[Epidemiological and clinical features of newly reported advanced schistosomiasis cases in Sichuan Province from 2011 to 2022]

OBJECTIVE

To analyze the epidemiological characteristics of newly reported advanced schistosomiasis cases in Sichuan Province, so as to provide the evidence for analyzing the causes and formulating targeted control measures of newly reported advanced schistosomiasis cases.

METHODS

Individual case investigation forms for advanced schistosomiasis cases were collected from the Sichuan Provincial Epidemic Annual Report System from 2011 to 2022, and patients' demographics, previous medical history and liver parenchymal grading were retrieved. All advanced schistosomiasis cases' medical records were reviewed, and the subtypes of schistosomiasis-endemic villages where the cases' household registration were, floating population, survival and death and time of death were collected.

RESULTS

A total of 321 newly reported advanced schistosomiasis cases were found in Sichuan Province from 2011 to 2022, with a male to female ratio of 0.99 to 1. There were 274 cases at ages of over 50 years (85.4%), with the highest proportion seen at ages of 60 to 69 years (87 cases, 27.1%), and splenomegaly was the most common type (180 cases, 56.1%), with no dwarfism type detected. The highest number of cases was reported in 2011 (78 cases), followed by in 2022 (74 cases), and the highest number of cases were reported in Meishan City (199 cases, 62.0%), Dongpo District (131 cases, 40.8%), and hilly subtype areas (136 cases, 42.4%). As of the end of 2022, there were 111 deaths due to advanced schistosomiasis, with the highest number of deaths seen in 2018 (25 deaths), and the highest mortality was seen among patients with the ascites type (41.2%). There were 47 (37.3%), 40 (59.5%) and 4 (23.5%) cases with grade III liver parenchyma among patients with splenomegaly, ascites, and colonic proliferation types, respectively, and there was a significant difference in the grading of III liver parenchyma among three types of patients (H = 12.092, P < 0.05), with more severe liver parenchyma injuries seen among patients with the ascites type than among those with splenomegaly and colonic proliferation type (Z = 24.262 and 44.738, both Padjusted values < 0.05).

CONCLUSIONS

There have been newly reported advanced schistosomiasis cases in Sichuan Province during recent years, and patients with the ascites type should be given a high priority among advanced schistosomiasis cases in Sichuan Province. Intensified clue surveys are needed for early identification and treatment of advanced schistosomiasis cases, so as to increase the survival rate and improve the quality of life.

In vitro and In vivo evidence demonstrating chronic absence of Ref-1 Cysteine 65 impacts Ref-1 folding configuration, redox signaling, proliferation and metastasis in pancreatic cancer

Ref-1/APE1 (Redox Effector/Apurinic Endonuclease 1) is a multifunctional enzyme that serves as a redox factor for several transcription factors (TFs), e.g., NF-kB, HIF-1α, which in an oxidized state fail to bind DNA. Conversion of these TFs to a reduced state serves to regulate various biological responses such as cell growth, inflammation, and cellular metabolism. The redox activity involves a thiol exchange reaction for which Cys65 (C65) serves as the nucleophile. Using CRISPR editing in human pancreatic ductal adenocarcinoma (PDAC) cells, we changed C65 to Ala (C65A) in Ref-1 to evaluate alteration of Ref-1 redox dynamics as well as chronic loss of Ref-1 redox activity on cell signaling pathways, specifically those regulated by NF-kB and HIF-1α. The redox activity of Ref-1 requires partial unfolding to expose C65, which is buried in the folded structure. Labeling of Ref-1 with polyethylene glycol-maleimide (PEGm) provides a readout of reduced Cys residues in Ref-1 and thereby an assessment of partial unfolding in Ref-1. In comparing Ref-1WT vs Ref-1C65A cell lines, we found an altered distribution of oxidized versus reduced states of Ref-1. Accordingly, activation of NF-kB and HIF-1α in Ref-1C65A lines was significantly lower compared to Ref-1WT lines. The bioinformatic data revealed significant downregulation of metabolic pathways including OXPHOS in Ref-1C65A expressing clones compared to Ref-1WT line. Ref-1C65A also demonstrated reduced cell proliferation and use of tricarboxylic acid (TCA) substrates compared to Ref-1WT lines. A subcutaneous as well as PDAC orthotopic in vivo model demonstrated a significant reduction in tumor size, weight, and growth in the Ref-1C65A lines compared to the Ref-1WT lines. Moreover, mice implanted with Ref-1C65A redox deficient cells demonstrate significantly reduced metastatic burden to liver and lung compared to mice implanted with Ref-1 redox proficient cells. These results from the current study provide direct evidence that the chronic absence of Cys65 in Ref-1 results in redox inactivity of the protein in human PDAC cells, and subsequent biological results confirm a critical involvement of Ref-1 redox signaling and tumorigenic phenotype.

[Tracking evaluation on the implementation of Survey of oncomelanid snails (WS/T 563-2017) in Sichuan and Anhui provinces]

To evaluate the implementation of Survey of oncomelanid snails (WS/T 563-2017) in schistosomiasis-endemic foci, two schistosomiasis-endemic counties were selected from two provinces of Sichuan and Anhui. Professional staff working in province-, city-, county- and township-level disease control and prevention institutions, parasitic disease control institutions or medical institutions were recruited, and the understanding, use and implementation of Survey of oncomelanid snails (WS/T 563-2017) were investigated using questionnaires and interviews. The awareness, use, proportion of propagation and implementation and correct rate of answering questions pertaining to Survey of oncomelanid snails (WS/T 563-2017) were analyzed. A total of 270 questionnaires were allocated, and 269 were recovered, including 254 valid questionnaires. The overall awareness of Survey of oncomelanid snails (WS/T 563-2017) was 84.64% (215/254), and propagation and implementation of Survey of oncomelanid snails (WS/T 563-2017) was not performed in 23.28% (17/73) of the survey institutions following implementation of Survey of oncomelanid snails (WS/T 563-2017), with meeting training and allocation of propagation materials as the main type of propagation and implementation. Among 254 respondents, 77.16% (196/254) were familiar with the standard, 66.14% (168/254) understood the conditions for use of the standard during snail surveys, and 96.85% (246/254) had the approach for identifying snails. In addition, there were 41.73% (106/254), 50.78% (129/254) and 7.48% (19/254) of respondents that considered the operability of Survey of oncomelanid snails (WS/T 563-2017) was very good, good and general, respectively. The findings demonstrate that the issue and implementation of Survey of oncomelanid snails (WS/T 563-2017) has filled the gap for the standardization of snail control techniques, and which plays an importang guiding role in the national schistosomiasis control program.

[Risk factors for the occurrence of laryngopharyngeal reflux disease in the aged and the clinical characteristics of patients complicated with pneumonia]

Objective: To investigate the risk factors for the occurrence of laryngopharyngeal reflux disease in the aged, and to analyze the characteristics of patients with pneumonia. Methods: Patients who underwent 24-hour laryngopharyngeal pH monitoring from June 2020 to July 2022 and the positive patients of those who underwent 24-hour esophageal pH monitoring from March 2017 to July 2022 at the Second Medical Center of the PLA General Hospital were enrolled retrospectively. Positive results of 24-hour laryngopharyngeal reflux monitoring were in the laryngopharyngeal reflux group, and the negative results were in the non-laryngopharyngeal reflux group. Patients with pneumonia and simple gastroesophageal reflux disease were in the esophageal reflux pneumonia group, and patients with pneumonia and simple laryngopharyngeal reflux disease were in the laryngopharyngeal reflux pneumonia group. Patients' basic data, co-morbidities, drug use and relevant examination and test results were collected. Multivariate logistic regression analysis was used to analyze the risk factors of laryngopharyngeal reflux disease in the aged and its relationship with pneumonia. Results: A total of 80 patients with 24-hour laryngopharyngeal pH monitoring were enrolled finally, including 34 cases, all male, aged (73±12) years, in the laryngopharyngeal reflux group, and 46 cases [44 males, 2 females, aged (78±11) years] in the non-laryngopharyngeal reflux group. Multivariate logistic regression analysis showed that the risk factors of laryngopharyngeal reflux disease in the aged included age ≤70 years (OR=13.07, 95%CI: 2.53-67.68), body mass index (BMI) (OR=1.37, each additional 1 kg/m2, 95%CI: 1.03-1.83), use of antipsychotic drugs (OR=8.00, 95%CI: 1.40-45.73) and calcium channel blockers (OR=5.27, 95%CI: 1.13-24.53) (all P<0.05). The protective factors of the laryngopharyngeal reflux disease in the aged included antacids (OR=0.19, 95%CI: 0.04-0.90, P=0.035). The incidence of pneumonia was higher in the laryngopharyngeal reflux group compared with the non-laryngopharyngeal reflux group [44.1% (15/34) vs 21.7% (10/46), P=0.033]. The esophageal reflux pneumonia group included 32 cases [31 males and 1 females, aged (84±12) years]. The laryngopharyngeal reflux pneumonia group included 15 cases [ 15 males, aged (79±11) years]. Compared to the patients in the laryngopharyngeal reflux pneumonia group, the patients in the esophageal reflux pneumonia group had a longer course of antibiotics [(27.7±27.0) vs (14.6±13.9) days, P=0.034], a higher frequency of seizure frequency [(4.3±3.0) vs (1.8±1.5) times/year, P<0.001] and a higher maximal body temperature [(38.2±0.9) vs (37.6±1.1) ℃, P=0.037]. Conclusions: The risk factors of laryngopharyngeal reflux disease in the aged included age ≤70 years, higher BMI, use of antipsychotic drugs and calcium channel blockers. The incidence of pneumonia in laryngopharyngeal reflux disease is higher, but the condition of pneumonia is milder.

