Jianpi Huayu decoction inhibits the epithelial-mesenchymal transition of hepatocellular carcinoma cells by suppressing exosomal miR-23a-3p/Smad signaling.

ETHNOPHARMACOLOGICAL RELEVANCE: Jianpi Huayu decoction (JHD) is a traditional Chinese medicinal preparation used to treat a variety of malignant tumors including HCC, although the underlying mechanism remains unknown. Exosomes in the tumor microenvironment mediate intercellular signaling among cancer cells, but precise contributions to hepatocellular carcinoma (HCC) progression are still elusive. AIM OF THE STUDY: In this work, the main objective was to examine the mechanisms underlying anti-tumor effects of JHD and the potential contributions of exosomal signaling. MATERIALS AND METHODS: LC-MS/MS was used for quality control of JDH preparation, while nanoparticle tracking analysis (NTA), transmission electron microscopy (TEM) and western blotting were used for verification of exosomes. In vitro assays included CCK8, wound healing assay, transwell invasion assay, qRT-PCR and western blotting were performed to investigate the effects of JHD on HCC cells and the molecular mechanism. Furthermore, the effects of JHD on subcutaneous tumor model of nude mice were also determined. RESULTS: JHD inhibited the proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) of cultured HCC cells. Further, exosomes isolated from EMT-induced HCC cells promoted the migration, invasion and EMT of other cultured HCC cells, while exosomes isolated from EMT-induced HCC cells after JHD treatment had little effect. In addition, JHD reduced the expression of exosomal miR-23a-3p in cultured HCC cells. miR-23a-3p was significantly up-regulated in tumor compared with that in adjacent non-cancerous tissues of patients with HCC. HCC patients with high miR-23a-3p expression had poor overall survival after hepatectomy. Meanwhile, miR-23a-3p enhanced HCC cell proliferation, EMT, and expression of Smad signaling proteins. More importantly, overexpression of miR-23a-3p can reverse the inhibition of EMT and Smad signaling pathway caused by JHD treatment. In vivo assays, treatment with JHD also reduced the growth of HCC-derived tumors in nude mice, reduced the expression of miR-23a-3p in serum exosomes and the level of EMT in tumor cells. CONCLUSIONS: the antitumor effects of JHD on HCC are mediated at least in part by inhibition of EMT due to downregulation of exosome-mediated intercellular miR-23a-3p transfer and subsequent blockade of Smad signaling. Disrupting this exosomal miR-23a-3p/Smad signaling pathway may be an effective treatment.

JPHYD Inhibits miR-21-5p/Smad7-Mediated Epithelial-Mesenchymal Transition of Hepatocellular Carcinoma Cells.

Background: Studies have shown that Jianpi Huayu Decoction (JPHYD) can inhibit the growth of hepatocellular carcinoma cells, but the mechanism of its effect was not clear at present. Methods: We assessed the effect of JPHYD using liver cancer cells as in vitro cell model and xenograft tumor as in vivo model. CCK8, EdU, wound-healing, and transwell assays were performed to assess the cell growth, migration, and invasion of hepatocellular carcinoma (HCC) cell lines HepG2 and MHCC97H. Western blot assay was performed to observe the protein level of E-cadherin, Smad7, N-cadherin, Snail, Smad3, Vimentin, and Zeb1. qRT-PCR assay was used to observe the expression of miR-21-5p in clinical liver cancer tissue samples and in HepG2 and MHCC97H cells. Animal tumorigenesis experiments and in vivo imaging experiments were performed to assess the results of in vitro experiments. Results: We found that JPHYD could inhibit the proliferation, invasion, and migration of hepatocellular carcinoma cells and JPHYD decreased the level of N-cadherin, Snail, Vimentin, Smad3, and Zeb1 and increased E-cadherin and Smad7 proteins. The expression of miR-21-5p was increased while that protein of Smad7 was decreased in HCC tissues. The vivo experiments also showed that miR-21-5p could promote the migration of HCC cells. JPHYD decreased miR-21-5p expression. The same results have been found in animal studies. Conclusion: Our results indicated that JPHYD inhibited epithelial-mesenchymal transition by increasing Smad7 expression and inhibiting miR-21-5p. Therefore, blocking the occurrence and development of EMT may be a new mechanism of JPHYD's anti-liver cancer effect.

CircFGGY Inhibits Cell Growth, Invasion and Epithelial-Mesenchymal Transition of Hepatocellular Carcinoma via Regulating the miR-545-3p/Smad7 Axis.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide. Circular RNAs (circRNAs) play critical roles in the progression of HCC. However, the role of the newly identified circFGGY (hsa_circ_0006633) in the development and progression of HCC has not been explored. In this study, we found that circFGGY was significantly downregulated in tumor compared with that in adjacent normal liver tissues of patients with HCC. HCC patients with low circFGGY expression had poor overall survival after hepatectomy. Moreover, it was found that circFGGY could inhibit the proliferation, invasion and epithelial-mesenchymal transition of HCC both in vivo and in vitro. Mechanistically, circFGGY promoted the expression of Smad7, a well-known suppressor of the transforming growth factor-ß signaling pathway. In addition, miR-545-3p, a tumor promoter targeting both circFGGY and Smad7, suppressed the upregulation of Smad7 caused by circFGGY overexpression. Collectively, our data revealed that circFGGY inhibits the proliferation and invasion of HCC cells by sponging miR-545-3p and promote the expression of Smad7, indicating that circFGGY functions as a tumor suppressor and could be a prognostic biomarker for HCC.

[Using changes of left cardiac functional parameters and CPET evaluated the clinical effectiveness of individualized precise exercise overall program management of chronic disease I --Analysis between groups].

