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BACKGROUND: Fabry disease is rare, and the diagnosis is often delayed. Here, we describe a case of Fabry disease resulting in vasculopathy of the central nervous system. Magnetic resonance (MR) black-blood sequence (three-dimensional T1 volumetric isotropic turbo spin echo acquisition), with the unique advantage of imaging the vascular wall, facilitated a clear identification of the vasculopathy. CASE PRESENTATION: A 27-year-old man visited our hospital for the treatment of " double vision 6d." After a series of examinations, the patient was diagnosed with Fabry disease, which caused vasculopathy of the central nervous system. Subsequently, the patient was treated with corticosteroids and his symptoms were attenuated. Two months after the initial treatment, the initial lesion in the vascular vessel disappeared, however, a new lesion appeared. Similarly, four months after the initial treatment, although the previous lesion disappeared, a new lesion appeared. CONCLUSIONS: This case highlights that clinicians should use MR black-blood sequence scan in a timely manner in case of young patients with migratory lesions of brain. In case of detection of a vascular lesion in combination with other systemic lesions, the possibility of Fabry disease should be considered.
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Trastornos Cerebrovasculares , Enfermedad de Fabry/diagnóstico , Adulto , Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/patología , Trastornos Cerebrovasculares/fisiopatología , Enfermedad de Fabry/complicaciones , Femenino , Humanos , Imagen por Resonancia Magnética , MasculinoRESUMEN
BACKGROUND: To summarize the characteristics of primary central nervous system vasculitis from clinical, imaging, and pathological aspects by retrospective study. METHODS: From March 2015 to December 2017, the data of the inpatients of primary central nervous system vasculitis in first Hospital of Jilin University were collected, and their clinical manifestation, imaging, and pathological characteristics were analyzed by using a descriptive method. RESULTS: There were 18 patients, 10 males (55.56%) and 8 females (44.44%) separately. The age ranges from 16 years old to 49 years old, with the median age of 32 years old. There were 8 cases (44.44%) of epileptic seizure, 6 cases (33.33%) of abnormal behavior and cognition, 10 cases (55.56%) with sensorimotor abnormalities, 4 cases (22.22%) with dizziness, 4 cases (22.22%) with headache, 2 cases (11.11%) with facial pain, 2 cases (11.11%) with blurred vision, and 2 cases (11.11%) with unstable walking. Eight patients (44.44%) were identified with cerebral spinal fluid abnormalities. There were 12 cases (66.67%) with bilateral lesions and 6 cases (33.33%) with unilateral lesions, including the frontal lobe (18 cases, 100%), the parietal lobe (10 cases, 55.56%), the temporal and occipital lobe (8 cases, 44.44%). There were 12 cases (66.67%) combined with subcortical white matter involvement, 6 cases (33.33%) combined with meningeal involvement, 2 cases (11.11%) complicated with basal ganglia involvement and 2 cases (11.11%) complicated with spinal cord involvement. Most of the lesions were with unclear border (16 cases, 88.89%), 2 cases (11.11%) were with clear border. Cortical atrophy was identified in 6 cases (33.33%). There were 12 cases (66.67%) with the enhancement of the lesions and meningeal. The 3D Vessel Wall magnetic resonance imaging (VW-MRI) showed uniform thickness in all patients (18/18) with contrast enhancement of the vessel wall of the vasculitis artery. CONCLUSIONS: The clinical manifestation and imaging in primary central nervous system vasculitis are diverse. The 3D VW-MRI could achieve quantification assessment of vasculitis and provide more utility for primary angiitis of the central nervous system.
