Profiles of Cough and Associated Risk Factors in Nonhospitalized Individuals With SARS-CoV-2 Omicron Variant Infection: Cross-Sectional Online Survey in China

BACKGROUND

Cough is a common symptom during and after COVID-19 infection; however, few studies have described the cough profiles of COVID-19.

OBJECTIVE

The aim of this study was to investigate the prevalence, severity, and associated risk factors of severe and persistent cough in individuals with COVID-19 during the latest wave of the Omicron variant in China.

METHODS

In this nationwide cross-sectional study, we collected information of the characteristics of cough from individuals with infection of the SARS-CoV-2 Omicron variant using an online questionnaire sent between December 31, 2022, and January 11, 2023.

RESULTS

There were 11,718 (n=7978, 68.1% female) nonhospitalized responders, with a median age of 37 (IQR 30-47) years who responded at a median of 16 (IQR 12-20) days from infection onset to the time of the survey. Cough was the most common symptom, occurring in 91.7% of participants, followed by fever, fatigue, and nasal congestion (68.8%-87.4%). The median cough visual analog scale (VAS) score was 70 (IQR 50-80) mm. Being female (odds ratio [OR] 1.31, 95% CI 1.20-1.43), having a COVID-19 vaccination history (OR 1.71, 95% CI 1.37-2.12), current smoking (OR 0.48, 95% CI 0.41-0.58), chronic cough (OR 2.04, 95% CI 1.69-2.45), coronary heart disease (OR 1.71, 95% CI 1.17-2.52), asthma (OR 1.22, 95% CI 1.02-1.46), and gastroesophageal reflux disease (GERD) (OR 1.21, 95% CI 1.01-1.45) were independent factors for severe cough (VAS>70, 37.4%). Among all respondents, 35.0% indicated having a productive cough, which was associated with risk factors of being female (OR 1.44, 95% CI 1.31-1.57), having asthma (OR 1.84, 95% CI 1.52-2.22), chronic cough (OR 1.44, 95% CI 1.19-1.74), and GERD (OR 1.22, 95% CI 1.01-1.47). Persistent cough (>3 weeks) occurred in 13.0% of individuals, which was associated with the risk factors of having diabetes (OR 2.24, 95% CI 1.30-3.85), asthma (OR 1.70, 95% CI 1.11-2.62), and chronic cough (OR 1.97, 95% CI 1.32-2.94).

CONCLUSIONS

Cough is the most common symptom in nonhospitalized individuals with Omicron SARS-CoV-2 variant infection. Being female, having asthma, chronic cough, GERD, coronary heart disease, diabetes, and a COVID-19 vaccination history emerged as independent factors associated with severe cough, productive cough, and persistent cough.

Engaging stakeholders to level up COPD care in LMICs: lessons learned from the "Breathe Well" programme in Brazil, China, Georgia, and North Macedonia

BACKGROUND

Effective stakeholder engagement in health research is increasingly being recognised and promoted as an important pathway to closing the gap between knowledge production and its use in health systems. However, little is known about its process and impacts, particularly in low-and middle-income countries. This opinion piece draws on the stakeholder engagement experiences from a global health research programme on Chronic Obstructive Pulmonary Disease (COPD) led by clinician researchers in Brazil, China, Georgia and North Macedonia, and presents the process, outcomes and lessons learned.

MAIN BODY

Each country team was supported with an overarching engagement protocol and mentored to develop a tailored plan. Patient involvement in research was previously limited in all countries, requiring intensive efforts through personal communication, meetings, advisory groups and social media. Accredited training programmes were effective incentives for participation from healthcare providers; and aligning research findings with competing policy priorities enabled interest and dialogue with decision-makers. The COVID-19 pandemic severely limited possibilities for planned engagement, although remote methods were used where possible. Planned and persistent engagement contributed to shared knowledge and commitment to change, including raised patient and public awareness about COPD, improved skills and practice of healthcare providers, increased interest and support from clinical leaders, and dialogue for integrating COPD services into national policy and practice.

CONCLUSION

Stakeholder engagement enabled relevant local actors to produce and utilise knowledge for small wins such as improving day-to-day practice and for long-term goals of equitable access to COPD care. For it to be successful and sustained, stakeholder engagement needs to be valued and integrated throughout the research and knowledge generation process, complete with dedicated resources, contextualised and flexible planning, and commitment.

Randomised controlled trial testing effectiveness of feedback about lung age or exhaled CO combined with very brief advice for smoking cessation compared to very brief advice alone in North Macedonia: findings from the Breathe Well group

INTRODUCTION

In 2019, smoking prevalence in North Macedonia was one of the world's highest at around 46% in adults. However, access to smoking cessation treatment is limited and no co-ordinated smoking cessation programmes are provided in primary care.

METHODS

We conducted a three parallel-armed randomised controlled trial (n = 1368) to investigate effectiveness and cost-effectiveness of lung age (LA) or exhaled carbon monoxide (CO) feedback combined with very brief advice (VBA) to prompt smoking cessation compared with VBA alone, delivered by GPs in primary care in North Macedonia. All participants who decided to attempt to quit smoking were advised about accessing smoking cessation medications and were also offered behavioural support as part of the "ACT" component of VBA. Participants were aged ≥ 35 years, smoked ≥ 10 cigarettes per day, were recruited from 31 GP practices regardless of motivation to quit and were randomised (1:1:1) using a sequence generated before the start of recruitment. The primary outcome was biochemically validated 7-day point prevalence abstinence at 4 weeks (wks). Participants and GPs were not blinded to allocation after randomisation, however outcome assessors were blind to treatment allocation.

RESULTS

There was no evidence of a difference in biochemically confirmed quitting between intervention and control at 4wks (VBA + LA RR 0.90 (97.5%CI: 0.35, 2.27); VBA + CO RR 1.04 (97.5%CI: 0.44, 2.44)), however the absolute number of quitters was small (VBA + LA 1.6%, VBA + CO 1.8%, VBA 1.8%). A similar lack of effect was observed at 12 and 26wks, apart from in the VBA + LA arm where the point estimate was significant but the confidence intervals were very wide. In both treatment arms, a larger proportion reported a reduction in cigarettes smoked per day at 4wks (VBA + LA 1.30 (1.10, 1.54); VBA + CO 1.23 (1.03, 1.49)) compared with VBA. The point estimates indicated a similar direction of effect at 12wks and 26wks, but differences were not statistically significant. Quantitative process measures indicated high fidelity to the intervention delivery protocols, but low uptake of behavioural and pharmacological support. VBA was the dominant intervention in the health economic analyses.

CONCLUSION

Overall, there was no evidence that adding LA or CO to VBA increased quit rates. However, a small effect cannot be ruled out as the proportion quitting was low and therefore estimates were imprecise. There was some evidence that participants in the intervention arms were more likely to reduce the amount smoked, at least in the short term. More research is needed to find effective ways to support quitting in settings like North Macedonia where a strong smoking culture persists.

