Germline mutations of homologous recombination genes and clinical outcomes in pancreatic cancer: a multicenter study in Taiwan

BACKGROUND

Cancer susceptibility germline mutations are associated with pancreatic ductal adenocarcinoma (PDAC). However, the hereditary status of PDAC and its impact on survival is largely unknown in the Asian population.

METHODS

Exome sequencing was performed on 527 blood samples from PDAC individuals and analyzed for mutations in 80 oncogenic genes. Pathogenic and likely pathogenic (P/LP) germline variants were diagnosed according to the ACMG variant classification categories. The association between germline homologous recombination gene mutations (gHRmut, including BAP1, BRCA1, BRCA2, PALB2, ATM, BLM, BRIP1, CHEK2, NBN, MUTYH, FANCA and FANCC) and the treatment outcomes was explored in patients with stage III/IV diseases treated with first-line (1L) platinum-based versus platinum-free chemotherapy.

RESULTS

Overall, 104 of 527 (19.7%) patients carried germline P/LP variants. The most common mutated genes were BRCA2 (3.60%), followed by ATR (2.66%) and ATM (1.9%). After a median follow-up duration of 38.3-months (95% confidence interval, 95% CI 35.0-43.7), the median overall survival (OS) was not significantly different among patients with gHRmut, non-HR germline mutations, or no mutation (P = 0.43). Among the 320 patients with stage III/IV disease who received 1L combination chemotherapy, 32 (10%) had gHRmut. Of them, patients receiving 1L platinum-based chemotherapy exhibited a significantly longer median OS compared to those with platinum-free chemotherapy, 26.1 months (95% CI 12.7-33.7) versus 9.6 months (95% CI 5.9-17.6), P = 0.001. However, the median OS of patients without gHRmut was 14.5 months (95% CI 13.2-16.9) and 12.6 months (95% CI 10.8-14.7) for patients receiving 1L platinum-based and platinum-free chemotherapy, respectively (P = 0.22). These results were consistent after adjusting for potential confounding factors including age, tumor stage, performance status, and baseline CA 19.9 in the multivariate Cox regression analysis.

CONCLUSIONS

Our study showed that nearly 20% of Taiwanese PDAC patients carried germline P/LP variants. The longer survival observed in gHRmut patients treated with 1L platinum-based chemotherapy highlights the importance of germline testing for all patients with advanced PDAC at diagnosis.

[Progress in epidemiological characteristics and surveillance and early warning of dengue fever in China]

Dengue fever is an acute mosquito-borne infectious disease caused by dengue virus and widely spread worldwide. Many factors, such as pathogens, vector organisms, climate, and social environment, affect its transmission and prevalence. The local dengue fever epidemic caused by imported cases in China shows a trend of increasing epidemic latitude and more widespread epidemic areas. However, the traditional monitoring and early warning models of dengue fever mainly focus on researching a single factor and a single area. Establishing a multi-factor forecast and early warning system is urgent to strengthen the early warning capability for the dengue fever epidemic. This paper mainly discusses the epidemic characteristics, the influencing factors, and the surveillance and early warning models of dengue fever in China to provide a reference for the effective prevention and control of dengue fever in China.

Prediction of surgical outcomes in severe encapsulating peritoneal sclerosis using a computed tomography scoring system

BACKGROUND/PURPOSE

Encapsulating peritoneal sclerosis (EPS) is a rare and potential lethal complication of peritoneal dialysis characterized by bowel obstruction. Surgical enterolysis is the only curative therapy. Currently, there are no tools for predicting postsurgical prognosis. This study aimed to identify a computed tomography (CT) scoring system that could predict mortality after surgery in patients with severe EPS.

METHODS

This retrospective study enrolled patients with severe EPS who underwent surgical enterolysis in a tertiary referral medical center. The association of CT score with surgical outcomes including mortality, blood loss, and bowel perforation was analyzed.

RESULTS

Thirty-four patients who underwent 37 procedures were recruited and divided into a survivor and non-survivor group. The survivor group had higher body mass indices (BMIs, 18.1 vs. 16.7 kg/m2, p = 0.035) and lower CT scores (11 vs. 17, p < 0.001) than the non-survivor group. The receiver operating characteristic curve revealed that a CT score of ≥15 could be considered a cutoff point to predict surgical mortality, with an area under the curve of 0.93, sensitivity of 88.9%, and specificity of 82.1%. Compared with the group with CT scores of <15, the group with CT scores of ≥15 had a lower BMI (19.7 vs. 16.2 kg/m2, p = 0.004), higher mortality (4.2% vs. 61.5%, p < 0.001), greater blood loss (50 vs. 400 mL, p = 0.007), and higher incidence of bowel perforation (12.5% vs. 61.5%, p = 0.006).

CONCLUSION

The CT scoring system could be useful in predicting surgical risk in patients with severe EPS receiving enterolysis.

[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.

Application of mobile-based web app to enhance simple suturing skills of nurse practitioners

BACKGROUND

Suturing is a crucial clinical skill for nurse practitioners (NPs), but the effectiveness of traditional training methods (e.g., physical suture kits combined with video content) is low.

OBJECTIVE

This study compared the effectiveness and usability of a mobile-based web app (MoWa) developed for NPs to learn simple suturing skills with those of traditional instructional video-based training.

METHODS

The MoWa system utilizes mobile devices to simulate hands-on suturing and provides learning guidance and feedback to support self-learning with a physical suturing kit. Fifty-four suturing novices (NPs) were recruited as participants, divided into an experimental group (EG: 28 participants) and a control group (CG: 26 participants), and instructed to self-learn for 3 weeks. Learning effectiveness and system usability were evaluated through a pretest and posttest.

RESULTS

The EG exhibited significant improvements in learning outcomes, self-confidence, self-efficacy, and learning anxiety and expressed satisfaction with the MoWa system. Furthermore, the EG also considerably enhanced learning outcomes, self-efficacy, and learning anxiety compared to the CG, with no significant difference in self-confidence.

CONCLUSION

The MoWa system combined with deliberate practice is an effective strategy for supporting suturing skills training.

[Diagnosis status and genetic characteristics analysis of Fanconi anemia in China]

Objective: To analyze the clinical and molecular diagnostic status of Fanconi anemia (FA) in China. Methods: The General situation, clinical manifestations and chromosome breakage test and genetic test results of 107 pediatric FA cases registered in the Chinese Blood and Marrow Transplantation Registry Group (CBMTRG) and the Chinese Children Blood and Marrow Transplantation Registry Group (CCBMTRG) from August 2009 to January 2022 were analyzed retrospectively. Children with FANCA gene variants were divided into mild and severe groups based on the type of variant, and Wilcoxon-test was used to compare the phenotypic differences between groups. Results: Of the 176 registered FA patients, 69 (39.2%) cases were excluded due to lack of definitive genetic diagnosis results, and the remaining 107 children from 15 hospitals were included in the study, including 70 males and 37 females. The age at transplantation treatment were 6 (4, 9) years. The enrolled children were involved in 10 pathogenic genes, including 89 cases of FANCA gene, 7 cases of FANCG gene, 3 cases of FANCB gene, 2 cases of FANCE gene and 1 case each of FANCC, FANCD1, FANCD2, FANCF, FANCJ, and FANCN gene. Compound heterozygous or homozygous of loss-of-function variants account for 69.2% (72/104). Loss-of-function variants account for 79.2% (141/178) in FANCA gene variants, and 20.8% (37/178) were large exon deletions. Fifty-five children (51.4%) had chromosome breakage test records, with a positive rate of 81.8% (45/55). There were 172 congenital malformations in 80 children.Café-au-Lait spots (16.3%, 28/172), thumb deformities (16.3%,28/172), polydactyly (13.9%, 24/172), and short stature (12.2%, 21/172) were the most common congenital malformations in Chinese children with FA. No significant difference was found in the number of congenital malformations between children with severe (50 cases) and mild FANCA variants (26 cases) (Z=-1.33, P=0.185). Conclusions: FANCA gene is the main pathogenic gene in children with FA, where the detection of its exon deletion should be strengthened clinically. There were no phenotypic differences among children with different types of FANCA variants. Chromosome break test is helpful to determine the pathogenicity of variants, but its accuracy needs to be improved.

The experience of neoadjuvant chemotherapy versus upfront surgery in resectable pancreatic cancer: a cross sectional study

BACKGROUND

Upfront resection (UR) followed by adjuvant chemotherapy remains the standard treatment for resectable pancreatic cancer. There is increasing evidence suggesting favourable outcomes toward neoadjuvant chemotherapy (NAC) followed by surgery.

METHODS

All clinical staging with resectable pancreatic cancer patients treated at a tertiary medical centre from 2013 to 2020 were identified. The baseline characteristics, treatment course, surgery outcome and survival results of UR or NAC were compared.

