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Insulin resistance (IR) is an independent risk factor of cardiovascular disease. Recent research has proposed a new inexpensive and reliable indicator of IR: triglyceride glucose index (TyG index). We aim to evaluate the dose-response association between the TyG index and stroke through meta-analysis. Literature published from inception until October 2021 were searched in PubMed, Embase, Cochrane Library and Web of science. Cohort studies published in English and focusing on the association between the TyG index and stroke were included in our meta-analysis. I2 statistic and Chi-square were used to assess the heterogeneity. When I2≥30% or p≤0.10, the random-effect model was used to pool the effect; otherwise, we chose the fixed-effect model. Eleven cohort studies, including 5 721 077 subjects and 95 490 stroke patients, were included in our study. After pooling the effect adjusted by multiple confounders, we found that compared with the lowest baseline TyG index group, the highest one was independently associated with increased stroke risk (RR: 1.27; 95% CI, 1.24 to 1.29; I2=6%). Dose-response meta-analysis showed that the association between the two variables had a non-linear trend (p-nonlinearity

BACKGROUND Polycythemia vera (PV) is a chronic myeloproliferative disorder characterized by an increase in red blood cells in the peripheral blood. Previous work has reported the occurrence of thrombosis or hemorrhage arising in the cerebral vasculature secondary to PV. However, hemorrhagic transformation after PV-associated acute ischemic stroke has not been previously described. CASE SUMMARY We herein present two cases of PV where hemorrhagic transformation occurred after an acute ischemic stroke. Case 1 was a 57-year-old woman with a history of hypertension who was admitted for left-sided weakness. Case 2 was a 68-year-old man who was admitted for a 10-d sudden left arm weakness. Imaging examinations for the two patients revealed hemorrhagic transformation after acute ischemic stroke. Both patients had JAK-2-V617F mutation and received antiplatelet therapy. Both of them had a good prognosis during the follow-up. CONCLUSION This report suggested that hemorrhagic transformation may occur in acute ischemic stroke caused by PV. Antiplatelet drugs do not seem to influence the long-term outcomes in such patients. Future research should focus on establishing a standard antiplatelet treatment strategy for this condition.

Grey matter (GM) alterations may contribute to cognitive decline in individuals with white matter hyperintensities (WMH) but no consensus has yet emerged. Here, we investigated cortical thickness and grey matter volume in 23 WMH patients with mild cognitive impairment (WMH-MCI), 43 WMH patients without cognitive impairment, and 55 healthy controls. Both WMH groups showed GM atrophy in the bilateral thalamus, fronto-insular cortices, and several parietal-temporal regions, and the WMH-MCI group showed more extensive and severe GM atrophy. The GM atrophy in the thalamus and fronto-insular cortices was associated with cognitive decline in the WMH-MCI patients and may mediate the relationship between WMH and cognition in WMH patients. Furthermore, the main results were well replicated in an independent dataset from the Alzheimer's Disease Neuroimaging Initiative database and in other control analyses. These comprehensive results provide robust evidence of specific GM alterations underlying WMH and subsequent cognitive impairment. Supplementary Information The online version contains supplementary material available at 10.1007/s12264-021-00657-0.

Objectives Subacute combined degeneration (SCD) is a demyelinating disease commonly caused by vitamin B12 deficiency. Several studies have been reported SCD could be accompanied by anemia. However, the correlation between anemia and clinical severity of SCD patients is unclear. In this study, we aim to analyze the clinical characteristics of SCD concomitant with anemia, and investigate the effect of anemia in predicting the severity of SCD. Methods A total 42 patients were included in the study. Clinical, laboratory, radiological findings, and outcomes from the patients were analyzed. All patients were treated with vitamin B12 for no less than 6 months and a functional disability rating scale was used to evaluate severity of neurological impairment at the time of admission and 3 and 6 months after admission in our study. Results 85.7% patients had macrocytosis. Decreased serum vitamin B12 levels were found in 27 patients (64.3%). MRI showed long-segment abnormality on the spinal cord in 22 patients. No differences in rating score were found in patients grouped by sex, age, clinical course, serum vitamin B12, or MRI manifestations at the time of admission or at the follow-up visits. Negative correlation was seen between hemoglobin levels and the clinical severity scores on admission. Conclusion Not all patients with SCD concomitant with anemia had decreased serum vitamin B12 level. The inverse correlation between hemoglobin level and clinical severity suggests the degree of anemia can help in evaluating the extent of neurologic impairment.

Functional constipation (FC) is a chronic disease that significantly affects the life quality of patients. Acupuncture has been used for the treatment of FC for many years, but its effectiveness has not been scientifically assessed. The present study aimed to evaluate the efficacy of electro-acupuncture (EA) in relieving the symptoms, mental states and quality of life (QOL) of FC patients. A total of 96 FC patients were randomly allocated into EA, mosapride & sham EA group (MS) and mosapride control group (MC). In the EA group, patients were treated with 16 sessions of needling at Quchi (LI11) and Shangjuxu (ST37) bilaterally, 5 times a week in the first 2 weeks, and 3 times a week in the last 2 weeks. In the MC group, patients were treated with 5 mg mosapride citrate three times a day for 4 weeks. In the MS group, patients underwent sham EA and the same mosapride citrate treatment as in the MC group. The primary outcome was the number of weekly spontaneous bowel movements (SBMs). The secondary outcomes included stool consistency, intensity of defecating difficulty, 36-Item Short-Form Health Survey (SF-36), Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and the validated Patient Assessment of Constipation-Quality of Life (PAC-QOL). The results showed that as compared with the baseline, EA significantly improved the weekly SBMs, stool consistency and intensity of defecating difficulty (P