TRIAL REGISTRATION

The trial was registered at http://www.isrctn.com (ISRCTN54228638) on the 07/09/2018.

pH-dependent water permeability switching and its memory in MoS2 membranes

Intelligent transport of molecular species across different barriers is critical for various biological functions and is achieved through the unique properties of biological membranes1-4. Two essential features of intelligent transport are the ability to (1) adapt to different external and internal conditions and (2) memorize the previous state5. In biological systems, the most common form of such intelligence is expressed as hysteresis6. Despite numerous advances made over previous decades on smart membranes, it remains a challenge to create a synthetic membrane with stable hysteretic behaviour for molecular transport7-11. Here we demonstrate the memory effects and stimuli-regulated transport of molecules through an intelligent, phase-changing MoS2 membrane in response to external pH. We show that water and ion permeation through 1T' MoS2 membranes follows a pH-dependent hysteresis with a permeation rate that switches by a few orders of magnitude. We establish that this phenomenon is unique to the 1T' phase of MoS2, due to the presence of surface charge and exchangeable ions on the surface. We further demonstrate the potential application of this phenomenon in autonomous wound infection monitoring and pH-dependent nanofiltration. Our work deepens understanding of the mechanism of water transport at the nanoscale and opens an avenue for the development of intelligent membranes.

Effectiveness of synchronous teleconsultation for patients with type 2 diabetes mellitus: a systematic review and meta-analysis

The popularity of teleconsultation during the COVID-19 pandemic enabled increased accessibility for individuals with type 2 diabetes mellitus (T2DM). However, previous studies did not distinguish between synchronous and asynchronous teleconsultation. We evaluated the effectiveness of synchronous teleconsultation for patients with T2DM. We searched Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library and Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to July 2021. All included studies were randomized controlled trials of synchronous teleconsultation for adults with T2DM compared with usual care. Reviewers independently extracted data and used the Cochrane tool to evaluate risk of bias. Meta-analyses were conducted using random-effects models. A pooled mean difference for both HbA1c (%) and body mass index (BMI) (kg/m²), systolic blood pressure (SBP) (mm Hg), diastolic blood pressure (DBP) (mm Hg), and low density lipoprotein cholesterol (LDL-cholesterol) (mg/dL) were calculated. Patient-reported outcomes, such as depression, medication adherence, and quality of life, were also assessed. A total of 9807 abstracts were identified and 27 trials were included. Synchronous teleconsultation significantly resulted in greater decrease in HbA1c compared with usual care group (n=8746, 0.35, 95% CI 0.20 to 0.49, I²=73%, p<0.001). No significant effects on BMI (n=699, 0.08 kg/m², 95% CI -0.54 to 0.69), SBP (n=5512, 1.32 mm Hg, 95% CI -0.09 to 2.73), DBP (n=2898, 0.17 mm Hg, 95% CI -1.18 to 1.52), or LDL-cholesterol (n=5276, 3.21 mg/dL, 95% CI -1.75 to 8.17) were found. The effect of teleconsultation in improving patient-reported outcomes was uncertain. Thus, synchronous teleconsultation could be an alternative to usual care. Systematic review registration is PROSPERO CRD42021267019.

Accuracy and economic evaluation of screening tests for undiagnosed COPD among hypertensive individuals in Brazil

In Brazil, prevalence of diagnosed COPD among adults aged 40 years and over is 16% although over 70% of cases remain undiagnosed. Hypertension is common and well-recorded in primary care, and frequently co-exists with COPD because of common causes such as tobacco smoking, therefore we conducted a cross-sectional screening test accuracy study in nine Basic Health Units in Brazil, among hypertensive patients aged ≥40 years to identify the optimum screening test/combinations to detect undiagnosed COPD. We compared six index tests (four screening questionnaires, microspirometer and peak flow) against the reference test defined as those below the lower limit of normal (LLN-GLI) on quality diagnostic spirometry, with confirmed COPD at clinical review. Of 1162 participants, 6.8% (n = 79) had clinically confirmed COPD. Peak flow had a higher specificity but lower sensitivity than microspirometry (sensitivity 44.3% [95% CI 33.1, 55.9], specificity 95.5% [95% CI 94.1, 96.6]). SBQ performed well compared to the other questionnaires (sensitivity 75.9% [95% CI 65.0, 84.9], specificity 59.2% [95% CI 56.2, 62.1]). A strategy requiring both SBQ and peak flow to be positive yielded sensitivity of 39.2% (95% CI 28.4, 50.9) and specificity of 97.0% (95% CI 95.7, 97.9). The use of simple screening tests was feasible within the Brazilian primary care setting. The combination of SBQ and peak flow appeared most efficient, when considering performance of the test, cost and ease of use (costing £1690 (5554 R$) with 26.7 cases detected per 1,000 patients). However, the choice of screening tests depends on the clinical setting and availability of resources.ISRCTN registration number: 11377960.

Inequalities of spatial primary healthcare accessibility in China

A key step to the establishment of a tiered healthcare system is equitable access to basic primary healthcare services for all. However, no quantitative research on the national status quo of primary healthcare accessibility in China exists. We filled this gap by estimating spatial accessibility to primary healthcare centers (PHCs) and mapping its inequality across the mainland China. Four national datasets during 2015-2018, including administrative boundaries, residential communities, points-of-interest (including PHCs), and road networks, were collected to calculate the distance to the nearest PHC for each community. Five other national datasets including census, elevation, land use, vegetation, and nightlight, were collected to model 100m × 100 m population grids, based on which geographical modeling was used to calculate PHC accessibility of each community. Inequalities in PHC accessibility across China were described with concentration indices. About 44% of communities across China representing approximately 30% of the overall population had no access to PHCs within their 6-km catchment areas; about 78% of communities across China representing approximately 68.4% of the overall population had no access to PHCs within their 1.5-km catchment areas. Some municipalities/provinces like Shanghai, Beijing, Tianjin, Jiangsu, Shandong, and Zhejiang generally had higher proximity to the nearest PHCs, while others like Tibet, Guizhou, and Guangxi had lower proximity to the nearest PHCs. However, assuming similar basic service capacity across all PHCs, Shanghai, Tianjin, and Chongqing showed the lowest PHC accessibility due to high population density. Variations in PHC accessibility existed, with more inequalities observed in the north and northeastern provinces and less inequalities in southwestern and south-central provinces. This study demonstrates primary healthcare accessibility and inequality at province and city levels, and identifies communities with lower proximity and accessibility to PHCs in China. It would serve as a starting point to facilitate precise healthcare planning and preparedness for health emergencies in China.

Feasibility of a pulmonary rehabilitation programme for patients with symptomatic chronic obstructive pulmonary disease in Georgia: a single-site, randomised controlled trial from the Breathe Well Group

OBJECTIVES

To assess the feasibility of delivering a culturally tailored pulmonary rehabilitation (PR) programme and conducting a definitive randomised controlled trial (RCT).

DESIGN

A two-arm, randomised feasibility trial with a mixed-methods process evaluation.

SETTING

Secondary care setting in Georgia, Europe.

PARTICIPANTS

People with symptomatic spirometry-confirmed chronic obstructive pulmonary disease recruited from primary and secondary care.

INTERVENTIONS

Participants were randomised in a 1:1 ratio to a control group or intervention comprising 16 twice-weekly group PR sessions tailored to the Georgian setting.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility of the intervention and RCT were assessed according to: study recruitment, consent and follow-up, intervention fidelity, adherence and acceptability, using questionnaires and measurements at baseline, programme end and 6 months, and through qualitative interviews.

