[Brain death: from the transformation of medical concept to the change of medical practice]

The implementation of death determination by clinicians usually involves three steps: learning the concept of death, mastering the skills of death determination, and recording the results of death determination. Each process needs to be changed with the progress of medical science. The transformation of brain death concept is the establishment and formation of the latest cognition of "irreversible brain function", which needs to be completed based on the theoretical learning of recognized standards. The transformation of brain death determination is the learning and mastering of the latest skills of brain death determination, which requires relearning and retraining based on special technologies. The transformation of brain death determination is the habit formation of standardized records of brain death judgement results, which needs to be completed based on the continuous improvement of case quality control. The gradual advancement of the three steps will accelerate the process of determining brain death in China.

Magnetic resonance imaging-based deep learning imaging biomarker for predicting functional outcomes after acute ischemic stroke

PURPOSE

Clinical risk scores are essential for predicting outcomes in stroke patients. The advancements in deep learning (DL) techniques provide opportunities to develop prediction applications using magnetic resonance (MR) images. We aimed to develop an MR-based DL imaging biomarker for predicting outcomes in acute ischemic stroke (AIS) and evaluate its additional benefit to current risk scores.

METHOD

This study included 3338 AIS patients. We trained a DL model using deep neural network architectures on MR images and radiomics to predict poor functional outcomes at three months post-stroke. The DL model generated a DL score, which served as the DL imaging biomarker. We compared the predictive performance of this biomarker to five risk scores on a holdout test set. Additionally, we assessed whether incorporating the imaging biomarker into the risk scores improved the predictive performance.

RESULTS

The DL imaging biomarker achieved an area under the receiver operating characteristic curve (AUC) of 0.788. The AUCs of the five studied risk scores were 0.789, 0.793, 0.804, 0.810, and 0.826, respectively. The imaging biomarker's predictive performance was comparable to four of the risk scores but inferior to one (p = 0.038). Adding the imaging biomarker to the risk scores improved the AUCs (p-values) to 0.831 (0.003), 0.825 (0.001), 0.834 (0.003), 0.836 (0.003), and 0.839 (0.177), respectively. The net reclassification improvement and integrated discrimination improvement indices also showed significant improvements (all p < 0.001).

CONCLUSIONS

Using DL techniques to create an MR-based imaging biomarker is feasible and enhances the predictive ability of current risk scores.

Immunogenicity and safety of an ORF7-deficient skin-attenuated and neuro-attenuated live vaccine for varicella: a randomised, double-blind, controlled, phase 2a trial

BACKGROUND

The Oka varicella vaccine strain remains neurovirulent and can establish lifelong latent infection, raising safety concerns about vaccine-related herpes zoster. In this study, we aimed to evaluate the immunogenicity and safety of a skin-attenuated and neuro-attenuated varicella vaccine candidate (v7D vaccine).

METHODS

We did this randomised, double-blind, controlled, phase 2a clinical trial in Jiangsu, China. Healthy children aged 3-12 years with no history of varicella infection or vaccination were enrolled and randomly assigned (1:1:1:1) to receive a single subcutaneous injection of the v7D vaccine at 3·3 log10 plaque forming units (PFU; low-dose v7D group), 3·9 log10 PFU (medium-dose v7D group), and 4·2 log10 PFU (high-dose v7D group), or the positive control varicella vaccine (vOka vaccine group). All the participants, laboratory personnel, and investigators other than the vaccine preparation and management staff were masked to the vaccine allocation. The primary outcome was assessment of the geometric mean titres (GMTs) and seroconversion rates of anti-varicella zoster virus immunoglobulin G (IgG) induced by different dose groups of v7D vaccine at 0, 42, 60, and 90 days after vaccination in the per-protocol set for humoral immune response analysis. Safety was a secondary outcome, focusing on adverse events within 42 days post-vaccination, and serious adverse events within 6 months after vaccination. This study was registered on Chinese Clinical Trial Registry, ChiCTR2000034434.

FINDINGS

On Aug 18-21, 2020, 842 eligible volunteers were enrolled and randomly assigned treatment. After three participants withdrew, 839 received a low dose (n=211), middle dose (n=210), or high dose (n=210) of v7D vaccine, or the vOka vaccine (n=208). In the per-protocol set for humoral immune response analysis, the anti-varicella zoster virus IgG antibody response was highest at day 90. At day 90, the seroconversion rates of the low-dose, medium-dose, and high-dose groups of v7D vaccine and the positive control vOka vaccine group were 100·0% (95% CI 95·8-100·0; 87 of 87 participants), 98·9% (93·8-100·0; 87 of 88 participants), 97·8% (92·4-99·7; 91 of 93 participants), and 96·4% (89·8-99·2; 80 of 83 participants), respectively; the GMTs corresponded to values of 30·8 (95% CI 26·2-36·0), 31·3 (26·7-36·6), 28·2 (23·9-33·2), and 38·5 (31·7-46·7). The v7D vaccine, at low dose and medium dose, elicited a humoral immune response similar to that of the vOka vaccine. However, the high-dose v7D vaccine induced a marginally lower GMT compared with the vOka vaccine at day 90 (p=0·027). In the per-protocol set, the three dose groups of the v7D vaccine induced a similar humoral immune response at each timepoint, with no statistically significant differences. The incidence of adverse reactions in the low-dose, medium-dose, and high-dose groups of v7D vaccine was significantly lower than that in the vOka vaccine group (17% [35 of 211 participants], 20% [41 of 210 participants], and 13% [27 of 210 participants] vs 24% [50 of 208 participants], respectively; p=0·025), especially local adverse reactions (10% [22 of 211 participants], 14% [30 of 210 participants] and 9% [18 of 210 participants] vs 18% [38 of 208 participants], respectively; p=0·016). None of the serious adverse events were vaccine related.

INTERPRETATION

The three dose groups of the candidate v7D vaccine exhibit similar humoral immunogenicity to the vOka vaccine and are well tolerated. These findings encourage further investigations on two-dose vaccination schedules, efficacy, and the potential safety benefit of v7D vaccine in the future.

FUNDING

The National Natural Science Foundation of China, CAMS Innovation Fund for Medical Sciences, the Fundamental Research Funds for the Central Universities, and Beijing Wantai.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

A Review on Traditional Uses, Phytochemistry, Pharmacology and Clinical Application of Tinospora sinensis (Lour.) Merr

Tinospora sinensis (T. sinensis), whose Tibetan name is "Lezhe", as a traditional medicine, is widely distributed in China, India and Sri Lanka. It is used for the treatment of rheumatic arthralgia, sciatica, lumbar muscle strain and bruises. Research over the previous decades indicated that T. sinensis mainly contains terpenes, lignans, alkaloids, phenol glycosides and other chemical components. A wide range of pharmacologic activities such as anti-inflammatory, analgesic, immunosuppressive, anti-aging, anti-radiation, anti-leishmania and liver protection have been reported. However, the scholar's research on the pharmacodynamic material basis of T. sinensis is relatively weak. Data regarding many aspects such as links between the traditional uses and bioactivities, pharmacokinetics, and quality control standard of active compositions is still limited and need more attention. This review reports a total of 241 compounds, the ethnopharmacology and clinical application of T. sinensis, covering the literature which were searched by multiple databases including Web of Science, PubMed, Google Scholar, Science Direct, CNKI and other literature sources from 1996 to date, with a view to provide a systematic and insightful reference and lays a foundation and inspiration for the application and further in-depth research of T. sinensis resources.

[The effect of Ba Duan Jin on the balance of community-dwelling older adults: a cluster randomized control trial]

Objective: To assess the effectiveness of a 6-month Ba Duan Jin exercise program in improving the balance of community-dwelling older adults. Methods: A two arms, parallel-group, cluster randomized controlled trial was conducted in 1 028 community residents aged 60-80 years in 40 communities in 5 provinces of China. Participants in the intervention group (20 communities, 523 people) received Ba Duan Jin exercise 5 days/week, 1 hour/day for 6 months, and three times of falls prevention health education, and the control group (20 communities, 505 people) received falls prevention health education same as the intervention group. The Berg balance scale (BBS) score was the leading outcome indicator, and the secondary outcome indicators included the length of time of standing on one foot (with eyes open and closed), standing in a tandem stance (with eyes open and closed), the closed circle test, and the timed up to test. Results: A total of 1 028 participants were included in the final analysis, including 731 women (71.11%) and 297 men (28.89%), and the age was (69.87±5.67) years. After the 3-month intervention, compared with the baseline data, the BBS score of the intervention group was significantly higher than the control group by 3.05 (95%CI: 2.23-3.88) points (P<0.001). After the 6-month intervention, compared with the baseline data, the BBS score of the intervention group was significantly higher than the control group by 4.70 (95%CI: 4.03-5.37) points (P<0.001). Ba Duan Jin showed significant improvement (P<0.05) in all secondary outcomes after 6 months of exercise in the intervention group compared with the control group. Conclusions: This study showed that Ba Duan Jin exercise can improve balance in community-dwelling older adults aged 60-80. The longer the exercise time, the better the improvement.