[Schistosomiasis control in Sichuan Province since the 12th Five - Year Plan period: progress and prospects]

An ambitious goal has been set for elimination of schistosomiasis in all endemic counties (districts) in Sichuan Province by 2023. To achieve this goal, and to continue to consolidate the control achievements, it is necessary to understand the current endemic status of schistosomiasis, identify the challenges and analyze the experiences and lessons from the schistosomiasis control program, and develop targeted control strategies and interventions in the province. This paper reviews the progress of schistosomiasis control in Sichuan Province since the 12th Five-Year Plan period, analyzes the challenges in the schistosomiasis elimination program, and proposes recommendations for future directions and priorities.

Dosimetric Predictors of Acute Diarrhea in Locally Advanced Rectal Cancer Patients Treated with Neoadjuvant Chemoradiation with Capecitabine and Irinotecan: A Discovery and Validation Study

PURPOSE/OBJECTIVE(S)

Additional irinotecan can increase the pCR rate from 15% to 30% compared with capecitabine-based neoadjuvant chemoradiotherapy in locally advanced rectal cancer, while more acute diarrhea was induced and predictors of diarrhea have yet to be fully elucidated. In this analysis, we report the incidence of and factors associated with grade 3+ acute diarrhea in LARC patients treated with the CaplriRT regimen in the CinClare trial.

MATERIALS/METHODS

We identified the dosimetric markers with a lasso-Cox risk scoring model tested on CaplriRT group patients in the CinClare trial at our institution from 2015 to 2017 (CinClare, NCT02605265), and then independently validated according to a predefined protocol in patients treated with neoadjuvant chemoradiation with capecitabine and irinotecan from 2019 to 2022 (NCT05688033). Clinical documentation and patient-reported outcomes were reviewed to determine grade 3+ acute diarrhea events.

RESULTS

A total of 116 patients from Cinclare trial treated with CaplriRT regimen were used as a training cohort to obtain dosimetric prediction model and 168 patients were used for independent validation. The majority received 50 Gray (Gy) in 25 fractions with concurrent capecitabine and irinotecan. Median number of concurrent chemotherapy cycles received was 4 (IQR: 3-4). Seventeen (23.6%) patients treated with the CaplriRT regimen in the CinClare trial experienced grade 3+ acute diarrhea. Dosimetric predictors of acute diarrhea included peritoneal space volume receiving 25 Gy or greater (V25Gy). The single multivariate Cox regression, and receiver operating characteristic (ROC) curve analysis showed that the model had good predictive ability (p<0.05). It was also validated using the validation cohort. Patients with peritoneal space V25Gy>950 cm3 were associated with a higher risk of 3+ acute diarrhea compared with those without constraints of V25Gy (p = 0.002).

CONCLUSION

Peritoneal space V25Gy as an important predictor of acute diarrhea during capecitabine and irinotecan neoadjuvant chemoradiation treatment. Peritoneal space V25Gy < 950 cm3 may reduce acute diarrhea toxicity.

The role of a photographic atlas in reducing unanticipated healthcare utilization following circumcision

INTRODUCTION

Circumcision is a common procedure that can evoke caregiver anxiety in the postoperative period due to unfamiliarity with the healing process. To mitigate unnecessary healthcare utilization such as phone calls and unanticipated clinic or emergency department (ED) visits, photographic atlases have been developed to better prepare caregivers for the recovery process. The objective of our study is to further investigate the efficacy of a photographic atlas in its ability to decrease postoperative healthcare utilization using an increased sample size and extended study period compared to previous studies.

MATERIALS AND METHODS

In this study, we compared a prospective intervention cohort of patients undergoing circumcision at our institution who received a photographic atlas during postoperative teaching to a retrospective cohort of patients who had not received it. Our primary outcome was unanticipated healthcare utilization, defined as postoperative telephone calls and unanticipated presentations to the urology clinic or ED.

RESULTS

The retrospective no-atlas cohort included 105 patients, and the prospective intervention atlas cohort included 80 patients. Both groups were similar with respect to age (p = 0.47) and other demographics. There was no statistically significant difference in healthcare utilization between the no-atlas and atlas cohort. Specifically, we identified no difference in the number of phone calls to clinic staff (12 [11.4%] vs. 11 [13.8%], p = 0.64) or unanticipated postoperative clinic or ED visits (2 [1.9%] vs. 4 [5.0%], p = 0.41).

DISCUSSION

The use of a photographic atlas as part of caregiver support for circumcision patients did not demonstrate a statistically significant reduction in either postoperative phone calls or clinic/ED visits. The decrease in absolute number of caregiver phone calls was minimal (12-11), with a small increase in follow-up presentations (2-4). The lack of significant change may be due to the already infrequent occurrence of these events following circumcision, as demonstrated by the no-atlas cohort. Other potential advantages of the atlas, such as improved caregiver confidence and satisfaction, may have been present, but were not measured in this study.

CONCLUSIONS

Adding to the mixed results of previous studies, these findings do not support that photographic atlases decrease unanticipated healthcare utilization in children undergoing a circumcision. However, utilization was found to be low. Additionally, further studies are needed to determine other significant benefits of this form of education, such as improved caregiver confidence and satisfaction.

Differentially Expressed Circulating Long-Noncoding RNAS in Premature Infants with Respiratory Distress Syndrome

Purpose

Recent studies have addressed the association between lung development and long-noncoding RNAs (lncRNAs). But few studies have investigated the role of lncRNAs in neonatal respiratory distress syndrome (RDS). Thus, this study aimed to compare the expression profile of circulating lncRNAs between RDS infants and controls.

Methods

10 RDS infants and 5 controls were enrolled. RDS patients were further divided into mild and severe RDS subgroups. Blood samples were collected for the lncRNA expression profile. Subsequently, differentially expressed lncRNAs were screened out. Bioinformatics analysis was applied to establish a co-expression network of differential lncRNAs and mRNAs, and predict the underlying biological functions.

Results

A total of 135 differentially expressed lncRNAs were identified, including 108 upregulated and 27 downregulated lncRNAs (fold-change>2 and P<0.05) among the three groups (non-RDS, mild RDS and severe RDS groups). Of these lncRNAs, four were selected as showing higher fold changes and validated by qRT-PCR. ENST00000470527.1, ENST00000504497.1, ENST00000417781.5, and ENST00000440408.5 were increased not only in the plasma of total RDS patients but also in the severe RDS subgroup. Gene Ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) analyses showed that differentially expressed lncRNAs may play important roles in RDS through regulating PI3KAkt, RAS, MAPK, and TGF-β signaling pathways.

Conclusion

The present results found that ENST00000470527.1, ENST00000504497.1, ENST00000417781.5, and ENST00000440408.5 may be invol ved in RDS. This could provide new insight into research of the potential pathophysiological mechanisms of preterm RDS.