RESULTS

The study recruited 60 participants (as planned): 54 (90%) were male, 10 (17%) had a forced expiratory volume in 1 second of ≤50% predicted. The mean MRC Dyspnoea Score was 3.3 (SD 0.5), and mean St George's Respiratory Questionnaire (SGRQ) 50.9 (SD 17.6). The rehabilitation specialists delivered the PR with fidelity. Thirteen (43.0%) participants attended at least 75% of the 16 planned sessions. Participants and rehabilitation specialists in the qualitative interviews reported that the programme was acceptable, but dropout rates were high in participants who lived outside Tbilisi and had to travel large distances. Outcome data were collected on 63.3% participants at 8 weeks and 88.0% participants at 6 months. Mean change in SGRQ total was -24.9 (95% CI -40.3 to -9.6) at programme end and -4.4 (95% CI -12.3 to 3.4) at 6 months follow-up for the intervention group and -0.5 (95% CI -8.1 to 7.0) and -8.1 (95% CI -16.5 to 0.3) for the usual care group at programme end and 6 months, respectively.

CONCLUSIONS

It was feasible to deliver the tailored PR intervention. Approaches to improve uptake and adherence warrant further research.

TRIAL REGISTRATION NUMBER

ISRCTN16184185.

Community lung health service design for COPD patients in China by the Breathe Well group

COPD is increasingly common in China but is poorly understood by patients, medications are not used as prescribed and there is no access to recommended non-pharmacological treatment. We explored COPD patients’ and general practitioners’ (GPs) knowledge of COPD, views on its management and the acceptability of a flexible lung health service (LHS) offering health education, exercise, self-management, smoking cessation and mental health support. Using a convergent mixed methods design, data were collected from patients and GPs using focus groups (FGs) in four Chinese cities, questionnaires were also used to collect data from patients. FGs were audio-recorded and transcribed. Quantitative data were analysed descriptively, thematic framework analysis was used for the qualitative data. Two-hundred fifty-one patients completed the questionnaire; 39 patients and 30 GPs participated in ten separate FGs. Three overarching themes were identified: patients’ lack of knowledge/understanding of COPD, current management of COPD not meeting patients’ needs and LHS design, which was well received by patients and GPs. Participants wanted COPD education, TaiChi, psychological support and WeChat for social support. 39% of survey responders did not know what to do when their breathing worsened and 24% did not know how to use their inhalers. 36% of survey respondents requested guided relaxation. Overall, participants did not fully understand the implications of COPD and current treatment was sub-optimal. There was support for developing a culturally appropriate intervention meeting Chinese patients’ needs, health beliefs, and local healthcare delivery. Further research should explore the feasibility of such a service.

An online survey of primary care physicians’ knowledge of common respiratory diseases in China

China has a huge population with respiratory diseases, these diseases should be managed well in primary care, however, primary care physicians’ knowledge level of these diseases were unknown. The aim of the study was to assess primary care physicians’ knowledge of asthma, CAP, COPD, and influenza in China. An e-questionnaire was distributed to attendees of respiratory diseases academic conferences in China from July, 2017 to December, 2018. 7391 questionnaires were returned and 4815 valid questionnaires were analyzed, 3802 (79.0%) from community health service centers and 1013 (21.0%) from township hospitals. The average score of the questionnaire was 83.3 (±20.397) and 72.1 (±20.898) in township and community hospitals, respectively (P < 0.05). 61.4%, 48.7%, and 42.5% of the primary care physicians were aware of clinical manifestations of COPD, asthma, and simple influenza. 85.7%, 8.1%, 16.1%, and 1.0% knew how to diagnose COPD, asthma, CAP and influenza, respectively. 94.4% of the physicians lacked the knowledge of treating COPD with bronchodilators; 53.7% knew non-pharmacological treatments for COPD. 73.6% were unable to deal with asthma attacks. 65.1% did not know what the most essential and important treatment for influenza was. 92% of physicians did not know the management for stable COPD; 3.0% knew all prevention and management measures for asthma. 37.9% knew all the preventive measures for CAP. 44.9% did not know the important role of influenza vaccine in preventing influenza and its complications. Primary care physicians in China had a poor knowledge of CAP, asthma, Influenza, COPD. There is a need for improved training of common respiratory diseases.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Anti-inflammatory effects of anemonin on acute ulcerative colitis via targeted regulation of protein kinase C-θ

Background

Ulcerative colitis (UC) is an inflammatory bowel disease that causes continuous mucosal inflammation. Anemonin is a natural molecule from the Ranunculaceae and Gramineae plants that exerts anti-inflammatory properties. This study aimed to explore the effects and mechanisms of anemonin on UC.

Methods

C57BL/6 mice were administered dextran sulphate sodium (DSS; 3% [w/v]) to establish an animal model of UC. Mice were treated with an intraperitoneal injection of anemonin. Body weight and the disease activity index (DAI) were recorded. Haematoxylin and eosin staining, RT-qPCR, ELISA, and western blotting were performed to evaluate the histopathological changes and tissue inflammation. HT-29 cells were treated with lipopolysaccharide (LPS) and anemonin. Cell inflammation was evaluated using RT-qPCR and western blotting. The target proteins of anemonin were predicted using bioinformatics analysis and confirmed in vitro and in vivo.

Results

Anemonin improved DSS-induced body weight loss, shortened colon length, increased DAI, and induced pathological changes in the colon tissue of mice. Anemonin inhibited DSS-induced colon tissue inflammation as the release of IL-1β, TNF-α, and IL-6 was significantly suppressed. Additionally, anemonin attenuated LPS-induced cytokine production in HT-29 cells. PKC-θ was predicted as a target protein of anemonin. Anemonin did not affect PRKCQ gene transcription, but inhibited its translation. PRKCQ overexpression partially reversed the protective effects of anemonin on HT-29 cells. Adeno-associated virus delivery of the PRKCQ vector significantly reversed the protective effects of anemonin on the mouse colon.

Conclusions

Anemonin has the potential to treat UC. The anti-inflammatory effects of anemonin may be mediated through targeting PKC-θ.

ISLR affects colon cancer progression by regulating the epithelial-mesenchymal transition signaling pathway

This study aims to determine the mechanism of ISLR on the progression of colon cancer. TCGA database was used to analyze ISLR expression in colon cancer tumor tissues. QRT-PCR and western blotting were used to detect ISLR expression in colon cancer cells. CCK-8, colony formation, EDU, wound healing and transwell assays were used to measure cell viability, proliferation, migration and invasion of colon cancer cells, respectively. The signaling pathway enrichment analysis of ISLR was analyzed on the basis of the KEGG database. The protein expression of genes related to signaling pathway was measured by western blotting. Results of TCGA analysis, qRT-PC and western blotting showed that ISLR was upregulated in colon cancer tumor tissues and cells. High level of ISLR was related to low overall survival of patients with colon cancer. ISLR silence significantly inhibited cell viability, proliferation, migration and invasion of colon cancer cells. ISLR overexpression markedly enhanced the cell viability, proliferation, migration and invasion of colon cancer cells. KEGG database analyzed showed that ISLR can activate the EMT signaling pathway. Inhibition of the EMT signaling pathway can suppress the growth, migration, and invasion of colon cancer cells and eliminate the promoted effect of ISLR overexpression on colon cancer progression. ISLR promotes the progression of colon cancer by activating the EMT signaling pathway.

Perspectives and Management of Atypical Asthma in Chinese Specialists and Primary Care Practitioners-A Nationwide Questionnaire Survey

Background and objective: To evaluate the awareness/knowledge and clinical practice for the treatment of atypical asthma among respiratory specialists and primary care practitioners (PCPs) in China.

Methods: A total number of 1,997 physicians participated in the survey via WeChat. The questionnaire included six main items: physician demographic characteristics, awareness, diagnosis, medical prescription, assessment/education, and proposal.

