Risk of cardiovascular death in patients with hepatocellular carcinoma based on the Fine-Gray model

BACKGROUND Hepatocellular carcinoma(HCC)is one of the most common types of cancers worldwide,ranking fifth among men and seventh among women,resulting in more than 7 million deaths annually.With the development of medical tech-nology,the 5-year survival rate of HCC patients can be increased to 70%.How-ever,HCC patients are often at increased risk of cardiovascular disease(CVD)death due to exposure to potentially cardiotoxic treatments compared with non-HCC patients.Moreover,CVD and cancer have become major disease burdens worldwide.Thus,further research is needed to lessen the risk of CVD death in HCC patient survivors.METHODS This study was conducted on the basis of the Surveillance,Epidemiology,and End Results database and included HCC patients with a diagnosis period from 2010 to 2015.The independent risk factors were identified using the Fine-Gray model.A nomograph was constructed to predict the CVM in HCC patients.The nomograph performance was measured using Harrell’s concordance index(C-index),calibration curve,receiver operating characteristic(ROC)curve,and area under the ROC curve(AUC)value.Moreover,the net benefit was estimated via decision curve analysis(DCA).RESULTS The study included 21545 HCC patients,of whom 619 died of CVD.Age(<60)[1.981(1.573-2.496),P<0.001],marital status(married)[unmarried:1.370(1.076-1.745),P=0.011],alpha fetoprotein(normal)[0.778(0.640-0.946),P=0.012],tumor size(≤2 cm)[(2,5]cm:1.420(1.060-1.903),P=0.019;>5 cm:2.090(1.543-2.830),P<0.001],surgery(no)[0.376(0.297-0.476),P<0.001],and chemotherapy(none/unknown)[0.578(0.472-0.709),P<0.001]were independent risk factors for CVD death in HCC patients.The discrimination and calibration of the nomograph were better.The C-index values for the training and validation sets were 0.736 and 0.665,respectively.The AUC values of the ROC curves at 2,4,and 6 years were 0.702,0.725,0.740 in the training set and 0.697,0.710,0.744 in the validation set,respectively.The calibration curves showed that the predicted probab-ilities of the CVM prediction model in the training set vs the validation set were largely consistent with the actual probabilities.DCA demonstrated that the prediction model has a high net benefit.CONCLUSION Risk factors for CVD death in HCC patients were investigated for the first time.The nomograph served as an important reference tool for relevant clinical management decisions.

孕产妇流感及疫苗的流行病学研究进展

流行性感冒(以下简称“流感”)每年呈季节性流行,孕妇作为流感的高危人群,感染后更易发展为严重疾病及并发症,也可对胎儿和新生儿产生不良影响。我国研究提示,孕妇对流感普遍易感,与一般健康育龄女性相比,孕妇出现严重疾病的风险增加至3.3倍[95%CI(2.7,4.0)]。妊娠女性感染流感可导致不良妊娠及分娩结局的发生,主要表现在住院患者中,特别是患有重症流感的妊娠女性。国外多项研究证实,孕前或孕期免疫接种流感疫苗可以起到明显的预防效果,妊娠期接种流感疫苗可降低其自身和新生儿流感发病率和死亡率。流感疫苗接种对妊娠结局也具有一定的保护作用,可降低母体发生流感感染相关胎盘早剥、早产、低出生体重和小于胎龄儿等风险。国际上大量的临床试验、观察性研究、疫苗上市后不良反应报告系统数据和相关临床指南均证实孕妇接种流感疫苗的安全性,但该人群流感疫苗的接种率一直很低,主要影响因素包括对流感及疫苗认知态度、既往疫苗接种行为、付费意愿以及卫生保健专业人员的推荐等。我国尚缺乏孕妇流感疫苗接种安全性评价的数据,部分流感疫苗产品说明书仍将孕产妇列为禁忌证。本文对孕产妇流感的流行特征及疫苗的流行病学研究进行综述,为相关防控政策制定及研究等提供科学依据。

Combining local regional therapy and systemic therapy:Expected changes in the treatment landscape of recurrent hepatocellular carcinoma