Introduction. The association between arterial tortuosity and acute ischemic stroke (AIS) has been reported, but showing inconsistent results. We hypothesized that tortuosity of extra- and intracranial large arteries might be higher in AIS patients. Furthermore, we explored the correlation between artery tortuosity and white matter hyperintensity (WMH) severity in AIS patients. Methods. 166 AIS patients identified as large artery atherosclerosis, and 83 control subjects were enrolled. All subjects received three-dimensional computed tomography angiography (CTA). Arterial tortuosity was evaluated using the tortuosity index. WMHs were evaluated using magnetic resonance imaging in all AIS patients. Results. AIS patients showed significantly increased arterial tortuosity index relative to controls, including left carotid artery (CA) ( p = 0.001 ), right CA ( p < 0.001 ), left common carotid artery (CCA) ( p < 0.001 ), right CCA ( p < 0.001 ), left internal carotid artery ( p = 0.001 ), right internal carotid artery ( p = 0.01 ), left extracranial internal carotid artery (EICA) ( p < 0.001 ), right EICA ( p = 0.01 ), and vertebral artery dominance (VAD) ( p = 0.001 ). The tortuosity of all above arteries was associated with the presence of AIS. AIS patients with moderate or severe WMHs had a higher tortuosity index in left CA ( p = 0.005 ), left CCA ( p = 0.003 ), left EICA ( p = 0.07 ), and VAD ( p = 0.001 ). In addition, the tortuosity of left EICA and VAD was associated with WMH severity in AIS patients. Conclusions. Increased extra- and intracranial large arteries tortuosity is associated with AIS. The tortuosity of left carotid artery system and vertebral artery may be the independent risk factors for WMH severity in AIS patients. Clinical Trial Registration. This trial is registered with NCT03122002 (http://www.clinicaltrials.gov).

Introduction Previous studies have shown that low serum lipids and statins may be related to cerebral hemorrhage. We made the meta-analysis to evaluate the associations between serum lipid levels or statins treatment and cerebral microbleeds (CMBs) to identify whether the similar correlation also existed. Method We comprehensively searched the Medline, Embase, Cochrane library, Web of Science, only included English journal articles, and systematically collected the observational studies and randomized controlled trials (RCTs) from September 1975 to August 2021. Random-effects model was used to pool data. Statistical heterogeneity was assessed by I2 statistic and chi-square. 11 items checklists recommended by the Agency for Healthcare Research and Quality (AHRQ), Newcastle–Ottawa Scale (NOS), and Cochrane Risk of Bias tool (ROB) were used to evaluate the methodological quality of cross-sectional studies, cohort studies and randomized controlled trial, respectively. Results Five cohort studies, two RCTs, and ten cross-sectional studies, including 16,637 subjects and 2663 CMBs patients, were included in our quantitative synthesis. Our study found that after adjusting the covariates, total cholesterol (TC) was significantly inversely correlated with the prevalent CMBs in any location, while total triglycerides (TG) and High-density lipoprotein (HDL) were significantly inversely associated with prevalent deep CMBs. Low-density lipoprotein (LDL) was negatively associated with incident CMBs after adjusted confounders. We did not found statistical differences between statin and CMBs after adjusted covariates. Conclusion Serum major lipid (TC TG HDL LDL) levels may be inversely associated with CMBs. Currently, no sufficient evidence proves that statin therapy is the risk factor of CMBs.

The outbreak of COVID-19 poses an unprecedented threat and a great challenge to health workers (HWs) in Wuhan, China.1 The situation of women HWs in Wuhan is even more difficult. According to 2019 Chinese Health Statistics Yearbook, the number of women HWs in China accounted for 71.8% of Chinese HWs, far exceeding that of men HWs. Women HWs has become the major force to tackle the COVID-19 epidemic. Owing to entrenched traditional social roles in China, women HWs are placed at a considerable dilemma of how to balance work and family care. Previous studies have also suggested that women were vulnerable to mental health problems.2 The mental health problems of women HWs may affect their attention and decision-making ability and could have a lasting effect on their overall well-being. Hence, psychological impact of COVID-19 on women HWs in Wuhan should be pronounced. Tongji Hospital, one of the biggest hospitals in Wuhan, was officially designated as ‘the specific hospital for the treatment of severe patients with COVID-19’, with a women HWs proportion of 81.0%. This hospital has opened 2000 beds specifically for patients with severe COVID-19, and women HWs from all clinic departments of this hospital are sent to the frontline of COVID-19. Given the high infectivity of the COVID-19, the hospital administrators arranged lodging support for the frontline HWs living apart from their families. A cross-sectional study was designed to evaluate the immediate psychological impact on women HWs of Tongji Hospital, determine the predictors of acute stress, depression and anxiety symptoms and investigate the sources of acute stress among the women HWs. ### Study design and participants The study was a cross-sectional, single-centre survey, covering doctors, nurses and medical technicians in all clinical departments of Tongji Hospital. The study was conducted between 8 February and 15 February 2020, …

Background White matter hyperintensities (WMH) are common in older adults and are associated with cognitive decline. However, little is known about the functional changes underlying cognitive decline in WMH subjects. Objectives To investigate whole-brain functional connectivity (FC) underpinnings of cognitive decline in WMH subjects using univariate and multivariate analyses. Methods Twenty-three WMH subjects with mild cognitive impairment (WMH-MCI), 43 WMH subjects with no cognitive impairment (WMH-nCI), and 55 healthy controls underwent resting-state functional MRI scans. Whole-brain FC was calculated using the fine-grained human Brainnetome Atlas, followed by performance of between-group comparisons and FC-cognition correlation analysis. A multivariate analysis using support vector machine (SVM) was performed to classify WMH-MCI and WMH-nCI subjects based on FC. Results Both the WMH-MCI and WMH-nCI subjects exhibited characteristic impaired FC patterns. Markedly reduced FC involving subcortical nuclei and cortical hub regions of cognitive networks, especially the cingulate cortex, was identified in the WMH-MCI patients. In the WMH-MCI group, several connections involving the cingulate cortex were associated with cognitive decline. The exploratory mediation analyses indicated that FC alterations could partially explain the association between WMH and cognition. Furthermore, an SVM classifier based on FC distinguished WMH-MCI and WMH-nCI subjects with 78.8% accuracy. Connections that contributed most to the classification showed a similar distribution as the connections identified in the univariate analysis. Conclusions This study provides a new window into the pathophysiology of cognitive impairment in WMH subjects and offer a novel and potential approach for early detection of the cognitive impairment in WMH subjects at the individual level.

