[Multicenter evaluation of minimal residual disease monitoring in early induction therapy for treatment of childhood acute lymphoblastic leukemia]

Objective: To evaluate the role of minimal residual disease (MRD) monitoring during early induction therapy for the treatment of childhood acute lymphoblastic leukemia (ALL). Methods: This was a multicenter retrospective cohort study. Clinical data of 1 164 ALL patients first diagnosed between October 2016 and June 2019 was collected from 16 hospitals in South China Children's Leukemia Group. According to MRD assay on day 15 of early induction therapy, they were divided into MRD<0.10% group, MRD 0.10%-<10.00% group and MRD≥10.00% group. According to MRD assay on day 33, they were divided into MRD<0.01% group, MRD 0.01%-<1.00% group and MRD≥1.00% group. Age, onset white blood cell count, central nervous system leukemia (CNSL), molecular genetic characteristics and other data were compared between groups. Kaplan-Meier method was used for survival analysis. Cox regression model was used to analyze prognostic factors. Results: Of the 1 164 enrolled patients, there were 692 males and 472 females. The age of diagnosis was 4.7 (0.5, 17.4) years. The white blood cell count at initial diagnosis was 10.7 (0.4, 1 409.0) ×109/L. Among all patients, 53 cases (4.6%) had CNSL. The follow-up time was 47.6 (0.5, 68.8) months. The 5-year overall survival (OS) and 5-year relapse-free survival (RFS) rates were (93.1±0.8) % and (90.3±1.1) %. On day 15 of early induction therapy, there were 466 cases in the MRD<0.10% group, 523 cases in the MRD 0.10%-<10.00% group and 175 cases in the MRD≥10.00% group. The 5-year OS rates of the MRD<0.10% group, MRD 0.10%-<10.00% group and MRD≥10.00% group were (95.4±1.0) %, (93.3±1.1) %, (85.4±2.9) %, respectively, while the RFS rates were (93.2±1.6) %, (90.8±1.4) %, (78.9±4.3) %, respectively (χ2=16.47, 21.06, both P<0.05). On day 33 of early induction therapy, there were 925 cases in the MRD <0.01% group, 164 cases in the MRD 0.01%-<1.00% group and 59 cases in the MRD≥1.00% group. The 5-year RFS rates in the MRD 0.01%-<1.00% group was lowest among three groups ((91.4±1.2) % vs. (84.5±3.2) % vs. (87.9±5.1) %). The difference between three groups is statistically significant (χ2=9.11, P=0.010). Among ALL patients with MRD≥10.00% on day 15 of induction therapy, there were 80 cases in the MRD <0.01% group on day 33, 45 cases in the MRD 0.01%-<1.00% group on day 33 and 45 cases in the MRD≥1.00% group on day 33. The 5-year RFS rates of three groups were (83.9±6.0)%, (67.1±8.2)%, (83.3±6.9)% respectively (χ2=6.90, P=0.032). Univariate analysis was performed in the MRD≥10.00% group on day 15 and the MRD 0.01%-<1.00% group on day 33.The 5-year RFS rate of children with CNSL was significantly lower than that without CNSL in the MRD≥10.00% group on day 15 ((50.0±20.4)% vs. (80.3±4.4)%,χ2=4.13,P=0.042). Patients with CNSL or MLL gene rearrangement in the MRD 0.01%-<1.00% group on day 33 had significant lower 5-year RFS rate compared to those without CNSL or MLL gene rearrangement ((50.0±25.0)% vs. (85.5±3.1)%,χ2=4.06,P=0.044;(58.3±18.6)% vs. (85.7±3.2)%,χ2=9.44,P=0.002). Multivariate analysis showed that age (OR=0.58, 95%CI 0.35-0.97) and white blood cell count at first diagnosis (OR=0.43, 95%CI 0.27-0.70) were independent risk factors for OS. The MRD level on day 15 (OR=0.55,95%CI 0.31-0.97), ETV6-RUNX1 fusion gene (OR=0.13,95%CI 0.03-0.54), MLL gene rearrangement (OR=2.55,95%CI 1.18-5.53) and white blood cell count at initial diagnosis (OR=0.52,95%CI 0.33-0.81) were independent prognostic factors for RFS. Conclusions: The higher the level of MRD in early induction therapy, the worse the OS. The MRD levels on day 15 is an independent prognostic factor for RFS.The MRD in early induction therapy guided accurate risk stratification and individualized treatment can improve the survival rate of pediatric ALL.

[Clinical features and prognosis of core binding factor acute myeloid leukemia children in South China: a multicenter study]

Objective: To analyze the clinical features, efficacy and prognosis factors of core binding factor (CBF) acute myeloid leukemia (AML) children in South China. Methods: This was a retrospective cohort study. Clinical data of 584 AML patients from 9 hospitals between January 2015 to December 2020 was collected. According to fusion gene results, all patients were divided into two groups: CBF-AML group (189 cases) and non-CBF-AML group (395 cases). CBF-AML group were divided into AML1-ETO subgroup (154 cases) and CBFβ-MYH11 subgroup (35 cases). Patients in CBF-AML group chosen different induction scheme were divided into group A (fludarabine, cytarabine, granulocyte colony stimulating factor and idarubicin (FLAG-IDA) scheme, 134 cases) and group B (daunorubicin, cytarabine and etoposide (DAE) scheme, 55 cases). Age, gender, response rate, recurrence rate, mortality, molecular genetic characteristics and other clinical data were compared between groups. Kaplan-Meier method was used for survival analysis and survival curve was drawn. Cox regression model was used to analyze prognostic factors. Results: A total of 584 AML children were diagnosed, including 346 males and 238 females. And a total of 189 children with CBF-AML were included, including 117 males and 72 females. The age of diagnosis was 7.3 (4.5,10.0)years, and the white blood cell count at initial diagnosis was 21.4 (9.7, 47.7)×109/L.The complete remission rate of the first course (CR1) of induction therapy, relapse rate, and mortality of children with CBF-AML were significantly different from those in the non-CBF-AML group (91.0% (172/189) vs. 78.0% (308/395); 10.1% (19/189) vs. 18.7% (74/395); 13.2% (25/189) vs. 25.6% (101/395), all P<0.05). In children with CBF-AML, the CBFβ-MYH11 subgroup had higher initial white blood cells and lower proportion of extramedullary invasion than the AML1-ETO subgroup, with statistical significance (65.7% (23/35) vs. 14.9% (23/154), 2.9% (1/35) vs. 16.9% (26/154), both P<0.05). AML1-ETO subgroup had more additional chromosome abnormalities (75/154), especially sex chromosome loss (53/154). Compared with group B, group A had more additional chromosome abnormalities and a higher proportion of tumor reduction regimen, with statistical significance (50.0% (67/134) vs. 29.1% (16/55), 34.3% (46/134) vs. 18.2% (10/55), both P<0.05). Significant differences were found in 5-years event free survival (EFS) rate and 5-year overall survival (OS) rate between CBF-AML group and non-CBF-AML group ((77.0±6.4)%vs. (61.9±6.7)%,(83.7±9.0)%vs. (67.3±7.2)%, both P<0.05).EFS and OS rates of AML1-ETO subgroup and CBFβ-MYH11 subgroup in children with CBF-AML were not significantly different (both P>0.05). Multivariate analysis showed in the AML1-ETO subgroup, CR1 rate and high white blood cell count (≥50×109/L) were independent risk factors for EFS (HR=0.24, 95%CI 0.07-0.85,HR=1.01, 95%CI 1.00-1.02, both P<0.05) and OS (HR=0.24, 95%CI 0.06-0.87; HR=1.01, 95%CI 1.00-1.02; both P<0.05). Conclusions: In CBF-AML, AML1-ETO is more common which has a higher extramedullary involvement and additional chromosome abnormalities, especially sex chromosome loss. The prognosis of AML1-ETO was similar to that of CBFβ-MYH11. The selection of induction regimen group FLAG-IDA for high white blood cell count and additional chromosome abnormality can improve the prognosis.

Preoperative alpha fetoprotein, total bilirubin, fibrinogen, albumin, and lymphocytes predict postoperative survival in hepatocellular carcinoma

AIMS

Our study focused on exploring the feasible prognostic laboratory parameters of HCC and establishing a score model to estimate individualized overall survival (OS) in HCC after resection.

METHODS

Four hundred and sixty-one patients with HCC who underwent hepatectomy between January 2010 and December 2017 was enrolled in this investigation. Cox proportional hazards model was conducted to analyze the prognostic value of laboratory parameters. The score model construction was based on the forest plot results. Overall survival was evaluated by Kaplan-Meier method and the log-rank test. The novel score model was validated in an external validation cohort from a different medical institution.

