Role of the stability of deoxyribonucleoside triphosphate pool in the development and progression of tumors / 肿瘤研究与临床

The stability of deoxyribonucleoside triphosphate (dNTP) pool is essential for the normal synthesis of nuclear and mitochondrial DNA. The lack or excess of any dNTP may cause DNA damage and genomic instability, and increase mutation rate. Present studies have confirmed that the instability of dNTP pool is closely related to a variety of tumorigenesis. In addition, dNTP pool is involved in the development of tumor via multiple pathways, while the mechanisms of tumors caused by the instability of dNTP are complicated. This paper discusses the relationship between the stability of dNTP pool and DNA damage repair to provide a theoretical basis for early diagnosis and targeted treatment of tumors.

Thyroid function abnormalities in COVID-19 patients

BackgroundThe novel coronavirus COVID-19, has caused a worldwide pandemic, impairing several human organs and systems. Whether COVID-19 affects human thyroid function remains unknown. Methods84 hospitalized COVID-19 patients in the First Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) were respectively enrolled in this study. In addition, 91 other patients with pneumonia and 807 healthy subjects were included as controls. FindingsWe found that the levels of TT3 and TSH were lower in COVID-19 patients than control groups (p<0{middle dot}001). Within the group of COVID-19 patients, 61.9% patients (52/84) presented with thyroid function abnormalities. We found a larger proportion of patients in severe condition exhibited thyroid dysfunction than mild/moderate cases (74{middle dot}6% vs. 23{middle dot}8%, p < 0{middle dot}001). Patients with thyroid dysfunction tended to have increased interval time for negative conversion of viral nucleic acid (14{middle dot}1 {+/-} 9{middle dot}4 vs. 10{middle dot}6 {+/-} 8{middle dot}3 days, p = 0{middle dot}088). To note, thyroid dysfunction was also associated with decreased lymphocytes (p < 0{middle dot}001) and increased CRP (p = 0{middle dot}002). In 7 patients with dynamic changes of thyroid function, we observed the levels of TT3 and TSH gradually increased and reached normal range without thyroid hormone replacement at Day 30 post-admission. The correlation between TT3 and TSH level seemed to be positive rather than negative in the early stage, and gradually turned to be negatively related over time. InterpretationsThyroid function abnormalities are common in COVID-19 patients, especially in severe cases. This might be caused by virus attack and damage to the thyroid-pituitary axis. Therefore, more attention should be paid to thyroid function during treatment of COVID-19, and close follow-up is also needed after discharge. FundingThis study was supported by Zhejiang Provincial Science and technology department key R & D plan emergency project (No. 2020c03123-8).

Cross-neutralization antibodies against SARS-CoV-2 and RBD mutations from convalescent patient antibody libraries

The emergence of coronavirus disease 2019 (COVID-19) pandemic led to an urgent need to develop therapeutic interventions. Among them, neutralizing antibodies play crucial roles for preventing viral infections and contribute to resolution of infection. Here, we describe the generation of antibody libraries from 17 different COVID-19 recovered patients and screening of neutralizing antibodies to SARS-CoV-2. After 3 rounds of panning, 456 positive phage clones were obtained with high affinity to RBD (receptor binding domain). Then the positive clones were sequenced and reconstituted into whole human IgG for epitope binning assays. After that, all 19 IgG were classified into 6 different epitope groups or Bins. Although all these antibodies were shown to have ability to bind RBD, the antibodies in Bin2 have more superiority to inhibit the interaction between spike protein and angiotensin converting enzyme 2 receptor (ACE2). Most importantly, the antibodies from Bin2 can also strongly bind with mutant RBDs (W463R, R408I, N354D, V367F and N354D/D364Y) derived from SARS-CoV-2 strain with increased infectivity, suggesting the great potential of these antibodies in preventing infection of SARS-CoV-2 and its mutations. Furthermore, these neutralizing antibodies strongly restrict the binding of RBD to hACE2 overexpressed 293T cells. Consistently, these antibodies effectively neutralized pseudovirus entry into hACE2 overexpressed 293T cells. In Vero-E6 cells, these antibodies can even block the entry of live SARS-CoV-2 into cells at only 12.5 nM. These results suggest that these neutralizing human antibodies from the patient-derived antibody libraries have the potential to become therapeutic agents against SARS-CoV-2 and its mutants in this global pandemic.

