[Interpretation of global lung cancer statistics]

Lung cancer remains one of the leading cause of global cancer-related mortality, posing a significant burden of disease. Tobacco exposure stands as the foremost risk factor for lung cancer. Since the 1960, global efforts have gradually been implemented to control tobacco exposure, consequently reducing tobacco exposure levels within populations. This shift in exposure levels may have altered the epidemiological characteristics of lung cancer globally. This study aims to describe global lung cancer incidence data across five dimensions: age, gender, region, stage at diagnosis, and survival status, using global cancer registry data and relevant research findings. The objective is to elucidate the current epidemiological features of lung cancer worldwide, providing a scientific basis for lung cancer prevention and control. Furthermore, this study offers corresponding measures and recommendations for lung cancer prevention and control, aligning with the three-tiered cancer prevention strategy. Findings indicate that the incidence and mortality burden of lung cancer is significantly higher among the elderly population (aged 65 years and above) compared to the working-age population (aged 15-64 years). The aged-standardized incidence rate of lung cancer remains higher in males than in females, but the overall aged-standardized incidence rate of lung cancer in males shows a declining trend, while that in females shows an increasing trend. Regions with high and very high human development index (HDI) exhibit a substantially higher incidence and mortality burden of lung cancer compared to regions with low and very low HDI. Japan ranks highest in the diagnosis of stage Ⅰ lung cancer, with a diagnosis rate of 38.6%. Its age-standardized 5-year net survival rate is relatively high at 32.9%. Despite improvements in the survival status of lung cancer in certain countries like China and Japan, the overall prognosis for lung cancer remains pessimistic. Given the current epidemiological characteristics of lung cancer, reinforcing tobacco control measures and reducing female-specific lung cancer risk factors stand as significant goals for primary prevention. Promoting low-dose computed tomography screening for high-risk population, minimizing false-positive rates in lung cancer screening, and promoting medical system reforms and standardized treatment constitute principal measures for secondary and tertiary lung cancer prevention, respectively.

Poor personal protective equipment practices were associated with heat-related symptoms among Asian healthcare workers: a large-scale multi-national questionnaire survey

BACKGROUND

It is pertinent to understand the perceptions of healthcare workers (HCWs) with their associated personal protective equipment (PPE) usage and heat strain symptoms experienced to effectively combat the negative effects of heat stress during treatment and care activities.

METHODS

We evaluated the associated heat stress perceived by HCWs across Asia and validated a questionnaire on perceptions of heat stress, associated PPE usage, and heat strain symptoms experienced. The questionnaire was administered to 3,082 HCWs in six Asian regions. Factor analyses, including Cronbach's alpha, assessed the questionnaire's validity and reliability. Structural equation modelling analysed the effects of knowledge, attitudes and practices, and heat strain symptoms.

RESULTS

The questionnaire was found to be reliable in assessing HCWs' knowledge, and attitudes and practices towards heat stress and PPE usage (both Cronbach's alpha = 0.9), but not heat strain symptoms (Cronbach's alpha = 0.6). Despite knowledge of heat stress, HCWs had negative attitudes and practices regarding PPE usage (β1 = 0.6, p < 0.001). Knowledge (path coefficient = 0.2, p < 0.001), and negative attitudes and practices (path coefficient = 0.2, p < 0.001) of HCWs towards heat stress and PPE usage adversely affected symptoms experienced.

CONCLUSIONS

The questionnaire was not reliable in assessing symptoms. HCWs should, nevertheless, still self-assess their symptoms for early detection of heat strain. To effectively attenuate heat strain, understanding HCWs' attitudes and practices towards PPE usage should guide policymakers in implementing targeted heat management strategies.

Heat exposure and chronic kidney disease: a temporal link in a Taiwanese agricultural county

Heat stress-related kidney injury has drawn public health attention. This study explored the temporal relationships between impaired kidney function and preceding outdoor heat exposure Taiwan. Data of participants collected through a health screening program was used to assess the association between chronic kidney disease (CKD) and average ambient temperature with various time lag structures. A total of 1,243 CKD cases and 38,831 non-CKD participants were included in the study. After adjusting for demographic, socioeconomic, lifestyle factors, and comorbidities, CKD was positively associated with the ambient temperature within 1-9 months. The 9-month average ambient temperature yielded the highest odds ratio of CKD (OR = 1.22; 95% CI = 1.09-1.37). Furthermore, females and farmers were found to be more vulnerable to CKD risk after outdoor heat exposure. These findings suggest that the prevention of heat stress-related kidney injury should consider relevant time frames and focus on vulnerable populations.

Environmental asbestos exposure from nephrite jade mining and lung cancer

BACKGROUND

Nephrite is an asbestos mineral composed of tremolite and actinolite. Fengtian is a community where nephrite was mined between 1970 and 1980 and asbestos was mined between 1960 and 1985. The lung cancer risk to the surrounding community is unknown.

AIMS

To analyse the trend of lung cancer caused by environmental contamination from nephrite mining.

METHODS

We conducted a field survey of nephrite mines and tracked new cases of lung cancer from 1980 to 2019. We calculated the age-standardized incidence rates (ASIRs) and applied join-point regression to examine the lung cancer trend. We assessed the age effect, period effect, and birth cohort effect on lung cancer risk.

RESULTS

The nephrite mines were contaminated with chrysotile and tremolite/actinolite asbestos. A total of 278 new cases of lung cancer were reported during the study period. There was an apparent age effect and a slight period effect for lung cancer. After adjustment for the age and period effects, the birth cohort born between 1970 and 1980 during the period of nephrite mass production had the highest relative risk compared with other birth cohorts. The ASIR of lung cancer increased significantly from 1980 to 2010 (the annual percentage change = 6.8 %, 95 % CI: 4.0-9.7 %, P < 0.01) and then decreased 30 years after the cessation of nephrite jade mining.

CONCLUSIONS

Nephrite mining increases the risk of lung cancer in nearby communities.

[Current status of global colorectal cancer prevalence, prevention and control]

Objective: This paper provides a brief overview of the epidemiology of colorectal cancer in China and around the world, and discusses how to prevent colorectal cancer to reduce its disease burden. Method: Using the official database of GLOBOCAN 2020, the China Cancer Registry Annual Report compiled by the National Cancer Center, and data from CONCORD-3.Data management was performed by Microsoft Excel 2016 and R 4.2.1 Relevant graphs were generated using the ggplot2 package for result visualization. Result: An estimated 1 931 590 people were diagnosed with colorectal cancer worldwide in 2020 with an age-standardized incidence rate of 19.5 per 100 000. There were about 935 173 deaths caused by colorectal cancer internationally, with an age-standardized mortality rate of 9.0 per 100 000. Overall, colorectal cancer was the fourth most commonly diagnosed cancer and the third leading cause of cancer-related death worldwide in 2020. In China, the age-standardized incidence rate and mortality rate of colorectal cancer was 17.3 per 100 000 and 7.8 per 100 000, respectively. Gender differences in trends were observed, with a decreasing trend in incidence and mortality among females and an increasing trend in incidence and mortality among males. The primary risk factors for colorectal cancer include age, genetic factors, gastrointestinal disorders, dietary habits, and lifestyle et al. Conclusions: Colorectal cancer poses a significant burden globally and in China. The occurrence of colorectal cancer is closely related to physiology, genetics, behavioral habits, lifestyle, and disease factors. To better control the colorectal cancer burden with the lowest cost, specific measures should be taken to reduce exposure to established risk factors. By combining the disease prevention and control strategies of tertiary prevention in China with the characteristic factors of colorectal cancer, the incidence and mortality of colorectal cancer may be effectively controlled.

