Effect of Lipid Abnormality on CKD Progression from Moderate to Severe Stage: Application of Flexible Parametric Proportional-Hazards and Proportional-Odds Models

Background: Lipid disorders are a well-documented risk factor for chronic kidney disease (CKD), but the impact of lipid abnormalities in the progression of the disease remains mixed. Objectives: The current study aimed to extend the existing knowledge about the effect of lipid disorders in disease progression from moderate to severe stage using Flexible parametric survival models. Methods: This retrospective cohort study included 308 moderate CKD patients who received the nephrologist follow-up visits at the nephrology clinic, Ilam (Iran), from 2012 to 2019. The survival time was determined based on the time medically diagnosed with moderate stages (GFR = 59 - 55 mL/min per 1.73 m2) to the time of progression to the severe stage (GFR = 29 - 25 mL/min per 1.73 m2) hazard using flexible parametric survival models. Results: In univariate analysis, high levels of TG, LDL, and cholesterol were important risk factors which affect the CKD progression. The hazard of patients with TG > 200 mg/dL was 1.69 times higher than patients with desirable TG levels (P = 0.09). Moreover, for patients with LDL > 160 mg/dL, the hazard was 2.12 times higher than patients with desirable LDL levels (P = 0.01). The hazard of patients with total cholesterol levels > 240 mg/dL was 2.10 times higher than patients with desirable cholesterol levels (P = 0.003). The adjusted model was shown to better fit the PH model. Cholesterol levels > 240 mg/dL remains a significant risk factor for CKD progression (P = 0.03). Conclusions: Effective treatment programs should pay closer attention to screening and treatment of hyperlipidemia in patients diagnosed with moderate CKD.

The Long-Term Efficacy of Radiofrequency Ablation Versus Laparoscopic Hepatectomy for Small Hepatocellular Carcinoma in East Asia: A Systematic Review and Meta-Analysis

Context: Hepatocellular carcinoma (HCC) is a common malignant cancer and the second leading cause of cancer-related deaths around the world. Radiofrequency ablation (RFA) and laparoscopic hepatectomy (LH) have been adopted for the treatment of HCC. The aim of the meta-analysis was to explore the long-term efficacy of RFA compared with LH for small HCC (sHCC) patients in the East Asian population. Evidence Acquisition: We performed a systematic review and meta-analysis by the literature search on PubMed, Cochrane Library, EMBASE, Chinese Biological Medical Literature (CBM), Chinese National Knowledge Infrastructure (CNKI), and Wanfang from their inception until October 10, 2019, for comparing the long-term efficacy outcomes of RFA with LH. Results: Fourteen retrospective studies with 1,390 subjects were included in the meta-analysis. Compared with the LH-treated group, RFA could raise the local recurrence rate under median follow-up duration and reduce disease-free survival (DFS) rates at 1 - 3 years. However, it failed to affect 5-year overall survival (OS) and DFS rates. In the subgroup analyses, different RFA approaches had significantly higher local recurrence rates than the LH group. A similar effect on OS and DFS rates within five years for single early (≤ 3 cm) HCCs and on the 1- and 5-year DFS rates for nodules ≤ 5 cm were observed between the two groups, but RFA approaches could reduce the 3-y OS and DFS rates for single nodules ≤ 5 cm. The percutaneous radiofrequency ablation (PRFA) group had significantly lower 3- and 5-year OS and the 1- and 3-year DFS rates than the LH group, while no significant difference in OS and DFS rates in the laparoscopic radiofrequency ablation (LRFA) approach. The RFA approach improved the 3-year OS compared with the LH group in Japan, but reduced the 3-year OS and DFS rates within 3 years in China. Conclusions: Our results support that LH treating sHCC had a better long-term efficacy and a lower local recurrence rate than RFA in the East Asian population. Further high-quality prospective studies are required to confirm the long-term efficacy.

