Summary Background The avian influenza A H7N9 virus has caused infections in human beings in China since 2013. A large epidemic in 2016–17 prompted concerns that the epidemiology of the virus might ...have changed, increasing the threat of a pandemic. We aimed to describe the epidemiological characteristics, clinical severity, and time-to-event distributions of patients infected with A H7N9 in the 2016–17 epidemic compared with previous epidemics. Methods In this epidemiological study, we obtained information about all laboratory-confirmed human cases of A H7N9 virus infection reported in mainland China as of Feb 23, 2017, from an integrated electronic database managed by the China Center for Disease Control and Prevention (CDC) and provincial CDCs. Every identified human case of A H7N9 virus infection was required to be reported to China CDC within 24 h via a national surveillance system for notifiable infectious diseases. We described the epidemiological characteristics across epidemics, and estimated the risk of death, mechanical ventilation, and admission to the intensive care unit for patients admitted to hospital for routine clinical practice rather than for isolation purpose. We estimated the incubation periods, and time delays from illness onset to hospital admission, illness onset to initiation of antiviral treatment, and hospital admission to death or discharge using survival analysis techniques. Findings Between Feb 19, 2013, and Feb 23, 2017, 1220 laboratory-confirmed human infections with A H7N9 virus were reported in mainland China, with 134 cases reported in the spring of 2013, 306 in 2013–14, 219 in 2014–15, 114 in 2015–16, and 447 in 2016–17. The 2016–17 A H7N9 epidemic began earlier, spread to more districts and counties in affected provinces, and had more confirmed cases than previous epidemics. The proportion of cases in middle-aged adults increased steadily from 41% (55 of 134) to 57% (254 of 447) from the first epidemic to the 2016–17 epidemic. Proportions of cases in semi-urban and rural residents in the 2015–16 and 2016–17 epidemics (63% 72 of 114 and 61% 274 of 447, respectively) were higher than those in the first three epidemics (39% 52 of 134, 55% 169 of 306, and 56% 122 of 219, respectively). The clinical severity of individuals admitted to hospital in the 2016–17 epidemic was similar to that in the previous epidemics. Interpretation Age distribution and case sources have changed gradually across epidemics since 2013, while clinical severity has not changed substantially. Continued vigilance and sustained intensive control efforts are needed to minimise the risk of human infection with A H7N9 virus. Funding The National Science Fund for Distinguished Young Scholars.
Abstract Background and aims The body composition of patients with ulcerative colitis (UC) remains unclear. This study evaluated body composition in adult patients with UC and the associations of ...body composition with disease activity and surgical intervention. Methods This study included 99 patients with UC, 105 with Crohn’s disease (CD) and 60 controls. Skeletal muscle area (SMA), visceral fat area (VFA) and subcutaneous fat area (SFA) of the third lumbar vertebrae were evaluated by abdominal computed tomography. The effects of medical therapy and surgery on body composition in UC patients were determined. Results Sarcopenia was more frequent in UC patients (27.3%) than in controls (8.3%), but less frequent than in CD patients (59.0%). The prevalence of sarcopenia was significantly higher (33.8% vs. 4.5%, p <0.001), and SMA (144.26 vs. 182.32 cm2 , p <0.001), skeletal muscle index (SMI) (52.22 vs. 65.52 cm2 /m2 , p <0.001)significantly lower, in UC patients with high (≥6) than low (<6) Mayo score, but SFA and VFA were similar. The prevalence of sarcopenia and alterations in body composition were reversed, along with UC disease activity, following medical treatment or surgery. SMA and SMI correlated significantly with disease activity in UC patients. Multivariate analysis showed that sarcopenia (odds ratio, 8.49; 95% confidence interval, 1.80-40.10; p =0.007) was a negative predictor of high Mayo score in UC patients. Sarcopenic patients with UC had high probability of need for colectomy in Kaplan-Meier survival curves. Conclusions Sarcopenia is associated with high disease activity and poor clinical outcome in UC patients. Medical treatment and colectomy have positive effects on sarcopenia and skeletal muscle depletion.