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Angiografía Cerebral/métodos , Arterias Cerebrales , Imagen de Difusión por Resonancia Magnética , Angiografía por Resonancia Magnética , Vasculitis del Sistema Nervioso Central/diagnóstico , Adolescente , Adulto , Angiografía de Substracción Digital , Biopsia , Arterias Cerebrales/diagnóstico por imagen , Arterias Cerebrales/patología , Arterias Cerebrales/fisiopatología , Niño , China , Angiografía por Tomografía Computarizada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Vasculitis del Sistema Nervioso Central/diagnóstico por imagen , Vasculitis del Sistema Nervioso Central/patología , Vasculitis del Sistema Nervioso Central/fisiopatología , Adulto JovenRESUMEN
Rivers are important reservoirs of antibiotic resistance genes (ARGs). However, most current studies have focused on the temporal and spatial distribution, and data on the differences in the species and abundance of ARGs between urban and rural rivers is still lacking for certain areas. In view of this, two rural rivers and three urban rivers were selected in Shijiazhuang City. In both December 2020 and April 2021, sediments were collected at 15 sampling sites. Metagenomic sequencing technology was used to compare the differences in temporal-spatial variation for ARGs in sediments. The results showed that:â 162 and 79 ARGs were detected in urban (4 776 ±4 452) and rural rivers (1 043 ±632), respectively. The abundance and species of ARGs in urban rivers were higher than those in rural rivers. â¡ The relative abundances of sulfonamide (SAs,27 %), aminoglycoside (AGs,26 %), and multidrug (MDs,15 %) ARGs had the highest abundance in urban rivers, whereas the relative abundance of MDs ARGs was highest in rural rivers (65 %). On the whole, the complexity of ARGs in urban rivers was higher than that in rural rivers. ⢠There was a significant positive correlation between SAs, AGs, MDs, tetracycline, phenicol, macrolides-lincosamids-streptogramins (MLS), ß-lactams, and diaminopyrimidine ARGs in urban rivers (P < 0.01); however, there was a significant negative correlation between glycopeptide ARGs and all types of ARGs (P < 0.05 and P < 0.01). There was a significant positive correlation between MDs and SAs ARGs in rural rivers (P < 0.05), but there was a significant negative correlation between amino aminocoumarin, peptide, rifamycin, and fosfomycin ARGs (P < 0.05 and P < 0.01). ⣠For the temporal variation in urban rivers, 162 ARGs (4 776 ±4 452) and 148 ARGs (5 673 ±5 626) were detected in December and April, respectively. For the temporal variation in rural rivers, 79 species (1 043 ±632) and 46 species (467 ±183) were detected in December and April, respectively. ⤠RDA analysis results showed that the spatial-temporal distributions of ARGs in urban and rural rivers were different. Correlation analysis showed that the ARGs in urban rivers were significantly correlated with the number of industrial enterprises, whereas the ARGs in rural rivers were significantly correlated with the output value of animal husbandry. In general, this study identified the main influencing factors for ARGs in different rivers and provided data support for ARGs risk management in different rivers.
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Ciudades , Farmacorresistencia Microbiana , Sedimentos Geológicos , Ríos , Sedimentos Geológicos/microbiología , China , Farmacorresistencia Microbiana/genética , Monitoreo del Ambiente , Genes Bacterianos , Análisis Espacio-Temporal , Antibacterianos/análisisRESUMEN
Microbial communities play an important role in water quality regulation and biogeochemical cycles in lakes, and their community structure and function are affected by environmental factors. Therein, antibiotics affect the abundance, diversity, composition, and function of microbial communities. In this study, Baiyangdian Lake was selected as the study area. Sediment samples of 16 sites were collected in August 2018 and April 2019, respectively. Ultra-high performance liquid chromatography-mass spectrometry ï¼HPLC-MS/MSï¼ was used to determine the content of typical antibiotics-quinolones ï¼QNsï¼ in sediment. Through high-throughput sequencing technology, the structure and function of microbial communities was analyzed in the sediments to explore the spatiotemporal variation. Thereinto, redundancy analysis ï¼RDAï¼ was used to identify the key influencing factors of spatiotemporal variation of microbial communities. The results showed thatï¼ â From August to April, the average ωï¼QNsï¼ showed an increasing trend, and its mean value changed from 3.91 ng·g-1 to 6.34 ng·g-1, with significant seasonal differences in oxolinic acid ï¼OXOï¼ and total QNs content ï¼P < 0.05ï¼. â¡ In terms of temporal variation, the dominant bacteria were Proteobacteria and Chloroflexi. The relative abundance of Proteobacteria showed a decreasing trend, whereas Chloroflexi showed an increasing trendï¼ at the genus level, the dominant bacteria genera in August were norank_ f__Anaerolineaceae and Thiobacilus, and the dominant bacteria genera in April were Acinetobacter and norank_ f_Anaerolineaceae, and the dominant bacteria genera had significant seasonal differences ï¼P < 0.05ï¼. ⢠In terms of temporal variation, the index of Simpson, Chao, Ace, and OTU number all showed an increasing trend, and the seasonal differences were significant ï¼P < 0.05ï¼. ⣠In terms of spatial variation, there were no significant spatial differences among functional genes of COG. In terms of temporal variation, there were significant seasonal differences in functional genes of energy production and conversion, carbohydrate transport and metabolism, transcription, cell wall/membrane/envelope biogenesis, and signal transduction mechanisms ï¼P < 0.01 and P < 0.05ï¼. ⤠Microbial community structure and functional genes were significantly correlated with QNs ï¼P < 0.01 and P < 0.05ï¼, and QNs were the main influencing factors. Therefore, QNs were the main factor affecting the changes in microbial community structure and functional genes in sediments of Baiyangdian Lake. Thus, comprehensive control of antibiotic pollution in sediments should be further strengthened.