Advancing accuracy in breath testing for lung cancer: strategies for improving diagnostic precision in imbalanced data

BACKGROUND

Breath testing using an electronic nose has been recognized as a promising new technique for the early detection of lung cancer. Imbalanced data are commonly observed in electronic nose studies, but methods to address them are rarely reported.

OBJECTIVE

The objectives of this study were to assess the accuracy of electronic nose screening for lung cancer with imbalanced learning and to select the best mechanical learning algorithm.

METHODS

We conducted a case‒control study that included patients with lung cancer and healthy controls and analyzed metabolites in exhaled breath using a carbon nanotube sensor array. The study used five machine learning algorithms to build predictive models and a synthetic minority oversampling technique to address imbalanced data. The diagnostic accuracy of lung cancer was assessed using pathology reports as the gold standard.

RESULTS

We enrolled 190 subjects between 2020 and 2023. A total of 155 subjects were used in the final analysis, which included 111 lung cancer patients and 44 healthy controls. We randomly divided samples into one training set, one internal validation set, and one external validation set. In the external validation set, the summary sensitivity was 0.88 (95% CI 0.84-0.91), the summary specificity was 1.00 (95% CI 0.85-1.00), the AUC was 0.96 (95% CI 0.94-0.98), the pAUC was 0.92 (95% CI 0.89-0.96), and the DOR was 207.62 (95% CI 24.62-924.64).

CONCLUSION

Electronic nose screening for lung cancer is highly accurate. The support vector machine algorithm is more suitable for analyzing chemical sensor data from electronic noses.

[Epidemiological characteristics and spatiotemporal distribution of schizophrenia in Ningbo, 2018-2022]

Objective: To explore the temporal and spatial distribution characteristics of reported incidence of schizophrenia in Ningbo from 2018 to 2022 and to provide a scientific basis for rational allocation of mental health resources and comprehensive prevention and treatment of schizophrenia. Methods: The reported incidence data of schizophrenia from 2018 to 2022 were collected from Ningbo's mental health information management system, and the reported incidence was calculated by township. The spatial correlation analysis and the spatiotemporal scan analysis were used to study the spatiotemporal distribution of schizophrenia. Results: The reported incidence of schizophrenia decreased from 2018 to 2022, with 4 133 new cases reported, and the annual average reported incidence was 9.76/100 000. Global and local spatial autocorrelation analysis showed positive spatial correlations and hot spots in 2018-2020. The space-time scan analysis showed an incidence cluster in Dongqiao Town, Haishu District, during 2018-2019. The RR was 2.46, and the log-likelihood ratio was 256.89. Conclusions: The reported incidence of schizophrenia in Ningbo has obvious temporal and spatial aggregation, and the high incidence area explored can provide clues for further research on the correlation between environmental factors and the incidence of schizophrenia and has certain guiding significance for the rational allocation of mental health resources in Ningbo.

Chronic Kidney Disease Among Agricultural Workers in Taiwan: A Nationwide Population-Based Study

Introduction

Chronic kidney disease (CKD) in agricultural communities is a significant public health issue. We aimed to investigate the epidemiology of CKD among Taiwanese farmers and its association with outdoor heat exposure.

Methods

A nested case-control study was conducted on participants in the National Adult Health Examination (NAHE) from 2012 to 2018. The farming occupation was identified through National Health Insurance data. The primary outcomes of interest were the development of CKD, defined as a decreased estimated glomerular filtration rate (eGFR) with diagnosis by physicians, and CKD of undetermined etiology (CKDu), defined as CKD excluding common traditional etiologies. We calculated the county-wide average ambient temperature from a climate reanalysis dataset (ERA5-Land). All CKD cases were matched 1:2 to non-CKD participants by age and biological sex. We estimated the odds ratios (ORs) of CKD and CKDu for farmers and changes in mean ambient temperature (°C) before the examination.

Results

We identified 844,412 farmers and 3,750,273 nonfarmers. Among 24.9% of farmers and 7.4% of nonfarmers with reduced kidney function, only 1 in 7 received a diagnosis of CKD. The farming occupation was independently predictive of CKDu (OR = 1.09, 95% confidence interval [CI] = 1.001-1.18) but not CKD. Increased ambient temperature (°C) was associated with a higher risk of CKD (OR = 1.023, 95% CI = 1.017-1.029), with particularly strong associations observed among middle-aged participants and diabetics.

Conclusions

Taiwanese farmers might have a higher risk of developing CKDu. Outdoor heat exposure is associated with the development of CKD, and middle-aged participants and those with diabetes are more vulnerable than the general population.

Relationship of long working hours and night shift working hours with incident diabetes: a retrospective cohort study in Taiwan

PURPOSE

The relationship among long working hours, night shift working hours, and diabetes is still unclear. We aimed to evaluate the association of long working hours and night shift working hours with diabetes among health care workers.

METHODS

We conducted a retrospective cohort study among health care workers in a tertiary medical center in Taiwan from 2002 to 2019. We compared the risk of diabetes among tertiles of total working hours (35-41, 42-45, and ≥46 h per week) and evaluated the relationship between long working hours and diabetes risk. We divided participants into three work patterns: day work only, evening shift workers, and night shift workers. In night shift workers, we further evaluated night shift working hours and incident diabetes using tertiles of night shift working hours (<17, 17-45, and ≥46 h per month). We estimated hazard ratios and 95% confidence intervals for incident diabetes using multivariable Cox proportional hazards models.

RESULTS

The study included 7081 participants. There were 301 incident cases of diabetes during 52,454 person-years. The adjusted hazard ratio (95% confidence interval) for participants who worked greater than or equal to 46 working hours per week was 3.45 (1.27, 9.39) compared with those who worked 35-41 hours. Compared with night shift workers who worked less than 17 h, the adjusted hazard ratios (95% confidence interval) for those who worked 17-45 and ≥46 night shift working hours per month were 2.26 (1.08, 4.75) and 2.60 (1.27, 5.33), respectively.

CONCLUSIONS

Long working hours and night shift working hours increased the risk of diabetes.

[Epidemiological investigation on the local epidemic situation in Zhengzhou High-Tech Zone caused by SARS-CoV-2 Delta variant]

This study collected epidemic data of COVID-19 in Zhengzhou from January 1 to January 20 in 2022. The epidemiological characteristics of the local epidemic in Zhengzhou High-tech Zone caused by the SARS-CoV-2 Delta variant were analyzed through epidemiological survey and big data analysis, which could provide a scientific basis for the prevention and control of the Delta variant. In detail, a total of 276 close contacts and 599 secondary close contacts were found in this study. The attack rate of close contacts and secondary close contacts was 5.43% (15/276) and 0.17% (1/599), respectively. There were 10 confirmed cases associated with the chain of transmission. Among them, the attack rates in close contacts of the first, second, third, fourth and fifth generation cases were 20.00% (5/25), 17.86% (5/28), 0.72% (1/139) and 14.81% (4/27), 0 (0/57), respectively. The attack rates in close contacts after sharing rooms/beds, having meals, having neighbor contacts, sharing vehicles with the patients, having same space contacts, and having work contacts were 26.67%, 9.10%, 8.33%, 4.55%, 1.43%, and 0 respectively. Collectively, the local epidemic situation in Zhengzhou High-tech Zone has an obvious family cluster. Prevention and control work should focus on decreasing family clusters of cases and community transmission.