Results: Cough variant asthma (CVA) was recognized by 97.51% of physicians (1,166 respiratory specialists and 799 PCPs), followed by chest tightness variant asthma (CTVA, 83.72%) and occult asthma (73.54%). Specialists were more likely to follow diagnostic recommendations than PCPs (P < 0.01); however, 34.15% of physicians reported the utility of bronchodilation tests, airway provocation tests, and peak expiratory flow monitoring. A total of 91.70% and 92.01% of physicians prescribed inhaled corticosteroids (ICS) or ICS plus long-acting beta-agonists (LABA) for CVA and CTVA, respectively. Physicians prescribed an ICS or ICS/LABA for 4 (2–8) or 8 (4–12) weeks for CVA and 4 (2–8) or 5 (4–12) weeks for CTVA, and the prescription durations were significantly shorter for PCPs than for specialists (P < 0.01). Further, 52.42% and 35.78% reported good control of CVA and CTVA, respectively, with significantly lower control rates for PCPs than for specialists (P < 0.01). Additionally, specialists exhibited better assessment and educational habits than PCPs.

Conclusion: While atypical asthma was identified by most specialists and PCPs, there remains a gap between management in real clinical practice and guideline recommendations, especially for PCPs. Further training of PCPs and clinical studies of atypical asthma are required to improve practice.

Accuracy and cost-effectiveness of different screening strategies for identifying undiagnosed COPD among primary care patients (≥40 years) in China: a cross-sectional screening test accuracy study: findings from the Breathe Well group

OBJECTIVES

To examine the accuracy and cost-effectiveness of various chronic obstructive pulmonary disease (COPD) screening tests and combinations within a Chinese primary care population.

DESIGN

Screening test accuracy study.

SETTING

Urban and rural community health centres in four municipalities of China: Beijing (north), Chengdu (southwest), Guangzhou (south) and Shenyang (northeast).

PARTICIPANTS

Community residents aged 40 years and above who attended community health centres for any reason were invited to participate. 2445 participants (mean age 59.8 (SD 9.6) years, 39.1% (n=956) male) completed the study (February-December 2019), 68.9% (n=1684) were never-smokers and 3.6% (n=88) had an existing COPD diagnosis. 13.7% (n=333) of participants had spirometry-confirmed airflow obstruction.

INTERVENTIONS

Participants completed six index tests (screening questionnaires (COPD Diagnostic Questionnaire, COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE), Chinese Symptom-Based Questionnaire (C-SBQ), COPD-SQ), microspirometry (COPD-6), peak flow (model of peak flow meters used in the study (USPE)) and the reference test (ndd Easy On-PC).

PRIMARY AND SECONDARY OUTCOMES

Cases were defined as those with forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) below the lower limit of normal (LLN-GLI) on the reference test. Performance of individual screening tests and their combinations was evaluated, with cost-effectiveness analyses providing cost per additional true case detected.

RESULTS

Airflow measurement devices (sensitivities 64.9% (95% CI 59.5% to 70.0%) and 67.3% (95% CI 61.9% to 72.3%), specificities 89.7% (95% CI 88.4% to 91.0%) and 82.6% (95% CI 80.9% to 84.2%) for microspirometry and peak flow, respectively) generally performed better than questionnaires, the most accurate of which was C-SBQ (sensitivity 63.1% (95% CI 57.6% to 68.3%) specificity 74.2% (95% CI 72.3% to 76.1%)). The combination of C-SBQ and microspirometry used in parallel maximised sensitivity (81.4%) (95% CI 76.8% to 85.4%) and had specificity of 68.0% (95% CI 66.0% to 70.0%), with an incremental cost-effectiveness ratio of £64.20 (CNY385) per additional case detected compared with peak flow.

CONCLUSIONS

Simple screening tests to identify undiagnosed COPD within the primary care setting in China is possible, and a combination of C-SBQ and microspirometry is the most sensitive and cost-effective. Further work is required to explore optimal cut-points and effectiveness of programme implementation.

TRIAL REGISTRATION NUMBER

ISRCTN13357135.

Anaemia among intensive care unit survivors and association with days alive and at home: an observational study

Anaemia is highly prevalent at the time of intensive care unit discharge and is persistent for a high proportion of intensive care unit survivors. Whether anaemia is a driver of impaired recovery after critical illness is uncertain. The aim of this study was to test the hypothesis that, in adult intensive care survivors, anaemia at the time of intensive care unit discharge independently predicts decreased days at home-90. This retrospective cohort study was conducted in a tertiary intensive care unit in Perth, Western Australia. All patients aged ≥ 16 years, discharged alive from their index intensive care unit admission and without documented treatment limitations were included. Median (IQR [range]) age of the 6358 participants was 61 (46-72 [16-95]) years and included 3385 (53.2%) unplanned admissions. Intensive care unit discharge with a haemoglobin concentration < 100 g.l^-1 occurred in 2886 (45.4%) patients, a threshold that identified a cohort with significantly lower days at home-90 (median (IQR [range]) 80 (64-85 [0-90]) days vs. 85 (77-88 [0-90]) days (median difference 5 days, 95%CI 4.4-5.5, p < 0.0001). The association followed a severity-response relationship with more severe anaemia predicting lower days at home-90. When accounting for prespecified covariates including admission haemoglobin concentration and red blood cell transfusion, anaemia at intensive care unit discharge remained a significant predictor of decreased days at home-90, relative risk 0.96 (0.93-0.98), p < 0.002. These findings support the need for interventional trials investigating whether this risk is modifiable.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Study to evaluate the effectiveness and cost-effectiveness of different screening strategies for identifying undiagnosed COPD among residents (≥40 years) in four cities in China: protocol for a multicentre cross-sectional study on behalf of the Breathe Well group

INTRODUCTION

The latest chronic obstructive pulmonary disease (COPD) epidemiology survey in China estimated that there were 99 million potential COPD patients in the country, the majority of whom are undiagnosed. Screening for COPD in primary care settings is of vital importance for China, but it is not known which strategy would be the most suitable for adoption in primary care. Studies have been conducted to test the accuracy of questionnaires, expiratory peak flow meters and microspirometers to screen for COPD, but no study has directly evaluated and compared the effectiveness and cost-effectiveness of these methods in the Chinese setting.

METHODS AND ANALYSIS

We present the protocol for a multicentre cross-sectional study, to be conducted in eight community hospitals from four cities among Chinese adults aged 40 years or older to investigate the effectiveness and cost-effectiveness of different case-finding methods for COPD, and determine the test performance of individual and combinations of screening tests and strategies in comparison with quality diagnostic spirometry. Index tests are screening questionnaires (COPD Diagnostic Questionnaire (CDQ), COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk Questionnaire (CAPTURE), symptom-based questionnaire, COPD Screening Questionnaire (COPD-SQ)), microspirometer and peak flow. Each participant will complete all of these tests in one assessment. The primary analysis will compare the performance of a screening questionnaire with a handheld device. Secondary analyses will include the comparative performance of each index test, as well as a comparison of strategies where we use a screening questionnaire and a handheld device. Approximately 2000 participants will be recruited over 9 to 12 months.

ETHICS AND DISSEMINATION

The study has been approved by Peking University Hospital and University of Birmingham. All study participants will provide written informed consent. Study results will be published in appropriate journal and presented at national and international conferences, as well as relevant social media and various community/stakeholder engagement activities.

TRIAL REGISTRATION NUMBER

ISRCTN13357135.

