Summary Background The novel influenza A H7N9 virus emerged recently in mainland China, whereas the influenza A H5N1 virus has infected people in China since 2003. Both infections are thought to be ...mainly zoonotic. We aimed to compare the epidemiological characteristics of the complete series of laboratory-confirmed cases of both viruses in mainland China so far. Methods An integrated database was constructed with information about demographic, epidemiological, and clinical variables of laboratory-confirmed cases of H7N9 (130 patients) and H5N1 (43 patients) that were reported to the Chinese Centre for Disease Control and Prevention until May 24, 2013. We described disease occurrence by age, sex, and geography, and estimated key epidemiological variables. We used survival analysis techniques to estimate the following distributions: infection to onset, onset to admission, onset to laboratory confirmation, admission to death, and admission to discharge. Findings The median age of the 130 individuals with confirmed infection with H7N9 was 62 years and of the 43 with H5N1 was 26 years. In urban areas, 74% of cases of both viruses were in men, whereas in rural areas the proportions of the viruses in men were 62% for H7N9 and 33% for H5N1. 75% of patients infected with H7N9 and 71% of those with H5N1 reported recent exposure to poultry. The mean incubation period of H7N9 was 3·1 days and of H5N1 was 3·3 days. On average, 21 contacts were traced for each case of H7N9 in urban areas and 18 in rural areas, compared with 90 and 63 for H5N1. The fatality risk on admission to hospital was 36% (95% CI 26–45) for H7N9 and 70% (56–83%) for H5N1. Interpretation The sex ratios in urban compared with rural cases are consistent with exposure to poultry driving the risk of infection—a higher risk in men was only recorded in urban areas but not in rural areas, and the increased risk for men was of a similar magnitude for H7N9 and H5N1. However, the difference in susceptibility to serious illness with the two different viruses remains unexplained, since most cases of H7N9 were in older adults whereas most cases of H5N1 were in younger people. A limitation of our study is that we compared laboratory-confirmed cases of H7N9 and H5N1 infection, and some infections might not have been ascertained. Funding Ministry of Science and Technology, China; Research Fund for the Control of Infectious Disease and University Grants Committee, Hong Kong Special Administrative Region, China; and the US National Institutes of Health.
Abstract Background A sizeable gap exists between guideline recommendations for treatment of acute coronary syndrome (ACS) and application of these recommendations in clinical practice. The Improving ...Care for Cardiovascular Disease in China (CCC)-ACS project is a novel quality enhancement registry designed to help medical care providers bridge this gap, thereby improving clinical outcomes for ACS patients in China. Methods and Results The CCC-ACS project uses data collection, analysis, feedback, rapid-cycle improvement, and performance recognition to extend the use of evidence-based guidelines throughout the healthcare system and improve cardiovascular health. The project was launched in 2014 with 150 centers recruited representing the diversity of care for ACS patients in tertiary hospitals across China. Clinical information for patients with ACS is collected via a web-based data collecting platform, including patients’ demographics, medical history, symptoms on arrival, in-hospital treatment and procedures, in-hospital outcomes, discharge medications for secondary prevention. Improvement in adherence to guideline recommendations is facilitated through monthly benchmarked hospital quality reports, recognition of hospital quality achievement, and regular webinars. As of April 16th 2016, a total of 35616 ACS cases have been enrolled. Conclusions The CCC-ACS is a national hospital-based quality improvement program, aiming to increase adherence to ACS guidelines in China and improve patient outcomes.