Head-to-head immunogenicity comparison of an Escherichia coli-produced 9-valent human papillomavirus vaccine and Gardasil 9 in women aged 18-26 years in China: a randomised blinded clinical trial

BACKGROUND

An Escherichia coli-produced human papillomavirus (HPV) 16 and 18 bivalent vaccine (Cecolin) was prequalified by WHO in 2021. This study aimed to compare the immunogenicity of the E coli-produced HPV 9-valent vaccine Cecolin 9 (against HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58) with Gardasil 9.

METHODS

This was a randomised, single-blind trial conducted in China. Healthy non-pregnant women aged 18-26 years, who were not breastfeeding and with no HPV vaccination history, were enrolled in the Ganyu Centre for Disease Control and Prevention (Lianyungang City, Jiangsu Province, China). Women were stratified by age (18-22 years and 23-26 years) and randomly assigned (1:1) using a permutated block size of eight to receive three doses of Cecolin 9 or Gardasil 9 at day 0, day 45, and month 6. All participants, as well as study personnel without access to the vaccines, were masked. Neutralising antibodies were measured by a triple-colour pseudovirion-based neutralisation assay. The primary outcomes, seroconversion rates and geometric mean concentrations (GMCs) at month 7, were analysed in the per-protocol set for immunogenicity (PPS-I). Non-inferiority was identified for the lower limit of the 95% CI of the GMC ratio (Cecolin 9 vs Gardasil 9) at a margin of 0·5 and a seroconversion rate difference (Cecolin 9-Gardasil 9) at a margin of -5%. This study was registered at ClinicalTrials.gov (NCT04782895) and is completed.

FINDINGS

From March 14 to 18, 2021, a total of 553 potential participants were screened, of which 244 received at least one dose of Cecolin 9 and 243 received at least one dose of Gardasil 9. The seroconversion rates for all HPV types in both groups were 100% in the PPS-I, with the values of the lower limits of 95% CIs for seroconversion rate differences ranging between -1·8% and -1·7%. The GMC ratios of five types were higher than 1·0, with the highest ratio, for HPV 58, at 1·65 (95% CI 1·38-1·97), and those of four types were lower than 1·0, with the lowest ratio, for HPV 11, at 0·79 (0·68-0·93). The incidence of adverse reactions in both groups was similar (43% [104/244] vs 47% [115/243]).

INTERPRETATION

Cecolin 9 induced non-inferior HPV type-specific immune responses compared with Gardasil 9 and is a potential candidate to accelerate the elimination of cervical cancer by allowing for global accessibility to 9-valent HPV vaccinations, especially in low-income and middle-income countries.

FUNDING

National Natural Science Foundation, Fujian Provincial Natural Science Foundation, Xiamen Science and Technology Plan Project, Fundamental Research Funds for the Central Universities, CAMS Innovation Fund for Medical Sciences of China, and Xiamen Innovax.

Immunogenicity and safety of an Escherichia coli-produced human papillomavirus (types 6/11/16/18/31/33/45/52/58) L1 virus-like-particle vaccine: a phase 2 double-blind, randomized, controlled trial

The Escherichia coli-produced human papillomavirus (HPV) 16/18 bivalent vaccine (Cecolin) has received prequalification by the World Health Organization based on its high efficacy and good safety profile. We aimed to evaluate the immunogenicity and safety of the second-generation nonavalent HPV 6/11/16/18/31/33/45/52/58 vaccine (Cecolin 9) through the randomized, blinded phase 2 clinical trial. Eligible healthy women aged 18-45 years were randomly (1:1) allocated to receive three doses of 1.0 mL (270 µg) of Cecolin 9 or placebo with a 0-1-6-month schedule. The primary endpoint was the seroconversion rate and geometric mean titer of neutralizing antibodies (nAbs) one month after the full vaccination course (month 7). The secondary endpoint was the safety profile including solicited adverse reactions occurring within 7 d, adverse events (AEs) occurring within 30 d after each dose, and serious adverse events (SAEs) occurring during the 7-month follow-up period. In total, 627 volunteers were enrolled and randomly assigned to Cecolin 9 (n = 313) or placebo (n = 314) group in Jiangsu Province, China. Almost all participants in the per-protocol set for immunogenicity (PPS-I) seroconverted for nAbs against all the nine HPV types at month 7, while two failed to seroconvert for HPV 11 and one did not seroconvert for HPV 52. The incidence rates of total AEs in the Cecolin 9 and placebo groups were 80.8% and 72.9%, respectively, with the majority of them being mild and recovering shortly. None of the SAEs were considered related to vaccination. In conclusion, the E. coli-produced 9-valent HPV (9vHPV) vaccine candidate was well tolerated and immunogenic, which warrants further efficacy studies in larger populations.

Clinical narratives as a predictor for prognosticating functional outcomes after intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a devastating stroke type that causes high mortality rates and severe disability among survivors. Many prognostic models are available for prognosticating patients with ICH. This study aimed to investigate whether clinical narratives can improve the performance for predicting functional outcomes after ICH.

METHODS

This study used data from the hospital stroke registry and electronic health records. The study population (n = 1363) was randomly divided into a training set (75%, n = 1023) and a holdout test set (25%, n = 340). Five risk scores for ICH were used as baseline prognostic models. Using natural language processing (NLP), text-based markers were generated from the clinical narratives of the training set through machine learning (ML) and deep learning (DL) approaches. The primary outcome was a poor functional outcome (modified Rankin Scale score of 3 to 6) at hospital discharge. The predictive performance was compared between the baseline models and models enhanced by incorporating the text-based markers using the holdout test set.

RESULTS

The enhanced prognostic models outperformed the baseline models, regardless of whether ML or DL approaches were used. The areas under the receiver operating characteristic curve (AUCs) of the baseline models were between 0.760 and 0.892. Adding the text-based marker to the baseline models significantly increased the model discrimination, with AUCs ranging from 0.861 to 0.914. The net reclassification improvement and integrated discrimination improvement indices also showed significant improvements.

CONCLUSIONS

Using NLP to extract textual information from clinical narratives could improve the predictive performance of all baseline prognostic models for ICH.

[Clinical effects of retrograde anterolateral thigh flaps in repairing anterior knee joint wounds under the concept of precise flap surgery]

Objective: To introduce the methods of retrograde anterolateral thigh flaps in repairing anterior knee joint wounds under the concept of precise flap surgery and to explore the clinical effects. Methods: A retrospective observational study was conducted. From August 2014 to March 2022, 7 patients with anterior knee joint wounds were treated with retrograde anterolateral thigh flap under the guidance of the concept of precise flap surgery in the 920th Hospital of Joint Logistic Support Force of PLA. Among them, 6 were males and 1 was female, aged 36 to 66 years. The sizes of wounds were 7 cm×5 cm to 15 cm×11 cm after debridement. All the patients were performed with computed tomography angiography (CTA), the donor and recipient sites were evaluated according to the precise flap surgery method, and the optimal pedicle, perforator, and pivot of flaps were chosen. The flap sizes were 10 cm×6 cm to 20 cm×9 cm, and all the donor sites of flaps were sutured directly. The consistency of the intraoperative exploration with preoperative CTA was observed. The flap survival and occurrence of complications were observed after surgery. The color, appearance, texture, and occurrence of complications were followed up. At the last follow-up, the blood supply of flaps was evaluated using the blood circulation evaluation indicators of Chinese Medical Association Hand Surgery Branch's trial criteria for digital replantation function evaluation, and the function of knee joint was evaluated using knee joint scoring system of hospital for special surgery. Results: The flap condition of the intraoperative exploration was completely consistent with that of preoperative CTA. The flaps survived completely after surgery in 6 patients, while necrosis at the edge of the flap occurred in 1 patient, which healed after dressing change. All the flaps were hyperperfused after surgery, and the color of the flaps gradually became normal after 1 week. Follow-up of 7 to 44 months showed that the color, appearance, and texture were well in all the patients, while local osteomyelitis at the proximal tibia occurred in 1 patient. At the last follow-up, all the 7 patients had excellent blood circulation; the function score of knee joint was 69 to 91, which was evaluated as excellent in 3 cases, good in 3 cases, and fair in 1 case. Conclusions: The retrograde anterolateral thigh flap has large variations, and the application of precise flap surgery method can accurately understand the variations before surgery, guide the design and cutting of the flaps, thus achieving precise repair of anterior knee joint wounds, with good repair outcome.