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Antibacterianos , Sedimentos Geológicos , Lagos , Microbiota , Contaminantes Químicos del Agua , Lagos/microbiología , Sedimentos Geológicos/microbiología , Microbiota/genética , China , Contaminantes Químicos del Agua/análisis , Monitoreo del Ambiente , Quinolonas/análisis , Bacterias/clasificación , Bacterias/genéticaRESUMEN
Increasing attention has been paid to the heavy metal pollution in groundwater. The source analysis and risk assessment of heavy metals will provide data and method support for the targeted control of heavy metal pollution in groundwater. In this study, 20 sampling sites were selected in Shijiazhuang City. The APCS-MLR model and health risk model were applied to analyze and evaluate the pollution sources and health risks of 10 types of heavy metals in the groundwater of Shijiazhuang. The results showed that â the mean concentration of heavy metals in groundwater followed the order of Fe>Zn>Mn>Cu>Al>Pb>Cr>As>Cd>Hg, and the mean ρ(Fe) and ρ(Pb) were 260.3 µg·L-1 and 10.01 µg·L-1, respectively. According to the results of the single factor and Nemerow index, Pb, Fe, and Cd primarily contributed to the heavy metal pollution in the groundwater. â¡ The concentration of heavy metals ranged from 47.30 to 2560 µg·L-1. In terms of spatial distribution, the highest concentration appeared at S3 (2560 µg·L-1), whereas the lowest concentration was at S9 (47.30 µg·L-1). ⢠Source analysis results showed that industrial and agricultural activities, transportation emission, and geological background were the major heavy metal sources, among which the contribution of industrial and agricultural activities was the highest (47.83%). ⣠The industrial-agricultural activities posed a potential threat to adults (HI>1); however, the non-cancer and the cancer risks of other sources for both adults and children were at an acceptable level (HI<1) and potential threat level, respectively; industrial-agricultural activities were the major source of non-cancer (adults:52.46%, children:52.45%) and cancer risks (adults:65.22%, children:65.69%), among which Cd and As showed high cancer risk. Therefore, to ensure the safety of the groundwater environment, strictly controlling the pollution sources and further strengthening the risk control of heavy metal pollution in groundwater are necessary.
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Agua Subterránea , Metales Pesados , Adulto , Niño , Humanos , Cadmio , Plomo , Medición de Riesgo , ChinaRESUMEN
The current situation of antibiotic pollution in lakes is critical. At present, most of the previous studies on antibiotics in lakes have focused on the spatiotemporal distribution and risk assessment, while less attention has been paid to the source apportionment. Ultra-high performance liquid chromatography-mass spectrometry was used to determine the concentration of tetracyclines (TCs), sulfonamides (SAs), and quinolones (QNs) in the samples. The source apportionment and source-specific risk of typical antibiotics in the study area were analyzed using the combination of a PMF model and risk quotients (RQ). The results showed that â the total concentrations of target antibiotics (Σ antibiotics) ranged from ND to 2635 ng·L-1 for surface water and from ND to 259.8 ng·g-1 for sediments. â¡ The spatial distribution of QNs in surface water decreased from west to east, SAs decreased from middle to north and south, and TCs increased from middle to north and south. In the sediment, QNs decreased from middle to east and west, whereas SAs and TCs increased from east to west. ⢠Aquaculture was the major antibiotic source, accounting for the highest proportion (33.2%), followed by sewage treatment plants (29.2%), livestock activities (18.9%), and domestic sewage (18.7%). ⣠The ecological risk assessment results showed that enrofloxacin and flumequine were at a medium-high risk level. ⤠For the spatial distribution of source-specific risk, the results showed that the aquaculture at S1 was at a high risk level, whereas the source-specific risks for other sites were at a medium-low risk level. In terms of source types, aquaculture was at a medium-high risk level, whereas the other sources were at a medium-low risk level. Therefore, considering the major sources and source-specific risk level of antibiotics, more precise and scientific antibiotic risk control should be adopted in Baiyangdian Lake.