Objective: To explore and study the clinical usefulness of continuous dynamic recording of left cardiac function changes forevaluation the improvement in patients with chronic disease after 3 months of intensive control of individualized precision exercise overall manage program. Methods: From 2018 to 2021, 21 patients with chronic cardiovascular and cerebrovascular metabolic diseases mainly controlled by our team were selected to complete the cardiopulmonary exercise test (CPET) and Non-invasive synchronous cardiac function detector (N-ISCFD), electrocardiogram, radial pulse wave, jugular pulse wave and cardiogram data were continuously recorded for 50s.According to the titration results under CPET and continuous functional parameters monitoring, a holistic plan with individualized moderate exercise intensity as the core was developed for 3 months of intensive management, and then N-ISCFD data collection was repeatedafter signing the informed consent. All N-ISCFD data were analyzed in the 50s according to the optimal report mode of Fuwai Hospital and 52 cardiac functional indexes were calculated. The data before and after the enhanced control were compared and the paired T-test was used to statistically analyze the changes of groups. Results: Twenty-one patients with chronic diseases (16 male and 5 female) were (54.05±12.77,29~75) years, BMI (25.53±4.04,16.62~31.7) kg/m2.Comparison with baseline,the whole group analysis: ①The body weight, BMI, systolic blood pressure and diastolic blood pressure of patients were significantly decreased(P＜0.01).②CPET Peak VO2 was (64.93±24.22, 26.96~103.48) %Pred before enhanced control, and (85.22±30.31, 43.95~140.48) %Pred after enhanced control, and increased (35.09±27.87, 0.12~129.35) % after enhanced control compared with before enhanced control. The AT, Peak VO2/HR, Peak Work Rate, OUEP, FVC, FEV1, FEV3/FVC% and MVV were significantly increased (P＜0.01) and the Lowest VE/VCO2 and VE/VCO2 Slope were significantly decreased(P＜0.01).③Core indicators of left heart function:Ejection fraction was significantly increased from (0.60±0.12,0.40~0.88) to(0.66±0.09, 0.53~0.87)(P＜ 0.01), by (12.39±14.90,-12.32~41.11)%. The total peripheral resistance was significantly decreased from (1579.52±425.45,779.46~2409.61) G/(cm4·s),to(1340.44±261.49,756.05~1827.01) G/(cm4·s)(P＜0.01), by (12.00±17.27,37.79~28.61) %.The left stroke index, cardiac total power, ejective pressure and left ventricular end diastolic volumewere significantly improved (P＜0.05).The change analysis of each indicator for each patient is shown in the individualized analysis section of this study. Conclusion: Use CPET and continuous functional monitoring we can safely and effectively develop the overall program of individualized exercise in patients with chronic diseases. Long-term intensive management and control can safely and effectively significantly improve the cardiovascular function of patients. Continuous dynamic recording of changes in left and right cardiac functional parameters can be a simple way to supplement CPET to evaluate cardiovascular function.

[Individualization analysis of pulse wave shape characteristics before and after single precise power exercise in young healthy subjects].

Objective: To observe and study the resting radial artery pulse wave and the pulse wave changes after a single individualized exercise in young healthy normal subjects. Methods: We selected 16 young healthy graduate students, advanced training doctors, and visiting scholars from Fuwai Hospital without any disease diagnosis and low daily exercise. They first completed the symptom-restricted limit cardiopulmonary exercise testing (CPET). A single individualized exercise with Δ50% power as the exercise intensity was completed within one week after CPET. We measured and recorded 50 s pulse wave data before exercise and 10 min, 20 min, 30min after exercise, let the instrument automatically fix the point and then manually recheck to obtain each pulse wave characteristic point: starting point (B), main wave peak point (P1), trough of a repulse point (PL), crest of a repulse point (P2), and end point (E), and the raw data of the abscissa (time T) and ordinate (amplitude Y) corresponding to each point were derived from the instrument. We treated the end point E of the previous pulse wave as the start point B of the next wave, returned TB to zero, and got the main observation indicators: YB, YP1, YPL, YP2 and TP1, TPL, TP2, TE, and calculated out ΔYP1 (YP1-YB), ΔYPL (YPL-YB), ΔYP2 (YP2-YB), TE-TPL, (TE-TPL)/TPL, pulse rate, S1 (the slope of main wave ascending branch), S2 (the slope of dicrotic ascending branch), ΔYP2-ΔYPL and TP2-TPL as secondary observation indicators; defined the dicrotic wave with obvious crest as YP2>YPL, and calculated the occurrence rate of dicrotic wave with obvious crest (number of waveforms with YP2>YPL in 50 s /total number of waveforms×100%). We analyzed individually the 50 s pulse wave data of each subject before and after exercise, and then averaged all the data for overall analysis. Results: ①16 healthy young subjects (males 10, females 6), age (30.6±6.4, 24~48) years old; height (170.4±8.2, 160~188) cm; body mass (63.9±12.8, 43~87) kg. ②YB (87.2±5.8, 78.1~95.9), YP1 (223.5±15.8, 192.7~242.3), YPL (122.8±7.8, 110.0~133.8), YP2 (131.4±4.9, 116.7~137.5), TP1 (126.2±42.2, 94.2~280.0), TPL (360.2±44.8, 311.5~507.3), TP2 (432.4±50.8, 376.2~589.0), TE (899.7±86.9, 728.3~1042.0). ΔYP1 (136.3±19.9, 96.8~ 158.6), ΔYPL (35.7±10.7, 16.0~55.7), ΔYP2 (44.3±8.1, 22.5~56.5), TE-TPL (539.5±79.3, 405.9~691.3), (TE-TPL)/TPL (1.5±0.3, 0.8~2.0), pulse rate (67.3±6.6, 57.6~82.4), S1 (1.1±0.2, 0.6~1.4), S2 (0.1±0.1, 0.0~0.2), ΔYP2-ΔYPL (8.6±6.1, 0.9 ~19.8), TP2-TPL (72.3±19.9, 38.3~108.4). ③10 min after exercise, YPL (97.0±13.2 vs 122.8±7.8), YP2 (109.6±12.8 vs 131.4±4.9), ΔYPL (6.6±9.8 vs 35.7±10.7), ΔYP2 (19.3±11.2 vs 44.3±8.1), TE (667.8±123.1 vs 899.7±86.9), TE-TPL (330.2±128.4 vs 539.5±79.3), (TE-TPL)/TPL (1.0±0.4 vs 1.5±0.3) decreased, while the pulse rate (92.2± 14.0 vs 67.3±6.6), ΔYP2-ΔYPL (12.7±9.7 vs 8.6±6.1), TP2-TPL (98.0±38.1 vs 72.3±19.9) increased (all P<0.05). The trend of pulse wave changes at 20 min and 30 min after exercise was consistent with that at 10 min after exercise, but from 20 min, most of the indicators gradually recovered to the resting level before exercise. ④The incidence of dicrotic waves with obvious peaks in 16 young healthy persons at rest was 94.5%, and increased at 10 min (96.3%), 20 min (98.5%), and 30 min (99.8%) after exercise (all P<0.01). Among them, the incidence of dicrotic waves with obvious peaks before and after exercise was maintained at about 100% in 10 subjects. The appearance rate of 2 cases had reached 100% before exercise, but it decreased at 10 minutes after exercise, and then continued to increase, at 30 minutes recovered to 100%. Three subjects had a low resting rate and started to increase after exercise. In 1 case, the rate was low only 20 minutes after exercise, considering the influence of human factors. Conclusion: The influence of exercise on the pulse wave of normal people is mainly reflected in the dicrotic wave. On the whole, after a single precise power exercise, the position of the dicrotic wave is reduced, the amplitude is deepened, and the appearance rate of the dicrotic wave with obvious crest is generally increased, and this change can be maintained for at least 30 minutes. From an individual point of view, the response trend of each subject is different.