RESULTS

We identified that alpha fetoprotein (AFP), total bilirubin (TB), fibrinogen (FIB), albumin (ALB), and lymphocyte (LY) were independent prognostic factors. High AFP, TB, FIB (HR > 1, p < 0.05), and low ALB, LY (HR < 1, p < 0.05) were associated with the survival of HCC. The novel score model of OS based on these five independent prognostic factors achieved high C-index of 0.773 (95% confidence interval [CI]: 0.738-0.808), which was significantly higher than those of the single five independent factors (0.572-0.738). The score model was validated in the external cohort whose C-index was 0.7268 (95% CI: 0.6744-0.7792).

CONCLUSION

The novel score model we established was an easy-to-use tool which could enable individualized estimation of OS in patients with HCC who underwent curative hepatectomy.

Effects of centrifugation prior to pneumatic tube system transport on routine biochemical and immunological tests of susceptibility to hemolysis

BACKGROUND

Pneumatic tube system (PTS) may be associated with preanalytical hemolysis. The objective of this study was to evaluate the effects of PTS on biochemical and immunological tests susceptible to hemolysis and try to find ways to reduce the result bias caused by PTS.

METHODS

Laboratory parameters were compared between PTS without centrifuging group, PTS after centrifuging group, PTS with serum group, and hand-delivered (HD) group. Studies were performed to access the influence of different PTS transport frequencies on laboratory assays.

RESULTS

PTS transportation resulted in obviously increase in LDH (lactate dehydrogenase) and NSE (neuron-specific enolase) results (LDH: Bias = 17.95%, 95% confidence interval (CI) = -3.13-39.02; p < 0.001; NSE: Bias = 64.26%, 95% CI = -21.29-149.82; p < 0.001; respectively). After pre-centrifugation, no statistical difference was observed in LDH results (Bias = 2.83%, 95% CI = -13.00-18.65; p = 0.737). However, the bias of NSE still reach 19.16% (95% CI = -41.78-80.11), which exceeded the clinical acceptable range (p = 0.017). Both LDH(p = 0.931) and NSE(p > 0.999) show no statistical difference between PTS with serum group and HD group (LDH: Bias = -1.60%, 95% CI = -6.00-2.81; NSE: Bias = -3.68%, 95% CI = -11.35-3.99).

CONCLUSION

PTS can lead to falsely increased LDH and NSE test results. Only loading the centrifuged upper serum in new tubes during PTS transport can eliminate the results bias of NSE.

Diagnostic Accuracy of Fecal Calprotectin for Predicting Relapse in Inflammatory Bowel Disease: A Meta-Analysis

Fecal calprotectin (FC) levels correlate with the disease activity of inflammatory bowel diseases (IBD); however, the utility of FC in predicting IBD relapse remains to be determined. We aim to evaluate the efficacy of fecal calprotectin in predicting the relapse of inflammatory bowel disease. We searched Pubmed (MEDLINE), Embase, Web of Science, and the Cochrane library databases up to 7 July 2021. Our study estimated the pooled sensitivity and specificity, summary receiver operating characteristic (SROC) curve, and the optimal cut-off value for predicting IBD relapse using a multiple threshold model. A total of 24 prospective studies were included in the meta-analysis. The optimal FC cut-off value was 152 μg/g. The pooled sensitivity and specificity of FC was 0.720 (0.528 to 0.856) and 0.740 (0.618 to 0.834), respectively. FC is a useful, non-invasive, and inexpensive biomarker for the early prediction of IBD relapse. An FC value of 152 μg/g is an ideal threshold to identify patients with a high relapse probability.

NF-κB regulates the expression of STING via alternative promoter usage

AIMS

Stimulator of interferon genes (STING) is a transmembrane protein in endoplasmic reticulum and plays crucial roles in autophagy, antiviral and anti-tumor responses. However, there are few studies on the transcriptional regulation mechanism of STING.

MAIN METHODS

The 5' RACE experiment was used to determine the location of STING promoters. Luciferase reporting assay confirmed the activity and core region of STING internal promoter. Site-directed mutagenesis confirmed that NF-κB regulates the activity of STING promoters. The regulation of NF-κB on STING was investigated by real-time quantitative PCR, western blot, chromatin immunoprecipitation assay and lipopolysaccharide (LPS) inflammatory cell model.

KEY FINDINGS

There was also a transcription start site at the 17 bp sequence upstream of STING second exon. STING-285 was the core region of the internal promoter. After NF-κB binding site mutation, the activity of STING internal promoter decreased significantly. In addition, we found that NF-κB can bind to the promoter region of wild-type STING. Overexpression of NF-κB significantly increased the activity of STING internal promoter and wild-type promoter, while knockdown of endogenous NF-κB significantly inhibited the activity of STING promoters. The binding of NF-κB to STING promoters in vivo were confirmed by chromatin immunoprecipitation assay. Meanwhile, we stimulated HeLa cells with LPS to activate the NF-κB pathway and found that STING expression was up-regulated.

SIGNIFICANCE

These results suggest that transcription factor NF-κB positively regulates the expression of STING via alternative promoter usage. This provides a new basis and potential drug targets for the clinical treatment of STING related diseases.

Identification of IRF-associated molecular subtypes in clear cell renal cell carcinoma to characterize immunological characteristics and guide therapy

Background

Recently studies have identified a critical role for interferon regulatory factor (IRF) in modulating tumour immune microenvironment (TME) infiltration and tumorigenesis.

Methods

Based on IRF1-9 expression profiles, we classified all ccRCC samples into three molecular subtypes (clusters A-C) and characterized the prognosis and immune infiltration of these clusters. IRFscore constructed by principal component analysis was performed to quantify IRF-related subtypes in individual patients.

Results

We proved that IRFscore predicted multiple patient characteristics, with high IRFscore group having poorer prognosis, suppressed TME, increased T-cell exhaustion, increased TMB and greater sensitivity to anti- PD-1/CTLA-4 therapies. Furthermore, analysis of metastatic ccRCC (mccRCC) molecular subtypes and drug sensitivity proved that low IRFscore was more sensitive to targeted therapies. Moreover, IRFscore grouping can be well matched to the immunological and molecular typing of ccRCC. qRT-PCR showed differential expression of IRFs in different cell lines.

Conclusions

Evaluating IRF-related molecular subtypes in individual ccRCC patients not only facilitates our understanding of tumour immune infiltration, but also provides more effective clinical ideas for personalised treatment.

5-Methylcytosine (m5C) Modification Patterns and Tumor Immune Infiltration Characteristics in Clear Cell Renal Cell Carcinoma

Recently, studies have revealed the prognostic value of 5-methylcytosine (m5C) in clear cell renal cell carcinoma (ccRCC). However, the role of m5C methylation in ccRCC immune infiltration and the immunotherapeutic response remains unknown. Based on the mRNA expressions of 14 m5C regulators, we evaluated the m5C modification patterns of 530 tumor samples from the TCGA-ccRCC database. We used the principal component analysis (PCA) algorithm to construct individual patient m5Cscores to facilitate individual analysis of m5C modification patterns in ccRCC patients. We finally defined three different m5C modification patterns. Different clinical features and immune heterogeneity existed among the three patterns, and their immune infiltration characteristics could correspond to different immune phenotypes, including the immune-inflamed, immune-excluded, and immune-desert phenotype. We designed the m5Cscore calculated by the PCA algorithm to measure individual patients' m5C modification patterns. The low m5Cscore group presented with a positive prognosis, increased TMB, and immune activation. Additionally, low m5Cscore patients showed an increased response to immune checkpoint inhibitors. We further the value of the m5Cscore in predicting OS verified in four other tumor cohorts. Our findings revealed that m5C methylation modifications are essential in regulating ccRCC immune infiltration. Assessing single ccRCC patients' m5C modification patterns can fully improve our comprehension of tumor immune characteristics and be used to provide effective personalized immunotherapy strategies for clinical use.