Puerarin: a potential natural neuroprotective agent for neurological disorders

Puerarin is an isoflavone compound derived from Pueraria lobata in traditional Chinese medicine. Accumulating evidence has indicated that puerarin demonstrates multiple pharmacological effects and exhibits treatment potential for various neurological disorders. Based on the latest research progress on puerarin as a neuroprotective agent, its pharmacological activity, molecular mechanism, and therapeutic application were systematically reviewed with emphasis on pre-clinical studies. The related information was extracted and compiled from major scientific databases, including PubMed, ScienceDirect, SpringerLink, and Chinese National Knowledge Infrastructure, using 'Puerarin', 'Neuroprotection', 'Apoptosis', 'Autophagy', 'Antioxidant', 'Mitochondria', 'Anti-inflammation' as keywords. This review complied with The Preferred Reporting Items for Systematic Reviews criteria. Forty-three articles met established inclusion and exclusion criteria. Puerarin has shown neuroprotective effects against a variety of neurological disorders, including ischemic cerebrovascular disease, subarachnoid hemorrhage, epilepsy, cognitive disorders, traumatic brain injury, Parkinson's disease, Alzheimer's disease, anxiety, depression, diabetic neuropathy, and neuroblastoma/glioblastoma. Puerarin demonstrates anti-apoptosis, proinflammatory mediator inhibitory, autophagy regulatory, anti-oxidative stress, mitochondria protection, Ca²⁺ influx inhibitory, and anti-neurodegenerative activities. Puerarin exerts noticeable neuroprotective effects on various models of neurological disorders in vivo (animal). This review will contribute to the development of puerarin as a novel clinical drug candidate for the treatment of neurological disorders. However, well-designed, high-quality, large-scale, multicenter randomized clinical studies are needed to determine the safety and clinical utility of puerarin in patients with neurological disorders.

[Clinical features and CT findings of fibrosing mediastinitis associated pulmonary hypertension]

Objective: To investigate the clinical features and CT findings of pulmonary hypertension (PH) in patients with fibrosing mediastinitis (FM). Methods: Thirteen patients with FM diagnosed between September 2015 and June 2022 were studied retrospectively, including patients with PH (FM-PH group) and patients without PH (FM group) confirmed on right heart catheterization. The t test of two independent samples, Mann-Whitney U rank sum and Fisher's test were used to compare the general information, symptoms, laboratory examination, right ventricular and pulmonary artery measurement data and pulmonary artery CT findings between the two groups, respectively. Results: Compared with the 7 FM patients aged 28-79 (60.00±17.69) years, the 6 patients in the FM-PH group, aged from 60 to 82 (68.83±8.35) years, had more peripheral edema, lower percentage of PaO₂, wider inner diameters of pulmonary artery and right ventricle, a higher ratio of right ventricle and left ventricular transverse diameter, faster tricuspid regurgitation velocity and higher estimated systolic pulmonary artery pressure (P<0.05). There were no differences in BNP levels and tricuspid annular plane systolic excursion between groups (P>0.05). Of the 6 patients with PH, 5 had precapillary PH and 1 had mixed PH. Except that the pulmonary vascular resistance in patients of the FM-PH group was significantly higher than that in the FM group (P<0.05), there were no significant differences in cardiac output, mixed venous oxygen saturation and pulmonary capillary wedge pressure between the two groups. CT pulmonary angiography (CTPA) showed pulmonary artery and vein stenosis. Patients in the FM-PH group had more severe stenosis and occlusion of pulmonary artery and pulmonary vein (P<0.05), and more involvement of multiple pulmonary veins (P<0.05). Conclusions: The clinical manifestation of FM complicated with PH is related to the degree of involvement of pulmonary artery, vein and airway. It is recommended that the disease be evaluated in combination with multiple parameters such as clinical manifestations, cardiac ultrasound, right cardiac catheter and CTPA.

[Epidemiological characteristics of a 2019-nCoV outbreak caused by Omicron variant BF.7 in Shenzhen]

Objective: To explore the epidemiological characteristic of a COVID-19 outbreak caused by 2019-nCoV Omicron variant BF.7 and other provinces imported in Shenzhen and analyze transmission chains and characteristics. Methods: Field epidemiological survey was conducted to identify the transmission chain, analyze the generation relationship among the cases. The 2019-nCoV nucleic acid positive samples were used for gene sequencing. Results: From 8 to 23 October, 2022, a total of 196 cases of COVID-19 were reported in Shenzhen, all the cases had epidemiological links. In the cases, 100 were men and 96 were women, with a median of age, M (Q₁, Q₃) was 33(25, 46) years. The outbreak was caused by traverlers initial cases infected with 2019-nCoV who returned to Shenzhen after traveling outside of Guangdong Province.There were four transmission chains, including the transmission in place of residence and neighbourhood, affecting 8 persons, transmission in social activity in the evening on 7 October, affecting 65 persons, transmission in work place on 8 October, affecting 48 persons, and transmission in a building near the work place, affecting 74 persons. The median of the incubation period of the infection, M (Q₁, Q₃) was 1.44 (1.11, 2.17) days. The incubation period of indoor exposure less than that of the outdoor exposure, M (Q₁, Q₃) was 1.38 (1.06, 1.84) and 1.95 (1.22, 2.99) days, respcetively (Wald χ²=10.27, P=0.001). With the increase of case generation, the number and probability of gene mutation increased. In the same transmission chain, the proportion of having 1-3 mutation sites was high in the cases in the first generation. Conclusions: The transmission chains were clear in this epidemic. The incubation period of Omicron variant BF.7 infection was shorter, the transmission speed was faster, and the gene mutation rate was higher. It is necessary to conduct prompt response and strict disease control when epidemic occurs.

Circ_0004104 participates in the regulation of ox-LDL-induced endothelial cells injury via miR-942-5p/ROCK2 axis

BACKGROUND

Cardiovascular disease was the most common disease among the elderly with high morbidity and mortality. Circ_0004104 was demonstrated to be involved in the regulation of atherosclerosis.

METHODS

Quantitative real-time polymerase chain reaction was employed to measure the expression of circ_0004104, miR-942-5p and Rho associated coiled-coil containing protein kinase 2 (ROCK2). Cell proliferation was tested by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) assay. Cell apoptosis was measured by flow cytometry, and tube formation assay was used to detect the angiogenesis ability of cells. Western blot assay was performed to assess protein levels. Enzyme‑linked immunosorbent assay was used to detect the release of IL-1β and TNF-α. The relationship between miR-942-5p and circ_0004104 or ROCK2 was identified by dual-luciferase reporter assay, RNA immunoprecipitation (RIP) assay, and RNA pull-down assay.

RESULTS

Oxidized low-density lipoprotein (ox-LDL) inhibited the proliferation of human umbilical vein endothelial cells (HUVECs) and promoted apoptosis in a dose-dependent manner. Circ_0004104 was increased in serum of atherosclerosis patients and ox-LDL-treated HUVECs, and silence of circ_0004104 promoted the proliferation of ox-LDL-exposed HUVECs and inhibited cell apoptosis. MiR-942-5p downregulation reversed si-circ_0004104-mediated influences in HUVECs upon ox-LDL exposure. ROCK2 was the target of miR-942-5p and circ_0004104 regulated the expression of ROCK2 through sponging miR-942-5p. ROCK2 abated the influences of miR-942-5p in ox-LDL-stimulated HUVECs. Circ_0004104 was increased in the exosomes derived from ox-LDL-exposed HUVECs, and the expression of circ_0004104 was promoted in HUVECs after stimulation with ox-LDL-treated HUVECs cells-derived exosomes.

CONCLUSION

Circ_0004104 downregulation receded ox-LDL-induced injury in HUVECs through miR-942-5p and ROCK2.