[Two types of exercise-induced abnormal blood pressure response in hypertrophic cardiomyopathy].

Objective: Insufcient exercise blood pressure response(blunted ABPR) and lower blood pressure during the recovery period (LBP)after exercise are common abnormalities in patients with hypertrophic cardiomyopathy (HCM). The purpose of this study was to analyze the related factors of these two types of abnormal blood pressure response in HCM patients and their relationship with cardiopulmonary function. Methods: A total of 219 consecutive HCM patients who underwent CPET in Fuwai hospital were recruited from April 1, 2018 to Jan 31, 2020 with a complete clinical assessment, including electrocardiography, HOLTER, rest echocardiography and cardiac MRI. One hundred and eleven healthy age- and gender-matched volunteers enrolled as control group. Results: The incidences of blunted ABPR and LBP in HCM patients were much higher than normal control group (8.7% vs 1.8%, P=0.016; 6.8% vs 0.0%, P=0.003, respectively). In HCM group, patients with blunted ABPR combined more coronary artery disease (CAD) (P=0.029), pulmonary hypertension (PH) (P=0.002) and atrial fibrillation/flutter (P=0.036) compared with patients without blunted ABPR. Compared with HCM patients without LBP, the patients with LBP had higher rest left ventricular outflow tract (LVOT) gradient (P=0.017) and left ventricular ejection fraction (P=0.043), more incidence of LVOT obstructive (P=0.015) and systolic anterior motion (P=0.022). After Logistic regression analysis, CAD and PH were independent factor of blunted ABPR, while LBP was only independently associated with rest LVOT gradient. Blunted ABPR was associated with lower Peak VO2, peak heart rate and hear rate reserve, and higher NT-proBNP (P=0.019), VE/VO2 (P=0.000). LBP was not associated with any index of cardiopulmonary function. Conclusion: The incidences of blunted ABPR and LBP in HCM patients were much higher than normal control group. In HCM patients, CAD and PH were independent determinants of blunted ABPR, while LBP was only independently associated with rest LVOT gradient. Patients with blunted ABPR had lower cardiopulmonary function, but LBP was not associated cardiopulmonary function.

[The characteristics of core parameters during cardiopulmonary exercise testing in patients with hypertrophy cardiomyopathy].

Objective: The patients with Hypertrophic CardioMyopathy (HCM), characterized by hypertrophy of the myocardium with a high risk of sudden death, was less clear for the exercise pathophysiology. Under the guidance of holistic integrative physiology and medicine (HIPM), the ramp protocol symptom-limited CardioPulmonary Exercise Testing (CPET) is the only method to evaluate the overall functional status of human body. We investigated the CPET pathophysiology in patients with HCM. Methods: From April 2017 to January 2020, 244 subjects were enrolled after signed the informed consent form and completing CPET in Fuwai Hospital. They 219 HCM patients and 25 healthy normal subjects as control (NS). The changes of CPET core parameters between two them were calculated, compared and did Individual analysis. Results: ①The gender of HCM was 163 maleand 56 female. The gender of NS was 11 male and 14 female. The age of HCM was (46.7±12.8, 16.0~71.0) year; NS was (43.7±10.4, 26.0~61.0) year.②The core CPET parameters of HCM: peak oxygen uptake (Peak VO2) was (65.2±13.8, 22.8~103.4) %pred; anaerobic threshold (AT) was (66.4±13.0, 33.7~103.5) %pred; Peak O2 pulse was (84.3±19.0, 90.9~126.0)%pred; oxygen uptake efficiency platform (OUEP) was (99.2±13.4, 69.1~155.5) %pred; Lowest VE/VCO2 was (108.0±13.2, 70.4~154.0)%pred; VE/VCO2 Slope was (108.5±17.9, 66.9~164.9)%pred. Compared with NS, the Peak VO2, AT, Peak O2 pulse, and OUEP were significantly decreased (P<0.01 or P<0.05), but the Lowest VE/VCO2 and VE/VCO2 Slope were significantly increased (P<0.05). For Individual analysis of the overall functional status of CPET, some were very sever but some HCM were still within the normal range.③ The Peak VO2 was positively correlated with AT, OUEP, Peak O2 pulse, and peak systolic blood pressure, but was negative correlated with Lowest VE/VCO2 and VE/VCO2 Slope. Conclusion: CPET is safe and specific characteristics for patients with HCM, which deserve further research and clinical application. Under HIPM guidance, CPET can not only be used for overall functional evaluation, disease diagnosis and differential diagnosis, risk stratification, curative effect evaluation and accurate prognostic prediction, but also be utilized in formulating the individualized training prescription and management of chronic diseases.

[Cardiopulmonary exercise testing (CPET)to evaluate the efficacy after intensive control of personalized precise exercise training for cardiovascular and cerebrovascular chronic diseases].