Improvements in early screening,new diagnostic techniques,and surgical treatment have led to continuous downward trends in hepatocellular carcinoma(HCC)morbidity and mortality rates.However,high recurrence and refractory cancer after hepatectomy remain important factors affecting the long-term prognosis of HCC.The clinical characteristics and prognosis of recurrent HCC are heterogeneous,and guidelines on treatment strategies for recurrent HCC are lacking.Therapies such as surgical resection,radiofrequency ablation,and transhepatic arterial chemoembolization are effective for tumors confined to the liver,and targeted therapy is a very important treatment for unresectable recurrent HCC with systemic metastasis.With the deepening of the understanding of the immune microenvironment of HCC,blocking immune checkpoints to enhance the antitumor immune response has become a new direction for the treatment of HCC.In addition,improvements in the tumor immune microenvironment caused by local treatment may provide an opportunity to improve the therapeutic effect of HCC treatment.Ongoing and future clinical trial data of combined therapy may develop the new treatment scheme for recurrent HCC.This paper reviews the pattern of recurrent HCC and the characteristics of the immune microenvironment,demonstrates the basis for combining local treatment and systemic treatment,and reports current evidence to better understand current progress and future approaches in the treatment of recurrent HCC.

无夹层底水油藏直井水锥定量描述

针对无夹层底水油藏,基于剩余油分布预测的目的,进行水锥定量描述非常必要。由于影响水锥范围的因素众多,采用渗流力学方法和数值模拟技术分别定性和定量研究了各因素的影响规律。根据静力学和渗流力学原理,分别考虑远井地带平面径向流和近井地带半球状向心流渗流特征,采用解析方法推导了水锥高度与水锥半径的关系,定性分析了影响水锥范围的主要因素,包括产液量、油水粘度比和避射高度。在此基础上建立典型底水油藏数值概念模型,计算了多种影响因素下的水锥形态,利用多元非线性回归方法得到水锥高度计算公式,通过积分得到水锥体积计算公式。以Z1油藏1口生产井为例,比较并分析了解析方法和定量计算公式的结果,定量计算公式更适用于水锥高度和体积的计算,可以广泛应用于无夹层底水油藏直井水锥范围的计算和预测。

Prognostic significance of combined preoperative fibrinogen and CA199 in gallbladder cancer patients

AIM To investigate the prognostic value of the combination of preoperative plasma fibrinogen and CA199 in patients with gallbladder carcinoma(GBC).METHODS The clinicopathological data of 154 GBC patients were retrospectively reviewed after surgery. A receiver operating characteristic(ROC) curve was plotted to verify the optimum cut-off values for plasma fibrinogen and CA199. Univariate and multivariate survival analyses were performed to identify the factors associated with GBC prognosis. based on the HRs calculated via multivariate survival analyses, patients with elevated plasma fibrinogen and CA199 levels were allocated a score of 2.1; those with an elevated plasma fibrinogen level only were allocated a score of 1, those with an elevated CA199 level only were allocated a score of 1.1, and those with neither of these abnormalities were allocated a score of 0.RESULTS ROC curve analysis showed that the optimum cut-off values for preoperative plasma fibrinogen and CA199 were 3.47 g/L and 25.45 U/mL, respectively. Multivariate analysis indicated that elevated preoperative plasma fibrinogen and CA199 levels were significantly correlated with worse overall survival(OS)(HR = 1.711, 95%CI: 1.114-2.627, P = 0.014, and HR = 1.842, 95%CI: 1.111-3.056, P = 0.018). When we combined these two parameters, the area under the ROC curve increased from 0.735(for preoperative plasma fibrinogen only) and 0.729(for preoperative CA199 only) to 0.765. When this combined variable was added to the multivariate analysis, the combination of plasma fibrinogen and CA199(P < 0.001), resection margin(P < 0.001) and TNM stage(P = 0.010) were independent prognostic factors for GBC.CONCLUSION The combination of plasma fibrinogen and CA199 may serve as a more efficient independent prognostic biomarker for postoperative GBC patients than either parameter alone.

