[The clinicopathological features of adult thyroid tumors with DICER1 mutation]

A total of 37 cases of thyroid tumors with pathological features suggestive of DICER1 gene mutation were selected to detect the DICER1 gene and BRAF gene using Sanger sequencing. A total of 10 patients (27.0%) exhibited DICER1 gene mutation all of whom were female with an age of [M(Q1, Q3)] 38.0 (30.5, 47.5) years. All patients had wild-type BRAFV600E gene. The ultrasound examination showed high-low echogenic well-demarcated intra-thyroidal nodules with abundant peripheral and internal blood flow signals in the DICER1 mutated thyroid tumor. The tumor was confined within the thyroid gland, with a diameter of (3.68±1.31) cm. The pathological features are as follows: the majority of tumors are encapsulated, which mainly composed of large follicles rich in colloid and some are small and micro follicles. The nucleus is round and deeply stained or slightly light stained, small to medium-sized, with occasional nuclear grooves and a lack of nuclear pseudoinclusion bodies within the nucleus. Immunohistochemical staining shows that Ki67 proliferation index of approximately 2%-10%. All cases were followed up for 11 to 18 months, and there was no recurrences or distant metastase. This study confirmed that the DICER1 gene mutation is mutually exclusive with the BRAFV600E gene mutation. The thyroid tumor with DICER1 mutation are in big size and are more common in young females with a good prognosis. Cases with the wild-type DICER1 gene may exhibit similar morphological features, and molecular testing is recommended. If somatic DICER1 mutation is confirmed, patients should undergo germline mutation testing to rule out DICER1 syndrome in order to define whether genetic counseling is necessary.

[Interpretation of the pathological diagnostic criteria and characteristics of high-grade thyroid follicular-derived carcinoma in the 5th edition WHO classification]

The 5th edition WHO classification of thyroid tumors proposed high-grade non-anaplastic thyroid carcinoma, which includes traditional poorly differentiated thyroid carcinoma (PDTC) and differentiated high-grade thyroid carcinoma (DHGTC), with a prognosis between highly differentiated thyroid carcinoma and anaplastic thyroid carcinoma (ATC), in which about 50% of patients do not take radioactive iodine. Therefore, this classification is of great clinical significance. This article interprets the diagnostic criteria and genetic features of high-grade non-anaplastic thyroid carcinoma in 5th edition WHO classification, comparing with ATC.

Antiphospholipid antibody-related hepatic vasculitis in a juvenile after non-severe COVID-19: a case report and literature review

Antiphospholipid antibodies (aPL) are both laboratory evidence and causative factors for a broad spectrum of clinical manifestations of antiphospholipid syndrome (APS), with thrombotic and obstetric events being the most prevalent. Despite the aPL-triggered vasculopathy nature of APS, vasculitic-like manifestations rarely exist in APS and mainly appear associated with other concurrent connective tissue diseases like systemic lupus erythematous. Several studies have characterized pulmonary capillaritis related to pathogenic aPL, suggesting vasculitis as a potential associated non-thrombotic manifestation. Here, we describe a 15-year-old girl who develops hepatic infarction in the presence of highly positive aPL, temporally related to prior non-severe COVID-19 infection. aPL-related hepatic vasculitis, which has not been reported before, contributes to liver ischemic necrosis. Immunosuppression therapy brings about favorable outcomes. Our case together with retrieved literature provides supportive evidence for aPL-related vasculitis, extending the spectrum of vascular changes raised by pathogenic aPL. Differentiation between thrombotic and vasculitic forms of vascular lesions is essential for appropriate therapeutic decision to include additional immunosuppression therapy. We also perform a systematic review to characterize the prevalence and clinical features of new-onset APS and APS relapses after COVID-19 for the first time, indicating the pathogenicity of aPL in a subset of COVID-19 patients.

Coexisting of Primary Central Nervous System Lymphoma and Talaromyces marneffei Brain Abscess in an AIDS Patient, A Case Report and Review of the Literature

Background

Talaromyces marneffei is prevalent in South Asia. Latent Talaromyces marneffei infection of travellers make the diagnosis difficult. There are similarities in clinical manifestations between Talaromyces marneffei infection and lymphoma. Brain abscess is a rare form of Talaromyces marneffei infection.

Case Presentation

We reported a very rare case of a 19-year-old man with HIV infection who suffered from a brain mass and lymphadenopathy. His blood culture, bone marrow culture and sputum culture all grew Talaromyces marneffei. One month after treatment with voriconazole, the symptoms improved except brain mass. Surgical incision of the brain mass showed a compact mass, and pathological analysis showed the coexisting Talaromyces marneffei abscess and lymphoma. The patient is currently in a stable condition after receiving antifungal therapy and chemotherapy.

Conclusion

Based on a case report of a traveller who suffered from a brain mass of Talaromyces marneffei abscess and lymphoma after a visit to an endemic area, this review summarized the cases where there was confusion between lymphoma and the brain abscess of Talaromyces marneffei. Talaromyces marneffei infection can be found globally due to the increasing number of international travels. Talaromyces marneffei infection and lymphoma had similar characteristics which is easy to misdiagnose in clinic. Infection may also be accompanied by tumors, especially in patients infected with HIV. The manifestations and imaging of brain abscess of Talaromyces marneffei were not characteristic in different patients.

Clinical Outcomes and Bacterial Characteristics of Carbapenem-resistant Acinetobacter baumannii Among Patients From Different Global Regions

BACKGROUND

Carbapenem-resistant Acinetobacter baumannii (CRAb) is 1 of the most problematic antimicrobial-resistant bacteria. We sought to elucidate the international epidemiology and clinical impact of CRAb.

METHODS

In a prospective observational cohort study, 842 hospitalized patients with a clinical CRAb culture were enrolled at 46 hospitals in five global regions between 2017 and 2019. The primary outcome was all-cause mortality at 30 days from the index culture. The strains underwent whole-genome analysis.

RESULTS

Of 842 cases, 536 (64%) represented infection. By 30 days, 128 (24%) of the infected patients died, ranging from 1 (6%) of 18 in Australia-Singapore to 54 (25%) of 216 in the United States and 24 (49%) of 49 in South-Central America, whereas 42 (14%) of non-infected patients died. Bacteremia was associated with a higher risk of death compared with other types of infection (40 [42%] of 96 vs 88 [20%] of 440). In a multivariable logistic regression analysis, bloodstream infection and higher age-adjusted Charlson comorbidity index were independently associated with 30-day mortality. Clonal group 2 (CG2) strains predominated except in South-Central America, ranging from 216 (59%) of 369 in the United States to 282 (97%) of 291 in China. Acquired carbapenemase genes were carried by 769 (91%) of the 842 isolates. CG2 strains were significantly associated with higher levels of meropenem resistance, yet non-CG2 cases were over-represented among the deaths compared with CG2 cases.

CONCLUSIONS

CRAb infection types and clinical outcomes differed significantly across regions. Although CG2 strains remained predominant, non-CG2 strains were associated with higher mortality. Clinical Trials Registration. NCT03646227.

[Research hot spots and trends of keratoconus in China: a bibliometric analysis]

Objective: To review the studies related to keratoconus in China, investigate research hotspots and development trends in this field, and provide reference for future research. Methods: This is a bibliometrics study. The relevant literature written in Chinese was retrieved from the WanFang DATA and the China National Knowledge Infrastructure, English articles were collected from the Web of Science Core Collection database. Searched for journal articles related to keratoconus VOSviewer software, CiteSpace, and Bibliometrix in the R language were employed to create the knowledge map. The analysis encompassed the distribution of published journals, research collaboration networks of countries/regions, institutions, and authors. Additionally, core authors, high-frequency keyword co-occurrence, keyword topic maps, and keyword emergence time ranking were examined. Results: The study ultimately included 1 100 Chinese articles and 668 English articles. Chinese literature and English literature began to increase in 1997 and 2009, respectively, indicating that the field is currently in a developmental stage. The publications involved 244 Chinese journals and 150 English journals, predominantly in the field of ophthalmology. The United States collaborated the most with China, contributing to 123 articles, followed by other countries such as the United Kingdom and Switzerland. Chinese literature and English literature involved 552 and 883 institutions, respectively. The institution with the highest number of Chinese literature publications was the Eye Institute of Shandong First Medical University (63 papers), while Wenzhou Medical University had the highest number of English literature publications (91 papers). Chinese literature involved 2 435 authors, and English literature involved 2 073 authors. The largest collaboration cluster in Chinese literature was formed by the teams of Xie Lixin and Shi Weiyun, while the Gao Hua team formed the largest cluster in English literature. However, collaboration between authors was primarily limited to within each team. A total of 622 and 1 611 keywords were extracted from Chinese and English literature, respectively. The node centrality of the four Chinese keywords, "keratoconus", "cornea", "corneal transplantation" and "myopia" as well as the three English keywords, "keratoconus", "collagen cross-linking" and "penetrating keratoplasty" was greater than 0.1. "Collagen", "riboflavin", "corneal transplantation" and "ultraviolet A" were identified as common core hotspots and important research topics in Chinese and English literature on keratoconus. Keyword emergence analysis indicated that the keywords with the highest intensity of emergence in Chinese and English literature were "myopia" (13.54) and "penetrating keratoplasty" (9.99), respectively. The longest emergence time was observed for "contact lenses" (1995-2006) and "penetrating keratoplasty" (2003-2014). Conclusions: At present, research on keratoconus in China is on the rise, with research hotspots including pathogenesis, various new surgical methods, and improvement in quality of life. The future research trend mainly focuses on early diagnosis and screening methods, artificial intelligence, biomechanical examination, subclinical keratoconus, and small incision lenticule extraction.