[A study on the burden of myocarditis in China in 1990 and 2019]

Objective: To investigate Chinese myocarditis burden and trends in 1990 and 2019. Methods: Based on the Global Burden of Disease (GBD) 2019 data, the number of patients, the number of new cases, the number of deaths, the disability-adjusted life years (DALYs), as well as the morbidity, mortality, DALYs rate and their age-standardized rates were used to analyze the trend and the burden of myocarditis in the Chinese population in 1990 and 2019. Results: In 2019, the number of patients, the number of new cases and the number of deaths with myocarditis in China were 234 900, 275 100 and 13 100 respectively, increasing by 85.62%, 47.51% and 50.22% compared with 1990. The age-standardized incidence and mortality were 16.94/100 000 and 0.92/100 000, respectively. Compared with 1990, the age-standardized incidence in 2019 decreased by 6.06%, and the mortality decreased by 16.04% respectively. The age-standardized incidence and mortality of Chinese male patients with myocarditis were higher than that of female. Compared with 1990, the age group with the largest incidence and mortality of myocarditis in China in 2019 all shifted to the elder group. And, DALYs and age-normalized DALYs due to myocarditis in China showed a decreasing trend in 2019, from 458 600 and 42.51/100 000 in 1990 to 341 300 and 25.39/100 000 in 2019, respectively. The rate of DALYs and age-standardized DALYs in male patients was always higher than female. Conclusions: Compared with 1990, the overall burden of myocarditis in China showed a downward trend in 2019, and the burden of myocarditis in male patients was higher than female. More attention should be paid to the burden of myocarditis in Chinese elderly population.

Microfluidics-enabled functional 3D printing

Microfluidic technology has established itself as a powerful tool to enable highly precise spatiotemporal control over fluid streams for mixing, separations, biochemical reactions, and material synthesis. 3D printing technologies such as extrusion-based printing, inkjet, and stereolithography share similar length scales and fundamentals of fluid handling with microfluidics. The advanced fluidic manipulation capabilities afforded by microfluidics can thus be potentially leveraged to enhance the performance of existing 3D printing technologies or even develop new approaches to additive manufacturing. This review discusses recent developments in integrating microfluidic elements with several well-established 3D printing technologies, highlighting the trend of using microfluidic approaches to achieve functional and multimaterial 3D printing as well as to identify potential future research directions in this emergent area.

[Safety and feasibility of intrathoracic modified overlap esophagojejunostomy in laparoscopic radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction]

Objective: The study aimed to investigate the safety and feasibility of intrathoracic modified overlap method in laparoscopic radical resection of Siewert type II adenocarcinoma of the esophagogastric junction (AEG). Methods: A descriptive case series study was conducted. The clinical data of 27 patients with Siewert type II AEG who underwent transthoracic single-port assisted laparoscopic total gastrectomy and intrathoracic modified overlap esophagojejunostomy in Guangdong Provincial Hospital of Chinese Medicine from May 2017 to December 2020 were retrospectively analyzed. The intrathoracic modified overlap esophagojejunostomy was performed as follows: (1) The Roux-en-Y loop was made; (2) The jejunum side was prepared extraperitoneal for overlap anastomosis; (3) The esophagus side was prepared intraperitoneal for overlap anastomosis; (4) The overlap esophagojejunostomy was performed; (5) The common outlet was closed after confirmation of anastomosis integrity without bleeding; (6) A thoracic drainage tube was inserted into the thoracic hole with the diaphragm incision closed. The intraoperative and postoperative results were reviewed. Results: All 27 patients were successfully operated, without mortality or conversion to laparotomy. The operative time, digestive tract reconstruction time and esophageal-jejunal anastomosis time were (327.5±102.0) minute, 50 (28-62) minute and (29.0±7.4) minute, respectively. The blood loss was 100 (20-150) ml. The postoperative time to flatus and postoperative hospital stay were (4.7±3.7) days and 9(6-73) days, respectively. Three patients (11.1%) developed postoperative grade III complications according to the Clavien-Dindo classification, including 1 case of anastomotic fistula with empyema, 1 case of pleural effusion and 1 case of pancreatic fistula, all of whom were cured by puncture drainage and anti-infective therapy. Conclusions: The intrathoracic modified overlap esophagojejunostomy is safe and feasible in laparoscopic radical resection of Siewert type II AEG.

[The disease burden of degenerative mitral valve disease in the Chinese population from 1990 to 2019]

Objective: To explore the trend of disease burden of degenerative mitral valve disease (DMVD) in the Chinese population from 1990 to 2019. Methods: Based on the 2019 Global Burden of Disease database (GBD 2019), the number of patients, the number of new cases, the number of deaths, the disability-adjusted life years (DALY) as well as the prevalence, incidence and death rate, DALY rate and their age-standardized rates were used to analyze the trend of the burden of DMVD in the Chinese population from 1990 to 2019. Results: In 2019, the number of patients, the number of new cases, and the number of deaths with DMVD in China were 461.2, 27.0 and 0.129 ten thousand, respectively, which increased by 209.0%, 199.1% and 13.2% when compared with 1990. In 2019, the age-standardized prevalence, incidence and death rate were 228.1/100 000, 12.7/100 000 and 0.075/100 000, respectively. Compared with 1990, the change of the age-standardized prevalence, incidence and death rate were 32.6%, 42.8% and -54.1%, respectively. In addition, the 2019 data also showed that the age-standardized prevalence and incidence were higher in females than in males (the age-standardized prevalence was 190.1 (181.5-198.9)/100 000 for males and 262.0 (250.3-273.9)/100 000 for females); the age-standardized incidence was 10.5 (10.0-11.0)/100 000 for males and 14.9 (14.3-15.6)/100 000 for females. The age group with the largest number of DMVD patients was 65 to 69 years old, and the highest incidence was 60 to 64 years old. From 1990 to 2019, DALY caused by DMVD showed an upward trend in China, from 46 439 person-years in 1990 to 69 402 person-years in 2019, with an increase of 49.4%. While the age-standardized DALY rate continued to decline, from 5.5/100 000 in 1990 to 3.8/100 000 in 2019, with a drop of 30.8%. The DALY and the age-standardized DALY rate of females were always higher than that of males in different years. Conclusion: From 1990 to 2019, DALY and the age-standardized prevalence and incidence of DMVD in China shows an increasing trend, and the disease burden caused by DMVD is severe in China.

[Induction of peripheral blood mononuclear cells to hepatocyte-like cells and preliminary study of cell response to injury under the effect of acetaminophen]

Objective: To establish a method for the induction of peripheral blood mononuclear cells to hepatocyte-like cells, and preliminarily investigate cell response to injury under the effect of acetaminophen (APAP). Methods: The surface marker CD45 of peripheral blood mononuclear cells wase detected cells by using flow cytometry and immunofluorescence methods. The cellular morphology of induced hepatocyte-like cells was observed under an inverted microscope. Real-time fluorescent quantitative PCR (RT-PCR) was used to detect the expression level of hepatocyte-specific genes, such as cytochrome (CY) P1A2, CYP3A4, CYP2C9, albumin (ALB), alpha-fetoprotein (AFP), and hepatocyte nuclear factor (HNF)4α mRNA. Immunofluorescence method was used to detect intracellular hepatocyte markers AFP, HNF4α, and ALB expression at the protein level. Biochemical analyzer was used to detect hepatocyte-specific secretory functions of AFP, ALB, and urea. Luciferase chemiluminescence method was used to detect the activity of key drug metabolizing enzyme CYP3A4. Colorimetric assay was used to detect the effect of the drug acetaminophen on hepatocyte-like cells, and alanine aminotransferase (ALT) was used as an indicator of liver cell injury. The statistical differences between the data were compared with t-test and rank-sum test. Results: The positive expression rate of CD45 cell surface markers isolated from peripheral blood mononuclear cells was about 98%, and hepatocyte-like cell morphology changes appeared on 15th day of induction. Compared with isolated mononuclear cells, CYP1A2, CYP3A4, CYP2C9, ALB, AFP and HNF4α mRNA was markedly elevated. The expression level of AFP, ALB and HNF4α protein were equally increased, and the secretory function of AFP, ALB and urea were enhanced. Compared with primary hepatocytes, CYP1A2, CYP2C9, AFP, HNF4α mRNA, and CYP3A4 mRNA did not decrease. The expression levels of AFP, ALB, and HNF4α proteins in the cells did not decrease, and the secretory function of AFP, ALB, and urea did not decrease. In addition, the CYP3A4 enzyme activity produced by hepatocyte-like cells was similar to that of primary hepatocytes. Compared with hepatocyte-like cells incubated without APAP, hepatocyte-like cells incubated with APAP had higher ALT level. Under the effect of APAP, the ALT level of hepatocyte-like cells was higher than isolated mononuclear cells. Conclusion: Peripheral blood mononuclear cells can be induced into hepatocyte-like cells with partial characteristics of hepatocytes, including the activity of CYP3A4, a key enzyme of hepatocyte drug metabolism. Additionally, preliminarily ALT secretory features reflect the hepatocytes injury under the effect of acetaminophen.