[Effects and mechanism of human umbilical vein endothelial cells-derived exosomes on wound healing in diabetic rabbits]

Objective: The investigate the effects and mechanism of exosomes derived from human umbilical vein endothelial cells (HUVECs) on wound healing in diabetes rabbits. Methods: The experimental research methods were used. The primary vascular endothelial cells (VECs) and human skin fibroblasts (HSFs) were extracted from skin tissue around ulcer by surgical excision of two patients with diabetic ulcer (the male aged 49 years and the female aged 58 years) admitted to Xiangya Third Hospital of Central South University in June 2019. The cells were successfully identified through morphological observation and flow cytometry. The HUVEC exosomes were extracted by ultracentrifugation and identified successfully by morphological observation, particle size detection, and Western blotting detection. Twenty female 3-month-old New Zealand rabbits were taken to create one type 2 diabetic full-thickness skin defect wound respectively on both sides of the back. The wounds were divided into exosomes group and phosphate buffer solution (PBS) group and treated accordingly, with 20 wounds in each group, the time of complete tissue coverage of wound was recorded. On PID 14, hematoxylin-eosin staining or Masson staining was performed to observe angiogenesis or collagen fiber hyperplasia (n=20). The VECs and HSFs were co-cultured with HUVEC exosomes for 24 h to observe the uptake of HUVEC exosomes by the two kinds of cells. The VECs and HSFs were divided to exosome group treated with HUVEC exosomes and PBS group treated with PBS to detect the cell proliferation on 4 d of culture with cell count kit 8, to detect and calculate the cell migration rate at 24 and 48 h after scratch by scratch test, to detect the cell migration number at 24 h of culture with Transwell test, and to detect the mRNA expressions of nuclear factor-erythroid 2-related factor 2 (NRF2) and transcription activating factor 3 (ATF3) by real time fluorescence quantitative reverse transcription polymerase chain reaction. Besides, the number of vascular branches and vascular length were observed in the tube forming experiment after 12 h of culture of VECs (n=3). The VECs and HSFs were taken and divided into PBS group and exosome group treated as before, and NRF2 interference group, ATF3 interference group, and no-load interference group with corresponding gene interference. The proliferation and migration of the two kinds of cells, and angiogenesis of VECs were detected as before (n=3). Data were statistically analyzed with analysis of variance for repeated measurement, one-way analysis of variance, independent sample t test, and least significant difference test. Results: The time of complete tissue coverage of wound in exosome group was (17.9±1.9) d, which was significantly shorter than (25.2±2.3) d in PBS group (t=4.54, P<0.05). On PID14, the vascular density of wound in PBS group was significantly lower than that in exosome group (t=10.12, P<0.01), and the collagen fiber hyperplasia was less than that in exosome group. After 24 h of culture, HUVEC exosomes were successfully absorbed by VECs and HSFs. The proliferative activity of HSFs and VECs in exosome group was significantly higher than that in PBS group after 4 d of culture (with t values of 54.73 and 7.05, respectively, P<0.01). At 24 and 48 h after scratch, the migration rates of HSFs (with t values of 3.42 and 11.87, respectively, P<0.05 or P<0.01) and VECs (with t values of 21.42 and 5.49, respectively, P<0.05 or P<0.01) in exosome group were significantly higher than those in PBS group. After 24 h of culture, the migration numbers of VECs and HSFs in exosome group were significantly higher than those in PBS group (with t values of 12.31 and 16.78, respectively, P<0.01). After 12 h of culture, the mRNA expressions of NRF2 in HSFs and VECs in exosome group were significantly higher than those in PBS group (with t values of 7.52 and 5.78, respectively, P<0.05 or P<0.01), and the mRNA expressions of ATF3 were significantly lower than those in PBS group (with t values of 13.44 and 8.99, respectively, P<0.01). After 12 h of culture, the number of vascular branches of VECs in exosome group was significantly more than that in PBS group (t=17.60, P<0.01), and the vascular length was significantly longer than that in PBS group (t=77.30, P<0.01). After 4 d of culture, the proliferation activity of HSFs and VECs in NRF2 interference group was significantly lower than that in PBS group and exosome group (P<0.05 or P<0.01); the proliferation activity of HSFs and VECs in ATF3 interference group was significantly higher than that in PBS group (P<0.05 or P<0.01) and significantly lower than that in exosome group (P<0.05 or P<0.01). At 24 and 48 h after scratch, the migration rates of HSFs and VECs in ATF3 interference group were significantly higher than those in PBS group (P<0.05 or P<0.01) and significantly lower than those in exosome group (P<0.05 or P<0.01). At 24 and 48 h after scratch, the migration rates of HSFs and VECs in NRF2 interference group were significantly lower than those in PBS group and exosome group (P<0.05 or P<0.01). After 24 h of culture, the migration numbers of VECs and HSFs in ATF3 interference group were significantly more than those in PBS group (P<0.05) and significantly less than those in exosome group (P<0.05 or P<0.01); the migration numbers of VECs and HSFs in NRF2 interference group were significantly less than those in PBS group and exosome group (P<0.01). After 12 h of culture, the vascular length and number of branches of VECs in NRF2 interference group were significantly decreased compared with those in PBS group and exosome group (P<0.01); the vascular length and number of branches of VECs in ATF3 interference group were significantly increased compared with those in PBS group (P<0.01) and were significantly decreased compared with those in exosome group (P<0.01). Conclusions: HUVEC exosomes can promote the wound healing of diabetic rabbits by promoting the proliferation and migration of VECs and HSFs, and NRF2 and ATF3 are obviously affected by exosomes in this process, which are the possible targets of exosome action.

Diagnostic Utility of Non-invasive Tests for Inflammatory Bowel Disease: An Umbrella Review

Background

This study aims to consolidate evidence from published systematic reviews and meta-analyses evaluating the diagnostic performances of non-invasive tests for inflammatory bowel disease (IBD) in various clinical conditions and age groups.

Methods

Two independent reviewers systematically identified and appraised systematic reviews and meta-analyses assessing the diagnostic utility of non-invasive tests for IBD. Each association was categorized as adults, children, and mixed population, based on the age ranges of patients included in the primary studies. We classified clinical scenarios into diagnosis, activity assessment, and predicting recurrence.

Results

In total, 106 assessments from 43 reviews were included, with 17 non-invasive tests. Fecal calprotectin (FC) and fecal lactoferrin (FL) were the most sensitive for distinguishing IBD from non-IBD. However, anti-neutrophil cytoplasmic antibodies (ANCA) and FL were the most specific for it. FC and FL were the most sensitive and specific tests, respectively, to distinguish IBD from irritable bowel syndrome (IBS). Anti-Saccharomyces cerevisiae antibodies (ASCA), IgA, were the best test to distinguish Crohn’s disease (CD) from ulcerative colitis (UC). Interferon-γ release assay was the best test to distinguish CD from intestinal tuberculosis (ITB). Ultrasound (US) and magnetic resonance enterography (MRE) were both sensitive and specific for disease activity, along with the high sensitivity of FC. Small intestine contrast ultrasonography (SICUS) had the highest sensitivity, and FC had the highest specificity for operative CD recurrence.

Conclusion

In this umbrella review, we summarized the diagnostic performance of non-invasive tests for IBD in various clinical conditions and age groups. Clinicians can use the suggested non-invasive test depending on the appropriate clinical situation in IBD patients.

Development of Laboratory Parameters-Based Formulas in Predicting Short Outcomes for Adult Hemophagocytic Lymphohistiocytosis Patients with Different Underlying Diseases

PURPOSE

Hemophagocytic lymphohistiocytosis (HLH) is a severe disease with high mortality. The purpose of this investigation was to build models to predict 30-day death in total and subgroup HLH patients based on available and cheap laboratory parameters.

METHOD

The research contained 431 adults HLH patients from January 2015 to September 2021 in the hospital. Logistic regression and receiver operating characteristic (ROC) were utilized to build models.

RESULTS

Results suggested that age, ferritin, lymphocyte (LY), international normalized ratio (INR), thrombin time (TT), globulin, uric acid (UA), chloride, activated partial thromboplastin time (APTT), aspartate aminotransferase (AST), triglycerides (TG), total bilirubin (TB), and indirect bilirubin (IB) were independent factors in HLH and subgroups. Then, models adapted to patients with different underlying diseases were established based on these factors. Area under curve (AUC) of these models was excellent: HLH patients: 0.838 (p < 0.001); infection-associated HLH (I-HLH) patients: 0.913 (p < 0.001); malignancy-associated HLH (M-HLH): 0.921 (p < 0.001) and 0.809 (p < 0.001) for two or more different etiologies-associated HLH (Mix-HLH patients). In addition, UA, TT, and chloride were firstly confirmed as independent factors in adult HLH.

CONCLUSION

Four models depending on biomarkers that available and affordable in clinical practice were built. With these models, high-risk patients with different underlying diseases could be easily identified.

