[Therapeutic efficacy analysis of endoscopic combined with serological diagnosis strategy and endoscopic in G1 and G2 gastric neuroendocrine neoplasms]

Objective: To investigate the endoscopic combined serological diagnosis strategy for G1 and G2 gastric neuroendocrine neoplasms (G-NENs), and to evaluate the safety, short-term, and long-term efficacy of two endoscopic treatment procedures: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Methods: This study retrospectively analyzed the clinical data of 100 consecutive patients with G-NENs who were hospitalized at the Cancer Hospital of the Chinese Academy of Medical Sciences from January 2011 to October 2023. These patients underwent endoscopic treatment, and propensity score matching (PSM) was used to compare clinicopathological characteristics, as well as short-term and long-term efficacy of lesions in the EMR group and ESD group before and after treatment. Results: Among the 100 patients with G-NENs, the median age was 54 years old. Before surgery, 29 cases underwent endoscopic combined serological examination, and 24 of them (82.2%) had abnormally elevated plasma chromogranin A. The combined diagnostic strategy for autoimmune atrophic gastritis (AIG) achieved a diagnostic accuracy of 100%(22/22). A total of 235 G-NEN lesions were included, with 84 in the ESD group and 151 in the EMR group. The median size of the lesions in the ESD group (5.0 mm) was significantly larger than that in the EMR group (2.0 mm, P＜0.001). Additionally, the ESD group had significantly more lesions with pathological grade G2[23.8%(20/84) vs. 1.3%(2/151), P＜0.001], infiltration depth reaching the submucosal layer [78.6%(66/84) vs. 51.0%(77/151), P＜0.001], and more T2 stage compared to the EMR group[15.5%(13/84) vs. 0.7%(1/151), P＜0.001]. After PSM, 49 pairs of lesions were successfully matched between the two groups. Following PSM, there were no significant differences in the en bloc resection rate [100.0%(49/49) vs. 100.0%(49/49)], complete resection rate [93.9%(46/49) vs. 100.0%(49/49)], and complication rate [0(0/49) vs. 4.1%(2/49)] between the two groups. During the follow-up period, no recurrence or distant metastasis was observed in any of the lesions in both groups. Conclusions: The combination of endoscopy and serology diagnostic strategy has the potential to enhance the accuracy of diagnosing G1 and G2 stage G-NENs and their background mucosa. Endoscopic resection surgery (EMR, ESD) is a proven and safe treatment approach for G1 and G2 stage G-NENs.

[Clinical significance and research progress of quantitative hepatitis B virus core antibody measurement]

Hepatitis B virus core antibodies are specific antibodies produced after viral infection that appear early and last for a long time, and its levels in serum are measured by the double-antigen sandwich chemiluminescent microparticle immunoassay method, which has higher sensitivity and specificity, providing new clinical indicators for hepatitis B patients diagnosis, treatment, and drug withdrawal management. This article reviews the clinical significance and research progress of quantitative hepatitis B core antibody measurement and expounds on its research applications and prospects in clinical practice.

[Endoscopic hand-suturing combined with titanium clips for rectal defects closure after endoscopic submucosal dissection: a pilot study]

Objective: To explore the feasibility of endoscopic hand-suturing (EHS) for rectal defects closure after endoscopic submucosal dissection (ESD), and the clinical practicability of EHS combined with titanium clips. Methods: This is a prospective study performed by two experienced endoscopists from the Cancer Hospital, Chinese Academy of Medical Sciences who had received EHS training in sixporcine gastric ESD defects in vivo before the study. From December 2022 to February 2022, 20 patients with rectal mucosal lesions or submucosal diseases underwent ESD. Then EHS combined with titanium clips was adopted to close the rectal ESD defects. Specifically, we first sutured the defects as much as possible through EHS, then use titanium clips to fix the tail of the suture, and finally use additional titanium clips to close the residual parts of the defects that cannot be sutured. The main observational indicators were complete closure of the wound and delayed bleeding within one month after surgery. Results: In the 20 rectal cases, the size of defects ranged from 2.2 to 3.6 cm, with a median of 2.7 cm. All cases achieved complete closure without delayed bleeding, of which 12 (60.0%) were completely sutured with EHS and 8 (40.0%) required additional titanium clips to achieve complete closure after suturing. Conclusion: EHS technique is feasible and safe for rectum. EHS combined with titanium clips can also effectively close the rectal ESD defects, prevent postoperative delayed bleeding, and may be easier to be implemented in clinical practice.

[Risk factors analysis and prediction model construction of submucosal deep infiltration of early colorectal tumor]

Objective: To investigate the risk factors for the development of deep infiltration in early colorectal tumors (ECT) and to construct a prediction model to predict the development of deep infiltration in patients with ECT. Methods: The clinicopathological data of ECT patients who underwent endoscopic treatment or surgical treatment at the Cancer Hospital, Chinese Academy of Medical Sciences from August 2010 to December 2020 were retrospectively analyzed. The independent risk factors were analyzed by multifactorial regression analysis, and the prediction models were constructed and validated by nomogram. Results: Among the 717 ECT patients, 590 patients were divided in the within superficial infiltration 1 (SM1) group (infiltration depth within SM1) and 127 patients in the exceeding SM1 group (infiltration depth more than SM1). There were no statistically significant differences in gender, age, and lesion location between the two groups (P>0.05). The statistically significant differences were observed in tumor morphological staging, preoperative endoscopic assessment performance, vascular tumor emboli and nerve infiltration, and degree of tumor differentiation (P<0.05). Multivariate regression analysis showed that only erosion or rupture (OR=4.028, 95% CI: 1.468, 11.050, P=0.007), localized depression (OR=3.105, 95% CI: 1.584, 6.088, P=0.001), infiltrative JNET staging (OR=5.622, 95% CI: 3.029, 10.434, P<0.001), and infiltrative Pit pattern (OR=2.722, 95% CI: 1.347, 5.702, P=0.006) were independent risk factors for the development of deep submucosal infiltration in ECT. Nomogram was constructed with the included independent risk factors, and the nomogram was well distinguished and calibrated in predicting the occurrence of deep submucosal infiltration in ECT, with a C-index and area under the curve of 0.920 (95% CI: 0.811, 0.929). Conclusion: The nomogram prediction model constructed based on only erosion or rupture, local depression, infiltrative JNET typing, and infiltrative Pit pattern has a good predictive efficacy in the occurrence of deep submucosal infiltration in ECT.

[Risk factors for residual cancer or lymph node metastasis after endoscopic noncurable resection of early colorectal cancer]

Objective: Risk factors related to residual cancer or lymph node metastasis after endoscopic non-curative resection of early colorectal cancer were analyzed to predict the risk of residual cancer or lymph node metastasis, optimize the indications of radical surgical surgery, and avoid excessive additional surgical operations. Methods: Clinical data of 81 patients who received endoscopic treatment for early colorectal cancer in the Department of Endoscopy, Cancer Hospital, Chinese Academy of Medical Sciences from 2009 to 2019 and received additional radical surgical surgery after endoscopic resection with pathological indication of non-curative resection were collected to analyze the relationship between various factors and the risk of residual cancer or lymph node metastasis after endoscopic resection. Results: Of the 81 patients, 17 (21.0%) were positive for residual cancer or lymph node metastasis, while 64 (79.0%) were negative. Among 17 patients with residual cancer or positive lymph node metastasis, 3 patients had only residual cancer (2 patients with positive vertical cutting edge). 11 patients had only lymph node metastasis, and 3 patients had both residual cancer and lymph node metastasis. Lesion location, poorly differentiated cancer, depth of submucosal invasion ≥2 000 μm, venous invasion were associated with residual cancer or lymph node metastasis after endoscopic (P<0.05). Logistic multivariate regression analysis showed that poorly differentiated cancer (OR=5.513, 95% CI: 1.423, 21.352, P=0.013) was an independent risk factor for residual cancer or lymph node metastasis after endoscopic non-curative resection of early colorectal cancer. Conclusions: For early colorectal cancer after endoscopic non-curable resection, residual cancer or lymph node metastasis is associated with poorly differentiated cancer, depth of submucosal invasion ≥2 000 μm, venous invasion and the lesions are located in the descending colon, transverse colon, ascending colon and cecum with the postoperative mucosal pathology result. For early colorectal cancer, poorly differentiated cancer is an independent risk factor for residual cancer or lymph node metastasis after endoscopic non-curative resection, which is suggested that radical surgery should be added after endoscopic treatment.

[Interpretation of the essential updates in guidelines for the prevention and treatment of chronic hepatitis B (Version 2022)]

Chinese Society of Hepatology and Chinese Society of Infectious Diseases, Chinese Medical Association update the guidelines for the prevention and treatment of chronic hepatitis B (version 2022) in 2022. The latest guidelines recommend more extensive screening and more active antiviral treating for hepatitis B virus infection. This article interprets the essential updates in the guidelines to help deepen understanding and better guide the clinical practice.

Unintrusive multi-cancer detection by circulating cell-free DNA methylation sequencing (THUNDER): development and independent validation studies

BACKGROUND

Early detection of cancer offers the opportunity to identify candidates when curative treatments are achievable. The THUNDER study (THe UNintrusive Detection of EaRly-stage cancers, NCT04820868) aimed to evaluate the performance of ELSA-seq, a previously described cfDNA methylation-based technology, in the early detection and localization of six types of cancers in the colorectum, esophagus, liver, lung, ovary and pancreas.