Objectives Our aim was to identify important microRNAs (miRNAs) that might play an important role in contributing to aortic dissection by conducting a miRNA profile comparison between thoracic aortic ...dissection (TAD) and normal thoracic aorta. Methods The differentially expressed miRNA profiles of the aortic tissue between TAD patients (n = 6) and age-matched donors without aortic diseases (NA; n = 6) were analyzed by miRNA microarray. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was further performed to verify the expression of 12 selected miRNAs with an increased number of samples (TAD n = 12; NA n = 8). The potential targets of the differentially expressed miRNAs were predicted using computational searches. Bioinformatic analyses of the predicted target genes (gene ontology, pathway and network analysis) were done for further research. Additionally, Western blotting was performed to confirm the bioinformatics findings. Results The miRNA microarray revealed differentially expressed miRNAs between the TAD and NA groups. In the TAD group, 18 miRNAs were upregulated and 56 were downregulated (fold change >2, P < .01). qRT-PCR verified statistically consistent expression of seven selected miRNAs with microarray analysis. Combined with our previous proteomics study, target gene prediction revealed that some miRNAs reciprocally expressed with their targeted proteins. Target gene-related pathway analysis showed a significant change in five pathways in the TAD group compared with the NA group, especially the focal adhesion and the mitogen-activated protein kinase (MAPK) signaling pathways. By further conducting miRNA gene network analysis, we found that the mir-29 and mir-30 families are likely to play a role in the regulation of these two pathways, respectively. Conclusions Our results indicate that miRNAs expression profiles in aortic media from TAD were significantly changed. These results may provide important insights into TAD disease mechanisms. This study also suggests that the focal adhesion and MAPK signaling pathways might play important roles in the pathogenesis of TAD.
Abstract Background Postoperative ileus is a common problem after colorectal surgery. The aim of the study was to investigate the incidence and risk factors for prolonged postoperative ileus (POI) ...after colectomy for inflammatory bowel diseases (IBD). Method Consecutive patients who underwent colorectal resection for IBD vs. colorectal cancer (CRC) patients under enhanced recovery after surgery (ERAS) protocol were retrospectively analyzed. Primary assessment endpoint is the incidence of prolonged POI (> 4 days); secondary endpoints were GI-2 recovery (time to first toleration of solid food and first bowel movement), nasogastric tube re-insertion, and postoperative length of stay. Risk factors for prolonged POI in IBD patients were assessed by multiple logistic regression analysis with p-score matching. Results The incidence of prolonged POI was higher in IBD vs. CRC group (28.8 vs. 14.8%, P < 0.001). Patients with IBD had a longer time to GI-2 recovery (4.8±2.1 vs 3.7 ± 1.4 d, P < 0.001), postoperative length of stay (10.7 ± 6.2 vs. 7.9 ± 5.3 d, P < 0.001), higher incidence of nasogastric tube re-insertion (9.8 vs. 4.0%, P = 0.02). After propensity-score matching analysis, the differences were still significant. Preoperative steroid use > 20mg/d (OR = 2.19, P =0.048), hypo-albuminemia (<35g/L) (OR 2.72, P = 0.03), systemic inflammatory response syndrome (SIRS) status (OR 4.91, P =0.03) and postoperative intra-abdominal sepsis (IAS) (OR 9.31, P = 0.001) were independent risk factors for prolonged POI in IBD patients. Conclusion In the setting of ERAS, colectomy for IBD is associated with delayed gastrointestinal function recovery and higher incidence of prolonged POI compared to CRC patients. Normalizing preoperative albumin level, weaning off steroids, reducing preoperative SIRS and early management of postoperative IAS may reduce POI in IBD population.
Abstract Objective We evaluated whether video-assisted thoracoscopic lobectomy for locally advanced non–small cell lung cancer could be performed safely and with acceptable long-term outcomes by our ...improved technique and compared with standard thoracotomy lobectomy in a well-balanced population. Methods Patients with clinical stage II and III A non–small cell lung cancers who received lobectomy were reviewed. Video-assisted thoracoscopic lobectomies were all performed with Wang's technique by the surgeons who had overcome the learning curve and achieved proficiency. By using propensity-matched analysis, perioperative outcomes and long-term survival were compared. Results Matching based on propensity scores produced 120 patients in each group. Conversion rate to thoracotomy was 11.7%. After thoracoscopic lobectomy, hospital length of stay was shorter compared with thoracotomy (9.2 vs 12 days; P = .014) despite similar rates of postoperative complications (30/125 25% vs 34/125 28.3%; P = .56). Disease-free survival (49.1% vs 42.2%; P = .40) and overall survival (55.0% vs 57.1%; P = .73) at 5 years were similar between groups. Although advanced pathologic stage (hazard ratio HR, 2.018; 95% confidence interval CI, 1.330-3.062) and no postoperative chemotherapy (HR, 1.880; 95% CI, 1.236-2.858) were independently associated with increased hazard of death in multivariable Cox regression at each time point in follow-up, thoracoscopic lobectomy was not (HR, 1.075; 95% CI, 0.714-1.620; P = .73). Conclusions With continued experience and optimized technique, video-assisted thoracoscopic lobectomy can be performed in the majority of cases without compromising perioperative outcomes and oncologic efficacy.