[Cardiac amyloidosis: pathological classification and clinical analysis of 48 cases]

Objective: To investigate the histological features and clinical manifestations in different types of cardiac amyloidosis to improve diagnostic accuracy. Methods: The histopathological features and clinical manifestations of 48 patients diagnosed with cardiac amyloidosis by Congo red stain and electron microscopy through endomyocardial biopsy were collected in West China Hospital of Sichuan University from January 2018 to December 2021. Immunohistochemical stains for immunoglobulin light chains (κ and λ) and transthyretin protein were carried out, and a review of literature was made. Results: The patients age ranged from 42 to 79 years (mean 56 years) and the male to female ratio was 1.1 to 1.0. The positive rate of endomyocardial biopsy was 97.9% (47/48), which was significantly higher than that of the abdominal wall fat (7/17). Congo red staining and electron microscopy were positive in 97.9% (47/48) and 93.5% (43/46), respectively. Immunohistochemical stains showed 32 cases (68.1%) were light chain type (AL-CA), including 31 cases of AL-λ type and 1 case of AL-κ type; 9 cases (19.1%) were transthyretin protein type (ATTR-CA); and 6 cases (12.8%) were not classified. There was no significant difference in the deposition pattern of amyloid between different types (P>0.05). Clinical data showed that ATTR-CA patients had less involvement of 2 or more organs and lower N-terminal pro-B-type natriuretic peptide (NT-proBNP) than the other type patients (P<0.05). The left ventricular stroke volume and right ventricular ejection fraction of ATTR-CA patients were better than the other patients (P<0.05). Follow-up data of 45 patients was obtained, and the overall mean survival time was 15.6±2.0 months. Univariate survival analysis showed that ATTR-CA patients had a better prognosis, while cardiac amyloidosis patients with higher cardiac function grade, NT-proBNP >6 000 ng/L, and troponin T >70 ng/L had a worse prognosis (P<0.05). Multivariate survival analysis showed that NT-proBNP and cardiac function grade were independent prognostic factors for cardiac amyloidosis patients. Conclusions: AL-λ is the most common type of cardiac amyloidosis in this group. Congo red staining combined with electron microscopy can significantly improve the diagnosis of cardiac amyloidosis. The clinical manifestations and prognosis of each type are different and can be classified based on immunostaining profile. However, there are still a few cases that cannot be typed; hence mass spectrometry is recommended if feasible.

Four new diastereoisomeric neolignan glycosides from the root bark of Lycium chinense Miller. And their α-glucosidase inhibitory activity

Four new diastereoisomeric neolignan glycosides (1-4) along with nine known lignan glycosides (5-13) were isolated from the root bark of Lycium chinense Mill. Their structures with absolute configurations were elucidated on the basis of NMR spectroscopy, ECD, Mo₂(OAc)₄-induced ECD spectra, enzymatic hydrolysis and acid hydrolysis. The isolated compounds were evaluated for their α-glucosidase inhibitory activity. Compounds 8 and 13 exhibited moderate inhibitory activities against α-glucosidase with IC₅₀ values of 26.82 ± 2.71 and 43.14 ± 2.81 μg/mL.

Prognosis of hepatitis E infection in patients with chronic liver disease: A meta-analysis

In individuals with underlying chronic liver disease (CLD), hepatitis E virus (HEV) infection is a potential trigger of acute-on-chronic liver failure. In this systematic review, seven electronic databases were searched. Pooled incidence rates with 95% confidence intervals (95% CIs) were calculated by the Freeman-Tukey double arcsine transformation method. The association between death or liver failure and HEV superinfection in CLD patients was estimated by the odds ratios (OR) with a 95% CI. A total of 18 studies from 5 countries were eligible for systematic review. The prevalence of acute HEV infection in hospitalized CLD patients with clinical manifestations of hepatitis was 13.6%, which was significantly higher than that in CLD patients from the community (pooled prevalence 1.1%). The overall rates of liver failure and mortality in CLD patients with HEV superinfection were 35.8% (95% CI: 26.7%-45.6%) and 14.3% (95% CI: 10.6%-18.5%), respectively, with the rates in cirrhotic patients being approximately 2-fold and 4-fold higher than those in noncirrhotic patients, respectively. The risks of liver failure (OR = 5.5, 95% CI: 1.5-20.1) and mortality (OR = 5.0, 95% CI: 1.9-13.3) were significantly higher in CLD patients with HEV superinfection than in those without HEV superinfection. HEV testing in hospitalized CLD patients is necessary due to the high prevalence of HEV infection observed in hospitalized CLD patients. HEV superinfection could accelerate disease progression in patients with underlying CLD and increase mortality in these patients. HEV vaccination is appropriate for patients with pre-existing CLD.

Clinical characteristics and prognosis of paroxysmal sympathetic hyperactivity in patients with severe nontraumatic brain injury

OBJECTIVE

This prospective study investigated and analyzed the clinical characteristics and prognosis of paroxysmal sympathetic hyperactivity (PSH) in patients with severe nontraumatic brain injury.

METHODS

Patients presenting with severe nontraumatic brain injury with PSH from July 2018 to June 2019 were enrolled. A PSH assessment measure ≥ 8 points was used as the criterion for PSH. Clinical data, indicators related to PSH, treatment effects and the prognosis were prospectively collected and analyzed.

RESULTS

A total of 220 patients with severe nontraumatic brain injury were analyzed, and PSH occurred in 8 patients (3.6%).     The primary neurological diseases included acute cerebral infarction, anti-N-methyl-D-aspartate receptor encephalitis, hypoxic encephalopathy and acute disseminated encephalitis. The Glasgow Coma Scale score was lower than 8 in the 8 patients with PSH. Seven of these eight patients had a Glasgow outcome scale (GOS) score of 3 or less than 3, and one patient had a GOS of 5 after 6 months. The medicines that effectively controlled PSH included dexmedetomidine, clonazepam, midazolam and diazepam.

CONCLUSIONS

Although the incidence was lower for nontraumatic brain injury complicated with PSH than for traumatic brain injury, patients with PSH had a more severe disease state and poorer prognoses. Dexmedetomidine might effectively control PSH.

Efficacy, safety, and immunogenicity of an Escherichia coli-produced Human Papillomavirus (16 and 18) L1 virus-like-particle vaccine: end-of-study analysis of a phase 3, double-blind, randomised, controlled trial

BACKGROUND

This Escherichia coli-produced bivalent HPV 16 and 18 vaccine was well tolerated and effective against HPV 16 and 18 associated high-grade genital lesions and persistent infection in interim analysis of this phase 3 trial. We now report data on long-term efficacy and safety after 66 months of follow-up.

METHODS

This phase 3, double-blind, randomised, controlled trial was done in five study sites in China. Eligible participants were women aged 18-45 years, with intact cervix and 1-4 lifetime sexual partners. Women who were pregnant or breastfeeding, had chronic disease or immunodeficiency, or had HPV vaccination history were excluded. Women were stratified by age (18-26 and 27-45 years) and randomly (1:1) allocated by software (block randomisation with 12 codes to a block) to receive three doses of the E coli-produced HPV 16 and 18 vaccine or hepatitis E vaccine (control) and followed-up for 66 months. The primary outcomes were high-grade genital lesions and persistent infection (longer than 6 months) associated with HPV 16 or 18 in the per-protocol susceptible population. This trial was registered with ClinicalTrials.gov, NCT01735006.

FINDINGS

Between Nov 22, 2012, and April 1, 2013, 8827 women were assessed for eligibility. 1455 women were excluded, and 7372 women were enrolled and randomly assigned to receive the HPV vaccine (n=3689) or control (n=3683). Vaccine efficacy was 100·0% (95% CI 67·2-100·0) against high-grade genital lesions (0 [0%] of 3310 participants in the vaccine group and 13 [0·4%] of 3302 participants in the control group) and 97·3% (89·9-99·7) against persistent infection (2 [0·1%] of 3262 participants in the vaccine group and 73 [2·2%] of 3271 participants in the control group) in the per-protocol population. Serious adverse events occurred at a similar rate between vaccine (267 [7·2%] of 3691 participants) and control groups (290 [7·9%] of 3681); none were considered related to vaccination.

INTERPRETATION

The E coli-produced HPV 16 and 18 vaccine was well tolerated and highly efficacious against HPV 16 and 18 associated high-grade genital lesions and persistent infection and would supplement the global HPV vaccine availability and accessibility for cervical cancer prevention.

FUNDING

National Natural Science Foundation of China, National Key R&D Program of China, Fujian Provincial Project, Fundamental Funds for the Central Universities, Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, and Xiamen Innovax.

Safety and immunogenicity of an Escherichia coli-produced bivalent human papillomavirus type 6/11 vaccine: A dose-escalation, randomized, double-blind, placebo-controlled phase 1 trial

A dose-escalation, randomized, double-blind, placebo-controlled phase 1 clinical trial enrolled 145 eligible participants aged 18-55 years in March 2015 in Liuzhou, China. Stratified by age and sex, the participants were randomly assigned to receive either 30, 60, or 90 μg of the HPV-6/11 vaccine (n = 41/40/40) or the parallel placebo vaccine (n = 8/8/8) with a 0/1/6-month dose-escalation schedule. Participants were actively followed-up to record local and systemic AEs occurring within 30 days after each vaccination, and SAEs occurred in 7 months. Blood and urine samples of each participant were collected before and 2 days after the first and third vaccination to determine changes in routine blood, serum biochemical, and urine indexes. Serum HPV-6/11-specific IgG and neutralizing antibody levels at month 7 were analyzed. A total of 79 adverse events were reported, and no SAEs occurred. The incidences of total adverse reactions in the 30 μg, 60 μg, and 90 μg HPV vaccine groups and the control group were 31.7%, 50.0%, 42.5%, and 62.5%, respectively. All but one of the adverse reactions was mild or moderate with grade 1 or 2. No vaccine-related changes with clinical significance were found in paired blood and urine indexes before and after vaccinations. All the participants in the per-protocol set seroconverted at month 7 for both IgG and neutralizing antibodies. The candidate novel Escherichia-coli-produced bivalent HPV-6/11 vaccine has been preliminarily proven to be well tolerated and with robust immunogenicity in a phase 1 clinical study, supporting further trials with larger sample size. The study has been registered at ClinicalTrials.gov (NCT02405520).