Correlation of Four Single Nucleotide Polymorphisms of the RELN Gene With Schizophrenia

OBJECTIVE

This study aims to determine the association between single-nucleotide polymorphisms (SNPs) of the RELN gene and schizophrenia.

METHODS

134 patients aged 16 to 58 (mean, 38.0) years who were diagnosed with acute or chronic schizophrenia at the Zhongshan Third People's Hospital between January 2018 and April 2020 were recruited, as were 64 healthy controls aged 22 to 59 (mean, 45.6) years who matched with the age and sex of the patients. MassARRAY mass spectrometry genotyping technology was used to determine the genotypes of four SNPs of RELN (rs2073559, rs2229864, rs362691, and rs736707).

RESULTS

There were no significant between-group or between-sex differences in terms of genotype, allele frequency, or haplotype frequency of the SNPs (all p > 0.05). In the association analysis between genotypes and quantitative traits in the Positive and Negative Syndrome Scale, rs2229864 and rs736707 were associated with the scores for items P3 (hallucinatory behaviour) and G11 (attention disorder), and rs362691 was associated with G10 (disorientation). However, the associations did not remain significant after Bonferroni correction.

CONCLUSION

Multiple pathogenic polymorphisms of RELN might be associated with hallucinatory behaviour and attention disorder in Chinese patients with schizophrenia.

Risk of herpesvirus, serious, and opportunistic infections in atopic dermatitis: a population-based cohort study

BACKGROUND

Staphylococcal and herpes simplex virus (HSV) infections are commonly recognized in atopic dermatitis (AD) but less is known about other types of infections.

OBJECTIVES

To determine the risk of herpesvirus infections, serious infections, and opportunistic infections in patients with AD.

METHODS

We conducted a population-based cohort study using UK-based electronic medical records data. Patients with AD were each matched to up to 5 unaffected patients on age, practice, and index date. AD severity was defined using treatments. The outcomes were incident herpesvirus infections (cytomegalovirus [CMV], Epstein-Barr virus [EBV], HSV, or varicella zoster virus [VZV]), serious infections, and opportunistic infections.

RESULTS

409,431 children and 625,083 adults with AD were matched to 1,809,029 children and 2,678,888 adults without AD, respectively. In adjusted Cox regression models, children and adults with AD had 50-52% greater risk of HSV and 18-33% greater risk of VZV, with risk increasing in parallel with AD severity. CMV risk was elevated among children with AD (HR 2.50 [1.38-4.54]) and adults with severe AD (4.45 [1.76-11.25]). Patients with AD had 26-40% increase in risk of serious infections, with severe AD carrying greatest risk. Although rare, opportunistic infections were not associated with AD in children but were associated with all severities of AD in adults (overall HR 1.31 [1.20-1.42]). All estimates remained consistent after excluding patients receiving immunosuppressive treatments for AD.

CONCLUSIONS

AD is significantly associated with herpesvirus infections, serious infections, and opportunistic infections in a dose-responsive manner with severity. AD may increase susceptibility to infections exclusive of immunosuppressive medications.

Adipose-derived exosomes impairs endothelial transient receptor potential vanilloid 4 channels and elevates blood pressure in abdominal obesity

Aim

Large epidemiological studies have found that abdominal obesity is a strong risk factor for hypertension. Impaired endothelium-dependent vasodilation is a hallmark of obesity-induced hypertension. Adipose-derived exosomes can regulate distant tissues as novel adipokines, providing a new mechanism for cell-cell interactions. However, the effects of adipose-derived exosomes on obesity-induced hypertension are unknown.

Methods

We extracted three adipose-derived exosomes, including high-fat diet (HFD) mouse serum exosome, adipose tissue exosome, and adipose-derived stem cell exosome, and further explored their effects on endothelium-dependent vasodilation in vivo and in vitro.

Results

Impairment of endothelial transient receptor potential vanilloid 4 (TRPV4) channel activity and vasodilation were observed in the arteries from abdominal obesity patients. Ca2+ influx through TRPV4 channels at myoendothelial projections to smooth muscle cells decreases resting blood pressure in nonobese mice, a response that is diminished in HFD mice. Administration of three exosomes elevated blood pressure by promoting artery endothelial barrier permeability, impairing the expression of adherens junctions, and aggravating inflammatory response in vivo and in vitro, accompanied by TRPV4/Ca2+ pathway inhibition.

Conclusions

Impairment of endothelial TRPV4 channels contributes to obesity-induced hypertension and imply that HFD-induced obesity plays a role in blood pressure by aggravating the artery endothelial barrier injury and inflammatory response via adipose-derived exosomes, at least partially, through inhibiting the TRPV4/Ca2+ pathway.

Funding Acknowledgement

Type of funding sources: None. Main funding source(s): This research was supported by grants from the National Natural Science Foundation of China (81970262) (P.J.W.), Innovation Team Project Department of Education of Sichuan Province (18TD0030) (PJW), Central Funds Guiding the Local Science and Technology Development of Sichuan Province (2020ZYD036, P.W.), and grants from the Scientific Research Fund of Chengdu Medical College (CYZYB20-07) (J.W.).

[Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction]

Objective: Surgical operation is the main treatment for advanced adenocarcinoma of esophagogastric junction (AEG). Due to its special anatomic location and unique lymph node reflux mode, the surgical treatment of Siewert II AEG is controversial. Lower mediastinal lymph node dissection is one of the most controversial points and a standard technique has not yet been established. This study is aim to explore the safety and feasibility of five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type II AEG. Methods: A descriptive case series study was conducted. The intraoperative and postoperative data of 25 patients with Siewert type II AEG who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection in Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2019 to April 2021 were retrospectively analyzed. Five-step maneuver was as follows: In the first step, the subcardiac sac was exposed; the right pulmonary ligament lymph nodes and the anterior thoracic paraaortic lymph nodes were dissected cranial to inferior pericardium, left to left edge of thoracic aorta. In the second step, the left diaphragm was opened, and a 12 mm trocar was placed through the 6-7 rib in the left anterior axillary line. The supra-diaphragmatic nodes were dissected through the thoracic operation hole. In the third step, the left inferior pulmonary ligament was severed. The anterior fascia of thoracic aorta was incised to join the anterior space of thoracic aorta formed in the first step and then the lymphatic tissue was dissected upward until the exposure of left inferior pulmonary vein. In the fourth step, the posterior pericardium was denuded retrogradely from ventral side to oral side to the level of left inferior pulmonary vein, right to right pleura, and then the right pulmonary ligament lymph nodes were completely removed. In the fifth step, the esophagus was denuded, and the esophagus was transected 5 cm above the tumor using a linear stapler to complete the dissection of lower thoracic paraesophageal lymph nodes. Results: Operations were successfully completed in 25 patients without conversion, intra-operative complication and perioperative death. Total gastrectomy was performed in 19 cases and proximal gastrectomy in 6 cases. The mean operative time was (268.7±85.6) minutes, the mean estimated blood loss was (90.4±44.2) ml, the mean time of lower mediastinal lymph node dissection was (38.6±10.3) minutes, and the mean harvested number of lower mediastinal lymph node was 5.9±2.9. The length of esophageal invasion was >2 cm in 7 cases and ≤ 2 cm in 18 cases. Eight patients (33.0%) had lower mediastinal lymph node metastasis, including 3 cases with esophageal invasion >2 cm and 5 cases with esophageal invasion ≤ 2 cm. The mean time to postoperative first flatus was (5.5±3.1) days. The average time of postoperative thoracic drainage was (5.9±2.9) days. The mean hospital stay was (9.7±3.1) days. Two patients (8.0%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pancreatic fistula and 1 case of pleural effusion, both of whom were cured by puncture drainage. Conclusions: Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph nodes dissection for Siewert type II AEG is safe and feasible. Which can ensure sufficient lower mediastinal lymph node dissection to the level of left inferior pulmonary vein.