Global prevalence of occult hepatitis B: A systematic review and meta-analysis

The study aimed to investigate the prevalence and risk factors associated with occult hepatitis B virus (HBV) infection (OBI) in the global population. We searched PubMed, Embase, CINAHL, Cochrane and Web of Science from database inception through 27 Dec, 2018. Studies reporting HBV-DNA serological data in previously undiagnosed hepatitis B patients were included. The data were further categorized according to the presence of risk factors. After an initial screening of 2,325 records, we finally included 98 articles about the prevalence of OBI from 34 countries and regions. The OBI prevalence was 0.82% (95% CI:0.69-0.96) in the general population, 16.26% (95% CI:10.97-22.34) in HIV patients, 13.99% (95% CI:8.33-20.79) in patients with other liver diseases, 4.25% (95% CI:1.64-7.87) in haemodialysis patients and 5.14% (95% CI:2.26-9.01) patients with other risk factors. In conclusion, OBI prevalence varies significantly across different populations and nations, which deserve attention from the public health authorities. Our results generate further epidemiological data to identify the population with OBI, which has important clinical implications in finding these high-risk populations to design preventive and management strategies.

Construction and validation of a prognostic model for kidney renal clear cell carcinoma based on podocyte-associated genes

Background

As the most common renal malignancy, kidney renal clear cell carcinoma (KIRC) has a high prevalence and death rate as well as a poor response to treatment. Developing an efficient prognostic model is essential for accurately predicting the outcome and therapeutic benefit of KIRC patients.

Methods

Gene expression profiles of podocyte‐associated genes (PAGs) were obtained from The Cancer Genome Atlas and GEO datasets. Cox regression and Lasso regression analyses were then used for filtering prognosis‐associated PAGs. Risk score (RS) was computed from these genetic characteristics. Kaplan–Meier analysis and receiver operating characteristic (ROC) curves were applied for ascertaining the prognostic value. Stratified analysis was used to sufficiently validate model performance. Concordance index was used to compare the predictive ability of different models. Immuno‐infiltration analysis and immunophenoscore were utilized for the prediction of patient reaction to immune checkpoint inhibitors (ICIs).

Results

WT1, ANLN, CUBN, OSGEP, and RHOA were significantly associated with KIRC prognosis. Prognostic analysis indicated that high‐RS patients have a significantly poorer outcome. Cox regression analysis demonstrated a potential for RS to be an independent prognostic factor. Pathway enrichment results indicated a lower enrichment of cancer‐related biological pathways in the low‐RS subgroup. Immune infiltration analysis and IPS demonstrated greater responsiveness to ICIs in the high RS group.

Conclusions

This podocyte‐associated KIRC prognostic model can effectively predict KIRC prognosis and immunotherapy response, which may help to provide clinicians with more effective treatment strategies.

Nomogram for preoperative estimation of histologic grade in gastrointestinal neuroendocrine tumors

BACKGROUND

The treatment strategies and prognosis for gastroenteropancreatic neuroendocrine tumors were associated with tumor grade. Preoperative predictive grading could be of great benefit in the selection of treatment options for patients. However, there is still a lack of effective non-invasive strategies to detect gastrointestinal neuroendocrine tumors (GI-NETs) grading preoperatively.

METHODS

The data on 147 consecutive GI-NETs patients was retrospectively collected from January 1, 2012, to December 31, 2019. Logistic regression was used to construct a predictive model of gastrointestinal neuroendocrine tumor grading using preoperative laboratory and imaging parameters.The validity of the model was assessed by area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA).

RESULTS

The factors associated with GI-NETs grading were age, tumor size, lymph nodes, neuron-specific enolase (NSE), hemoglobin (HGB) and sex, and two models were constructed by logistic regression for prediction. Combining these 6 factors, the nomogram was constructed for model 1 to distinguish between G3 and G1/2, achieving a good AUC of 0.921 (95% CI: 0.884-0.965), and the sensitivity, specificity, accuracy were 0.9167, 0.8256, 0.8630, respectively. The model 2 was to distinguish between G1 and G2/3, and the variables were age, tumor size, lymph nodes, NSE, with an AUC of 0.847 (95% CI: 0.799-0.915), and the sensitivity, specificity, accuracy were 0.7882, 0.8710, 0.8231, respectively. Two online web servers were established on the basis of the proposed nomogram to facilitate clinical use. Both models showed an excellent calibration curve through 1000 times bootstrapped dataset and the clinical usefulness were confirmed using decision curve analysis.

CONCLUSION

The model served as a valuable non-invasive tool for differentiating between different grades of GI-NETs, personalizing the calculation which can lead to a rational treatment choice.

Hepatitis D: challenges in the estimation of true prevalence and laboratory diagnosis

Hepatitis delta virus (HDV) is a defective single negative chain RNA virus, as its envelope protein synthesis is dependent on hepatitis B virus (HBV). Studies have consistently shown that coinfection of HBV and HDV is the most serious form of viral hepatitis, with accelerated progression to liver cirrhosis and hepatocellular carcinoma. About 74 million of HBV surface antigen (HBsAg) positive patients worldwide are also co-infected with HDV. Besides, patients with intravenous drug use and high-risk sexual behavior are at higher risk of HDV infection. Therapeutic schedules for HDV are limited, and relapse of HDV has been observed after treatment with pegylated interferon alpha. To reduce the transmission of HDV, all people infected with HBV should be screened for HDV. At present, several serological and molecular detection methods are widely used in the diagnosis of HDV. However, due to the lack of international standards diagnostic results from different laboratories are often not comparable. Therefore, the true prevalence of HDV is still unclear. In this manuscript, we have analyzed various factors influencing the estimation of HDV prevalence. We have also discussed about the advantages and disadvantages of currently available HDV laboratory diagnostic methods, in order to provide some ideas for improving the detection of HDV.

Clinical utility of procalcitonin and its association with pathogenic microorganisms

In this review, we summarize the relationship of PCT with pathogens, evaluate the clinical utility of PCT in the diagnosis of clinical diseases, condition monitoring and evaluation, and guiding medical decision-making, and explore current knowledge on the mechanisms by which pathogens cause changes in PCT levels. The lipopolysaccharides of the microorganisms stimulate cytokine production in host cells, which in turn stimulates production of serum PCT. Pathogens have different virulence mechanisms that lead to variable host inflammatory responses, and differences in the specific signal transduction pathways result in variable serum PCT concentrations. The mechanisms of signal transduction have not been fully elucidated. Further studies are necessary to ascertain the PCT fluctuation range of each pathogen. PCT levels are helpful in distinguishing between certain pathogens, in deciding if antibiotics are indicated, and in monitoring response to antibiotics.

Association of Serum Neuron-Specific Enolase and C-Reactive Protein With Disease Location and Endoscopic Inflammation Degree in Patients With Crohn's Disease

Objective: The objective of this study was to explore the association between serum markers neuron-specific enolase (NSE) and C-reactive protein (CRP) with intestinal lesion location and degree of inflammation in patients with Crohn's disease (CD).

Design: The levels of serum NSE, CRP, and fecal calprotectin (FC) in patients with CD were analyzed retrospectively. The severity of inflammatory lesions in the intestinal wall was accessed using the Simple Endoscopic Score for Crohn's disease (SES-CD).

Results: The levels of NSE in patients with CD were higher than those of healthy individuals (14.87 vs. 12.68 ng/ml, P < 0.001). The levels of CRP in patients with CD were higher than those of healthy individuals (12.30 vs. 3.40 mg/l, P < 0.001). The FC levels in patients with CD were higher than those of patients with non-inflammatory bowel disease (1,143.90 vs. 114.21 μg/g, P < 0.05). The levels of NSE in CD with ileal lesions and simultaneous ileal and colon lesions were significantly higher than those in patients with CD with colonic lesions. However, the CRP was higher in patients with colonic lesions than those with ileal lesions. The levels of NSE in patients with severe inflammation were higher than those in patients with moderate inflammation (15.95 vs. 13.89 ng/ml, P < 0.05). Similarly, the NSE levels in patients with CD with severe inflammation were higher than those in patients with CD with mild inflammation (15.95 vs. 13.53 ng/mL, P < 0.05). The levels of CRP in severe inflammation were higher than those in moderate inflammation (29.80 vs. 19.60 mg/l, P < 0.05). In addition, the CRP levels in severe inflammation were higher than those in mild inflammation (29.80 vs. 5.86 mg/l, P < 0.05). ROC curve analysis showed that when NSE was combined with CRP for distinguishing between patients with CD and those without CD, sensitivity increased to 80.41%, specificity increased to 74.66%, and a highest AUC was equal to 0.843.

Conclusion: Our study shows that serum NSE and CRP can be used to assess the severity of CD as well as the location of intestinal involvement. Therefore, NSE and CRP could be used as the non-invasive tests in detecting the location and severity of disease in patients with CD in daily routine practice.

