Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: an evidence review and modelling analysis.

National action plans enumerate many interventions as potential strategies to reduce the burden of bacterial antimicrobial resistance (AMR). However, knowledge of the benefits achievable by specific approaches is needed to inform policy making, especially in low-income and middle-income countries (LMICs) with substantial AMR burden and low health-care system capacity. In a modelling analysis, we estimated that improving infection prevention and control programmes in LMIC health-care settings could prevent at least 337 000 (95% CI 250 200-465 200) AMR-associated deaths annually. Ensuring universal access to high-quality water, sanitation, and hygiene services would prevent 247 800 (160 000-337 800) AMR-associated deaths and paediatric vaccines 181 500 (153 400-206 800) AMR-associated deaths, from both direct prevention of resistant infections and reductions in antibiotic consumption. These estimates translate to prevention of 7·8% (5·6-11·0) of all AMR-associated mortality in LMICs by infection prevention and control, 5·7% (3·7-8·0) by water, sanitation, and hygiene, and 4·2% (3·4-5·1) by vaccination interventions. Despite the continuing need for research and innovation to overcome limitations of existing approaches, our findings indicate that reducing global AMR burden by 10% by the year 2030 is achievable with existing interventions. Our results should guide investments in public health interventions with the greatest potential to reduce AMR burden.

Government fiscal decentralization and haze and carbon reduction: Evidence from the fiscal Province-Managing-County reform.

Government governance reform is not only a vital motivation for high economic quality but also an important factor in stimulating the government's environmental governance responsibility. The article empirically examines the fiscal Province-Managing-County (PMC) pilot reform on the synergic governance of haze and carbon reduction and its mechanism. The results show that the policy helps to realize the synergic governance of haze and carbon reduction, and the reform of fiscal Province-Managing-County promotes regional haze and carbon reduction mainly through structural effect, innovation effect, and fiscal expenditure responsibility effect. The heterogeneity analysis shows that the policy has an asymmetric effect on haze and carbon reduction under different administrative structures, economic structures and levels of government intervention. Further analysis shows a policy linkage effect between this policy and the Green Fiscal Policy. The policy has the situation of blood-sucking in the provincial capital city and leads to an increase in financial funds. The above results prove that the policy can help to realize haze and carbon reduction and provide practical ideas for the further expansion of the policy. At the same time, it provides the direction for the local government to realize the double-carbon goal.

Applying self-determination theory towards motivational factors of physical activity in people undergoing haemodialyses: A qualitative interview study.

INTRODUCTION: The level of physical activity of people undergoing haemodialyses is low, so understanding what factors underlie the motivation to be physically active in people undergoing haemodialyses is important. Therefore, this qualitative study aims to explore the different motivation types and corresponding basic psychological needs (BPNs) of people undergoing haemodialyses based on self-determination theory. METHODS: We adopted the objective sampling method to select 19 patients with the end-stage renal disease aged from 28 to 66 years old from a tertiary hospital in Xi'an. They underwent haemodialyses five to six times every 2 weeks for more than 3 months. Then, we conducted semistructured one-on-one interviews with 19 people undergoing haemodialyses using qualitative content analysis. All interviews were recorded, transcribed verbatim and analyzed on a thematic analysis. RESULTS: We analyzed four motivation types of patients, namely four themes, including entrenching in physical inactivity (Amotivation), breaking physical inactivity (Controlled motivation), finding one's way (Autonomous regulation) and enjoying the positive effects of physical activity (Intrinsic motivation). Each motivation is dominated by one or more BPNs. For example, inadequate Competence such as decreased physical function is the reason why the patient does not perform physical activities. Due to the lack of health education on physical activity, people undergoing haemodialyses often lack the motivation for controlled regulation. The motivation for self-regulation is generated by the patients' promotion of meeting BPNs, such as normal social interactions. The formation of patients' autonomous motivation can't be separated from the effective understanding felt by other patients, because their situations are similar. Enjoying physical activity promotes the formation of patients' intrinsic motivation and the maintenance of this behaviour. CONCLUSION: Perceived Competence, Relatedness and Autonomous Motivation are important determinants for physical activity in people undergoing haemodialyses. Patients need to internalize the changed values and skills, so as to generate the motivation of self-regulation, rather than external or controlled forms of motivation regulation, to better maintain behaviour change. PATIENT OR PUBLIC CONTRIBUTION: People undergoing haemodialyses were involved in the development of the interview topic guide to ensure all relevant topics were explored.

