scholarly journals Cumulative prognostic effect of diabetes and myocardial injury in patients attended in the emergency room

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
V Del Moral Ronda ◽  
R Sanchez Gimenez ◽  
N Lal-Trehan Estrada ◽  
G Bonet Pineda ◽  
A Carrasquer Cucarella ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Emergency Room ◽  
Cardiac Troponin ◽  
Myocardial Injury ◽  
Diabetic Patients ◽  
Prognostic Impact ◽  
Elevated Troponin ◽  
Prognostic Effect

Abstract Background Diabetes and myocardial injury are clinical conditions associated with cardiovascular events and increased mortality during follow-up. It is not known to what extent both conditions enhance their prognostic effect in patients seen in the emergency room with cardiac troponin determination. Purpose This study aims to evaluate the prognostic implication of diabetes and myocardial injury in patients attended in the emergency room with cardiac troponin determination. Methods Retrospective observational cohorts study, in which all the patients attended the emergency room from January 2012 and December 2013 with a troponin determination. The sample was categorized according to the diabetes mellitus condition and myocardial injury (troponin below 99 th), studying four groups: non-diabetic without myocardial injury (G1), diabetic without myocardial injury (G2), non-diabetic with myocardial injury (G3), and diabetic with myocardial injury (G4). Baseline clinic characteristics and prognostic data were studied with a four years follow-up. Results A total of 3622 patients were studied; 924 (25'55%) diabetics. Three hundred seventy-one diabetic patients (40% of all diabetic patients) had an elevated troponin determination, while six hundred seventy-eights non-diabetic patients had elevated troponin (25'13% from all non-diabetics). Diabetic patients were significantly older (mean age 74 vs. 67 years). They had more frequently history of hypertension (81'9% vs 53'2%), acute myocardial infarction (31'6% vs 15'8%), heart failure (11'1% vs 5'7%), peripheral vascular disease (11'1% vs 5'2%), cerebrovascular disease (11'4% vs 6'6%), chronic pulmonary disease (23'3% vs 16'2%) and renal impairment (16'8% vs 5'2%). At four years of follow-up, G2, G3 and G4 had higher mortality than G1 (HR (95IC): 1,352 (1,080–1,693), 2,896 (2,896–3,477), and 3,441 (2,809–4,216), respectively). A multivariate competing risk model was used to obtain the HRs for readmission for myocardial infarction and heart failure between G2, G3 and G4 in relation to G1 (HR (IC 95%) 2,511 (1,592–3,96), 2,682 (1,739–4,138) and 5,036 (3,221–7,876), respectively for myocardial infarction, and 2,663 (1,825–3,886), 2,562 (1,753–3,744) and 4,292 (2,936–6,274) respectively for heart failure). Conclusions Both conditions, myocardial injury, and diabetes have a prognostic impact at a long-term follow-up with a cumulative effect, being the troponin elevation, a better prognostic marker of death risk, and similar to diabetes history for the risk of myocardial infarction and heart failure. FUNDunding Acknowledgement Type of funding sources: None. ICC hospitalization cumulativeincidence IAM cumulative incidence

scholarly journals Prognostic value of myocardial injury and chronic kidney disease in an emergency unit

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
N Lal-Trehan Estrada ◽  
A Carrasquer ◽  
V Del Moral ◽  
R Sanchez ◽  
G Bonet ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Renal Impairment ◽  
Emergency Room ◽  
Myocardial Injury ◽  
Risk Of Death ◽  
Cardiovascular Profile