Association of Rotavirus Vaccines With Reduction in Rotavirus Gastroenteritis in Children Younger Than 5 Years: A Systematic Review and Meta-analysis of Randomized Clinical Trials and Observational Studies

IMPORTANCE

Rotavirus vaccines have been introduced worldwide, and the clinical association of different rotavirus vaccines with reduction in rotavirus gastroenteritis (RVGE) after introduction are noteworthy.

OBJECTIVE

To evaluate the comparative benefit, risk, and immunogenicity of different rotavirus vaccines by synthesizing randomized clinical trials (RCTs) and observational studies.

DATA SOURCES

Relevant studies published in 4 databases: Embase, PubMed, the Cochrane Library, and Web of Science were searched until July 1, 2020, using search terms including "rotavirus" and "vaccin*."

STUDY SELECTION

Randomized clinical trials and cohort and case-control studies involving more than 100 children younger than 5 years that reported the effectiveness, safety, or immunogenicity of rotavirus vaccines were included.

DATA EXTRACTION AND SYNTHESIS

A random-effects model was used to calculate relative risks (RRs), odds ratios (ORs), risk differences, and 95% CIs. Adjusted indirect treatment comparison was performed to assess the differences in the protection of Rotarix and RotaTeq.

MAIN OUTCOMES AND MEASURES

The primary outcomes were RVGE, severe RVGE, and RVGE hospitalization. Safety-associated outcomes involved serious adverse events, intussusception, and mortality.

RESULTS

A meta-analysis of 20 RCTs and 38 case-control studies revealed that Rotarix (RV1) significantly reduced RVGE (RR, 0.316 [95% CI, 0.224-0.345]) and RVGE hospitalization risk (OR, 0.347 [95% CI, 0.279-0.432]) among children fully vaccinated; RotaTeq (RV5) had similar outcomes (RVGE: RR, 0.350 [95% CI, 0.275-0.445]; RVGE hospitalization risk: OR, 0.272 [95% CI, 0.197-0.376]). Rotavirus vaccines also demonstrated higher protection against severe RVGE. Additionally, no significant differences in the protection of RV1 and RV5 against rotavirus disease were noted in adjusted indirect comparisons. Moderate associations were found between reduced RVGE risk and Rotavac (RR, 0.664 [95% CI, 0.548-0.804]), Rotasiil (RR, 0.705 [95% CI, 0.605-0.821]), and Lanzhou lamb rotavirus vaccine (RR, 0.407 [95% CI, 0.332-0.499]). All rotavirus vaccines demonstrated no risk of serious adverse events. A positive correlation was also found between immunogenicity and vaccine protection (eg, association of RVGE with RV1: coefficient, -1.599; adjusted R2, 99.7%).

CONCLUSIONS AND RELEVANCE

The high protection and low risk of serious adverse events for rotavirus vaccines in children who were fully vaccinated emphasized the importance of worldwide introduction of rotavirus vaccination. Similar protection provided by Rotarix and RotaTeq relieves the pressure of vaccines selection for health care authorities.

Epidemiology estimates of hepatitis D in individuals co-infected with human immunodeficiency virus and hepatitis B virus, 2002-2018: A systematic review and meta-analysis

Hepatitis delta virus (HDV) is an obligate satellite of hepatitis B virus (HBV). HIV/HDV co-infection is associated with a high rate of hepatic decompensation events and death. We aimed to characterize the epidemiology of HDV infection in HIV/HBV co-infected individuals. We systematically searched PubMed, Embase, Cochrane Library, Web of Science, CINAHL and Scopus for studies published from 1 Jan 2002 to 7 May 2018 measuring prevalence of HDV among the HIV population. Pooled seroprevalence was calculated with the DerSimonian-Laird random-effects model. Our search returned 4624 records, 38 of which met the inclusion and exclusion criteria. These studies included data for 63 cohorts from 18 countries and regions. The overall HDV seroprevalence of HIV-infected individuals was 1.03% (95% CI 0.43-1.85) in 2002-2018 globally. Moreover, the estimated pooled HDV seroprevalence among the general population was 1.07% (95% CI 0.65-1.59) in 2002-2018, which was not significantly different from the HDV seroprevalence of individuals living with HIV (p = 0.951). The overall HDV seroprevalence of the HBsAg positive population was 12.15% (95% CI 10.22-14.20), p = 0.434 when compared with the corresponding data of HIV/HBV co-infected individuals. This meta-analysis suggested that there was no difference between the HDV seroprevalence in HIV-infected individuals and the general population.

Development and Validation of Novel Nomograms Using Serum Tumor Markers for the Prediction of Preoperative Histologic Grades in Gastroenteropancreatic Neuroendocrine Tumors

Background

To develop and validate nomogram models for the preoperatively prediction of the histologic grade of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) to provide appropriate treatments.

Methods

A total of 1014 participants, including 211 healthy controls, 293 patients with benign diseases, 299 patients with cancers, and 211 patients with GEP-NETs were included in the final analysis. Their sociodemographic and laboratory information, including serum tumor markers such as AFP, CEA, CA19-9, CA72-4, Cyfra21-1 and NSE were collected. Nomogram models were developed to preoperatively predict histologic grades of GEP-NETs.

Results

Among six serum tumor markers, only NSE was found to have a statistically significant association with the histologic grades in GEP-NETs (G1 vs. G2: p < 0.05; G2 vs. G3: p < 0.001; G1 vs. G3: p < 0.0001), which was combined with sex and age to develop the nomogram models. The first nomogram (to differentiate grade 1(G1) and grade 2/3 tumor (G2/G3)) showed a strong association to differentiate with an AUC of 0.747 (95% CI: 0.663-0.832) and 0.735 (95% CI: 0.624-0.847) in the training and validation datasets, respectively. The second nomogram (to differentiate G1/G2 and G3 tumors) showed a strong association to differentiate with an AUC of 0.827 (95% CI: 0.744-0.911) and 0.847 (95% CI: 0.744-0.950) in the training and validation datasets, respectively. The ROC, area under ROC curve (AUC), calibration curve and decision curve analysis (DCA) demonstrated the clinical usefulness of both models.

Conclusions

We proposed two novel nomogram models based on sex, age and serum NSE levels to preoperatively predict the histologic grades in GEP-NETs to assist the clinical decision-making.

[Eltrombopag for thrombocytopenia in 24 children after hematopoietic stem cell transplantation]

Objective: To evaluate the efficacy and safety of eltrombopag for children with thrombocytopenia after hematopoietic stem cell transplantation (HSCT). Methods: Clinical data of 24 patients with thrombocytopenia after HSCT,who were treated with eltrombopag in the Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from August 1, 2018 to April 1, 2019 were analyzed retrospectively. The response rate and adverse reactions of eltrombopag were evaluated. Patients were divided into groups by source of hematopoietic stem cells (umbilical cord blood group and peripheral stem cell group) and type of disease (malignant and non-malignant disease group) and the clinical outcomes between groups were compared. Rank Sum test was used for comparisons between groups. Results: Among 24 cases, 15 were males and 9 females, the age of starting eltrombopag was 7.7 (2.6-13.7) years, the time of eltrombopag treatment after HSCT was 27.5 (8.0-125.0) days, the time from treatment to complete response (CR) was 23.5 (6.0-83.0) days, with the treatment course 36.5 (8.0-90.0) days. The total dose of eltrombopag was 1 400(200-5 900) mg. Complete response rate was 92% (22/24),without eltrombopag related adverse reactions. Comparing with peripheral stem cell group (n=8), the course and total dose of eltrombopag in umbilical cord blood group (n=16) were significantly reduced(24.5 (8.0-81.0) vs. 65.5 (35.0-90.0) d, Z=-3.004, P=0.002; 900.0 (200.0-3 850.0) vs. 2 862.5 (1 175.0-5 900.0) mg, Z=-2.604, P=0.007), but no significant differences were found in the time from treatment to complete response, platelet count after 2 weeks of eltrombopag withdrawal or platelet count at the end point of follow-up (all P>0.05). Comparing malignant patients (n=12) and non-malignant patients (n=12), no significant differences were found in the time from treatment to complete response, course, total dose, platelet count after 2 weeks of eltrombopag withdrawal, and platelet count at the end point of follow-up in non-malignant patients (all P>0.05). Conclusion: Eltrombopag is safe and maybe effective for thrombocytopenia after HSCT, especially for umbilical cord blood transplantation.

Ferritin index is a strong prognostic marker in adult hemophagocytic lymphohistiocytosis

AIMS

The relationship between ferritin levels and survival in adult hemophagocytic lymphohistiocytosis (HLH) has been evaluated in previous studies. However, Admission-to-discharge percentage ferritin reduction (named as ferritin index) level in adult patients with HLH has never been evaluated to predict 6-month survival.