Epidemiological features, risk factors and disease burden of respiratory viruses among hospitalized children with acute respiratory tract infections in Xiamen, China

Well-established surveillance and monitoring system for respiratory viruses need be improved and epidemiological data about respiratory viruses is scarce in China. This study aimed to investigate epidemiological characteristics of respiratory viruses among hospitalized children ≤ 2 years old with acute respiratory tract infections (ARTIs) in Xiamen, China from October 2014 to September 2017. The clinical records of 7248 children hospitalized for ARTIs were analyzed retrospectively. Respiratory syncytial virus (RSV) (22.3%) was the most common virus among hospitalized children ≤ 2 years old, followed by parainfluenza (5.0%), adenovirus (3.5%) and influenza (1.7%). RSV-infected children possessed a higher disease burden including higher ICU admission rate (12.7%) and hospital charges ($635.36). Especially, infants < 6 months of age had the highest risk of RSV infection (OR= 2.4, 95% CI: 1.9-2.9) and higher ICU admission rate (12.1% vs. 4.5%, 4.6%) and hospital costs ($923.3 vs. $785.5, $811.7) than other age groups. Therefore, infants aged 0-6 months, especially premature infants and children with congenital diseases, should receive more concern. There is an urgent need to develop effective immunization strategies to protect these infants through the first 6 months of life or RSV season.

Distribution and changes in hepatitis C virus genotype in China from 2010 to 2020

BACKGROUND

Hepatitis C virus (HCV) causes a large number of infections worldwide. New infections seem to be increasing according to a report of the World Health Organization in 2015. Although direct-acting antivirals are quite effective for most genotypes of the HCV, some genotypes fail to respond. Therefore, the trend of genotype distribution is vital to better control the development of this infection.

AIM

To analyze the distribution and trends of the HCV genotype before and after the emergence of direct-acting antivirals in China.

METHODS

We searched all literature published in five electronic databases-China National Knowledge Infrastructure, Wan Fang Data, VIP Chinese Journal Database, Chinese Biomedical Literature Service System, and PubMed-from January 1, 2010 to December 31, 2020. The search strategy combined medical subject headings and free-text terms, including “hepatitis C virus” or “HCV” and “genotype” or “subtype” and ”China” or “Chinese”. Additional relevant articles were searched by manual selection. Data were extracted to build a database. All of the data were totaled according to regions, periods, routes of transmission, and sexes. The percentages in various stratifications were calculated.

RESULTS

There were 76110 samples from 30 provinces included in the study. Genotype 1 (G1) accounted for 58.2% of cases nationwide, followed by G2, G6, G3b, G3a, unclassified and mixed infections (17.5%, 7.8%, 6.4%, 4.9%, 1.8%, and 1.2%, respectively). The constitution of genotype varied among different regions, with G6 and G3b being more common in the south and southwest, respectively (28.1%, 15.4%). The past ten years have witnessed a decrease in G1 and G2 and an increase in G3 and G6 in almost all regions. The drug-use population had the most abundant genotypes, with G6 ranking first (33.3%), followed by G1 and G3b (23.4%, 18.5%).

CONCLUSION

G3 and G6 pose a new challenge for HCV infection. This study revealed the distribution of HCV genotypes in China over the past 10 years, providing information for HCV management strategies.

Risk of hepatocellular carcinoma in antiviral treatment-naïve chronic hepatitis B patients treated with entecavir or tenofovir disoproxil fumarate: a network meta-analysis

Background

Long-term antiviral treatments are associated with a significantly lower hepatocellular carcinoma (HCC) incidence in chronic hepatitis B (CHB) patients by reducing HBV DNA concentrations. However, it is still controversial whether antiviral strategies affect HCC development in antiviral treatment-naïve CHB patients. This study aimed to estimate the incidence of HCC in antiviral treatment-naïve CHB patients who were treated with Entecavir (ETV) and Tenofovir Disoproxil Fumarate (TDF) and compare the efficacy of two treatment regimens in HCC reduction.

Methods

The PubMed, Embase, China National Knowledge Infrastructure, and Wanfang databases were systematically searched until June 24, 2021. The pooled incidence and 95% confidence interval of HCC were calculated by the Freeman-Tukey double arcsine transformation method. The efficacies of ETV and TDF treatments in HCC reduction were compared through a network meta-analysis.

Results

A total of 27 studies were identified as eligible for this systematic review. The incidence densities in the ETV and TDF treatment groups were 2.78 (95% CI: 2.21-3.40) and 2.59 (95% CI: 1.51-3.96) per 100 persons-year among patients with preexisting cirrhosis and 0.49 (95% CI: 0.32-0.68) and 0.30 (95% CI: 0.06-0.70) per 100 persons-year among patients without preexisting cirrhosis. As the proportion of CHB patients with preexisting cirrhosis increased, the incidence density of HCC also increased gradually. Compared with other Nucleos(t)ide analogs (NAs) treatments, ETV and TDF treatments significantly lowered the risk of HCC, with hazard ratios (HRs) of 0.60 (95% CI: 0.40-0.90) and 0.56 (95% CI: 0.35-0.89), respectively. However, there was no difference in the incidence density of HCC between ETV and TDF treatments (HR = 0.92, 95% CI: 0.71-1.20) regardless of preexisting cirrhosis.

Conclusion

ETV and TDF treatments were associated with significantly lower risks of HCC than other NAs treatments. However, no difference was observed between ETV and TDF treatments in the risk of HCC development regardless of preexisting cirrhosis among treatment-naïve CHB patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09413-7.

Epidemiology of Respiratory Pathogens Among Children Hospitalized for Pneumonia in Xiamen: A Retrospective Study

OBJECTIVES

To investigate the etiology of common respiratory pathogens in children < 2 years of age hospitalized with pneumonia in Xiamen from 2014 to 2017.

METHODS

The medical records of 5581 children with pneumonia were retrospectively reviewed. Direct immunofluorescent test was used for respiratory virus testing. Bacteria were detected by conventional culture method. The results of pathogen detection at admission were analyzed as well as the clinical outcomes of children.

RESULTS

The burden of hospitalized children with pneumonia was highest among infants < 6 months old (58.2%). Respiratory syncytial virus (RSV) was the most common respiratory virus (26.0%) followed by parainfluenza (4.8%) and adenovirus (3.2%). Haemophilus influenzae was the most common bacteria detected (16.6%) followed by Moraxella catarrhalis (13.4%), Staphylococcus aureus (13.0%), Streptococcus pneumoniae (12.3%), Escherichia coli (5.1%) and Klebsiella pneumoniae (4.8%). Notably, RSV and K. pneumoniae were detected more frequently in severe pneumonia (35.0% and 10.9%) versus mild pneumonia (25.6% and 4.6%), with higher rates of ICU admissions, longer hospital stays and higher hospital costs compared to those infected with other respiratory pathogens.

CONCLUSIONS

Among children < 2 years of age hospitalized with pneumonia in Xiamen, RSV was the most common respiratory virus, while H. influenzae and S. pneumoniae remained the predominant bacterial pathogens detected. Considering the low implementation rate of vaccines against pneumococcal and Hib pneumonia in China, there is an urgent need to increase both vaccination rates to reduce pneumococcal and Hib disease burden.

Inflammation-related adverse reactions following vaccination potentially indicate a stronger immune response

Concerns about vaccine safety are an important reason for vaccine hesitancy, however, limited information is available on whether common adverse reactions following vaccination affect the immune response. Data from three clinical trials of recombinant vaccines were used in this post hoc analysis to assess the correlation between inflammation-related solicited adverse reactions (ISARs, including local pain, redness, swelling or induration and systematic fever) and immune responses after vaccination. In the phase III trial of the bivalent HPV-16/18 vaccine (Cecolin®), the geometric mean concentrations (GMCs) for IgG anti-HPV-16 and -18 (P<0.001) were significantly higher in participants with any ISAR following vaccination than in those without an ISAR. Local pain, induration, swelling and systemic fever were significantly correlated with higher GMCs for IgG anti-HPV-16 and/or anti-HPV-18, respectively. Furthermore, the analyses of the immunogenicity bridging study of Cecolin® and the phase III trial of a hepatitis E vaccine yielded similar results. Based on these results, we built a scoring model to quantify the inflammation reactions and found that the high score of ISAR indicates the strong vaccine-induced antibody level. In conclusion, this study suggests inflammation-related adverse reactions following vaccination potentially indicate a stronger immune response.

[Current situation and advancement of brain death determination in China]

China's "Criteria and practical guidance for determination of brain death (BD)" based on medicine was launched eight years ago. After joining the writing and publishing work of "The World Brain Death Project-Determination of Brain Death/Death by Neurologic Criteria", China has accelerated the process of internationalization. For this reason, the author expressed his own opinions on the related work progress and existing problems. (1) Although the criteria of BD in different countries are different due to various national conditions, cultures, religions and laws, we can seek common ground while reserving differences, such as the unification of the minimum criteria and the choice of confirmatory tests. (2) Although there are differences in the executive force of BD evaluation among countries around the world due to whether legislation or not, all walks of life and the public can respect the development of medicine. (3) Although there are still life support and organ donation problems to be solved after the determination of BD, they will be solved one by one through medical practice. In a word, we believe that the specification of BD determination in China will continue to advance orderly and rapidly.