[Retrospective study of 70 cases with the head and neck non-parameningeal rhabdomyosarcoma]

Objective: To analyze the treatment outcomes and prognoses of children with head and neck non-parameningeal rhabdomyosarcoma (HNnPM RMS). Methods: A retrospective analysis was performed on the clinical data of children with HNnPM RMS admitted to Beijing Children's Hospital from September 2012 to September 2022. The clinical features, comprehensive treatment modes and prognoses of the patients were analyzed. The overall survival rate (OS) and event free survival rate (EFS) were calculated using the Kaplan-Meier method, and univariate analysis was performed using the Log-rank test. Results: A total of 70 children were included in this study, 38 males and 32 females, with a median age of 47 months (2-210 months). Pathological subtypes including the embryonal in 27 cases, the alveolar in 36 cases and the spindle cell and sclerosing in 7 cases. Thirty children (83.3%) with alveolar type were positive for FOXO1 gene fusion. All 70 children underwent chemotherapy, including 38 with neoadjuvant chemotherapy and 32 with adjuvant chemotherapy. Sixty of 70 children underwent surgery, of whom, 10 underwent two or more surgeries. There were 63 children underwent radiotherapy, including 54 with intensity-modulated radiation therapy, 4 with particle implantation and 5 with proton therapy. The median follow-up was 45 (5-113) months, the 5-year OS was 73.2%, and the 5-year EFS was 57.7%. Univariate analysis showed lymph node metastasis (χ2=5.022, P=0.025), distant metastasis (χ2=8.258, P=0.004), and high Intergroup Rhabdomyosarcoma Study (IRS) group (χ2=9.859, P=0.029) as risk factors for poor prognosis. Before June 2016, the 5-year OS based on BCH-RMS-2006 scheme was 63.6%, and after 2016, the 5-year OS based on CCCG-RMS-2016 scheme was 79.6%. Conclusion: Multidisciplinary combined standardized treatment can offer good treatment outcome and prognosis for children with HNnPM RMS. Local control is a key to the efficacy of comprehensive treatment.

[Research progress and prospects of artificial intelligence in diagnosis and treatment of colorectal cancer]

Colorectal cancer is one of the most common malignant tumors worldwide. Due to the heterogeneity in patient outcomes and treatment responses to standard therapy regimens, personalized diagnostic and therapeutic strategies have remained a focus of sustained interest in research. In recent years, with the rapid progression of artificial intelligence (AI) technology in the medical field, an abundance of phased research results has emerged in the decision-making for preoperative, intraoperative, and postoperative diagnostic and therapeutic plans for colorectal cancer, demonstrating great potential for application. This new and efficient solution provides for the personalized evaluations and auxiliary diagnoses and treatments of patients with colorectal cancer. In the future, AI systems may continue to advance towards multimodal, multi-omics, and real-time directions. This paper aims to explore the current state of research on the multi-faceted auxiliary applications of AI in the diagnosis and treatment of colorectal cancer, as well as to present a prospective view of the innovations that AI technology could bring to personalized colorectal cancer treatment in the future and the challenges it may face.

[Mediating effect of unhealthy lifestyle and depressive symptom on association between life course factors and ageing health]

Objective: To explore the mediating effect of unhealthy lifestyle and depressive symptom on the associations between life course factors and aging health. Methods: The study included 6 217 participants (aged ≥45 years) from the China Health and Retirement Longitudinal Study (CHARLS). We used principal component analysis (PCA) and hierarchical clustering analysis (HCA) to divide participants into six subgroups based on 70 life course factors. Five key life course factors were identified based on correlation analysis and their contribution to aging health. Physiological dysregulation (PD) was calculated by using eight biomarkers in the 2015 CHARLS biomarker dataset. Linear regression, logistic regression, and mediation models were used to explore the complex associations of life course subgroups, key factors, unhealthy lifestyle, depression symptom with PD. Results: Life course subgroups were significantly associated with PD after adjusting chronological age and gender (β: 0.08-0.17, all P<0.05). Life-course subgroups and key factors, including adverse experiences in adulthood and lower education level, were significantly associated with unhealthy lifestyle (β: 0.04-0.52, all P<0.05). Life-course subgroups and key factors, including childhood trauma, parental health in childhood, adverse experiences in adulthood, and lower education level, were significantly associated with depression symptom (OR: 1.16-4.76, all P<0.05). Mediation analysis showed that unhealthy lifestyle had partial mediating effect on the association of life course subgroups and key factors, including adverse experiences in adulthood, and lower education levels, with PD (3.1%-3.6%). Depression symptom had partial mediating effect on the association of life course subgroups and key factors, including childhood trauma, adverse experience in adulthood, and lower education level, with PD (6.0%-16.2%). Conclusions: Unhealthy lifestyle and depression symptom has partial mediating effect on the impact of life course factors on aging health. It is important to pay attention to these two modifiable factors while targeting childhood trauma and adverse experience in adulthood.

[Interpretation of the 5th edition WHO classification of adrenal cortical tumors]

Non-neoplastic lesions were added in the 5th edition WHO classification of adrenal cortical tumor based on the recent update, including adrenal rests, adrenal cysts, congenital adrenal hyperplasia and adrenocortical nodular disease. A range of tumor concepts were updated or refined based on tumor cell origin, histopathology, oncology and molecular biology. The most significant nomenclature change in the field of adrenal cortical pathology involves the refined classification of adrenal cortical nodular disease, which now includes sporadic nodular adrenocortical disease, bilateral micronodular adrenal cortical disease, and bilateral macronodular adrenal cortical disease. The 5th edition WHO classification endorses the nomenclature of the HISTALDO classification to help the classification of aldosterone producing adrenal cortical lesions, which uses CYP11B2 immunohistochemistry to identify functional sites of aldosterone production. The 5th edition WHO classification does not change the Weiss and Lin-Weiss-Bisceglia histopathologic criteria for diagnosing adrenal cortical carcinomas, and underscores the diagnostic and prognostic impact of angioinvasion in these tumors. Reticulin algorithm and Helsinki scoring system were added to assist the differential diagnosis of adrenal cortical neoplasms in adults. Pediatric adrenal cortical neoplasms are assessed using the Wieneke system. The 5th edition WHO classification places an emphasis on an accurate assessment of tumor proliferation rate using both the mitotic count (mitoses per 10 mm2) and Ki-67 labeling index which play an essential role in the dynamic risk stratification of affected patients. This review highlights advances in knowledge of histological features, ancillary studies, and associated genetic findings that increase the understanding of the adrenal cortex pathologies in the 5th edition WHO classification.

[Epidemiological investigation of constipation in urban areas of Hangzhou, China]

Objective: To determine the prevalence and risk factors of constipation in Hangzhou urban areas by analyzing data from a recent epidemiological survey. Methods: From August 2022 to June 2023, a cross-sectional survey was conducted on 43 communities on eight streets in suburbs of Hangzhou, including Wangjiang, Sijiqing, Puyan, Changhe, Ziyang, Xiaoshanchengxiang, Zhuantang, and Banshan. Written questionnaires were filled out face to face by community doctors. The prevalence of constipation was investigated using a combination of the Bristol stool typing method and the Rome IV criteria. The risk factors for constipation were analyzed using multivariate logistic regression analysis. Results: The study cohort comprised 10,479 participants, 5551 of whom were male (53.0%) and 4928 female (47.0%). The overall prevalence of constipation was 10.6% (1107/10,479). The prevalence was 11.0% (613/5551) for male and 10.0% (494/4928) for female participants; this difference is not statistically significant (P>0.05).There were no significant differences in the prevalence of constipation between different categories of body mass index (P>0.05). The prevalence of constipation was highest in individuals aged 70 years and above, accounting for 15.4% (264/1717) of all cases. There were significant differences in the prevalence of constipation between different occupations, marital statuses, and educational levels (P<0.001). Patients with hypertension or diabetes mellitus had a higher prevalence of constipation than those without these conditions, those who had been taking long-term medication had a higher prevalence of constipation than those who did not, parents of children with constipation had a higher prevalence of constipation than those with children who did not have constipation, and there were other significant differences in various variables (P<0.001). Multivariate logistic regression analysis of modifiable factors revealed that eating less fruit (OR=1.284, 95%CI: 1.061-1.553, P=0.010), liking spicy and salty food (OR=1.234, 95%CI: 1.039-1.466, P=0.016), sleeping for too long (OR=1.644, 95%CI: 1.260-2.144, P<0.001), irregular sleep patterns (OR=1.370, 95%CI: 1.127-1.665, P=0.002) and minimal exercise (OR=1.388, 95% CI: 1.168-1.649, P<0.001) were all risk factors for constipation; whereas mix diets (OR=0.709,95%CI:0.608-0.826, P<0.001), meat diets (OR=0.604,95%CI: 0.495-0.736, P<0.001), moderate alcohol consumption (OR=0.659, 95% CI: 0.534-0.812, P<0.001), less or no drinking (OR=0.523, 95% CI: 0.428-0.638, P<0.001), and non-smoking (OR=0.819, 95%CI:0.674-0.995, P<0.001) protected against constipation. We found no association between dietary preferences and the risk of constipation (refined grains: OR=1.147, 95%CI:0.944-1.393, P=0.167; no specific preference: OR=0.935, 95%CI:0.783-1.117, P=0.459). The rate of agreement between self-evaluation of constipation by the respondents and objective criteria was higher for negatives (95.8%) than for positives (38.0%). Conclusion: The prevalence of constipation is relatively high in the urban population of Hangzhou. A good lifestyle and diet can significantly reduce its incidence. There should be more emphasis on preventive education, promotion of prevention of constipation, and advocacy for a healthy lifestyle.

Metagenomics assists in the diagnosis of a refractory, culture-negative pyoderma gangrenosum-like ulcer caused by Helicobacter cinaedi in a patient with primary agammaglobulinemia

Helicobacter cinaedi is known to cause various infections in immunocompromised hosts ranging from skin lesions to disseminated septicemia. Identification of H. cinaedi is difficult through conventional identification methods due to its fastidious nature. We reported a refractory and culture-negative pyoderma gangrenosum-like ulcer caused by H. cinaedi in a patient with primary agammaglobulinemia. Metagenomic next-generation sequencing (mNGS) was applied for the identification of H. cinaedi and prolonged minocycline and amoxicillin-clavulanate potassium was used to eradicate the infection. Given the difficulties in culturing this organism, it's highly possible that H cinaedi infections have been overlooked. We suggest that early consideration of H. cinaedi infection should be suspected in immunocompromised patients presenting with unexplained skin lesions as the appropriate antibiotic choice plus a prolonged treatment course is essential for the prognosis. Application of mNGS could contribute to the early identification of rare and cryptogenic pathogens.

