAPT duration>24 months group. The patients in standard DAPT duration group and the prolonged DAPT duration groups accounted for 29.9% (467/1 562) and 70.1% (1 095/1 562), respectively. The 5-year follow-up results showed that the incidence of all-cause death in 13<DAPT duration≤ 24 months group (4.8%(33/684) vs. 8.6%(40/467),P=0.011) and DAPT duration>24 month group(4.1%(17/411) vs. 8.6%(40/467),P=0.008) were significantly lower than in standard DAPT group. The incidence of myocardial infarction in 13<DAPT duration≤ 24 months group was lower than in standard DAPT duration group (1.9%(13/684) vs. 5.1%(24/467),P=0.002). The incidence of MACCE in 13<DAPT duration≤ 24 months group was the lowest (standard DAPT duration group, 13<DAPT duration≤ 24 months group and DAPT duration>24 month group were 19.3% (90/467), 12.3% (84/684), 20.2% (83/411), respectively, P<0.001). There was no significant difference in the incidence of stroke and bleeding events among the three groups (all P>0.05). Multivariate Cox analysis showed that compared with the standard DAPT group, prolonged DAPT to 13-24 months was negatively correlated with MACCE (HR=0.601, 95%CI 0.446-0.811, P=0.001), all-cause death (HR=0.568, 95%CI 0.357-0.903, P=0.017) and myocardial infarction (HR=0.353, 95%CI 0.179-0.695, P=0.003). DAPT>24 months was negatively correlated with all-cause death (HR=0.687, 95%CI 0.516-0.913, P=0.010) and positively correlated with revascularization (HR=1.404, 95%CI 1.116-1.765, P=0.004). There was no correlation between prolonged DAPT and bleeding events. Conclusions: For elderly patients with coronary heart disease complicated with diabetes mellitus underwent DES implantation, and had no MACCE and bleeding events within 1 year after operation, appropriately prolonging of the DAPT duration is related to the reduction of the risk of cardiovascular adverse events. Patients may benefit the most from the DAPT between 13 to 24 months. In addition, prolonging DAPT duration does not increase the incidence of bleeding events in this patient cohort.

Total inferior border ostectomy versus T-shape genioplasty for chin narrowing combined with mandibular contouring

The objective of this study was to compare the indications and outcomes of the total inferior border ostectomy and T-shape genioplasty. A retrospective study was conducted using the clinical notes and records of patients who underwent total inferior border ostectomy (group 1, n = 42) and T-shape genioplasty (group 2, n = 60). The outcomes were evaluated by assessment of computed tomography images combined with medical records and photographs. Lower facial height, chin width, chin symmetry, and facial proportions, as well as patient satisfaction and complications were investigated. The data were collected preoperatively and 6-24 months postoperatively. All 102 patients showed an improved lower facial contour. No severe complications were observed during the follow-up period. Although the postoperative lower to midfacial height ratios were similar in the two groups (P = 0.080), both the preoperative and postoperative chin width to lower facial height ratios were lower in group 1 (both P < 0.001). A larger amount of chin narrowing, as well as better chin symmetry were observed in group 1 (P < 0.001). In conclusion, compared to the T-shape genioplasty, the total inferior border ostectomy is well suited for a longer, wider, and more asymmetrical chin. The surgical options should be considered and chosen quantitatively to achieve aesthetically pleasing results.

[A nested case-control study on the relationship between red blood cell folate and the prognosis of low-grade cervical intraepithelial neoplasia]