Abstract Background Cardiac troponin is independently associated with cardiovascular events and mortality in patients with chronic kidney disease (CKD). Their joint effect is yet to be clarified. Purpose This study aims to evaluate the prognostic implication of myocardial injury and CKD in patients attended in an emergency room. Methods Retrospective study carried out between January 2012 and December 2013 with consecutive patients attended in an emergency room with troponin determination, who were distributed into four cohorts according to positive troponin and/or glomerular filtration rate (GFR) <45ml/min/ 1.7. We analysed their baseline characteristics and the four-year prognosis. Results 3622 patients were included (median age 68.5 years [IQR 55.5–79.5]; 43% were women). Compared to subjects with normal GFR, the 565 subjects with CKD were significantly older (80.5 vs 66.5 years), with worse cardiovascular profile (arterial hypertension: 87% vs 56%; diabetes mellitus: 46% vs 22%) and greater comorbidity (history of myocardial infarction: 29% vs 18%; heart failure: 17% vs 5%; peripheral vascular disease: 16% vs 5%; cerebrovascular disease: 13% vs 7%%). Myocardial injury was also related to elderly and worse cardiovascular profile and comorbidity, especially in normal GFR subjects. 23.5% (718 subjects) of normal GFR subjects presented with myocardial injury. This percentage was much higher in the presence of renal impairment (331 subjects, 58.6%). Troponin was associated with a higher risk of death (both in-hospital and during follow-up) and of readmission due to infarction or heart failure, regardless of GFR. The reference cohort in the multivariate competing risk mode was that with subjects without myocardial injury or kidney disease. This analysis showed the worst MACE (all-cause death, non-fatal myocardial infarction and heart failure admission) in four-year follow-up in patients with renal impairment and positive troponin (HR 3.94, 95% CI 3.317–4.682), second worst MACE in those with myocardial injury and with normal GFR (HR 2.408, 95% CI 2.064–2.811), and then abnormal GFR patients with negative troponin (HR 1.532, 95% CI 1.220–1.923). Patients with both myocardial injury and renal impairment had the highest mortality (HR 4.633, 95% CI 3.829–5.604) and more readmissions for heart failure (HR 2.163, 95% CI 1.647–2.841). The myocardial-injury-and-normal-GFR cohort showed significantly higher mortality than the renal-impairment-with-negative-troponin cohort (HR 2.669 vs HR 1.794), more heart failure (HR 1.951 vs 1.067) and more myocardial infarctions (HR 2.439 vs 1.235) in the follow-up. Conclusion The results suggest that myocardial injury has better predictive power than chronic kidney disease for MACE events and also for individually mortality, readmission for heart failure or myocardial infarction. FUNDunding Acknowledgement Type of funding sources: None.

Abstract MP85: Prognostic Impact of Heart Failure with Preserved and Reduced Ejection Fraction after Myocardial Infarction in the Community

Circulation ◽  
2014 ◽  
Vol 129 (suppl_1) ◽  
Author(s):  
Yariv Gerber ◽  
Susan A Weston ◽  
Cecilia Berardi ◽  
Alanna M Chamberlain ◽  
Sheila M McNallan ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Ejection Fraction ◽  
Early Onset ◽  
Late Onset ◽  
Secular Trends ◽  
Prognostic Impact ◽  
Reduced Ejection Fraction ◽  
Risk Of Death

Background: Contemporary community data on the prognostic importance of heart failure (HF) after myocardial infarction (MI) according to (1) preserved or reduced ejection fraction (EF) and (2) the time of its occurrence are lacking. We examined HF-associated mortality and secular trends in survival among patients with and without HF in a geographically defined cohort of MI survivors. Methods: All residents of Olmsted County, Minnesota (n=2,596) who had a first MI diagnosed in 1990-2010 and no prior HF were followed through 2012 for HF incidence and mortality. Framingham Heart Study criteria were used to define HF, which was further classified according to EF. Cox models were used to examine (1) the hazard ratios (HRs) for death associated with HF type (preserved or reduced) and timing (early- or late-onset); and (2) secular trends in survival by HF status. Results: During a mean (SD) follow-up of 4 (3) years, 748 patients developed HF (519 within 30 days) and 673 died. After adjusting for age, sex, and year of index MI, HF as a time-dependent variable was strongly associated with mortality (HR=3.33 vs. HF-free subjects). Mortality did not differ by HF type, but was markedly higher for late-onset (>30 days) than for early-onset HF. Further adjustment for indicators of MI severity and comorbidity burden, acute intervention, and recurrent MI attenuated the association (Table). The age- and sex-adjusted HRs for mortality in 2001-2010 vs. 1990-2000 were 0.71 (95% CI: 0.58-0.88) in HF and 0.74 (95% CI: 0.59-0.93) in HF-free patients. These estimates equate to 10.18 (95% CI: 3.82-16.54) and 3.75 (95% CI: 0.90-6.61) fewer deaths per 100 subjects at 5 years of follow-up in participants with and without HF, respectively. Conclusions: HF markedly increases the risk of death after MI. The magnitude of this excess risk is similar between preserved and reduced EF but greater for late- vs. early-onset HF. Mortality declined over time in all patients with MI, and the absolute reduction in the risk of death was substantially greater for those with HF.