Epithelial Membrane Antigen in Papillary Thyroid Carcinoma and Multinodular Goiter; a Marker of Discrimination

Background: Papillary thyroid cancer is the most common type of thyroid malignancies. For a more accurate diagnosis, immunohistochemistry has been used widely in recent years. Epithelial membrane antigen has been detected in several benign and malignant lesions, and its use as a marker of malignancy has been sought in some studies. Objectives: The current study aimed to determine the presence and level of expression of epithelial membrane antigen in papillary thyroid carcinoma and multinodular goiter. Methods: Eighty-five samples of papillary thyroid carcinoma and 40 cases of multinodular goiter were stained histochemically for epithelial membrane antigen. The intensity of staining was classified in a semi-quantitative manner (1+ to 4+). Demographic data of the index cases, history of metastasis, and lymph node involvement, if any, were collected as well. Results: All PTCs and 87.5% of MNGs were positive for EMA. EMA was expressed more strongly in PTCs than in MNGs (P < 0.00). EMA reactivity was directly associated with lymph node involvement, capsular invasion, and size of the tumor (P = 0.008, P < 0.001, and P < 0.001, respectively). The intensity level of 2 or higher had high specificity for differentiating PTC from MNG. Conclusions: Strong expression of EMA may be a good marker of malignancy in differentiating PTC from MNG. This marker may also be regarded as an index of invasive behavior of PTC.

Association Between SYNTAX Score and Carotid Artery Stenosis in Patients Undergoing Coronary Artery Bypass Graft (CABG)

Background: Stroke as a complication of open-heart surgery can be a cause of death and widespread disability. Objectives: This study aimed to determine the relationship between the SYNTAX Score and carotid artery stenosis and evaluate patients undergoing open-heart surgery in terms of postoperative complications and mortality in a six-month to two-year follow-up period. Methods: A cross-sectional study was conducted on 113 patients with CAD who underwent open-heart surgery at our hospital from 2016 to 2017. After collecting demographic data, the SYNTAX score, and color Doppler sonography report, the data were recorded and analyzed by SPSS22. Results: In our study, most patients were male and aged between 50 and 70 years. The mean SYNTAX score was 32.667 + 13.668 in the group with significant carotid stenosis, 33.926 + 9.387 in the group with no significant carotid stenosis, and 30.868 + 9.963 in the group without carotid stenosis. The results showed no significant relationship between carotid artery stenosis and the SYNTAX score (P = 0.512) and no significant relationship between the SYNTAX score and surgical complications (P = 0.666). Conclusions: According to the results, there is no significant relationship between the SYNTAX score and various indices related to heart disease, carotid artery stenosis, and postoperative morbidity and mortality. Thus, this index cannot be used to check and follow patients. However, further studies are needed to reach a definitive conclusion.

Incidence of Insufficient Physical Activity Among Adults and Its Relationship with the Human Development Index: A Global Study

Background: Insufficient physical activity, particularly in low- and middle-income countries, plays an important role in the spread of non-communicable diseases. Objectives: The purpose of this study is to investigate the incidence of insufficient physical activity and its relationship with the human development index (HDI) in the world. Methods: This is an ecological study, and the study data, including the human development index and the incidence of insufficient physical activity, were extracted from the World Bank’s database. The descriptive analysis included mean and standard deviation. The inferential analysis consisted of two-way correlation and ANOVA at a significance level of less than 0.05. The analyses were performed using Stata-14 software. Results: The highest incidence of insufficient physical activity in both sexes (39.26 [37.42, 40.95]) was found in the Americas, especially in high-income regions. There was a significant positive correlation between the incidence of insufficient physical inactivity and HDI in the world (r = 0.446, P < 0.0001). This correlation was also significant in Asia and Africa (P < 0.05). The results showed a positive correlation between components of HDI (i.e., gross national income per 1000 capita, mean years of schooling, life expectancy at birth, and expected years of schooling) and insufficient activity (P < 0.0001). The results of ANOVA also exhibited a significant relationship between the mean prevalence of physical inactivity and the level of development (P < 0.0001). Conclusions: Given the significant correlation between the incidence of insufficient physical inactivity and HDI, understanding this correlation and its components, especially in low- and middle-income countries can alleviate the impact of physical inactivity epidemics in the future, thereby contributing to the effective global prevention of non-communicable diseases.