A previously healthy 15-year-old boy with no relevant medical history presented with 3 weeks of severe, persistent, holocephalic pain associated with nausea and vomiting, without fever or alteration of consciousness. A brain MRI including magnetic resonance angiography and magnetic resonance venography (MRV) at a local hospital was normal. A lumbar puncture revealed a CSF pressure of 240 mm H2O. An intracranial infection was suspected based on clinical symptoms and signs. He received empiric antiviral therapy and rehydration for 1 week, but there was no relief of symptoms. He was subsequently transferred to our hospital.

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome, reversible vasogenic edema predominantly within parieto-occipital regions. However, isolated brainstem involvement in PRES has been rarely reported, little is known about its clinical manifestations, radiological features and outcomes. We reported a case with PRES with only brainstem involvement and performed a systematic review of published cases. Twenty-four cases, together with our case, were included in the analysis. Mean age was 43 years and 63% were males. Hypertension (50%), nephropathy (25%) and chemotherapy (21%) were the major risk factors. All patients except two had acute hypertension and 50% of patients had renal dysfunction at onset. The most common symptoms were altered consciousness (46%) and headache (46%), Seizure was only presented in 21% of patients. All patients except two were treated with antihypertension. Most patients recovered to their neurological baseline. Clinicians should recognize this unique variant finding in PRES. which always affects males with severe hypertension, especially combined with renal dysfunction. Antihypertensive treatment is the most widely used therapy. Outcome is usually well.

Summary Background China is the world's largest consumer of tobacco and has a large smoking-related chronic disease burden. In this nationwide study, we aimed to evaluate smoking prevalence and its implication on chronic diseases in the Chinese population. Methods We collected data from serial cross-sectional National Health Service Surveys done in China in 2003, 2008, and 2013. These surveys cover all 31 provinces, autonomous regions, and municipalities in mainland China, and use multistage stratified cluster sampling. We divided mainland China into east, central, and west regions and then sampled counties from each region stratified by urban and rural areas. All respondents aged 15 years or older in the selected households were eligible. We analysed the variation in smoking prevalence from 2003 to 2013, further identified risk factors for smoking, and assessed the association between smoking and chronic diseases by using multiple logistic regression. Findings The number of individuals interviewed and involved in the study was 153 450 in 2003, 145 223 in 2008, and 229 676 in 2013. The standardised smoking prevalence in China was consistently high, with a proportion of current smokers of 26·0% (95% CI 25·8–26·2) in 2003, 24·9% (24·8–25·1) in 2008, and 25·2% (25·1–25·4) in 2013 (p value for trend 0·5062). For men, prevalence was 48·4% (48·1–48·7) in 2003, 47·0% (46·6–47·4) in 2008, and 47·2% (46·9–47·5) in 2013. For women, prevalence was 3·1% (3·0–3·2) in 2003, 2·3% (2·2–2·5) in 2008, and 2·7% (2·6–2·8) in 2013. Smoking prevalence varied in different regions, and we identified four major patterns. While a consistently high proportion of Chinese men smoked, the standardised smoking prevalence in women younger than 40 years increased from 1·0% in 2003 to 1·6% in 2013. Moreover, the smoking prevalence among adolescent smokers aged 15–24 years increased from 8·3% in 2003 to 12·5% in 2013. Alcohol consumption was closely linked to smoking in adolescents (odds ratio 7·5, 95% CI 6·9–8·1). Risk factors for adolescent smoking were having older family members who smoke (1·9, 1·8–1·9) and low level education (1·3, 1·2–1·4). Increased risks of chronic diseases were related to smoking (1·1, 1·0–1·1), with higher risks related to early smoking initiation (1·1, 1·0–1·1) and long-term smoking (1·2, 1·2–1·3). Interpretation The implementation of tobacco control policies in China since the signing of the WHO Framework Convention on Tobacco Control in 2003 has not been effective in reducing smoking prevalence. Smoking prevalence among adolescents of both genders has increased substantially and there has been a steady increase among young women. More practical and effective policies targeting adolescents and women are urgently needed. Action is needed to prevent the large and growing smoking-related chronic disease burden further increasing as China's population ages. Funding National Health Commission of the People's Republic of China.

To predict the mortality of patients with coronavirus disease 2019 (COVID-19). We collected clinical data of COVID-19 patients between January 18 and March 29 2020 in Wuhan, China . Gradient boosting decision tree (GBDT), logistic regression (LR) model, and simplified LR were built to predict the mortality of COVID-19. We also evaluated different models by computing area under curve (AUC), accuracy, positive predictive value (PPV), and negative predictive value (NPV) under fivefold cross-validation. A total of 2924 patients were included in our evaluation, with 257 (8.8%) died and 2667 (91.2%) survived during hospitalization. Upon admission, there were 21 (0.7%) mild cases, 2051 (70.1%) moderate case, 779 (26.6%) severe cases, and 73 (2.5%) critically severe cases. The GBDT model exhibited the highest fivefold AUC, which was 0.941, followed by LR (0.928) and LR-5 (0.913). The diagnostic accuracies of GBDT, LR, and LR-5 were 0.889, 0.868, and 0.887, respectively. In particular, the GBDT model demonstrated the highest sensitivity (0.899) and specificity (0.889). The NPV of all three models exceeded 97%, while their PPV values were relatively low, resulting in 0.381 for LR, 0.402 for LR-5, and 0.432 for GBDT. Regarding severe and critically severe cases, the GBDT model also performed the best with a fivefold AUC of 0.918. In the external validation test of the LR-5 model using 72 cases of COVID-19 from Brunei, leukomonocyte (%) turned to show the highest fivefold AUC (0.917), followed by urea (0.867), age (0.826), and SPO2 (0.704). The findings confirm that the mortality prediction performance of the GBDT is better than the LR models in confirmed cases of COVID-19. The performance comparison seems independent of disease severity. Supplementary Information The online version contains supplementary material available at(10.1007/s00521-020-05592-1)