scholarly journals The impact of heart failure on prognosis of diabetic and non-diabetic patients with myocardial infarction: a 15-year follow-up study

2001 ◽  
Vol 3 (1) ◽  
pp. 83-90 ◽  
Author(s):  
Thomas Melchior ◽  
Christian Rask-Madsen ◽  
Christian Torp-Pedersen ◽  
Per Hildebrandt ◽  
Lars Køber ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Diabetic Patients ◽  
Follow Up Study ◽  
The Impact

scholarly journals Prognosis of diabetes mellitus and timing of heart failure in patients with acute myocardial infarction. An analysis of a French nationwide hospital database

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
L Fauchier ◽  
C Semaan ◽  
G Fauchier ◽  
J Herbert ◽  
T Genet ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Stage ◽  
First Year ◽  
Diabetic Patients ◽  
History Of ◽  
One Year ◽  
Long Term Mortality

Abstract Background Diabetes mellitus (DM) is a factor of increased mortality in patients with acute myocardial infarction (AMI). DM is also associated with a higher risk of heart failure (HF) in patients with coronary artery disease as in the general population. The aim of the present study was to assess the incidence of HF developing at the acute stage of MI and of HF occurring in the year following hospital discharge, according to presence of DM. We also assessed the association between DM, HF and long-term mortality in this AMI population. Methods We used the French administrative hospital-discharge database, including all patients without history of HF admitted for AMI between 2010 and 2019 (n=797,212, mean age 69 years, 66% male). Among them, 520,258 patients (65%) had ST-segment elevation myocardial infarction (STEMI), 276,954 (35%) had non-STEMI, 192,456 patients (24%) had a history of DM. Occurrence of HF during the initial hospital stay was analysed in the whole population. In patients without HF during the index hospitalisation, discharged and alive at day 8 (n=535,813), we collected all hospitalisations for HF occurring during the year after discharge and analysed subsequent long-term mortality in those alive at one year (n=270,534) (length of follow-up 2.0±2.5 years, median 0.9, IQR 0.1–3.5). Results Overall, DM patients were older than non-DM patients (71±12 vs 67±15 years) and had more frequent comorbidities. At the acute stage, DM was associated with a higher risk of HF (28.7% vs 20.5% adjusted OR 1.40, 1.38–1.42, p<0.0001). In patients without HF at the acute stage and discharged alive at day 8, DM was associated with a higher risk of being hospitalised with HF in the first year (5.6% vs 2.8%, adjusted HR 1.52, 1.49–1.56, p<0.0001). In patients alive at one year, rates of all-cause death per year during subsequent follow-up were 2.2% in those without DM or HF during the first year (reference), 3.4% in those with DM and no HF during the first year (adjusted HR 1.22, 1.18–1.25, p<0.0001), 7.7% in those without DM and with HF during the first year (adjusted HR 1.92, 1.83–2.02, p<0.0001) and 8.9% in those with DM hospitalised with HF during the first year (adjusted HR 2.23, 2.09–2.37, p<0.0001) (see figure). Conclusion After AMI, patients with diabetes are at increased risk of heart failure both at the acute stage and in the year following myocardial infarction, compared with non-diabetic patients. Non-fatal HF developing in the year following discharge is associated with noticeably higher subsequent mortality, and the combination of DM and HF is particularly at risk. Improved management is needed in diabetic patients following an AMI to avoid development of heart failure and its longer-term consequences. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Clinical characteristics and prognostic implications of diabetes and myocardial injury in patients admitted to the emergency room