Laboratory Abnormalities in Patients with COVID-19 in Mazandaran Province, Iran

Background: Coronavirus is a single-stranded RNA virus, causing an epidemic of pneumonia and acute respiratory distress syndrome (ARDS) worldwide in late 2019. Objectives: In addition to the clinical symptoms, laboratory diagnosis can greatly help diagnose the diseases; therefore, this study aimed to analyze laboratory parameters in patients with COVID-19. Methods: In this cross-sectional study, the laboratory data of 2563 patients with COVID-19 admitted to hospitals affiliated with Mazandaran University of Medical Sciences were extracted from hospital information systems (HIS). The data were recorded on Excel and analyzed through t-test, chi-squared, and Fisher’s exact tests in SPSS 19 at the significance level of P < 0.05. Results: Out of 2563 patients with a mean age of 55.1 ± 16.7 years, 1409 (55%) were male, and 1154 (45%) were female with a mean age of 55.7 ± 16.8, and 54.3 ± 16.6 years, respectively. As the most frequent clinical findings, ESR, CRP, and LDH were increased by 83.5%, 71%, and 69.3% of the patients, respectively. Other research findings included lymphopenia, disturbed INR, abnormal SGOT, abnormal alkaline phosphatase (ALP), and increased lactate dehydrogenase (LDH), which were significantly higher in men than in women and was different between age groups. Conclusions: Conducting simple, convenient, and inexpensive laboratory tests can be helpful in the diagnosis of COVID-19.

Analysis of the Risk Factors for the Recurrence of Ischemic Stroke with Diabetes Mellitus and Establishment of Cox’s Regression Model and the Personal Prognosis Index in Two Years of Follow-Up

Background: Ischemic stroke is a major cause of disability and mortality in patients with type 2 diabetes mellitus (T2DM), and diabetic stroke has a high recurrence rate. Objectives: This prospective cohort study aimed at investigating the risk factors and establishing Cox’s regression model and personal prognosis index for the recurrence of ischemic stroke at a two-year follow-up in T2DM patients. Methods: T2DM patients with ischemic stroke, who were consecutively admitted to the Neurology Department of North China University of Science and Technology Affiliated Hospital between January 1, 2015, and December 31, 2015, were retrospectively reviewed. These cases were followed up since the onset of ischemic stroke for 2 years. Univariate and multivariate Cox’s proportional hazard regression model was used to analyze risk factors associated with the recurrence rate. Thus, a recurrence model and personal prognosis index were set up. Results: During the follow-up period, 44 cases relapsed. Furthermore, the 1-year recurrence rate was 16.48%, while the 2-year recurrence rate was 24.18%. The univariate and multivariate Cox proportional hazard regression model revealed that the independent risk factors associated with recurrence were TOAST criteria (X1) (RR = 1.663; 95% CI = 1.015 - 2.760, P = 0.032), hypertension grade (X2) (RR = 1.897; 95% CI = 1.097 - 3.280, P = 0.022), duration of diabetes mellitus (X3) (RR = 1.151; 95% CI = 1.009 - 1.991, P = 0.039), total cholesterol (X4) (RR = 1.13; 95% CI = 1.006 - 1.876, P = 0.035), and Essen stroke risk score (ESRS) (X5) (RR = 2.055; 95% CI = 1.357 - 3.134, P = 0.001). The personal prognosis index of the recurrence model was as follows: PI = 0.504 X1 + 0.640 X2 + 0.345 X3 + 0.759 X4 + 0.823 X5. Conclusions: TOAST criteria, hypertension grade, duration of diabetes mellitus, total cholesterol, and ESRS were the independent risk factors associated with the recurrence of ischemic stroke with diabetes mellitus. The recurrence model and personal prognosis index equation were successfully established.

Chronic Active Epstein-Barr Virus Infection in a Patient with Enteritis, Myositis, and Pericardial Effusion: A Case Report

Introduction: Chronic active Epstein-Barr virus infection (CAEBV) is a rare, life-threatening disease entity involving multiple organs and systems. The disease could be presented in a single organ with atypical symptoms, be misdiagnosed at the early phase, and resolved without aggressive treatment. Previous studies reported favorable outcomes with early diagnosis and treatment, while in other cases, disease progression and presenting in other organs could result in a very poor outcome. Clinicians from any department should be aware of the CAEBV entity when an unresolved systemic inflammation presents. Case Presentation: A 61-year-old female presented to the cardiology department due to edema and fatigue with the progression of symptoms, including fever, muscle weakness, and shortness of breath. MR images showed muscular edema, and ultrasound analysis revealed massive pericardial effusion. Results of laboratory tests indicated hematological involvement, liver damage, and positivity for EBV DNA, and EBER in muscle and intestine by staining. She was first misdiagnosed with ulcerative colitis, but the disease evolved to the muscles and cardiovascular system later on. Altogether, the CAEBV infection with enteritis, myositis, and pericardial effusion was confirmed in the case. Although diagnosed, the treatment of the elderly population remains rather challenging in severe cases. The patient died after disease onset for less than three years. Conclusions: Elderly patients with CAEBV infection tend to have a poor prognosis. Early diagnosis would facilitate early treatment and the utilization of available options, which might reduce the disease mortality rate eventually. Individualized therapy and promising approaches should be further developed for CAEBV infection.