Peripheral artery disease impairs myocardial perfusion through increasing pulse wave reflection: the Northern Shanghai study

Background

Peripheral artery disease (PAD) is prevalent and substantially contributes to cardiovascular mortality particularly in the elderly, although the pathophysiological impact of PAD on heart itself still needs further investigation. In theory, PAD can increase pulse wave reflection which is an important determinant of subendocardial viability ratio (SEVR), a valuable estimate of myocardial perfusion as indicated by previous invasive studies. Thus, we hypothesize that PAD impairs myocardial perfusion through increasing pulse wave reflection. In this study, we aim to test this hypothesis in a large cohort from the Northern Shanghai Study.

Methods

A total of 2947 community-dwelling elderly Chinese (43.6% male, mean age: 71.3±5.9 years) were recruited. Ankle-brachial index were measured with the VP1000 device and used to diagnose PAD. Pulse wave reflection was estimated as aortic augmentation pressure (AP). Aortic BP, AP and SEVR were assessed by radial applanation tonometry. Multiple linear regression with SEVR and AP as dependent variable and PAD as independent variable, meanwhile adjusted for other covariates, were performed, respectively.

Results

375 (12.7%) participants presented PAD. Compared to subjects without PAD, those with PAD showed significantly lower SEVR (126 vs. 132, P&lt;0.001) but higher AP (19 vs. 17 mmHg, P&lt;0.001). Multiple regression analysis revealed that both SEVR (regression coefficient [B] = −1.69, P=0.04, R2=0.61) and AP (B=1.19, P=0.04, R2=0.56) significantly associated with PAD, respectively. However, the association between SEVR and PAD was abolished when further adjusted for AP (B=−0.49, P=0.52). Similar results were obtained when inter-leg systolic BP difference was used to diagnose PAD.

Conclusions

PAD significantly and independently associates with myocardial perfusion; moreover, this association is mediated by increased pulse wave reflection. These findings provide a new dimension for understanding the pathophysiological mechanisms of cardiac damage of PAD.

Funding Acknowledgement

Type of funding source: None

Is training policy for general practitioners in China charting the right path forward? a mixed methods analysis

OBJECTIVES

Since 2010, the Chinese government has gradually increased its investment in the training of general practitioners (GPs) to support their role as 'gatekeepers' in the healthcare system. However, this training is still organised from the perspective of specialist care. We aimed to assess the appropriateness of the principal GP admission training programme curricula in China, including Residents Training for GPs (RTGP), Residents Training for Assistant GPs (RTAGP) and Training for Specialists with General Practice interest (TSGP).

SETTING

The study focussed on GP training programmes in Shanghai, China.

PARTICIPANTS

Data on disease competences developed in three GP clinical training programmes (RTGP, RTAGP and TSGP) were derived from official programme training manuals. Data on the proportion of outpatient visits for each disease were taken from the Shanghai community healthcare centres grassroots outpatient database.

PRIMARY AND SECONDARY OUTCOME MEASURES

We first conducted a quantitative analysis by comparing the structure of current training curricula with actual outpatient utilisation patterns across all community healthcare institutions in Shanghai from 2014 to 2018. Qualitative analysis was then conducted to evaluate GP training programmes based on Donabedian's model.

RESULTS

Quantitative analysis showed that the distribution of diseases for which competences were taught did not match the composition of outpatient visits in community healthcare institutions. Concerns identified through qualitative analysis included teachers who were mostly specialists, lack of equipment for differential diagnosis in community healthcare institutions, insufficient teaching of referral standards and GP training in large hospitals that consistently neglected communication skills.

CONCLUSIONS

The establishment and implementation of admission training programmes for GPs in China lacks a focus on general practice training and may be improved by adopting an evidence-based general perspective aligned with the medical needs of the community.

The role of CARDPC in response to COVID-19 in primary care in China

COVID-19 is wreaking havoc around the world, which is a serious challenge to all our health systems. China reacted quickly in the early stage of the pandemic, and accumulated a lot of experiences, especially in the prevention and control of COVID-19 at the primary care level. Here, we would like to share how the Chinese Alliance for Respiratory Diseases in Primary Care (CARDPC) played a role in the pandemic, hoping to provide guidance and hope for effective control of the outbreak worldwide, for future public health emergencies and for systematic management of chronic respiratory diseases in the community.

Examining health disparities and characteristics in general practice utilization: based on outpatient data from 2014 - 2018 in Shanghai

BACKGROUND

Since 2000, China has been developing primary care institutions to serve as the gateway to the healthcare system. However, the investment of resources in primary care institutions is not based on the actual medical demands of the public. This study analysed primary care utilization to provide targeted guidance for the improvement of primary healthcare delivery in China.

METHODS

We extracted outpatient visit data from all community healthcare centres in Shanghai from 2014 to 2018. Diseases were then classified according to ICD-10 codes. The disease spectrum (frequency, proportion, rank) was stratified by sex, age, and region.

RESULTS

Most primary care outpatients were female (58.20%), 60-79 years old (57.91%), and in suburban regions (62.18%). Chronic diseases accounted for the majority (91.41%). Hypertension, chronic ischaemic heart disease, diabetes, and acute upper respiratory tract infections were the top four disorders for primary care visits regardless of sex. In the group aged 0-18 years, symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified accounted for 37.96% of the top 20 reasons. Acute upper respiratory tract infections were the most common diseases in the groups aged 0-18 (11.20%) and 19-39 (11.14%) years. However, hypertension was the most common disease in the group aged > 39 years old (> 20%). There were more outpatients with respiratory and digestive diseases in suburban areas than in urban areas. In addition, problems associated with medical equipment and other healthcare deficiencies were relatively more common in suburban areas (suburban: 4.13%, rank 5; urban: 2.29%, rank 10).

CONCLUSIONS

To meet the patients' needs and to develop the primary care system, the Shanghai government should focus on diseases with regionally high proportions. Disease diagnosis and treatment should be improved in the younger and suburban populations.

Comparison of general practice residents' attitudes and perceptions about training in two programmes in China: a mixed methods survey

Objective

To understand general practice (GP) residents’ attitudes about their residency training in China.

Design

Mixed methods survey administered cross-sectionally.

Setting

Two GP training programmes similar in most regards according to current GP training policy of 5 years’ undergraduate degree in medicine and 3 years of postgraduate GP residency training—but differing as the Beijing programme has adopted educational innovations beyond the nationally prescribed standard curriculum used by the second Shenzhen programme.

Participants

105 (85%) of eligible GP trainees, 35 (90%) in the innovative Beijing programme and 70 (83%) in the standard training Shenzhen programme.

Results

Overall, residents felt discrimination because of specialty choice, and that they lacked competency as a general practitioner. Many residents commented faculty had negative teaching attitudes. Beijing residents were more satisfied than Shenzhen residents with their training (p=0.001), and felt teaching faculty had sufficient knowledge (p<0.001), and appropriate attitudes towards teaching (p=0.004). Beijing residents more strongly agreed on five items about good future job prospects (all p<0.05).

Conclusion

These Chinese GP residents identify areas for improvement in their training as well as strengths. Higher satisfaction with faculty teaching and job optimism in Beijing where GP residents receive training from specifically qualified faculty, and can earn special certification, suggest that the educational innovations enhance training and promote positivity about job prospects. These findings imply that GP residents in China face many training challenges that are similar to other international reports, while also implicating benefits of using an innovative curricular approach.