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Antibacterianos , Lagos , Aguas del Alcantarillado , Sulfanilamida , Enrofloxacina , SulfonamidasRESUMEN
Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an urgent threat to human health. Major outer membrane proteins (OMPs) porin mutation is one important resistance mechanism of CRKP, and may also affect the inhibition activity of ß-lactam and ß-lactamase inhibitor combinations. The ertapenem-resistant K. pneumoniae strain 2018B120 with major porin mutations was isolated from a clinical patient. Genomic and time-series proteomic analyses were conducted to retrieve the ertapenem-challenged response of 2018B120. The abundance changing of proteins from PTS systems, ABC transporters, the autoinducer 2 (AI-2) quorum sensing system, and antioxidant systems can be observed. Overexpression of alternative porins was also noticed to balance major porins' defection. These findings added a detailed regulation network in bacterial resistance mechanisms and gave new insights into bypass adaptation mechanisms the porin deficient bacteria adopted under carbapenem antibiotics pressure. SIGNIFICANCE: Outer membrane porins deficiency is an important mechanism of carbapenem resistance in K. pneumoniae. Comprehensive genomic and proteomic profiling of an ertapenem-resistant K. pneumoniae strain 2018B120 gives a detailed systematic regulation network in bacterial resistance mechanisms. Overexpression of alternative porins to balance major porins' defection was noticed, giving new insights into bypass adaptation mechanisms of porin deficient bacteria.
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Klebsiella pneumoniae , Porinas , Resistencia betalactámica , Transportadoras de Casetes de Unión a ATP/metabolismo , Antibacterianos/farmacología , Antioxidantes/metabolismo , Proteínas Bacterianas/metabolismo , Carbapenémicos/metabolismo , Carbapenémicos/farmacología , Ertapenem/metabolismo , Ertapenem/farmacología , Humanos , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/genética , Klebsiella pneumoniae/metabolismo , Pruebas de Sensibilidad Microbiana , Porinas/genética , Porinas/metabolismo , Proteómica/métodos , Resistencia betalactámica/genética , Inhibidores de beta-Lactamasas/metabolismo , beta-Lactamasas/genética , beta-Lactamasas/metabolismo , beta-Lactamas/metabolismo , beta-Lactamas/farmacologíaRESUMEN
Laribacter hongkongensis is a new emerging foodborne pathogen that causes community-acquired gastroenteritis and traveler's diarrhea. However, the genetic features of L. hongkongensis have not yet been properly understood. A total of 45 aquatic animal-associated L. hongkongensis strains isolated from intestinal specimens of frogs and grass carps were subjected to whole-genome sequencing (WGS), along with the genome data of 4 reported human clinical strains, the analysis of virulence genes, carbohydrate-active enzymes, and antimicrobial resistance (AMR) determinants were carried out for comprehensively understanding of this new foodborne pathogen. Human clinical strains were genetically more related to some strains from frogs inferred from phylogenetic trees. The distribution of virulence genes and carbohydrate-active enzymes exhibited different patterns among strains of different sources, reflecting their adaption to different host environments and indicating different potentials to infect humans. Thirty-two AMR genes were detected, susceptibility to 18 clinical used antibiotics including aminoglycoside, chloramphenicol, trimethoprim, and sulfa was checked to evaluate the availability of clinical medicines. Resistance to Rifampicin, Cefazolin, ceftazidime, Ampicillin, and ceftriaxone is prevalent in most strains, resistance to tetracycline, trimethoprim-sulfamethoxazole, ciprofloxacin, and levofloxacin are aggregated in nearly half of frog-derived strains, suggesting that drug resistance of frog-derived strains is more serious, and clinical treatment for L. hongkongensis infection should be more cautious.