Aims Lifestyle interventions are an important and viable approach for preventing cognitive deficits. However, the results of studies on alcohol, coffee and tea consumption in relation to cognitive decline have been divergent, likely due to confounds from dose–response effects. This meta-analysis aimed to find the dose–response relationship between alcohol, coffee or tea consumption and cognitive deficits. Methods Prospective cohort studies or nested case-control studies in a cohort investigating the risk factors of cognitive deficits were searched in PubMed, Embase, the Cochrane and Web of Science up to 4th June 2020. Two authors searched the databases and extracted the data independently. We also assessed the quality of the studies with the Newcastle-Ottawa scale. Stata 15.0 software was used to perform model estimation and plot the linear or nonlinear dose–response relationship graphs. Results The search identified 29 prospective studies from America, Japan, China and some European countries. The dose–response relationships showed that compared to non-drinkers, low consumption (11 g/day). Low consumption of coffee reduced the risk of any cognitive deficit ( Conclusions Light consumption of alcohol (

Summary Background Prompt identification of patients suspected to have COVID-19 is crucial for disease control. We aimed to develop a deep learning algorithm on the basis of chest CT for rapid triaging in fever clinics. Methods We trained a U-Net-based model on unenhanced chest CT scans obtained from 2447 patients admitted to Tongji Hospital (Wuhan, China) between Feb 1, 2020, and March 3, 2020 (1647 patients with RT-PCR-confirmed COVID-19 and 800 patients without COVID-19) to segment lung opacities and alert cases with COVID-19 imaging manifestations. The ability of artificial intelligence (AI) to triage patients suspected to have COVID-19 was assessed in a large external validation set, which included 2120 retrospectively collected consecutive cases from three fever clinics inside and outside the epidemic centre of Wuhan (Tianyou Hospital [Wuhan, China; area of high COVID-19 prevalence], Xianning Central Hospital [Xianning, China; area of medium COVID-19 prevalence], and The Second Xiangya Hospital [Changsha, China; area of low COVID-19 prevalence]) between Jan 22, 2020, and Feb 14, 2020. To validate the sensitivity of the algorithm in a larger sample of patients with COVID-19, we also included 761 chest CT scans from 722 patients with RT-PCR-confirmed COVID-19 treated in a makeshift hospital (Guanggu Fangcang Hospital, Wuhan, China) between Feb 21, 2020, and March 6, 2020. Additionally, the accuracy of AI was compared with a radiologist panel for the identification of lesion burden increase on pairs of CT scans obtained from 100 patients with COVID-19. Findings In the external validation set, using radiological reports as the reference standard, AI-aided triage achieved an area under the curve of 0·953 (95% CI 0·949–0·959), with a sensitivity of 0·923 (95% CI 0·914–0·932), specificity of 0·851 (0·842–0·860), a positive predictive value of 0·790 (0·777–0·803), and a negative predictive value of 0·948 (0·941–0·954). AI took a median of 0·55 min (IQR: 0·43–0·63) to flag a positive case, whereas radiologists took a median of 16·21 min (11·67–25·71) to draft a report and 23·06 min (15·67–39·20) to release a report. With regard to the identification of increases in lesion burden, AI achieved a sensitivity of 0·962 (95% CI 0·947–1·000) and a specificity of 0·875 (95 %CI 0·833–0·923). The agreement between AI and the radiologist panel was high (Cohen's kappa coefficient 0·839, 95% CI 0·718–0·940). Interpretation A deep learning algorithm for triaging patients with suspected COVID-19 at fever clinics was developed and externally validated. Given its high accuracy across populations with varied COVID-19 prevalence, integration of this system into the standard clinical workflow could expedite identification of chest CT scans with imaging indications of COVID-19. Funding Special Project for Emergency of the Science and Technology Department of Hubei Province, China.

Background China has experienced rapid economic growth and reduced poverty, but the associated changes of BMI categories of the Chinese population in recent years are unclear. Methods We collected data from two-round cross-sectional National Health Service Surveys (NHSSs) conducted in China in 2013 and 2018. All family members with BMI available from the households sampled in NHSSs were included. We analyzed the standardized prevalence and changes of obesity and overweight by year, age, sex, and urban-rural area, and further identified risk factors for obesity and overweight. Findings 273,688 individuals were included in 2013 and 25,6304 included in 2018. The standardized prevalence of obesity and overweight in adults were 19.3% (95%CI 19.1–19.4%) in 2013 and 25.6% (95%CI 25.3–25.8%) in 2018, versus 19.4% (95%CI 19·1–19.8%) in children and adolescents in 2013 and 15.8% (95%CI 15.5–16.1%) in 2018. The standardized prevalence of obesity and overweight was 16.9% (95%CI 16.0–17.3%) in young adults aged 19–29 in 2018, 48.2% higher than that in 2013 (11.4% [95%CI 11.0–11.6%]). Although the obesity and overweight prevalence was higher in urban areas, the growth rate in rural areas was 1.8 times higher than that in urban areas. Low education levels, low-income quintiles, marital status, alcohol consumption and former-smoking status were associated with higher obesity and overweight prevalence in adults. Interpretation The rapidly increasing prevalence in young adults may lead to the growing chronic disease burden in the future, to the detriment of recent economic gains of rural families. Funding National Health Commission of the People's Republic of China.