GAS5 promotes myocardial apoptosis in myocardial ischemia-reperfusion injury via upregulating LAS1 expression

OBJECTIVE

This study aims at investigating whether GAS5 (grow arrest-specific 5) could promote cardiomyocyte apoptosis by upregulating LAS1 expression, thereby participating in the development of myocardial ischemia-reperfusion injury.

MATERIALS AND METHODS

The expression level of GAS5 in H9c2 cells after hypoxia/reoxygenation (H/R) treatment was detected by quantitative Real time-polymerase chain reaction (qRT-PCR). Myocardial injury markers in H9c2 cells were evaluated using relative commercial kits, including activities of LDH (lactate dehydrogenase), MDA (malondialdehyde), SOD (superoxide dismutase) and GSH-PX (glutathione peroxidase). Cell proliferation and apoptosis were detected by cell counting kit-8 (CCK-8) assay and flow cytometry, respectively. The protein expressions of apoptosis-related genes and p38/MAPK pathway-related genes were detected by Western blot. The regulatory effects of GAS5 on the p38/MAPK pathway were assessed after treatment with p38/MAPK pathway inhibitor in H9c2 cells.

RESULTS

QRT-PCR results showed that the expression levels of GAS5 and LAS1 in H/R-treated H9c2 cells were remarkably upregulated compared to those of controls. GAS5 overexpression increased activities of LDH, MDA, SOD and GSH-PX in H/R-treated H9c2 cells. Meanwhile, GAS5 overexpression reduced cell proliferation and apoptosis of H/R-treated cells. Western blot results suggested that the pro-apoptosis genes Bax and cytochrome C were upregulated, whereas the anti-apoptosis gene Bcl-2 was downregulated after GAS5 overexpression. The overexpression of LAS1 in H9c2 cells obtained the same results as GAS5 overexpression. Furthermore, the expressions of p-p38 and p-ERK were upregulated by GAS5 overexpression. SB203580, the p38/MAPK pathway inhibitor, could reverse the inhibited proliferation and increase apoptosis induced by overexpression of GAS5.

CONCLUSIONS

GAS5 promotes myocardial apoptosis in myocardial ischemia-reperfusion injury by upregulating LAS1 expression via p38/MAPK pathway. GAS5 may be a potential therapeutic target for myocardial ischemia-reperfusion injury.

Health outcomes, utilization, and equity in Chile: an evolution from 1990 to 2015 and the effects of the last health reform

OBJECTIVE

Chile is an attractive case study because of the deep political changes that it underwent over a short period of time: from a universal health service (60s), through a neoliberal reform (70s) and onto a series of legislative reforms (80s-90s). This article aims to explore and assess the evolution of health outcomes, equity, and utilization in Chile through the last period of these reforms (1990-2015).

STUDY DESIGN

Standardized health equity analysis.

METHODS

We conducted a standardized economic analysis on health equity and healthcare utilization using the ADePT software (by the World Bank) and using data from the Chilean National Socio-economic Survey. We evaluated trends of health equity and examined concentration curves of health utilization of healthcare services and health outcomes such as children/elder/pregnant nutritional status, self-reported health, and physical limitations.

RESULTS

Health outcomes such as nutritional problems in children and pregnant women were concentrated among the poor, while others such as high-relevance health conditions were similar for poorest and richest households. The concentration indexes for health outcomes suggested that income makes the distribution pro-poor. However, the opposite was true for age, in which the probability of health problems among rich individuals increased with age. The concentration curves for utilization of healthcare services showed that dental visits, laboratory exams, specialty visits, and hospitalizations were concentrated on the richest households, while the use of emergency services and preventive medicine were highly concentrated among poor individuals.

CONCLUSIONS

Although a positive trend in the increase of healthcare service use among income groups was observed, a significant impact of the latest health reform was not observed.

Glioma cell proliferation is inhibited by miR-342-3p, miR-377 / E2F1 signaling pathway

Recent years, micoRNAs (miRNAs) have been reported to be critical regulators to influence tumor genesis or further progression by directly targeting downstream tumor related genes in glioma. However, there're still many underlying mechanisms related to miRNAs signaling pathway remain to be uncovered in glioma. In the present study, we found that miR-342-3p and miR-377 inhibited the glioma cell line proliferation and arrested the cell cycle at G1 phase. Inhibition of the function of miR-342-3p and miR-377 promoted the cell proliferation. miR-342-3p and miR-377 target the E2F1 3'UTR to repress its expression on both mRNA and protein level. Downregulation of E2F1 inhibited the cell proliferation and arrested the cell cycle. Overexpression of E2F1 blocked the proliferation repression caused by miR-342-3p or miR-377 in glioma cells. This study showed the function of miR-342-3p, miR-377/E2F1 axis in regulating glioma cells proliferation and provided the potential therapeutic target.

Training Pathways to Working as a General Practitioner in China

BACKGROUND AND OBJECTIVES

To achieve the goal of 300,000 general practitioners by 2020-an increase of 215,200 in a decade-China is utilizing multiple training pathways. To comprehensively illustrate general practitioner training strategies in China, this article introduces and describes these pathways.

METHODS

We used descriptive policy analysis. This involved taking an inventory of existing literature and source documents and developing a model to illustrate pathways for training general practice physicians.

RESULTS

The rural doctor pathway represents rural clinicians who had only basic training and practiced multiple years prior to training reforms. The 3+2 pathway to assistant general practitioners requires 3 years of junior college and 2 years of clinical training. The transfer pathway for current physicians requires 1-2 years of training. The 5+3 pathway comprises 5 years of bachelor of science degree training in clinical medicine and 3 years of standardized residency training. Despite the development of advanced degree programs, their use remains limited.

CONCLUSIONS

These pathways illustrate significant heterogeneity in training of general practitioners. Training ranges from a 2-year technical degree to a doctorate with research. Emphasis on the 5+3 track shows promise for China's goals of improved quality and new goal of 500,000 additional general practitioners by 2030.

Clinical characteristics and treatments of patients with alpha-fetoprotein producing gastric carcinoma

Alpha-fetoprotein (AFP) is a well-known tumor marker of hepatic carcinoma and yolk sac tumor. Alpha-fetoprotein producing gastric carcinoma (AFPGC) is a rare type of gastric cancer with high malignancy and poor prognosis, which make it different from other types of gastric cancer. This rare gastric cancer patient subgroup is likely frequently misdiagnosed which may be related to lack of knowledge of the disease. The purpose of this article is to summarize the mechanism of AFP positive gastric cancer, classification, biological behavior and treatment, in order to assist clinical practitioners to detect AFPGC earlier and treat it better. Previous studies have showed that AFPGC has a complex pathophysiology mechanism. AFPGC is more aggressive and characterized by stronger proliferation, neovascularization, lymphatic invasion and distant metastasis. Furthermore, so far there has been no standard treatment for patients with AFPGC. Nevertheless, our present study summarizes some effective treatments based on previous research outcome. In conclusion, the present study demonstrates that the importance of detecting AFP routinely in serum and tissues in gastric cancer cases, which will greatly improve the diagnosis rate of AFPGC, and in regards to treatment, surgery, chemotherapy, targeted therapy and interventional treatment may have positive impacts on AFPGC treatment outcome. However, further study with a larger sample is required to confirm the reliability and validity of these methods.

Female adiposity and time-to-pregnancy: a multiethnic prospective cohort

STUDY QUESTION

Are higher overall and central adiposity associated with reduced fecundability, measured by time-to-pregnancy (TTP), in Asian women?