Prognostic significance of the fibrinogen-to-albumin ratio in gallbladder cancer patients

AIM To investigate the prognostic role of fibrinogen-toalbumin ratio(FAR) on patients with gallbladder cancer(Gbc) in this study.METHODS One hundred and fifty-four Gbc patients were retro-spectively analyzed, who received potentially curative cholecystectomy in our institute from March 2005 to December 2017. Receiver operating characteristic curve(ROc curve) was used to determine the optimal cut-offs for these biomarkers. In addition, Kaplan-Meier survival analysis as well as multivariate analysis were applied for prognostic analyses.RESULTS ROc curve revealed that the optimal cut-off value for FAR was 0.08. FAR was significantly correlated with age(P = 0.045), jaundice(P < 0.001), differentiation(P = 0.002), resection margin status(P < 0.001), T stage(P < 0.001), TNM stage(P < 0.001), and c A199(P < 0.001) as well as albumin levels(P < 0.001). Multivariate analysis indicated that the resection margin status [hazard ratio(HR): 2.343, 95% confidence interval(c I): 1.532-3.581, P < 0.001], TNM stage(P = 0.035), albumin level(HR = 0.595, 95%c I: 0.385-0.921, P = 0.020) and FAR(HR: 2.813, 95%c I: 1.765-4.484, P < 0.001) were independent prognostic factors in Gbc patients.CONCLUSION An elevated preoperative FAR was significantly correlated with unfavorable overall survival in Gbc patients, while an elevated preoperative albumin level was a protective prognostic factor for patients with Gbc. The preoperative FAR could be used to predict the prognosis of Gbc patients, which was easily accessible, costeffective and noninvasive.

Nomogram to predict overall survival after gallbladder cancer resection in China

AIM To integrate clinically significant variables related to prognosis after curative resection for gallbladder carcinoma(GBC) into a predictive nomogram.METHODS One hundred and forty-two GBC patients who underwent curative intent surgical resection at Peking Union Medical College Hospital(PUMCH) were included. This retrospective case study was conducted at PUMCH of the Chinese Academy of Medical Sciences and Peking Union Medical College(CAMS & PUMC) in China from January 1, 2003 to January 1, 2018. The continuous variable carbohydrate antigen 19-9(CA19-9) was converted into a categorical variable(cCA19-9) based on the normal reference range. Stages 0 to IIIA were merged into one category, while the remaining stages were grouped into another category. Pathological grade X(GX) was treated as a missing value. A multivariate Cox proportional hazards model was used to select variables to construct a nomogram. Discrimination and calibration of the nomogram were performed via the concordance index(C-index) and calibration plots. The performance of the nomogram was estimated using the calibration curve. Receiver operating characteristic(ROC) curve analysis and decision curve analysis(DCA) were performed to evaluate the predictive accuracy and net benefit of the nomogram, respectively.RESULTS Of these 142 GBC patients, 55(38.7%) were male, and the median and mean age were 64 and 63.9 years, respectively. Forty-eight(33.8%) patients in this cohort were censored in the survival analysis. The median survival time was 20 months. A series of methods, including the likelihood ratio test and Akaike information criterion(AIC) as well as stepwise, forward, and backward analyses, were used to select the model, and all yielded identical results. Jaundice [hazard ratio(HR) = 2.9; 95% confidence interval(CI): 1.60-5.27], cCA19-9(HR = 3.2; 95%CI: 1.91-5.39), stage(HR = 1.89; 95%CI: 1.16-3.09), and resection(R)(HR = 2.82; 95%CI: 1.54-5.16) were selected as significant predictors and combined into a survival time predictive nomogram(C-index = 0.803; 95%CI: 0.766-0.839). High prediction accuracy(adjusted C-index = 0.797) was further verified via bootstrap validation. The calibration plot demonstrated good performance of the nomogram. ROC curve analysis revealed a high sensitivity and specificity. A high net benefit was proven by DCA.CONCLUSION A nomogram has been constructed to predict the overall survival of GBC patients who underwent radical surgery from a clinical database of GBC at PUMCH.

Prognostic impact of the red cell distribution width in esophageal cancer patients: A systematic review and meta-analysis