[Interpretation of the third edition Bethesda system for reporting thyroid cytopathology]

Based on the changes of the classification and nomenclature in the fifth edition of the World Health Organization (WHO) classification of thyroid neoplasms, the third edition Bethesda system for reporting thyroid cytopathology (TBSRTC) was revised in June 2023. Two new chapters have been added: one addressing the clinical perspectives and imaging findings in thyroid disease and another summarizing the molecular test for thyroid cytology. A discussion of risk of malignancy (ROM) and clinical management algorithms for pediatric thyroid carcinoma have been added. The third edition provides an average ROM for each category, in addition to the expected range of cancer risk. This paper aims to interpret the main changes in the third edition TBSRTC and to provide guidelines for the clinical management of thyroid nodules.

[Clinical manifestations, pathogenesis, and management strategies for permanent teeth with external root resorption after trauma]

External root resorption is physiological or pathological destruction of the hard tissues on the root's external surface caused by various factors. Dental trauma is one of the main causes of pathological external root resorption. The manifestation and prognosis of external root resorption are closely related to the type of dental trauma, the degree of root damage, the stage of root development, and the presence of microbial infection et al. Effective management can prevent the occurrence of external root resorption or stop the progress of root resorption to avoid the early loss of traumatic teeth. This review focuses on the clinical manifestations, pathogenesis, and management strategies for permanent teeth with external root resorption after dental trauma, in order to provide a reference for the prevention and intervention of external root resorption after trauma in permanent teeth.

[Analysis of the common respiratory viruses in children with acute respiratory infection in a hospital in Lanzhou City from 2021 to 2022]

To explore the situation of 8 common respiratory pathogens in children with acute respiratory infection (ARI) from 2021 to 2022.The retrospective study selected 8 710 ARI patients from September 2021 to August 2022 in the Maternal and Child Health Hospital of Gansu Province as the study object, patients aged 0 to 17 years old, including 5 048 male children and 3 662 female children. Indirect immunofluorescence was used to detect 8 common respiratory pathogens, including influenza virus A (FluA), influenza virus B (FluB), parainfluenza virus (PIV), respiratory syncytial virus (RSV), adenovirus (ADV), Mycoplasma pneumoniae (MP), Chlamydia pneumoniae (CP), and Coxsackie virus group B (CoxB) IgM antibodies. χ2 test was used to analyze the results. The results showed that 1 497 of 8 710 children with ARI were positive, with a positive rate of 17.19%. The detection rate of MP among 8 common respiratory pathogens was 11.34%, accounting for 66.0%, followed by FluB, CoxB, PIV, RSV, ADV, FluA and CP, accounting for 13.83%, 9.55%, 6.01%, 2.61%, 1.47%, 0.40% and 0.13%, respectively. Respiratory tract viruses (FluA, FluB, RSV, ADV, PIV, CoxB) accounted for 33.86%.There were significant differences in the detection rates of PIV, ADV and MP among children of different genders (χ2=6.814, 5.154 and 17.784, P<0.05). The detection rate of school-age children (6-17 years old) was the highest, accounting for 33.27% (184/553). The detection rates of 8 common respiratory pathogens in patients with ARI were higher in spring and winter and lower in summer and autumn. To sum up, from 2021 to 2022, MP and FluB infection were dominant in ARI patients in our hospital. The peak period of 8 common respiratory pathogens was in spring and winter. The physical examination rate of 8 common respiratory pathogens in ARI patients aged 6-17 years old was the highest.

International Epidemiology of Carbapenemase-Producing Escherichia coli

BACKGROUND

Carbapenemase-producing (CP) Escherichia coli (CP-Ec) are a global public health threat. We aimed to describe the clinical and molecular epidemiology and outcomes of patients from several countries with CP-Ec isolates obtained from a prospective cohort.

METHODS

Patients with CP-Ec were enrolled from 26 hospitals in 6 countries. Clinical data were collected, and isolates underwent whole-genome sequencing. Clinical and molecular features and outcomes associated with isolates with or without metallo-β-lactamases (MBLs) were compared. The primary outcome was desirability of outcome ranking (DOOR) at 30 days after the index culture.

RESULTS

Of the 114 CP-Ec isolates in Consortium on resistance against carbapenems in Klebsiella and other Enterobacterales-2 (CRACKLE-2), 49 harbored an MBL, most commonly blaNDM-5 (38/49, 78%). Strong regional variations were noted with MBL-Ec predominantly found among patients in China (23/49). Clinically, MBL-Ec were more often from urine sources (49% vs 29%), less often met criteria for infection (39% vs 58%, P = .04), and had lower acuity of illness when compared with non-MBL-Ec. Among patients with infection, the probability of a better DOOR outcome for a randomly selected patient with MBL-Ec as compared with non-MBL-Ec was 62% (95% CI: 48.2-74.3%). Among infected patients, non-MBL-Ec had increased 30-day (26% vs 0%; P = .02) and 90-day (39% vs 0%; P = .001) mortality compared with MBL-Ec.

CONCLUSIONS

Emergence of CP-Ec was observed with important geographic variations. Bacterial characteristics, clinical presentations, and outcomes differed between MBL-Ec and non-MBL-Ec. Mortality was higher among non-MBL isolates, which were more frequently isolated from blood, but these findings may be confounded by regional variations.

[Clinical application of combination of different types of free perforator flaps in the repair of complex wounds in extremities]

Objective: To investigate the clinical application effects of combination of different types of free perforator flaps in the repair of complex wounds in extremities. Methods: A retrospective observational study was conducted. From January 2018 to June 2022, 11 patients with complex wounds in extremities who met the inclusion criteria was admitted to the Affiliated Hospital of Zunyi Medical University, including 8 males and 3 females, aged 28 to 55 years. The wounds in the upper extremities in 4 cases and in the lower extremities in 7 cases were repaired with different combination of free perforator flaps. After debridement, the wound area was 7.0 cm×6.0 cm-28.0 cm×12.0 cm. A combination of different types of perforator flaps were applied, including the perforator tri-leaf flap of the descending branch of the lateral femoral circumflex artery in 6 cases, the descending branch of lateral femoral circumflex artery combined with oblique branch perforating branch flap in 2 cases, the lobulated flap of the descending branch of the lateral femoral circumflex artery combined with the contralateral medial plantar artery perforator flap in 2 cases, and the bilateral perforator flap of the descending branch of lateral femoral circumflex artery combined with great toe nail flap in 1 case, with the size of a single flap ranged from 2.0 cm×2.0 cm-25.0 cm×6.0 cm. The donor site was repaired by direct suture, skin grafting, or flap transplantation. During free flap transplantation, the flap was cut and split according to the distribution of perforators, and end-to-end or end-to-side anastomosis was performed between the donor area and the recipient area. After surgery, the survival of transplanted flap in the primary recipient site, the occurrence of vascular crisis, the wound healing in the flap donor site, and the survival of transplanted skin or flap in the flap donor site were observed. During follow-up, the blood supply, appearance and texture of the transplanted flap in the primary recipient site were observed; and at the same time, the weight bearing of the plantar receiving area, the presence of sliding, ulcers, and sinus tracts of the flap, and the appearance and function of the hand were observed; the complications in the donor area were observed. Results: After surgery, one patient's transplanted flap in the primary recipient site had vascular crisis but survived after exploration+vein graft bridging; partial necrosis occurred in one lobe of anterolateral thigh lobulated flap transplanted to the primary recipient site in one patient and recovered after dressing change+skin grafting, and the different types of perforator flap transplanted to the primary recipient site in the other 9 patients all survived. After surgery, the wound with direct suture at the donor site healed well, and the skin or flap transplanted to the donor area survived well. During 3-24 months of follow-up, the blood supply, appearance, and texture of the transplanted flap at the primary recipient site were good. In two patients, the anterolateral thigh flap combined with the medial plantar flap were used to repair plantar defects. The plantar receiving area was able to bear weight, and the texture of the flaps in the recipient area was close to the normal plantar skin, without flap sliding, ulcer, or sinus tract formation. In one patient, bilateral anterolateral thigh flap combined with great toe nail flap were used to repair hand combined with soft forearm defect, and the appearance and function of hand, especially thumb were good. Only linear scar was left in the donor site without other obvious complications. Conclusions: The combination of different types of perforator flaps is a reliable clinical method to repair complex wounds in extremities with high safety, good efficacy, and less complications.

Combination Therapy of Ceftazidime/Avibactam for the Treatment of Patients Infected with Carbapenem-Resistant Klebsiella pneumoniae: A Multicenter Retrospective Study

INTRODUCTION

This study aimed to evaluate the different efficacies between monotherapy and combination therapy with ceftazidime/avibactam (CAZ/AVI) in treating carbapenem-resistant Klebsiella pneumoniae (CRKP) infection.

METHODS

We retrospectively analyzed observational multicenter data from 38 hospitals in China. Multivariate regression analysis was used to explore the association between combination therapy with CAZ/AVI and in-hospital mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were performed to validate our findings.

RESULTS

A total of 132 eligible patients were divided into CAZ/AVI combination therapy (n = 43) and monotherapy (n = 89) cohorts. Multivariate logistic regression showed that there was no statistically significant relationship between combination therapy and a lower risk of in-hospital mortality [odds ratio (OR) 0.907, 95% confidence interval (CI) 0.329-2.498, p = 0.850]. In the subgroup of critical patients who were in the intensive care unit (ICU) (OR 0.943, 95% CI 0.221-4.033, p = 0.937) or with sequential organ failure assessment (SOFA) ≥ 3 (OR 0.733, 95% CI 0.191-2.808, p = 0.650), CAZ/AVI combination therapy was not a lower risk factor for in-hospital mortality. Moreover, in the subgroup of patients using CAZ/AVI plus tigecycline (accounting for 46.5% in the combination therapy) compared with CAZ/AVI monotherapy, there was no statistical difference between the two groups in in-hospital mortality, nor in the subgroup of patients with CRKP-associated pneumonia.