SUMMARY ANSWER

Higher overall adiposity, but not central adiposity, was associated with longer TTP in Asian women.

WHAT IS KNOWN ALREADY

High body mass index (BMI) has been associated with a longer TTP, although the associations of body composition and distribution with TTP are less clear. There are no previous studies of TTP in Asian women, who have a relatively higher percentage of body fat and abdominal fat at relatively lower BMI.

STUDY DESIGN, SIZE, DURATION

Prospective preconception cohort using data from 477 Asian (Chinese, Malay and Indian) women who were planning to conceive and enrolled in the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) study, 2015-2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women's mean age was 30.7 years. Overall adiposity was assessed by BMI, sum of 4-site skinfold thicknesses (SFT) and total body fat percentage (TBF%, measured using air displacement plethysmography); central adiposity was assessed by waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and A body Shape Index (ABSI). Pregnancy occurring within one year from recruitment was ascertained by ultrasonography. Those who did not conceive within one year of recruitment, were lost to follow-up, or initiated fertility treatment were censored. TTP was measured in cycles. Discrete-time proportional hazards models were used to estimate the fecundability ratio (FR) and 95% confidence interval (CI) for each anthropometric measure in association with fecundability, adjusting for confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to women with a normal BMI of 18.5-22.9 kg/m2, women with higher BMI of 23-27.4 and ≥27.5 kg/m2 showed lower FR of 0.66 (95% CI 0.45, 0.97) and 0.53 (0.31, 0.89), respectively. Compared to women in the lowest quartile of SFT (25-52.9 mm), those in the highest quartile of ≥90.1 mm showed lower FR of 0.58 (95% CI 0.36, 0.95). Compared to women in the lowest quartile of TBF% (13.6-27.2%), those in the upper two quartiles of 33.0-39.7% and ≥39.8% showed lower FR of 0.56 (95% CI 0.32, 0.98) and 0.43 (0.24, 0.80), respectively. Association of high BMI with reduced fecundability was particularly evident among nulliparous women. Measures of central adiposity (WC, WHR, WHtR, ABSI) were not associated with fecundability.

LIMITATIONS REASONS FOR CAUTION

Small sample size could restrict power of analysis.The analysis was confined to planned pregnancies, which could limit generalizability of findings to non-planned pregnancies, estimated at around 44% in Singapore. Information on the date of last menstrual period for each month was not available, hence the accuracy of self-reported menstrual cycle length could not be validated, potentially introducing error into TTP estimation. Measures of exposures and covariates such as cycle length were not performed repeatedly over time; cycle length might have changed during the period before getting pregnant.

WIDER IMPLICATIONS OF THE FINDINGS

Other than using BMI as the surrogate measure of body fat, we provide additional evidence showing that higher amounts of subcutaneous fat that based on the measure of SFT at the sites of biceps, triceps, suprailiac and subscapular, and TBF% are associated with longer TTP. Achieving optimal weight and reducing total percentage body fat may be a potential intervention target to improve female fertility. The null results observed between central adiposity and TTP requires confirmation in further studies.

STUDY FUNDING/COMPETING INTEREST(S)

This research is supported by Singapore National Research Foundation under its Translational and Clinical Research Flagship Programme and administered by the Singapore Ministry of Health's National Medical Research Council, (NMRC/TCR/004-NUS/2008; NMRC/TCR/012-NUHS/2014). Additional funding is provided by the Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR), Singapore. Y.S.C., K.M.G., F.Y. and Y.S.L. have received reimbursement to speak at conferences sponsored by companies selling nutritional products. Y.S.C., K.M.G. and S.Y.C. are part of an academic consortium that has received research funding from Abbott, Nutrition, Nestle and Danone. Other authors declared no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

First report of carp oedema virus infection of koi (Cyprinus carpio haematopterus) in the Republic of Korea

Twenty-five koi (Cyprinus carpio haematopterus) bought from a wholesale fish market in Korea, showed lethargic behaviour and 100% mortality within 20 days. Carp oedema virus (CEV) was detected by PCR in all 25 koi. Results of detailed histopathological and clinical examinations of 17 koi indicated loss of body balance, severe infiltration of inflammatory cells into the inter-lamellar spaces of the gills and vacuolization and inclusion bodies in gill epithelial cells. Sequence analysis of PCR products of these koi showed up to 99% identity to the previously reported sequences, suggesting that the observed mass mortality resulted from koi sleepy disease (KSD) due to CEV infection. To the best of our knowledge, this study is the first report of KSD in the Republic of Korea. Partial sequences of 4a protein from the virus indicated that the present CEV detected in koi from Korea is more closely related to that from the UK and Poland than from Japan. The present findings indicate that the prevalence and spread of KSD must be closely monitored in both European and Asian countries to avoid potential economic losses to the global koi industry.

Ultrathin graphene-based membrane with precise molecular sieving and ultrafast solvent permeation

Graphene oxide (GO) membranes continue to attract intense interest due to their unique molecular sieving properties combined with fast permeation. However, their use is limited to aqueous solutions because GO membranes appear impermeable to organic solvents, a phenomenon not yet fully understood. Here, we report efficient and fast filtration of organic solutions through GO laminates containing smooth two-dimensional (2D) capillaries made from large (10-20 μm) flakes. Without modification of sieving characteristics, these membranes can be made exceptionally thin, down to ∼10 nm, which translates into fast water and organic solvent permeation. We attribute organic solvent permeation and sieving properties to randomly distributed pinholes interconnected by short graphene channels with a width of 1 nm. With increasing membrane thickness, organic solvent permeation rates decay exponentially but water continues to permeate quickly, in agreement with previous reports. The potential of ultrathin GO laminates for organic solvent nanofiltration is demonstrated by showing >99.9% rejection of small molecular weight organic dyes dissolved in methanol. Our work significantly expands possibilities for the use of GO membranes in purification and filtration technologies.

Electronic-based lifestyle interventions in overweight or obese perinatal women: a systematic review and meta-analysis

Electronic-based (e-based) lifestyle interventions provide potential and cost-effective delivery of remote interventions for overweight and obese perinatal women. To date, no meta-analysis has reported the efficacy of maternal and neonatal outcomes. Seven electronic databases were searched from inception up to July 13, 2016, including the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, EMBASE, ProQuest Dissertations and Theses, PsycINFO, PubMed and Scopus. Among the 1,145 studies retrieved, 14 randomized controlled trials were selected among 17 publications. The Cochrane risk of bias tool was used to appraise the quality assessment. The meta-analyses demonstrated a significant result for limiting gestational weight gain, losing postnatal weight in 1-2 months, increasing self-reported moderate and vigorous physical activity and reducing caloric intake using diet-related software. Our review shows that an e-based lifestyle intervention is an acceptable approach. The findings reveal the variability in intervention methods and provide limited conclusive evidence. Thus, future studies should examine the efficacy and essential components as well as the various approaches using optimal portions of in-person and phone sessions. Further evaluations comparing the effectiveness of different e-based lifestyle intervention approaches toward activity-related and diet-related outcomes are necessary.