Citral protects against LPS-induced endometritis by inhibiting ferroptosis through activating Nrf2 signaling pathway.

INTRODUCTION: Endometritis is the inflammatory condition of the uterus. Citral, a component of lemongrass oil, is known to exhibit anti-inflammatory activity. AIM: The effects of citral on LPS-induced endometritis were tested and the mechanisms were investigated. METHODS: LPS-induced endometritis mice model was established and the effects of citral were detected using this model. Inflammatory cytokines were tested by ELISA. Ferroptosis was assessed by detecting GSH, ATP, MDA, and Fe2+ levels. Signaling pathway was tested by western blot analysis. RESULTS: Citral prevented LPS-induced endometritis through attenuating uterine pathological changes and inflammatory cytokine release. Meanwhile, citral prevents LPS-induced ferroptosis through attenuating MDA and Fe2+ levels, as well as increasing ATP and GSH levels. Furthermore, citral up-regulated Nrf2 and HO-1 expression and attenuated NF-κB activation. In addition, in Nrf2 knockdown mice, the inhibitory roles of citral on ferroptosis and endometritis were largely reversed. CONCLUSION: Taken together, citral inhibited LPS-induced endometritis through preventing ferroptosis, which were regulated by Nrf2 signaling pathway.

Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe.

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.

Anlotinib combined with PD-1 blockade for the treatment of lung cancer: a real-world retrospective study in China.

BACKGROUND: This study evaluated the efficacy and safety of anlotinib combined with programmed cell death protein 1 (PD-1) blockade for the treatment of small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: SCLC (n = 28) and NSCLC (n = 177) patients who received treatment at Hunan Cancer Hospital between June 1, 2019, and July 1, 2020, were retrospectively analyzed. Progression-free survival (PFS) and treatment responses were compared among patients who received combination therapy of anlotinib plus PD-1 inhibitor, or monotherapy of either chemotherapy or PD-1 inhibitor. Independent prognostic factors were identified by Cox regression analysis. RESULTS: Patients with relapsed SCLC who received anlotinib plus PD-1 inhibitor as a ≥ second-line therapy (n = 14) had a significantly longer PFS than those who received PD-1 inhibitor alone (n = 14, 5.0 vs. 3.0 months; P = 0.005). For patients with previously untreated wild-type NSCLC, the combination therapy in the first-line setting (n = 6) provided a marginally longer PFS than mono-chemotherapy (n = 6, 8.0 vs. 3.0 months; P = 0.075). For patients with relapsed NSCLC, the combination therapy in the ≥ second-line setting (n = 62) resulted in significantly higher objective response rate (19.3 vs. 5.0 vs. 2.4%; P = 0.013) and longer PFS (8.0 vs. 2.0 vs. 2.0 months; P <0.001) as compared to monotherapy of either chemotherapy (n = 41) or PD-1 inhibitor (n = 62). Anlotinib and PD-1 blockade combination therapy was an independent predictive factor of longer PFS (P <0.001). CONCLUSION: The combination of anlotinib and PD-1 inhibitor has promising efficacy and manageable toxicity as a second- or later-line treatment of relapsed NSCLC and possibly for relapsed SCLC.

Anti-tuberculosis drug-induced acute liver failure requiring transplantation in the second trimester of pregnancy: a case report.