Extreme temperature increases the risk of stillbirth in the third trimester of pregnancy

Epidemiological studies have reported the association between extreme temperatures and adverse reproductive effects. However, the susceptible period of exposure during pregnancy remains unclear. This study aimed to assess the impact of extreme temperature on the stillbirth rate. We performed a time-series analysis to explore the associations between temperature and stillbirth with a distributed lag nonlinear model. A total of 22,769 stillbirths in Taiwan between 2009 and 2018 were enrolled. The mean stillbirth rate was 11.3 ± 1.4 per 1000 births. The relative risk of stillbirth due to exposure to extreme heat temperature (> 29 °C) was 1.18 (95% CI 1.11, 1.25). Pregnant women in the third trimester were most susceptible to the effects of extreme cold and heat temperatures. At lag of 0-3 months, the cumulative relative risk (CRR) of stillbirth for exposure to extreme heat temperature (29.8 °C, 97.5th percentile of temperature) relative to the optimal temperature (21 °C) was 2.49 (95% CI: 1.24, 5.03), and the CRR of stillbirth for exposure to extreme low temperature (16.5 °C, 1st percentile) was 1.29 (95% CI: 0.93, 1.80). The stillbirth rate in Taiwan is on the rise. Our findings inform public health interventions to manage the health impacts of climate change.

[Perioperative management and complication control of Le Fort Ⅲ osteotomy in children with syndromic craniosynostosis]

Objective: To summarize the preliminary efficacy, perioperative management and complications of Le Fort Ⅲ osteotomy and midface distraction in patients with syndromic craniosynostosis by retrospective analysis, and to provide clinical experience for reference. Methods: From October 2017 to January 2020, 20 patients with syndromic craniosynostosis underwent Le Fort Ⅲ osteotomy and distraction in The Department of Oral and Maxillofacial Surgery of Peking University International Hospital, including 11 males and 9 females, were involved. The median age was 7 years (1.5 to 15 years). Preoperative risk prevention plan was put forward by multidisciplinary evaluation, and preoperative intervention was carried out. The diagnostic data of SNA, airway volume, polysomnography (PSG), ophthalmology and occlusal relationship were obtained through specialized examination, and osteotomy and distraction surgical plan was formulated through virtual surgical planning. CT was taken 1 week and 3, 6, 12 months after operation, PSG and eye protrudence examination were conducted to evaluate the therapeutic effect, syndrome type, multiple disciplinary treatment (MDT) intervention, occurrence and outcome of complications were summarized. Results: There were 15 cases of Crouzon syndrome and 5 cases of Pfeiffer syndrome. Sleep apnea was the first complaint in 18 cases and exophthalmia in 2 cases. Preoperative interventional therapy included 4 cases of adenoid surgery, 2 cases of continuous positive airway pressure and 2 cases of maxillary expansion. The most common surgical complications were accidental fracture (14/20 cases, 70%), cerebrospinal fluid fistula (2 cases), internal carotid cavernous sinus fistula (1 case), postoperative hyponatraemia (5 cases), crying syndrome (2 cases), wound infection (2 cases), trichiasis of lower eyelid (4 cases), and nasal malformation (1 case). Three cases underwent unplanned secondary surgery. SNA, airway volume and mean percutaneous arterial oxygen saturation (SpO₂) six months after operation were significantly higher than those before operation (F=10.09, P=0.001; F=5.13, P<0.001; F=10.78, P=0.001), and the protrusion and apnea hypopnea index were significantly lower than those before surgery (F=6.73, P=0.010; F=18.47, P<0.001). There were no significant differences in SNA, airway volume, mean SpO₂, ophthalmology between 6 months after surgery and 1 year after surgery (P>0.05). Conclusions: Perioperative safety assessment and early intervention of MDT is an effective diagnosis and treatment model of Le Fort Ⅲ osteotomy and distraction for syndromic craniosynosis. The operative complications are mainly local, and systemic complications are controllable.

Aristolochic acid and the risk of cancers in patients with type 2 diabetes: Nationwide population-based cohort study

BACKGROUND

Both aristolochic acid (AA) exposure and diabetic can increase risk of certain cancers,whetherAAexposureincreases cancer risk in diabetic patientsisunknown. The purpose of this study was to investigate the association between the use of Chinese herbal products containing AA and the risk of cancer in diabetic patients.

METHODS

A cohort study was conducted using the National Health Insurance Research Database in Taiwan. Patients older than 18 years who were diagnosed with diabetes between 1997 and 2010 were enrolled in our cohort. The use of Chinese herbal products containing AA was recorded from the beginning of 1997 until the ban of herbs containing AA in November 2003. Patients were individually tracked to identify cancer incidence between 1997 and 2013. Only patients who visited traditional Chinese medicine clinics between 1997 and 1 year before the end of follow-up were included in the cohort to ensure comparability. Cox proportional hazards regression was used to calculate the hazard ratio for the association between the use of Chinese herbal products containing AA and the occurrence of cancer.

RESULTS

Among the 430 377 male and 431 956 female patients with diabetes enrolled in our cohort, 37 554 and 31 535 cancer diagnoses were recorded during the study period, respectively. The use of AA-containing herbal products was associated with a significantly higher risk of liver, colorectum, kidney, bladder, prostate, pelvis, and ureter cancer in a dose-dependent manner. An increased risk of extrahepatic bile duct cancer in women was also associated with AA exposure at doses of more than 500 mg.

CONCLUSIONS

Association between AA exposure and the risk of some cancers were found in this study. AA exposure might increase risk of kidney,bladder,pelvis, ureter,liver,colorectum,andprostatecancer in all patientsandextrahepatic bile duct cancerin women.

Indoor Air Pollution Increases the Risk of Lung Cancer

(1) Background: Cooking and burning incense are important sources of indoor air pollutants. No studies have provided biological evidence of air pollutants in the lungs to support this association. Analysis of pleural fluid may be used to measure the internal exposure dose of air pollutants in the lung. The objective of this study was to provide biological evidence of indoor air pollutants and estimate their risk of lung cancer. (2) Methods: We analyzed 14 common air pollutants in the pleural fluid of 39 cases of lung adenocarcinoma and 40 nonmalignant controls by gas chromatography-mass spectrometry. (3) Results: When we excluded the current smokers and adjusted for age, the adjusted odds ratios (ORs) were 2.22 (95% confidence interval CI = 0.77-6.44) for habitual cooking at home and 3.05 (95% CI = 1.06-8.84) for indoor incense burning. In females, the adjusted ORs were 5.39 (95% CI = 1.11-26.20) for habitual cooking at home and 6.01 (95% CI = 1.14-31.66) for indoor incense burning. In pleural fluid, the most important exposure biomarkers for lung cancer were naphthalene, ethylbenzene, and o-xylene. (4) Conclusions: Habitual cooking and indoor incense burning increased the risk of lung adenocarcinoma.