RESULTS

Finally, in 159 resectable patients, 46 patients (29%) underwent NAC and 113 patients (71%) received UR. In NAC, 11 patients (24%) did not receive resection, 4 (36.4%) for comorbidity, 2 (18.2%) for patient refusal and 2 (18.2%) for disease progression. In UR, 13 patients (12%) were unresectable intraoperatively; 6 (46.2%) for locally advanced and 5 (38.5%) for distant metastasis. Overall, 97% of patients in NAC and 58% of patients in UR completed adjuvant chemotherapy. As of data cut-off, 24 patients (69%) in NAC and 42 patients (29%) in UR were still tumour free. The median recurrence-free survival in NAC, UR with adjuvant chemotherapy and without adjuvant chemotherapy were 31.3 months (95% CI, 14.4-not estimable), 10.6 months (95% CI, 9.0-14.3) and 8.5 months (95% CI, 5.8-11.8), P =0.036; and the median overall survival in each group were not reached (95% CI, 29.7-not estimable), 25.9 months (95% CI, 21.1-40.5) and 21.7 months (12.0-32.8), P =0.0053. Based on initial clinical staging, the median overall survival of NAC was not significantly different from UR with a tumour less than or equal to 2 cm, P =0.29. NAC patients had a higher R0 resection rate (83% versus 53%), lower recurrence rate (31% versus 71%) and harvested median number lymph node (23 versus 15).

CONCLUSION

This study demonstrates that NAC is superior to UR in resectable pancreatic cancer with better survival.

Is delayed fixation worthwhile in patients with long bone fracture concomitant with mild traumatic brain injury? A propensity score-matched study

INTRODUCTION

Early definite treatment for orthopedic patients is strongly advocated. However, a consensus has not been reached on the optimal timing of long bone fracture fixation for patients with associated mild traumatic brain injury (TBI). Surgeons lack evidence on the basis on which they should decide on the operation timing.

METHODS

We retrospectively reviewed the data of patients with mild TBI and lower extremity long bone fractures from 2010 to 2020. The patients receiving internal fixation within and after 24 h were defined as the early- and delayed-fixation groups. We compared the discharge Glasgow Coma Scale (GCS) scores, lengths of stay, and in-hospital complications. Propensity score matching (PSM) with multiple adjusted variables and a 1:1 matching ratio was applied to reduce selection bias.

RESULTS

In total, 181 patients were enrolled; 78 (43.1%) and 103 (56.9%) patients received early and delayed fracture fixation, respectively. After matching, each group had 61 participants and were statistically identical. The delayed group did not have better discharge GCS scores (early vs. delayed: 15.0 ± 0 vs. 15.0 ± 0.1; p = 0.158). The groups did not differ in their lengths of hospital stay (15.3 ± 10.6 vs. 14.8 ± 7.9; p = 0.789), intensive care unit stay (2.7 ± 4.3 vs. 2.7 ± 3.8; p = 0.947), or incidence of complications (23.0% vs. 16.4%; p = 0.494).

CONCLUSIONS

Delayed fixation for patients with lower extremity long bone fractures concurrent with mild TBI does not result in fewer complications or improved neurologic outcomes compared with early fixation. Delaying fixation may not be necessary to prevent the second hit phenomenon and has not demonstrated any clear benefits.

Feasibility of simultaneous development of laparoscopic and robotic pancreaticoduodenectomy

Laparoscopic (LPD) and robotic pancreaticoduodenectomy (RPD) are both challenging procedures. The feasibility and safety of simultaneously developing LPD and RPD remain unreported. We retrospectively reviewed the data of patients undergoing LPD or RPD between 2014 and 2021. A total of 114 patients underwent minimally invasive pancreaticoduodenectomy (MIPD): 39 LPDs and 75 RPDs. The learning process of LPD and RPD were similar. The cutoff points of the learning curve were LPD, 13th patient (the 27th patient of MIPD), and RPD, 18th patient (the 31st patient of MIPD) according the cumulative sum analysis of operative time. A decrease in the operative time was associated with the case sequence (p < 0.001) but not with the surgical approach (p = 0.36). The overall surgical outcomes were comparable between both the LPD and RPD groups. When evaluating the learning curve impact on MIPD, LPD had higher major complication (≧ Clavien-Dindo grade III), bile leak and wound infection rates in the pre-learning curve phase than those in the after-learning curve phase, while RPD had similar surgical outcomes between two phases. Simultaneous development of LPD and RPD is feasible and safe for experienced surgeons, with similar learning process and comparable surgical outcomes.

Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan

High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.

Tumor-associated macrophages promote resistance of hepatocellular carcinoma cells against sorafenib by activating CXCR2 signaling

BACKGROUND

Sorafenib (SOR) is the first line treatment for advanced hepatocellular carcinoma (HCC), but resistance develops frequently. Tumor-associated macrophages (TAMs) have been reported to affect the progression of HCC. We therefore aimed to study the role of TAMs in promoting SOR resistance.

METHODS

Immunofluorescence staining for the M2 marker CD204 and the cancer stem cell (CSC) markers CD44 and CD133 was performed in paired HCC and adjacent noncancerous tissues and HCC tissues stratified by response of SOR treatment. HCC/U937 coculture system and cytokines were used to induce M2 polarization for studying the effects of M2 TAMs on CSC properties and apoptotic death of HCC cells after SOR treatment.

RESULTS

Higher expression of CD204, CD44, and CD133 was observed in patients with SOR nonresponse (SNR) than in those with SOR response (SR), suggesting that SNR is positively correlated to levels of CSCs and M2 TAMs. After coculture, M2 TAMs could increase the level of CSCs but decrease SOR-induced apoptosis. Incubation of HCC cells with coculture conditioned medium increased the formation of spheres that were resistant to SOR. Furthermore, CXCL1 and CXCL2 were found to be the potential paracrine factors released by M2 TAMs to upregulate SOR resistance in HCC cells. Treatment with CXCL1 and CXCL2 could increase HCC CSC activity but decrease SOR-induced apoptosis by affecting BCL-2 family gene expression. Using pharmacological inhibitors, CXCR2/ERK signaling was found to be critical to CXCL1- and CXCL2-mediated SOR resistance.

CONCLUSION

This study identified CXCL1, CXCL2, and their downstream CXCR2/ERK signaling as potential therapeutic targets to overcome SOR resistance in HCC.

Effectiveness of protocolized management for patients sustaining maxillofacial fracture with massive oronasal bleeding: a single-center experience

BACKGROUND

Maxillofacial fractures can lead to massive oronasal bleeding; however, surgical hemostasis and packing procedures can be challenging owing to complex facial anatomy. Only a few studies investigated maxillofacial fractures with massive oronasal hemorrhage. However, thus far, no studies have reported a protocolized management approach for maxillofacial trauma from a single center. This study aimed to evaluate the effectiveness of protocolized management for maxillofacial fractures with oronasal bleeding.

METHODS

Patients were identified from the National Cheng University Hospital trauma registry from 2010 to 2020. We included patients with a face Abbreviated Injury Scale (AIS) score of > 3 and active oronasal bleeding. Patients' characteristics were compared between the angiography and non-angiography groups and between survivors and nonsurvivors.

RESULTS

Forty-nine patients were included. Among them, 34 (69%) underwent angiography, of whom 21 received arterial embolization. Forty-seven patients (96%) successfully achieved hemostasis by adhering to the treatment protocol at our institution. Compared with the non-angiography group, the angiography group had significantly more patients requiring oral intubation (97% vs. 53%, P < 0.001), Glasgow Coma Scale < 9 (GCS; 79% vs. 27%, P < 0.001), head AIS > 3 (65% vs. 13%, P = 0.001), higher Injury Severity Score (ISS; 43 [33-50] vs. 22 [18-27], P < 0.001), higher incidence of cardiopulmonary resuscitation (CPR; 41% vs. 0%, P = 0.002), higher mortality rate (35% vs. 7%, P = 0.043), and more units of packed red blood cells (PRBC) transfused within 24 h (12 [6-20] vs. 2 [0-4], P < 0.001). The nonsurvivor group had significantly more patients with hypotension (62% vs. 8%; P < 0.001), higher need for CPR (85% vs. 8%; P < 0.001), head AIS > 3 (92% vs. 33%; P < 0.001), skull base fracture (100% vs. 64%; P = 0.011), GCS score < 9 (100% vs. 50%; P = 0.003), higher ISS (50 [43-57] vs. 29 [19-48]; P < 0.001), and more units of PRBC transfused within 24 h (18 [13-22] vs. 6 [2-12]; P = 0.001) than the survivor group. More patients underwent angiography in the nonsurvivor group than in the survivor group (92% vs. 61%; P = 0.043). Among embolized vessels, the internal maxillary artery (65%) was the most common bleeding site. Hypoxic encephalopathy accounted for 92% of deaths.