BACKGROUND: Treatment of tuberculosis (TB) during pregnancy can reduce maternal and foetal complications. However, it may also induce fatal liver injury. CASE PRESENTATION: We present a case of a 26-year-old pregnant woman who underwent orthotopic liver transplantation for anti-TB drug-induced fulminant hepatic failure (FHF). Her tuberculous pleurisy was treated with rifampin, isoniazid and pyrazinamide. An artificial liver support system (ALSS) was unable to reverse the liver injury while serving as a bridge to liver transplantation. She had a successful liver transplantation operation at 17 3/7 weeks of gestation. The foetal ultrasound scan showed mild foetal bilateral ventriculomegaly at 21 5/7 weeks of gestation, and labour was induced via double-balloon catheter as soon as the allograft function was stable. Despite immunosuppression, the TB was well controlled with linezolid, levofloxacin and pyridoxine at the 8 months follow-up. CONCLUSIONS: Anti-TB drug-induced liver failure during pregnancy is rare. We present a case of successful treatment of FHF in which an artificial liver support system combined with liver transplantation. The FHF was caused by anti-TB drugs with difficulties due to pregnancy status and post-transplant anti-TB treatment. Mild foetal ventriculomegaly was found in our case. Further research is still needed to identify the risks of TB treatment and liver transplantation in pregnant women. A multidisciplinary team coordinated properly to optimize patient outcomes.

A giant posterior mediastinal malignant peripheral nerve sheath tumor and benign neurofibroma in body surface: a case report.

BACKGROUND: Neurofibromatosis comprises neurofibromatosis type 1 (NF1) and type 2 (NF2). Major tumor type of NF1 are neurofibroma recognized as benign peripheral nerve tumor, malignant peripheral nerve sheath tumor (MPNST), and glioma. CASE PRESENTATION: We report a woman with a special condition, whose tumors in body surfaces were benign neurofibroma and tumors in posterior mediastinum are MPNST. The chest-enhanced CT suggested a round soft tissue density in posteriormediastium. The diagnosis was established by pathology and immunohistochemistry. A single-stage thoracoscopic mediastinal mass resection was performed. The whole operation went smoothly and the CT scan of lungs did not show relapse of tumor three months later. CONCLUSIONS: The appearance of neurofibroma should draw particular attention to the possibility of developing MPNST. More careful imaging examinations should be carried out, and pathological examination could diagnose it.

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft.

BACKGROUND: To determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up. METHODS: We reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications. RESULTS: Mean follow-up period was 15 ± 3 months (range, 12-18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients' mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes. CONCLUSION: Endoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.

Impact of national interventions to promote responsible antibiotic use: a systematic review.

BACKGROUND: Global recognition of antimicrobial resistance (AMR) as an urgent public health problem has galvanized national and international efforts. Chief among these are interventions to curb the overuse and misuse of antibiotics. However, the impact of these initiatives is not fully understood, making it difficult to assess the expected effectiveness and sustainability of further policy interventions. We conducted a systematic review to summarize existing evidence for the impact of nationally enforced interventions to reduce inappropriate antibiotic use in humans. METHODS: We searched seven databases and examined reference lists of retrieved articles. To be included, articles had to evaluate the impact of national responsible use initiatives. We excluded studies that only described policy implementations. RESULTS: We identified 34 articles detailing interventions in 21 high- and upper-middle-income countries. Interventions addressing inappropriate antibiotic access included antibiotic committees, clinical guidelines and prescribing restrictions. There was consistent evidence that these were effective at reducing antibiotic consumption and prescription. Interventions targeting inappropriate antibiotic demand consisted of education campaigns for healthcare professionals and the general public. Evidence for this was mixed, with several studies showing no impact on overall antibiotic consumption. CONCLUSIONS: National-level interventions to reduce inappropriate access to antibiotics can be effective. However, evidence is limited to high- and upper-middle-income countries, and more evidence is needed on the long-term sustained impact of interventions. There should also be a simultaneous push towards standardized outcome measures to enable comparisons of interventions in different settings.

Fighting against COVID-19: preparedness and implications on clinical practice in primary care in Shenzhen, China.