Background To develop and evaluate the prognostic machine-learning model for mortality in patients with coronavirus disease 2019 (COVID-19).Methods Clinical data of confirmed COVID-19 were retrospectively collected from Wuhan between 18th January and 29th March 2020. Gradient Boosting Decision Tree (GBDT), logistic regression (LR) model, and simplified LR with selected 5 features (LR-5) model were built to predict the mortality of COVID-19. 5-fold area under curve (AUC), accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated and compared between models.Results A total of 2,924 patients were included in the final analysis, 257(8.8%) of whom died during hospitalization and 2,667 (91.2%) survived. There were 21(0.7%) mild cases, 2,051(70.1%) moderate case, 779(26.6%) severe cases, and 73(2.5%) critically severe cases of COVID-19 on admission. The overall 5-fold AUC was observed highest in GBDT model (0.941), followed by LR (0.928) and LR-5 (0.913). The diagnostic accuracy were 0.889 in GBDT, 0.868 in LR and 0.887 in LR-5. GBDT model also showed the highest sensitivity (0.899) and speciality (0.889). The NPV of all three models exceeded 97%, while the PPV were relatively low in all models, 0.381 for LR, 0.402 for LR-5 and 0.432 for GBDT. In subgroups analysis with severe cases only, GBDT model also performed the best with a accuracy of 0.799 and 5-fold AUC (0.918).Conclusion The finding revealed that mortality prediction performance of the GBDT was superior to the LR models in confirmed cases of COVID-19, regardless of disease severity.

Background Since December 2019, COVID-19 has emerged in Wuhan, China and spread globally. As of now, there is still no explicit therapeutic regimen and the use of corticosteroid is also controversial. We aimed to explore the effectiveness of corticosteroid and provide evidence for the rational use of corticosteroid in different patients with COVID-19.Methods In this multi-centered, retrospective study, we extracted the clinical data of 649 cases with COVID-19 with definite outcome (discharged or dead) from 14 hospitals in Hubei province, and evaluated the clinical characteristics, treatment regimens, and their association with outcomes.Results Ninety-five of 649 patients had died. Older male patients with comorbidities had an increased risk of death and more obvious abnormalities in clinical indicators. Corticosteroid, γ-globulin treatment and invasive ventilation were more frequently used in non-survivors. Survivors with corticosteroid treatment had a prolonged hospitalization. The median time duration for temperature restore for non-survivors after corticosteroid treatment was longer than that of both survivors. The lymphocyte count on admission was lower in the patients treated with corticosteroids compared to those without corticosteroid treatment. Lymphocyte count recovered significantly after corticosteroid treatment in survivors, but not in non-survivors.Conclusions The responses to corticosteroid treatment were different in COVID-19 patients with different outcomes. The surviving patients with relatively lower lymphocyte count were more likely to be given corticosteroids. For non-survivors, the lymphocyte count was too low and the effect of corticosteroids was poor. Survivors under corticosteroid treatment had a prolonged hospitalization, but had a recovery of lymphocytes. The recovery of lymphocyte count and temperature after corticosteroid treatment may be used as predictors of prognosis of patients with COVID-19.

Background: The outbreak of COVID-19 has laid unprecedented threats and challenges to health workers (HWs) in Wuhan, China. We aimed to assess the sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on HWs at Tongji Hospital in Wuhan during COVID-19 outbreak. Methods: We conducted a single-center, cross-sectional survey of HWs via online questionnaires between February 8th and 10th, 2020. We evaluated stress, depression and anxiety by IES-R, PHQ-9, and GAD-7, respectively. We also designed a questionnaire to assess the perceptions of threat of COVID-19, and the satisfactions of the hospital's support measures. Multivariate logistic regressions were used to identify associated variables of acute stress, depression, and anxiety. Findings: We received 5062 completed questionnaires (response rate, 77.1%). 29.8%, 13.5% and 24.1% HWs reported stress, depression and anxiety symptoms. Women (odds ratio [OR], 1.31; 95% CI, 0.47–0.97; p = 0.032), years of working >10 years (OR, 2.02; 95% CI, 1.47–2.79; p

Objective To assess the efficacy of manual acupuncture as prophylactic treatment for acupuncture naive patients with episodic migraine without aura. Design Multicentre, randomised, controlled clinical trial with blinded participants, outcome assessment, and statistician. Setting Seven hospitals in China, 5 June 2016 to 15 November 2018. Participants 150 acupuncture naive patients with episodic migraine without aura. Interventions 20 sessions of manual acupuncture at true acupuncture points plus usual care, 20 sessions of non-penetrating sham acupuncture at heterosegmental non-acupuncture points plus usual care, or usual care alone over 8 weeks. Main outcome measures Change in migraine days and migraine attacks per four weeks during weeks 1-20 after randomisation compared with baseline (four weeks before randomisation). Results Among 150 randomised patients (mean age 36.5 (SD 11.4) years; 123 (82%) women), 147 were included in the full analysis set. Compared with sham acupuncture, manual acupuncture resulted in a significantly greater reduction in migraine days at weeks 13 to 20 and a significantly greater reduction in migraine attacks at weeks 17 to 20. The reduction in mean number of migraine days was 3.5 (SD 2.5) for manual versus 2.4 (3.4) for sham (adjusted difference −1.4, 95% confidence interval −2.4 to −0.3; P=0.005) at weeks 13 to 16 and 3.9 (3.0) for manual versus 2.2 (3.2) for sham (adjusted difference −2.1, −2.9 to −1.2; Pv 75%; P=0.891). Conclusions Twenty sessions of manual acupuncture was superior to sham acupuncture and usual care for the prophylaxis of episodic migraine without aura. These results support the use of manual acupuncture in patients who are reluctant to use prophylactic drugs or when prophylactic drugs are ineffective, and it should be considered in future guidelines. Trial registration Clinicaltrials.gov NCT02765581 .