Objective: To evaluate the relationship between red blood cell folate (RBC folate) and the prognosis of low-grade cervical intraepithelial neoplasia (CIN 1). Methods: In the married women cohort established in 2014, 564 women with CIN 1 diagnosed by pathology were recruited. The demographic characteristics and factors of cervical intraepithelial neoplasia were collected. Meanwhile, the infection status of human papillomavirus (HPV) was detected by molecular diversion hybridization, and the level of RBC folate was measured by chemical photoimmunoassay. After 24 months of follow-up, pathological examination was performed again to observe the prognosis of participants. The women with reversal were taken as the control group,and those with continuous and progressive CIN 1 were taken as the case group respectively. The relationship between RBC folate and CIN 1 outcome was evaluated by logistic regression model. Results: 453 women completed the follow-up, aged (49.72±6.84) years old. CIN 1 was reversed in 342 women, continued in 58 cases and progressed in 53 cases. The RBC folate level M (Q_1,Q₃) were 399.01 (307.10, 538.97) ng/ml, 316.98 (184.74, 428.49) ng/ml and 247.14 (170.54, 348.97) ng/ml, respectively. With the decrease of RBC folate, the risk of continuous and progressive CIN 1 increased (all P<0.001), while the risk of reversal CIN 1 decreased gradually (P<0.001). Combined with high-risk human papillomavirus (HR-HPV) infection status, low level of RBC folate could increase the risk of CIN 1 progression regardless of HR-HPV infection (HR-HPV infection: OR=21.34, 95%CI: 3.98-114.54; HR-HPV uninfection: OR=11.15, 95%CI: 2.34-53.13). Conclusion: Low level of RBC folate could increase the risk of CIN 1 persistence and progression regardless of HR-HPV infection.

[The short-term and long-term prognostic analysis in patients with chronic total occlusion acute non-ST segment elevation myocardial infarction]

Objectives: To investigate the clinical impacts of chronic total occlusion (CTO) in acute non-ST segment elevation myocardial infarction (NSTEMI) patients underwent primary percutaneous coronary intervention (PCI). Methods: A total of 2 271 acute NSTEMI patients underwent primary PCI from China Acute Myocardial Infarction Registry were enrolled in this study and divided into the CTO group and the non-CTO group according to the angiography. The primary endpoint was in-hospital mortality and mortality during a 2-year follow-up. The secondary endpoint was major adverse cardiovascular events (MACE) including revascularization, death, re-myocardial infarction, heart failure readmission, stroke and major bleeding. Results: Thirteen-point four percent of the total acute NSTEMI patients had concurrent CTO. In-hospital mortality (3.6% vs. 1.4%, P<0.01) and 2-year mortality (9.0% vs. 5.1%, P<0.01) were significantly higher in the CTO group than those in the non-CTO group, respectively. Multiple regression analyses showed that chronic obstructive pulmonary disease (HR 7.28, 95%CI 1.50-35.35, P=0.01) was an independent risk factor of in-hospital mortality, and advanced age (HR 1.04, 95%CI 1.01-1.07, P<0.01), and low levels of ejection fraction (HR 0.95, 95%CI 0.93-0.98, P<0.01) were independent risk factors of 2-year mortality. CTO (HR1.67, 95%CI 1.10-2.54, P=0.02) was an independent risk factor of revascularization, but not a risk factor of mortality. Conclusions: Although acute NSTEMI patients concurrent with CTO had higher mortality, CTO was only an independent risk factor of revascularization, but not of mortality. Advanced age and low levels of ejection fraction were independent risk factors of long-term death among acute NSTEMI patients.

[Diagnostic value of surgical lung biopsies for diffuse parenchymal lung disease: the change of disease spectrum in the past 28 years in a single institution in China]