CONCLUSION

Combination therapy (or CAZ/AVI combined with tigecycline) and monotherapy with CAZ/AVI had similar prognoses in patients with only CRKP infection (or CRKP-associated pneumonia), as well as in critically ill patients. Larger randomized controlled trials are warranted to confirm these findings.

Guidelines for the diagnosis, treatment, prevention and control of infections caused by carbapenem-resistant gram-negative bacilli

The dissemination of carbapenem-resistant Gram-negative bacilli (CRGNB) is a global public health issue. CRGNB isolates are usually extensively drug-resistant or pandrug-resistant, resulting in limited antimicrobial treatment options and high mortality. A multidisciplinary guideline development group covering clinical infectious diseases, clinical microbiology, clinical pharmacology, infection control, and guideline methodology experts jointly developed the present clinical practice guidelines based on best available scientific evidence to address the clinical issues regarding laboratory testing, antimicrobial therapy, and prevention of CRGNB infections. This guideline focuses on carbapenem-resistant Enterobacteriales (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB), and carbapenem-resistant Pseudomonas aeruginosa (CRPA). Sixteen clinical questions were proposed from the perspective of current clinical practice and translated into research questions using PICO (population, intervention, comparator, and outcomes) format to collect and synthesize relevant evidence to inform corresponding recommendations. The grading of recommendations, assessment, development and evaluation (GRADE) approach was used to evaluate the quality of evidence, benefit and risk profile of corresponding interventions and formulate recommendations or suggestions. Evidence extracted from systematic reviews and randomized controlled trials (RCTs) was considered preferentially for treatment-related clinical questions. Observational studies, non-controlled studies, and expert opinions were considered as supplementary evidence in the absence of RCTs. The strength of recommendations was classified as strong or conditional (weak). The evidence informing recommendations derives from studies worldwide, while the implementation suggestions combined the Chinese experience. The target audience of this guideline is clinician and related professionals involved in management of infectious diseases.

[The impact of LDL-C/HDL-C ratio on severity of coronary artery disease and 2-year outcome in patients with premature coronary heart disease: results of a prospective, multicenter, observational cohort study]

Objective: To explore the relationship between low density lipoprotein cholesterol (LDL-C)/high density lipoprotein cholesterol (HDL-C) ratio with the severity of coronary artery disease and 2-yeat outcome in patients with premature coronary heart disease. Methods: This prospective, multicenter, observational cohort study is originated from the PROMISE study. Eighteen thousand seven hundred and one patients with coronary heart disease (CHD) were screened from January 2015 to May 2019. Three thousand eight hundred and sixty-one patients with premature CHD were enrolled in the current study. According to the median LDL-C/HDL-C ratio (2.4), the patients were divided into two groups: low LDL-C/HDL-C group (LDL-C/HDL-C≤2.4, n=1 867) and high LDL-C/HDL-C group (LDL-C/HDL-C>2.4, n=1 994). Baseline data and 2-year major adverse cardiovascular and cerebrovascular events (MACCE) were collected and analyzed in order to find the differences between premature CHD patients at different LDL-C/HDL-C levels, and explore the correlation between LDL-C/HDL-C ratio with the severity of coronary artery disease and MACCE. Results: The average age of the low LDL-C/HDL-C ratio group was (48.5±6.5) years, 1 154 patients were males (61.8%); the average age of high LDL-C/HDL-C ratio group was (46.5±6.8) years, 1 523 were males (76.4%). The number of target lesions, the number of coronary artery lesions, the preoperative SNYTAX score and the proportion of three-vessel coronary artery disease in the high LDL-C/HDL-C group were significantly higher than those in the low LDL-C/HDL-C group (1.04±0.74 vs. 0.97±0.80, P=0.002; 2.04±0.84 vs. 1.85±0.84, P<0.001; 13.81±8.87 vs. 11.70±8.05, P<0.001; 36.2% vs. 27.4%, respectively, P<0.001). Correlation analysis showed that there was a significant positive correlation between LDL-C/HDL-C ratio and preoperative SYNTAX score, the number of coronary artery lesions, the number of target lesions and whether it was a three-vessel coronary artery disease (all P<0.05). The 2-year follow-up results showed that the incidence of MACCE was significantly higher in the high LDL-C/HDL-C group than that in the low LDL-C/HDL-C group (6.9% vs. 9.1%, P=0.011). There was no significant difference in the incidence of all-cause death, cardiac death, myocardial infarction, stroke, revascularization and bleeding between the two groups. Cox multivariate regression analysis showed that the LDL-C/HDL-C ratio has no correlation with 2-year MACCE, death, myocardial infarction, revascularization, stroke and bleeding events above BARC2 in patients with premature CHD. Conclusion: High LDL-C/HDL-C ratio is positively correlated with the severity of coronary artery disease in patients with premature CHD. The incidence of MACCE of patients with high LDL-C/HDL-C ratio is significantly higher during 2 years follow-up; LDL-C/HDL-C ratio may be an indicator for evaluating the severity of coronary artery disease and long-term prognosis in patients with premature CHD.

Global epidemiology and clinical outcomes of carbapenem-resistant Pseudomonas aeruginosa and associated carbapenemases (POP): a prospective cohort study

BACKGROUND

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a global threat, but the distribution and clinical significance of carbapenemases are unclear. The aim of this study was to define characteristics and outcomes of CRPA infections and the global frequency and clinical impact of carbapenemases harboured by CRPA.

METHODS

We conducted an observational, prospective cohort study of CRPA isolated from bloodstream, respiratory, urine, or wound cultures of patients at 44 hospitals (10 countries) between Dec 1, 2018, and Nov 30, 2019. Clinical data were abstracted from health records and CRPA isolates were whole-genome sequenced. The primary outcome was 30-day mortality from the day the index culture was collected. We compared outcomes of patients with CRPA infections by infection type and across geographic regions and performed an inverse probability weighted analysis to assess the association between carbapenemase production and 30-day mortality.

FINDINGS

We enrolled 972 patients (USA n=527, China n=171, south and central America n=127, Middle East n=91, Australia and Singapore n=56), of whom 581 (60%) had CRPA infections. 30-day mortality differed by infection type (bloodstream 21 [30%] of 69, respiratory 69 [19%] of 358, wound nine [14%] of 66, urine six [7%] of 88; p=0·0012) and geographical region (Middle East 15 [29%] of 52, south and central America 20 [27%] of 73, USA 60 [19%] of 308, Australia and Singapore three [11%] of 28, China seven [6%] of 120; p=0·0002). Prevalence of carbapenemase genes among CRPA isolates also varied by region (south and central America 88 [69%] of 127, Australia and Singapore 32 [57%] of 56, China 54 [32%] of 171, Middle East 27 [30%] of 91, USA ten [2%] of 527; p<0·0001). KPC-2 (n=103 [49%]) and VIM-2 (n=75 [36%]) were the most common carbapenemases in 211 carbapenemase-producing isolates. After excluding USA patients, because few US isolates had carbapenemases, patients with carbapenemase-producing CRPA infections had higher 30-day mortality than those with non-carbapenemase-producing CRPA infections in both unadjusted (26 [22%] of 120 vs 19 [12%] of 153; difference 9%, 95% CI 3-16) and adjusted (difference 7%, 95% CI 1-14) analyses.

INTERPRETATION

The emergence of different carbapenemases among CRPA isolates in different geographical regions and the increased mortality associated with carbapenemase-producing CRPA infections highlight the therapeutic challenges posed by these organisms.

FUNDING

National Institutes of Health.

Immune Responses to HBV Vaccine in People Living with HIV (PLWHs) Who Achieved Successful Treatment: A Prospective Cohort Study

BACKGROUND

Understanding immune responses after HBV vaccination is important to prevent HBV infection in PLWH and to achieve successful treatment.

METHODS

Thirty-two PLWHs with CD4⁺ cell count > 350 cells/µL and HIV RNA < 200 copies/mL were vaccinated with 20 µg of HBV vaccine at weeks 0, 4, and 24 in this prospective study. We measured total HIV DNA levels, HBsAb titers and HBsAg-specific T-cell responses during follow-up time.

RESULTS

All patients achieved protective HBsAb titer after immunization. The magnitude of the IFN-r and TNF-a response to HBsAg was 22.0 (IQR: 6.5-65.0) and 106.50 (IQR: 58.5-203.0) spot-forming cells (SFC)/10⁵ PBMC, respectively at week 0. The level of IFN-r secreted at weeks 12 and weeks 36 to 48 was comparable with that at week 0. However, IFN-r response was higher at weeks 12 than that at weeks 36 to 48 (p = 0.02). The level of TNF-a secreted at weeks 12 was higher than that at week 0 (p < 0.001). Total HIV DNA levels were 2.76 (IQR: 2.47-3.07), 2.77 (IQR: 2.50-3.09), 2.77 (IQR: 2.41-2.89) log₁₀ copies/10⁶ PBMCs at weeks 0, 12, 36 to 48, respectively. No correlation was observed between IFN-r and TNF-a levels and HBsAb titer as well as total HIV DNA levels after immunization.

CONCLUSION

Humoral immunity was satisfactory, but cellular immunity and decline in HIV reservoir were not optimal after HBV vaccine immunization in these patients.