Background Since 2008, severe cases of emerging human adenovirus (HAdV) type 55 (HAdV-55) were reported sporadically in China. But no comparative studies had been conducted to discern the differences ...in epidemiologic and clinical abnormalities between HAdV-55 and other types (HAdV-7, HAdV-3, HAdV-14, HAdV-50, and HAdV-C). Methods A multicenter surveillance study for adult and adolescent community-acquired pneumonia (CAP) was conducted prospectively in Beijing and Yan Tai between November 2010 and April 2012. A standardized data form was used to record clinical information. The viral DNA extracted from the clinical samples or adenovirus viral isolates was sequenced. Results Among 969 cases, 48 (5%) were identified as adenovirus pneumonia. Six branches were clustered: HAdV-55 in 21, HAdV-7 in 11, HAdV-3 in nine, HAdV-14 in four, HAdV-50 in two, and HAdV-C in one. Most HAdV-55 cases were identified during February and March. All the hypervariable regions of the hexon genes of the 21 HAdV-55 strains were completely identical. Patients who had HAdV-55 were about 10 years older ( P = .027) and had higher pneumonia severity index scores ( P = .030) compared with those with other types (HAdV-7, HAdV-3, HAdV-14, HAdV-50, and HAdV-C). Systemic BP was also higher among patients in the HAdV-55 group ( P = .006). Unilateral or bilateral consolidations were the most common radiologic findings in both patients with HAdV-55 and those with other types (57.9% vs 36%). More than one-half of the patients were admitted to hospital; oxygen therapy was given to 29.2% of the 48 patients, and two needed mechanical ventilation. Conclusions HAdV-55 has established itself as a major pneumonia pathogen in the Chinese population, and further surveillance and monitoring of this agent as a cause of CAP is warranted.
Background The Oxford classification of immunoglobulin A (IgA) nephropathy (IgAN) provides a histopathologic grading system that is associated with kidney disease outcomes independent of clinical ...features. We evaluated the Oxford IgAN classification in a large cohort of patients from China. Study Design Retrospective study. Setting & Participants 1,026 adults with IgAN from 18 referral centers in China. Inclusion criteria and statistical analysis were similar to the Oxford study. Predictors Histologic findings of mesangial hypercellularity score, endocapillary proliferation, segmental sclerosis or adhesion, crescents, necrosis, and tubular atrophy/interstitial fibrosis. Clinical features, blood pressure, estimated glomerular filtration rate (eGFR), proteinuria, and treatment modalities. Outcomes Time to a 50% reduction in eGFR or end-stage renal disease (the combined event); the rate of eGFR decline (slope of eGFR); proteinuria during follow-up. Results Compared with the Oxford cohort, the Chinese cohort had a lower proportion of patients with mesangial hypercellularity (43%) and endocapillary proliferation (11%), higher proportion with segmental sclerosis or adhesion (83%) and necrosis (15%), and similar proportion with crescents (48%) and tubular atrophy/interstitial fibrosis (moderate, 24%; severe, 3.3%). During a median follow-up of 53 (25th-75th percentile, 36-67) months, 159 (15.5%) patients reached the combined event. Our study showed that patients with a mesangial hypercellularity score higher than 0.5 were associated with a 2.0-fold (95% CI, 1.5-2.8; P <0.001) higher risk of the combined event than patients with a score of 0.5 or lower. Patients with tubular atrophy/interstitial fibrosis of 25%-50% and >50% versus <25% were associated with a 3.7-fold (95% CI, 2.6-5.1; P <0.001) and 15.1-fold (95% CI, 9.5-24.2; P <0.001) higher risk of the combined event, respectively. Endocapillary proliferation, glomerular crescents, and necrosis were not significant. Limitations Retrospective study; the therapeutic interventions were miscellaneous. Conclusions We confirmed the associations of mesangial hypercellularity and tubular atrophy/interstitial fibrosis with kidney disease outcomes.