BACKGROUND: The new coronavirus pneumonia (NCP) caused by COVID-19 has affected more than 46 million people worldwide. In China, primary care has played a vital role during the COVID-19 outbreak, and it is important to examine the challenges faced by general practitioners (GPs). This study investigated the roles, preparedness and training needs of GPs in China in managing the NCP outbreak. Based on the outcomes of the study, we hope to take lessons and identify how GPs could be supported in delivering their gatekeeping roles and clinical duties in times of infectious disease outbreak. METHODS: An online survey on the official website of Shenzhen Continuing Education Center. It included questions on GPs' demographics, their awareness of COVID-19 and their preparedness in managing suspected cases of NCP, as well as referrals and their training needs. Conditional multi-variate logistic models were used to investigate the relationships between GPs' preparedness, situational confidence and anxiety. RESULTS: GPs' clinical practice was significantly affected. GPs endeavoured to answer a flood of COVID-19-related enquiries, while undertaking community preventive tasks. In addition to in-person consultations, GP promoted COVID-19 awareness and education through telephone consultations, physical posters and social media. Overall GPs in Shenzhen felt well supported with adequate Personal Protective Equipment (PPE) and resources from secondary care services. Higher levels of self-perceived preparedness (OR = 2.19; 95%CI, 1.04-4.61), lower level of anxiety (OR = 0.56; 95%CI, 0.29-1.09) and fewer perceived family worries (OR = 0.37; 95%CI, 0.12-1.12) were associated with better confidence in coping at work. CONCLUSIONS: Training and supporting GPs while reducing their (and their families') anxiety increase their confidence in delivering the important roles of gatekeeping in face of major disease outbreaks.

'Antibiotic footprint' as a communication tool to aid reduction of antibiotic consumption.

'Superbugs', bacteria that have become resistant to antibiotics, have been in numerous media headlines, raising awareness of antibiotic resistance and leading to multiple action plans from policymakers worldwide. However, many commonly used terms, such as 'the war against superbugs', risk misleading people to request 'new' or 'stronger' antibiotics from their doctors, veterinary surgeons or pharmacists, rather than addressing a fundamental issue: the misuse and overuse of antibiotics in humans and animals. Simple measures of antibiotic consumption are needed for mass communication. In this article, we describe the concept of the 'antibiotic footprint' as a tool to communicate to the public the magnitude of antibiotic use in humans, animals and industry, and how it could support the reduction of overuse and misuse of antibiotics worldwide. We propose that people need to make appropriate changes in behaviour that reduce their direct and indirect consumption of antibiotics.

Efficacy of Oral Nicorandil to Prevent Contrast-Induced Nephropathy in Patients with Chronic Renal Dysfunction Undergoing an Elective Coronary Procedure.

OBJECTIVES: This prospective, randomized study was to investigate the role of nicorandil in the prevention of contrast-induced nephropathy (CIN) in patients with chronic renal dysfunction undergoing an elective coronary procedure. METHODS: A total of 252 eligible patients were enrolled in this study and allocated into the control group (n = 125) or nicorandil group (n = 127). Both groups received the standard hydration treatment, and patients in the nicorandil group were orally administrated 10 mg of nicorandil (t.i.d.) beginning 2 days before and continuing for 2 days after an elective coronary procedure. Serum creatinine (SCr) and cystatin C (CysC) were measured at 24 h before and 24, 48, and 72 h after the procedure. The occurrences of CIN and adverse events within 1 year were recorded. RESULTS: The nicorandil group had relatively lower SCr and CysC levels and a higher eGFR at 24 and 48 h after the procedure than the control group (p < 0.05). The incidence of CIN was significantly decreased in the nicorandil group compared to the control group. The multivariate logistic regression model revealed that nicorandil treatment was an independent protective factor for CIN (OR 0.669, 95% CI 0.522-0.857, p = 0.001). The multivariate COX proportional hazard model showed that nicorandil treatment was an independent protective predictor for adverse events (HR 0.881, 95% CI 0.781-0.993, p = 0.037). CONCLUSIONS: Nicorandil could exhibit a protective effect against CIN in patients with chronic renal dysfunction undergoing an elective coronary procedure and reduce the adverse events within 1 year after the procedure, which is superior to hydration treatment only.

Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review.

Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.

Pseudoaneurysm of a high-division anterior tibial artery following primary TKA.