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As a potential "Superbug," Pseudomonas aeruginosa remains the leading concern in antimicrobial resistance. In this study, the emergence of clinical P. aeruginosa isolate was found to carry crpP and blaGES-5 on the chromosome and blaKPC-2 on a plasmid. A clinical P. aeruginosa strain Guangzhou-PaeC79 with an extensively drug-resistant phenotype was isolated, which was resistant to all classes of clinical commonly used antibiotics. It contains one chromosomal DNA and one plasmid, with seven acquired antimicrobial resistance genes identified on the chromosome, including carbapenem resistance gene blaGES-5 and fluoroquinolone resistance gene crpP, and carbapenem resistance gene blaKPC-2 located on an IncP-6-type plasmid pPAEC79 carrying a Tn3-like element. Carriage of any two of the resistance genes has never been previously reported, and simultaneous carriage of three bla and crpP may explain the bacterial phenotype as high-level resistance to imipenem and meropenem (≥16 µg/mL) and resistance to ciprofloxacin and levofloxacin.
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Antibacterianos/farmacología , Farmacorresistencia Bacteriana Múltiple/genética , Genes Bacterianos/genética , Pseudomonas aeruginosa/efectos de los fármacos , Pseudomonas aeruginosa/genética , Adulto , China , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Plásmidos , Infecciones por Pseudomonas/tratamiento farmacológico , Infecciones por Pseudomonas/genética , Pseudomonas aeruginosa/aislamiento & purificaciónRESUMEN
OBJECTIVE: To investigate lead distribution and the change of 78 000 glucose regulated protein (GRP78) in various organs of weaned rats challenged with low-level maternal origin lead. METHODS: Male littermates, bred from the female Fisher 344 rats gavaged with lead acetate or sodium acetate (1 ml of 10 mg/ml per day per animal) with male Fisher 344 rats without lead treatment, were divided into 4 groups including control (group A), gestation plus lactation (group B), gestation only (group C), and lactation only (group D). Each group had 6 litters. These littermates were weaned and terminated at postnatal day 21. Lead contents and GRP78 levels in various organs of these littermates were determined by atomic absorbance spectrometry (AAS) and Western blotting analysis, respectively. RESULTS: Maternal lead was observed to transfer to littermates through gestation and lactation. Concentrations of littermate blood lead in groups A to D were (0.0010+/-0.0010), (0.1420+/-0.0190), (0.0250+/-0.0040), and (0.1490+/-0.0160) microg/ml, respectively. Concentrations of littermate brain lead in groups A to D were (0.0005+/-0.0005), (0.1120+/-0.0130), (0.0125+/-0.0042), and (0.0700+/-0.0058) microg/g, respectively. Concentrations of littermate kidney lead in groups A to D were (0.0050+/-0.0050), (1.0400+/-0.1000), (0.1040+/-0.0330), and (0.9920+/-0.0850) microg/g, respectively. Concentrations of littermate liver lead in groups A to D were (0.0030+/-0.0050), (0.3600+/-0.0550), (0.0567+/-0.0126), and (0.3030+/-0.0310) microg/g, respectively. Blood, brain, kidney and liver lead concentrations in groups B and D were significantly higher than those in group C and differences were 5-10 folds. Arbitrary units of littermate leukocytic GRP78 concentration normalized with actin protein in groups A to D were 1.000+/-0.038, 1.180+/-0.060, 0.998+/-0.109, and 1.290+/-0.110, respectively. Arbitrary units of littermate brain GRP78 concentration normalized with actin protein level in groups A to D were 0.996+/-0.128, 0.922+/-0.246, 1.150+/-0.170, and 0.750+/-0.126, respectively. CONCLUSION: Lead in maternal bodies could be transferred to litter bodies through gestation and lactation and distributed in various organs. Lead might also changed GRP78 expression in leukocytes.