CONCLUSIONS

Protocol-guided management effectively optimizes outcomes in patients with maxillofacial bleeding.

Abdominal pain is a main manifestation of delayed bleeding after splenic injury in patients receiving non-operative management

Delayed bleeding is a major issue in patients with high-grade splenic injuries who receive non-operative management (NOM). While only few studies addressed the clinical manifestations of delayed bleeding in these patients. We reviewed the patients with high-grade splenic injuries presented with delayed bleeding, defined as the need for salvage procedures following NOM. There were 138 patients received NOM in study period. Fourteen of 107 patients in the SAE group and 3 of 31 patients in the non-embolization group had delayed bleeding. Among the 17 delayed bleeding episodes, 6 and 11 patients were salvaged by splenectomy and SAE, respectively. Ten (58.9%, 10/17) patients experienced bleeding episodes in the intensive care unit (ICU), whereas seven (41.1%, 7/17) experienced those in the ward or at home. The clinical manifestations of delayed bleeding were a decline in haemoglobin levels (47.1%, 8/17), hypotension (35.3%, 6/17), tachycardia (47.1%, 8/17), new abdominal pain (29.4%, 5/17), and worsening abdominal pain (17.6%, 3/17). For the bleeding episodes detected in the ICU, a decline in haemoglobin (60%, 6/10) was the main manifestation. New abdominal pain (71.43%, 5/7) was the main presentation when the patients left the ICU. In conclusion, abdominal pain was the main early clinical presentation of delayed bleeding following discharge from the ICU or hospital.

Tailored Surgical Stabilization of Rib Fractures Matters More Than the Number of Fractured Ribs

BACKGROUND

Patients sustaining multiple rib fractures have a significant risk of developing morbidity and mortality. More evidence is emerging that the indication of surgical stabilization of rib fractures (SSRF) should expand beyond flail chest. Nevertheless, little is known about factors associated with poor outcomes after surgical fixation. We reviewed patients with rib fractures to further explore the role of SSRF; we matched two groups by propensity score (PS).

METHOD

A comparison of patients with blunt thoracic trauma treated with SSRF between 2010 and 2020 was compared with those who received conservative treatment for rib fractures. Risk factors for poor outcomes were analyzed by multivariate regression analysis.

RESULTS

After tailored SSRF, the number of fractured ribs was not associated with longer ventilator days (p = 0.617), ICU stay (p = 0.478), hospital stay (p = 0.706), and increased nonprocedure-related pulmonary complications (NPRCs) (p = 0.226) despite having experienced much more severe trauma. In the multivariate regression models, lower GCS, delayed surgery, thoracotomy, and flail chest requiring mechanical ventilation were factors associated with prolonged ventilator days. Lower GCS, higher ISS, delayed surgery, and flail chest requiring mechanical ventilation were factors associated with longer ICU stays. Lower GCS and older age were factors associated with increased NPRCs. In the PS model, NPRCs risk was reduced by SSRF.

CONCLUSIONS

The risk of NPRCs was reduced once ribs were surgically fixed through an algorithmic approach, and poor consciousness and aging were independent risk factors for NPRCs.

[Clinical characteristics of convalescent children infected with SARS-CoV-2 Omicron variant in Tianjin]

Objective: To analyze the clinical characteristics of SARS-CoV-2 Omicron variant infected children in convalescence in Tianjin. Methods: A total of 104 pediatric patients infected by SARS-CoV-2 Omicron variant Tianjin First Central Hospital (designated hospital for SARS-CoV-2 infection in Tianjin) for convalescent treatment from January 22^nd, 2022 to February 24^th were included for a retrospective study.Clinical data including clinical typing, SARS-CoV-2 IgG and IgM test and 2019-nCoV nucleic acid test were collected.The cases were divided into 2-dose group and zero-dose group based on the doses of inactivated SARS-CoV-2 vaccine. The children were divided into repositive group and negative group, according to the nucleic acid test during hospitalization. Chi-square test was used for the comparison between the groups. Results: The age of these 104 children was 10.0 (0.3, 14.0) years on admission, 53 children were males and 51 were females, 92 cases (88.5%) had mild symptoms, 12 cases (11.5%) had common symptoms.The age and SARS-CoV-2 IgG level of zero-dose group was lower (2.0 (0.3, 10.2) vs. 10.0 (3.2, 14.0) years, 10 (2, 17) vs. 193 (157, 215), χ²=-5.57, Z=-48.76,both P<0.001) than that of 2-dose group. The zero-dose group had a high rate of transmission among family members and a high level of SARS-CoV-2 IgM level (13/14 vs. 62.2% (56/90), 0.4 (0.2, 0.8) vs. 0.4 (0.2, 1.1),χ²=5.09, Z=-48.95, both P<0.05) than the 2-dose group. Repositive group had a high rate of underlying diseases and SARS-CoV-2 IgM level was higher (2/13) vs. 1.1% (1/91), (0.6 (0.2, 1.0) vs. 0.3 (0.2, 0.7), χ²=8.29, Z=2.70, both P<0.05) than negative group. The SARS-CoV-2 IgG level of repositive group was lower than that of negative group (160 (78, 197) vs. 213 (186, 231), χ²=-3.20, P<0.05). Conclusions: Children infected with SARS-CoV-2 Omicron variant in Tianjin were mainly transmitted by family members, and most of them had mild symptoms. Two-dose group had higher IgG levels and lower IgM levels than zero-dose group.The probability of SARS-CoV-2 nucleic acid test repositivity increased in children with underlying diseases and lower IgG levels.

[Mendelian randomization analysis: the causal relationship between the DNA methylation levels of JAK2 and obesity]

Objective: Based on the Mendelian randomization analysis, to assess the causal relationship between DNA methylation levels of Janus kinase 2 (JAK2) and obesity. Methods: A case-control study was carried out, including 1 021 individuals [obesity (visceral fat index ≥10) vs. no obesity (visceral fat index <10) was 440 vs. 581] from the Henan Rural Cohort Study. MethylTarget^TM target region methylation sequencing technology was used for testing the DNA methylation level of JAK2. logistic regression models were used to assess the association between the DNA methylation level of JAK2 and obesity. With SNP as the instrumental variable, the association between the DNA methylation level of JAK2 and obesity was explored by using the Mendelian randomization analysis method. Results: There was a positive association between Chr9:4984943 (one DNA methylation site in the promoter of JAK2) and obesity, and the OR (95%CI) was 1.22(1.04-1.42). Methylation level of five sites in the exon of JAK2 (Chr9:4985378, Chr9:4985404, Chr9:4985407, Chr9:4985409 and Chr9:4985435) were negatively associated with obesity, the corresponding OR (95%CI) were 0.53 (0.29-0.95), 0.58(0.36-0.93), 0.69 (0.49-0.97), 0.72 (0.53-0.99) and 0.58 (0.35-0.98) , respectively. Mendelian randomization analysis showed that there was a causal relationship between the DNA methylation levels of JAK2 and obesity, and the corresponding β (95%CI) were -1.985 (-3.520 - -0.450),-3.547 (-6.301 - -0.792) and -3.900 (-6.328 - -1.472) for Mendelian randomization method of inverse variance weighted, Mendelian randomization method of median based and Maximum-likelihood method, respectively. Conclusion: This study supported there was a causal relationship between the DNA methylation level of JAK2 and obesity.

The Differential Clinical Impacts of Cachexia and Sarcopenia on the Prognosis of Advanced Pancreatic Cancer

Simple Summary

Pancreatic cancer (PC) is one of the most lethal malignancies across the world. More than 80% patients are diagnosed at an advanced stage with limited treatment options. PC has the highest frequency of developing cancer cachexia (CC)–sarcopenia (SC) syndrome, but there is no optimal efficient intervention for CC or SC targeting their complicated biological and irreversible processes. As a result, identifying the clinicopathological features and patient characteristics in each advanced PC patient with CC and/or SC is urgently needed to distinguish different wasting phenotypes or body composition and thus support precision medicine and achieve optimal outcomes. We performed a retrospective cohort study of 232 advanced PC patients to determine the differential clinical characteristics of CC and SC and the overlap of CC- or SC-related factors in each patient. The impacts of CC, SC, and their relevant factors on the outcomes of PC patients were also evaluated.