PATIENTS AND METHODS

A customized panel of 161,984 CpG sites was constructed and validated by public and in-house (cancer: n=249; non-cancer: n=288) methylome data, respectively. The cfDNA samples from 1,693 participants (cancer: n=735; non-cancer: n=958) were retrospectively collected to train and validate two multi-cancer detection blood test models (MCDBT-1/2) for different clinical scenarios. The models were validated on a prospective and independent cohort of age-matched 1,010 participants (cancer: n=505; non-cancer: n=505). Simulation using the cancer incidence in China was applied to infer stage-shift and survival benefits to demonstrate the potential utility of the models in the real world.

RESULTS

MCDBT-1 yielded a sensitivity of 69.1% (64.8%‒73.3%), a specificity of 98.9% (97.6%‒99.7%) and tissue origin accuracy of 83.2% (78.7%‒87.1%) in the independent validation set. For early stage (I‒III) patients, the sensitivity of MCDBT-1 was 59.8% (54.4%‒65.0%). In the real-world simulation, MCDBT-1 achieved the sensitivity of 70.6% in detecting the six cancers, thus decreasing late-stage incidence by 38.7%‒46.4%, and increasing 5-year survival rate by 33.1%‒40.4%, respectively. In parallel, MCDBT-2 was generated at a slightly low specificity of 95.1% (92.8%-96.9%) but a higher sensitivity of 75.1% (71.9%-79.8%) than MCDBT-1 for populations at relatively high risk of cancers, and also had ideal performance.

CONCLUSION

In this large-scale clinical validation study, MCDBT-1/2 models showed a high sensitivity, specificity, and accuracy of predicted origin in detecting six types of cancers.

[The effective analysis of refractory esophageal stricture after endoscopic mucosal dissection of early esophageal cancer treated by endoscopic radiotomy combined with local injection of triamcinolone acetonide]

Refractor esophageal stenosis after endoscopic submucosal dissection of early esophageal carcinoma is a difficult clinical problem. To verify the effect of endoscopic radial incision combined local triamcinolone injection to treat refractory esophageal stenosis, we retrospectively analyzed 7 patients diagnosed with refractory esophageal stricture after endoscopic mucosal dissection of early esophageal cancer in this study, of whom 4 male and 3 female patients, aged 50-76 years, with the mean age of 63 years. We performed the endoscopic radial incision in the thickness point of the scar stricture and injected the triamcinolone locally. The results showed it was safe and effective. The follow-up showed no esophageal stenosis occured and no adverse reaction such as hemorrhage, perforation, tumor-recurrence and triamcinolone-allergy occured.

[Efficacy of in-situ full-left/full-right split liver transplantation for adult recipients using the living donor liver transplantation technique:a single-center report of 25 cases]

Objective: To evaluate the efficacy of in-situ full size split liver transplantation(fSLT) for adult recipients using the living donor liver transplantation(LDLT) technique and to compare the characteristics of the left hemiliver graft (LHG) and the right hemiliver graft(RHG)transplantation. Methods: Deceased donor and recipient data of 25 consecutive cases of fSLT at Department of Hepatopancreatobiliary Surgery, Ningbo Medical Center Lihuili Hospital from March to December 2021 was retrieved and the patients divided into two groups:LHG group and RHG group. Among the 13 donors,11 were male and 2 were female,aged (M(IQR))38(19) years(range: 25 to 56 years),with height of 168(5) cm(range:160 to 175 cm) and weight of 65(9) kg(range: 50 to 75 kg). The median age of the 25 recipients was 52(14) years(range:35 to 71 years),17 were male and 8 were female,15 had primary liver cancer and 10 had benign end-stage liver disease,model for end-stage liver disease score was 10(9) points(range:7 to 23 points). Of the 25 recipients,10 recipients had previously undergone hepatobiliary surgery. The follow-up period was to January 2022. Demographic,clinicopathological,surgical outcomes and postoperative complications were evaluated and compared between the two groups. Continuous quantitative data were compared using Mann-Whitney U test. Classification data were expressed as frequencies,and were compared between groups using χ² test or Fisher exact probability method. Results: Using LDLT technique,in-situ full-left/full-right liver splitting was performed and 13 viable pairs of hemiliver grafts were harvested with acquisition time of 230(53) minutes(range:125 to 352 minutes) and blood loss of 250(100) ml(range:150 to 1 000 ml). A total of 25 hemiliver grafts(13 LHG and 12 RHG) were allocated to patients listed for liver transplantation in our center by China Organ Transplant Response System. In the LHG group(13 cases),there were more females and more patients with benign end-stage liver disease than in the RHG group(12 cases)(P<0.05). The body weight and graft weight of recipients in the LHG group were lower than that in RHG group(both P<0.05). There were no significant differences in other baseline data between the two groups(all P>0.05). The graft to recipient weight ratio(GRWR) was 1.2(0.4)%(range:0.7% to 1.9%) for 25 recipients,1.1(0.5)%(range:0.7% to 1.6%)for the LHG group and 1.3(0.5)%(range:0.9% to 1.9%)for the RHG group. There was no significant difference between the two groups (P>0.05). Sharing patterns of hepatic vessels and the common bile duct are as follows:all the trunk of middle hepatic vein were allocated to the LHG group. The proportion of celiac trunk,main portal vein and common bile duct assigned to LHG and RHG was 10∶3 (P=0.009), 9∶4 (P>0.05) and 4∶9 (P=0.027),respectively. The vena cava of 12 donors in early stage retained in LHG and that of last one was shared between LHG and RHG (P<0.01). The median cold ischemia time of 25 hemiliver grafts was 240(90) minutes(range:138 to 420 minutes). For the total of 25 fSLT,the median anhepatic phase was 50(16) minutes(range:31 to 98 minutes) and the operation time was 474(138)minutes(range:294 to 680 minutes) with blood loss of 800(640) ml(range:200 to 5 000 ml). There were no significant differences in all of operation data between two groups. In the LHG group,3 patients with GRWR≤0.8% had postoperative small-for-size syndrome which improved after treatment. Postoperative Clavien-Dindo grade≥Ⅲ complications were observed in 6 cases(24.0%),4 cases(4/13) in the LHG group and 2 cases(2/12) in the RHG group,respectively. The difference was not statistically significant. Among them,5 cases improved after re-operation and intervention,1 case in LHG group died of secondary infection 2 weeks after operation,and the mortality was 4.0%. Analysis of serious postoperative complications and death has suggested that conventional caval interposition should not be used for LHG transplantation. Conclusion: Relying on accurate donor-recipient evaluation and the apply of LDLT technique,the morbidity and mortality of in-situ fSLT in adults is acceptable.

[The clinical value of multi-target stool fecal immunochemical test-DNA in early screening and diagnosis for colorectal cancer]

Objective: To investigate the clinical diagnostic value of multi-target stool fecal immunochemical test-DNA (FIT-DNA) test in colorectal cancer (CRC) and advanced adenoma (AA). Methods: A total of 235 patients who were undergoing colonoscopy or colorectal cancer surgery in the Cancer Hospital, Chinese Academy of Medical Sciences from April 2021 to January 2022 were prospectively enrolled. There were 141 males and 94 females, with an average age of (55±13) years (22-86). The patients were divided into two groups, including 215 patients who were first diagnosed but not treated (86 cases of CRC, 12 cases of AA, 25 cases of non-advanced adenoma, 8 cases of hyperplastic or other polyps and 84 apparently healthy cases) and 20 patients in the intervention group (2 cases with a history of CRC surgery, 6 cases with a history of endoscopic surgery, 4 non-CRC patients with special diseases and 8 cases with a history of neoadjuvant chemoradiotherapy). Fresh stool samples were collected before intestinal preparation or surgery for FIT-DNA test using the matching kit for sample processing and nucleic acid purification. KRAS mutation and methylation of BMP3 and NDRG4 genes were detected by fluorescence probe method, and FIT method was employed to detect fecal occult blood. Colonoscopy or pathological biopsy results were used as the gold standard. And the screening and diagnostic efficacy of FIT-DNA test for colorectal cancer and advanced adenoma were evaluated by receiver operating curve (ROC). Results: The sensitivity of FIT-DNA test for early colorectal cancer and advanced adenoma was 7/7 and 8/12, respectively. And the negative predictive value was 98.1% (104/106) and 93.7% (104/111), respectively. The overall screening sensitivity for both early colorectal cancer and advanced adenoma was 15/19, and the negative predictive value was 96.3% (104/108). Besides, the area under the curves (AUCs) were 0.982 (95%CI: 0.960-1.000, P<0.05), 0.758 (95%CI: 0.592-0.924, P<0.05) and 0.841 (95%CI: 0.724-0.957, P<0.05), respectively. Moreover, the diagnostic sensitivity of FIT-DNA test was 98.8% (85/86) for colorectal cancer, 8/12 for advanced adenoma, and 94.9% (93/98) for both colorectal cancer and advanced adenoma, with a specificity of 88.9% (104/117). The AUCs were 0.968 (95%CI: 0.937-0.997, P<0.05), 0.758 (95%CI: 0.592-0.924, P<0.05) and 0.942 (95%CI: 0.905-0.979, P<0.05), respectively. After the inclusion of intervention group, the overall diagnostic sensitivity and specificity of FIT-DNA test was 91.6% (98/107) and 89.1% (114/128), respectively. Conclusion: FIT-DNA test has a high early screening and diagnostic efficacy for colorectal cancer.