BACKGROUNDThe outbreak of COVID-19 has laid unprecedented psychological stress on health workers (HWs). We aimed to assess the immediate psychological impact on HWs at Tongji Hospital in Wuhan, China.METHODSWe conducted a single-center, cross-sectional survey of HWs via online questionnaires between February 8th and 10th, 2020. We evaluated stress, depression and anxiety by Impact of Event Scale-Revised (IES-R), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder 7-item (GAD-7), respectively. We also designed a questionnaire to assess the effect of psychological protective measures taken by Tongji Hospital. Multivariate logistic regression was used to identify predictors of acute stress, depression, and anxiety.RESULTSWe received 5062 completed questionnaires (response rate, 77.1 percent). 1509 (29.8 percent), 681 (13.5 percent) and 1218 (24.1 percent) HWs reported stress, depression and anxiety symptoms. Women (hazard ratio[HR], 1.31; P=0.032), years of working> 10 years (HR, 2.02; PCONCLUSIONSWomen and those who have more than 10 years of working, concomitant chronic diseases, history of mental disorders, and family members or relatives confirmed or suspected are susceptible to stress, depression and anxiety among HWs during the COVID-19 pandemic. Psychological protective measures implemented by the hospital could be helpful.

Background: We aimed to assess the safety, tolerability and immunogenicity of a recombinant adenovirus type 5 (Ad5) vectored COVID-19 vaccine expressing the spike glycoprotein of a SARS-Cov-2 strain. This is the first-in-human study of a candidate vaccine against COVID-19. Methods: We conducted a single-center, open-label, dose-escalating clinical trial of Ad5 vectored COVID-19 vaccine. Healthy adults aged between 18-60 years were sequentially enrolled and allocated to receive a single intramuscular injection in one of three dose groups: 5 × 10^10, 1×10^11, and 1·5×10^11 viral particles. Safety was assessed over the next 28 days. Specific antibodies were measured on enzyme-linked immunosorbent assay (ELISA), and the neutralizing antibody responses induced by vaccination were detected by using SARS-CoV-2 virus neutralization and pseudovirus neutralization tests. T-cell responses were accessed by enzyme-linked immunospot (ELISpot) and flow-cytometry assays. Results: A total of 108 participants were recruited and received low dose, middle dose, or high dose vaccine, with 36 in each dose group. 30(83·3%), 30(83·3%), and 27(75·0%) recipients in the low dose, middle dose, and high dose groups reported at least one adverse reaction within the first 7 days after the vaccination. The most common injection-site adverse reaction was pain, the most commonly reported systematic adverse reactions were fever, fatigue, headache, and muscle pain. A majority of the adverse reactions that were reported in all dose groups were mild or moderate in severity. No serious adverse event was noted within 28 days post-vaccination. Both ELISA antibodies and neutralizing antibodies increased significantly at day 14, and peaked 28 days post-vaccination. Specific T cell response peaked at day 14 post-vaccination. Conclusions: The Ad5 vectored COVID-19 vaccine is tolerable and immunogenic. Humoral responses against SARS-CoV-2 peaked at day 28 post-vaccination in health adults, and rapid specific T cell responses were noted since day 14. Trial Registration: The study is registered with ClinicalTrials.gov, number NCT04313127. Funding Statement: National Key R&D Program of China (2020YFC10841400), National Science and Technology Major Project (2016ZX10004001, 2018ZX09201005), and CanSino Biotechnology Inc. Declaration of Interests: Mr. Gou report being employees of Tianjin CanSino Biotechnology Inc, No other potential conflict of interest relevant to this article was reported. Ethics Approval Statement: The protocol and informed consent were approved by the Institutional Review Board of the Jiangsu Provincial Center of Disease Control and Prevention. Written informed consents from all participants were obtained before screening. This study was undertaken by Jiangsu Provincial Center of Disease Control and Prevention, Hubei Provincial Center for Disease Control and Prevention and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology in accordance with the Declaration of Helsinki and Good Clinical Practice.

Additional file 1. SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.

Background: Since December 2019, COVID-19 has emerged in Wuhan, China and spread rapidly throughout China So far, there is still no explicit therapeutic regime

Background: The outbreak of COVID-19 has laid unprecedented threats and challenges to health workers (HWs) in Wuhan, China. We aimed to assess the sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on HWs at Tongji Hospital in Wuhan during COVID-19 outbreak. Methods: We conducted a single-center, cross-sectional survey of HWs via online questionnaires between February 8th and 10th, 2020. We evaluated stress, depression and anxiety by IES-R, PHQ-9, and GAD-7, respectively. We also designed a questionnaire to assess the perceptions of threat of COVID-19, and the effect of the hospital’s support measures. Multivariate logistic regression was used to identify predictors of acute stress, depression, and anxiety. Findings: We received 5062 completed questionnaires (response rate, 77.1%). 29.8%, 13.5% and 4.1% HWs reported stress, depression and anxiety symptoms. Women (odds ratio[OR], 1.31; 95%CI, 0.47-0.97; p=0.032), years of working >10 years (OR, 2.02; 95%CI, 1.47-2.79; p