Abstract Background The association between habitual caffeine intake with incident atrial fibrillation (AF) was unknown. We conducted a meta-analysis to investigate the association between chronic ...exposure of caffeine and the risk of AF and to evaluate the potential dose-response relation. Methods We searched PubMed, EMBASE, and the Cochrane Library up to November 2013 and references of relevant retrieved articles. Prospective cohort studies were included with relative risk (RR) or hazard ratio and 95% confidence intervals (CIs) for AF according to coffee/caffeine intake. Results Six prospective cohort studies with 228,465 participants were included. In the primary meta-analysis, caffeine exposure was weakly associated with a reduced risk of AF (RR, 0.90; 95% CI, 0.81-1.01; P = 0.07; I2 = 73%). In subgroup analyses, pooled results from studies with adjustment of potential confounders showed an 11% reduction for low doses (RR, 0.89; 95% CI, 0.80-0.99, P = 0.032; I2 = 30.9%, P = 0.227) and 16% for high doses (RR, 0.84; 95% CI, 0.75-0.94, P = 0.002; I2 = 24.1%, P = 0.267) of caffeine consumption in AF risk. An inverse relation was found between habitual caffeine intake and AF risk ( P for overall trend = 0.015; P for nonlinearity = 0.27) in dose-response meta-analysis and the incidence of AF decreased by 6% (RR, 0.94; 95% CI, 0.90-0.99) for every 300 mg/d increment in habitual caffeine intake. Conclusions It is unlikely that caffeine consumption causes or contributes to AF. Habitual caffeine consumption might reduce AF risk.
The true incidence of occult N2 lymph node metastasis in patients with clinical N0 non-small cell lung cancer (NSCLC) remains controversial. Estimation of the probability of N2 lymph node metastasis ...can assist physicians when making diagnosis and treatment decisions.
We reviewed the medical records of 605 patients (group A) and 211 patients (group B) with computed tomography-defined N0 NSCLC that had an exact tumor-node-metastasis stage after surgery. Logistic regression analysis of group A's clinical characteristics was used to estimate the independent predictors of N2 lymph node metastasis. A prediction model was then built and internally validated by using cross validation and externally validated in group B. The model was also compared with 2 previously described models.
We identified 4 independent predictors of N2 disease: a younger age; larger tumor size; central tumor location; and adenocarcinoma or adenosquamous carcinoma pathology. The model showed good calibration (Hosmer-Lemeshow test: p = 0.96) with an area under the receiver operating characteristic curve (AUC) of 0.756 (95% confidence interval, 0.699 to 0.813). The AUC of our model was better than those of the other models when validated with independent data.
Our prediction model estimated the pretest probability of N2 disease in computed tomography-defined N0 NSCLC and was more accurate than the existing models. Use of our model can be of assistance when making clinical decisions about invasive or expensive mediastinal staging procedures.
To calculate crystalline lens power and to determine the relationship between ocular biometry and diabetic retinopathy (DR) in an adult population with type 2 diabetes mellitus (T2DM).
...Cross-sectional, population-based study.
Patients with T2DM from the Beixinjing community, Changning district, Shanghai.
Random clustering sampling was used to identify adults with T2DM in the Beixinjing community. Spherical equivalent (SE) was determined by subjective refraction that achieved the best corrected vision. Axial length (AL), corneal power (CP), and anterior chamber depth (ACD) were measured using the IOLMaster. Diabetic retinopathy and diabetic macular edema (DME) were assessed according to the international DR classification.
The crystalline lens power was calculated using the Bennett-Rabbetts formula. The AL-to-corneal radius ratio (AL/CR ratio) was defined as the axial length divided by the mean corneal radius of curvature.