Abstract

Pancreatic cancer (PC) has the highest frequency of developing cancer cachexia (CC)–sarcopenia (SC) syndrome, which negatively influences patients’ outcome, quality of life, and tolerance/response to treatments. However, the clinical impacts of CC, SC, and their associated factors on outcomes for advanced PC has yet to be fully investigated. A total of 232 patients were enrolled in this study for the retrospective review of their clinical information and the measurement of skeletal muscle areas at the third lumber vertebra by computed tomography scan to identify CC or SC. The association and concurrent occurrence of clinicopathological features in each patient, prevalence rates, and prognosis with the CC or SC were calculated. CC and SC were observed in 83.6% (n = 194) and 49.1% (n = 114) of PC patients, respectively. Low hemoglobin levels more often occurred in CC patients than in non-CC patients (p = 0.014). Older age (p = 0.000), female gender (p = 0.024), low body mass index (BMI) values (p = 0.004), low hemoglobin levels (p = 0.036), and low albumin levels (p = 0.001) were more often found in SC patients than in non-SC patients. Univariate and multivariate analyses showed that CC was an independent poor prognostic factor of overall survival (OS) and progression-free survival for all patients, the chemotherapy (C/T) subgroup, and the high BMI subgroup. Meanwhile, SC was an independent predictor of poor OS for the subgroups of C/T or high BMI but not for all patients. These findings reveal the clinical differences for CC and SC and provide useful information for predicting the prognosis of advanced PC patients and conducting personalized medicine.

Improved survival with induction chemotherapy and conversion surgery in locally advanced unresectable pancreatic cancer: a single institution experience

Both efficacy and tolerability are critical issues in choosing neoadjuvant chemotherapy in patients with unresectable locally advanced pancreatic cancer (LAPC). The optimal regimen and the impact of conversion surgery on patient survival remains insufficiently reported in Asain population. Therefore, we conducted a retrospective study aiming to evaluate the resection rate after different induction chemotherapy regimen and its impact toward survival. All patients with pancreatic cancer treated in our institute from 2013 to 2020, a total of 730 patients, were reviewed and 131 patients with LAPC were identified. For cohort homogeneity, 14 patients receiving induction concurrent chemoradiotherapy initially were excluded and 117 patients receiving induction chemotherapy were included in the study. Most patients (90 of 117, 77%) received triplet induction chemotherapy, including the combination of S1, leucovorin, oxaliplatin and gemcitabine (SLOG) in 48, modified FOLFIRINOX in 21 and the combination of gemcitabine, oxaliplatin, fluorouracil and leucovorin (GOFL) in 21. The tumor response rate (19%-33%), the surgical exploration rate (38%-52%) and the mOS (15.4-23.0 months) were not significantly different among the three triplets. Both GOFL and SLOG regimen had comparable efficacy and less neutropenia as compared to mFOLFIRINOX. Conversion surgery was performed in 34 of 117 (29%) patients after induction chemotherapy. The median overall survival (mOS) in patients with and without conversion surgery were 29.1 and 14.1 months, respectively (P<0.0001). Radiological response alone was not a reliable indicator of successful conversion surgery. Patients who underwent conversion surgery had significantly better survival and thus highlighted the importance of surgical exploration in all patients who did not have progressive disease after induction chemotherapy.

[Clinical characteristics and risk factors of pericardial effusion after hematopoietic stem cell transplantation in children with thalassemia major]

Objective: To investigate the characteristics, risk factors and outcomes of thalassemia major (TM) children with pericardial effusion (PE) after allo-geneic hematopoietic stem cell transplantation (allo-HSCT). Methods: Clinical data of 446 TM children received allo-HSCT at Shenzhen Children's Hospital between January 2012 and December 2020 were analyzed retrospectively. Patients were divided into PE and non-PE group according to the occurrence of PE. Chi-square tests were used to investigate the risk factors that were associated with the development of PE. Kaplan-Meier method was used for survival analysis of the 2 groups. Results: Twenty-five out of 446 patients (5.6%) developed PE at a time of 75.0 (66.5, 112.5) days after allo-HSCT. Among these patients, 22 cases (88.0%) had PE within 6 months after allo-HSCT and 19 patients (76.0%) had PE within 100 days after allo-HSCT. The diagnoses of PE were confirmed using echocardiography. Pericardial tamponade was observed in only 1 patient, who later undergone emergency pericardiocentesis. The rest of patients received conservative managements alone. PE disappeared in all patients after treatment. Risk factors that were associated with the development of PE after allo-HSCT included the gender of patients, the type of transplantation, the number of mononuclear cells (MNC) infuse, pulmonary infection after HSCT and transplantation associated thrombotic microangiopathy (TA-TMA) (χ²=3.99, 10.20, 14.18, 36.24, 15.03, all P<0.05). In 239 patients that received haploidentical HSCT, the development of PE was associated with the gender of patients, pulmonary infection after HSCT and TA-TMA (χ²=4.48, 20.89, 12.70, all P<0.05). The overall survival rates of PE and non-PE groups were 96.0% (24/25) and 98.6% (415/421). The development of PE was not associated with the overall survival of TM children after allo-HSCT (χ²=1.73, P=0.188). Conclusions: PE mainly develop within 100 days after allo-HSCT in pediatric TM recipients. Haploidentical grafts, female gender, pulmonary infection after HSCT and TA-TMA are the main risk factors associated with PE development after transplant. However, the presence of PE don't have a significant impact on the outcomes of pediatric TM patients after allo-HSCT.

[Comprehensive treatment options and influencing factors in elderly patients with breast cancer]

Objective: To investigate the treatment options for breast cancer patients aged 65 and over, and analyze the influencing factors. Methods: The clinical data of 521 elderly patients aged 65 years or older,who underwent surgery in Peking Union Medical College Hospital from January 2009 to December 2015, were collected. They were all female and 65-98 years old. The patients were divided into 65-74 years old group (n=353) and ≥ 75 years old group (n=168). The differences of variables including age, functional status, treatment methods, pathological characteristics, comorbidities and survival time between the two groups were compared, and the differences of comprehensive treatment methods and their impact on clinical efficacy were analyzed. Results: The main operation methods of the two groups were modified radical mastectomy [39.1% (138/353) and 33.9% (57/168), respectively], breast conserving surgery [56.9% (201/353) and 61.3% (103/353), respectively]. Among the patients choosing adjuvant therapy, there was no significant difference between the two groups except chemotherapy (all P>0.05). Univariate analysis showed that the choice of chemotherapy was related to age, surgical methods, pathological types, tumor burden, molecular typing, functional status and comorbidities (all P<0.05). The Eastern Cooperative Oncology Group (ECOG) score and the number of comorbidities were independent factors affecting the choice of chemotherapy for breast cancer in the elderly: [ECOG score: adjusted OR=0.45 (95CI: 0.26-0.75), number of comorbidities: adjusted OR = 0.63 (95CI:0.41-0.98); all P<0.05]. The 5-year disease-free survival rate of 521 elderly patients with breast cancer was 86.3%, 5-year overall survival rate was 88.8%, and the breast cancer specific survival rate was 94.3%. Conclusions: The comprehensive treatment of breast cancer patients aged 65 and above is not affected by age, but is associated with tumor burden, pathological type, molecular typing, comorbidities and ECOG score. Among them, ECOG score and the number of comorbidities are the independent factors influencing the choice of adjuvant chemotherapy.

[Fibrinogen gamma-chain mutation, p.Ile171His, leads to hereditary hypofibrinogenemia]

Objective: To explore the clinical phenotype and genotype of a family with hereditary hypofibrinogenemia. Methods: Activated partial thrombin time (APTT), prothrombin time (PT),thrombin time (TT) and thrombelastogram (TEG) were tested in all family members. Fibrinogen activity and antigen were detected by Clauss method and immunoturbidimetric method respectively. All exons and flanking sequences of fibrinogen FGA,FGB,FGG genes were analyzed by PCR, and the products were subjected to Sanger sequencing. Results: The proband represented prolonged PT and TT, low Fg activity and antigen, elevated K value and decreased Angle value in TEG. Other family members reported similar changes including proband's father,daughter and son, and his elder brother and his niece. Exon 5 c.510_512 of FGG gene in the proband revealed a minor deletion mutation. Conclusion: The novel heterozygous missense mutation of exon 5 c.510_512del (Gln170_Ile171 del ins His) of FGG gene is the molecular mechanism that leads to hereditary hypofibrinogenemia in this family.

Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study

Background

Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes.

Method

This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed.

Results

A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p <  0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076).

Conclusion

This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.

[Clinical characteristics and prognosis of MLL-AF6 positive patients with acute myeloid leukemia]

OBJECTIVE

To investigate the clinical features and prognosis of acute myeloid leukemia (AML) patients with the mixed lineage leukemia (MLL) gene rearrangements AF6 (MLL-AF6) positive.

METHODS

In the study, 11 patients who were newly diagnosed with MLL-AF6 positive AML were analyzed retrospectively, related literature was reviewed to clarify the clinical features and prognosis of MLL-AF6 positive patients.