[Fibrocartilaginous mesenchymoma: a clinicopathological analysis of four cases]

Objective: To investigate the clinical, radiological, histological and molecular features and the differential diagnosis of fibrocartilaginous mesenchymoma (FM). Methods: Four cases of FM diagnosed in the Department of Pathology, the Sixth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine from 2020 to 2022 were analyzed. Related literature was also reviewed. Results: Case 1 was a 10-year-old girl with bone destruction in the sacrum and L5 articular processes revealed by CT scan. Case 2 was a 7-year-old girl with an aggressive lesion in her right distal ulna. Case 3 was an 11-year-old boy with a lesion in the metaphysis of his left proximal tibia. Case 4 was an 11-year-old boy with bone destruction in the distal portion of a radius. Microscopically, the four tumors all consisted of numerous spindle cells, hyaline cartilage nodules, and bone trabeculae. The hypocellular to moderately cellular spindle cell component contained elongated cells with slightly hyperchromatic, mildly atypical nuclei arranged in bundles or intersecting fascicles. Benign-appearing cartilaginous nodules of various sizes and shapes were scattered throughout the tumors. There were areas mimicking epiphyseal growth-plate characterized by chondrocytes arranged in parallel columns and areas of enchondral ossification. The stroma was rich in mucus in case 1. Mutation of GNAS and IDH1/IDH2 and amplification of MDM2 gene were not found in any of the three tested cases. Conclusions: FM is very rare and tends to affect young patients. It most frequently occurs in the metaphysis of long tubular bones, followed by the iliac-pubic bones and vertebrae. FM is characterized by a mixed population of spindle cells, hyaline cartilage nodules and trabeculae of bone, without specific immunophenotypes and molecular alternations. As a borderline, locally aggressive neoplasm, surgical removal with a wide margin is generally the treatment of choice for FM.

[Interpretation of low-risk neoplasms in the 5th edition of WHO classification of thyroid tumors]

The fifth edition of World Health Organization (WHO) classification of thyroid tumors replaced the "borderline tumors" in the fourth edition with "low-risk tumors", including noninvasive follicular thyroid neoplasms with papillary-like nuclear features, uncertain malignant potential and hyalinizing trabecular tumors. All of them are thyroid tumors with follicular epithelial cell origin, capsule/clear boundary, no lymph node and distant metastasis (EX0, N0, M0). The spread probability of "low-risk tumor" is extremely low, and this new classification can protect the pathologists from medical litigation when encountering rare and special metastatic cases. Based on the interpretation of the thyroid tumor classification, this paper further discussed several low-risk tumors, which were not listed in the current WHO classification.

[Clinical analysis of 25 cases of acute oral 84 disinfectant poisoning]

Objective: To summarize the clinical characteristics and treatment effect of patients with acute oral 84 disinfectant poisoning, so as to improve the understanding, diagnosis and treatment of the disease. Methods: In January 2022, 25 hospitalized patients with acute oral 84 disinfectant poisoning admitted to our department from March 2016 to August 2021 were selected as the research objects, and their general conditions, poisoning reasons, poisoning time, dose of poisoning, clinical manifestations, blood routine and biochemical indicators, diagnosis, treatment and prognosis were selected. Results: A retrospective analysis was performed. Among the 25 patients, there were 4 males and 21 females, aged from 20 to 91 years, and M (Q(1), Q(3)) was 38.7 (27, 46) years; The poisoning time (from exposure to poison to treatment) was 1~72 h, and M (Q(1), Q(3)) was 10.5 (3, 11.5) h. The length of stay was 1~20 days, and M (Q(1), Q(3)) was 5.72 (2, 7) days.The dose was 40-500 ml, and the M (Q(1), Q(3)) was 219.6 (100, 330) ml. Chest CT showed exudative changes in both lungs in 4 patients, excessive decreased permeability in 1 case and pleural effusion in 1 case. Gastroscope showed 2 cases of erosive inflammation of gastric body and antrum, 1 case of esophageal ulcer and cardiac ulcer, 1 case of corrosive gastritis, gastric fundus ulcer and esophageal stenosis. Abdominal X-ray showed 1 case of abdominal intestinal dilatation and pneumatosis with multiple gas-liquid planes.There were 1 case of type I respiratory failure, 6 cases of gastrointestinal bleeding and 1 case of incomplete intestinal obstruction. There were 19 cases of nausea and vomiting, 9 cases of abdominal pain, 6 cases of pharyngeal pain and 6 cases of retrosternal burning pain, 1 case of cough and 2 cases of fatigue. Conclusion: Acute oral 84 disinfectant will cause varying degrees of damage to the human digestive tract and lungs. In severe cases, gastrointestinal bleeding, intestinal obstruction, hypoxemia, etc, and even life-threatening, should be paid attention to clinically. The treatment is mainly symptomatic support treatment, such as protecting gastrointestinal mucosa, controlling acute inflammatory reaction, protecting the functions of liver and kidney and other important organs.

[Efficacy and influencing factors of surgery combined with neoadjuvant chemoradiotherapy in the treatment of children with non-orbital head and neck rhabdomyosarcoma]

Objective: To evaluate the efficacy and influencing factors of surgery combined with neoadjuvant chemoradiotherapy in the treatment of children with non-orbital head and neck rhabdomyosarcoma (HNRMS). Methods: Information from 45 children diagnosed as non-orbital HNRMS and subjected to surgery combined with neoadjuvant chemoradiotherapy in Beijing Children's Hospital affiliated to Capital Medical University from August 2017 to July 2021 was analyzed. The patients included 25 males and 20 females, aged from 1 to 17 years old. The primary tumor site, pathological subtype, clinical stage, risk group, therapeutic regimen, resection range and outcome of all cases were also collected. The survival curves were made using the Kaplan-Meier method and the potential prognostic factors were investigated by Cox regression analysis. Results: Fifteen (33.3%) of 45 children achieved negative surgical margin under complete tumor resection. The postoperative pathological results showed that there were 20 cases of embryonic subtype, 19 cases of alveolar subtype and 6 cases of spindle sclerosis subtype. The postoperative follow-up time ranged from 4 to 71 months, with a median of 26 months. During the follow-up period, 13 children died, among whom brain metastasis was the most common cause of death, accounting for 7/13. The 3-year overall survival rate was 67.6%. Multivariate analysis showed that non-embryonic subtype (HR=6.26, 95%CI: 1.52-25.87, P=0.011) and failure to reach R0 resection (HR=9.37, 95%CI: 1.18-74.34, P=0.034) were independent risk factors affecting overall survival rate. Conclusion: Surgery combined with neoadjuvant chemoradiotherapy can offer a good efficacy for children with non-orbital HNRMS. Non-embryonic subtype and resection without negative operative microscopic margins are independent risk factors for poor prognosis, and brain metastasis is the main cause of death in these children.

[Predictive value of mismatch negativity and P3a combined with electroencephalogram reactivity for the prognosis of comatose patients after severe brain injury]

Objective: To explore the clinical value of mismatch negativity and P3a combined with electroencephalogram (EEG) reactivity to predict the prognosis of patients after severe brain injury. Methods: The clinical data of patients with severe brain injury who were admitted to the neurosurgical intensive care unit of Xiangya Hospital of Central South University from October 2019 to July 2020 were retrospectively analyzed. All patients underwent evaluation of auditory mismatch negativity (MMN), P3a, and EEG reactivity (EEG-R) within 28 days after the onset of coma. Patients were divided into two groups using the 3-month Glasgow Outcome Scale (GOS) after coma onset, a GOS score of 3-5 was defined as a favorable outcome, and GOS grades 1-2 were defined as an unfavorable outcome. The correlation between clinical indicators and prognosis was analyzed, and the predictive values of statistically significant indicators and the cut-off values were determined using the receiver operating characteristic (ROC) curve. Results: A total of 48 patients were enrolled in the study, including 35 males and 13 females (age range:18-68 years old). Twenty-nine of the patients had a favorable outcome and 19 had an unfavorable outcome. The Glasgow Coma Scale (GCS), EEG-R, absolute amplitude of MMN at Fz (FzMMNA), and amplitude of P3a at Cz (CzP3aA) were significantly correlated with the prognosis of comatose patients (P<0.001). Multivariate logistic regression analysis revealed that only EEG-R, FzMMNA, and CzP3aA were independent predictors for the prognosis of comatose patients after severe brain injury (all P<0.05), with the area under the curve (AUC) of 0.757 (0.613-0.900), 0.912 (0.830-0.994) and 0.887 (0.793-0.981), respectively. The combination of FzMMNA and CzP3aA and the combinationof EEG-R, FzMMNA and CzP3aA increased the value of AUC to 0.942 (0.879-1.000) and 0.964 (0.920-1.000), respectively. Moreover, a cut-off value of 1.27 μV and 2.64 μV for FzMMNA and CzP3aA, respectively, yielded the best sensitivity and specificity for the prognosis prediction of patients with severe brain injury [FzMMNA: 89.66%(26/29) and 84.21%(16/19); CzP3aA:82.76%(24/29) and 84.21%(16/19)]. Conclusion: This study indicates that the combination of EEG-R, FzMMNA, and CzP3aA may serve as a favorable prognostic indicator for comatose patients after severe brain injury.

[A case of arrhythmia caused by barium carbonate poisoning]

Barium carbonate poisoning is mostly caused by mistaken ingestion in clinical cases, and self-administration of poisoning is rare. In November 2020, Tianjin Occupational Disease Prevention Hospital admitted a patient with severe hypokalemia complicated with arrhythmia after taking poison. It is very important to take timely and effective potassium supplementation, symptomatic and detoxification treatment in the course of treatment. At the same time, closely observing the changes of vital signs and taking quick and accurate rescue measures in the event of malignant arrhythmia are the keys to ensuring the success of rescue. In this paper, the clinical data of the case were retrospectively analyzed, providing reference for the diagnosis and treatment of similar clinical cases.

[Clinical features and influencing factors of long-term prognosis in patients with tuberculous meningitis]

Objective: To investigate the clinical features and influencing factors of long-term prognosis of tuberculous meningitis(TBM), and to provide a recommendation for treatment and early intervention of TBM. Methods: Clinical data of TBM patients were retrospectively collected at Peking Union Medical College Hospital from January 2014 to December 2021. Patients who were followed-up more than one year were divided into two groups according to modified Rankin Scale (mRS). Risk factors associated with long-term prognosis were analyze by conditional logistic stepwise regression. Results: A total of 60 subjects were enrolled including 33 (55%) males and 27 (45%) females with age 15-79 (44.5±19.8) years. There were 30 cases (50%) complicated with encephalitis, 21 cases (35%) with miliary tuberculosis. The diagnosis was microbiologically confirmed in 22 patients (36.7%), including 5 cases (22.7%, 5/22) by acid-fast staining, 8 cases (36.4%, 8/22) by Mycobacterium tuberculosis (MTB) culture, and 20 cases (90.9%, 20/22) by molecular biology. The median follow-up period was 52(43, 66 ) months in 55 cases surviving more than one year. Among them, 40 cases (72.7%) were in favorable group (mRS 0-2) and 15 cases (27.3%) were in unfavorable group (mRS 3-6) with poor prognosis. The mortality rate was 20% (11/55). Elderly (OR=1.06, P=0.048 ) , hyponatremia(OR=0.81,P=0.020), high protein level in cerebrospinal fluid (CSF) (OR=3.32,P=0.033), cerebral infarction(OR=10.50,P=0.040) and hydrocephalus(OR=8.51,P=0.049) were associated with poor prognosis in TBM patients. Conclusions: The mortality rate is high in patients with TBM. Molecular biology tests improves the sensitivity and shorten the diagnosis time of TBM. Elderly, hyponatremia, high protein level in CSF, cerebral infarction and hydrocephalus are independent risk factors of long-term survival in TBM patients.