AIM To clarify the previous discrepant conclusions, we performed a meta-analysis to evaluate the prognostic value of red cell distribution width(RDW) in esophageal cancer(EC). METHODS We searched the PubM ed, EMBASE, Web of Science and Cochrane Library databases to identify clinical studies, followed by using STATA version 12.0 for statistical analysis. Studies that met the following criteria were considered eligible:(1) Studies including EC patients who underwent radical esophagectomy;(2) studies including patients with localized disease without distant metastasis;(3) studies including patients without preoperative neoadjuvant therapy;(4) studies including patients without previous antiinflammatory therapies and with available preoperative laboratory outcomes;(5) studies reporting association between the preoperative RDW and overall survival(OS)/disease-free survival(DFS)/cancer-specific survival(CSS); and(6) studies published in English.RESULTS A total of six articles, published between 2015 and 2017, fulfilled the selection criteria in the end. Statistical analysis showed that RDW was not associated with the prognosis of EC patients, irrespective of OS/CSS [hazard ratio(HR) = 1.27, 95% confidence interval(CI): 0.97-1.57, P = 0.000] or DFS(HR = 1.42, 95%CI: 0.96-1.88, P = 0.000). Subgroup analysis indicated that elevated RDW was significantly associated with worse OS/CSS of EC patients when RDW > 13%(HR = 1.45, 95%CI: 1.13-1.76, P = 0.000), when the patient number ≤ 400(HR = 1.45, 95%CI: 1.13-1.76, P = 0.000) and when the study type was retrospective(HR = 1.42, 95%CI : 1.16-1.69, P = 0.000).CONCLUSION Contrary to our general understanding, this meta-analysis revealed that RDW cannot serve as an indicator of poor prognosis in patients with EC. However, it may still be a useful predictor of unfavorable prognosis using an appropriate cut-off value.

Efficacy and safety of lenvatinib for patients with advanced hepatocellular carcinoma: A retrospective, real-world study conducted in China

BACKGROUND Lenvatinib has become an indispensable part of treatment regimens for patients with advanced hepatocellular carcinoma(aHCC).Several recent real-world studies appear to have confirmed this;however,there are etiological differences.This necessitates further real-world studies of lenvatinib across diverse populations,such as in China.AIM To investigate the efficacy and safety of lenvatinib in a Chinese HCC patient population under real-world conditions.METHODS This is a retrospective and multiregional study involving patients with aHCC receiving lenvatinib monotherapy.Efficacy was assessed using the Response Evaluation Criteria in Solid Tumors version 1.1.Baseline characteristics and adverse events(AEs)were recorded throughout the entire study.RESULTS In total,54 HCC patients treated with lenvatinib monotherapy were included for final analysis.The objective response rate was 22%(n=12)with a progressionfree survival(PFS)of 168 d;however,AEs occurred in 92.8%of patients.Multivariate analysis showed that the Barcelona Clinic Liver Cancer stage[hazard ratio(HR)0.465;95%CI:0.23-0.93;P=0.031],portal vein tumor thrombus(HR 0.38;95%CI:0.15-0.94;P=0.037)and Child-Pugh classifications(HR 0.468;95%CI:and specificity(83.3%)of decreasing serum biomarkers including alphafetoprotein were calculated in order to predict tumor size reduction.Gene sequencing also provided insights into potential gene mutation signatures related to the effect of lenvatinib.CONCLUSION Our findings confirm previous evidence from the phase III REFLECT study.The majority of patients in this Chinese sample were suffering from concomitant hepatitis B virus-related HCC.However,further analysis suggested that baseline characteristics,changes in serum biomarkers and gene sequencing may hold the key for predicting lenvatinib responses.Further large-scale prospective studies that incorporate more basic medical science measures should be conducted.

Albumin-to-alkaline phosphatase ratio: A novel prognostic index of overall survival in cholangiocarcinoma patients after surgery

AIM To clarify the prognostic significance of preoperative albumin-to-alkaline phosphatase ratio(AAPR) in cholangiocarcinoma(CCA) subjects receiving surgery.METHODS In this retrospective study, we included 303 CCA patients receiving surgery without preoperative therapy between 2002 and 2014. Clinicopathological characteristics(including AAPR) were analyzed to determine predictors of postoperative overall survival and recurrence-free survival(RFS). In addition,univariate and multivariate Cox proportional hazards models were conducted,followed by application of time-dependent receiver operating curves to identify the optimal cut-off.RESULTS Univariate and multivariate analyses revealed both decreased overall survival[hazard ratio(HR): 2.88, 95%CI: 1.19-5.78] and recurrence-free survival(HR: 2.31,95%CI: 1.40–3.29) in patients with AAPR < 0.41 compared to those with AAPR ≥0.41. The optimal cut-off of AAPR was 0.41. Of the 303 subjects, 253(83.5%) had an AAPR over 0.41. The overall 1-, 3- and 5-year survival rates were 70.2%, 38.0% and 16.5%, respectively in the low(< 0.41) AAPR group, which were significantly lower than those in the high(≥ 0.41) AAPR group(81.7%, 53.9%, and 33.4%,respectively)(P < 0.0001). Large tumor size, multiple tumors, and advanced clinical stage were also identified as significant predictors of poor prognosis.CONCLUSION Our outcomes showed that AAPR was a potential valuable prognostic indicator in CCA patients undergoing surgery, which should be further confirmed by prospective studies. Moreover, it is necessary to investigate the mechanisms concerning the correlation of low AAPR with poor post-operative survival in CCA patients.