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Gil Bonet ◽  
Anna Carrasquer ◽  
Óscar M. Peiró ◽  
Raul Sanchez-Gimenez ◽  
Nisha Lal-Trehan ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Emergency Department ◽  
Myocardial Injury ◽  
Troponin I ◽  
Risk Model ◽  
Similar Proportion ◽  
Clinical Events ◽  
The Status

Abstract Background This study aimed to investigate the clinical features and prognosis of diabetes and myocardial injury in patients admitted to the emergency department. Methods We analyzed the clinical data of all consecutive patients admitted to the emergency department during the years 2012 and 2013 with at least 1 cardiac Troponin I (cTnI Ultra Siemens, Advia Centaur) determination, and were classified according to the status of diabetes mellitus (DM) and myocardial injury (MI). Clinical events were evaluated in a 4-year follow-up. Results A total of 3622 patients were classified according to the presence of DM (n = 924 (25.55%)) and MI (n = 1049 (28.96%)). The proportion of MI in patients with DM was 40% and 25% in patients without DM. Mortality during follow-up was 10.9% in non-DM patients without MI, 21.3% in DM patients without MI, 40.1% in non-DM patients with MI, and 52.8% in DM patients with MI. A competitive risk model was used to obtain the Hazard Ratio (HR) for readmission for myocardial infarction or heart failure. There was a similar proportion of readmission for myocardial infarction and heart failure at a four-year follow-up in patients with DM or MI, which was much higher when DM was associated with MI, with respect to patients without DM or MI. The HR (95% Coefficient Interval) for myocardial infarction in the DM without MI, non-DM with MI, and DM with MI groups with respect to the non-DM without MI group was 2511 (1592–3960), 2682 (1739–4138), and 5036 (3221–7876), respectively. The HR (95% CI) for the risk of readmission for heart failure in the DM without MI, non-DM with MI, and DM with MI groups with respect to the non-DM without MI group was 2663 (1825–3886), 2562 (1753–3744) and 4292 (2936–6274), respectively. Conclusions The association of DM and MI in patients treated in an Emergency Service identifies patients at very high risk of mortality and cardiovascular events.

KAsH score beyond myocardial infarction: a new risk stratification tool for myocardial injury?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J Sousa ◽  
J.P Monteiro ◽  
F Mendonca ◽  
M Santos ◽  
M Temtem ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Multivariate Analysis ◽  
Hospital Mortality ◽  
Myocardial Injury ◽  
Predictive Power ◽  
Risk Scores ◽  
Hemodynamic Variables ◽  
Risk Stratification Tool