Clinical Outcomes and Plasma Concentrations of Baloxavir Marboxil and Favipiravir in COVID-19 Patients: an Exploratory Randomized, Controlled Trial

BackgroundEffective antiviral drugs for COVID-19 are still lacking. This study aims to evaluate the clinical outcomes and plasma concentrations of baloxavir marboxil and favipiravir in COVID-19 patients. MethodsFavipiravir and baloxavir acid were evaluated for their antiviral activity against SARS-CoV-2 in vitro before the trial initiation. We conducted an exploratory trial with 3 arms involving hospitalized adult patients with COVID-19. Patients were randomized assigned in a 1:1:1 ratio into baloxavir marboxil group, favipiravir group, and control group. The primary outcome was the percentage of subjects with viral negative by Day 14 and the time from randomization to clinical improvement. Virus load reduction, blood drug concentration and clinical presentation were also observed. The trial was registered with Chinese Clinical Trial Registry (ChiCTR 2000029544). ResultsBaloxavir showed antiviral activity in vitro with the half-maximal effective concentration (EC50) of 5.48 {micro}M comparable to arbidol and lopinavir, but favipiravir didnt demonstrate significant antiviral activity up to 100 {micro}M. Thirty patients were enrolled. The percentage of patients who turned viral negative after 14-day treatment was 70%, 77%, and 100% in the baloxavir, favipiravir, and control group respectively, with the medians of time from randomization to clinical improvement was 14, 14 and 15 days, respectively. One reason for the lack of virological effect and clinical benefits may be due to insufficient concentrations of these drugs relative to their antiviral activities. ConclusionsOur findings do not support that adding either baloxavir or favipiravir under the trial dosages to the existing standard treatment.

Management of corona virus disease-19 (COVID-19): the Zhejiang experience / 浙江大学学报·医学版

The current epidemic situation of corona virus disease-19 (COVID-19) still remained severe. As the National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital of Zhejiang University School of Medicine is the primary medical care center for COVID-19 inZhejiang Province. Based on the present expert consensus carried out by National Health Commission and National Administration of Traditional Chinese Medicine, our team summarized and established an effective treatment strategy centered on "Four-Anti and Two-Balance" for clinical practice. The "Four-Anti and Two-Balance"strategy included antivirus, anti-shock, anti-hyoxemia, anti-secondary infection, and maintaining of water, electrolyte and acid base balance and microecological balance. Meanwhile, integrated multidisciplinarypersonalized treatment was recommended to improve therapeutic effect. The importance of early viralogical detection, dynamic monitoring of inflammatory indexes and chest radiograph was emphasized in clinical decision-making. Sputum was observed with the highest positive rate of RT-PCR results. Viral nucleic acids could be detected in10% patients'blood samples at acute periodand 50% of patients had positive RT-PCR results in their feces. We also isolated alive viral strains from feces, indicating potential infectiousness of feces.Dynamic cytokine detection was necessary to timely identifyingcytokine storms and application of artificial liver blood purification system. The "Four-Anti and Two-Balance"strategyeffectively increased cure rate and reduced mortality. Early antiviral treatment could alleviate disease severity and prevent illness progression, and we found lopinavir/ritonavir combined with abidol showed antiviraleffects in COVID-19. Shock and hypoxemia were usually caused by cytokine storms. The artificial liver blood purification system could rapidly remove inflammatory mediators and block cytokine storm.Moreover, it also favoredthe balance of fluid, electrolyte and acid-base and thus improved treatment efficacy in critical illness. For cases of severe illness, early and also short periods of moderate glucocorticoid was supported. Patients with oxygenation index below 200 mmHg should be transferred to intensive medical center. Conservative oxygen therapy was preferred and noninvasive ventilation was not recommended. Patients with mechanical ventilation should be strictly supervised with cluster ventilator-associated pneumonia prevention strategies. Antimicrobial prophylaxis should be prescribed rationally and was not recommended except for patients with long course of disease, repeated fever and elevated procalcitonin (PCT), meanwhile secondary fungal infection should be concerned.Some patients with COVID-19 showed intestinal microbialdysbiosis with decreasedprobiotics such as and . Nutritional and gastrointestinal function should be assessed for all patients.Nutritional support and application of prebiotics or probiotics were suggested to regulate the balance of intestinal microbiota and reduce the risk of secondary infection due to bacterial translocation. Anxiety and fear were common in patients with COVID-19. Therefore, we established dynamic assessment and warning for psychological crisis. We also integrated Chinese medicine in treatment to promote disease rehabilitation through classification methods of traditional Chinese medicine. We optimized nursing process for severe patients to promote their rehabilitation. It remained unclear about viral clearance pattern after the SARS-CoV-2 infection. Therefore, two weeks' quarantine for discharged patients was required and a regular following up was also needed.The Zhejiang experience above and suggestions have been implemented in our center and achieved good results. However, since COVID-19 was a newly emerging disease, more work was warranted to improve strategies of prevention, diagnosis and treatment for COVID-19.