Complete or partial split in associating liver partition and portal vein ligation for staged hepatectomy: A systematic review and meta-analysis

BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been adopted by liver surgeons in recent years.However,high morbidity and mortality rates have limited the promotion of this technique.Some recent studies have suggested that ALPPS with a partial split can effectively induce the growth of future liver remnant(FLR)similar to a complete split with better postoperative safety profiles.However,some others have suggested that ALPPS can induce more rapid and adequate FLR growth,but with the same postoperative morbidity and mortality rates as in partial split of the liver parenchyma in ALPPS(p-ALPPS).AIM To perform a systematic review and meta-analysis on ALPPS and p-ALPPS.METHODS A systematic literature search of PubMed,Embase,the Cochrane Library,and ClinicalTrials.gov was performed for articles published until June 2019.Studies comparing the outcomes of p-ALPPS and ALPPS for a small FLR in consecutive patients were included.Our main endpoints were the morbidity,mortality,and FLR hypertrophy rates.We performed a subgroup analysis to evaluate patients with and without liver cirrhosis.We assessed pooled data using a random-effects model.RESULTS Four studies met the inclusion criteria.Four studies reported data on morbidity and mortality,and two studies reported the FLR hypertrophy rate and one study involved patients with cirrhosis.In the non-cirrhotic group,p-ALPPS-treated patients had significantly lower morbidity and mortality rates than ALPPStreated patients[odds ratio(OR)=0.2;95%confidence interval(CI):0.07–0.57;P=0.003 and OR=0.16;95%CI:0.03-0.9;P=0.04].No significant difference in the FLR hypertrophy rate was observed between the two groups(P>0.05).The total effects indicated no difference in the FLR hypertrophy rate or perioperative morbidity and mortality rates between the ALPPS and p-ALPPS groups.In contrast,ALPPS seemed to have a better outcome in the cirrhotic group.CONCLUSION The findings of our study suggest that p-ALPPS is safer than ALPPS in patients without cirrhosis and exhibits the same rate of FLR hypertrophy.

Factors related to improved American Spinal Injury Association grade of acute traumatic spinal cord injury

BACKGROUND Acute traumatic spinal cord injury(ATSCI)usually results in disability,yet data on contemporary national trends of ATSCI incidence are limited.AIM To provide a systematic and basic theoretical basis for improving the treatment of acute spinal cord injury.METHODS Data from the Peking University Third Hospital Inpatient Sample databases were analyzed.A total of 304 patients with ATSCI were included from 2012 to 2017.The epidemiological data,treatment,complications and clinical outcomes of these patients were reviewed.RESULTS Of the 304 patients,257(84.5%)were male,and 75%of the patients were 55 years old or younger.135 patients had improved follow-up American Spinal Injury Association(ASIA)grades(44.4%).Only 14 patients with ASIA grade A improved.A statistically significant difference in prognosis between patients who underwent surgery within 72 h and those who underwent surgery after 72 h was observed(P<0.05).Surgery within 72 h resulted in better prognosis.The Steroid group and the Non-Steroid group showed a significant difference in outcome among patients with ASIA grades A and B(P<0.05).Patients with pneumonia had a poorer prognosis than patients without pneumonia(P<0.05).Surgery within 72 h resulted in better prognosis.CONCLUSION This study found that there was no significant difference in hospitalization time and prognosis between the Steroid group and the Non-Steroid group,but the patients with severe spinal cord injury(ASIA grades A and B)who underwent surgery combined with steroid therapy had a better prognosis than those who underwent surgery alone.The disastrous consequences of ATSCI and lack of consensus on the management strategy are obvious.Further improvements in treatment planns are needed in order to obtain more reliable functional outcomes.