Accuracy of the Electronic Nose Breath Tests in Clinical Application: A Systematic Review and Meta-Analysis

(1) Background: An electronic nose applies a sensor array to detect volatile biomarkers in exhaled breath to diagnose diseases. The overall diagnostic accuracy remains unknown. The objective of this review was to provide an estimate of the diagnostic accuracy of sensor-based breath tests for the diagnosis of diseases. (2) Methods: We searched the PubMed and Web of Science databases for studies published between 1 January 2010 and 14 October 2021. The search was limited to human studies published in the English language. Clinical trials were not included in this review. (3) Results: Of the 2418 records identified, 44 publications were eligible, and 5728 patients were included in the final analyses. The pooled sensitivity was 90.0% (95% CI, 86.3-92.8%, I² = 47.7%), the specificity was 88.4% (95% CI, 87.1-89.5%, I² = 81.4%), and the pooled area under the curve was 0.93 (95% CI 0.91-0.95). (4) Conclusion: The findings of our review suggest that a standardized report of diagnostic accuracy and a report of the accuracy in a test set are needed. Sensor array systems of electronic noses have the potential for noninvasiveness at the point-of-care in hospitals. Nevertheless, the procedure for reporting the accuracy of a diagnostic test must be standardized.

[Influence of female age on the fresh cycle live birth rate of different controlled ovarian hyperstimulation protocols in poor ovarian response patients]

Objective: To investigate the influence of age on the fresh cycle live birth rate in patients with poor ovarian response in different controlled ovarian hyperstimulation groups. Methods: The clinical data of 3 342 patients in The First Affiliated Hospital of Zhengzhou University from February 2014 to November 2018 were retrospectively collected, including early-follicular phase long-acting gonadotropin-releasing hormone (GnRH) agonist long protocol group (1 375 cases), mid-luteal phase short-acting GnRH agonist long protocol group (1 161 cases) and GnRH antagonist protocol group (806 cases); each group was divided into 4 subgroups according to age: ≤30 years, 31－35 years, 36－40 years and >40 years, the pregnancy outcomes in each age subgroup were analyzed under different controlled ovarian hyperstimulation protocols. Results: In early-follicular phase long-acting GnRH agonist long protocol group, the final live birth rates of each age subgroup were 39.4% (228/579), 36.1% (135/374), 16.6% (48/290) and 3.0% (4/132); in mid-luteal phase short-acting GnRH agonist long protocol group, live birth rates of each age subgroup were 32.1% (99/308), 20.8% (55/264), 13.0% (45/346) and 7.0% (17/243); in GnRH antagonist protocol group, live birth rates of each age subgroup were 22.8% (26/114), 16.3% (25/153), 11.2% (31/278), and 3.8% (10/261); the live birth rate of each group decreased significantly with the increase of age (all P<0.01). When the age≤35 years old, the fresh cycle live birth rate of the early-follicular phase long-acting GnRH agonist long protocol group was significantly better than those of the other two groups (all P<0.01). The multivariate logistic regression analysis of age and live birth rate of the three controlled ovarian hyperstimulation groups showed age was the independent influence factor (OR=0.898, 95%CI: 0.873-0.916, P<0.01; OR=0.926, 95%CI: 0.890-0.996, P<0.01; OR=0.901, 95%CI: 0.863-0.960, P<0.01). Conclusions: Age is an independent influencing factor for the prediction of fresh cycle live birth rate in low ovarian response patients. No matter which controlled ovarian hyperstimulation protocol is adopted, the final live birth rate decreases significantly with the increase of women's age. In addition, the early-follicular phase long-acting GnRH agonist long protocol has the highest fresh cycle live birth rate among all controlled ovarian hyperstimulation groups.

The investigation of the volatile metabolites of lung cancer from the microenvironment of malignant pleural effusion

For malignant pleural effusions, pleural fluid cytology is a diagnostic method, but sensitivity is low. The pleural fluid contains metabolites directly released from cancer cells. The objective of this study was to diagnose lung cancer with malignant pleural effusion using the volatilomic profiling method. We recruited lung cancer patients with malignant pleural effusion and patients with nonmalignant diseases with pleural effusion as controls. We analyzed the headspace air of the pleural effusion by gas chromatography-mass spectrometry. We used partial least squares discriminant analysis (PLS-DA) to identify metabolites and the support vector machine (SVM) to establish the prediction model. We split data into a training set (80%) and a testing set (20%) to validate the accuracy. A total of 68 subjects were included in the final analysis. The PLS-DA showed high discrimination with an R² of 0.95 and Q² of 0.58. The accuracy of the SVM in the test set was 0.93 (95% CI 0.66, 0.998), the sensitivity was 83%, the specificity was 100%, and kappa was 0.85, and the area under the receiver operating characteristic curve was 0.96 (95% CI 0.86, 1.00). Volatile metabolites of pleural effusion might be used in patients with cytology-negative pleural effusion to rule out malignancy.

Epidemiology of chronic kidney disease of undetermined aetiology in Taiwanese farmers: a cross-sectional study from Changhua Community-based Integrated Screening programme

OBJECTIVES

Chronic kidney disease of undetermined or non-traditional aetiology (CKDu or CKDnT) has been reported in Mesoamerica among farmers under heat stress. Epidemiological evidence was lacking in Asian countries with similar climatic conditions. The objective of this study was to investigate the prevalence of CKDu and possible risk factors.

METHODS

We used the data from the Changhua Community-based Integrated Screening programme from 2005 to 2014, which is the annual screening for chronic diseases in Taiwan's largest rice-farming county since 2005. Our study population included farmers and non-farmers aged 15-60 years. CKDu was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m² at age under 60 years without hypertension, diabetes, proteinuria, haematuria or using Chinese herbal medicine. We estimated the adjusted prevalence OR (POR) of CKDu by farmers, age, sex, education, urbanisation, smoking, body mass index, hyperuricaemia, hyperlipidaemia, heart disease and chronic liver disease.

RESULTS

5555 farmers and 35 761 non-farmers were included in this study. CKDu accounted for 48.9% of all CKD cases. The prevalence of CKDu was 2.3% in the farmers and 0.9% in the non-farmers. The crude POR of CKDu in farmers compared with non-farmers was 2.73 (2.13-3.50), and the adjusted POR was 1.45 (1.10-1.90). Dehydration (blood urea nitrogen-to-creatinine ratio >20) was found in 22% of the farmers and 14% of the non-farmers.

CONCLUSIONS

Farmers in subtropical Asian countries are at increased risk of CKDu. Governments should take the CKDu epidemics seriously and provide farmers with occupational health education programmes on thermal hazards.

[Analysis on monitoring results of individual dose of occupational external radiation among radiation workers in Lanzhou in 2019]

Objective: To analyze the individual dose level of occupational external radiation of radiation workers in Lanzhou in 2019, so as to provide reference for radiation protection and occupational health management. Methods: In April 2020, a total of 1460 radiation workers in Gansu Provincial Center for Disease Control and Prevention in 2019 were selected as the research objects. The unit nature, hospital level and occupational category of the monitored workers were collected, and the monitoring results of external radiation personal dose in 2019 were analyzed and compared. Results: In the occupational external radiation monitoring of radiation workers in Lanzhou in 2019, the effective dose of 48 persons was 1.0~<5.0 mSv, the effective dose of 2 persons was 5.0~<10.0 mSv, the annual collective effective dose was 308.21 people·mSv, and the average annual effective dose of monitored persons was 0.21 mSv/a. There was significant difference in the distribution of annual effective dose per capita among different occupational groups (H=34.43, P<0.05) . The annual effective dose per capita of nuclear medicine personnel was higher (0.56 mSv/a) , followed by interventional radiology (0.33 mSv/a) . The ratio of annual collective dose to total annual collective dose with annual individual dose more than 5 mSv (SR(5)) and the ratio of the number of staff with annual individual dose more than 1mSv to the total number of monitored personnel (NR(1)) were higher in nuclear medicine and interventional radiology personnel. The average annual effective dose distribution of diagnostic radiologists in different level hospitals was statistically significant (H=16.46, P<0.05) . The average annual effective dose in private hospitals, community hospitals and health centers was higher (0.32 mSv) , followed by county hospitals (0.23 mSv) . Conclusion: The individual dose of occupational external radiation of radiation workers in Lanzhou is generally low, and the annual effective dose of nuclear medicine and interventional radiology workers is high. The management of radiation protection should be emphasis on this people. And it is suggested to strengthen the supervision of private hospitals and update and maintain the equipment of community health centers.