Arterial complications following total knee arthroplasty are rare but carry a high risk of significant morbidity and mortality. Herein, the authors report a case of pseudoaneurysm in a branch of a high-division anterior tibial artery caused by laceration by the retractor following primary total knee arthroplasty in a 72-year-old woman. The patient presented with an unexplained hematoma and an enlarging swelling, with pallor and acute hemorrhage on the first postoperative day. The diagnosis was confirmed by arteriography and the patient was successfully treated using endovascular embolization without long-term complications. Because of the high risk of progression to a potentially limb- or life-threatening condition, it is important to discuss the risk factors for this complication, as well as its early diagnosis and treatment methods.

Surgical Treatment of Intracardiac-Extending Intravenous Leiomyomatosis: A Single Center Experience.

BACKGROUND: Few data were known on surgical management of intracardiac-extending in patients with intravenous leiomyomatosis (IVL). METHODS: From June 2007 to December 2014, six women (mean age, 39.3 ± 7.5 years; range, 24-55 years) with intracardiac-extending IVL were treated surgically at our hospital. Data were obtained from medical and pathological records, including characteristics of patients, surgical management, and follow-up. RESULTS: Surgery was performed successfully in all patients. Of 6 patients, 4 underwent one-stage operation and 2 underwent two-stage procedures. Circulatory arrest with hypothermia was used for a cardiotomy combined with venotomy in 5 patients. Complete resection was done in 5 patients. There were no perioperative deaths or complications in any of the patients. Hospital stay was 11.2 ± 2.9 days (range 7-15 days). All patients were followed-up for a mean of 41.0 ± 19.1 months (range, 17-69 months) after surgery. A recurrence of pelvic mass was found in 1 patient, but no symptoms or intravenous mass were reported. No obstruction occurred in any patient with a venotomy. CONCLUSION: Surgery is a better therapy for IVL and complete removal has favorable outcomes.

Serum Levels of 25-hydroxyvitamin D and Functional Outcome in Older Patients with Hip Fracture.

The aim was to assess prognostic value of serum 25-hydroxyvitamin D (25[OH] D) levels in older Chinese patients with hip fracture. From June, 2012 to February, 2014, older patients with hip fracture were included. Serum 25(OH) D levels were measured at admission. The functional evaluation at the time of discharge was performed by the Barthel Index. In the 66 patients with an unfavorable outcome, serum 25(OH) D levels were lower compared with those with a favorable outcome. In multivariate analyses, there was an increased risk of unfavorable outcome associated with serum 25(OH) D levels ≤ 20 ng/ml (OR 5.25, 95% CI: 3.12-8.16). Our data supported an association between serum 25[OH] D levels at admission and short-term prognosis in Chinese older patients with hip fracture.

Treatment of severe hemifacial atrophy with dorsal thoracic adipofascial free flap and concurrent lipoinjection.

BACKGROUND: Parry-Romberg syndrome is an infrequent, acquired disorder characterized by progressive facial atrophy of the skin and soft tissue of the face and, in some cases, results in atrophy of muscles, cartilage, and the underlying bony structures. We investigated dorsal thoracic adipofascial free flap and concurrent lipoinjection as a reconstructive option for Parry-Romberg syndrome. METHODS: Thirteen patients with hemifacial atrophy caused by Parry-Romberg syndrome underwent surgical correction after their deformitiesreached a stable stage. All patients were classified as having severe atrophy; they had either atrophy of the skin and subcutaneous tissues observable in all 3 sensory branches of the trigeminal nerve or bone involvement. In all cases, we applied dorsal thoracic adipofascial free flap and concurrent lipoinjection followed by secondary revision with debulking or lipoinjection. RESULTS: The adipofascial flaps survived after the initial operation in all 13 patients. After the second-stage operation, 11 of 13 patients had achieved a natural appearance without any sagging or insufficient filling in the upper face. CONCLUSIONS: For patients with severe hemifacial atrophy with little or no bone involvement, dorsal thoracic adipofascial free flap and concurrent lipoinjection was a feasible and reliable reconstructive option.