Management of COVID-19: the Zhejiang experience / 浙江大学学报·医学版

The current epidemic situation of coronavirus disease 2019 (COVID-19) still remained severe. As the National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital of Zhejiang University School of Medicine is the primary medical care center for COVID-19 in Zhejiang province. Based on the present expert consensus carried out by National Health Commission and National Administration of Traditional Chinese Medicine, our team summarized and established an effective treatment strategy centered on "Four-Anti and Two-Balance" for clinical practice. The "Four-Anti and Two-Balance" strategy included antivirus, anti-shock, anti-hyoxemia, anti-secondary infection, and maintaining of water, electrolyte and acid base balance and microecological balance. Meanwhile, integrated multidisciplinary personalized treatment was recommended to improve therapeutic effect. The importance of early viralogical detection, dynamic monitoring of inflammatory indexes and chest radiograph was emphasized in clinical decision-making. Sputum was observed with the highest positive rate of RT-PCR results. Viral nucleic acids could be detected in 10%patients' blood samples at acute period and 50%of patients had positive RT-PCR results in their feces. We also isolated alive viral strains from feces, indicating potential infectiousness of feces.Dynamic cytokine detection was necessary to timely identifying cytokine storms and application of artificial liver blood purification system. The "Four-Anti and Two-Balance" strategy effectively increased cure rate and reduced mortality. Early antiviral treatment could alleviate disease severity and prevent illness progression, and we found lopinavir/ritonavir combined with abidol showed antiviral effects in COVID-19. Shock and hypoxemia were usually caused by cytokine storms. The artificial liver blood purification system could rapidly remove inflammatory mediators and block cytokine storm.Moreover, it also favored the balance of fluid, electrolyte and acid-base and thus improved treatment efficacy in critical illness. For cases of severe illness, early and also short period of moderate glucocorticoid was supported. Patients with oxygenation index below 200 mmHg should be transferred to intensive medical center. Conservative oxygen therapy was preferred and noninvasive ventilation was not recommended. Patients with mechanical ventilation should be strictly supervised with cluster ventilator-associated pneumonia prevention strategies. Antimicrobial prophylaxis was not recommended except for patients with long course of disease, repeated fever and elevated procalcitonin (PCT), meanwhile secondary fungal infection should be concerned.Some patients with COVID-19 showed intestinal microbial dysbiosis with decreased probiotics such as and , so nutritional and gastrointestinal function should be assessed for all patients.Nutritional support and application of prebiotics or probiotics were suggested to regulate the balance of intestinal microbiota and reduce the risk of secondary infection due to bacterial translocation. Anxiety and fear were common in patients with COVID-19. Therefore,we established dynamic assessment and warning for psychological crisis. We also integrated Chinese medicine in treatment to promote disease rehabilitation through classification methods of traditional Chinese medicine. We optimized nursing process for severe patients to promote their rehabilitation. It remained unclear about viral clearance pattern after the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Therefore, two weeks' quarantine for discharged patients was required and a regular following up was also needed.The Zhejiang experience and suggestions have been implemented in our center and achieved good results. However, since COVID-19 was a newly emerging disease, more work was warranted to improve strategies of prevention, diagnosis and treatment for COVID-19.

Pharmaceutical care for severe and critically ill patients with COVID-19 / 浙江大学学报·医学版

Severe and critically ill patients with coronavirus disease 2019 (COVID-19) were usually with underlying diseases, which led to the problems of complicated drug use, potential drug-drug interactions and medication errors in special patients. Based on ( 6), and -19: , we summarized the experience in the use of antiviral drugs, corticosteroids, vascular active drugs, antibacterial, probiotics, nutrition support schemes in severe and critically ill COVID-19 patients. It is also suggested to focus on medication management for evaluation of drug efficacy and duration of treatment, prevention and treatment of adverse drug reactions, identification of potential drug-drug interactions, individualized medication monitoring based on biosafety protection, and medication administration for special patients.

Construction of data remote monitoring and auditing system for clinical trials / 浙江大学学报·医学版

Clinical trial management system is independently developed by our hospital, which basically realized the whole process management and data collection of clinical trials. Based on the platform, the functional architecture of data remote monitoring and auditing was established. By desensitizing and encrypting of data, the project and subject hologram were visualized to facilitate to review of data. The data remote monitoring and auditing cloud platform adopts the B/S architecture pattern. Users register to apply for an account through the cloud platform, and access to the account via HTTPS security protocol. The authorized users were able to view the relevant items online to ensure the secure data transmission and easy operating. The electronic management of data is the direction of future efforts. By compliance with laws and regulations, the remote monitoring/auditing can be realized, and the data security and personal privacy can be ensured with the application of information technology. In this paper, the feasibility of remote monitoring/auditing mode is explored, specific technical schemes and system functions are suggested, and the realization scenarios are conceived in case of major public health emergencies.