Background. Hypertrophic pachymeningitis (HP) is generally regarded as a rare inflammatory disease, which results in a diffuse thickening of the dura mater. We retrospectively collected data from patients with HP. Methods. A total of 16 patients with HP were included in our study. The clinical features, laboratory evaluation, imaging findings, treatment, and outcome were reviewed. Results. Of the 16 cases, half were male, with a mean age of 52.6±13.2 years. The mean duration from onset to diagnosis was 8.6 months. The most frequent presenting symptoms in HP cases were a recurrently chronic headache (81.3%) and multiple cranial nerve injury (50%). Antineutrophil cytoplasmic antibody- (ANCA-) related HP was found in 5 cases and IgG4-related HP in 1 case. The intracranial pressure was elevated in 4 cases. The cerebrospinal fluid (CSF) had lymphocytosis in 5 cases and increased protein in 12 cases. Immunoglobulins (IgG, IgA, and IgM) and protein showed linear relationships in the CSF. On magnetic resonance imaging (MRI), localized or diffuse dura maters were thickened in all cases. HP combined with subacute subdural hemorrhage or hypertrophic spinal pachymeningitis was also observed in individual cases. Biopsy of the dura mater in one case showed amounts of inflammatory cells infiltrating, with an increased percentage of IgG4-positive plasma cells. Of all cases referring to glucocorticoid treatment, the symptoms have improved significantly in 10 cases. In other 6 cases, mycophenolate mofetil or azathioprine was added. All patients showed clinical improvement at the follow-up visits. Conclusion. The clinical characters of HP are chronic onset, recurrently chronic headache, and multiple cranial nerves paralysis. Inflammatory changes in CSF caused by intrathecal synthesis of immunoglobulin, characteristic dural enhancement on MRI, and pathologic biopsy are all helpful for diagnosis. The addition of immunosuppressant, especially mycophenolate mofetil, is a good choice for steroid-resistance HP.

Objectives The higher than expected PFO rate in CS patients has raised concerns that paradoxical embolism maybe the pathophysiologic mechanism for strokes. However, only a small proportion of pathogenic PFOs cause CS. Therefore, accurate recognition of patients with pathogenic PFOs among all CS patients could guide clinical decision making in selecting the most appropriate treatment. The aim of this study was to devise a new algorithm to stratify cryptogenic stroke (CS) patients into pathogenic patent foramen ovale (p‐PFO)‐ and non‐p‐PFO‐related patients. Methods A total of 1201 patients with acute ischemic stroke were recruited from two different medical centers, and 253 CS patients were identified. Of the 253 patients, 111 were diagnosed with PFO using contrast transcranial Doppler. Data on medical histories, neuroimaging and laboratory tests were compared in CS patients with or without PFO. Results Compared with PFO‐negative CS patients, PFO‐positive CS patients showed younger onset age, lower incidence of hypertension and dyslipidemia, characteristic infarction pattern in magnetic resonance imaging and specifically altered platelet activity and coagulation function. Based on the above information, we constructed a PFO judgment formula (Hr‐PFOJ) by means of feature weight estimation and predictive performance evaluation to predict pathogenic PFO in CS patients with a sensitivity of 76.3% and a specificity of 66.5%. Interpretations Hr‐PFOJ judgment formula is a useful screening tool for identification of patients with pathogenic PFO who may benefit from PFO‐related treatment.

Background: The study aimed to determine the multiple related risk factors and their prognostic significance of intracerebral hemorrhage (ICH), and to develop models for predicting poor outcome and mortality. Methods: We retrospectively analyzed 141 consecutive patients with acute ICH presenting to the neurological department of Tongji Hospital from December 2016 to April 2018. Independent predictors of 6-month prognostic significance were identified by logistic regression, and discriminative performance was assessed by using the area under curve (AUC) of receiver-operating characteristic (ROC). Models of poor prognosis and mortality were developed. Results: Independent predictors of poor outcome (mRS≥3) were as follows: NIHSS score, D-Dimer, mixed hematoma density, irregular hematoma shape, ICH volume, cerebral cortical atrophy and midline shift. The sensitivity and specificity of poor prognosis model were 87.5% and 87.4%, respectively. Independent factors associated with 6-month mortality included：platelet counts at admission, NIHSS score, eGFR, presence of intraventricular hemorrhage ( IVH ), third ventricle Sylvian fissure distance. The sensitivity and specificity of the model for mortality were 90.0% and 94.4%, respectively. Conclusions: Two models for prognostic significance of ICH were developed and could well predict the poor prognosis and mortality.

BackgroundDespite recent efforts, a single factor underlying the gut microbiota dysbiosis in intestinal diseases is not identified. We hypothesized that compromised intestinal barrier (CIB) could lead to increased host-derived contents including human cells in the gut, change its physio-metabolic properties, and globally alter gut microbiota and their metabolic capacities.ResultsConsistently, we found human DNA contents (HDCs), calculated as the percentage of metagenomic sequencing reads mapped to the human genome, were significantly elevated in colorectal cancer (CRC) patients; HDC correlated with microbial- and metabolic-pathway-biomarkers of CRC, and was the most important contributor to patient stratification. We found similar results in Crohn’s disease (CD); additionally, patients treated with diet and drug intervention showed reduced HDC levels over time, and were accompanied by reversing changes of many CD-signature species.ConclusionsOur results suggested that host-derived contents may have greater impact on gut microbiota than previously anticipated, and CIB could be an ideal treatment target that could reverse dysbiosis globally and precisely.

Purpose: The study aimed to analyze the clinical characteristics, laboratory test results, neuroimaging findings, and outcomes in patients diagnosed with subacute combined degeneration (SCD). Materials and Methods: A total of 68 patients with SCD who had been appropriately treated for no less than 6 months were included in our study. Histories, results of routine blood tests, biochemical indices, serum vitamin B12 levels, and spinal magnetic resonance imaging (MRI) findings from the patients were studied and analyzed. Clinical signs and symptoms, graded using a functional disability rating scale, were scored at the time of admission and 3 and 6 months after admission. Results: Limb numbness, limb weakness, and gait disturbances were the most common symptoms in patients with SCD. All patients showed clinical improvement to different degrees at the follow-up visits after vitamin B12 treatment. No differences in rating score were found in patients grouped by sex, hemoglobin level, serum vitamin B12, or MRI manifestations at the time of admission or at the follow-up visits. Younger patients and those with shorter disease courses had better rating scores at the short-term follow-up visits. Conclusion: Anemia, low levels of serum vitamin B12, and MRI abnormalities in the spinal cord are not expected to be associated with worse clinical manifestations. The age of onset and course of disease are important in evaluating the short-term prognosis of patients with SCD.