[Role of Bruton's tyrosine kinase in endotoxin/lipopolysaccharide-induced pyroptosis of intestinal cells in scalded mice]

Objective: To investigate the role of Bruton's tyrosine kinase (BTK) in pyroptosis of intestinal cells caused by endotoxin/lipopolysaccharide (LPS) in scalded mice. Methods: The experimental research method was applied. One hundred and twenty-eight male C57BL/6 mice aged 6-8 weeks were divided into sham injury group, scald alone group, scald+LPS group, scald+LPS+3 mg/kg LFM-A13 group, scald+LPS+10 mg/kg LFM-A13 group, and scald+LPS+30 mg/kg LFM-A13 group. There were 8 mice in sham injury group, and there were 24 mice in the other 5 groups, respectively. Mice in 5 scald groups were inflicted with 10% total body surface area full-thickness scald on the back, and mice in sham injury group were sham injured on the back. At post injury hour (PIH) 0 (immediately), mice in sham injury group and scald alone group were intraperitoneally injected with normal saline, mice in scald+LPS group were intraperitoneally injected with LPS, and mice in scald+LPS+3 mg/kg LFM-A13 group, scald+LPS+10 mg/kg LFM-A13 group, and scald+LPS+30 mg/kg LFM-A13 group were intraperitoneally injected with LPS and LFM-A13 in corresponding doses. Mice in sham injury group were sacrificed at PIH 0 to collect serum and intestinal tissue, and 8 mice in each group of 5 scald groups were sacrificed at PIH 0, 12, and 24 to collect intestinal tissue and serum at PIH 12. Immunohistochemistry was used to detect phosphorylation of BTK in intestinal tissue of mice. Western blotting was used to detect the protein expressions of phosphorylated BTK (p-BTK), cleaved cysteine aspartic acid specific protease 1 (caspase-1), and cleaved caspase-11 in intestinal tissue of mice. Enzyme-linked immunosorbent assay method was used to detect interleukin-1β (IL-1β) in serum and intestinal tissue of mice. Data were statistically analyzed with one-way analysis of variance and least significant difference test. Results: There was no obvious phosphorylation of BTK in intestinal tissue of mice in 6 groups at PIH 0 and scald alone group at PIH 12 and 24. Phosphorylation of BTK in intestinal tissue of mice in scald+LPS group at PIH 12 and 24 were obviously increased compared with those in scald alone group. Phosphorylation of BTK in intestinal tissue of mice in scald+LPS+3 mg/kg LFM-A13 group, scald+LPS+10 mg/kg LFM-A13 group, and scald+LPS+30 mg/kg LFM-A13 group were obviously decreased compared with those in scald+LPS group, and the degrees of decline gradually increased with increase of dose in LFM-A13. Compared with (0.130±0.010) of sham injury group and (0.120±0.040 and 0.110±0.040) of scald alone group, protein expressions of p-BTK in intestinal tissue of mice in scald+LPS group at PIH 12 and 24 were obviously increased (0.470±0.090 and 0.430±0.080, P<0.01). Compared with those in scald+LPS group, protein expressions of p-BTK in intestinal tissue of mice in scald+LPS+3 mg/kg LFM-A13 group at PIH 24, and scald+LPS+10 mg/kg LFM-A13 group and scald+LPS+30 mg/kg LFM-A13 group at PIH 12 and 24 were obviously decreased (0.280±0.060, 0.300±0.120, 0.150±0.050, 0.280±0.090, 0.140±0.040, P<0.05 or P<0.01). Compared with those in scald+LPS+3 mg/kg LFM-A13 group, protein expressions of p-BTK in intestinal tissue of mice in scald+LPS+10 mg/kg LFM-A13 group and scald+LPS+30 mg/kg LFM-A13 group at PIH 24 were obviously decreased (P<0.01). Compared with those in sham injury group and scald alone group, protein expressions of cleaved caspase-1 and caspase-11 in intestinal tissue of mice in scald+LPS group were obviously increased at PIH 12 and 24 (P<0.01). Compared with those in scald+LPS group, protein expressions of cleaved caspase-1 at PIH 12 and cleaved caspase-11 at PIH 12 and 24 in intestinal tissue of mice in scald+LPS+3 mg/kg LFM-A13 group and protein expressions of cleaved caspase-1 and caspase-11 in intestinal tissue of mice in scald+LPS+10 mg/kg LFM-A13 group and scald+LPS+30 mg/kg LFM-A13 group at PIH 12 and 24 were obviously decreased (P<0.01). Compared with those in scald+LPS+3 mg/kg LFM-A13 group, protein expressions of cleaved caspase-1 and caspase-11 in intestinal tissue of mice in scald+LPS+10 mg/kg LFM-A13 group and scald+LPS+30 mg/kg LFM-A13 group at PIH 12 and 24 were obviously decreased (P<0.05 or P<0.01). At PIH 12, content of IL-1β in intestinal tissue and serum of mice in scald+LPS group were obviously higher than those in sham injury group and scald alone group (P<0.01), and content of IL-1β in intestinal tissue and serum of mice in scald+LPS+30 mg/kg LFM-A13 group were obviously lower than those in scald+LPS group (P<0.01). Conclusions: Phosphorylation of BTK is related to increases of cleaved caspase-1 and caspase-11 in intestinal tissue, and IL-1β content in intestinal tissue and serum of scalded septic mice caused by LPS. Phosphorylation of BTK mediates intestinal cell pyroptosis of scalded mice caused by LPS. Inhibiting phosphorylation of BTK can alleviate intestinal cell pyroptosis of scalded mice, with protective effect on intestinal injury intestine.

986 A Systematic Review of Medical Student Willingness to Volunteer and Preparedness for Pandemics and Disasters

Introduction

We aimed to identify motivators and barriers to volunteering during a disaster and knowledge and medical school curriculum of disaster and pandemic medicine.

Method

We systematically searched the literature on 28/6/2020, following PRISMA guidelines.

Results

A total of 37 studies met inclusion criteria including 11,168 medical students and 91 medical schools. 24 studies evaluated knowledge (64.9%), 16 evaluated volunteering (43.2%), and five evaluated medical school curricula (13.5%). Weighted mean willingness to volunteer during a disaster was 68.4% (SD = 21.7%, n = 2911), and there was a significant difference between those planning to volunteer and those who actually volunteered (P<.001). We identified a number of modifiable barriers which may contribute to this difference. Overall, knowledge of disasters was poor with a weighted mean of 48.9% (SD = 15.1%, n = 2985).

Conclusions

There is a large number of students who are willing to volunteer during pandemics. However, they are likely to be under-prepared for these roles due to poor overall knowledge and limited teaching. During the current COVID-19 pandemic and in future disasters, medical students may be required to volunteer as auxiliary staff. Medical schools need to develop infrastructure to facilitate this process as well as providing education and training to ensure students are adequately prepared for these roles.

967 COVID READY Study: Cross-Sectional Survey of Medical Students Volunteering During the Coronavirus Pandemic (COVID-19) In the United Kingdom

Introduction

We aimed to identify the willingness, attitudes, and practice of medical students towards volunteering in a clinical capacity during the COVID-19 pandemic.

Method

We distributed a cross-sectional survey from 2/5/2020 to 14/6/2020 to all medical students at UK medical schools.

Results

A total of 1145 medical students from 36 medical schools completed the questionnaire. 82.7% of students were willing to volunteer, but only 34.3% had volunteered. The strongest predictors of willingness to volunteer on multiple linear regression were the beliefs that volunteering to work would benefit their medical education (estimate=0.35±0.03, adjusted P < 0.001) and that they would have a positive impact (estimate=0.33±0.03, adjusted P < 0.001). The majority of students were willing to take up a clinical role and were confident in having the necessary skills, but there was a discrepancy between the role’s students were comfortable performing and those they were assigned. Thematic analysis of the issue’s students would face when volunteering identified five themes: safety, professional practice, pressure to volunteer, finances and logistics, and education.

Conclusions

This study identifies areas for consideration from those responsible for workforce planning, healthcare provision, and student safety. We provide recommendations to facilitate a volunteering process that is safer for students, staff, and patients.