The Impact of Temperature on the Risk of COVID-19: A Multinational Study

The current understanding of ambient temperature and its link to the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. The objective of this study was to explore the environmental and climatic risk factors for SARS-CoV-2. For this study, we analyzed the data at the beginning of the outbreak (from 20 January to 31 March 2020) to avoid the influence of preventive or control measures. We obtained the number of cases and deaths due to SARS-CoV-2, international tourism, population age, universal health coverage, regional factors, the SARS-CoV-2 testing rate, and population density of a country. A total of 154 countries were included in this study. There were high incidence rates and mortality risks in the countries that had an average ambient temperature between 0 and 10 °C. The adjusted incidence rate for temperatures between 0 and 10 °C was 2.91 (95% CI 2.87–2.95). We randomly divided the data into a training set (80% of data) for model derivation and a test set (20% of data) for validation. Using a random forest statistical model, the model had high accuracy for predicting the high epidemic status of a country (ROC = 95.5%, 95% CI 87.9–100.0%) in the test set. Population age, temperature, and international tourism were the most important factors affecting the risk of SARS-CoV-2 in a country. An understanding the determinants of the SARS-CoV-2 outbreak can help to design better strategies for disease control. This study highlights the need to consider thermal effect in the prevention of emerging infectious diseases.

[Research progress of liposome drug delivery system in stomatology]

Liposomes are spherical vesicles with bilayer membrane structure spontaneously formed by phospholipids dispersed in an aqueous medium. Liposomes are excellent drug carrier with amphiphilic properties. Liposomes have good biocompatibility, biodegradability and no immunogenicity. Liposomes can achieve the delivery of the drug, enhance the solubility, improve the stability, reduce the toxic effect of the drug, and improve the therapeutic effect of the loaded drug. In recent years, liposome drug delivery systems have been widely used in dentistry. This article reviews the application of liposome drug delivery systems in caries, dental pulp diseases, periodontitis, implantation, oral anesthesia and oral candidiasis.

Impact of team-based community healthcare on preventable hospitalisation: a population-based cohort study in Taiwan

OBJECTIVES

The objective of this study was to explore the impact of Taiwan's Family Practice Integrated Care Project (FPICP) on hospitalisation.

DESIGN

A population-based cohort study compared the hospitalisation rates for ambulatory care sensitive conditions (ACSCs) among FPICP participating and non-participating patients during 2011-2015.

SETTING

The study accessed the FPICP reimbursement database of Taiwan's National Health Insurance (NHI) administration containing all NHI administration-selected patients for FPICP enrolment.

PARTICIPANTS

The NHI administration-selected candidates from 2011 to 2015 became FPICP participants if their primary care physicians joined the project, otherwise they became non-participants.

INTERVENTIONS

The intervention of interest was enrolment in the FPICP or not. The follow-up time interval for calculating the rate of hospitalisation was the year in which the patient was selected for FPICP enrolment or not.

PRIMARY OUTCOME MEASURES

The study's primary outcome measures were hospitalisation rates for ACSC, including asthma/chronic obstructive pulmonary disease (COPD), diabetes or its complications and heart failure. Logistic regression was used to calculate the ORs concerning the influence of FPICP participation on the rate of hospitalisation for ACSC.

RESULTS

The enrolled population for data analysis was between 3.94 and 5.34 million from 2011 to 2015. Compared to non-participants, FPICP participants had lower hospitalisation for COPD/asthma (28.6‰-35.9‰ vs 37.9‰-42.3‰) and for diabetes or its complications (10.8‰-14.9‰ vs 12.7‰-18.1‰) but not for congestive heart failure. After adjusting for age, sex and level of comorbidities by logistic regression, participation in the FPICP was associated with lower hospitalisation for COPD/asthma (OR 0.91, 95% CI 0.87 to 0.94 in 2015) and for diabetes or its complications (OR 0.87, 95% CI 0.83 to 0.92 in 2015).

CONCLUSION

Participation in the FPICP is an independent protective factor for preventable ACSC hospitalisation. Team-based community healthcare programs such as the FPICP can strengthen primary healthcare capacity.

[The effect of endocapillary hypercellularity lesions on the renal prognosis and response to immunosuppressive therapy in IgA nephropathy]

In this retrospective cohort study, we aim to evaluate the effect of endocapillary hypercellularity (E) lesions on the renal prognosis and response to immunosuppressive therapy, especially diffuse endocapillary hypercellularity lesion in IgA nephropathy (IgAN). A total of 365 patients with IgAN and E lesions and 31 patients with diffuse E lesions and over 12-month follow-up period were included in this study. We performed an 1∶1 propensity score to identify controls with matched clinical and pathological features from 769 IgAN patients without E lesions. The end-point was defined as a 30% decrease in estimated glomerular filtration rate (eGFR) or end-stage kidney disease. The kidney survival of the two groups was compared by Kaplan-Meier analysis. During median follow-up period of 41 months, kidney survival rates in patients with E lesions were 96.0% at 1 year, 83.6% at 3 years, 67.7% at 5 years; while they were 96.9% at 1 year, 83.6% at 3 years, and 68.7% at 5 years in patients without E lesions (P=0.265).The HR of immunosuppressive therapy was 1.038 (95%CI 0.749-1.440) and 1.113 (95%CI 0.770-1.609) in patients not receiving immunosuppressive therapy (P=0.781). (2) During median follow-up period of 52.5 months, the kidney survival rates in patients with diffuse E-lesion were 100.0% at 1 year, 96.2% at 3 years, 74.5% at 5 years; while they were 96.2% at 1 year, 82.3% at 3 years, and 63.7% at 5 years in patients without E-lesion (P=0.158). The HR of immunosuppressive therapy was 0.625 (95%CI 0.213-1.839) and 0.447 (95%CI 0.028-7.191) in patients not receiving immunosuppressive therapy (P=0.825). E lesion or diffuse E lesion may not be associated with prognosis or response to immunosuppressive therapy.