Hyperthyroid heart disease in pregnancy: Retrospective analysis of a case series and review of the literature

BACKGROUND Hyperthyroidism in pregnancy may pose a great threat to maternal and fetal health.The risk of hyperthyroid heart disease(HHD),even heart failure,is significantly elevated in pregnant women.AIM To investigate the clinical characteristics,prognosis,and therapy of HHD in pregnant women.METHODS We searched the patient registry data at West China Second University Hospital of Sichuan University in Chengdu,China,following the approval by the Ethics Committee.We retrospectively analyzed the clinical characteristics of pregnant women diagnosed with HHD.The medical records of women with HHD during pregnancy from January 2012 to December 2017 were obtained from the electronic medical records system.All the included patients were followed in outpatient clinics and by telephone interviews until October 2018.RESULTS A total of 155 patients were diagnosed with thyrotoxicosis,of whom six were diagnosed with HHD.Three of them had regular antenatal care.Two patients were complicated with acute heart failure attacks,and one of them had a stillbirth.Both of these patients had a long history of Graves’disease with poor treatment compliance.Treatments of precipitating factors such as the control of infection could relieve the symptoms and prolong gestation for a better prognosis.Hyperthyroid heart failure could be controlled with aggressive diuretics and management of the coexisting complications.Intense monitoring and timely anti-heart failure treatment were crucial in patients with severe cardiac damage.Our findings indicated the importance of regular antenatal care and treatment adherence in patients with hyperthyroidism.CONCLUSION The timely and accurate diagnosis of HHD and the implementation of effective management are important for a better prognosis in pregnant women with HHD.Improvement in patients’awareness of thyrotoxicosis is needed.

Application value of mixed reality in hepatectomy for hepatocellular carcinoma

BACKGROUND As a new digital holographic imaging technology,mixed reality(MR)technology has unique advantages in determining the liver anatomy and location of tumor lesions.With the popularization of 5 G communication technology,MR shows great potential in preoperative planning and intraoperative navigation,making hepatectomy more accurate and safer.AIM To evaluate the application value of MR technology in hepatectomy for hepatocellular carcinoma(HCC).METHODS The clinical data of 95 patients who underwent open hepatectomy surgery for HCC between June 2018 and October 2020 at our hospital were analyzed retrospectively.We selected 95 patients with HCC according to the inclusion criteria and exclusion criteria.In 38 patients,hepatectomy was assisted by MR(Group A),and an additional 57 patients underwent traditional hepatectomy without MR(Group B).The perioperative outcomes of the two groups were collected and compared to evaluate the application value of MR in hepatectomy for patients with HCC.RESULTS We summarized the technical process of MR-assisted hepatectomy in the treatment of HCC.Compared to traditional hepatectomy in Group B,MR-assisted hepatectomy in Group A yielded a shorter operation time(202.86±46.02 min vs 229.52±57.13 min,P=0.003),less volume of bleeding(329.29±97.31 mL vs 398.23±159.61 mL,P=0.028),and shorter obstructive time of the portal vein(17.71±4.16 min vs 21.58±5.24 min,P=0.019).Group A had lower alanine aminotransferas and higher albumin values on the third day after the operation(119.74±29.08 U/L vs 135.53±36.68 U/L,P=0.029 and 33.60±3.21 g/L vs 31.80±3.51 g/L,P=0.014,respectively).The total postoperative complications and hospitalization days in Group A were significantly less than those in Group B[14(37.84%)vs 35(60.34%),P=0.032 and 12.05±4.04 d vs 13.78±4.13 d,P=0.049,respectively].CONCLUSION MR has some application value in three-dimensional visualization of the liver,surgical planning,and intraoperative navigation during hepatectomy,and it significantly improves the perioperative outcomes of hepatectomy for HCC.