Abstract Introduction Our group has recently validated and published a new score - KAsH score. KAsH consists of a continuous, multiplicative score based on 4 simple clinical variables available at first medical contact, proven to be a robust predictor of in-hospital mortality and all-cause mortality at 1 year follow-up in patients with myocardial infarction, putting it next to other well established risk scores. However, the role of KAsH in patients with myocardial injury (Mi), a largely uncharacterized group in the literature, remains unknown. Purpose We aim to assess the predictive power of KAsH in patients with myocardial injury (Mi), regarding in-hospital mortality and at 1 year follow-up. Methods Prospective registry of 250 patients admitted consecutively through the emergency department from January 2018 onward, with higher than P99th high-sensitive troponin assay. The kit used was Roche's Elecsys hsSTAT, and the P99th appointed by the manufacturer was 14 ng/L. All patients with chronic kidney disease ClCr<15ml/min and myocardial infarction, were excluded from the analysis. We were left with 236 patients diagnosed with Mi. KAsH = (Killip Kimbal × Age × Heart Rate) / Systolic BP We used a simplified Killip classification: without heart failure (1 point), with heart failure (2 points) and in shock (3 points). We assessed the score's association to mortality and its predictive value through ROC curves and their respective area under the curve (AUC). Results Both Killip and KAsH had a significant and positive association with in-hospital mortality (KK: p=0.02; KAsH: p<0.001) and cumulative mortality (KK: p=0.002; KAsH: p=0.008). In multivariate analysis, KAsH score as a continuous variable proved to be an independent predictor of in-hospital mortality (p=0.004) but not KK classification (p=0.96). We then categorized KAsH in its 4 different strata (1–4). Multivariate analysis indentified categorized KAsH as the only significant predictor of in-hospital mortality (OR 4.1, CI 2.1–8.1, p<0.001), with the predictive power of KAsH being even mildly superior (AUCs: KAsHcont 0.767, KAsHcat 0.743, KK 0.685). However, the same trend was not observed during follow-up, as none of them were significant predictors of mortality (all p>0.1). Conclusions KAsH seems to maintain its in-hospital predictive value even in patients with Mi. To our knowledge, this is the first study that tries to apply risk scores and stratification tools to such a heterogeneous group of patients. By comprising hemodynamic variables, KAsH may actually be a better risk stratification tool than just the severity of heart failure on admission. However, unlike previously proven in myocardial infarction (MI), KAsH score and its hemodynamic variables do not seem to justify the high mortality on the long run behind these patients. More studies will be needed to address the complex causes behind long-term mortality of Mi patients. KASH table graph Funding Acknowledgement Type of funding source: None

Predicting long-term cardiovascular outcomes of patients with acute myocardial infarction using soluble ST2

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Mustafa Umut Somuncu ◽  
Belma Kalayci ◽  
Ahmet Avci ◽  
Tunahan Akgun ◽  
Huseyin Karakurt ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Cox Regression ◽  
High Serum ◽  
Major Adverse Cardiovascular Events ◽  
Lower Systolic Blood Pressure ◽  
Cox Regression Analysis ◽  
Killip Class ◽  
Target Vessel Revascularization

AbstractBackgroundThe increase in soluble suppression of tumorigenicity 2 (sST2) both in the diagnosis and prognosis of heart failure is well established; however, existing data regarding sST2 values as the prognostic marker after myocardial infarction (MI) are limited and have been conflicting. This study aimed to assess the clinical significance of sST2 in predicting 1-year adverse cardiovascular (CV) events in MI patients.Materials and methodsIn this prospective study, 380 MI patients were included. Participants were grouped into low sST2 (n = 264, mean age: 60.0 ± 12.1 years) and high sST2 groups (n = 116, mean age: 60.5 ± 11.6 years), and all study populations were followed up for major adverse cardiovascular events (MACE) which are composed of CV mortality, target vessel revascularization (TVR), non-fatal reinfarction, stroke and heart failure.ResultsDuring a 12-month follow-up, 68 (17.8%) patients had MACE. CV mortality and heart failure were significantly higher in the high sST2 group compared to the low sST2 group (15.5% vs. 4.9%, p = 0.001 and 8.6% vs. 3.4% p = 0.032, respectively). Multivariate Cox regression analysis concluded that high serum sST2 independently predicted 1-year CV mortality [hazard ratio (HR) 2.263, 95% confidence interval (CI) 1.124–4.557, p = 0.022)]. Besides, older age, Killip class >1, left anterior descending (LAD) as the culprit artery and lower systolic blood pressure were the other independent risk factors for 1-year CV mortality.ConclusionsHigh sST2 levels are an important predictor of MACE, including CV mortality and heart failure in a 1-year follow-up period in MI patients.