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Proteínas HSP70 de Choque Térmico/metabolismo , Plomo/metabolismo , Proteínas de la Membrana/metabolismo , Animales , Animales Recién Nacidos , Encéfalo/metabolismo , Femenino , Riñón/química , Leucocitos/metabolismo , Hígado/química , Masculino , Embarazo , Ratas , Ratas Endogámicas F344RESUMEN
RATIONALE: An accessory thyroid gland (ATG) in the right ventricle is an extremely rare condition. Described herein are histological findings of ATG in the right ventricle found in a patient with a normal cervical thyroid gland. PATIENT CONCERNS: A 53-year-old woman was referred to our hospital after experiencing intermittent precordial pain for 2 years. DIAGNOSES: The mass in the right ventricle was diagnosed pathologically as ATG. INTERVENTIONS: Complete excision was performed because of the patient's intermittent precordial pain and to exclude the possibility of malignancy. OUTCOME: The patient's pain was resolved. No recurrence was observed during the 6-month follow-up. LESSONS: After review and analysis of the case, we found that plain and contrast-enhanced computed tomography scans showed that the mass had a similar intensity and enhancement to a cervical thyroid gland, which we think may be a useful clue for making a preoperative diagnosis of ATG.
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Neoplasias Cardíacas/diagnóstico , Corazón , Disgenesias Tiroideas/diagnóstico , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , Disgenesias Tiroideas/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To observe the effect of preconditioning of catgut implantation on changes of behavior and EEG of rats with epilepsy. METHODS: Forty male Wistar rats were randomly divided into control, model, catgut implantation, medication groups (10 rats/group). The catgut implantation was performed at "Yintang" (EX 2) to "Baihui" (GV 20) and "Changqiang" (GV 1) on day 1, 4 and 7. The epileptic model was made by intraperitoneal injection of penicillin sodium on the last day of the treatment. In the medication group, intragastric administration of valproic acid sodium was conducted once a day for consecutive 7 days. Behavior measurement and EEG recording were carried out shortly after the penicillin administration. RESULTS: Compared with the model group, the seizure latency was notably increased in the catgut implantation group and the medication group (P < 0.01), without significant difference between the last two groups (P > 0.05). The degree of the seizure attack was less severe in the catgut implantation group and the medication group (P < 0.01), without significant difference between the two groups (P > 0.05). Similar to valproic acid sodium, catgut implantation significantly reduced the amplitude and accelerated the frequency of EEG (P < 0.01). CONCLUSION: Catgut implantation can delay the seizure attack latency, alleviate the severity, regulate the amplitude and frequency of the epileptiform discharges, giving rise to evident antiepileptic effect.
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Puntos de Acupuntura , Terapia por Acupuntura , Epilepsia/terapia , Animales , Conducta Animal , Encéfalo/fisiopatología , Catgut/estadística & datos numéricos , Electroencefalografía , Epilepsia/fisiopatología , Epilepsia/psicología , Humanos , Masculino , Ratas , Ratas WistarRESUMEN
Objective@#To analyze evolution and research hot sports of sports intervention on youth health promotion, and to provide the theoretical data for the researchers to make sure their future research directions.@*Methods@#The Web of Science was searched through with core collection database to obtain original articles in this domain on November 10th 2018, and 1 242 articles were selected as research samples. Citespace was used to analyze the following data, including co-word, cited-reference, cite-author and so on.@*Results@#Research on this domain was performed in 43 countries. The leading 5 countries of publishing papers were as follows: USA,Australia,England, Canada and Holland, accounting for 1 017 articles published, occupying 81.9% of the published papers. The most productive organizations were in USA and Australia. The team of Luban DR and Pate RR was most representative in this domain. Recently more and more researchers were paying attention to sport intervention of adolescents. The leading issues were about: application of intelligent electronic products in intervening adolescents’ health, the positive effect of sports environment on adolescents’ participation in sports and the sport intervention of adolescent’s brain.@*Conclusion@#We must recognize that the field in sports intervention among adolescents is still in its infancy and shows huge potential for further improvement. Scientists from the United States and Australia are leading the world in this field. It’s important for China to participate and refer to their cutting-edge researches, and to invest in specific sports intervention strategies paving the road to good health among adolescents.