Objective: To study the symptom-restricted extreme cardiopulmonary exercise testing (CPET) to evaluate the improvement of the overall function of patients with long-term chronic diseases after intensive control of personalized precise exercise training for 3 months. Methods: We selected 20 patients with chronic cardiovascular and cerebrovascular metabolic diseases who were intensively controlled by our team from 2014 to 2016. After signing the informed consent form, based on the results of CPET and continuous functional tests, we formulated the overall management plan with individualized moderate exercise intensity as the core. After 3 months, CPET was performed. The changes of CPET indicators before and after intensive control in each patient were analyzed individually. Then the difference value and percentage difference value were calculated. Results: In this study, 20 patients (18 males and 2 females) with chronic cardiovascular and cerebrovascular metabolic diseases, aged (55.75±10.80, 26~73) years, height (172.20±8.63, 153~190) cm, weight (76.35±15.63, 53~105) kg, all patients were not any dangerous events during the period of CPET and intensive control.①After intensive control, the static pulmonary function index, resting systolic blood pressure, rate blood pressure product and fasting blood glucose were significantly improved (P<0.05).②Before intensive control, the peak oxygen uptake is (55.60±15.69, 34.37~77.45) % pred and anaerobic threshold is (60.11±12.26, 43.29~80.63)% pred; after intensive control, the peak oxygen uptake is (71.85±21.04, 42.40~102.00) % pred and anaerobic threshold (74.95±17.03, 51.90~99.47) %pred. Compared with before the intensive control, the peak oxygen uptake and anaerobic threshold of all patients after intensive control were significantly increased by (29.09±7.38,17.78~41.80) % and(25.16±18.38, 1.77~81.86)%(all P<0.01). Other core indexes were also improved significantly, including peak oxygen uptake,peak heart rate, peak work rate, oxygen uptake efficiency plateau, lowest value of carbon dioxide ventilatory efficiency, slope of ventilatory equivalent for carbon dioxide, ramp exercise duration(all P<0.01).③In terms of individualized analysis, after intensive control, the above 8 CPET core indexes were all improved in 15 cases, and 7 indexes in 5 cases were improved; the peak oxygen uptakeof all cases increased by more than 15%, 16 cases > 20%, 13 cases > 25%, 10 cases > 30%. Conclusion: CPET can safely, objectively and quantitatively evaluate the overall functional status and therapeutic effects, and guide the formulation of individualized precise exercise intensity. The overall plan of individualized precision exercise for three months can safely and effectively reverse the overall functional status of patients with long-term cardio-cerebrovascular metabolism diseases.

[Clinical observation and research on the use of precise electromagnetic power meter (arm dynamometer) for upper limbs to evaluate the holistic function of cardiopulmonary metabolism].

Objective: Subjects used upper limb (arm dynamometer) and lower limb precision electromagnetic power meter (cycle ergometer) to perform symptom-restricted limit cardiopulmonary exercise testing (CPET). Then we analyzed the clinical value of arm ergometer CPET. Methods: The upper limb and lower limb precision electromagnetic power meters were used to complete the CPET in two different days for 6 normal people and 9 chronic patients. We analyzed CPET data, calculated related core indicators, and compared normal subjects and chronic patients to analyze the similarities and differences between upper and lower extremities and their correlations. Results: ①Compared with 9 patients with chronic diseases, there were significant differences in age ((33.2±12.7) vs (53.6±8.5) years) and diagnosis in 6 normal people. ②The Peak HR ((131.0±19.0) vs (153.0±22.0) bpm,P<0.05) of upper limb CPET of 15 subjects were lower than lower limb CPET, but the difference in blood pressure was not statistically significant (P>0.05). The Peak VT ((1.3±0.4) vs (1.8±0.4) L) and Peak VE ((51.4±21.1) vs (67.9±22.1) L/min) of lower limb CPET were significantly higher than that of upper limb (all P<0.05), and there was no significant difference in Peak BF When upper limb CPET was used, EX-time ((6.4±0.6) vs (8.5±1.2) min) was shorter than lower limb CPET; Peak Work Rate((73.2±19.6) vs (158.5±40.3) W/min), Peak VO2 ((1.1±0.4) vs (1.7±0.4) L/min), AT ((0.6±0.2) vs (0.9±0.2) L/min), Peak VO2/HR ((8.6±2.3) vs (10.9±2.6) ml/beat), OUEP (34.7±4.3 vs 39.8±5.3)were lower, and the Lowest VE/VCO2(32.6±3.8 vs 28.7±4.9), VE/VCO2 Slope (33.9±4.3 vs 28.3±6.2)were higher than those of lower limb CPET (all P<0.05). The comparison results of the two subgroups of normal and chronic patients were the same as the holistic comparison results. ③EX-time, Peak HR, Peak BF, Peak VT and Peak VE of upper limb CPET had good correlation with the results of lower limb CPET. Besides, the measured value and percentage of the projected value of Peak Work Rate, the measured value, kilogram weight value of Peak VO2 and AT, and percentage of the projected value of Peak VO2, the measured value of Peak VO2/HR also had good correlation. The measured value of OUEP, the measured value and percentage of the projected value of Lowest VE/VCO2 and VE/VCO2 Slope were also the same, when the other indicators had no significant correlation. Conclusion: As a supplement to lower limb CPET, upper limb CPET is highly feasible and safe for holistic functional status assessment. It provides an important supplement to guide the implementation of the holistic plan of individualized precision exercise, which is worthy of our further exploration.

[A preliminary report on the variation of respiratory heart rate during sleep in normal subjects and patients with chronic diseases without sleep apnea].