METHODS

The demographic, laboratory and clinical information of 102 newly diagnosed adult HLH patients were collected. Regression analysis, receiver operating curve and Kaplan-Meier curves were analysed to explore the performance of ferritin levels.

RESULTS

Ferritin index and discharge ferritin level were significantly different between survivour and non-survivour group (all P < .001). Ferritin index had the highest area under the curve (AUC) for predicting the survival (AUC = 0.802, P < .001) followed by discharge ferritin (AUC = 0.746, P < .001). Kaplan-Meier analysis showed a significant difference in survival according to optimum cutoff values of ferritin index ≥ 10.19% (P < .001) or discharge ferritin ≤ 1056.1 μg/L (P < .001). Multivariate analysis confirmed that ferritin index and discharge ferritin are independent predictors of 6-month survival (ferritin index: odds ratio (HR) 6.237, 95% confidence interval (CI) 2.075-18.774, P = .001; discharge ferritin: HR 6.024, 95% CI 1.894-19.231, P = .002). In addition, the combination of a ferritin index ≥ 10.19% and discharge ferritin ≤ 1056.1 μg/L had a significantly higher 6-month survival (P < .001).

CONCLUSION

Ferritin index is a better predictor of 6-month survival than admission and discharges ferritin levels in adult patients with HLH.

The effect of rheumatoid factor on three commercial immunoassays for serum cystatin C

Cystatin C (CysC) can be used to diagnose early changes in renal insufficiency. However, there are little researches to study whether there is an interference between the level of CysC and RF. Thus, we conducted this study to investigate it. We randomly selected 30 patients with high RF (RF concentration: 552.05 ± 476.23 IU/mL) and 33 healthy subjects with RF concentration <11.1 IU/mL and CysC were measured with different reagents and instruments; Interference experiment was also be included. The results showed that the measured CysC concentration increases with increasing RF concentration in a dose-dependent manner and CysC levels are falsely increased by RF interference depends on the reagents used (CysC reagent: Whitman, Nanjing, China). Reagent manufacturers should fully consider RF interference when developing CysC reagents, and evaluate them before they are sold. When selecting CysC reagents, we should evaluate RF interference to the measurement to avoid misleading results.

Systemic autoimmune abnormalities complicated by cytomegalovirus-induced hemophagocytic lymphohistiocytosis: A case report

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening disorder, characterized by a hyperimmune response. The mortality is high despite progress being made in the diagnosis and treatment of the disease. HLH is traditionally divided into primary (familial or genetic) and secondary (reactive) according to the etiology. Secondary HLH (sHLH), more common in adults, is often associated with underlying conditions including severe infections, malignancies, autoimmune diseases, or other etiologies.

CASE SUMMARY

The case involves a 31-year-old woman, presented with a high persistent fever, rash, and splenomegaly. She met the diagnostic criteria of the HLH-2004 guideline and thus was diagnosed with HLH, with positive anti-nuclear antibody (ANA) and positive cytomegalovirus (CMV)-DNA. The patient responded well to a combination of immunomodulatory, chemotherapy, and supportive treatments. When her PCR evaluation for CMV turned negative, her serum ferritin also dropped significantly. Her clinical symptoms improved dramatically, and except for ANA, the abnormal laboratory findings associated with HLH returned to normal. Our previous study has shown that the median overall survival of HLH patients is only 6 mo; however, our patient has been cured and has not presented with any relapse of the disease for 6 years.

CONCLUSION

This case emphasizes that thorough early removal of the CMV infection is significant for the prognosis of this HLH patient.

Platelet counts during pregnancy in Chinese women

Objectives

Gestational thrombocytopenia (GT) is the most common cause of thrombocytopenia during pregnancy. However, the occurrence and severity of thrombocytopenia throughout pregnancy in Chinese women are not fully defined.

Methods

We analyzed platelet counts in Chinese women who received prenatal care and/or delivered at the First Affiliated Hospital with Nanjing Medical University between January 2, 2018 and July 19, 2018 in China. These platelet counts were compared with those of nonpregnant women in the same study period.

Results

The platelet counts of all women continued to decrease significantly each trimester (p < 0.0001). The mean platelet counts of the 818 women who had pregnancy-related complications were lower than those of the 796 women who had uncomplicated pregnancies during the third trimester (p = 0.047). At the time of delivery, platelet counts less than 150 × 109/L were more common in women with pregnancy-related complications than in women with uncomplicated pregnancy (26.7% vs. 19.7%, p = 0.03).

Conclusions

Platelet counts decrease throughout pregnancy in Chinese women and platelet counts less than 150 × 109/L were more common in women with pregnancy-related complications than in women with uncomplicated pregnancy. The pregnant women should be paid more attention for thrombocytopenia to avoid the occurrence of bleeding events.

A novel prognostic model for adult patients with Hemophagocytic Lymphohistiocytosis

BACKGROUND

Hemophagocytic Lymphohistiocytosis (HLH) is a type of rare disease with low survival rate. We aimed to develop a model to evaluate the six-month prognosis in adult HLH patients. The data at discharge (will be called as post-treatment) for newly diagnosed adult HLH patients was collected and independent prognostic variables were selected for inclusion in the model.

RESULTS

Three laboratory markers were confirmed to be the independent risk factors (ferritin: hazard ratio (HR) 0.101, 95% confidence interval (CI) 0.036-0.282, P<0.001; platelets: HR 4.799, 95% CI 1.884-12.223, P = 0.001; alanine aminotransferase (ALT): HR 0.423, 95% CI 0.180-0.997, P = 0.049). These were included in the final clinical prediction model. Receiver operating characteristic (ROC) curves disclosed that this model had a better discrimination (area under the curve (AUC) = 0.842, 95% CI 0.773-0.910, P < 0.001) than each of them alone and the calibration curves aligned completely with the model predictions and actual observations. Kaplan-Meier curves revealed a significant difference in the overall survival (OS) in patients stratified by the model with higher values associated with a better OS.

CONCLUSION

These results point out that serum ferritin, platelets and ALT levels are independent elements of OS in adult patients with HLH, and that the proposed model have a better prognostic value than any of these markers alone.

Association Between Rotavirus Vaccination and Risk of Intussusception Among Neonates and Infants: A Systematic Review and Meta-analysis

IMPORTANCE

The conclusions from the multiple randomized clinical trials exploring the relationship between development of intussusception and rotavirus vaccination among neonates and infants have been controversial.

OBJECTIVE

To evaluate the association between rotavirus vaccination and risk of intussusception.

DATA SOURCES

For this systematic review and meta-analysis, PubMed, Web of Science, Cochrane library, and Embase databases were searched from January 1, 1999, through December 31, 2018, using no language restrictions. The search terms were rotavirus or RV (rotavirus vaccine) or HRV (human rotavirus vaccine), vaccin*, and intussusception.

STUDY SELECTION

Randomized clinical trials of neonates and infants that compared the risk of intussusception after the vaccination with a placebo group were included.

DATA EXTRACTION AND SYNTHESIS

A fixed-effects model was used to pool the data. Statistical heterogeneity was assessed with Q test and I2 statistic; relative risk (RR), risk difference (RD), and 95% CIs were calculated using the Mantel-Haenszel method.

MAIN OUTCOMES AND MEASURES

The main outcome was the diagnosis of intussusception in the analysis. The pooled and subtotal results of RR, RD, and 95% CI for the risk of intussusception were estimated at 31 days, 1 year, and 2 years after vaccination.

RESULTS

A total of 25 randomized clinical trials including 200 594 participants (104 647 receiving vaccine and 95 947 receiving placebo) in 33 countries from 4 continents were included in this meta-analysis. Twenty cases of definite intussusception were diagnosed within 31 days after rotavirus vaccination, with 11 cases (55%) in the vaccine group and 9 cases (45%) in the placebo group (RD, 0.17 per 10 000 infants [95% CI, -1.16 to 1.50 per 10 000 infants], P = .80; RR, 1.14 [95% CI, 0.49 to 2.64], P = .77). Seventy-four cases were reported within 1 year, with 37 cases (50%) in the vaccine group and 37 cases (50%) in the placebo group (RD, -0.65 per 10 000 infants [95% CI, -2.68 to 1.39 per 10 000 infants], P = .53; RR, 0.84 [95% CI, 0.53 to 1.32], P = .45). Fifty-nine cases were reported within 2 years, with 29 cases (49%) in the vaccine group and 30 cases (51%) in the placebo group (RD, -0.48 per 10 000 infants [95% CI, -3.64 to 2.69 per 10 000 infants], P = .77; RR, 0.91 [95% CI, 0.55 to 1.52], P = .73).