A total of 4011 eyes of 2057 subjects with T2DM were included in the analysis. In multivariate logistic models adjusting for age, sex, duration of diabetes, glycosylated hemoglobin A1c, serum creatinine, body mass index, systolic blood pressure, and cataract, after categorizing values into quartiles, there were trend associations between lens power and any DR (P = 0.01), between AL/CR ratio and any DR (P = 0.02), and between AL and any DR (P = 0.03), between lens power and moderate DR (P = 0.02), and between AL and moderate DR (P = 0.02); eyes with higher AL/CR ratio were less likely to have any DR (odds ratio OR, 0.43; 95% confidence interval CI, 0.24-0.78; P = 0.01 per 1 increase) and moderate DR (OR, 0.44; 95% CI, 0.21-0.93; P = 0.03 per 1 increase), eyes with longer AL were less likely to have any DR (OR, 0.88; 95% CI, 0.81-0.95; P = 0.002 per millimeter increase) or moderate DR (OR, 0.89; 95% CI, 0.80-0.98; P = 0.02 per millimeter increase), and eyes with higher SE were more likely to have any DR (OR, 1.08; 95% CI, 1.03-1.13; P = 0.003 per diopter increase).
In persons with T2DM, lens power, AL/CR ratio, and AL were associated with the presence of any DR and moderate DR. These findings suggested that globe elongation plays a major role in protective effects against DR, with contributions from lens power and other refractive components.
Summary Background Since insulin resistance is thought to be the underlying mechanism for metabolic syndrome, affected individuals might be sensitive to a dietary sodium intervention. We aimed to ...examine the association between metabolic syndrome and salt sensitivity of blood pressure. Methods 1906 Chinese participants without diabetes, aged 16 years or more, were selected to receive a low-sodium diet (51·3 mmol per day) for 7 days followed by a high-sodium diet (307·8 mmol per day) for an additional 7 days. Participants were excluded from the analysis if metabolic risk factor information was missing or if they did not complete their dietary interventions. Blood pressure was measured at baseline and on days 2, 5, 6, and 7 of each intervention. Metabolic syndrome was defined as the presence of three or more of: abdominal obesity, raised blood pressure, high triglyceride concentration, low HDL cholesterol, or high glucose. High salt sensitivity was defined as a decrease in mean arterial blood pressure of more than 5 mm Hg during low-sodium or an increase of more than 5 mm Hg during high-sodium intervention. This study is registered with ClinicalTrials.gov , number NCT00721721. Findings Of the 1881 participants with information regarding metabolic syndrome, 283 had metabolic syndrome. 1853 participants completed the low-sodium diet and 1845 completed the high-sodium diet. Multivariable-adjusted mean changes in blood pressure were significantly greater in participants with metabolic syndrome than in those without on both low-sodium and high-sodium diets (p<0·0001 for all comparisons). Additionally, risk of salt sensitivity rose with increasing numbers of risk factors for metabolic syndrome. Compared with those with no risk factors, participants with four or five had a 3·54-fold increased odds (95% CI 2·05–6·11) of high salt-sensitivity during the low-sodium and a 3·13-fold increased odds (1·80–5·43) of high salt-sensitivity during the high-sodium intervention. Interpretation These results suggest that metabolic syndrome enhances blood pressure response to sodium intake. Reduction in sodium intake could be an especially important component in reducing blood pressure in patients with multiple risk factors for metabolic syndrome. Funding National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
Background Studies have demonstrated that villous atrophy in celiac disease is patchy and have suggested that duodenal bulb biopsies aid in diagnosis. Objective To determine the role of the addition ...of duodenal bulb biopsies to distal duodenum (D2) biopsies in the diagnosis of celiac disease. Design Prospective, case-control study. Setting Tertiary referral hospital. Patients Patients undergoing upper endoscopy with biopsy for diagnosis or follow-up of celiac disease and control patients. Interventions Blinded review of duodenal biopsy samples. Main Outcome Measurements Increasing the yield as well as accuracy of the histologic diagnosis of celiac disease with the addition of bulb biopsies. Results Of 128 patients enrolled in the study, 67 had celiac disease. Of 1079 biopsy specimens, only 319 (30%) were adequate for complete histologic analysis, resulting in 40 celiac patients and 40 control patients for analysis. Of the 40 celiac patients, 35 (87.5%) had atrophy in either the bulb or D2, 30 (75%) exhibited atrophy at both sites with an identical grade of atrophy seen in 18 patients (45%). Fourteen patients (35%) had identical types of Marsh lesions in both biopsy sites. Twelve patients (30%) had atrophy detected in the bulb, D2, or both, but lacked intraepithelial lymphocytes and thus could not be assigned a Marsh grade. Five patients (13%) had a diagnosis of celiac disease based on findings in the bulb biopsy only. Limitations Small sample size and study performed in an academic medical center. Conclusions Our study confirms the patchy nature of villous atrophy as well as intraepithelial lymphocytosis in biopsy specimens from individuals with celiac disease. Adding duodenal bulb biopsies to our sampling regimen increased the diagnostic yield of celiac disease.
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