Objective: The new theory of holistic integrative physiology and medicine, which describes the integrative regulation of respiratory, circulatory and metabolic systems in human body, generates the hypothesis of that breath is the origin of variability of circulatory parameters. We investigated the origin of heart rate variability by analyzing relationship between the breath and heart rate variability (HRV) during sleep. Methods: This retrospective study analyzed 8 normal subjects (NS) and 10 patients of chronic diseases without sleep apnea (CDs-no-SA). After signed the informed consent form, they performed cardiopulmonary exercise testing (CPET) in Fuwai Hospital and monitored polysomnography (PSG) and electrocardiogram (ECG) during sleep since 2014. We dominantly analyzed the correlation between the respiratory cycle during sleep and the heart rate variability cycle of the ECG R-R interval. The HRV cycle included the HR increase from the lowest to the highest and decrease from the highest to the lowest point. The number of HRV (HRV-n), average HRV time and other parameters were calculated. The breath cycle included complete inhalation and subsequent exhalation. The number of breath (B-n), average breath time and other breath parameters were analyzed and calculated. We analyzed each person's relationship between breath and HRV; and the similarities and differences between the NS and CDs-no-SA groups. Independent sample t test was used for statistical analysis, with P<0.05. Results: CPET core parameter such as Peak VO2 (83.8±8.9)% in NS were significantly higher than that (70.1±14.9)% in patients of chronic diseases without sleep apnea (P<0.05), but there was no difference between their AHI (1.7±1.3) in NS and AHI (2.9±1.2) in CDs-no-SA (P>0.05). The B-n and the HRV-n (6581.63±1411.90 vs 6638.38±1459.46), the average B time and the average HRV time (4.19±0.57)s vs (4.16±0.62)s in NS were similar without significant difference (P>0.05). The comparison of the numbers in CDs-no-SA were the number (7354.50±1443.50 vs 7291.20±1399.31) and the average times ((4.20±0.69)s vs (4.23±0.68)s) of B and HRV were similar without significant difference (P>0.05). The ratios of B-n/HRV-n in NS and CDs-no-SA were (0.993±0.027 vs 1.008±0.024) and both were close to 1 and similar without significant difference (P>0.05). The average magnitude of HRV in NS ((5.74±3.21) bpm) was significantly higher than that in CDs-no-SA ((2.88±1.44) bpm) (P<0.05). Conclusion: Regardless of the functional status of NS and CDs-no-SA, there is a similar consistency between B and HRV. The origin of initiating factors of HRV is the respiration.

[Preliminary analysis of the influence of breathing on heart rate variability in chronically ill patients with sleep apnea].

Objective: Based on the hypothesis that respiration causes variability of circulatory indicators proposed by the holistic integrated physiology and medicine theory, the correlation between respiration and heart rate variability during sleep in chronically ill patients with abnormal sleep breathing is analyzed. Methods: Eleven chronically ill patients with abnormal sleep breathing and apnea-hypopnea index (AHI) ≥15 times/hr are recruited. After signing the informed consent, they completed the standardized symptomatic restrictive extreme exercise cardiopulmonary exercise testing (CPET) and sleep breathing monitoring Calculate and analyze the rules of respiratory nasal airflow and ECG RR interval heart rate variability during the oscillatory breathing (OB) phase and the normal steady breathing phase of the patient during sleep, and use the independent sample t test to compare with normal people and no sleep breathing abnormalities in the same period in this laboratory. Of patients with chronic diseases are more similar and different. Results: The peak oxygen uptake and anaerobic threshold (AT) of CPET in chronic patients with abnormal sleep apnea were (70.8±13.6)% Pred and (71.2±6.1)% Pred; 5 cases of CPET had exercise induced oscillatory breathing (EIOB), 6 An example is unstable breathing, which indicates that the overall functional status is lower than normal. In this group of patients with chronic diseases, AHI (28.8±10.0) beats/h, the ratio of the total time of abnormal sleep breathing to the total time of sleep (0.38±0.25); the length of the OB cycle (51.1±14.4)s. The ratio (Bn/HRV-B-n) of the number of breathing cycles in the normal and steady breathing period to the number of heart rate variability cycles in this group of patients with chronic diseases is 1.00±0.04, and the CV (SD of HRV-B-M/x) is (0.33 ±0.11), blood oxygen saturation (SpO2) did not decrease significantly, the average amplitude of heart rate variability (HRV-B-M) of each respiratory cycle rhythm was (2.64±1.59) bpm, although it was lower than normal people (P<0.05) , But it was similar to chronic patients without sleep apnea (P>0.05). In this group of patients with chronic diseases, the ratio of the number of respiratory cycles to the number of heart rate variability cycles (OB-Bn/OB-HRV-B-n) during OB is (1.22±0.18), and the average amplitude of heart rate variability for each respiratory cycle rhythm in OB (OB -HRV-B-M) is (3.56±1.57)bpm and its variability (OB-CV = SD of OB-HRV-B-M/x) is (0.59±0.28), the average amplitude of heart rate variability in each OB cycle rhythm (OB-HRV-OB-M) is (13.75±4.25)bpm, SpO2 decreases significantly during hypoventilation during OB, and the average decrease in SpO2 during OB (OB-SpO2-OB-M) is (4.79±1.39)%. The OB-Bn/OB-HRV-B-n ratio, OB-HRV-OB-M and OB-SpO2-OB-M in the OB period are all significantly higher than the corresponding indicators in the normal stable breathing period Large (P<0.01). Although OB-HRV-B-M has no statistically significant difference compared with HRV-B-M in normal stable breathing period (P>0.05), its variability OB-CV is significantly increased (P<0.01). Conclusion: The heart rate variability of chronic patients with abnormal sleep breathing in the OB phase is greater than that of the normal stable breathing period. When the breathing pattern changes, the heart rate variability also changes significantly. The number of breathing cycles in the stable breathing period is equal to the number of heart rate variability cycles.The ratio is the same as that of normal people and chronically ill patients without sleep apnea, confirming that heart rate variability is respiratory origin; and the reduction of heart rate variability relative to the respiratory cycle during OB is directly caused by hypopnea or apnea at this time, and heart rate variability is also breathing source.

[Max test verify further clinical research for whether individualized symptom-limited cardiopulmonary exercise testing is the maximum extreme exercise].