RESULTS

Among the 11 patients, there were 6 males and 5 females, with a median age of 36 years. Six patients were diagnosed with AML M5 and five with M4 according to FAB classification (French-American-British classification systems). Gingival swelling and pain occurred in 6 cases and fever occurred in 5 cases. At first diagnosis, the median white blood cells were 55.5×109/L. Immunotype showed the expression of myeloid/monocyte and early stem cell series antigens. The expression level of MLL-AF6 fusion gene (real-time quantitative PCR) was 14.2%-214.5%, and 6/11 cases (54.5%) were associated with high EVI1 gene expression. Mutations of KRAS, TET2, ASXL1, TP53, DNMT3A, and FLT3-ITD were detected by next generation sequencing (NGS) in 4 patients. Chromosome G banding examination showed that 2 cases were t(6;11)(q27, q23) with complex karyotype abnormality, 4 cases with +8 abnormality and 2 cases with normal karyotype. Hematological complete remission (CR) was achieved in 8/11 patients (72.7%) after conventional induction chemotherapy, and primary drug resistance was observed in 3 patients. Two of the eight patients with CR were negative for minimal residual disease (MRD), with a median CR duration of 4.5 months. Two patients with positive MRD and three patients with refractory recurrence underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT), but all died due to leukemia progression. At the end of follow-up on December 1, 2019, 2 patients were alive and 9 died, with median survival time of 9 months.

CONCLUSION

The AML patients with MLL-AF6 positive were mostly young, the majority of FAB types were M4 and M5, and most of the patients often had fever as the first symptom, with increased white blood cells, accompanied by organ infiltration, and high EVI1 gene expression. The hematological remission rate of routine chemotherapy is not low, but it is difficult to achieve molecular remission, most of which have early recurrence. Early allo-HSCT in a molecular negative state may prolong the CR duration.

[Fitting and predicting trend of COVID-19 by SVEPIUHDR dynamic model]

Objective: To fit and predict the trend of COVID-19 epidemics in the United States (USA) and the United Kingdom (UK), and analyze the effect of vaccination. Methods: Based on the SEIR dynamic model, considering the presymptomatic infections, isolation measures, vaccine vaccination coverage, etc., we developed a SEIR with vaccine inoculation, Presymptomatic infectious, unconfirmed infectious, hospital isolation and domiciliary isolation dynamics model. The publicly released incidence data of COVID-19 from November 6, 2020 to January 31, 2021 in USA and from November 23, 2020 to January 31, 2021 in UK were used to fit the model and the publicly released incidence data of COVID-19 from February 1, 2021 to April 1 were used to evaluate the predicting power of the model by software R 4.0.3 and predict changes in the daily new cases in the context of different vaccination coverage. Results: According to the cumulative confirmed cases, the fitting bias and the predicting bias of the SVEPIUHDR model for USA and UK were less than 5%, respectively. From the model prediction results, the cumulative cases after COVID-19 vaccination in USA in early April reached 31 864 970. If there had not had such vaccination, the cumulative cases of COVID-19 would have reached to 35 317 082, with a gap of more than 3.4 million cases. In UK, the cumulative cases of COVID-19 after the vaccination was estimated to be 4 195 538 in early April, compared with 4 268 786 cases if no COVID-19 vaccination had been provided, there would have heen a gap of more than 70 000 cases. Conclusion: SVEPIUHDR model shows a good prediction effect on the epidemic of COVID-19 in both USA and UK.

Impact of body mass index on the early experience of robotic pancreaticoduodenectomy

Obesity increases surgical morbidity and mortality in open pancreaticoduodenectomy (OPD). Its influence on robotic pancreaticoduodenectomy (RPD) remains uncertain. This study aimed to investigate the impact of body mass index (BMI) on the early experience of RPD. Between June 2015 and April 2020, 68 consecutive RPDs were performed at the National Cheng Kung University Hospital. The patients were categorized as normal-weight (BMI < 23 kg/m²), overweight (BMI = 23–27.5 kg/m²), and obese (BMI > 27.5 kg/m²) according to the definition of obesity in Asian people from the World Health Organization expert consultation. Preoperative characteristics, operative details, and postoperative outcomes were prospectively collected. The cumulative sum was used to assess the learning curves. The average age of the patients was 64.8 ± 11.7 years with an average BMI of 24.6 ± 3.7 kg/m² (23 normal-weight, 29 overweight, and 16 obese patients). Eighteen patients were required to overcome the learning curve. The overall complication rate was 51.5%, and the major complication rate (Clavien grade ≥ III) was 19.1%. The normal-weight group showed the most favorable outcomes. The blood loss, major complication rate, peripancreatic fluid collection rate, and conversion rate were higher in the obese group than in the non-obese group. There were no differences in the operative time, clinically relevant postoperative pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, bile leak, wound infection, reoperation, hospital stay, and readmission rate between the obese and non-obese groups. Multivariate analysis showed obesity as the only independent factor for major complications (OR: 5.983, CI: 1.394–25.682, p = 0.001), indicating that obesity should be considered as a surgical risk factor during the implementation of RPD.

[ Ⅲ ]

Objective: To compare the efficacy and safety of Changsulin^® with Lantus^® in treating patients with type 2 diabetes mellitus (T2DM). Methods: This was a phase Ⅲ, multicenter, randomized, open-label, parallel-group, active-controlled clinical trial. A total of 578 participants with T2DM inadequately controlled on oral hypoglycemic agents were randomized 3∶1 to Changsulin^® or Lantus^® treatment for 24 weeks. The efficacy measures included changes in glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), 2h postprandial plasma glucose (2hPG), 8-point self-monitoring of blood glucose (SMBG) profiles from baseline, and proportions of subjects achieving targets of HbA1c and FPG. The safety outcomes included rates of hypoglycemia, adverse events (AEs) and anti-insulin glargine antibody. Results: After 24 weeks of treatment, mean HbAlc decreased 1.16% and 1.25%, FPG decreased 3.05 mmol/L and 2.90 mmol/L, 2hPG decreased 2.49 mmol/L and 2.38 mmol/L in Changsulin^® and in Lantus^®, respectively. No significant differences could be viewed in above parameters between the two groups (all P>0.05). There were also no significant differences between Changsulin^® and Lantus^® in 8-point SMBG profiles from baseline and proportions of subjects achieving the targets of HbA1c and FPG (all P>0.05). The rates of total hypoglycemia (38.00% and 39.01% for Changsulin^® and Lantus^®, respectively) and nocturnal hypoglycemia (17.25% and 16.31% for Changsulin^® and Lantus^®, respectively) were similar between the two groups (all P>0.05). Most of the hypoglycemia events were asymptomatic, and no severe hypoglycemia were found in both groups. No differences were observed in rates of AEs (61.77% vs.52.48%) and anti-insulin glargine antibody (after 24 weeks of treatment, 6.91% vs.3.65%) between the two groups (all P>0.05). Conclusions: Changsulin^® shows similar efficacy and safety profiles compared with Lantus^® and Changsulin^® treatment was well tolerated in patients with T2DM.

[Threshold effects of body mass index on the bone mineral density of Chinese rural women in fluorosis area]

To explore the threshold effect of body mass index (BMI) on bone mineral density (BMD) in Chinese women living in the fluorosis area, we conducted a cross-sectional study and recruited 722 women in rural areas in Henan Province, China. After detection and analyses, we found that compared with the normal BMI group, the risk of osteoporosis in the overweight and obese groups were reduced by 32% and 69%, respectively. Threshold effect analysis showed that BMD was positively correlated with BMI when BMI was 16.8-31.2 kg/m²; while when BMI was greater than 31.2 kg/m², the correlation reached saturation. The correlation observed between low-to-moderate fluoride exposure and BMD in rural women was not significant.

[Development and applications of makeshift emergency hospitals]

When wars, major disasters, or epidemics of the infectious diseases occur, existing medical facilities are usually unable to implement timely and effective treatment for patients, or the reception capacity is difficult to meet the surge in demand for health care. The makeshift emergency hospitals are built for patient reception, treatment and even isolation for infectious disease control. The makeshift hospitals have developed and improved in modern times, including mobile field hospitals, field tent hospitals and navy hospital ships equipped with advanced equipment and commonly used for military purposes, or temporary hospitals built in large public buildings and newly built hospitals in support of disaster relief and humanitarian operation. Makeshift hospitals have played an important role in response to many disasters and epidemics globally. This paper briefly summarizes the history, types, and applications of makeshift hospitals in disasters and epidemic responses.