[Preliminary analysis on COVID-19 case spectrum and spread intensity in different provinces in China except Hubei province]

Objective: To analyze the characteristics of COVID-19 case spectrum and spread intensity in different provinces in China except Hubei province. Methods: The daily incidence data and case information of COVID-19 were collected from the official websites of provincial and municipal health commissions. The morbidity rate, severity rate, case-fatality rate, and spread ratio of COVID-19 were calculated. Results: As of 20 March, 2020, a total of 12 941 cases of COVID-19 had been conformed, including 116 deaths, and the average morbidity rate, severity rate and case-fatality rate were 0.97/100 000, 13.5% and 0.90%, respectively. The morbidity rates in Zhejiang (2.12/100 000), Jiangxi (2.01/100 000) and Beijing (1.93/100 000) ranked top three. The characteristics of COVID-19 case spectrum varied from province to province. The first three provinces (autonomous region, municipality) with high severity rates were Tianjin (45.6%), Xinjiang (35.5%) and Heilongjiang (29.5%). The case-fatality rate was highest in Xinjiang (3.95%), followed by Hainan (3.57%) and Heilongjiang (2.70%). The average spread ratio was 0.98 and the spread intensity varied from province to province. Tibet had the lowest spread ratio (0), followed by Qinghai (0.20) and Guangdong (0.23). Conclusion: The intervention measures were effective in preventing the spread of COVID-19 and improved treatment effect in China. However, there were significant differences among different regions in severity, case-fatality rate and spread ratio.

Team-based care improves quality of diabetes care -Family Practice Integrated Care Project in Taiwan

BACKGROUND

The Family Practice Integrated Care Project (FPICP) is a team-based program in Taiwan initiated in 2003. This study investigates the influence of FPICP on the quality of diabetes care.

METHODS

This population-based cohort study used Taiwan's National Health Insurance Administration data on FPICP (fiscal year 2015-2016, with follow-up duration of one year). Participants included diabetic patients aged ≥30 in primary care clinics. We used conditional logistic regression modeling of patient characteristics and annual diabetes examinations and compared FPICP participants with non-participating candidates. Main outcome measures included completion of annual diabetes examinations, including glycated hemoglobin (A1c), low-density lipoprotein (LDL), urine microalbumin (MAU), routine urinalysis (UR), and fundus examination (FE).

RESULTS

The sample included 298,208 FPICP participants and 478,778 non-participating candidates. After 1:1 propensity score matching, the examination completion rates for FPICP participants and non-participants, respectively, were 94.4% versus 93.6% in A1c, 84.2% versus 83.8% in LDL, 61.9% versus 60.1% in MAU, 59.2% versus 58.0% in UR, and 30.1% versus 32.4% in FE.

CONCLUSION

Our findings indicate that a program like FPICP helps improve the quality of diabetes care through regular examinations of Alc, LDL, MAU, and UR.

Automated Measurements of Key Morphological Features of Human Embryos for IVF

A major challenge in clinical In-Vitro Fertilization (IVF) is selecting the highest quality embryo to transfer to the patient in the hopes of achieving a pregnancy. Time-lapse microscopy provides clinicians with a wealth of information for selecting embryos. However, the resulting movies of embryos are currently analyzed manually, which is time consuming and subjective. Here, we automate feature extraction of time-lapse microscopy of human embryos with a machine-learning pipeline of five convolutional neural networks (CNNs). Our pipeline consists of (1) semantic segmentation of the regions of the embryo, (2) regression predictions of fragment severity, (3) classification of the developmental stage, and object instance segmentation of (4) cells and (5) pronuclei. Our approach greatly speeds up the measurement of quantitative, biologically relevant features that may aid in embryo selection.

[Analysis on the epidemic factors for COVID-19]

As a new infectious disease, the epidemic process of COVID-19 has a series of special influencing factors and conditions. In this paper, some obvious characteristics of this widespread epidemic are discussed, including the new pathogen making people feel confused, the slow onset bringing confusion to the clinic, the miscellaneous source of infection also causing confusion to prevention and control work, the easy route of transmissions leading to a sharp increase of confirmed cases, the high susceptibility of the population leading to a high incidence, and the natural epidemic process coupled with the complexity of natural factors and the superposition of social factors. The positive and effective prevention and control strategies and measures adopted by China have greatly changed the natural epidemic process and trajectory of this epidemic, which has been highly affirmed by the expert group of the World Health Organization and praised by many countries and international organizations. However, to sum up carefully and think deeply, it will be a long-term and arduous work to plan and realize public health security in China and even the world in the future.

[The preliminary analysis on the characteristics of the cluster for the COVID-19]

Since December 2019, COVID-19, a new emerging infection disease, has spread in 27 countries and regions. The clusters of many cases were reported with the epidemic progresses. We collected currently available information for 377 COVID-19 clusters (1 719 cases), excluded the hospital clusters and Hubei cases, during the period from January 1 to February 20, 2020. There were 297 family clusters (79%), case median was 4; 39 clusters of dining (10%), case median was 5; 23 clusters of shopping malls or supermarkets (6%), case median was 13; 12 clusters of work units (3%), case median was 6, and 6 clusters of transportation. We selected 325 cases to estimate the incubation period and its range was 1 to 20 days, median was 7 days, and mode was 4 days. The analysis of the epidemic situation in a department store in China indicated that there was a possibility of patients as the source of infection during the incubation period of the epidemic. From February 5 to 21, 2020, 634 persons were infected on the Diamond Princess Liner. All persons are susceptible to the 2019 coronavirus. Age, patients during the incubation period and the worse environment might be the cause of the cases rising. The progress of the two typical outbreaks clearly demonstrated the spread of the early cases in Wuhan. In conclusion, screening and isolating close contacts remained essential other than clinical treatment during the epidemic. Especially for the healthy people in the epidemic area, isolation was the key.

[Cloning and sequence analysis of leptin receptor overlapping transcript-like 1 gene from Dermatophagoides farinae]

OBJECTIVE

To obtain the leptin receptor overlapping transcript-like 1 encoding gene (LepROTL1 gene) from Dermatophagoides farina, investigate the molecular characteristics of the gene and construct a prokaryotic expression vector to express this gene.

METHODS

The LepROTL1 gene-encoding sequence fragments were captured based on the transcriptome sequencing results, and the full-length gene fragments were amplified from total RNA of D. farinae using a RT-PCR assay, and used to construct the expression plasmid pET28a(+)-LepROTL1, followed by sequencing. The plasmid was transformed into E. coli BL21 (DE3) T1R for the induction of IPTG expression. The expression product was characterized by SDS-PAGE and Western blotting. Bioinformatics analyses were performed to analyze the sequence and the molecular characteristics of its encoded protein.

RESULTS

The amplification products of the RT-PCR assay showed a clear band on agarose gel electrophoresis, and sequencing analysis of the pET28a(+)-LepROTL1 plasmid showed 417 bp in length of the coding gene from the start codon ATG to the termination codon TAA. Following the plasmid transformation into E. coli and induction with IPTG, a specific band was seen on SDS-PAGE, indicating successful expression. Bioinformatics analysis showed that the LepROTL1 gene-encoded protein was composed of 134 amino acids, and had a relative molecular weight of 14 378.13 Da, a hydrophilicity index of 1.149, and certain hydrophobicity. The secondary structure was composed of alpha-helix (19 aa, 14.18%), extended strand (48 aa, 35.82%) and random coil (67 aa, 50.00%). The deduced amino acid sequence was used to obtain homologous genes by BLAST, and the phylogenetic tree showed that D. farinae was clustered with D. pteronyssinus.

CONCLUSIONS

The full-length sequences and expression plasmid of the LepROTL1 gene are obtained, and the molecular features of the gene are demonstrated using bioinformatics analyses, which provide insights into further studies on the gene.