[Effectiveness of the "14 plus 7 day quarantine" and "nucleic acid plus total antibody testing" strategy for screening imported patients with COVID-19 in Xiamen]

Objective: To analysis effectiveness of the "14 plus 7 day quarantine" and "nucleic acid plus total antibody testing" strategy (combined screening strategy) for screenin the imported patients with COVID-19 in Xiamen. Methods: The study populations were overseas travelers arriving in Xiamen from March 17 to December 31, 2020, and overseas travelers who had quarantine outside Xiamen for less than 21 days from July 18 to December 31, 2020. Data were collected and analyzed on the timing of detection, pathways, and test results of the imported patients with COVID-19 after implementing combined screening strategy. Results: A total of 304 imported patients with COVID-19 were found from 174 628 overseas travelers and 943 overseas travelers from other cities. A total of 163 cases (53.6%) were diagnosed by multitime, multisite intensive nucleic acid testing after positive finding in total antibody testing. Among them, 27 (8.9%) were first positive for nucleic acid in 14 plus 7 day quarantine and 136 were first positive for nucleic acid in 14-day quarantine. Only 8 of these individuals were tested positive for nucleic acid after positive total antibody testing. The other 128 individuals were tested positive for nucleic acid after being negative for average 2.3 times (maximum of 6 times). Aditional 155 cases might be detected by using the combined "14 plus 7 day quarantine" and " nucleic acid plus total antibody testing" strategy compared with "14-day quarantine and nucleic acid testing" strategy, accounting for 51.0% of the total inbound infections. So the combined screening strategy doubled the detection rate for imported patients with COVID-19. No second-generation case caused by overseas travelers had been reported in Xiamen as of February 26, 2021. Conclusions: Xiamen's combined screening strategy can effectively screen the imported patients with COVID-19 who were first positive for nucleic acid after 14 day quarantine. Compared with "14 day quarantine and nucleic acid testing", the combined screening strategy improved detection rate and further reduced the risk of the secondary transmission caused by the imported patients with COVID-19.

Antibody response in COVID-19 patients with and without re-positive RT-PCR results during the convalescent phase

Nucleic acid testing and antibody testing data from 143 recovered COVID-19 patients during the convalescent phase were retrospectively analyzed. A total of 23 (16.1%) recovered patients re-tested positive for SARS-CoV-2 RNA by RT-PCR. Three months after symptom onset, 100% and 99.3% of the patients remained positive for total and IgG antibodies, and the antibody levels remained high. IgM antibodies declined rapidly, with a median time to seroconversion of 67 (95% CI: 59, 75) days after onset. Approximately 25% of patients were seronegative for IgA antibodies at three months after onset. There was no statistically significant difference in antibody kinetics between patients with and without re-positive RT-PCR results during the convalescent phase.

[Preliminary audiological evaluation of the SoundBite bone conduction devices in adults with single-sided deafness]

Objective: The auditory deficits of single-sided deafness (SSD) can be treated with a novel intra-oral device, SoundBite, which delivers sound by applying vibratory signal to the teeth. The purpose of this study was to evaluate the efficacy and benefit of the bone conduction device for Chinese adults with SSD. Methods: Eighteen patients aged 19-66 yrs with acquired, permanent sensorineural SSD and no current treatment by any other devices for SSD, were recruited in a prospective controlled, nonrandomized, unblinded study. They were requested the continually daily wear of the new device over a 30-day free trial period. The intra-oral hearing device was placed around two maxillary teeth and was similar to a small partial denture or retainer. The audiological tests included pure tone air conduction thresholds, monosyllable word recognition score (WRS) in quiet and sentence reception thresholds in noise (via CMNmatrix test). The benefit was determined with the Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Speech, Spatial and Qualities of Hearing Scale (SSQ) questionnaire. Results: The monosyllable WRS and the 50% threshold of signal-to-noise ratio (SNR₅₀) were significantly better in all aided conditions. The head shadow effect, assessed by the SNR₅₀ via CMNmatrix test improved an average of 2.6 dB after 30 days' wearing compared with unaided condition (P<0.001). The APHAB scores improved (P<0.05) for all subjects for the Global and Ease of Communication, Reverberation, Background Noise subscales. The SSQ scores improved (P<0.05) for all subjects for Speech, Spatial and Qualities of Hearing subscales. Conclusion: The SoundBite is a good alternative to the well-established implantable bone conduction devices in patients with SSD. An improvement in listening ability in noise and quiet as well as a decrease of the head shadow effect is validated as the expected.

Clinical efficacy of plasma exchange in patients with autoimmune encephalitis

Objective

To determine the clinical and antibody response after therapeutic plasma exchange (TPE) in patients with severe refractory antibody‐associated autoimmune encephalitis (AE).

Methods

This single‐center prospective cohort included all patients consecutively admitted to our hospital because of severe refractory AE over the period from July 2014 to June 2019. All patients received immunotherapy (steroids, intravenous immunoglobulin (IVIG), and/or TPE). The primary outcome was evaluated at 1‐ and 2‐month postenrollment, and the long‐term outcome was followed up at 6 and 12 months. AE antibody titers in the cerebrospinal fluid and plasma were evaluated before and after TPE/IVIG.

Results

This study enrolled 57 patients with severe refractory AE, including anti‐NMDA receptor encephalitis (n = 51), anti‐GABAb receptor encephalitis (n = 3), anti‐LGI 1 encephalitis (n = 2), and anti‐AMPA receptor encephalitis (n = 1). Of all 57 patients, 33 patients received TPE for a total of 193 procedures, and 24 patients with contraindications or refusal of TPE were in the non‐TPE group. Compared with the non‐TPE group, the TPE group exhibited greater clinical improvement: 21 (37%) versus 8 (14%) after 1 month (P = 0.03) and 31 (54%) versus 16 (28%) after 2 months (P = 0.01), respectively. Complications and adverse events associated with TPE occurred in 91 procedures (47%) without serious adverse events associated with the use of TPE.

Interpretation

TPE might be an effective rescue therapy associated with rapid functional improvement in patients with severe steroid/IVIG refractory antibody‐associated AE from this nonrandomized control trial.

[Electroacupuncture at "Ganshu" (BL18) and "Yanglingquan" (GB34) alleviates hepatic ischemia-reperfusion injury by inhibiting translocation and release of high mobility group protein 1 in rats]

OBJECTIVE

To explore the protective effect of electroacupuncture (EA) on hepatic ischemia-reperfusion injury (HIRI) and the expression of high mobility group protein 1 (HMGB1) in liver tissues in rats.

METHODS

A total of 40 male SD rats were randomly divided into 4 groups, namely sham control, HIRI model, "Ganshu"(BL18) -"Yanglingquan"(GB34) and non-acupoint group, with 10 rats in each group. The HIRI model was induced by blocking the arteries, veins and bile ducts supplying the middle and left lobes of the liver for 1 h, and reperfusion for 4 h to induce an area of about 70% HIRI. EA was applied to bila-teral BL18 and GB34, or non-acupoints about 6-8 mm to the bilateral BL18 for 30 min before modeling. Serum alanine transaminase (ALT) and aspartate aminotransferase (AST) levels were measured by using an automatic biochemical analyzer. Serum tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and HMGB1 levels were assayed by ELISA. Hematoxylin - eosin (H.E.) staining was used to observe histopathological changes of the liver tissue by using tissue injury scaling (0-3 scores). The expression of HMGB1 protein in liver tissues was detected by immunohistochemical staining, Western blot and PCR, separately.

RESULTS

Following modeling and compared with the sham group, the levels of serum ALT, AST, TNF-α, IL-6, and HMGB1 contents, the number of HMGB1 immunoreaction (IR)-positive cells, and HMGB1 protein and mRNA were significantly increased (P＜0.01). After the treatment, the contents of serum ALT, AST, TNF-α, IL-6, and HMGB1, liver HMGB1 IR-positive cells, protein and mRNA were considerably down-regulated in the BL18-GB34 group (P<0.05), rather than in the non-acupoint group (P>0.05) in contrast to the model group. H.E. stain showed a higher liver injury score in the model group than in the sham group (P<0.01), and a lower liver injury score in the BL18-GB34 group (not the non-acupoint group) relevant to the model group (P<0.05).

CONCLUSION

EA of BL18 and GB34 points has a protective effect on ischemic liver injury in rats with HIRI, which may be associated with its functions in inhibiting the migration and release of HMGB1 from the nucleus to the cytoplasm and in down-regulating the expression of inflammatory factors.

Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

IMPORTANCE

There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

OBJECTIVE

To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

PROCESS

Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

EVIDENCE SYNTHESIS

Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

RECOMMENDATIONS

Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

CONCLUSIONS AND RELEVANCE

This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

Serology characteristics of SARS-CoV-2 infection after exposure and post-symptom onset

BACKGROUND

Timely diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a prerequisite for treatment and prevention. The serology characteristics and complement diagnosis value of the antibody test to RNA test need to be demonstrated.