Determinants of child resilience in poverty: findings from the Taiwan Birth Cohort Study

Background

Poverty has adverse effects on child health. While children in poverty face greater health challenges, some still achieve positive health outcomes. This is in part due to their resilience when facing adversity. Identifying the factors that foster child resilience can aid in developing strategies to promote child resilience and reduce the harmful effects of child poverty. This study aims to identify the biological and social factors of resilience among children in poverty from birth to age 12.

Methods

Data for the analysis came from the Taiwan Birth Cohort Study, a nationally representative sample of 17,354 children who completed six waves of interview surveys between 2005 and 2017. Our sample included 4,570 children who experienced poverty from birth to age 12. The primary outcome variable was child resilience, defined as impoverished children who maintained good health outcomes over the 12-year survey period. Multiple logistic regression was used to examine the factors of child resilience.

Results

Of the 4,570 children, 36.1% always had good health despite experiencing poverty before the age of 12. An easy temperament (OR = 2.5, 95% CI: 1.9-3.0), female (OR = 1.1, 95% CI: 1.0-1.3), a birth weight greater than 2,500 grams (OR = 1.6, 95% CI: 1.2-2.1), having a foreign-born mother (OR = 1.5, 95% CI: 1.2-1.7), receiving breast milk after birth (OR = 1.3, 95% CI: 1.1-1.5), and good parent-child interaction at 3 years of age (OR = 1.4, 95% CI: 1.2-1.7) were associated with child resilience. Early parent-child interactions can moderate the effect of children's birth weight on later resilience.

Conclusions

Our findings indicated the factors associated with child resilience in the context of poverty, suggesting that supporting breastfeeding and nurturing parent-child relationships are effective public health actions to foster child resilience. Future research is needed to unravel the underlying mechanisms of biological factors associated with child resilience.

Key messages

Breastfeeding after birth and high-quality parent-child interaction can lead to positive adaptations to child poverty. Children with difficult temperaments, boys and those born at low birthweight are more vulnerable to poverty and should be targeted for building resilience against poverty.

[Development and applications of makeshift emergency hospitals]

When wars, major disasters, or epidemics of the infectious diseases occur, existing medical facilities are usually unable to implement timely and effective treatment for patients, or the reception capacity is difficult to meet the surge in demand for health care. The makeshift emergency hospitals are built for patient reception, treatment, and even isolation for infectious disease control. The makeshift hospitals have developed and improved in modern times, including mobile field hospitals, field tent hospitals, and navy hospital ships equipped with advanced equipment and commonly used for military purposes or in support of disaster relief and humanitarian operation, and temporary hospitals built in large public buildings, and newly built hospitals. Makeshift hospitals have played an important role in response to many disasters and epidemics globally. This paper briefly summarizes the history, types, and applications of makeshift hospitals in disaster and epidemic response.

[Three-dimensional finite element analysis on en-mass retraction of anterior teeth with clear aligner]

Objective: To investigate the mechanical effects during en-mass retraction of maxillary anterior teeth with clear aligner using three-dimensional finite element method. Methods: Cone-beam CT (CBCT) was used to scan a female orthodontic patient (26 years old, from Department of Orthodontics, Stomatological Hospital of Chongqing Medical University) whose maxillary first premolars were extracted and maxillary dentition had been aligned and leveled. A finite element model including maxillary teeth-periodontal ligament (PDL)-alveolar bone-clear aligner was established by using Mimics 17.0, SolidWorks 2016 and Geomagic Studio 2015 software packages. The process of 0.2 mm en-mass retraction of anterior teeth using clear aligner was simulated by using non-linear contact method of Abaqus 6.14. The trend and displacement of maxillary teeth, the stress distribution of PDL and alveolar fossae, and the deformation trend of clear aligner were obtained and analyzed. Results: Under the experimental condition, lingual crown tipping and distal tipping movement of anterior teeth were observed, and all of them had the tendency of overbite increasing.The maximum displacement of the central incisor, lateral incisor and canine were 25.16, 50.34 and 24.98 μm, respectively. Meanwhile, the second premolar, first molar and second molar had the tendency of mesial tipping movement, and the maximum displacement of them were 33.04, 2.90 and 16.63 μm, respectively. The stress distribution both at the PDL and alveolar fossae were consistent with tooth movement pattern. It was noted that the stress in the PDL of the canine and second premolar were comparatively big, and the corresponding apical areas of alveolar fossae appeared stress concentration. Concurrently, it was found that the clear aligner showed stress concentration at the junction of adjacent teeth with a tendency of crown directional dislocation. Conclusions: During en-mass retraction of anterior teeth with clear aligner, attention should be paid to the overbite and torque in anterior teeth, and the anchorage protection of posterior teeth. At the same time, we should be careful of root resorption of the teeth on both sides of the extraction space.

[Observation on the efficacy of consolidation chemotherapy combined with allogeneic natural killer cell infusion in the treatment of low and moderate risk acute myeloid leukemia]

Objective: To evaluate the efficacy of consolidation chemotherapy combined with allogeneic natural killer (NK) cell infusion in the treatment of low or intermediate-risk (LIR) acute myeloid leukemia (AML) . Methods: A cohort of 23 LIR AML patients at hematologic complete remission (CR) received NK cell transfusion combined with consolidation chemotherapy after 3 consolidation courses from January 2014 to June 2019 were reviewed. Control group cases were concurrent patients from Department of Hematology, and their gender, age, diagnosis, risk stratification of prognosis, CR and the number of courses of consolidate chemotherapy before NK cell transfusion were matched with LIR AML patients. Results: A total of 45 times of NK cells were injected into 23 LIR AML patients during 4 to 7 courses of chemotherapy. The median NK cell infusion quantity was 7.5 (6.6-8.6) ×10(9)/L, and the median survival rate of NK cells was 95.4% (93.9%-96.9%) . Among them, the median CD3(-)CD56(+) cell number was 5.0 (1.4-6.4) ×10(9)/L, accounting for 76.8% (30.8%-82.9%) ; The number of CD3(+) CD56(+) cells was 0.55 (0.24-1.74) ×10(9)/L, accounting for 8.8% (4.9%-20.9%) . Before NK cell infusion, the number of patients with positive MRD in the treatment and control groups were 9/23 (39.1%) and 19/46 (41.3%) (χ(2)=0.030, P=0.862) respectively. After NK infusion, There was no significant difference in terms of MRD that went from negative to positive between the treatment and the control groups (14.3% vs 22.2%, χ(2)=0.037, P=0.847) . In the treatment group, 66.7% (6/9) of the MRD were converted from positive to negative, which was significantly higher than that in the control group (10.5%, 2/19) (χ(2)=6.811, P=0.009) . Morphological recurrence occurred in 1 case of MRD negative in the treatment group and 2 cases of MRD positive in the control group. By the end of follow-up, the median follow-up was 35 (10-59) months, the number of patients with morphological recurrence in the treatment group was 30.4% (7/23) , which was significantly lower than that in the control group (50.2%, 24/46) (χ(2)=2.929, P=0.087) , although there was no statistically significant difference between the two groups. There was no significant difference on MRD-negative between the treatment and the control groups (43.5% vs 43.5%, χ(2)=1.045, P=0.307) . The 3-year leukemia-free survival was better in the treatment group [ (65.1±11.1) %] than that in the control group [ (50.0±7.4) %] (P=0.047) . The 3-year overall survival in the treatment and control groups were (78.1±10.2) % and (65.8±8.0) % (P=0.212) , respectively. Conclusion: The consolidation of chemotherapy combined with allogeneic NK cell infusion contributed to the further remission of patients with LMR AML and the reduction of long-term recurrence.

[Comparative analysis of the correlation between axillary treatment and upper limb lymphedema]

In the surgical treatment of breast cancer, "de-escalating" is becoming more popular, especially in the treatment of axilla. Axillary sentinel lymph node biopsy has become a routine treatment for axillary-negative breast cancer patients because it can effectively reduce the occurrence of upper limb lymphedema, so that some patients with sentinel lymph node negative can be exempted from axillary lymph node dissection. However, in recent years, several international clinical studies, such as AMAROS trial, explored the use of radiotherapy instead of dissection when 1 to 2 sentinel lymph nodes were positive. The results showed that radiotherapy can reduce the incidence of upper limb edema by nearly 50% compared with dissection. How to interpret the results of such non-inferiority studies, and how to treat the impact of axillary dissection and axillary radiotherapy on the occurrence of lymphedema? Based on the review of literature in recent 10 years, the incidence and hazard ratio of edema related to the two axillary treatments were compared. The conclusion is the hazard ratios are close to each other, around 3 for both arms. The results of clinical studies such as radiotherapy instead of axillary dissection need to be carefully interpreted. At the same time, axillary dissection is still suitable for some patients at current stage, and the corresponding prevention of upper limb lymphedema still needs attention.