[Clinical characteristics and prognostic analyses of cervical neuroblastoma]

Objective: To determine the characteristics of cervical neuroblastoma and the effect of resection extent on survival and outcomes. Methods: We performed a retrospective review of 32 children with cervical neuroblastoma treated at Beijing Children's Hospital between April 2013 and August 2020. Data were collected from the medical record. The individualized therapy was designed based on staging and risk group. Based on the extent of resection, patients were divided into incomplete and complete resection groups. Event free and overall survival rates were compared between two groups using the Kaplan-Meier method. Results: The ages of patients ranged from 1 month to 81 months, with a median age of 11 months, including 7 males and 15 females. Twenty-nine patients (90.6%) presented with cervical painless mass. The average diameter of the primary tumors was (5.12±1.43) cm. Tumors were located in the parapharyngeal space in 25 cases (78.1%) and in the root of the neck in 7 cases (21.9%). None had MYCN amplification. According to International Neuroblastoma Staging System (INSS), 15 patients (46.9%) were identified as stage 1, 11 patients (34.3%) as stage 2B, 3 patients (9.4%) as stage 3 and 3 patients (9.4%) as stage 4. There were 12 patients (37.5%) at low risk, 17 patients (53.1%) at intermediate risk and 3 patients at high risk according to Children's Oncology Group (COG) risk classification system. All patients underwent tumor resection. Postoperatively Horner's syndrome occurred in 13 patients (40.6%), pneumonia in 9 patients (28.1%), pharyngeal dysfunction in 8 patients (25.0%) and transient hoarseness in 4 patients (12.5%). At a median follow-up of 36.5 months, the overall survival rate was 96.4%, with no significant difference between incomplete and complete resection groups (100.0% vs. 96.3%, χ²=0.19, P=0.667); the event free survival rate was 78.1%, with a significant difference between the two groups (40.0% vs. 85.2%, χ²=6.71, P=0.010). Conclusions: Primary cervical neuroblastoma has a young onset age, mostly in low and medium risk groups, and represents favorable lesions with good outcomes after multidisciplinary therapy. Less aggressive surgery with preservation of important structures is recommended. Complete resection should not be attempted if it would compromise vital structures.

[Role and mechanism of Vγ4 T cells in impaired wound healing of rapamycin-induced full-thickness skin defects in mice]

Objective: To investigate the role and mechanism of Vγ4 T cells in impaired wound healing of rapamycin-induced full-thickness skin defects in mice. Methods: The experimental research methods were applied. Eighty-six C57BL/6J male mice (hereinafter briefly referred to as wild-type mice) aged 8-12 weeks were selected for the following experiments. Vγ4 T cells were isolated from axillary lymph nodes of five wild-type mice for the following experiments. Intraperitoneal injection of rapamycin for 42 mice was performed to establish rapamycin-treated mice model for the following experiments. Eighteen wild-type mice were divided into normal control group without any treatment, trauma only group, and trauma+CC chemokine ligand 20 (CCL20) inhibitor group according to the random number table (the same grouping method below), with 6 mice in each group. The full-thickness skin defect wound was made on the back of mice in the latter two groups (the same wound model below), and mice in trauma+CCL20 inhibitor group were continuously injected subcutaneously with CCL20 inhibitor at the wound edge for 3 days after injury. Another 6 rapamycin-treated mice were used to establish wound model as rapamycin+trauma group. On post injury day (PID) 3, the epidermal cells of the skin tissue around the wound of each trauma mice were extracted by enzyme digestion, and the percentage of Vγ4 T cells in the epidermal cells was detected by flow cytometry. In normal control group, the epidermal cells of the normal skin tissue in the back of mice were taken at the appropriate time point for detection as above. Five wild-type mice were used to establish wound models. On PID 3, the epidermal cells were extracted from the skin tissue around the wound. The cell populations were divided into Vγ4 T cells, Vγ3 T cells, and γδ negative cells by fluorescence-activated cell sorter, which were set as Vγ4 T cell group, Vγ3 T cell group, and γδ negative cell group (with cells in each group being mixed with B16 mouse melanoma cells), respectively. B16 mouse melanoma cells were used as melanoma cell control group. The expression of interleukin-22 (IL-22) mRNA in cells of each group was detected by real-time fluorescence quantitative reverse transcription polymerase chain reaction (RT-PCR), with the number of samples being 6. Thirty rapamycin-treated mice were used to establish wound models, which were divided into Vγ4 T cell only group and Vγ4 T cell+IL-22 inhibitor group performed with corresponding injections and rapamycin control group injected with phosphate buffer solution (PBS) immediately after injury, with 10 mice in each group. Another 10 wild-type mice were taken to establish wound models and injected with PBS as wild-type control group. Mice in each group were injected continuously for 6 days. The percentage of wound area of mice in the four groups was calculated on PID 1, 2, 3, 4, 5, and 6 after injection on the same day. Six wild-type mice and 6 rapamycin-treated mice were taken respectively to establish wound models as wild-type group and rapamycin group. On PID 3, the mRNA and protein expressions of IL-22 and CCL20 in the peri-wound epidermis tissue of mice in the two groups were detected by real-time fluorescence quantitative RT-PCR and Western blotting, respectively. The Vγ4 T cells were divided into normal control group without any treatment and rapamycin-treated rapamycin group. After being cultured for 24 hours, the mRNA and protein expressions of IL-22 of cells in the two groups were detected by real-time fluorescence quantitative RT-PCR and Western blotting, respectively, with the number of samples being 6. Data were statistically analyzed with independent sample t test, analysis of variance for repeated measurement, one-way analysis of variance, Bonferroni method, Kruskal-Wallis H test, and Wilcoxon rank sum test. Results: The percentage of Vγ4 T cells in the epidermal cells of the skin tissue around the wound of mice in trauma only group on PID 3 was 0.66% (0.52%, 0.81%), which was significantly higher than 0.09% (0.04%, 0.14%) in the epidermal cells of the normal skin tissue of mice in normal control group (Z=4.31, P<0.01). The percentages of Vγ4 T cells in the epidermal cells of the skin tissue around the wound of mice in rapamycin+trauma group and trauma+CCL20 inhibitor group on PID 3 were 0.25% (0.16%, 0.37%) and 0.24% (0.17%, 0.35%), respectively, which were significantly lower than that in trauma only group (with Z values of 2.27 and 2.25, respectively, P<0.05). The mRNA expression level of IL-22 of cells in Vγ4 T cell group was significantly higher than that in Vγ3 T cell group, γδ negative cell group, and melanoma cell control group (with Z values of 2.96, 2.45, and 3.41, respectively, P<0.05 or P<0.01). Compared with that in wild-type control group, the percentage of wound area of mice in rapamycin control group increased significantly on PID 1-6 (P<0.01), the percentage of wound area of mice in Vγ4 T cell+IL-22 inhibitor group increased significantly on PID 1 and PID 3-6 (P<0.05 or P<0.01). Compared with that in rapamycin control group, the percentage of wound area of mice in Vγ4 T cell only group decreased significantly on PID 1-6 (P<0.05 or P<0.01). Compared with that in Vγ4 T cell only group, the percentage of wound area of mice in Vγ4 T cell+IL-22 inhibitor group increased significantly on PID 3-6 (P<0.05 or P<0.01). On PID 3, compared with those in wild-type group, the expression levels of IL-22 protein and mRNA (with t values of -7.82 and -5.04, respectively, P<0.01) and CCL20 protein and mRNA (with t values of -7.12 and -5.73, respectively, P<0.01) were decreased significantly in the peri-wound epidermis tissue of mice in rapamycin group. After being cultured for 24 hours, the expression levels of IL-22 protein and mRNA in Vγ4 T cells in rapamycin group were significantly lower than those in normal control group (with t values of -7.75 and -6.04, respectively, P<0.01). Conclusions: In mice with full-thickness skin defects, rapamycin may impair the CCL20 chemotactic system by inhibiting the expression of CCL20, leading to a decrease in the recruitment of Vγ4 T cells to the epidermis, and at the same time inhibit the secretion of IL-22 by Vγ4 T cells, thereby slowing the wound healing rate.

Pressure-Induced Superconductivity up to 9 K in the Quasi-One-Dimensional KMn_{6}Bi_{5}

The Mn-based superconductor is rare owing to the strong magnetic pair-breaking effect. Here we report on the discovery of pressure-induced superconductivity in KMn_{6}Bi_{5}, which becomes the first ternary Mn-based superconductor. At ambient pressure, the quasi-one-dimensional KMn_{6}Bi_{5} is an antiferromagnetic metal with T_{N}≈75  K. By measuring resistance and ac magnetic susceptibility under hydrostatic pressures up to 14.2 GPa in a cubic anvil cell apparatus, we find that its antiferromagnetic transition can be suppressed completely at a critical pressure of P_{c}≈13  GPa, around which bulk superconductivity emerges and displays a superconducting dome with the maximal T_{c}^{onset}=9.3  K achieved at about 14 GPa. The close proximity of superconductivity to a magnetic instability in the temperature-pressure phase diagram of KMn_{6}Bi_{5} and an unusually large μ_{0}H_{c2}(0) exceeding the Pauli paramagnetic limit suggests an unconventional magnetism-mediated paring mechanism. In contrast to the binary MnP, the flexibility of the crystal structure and chemical compositions in the ternary AMn_{6}Bi_{5} (A=alkali metal) can open a new avenue for finding more Mn-based superconductors.