[Efficacy observation of the caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy]

Objective: To investigate the safety and feasibility of caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy. Methods: A descriptive cohort study was conducted. Clinical data of 35 patients who underwent laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy at Department of Gastrointestinal Surgery, Guangdong Hospital of Chinese Medicine from April 2018 to May 2020 were retrospectively analyzed. All operations were performed consecutively by the same surgeon. The caudal-medial approach was used to dissect the right Toldt's fascia and the anterior pancreaticoduodenal space in a caudal-to-cranial and medial-to-lateral manner guided by the duodenum. The "page-turning" middle lymphadenectomy was used to dissect the mesocolon along the superior mesenteric vein with ileocolic vein, Henle's trunk and pancreas exposed preferentially. Results: All the 35 patients completed the operation successfully, and there was no damage and bleeding of superior mesenteric vessels and their branches. The operative time was (186.9±46.2) minutes, and the blood loss was 50 (10-200) ml. The first time to flatus was (2.1±0.6) days, and the time to fluid intake was (2.5±0.8) days. The postoperative hospital stay was 6 (3-18) d. The overall morbidity of postoperative complication was 8.6% (3/35), including grade II in 1 cases (2.8%) and grade IIIa in 2 case (5.7%) according to the Clavien-Dindo grading standard. The total number of lymph node dissected was 30.2±5.6, and the positive lymph node was 0 (0-7). Tumor staging revealed 5 cases of stage I, 18 cases of stage II, 11 cases of stage III, and 1 case of stage IVA. In this study, the median follow-up time was 15 (4-29) months. One patient died due to cerebrovascular accident 12 months after surgery, and no tumor recurrence or metastasis was observed in all other patients. Conclusions: Laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy is safe and feasible. The anterior pancreaticoduodenal space is preferentially mobilized, which reduces the difficulty of central vascular dissection.

A Low-Cost, Ear-Contactless Electronic Stethoscope Powered by Raspberry Pi for Auscultation of Patients With COVID-19: Prototype Development and Feasibility Study

Background

Chest examination by auscultation is essential in patients with COVID-19, especially those with poor respiratory conditions, such as severe pneumonia and respiratory dysfunction, and intensive cases who are intubated and whose breathing is assisted with a ventilator. However, proper auscultation of these patients is difficult when medical workers wear personal protective equipment and when it is necessary to minimize contact with patients.

Objective

The objective of our study was to design and develop a low-cost electronic stethoscope enabling ear-contactless auscultation and digital storage of data for further analysis. The clinical feasibility of our device was assessed in comparison to a standard electronic stethoscope.

Methods

We developed a prototype of the ear-contactless electronic stethoscope, called Auscul Pi, powered by Raspberry Pi and Python. Our device enables real-time capture of auscultation sounds with a microspeaker instead of an earpiece, and it can store data files for later analysis. We assessed the feasibility of using this stethoscope by detecting abnormal heart and respiratory sounds from 8 patients with heart failure or structural heart diseases and from 2 healthy volunteers and by comparing the results with those from a 3M Littmann electronic stethoscope.

Results

We were able to conveniently operate Auscul Pi and precisely record the patients’ auscultation sounds. Auscul Pi showed similar real-time recording and playback performance to the Littmann stethoscope. The phonocardiograms of data obtained with the two stethoscopes were consistent and could be aligned with the cardiac cycles of the corresponding electrocardiograms. Pearson correlation analysis of amplitude data from the two types of phonocardiograms showed that Auscul Pi was correlated with the Littmann stethoscope with coefficients of 0.3245-0.5570 for healthy participants (P<.001) and of 0.3449-0.5138 among 4 patients (P<.001).

Conclusions

Auscul Pi can be used for auscultation in clinical practice by applying real-time ear-contactless playback followed by quantitative analysis. Auscul Pi may allow accurate auscultation when medical workers are wearing protective suits and have difficulties in examining patients with COVID-19.

Trial Registration

ChiCTR.org.cn ChiCTR2000033830; http://www.chictr.org.cn/showproj.aspx?proj=54971.

Defining heart disease risk for death in COVID-19 infection

BACKGROUND

Cardiovascular disease (CVD) was in common in coronavirus disease 2019 (COVID-19) patients and associated with unfavorable outcomes. We aimed to compare the clinical observations and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients with or without CVD.

METHODS

Patients with laboratory-confirmed SARS-CoV-2 infection were clinically evaluated at Wuhan Seventh People's Hospital, Wuhan, China, from 23 January to 14 March 2020. Demographic data, laboratory findings, comorbidities, treatments and outcomes were collected and analyzed in COVID-19 patients with and without CVD.

RESULTS

Among 596 patients with COVID-19, 215 (36.1%) of them with CVD. Compared with patients without CVD, these patients were significantly older (66 vs. 52 years) and had higher proportion of men (52.5% vs. 43.8%). Complications in the course of disease were more common in patients with CVD, included acute respiratory distress syndrome (22.8% vs. 8.1%), malignant arrhythmias (3.7% vs. 1.0%) including ventricular tachycardia/ventricular fibrillation, acute coagulopathy(7.9% vs. 1.8%) and acute kidney injury (11.6% vs. 3.4%). The rate of glucocorticoid therapy (36.7% vs. 25.5%), Vitamin C (23.3% vs. 11.8%), mechanical ventilation (21.9% vs. 7.6%), intensive care unit admission (12.6% vs. 3.7%) and mortality (16.7% vs. 4.7%) were higher in patients with CVD (both P < 0.05). The multivariable Cox regression models showed that older age (≥65 years old) (HR 3.165, 95% CI 1.722-5.817) and patients with CVD (HR 2.166, 95% CI 1.189-3.948) were independent risk factors for death.

CONCLUSIONS

CVD are independent risk factors for COVID-19 patients. COVID-19 patients with CVD were more severe and had higher mortality rate, early intervention and vigilance should be taken.

[Detection of right-to-left shunt with transthoracic contrast echocardiography in patients with pulmonary hypertension]

Objective: To explore the value of right heart contrast echocardiography in etiological diagnosis and severity assessment of pulmonary hypertension (PH). Methods: A retrospective analysis was conducted on 74 patients who underwent transthoracic contrast echocardiography in China-Japan Friendship Hospital from May 2015 to July 2018, all of whom were diagnosed as PH by right heart catheterization. Patients were divided into three groups according to contrast echocardiography: the intra-cardiac shunt group (<4 cardiac cycles with microbubbles in the left heart); Intrapulmonary shunt group (>4 cardiac cycles with microbubbles in the left heart); non-shunt group. The etiology, partial arterial oxygen pressure (PO(2)), N-terminal pro-brain natriuretic peptide (NT-proBNP), mean pulmonary artery pressure (mPAP), right atrial pressure (RAP), pulmonary vascular resistance (PVR) and cardiac output (CO) were analyzed. Central nervous system complications were also compared among the three groups. Results: Among the 74 patients, right-to-left shunt was found in 28 cases (37.8%) by contrast echocardiography, including 11 cases (14.9%) of intra-cardiac shunt and 17 cases (23.0%) of intrapulmonary shunt. In the 11 cases of intra-cardiac shunt, 7 were diagnosed with congenital heart disease and 4 were patent foramen. Two with hereditary hemorrhagic telangiectasia (HHT) and 1 with pulmonary arteriovenous malformation (PAVM) were included in the 16 cases of intrapulmonary shunt. There was no statistical difference in PO(2), mPAP, PVR, NT-proBNP, RAP, CO and functional class among the three groups (all P>0.05). A total of 5 cases (6.8%) were found with nervous system comorbidities, 4 cases (5.4%) with cerebral infarction and 1 cases epilepsy, and 2 cases of cerebral infarction were diagnosed as paradoxical embolism. Nervous system complications were more common in patients with intra-cardiac shunt than in other groups. Conclusion: While right-to-left shunt detected by contrast echocardiography has no relationship with disease severity, it has complementary value in the etiological diagnosis of PH, and intra-cardiac shunt may increase the risk of nervous system complications.