Telehealth requires expansion of physicians' communication competencies training

We are in the midst of transformation of health systems where remote consulting (via video, telephone, email, and mobile messaging) is soon to become the dominant mode of consultation. Most of the literature on telehealth omits mentioning the need for telehealth communication competencies. Yet evidence base has been growing about how critical this training is - whether from clinical communication research or litigation claims analysis. In this article, we are calling for an urgent expansion of communication skills curricula to encompass these new telehealth domains from medical schools, specialty trainings to CMEs.

[Discussion on the indications of internal mammary sentinel lymph node biopsy in breast cancer in the era of precision medicine]

Objective: To determine the clinical benefits of internal mammary sentinel lymph node biopsy (IM-SLNB) acquired by breast cancer patients with clinically positive axillary lymph node (ALN), and further optimize the IM-SLNB indications. Methods: All primary breast cancer patients with clinically positive ALN from February 2014 to September 2017 were prospectively recruited in this study. IM-SLNB was performed under the guidance of the modified injection technique. The success rate and visualization rate of IM-SLNB, metastatic rate of internal mammary sentinel lymph node (IMSLN) and its related factors were analyzed, and the clinical benefits were accessed according to the current guidelines. Results: Among 126 patients, all of 94 patients (74.6%) who showed internal mammary drainage successfully underwent IM-SLNB. The incidence of internal mammary artery bleeding and pleural lesion were 4.3%(4/94) and 9.6%(9/94), respectively. The metastatic rate of IMSLN was 38.3% (36/94), which was significantly associated with the number of positive ALN (P<0.001) and tumor size (P=0.024). The lymph node staging of 94 patients who underwent IM-SLNB was more accurate. Among them, 36 cases with positive IMSLN underwent internal mammary radiotherapy (IMRT), while the other 58 cases with negative IMSLN avoided radiotherapy. Conclusions: IM-SLNB should be routinely performed in patients with positive ALN. IM-SLNB can provide more accurate staging and guide tailored IMRT to benefit more breast cancer patients.

[Advances in the role of exosome-derived long non-coding RNAs in hepatocellular carcinoma]

Exosomes are one kind of microvesicles secreted by living cells. It contains some small non-coding RNAs (microRNA, lncRNA, circRNA, etc.) which play an important role in signal transduction. In addition, they transfer information through circulating small vesicles, regulate epithelial-mesenchymal transition, tumor microenvironment, promote microangiogenesis, regulate tumor immunity, chemoradiation resistance, and regulate cellular energy metabolism pathways, thereby promoting the occurrence, development and metastasis of hepatocellular carcinoma. This article reviews the mechanism of lncRNA in exogenous and in vivo in relation to the occurrence, development and metastasis of hepatocellular carcinoma.

Elevated Serum Interleukin-8 Level Correlates with Cancer-Related Cachexia and Sarcopenia: An Indicator for Pancreatic Cancer Outcomes

Cancer cachexia (CC), characterized by body weight loss and sarcopenia, contributes to over 20% of all cancer-related death. Approximately 80% of pancreatic cancer (PC) patients develop CC during disease progression. Pro-inflammatory cytokines, including interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor (TNF)-α, have been correlated with CC; however, its prognostic significance remains unclear. In this study, serum levels of the CC-related cytokines were determined in normal donors and PC patients. IL-8 expression was assessed in PC tissue microarrays. The correlation of levels of each cytokine with disease progression, weight loss, and sarcopenia was calculated. The relationships among the baseline variables, CC, and IL-8 expression with disease progression were examined using univariate and multivariate analyses. Of these mentioned cytokines, only serum IL-8 level was elevated in the locally advanced group (n = 55) compared with the normal (n = 17) and resected groups (n = 55). Serum IL-8 level was positively correlated with CC status, weight loss, sarcopenia, but was negatively correlated with total psoas area (TPA). IL-8 expression in tissue samples was also positively associated with weight loss. Furthermore, serum IL-8 level was an independent predictor of survival. In conclusion, elevated serum IL-8 level significantly correlates with CC and sarcopenia and can be used as a prognostic indicator in PC.

Experimental investigation and micromagnetic simulations of hybrid CoCr2O4/Ni coaxial nanostructures

Multiphase CoCr₂O₄/Ni core-shell nanowires (NWs) have been synthesized within anodic aluminum oxide membranes by the combination of the sol-gel method with electrodeposition techniques. X-ray diffraction and x-ray photoemission spectroscopy results confirmed the formation of a cubic spinel structure of CoCr₂O₄ shell with space group Fd-3m (227). The morphology and composition of the as-grown NWs were studied by field emission scanning electron microscopy, as well as transmission electron microscopy. The magnetic properties of the CoCr₂O₄ NT shell and hybrid CoCr₂O₄/Ni NWs were measured at low temperature using a physical property measurement system. The temperature dependence of the magnetization curves showed that CoCr₂O₄ NTs undergo a transition from a paramagnetic state to a ferrimagnetic state at about 90 K and a spiral ordering transition temperature near 22 K. An enhanced coercivity and saturation field were observed for the CoCr₂O₄/Ni core-shell NWs compared to the single-phase Ni NWs. Micromagnetic simulation results indicated that there is a strong coupling between the shell and core layers during the magnetization reversal process. The combination of hard CoCr₂O₄ and soft Ni in a single NW structure may have potential applications in future multifunctional devices.

[Impact of the 21-gene recurrence score assay in clinical treatment and prognosis analysis for patients with hormone receptor positive early-stage breast cancer]

Objective: To explore the association between the 21-gene recurrence score (RS) and clinicopathologic characteristics as well as prognosis in patients with axillary lymph node negative, hormone receptor (HR) positive breast cancer. Methods: The clinicopathologic data of 439 early breast cancer patients who underwent 21 gene RS testing was retrospectively analyzed. According to the 21 gene RS, the patients were divided into low risk (295 cases), intermediate risk (111 cases) and high-risk (33 cases) group. The relationship between the 21 gene RS and clinicopathological characteristics, treatment, recurrence and metastasis was analyzed. Univariate and multivariate statistical analyses were used to analyze the risk factors for relapse free survival (RFS). Results: Tumor grade, estrogen receptor (ER), progesterone receptor (PR) and Ki-67 index were significantly different among the 3 risk cohorts (P<0.001 for all). After a median follow-up of 32 months, the recurrence rate in low risk group (3.7%) was significantly lower than that in the intermediate-high risk group (9.0%), the locoregional recurrence (LRR) rate of low, intermediate and high risk group was 2.4%, 6.3% and 9.1%; and the distant metastasis (DM) rate in low risk group was 1.4% and 2.1% in the intermediate-high risk group. Univariate analysis showed RS, ER status and endocrine therapy were prognostic factors for RFS (P<0.05 for all). Multivariate analysis showed that RS was an independent significant predictor for RFS (P=0.04). Conclusions: The 21-gene RS is related to tumor grade, ER, PR and Ki-67 index. RS is an independent risk factor for RFS in patients with hormone receptor positive early-stage breast cancer.

[Impact of the 21-gene recurrence score assay in clinical treatment and prognosis analysis for patients with hormone receptor positive early-stage breast cancer]

Objective: To explore the association between the 21-gene recurrence score (RS) and clinicopathologic characteristics as well as prognosis in patients with axillary lymph node negative, hormone receptor (HR) positive breast cancer. Methods: The clinicopathologic data of 439 early breast cancer patients who underwent 21 gene RS testing was retrospectively analyzed. According to the 21 gene RS, the patients were divided into low risk (295 cases), intermediate risk (111 cases) and high-risk (33 cases) group. The relationship between the 21 gene RS and clinicopathological characteristics, treatment, recurrence and metastasis was analyzed. Univariate and multivariate statistical analyses were used to analyze the risk factors for relapse free survival (RFS). Results: Tumor grade, estrogen receptor (ER), progesterone receptor (PR) and Ki-67 index were significantly different among the 3 risk cohorts (P<0.001 for all). After a median follow-up of 32 months, the recurrence rate in low risk group (3.7%) was significantly lower than that in the intermediate-high risk group (9.0%), the locoregional recurrence (LRR) rate of low, intermediate and high risk group was 2.4%, 6.3% and 9.1%; and the distant metastasis (DM) rate in low risk group was 1.4% and 2.1% in the intermediate-high risk group. Univariate analysis showed RS, ER status and endocrine therapy were prognostic factors for RFS (P<0.05 for all). Multivariate analysis showed that RS was an independent significant predictor for RFS (P=0.04). Conclusions: The 21-gene RS is related to tumor grade, ER, PR and Ki-67 index. RS is an independent risk factor for RFS in patients with hormone receptor positive early-stage breast cancer.