[Effect and mechanism of glucocorticoids in preventing stenosis after esophageal endoscopic submucosal dissection]

Objective: To explore the role and specific mechanism of glucocorticoids in preventing stenosis after esophageal endoscopic submucosal dissection (ESD). Methods: Data of 81 patients [51 cases were male and 30 cases were female, aged (62.09±7.95) years] undergoing early esophageal cancer or precancerous lesions with a stripping range ≥3/4 circle hospitalized from January 2019 to February 2021 in Department of Gastroenterology, Zhongda Hospital, Southeast University. They were randomly divided into the control group (n=23), oral prednisone acetate group (n=28) and/or combined with local injection Triamcinolone acetonide group (n=30). Analysis the stenosis rates, endoscopic stent dilatation times, the scores of the Atkinson classification and QLQ-OES18 after 12 weeks. Also the expression of carbohydrate sulfotransferase15 (CHST15) mRNA, TGF-β1 and Collagen-Ⅰ protein were compared by real-time PCR or immunohistochemistry. Results: The stenosis rates of the control group, oral prednisone acetate group and/or combined with local injection Triamcinolone acetonide group were 82.6% (19/23), 46.4% (13/28) and 20.0% (6/30) (P<0.001); endoscopic stent dilatation times [M (Q₁,Q₃)] in these three groups were 2 (1, 3), 0 (0, 0) and 0 (0, 0) (P<0.001). After ESD, the scores of the Atkinson classification and QLQ-OES18 in the three groups were lower than before (P<0.001); and the expression of CHST15 mRNA in the three groups were 4.31±0.13, 3.44±0.07 and 2.84±0.21 respectively (P<0.001). Compared with the control group, the expression of CHST15 mRNA in oral prednisone acetate group was down-regulated (P<0.001), and was the lowest in oral prednisone acetate combined with local injection Triamcinolone acetonide group (P<0.001). As CHST15 mRNA was down-regulated, the expression of TGF-β1 and Collagen-I protein was also down-regulated (P<0.05). Conclusions: Oral prednisone alone or combined with local injection of triamcinolone acetonide both can prevent esophageal stenosis effectively. Oral combined with local injection of glucocorticoid is particularly more effective. Glucocorticoid can reduce the expression of CHST15 mRNA, thereby inhibiting the expression of TGF-β1 and Collagen-I protein.

[Establishment and clinical validation of an artificial intelligence YOLOv51 model for the detection of precancerous lesions and superficial esophageal cancer in endoscopic procedure]

Objective: To construct the diagnostic model of superficial esophageal squamous cell carcinoma (ESCC) and precancerous lesions in endoscopic images based on the YOLOv5l model by using deep learning method of artificial intelligence to improve the diagnosis of early ESCC and precancerous lesions under endoscopy. Methods: 13, 009 endoscopic esophageal images of white light imaging (WLI), narrow band imaging (NBI) and lugol chromoendoscopy (LCE) were collected from June 2019 to July 2021 from 1, 126 patients at the Cancer Hospital, Chinese Academy of Medical Sciences, including low-grade intraepithelial neoplasia, high-grade intraepithelial neoplasia, ESCC limited to the mucosal layer, benign esophageal lesions and normal esophagus. By computerized random function method, the images were divided into a training set (11, 547 images from 1, 025 patients) and a validation set (1, 462 images from 101 patients). The YOLOv5l model was trained and constructed with the training set, and the model was validated with the validation set, while the validation set was diagnosed by two senior and two junior endoscopists, respectively, to compare the diagnostic results of YOLOv5l model and those of the endoscopists. Results: In the validation set, the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the YOLOv5l model in diagnosing early ESCC and precancerous lesions in the WLI, NBI and LCE modes were 96.9%, 87.9%, 98.3%, 88.8%, 98.1%, and 98.6%, 89.3%, 99.5%, 94.4%, 98.2%, and 93.0%, 77.5%, 98.0%, 92.6%, 93.1%, respectively. The accuracy in the NBI model was higher than that in the WLI model (P<0.05) and lower than that in the LCE model (P<0.05). The diagnostic accuracies of YOLOv5l model in the WLI, NBI and LCE modes for the early ESCC and precancerous lesions were similar to those of the 2 senior endoscopists (96.9%, 98.8%, 94.3%, and 97.5%, 99.6%, 91.9%, respectively; P>0.05), but significantly higher than those of the 2 junior endoscopists (84.7%, 92.9%, 81.6% and 88.3%, 91.9%, 81.2%, respectively; P<0.05). Conclusion: The constructed YOLOv5l model has high accuracy in diagnosing early ESCC and precancerous lesions in endoscopic WLI, NBI and LCE modes, which can assist junior endoscopists to improve diagnosis and reduce missed diagnoses.

[Analysis of risk factors for delayed bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm]

Objective: To determine the potential risk factors of delayed hemorrhage after endoscopic submucosal dissection (ESD) in patients with early gastric carcinomas or precancerous lesions. Methods: The clinical data of 637 patients with early gastric carcinomas (EGC) who treated with ESD in Department of Endoscopy at Cancer Hospital, Chinese Academy of Medical Sciences, from August 2013 to August 2019, were retrospectively analyzed. Univariate analysis and multivariate logistic analysis were conducted to evaluate the risk factors associated with delayed bleeding. Results: A total of 699 lesions in 637 patients, of which 696 lesions were resected enbloc, the curative resection rate was 92.1% (644/699). The pathological diagnosis after ESD showed that 46 cases were low-grade intraepithelial neoplasia, 71 were high-grade intraepithelial neoplasia, and 582 were cancer. Delayed bleeding occurred in 74 lesions, while other 625 lesions without postoperative bleeding. The incidence was 10.6%. Compared with the non-bleeding group, there were statistically significant differences in the maximum length of the lesion, the gross shape of the lesion, the control of intra operative bleeding, and the operation time in the delayed bleeding group (P<0.05). Multivariate logistic regression analysis showed that the maximum length of the lesion and the gross shape of the lesion were independent factors of delayed bleeding after ESD. Delayed bleeding was inclined to occur in patients with lesion size ≥3.0 cm (OR=1.958, 95% CI: 1.162-3.299) and the superficial and flat lesion (OR=10.598, 95% CI: 1.313-85.532) after ESD. Conclusions: The maximum length of the lesion and the gross shape of the lesion are independent impact factors of delayed bleeding occurring in patients with EGC and precancerous lesions after ESD. Patients with lesion size≥3 cm, or superficial flat lesion should be paid attention after ESD operation. It needs to take timely measures to prevent the very likely bleeding in order to ensure postoperative recovery and improve the quality of life for postoperative patients.

[Comparison of long-term outcomes between endoscopic submucosal dissection and surgical resection for early gastric cancer with undifferentiated histology]

Objective: Endoscopic submucosal dissection (ESD) of undifferentiated early gastric cancer (UD-EGC) remains controversial due to high positive rate of horizontal and vertical resection margins and the risk of lymph node metastasis. The purpose of this study was to compare long-term outcomes of patients with UD-EGC undergoing ESD versus surgery. Methods: This study was a retrospective cohort study. Inclusion criteria: (1) patients with early gastric cancer undergoing ESD or surgical resection; (2) histological types included poorly differentiated adenocarcinoma, poorly differentiated adenocarcima with signet ring cell carcinoma, and signet ring cell carcinoma; (3) no lymph node metastasis or distant metastasis was confirmed by preoperative CT and endoscopic ultrasonography. Exclusion criteria: (1) previous surgical treatment for gastric cancer; (2) synchronous tumors; (3) death with unknown cause; (4) additional surgical treatment was performed within 1 month after ESD. According to the above criteria, clinical data of patients with UD-EGC who received ESD or surgery treatment in Cancer Hospital of Chinese Academy of Medical Sciences from January 2009 to December 2016 were collected. After further comparing the clinical outcomes between the two groups by 1:1 propensity score matching, 61 patients in the ESD group and 61 patients in the surgery group were finally included in this study. The disease-free and overall survivals were analyzed by Kaplan-Meier method. Results: All patients in the two groups completed operations successfully. In the ESD group, the median operation time was 46.3 (26.5, 102.3) minutes, 61 cases (100%) were en-bloc resection, and 57 cases (93.4%) were complete resection. Positive margin was found in 4 (6.6%) patients, of whom 2 were positive in horizontal margin and 2 were positive both in horizontal and vertical margins. In the surgery group, only 1 case had positive horizontal margin and no positive vertical margin was observed. There was no significant difference in the positive rate of margin between the two groups (P>0.05). Median follow-up time was 59.8 (3.0, 131.5) months. The follow-up rate of ESD group and surgery group was 82.0% (50/61) and 95.1% (58/61), respectively. The 5-year disease-free survival rate in ESD group and surgery group was 98.2% and 96.7%, respectively (P=0.641), and the 5-year overall survival rate was 98.2% and 96.6%, respectively (P=0.680). In the ESD group, 1 patient (1.6%) had lymph node recurrence, without local recurrence or distant metastasis. In the surgery group, 1 case (1.6%) had anastomotic recurrence and 1 (1.6%) had distant metastasis. Conclusion: ESD has a sinilar long-term efficacy to surgery in the treatment of UD-EGC.