CONCLUSIONS AND RELEVANCE

Results of this systematic review and meta-analysis suggest that monovalent, pentavalent, monovalent human-bovine, oral bovine pentavalent, and human neonatal rotavirus vaccination was not associated with an elevated risk of intussusception among neonates or infants.

Transcriptional regulation of human cyclic GMP-AMP synthase gene

Cyclic GMP-AMP synthase (cGAS, cGAMP synthase) plays crucial roles in autoimmune disease, anti-tumor response, anti-senescence and anti-inflammatory response. Many studies have focused on cGAS-mediated signaling pathway. However, transcriptional mechanisms of cGAS gene have remained largely unknown. Here, we cloned the cGAS promoter region and characterized the molecular mechanisms controlling the cGAS transcriptional activity. By a series of 5' deletion and promoter constructions, we showed that the region (-414 to +76 relatives to the transcription start site) was sufficient for promoter activity. Mutation of Sp1 and CREB binding sites in this promoter region led to an apparent reduction of the cGAS promoter activity. Overexpression of Sp1 and CREB could obviously enhance promoter activity, whereas knocking-down of endogenous Sp1 and CREB markedly restrained the cGAS promoter activity. Sp1 and CREB binding to the cGAS promoter region in vivo was verified by Chromatin immunoprecipitation assay. These results pointed out that transcription factors Sp1 and CREB regulate the transcription of the cGAS gene.

Failure of internal quality control in detecting significant reagent lot shift in serum creatinine measurement

Background

Internal quality control (IQC) in clinical laboratories is carried out to monitor analytical stability. Usually, the satisfactory results of the IQC ensure the acceptability of the examination results. Here, we reported that patients' creatinine results are unreliable, although the internal quality control is satisfactory.

Methods

Creatinine levels were analyzed from two quality control materials and twenty patients' specimens using two different lots of reagents. Lot‐to‐lot comparison was performed. The daily median values of serum creatinine levels of patients were calculated from the test results recorded in our laboratory information system.

Results

Although IQC was consistent, serum creatinine concentrations were higher using lot B (median: 153 μmol/L; interquartile range: 122‐522 μmol/L) than using lot A (median: 133 μmol/L; interquartile range: 76‐508 μmol/L) for 20 patients (P = .001). The Deming linear regression showed a best fit of y = 0.9394 × x + 45.66. R² = .8919, and mean percentage difference between two lots was 34%. The new lot was considered unacceptable. Likewise, the median serum creatinine level from the 360 patients using lot B was 102 μmol/L, which was significantly higher than the daily medians of patients using lot A (median: 66 μmol/L; range: 61‐70 μmol/L) in the previous month.

Conclusion

The variations in creatinine concentrations proved to be due to different lots of reagents. However, IQC materials tested using both lots of reagent exhibited minimal variation. Therefore, IQC alone is insufficient for assessing laboratory analytical results. This finding prompts us to be vigilant in potential pitfall of interpreting test results based on satisfactory IQC alone.

Prevalence and burden of hepatitis D virus infection in the global population: a systematic review and meta-analysis

OBJECTIVE

Hepatitis D virus (HDV) is a defective virus that completes its life cycle only with hepatitis B virus (HBV). The HBV with HDV super-infection has been considered as one of the most severe forms of the chronic viral hepatitis. However, there is a scarcity of data on the global burden of HDV infection.

DESIGN

We searched PubMed, Embase, Cochrane Library and China Knowledge Resource Integrated databases from 1 January 1977 to 31 December 2016. We included studies with a minimum sample size of 50 patients. Our study analysed data from a total of 40 million individuals to estimate the prevalence of HDV by using Der-Simonian Laird random-effects model. The data were further categorised according to risk factors.

RESULTS

From a total of 2717 initially identified studies, only 182 articles from 61 countries and regions met the final inclusion criteria. The overall prevalence of HDV was 0.98% (95% CI 0.61 to 1.42). In HBsAg-positive population, HDV pooled prevalence was 14.57% (95% CI 12.93 to 16.27): Seroprevalence was 10.58% (95% CI 9.14 to 12.11) in mixed population without risk factors of intravenous drug use (IVDU) and high-risk sexual behaviour (HRSB). It was 37.57% (95% CI 29.30 to 46.20) in the IVDU population and 17.01% (95% CI 10.69 to 24.34) in HRSB population.

CONCLUSION

We found that approximately 10.58% HBsAg carriers (without IVDU and HRSB) were coinfected with HDV, which is twofold of what has been estimated before. We also noted a substantially higher HDV prevalence in the IVDU and HRSB population. Our study highlights the need for increased focus on the routine HDV screening and rigorous implementation of HBV vaccine programme.

False high testosterone of unknown reason in a clinically inconspicuous female

Background

This report investigates an unusual total testosterone result in a middle-aged female.

Case presentation

A 40-year-old female patient was found to have high serum total testosterone of 30.82 nmol/L on a Beckman Coulter UniCel® DxI800 automatic chemiluminescence immunoanalyzer without appropriate clinical appearance. Heterophile antibody interference was considered for elevated testosterone and investigated; reanalysis of the original serum sample and liquid chromatography with tandem mass spectrometry (LC-MS/MS) were performed. Reanalysis of the original serum sample using Roche® and Siemens® immunoassays both gave a normal total testosterone level. Beckman Coulter® also excluded the possibility of interference by heterophile antibodies. Finally, LC-MS/MS showed that the total testosterone level was in the normal range.

Conclusions

This report highlights the importance of ruling out the interfering factors for false high values of the analyte in laboratories.

Comparison of two commercial quality control sera for adrenocorticotropin (ACTH) used in Elecsys® immunoassay system

OBJECTIVES

The purpose of our study was to investigate whether the storage time and temperature of internal quality control (IQC) material influence the result of ACTH in IQC measurements.

DESIGN AND METHODS

Five levels of IQC materials from two manufacturers were tested through the precision of ACTH, the three freeze/thaw cycles, and the storage time and temperature to evaluate the stability of IQC material. All commercial control materials were simultaneously tested three times a day for five consecutive days.

RESULTS

Total precision of three levels of Bio-Rad IQC sera was 13.93%, 16.45%, and 15.98%, respectively, but repeatability was <2%. The concentration of ACTH decreased by 30%-50% after 3 freeze/thaw cycles. At room temperature, the concentration of ACTH from 3 levels decreased by 16.60%, 17.98%, and 17.20%, respectively, after 0.5 hours, and 70.54%, 74.36%, and 72.03%, respectively, after 4 hours. However, after 2 hours of storage at 4°C, the decline in the measured ACTH IQC was 8.04%, 11.84%, and 10.11%, respectively. Total precision of Roche IQC was 1.17% and 1.08%, respectively. After 3 freeze/thaw cycles, the concentration of ACTH decreased <5%. After 4 hours, the change of ACTH still steadied within 5% both at the room temperature and at 4°C.

CONCLUSION

Roche is a better choice for ACTH of IQC material in Elecsys^® immunoassay system in our study. If Bio-Rad control materials be used in Elecsys^® immunoassay system for ACTH IQC testing material, it should be stored at 4°C and testing should be completed within 1 hours.

[Clinical analysis of three cases with beta-thalassemia]

Objective: To study the diagnostic strategy of β-thalassemia through retrospective analysis of 3 cases of β-thalassemia. Methods: Three patients were admitted to the Department of Pediatrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University from January 2014 to June 2015. The clinical manifestations, hemoglobin electrophoresis and gene detection of these patients and their parents were analyzed, diagnostic ideas and key points were discussed when beta thalassemia gene detection did not explain clinical manifestations or hemoglobin electrophoresis. Results: Case 1, boy, 5 years old, was diagnosed as compound heterozygotes of β41-42 and IVS-Ⅱ-654 with hereditary persistence of fetal hemoglobin(HPFH) according to the clinical manifestations of mild anemia, normal size of liver and spleen, 92.8% fetal hemoglobin (HbF) and gene analysis. Case 2, girl, 3 years old, was confirmed the diagnosis of thalassemia intermedia with β41-42 heterozygote compound and ααα^anti3.7 heterozygote in accordance with the manifestations of severe anemia, hepatosplenomegaly, 8.6% HbF, 4.1% hemoglobin A₂(HbA₂) and gene analysis. Case 3, girl, 3 years old, with severe anemia, hepatosplenomegaly, 51.2% HbF and 3.7% HbA₂, was diagnosed as thalassemia major with compound heterozygotes of PolyA (T→C) and β17 by DNA sequencing. Conclusion: The diagnosis of β-thalassemia should be confirmed by clinical manifestations of hemolytic anemia, hemoglobin electrophoresis, gene diagnosis and family survey.