Diagnosis of ventilator-associated pneumonia using electronic nose sensor array signals: solutions to improve the application of machine learning in respiratory research

Background

Ventilator-associated pneumonia (VAP) is a significant cause of mortality in the intensive care unit. Early diagnosis of VAP is important to provide appropriate treatment and reduce mortality. Developing a noninvasive and highly accurate diagnostic method is important. The invention of electronic sensors has been applied to analyze the volatile organic compounds in breath to detect VAP using a machine learning technique. However, the process of building an algorithm is usually unclear and prevents physicians from applying the artificial intelligence technique in clinical practice. Clear processes of model building and assessing accuracy are warranted. The objective of this study was to develop a breath test for VAP with a standardized protocol for a machine learning technique.

Methods

We conducted a case-control study. This study enrolled subjects in an intensive care unit of a hospital in southern Taiwan from February 2017 to June 2019. We recruited patients with VAP as the case group and ventilated patients without pneumonia as the control group. We collected exhaled breath and analyzed the electric resistance changes of 32 sensor arrays of an electronic nose. We split the data into a set for training algorithms and a set for testing. We applied eight machine learning algorithms to build prediction models, improving model performance and providing an estimated diagnostic accuracy.

Results

A total of 33 cases and 26 controls were used in the final analysis. Using eight machine learning algorithms, the mean accuracy in the testing set was 0.81 ± 0.04, the sensitivity was 0.79 ± 0.08, the specificity was 0.83 ± 0.00, the positive predictive value was 0.85 ± 0.02, the negative predictive value was 0.77 ± 0.06, and the area under the receiver operator characteristic curves was 0.85 ± 0.04. The mean kappa value in the testing set was 0.62 ± 0.08, which suggested good agreement.

Conclusions

There was good accuracy in detecting VAP by sensor array and machine learning techniques. Artificial intelligence has the potential to assist the physician in making a clinical diagnosis. Clear protocols for data processing and the modeling procedure needed to increase generalizability.

Family physician system in Taiwan

Following economic development and increasing healthcare demand, Taiwan has not only built a universal healthcare coverage payment system in 1995, but has also developed an accountable family physician system, called the Family Practice Integrated Care Project (FPICP), to deal with the pressures of an ageing society, since 2003. The community healthcare group-based family physician system is not only an important milestone for the development of family medicine in Taiwan but may also even serve as a global example for future family doctor systems. In this review, we aim to review the development of family medicine in Taiwan, the implementation and achievement of the FPICP, as well as the future prospects of system-based healthcare system. We firmly believe that only when the family physician system is well developed and put into practice with person-centered, family as a care unit, and community-oriented holistic care, can the objective of "everyone has their own family doctor" and sustainable operation of National Health Insurance be achieved.

[Long-term efficacy analysis of laparoscopic-assisted anorectoplasty for high and middle imperforate anus]

Objective: To explore the long-term efficacy of laparoscopic-assisted anorectoplasty and conventional anorectoplasty in the treatment of children with high and middle anal atresia. Methods: A retrospective cohort study was used. Inclusion criteria: (1) children with high and middle anal atresia; (2) complicated with rectourethral or rectovesical fistula; (3) complete follow-up data. Exclusion criteria: (1) complicated with 21-trisomy; (2) cerebral palsy and other mentaldisabilities; (3) Currarino syndrome; (4) FG syndrome. Clinical data of 88 patients with middle and high anal atresia, who complicated with rectourethral fistula or rectovesical fistula, and underwent anoplasty at Department of Pediatric Surgery, the First Affiliated Hospital of Zhengzhou University from January 2009 to June 2014 were enrolled in the study and analyzed. There were 24 cases with middle atresia and 64 cases with high atresia. All the cases were divided into 2 groups based on the operative method: laparoscopic group (laparoscopic-assisted anorectoplasty, 49 cases), pena group (posterior sagittal anorectoplasty, 39 cases). The demographic features of two groups were comparable. There were no statistically significant differences in gender, age, body mass, classification of anomaly types and sacral ratio (all P>0.05). Student t test and Chi square tests were used to compare the surgical conditions (operative time, postoperative hospital stay and complications), anal function (Kelly score), constipation (Krickenbeck constipation score) and anorectal pressure. Results: Children of both groups all completed operation ssuccessfully. There were no statistically significant differences between laparoscopic group and pena group in the operative time [(120±31) minutes vs. (112±23) minutes, t=1.343, P=0.091] and postoperative hospital stay [(7.1±2.3) days vs. (10.7±3.3) days, t=6.021, P=1.000]. Complications were more common in the pena group [16.3% (8/49) vs. 35.9% (14/39), χ(2)=4.436, P=0.035]. The main complications in laparoscopic group were anal prolapse (8.2%, 4/49) and anal stenosis (6.2%, 3/49), while in pena group were anal stenosis (12.8%, 5/39) and perioperative perianal skin erosion (10.3%, 4/39). As for the anal function, the degree of feces, defecation control and sphincter contractility, the single scoring differences of Kelly scoring system were not statistically significant between the two groups, but the proportion of good function in the laparoscopic group was higher than that in the pena group [67.3% (8/49) vs. 38.5% (15/39), χ(2)=7.308, P=0.007]. Constipation occurred in 6 (12.2%) patients in the laparoscopic group, of whom 5 were improved by diet regulation and 1 required laxatives, while 9 (23.1%) patients developed constipation in the pena group, of whom 4 were improved by diet regulation and 5 required long-term laxatives. The difference of constipation ratio was not statistically significant (χ(2)=1.802, P=0.180). There were no cases of Krickenbeck constipation grade 3. Compared to the pena group, the laparoscopic group had higher anal resting pressure [(33.35±9.69) mmHg vs. (27.68±10.74) mmHg, t=2.599, P=0.011], higher dilating pressure [(9.00±5.61) mmHg vs.(6.51±3.24) mmHg, t=2.462, P=0.016], higher maximal squeeze pressure [(65.80±17.23) mmHg vs. (56.74±18.93) mmHg, t=2.389, P=0.019] and longer maximal contraction time [(21.16±5.02) seconds vs. (18.44±7.24) seconds, t=2.079, P=0.041]. The rectal resting pressure [(5.36±3.00) mmHg vs. (4.61±3.93) mmHg, t=1.015, P=0.312] was not statistically significantly different. Conclusions: Compared with posterior sagittal anorectoplasty, laparoscopic-assisted anorectoplasty in the treatment of high and middle anal atresia has better long-term efficacy with less perioperative complications.