Covered and Uncovered Self-Expandable Metallic Stents in the Treatment of Malignant Biliary Obstruction

Context: Self-expandable metal stents (SEMSs) are commonly used in the treatment of malignant biliary obstruction. We performed a meta-analysis to compare the efficacy of covered self-expandable metallic stents (CSEMSs) and uncovered self-expandable metallic stents (UCSEMSs) for patients with malignant distal biliary obstruction. Methods: A comprehensive search was conducted using PubMed, Embase, Cochrane, and CNKI databases from 2010 to 2019. All randomized controlled trials, which compared the use of the CSEMSs and UCSEMSs for the treatment of malignant distal biliary obstruction were included in this study. Results: This meta-analysis included 1,539 patients enrolled in 13 trials. There was no difference between the two groups in terms of patients’ survival (hazard ratio (HR) 0.96, 95% confidence interval (CI): 0.87 - 1.07; I2 = 32.6%), stent patency (HR 0.92, 95% CI: 0.69 - 1.22; I2 = 56.3%), and the overall complication rate (relative risks (RR) 1.35, 95% CI: 0.82 - 2.23; I2 = 0%). In particular, the CSEMSs group presented a lower rate of tumor ingrowth (RR 0.30, 95% CI: 0.15 - 0.57; I2 = 58.5%) than the UCSEMSs group. However, the CSEMSs group exhibited a higher rate of tumor overgrowth (RR 1.63, 95% CI: 1.00 - 2.66; I2 = 0%), sludge formation (RR 2.28, 95% CI: 1.36 - 3.82; I2 = 0%), and migration (RR 5.14, 95% CI: 1.90 - 13.88; I2 = 0%). Conclusions: Our meta-analysis indicated that there was no significant difference between the two stents, and each one had its advantages and disadvantages.

Chinese Medicine Treatment of Cytokine Storm Caused by COVID-19

Context: COVID-19 has turned into a pandemic, threatening the lives of millions of people worldwide. Research has found that some COVID-19 patients will suddenly aggravate, resulting in a cytokine storm, respiratory distress syndrome, and death. It is necessary to articulate the mechanism of cytokine storm and propose a Chinese medicine treatment strategy for COVID-19. Evidence Acquisition: A literature search was conducted using five databases on April 30, 2020, including PubMed, Google Scholar, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data with the keywords of “cytokine storm AND Chinese medicine AND COVID-19 “, “cytokine storm AND Chinese medicine AND SARS-CoV-2”. The outcome of interest was the concept and mechanism of cytokine storm, the characteristics, and the Chinese medicine treatment of COVID-19 cytokine storm, etc. A total of 43 articles were retrieved after removing duplicate articles. Results: The cytokine storm is also called cytokine cascade. The body overreacts with positive feedback without negative feedback, making a variety of abnormal cytokines accumulations, triggering a cytokine storm. COVID-19 cytokine storm does not occur in the early stages, but only after a period of development, it attacks not only the lungs but also the heart, kidneys, and other organs. The key pathogenesis is “toxins and blood stasis, lung failure” in Chinese medicine. The treatment is detoxification, removing blood stasis, and nourishing the lung. Chinese medicine should comprehensively regulate multiple targets and multiple pathways to intervene in the immune regulation of the body to intercept the progress of inflammation and focus on the integration of Chinese medicine with Western medicine to combine anti-virus and anti-inflammatory therapy. Conclusions: The immune response caused by cytokine storm is a complex signal network with multiple targets and pathways and various cytokines acting together. Immunomodulation can balance the excessive inflammatory response and effectively control the replication and spread of SARS-CoV-2. Returning the immune response to a balanced state is an ideal method for treating COVID-19 cytokine storm. Chinese medicine can achieve overall coordination and balance. Nevertheless, the pharmacology of Chinese medicine must be further studied, and the mechanism of cytokine storm treatment should be thoroughly clarified.