A Full Nesterov-Todd Step Infeasible Interior-point Method for Symmetric Optimization in the Wider Neighborhood of the Central Path

In this paper, an improved Interior-Point Method (IPM) for solving symmetric optimization problems is presented. Symmetric optimization (SO) problems are linear optimization problems over symmetric cones. In particular, the method can be efficiently applied to an important instance of SO, a Controlled Tabular Adjustment (CTA) problem which is a method used for Statistical Disclosure Limitation (SDL) of tabular data. The presented method is a full Nesterov-Todd step infeasible IPM for SO. The algorithm converges to ε-approximate solution from any starting point whether feasible or infeasible. Each iteration consists of the feasibility step and several centering steps, however, the iterates are obtained in the wider neighborhood of the central path in comparison to the similar algorithms of this type which is the main improvement of the method. However, the currently best known iteration bound known for infeasible short-step methods is still achieved.

[Efficacy and safety of endoscopic papillectomy of major duodenal papilla neoplasms]

Objective: To discuss the efficacy and safety of endoscopic papillectomy of major duodenal papilla neoplasms. Methods: The clinical-pathological data of 21 patients who were admitted to the Department of Endoscopy, Cancer Hospital, Chinese Academy of Medical Sciences and underwent endoscopic papillectomy of major duodenal papilla neoplasms from January 2014 to January 2020 were retrospectively studied, their postoperative outcomes and complication were also analyzed. Results: Tweenty-one patients were successfully performed endoscopic papillectomy of major duodenal papilla neoplasms. The resected lesions varied between 0.5-2.8 cm. Completed lesion was resected in 19 cases and lesion blocks in 2 cases. The incidence of postoperative complication was 52.4% (11/21), including 8 cases of postoperative bleeding (38.1%). Five patients stopped bleeding after endoscopic hemostasis and 3 patients stopped after interventional embolization. Two patients experienced perforation (9.5%) and recovered after conservative treatment including anti-inflammatory treatment and abdominal drainage. Five patients had pancreatitis (23.8%) and recovered after treatment with pre-somatostatin and anti-inflammatory rectal suppository. Preoperative pathological results of 21 patients suggested that 11 were high-grade intraepithelial neoplasia and 8 were low-grade intraepithelial neoplasia, and 2 were chronic inflammation. Postoperative pathological results suggested that 4 were adenocarcinoma, and the rest 17 were adenoma. The coincidence rate of preoperative biopsy results and postoperative pathology was 38.1%(8/21), and underestimate of the pathological stage occurred in 11 patients (52.4%) during the preoperative biopsy, overestimate occurred in two patients (9.5%). Four cases had a positive incisal margin. All patients had good prognoses and no death event occurred during the follow-up period. Conclusions: Early-stage major duodenal papilla neoplasms should be treated with aggressive resection. Endoscopic papillectomy of duodenal papilla neoplasms is safe, effective, and can be recommended as the preferred procedure for major duodenal papilla neoplasms.

[Application and progress of artificial intelligence in endoscopic diagnosis of superficial esophageal cancer]

China is a country with high incidence of esophageal cancer. Advanced esophageal cancer not only brings serious threat to the health of patients, but also brings heavy economic burden to their families and society. Early diagnosis and treatment of esophageal cancer are always the hot spot in clinical research, and gastroscopy screening is the key point. The development of artificial intelligence is expected to provide new mean for early diagnosis and treatment of esophageal cancer in the aspects of endoscopy procedure and quality control.Through a brief overview of the concept and development of artificial intelligence in endoscopic diagnosis of superficial esophageal cancer, this study summarizes and reviews the research progress of artificial intelligence in the diagnosis of superficial esophageal carcinoma, and illustrates the importance of its application. This study also discusses the main problems and difficulties of artificial intelligence in the endoscopic diagnosis of esophageal carcinoma. It prospects the application of artificial intelligence in endoscopic esophageal diagnosis in the future.

[Clinicopathological features of the colorectal serrated adenoma and analysis on influencing factors of malignancy]

Objective: Serrated adenoma is recognized as a precancerous lesion of colorectal cancer, and the serrated pathway is considered as an important pathway that can independently develop into colorectal cancer. However, little is known about the related risk factors of carcinogenesis of serrated adenoma. The purpose of this study was to analyze the distribution characteristics and potential malignant factors of serrated adenoma in the colon and rectum. Methods: A retrospective case-control study was conducted to collect the clinical data of patients with serrated adenoma who underwent colonoscopy and were pathologically diagnosed in the Cancer Hospital of Chinese Academy of Medical Sciences from April 2017 to July 2019, and exclude patients with two or more pathological types of lesions. The clinical characteristics of serrated adenoma were summarized, and univariate and logistic multivariate regression analysis was conducted to explore the influencing factors for serrated adenoma to develop malignant transformation. Results: Among 28 730 patients undergoing colonoscopy, 311 (1.08%) were found with 372 serrated adenomas, among which 22 (5.9%) were sessile serrated adenomas/polyps, 84 (22.6%) were traditional serrated adenomas, and 266 (71.5%) were unclassified serrated adenomas according to WHO classification. The pathological results showed that 106 (28.5%) lesions were non-dysplasia, 228 (61.3%) lesions were low grade intraepithelial neoplasia, and 38 (10.2%) lesions were high grade intraepithelial neoplasia or cancer. There were 204 (54.8%) lesions with long-axis diameter <10 mm and 168 (45.2%) lesions with length long-axis ≥ 10 mm. 238 (64.0%) lesions were found in the left side colon and rectum and 134 (36.0%) lesions in the right side colon. Gross classification under endoscopy: 16 flat type lesions (4.3%), 174 sessile lesions (46.8%), 117 semi-pedunculated lesions (31.5%), 59 pedunculated lesions (15.9%). Narrow-band imaging international colorectal endoscopic (NICE) classification: 85 (22.8%) type I lesions, 280 (75.3%) type II lesions, 4 (1.1%) type III lesions. Univariate analysis showed that lesion size, lesion location, lesion site and different WHO classifications were associated with malignant transformation of colorectal serrated adenoma (all P<0.05). For the serrated adenomas with different NICE classifications, there were statistically significant differences in the distribution of malignant lesions among groups (P=0.001). Multivariate analysis showed that the long-axis diameter of the lesion ≥10 mm (OR=6.699, 95% CI: 2.843-15.786) and the lesion locating in the left side colorectum (OR=2.657, 95% CI: 1.042-6.775) were independent risk factors for malignant transformation. Conclusions: Serrated adenomas mainly locate in the left side colon and rectum, and are prone to malignant transformation when the lesions are ≥10 mm in long-axis diameter or left-sided.

[Therapeutic effect of endoscopic submucosal dissection on the treatment of early gastric cancer]

Objective: To analyze the long-term therapeutic effect of endoscopic submucosal dissection (ESD) on the treatment of early gastric cancer (EGC). Methods: We retrospectively reviewed EGC patients who underwent ESD at Cancer Hospital, Chinese Academy of Medical Sciences (CAMS), from January 2009 to December 2016. The incidence rates of local recurrence, synchronous cancer and heterogeneous cancer were analyzed. Kaplan-Meier method was used to analyze 5-years recurrence free survival (RFS) and 5-years disease special survival (DSS) of all patients. Results: A total of 255 EGC patients were enrolled in this study, included 175 differentiated early gastric cancer (D-EGC) patients and 80 undifferentiated early gastric cancer (UD-EGC) patients. Among them, 171 patients within the extended indication of ESD while 84 patients beyond the extended indication of ESD. Among the 225 patients, the incidence rates of local recurrence, synchronous cancer and heterogeneous cancer were 2.0%, 2.0% and 2.4%, respectively. The local recurrence rates of D-EGC group and UD-EGC group was 1.7% and 2.5%, respectively, without significant difference (χ(2)=0.176, P=0.675). The incidence rates of synchronous and heterogenous cancer in the D-EGC group were 2.3% and 3.4%, higher than 1.2% and 0 of UD-EGC group, although there was no significant difference (χ(2)=0.306, P=0.580 vs χ(2)=2.809, P=0.094). There were no significant differences in 5-years RFS (91.3% vs 95.9%, P=0.236) and 5-years DSS (100% vs 98.6%, P=0.156) between D-EGC group and UD-EGC group. Conclusions: The long-term outcome of ESD in the treatment of EGS is good. More attention should be paid to the occurrence of local recurrence and heterogeneous cancer in EGC patients undergo ESD. These patients still have a good long-tern outcome even undergoing ESD for more than once.