De-escalation from Echinocandins to Azole Treatment in Critically Ill Patients with Candidemia

OBJECTIVES

This study aims to further explore the duration of echinocandins and analyze the de-escalation (DE) strategy in patients with candidemia.

METHODS

Multivariable logistic regression was used to evaluate the association between the duration of echinocandins (≤ 5-day group vs > 5-day group) and in-hospital mortality.

RESULTS

Of the 357 cases of candidemia, 200 patients (56.02%) were identified in the ≤5-day group. The ≤5-day group did not have a higher in-hospital mortality than the >5-day group in the multivariable model (odds ratio [OR] 1.536, 95% confidence interval (CI) 0.837-2.819, P-value = 0.166), and the finding was validated by the propensity score matching and inverse probability of treatment weighting models. Subgroup analyses showed that patients in the ≤5-day group without DE may have a poor prognosis (OR 4.223, 95% CI 1.773-10.055, P-value = 0.001). The patients in the ≤5-day group, with a sequential organ failure assessment (SOFA) score of ≥3 evaluated at the time of stopping echinocandins, may have a poor prognosis (OR 2.164, 95% CI 1.009-4.641, P-value = 0.047).

CONCLUSION

In critically ill adult patients with candidemia, the ≤5-day group with DE was feasible. However, the SOFA score was recommended when stopping echinocandins to ensure the safety of DE therapy.

[Bioinformatics analysis of nasal epithelial cell gene expression in seasonal and perennial allergic rhinitis]

Objective: Transcriptome sequencing and bioinformatics analysis were performed on the gene expression of nasal epithelial cells in patients with seasonal allergic rhinitis (AR) and perennial AR, so as to obtain the differences in the gene expression of nasal epithelial cells between seasonal AR and perennial AR. Methods: The human nasal epithelial cell line(HNEpC) was cultured in vitro, treated with 100 μg/ml mugwort or house dust mite (HDM) extracts for 24 hours. Total cell RNA was extracted, and quantitative real-time polymerase chain reaction (qPCR) was used to detect the expression of cytokines, including IL-6, IL-8, IL-33 and thymic stromal lymphopoietin (TSLP). From November 2019 to November 2020, 3 seasonal AR patients, 3 perennial AR patients, and 3 healthy controls who attended the Department of Otolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University were analyzed. The patients' primary nasal epithelial cells were cultured in vitro, treated with corresponding allergens for 24 hours. Total RNA was extracted for transcriptome sequencing, and the sequencing results were analyzed by bioinformatics. Results: The qPCR results showed that the cytokines IL-6, IL-8, IL-33 and TSLP of HNEpC treated with mugworts extracts and HDM extracts had the same trend of change. After the nasal epithelial cells from patients with seasonal AR and perennial AR were treated with corresponding allergens, there were differences in biological processes and signal pathways between those and control. Gene ontology (GO) enrichment analysis showed that the differentially expressed genes (DEG) in AR patients allergic to mugwort were mainly enriched in the oxidation-reduction process, the negative regulation of apoptosis process, and the cell adhesion; the DEG in AR patients allergic to HDM were mainly enriched in cell adhesion, the negative regulation of cell proliferation and the response to drug. Enrichment analysis of Kyoto Encyclopedia of Genes and Genomes (KEGG) signaling pathway showed that the DEG of AR patients allergic to mugwort were significantly enriched in arachidonic acid metabolism, p53 signaling pathway and transforming growth factor β (TGF-β) signaling pathway, while the DEG of AR patients allergic to HDM were mainly enriched in cells cycle, Fanconi anemia pathway and DNA replication. Gene Set Enrichment Analysis (GSEA) showed that the inflammatory response, TNF-α/NF-κB signaling pathway and IL-2/STAT5 signaling pathway were significantly up-regulated in AR patients allergic to mugwort, indicating the promotion of inflammatory response; and AR patients allergic to HDM had significant down-regulation of G2M, E2F, and MYC, indicating the inhibition of cell proliferation. The protein-protein interaction network showed that TNF and CDK1 were the most interacting proteins in mugwort and HDM allergic AR patients, respectively. Conclusion: Seasonal AR and perennial AR may affect the different biological processes and signal pathways of nasal epithelial cells, leading to differences in the occurrence and development of AR.

Feasibility Study on the Steel-Plastic Geogrid Instead of Wire Mesh for Bolt Mesh Supporting

Wire mesh is a common material for bolt mesh supporting structures, but its application in engineering has revealed many defects. At the same time, with the development of new materials for civil engineering, the new material mesh performance and cost show outstanding advantages over wire mesh. In this paper, the feasibility of replacing wire mesh with steel-plastic geogrid as an alternative material is carefully studied through indoor tests and field applications. The following conclusions were drawn from a comparative analysis with wire mesh, mainly in terms of mechanical properties, engineering characteristics, and construction techniques: (1) in terms of mesh wire strength, wire mesh is slightly better than steel-plastic geogrid, but in the case of similar tensile strength, the amount of steel used per unit length of steel geogrid bars is only 36.75% of that of steel-plastic geogrid, while the tensile strength of the high-strength steel wire attached to the steel-plastic geogrid belt is about 3.3 times that of steel bars; (2) in terms of junction peel strength, both values are similar, with the injection-moulded junction being 1154.56–1224.38 N and the welded junction of 4 mm mesh being 988.35 N; (3) in terms of the strength of the mesh, steel-plastic geogrid is better than wire mesh, and with the same mesh wire strength, the bearing capacity of steel-plastic geogrid is increased by about 63.17% and the contribution of the mesh wire bearing capacity is increased by 83.66%, with the damage mainly being in the form of wire breakage in the ribbon causing ribbon failure, leading to further damage to the mesh; (4) in terms of the engineering application of steel-plastic geogrid compared to wire mesh, the utilization rate of mesh increases by about 24.99%, the construction efficiency increases by about 14.10%, and the economic benefit increases by about 45.31%. In practical application, the steel-plastic geogrid has good adhesion with surrounding rock and strong corrosion resistance. According to the above research analysis, the steel-plastic geogrid is feasible to replace the wire mesh for bolt mesh supporting.

Molecular Characterization of Penicillin-Binding Protein2x, 2b and 1a of Streptococcus pneumoniae Causing Invasive Pneumococcal Diseases in China: A Multicenter Study

Streptococcus pneumoniae is a common human pathogen that can cause severe invasive pneumococcal diseases (IPDs). Penicillin-binding proteins (PBPs) are the targets for β-lactam antibiotics (BLAs), which are the common empirical drugs for treatment of pneumococcal infection. This study investigated the serotype distribution and antibiotic resistance patterns of S. pneumoniae strains causing IPD in China, including exploring the association between penicillin (PEN) susceptibility and PBPs variations. A total of 300 invasive S. pneumoniae isolates were collected from 27 teaching hospitals in China (2010-2015). Serotypes were determined by Quellung reaction. Serotypes 23F and 19F were the commonest serotypes in isolates from cerebrospinal fluid (CSF), whilst serotypes 19A and 23F were most commonly seen in non-CSF specimens. Among the 300 invasive S. pneumoniae strains, only one strain (serotype 6A, MIC = 0.25 μg/ml) with PEN MIC value ≤ 0.25 μg/ml did not have any substitutions in the PBPs active sites. All the strains with PEN MIC value ≥ 0.5 μg/ml had different substitutions within PBPs active sites. Substitutions in PBP2b and PBP2x active sites were common in low-level penicillin-resistant S. pneumoniae (PRSP) strains (MIC = 0.5 μg/ml), with or without PBP1a substitution, while all strains with PEN MIC ≥ 1 μg/ml had substitutions in PBP1a active sites, accompanied by PBP2b and PBP2x active site substitutions. Based on the three PBPs substitution combinations, a high degree of diversity was observed amongst the isolates. This study provides some new insights for understanding the serology and antibiotic resistance dynamics of S. pneumoniae causing IPD in China. However, further genomic studies are needed to facilitate a comprehensive understanding of antibiotic resistance mechanisms of S. pneumoniae.

Clinical outcomes and bacterial characteristics of carbapenem-resistant Klebsiella pneumoniae complex among patients from different global regions (CRACKLE-2): a prospective, multicentre, cohort study

BACKGROUND

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a global threat. We therefore analysed the bacterial characteristics of CRKP infections and the clinical outcomes of patients with CRKP infections across different countries.

METHODS

In this prospective, multicentre, cohort study (CRACKLE-2), hospitalised patients with cultures positive for CRKP were recruited from 71 hospitals in Argentina, Australia, Chile, China, Colombia, Lebanon, Singapore, and the USA. The first culture positive for CRKP was included for each unique patient. Clinical data on post-hospitalisation death and readmission were collected from health records, and whole genome sequencing was done on all isolates. The primary outcome was a desirability of outcome ranking at 30 days after the index culture, and, along with bacterial characteristics and 30-day all-cause mortality (a key secondary outcome), was compared between patients from China, South America, and the USA. The desirability of outcome ranking was adjusted for location before admission, Charlson comorbidity index, age at culture, Pitt bacteremia score, and anatomical culture source through inverse probability weighting; mortality was adjusted for the same confounders, plus region where relevant, through multivariable logistic regression. This study is registered at ClinicalTrials.gov, NCT03646227, and is complete.