Objective: To verify that the cardiopulmonary exercise testing (CPET) performed by clinical subjects is the maximum extreme exercise, we designed The Max test（Max）during clinical CPET. We used Max to verify the accuracy of the quantitative CPET evaluation result, and whether it is feasible and safe to use the specific value of a certain index as the standard for stopping CPET. Methods: Two hundred and sixteen cases from Fuwai Hospital were selected during June 2017 to January 2019,including 41 healthy person（control group） and 175with cardiovascular diseases（patient group）,The patients had a CPET peak RER ≤ 1.10, or the peak heart rate and peak blood pressure were basically non-responsive.The Max was first attempted in 60 subjects,and this study is further expanded . When the CPET ended, they had a 5-minute break, then the Max, during which, they cycled with a velocity of ≥ 60 r/min, at a constant intensity equivalent to to 130% of peak work,until exhausted.The difference and percentage difference between the peak heart rate and the peak oxygen uptake were calculated. ①If the percentage difference of heart rate and oxygen uptake are all less than -10%,then the Max is defined as failure,otherwise it is succesful. 2 If the percentage difference is between -10%~10%, then the Max is successful, which proved that the CPET is precise.③If the difference is ≥10%, the Max is successful, which proves that the CPET is non-extreme exercise. Results: Patient group's Peak VO2(L/min,ml/(min·kg)),anaerobic threshold (L/min,ml/(min·kg),%pred),Peak VO2/HR(ml/beat, % pred),Peak RER,Peak SBP,Peak WR,peak heart rate,OUEP （ratio,%pred） were lower than those of the control group(P<0.05)．The VE/ VCO2 Slope （ratio,%pred）and Lowest VE/ VCO2（ratio,%pred） were higher in the patient group than in the control group (P<0.05)．No adverse events occurred during the CPET and Max in all cases. Among the 216 cases,Max was successful in 198 cases(91.7%)．CPET was proved to be maximum extreme exercise for 182 cases,non-maximum extreme exercise for 16 cases,and failed in 18 cases(8.3%)．Conclusion: For CPET with a low peak RER and a maximum challenge,the Max can confirm the accuracy of the objective quantitative assessment of CPET. Max is safe and feasible,and that deserved further research and clinical application.

[A clinical research report on the pathophysiological characteristics of exercise in patients with mitral regurgitation].

Objective: Cardiopulmonary exercise testing (CPET) was used to investigate the exercise pathophysiology of mitral regurgitation. Methods: 26 patients with moderate and severe mitral regurgitation who completed standardized extreme exercise CPET under strict quality control after signing informed consent since 2016, and 11 normal subjects in the same period as the control group. The core indexes of CPET were analyzed and calculated according to the standard method and compared with normal subjects for intergroup statistical independent sample t-test. At the same time, the patients with heart failure and exercise oscillation breathing (OB) were divided into two subgroups: 11 cases without heart failure, 15 cases with heart failure, 8 cases with non-OB and 18 cases with OB, and their similarities and differences were compared between each subgroup. Results: The core indexes of CPET, such as peak oxygen uptake (85.60 ±9.06)%pred and anaerobic threshold (AT, (87.59 ±15.38)%pred) were normal. The peak oxygen uptake of CPET in patients with mitral regurgitation was (48.15 ±12.11)%pred, peak oxygen pulse was (66.57 ±12.20)%pred, AT was (56.75 ±11.50)%pred, oxygen uptake efficiency plateau was (88.24 ±16.42)%pred , lowest value of carbon dioxide ventilatory efficiency was (125.89 ±27.05)%pred and slope of carbon dioxide ventilatory efficiency was (128.31 ±31.68)%pred. Among them, only oxygen uptake efficiency plateau (OUEP) was normal and low, and the other indexes were significantly abnormal. There were significant differences between the patients and the control group (P<0.01). There was no significant difference between the non-OB group and the OB group, but there was significant difference between the non-OB group and the control group (P<0.05). There was no significant difference between the non-heart failure group and the heart failure group, but there was significant difference between the non-heart failure group and the control group. Conclusion: All the core indexes of cardiopulmonary exercise are significantly abnormal in patients with mitral regurgitation who are significantly lower than those in normal subjects except for the low effectiveness of oxygen ventilation. And with or without heart failure and OB did not affect the cardiopulmonary function.

[Individualized analysis of pulse wave shape before and after a single accurate power exercise in patients with long-term chronic diseases].

Objective: To observe and study the resting radial artery pulse wave and changes after a single individualized exercise in patients with long-term chronic diseases. Methods: We selected 16 patients with chronic disease (disease duration ≥5 years) who have been clearly diagnosed as hypertension and/or diabetes and/or hyperlipemia, and first completed the symptom-restricted limit cardiopulmonary exercise testing (CPET). Then a single individualized exercise with Δ50% power as the exercise intensity was completed within one week after CPET. We measured and recorded 50s pulse wave data before exercise and 10 min, 20 min, 30 min after exercise, then obtained each pulse wave characteristic point: starting point (B), main wave peak point (P1), trough of a repulse point (PL), crest of a repulse point (P2), and end point (E). The raw data of the abscissa (time T) and ordinate (amplitude Y) corresponding to each point were derived from the instrument. We treated the end point E of the previous pulse wave as the start point B of the next wave, returned TB to zero, and got the main observation indicators: YB, YP1, YPL, YP2 and TP1, TPL, TP2, TE, and calculated out ΔYP1, ΔYPL, ΔYP2, TE-TPL, (TE-TPL)/TPL, pulse rate, S1, S2 ,ΔYP2-ΔYPL and TP2-TPL as secondary observation indicators. Then calculated the occurrence rate of dicrotic wave with obvious crest. Finally we analyzed individually the 50 s pulse wave data of each patient before and after exercise, and then averaged all the data for overall analysis. Results: ①16 patients with long-term chronic diseases (males 14, females 2), ages (53.7±12.6, 28~80) years old, height (171.7±6.6, 155~183) cm, body weight (80.0±13.5, 54~98) kg. 2YB (91.5±10.8, 71.1~108.6), YP1 (203.6±24.7, 162.7~236.3), YPL (127.1±6.2, 118.2~140.3), YP2 (125.9±6.2, 115.7~137.7), TP1 ( 137.2±22.3, 103.0~197.1), TPL (368.7±29.5, 316.3~434.0), TP2 (422.7±32.8, 376.9~494.7), TE (883.4±95.0, 672.2~1003.3), ΔYP1 (112.1±33.8, 60.3~ 157.5), ΔYPL (35.5±14.2, 17.5~66.2), ΔYP2 (34.4±13.3, 20.0~62.9), TE-TPL (514.6±85.4, 341.4~621.9), (TE-TPL)/TPL (1.4±0.2, 1.0~1.7), pulse rate (68.8±8.4, 59.8~89.3), S1 (0.9±0.3, 0.4~1.4), S2 (0.0±0.0, -0.1~0.0), ΔYP2-ΔYPL (-1.2±2.6,- 6.5 ~ 2.5), TP2-TPL (54.0 ± 10.8, 33.6 ~ 81.1). ③10min after exercise, YB, YPL, YP2, TPL, TE decreased, YP1 increased. ΔYPL, TE-TPL, (TE-TPL)/TPL decreased, and ΔYP1, pulse rate, S1, ΔYP2-ΔYPL, TP2 -TPL increased (all P<0.05). The change trend of pulse wave at 20min and 30min after exercise was consistent with that at 10min after exercise, but most indicators gradually recovered to the resting level before exercise from 10 min. ④The appearance rate of dicrotic wave with obvious crest in 16 patients with long-term chronic disease at rest was 28.6%, and the appearance rate of 10 min (65.7%), 20 min (77.1%), 30 min (73.7%) after exercise was significantly increased (all P< 0.01). In 6 patients, the incidence of dicrotic waves with obvious peaks after exercise was significantly increased, and it could continue until 30 minutes. In 3 patients, the incidence increased significantly 10 minutes after exercise, and began to decrease at 20 minutes. In 1 patient, the rate of appearance only started to increase 20 minutes after exercise. In 2 patients, the incidence increased 10 minutes after exercise and then decreased. In 1 patient, the rate of occurrence increased briefly 20 minutes after exercise and then decreased. The incidence of 1 patient dropped after exercise and began to rise at 20 minutes. In 2 cases, the incidence rate did not increase after exercise, and it increased slightly after 30 minutes. Conclusion: In patients with long-term chronic diseases, the radial artery pulse wave is short and the dicrotic wave is not obvious or even disappears. After a single precise power exercise, the main wave increases, the position of the dicrotic wave decreases, and the amplitude increases. The specific response should be analyzed individually.