[Long-term outcome after endoscopic resection for early colorectal carcinoma]

Objective: To analysis the clinical and follow-up data of the early colorectal carcinoma (ECC) after endoscopic resection, and explore the long-term outcome of patients who underwent the endoscopic resection. Methods: During June 2008 to June 2016, data of endoscopic resection for 550 cases of ECC were collected, including general information and follow-up data. The influence factors of disease-free survival rate of ECC after endoscopic resection were analyzed and the risk factors on long-term outcomes such as submucosa invasion depth, poorly differentiated adenocarcinoma, vascular invasion and positive vertical margin were investigated. Results: The mean follow-up time of 550 patients treated with endoscopy was (60.7±36.8) months. Among them, 433 cases were high-level intra-mucosal neoplasia, 117 cases were submucosa invasion carcinoma (the invasion depth <1 000 μm were 33 cases, ≥1 000 μm were 84 cases), 461 cases were curative resection, while 89 cases were non-curative resection. During the follow-up, 6 patients occurred recurrence or metastasis, including 2 patients with local recurrence (1 patient accompanied by lymph node metastasis) and 4 patients with lymph node metastasis (2 patients accompanied by distant metastasis). The overall 5-years disease-free survival rate was 98.8%, the 5-years disease-free survival rate was 100.0% for patients with curative resection and 93.3% for patients with non-curative resection. A total of 89 cases underwent non-curative resection were accompanied with invasion depth ≥1 000 μm, vascular invasion, poorly differentiated adenocarcinoma and positive vertical margin. Among them, 62 cases were accompanied with 1 risk factor, 23 cases with 2 risk factors and 4 cases with 3 risk factors. The risks of lymph nodes and distant metastasis raised with the increase of risk factors. Conclusions: The incidence of lymph node metastasis in ECC is extremely low. Endoscopic treatment can achieve a good long-term outcome. Close follow-up should be conducted after endoscopic treatment, and additional treatment should be selected reasonably for the early colorectal carcinoma after endoscopic non-curative resection to improve the therapeutic efficacy of endoscopic resection.

[Clinical cure of hepatitis B: consensus and controversy]

Hepatitis B virus (HBV) infection is a serious global public health issue. At present, clinical cure is the ideal endpoint for hepatitis B treatment. That is to say, after the completion of treatment, the serum hepatitis B virus surface antigen (HBsAg) is negative, with or without the presence of antibody against hepatitis B virus surface antigen (anti-HBs), undetectable HBV DNA, liver biochemical indicators within normal range, and improved liver tissue lesions. However, it is difficult to achieve a satisfactory clinical cure effect based on the existing therapeutic drugs. To this end, scientists have conducted many explorations, whether it is a combination of nucleos(t)ide analogues and pegylated interferon therapy strategies, or timely termination of antiviral drug treatment, or accelerate the research and development of innovative drugs. The road to clinical cure of hepatitis B is obstructive and long, with full of opportunities and controversies, but the lead is about to come. We always believe that through unremitting efforts, the dream of helping chronic hepatitis B patients to obtain clinical cure or even complete cure will eventually come true.

[Clinical cure strategy for hepatitis B: immunomodulatory therapy]

Chronic hepatitis B virus (HBV) infection remains a major world public health problem. Current guidelines of chronic hepatitis B (CHB) suggest the clinical cure as the ideal thearapeutic goal. Although the optimization of the existing antiviral treatment can make some patients achieve clinical cure, but for most patients with chronic hepatitis B, it is difficult to achieve clinical cure according to the existing antiviral treatment plan. The medical community has begun to work together to seek new treatment strategies, especially the immune intervention measures aimed at restoring the immune response in the liver microenvironment. Notably, immune antiviral response plays a crucial role in HBV clearance, and the clinical cure of chronic hepatitis B is finally achieved through the optimized combination of antiviral and immunomodulatory drugs.

[Hereditary protein S deficiency: survey results from a Chinese pedigree]

Objective: To investigate the clinical characteristics and gene mutation, and analyze the association between genotype and phenotype of hereditary protein S deficiency in a Chinese pedigree. Methods: Hereditary protein S deficiency was diagnosed in January 2016 in our hospital. A total of 26 family members were surveyed in this study. Blood samples and clinical data were collected from them, and mutations were identified by Sanger sequencing. Pathogenicity of gene mutations was predicted by protein function prediction software including SIFT, PolyPhen_2, nsSNPAnalyzer and MutPred2. Swiss Model (https://swissmodel.expasy.org/) was used to perform homology modeling of the tertiary structure of the protein S wild-type and mutant-type, and observe the impact of gene mutation on the tertiary structure of the protein. Results: Four out of 26 family members of 4 generations were clinically diagnosed with hereditary protein S deficiency. The proband presented with recurrent pulmonary embolism and venous thromboembolism of the lower extremities, and her uncle and mother had a history of venous thromboembolism. Sequencing revealed a mutation in the c.200A>C gene in the second exon of the PROS1 gene of proband and part of her families (Ⅱ2, Ⅱ6, Ⅲ4, Ⅳ2). The prediction results of this gene mutation performed by SIFT, PolyPhen_2, nsSNPAnalyzer, MutPred2 were all harmful. The results of Swiss-Model homology modeling showed that the 67th amino acid was mutated from glutamic acid to alanine because of this gene mutation. Conclusion: A gene mutation cDNA (c. 200A>T) is identified in a Chinese pedigree with hereditary protein S deficiency. This gene mutation may reduce protein S activity, which may cause recurrent pulmonary embolism and venous thromboembolism of the patients.

[Clinical outcomes of endoscopic piecemeal mucosal resection for superficial esophageal carcinoma and precancerous lesions]

Objective: To explore the short and long-term outcomes of endoscopic piecemeal mucosal resection including endoscopic mucosal resection (EMR) and multiband mucosectomy (MBM) for superficial esophageal carcinoma and precancerous lesions, and analyze the risk factors for prognosis. Methods: From March 1 2001 to May 31 2017, 371 patients with 416 lesions who were diagnosed as superficial esophageal carcinoma or high-grade intraepithelial neoplasm and underwent EMR or MBM were retrospectively enrolled in this study. Long-term recurrence free survival (RFS) rate and the risk factors, including submucosal invasion, poorly differentiation, vascular invasion and positive vertical margin, for the long-term outcome were also analyzed. Results: The incidence of complication was 17.1% in the EMR group and 17.4% in the MBM group, without significant difference (P=1.000). The median follow-up period was 70.6 months. The 5-years RFS was 93.9% and 10-years RFS was 87.8%, respectively. Local recurrence was found in 2 cases in each group and they were curatively treated by endoscopic submucosal dissection. Heterogeneous multiple primary esophageal cancer was diagnosed in 5 and 3 cases for the EMR and MBM group, of whom 5 cases were curatively treated with endoscopic resection. Other 3 cases were diagnosed with advanced esophageal cancer, of whom 2 patients died. Lymph node metastasis (LNM) was found in 5 cases in the EMR group and 4 cases in the MBM group, of whom 6 patients died. Distant metastasis was found in 5 cases in the EMR group and 3 cases in the MBM group, of whom 5 patients died. There were 83 patients combined with risk factors including submucosal invasion, poorly differentiation, vascular invasion and positive vertical margin, of whom 8 patients were diagnosed as LNM and 8 patients as distant metastasis. The 5-years RFS of patients with 1, 2, and 3 risk factors were 93.6%, 82.2%, and 25.0%, and the difference was statistically significant (P<0.001). Conclusions: EMR and MBM are both safe and feasible procedures for superficial esophageal carcinoma and precancerous lesions. Additional treatments should be selected according to the variety of risk factors to acquire better long-term outcome and life quality.

[The diagnostic utility of thin-slice CT navigation combined with radial endobronchial ultrasound for peripheral pulmonary lesions]

Objective: To evaluate the diagnostic value of thin-slice CT navigation combined with radial endobronchial ultrasound in peripheral lung lesions. Methods: The clinical data of patients with peripheral lung lesions diagnosed by thin-slice CT navigation combined with radial endobronchial ultrasound in National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from November 2015 to August 2018 were retrospectively analyzed. The success rate of thin-slice CT for guiding radial endobronchial ultrasound was statistically analyzed, and the diagnostic rate, sensitivity and specificity of thin-slice CT combined with radial endobronchial ultrasound were analyzed. Results: 140 consecutive patients with 145 lesions were included, 139 lesions in 136 patients were found by thin-layer CT guidance, the success rate was 95.9%; 137 lesions in 135 patients were examined by histology and/or cytology, and 106 lesions were finally diagnosed, the diagnostic rate was 77.37%; and the diagnosis sensitivity and specificity was 88.45% and 99.96%. Histological and cytological diagnostic rate, sensitivity and specificity was 72.18% versus 63.50%, 70.58% versus 66.85%, 100% versus 88.23%, respectively. Factors influencing the diagnostic rate of thin-slice CT navigation combined with radial endobronchial ultrasound include the relationship between the lesion and the target bronchus, the location of the probe and the lesion, and the size of the lesion, and the difference between the farthest generation of bronchoscopy insertion and the bronchial generation of lesions. Five patients had mild bleeding and one ultrasonic probe was damaged. Conclusion: Thin-slice CT has a higher positive rate in guiding peripheral lung lesions with radial ultrasound, and this method has a higher diagnostic value for peripheral lung lesions.