MicroRNA-497 suppress osteosarcoma by targeting MAPK/Erk pathway

BACKGROUND

The aim of this study was to study the mechanism of miRNA-497 in the apoptosis of osteosarcoma cells.

METHODS

MG-63 cells were divided into the three groups: NC, BL and miRNA groups, NC group were treated with nothing; BL group were transfected with blank vector; miRNA group were transfected with miRNA-497. Cell proliferation rate was detected by MTT method; Apoptosis rate was detected by flow cytometry and measuring the gene and protein expression of MAPK, Erk and P 21 by RT-PCR and Western blot.

RESULTS

The cell proliferation rate of miRNA group was significantly lower compared to NC group and BL group (p < 0.05); while the apoptosis rate of miRNA group (32.17 ± 3.23 %) was significantly higher than that of NC group  (8.40 ± 1.78 %) and BL group (8.83 ± 0.99 %) (p < 0.05, respectively). Regarding the gene expression detection, we found that gene and protein expressions of MAPK, Erk and P21 of miRNA group were significantly different compared to NC and BL groups (p < 0.05, respectively).

CONCLUSION

MiR-497 can activate P21 expression by inhibiting the expression of MAPK/Erk signaling pathway, thus promoting the apoptosis of osteosarcoma cells (Fig. 5, Ref. 18).

Mechanisms of transcriptional activation of the stimulator of interferon genes by transcription factors CREB and c-Myc

Stimulator of interferon genes (STING) plays an important role in host defense, autoimmune disease, osteoclast differentiation and anti-tumor response. Although many downstream targets have been studied in depth, the regulation of STING gene expression remains largely unknown. Here we demonstrate that transcription factors CREB and c-Myc maintain the transcriptional activity of STING. By 5′-rapid amplification of cDNA ends analysis, we identified the transcriptional start site (TSS) of STING. We illustrated that the region -124/+1 relative to TSS was sufficient for full promoter activity by a series of 5′ deletion promoter constructs. Transcriptional activity of the STING minimal promoter was dependent on CREB and c-Myc binding motifs and was abolished after mutation of these two DNA elements. Chromatin immunoprecipitation assays demonstrated that transcription factors CREB and c-Myc bind to STING promoter in vivo. Overexpression of CREB and c-Myc increased the STING promoter activity. Meanwhile, knocking-down of CREB and c-Myc by a small interfering RNA (siRNA) strategy markedly reduced endogenous STING expression. In summary, these results demonstrated that transcription factors CREB and c-Myc are involved in the regulation of STING transcription.

High uric acid (UA) downregulates bone alkaline phosphatase (BALP) expression through inhibition of its promoter activity

Bone metastases often occur in prostate cancers, lung cancers and breast cancers. Bone alkaline phosphatase (BALP) is one of the most commonly used serological markers for clinical evaluation of bone metabolism. Here, we reported that high concentrations of uric acid (UA) caused decrease of BALP levels and revealed that the effect of high concentrations of UA on the BALP expression was through inhibition of its promoter activity. Our results suggested physicians to think about serum UA status of patients with advanced cancer to avoid misdiagnosis when BALP was used to diagnose or assess the extent of bone metastases.

Different free prostate-specific antigen to total prostate-specific antigen ratios using three detecting systems

BACKGROUND

Prostate-specific antigen (PSA) is used as an indicative marker of a pathologic condition of the prostate, and the ratio of free PSA (fPSA) to total PSA (tPSA) helps to distinguish benign prostatic hyperplasia (BPH) from prostate cancer (PCa). In this study, we present some reversed ratios of fPSA to tPSA and analyze the possible mechanism.

METHODS

Using the UniCel DxI800 Access Immunoassay System, eight reversed fPSA to tPSA ratios were obtained, and then these samples were retested with an Abbott Architect i2000 Immunoassay Analyser and Cobas e602.

RESULTS

Four of the eight reversed ratios kept a ratio >1 using Abbott Architect i2000, and seven of them turned into a ratio <1 using Cobas e602.

CONCLUSION

In consideration of the assay these three detecting systems apply, the possible reason of the reversed ratios can be heterophile antibodies. To get accurate reason, further study is required.

[Expression of signaling pathway of mammalian target of rapamycin in articular cartilage cell induced by interleukin 1β]

Objective: To observe effect of interleukin(IL)-1β on the expression of signaling pathway of mammalian target of rapamycin(mTOR) of articular cartilage. Methods: Articular cartilage of rats was isolated under sterile technique, cells were digested by type Ⅱ collagenase and trypsin and cultured in vitro, pre-culture the Ⅱ cells for three days, different concentrations of IL-1β were added for 24 hours.The cells were stained with toluidine blue and HE, to observe morphological changes of cells.RT-PCR was used to detect the mRNA expression of typeⅡcollagen gene, aggrecan gene, mTOR gene and P70S6K gene, Western blotting was used to detect the expression of protein related to mTOR. Results: With increasing concentrations of IL-1β, the phenotype of cells appeared polygon into a spindle, the mRNA expression of gene of type Ⅱ collagen (the control group: 0.821±0.014; 1 ng/ml: 0.614±0.014; 10 ng/ml: 0.549±0.009; 100 ng/ml: 0.520±0.008), aggrecan(0.867±0.005; 0.857±0.001; 0.554±0.008; 0.538±0.004) and mTOR(0.845±0.015; 0.785±0.009; 0.569±0.025; 0.518±0.014) reduced, but P70S6K(0.465±0.024; 0.566±0.022; 0.663±0.022; 0.896±0.015) increased by PCR .Expression of protein detected by Western blotting was similar to the trend of PCR. Conclusion: mTOR signaling pathway may play an important role on the degeneration of articular cartilage, regulating mTOR signaling pathway may provides a new idea of delaying the degeneration process of cells.

Individualized correction of insulin measurement in hemolyzed serum samples

Insulin measurement plays a key role in the investigation of patients with hypoglycemia, subtype classification of diabetes mellitus, insulin resistance, and impaired beta cell function. However, even slight hemolysis can negatively affect insulin measurement due to RBC insulin-degrading enzyme (IDE). Here, we derived and validated an individualized correction equation in an attempt to eliminate the effects of hemolysis on insulin measurement. The effects of hemolysis on insulin measurement were studied by adding lysed self-RBCs to serum. A correction equation was derived, accounting for both percentage and exposure time of hemolysis. The performance of this individualized correction was evaluated in intentionally hemolyzed samples. Insulin concentration decreased with increasing percentage and exposure time of hemolysis. Based on the effects of hemolysis on insulin measurement of 17 donors (baseline insulin concentrations ranged from 156 to 2119 pmol/L), the individualized hemolysis correction equation was derived: INS_corr = INS_meas/(0.705lgHb_plasma/Hb_serum - 0.001Time - 0.612). This equation can revert insulin concentrations of the intentionally hemolyzed samples to values that were statistically not different from the corresponding insulin baseline concentrations (p = 0.1564). Hemolysis could lead to a negative interference on insulin measurement; by individualized hemolysis correction equation for insulin measurement, we can correct and report reliable serum insulin results for a wide range of degrees of sample hemolysis. This correction would increase diagnostic accuracy, reduce inappropriate therapeutic decisions, and improve patient satisfaction with care.

Preanalytical stability of adrenocorticotropic hormone depends on both time to centrifugation and temperature

OBJECTIVE

The purpose of our study was to analyze the effects of temperature, time delay, and time to centrifugation on the stability of human plasma adrenocorticotropin (ACTH) measurements.

METHODS

Twenty-one EDTA whole blood sample pools were centrifuged at 1100 ×g for 10 minutes at 4°C either immediately or after storage for 2, 4, 8, and 24 hours at 4°C or room temperature. Plasma ACTH was then measured either immediately or after 2, 4, 8, and 24 hours storage at 4°C or room temperature.

RESULTS

The change in ACTH concentrations was affected significantly (from 8.1±5.0% to 12.4±2.9% at 4 hours, P<.005) by time to centrifugation at room temperature. However, it remained stable (<5% change) up to 8 hours at 4°C in samples both centrifuged immediately and uncentrifuged.

CONCLUSIONS

To get accurate values of plasma ACTH concentrations, if the samples cannot be transferred to the laboratory for analysis at room temperature within 2 hours, they should be immediately stored at 4°C, and analyzed within 8 hours.