METHOD

Serial sera of 80 patients with PCR-confirmed coronavirus disease 2019 (COVID-19) were collected at the First Affiliated Hospital of Zhejiang University, Hangzhou, China. Total antibody (Ab), IgM and IgG antibodies against SARS-CoV-2 were detected, and the antibody dynamics during the infection were described.

RESULTS

The seroconversion rates for Ab, IgM and IgG were 98.8%, 93.8% and 93.8%, respectively. The first detectible serology marker was Ab, followed by IgM and IgG, with a median seroconversion time of 15, 18 and 20 days post exposure (d.p.e.) or 9, 10 and 12 days post onset (d.p.o.), respectively. The antibody levels increased rapidly beginning at 6 d.p.o. and were accompanied by a decline in viral load. For patients in the early stage of illness (0-7 d.p.o), Ab showed the highest sensitivity (64.1%) compared with IgM and IgG (33.3% for both; p<0.001). The sensitivities of Ab, IgM and IgG increased to 100%, 96.7% and 93.3%, respectively, 2 weeks later. When the same antibody type was detected, no significant difference was observed between enzyme-linked immunosorbent assays and other forms of immunoassays.

CONCLUSIONS

A typical acute antibody response is induced during SARS-CoV-2 infection. Serology testing provides an important complement to RNA testing in the later stages of illness for pathogenic-specific diagnosis and helpful information to evaluate the adapted immunity status of patients.

A five-compartment model of age-specific transmissibility of SARS-CoV-2

BACKGROUND

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, also called 2019-nCoV) causes different morbidity risks to individuals in different age groups. This study attempts to quantify the age-specific transmissibility using a mathematical model.

METHODS

An epidemiological model with five compartments (susceptible-exposed-symptomatic-asymptomatic-recovered/removed [SEIAR]) was developed based on observed transmission features. Coronavirus disease 2019 (COVID-19) cases were divided into four age groups: group 1, those ≤ 14 years old; group 2, those 15 to 44 years old; group 3, those 45 to 64 years old; and group 4, those ≥ 65 years old. The model was initially based on cases (including imported cases and secondary cases) collected in Hunan Province from January 5 to February 19, 2020. Another dataset, from Jilin Province, was used to test the model.

RESULTS

The age-specific SEIAR model fitted the data well in each age group (P < 0.001). In Hunan Province, the highest transmissibility was from age group 4 to 3 (median: β43 = 7.71 × 10- 9; SAR43 = 3.86 × 10- 8), followed by group 3 to 4 (median: β34 = 3.07 × 10- 9; SAR34 = 1.53 × 10- 8), group 2 to 2 (median: β22 = 1.24 × 10- 9; SAR22 = 6.21 × 10- 9), and group 3 to 1 (median: β31 = 4.10 × 10- 10; SAR31 = 2.08 × 10- 9). The lowest transmissibility was from age group 3 to 3 (median: β33 = 1.64 × 10- 19; SAR33 = 8.19 × 10- 19), followed by group 4 to 4 (median: β44 = 3.66 × 10- 17; SAR44 = 1.83 × 10- 16), group 3 to 2 (median: β32 = 1.21 × 10- 16; SAR32 = 6.06 × 10- 16), and group 1 to 4 (median: β14 = 7.20 × 10- 14; SAR14 = 3.60 × 10- 13). In Jilin Province, the highest transmissibility occurred from age group 4 to 4 (median: β43 = 4.27 × 10- 8; SAR43 = 2.13 × 10- 7), followed by group 3 to 4 (median: β34 = 1.81 × 10- 8; SAR34 = 9.03 × 10- 8).

CONCLUSIONS

SARS-CoV-2 exhibits high transmissibility between middle-aged (45 to 64 years old) and elderly (≥ 65 years old) people. Children (≤ 14 years old) have very low susceptibility to COVID-19. This study will improve our understanding of the transmission feature of SARS-CoV-2 in different age groups and suggest the most prevention measures should be applied to middle-aged and elderly people.

Efficacy, Safety, and Immunogenicity of an Escherichia coli-Produced Bivalent Human Papillomavirus Vaccine: An Interim Analysis of a Randomized Clinical Trial

BACKGROUND

The high cost and insufficient supply of human papillomavirus (HPV) vaccines have slowed the pace of controlling cervical cancer. A phase III clinical trial was conducted to evaluate the efficacy, safety, and immunogenicity of a novel Escherichia coli-produced bivalent HPV-16/18 vaccine.

METHODS

A multicenter, randomized, double-blind trial started on November 22, 2012 in China. In total, 7372 eligible women aged 18-45 years were age-stratified and randomly assigned to receive three doses of the test or control (hepatitis E) vaccine at months 0, 1, and 6. Co-primary endpoints included high-grade genital lesions and persistent infection (over 6 months) associated with HPV-16/18. The primary analysis was performed on a per-protocol susceptible population of individuals who were negative for relevant HPV type-specific neutralizing antibodies (at day 0) and DNA (at day 0 through month 7) and who received three doses of the vaccine. This report presents data from a prespecified interim analysis used for regulatory submission.

RESULTS

In the per-protocol cohort, the efficacies against high-grade genital lesions and persistent infection were 100.0% (95% confidence interval = 55.6% to 100.0%, 0 of 3306 in the vaccine group vs 10 of 3296 in the control group) and 97.8% (95% confidence interval = 87.1% to 99.9%, 1 of 3240 vs 45 of 3246), respectively. The side effects were mild. No vaccine-related serious adverse events were noted. Robust antibody responses for both types were induced and persisted for at least 42 months.

CONCLUSIONS

The E coli-produced HPV-16/18 vaccine is well tolerated and highly efficacious against HPV-16/18-associated high-grade genital lesions and persistent infection in women.

Early neutrophil count relates to infarct size and fatal outcome after large hemispheric infarction

AIMS

To investigate the relationship between peripheral leukocyte dynamics and the outcome of large hemispheric infarction (LHI) patients.

METHODS

Patients with acute LHI admitted to the neuro-intensive care unit of Xuanwu Hospital from 2013 to 2017 were prospectively enrolled and followed up for 6 months after LHI.

RESULTS

A total of 84 LHI patients were included, 38 patients suffered brain herniation and 20 patients died from stroke. Compared to patients with benign course, LHI patients with fatal outcome showed larger infarcts and more severe brain edema (P < .01), as well as increased WBC and neutrophil counts throughout the first week after stroke (P < .05). Correlation analysis revealed that neutrophil counts on D2 after LHI positively correlated with infarct and edema volumes measured from CT/MRI (R²  = 0.22 and R²  = 0.15, P < .01) and negatively correlated with Glasgow Coma Scale (ρ = -0.234, P < .05). Patients with D2 neutrophils > 7.14 × 10⁹ /L had higher risk of brain herniation [odds ratio (OR) = 7.5, 95% CI: 2.0-28.1, P = .001], and patients with D2 neutrophils > 7.79 × 10⁹ /L had a higher risk of death (OR = 5.8, 95% CI: 1.2-27.0, P = .015).

CONCLUSION

Early peripheral neutrophil count after stroke relates to infarct size and the fatal outcome of LHI patients, which might help guiding acute LHI management such as reduction of intracranial pressure and potential antiinflammatory therapy in the future.

Obesity increases the risk of depression in children and adolescents: Results from a systematic review and meta-analysis

BACKGROUND

Clinical depression (including major depression, dysthymia, and unspecified depression) is common in children and adolescents with obesity and overweight. The objective of this systematic review and meta-analysis was to examine prevalence of clinical depression among overweight and obese children.

METHODS

PubMed, EMBASE, Web of Science, Medline, Cochrane library, and PsycINFO databases were systematically and independently searched by three researchers from the inception dates to April 01, 2019. The fixed-effects model was used to perform meta-analysis. Data analyses were performed with STATA Version 12.0.

RESULTS

Eleven studies with 69,893 subjects were included; 5 studies examined major depressive disorder (MDD), while the remaining 6 studies examined other types of clinical depression. In the overweight and obese group, the prevalence of clinical depression ranged from 1.7% to 26.7% in obese subjects and from 4.0% to 16.9% in overweight subjects. In studies on MDD, prevalence ranged from 10.1% to 26.7% in obese subjects and from 9.0% to 16.9% in overweight subjects. The odd ratios (ORs) of clinical depression ranged from 0.92 to 4.39 between obese subjects and healthy controls (i.e., normal-weight controls), and ranged from 0.96 to 1.67 between overweight subjects and controls. Compared to healthy controls, obese (OR = 1.851, 95% CI: 1.410-2.429) but not overweight (OR = 1.068, 95% CI: 0.889-1.283) children and adolescents were more likely to have MDD.

CONCLUSION

Obese children and adolescents had a significantly higher risk for MDD compared with healthy controls. Considering the negative health outcomes of depression, regular screening and effective treatments should be implemented for obese children and adolescents.

Clinical Outcomes Following Immediate Loading of Single-Tooth Implants in the Esthetic Zone: A Systematic Review and Meta-Analysis

PURPOSE

To identify whether or not immediate loading yields different clinical outcomes from conventional loading of single-tooth implants in the esthetic zone.