[The therapeutic strategy after noncurative endoscopic submucosal dissection for early gastric cancer]

Objective: To investigate the therapeutic strategy in patients with early gastric cancer after noncurative endoscopic submucosal dissection (ESD). Methods: A total of 107 cases with early gastric cancer receiving noncurative endoscopic submucosal dissection were collected and the patients were classified into an additional gastrectomy group (n=41) and a simple follow-up group (n=66) according to the therapeutic method used after noncurative ESD. The clinicopathological information, short- and long-term clinical outcomes between the two groups were analyzed and compared. Results: The mean age of the patients in the gastrectomy group and follow-up group was(59.2±8.7)years old and(64.7±8.8)years old, respectively. The depth of submucosal invasion was (1445.83±803.12) and (794.71±815.79) μm, respectively. The difference between the two groups was statistically significant (P=0.020 for age and P=0.010 for depth of submucosal invasion). Compared with follow-up group, the patients with undifferentiated histologic type, deep invasion of submucosa (SM2), diffuse type, lymphovascular invasion and neural invasion were more common in the gastrectomy group (P<0.05). The R0 resection rate of ESD in the gastrectomy group was significantly lower than the follow-up group(26.8% vs 65.2%, P<0.001). The positive residual tumor rate and LNM rate of additional gastrectomy group were 31.7%(13/41)and 9.76%(4/41)according to the pathological results after gastrectomy. The gastrectomy group had 2 cases of local recurrence (2/41, 4.9%), while 5(5/66, 7.6%)in the follow-up group(4.9% vs 7.6%, P=0.883). There was no significant difference in overall survival (OS) and disease-free survival (DFS) between the two study groups (P=0.066 and 0.938, respectively). Conclusions: Assessment of LNM risk should be performed in patients with noncurative endoscopic resection. For patients with low risk of LNM who are intolerance of additional gastrectomy due to old age and comorbidities, close follow-up with endoscopy can be considered as an alternative.

[Clinical analysis of laparoscopic remedial surgery for endoscopic lesions in early colorectal cancer]

Objective: To investigate the safety and feasibility of laparoscopic remedial surgery in patients who didn't reach the cure criterion of early colorectal cancer after endoscopic resection. Methods: The clinical and follow-up data of 12 patients who didn't reach the cure criterion of early colorectal cancer and then underwent endoscopic resection was collected. The clinicalpathological features and remedial indications were analyzed to evaluate the effects of laparoscopic remedial surgery. Results: The average number of lymph nodes in the lymph node dissection was 15 during remedial surgery, and 3 of them had lymph node metastasis. Among the 3 patients with residual cancer, two cases were poorly differentiated, 1 case was moderately differentiated, 1 case was positive for basal margin, and 1 case had vascular invasion. No lymph node metastasis occurred in the 9 patients who had no residual cancer. Among these, 8 cases were moderately differentiated, 1 case was poorly differentiated and 2 cases had positive basal margin. The average follow-up duration was 40 months and all 12 patients were in a state of survival at the last follow-up. During the follow-up of the 3 patients with residual cancer, 1 patient received adjuvant chemotherapy with unknown prognosis; 1 patient received postoperative adjuvant radiochemotherapy, and lung metastasis occurred; 1 patient did not receive any treatment after surgery and survived for 33 months. Conclusions: Laparoscopic remedial surgery is a safe and feasible remedy for patients who didn't reach the cure criterion of early colorectal cancer after endoscopic resection. However, the choice of remedial strategy for colorectal carcinoma needs further investigation for patients with no vascular invasion, high degree of differentiation, and negative basal margin.

[A new transition of the screening, early diagnosis and early treatment project of the upper gastrointestinal cancer: opportunistic screening]

The screening, early diagnosis and early treatment project of the upper gastrointestinal cancer had achieved good results since its launch. However, from a national perspective, the endoscopic screening of upper gastrointestinal cancer was still not optimistic, such as the poor rate of the early diagnosis, the low rate of 5-year survival in rural areas, and the disparity of the standardized screening and diagnosis in different areas. Therefore, the situation of upper gastrointestinal cancer prevention and treatment is still severe. Under the guidance of the "Healthy China 2030" plan, based on the international experience and domestic actual circumstance, it is suggested that the screening of high-risk population in high-risk areas should be changed into the opportunistic screening in primary medical institutions. The opportunistic screening could expand the coverage of the screening, early diagnosis and early treatment project of the upper gastrointestinal cancer, and increase the early diagnosis rate in rural areas and primary medical institutions, which could improve the 5-year survival rate of patients with the upper gastrointestinal cancer, and then achieve the sustainable development of the cancer prevention and treatment in China.

[Status of non-steroidal anti-inflammatory drugs use in areas with a high incidence of upper gastrointestinal cancer in China: a multi-center cross-sectional survey]

Objective: To describe the status of non-steroidal anti-inflammatory drugs (NSAIDs) use in areas with a high incidence of upper gastrointestinal cancer in China. Methods: This study was based on the National Key Research and Development Program of "National Precision Medicine Cohort of Esophageal Cancer" and "Study on Identification and Prevention of High-risk Populations of Gastrointestinal Malignancies (Esophageal cancer, Gastric cancer and Colorectal cancer)" . From January 2017 to August 2018, 212 villages or communities with a high incidence of esophageal cancer or gastric cancer were selected from 12 regions in 6 provinces. A total of 35 910 residents aged between 40 and 69 years old who met the inclusion criteria and signed the informed consent were investigated and enrolled in this study. The use of NSAIDs, demographic characteristics, health-related habits, height, weight, and blood pressure were collected by the questionnaire and physical examination. The status of main NSAIDs (aspirin, acetaminophen and ibuprofen) use with the difference varying in genders, age groups and regions were analyzed by using χ(2) test and Cochran-Armitage trend analysis method. Results: Of 35 910 subjects, the mean age was (54.6±7.1) years old and males accounted for 43.42% (15 591). The overall prevalence of NSAIDs intake was 4.56% (1 638), but it significantly varied in different provinces (P<0.001). The overall prevalence of NSAIDs intake was 4.87% (1 750) in females, which was significantly higher than that in males 4.24% (1 524) (P<0.001). The prevalence of NSAIDs intake increased with age (P for trend <0.001). As the frequency of NSAIDs intake increased, the incidence of gastrointestinal symptoms, gastrointestinal ulcers and black stools increased (P for trend <0.05 for all). Conclusion: The use of NSAIDs is prevalent in some areas with a high incidence of upper gastrointestinal cancer in China. The increased use of NSAIDs may lead to more adverse effects related to the gastrointestinal tract.

[Newborn screening program and blood amino acid profiling in early neonates with citrin deficiency]

Objective: To investigate the profiles of blood amino acid and acylcarnitine in early neonates with neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD) and the sensitivity of newborn screening, and to explore potential biochemical metabolic markers for newborn screening program. Methods: Amino acid and acylcarnitine profiles in dried blood spots of newborn screening program were analyzed by tandem mass spectrometry (MS/MS). A total of 158 651 neonates born in Guangzhou from January 1, 2015 to June 30, 2019 were enrolled in this newborn screening program, and additionally 55 patients with NICCD confirmed by SLC25A13 gene analysis in Guangzhou Women and Children Medical Center were included in this study. NICCD screen-positive was defined as the cutoff value of citrulline (Cit) ≥ 30 μmol/L. The values of blood sampling time of the true positive group and those of the false negative group were compared by t-test. The levels of amino acid and acylcarnitine among different groups, including true positive group (Cit≥30 μmol/L), false negative group (Cit 21-<30 μmol/L and Cit<21 μmol/L) and the normal control group, were analyzed by F test, respectively. Results: Among 158 651 neonates, 39 neonates were positive for NICCD screening. Three of them were confirmed NICCD and 4 cases were found to be false negatives. The positive predictive value was 7.7% and the sensitivity was about 43.0%. Among 55 patients with NICCD, 18 cases (18/55, 32.7%) were true positives and 37 cases (37/55, 67.3%) were false negatives based on the cutoff value of citrulline in the dried blood spots for newborn screening. The blood sampling time was significantly different between true positive group and false negative group ((4.28±1.6) vs. (2.98±0.74) d, t=4.06, P<0.01). The increased levels of tyrosine((176.0±98.4) μmol/L), methionine ((37.0±26.9) μmol/L) and phenylalanine ((133.0±80.9)μmol/L) in Cit≥30 μmol/L group (n=18) were significantly different as compared with those in the other three groups, respectively (F=117.0, 58.5, 135.0, P<0.01). The levels of arginine ( (10.0±9.2) , (11.0±9.3) , (9.0±17.8) μmol/L), valine ( (119.0±29.8) , (107.6±14.1) , (102±68) μmol/L) and leucine ( (167.0±37.1) , (161.0±37.7) , (163.5±180.6) μmol/L) were not statistically significant among groups of Cit≥30 μmol/L(n=18), Cit21-<30 μmol/L(n=7) and Cit<21μmol/L(n=30,P>0.05), but they were significantly higher than those of the normal control group ((4±3), (78±21), (114.0±31.5) μmol/L, n=1 000), respectively(F=30.1, 23.0, 29.8, P<0.01). Alanine (Ala) ( (150±50) , (156.0±30.2), (168±105), (152±52) μmol/L) levels showed no significant difference (F=0.86, P>0.05) but the ratios of Ala/Cit (1.52±1.44, 6.82±1.56, 12.06±7.71, 19.42±6.27) decreased significantly among the four groups (F=69.0, P<0.05). The acylcarnitine levels showed no statistically significant results among the different groups (P>0.05). With Cit≥30 μmol/L and Ala/Cit<7.5 as cutoff values, the number of screen-positive cases reduced from 39 to 22 cases with no additional false negative case. With Cit≥21 μmol/L and Ala/Cit<7.5 as cutoff values the number of screen-positive cases increased to 117 cases with 1 additional true positive. Conclusions: The profiles of blood amino acid in early neonates with NICCD present the increased levels of multiple amino acids including citrulline, tyrosine, methionine and phenylalanine, and decreased ratio of Ala/Cit. Taking citrulline and ratio of Ala/Cit as screening markers can improve the positive predictive value appropriately. The limited sensitivity of NICCD newborn screening may be related to early blood sampling time.