Objective: To investigate the changes of disease spectrum in diffuse parenchymal lung disease (DPLD) diagnosed by surgical lung biopsy, and to explore the diagnostic value of surgical lung biopsy in DPLD. Methods: Four hundred and fifty-five consecutive DPLD patients, who underwent surgical lung biopsy in Peking Union Medical College Hospital during the past 28 years, were analyzed retrospectively. Results: There were 211 males and 244 females. The average age at biopsy was (45±14) years. Four hundred and eleven cases (90.3%) were diagnosed by pathologic findings. Four hundred and forty-one cases (96.9%) were diagnosed by clinical-radiologic-pathologic multidisciplinary discussion. The 30-day mortality and 90-day mortality were 2.4% and 3.3% respectively. The disease spectrum included interstitial pneumonia in 209 cases (45.9%) (nonspecific interstitial pneumonia in 105 cases, usual interstitial pneumonia in 33 cases), other miscellaneous DPLD in 166 cases (36.5%) (including hypersensitivity pneumonitis in 49 cases), tumor in 39 cases (8.6%), and infectious diseases in 27 cases (5.9%). In the three consecutive periods (1993-2002, 2003-2012 and 2013-2020), the number of biopsies was 76 (16.7%), 297 (65.3%) and 82 (18%) respectively. The disease spectrum changes over time: in the above three periods, the percentage of interstitial pneumonia in DPLD was 68.4%, 45.1% and 28%, other miscellaneous DPLDs were 22.4%, 39.4% and 39.0%, the tumors were 2.6%, 7.4% and 18.3%, the infectious diseases were 5.3%, 5.1% and 9.8%. Conclusions: This study presented the changes of disease spectrum in DPLD diagnosed by surgical lung biopsy through single center real-world data, reflecting the progress of clinicians' understanding of DPLD and interstitial pneumonia. Surgical lung biopsy is still valuable for some difficult and complicated DPLD cases.

[The clinical efficacy of the stratification medical treatment based on the risk estimation of motor complications in Parkinson's disease]

Objectives: To evaluate the clinical efficacy of the stratification medical treatment based on the motor complications risk estimation in improving the quality of life, motor symptoms and delaying the motor complications in Parkinson's patients. Methods: Outpatients and inpatients from Xinhua Hospital, Shanghai Jiao Tong University, were recruited between November 2019 and June 2020. The participants were all clinically diagnosed with PD and treated with anti-PD medications, but had no history of motor complications, with the 8-item Parkinson's disease questionnaire summary index (PDQ-8 SI)>18.59. At baseline, the demographic characteristics, PD medical history, levodopa dosage (LD) and levodopa equivalent dosage (LED) were collected, and the evaluation of PDQ-8, Unified Parkinson's disease rating scale (UPDRS)-Ⅱ and Ⅲ, Hoehn and Yahr (H&Y) grade, Hamilton anxiety scale-14 (HAMA-14), Hamilton depression scale-24 (HAMD-24), mini-mental state examination (MMSE), Pittsburgh sleep quality index (PSQI), and Epworth sleepiness scale (ESS) tools was accomplished in all participants. Meanwhile, a Parkinson's disease risk estimation scale for motor complications was used to assess patients' risk of motor complications, and thus the medication was stratified in PD patients accordingly. During the 6-month and 12-month follow-ups, the evaluation of the above-mentioned parameters was repeated in all participants. At the 3-month and 9-month follow-ups, the information of anti-PD medications, the occurrence of motor complications (motor fluctuations and dyskinesia) and adverse drug reactions were recorded, and PDQ-8 was also evaluated. Results: Two hundred and fifty-one patients completed the 1-year follow-up, with 135 males and 116 females. At baseline, the median age of the patients was 66 (60, 71) years and the median PDQ-8 SI was 31.2 (21.9, 40.6). Additionally, 15.9% (40/251) of the patients were at high risk of motor fluctuation, and 7.2% (18/251) were at high risk of dyskinesia. There were significant differences in the age of onset, disease duration, PD treatment duration, the scores of UPDRS-Ⅱ and Ⅲ, H&Y Grade, and PDQ-8 SI among PD patients of different risk groups (all P<0.05). In the 12th month, the median of PDQ-8 SI, Δ PDQ-8 SI and Δ UPDRS-Ⅲ was 12.5 (9.4, 18.8), -15.6 (-21.9, -9.4) and -9(-16, -4), respectively, which was statistically different from that of baseline (all P<0.05). The change of UPDRS-Ⅱ scores in the group with high risk of motor fluctuation was statistically different from that in the groups with low and moderate risk (P<0.05). The changes of PSQI score, LD and LED in the group with high risk of dyskinesia was statistically different from those in the groups with low and moderate risk (all P<0.05). During the follow-up, the incidence of motor fluctuation and dyskinesia was 9.56% (24/251) and 5.97% (15/251), respectively. Conclusion: The stratification medical treatment might have a positive intervention effect on promoting a better quality of life, improving motor symptoms and delaying motor complications in PD patients.