Correlation between the warning symptoms and prognosis of cardiac arrest

BACKGROUND A low survival rate in patients with cardiac arrest is associated with failure to recognize the condition in its initial stage.Therefore,recognizing the warning symptoms of cardiac arrest in the early stage may play an important role in survival.AIM To investigate the warning symptoms of cardiac arrest and to determine the correlation between the symptoms and outcomes.METHODS We included all adult patients with all-cause cardiac arrest who visited Peking University Third Hospital or Beijing Friendship Hospital between January 2012 and December 2014.Data on population,symptoms,resuscitation parameters,and outcomes were analysed.RESULTS Of the 1021 patients in the study,65.9%had symptoms that presented before cardiac arrest,25.2%achieved restoration of spontaneous circulation(ROSC),and 7.2%survived to discharge.The patients with symptoms had higher rates of an initial shockable rhythm(12.2%vs 7.5%,P=0.020),ROSC(29.1%vs 17.5%,P=0.001)and survival(9.2%vs 2.6%,P=0.001)than patients without symptoms.Compared with the out-of-hospital cardiac arrest(OHCA)without symptoms subgroup,the OHCA with symptoms subgroup had a higher rate of calls before arrest(81.6%vs 0.0%,P<0.001),health care provider-witnessed arrest(13.0%vs 1.4%,P=0.001)and bystander cardiopulmonary resuscitation(15.5%vs 4.9%,P=0.002);a shorter no flow time(11.7%vs 2.8%,P=0.002);and a higher ROSC rate(23.8%vs 13.2%,P=0.011).Compared to the in-hospital cardiac arrest(IHCA)without symptoms subgroup,the IHCA with symptoms subgroup had a higher mean age(66.2±15.2 vs 62.5±16.3 years,P=0.005),ROSC(32.0%vs 20.6%,P=0.003),and survival rates(10.6%vs 2.5%,P<0.001).The top five warning symptoms were dyspnea(48.7%),chest pain(18.3%),unconsciousness(15.2%),paralysis(4.3%),and vomiting(4.0%).Chest pain(20.9%vs 12.7%,P=0.011),cardiac etiology(44.3%vs 1.5%,P<0.001)and survival(33.9%vs 16.7%,P=0.001)were more common in males,whereas dyspnea(54.9%vs 45.9%,P=0.029)and a non-cardiac etiology(53.3%vs 41.7%,P=0.003)were more common in females.CONCLUSION Most patients had warning symptoms before cardiac arrest.Dyspnea,chest pain,and unconsciousness were the most common symptoms.Immediately recognizing these symptoms and activating the emergency medical system prevents resuscitation delay and improves the survival rate of OHCA patients in China.

Angiotensin converting enzymes inhibitors or angiotensin receptor blockers should be continued in COVID-19 patients with hypertension

BACKGROUND Recent studies have revealed that sustained ingestion of angiotensin converting enzymes inhibitors or angiotensin receptor blockers(ACEIs/ARBs)had no harmful effects on coronavirus disease 2019(COVID-19)patients complicated with hypertension.AIM To investigate the impact on COVID-19 patients complicated with hypertension who discontinued using ACEIs/ARBs.METHODS All COVID-19 patients complicated with hypertension admitted to our isolated unit were consecutively recruited in this study.Some patients switched from ACEIs/ARBs to calcium channel blocker(CCBs)after admission,while others continued using non-ACEIs/ARBs.We compared characteristics and clinical outcomes between these two groups of patients.RESULTS A total of 53 patients were enrolled,27 patients switched from ACEIs/ARBs to CCBs while 26 patients continued with non-ACEIs/ARBs.After controlling potential confounding factors using the Cox proportional hazards model,hospital stay was longer in patients who discontinued ACEIs/ARBs,with a hazard ratio of 0.424(95%confidence interval:0.187-0.962;P=0.040),upon discharge than patients using other anti-hypertensive drugs.A sub-group analysis showed that the effect of discontinuing use of ACEIs/ARBs was stronger in moderate cases[hazard ratio=0.224(95%confidence interval:0.005-0.998;P=0.0497)].CONCLUSION Patients in the discontinued ACEIs/ARBs group had longer hospital stays.Our findings suggest that COVID-19 patients complicated with hypertension should continue to use ACEIs/ARBs.