[Combined anluohuaxianwan and entecavir treatment significantly improve the improvement rate of liver fibrosis in patients with chronic hepatitis B virus infection]

Objective: To explore the improvement rate of liver fibrosis in patients with chronic hepatitis B virus infection who received entecavir alone or in combination with anluohuaxianwan for 78 weeks. Methods: Patients with chronic HBV infection were randomly treated with entecavir alone or in combination with anluohuaxian for 78 weeks. Ishak fibrosis score was used for blind interpretation of liver biopsy specimens. The improvement in liver fibrosis condition before and after the treatment was compared. Student's t test and non-parametric test (Mann-Whitney U-Test and Kruskal-Wallis test) were used to analyze the measurement data. The categorical variables were analyzed by Chi-square test method and Spearman's rank correlation coefficient was used to test bivariate associations. Results: Liver fibrosis improvement rate after 78 weeks of treatment was 36.53% (80/219) and the progression rate was 23.29% (51/219). The improvement of liver fibrosis was associated to the degree of baseline fibrosis and treatment methods (P < 0.05). The improvement rate of hepatic fibrosis in patients treated with anluohuaxianwan combined with entecavir at baseline F < 3 (54.74%, 52/95) was significantly higher than that in patients treated only with entecavir (33.33%, 16/48), P = 0.016 and the progression rate of hepatic fibrosis (13.68%, 13/95) was lower than that in patients treated alone (18.75%, 9/48), P = 0.466. In patients with baseline F < 3, the proportion of patients with improved and stable liver fibrosis in the combined treatment group (68.1%, 32/47) was higher than that in the treatment group alone (51.7%, 15/29). Conclusion: Combined anluohuaxianwan and entecavir treatment can significantly improve the improvement rate of liver fibrosis in patients with chronic hepatitis B virus infection. Furthermore, it has the tendency to improve the stability rate and reduce the rate of progression of liver fibrosis.

[Application of auditory brainstem response in hearing impairment and prognosis of neonatal hypoxic ischemic encephalopathy]

Objective:To investigate the effect of auditory brainstem response in hearing impairment and prognosis of neonatal hypoxic ischemic encephalopathy（HIE）. Method:Forty-five children with HIE admitted were enrolled. All patients were tested for auditory brainstem response and followed up for 3 years to observe the prognosis of the children. Result:A total of 90 ears were included in 45 children, of which 77 ears had hearing impairment, accounting for 85.6%; 38 ears had mild hearing impairment, accounting for 49.4%; 19 ears had moderate hearing impairment, accounting for 24.7%; 20 ears had severe hearing impairment, accounting for 26.0%; the difference was statistically significant（P<0.05）. Children with moderate and severe HIE had better hearing impairment than children with mild HIE. Serious, the difference was statistically significant（χ²=7.921, P=0.009）. A total of 90 ears were included in 45 patients, 40 of whom completed 3 years of follow-up. The prognosis of children with hearing threshold ≤60 dBnHL was worse than the threshold ≥61 dBnHL, and the difference was statistically significant（P=0.001）. Abnormal manifestations of auditory brainstem response were mainly in 13 children with mild HIE（76.5%） with poor differentiation or prolongation of Ⅰwave PL; 26 patients with moderate and severe HIE（92.9%） With Ⅲ, Ⅴ wave PL extension, Ⅲ-Ⅴ wave IPL extension, Ⅰ-Ⅲ wave IPL extension, Ⅰ-Ⅴ wave PL extension, Ⅰ-Ⅲ/Ⅲ-Ⅴ wave IPL wave interval ratio less than 1, and Ⅴ/Ⅰ amplitude less than 0.5. Conclusion:The auditory brainstem response in the hearing impairment and prognosis of HIE can effectively reflect the relationship between the severity of HIE and the severity of hearing impairment, and the relationship between the prognosis of children and the severity of hearing impairment. It can be used as an effective means to help determine the degree of HIE hearing loss and prognosis.

Adhesion to pharyngeal epithelium and modulation of immune response: Lactobacillus salivarius AR809, a potential probiotic strain isolated from the human oral cavity

Microbiome modulators such as probiotics are known to modulate oral diseases. Very few probiotics are commercially available for use in the oral cavity. In this context, we selected human-origin Lactobacillus salivarius AR809 as a promising oropharyngeal probiotic and characterized its functional and immunomodulatory properties. Results demonstrated that AR809 could efficiently adhere to pharyngeal epithelial FaDu cells, antagonize Staphylococcus aureus, adapt to the oral environment, and modulate host innate immunity by inducing potentially protective effects. Particularly, AR809 diminished proinflammatory activity by enhancing the production of IL10 and inhibiting the expression of tumor necrosis factor-α, IL1B, inducible nitric oxide synthase, and RELA. Finally, we observed that AR809 grew efficiently when cultured in milk, suggesting that the preparation of a fermented milk product containing AR809 could be a practical way to administer this probiotic to humans. In conclusion, AR809 has high potential to adhere to the pharyngeal mucosa and could be applied in novel milk-based probiotic fermented food products.

[Clinical effect and safety of pegylated interferon-α-2b injection (Y shape, 40 kD) in treatment of HBeAg-positive chronic hepatitis B patients]

Objective: To investigate the clinical effect and safety of long-acting pegylated interferon-α-2b (Peg-IFN-α-2b) (Y shape, 40 kD) injection (180 μg/week) in the treatment of HBeAg-positive chronic hepatitis B (CHB) patients, with standard-dose Peg-IFN-α-2a as positive control. Methods: This study was a multicenter, randomized, open-label, and positive-controlled phase III clinical trial. Eligible HBeAg-positive CHB patients were screened out and randomized to Peg-IFN-α-2b (Y shape, 40 kD) trial group and Peg-IFN-α-2a control group at a ratio of 2:1. The course of treatment was 48 weeks and the patients were followed up for 24 weeks after drug withdrawal. Plasma samples were collected at screening, baseline, and 12, 24, 36, 48, 60, and 72 weeks for centralized detection. COBAS® Ampliprep/COBAS® TaqMan® HBV Test was used to measure HBV DNA level by quantitative real-time PCR. Electrochemiluminescence immunoassay with Elecsys kit was used to measure HBV markers (HBsAg, anti-HBs, HBeAg, anti-HBe). Adverse events were recorded in detail. The primary outcome measure was HBeAg seroconversion rate after the 24-week follow-up, and non-inferiority was also tested. The difference in HBeAg seroconversion rate after treatment between the trial group and the control group and two-sided confidence interval (CI) were calculated, and non-inferiority was demonstrated if the lower limit of 95% CI was > -10%. The t-test, chi-square test, or rank sum test was used according to the types and features of data. Results: A total of 855 HBeAg-positive CHB patients were enrolled and 820 of them received treatment (538 in the trial group and 282 in the control group). The data of the full analysis set showed that HBeAg seroconversion rate at week 72 was 27.32% in the trial group and 22.70% in the control group with a rate difference of 4.63% (95% CI -1.54% to 10.80%, P = 0.1493). The data of the per-protocol set showed that HBeAg seroconversion rate at week 72 was 30.75% in the trial group and 27.14% in the control group with a rate difference of 3.61% (95% CI -3.87% to 11.09%, P = 0.3436). 95% CI met the non-inferiority criteria, and the trial group was non-inferior to the control group. The two groups had similar incidence rates of adverse events, serious adverse events, and common adverse events. Conclusion: In Peg-IFN-α regimen for HBeAg-positive CHB patients, the new drug Peg-IFN-α-2b (Y shape, 40 kD) has comparable effect and safety to the control drug Peg-IFN-α-2a.

[Submucosal tunneling endoscopic resection for submucosal tumors originating from muscularis propria layer at esophagogastric junction]

Objective: To evaluate the short-term outcomes and safety of submucosal tunneling endoscopic resection (STER) for submucosal tumors (SMT) originating from muscularis propria (MP) layer at esophagogastric junction. Methods: The clinical data of 31 patients with SMT originating from MP layer at esophagogastric junction underwent STER were collected and retrospectively analyzed. Results: The success rate of STER of the thirty-one patients was 100%. The mean tumor size was (2.5±1.3) cm and the average operative time was (95.9±56.7) min. Perforation occurred in 3 patients and was successfully clipped by endo-clips during operation. One patient developed delayed bleeding and the bleeding was stopped by endoscopic hemostasis. Twenty-nine leiomyomas and two stromal tumors (GIST) were finally pathologically diagnosed. No local recurrence and distant metastasis were noted during the mean 15.4 months follow-up of 20 cases. According to the lesion size, 31 patients who received STER were divided into two groups. The operation time of maximum diameter ≥3.5 cm group was (134.0±70.6) min, significantly longer than (80.3±42.6) min of maximum diameter <3.5 cm group (P=0.014). However, the en bloc removal rate, postoperative hospital stay and the complication incidence between the two groups had no obvious differences (P>0.05). Univariate analysis showed that the piecemeal removal group had longer tumor diameter, higher incidence of irregular tumor morphology, and longer operative time than the en bloc removal group (all P<0.05). Stepwise logistic regression analysis showed that irregular shape was a risk factor for failure of en bloc removal (OR=18.000, 95% CI: 1.885~171.88, P=0.012). Conclusion: As a new method of minimally invasive treatment, STER technology appears to be a safe and effective option for patients with SMT originating from MP layer at esophagogastric junction.