MATERIALS AND METHODS

Various databases (MEDLINE/PubMed, Cochrane [CENTRAL], and Embase) were searched electronically to find articles published in the English language from January 2000 to April 2018. Only randomized controlled clinical trials (RCTs) that compared conventional and immediate implant loading with a minimum follow-up period of 1 year or more were considered. Available data were pooled for meta-analysis using the Review Manager software.

RESULTS

Seven RCTs were included. There was no significant difference between immediate and conventional loading protocols on implant survival at the 1-year follow-up (risk ratio [RR] = 0.99; 95% confidence interval [CI]: 0.95 to 1.02). The differences regarding marginal bone loss between the two protocols were statistically insignificant (mean difference [MD] = 0.03 mm; 95% CI: -0.09 to 0.15 mm at the 1-year follow-up, and MD = -0.01 mm; 95% CI: -0.16 to 0.15 mm at the 2-year follow-up). Soft tissue changes following different loading protocols revealed no significant differences in the mesial papillae (MD = 0.30 mm; 95% CI: -0.25 to 0.85 mm), the distal papillae (MD = -0.00 mm; 95% CI: -0.42 to 0.42 mm), and the midfacial mucosa (MD = -0.33 mm; 95% CI: -1.17 to 0.50 mm) at the 1-year follow-up. The esthetic outcomes and patient satisfaction were reported in two and three RCTs, respectively.

CONCLUSION

A short-term follow-up of single-tooth implants in the esthetic zone showed that the loading protocols (conventional or immediate loading) are not likely to influence the clinical outcomes, including implant survival and peri-implant stability of soft and hard tissues.

Single-nucleotide polymorphism screening and RNA sequencing of key messenger RNAs associated with neonatal hypoxic-ischemia brain damage

A single-nucleotide polymorphism (SNP) is an alteration in one nucleotide in a certain position within a genome. SNPs are associated with disease susceptibility. However, the influences of SNPs on the pathogenesis of neonatal hypoxic-ischemic brain damage remain elusive. Seven-day-old rats were used to establish a hypoxic ischemic encephalopathy model. SNPs and expression profiles of mRNAs were analyzed in hypoxic ischemic encephalopathy model rats using RNA sequencing. Genes exhibiting SNPs associated with hypoxic ischemic encephalopathy were identified and studied by gene ontology and pathway analysis to identify their possible involvement in the disease mechanism. We identified 89 up-regulated genes containing SNPs that were mainly located on chromosome 1 and 2. Gene ontology analysis indicated that the up-regulated genes containing SNPs are mainly involved in angiogenesis, wound healing and glutamatergic synapse and biological processing of calcium-activated chloride channels. Signaling pathway analysis indicated that the differentially expressed genes play a role in glutamatergic synapses, long-term depression and oxytocin signaling. Moreover, intersection analysis of high throughput screening following PubMed retrieval and RNA sequencing for SNPs showed that CSRNP1, DUSP5 and LRRC25 were most relevant to hypoxic ischemic encephalopathy. Significant up-regulation of genes was confirmed by quantitative real-time polymerase chain reaction analysis of oxygen-glucose-deprived human fetal cortical neurons. Our results indicate that CSRNP1, DUSP5 and LRRC25, containing SNPs, may be involved in the pathogenesis of hypoxic ischemic encephalopathy. These findings indicate a novel direction for further hypoxic ischemic encephalopathy research. This animal study was approved on February 5, 2017 by the Animal Care and Use Committee of Kunming Medical University, Yunnan Province, China (approval No. kmmu2019038). Cerebral tissue collection from a human fetus was approved on September 30, 2015 by the Ethics Committee of Kunming Medical University, China (approval No. 2015-9).

Lot-to-lot consistency study of an Escherichia coli-produced bivalent human papillomavirus vaccine in adult women: a randomized trial

An Escherichia. coli-produced HPV-16/18 bivalent vaccine has been proved to be well-tolerated and highly efficacious against diseases associated with vaccine HPV types. As a part of the multi-center, randomized, double-blind phase III clinical trial, this lot-to-lot consistency study aimed to assess the safety and immunogenicity consistency of this novel HPV vaccine, which is also one of the objectives of the phase III trial. A total of 3689 healthy women aged 18-45 years were enrolled and randomly assigned 1:1:1 to three lots of the HPV vaccine groups. The primary outcomes were the IgG antibody level at 1 month after the last dose (month 7). In the immunogenicity per-protocol set (PPS), almost all of the participants seroconverted at month 7 and remained seropositive at month 42. For each paired comparison of the three lot groups, the two-sides of 90% CIs of GMC ratios for both IgG and neutralizing antibodies for HPV-16 and HPV-18 at month 7 were within the equivalence interval [0.5, 2]. Lot consistency was also demonstrated at month 42. The majority of recorded solicited reactions were mild or moderate. The incidences of solicited reactions of Lot 2 and Lot 3 were slightly higher than Lot 1. However, the incidences of solicited reactions of ≥ grade 3 and solicited reactions by symptoms were all similar among the three lot groups. None of the SAEs was considered related to vaccination by the investigator. In conclusion, this study demonstrates lot-to-lot consistency of the 3 consecutive lots of the E. coli-produced HPV-16/18 bivalent vaccine.

[Introduction of papillomavirus rapid interface for modelling and economics (PRIME) and an example of China's data analysis]

Cervical cancer has become an important disease that jeopardizes women's health, causing hundreds of thousands of new cases annually. Human papillomavirus (HPV) is the leading cause for cervical cancer. Since the world's first HPV vaccine was licensed in 2006, 92 countries around the world have introduced them in national immunization programs. The WHO recommends that scientific economic evaluation should be achieved before the introduction, but this is more difficult for low-and middle-income countries. Therefore, this article introduces a mathematical model recommended by WHO in 2014 to quickly and easily accomplish economic evaluation of HPV vaccine -the PRIME, and take the China's 2018 data published by International Agency for Research on Cancer (IARC) as an example. The evaluation result shows that the introduction of HPV vaccine in Chinese 12-year-old women is cost-effective.

Gadoxetic acid-enhanced magnetic resonance imaging can predict the pathologic stage of solitary hepatocellular carcinoma

BACKGROUND

Although important for determining long-term outcome, pathologic stage of hepatocellular carcinoma (HCC) is difficult to predict before surgery. Current state-of-the-art magnetic resonance imaging (MRI) using gadoxetic acid provides many imaging features that could potentially be used to classify single HCC as pT1 or pT2.

AIM

To determine which gadoxetic acid-enhanced MRI (EOB-MRI) findings predict pathologic stage T2 in patients with solitary HCC (cT1).

METHODS

Pre-operative EOB-MRI findings were reviewed in a retrospective cohort of patients with solitary HCC. The following imaging features were examined: Hyperintensity in unenhanced T2-weighted images, hypointensity in unenhanced T1-weighted images, arterial enhancement, corona enhancement, washout appearance, capsular appearance, hypointensity in the tumor tissue during the hepatobiliary (HB) phase, peritumoral hypointensity in the HB phase, hypointense rim in the HB phase, intratumoral fat, hyperintensity on diffusion-weighted imaging, hypointensity on apparent diffusion coefficient map, mosaic appearance, nodule-in-nodule appearance, and the margin (smooth or irregular). Surgical pathology was used as the reference method for tumor staging. Univariate and multivariate analyses were performed to identify predictors of microvascular invasion or satellite nodules.

RESULTS

There were 39 (34.2%; 39 of 114) and 75 (65.8%; 75 of 114) pathological stage T2 and T1 HCCs, respectively. Large tumor size (≥ 2.3 cm) and two MRI findings, i.e., corona enhancement [odds ratio = 2.67; 95% confidence interval: 1.101-6.480] and peritumoral hypointensity in HB phase images (odds ratio = 2.203; 95% confidence interval: 0.961-5.049) were associated with high risk of pT2 HCC. The positive likelihood ratio was 6.25 (95% confidence interval: 1.788-21.845), and sensitivity of EOB-MRI for detecting pT2 HCC was 86.2% when two or three of these MRI features were present. Small tumor size and hypointense rim in the HB phase were regarded as benign features. Small HCCs with hypointense rim but not associated with aggressive features were mostly pT1 lesions (specificity, 100%).

CONCLUSION

Imaging features on EOB-MRI could potentially be used to predict the pathologic stage of solitary HCC (cT1) as pT1 or pT2.

Surgical drainage of lactational breast abscess with ultrasound-guided Encor vacuum-assisted breast biopsy system

Lactational breast abscess is a serious complication of mastitis and commonly diagnosed in breast‐feeding women. The traditional drainage of breast abscess was often performed with incisive technique which may result in prolonged healing time, regular dressings, dressing pain, interfering with breastfeeding and unsatisfactory cosmetic outcome. As minimal invasive alternatives to incisive drainage, needle aspiration or percutaneous catheter placement cannot completely replace incisive drainage for the inability to treat large, multiloculated or chronic abscess. Vacuum‐assisted breast biopsy system (VABB) has been successfully applied in the treatment of benign breast diseases with satisfactory cosmetic outcomes. Among VABB devices, EnCor system has some distinctive features that make it an appropriate candidate for the treatment of lactational breast abscesses. In this study, for the first time, we investigated the feasibility, efficacy, and cosmetic results of surgical drainage of lactational breast abscess with US‐guided Encor VABB system. Our data suggests this procedure could serve as a promising alternative for women with lactational breast abscess who require incisive intervention with high cure rate, relatively short healing time, low recurrence rate, few complications, satisfactory cosmetics outcome and without interfering with breastfeeding.