[Risk factors and clinical features of hospital-associated venous thromboembolism]

Objective: To investigate the clinical features and risk factors of hospital-associated venous thromboembolism (VTE). Methods: The study enrolled acute VTE patients admitted into China-Japan Friendship Hospital from January 1, 2017 to December 31, 2017. The hospital-associated VTE (HA-VTE) group and the community-associated VTE (CA-VTE) group were classified according to whether the VTE occurred during hospitalization or within a 90-day period of admission to hospital (including inpatient with at least two days of hospital stay or a surgical procedure under general or regional anaesthesia). Differences in clinical features, risk factors, and mortality rate were compared between the two groups. Results: A total of 437 patients with acute VTE were analyzed in the study. Among them, 266 patients were HA-VTE, 171 patients were CA-VTE. Patients in the CA-VTE group were more likely to have varicose veins, sedentary, long-distance travel, and patients in the HA-VTE group were more complicated with recent surgery (<1 month), bed rest, active malignant tumor, acute infections, acute cerebral infarction, fracture, central venous catheter (P<0.05). The CA-VTE group had more clinical symptoms such as lower extremity pain, dyspnea, chest pain and chest tightness (P<0.05). HA-VTE patients had less clinical symptoms but were more severe than the CA-VTE patients, with more sudden deaths (0 vs 3.4%, P=0.035). Among HA-VTE patients, 92.8% experienced VTE during hospitalization or within 1 month of the preceding hospital encounter, with a 13-day median time to VTE. The all-cause mortality rate was higher for HA-VTE group than CA-VTE group (8.3% vs 1.2%, P<0.001), and the in-hospital VTE was more common compared to VTE diagnosed post-discharge (12.2% vs 3.4%, P<0.001). Conclusions: More than half events of VTE are related to recent hospitalizations. HA-VTE has different risk factors from CA-VTE, combined with fewer clinical symptoms but higher all-cause mortality rate. More attention about VTE should be paid to hospitalized patients to reduce the incidence of HA-VTE events.

[Efficacy and safety of Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension]

Objective: To study the efficacy and safety of Balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Methods: Patients who were diagnosed CTEPH in China-Japan Friendship Hospital from Feb 2018 to Sep 2019 were evaluated. The ineligibility for pulmonary endarterectomy (PEA) and the indication for BPA were decided on the basis of a consensus among the multidisciplinary team for all CTEPH patients. 6-min walk distance (6MWD), the plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP), mixed venous oxygen saturation, mean pulmonary artery pressure (mPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were collected and analyzed before the first and the last BPA session. Results: A total of 67 BPA sessions were performed for 302 subsegmental pulmonary arteries in 25 inoperable CTEPH patients. 10 males (40.0%) and 15 females (60.0%), with the age of (57.8±7.1) years old. The median interval between CTEPH diagnosis and first BPA was 20.0 (9.0, 48.5) months. 18 patients were received more than 2 BPA sessions, the median follow-up time was 5.0 (3.5, 8.3) months. 6MWD, CI and the mixed venous oxygen saturation were significant improved after BPA [(425±74) vs (345±109) m, (1.99±0.45) vs (1.62±0.35) L·min(-1)·m(-2), (68.1%±6.5%) vs (61.2%±6.3%)](all P<0.05). The plasma level of NT-proBNP, mPAP and PVR were significantly decreased after BPA [259 (93, 739) vs 806 (148, 2 159) ng/L, (40.6±8.3) vs (47.3±10.7) mmHg (1 mmHg=0.133 kPa), (11.9±4.9) vs (17.2±6.5) WU (1 WU=80 dyn·s·cm(-5))](all P<0.05). Hemoptysis occurred in 5 sessions (7.5%) and reperfusion pulmonary edema (RPE) occurred in 2 sessions (1.5%), 1 patient needed non-invasive mechanical ventilation because of RPE, 1 patient died from right heart failure caused by hemoptysis during perioperative period. Conclusions: BPA can significantly improve the exercise tolerance and hemodynamic parameters for inoperable CTEPH patients, the risks of BPA are acceptable. BPA is an effective and relatively safe treatment for inoperable CTEPH patients.

[Clinical characteristics of patients with chronic thromboembolic pulmonary hypertension]

Objective: To investigate the clinical characteristics of patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods: CTEPH cases consecutively admitted into China-Japan Friendship Hospital from September 2015 to June 2019 were enrolled with prospective data collection. The medical histories, clinical characteristics, laboratory tests, imaging manifestation and hemodynamic parameters were analyzed. Patients were divided into high pulmonary vascular resistance (PVR) group and low PVR group according to the PVR level>1 000 dyn·s·cm(-5) or not, and clinical characteristics were compared between these two groups. Results: In the 148 cases of CTEPH, right heart catheterization was performed in 103 cases with mPAP (45.1±11.0) mmHg and PVR of (992±430) dyn·s·cm(-5). At diagnosis, 88 (59.5%) cases were in WHO functional class Ⅲ and 27 (18.2%) in class Ⅳ. Most common presenting symptoms were dyspnea (147, 99.3%), chest tightness (68, 45.9%), hemoptysis (42, 28.3%), syncope (30, 20.3%), and most common signs were P2 accentuation (95, 64.9%), edema (65, 43.9%), cyanosis (47, 31.8%), systolic murmur (44, 29.7%) and jugular vein distention (35, 23.6%). In 103 cases with right heart catheterization, 52 were in the low PVR group and 51 in high PVR group. Compared to the low PVR group, high PVR group patients had higher WHO functional class and more jugular vein distention (both P<0.05). In all the 148 cases, previous venous thromboembolism (VTE) was confirmed in 105 (70.9%) patients, with a higher prevalence of previous VTE in low PVR group than that in high PVR group (P<0.001). 30 (20.3%) patients had varicose veins of the lower extremities, and 21 (14.2%) had other thrombophilic disorders including antiphospholipid syndrome, protein C and S deficiency and antithrombin Ⅲ deficiency. Conclusions: Dyspnea, P2 accentuation and edema are the most common clinical presentation of CTEPH. Previous history of VTE is common in CTEPH patients with thrombophilia in some cases.

[Brain protection strategy and effectivity in pulmonary thromboendarterectomy]

Objective: To summarize the experience and effectivity of brain protection in 25 patients who suffered from chronic thromboembolic pulmonary hypertension (CTEPH) and received pulmonary thromboendarterectomy (PTE) under deep hypothermic circulatory arrest. Methods: Retrospective analysis of 25 PTE surgeries in our center from December 2016 to August 2018. All cases were completed underdeep hypothermic circulatory arrest. Standard brain protections were strictly executed, including: balanced and controlled extracorporeal circulation cooling, cerebral oxygen saturation (rSO(2)) monitoring, strictly control of circulatory arrest time, and etc. The neurological adverse events during the perioperative period were recorded and statistically analyzed, and the intelligence level and cognitive function of the patients were evaluated by MMSE scale and MoCA scale before surgery and discharge. Results: All the 25 patients successfully completed the surgery, and 1 patient (4%) died of postoperative infection. The mean pulmonary arterial pressure decreased from (52.9±16.7) mmHg before surgery to (23.6±8.1) mmHg immediately after surgery (t=10.01, P<0.01), and(20.7±7.9) mmHg at 3 months follow-up (t=10.73, P<0.01). Pulmonary vascular resistance decreased from 975.4 (788.6-1 292.8) dyn·s·cm(-5) to 376.1 (283.6-565.5) dyn·s·cm(-5) (Z=5.34, P<0.01). Neurological complications occurred in 3 patients during the perioperative period, including 2 patients with hypoxic encephalopathy, and 1 patient with cerebral hemorrhage. All 3 patients fully recovered before discharge. Univariate analysis showed that the duration of rSO(2)<40% and the maximum decrease rate of rSO(2) from baseline were significantly correlated with postoperative neurological damage. Multivariate analysis showed only time of rSO(2)<40% was significantly correlated with postoperative neurological damage. There was no significant difference in MMSE and MoCA score before and after surgery (P>0.05). Conclusions: Adequate brain protection measures are essential to reduce the neurological complications of PTE surgery. Real-time intraoperative monitoring of rSO(2) and strict control of circulatory arrest time can further reduce the occurrence of neurological damage.

Extracorporeal shock wave lithotripsy versus ureteroscopy for management of pediatric nephrolithiasis in upper urinary tract stones: multi-institutional outcomes of efficacy and morbidity

INTRODUCTION

As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children.

OBJECTIVE

The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities.

STUDY DESIGN

A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis.

RESULTS

A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4 mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P = 0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P = 0.03) and flank pain (3.6% vs. 10.9%, P = 0.05) and required fewer general anesthetics per treatment (1.2 vs. 2.0, P < 0.01) than those who underwent URS (Figure).

DISCUSSION

Stone clearance after both the initial and final treatments and need for repeat interventions were similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment support thoughtful utilization of these medications. Limitations of this study include its retrospective nature and the prolonged 20-year time period over which data were collected.

CONCLUSIONS

When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.