[The new theory CPET guides the overall plan of individualized precision exercise to effectively improve the overall functional status of "frailty"].

Objective: Under the guidance of the new theory of holistic integrated physiology and medicine, the effect of individualized accurate exercise program on the overall functional state was studied according to cardiopulmonary exercise testing (CPET). Methods: Li xx, female, 31 years old, has a fast heart rate since childhood (90~100 bpm), usually feel cold, especially in autumn and winter, and general health good. CPET was performed after signing the informed consent form at Fuwai Hospital in September 2019. Peak oxygen uptake, anaerobic threshold (AT), and peak cardiac output were (69~72)% pred, respectively, and the oxygen uptake ventilation efficiency and carbon dioxide exhaust ventilation efficiency were basically normal (96~100)% pred. The resting heart rate was fast, the blood pressure was low, the blood pressure response was weak during exercise, and the heart rate was mainly increased. The holistic integrated physiology medical theory pointed out that she was in weak health and heart weakness was the main manifestation. CPET was used to guide individualized precise exercise intensity titration, combine continuous beat-by-beat blood pressure, ECG, pulse and blood glucose dynamic monitoring to formulate an holisticplan of individualized quantitative exercise .Reexamine CPET after 8 weeks' strengthening management. Results: After 8 weeks of intensive holistic management, the limbs were warm and the cold symptoms disappeared. Re-examination of CPET peak oxygen uptake, AT and peak cardiac output were (90~98)% pred, which increased by (30~36)% respectively, and the holistic weak functional status was significantly improved; basically normal oxygen uptake ventilation efficiency and carbon dioxide exhaust ventilation efficiency also increased by (10~37)% respectively; resting heart rate and blood pressure basically returned to normal, and blood pressure and heart rate response during exercise were normal. Continuous ambulatory blood glucose monitoring indicated that the average blood glucose level decreased slightly and became more stable. Repeated measurement results of continuous ECG and beat-to-beat blood pressure also indicated a decrease in heart rate and an increase in blood pressure during rest, exercise and during sleep, and radial pulse wave. The amplitude of the dicrotic wave increases and becomes more pronounced. Conclusion: The new theoretical system to guide CPET to formulate an holistic plan for individualized precision exercise can safely and effectively enhance myocardial contractility, increase stroke volume, increase blood pressure, lower heart rate, stabilize and slightly lower blood glucose, and improve holistic functional status.

[The preliminary report of investigation: Using mask for cardiopulmonary exercise testing in Chinese children may result misinterpretation and misdiagnosis].

Objective: Observe the increased anatomical dead space of the mask, summarize the law of exercise induced oscillatory breathing (EIOB) in the results of CPET's new 9 figure, and analyze its incidence and age groups that are prone to oscillatory breathing. Methods: After signed the informed consent form by guardian, 501 children from pre-school to middle-school, aged 3~14 year, performed Harbor-UCLA standard protocol CPET with strict quality control in the CPET laboratory of Liaocheng Children's Hospital since 2014. CPET data was interpreted second by second from the breath by breath collection, averaged by 10s and then display by 9 plots. We analyzed the trends, pattern, incidence and age difference for EIOB and gas leakage. Results: The incidence of EIOB was the highest in the 3 to 6-year-old group, which was 42%. The 7 to 10-year-old group was 29.4% and the 11- to 14-year-old group was 29.9%. The three groups were tested by chi-square (x2=7.512), and the difference was statistically significant (P<0.05). 14 out of 508 children had air leakage during CPET, the incidence rate was 2.7%. Conclusion: The phenomenon of oscillatory breathing (OB) in children may be caused by the increased anatomical dead space of the mask, and it is not caused by disease. To improve the quality of CPET and to reduce clinical misdiagnosis, it is recommended to use a mouthpiece to decrease the dead space rather than the musk.

Using Integrated Bioinformatics Analysis to Identify Abnormally Methylated Differentially Expressed Genes in Hepatocellular Carcinoma.