[Measurement of uterine volume in patients with endometriosis and its clinical significance]

Objective: To measure the uterine volume by ultrasonic imaging in nullipara patients with endometriosis and analyze its clinical significance. Methods: From July 1st, 2016 to August 1st, 2017, 107 cases of nullipara patients with endometriosis hospitalized in Peking University First Hospital were selected as endometriosis group. Among 107 cases, 59 cases were in proliferative phase of menstrual cycle, 48 cases were in secretory phase; and 10 cases had an abortion history.Totally 101 cases of patients without endometriosis operated for other benign disease during the same period were chosen as the control group. All patients underwent laparoscopic surgery, and the diagnosis was confirmed by pathology. The uterine size was measured by transvaginal or transrectal color Doppler ultrasound, and the uterine volume was calculated according to the known formula. Results: The uterine volume of the endometriosis group [(69±26) cm(3)] was larger than that of the control group [(54±18) cm(3), P<0.01]. In the endometriosis group, the uterine volume of patients with pregnant history [(78±34) cm(3)] was larger than that of patients without pregnant history [(68±25) cm(3)]. The endometrial thickness in endometriosis group was higher than that of the control group [(9.1±3.5) versus (7.8±2.9) mm, P<0.05], and positively correlated with the uterine volume (r=0.39, P<0.05). The hemoglobin in endometriosis group was lower than that in the control group [(124±12) versus (131±10) g/L, P<0.01], and was negatively correlated with the uterine volume in the two groups (r(endometriosis)=-0.12, r(control)=-0.21; both P<0.05).The uterine volume of dysmenorrhea patients in the endometriosis group [(73±28) cm(3)] was greater than that of patients without dysmenorrhea [(62±19) cm(3), P<0.01]; both uterine volumes of patients with and without dysmenorrhea in endometriosis group were larger than those of patients with or without dysmenorrhea in the control group (P<0.05). The degree of dysmenorrhea in endometriosis group was positively correlated with the uterine volume (r=0.20, P=0.042). The uterine volume of stage Ⅳendometriosis patients [(79±30) cm(3)] was greater than that of stage Ⅲ patients in endometriosis group [(58±14) cm(3), P<0.01]. Conclusion: Patients with endometriosis are of increased uterine volume, which may be related to dysmenorrhea, menorrhagia and infertility.

An Investigation and Suggestions for the Improvement of Brain Death Determination in China

Background:

Brain death is the irreversible cessation of the function of the brain including the brainstem. In 2013, the Brain Injury Evaluation Quality Control Centre (BQCC) of the National Health and Family Planning Commission issued criteria and practical guidelines for the determination of brain death. This study aimed to evaluate whether the institutions have adopted these guidelines and to make suggestions for the improvement of the current criteria and practical guidelines for brain death determination in China.

Methods:

Consecutive brain death cases from 44 hospitals were evaluated for summary statistics for the following data: the performance of BQCC criteria and practical guidelines, clinical examination, apnea testing, ancillary testing, and the number of examinations as well as the waiting periods between examinations and details of who determined brain death. Data analysis was conducted from January 2013 to December 2017.

Results:

A total of 550 cases were obtained. All patients were determined to have deep coma and met the prerequisites for clinical testing. The performance rates of four brainstem reflex examinations (except cough reflex) ranged from 97.5% to 98.0%, and the completion rate as well as the coincidence rate were both 100.0%. The 238 cases (50.7%) completed apnea testing, and 231 cases (42.0%) had to stop apnea testing during the examination because of instability. The performance rates of the three ancillary tests, including electroencephalogram, short-latency somatosensory evoked potential, and transcranial Doppler, were 89.5%, 67.5%, and 79.5%, respectively; furthermore, the coincidence rates were 98.6%, 96.5%, and 99.5%, respectively. The combination of two ancillary tests was more accurate than one single ancillary test. A total of 401 (72.9%) cases successfully underwent two separate examinations to determine brain death with at least a 12-h waiting period. All brain death cases were determined by at least two qualified physicians.

Conclusion:

This study might provide suggestions for brain death determination in China.

Study of Simplified Coma Scales: Acute Stroke Patients with Tracheal Intubation

Background:

Whether the Glasgow Coma Scale (GCS) can assess intubated patients is still a topic of controversy. We compared the test performance of the GCS motor component (GCS-M)/Simplified Motor Score (SMS) to the total of the GCS in predicting the outcomes of intubated acute severe cerebral vascular disease patients.

Methods:

A retrospective analysis of prospectively collected observational data was performed. Between January 2012 and October 2015, 106 consecutive acute severe cerebral vascular disease patients with intubation were included in the study. GCS, GCS-M, GCS eye-opening component, and SMS were documented on admission and at 24, 48, and 72 h after admission to Neurointensive Care Unit (NCU). Outcomes were death and unfavorable prognosis (modified Rankin Scale: 5–6) at NCU discharge. The receiver operating characteristic (ROC) curve was obtained to determine the prognostic performance and best cutoff value for each scoring system. Comparison of the area under the ROC curves (AUCs) was performed using the Z-test.

Results:

Of 106 patients included in the study, 41 (38.7%) patients died, and 69 (65.1%) patients had poor prognosis when discharged from NCU. The four time points within 72 h of admission to the NCU were equivalent for each scale's predictive power, except that 0 h was the best for each scale in predicting outcomes of patients with right-hemisphere lesions. Nonsignificant difference was found between GCS-M AUCs and GCS AUCs in predicting death at 0 h (0.721 vs. 0.717, Z = 0.135, P = 0.893) and 72 h (0.730 vs. 0.765, Z = 1.887, P = 0.060), in predicting poor prognosis at 0 h (0.827 vs. 0.819, Z = 0.395, P = 0.693), 24 h (0.771 vs. 0.760, Z = 0.944, P = 0.345), 48 h (0.732 vs. 0.741, Z = 0.593, P = 0.590), and 72 h (0.775 vs. 0.780, Z = 0.302, P = 0.763). AUCs in predicting death for patients with left-hemisphere lesions ranged from 0.700 to 0.804 for GCS-M and from 0.700 to 0.824 for GCS, in predicting poor prognosis ranged from 0.841 to 0.969 for GCS-M and from 0.875 to 0.969 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). No significant difference between GCS-M AUCs and GCS AUCs was found in predicting death (0.964 vs. 0.964, P = 1.000) and poor prognosis (1.000 vs. 1.000, P = 1.000) for patients with right-hemisphere lesions at 0 h. AUCs in predicting death for patients with brainstem or cerebella were poor for GCS-M (<0.700), in predicting poor prognosis ranged from 0.727 to 0.801 for GCS-M and from 0.704 to 0.820 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). The SMS AUCs (<0.700) in predicting outcomes were poor.

Conclusions:

The GCS-M approaches the same test performance as the GCS in assessing the prognosis of intubated acute severe cerebral vascular disease patients. The GCS-M could be accurately and reliably applied in patients with hemisphere lesions, but caution must be taken for patients with brainstem or cerebella lesions.

Early Neurological Deterioration after Recanalization Treatment in Patients with Acute Ischemic Stroke: A Retrospective Study

Background:

Early neurological deterioration (END) is a prominent issue after recanalization treatment. However, few studies have reported the characteristics of END after endovascular treatment (EVT) as so far. This study investigated the incidence, composition, and outcomes of END after intravenous recombinant tissue plasminogen activator (IV rt-PA) and EVT of acute ischemic stroke, and identified risk factors for END.

Methods:

Medical records of patients who received recanalization treatment between January 1, 2014, and December 31, 2015 were reviewed. Patients were classified into IV rt-PA or EVT group according to the methods of recanalization treatment. The END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) ≥4 or an increase in Ia of NIHSS ≥1 within 72 h after recanalization treatment. Clinical data were compared between the END and non-END subgroups within each recanalization group.

Results:

Of the 278 patients included in the study, the incidence of END was 34.2%. The incidence rates of END were 29.8% in the IV rt-PA group and 40.2% in the EVT group. Ischemia progression (68.4%) was the main contributor to END followed by vasogenic cerebral edema (21.1%) and symptomatic intracranial hemorrhage (10.5%). Multivariate logistic regression showed that admission systolic blood pressure (SBP) ≥160 mmHg (odds ratio [OR]: 2.312, 95% confidence interval [CI]: 1.105–4.837) and large artery occlusion after IV rt-PA (OR: 3.628, 95% CI: 1.482–8.881) independently predicted END after IV rt-PA; and admission SBP ≥140 mmHg (OR: 5.183, 95% CI: 1.967–13.661), partial recanalization (OR: 4.791, 95% CI: 1.749–13.121), and nonrecanalization (OR: 5.952, 95% CI: 1.841–19.243) independently predicted END after EVT. The mortality rate and grave outcome rate at discharge of all the END patients (26.3% and 55.8%) were higher than those of all the non-END patients (1.1% and 18.6%; P < 0.01).

Conclusions:

END was not an uncommon event and associated with death and grave outcome at discharge. High admission SBP and unsatisfactory recanalization of occluded arteries might predict END.