Meta-analyzing the prevalence and prognostic effect of antipsychotic exposure in clinical high-risk (CHR): when things are not what they seem

2020 ◽  
pp. 1-9
Author(s):  
Andrea Raballo ◽  
Michele Poletti ◽  
Antonio Preti
Keyword(s):  
High Risk ◽  
Meta Analysis ◽  
Prognostic Impact ◽  
Clinical High Risk ◽  
Qualitative Synthesis ◽  
Prognostic Effect ◽  
Inverse Variance ◽  
Arcsine Transformation ◽  
Estimate Prevalence

Abstract Background The clinical high-risk (CHR) for psychosis paradigm is changing psychiatric practice. However, a widespread confounder, i.e. baseline exposure to antipsychotics (AP) in CHR samples, is systematically overlooked. Such exposure might mitigate the initial clinical presentation, increase the heterogeneity within CHR populations, and confound the evaluation of transition to psychosis at follow-up. This is the first meta-analysis examining the prevalence and the prognostic impact on transition to psychosis of ongoing AP treatment at baseline in CHR cohorts. Methods Major databases were searched for articles published until 20 April 2020. The variance-stabilizing Freeman-Tukey double arcsine transformation was used to estimate prevalence. The binary outcome of transition to psychosis by group was estimated with risk ratio (RR) and the inverse variance method was used for pooling. Results Fourteen studies were eligible for qualitative synthesis, including 1588 CHR individuals. Out of the pooled CHR sample, 370 individuals (i.e. 23.3%) were already exposed to AP at the time of CHR status ascription. Transition toward full-blown psychosis at follow-up intervened in 112 (29%; 95% CI 24–34%) of the AP-exposed CHR as compared to 235 (16%; 14–19%) of the AP-naïve CHR participants. AP-exposed CHR had higher RR of transition to psychosis (RR = 1.47; 95% CI 1.18–1.83; z = 3.48; p = 0.0005), without influence by age, gender ratio, overall sample size, duration of the follow-up, or quality of the studies. Conclusions Baseline AP exposure in CHR samples is substantial and is associated with a higher imminent risk of transition to psychosis. Therefore, such exposure should be regarded as a non-negligible red flag for clinical risk management.

Long-term impact of new-onset atrial fibrillation complicating acute myocardial infarction on heart failure: insights from the NOAFCAMI-SH registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S.L Xu ◽  
J Luo ◽  
H.Q Li ◽  
Z.Q Li ◽  
B.X Liu ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Acute Myocardial Infarction ◽  
Natural Science ◽  
Funding Source ◽  
Onset Atrial Fibrillation ◽  
New Onset

Abstract Background New-onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI) has been associated with poor survival, but the clinical implication of NOAF on subsequent heart failure (HF) is still not well studied. We aimed to investigate the relationship between NOAF following AMI and HF hospitalization. Methods This retrospective cohort study was conducted between February 2014 and March 2018, using data from the New-Onset Atrial Fibrillation Complicating Acute Myocardial Infarction in ShangHai registry, where all participants did not have a documented AF history. Patients with AMI who discharged alive and had complete echocardiography and follow-up data were analyzed. The primary outcome was HF hospitalization, which was defined as a minimum of an overnight hospital stay of a participant who presented with symptoms and signs of HF or received intravenous diuretics. Results A total of 2075 patients were included, of whom 228 developed NOAF during the index AMI hospitalization. During up to 5 years of follow-up (median: 2.7 years), 205 patients (9.9%) experienced HF hospitalization and 220 patients (10.6%) died. The incidence rate of HF hospitalization among patients with NOAF was 18.4% per year compared with 2.8% per year for those with sinus rhythm. After adjustment for confounders, NOAF was significantly associated with HF hospitalization (hazard ratio [HR]: 3.14, 95% confidence interval [CI]: 2.30–4.28; p<0.001). Consistent result was observed after accounting for the competing risk of all-cause death (subdistribution HR: 3.06, 95% CI: 2.18–4.30; p<0.001) or performing a propensity score adjusted multivariable model (HR: 3.28, 95% CI: 2.39–4.50; p<0.001). Furthermore, the risk of HF hospitalization was significantly higher in patients with persistent NOAF (HR: 5.81; 95% CI: 3.59–9.41) compared with that in those with transient NOAF (HR: 2.61; 95% CI: 1.84–3.70; p interaction = 0.008). Conclusion NOAF complicating AMI is strongly associated with an increased long-term risk of heart. Cumulative incidence of outcome Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): 1. National Natural Science Foundation of China, 2. Natural Science Foundation of Shanghai

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