Objectives Surgical lung biopsy plays an important role in providing pathologic results, thus complementing the diagnostic rationale for suspected interstitial lung diseases. We performed a ...systematic review and meta-analysis regarding the diagnostic yield and postoperative mortality rate of surgical lung biopsy in patients with suspected interstitial lung diseases because of the wide variation in previously reported effectiveness and safety concerns. Methods We systematically searched for published studies between 2000 and 2014 evaluating surgical lung biopsy in the diagnosis of interstitial lung diseases. Subgroup analysis was performed to identify the possible source of study heterogeneity. Results Twenty-three studies contributed 2148 patients for the analysis. The median diagnostic yield was 95% (range, 42%-100%), with idiopathic pulmonary fibrosis as the most frequent diagnosis (618, 33.5%). Surgical lung biopsy was mainly guided by high-resolution computed tomography manifestations. Biopsy site, biopsy number, and the surgical lung biopsy method may not be associated with the diagnostic accuracy. The pooled postoperative mortality rate for included studies was 3.6% (95% confidence interval, 2.1-5.5), with significant heterogeneity observed. Subgroup analysis revealed that exclusion criteria based on immunocompromised status, mechanical ventilation, and severe respiratory dysfunction (diffusing capacity of lung for carbon monoxide <35% or forced vital capacity <55% predicted), but not surgical lung biopsy technique or underlying interstitial lung disease subtype, may be possible sources of heterogeneity. Conclusions We demonstrated a satisfactory diagnostic performance with a favorable safety profile of surgical lung biopsy in the diagnosis of suspected interstitial lung diseases. Surgical lung biopsy is especially recommended in patients with clinical information indicative but atypical of idiopathic pulmonary fibrosis, whereas the benefit of surgical lung biopsy should be carefully balanced against the risk for patients with immunocompromised status, mechanical ventilation dependence, or severe respiratory dysfunction.
Background Autosomal recessive loss-of-function mutations in dedicator of cytokinesis 8 (DOCK8) cause a combined immunodeficiency characterized by atopy, recurrent infections, and cancer ...susceptibility. A genotype-phenotype explanation for the variable disease expression is lacking. Objective We investigated whether reversions contributed to the variable disease expression. Methods Patients followed at the National Institutes of Health's Clinical Center were studied. We performed detailed genetic analyses and intracellular flow cytometry to detect DOCK8 protein expression within lymphocyte subsets. Results We identified 17 of 34 DOCK8-deficient patients who had germline mutations with variable degrees of reversion caused by somatic repair. Somatic repair of the DOCK8 mutations resulted from second-site mutation, original-site mutation, gene conversion, and intragenic crossover. Higher degrees of reversion were associated with recombination-mediated repair. DOCK8 expression was restored primarily within antigen-experienced T cells or natural killer cells but less so in naive T or B cells. Several patients exhibited multiple different repair events. Patients who had reversions were older and had less severe allergic disease, although infection susceptibility persisted. No patients were cured without hematopoietic cell transplantation. Conclusions In patients with DOCK8 deficiency, only certain combinations of germline mutations supported secondary somatic repair. Those patients had an ameliorated disease course with longer survival but still had fatal complications or required hematopoietic cell transplantation. These observations support the concept that some DOCK8-immunodeficient patients have mutable mosaic genomes that can modulate disease phenotype over time.
Abstract Objective To evaluate the efficacy of the frozen elephant trunk (FET) and total arch replacement (TAR) technique (FET + TAR) in the management of type A aortic dissection (TAAD) with arch ...entry tear. Methods Clinical outcomes were analyzed for 104 TAAD patients with arch entry tear undergoing FET + TAR at 4.7 ± 3.5 days from symptom onset and compared with 728 TAAD patients with entry tears in elsewhere. The mean patient age was 49.3 ± 9.3 years, compared with 45.6 ± 10.8 years in other TAAD patients ( P < .001). There were 84 men (80.8%). Hypertension was seen in 84.6% (88/104). Results Operative mortality was 8.6% (9/104). Spinal cord injury occurred in 3 cases (2.9%), stroke in 2 (1.9%), renal failure in 4 (3.8%) and limb ischemia in 2 (1.9%). Follow-up was 100% (95/95) at mean 5.6 ± 2.6 years (range 1.3-11.6). Late death occurred in 2 cases (1.9%). Survival and freedom from late adverse events were 89.2% (95% confidence interval CI, 81.3%-93.9%) and 85.0% (95% CI, 76.3%-90.8%) at 8 years, respectively. Both the stented and unstented distal aortic segments showed significant trends of false lumen shrinkage and true lumen expansion over time ( P < .001). Of the 65 CT scans at mean 4.6 ± 2.9 years postoperatively, the false lumen was completely obliterated in 63. Risk factors for arch entry tear were hypertension (odds ratio OR, 2.091; 95% CI, 1.186-3.687; P = .011) and age (OR, 1.025; 95% CI, 1.002-1.048; P = .032). Conclusions TAAD with arch entry tear was treated safely and durably by FET + TAR. Although patients with arch entry tear were somewhat older than other patients, operative mortality was not substantially higher despite their older age and arch location of entry tear. These results argue favorably for the use of the FET + TAR technique in the management of TAAD patients with arch entry tears.