FINDINGS

Between June 13, 2017, and Nov 30, 2018, 991 patients were enrolled, of whom 502 (51%) met the criteria for CRKP infection and 489 (49%) had positive cultures that were considered colonisation. We observed little intra-country genetic variation in CRKP. Infected patients from the USA were more acutely ill than were patients from China or South America (median Pitt bacteremia score 3 [IQR 2-6] vs 2 [0-4] vs 2 [0-4]) and had more comorbidities (median Charlson comorbidity index 3 [IQR 2-5] vs 1 [0-3] vs 1 [0-2]). Adjusted desirability of outcome ranking outcomes were similar in infected patients from China (n=246), South America (n=109), and the USA (n=130); the estimates were 53% (95% CI 42-65) for China versus South America, 50% (41-61) for the USA versus China, and 53% (41-66) for the USA versus South America. In patients with CRKP infections, unadjusted 30-day mortality was lower in China (12%, 95% CI 8-16; 29 of 246) than in the USA (23%, 16-30; 30 of 130) and South America (28%, 20-37; 31 of 109). Adjusted 30-day all-cause mortality was higher in South America than in China (adjusted odds ratio [aOR] 4·82, 95% CI 2·22-10·50) and the USA (aOR 3·34, 1·50-7·47), with the mortality difference between the USA and China no longer being significant (aOR 1·44, 0·70-2·96).

INTERPRETATION

Global CRKP epidemics have important regional differences in patients' baseline characteristics and clinical outcomes, and in bacterial characteristics. Research findings from one region might not be generalisable to other regions.

FUNDING

The National Institutes of Health.

[Promoting the application of federated learning in medical imaging artificial intelligence]

Medical image-based artificial intelligence (AI) systems have shown great potential in assisting disease diagnosis and treatment. However, the challenges, such as data silos, privacy security and standardization, seriously impedes the application of AI in disease diagnosis and treatment. By integrating federated learning technology and FAIR data principle, it is possible to resolve the aforementioned obstacles. Then, it is able to maximize the value of multicenter data to develop a more efficient and accurate disease diagnosis and treatment AI systems, and promote the clinical application of medical image-based AI systems in the field of disease diagnosis and treatment.

[Value of radiomics model based on dynamic contrast-enhanced magnetic resonance imaging in differentiation fat-poor angiomyolipoma from alpha-fetoprotein-negative hepatocellular carcinoma in the background of non-cirrhotic liver]

Objective: To explore the value of radiomics model based on dynamic contrast-enhanced magnetic resonance imaging (MRI) in differentiation fat-poor angiomyolipoma (fp-AML) from alpha-fetoprotein-negative hepatocellular carcinoma (n-HCC) in the background of non-cirrhotic liver. Methods: The complete data of 121 patients from Guangdong Provincial People's Hospital, Zhongshan Hospital Affiliated to Fudan University and Sun Yat-sen University Cancer Center with hepatic fp-AML and n-HCC confirmed by pathology from October 2010 to July 2020 were retrospectively analyzed. Among them, 75 were males and 46 were females, aged from 23 to 80 (55±12) years. A total of 93 patients from Zhongshan Hospital Affiliated to Fudan University were divided into the training cohort (n=75) and internal test cohort (n=18) according to entry time, and the patients of other 2 hospitals were divided into external test cohort (n=28). The radiomics features were extracted from the preoperative triple-phase contrast-enhanced images. The feature selection algorithm based on Joint Mutual Information Maximisation (JMIM) was used to extract the optimal feature subset, and support vector machine (SVM) was used to build the radiomics model. The diagnostic performance of radiomics model was evaluated using the receiver operating characteristic (ROC) curve, and was compared with that of two radiologists. Results: In the internal cohort, the area under the curve (AUC) for the differential diagnosis between fp-AML and n-HCC of the radiomics model was 0.819 (with an accuracy of 72.2%), outperforming than radiologist 1 with 10 years of diagnostic experience (AUC=0.542, P=0.029) and radiologist 2 with 2 years of diagnostic experience (AUC=0.375, P=0.004). In the external cohort, the AUC of the radiomics model was 0.772 (with and accuracy of 71.4%), which was comparable to that of radiologist 1 (AUC=0.661, P=0.442) and better than that of radiologist 2 (AUC=0.400, P=0.008). Conclusion: The radiomics model based on dynamic contrast-enhanced MRI is of high accuracy for preoperatively differentiating hepatic fp-AML from n-HCC in the noncirrhotic liver.

[Paying attention to the clinical application of radiomics]

Since the concept of radiomics was proposed, both domestic and foreign scholars have successively carried out many scientific researches on radiomics. Domestic and foreign research teams and their corresponding research have achieved certain results in radiomics, but we still face many challenges on the clinical application of radiomics-based models. Currently radiomics is still facing challenges. We should certainly pay attention to the research hotspots, existing problems, and future perspectives of radiomics.

Serotype Distribution, Antimicrobial Susceptibility, Multilocus Sequencing Type and Virulence of Invasive Streptococcus pneumoniae in China: A Six-Year Multicenter Study

Background:Streptococcus pneumoniae is an important human pathogen that can cause severe invasive pneumococcal diseases (IPDs). The aim of this multicenter study was to investigate the serotype and sequence type (ST) distribution, antimicrobial susceptibility, and virulence of S. pneumoniae strains causing IPD in China.

Methods: A total of 300 invasive S. pneumoniae isolates were included in this study. The serotype, ST, and antimicrobial susceptibility of the strains, were determined by the Quellung reaction, multi-locus sequence typing (MLST) and broth microdilution method, respectively. The virulence level of the strains in the most prevalent serotypes was evaluated by a mouse sepsis model, and the expression level of well-known virulence genes was measured by RT-PCR.

Results: The most common serotypes in this study were 23F, 19A, 19F, 3, and 14. The serotype coverages of PCV7, PCV10, PCV13, and PPV23 vaccines on the strain collection were 42.3, 45.3, 73.3 and 79.3%, respectively. The most common STs were ST320, ST81, ST271, ST876, and ST3173. All strains were susceptible to ertapenem, levofloxacin, moxifloxacin, linezolid, and vancomycin, but a very high proportion (>95%) was resistant to macrolides and clindamycin. Based on the oral, meningitis and non-meningitis breakpoints, penicillin non-susceptible Streptococcus pneumoniae (PNSP) accounted for 67.7, 67.7 and 4.3% of the isolates, respectively. Serotype 3 strains were characterized by high virulence levels and low antimicrobial-resistance rates, while strains of serotypes 23F, 19F, 19A, and 14, exhibited low virulence and high resistance rates to antibiotics. Capsular polysaccharide and non-capsular virulence factors were collectively responsible for the virulence diversity of S. pneumoniae strains.

Conclusion: Our study provides a comprehensive insight into the epidemiology and virulence diversity of S. pneumoniae strains causing IPD in China.

[Corneal confocal microscopy detects small-fiber neuropathy in patients with amyotrophic lateral sclerosis]

Objective: To investigate small fiber neuropathy in patients with amyotrophic lateral sclerosis (ALS) by corneal confocal microscopy. Methods: A total of 57 ALS patients were consecutively enrolled in Department of Neurology between June 2015 and February 2016, including 37 men and 20 women with mean age 24-80 (52±11) years. There were 30 controls including 21 men and 9 women with mean age 23-76 (55±13) years. All subjects underwent corneal confocal microscopy (CCM), contact heat evoked potential (CHEP) and skin sympathetic reflection (SSR) to quantify small nerve fiber pathology. Four parameters, such as nerve fiber length (NFL), nerve branch density (NBD), nerve fiber density (NFD) and nerve fiber tortuosity (NFT) were assessed by corneal confocal microscopy. All statistical calculations were conducted using SPSS version 12.0. Results: Compared with control group, corneal nerve fiber length (NFL),nerve fiber density (NFD) were significantly decreased [(12.2±4.4)mm/mm² vs.(15.1±4.5) mm/mm²,P=0.028;(50.8±24.0)/mm² vs. (68.3±16.4)/mm²,P=0.002],and nerve fiber tortuosity (NFT) were significantly increased [(2.6±1.0)level vs.(1.0±0.5)level, P<0.01)] in SFN group, while nerve branch density (NBD) were comparable (P=0.700).The course of disease is correlated with NFT (r=0.25,P=0.030). Conclusions: CCM is a new sensitive noninvasive clinical technique that detects early small fiber nerve damage in patients with ALS.

[Evaluation of developmental toxicity of ammonium dinitramide by micromass culture and embryonic stem cells models]

Objective: To evaluated the potential developmental toxicity and teratogenicity of ammonium dinitroamide (ADN) by micromass test (MM Test) and embryonic stem cell test models. Methods: In September 2018, rat embryos were isolated and limb bud cells were collected. The limb bud cells were treated with different concentrations of ADN (0, 312.50, 625.00, 1250.00, 2500.00, 5000.00, 10000.00 μg/ml) . Half proliferation inhibitory concentration and half differentiation inhibitory concentration were calculated and the teratogenic effects were evaluated according to the criteria. For the embryonic stem cell test, the effects of different concentrations of ADN (0, 39.06, 78.13, 156.25, 312.50, 625.00, 1250.00, 2500.00 μg/ml) on the differentiation of mouse embryonic stem cells (mESCs) into myocardial cells and the cytotoxicity of mESCs and 3T3 cells were detected. The embryonic toxicity was evaluated according to the criteria. In this study, both 5-fluorouracil (5-FU) , a known strong embryonic toxic drug, and penicillin-G (P-G) , a non-embryonic toxic drug, were used to verify the effectiveness of the model, and the validated test model was applied to evaluate the embryonic toxicity of ADN. Results: In the MM Test, the inhibition rates of proliferation and differentiation of limb bud cells in ADN groups were higher than that in control group (P<0.05) . And the half proliferation inhibitory concentration and half differentiation inhibitory concentration of ADN on limb bud cells were 7480.32 and 4526.09 μg/ml, respectively. ADN was determined to be non-teratogenic by standard. In the embryonic stem cell test, the inhibition rates of mESCs proliferation in ADN groups were higher than that in control group, and the inhibition rates of 3T3 cells in 156.25, 312.50, 625.00, 1250.00, 2500.00 μg/ml ADN groups were higher than that in control group (P<0.05) . The half proliferation inhibitory concentration and half differentiation inhibitory concentration of ADN on mESCs were 1851.73 and 1796.39 μg/ml, respectively, and the half proliferation inhibitory concentration on 3T3 cells was 3334.35 μg/ml. ADN was determined to be non-embryotoxic by standard. Conclusion: After evaluation by MM Test and embryonic stem cell models, ADN has no embryo toxicity and is a non-teratogenic substance.