OBJECTIVE: For the identification of abnormally methylated differentially expressed genes (MDEGs) in hepatocellular carcinoma (HCC), this study integrated four microarray datasets to investigate the fundamental mechanisms of tumorigenesis. METHODS: We obtained the expression (GSE76427, GSE57957) and methylation (GSE89852, GSE54503) profiles from Gene Expression Omnibus (GEO). The abnormally MDEGs were identified by using R software. We used the clusterProfiler package for the functional and pathway enrichment analysis. The String database was used to build the protein-protein interaction (PPI) network and visualize it in Cytoscape. MCODE was employed in the module analysis. Additionally, Gene Expression Profiling Interactive Analysis (GEPIA) and The Cancer Genome Atlas (TCGA) were employed to validate results. Lastly, we used cBioPortal software to examine the hub genetic alterations. RESULTS: We identified 162 hypermethylated, down-regulated genes and 190 hypomethylated, up-regulated genes. Up-regulated genes with low methylation were enriched in biological processes, such as keratinocyte proliferation, and calcium homeostasis. Pathway analysis was enriched in the AMPK and PI3K-Akt signaling pathways. The PPI network identified PTK2, VWF, and ITGA2 as hypomethylated, high-expressing hub genes. Down-regulated genes with high methylation were related to responses to peptide hormones and estradiol, multi-multicellular organism process. Pathway analysis indicated enrichment in camp, oxytocin signaling pathways. The PPI network identified CFTR, ESR1, and CXCL12 as hypermethylated, low-expressing hub genes. Upon verification in TCGA databases, we found that the expression and methylation statuses of the hub genes changed significantly, and it was consistent with our results. CONCLUSION: The novel abnormally MDEGs and pathways in HCC were identified. These results helped us further understand the molecular mechanisms underlying HCC invasion, metastasis, and development. Hub genes can serve as biomarkers for an accurate diagnosis and treatment of HCC, and PTK2, VWF, ITGA2, CFTR, ESR1, and CXCL12 are included.

Prognostic and Predictive Model for Stage II Colon Cancer Patients With Nonemergent Surgery: Who Should Receive Adjuvant Chemotherapy?

No ideal prognostic model has been applied to clearly identify which suitable high-risk stage II colon cancer patients with negative margins undergoing nonemergent surgery should receive adjuvant chemotherapy routinely. Clinicopathologic and prognostic data of 333 stage II colon cancer patients who underwent D2 or D3 lymphadenectomy during nonemergent surgery were retrospectively analyzed. Four pathologically determined factors, including adjacent organ involvement (RR 2.831, P = 0.001), histologic differentiation (RR 2.151, P = 0.009), lymphovascular invasion (RR 4.043, P < 0.001), and number of lymph nodes retrieved (RR 2.161, P = 0.011), were identified as independent prognostic factors on multivariate analysis. Importantly, a simple cumulative scoring system clearly categorizing prognostic risk groups was generated: risk score = ∑ coefficient' × status (AOI + histological differentiated + lymphovascular invasion + LNs retrieved). Our new prognostic model may provide valuable information on the impact of lymphovascular invasion, as well as powerfully and reliably predicting prognosis and recurrence for this particular cohort of patients. This model may identify suitable patients with an R0 resection who should receive routine postoperative adjuvant therapy and may help clinicians to facilitate individualized treatment. In this study, we aim to provide an ideal and quantifiable method for clinical decision making in the nonemergent surgical treatment of stage II colon cancer. Our prognostic and predictive model should be applied in multicenter, prospective studies with large sample sizes, in order to obtain a more reliable clinical recommendation.

Laparoscopic versus open gastrectomy for early gastric cancer in Asia: a meta-analysis.

OBJECTIVE: To perform a meta-analysis comparing laparoscopic versus open gastrectomy (LG vs. OG) for early gastric cancer (EGC) in Asia. METHODS: PubMed, Embase, CINAHL, AMED, the Cochrane database of Systematic Reviews, the Cochrane Controlled Trials Register, and the China National Knowledge Infrastructure electronic databases were systematically searched for studies published between January 1, 1992 and July 1, 2012. A series of clinical indices, including operative time, incision length, blood loss, harvested lymph nodes, time to flatus postoperatively, time to first oral intake postoperatively, use of analgesics, complications, duration of hospital stay, recurrence, and mortality were compared using weighted mean differences (WMDs) and odds ratios (ORs). RESULTS: Five randomized controlled trials and 11 case controls were included, including 1665 patients with EGC (919 LG, 746 OG). LG was associated with less trauma (incision length: WMD -12.91 cm; P<0.00001), less blood loss (WMD -121.04 mL, P<0.00001), less postoperative pain (number of times to use analgesics: WMD -1.64; P=0.001), faster bowel recovery (time to flatus: WMD -0.62 d; P=0.0001), fewer serious complications (OR 0.57; P=0.01), and shorter postoperative hospital stay (WMD -3.73 d; P=0.0007). However, LG had longer operative times (WMD 44.09 min; P<0.00001). LG also had fewer harvested lymph nodes, although this difference was not statistically significant (WMD -3.43 lymph nodes; P=0.04). There was no difference in recurrence rates (OR 0.58; P=0.33) and mortality between LG and OG. CONCLUSIONS: For the treatment of EGC in Asia, LG has several advantages, including safety, less trauma, and faster recovery. Our results should be validated in western studies.

[Regional lymph node staging and establishment of prognostic model for stage III( colon cancer].

OBJECTIVE: To evaluate the clinical value of different regional lymph node staging system and to establish a predictive prognostic model for stage III( colon cancer. METHODS: A total of 256 Patients with stage III( colon cancer from January 1999 to December 2008 were identified from the China Medical University Cancer and underwent radical surgery. Based on information on regional lymph nodes, lymph nodes were staged LNR staging using pN stage in the 7th edition of the AJCC, the jN stage of the JGR, and LNR-stage on the basis of Log-rank statistics, respectively. Using the linear trend chi-square test, likelihood ratio Chi-square test, concordant index(c-index) to evaluate the homogeneity, monotonicity, and discrimination power of the staging system. Univariate and multivariate analyses were used to determine the clinical and pathological prognostic impact factors. After relevant diagnostic models were established, the Akaike Information Criterion (AIC) value was calculated to compare and identify the best diagnostic model. RESULTS: Log-rank statistics found that 0.11 and 0.39 were the optimal cut-off point. LNR staging system included LNR1 (LNR<0.11), LNR2 (0.11,0.39), and LNR3(0.39,1). The concordance indices were 0.624 for pN, 0.611 for jN, and 0.700 for LNR. The heterogeneity was the lowest for LNR. Cox regression model was used to establish prognostic models for pN, jN, and LNR, and the AIC was 99.937, 71.631, and 65.548, respectively. The prognostic value was the highest for LNR. CONCLUSION: LNR staging is the ideal staging system for stage III( colon cancer patients, which is better than the latest version of the current AJCC pN stage and JGR jN staging.