[Association between the time of sedentary behaviors and risk of type 2 diabetes]

Objective: To explore the relationship between the time of sedentary behaviors and the risk of type 2 diabetes mellitus (T2DM) among rural adults in Henan Province. Methods: A total of 1 227 adults from Houzhai village in Zhengzhou City and Qiaomiao village in Jiaozuo City in Henan Province were randomly selected to participate in the survey; each of them finished a questionnaire and accepted physical examination and test of biochemical indicators. The participants were divided into case and control groups according to whether suffering from T2DM. A Pearson linear correlation and linear regression model analysis were used to investigate the relevance between the time of sedentary behaviors and fasting plasma glucose (FPG); meanwhile, a multi factor logistic regression model was used to analyze the relationship between the time of sedentary behaviors and T2DM. Results: The average FPG level among the participants was (5.4±2.5) mmol/L, and the average time of sedentary behaviors was (234.5±156.5) min per day. The prevalence rate of T2DM in subgroups whose time of sedentary behaviors were separately 0-<2.5, 2.5-<4.5, 4.5-<6.5 and ≥6.5 h/day were 15.8% (72/457), 19.3% (73/379), 16.7% (35/210) and 20.4% (37/181), respectively. There was a linear regression relationship between the time of sedentary behaviors(x) and FPG(y), the regression equation was: y=5.081+0.001x (t=3.01, P=0.003). Logistic regression model analysis showed that participants whose time of sedentary behaviors ≥6.5 h/day had significantly higher risk of T2DM than those whose time of sedentary behaviors between 0-2.4 h/day (OR=1.77, 95%CI: 1.11-2.81) after age and gender adjusted. However, the associations only exist in males and adults ≥50 years old according to sex and age stratification. It showed that participants with sedentary time ≥6.5 h/day had significantly higher risk of T2DM than those with sedentary time between 0-<2.5 h/d, with the corresponding OR (95%CI) at 2.34 (1.21-4.52) and 2.22 (1.19-4.16), respectively. Conclusion: The prolonged sedentary time is a risk factor of type 2 diabetes. After stratification by gender and age, the correlation only found in males and adults aged ≥50 years old.

Effectiveness of trauma team on medical resource utilization and quality of care for patients with major trauma

BACKGROUND

Trauma is one of the leading causes of death in Taiwan, and its medical expenditure escalated drastically. This study aimed to explore the effectiveness of trauma team, which was established in September 2010, on medical resource utilization and quality of care among major trauma patients.

METHODS

This was a retrospective study, using trauma registry data bank and inpatient medical service charge databases. Study subjects were major trauma patients admitted to a medical center in Tainan during 2009 and 2013, and was divided into case group (from January, 2011 to August, 2013) and comparison group (from January, 2009 to August, 2010).

RESULTS

Significant reductions in several items of medical resource utilization were identified after the establishment of trauma team. In the sub-group of patients who survived to discharge, examination, radiology and operation charges declined significantly. The radiation and examination charges reduced significantly in the subcategories of ISS = 16 ~ 24 and ISS > 24 respectively. However, no significant effectiveness on quality of care was identified.

CONCLUSIONS

The establishment of trauma team is effective in containing medical resource utilization. In order to verify the effectiveness on quality of care, extended time frame and extra study subjects are needed.

Controllable synthesis of ferromagnetic-antiferromagnetic core-shell NWs with tunable magnetic properties

Several nanotechnology applications are based on the promising scheme of highly anisotropic magnetic nanomaterials. Using this idea, we investigated the structure, magnetic properties, and interfacial exchange anisotropy effects of the Ni/Cr₂O₃ and Fe/Cr₂O₃ core-shell nanowires (NWs) geometry. A template-based strategy was developed to synthesize Ni (Fe)-Cr₂O₃ core-shell NWs, which combines a wet-chemical route and electrodeposition within the nanopores of the membranes. Structural determination in correlation with magnetic testing shows that the crystalline Cr₂O₃-nanoshells (NSs) cause an enhanced exchange bias, providing an extra source of anisotropy that leads to their magnetic stability. This core-shell NWs geometry, with enhanced anisotropy, should, therefore, motivate further study related to the applicability of anisotropic nanostructures. Our design opens a new pathway to obtain optimized heterostructured nanomaterials exhibiting tunable magnetic properties.

Influences of high-voltage electrical burns on the pulmonary microcirculation in rabbits

This study was performed to investigate the effects of high-voltage electrical burns (HEB) on the pulmonary microcirculation in rabbits. Total of 120 rabbits were randomly divided into control and HEB group using a random number table. HEB model was developed with a voltage regulator and experimental transformer. Laser Doppler perfusion imager was utilized to monitor and quantify the blood perfusion in pulmonary microcirculation. The microvascular morphologic changes of the lung were observed using light microscopy and transmission electron microscope (TEM). The lung wet/dry weight ratio and the PaO2 were determined. The values of blood perfusion in rabbit pulmonary microcirculation in the HEB group were decreased at 5 min, but increased at 1 h after burn (P <  0.01) and then decreased gradually. Light microscopy reveals microthrombus formation in pulmonary venules and bleeding in venous capillaries in HEB group. We found the number of microvilli in the capillary endothelial cells decreased, the rough endoplasmic reticulum expanded and severe degranulation occurred, the mitochondrial cristae fused or disappeared, and severe edema surrounded the capillary endothelial cells by TEM. The values of lung wet/dry weight ratio were higher and the PaO2 were lower than that of before burn group (P <  0.01). These results demonstrated that microcirculatory disorders play a major role in the development of progressive lung damage after high-voltage electrical burns.

Harder and Stiffer Bone Osseointegrated to Roughened Titanium

Mechanisms underlying the beneficial anchorage of roughened titanium implants have not been identified. We hypothesized that the implant surface roughness alters intrinsic biomechanical properties of bone integrated to titanium. Nano-indentation performed on two- and four-week post-implantation bone specimens of rats revealed that bone integrated to acid-etched titanium was approximately 3 times harder than that integrated to the machined titanium, both at the osseointegration interface and at the inner area of the peri-implant bone. The hardness of the acid-etched surface-associated bone was equivalent to that of untreated cortical bone at week 4, while the bone hardness around the machined surface was equivalent to that of the untreated trabecular bone. The elastic modulus of the integrated bone was 1.5 to 2.5 times greater around the acid-etched surface than around the machined surface. Analysis of the data suggests that the implant surface roughness affects the biomechanical quality of osseo-integrated bone, and that the bone integrated to the acid-etched surface is harder and stiffer than the bone integrated to the machined surface.

The relevance of Tim-3 polymorphisms and F protein to the outcomes of HCV infection

Hepatitis C virus (HCV) is one of the major causes of liver inflammation. The aim of this study was to investigate the associations of T-cell immunoglobulin and mucin domain-3 (Tim-3) polymorphisms and the alternate reading frame protein (F protein) with the outcomes of HCV infection. Three single-nucleotide polymorphisms (SNPs; rs10053538, rs12186731, and rs13170556) of Tim-3 were genotyped in this study, which included 203 healthy controls, 558 hepatitis C anti-F-positive patients, and 163 hepatitis C anti-F-negative patients. The results revealed that the rs12186731 CT and rs13170556 TC and CC genotypes were significantly less frequent in the anti-F-positive patients [odds ratio (OR) = 0.54, 95 % confidence interval (CI) = 0.35-0.83, p = 0.005; OR = 0.26, 95 % CI = 0.18-0.39, p < 0.001; and OR = 0.19, 95 % CI = 0.10-0.35, p < 0.001, respectively), and the rs13170556 TC genotype was more frequent in the chronic HCV (CHC) patients (OR = 1.70, 95 % CI = 1.20-2.40, p = 0.002). The combined analysis of the rs12186731 CT and rs13170556 TC/CC genotypes revealed a locus-dosage protective effect in the anti-F-positive patients (OR = 0.22, 95 % CI = 0.14-0.33, p trend < 0.001). Stratified analyses revealed that the frequencies of the rs12186731 (CT + TT) genotypes were significantly lower in the older (OR = 0.31, 95 % CI = 0.15-0.65, p = 0.002) and female (OR = 0.30, 95 % CI = 0.17-0.52, p < 0.001) subgroups, and rs13170556 (TC + CC) genotypes exhibited the same effect in all subgroups (all p < 0.001) in the anti-F antibody generations. Moreover, the rs13170556 (TC + CC) genotypes were significantly more frequent in the younger (OR = 1.86, 95 % CI = 1.18-2.94, p = 0.007) and female (OR = 2.38, 95 % CI = 1.48-3.83, p < 0.001) subgroups of CHC patients. These findings suggest that the rs12186731 CT and rs13170556 TC/CC genotypes of Tim-3 provide potential protective effects with the F protein in the outcomes of HCV infection and that these effects are related to sex and age.