[Clinical study on topography-guided laser ablation combined with accelerated corneal collagen cross-linking for early keratoconus]

Objective: To study the safety and efficacy of topography-guided customized excimer laser subepithelial ablation combined with accelerated collagen cross-linking technique in treatment of early keratoconus. Methods: Ninteen patients(20 eyes) (13 males 14 eyes, and 6 females 6 eyes), aged 12 to 44 years (24.7±8.0) were diagnosed as keratoconus by three-dimensional corneal topography and tomography, clinical history and examinations, and classified as KC1~KC3. Based on the classical excimer laser subepithelial keratomileusis (LASEK) method, topography guided laser ablation was performed with an excimer laser system (WaveLight EX500). After laser ablation, the corneal stromal bed was immersed with 0.1% riboflavin for 10 minutes, and then was irradiated by ultraviolet light (Avedro KXL) at 30 mW/cm(2) for 4 minutes. All the patients were followed up for more than 12 months. The uncorrected visual acuity (UCVA), diopter, best corrected visual acuity (BSCVA), corneal topography, central corneal endothelial cell density (ECD), hexagonal cell percentage (HEX), coefficient of variation (CV) and other indicators were observed. For normal distribution variables, Dunnett-t test was used before and after operation, and Wilcoxon test was used for variables with abnormal distribution. And the complications were recorded. Results: There was no loss of BSCVA at 12 months postoperatively, 20% of the eyes had no change of BSCVA, and 15% of the eyes gained 1 line of BSCVA, 15% of the eyes gained 2 lines of BSCVA, 50% of the eyes gained 3 lines and more of BSCVA. There was no significant difference in UCVA, BSCVA, manifest refractive spherical equivalent (MRSE) and the cylinder at 3 months postoperatively (P>0.05). The BSCVA were significantly improved at 6 and 12 months postoperatively compared with those before operation (t=3.095, 3.079, <0.05). Although there was no significant difference in UCVA and MRSE, the cylinder was significantly reduced at 6 and 12 months postoperatively (t=-2.890, -2.435, P<0.05). Apex curvature (Kapex) and mean pupil power (MPP) within 4.5mm of central cornea decreased significantly (Z=-2.903, P<0.01; Z=-2.667, P<0.01). Even though the thinnest corneal thickness decreased from pre-operational (461.9±31.1) μm to post-operational (416.6±27.0) μm (Z=-3.059, P<0.01), the cornea became regular with keratometric asymmetry index of anterior corneal surface decreased (Z=-2.667, P<0.01). The corneal optical quality parameters were improved. There was no significant difference in ECD, HEX and CV at 12 months postoperatively (P>0.05). Twelve months after operation, grade 0, 0.5, 1 and 2 haze were seen on 20%, 55%, 20% and 5% corneas respectively. Conclusions: The topography guided excimer laser ablation combined with accelerated corneal collagen cross linking is safe and effective in treatment of early stage keratoconus. It can significantly improve corneal regularity while preventing keratoconus progression, so as to improve the best corrected visual acuity postoperatively. (Chin J Ophthalmol, 2019, 55: 904-910).

TNF-α Suppresses Autophagic Flux in Acinar Cells in IgG4-Related Sialadenitis

IgG4-related sialadenitis (IgG4-RS) is a newly recognized immune-mediated systemic fibroinflammatory disease that affects salivary glands and leads to hyposalivation. Tumor necrosis factor-α (TNF-α) is a critical proinflammatory cytokine involved in several salivary gland disorders, but its role and mechanism regarding acinar cell injury in IgG4-RS are unknown. Here, we found that TNF-α level was significantly increased in serum and submandibular gland (SMG) of patients and that serum TNF-α level was negatively correlated with saliva flow rate. Ultrastructural observations of IgG4-RS SMGs revealed accumulation of large autophagic vacuoles, as well as dense fibrous bundles, decreased secretory granules, widened intercellular spaces, swollen mitochondria, and expanded endoplasmic reticulum. Expression levels of LC3 and p62 were both increased in patients' SMGs. TNF-α treatment led to elevated levels of LC3II and p62 in both SMG-C6 cells and cultured human SMG tissues but did not further increase their levels when combined with bafilomycin A1 treatment. Moreover, transfection of Ad-mCherry-GFP-LC3B in SMG-C6 cells confirmed the suppression of autophagic flux after TNF-α treatment. Immunofluorescence imaging revealed that costaining of LC3 and the lysosomal marker LAMP2 was significantly decreased in patients, TNF-α-treated SMG-C6 cells, and cultured human SMGs, indicating a reduction in autophagosome-lysosome fusion. Furthermore, the ratio of pro/mature cathepsin D was elevated in vivo, ex vivo, and in vitro. TNF-α also appeared to induce abnormal acidification of lysosomes in acinar cells, as assessed by lysosomal pH and LysoTracker DND-26 fluorescence intensity. In addition, TNF-α treatment induced transcription factor EB (TFEB) redistribution in SMG-C6 cells, which was consistent with the changes observed in IgG4-RS patients. TNF-α increased the phosphorylation of extracellular signal-regulated kinase (ERK) 1/2, and inhibition of ERK1/2 by U0126 reversed TNF-α-induced TFEB redistribution, lysosomal dysfunction, and autophagic flux suppression. These findings suggest that TNF-α is a key cytokine related to acinar cell injury in IgG4-RS through ERK1/2-mediated autophagic flux suppression.

Herbal Medicine Containing Aristolochic Acid and the Risk of Primary Liver Cancer in Patients with Hepatitis C Virus Infection

BACKGROUND

We investigated the association between taking herbal medicine (HM) containing aristolochic acid (AA) and the risk of primary liver cancer (PLC) among patients with hepatitis C virus (HCV) infection.

METHODS

This is a prospective study for the long-term follow-up of a nationwide population-based cohort of patients ages 18 years or older diagnosed with HCV infection during 1997 to 2010. A total of 223,467 HCV-infected patients were identified using the National Health Insurance Research Database in Taiwan. The use of HM containing AA was evaluated among patients who had visited traditional Chinese medicine clinics beginning from 1997 to 1 year prior to the diagnosis of PLC or dates censored (2003). We tracked each individual patient from 1997 to 2013 to identify incident cases of PLC since 1999.

RESULTS

During the follow-up period of 3,052,132 person-years, we identified 25,502 PLC cases; this corresponded to an overall incidence rate of 835.5 PLCs per 100,000 person-years. The adjusted HRs were 1.21 [95% confidence interval (CI), 1.18-1.24], 1.48 (95% CI, 1.37-1.59), 1.50 (95% CI, 1.34-1.68), and 1.88 (95% CI, 1.61-2.19) for estimated AA usage groups: 1 to 250, 251 to 500, 501 to 1,000, and more than 1,000 mg, respectively, relative to no AA exposure (reference group).

CONCLUSIONS

The current findings suggest that among HCV-positive patients, increasing exposure to AA poses an increased risk of acquiring PLC.

IMPACT

AA may increase the risk of PLC in HCV-positive populations.

Stomach Cancer and Exposure to Talc Powder without Asbestos via Chinese Herbal Medicine: A Population-Based Cohort Study

The present investigation was designed to explore the risk of stomach cancer by oral intake of talc powder without asbestos. We conducted a population-based cohort study on a randomly sampled cohort from Taiwan's health insurance database, with population of 1,000,000. The study participants were followed up through 2013. The outcome event of interest was the diagnosis of stomach cancer. The exposure of interest was the prescription of talc powder. Cox regression analyses were performed respectively. There were 584,077 persons without talc exposure and 21,575 talc users, 1849 diagnosed with stomach cancer. Persons with exposure of talc had a higher hazard ratio of stomach cancer (adjusted hazard ratio, 2.13; 95% confidence interval (CI), 1.54⁻2.94; p < 0.001). Classification by cumulative exposure of talc yielded adjusted hazard ratios of stomach cancer of 1.58 (95% CI, 0.79⁻3.17; p = 0.19) and 2.30 (95% CI, 1.48⁻3.57; p < 0.001) among persons with high (>21 g) and medium (6⁻21 g) exposure of talc, as compared to the low-exposure counterparts. Our data demonstrated positive association between increased risk of stomach cancer and oral intake of talc without asbestos. Despite the absence of dose-response effect, there might be a link between stomach cancer and talc.