Abstract Background Epidemiologic studies have evaluated the association between tumor necrosis factor-alpha (TNF-α) gene -308A/G polymorphism and the risk of acute pancreatitis (AP), but the results ...are inconsistent. In order to derive a more precise estimation of the associations, a meta-analysis was performed. Materials and methods Systematic searches of electronic databases PubMed, Embase, and Web of Science, as well as hand searching of the references of identified articles, were performed. All case-control studies investigating the association between TNF-α gene -308A/G polymorphism and AP risk were included. The association was assessed by odds ratio (OR) with 95% confidence intervals (CIs). Publication bias was analyzed by Begg's funnel plot and Egger's regression test. Results The initial search revealed 818 potentially eligible studies. Having read the title, abstract, or full text, we included six relevant studies in the final meta-analysis, which contained 1,006 AP cases and 782 controls. Overall, no significant association was found between TNF-α gene -308A/G polymorphism and AP risk when all studies were pooled into the meta-analysis (for A/A+A/G versus G/G: OR = 1.03, 95% CI = 0.83-1.28, P = 0.79; for A/A versus A/G+G/G: OR = 0.97, 95% CI = 0.65-1.45, P = 0.87; for A/A versus G/G: OR = 1.23, 95% CI = 0.79-1.91, P = 0.37; for A allele versus G allele: OR = 0.99, 95% CI = 0.83-1.18, P = 0.90). In addition, the similar results were obtained in the subgroup analysis based on the ethnicity and subtype of AP. Conclusions The present meta-analysis reveals that the TNF-α gene -308A/G polymorphism is not associated with AP risk. However, due to the small number of subjects included in analysis and the selection bias in some studies, the results should be interpreted with caution.
Objective We seek to compare the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft (the Sun procedure) in patients with acute and chronic type A ...aortic dissection (TAAD), identify the risk factors for operative mortality, and determine whether the acuity of TAAD significantly affects operative mortality. Methods We performed univariate and multivariate analyses of the clinical data from 803 patients with TAAD who underwent the Sun procedure. Results The operative mortality was 6.5% (52 of 803). The overall incidence of stroke and spinal cord injury was 2.0% (16 of 803) and 2.4% (19 of 803), respectively. Patients with acute TAAD had a greater incidence of operative death (8.1% vs 4.3%; P = .031), stroke (2.2% vs 0.6%; P = .046), and respiratory morbidities (20.8% vs 8.6%; P < .001). However, acuity was not identified as a risk factor for operative mortality (odds ratio OR, 1.67; P = .152). The risk factors were previous cerebrovascular disease (OR, 7.01; P = .001); malperfusion of the brain (OR, 7.10; P = .002), kidneys (OR, 12.67; P = .005), spinal cord (OR, 22.79; P = .008), and viscera (OR 22.98; P = .002); concomitant extra-anatomic bypass (OR, 9.50; P < .001); and cardiopulmonary bypass time >180 minutes (OR, 1.01; P < .001). Conclusions In this group of patients with type A dissection, acuity was not a risk factor for operative mortality after the Sun procedure. Patients with previous cerebrovascular disease; malperfusion of the brain, kidneys, spinal cord, and/or viscera; concomitant extra-anatomic bypass; and a longer cardiopulmonary bypass time (>180 minutes) were at greater risk of operative mortality.
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