Background Understanding the complexities of immune memory to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is key to gain insights into the durability of protective immunity against reinfection. Objective We sought to evaluate the immune memory to SARS-CoV-2 in convalescent patients with longer follow-up time. Methods SARS-CoV-2–specific humoral and cellular responses were assessed in convalescent patients with coronavirus disease 2019 (COVID-19) at 1 year postinfection. Results A total of 78 convalescent patients with COVID-19 (26 moderate, 43 severe, and 9 critical) were recruited after 1 year of recovery. The positive rates of both anti–receptor-binding domain and antinucleocapsid antibodies were 100%, whereas we did not observe a statistical difference in antibody levels among different severity groups. Accordingly, the prevalence of neutralizing antibodies (nAbs) reached 93.59% in convalescent patients. Although nAb titers displayed an increasing trend in convalescent patients with increased severity, the difference failed to achieve statistical significance. Notably, there was a significant correlation between nAb titers and anti–receptor-binding domain levels. Interestingly, SARS-CoV-2–specific T cells could be robustly maintained in convalescent patients, and their number was positively correlated with both nAb titers and anti–receptor-binding domain levels. Amplified SARS-CoV-2–specific CD4+ T cells mainly produced a single cytokine, accompanying with increased expression of exhaustion markers including PD-1, Tim-3, TIGIT, CTLA-4, and CD39, while the proportion of multifunctional cells was low. Conclusions Robust SARS-CoV-2–specific humoral and cellular responses are maintained in convalescent patients with COVID-19 at 1 year postinfection. However, the dysfunction of SARS-CoV-2–specific CD4+ T cells supports the notion that vaccination is needed in convalescent patients for preventing reinfection.

Background and Aim. To investigate the efficacy and safety of electroacupuncture (EA) with different current intensities for functional constipation (FC) and to assess whether the effects of EA with different current intensities are superior to the mosapride.Methods. Patients with FC were randomly divided into low current intensity group (LCI), high current intensity group (HCI), and mosapride group (MC). The primary outcome was three or more spontaneous bowel movements (SBMs) per week and an increase of one or more SBMs from baseline during at least 3 of the 4 weeks.Results. The primary outcome was reached by 53.45%, 66.15%, and 52.24% of the patients who received LCI, HCI, and mosapride, respectively. EA can significantly improve the weekly SBMs and stool consistency and reduce straining severity (p<0.0001, all). HCI improved the quality of life better than mosapride (p<0.05) and reduced the proportion of severe constipation more than LCI and mosapride (p<0.05, both).Conclusions. EA is effective and safe at both current intensities for FC; therapeutic effects of LCI and HCI are not superior to mosapride. EA is superior to mosapride in improving patients’ life quality and satisfaction level of treatment; EA has fewer adverse events than mosapride.

Background Convexal subarachnoid hemorrhage (cSAH) is characterized by isolated bleeding in one or a few adjacent sulci and has diverse etiologies and symptoms. Acute ischemic stroke co-occurring with cSAH has been infrequently reported. Nearly all cases of cSAH have been described to occur on the side with acute ischemic stroke, and it is unusual for cSAH to occur on the opposite side of the infarct territory. Case presentation Our report presents two cases of acute ischemic stroke associated with contralateral cSAH. The first patient had left atherosclerotic internal carotid artery (ICA) occlusion with developing right parietal cSAH. The other patient developed left parietal cSAH in the setting of right ICA occlusion caused by cardiogenic embolism with acute right cerebral hemisphere infarction. Both patients remained clinically stable with good prognosis after antithrombotic treatment. Conclusions Our report suggest that cSAH may simultaneously occur on the opposite side of an infarction. Although there is no consensus on the etiology and treatment of this rare phenomenon, cSAH did not lead to a poor outcome in our patients.

Supplemental material, AIM818289_Supplemental_material_SP1 for Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis by Qing Zhang, Jing Gong, Haoxu Dong, Shabei Xu, Wei Wang and Guangying Huang in Acupuncture in Medicine

Background: It has not been solved what kind of needle sensation might influence outcomes of acupuncture treatment. Effects of personality factors on the therapeutic effect of acupuncture have not been investigated. This study aimed to find the effects of the traits of personality on the objective outcome when different acupuncture techniques were used in treating patients with Bell's palsy. Methods: We performed a secondary analysis of a prospective multicenter randomized controlled trial of acupuncture for Bell's palsy. Patients were randomly assigned to the de qi and control groups, respectively. The primary outcome was facial nerve function at month 6. The intensity of each needle sensation was rated by a visual analog scale. Psychosocial factors were assessed by the pretreatment mediator questionnaire; 16 Personality Factor Questionnaire (16PF) was used for assessing personality factors and digit cancellation test for assessing attention. Results: After 6 months, patients in the de qi group had better facial function (adjusted odds ratio [ OR ]: 4.16, 95% confidence interval [ CI ]: 2.23–7.78). Path analysis showed that intensity of needle sensation of fullness had direct effect on House-Brackmann (HB) score at month 6. In de qi group, the low HB score on day 1 ( OR : 0.13, 95% CI : 0.03–0.45) and the low Social Boldness score ( OR : 0.63, 95% CI : 0.41–0.97) in 16PF were associated with better facial function. In control group, low HB score on day 1 ( OR : 0.25, 95% CI : 0.13–0.50), low Vigilance score ( OR : 0.66, 95% CI : 0.50–0.88), and high Tension score ( OR : 1.41, 95% CI : 1.12–1.77) in 16PF were related to better facial function. Conclusions: The needle sensation of fullness could predict better facial function and personality traits might influence outcomes of acupuncture treatment. Both of them should be considered seriously in acupuncture treatment and research.