Adjuvant chemotherapy with bevacizumab (i.p.) can prolong survival time of patients with advanced ovarian cancer after cytoreduction

Objective To assess whether adjuvant chemotherapy with bevacizumab intraperitoneal (i.p.) is better than adjuvant chemotherapy with bevacizumab intravenous (i.v.) or adjuvant chemotherapy only for patients with advanced ovarian cancer after cytoreduction. Selected patients with advanced ovarian cancer after cytoreduction were divided into three groups depend on their will: adjuvant chemotherapy only; adjuvant chemotherapy combined with bevacizumab intravenous (i.v.); adjuvant chemotherapy combined with bevacizumab intraperitoneal (i.p.). Patients in three groups were given 4-6 cycles of treatment and followed up for 3 years. posttreatment outcome, longterm survival and side effects were prospectively recorded and analyzed. Disease control rate (DCR) of three groups are 73.3%, 90.0%, 93.3% respectively (P<0.05). Remission rate (RR) and DCR of patients with bevacizumab intraperitoneal (i.p.) are better than that of patients with bevacizumab intravenous (i.v.) (P<0.05). The mean progression free survival (PFS) of patients with bevacizumab intraperitoneal (i.p.) (15.34 months) was longer than patients with bevacizumab intravenous (i.v.) (13.19 months), and both of two were longer than that of patients with adjuvant chemotherapy only (9.60 months) (χ2=52.11, P<0.001). The mean overall survival (OS) of patients with bevacizumab intraperitoneal (i.p.) (17.32 months) is longer than that of patients with adjuvant chemotherapy only (13.55 months) and patients with bevacizumab intravenous (i.v.) (15.17 months) (χ2=75.01, P<0.001). Incidence of hypertension and arrhythmia of groups with bevacizumab are higher than that of patients with adjuvant chemotherapy only (P<0.05). Standard chemotherapy combined with bevacizumab is reliable, safe and feasible for advanced ovarian cancer after cytoreduction without severe adverse effects. Bevacizumab intraperitoneal perfusion is better than that intravenous drip.

Case Report Unicentric Castleman disease located in the anterior mediastinum misdiagnosed as invasive thymoma: a case report

Castleman disease is a rare lymphoproliferative disorder of unknown etiology. The localized form, which usually presents as a slow-growing mass, is most commonly located in the mediastinum. Invasion of the vena anonyma by a mass has rarely been reported. We herein describe a case of initially misdiagnosed invasive thymoma in a 72-year-old woman, but postoperatively proven to have anterior mediastinal Castleman disease with invasion of the vena anonyma.

Intraoperative mechanical ventilation strategies for obese patients: a systematic review and network meta-analysis

Several intraoperative ventilation strategies are available for obese patients. However, the same ventilation interventions have exhibited different effects on PaO2 /FIO2 concerning obese patients in different trials, and the issue remains controversial. Therefore, we conducted a network meta-analysis to identify the optimal mechanical ventilation strategy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Embase, MEDLINE, CINAHL and Web of Science for studies published up to June 2014, and the PaO2 /FIO2 in obese patients given different mechanical ventilation strategies was assessed. We assessed the studies for eligibility and extracted data and then pooled the data and used a Bayesian fixed-effect model to combine direct comparisons with indirect evidence. Eligible studies evaluated different ventilation strategies for obese patients and reported the intraoperative PaO2 /FIO2 ratio, atelectasis and pulmonary compliance. Thirteen randomized controlled trials were included for network meta-analysis, including 476 patients who received 1 of 12 ventilation strategies. Volume-controlled ventilation with higher PEEP plus single recruitment manoeuvres (VCV + higher PEEP + single RM) was associated with the highest PaO2 /FiO2 ratio, improving intraoperative pulmonary compliance and reducing the incidence of intraoperative atelectasis.

Heart failure with preserved ejection fraction in women: the Dutch Queen of Hearts program

Heart failure (HF) poses a heavy burden on patients, their families and society. The syndrome of HF comes in two types: with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The latter is on the increase and predominantly present in women, especially the older ones. There is an urgent need for mortality-reducing drugs in HFpEF, a disease affecting around 5 % of those aged 65 years and over. HFpEF develops in patients with risk factors and comorbidities such as obesity, hypertension, diabetes, COPD, but also preeclampsia. These conditions are likely to drive microvascular disease with involvement of the coronary microvasculature, which may eventually evolve into HFpEF. Currently, the diagnosis of HFPEF relies mainly on echocardiography. There are no biomarkers that can help diagnose female microvascular disease or facilitate the diagnosis of (early stages of) HFpEF. Recently a Dutch consortium was initiated, Queen of Hearts, with support from the Netherlands Heart Foundation, with the aim to discover and validate biomarkers for diastolic dysfunction and HFpEF in women. These biomarkers come from innovative blood-derived sources such as extracellular vesicles and circulating cells. Within the Queen of Hearts consortium, we will pursue female biomarkers that have the potential for further evolution in assays with point of care capabilities. As a spin-off, the consortium will gain knowledge on gender-specific pathology of HFpEF, possibly opening up novel treatment options.

RTN4/Nogo is an independent prognostic marker for gastric cancer: preliminary results

OBJECTIVE

Gastric cancer is the fourth most common malignant cancer and is the second leading cause of cancer death worldwide. We evaluated the association of the immunohistochemical RTN4 expression with clinicopathological variables and patient outcome, and to evaluate its prognostic value.

PATIENTS AND METHODS

Histological samples from 95 primary gastric carcinoma patients were retrospectively studied with monoclonal antibody to RTN4.

RESULTS

Tumors with high RTN4 expression were found in 57.9% of patients. High RTN4 were associated with advanced stages (p = 0.0377) and different histology (p = 0.0030). In the overall population (median follow-up 42 months), patients with high RTN4 had shorter survival time than those with low RTN4 expression (p = 0.0119). In Cox multivariate analysis, high RTN4 (p = 0.0160) is an independent prognostic factor for overall survival of gastric cancer patients.

CONCLUSIONS

Our data suggest that RTN4 may contribute to the malignant progression of gastric cancer and serve as a novel prognostic indicator for gastric cancer patients.

Retraction: Association between bevacizumab-related chemotherapy regimens and serum vascular endothelial growth factor-A165b level in patients with metastatic colorectal cancer

The article "Association between bevacizumab-related chemotherapy regimens and serum vascular endothelial growth factor-A165b level in patients with metastatic colorectal cancer" by L. Xu, C. Chi, C. Wang, L.M. Zhang, published in Eur Rev Med Pharmacol Sci 2014;  18 (18): 2687-2692 has been withdrawn.

Association between bevacizumab-related chemotherapy regimens and serum vascular endothelial growth factor-A165b level in patients with metastatic colorectal cancer

OBJECTIVE

Colorectal cancer is the third most common cancer and the third leading cause of cancer-related death. Bevacizumab improves survival for metastatic colorectal cancer patients with chemotherapy, but no proven predictive markers exist. The aim was to investigate the possible predictive value of vascular endothelial growth factor (VEGF)-A165b levels in this setting.

PATIENTS AND METHODS

Pre-treatment serum samples and response evaluations were available from 60 patients. Patients were randomized to bevacizumab + FOLFIRI (BF arm) or placebo + FOLFIRI (PF arm). The expression serum VEGF-A165b levels were analysed by an ELISA. Group comparisons were made using the Wilcoxon test and baseline characteristics of groups were compared using χ2 tests.

RESULTS

Patients with low baseline VEGF-A165b levels are more likely to have an increased probability of response with the addition of bevacizumab (32.3% response on BF arm versus 8.2% on PF arm, p = 0.01) than those with high VEGF-165b levels (27.5% response on BF arm versus 28.6% on PF arm, p = not significant).

CONCLUSIONS

In this correlative evaluation, pretreatment serum VEGF-A165b levels were predictive for bevacizumab-based treatment benefit.