Multidisciplinary management of hepatobiliary tumors in the era of precision medicine

Hepatobiliary tumor (HBT), one of the leading causes of cancer deaths globally, is more frequent in East Asia including China [1].HBTincludeslivercancer,cholangiocarcinomaandgallbladder cancer.HBTburdenvariesmarkedlybygenderandgeographic regionduetotheexposureofriskfactors.MajorityofthehepatocellularcarcinomasareassociatedwithhepatitisB-typevirus

Changes in plant debris and carbon stocks across a subalpine forest successional series

Background:As a structurally and functionally important component in forest ecosystems,plant debris plays a crucial role in the global carbon cycle.Although it is well known that plant debris stocks vary greatly with tree species composition,forest type,forest origin,and stand age,simultaneous investigation on the changes in woody and non-woody debris biomass and their carbon stock with forest succession has not been reported.Therefore,woody and non-woody debris and carbon stocks were investigated across a subalpine forest successional gradient in Wanglang National Nature Reserve on the eastern Qinghai-Tibet Plateau.Results:Plant debris ranged from 25.19 to 82.89 Mg∙ha−1 and showed a global increasing tendency across the subalpine forest successional series except for decreasing at the S4 successional stage.Accordingly,the ratios of woody to non-woody debris stocks ranged from 26.58 to 208.89,and the highest and lowest ratios of woody to non-woody debris stocks were respectively observed in mid-successional coniferous forest and shrub forest,implying that woody debris dominates the plant debris.In particular,the ratios of coarse to fine woody debris stocks varied greatly with the successional stage,and the highest and lowest ratios were found in later and earlier successional subalpine forests,respectively.Furthermore,the woody debris stock varied greatly with diameter size,and larger diameter woody debris dominated the plant debris.Correspondingly,the carbon stock of plant debris ranged from 10.30 to 38.87 Mg∙ha−1 across the successional series,and the highest and lowest values were observed in the mid-coniferous stage and shrub forest stage,respectively.Most importantly,the carbon stored in coarse woody debris in later successional forests was four times higher than in earlier successional forests.Conclusions:The stock and role of woody debris,particularly coarse woody debris,varied greatly with the forest successional stage and dominated the carbon cycle in the subalpine forest ecosystem.Thus,preserving coarse woody debris is a critical strategy for sustainable forest management.

A Resource-Based Pricing Collaborative Approach for Mitigating DDoS Attack in Mobile Edge Computing

Resource-constrainted and located closer to users,edge servers are more vulnerable to Distributed Denial of Service(DDoS)attacks.In order to mitigate the impact of DDoS attacks on benign users,this paper designed a Resource-based Pricing Collaborative approach(RPC)in mobile edge computing.By introducing the influence of resource prices on requester in economics,a collaboration model based on resource pricing was established,and the allocation of user request was regarded as a game strategy to obtain the overall minimum offloading cost of the user in network.The article theoretically proved the existence and rationality of the Nash equilibrium.Finally,simulation results verified the effectiveness and feasibility of the proposed approach in two experimental scenes.Experimental results shows that RPC can effectively improve the network ability to mitigate DDoS attacks,and alleviate the adverse effects of server attacks under delay constraints.

Single-cell transcriptome analysis reveals a cancer-associated fibroblast marker gene signature in hepatocellular carcinoma that predicts prognosis

Background and aims:Hepatocellular carcinoma(HCC)is one of the leading causes of cancer death.Multi-pathway combination therapy is used to treat HCC,and immunotherapy is also a routine part of treatment.As a major component of the tumor microenvironment(TME),cancer-associated fibroblasts(CAFs)actively participate in cancer progression through complex functions.However,because CAFs dynamically change during cancer development,most of the current treatment strategies targeting CAFs fail.We created a prognostic CAF marker gene signature(CAFMGS)to investigate the utility of CAFs as a prognostic factor and therapeutic target.Methods:Gene Expression Omnibus(GEO)single-cell RNA sequencing(Sc-RNA-seq)data were analyzed to identify CAF marker genes in HCC.The Cancer Genome Atlas(TCGA)database was used as a training cohort to construct the CAFMGS model and the International Cancer Genome Consortium(ICGC)dataset was used to validate the CAFMGS.Results:Marker genes in the CAFMGS model were(0.0001-SPP1),(0.0084-VCX3A),(0.0015-HMGA1),(0.0082-PLOD2),and(0.0075-CACYBP).The CAFMGS_score was separated into high-risk and low-risk groups based on the median of the patients’OS.Univariate and multivariate analyses confirmed that CAFMGS_score was an independent prognostic factor in the training group.CAFMGS_score was a more accurate prognostic indicator compared with clinicopathological score and tumor mutational burden score.Conclusion:CAFMGS offers a fresh perspective on stromal cell marker genes in HCC prognosis and expands our knowledge of CAF heterogeneity and functional diversity,perhaps paving the way for CAF-targeted immunotherapy in HCC patients.