[Clinical characteristics and prognosis of long-term glucocorticoid users with community-acquired pneumonia]

Objective: To explore the clinical features, etiological features and prognostic risk factors of long-term glucocorticoid users with community-acquired pneumonia (CAP). Methods: A retrospective study included 100 long-term glucocorticoid users with CAP (G-CAP group) from 11 hospitals of China between January 2014 and December 2014, while 100 non-immunocompromised patients with community-acquired pneumonia were enrolled as controls (nICH-CAP group). Characteristics including age, gender, underlying diseases, corticosteroids, symptoms, disease severity, imaging manifestations, etiology, respiratory failure, mechanical ventilation, whether the application of vasoactive drugs, antibiotics application, hospital mortality rate between the two groups were compared, and the prognostic factors of G-CAP were investigated using Logistic regression. Results: The peripheral blood lymphocytes[1.06(0.70, 1.68) vs 1.44 (0.87, 1.98)]in G-CAP group was less than nICH-CAP group (P<0.05). CT with pulmonary interstitial change (28.6% vs 9.9%), the proportion of patients with respiratory failure (25.0% vs 7.0%), mechanical ventilation (9.0% vs 2.0%), noninvasive mechanical ventilation (12.0% vs 2.0%), septic shock (9.0% vs 2.0%), and the hospital mortality rate (13.0% vs 3.0%) in G-CAP group were significantly higher than in nICH-CAP group (all P<0.05). Bacterial infection accounted for the highest proportion of infection (61.3%) in G-CAP group, but also virus infection (19.4%) and mixed infection (16.1%). Pseudomonas accounted for the highest proportion (47.4%) in bacterial infection of G-CAP. Logistic regression analysis showed that peripheral blood lymphocytes (OR=0.004, 95% CI: 0.000-0.234; P<0.05) and respiratory failure (OR=17.766, 95% CI: 4.933-131.0; P<0.05) were independent predictors of death in G-CAP group. Conclusions: The proportion of severe pneumonia and the mortality rate of patients with G-CAP are higher than the patients with nICH-CAP. Lymphopenia and respiratory failure are associated with poor outcome of patients with G-CAP.

[Efficacy and safety of ombitasvir/paritaprevir/ritonavir and dasabuvir combined with ribavirin in Asian adult patients with chronic HCV genotype 1b infection and compensated cirrhosis]

Objective: To evaluate the efficacy and safety of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) 25/150/100 mg once daily and dasabuvir (DSV) 250 mg twice daily combined with ribavirin in adult patients of Mainland China with chronic HCV genotype 1b infection and compensated cirrhosis. Methods: An open-label, multicenter, phase 3 clinical trial study was conducted in mainland China, Taiwan, and South Korea. Adult patients with compensated cirrhosis (Metavir score =F4) who were newly diagnosed and treated for hepatitis C virus genotype 1b infection with ombitasvir/paritaprevir/ritonavir and dasabuvir combined with ribavirin for 12 weeks were included. Assessed SVR rate of patients obtained at 12 and 24 weeks after drug withdrawal. Efficacy and safety were evaluated in patients who received at least one time study drugs. Results: A total of 63 patients from mainland China were enrolled, 62 of whom (98.4%) had a baseline Child-Pugh score of 5 points. The overall rate of SVR12 and SVR24 in patients was 100% (95% CI: 94.3% to 100.0%). Most of the adverse events that occurred were mild. The incidence of common (≥10%) adverse events and laboratory abnormalities included elevated total bilirubin (36.5%), weakness (19.0%), elevated unconjugated bilirubin (19.0%) and conjugated bilirubin (17.5%), and anemia (14.3%). Three cases (4.8%) of patients experienced Grade ≥ 3 adverse events that were considered by the investigators to be unrelated to the study drug. None patients had adverse events leading to premature drug withdrawal. Conclusion: Mainland Chinese patients with chronic HCV genotype 1b infection and compensated cirrhosis who were treated with OBV/PTV/r plus DSV combined with RBV for 12 weeks achieved 100 % SVR at 12 and 24 weeks after drug withdrawal. Tolerability and safety were good, and majority of adverse events were mild.

[General plan of Shanghai Diet and Health Survey]

Shanghai Diet and Health Survey (SDHS) was designed to prospectively access local residents' food consumption, energy and nutrient intake, related chemical contaminant exposure, and the seasonal change trend to explore the relationship of diet with health. Data from SDHS can be used as fundamental information and scientific evidences for the development of local nutrition and food safety policies.

[Screening results and influencing factors of upper gastrointestinal carcinoma and precancerous lesions in Feicheng City]

Objective: To clarify the situation of the detection of upper gastrointestinal cancer and precancerous lesions in the Feicheng city and discuss the possible influencing factors. Methods: A cluster sampling method was used to determine the participants. A unified questionnaire was used to investigate the basic information including history of alcohol intake, smoking and chinese tea, as well as other eating habits, medical history of digestive tract and cancer. Endoscopy was used to to screen the patients with upper gastrointestinal cancer and precancerous lesions. Influential factors were explored by non-conditional logistic regression model. Results: 911 of 7 291participants were positive, and the total detection rate was 12.49%. The total positive detection rate of male and female was 17.94% and 8.71%, respectively (P<0.001). Multivariate logistic regression analysis showed that the sex (OR=0.527, 95%CI: 0.440-0.631), age (OR=2.037, 95%CI: 1.849-2.245), smoking (OR=1.240, 95%CI: 1.014-1.516) and alcohol consumption (OR=1.232, 95%CI: 1.012-1.500) , meat and protein intake (OR=0.794, 95%CI: 0.638-0.987) and drink tea (OR=1.233, 95%CI: 1.056-1.440) may be influencing factors of the total detection rate of upper gastrointestinal cancer and precancerosis. Conclusions: In Feicheng city, intake of meat and protein is the protective factor of the upper gastrointestinal cancer and precancerous lesions. Men, aged, smoking, drinking and tea will increase the risk of upper gastrointestinal cancer and precancerous lesions.

[Expert consensus on the diagnosis and treatment of cryptococcal meningitis]

Cryptococcal meningitis is a common and refractory central nervous system infection, with high rates of mortality and disability. The experts of the Society of Infectious Diseases of Chinese Medical Association have reached this consensus after a thorough discussion. Based on the current situation of cryptococcal meningitis in China, the management of cryptococcal meningitis includes 6 aspects: introduction, microorganism identification, clinical manifestations and diagnosis, principles of antifungal therapy, treatment of refractory and recurrent meningitis, treatment of intracranial hypertension. There is not a separate consensus on human immunodeficiency virus (HIV) infection in patients with cryptococcal meningitis. This article focuses on different antifungal regimens and reducing intracranial pressure by reference to Infectious Disease Society of America (IDSA) guidelines. The importance of early diagnosis, combined long-term antifungal therapy, control of intracranial hypertension are emphasized.

Prevalence of pathogenicity island ETT2 in Escherichia coli isolated from piglets with diarrhea in northeast of China

Our aim was to investigate the prevalence of the pathogenicity island ETT2 and to examine the relationship between the ETT2 locus and other virulence factors in Escherichia coli (E. coli) isolated from piglets with diarrhea. A total of 354 E. coli strains isolated from scouring piglets were tested using PCR for the presence of the ETT2 locus. The E. coli strains were also analyzed for enterotoxins, fimbriae, non-fimbrial adhesin, Shiga toxins, pathogenicity islands, α-haemolysin (hlyA), afa8 gene cluster and autotransporter protease (sepA) genes. The results showed that 215 (60.7%) of the isolates possessed the ETT2 island. In 215 ETT2-positive E. coli strains, the virulence genes found were EAST1 (27.0%), irp2 (18.6%), paa (15.4%), STb (7.9%), LT (6.5%), ler (4.7%), hlyA (3.7%), AIDA-I (3.7%), K88 (3.7%), eae (3.3%), STa (2.8%), afaD (1.4%), afaE (1.4%), K99 (0.9%) and sepA (0.47%), respectively, and the isolates could be assigned into 25 different virulence factor patterns. In 139 ETT2-negative E. coli strains, the virulence genes detected were EAST1 (38.9%), paa (14.4%), STb (11.5%), AIDA-I (10.1%), irp2 (7.9%), sepA (2.16%), LT (0.7%), STa (0.7%), eae (0.7%), ler (0.7%), hlyA (0.7%) and K88 (0.7%), respectively, and the isolates could be classified into 13 different virulence factor patterns. Moreover, the occurrence of LT gene of ETT2-positive E. coli strains was far more than that of ETT2-negative E. coli strains.

[Role of nuclear factor-κB activation in sepsis-induced myocardial dysfunction]

As a common complication in patients with sepsis, cardiac dysfunction may significantly increase mortality of these patients, but its mechanism is still unclear. Nuclear factor-κB (NF-κB) is a pleiotropic transcription inducing factor, which involves in the regulation of multiple biological phenomena and disease status. NF-κB activation participates in cardiomyocyte apoptosis, cardiomyocyte autophagy, and release of inflammatory cytokines in patients with sepsis, indicating its important role in sepsis-induced myocardial dysfunction.