Management practice for critical COVID-19 patients rescue in designated hospitals / 中华医院管理杂志

December 2019 witnessed the outbreak of COVID-19 in Wuhan and spread of the epidemic across the country. As a provincial designated hospital for critical patients, the First Affiliated Hospital of Zhejiang University responded rapidly since then by advocating the four-concentration principles, namely " concentrating patients, experts, resources and treatment" . In its rescue of critical patients, the hospital formulated comprehensive emergency plans, optimized hospital-wide resources, effectively arranged rescue spacing, established medical echelons, and implemented multi-disciplinary strategy. These efforts ensured efficient rescue and treatment, achieving a cure rate up to 98.7% of such patients, with no deaths.

Expression and clinical significance of ribonucleotide reductase small subunit M2 in chronic HBV infection and other liver diseases / 中华临床感染病杂志

Objective@#To investigate the expression and clinical significance of ribonucleotide reductase small subunit M2 (RRM2) in chronic hepatitis B virus (HBV) infection and related liver diseases.@*Methods@#A total of 428 patients with chronic HBV infection and liver disease were enrolled from Songyang County People’s Hospital from October 2017 to September 2019. There were 166 cases of chronic hepatitis B (CHB), 53 cases of HBV-related cirrhosis, 28 cases of non-HBV-related cirrhosis, 57 cases of HBV-related liver cancer, 33 cases of non-HBV-related liver cancer, and 91 cases of non-viral hepatitis. In addition, 36 healthy subjects were selected as the control group. Among 166 cases of CHB, there were 87 patients with high viral load group (HBV DNA ≥4.0 lg IU/mL) and 79 patients with low viral load group (HBV DNA <4.0 lg IU/mL); while in 87 high viral load patients, 56 had high alanine transaminase (ALT) (≥40 U/L) and 31 had normal ALT (<40 U/L). The expression level of serum RRM2 protein in patients was detected by enzyme-linked immunosorbent assay (ELISA), and the relationship of RRM2 expression with HBV DNA and liver function was analyzed. SPSS 23.0 and PRISM 8.0 statistical software were used to analyze data. Correlation analysis was performed using Spearman analysis.@*Results@#The serum ALT and RRM2 levels in patients with high viral load CHB were higher than those in low viral load group (Z=-6.68, t=6.80, P<0.01). Patients with HBV-related cirrhosis had higher serum RRM2 levels than those with non-HBV-related cirrhosis (t=9.16, P<0.01). The serum RRM2 level was higher in patients with HBV-related liver cancer than that in patients with non-HBV-related liver cancer (t=12.42, P<0.01). Among patients with high viral load CHB, there was no significant difference in serum RRM2 levels between patients with ALT ≥40 U/L group and patients with ALT <40 U/L group (t=0.51, P>0.05). The level of ALT in the non-viral hepatitis group was higher than that in the healthy control group (Z=-8.43, P<0.01), but there was no significant difference in serum RRM2 levels between the two groups (t=1.03, P>0.05). Correlation analysis showed that serum RRM2 level was positively correlated with HBV DNA load (r=0.51, P<0.01), but not correlated with liver function indicators such as ALT and aspartate aminotransferase (all P>0.05) in patients with chronic HBV infection and related liver diseases.@*Conclusions@#Serum RRM2 level is positively correlated with HBV DNA load and has no significant correlation with ALT. RRM2 might be used as a target for the development of new hepatitis B drugs.

Progress on the resistance mechanism of Enterococcus to linezolid / 中华临床感染病杂志

Enterococcus is an opportunistic pathogen of nosocomial infection.In recent years, the resistance rate of Enterococcus to antimicrobial agents is increasing with the widespread use of antibiotics, even leading to the development of vancomycin-resistant Enterococcus(VRE).Linezolid is a synthetic oxazolidinone antibiotic, which less likely to generates the cross-resistance with other antimicrobial agents that inhibit bacterial protein synthesis,so it has been regarded as the last line of defense for VRE.However, since the linezolid has appeared on the market, the reports of linezolid-resistant Enterococcus have also emerged.This article reviews the resistance mechanisms of Enterococcus to linezolid in order to provide reference for resistance surveillance as well as the research and development of new antimicrobial agents.

"""Internet-plus"" practice focusing on medical service at tertiary general hospitals" / 中华医院管理杂志

The First Affiliated Hospital of Zhejiang University founded an online hospital campus leveraging the Internet-plus environment. Supported by the offline hospital, this campus made full use of Internet features and advantages in its attempts to optimize the distribution of medical resources,to improve the accessibility of medical service, to reduce medical costs, and to expand the service coverage among others. Meanwhile,this online system, via interconnection with the hospital′s HIS system, achieved online medical insurance payment,prescriptions checking and drug delivery service.

Advances in nucleotide reductase inhibitors for antiviral therapy / 中华临床感染病杂志

Ribonucleotide reductase ( RR ) is a rate-limiting enzyme, and it is responsible for reducing ribonucleotides to their corresponding deoxyribonucleotides , which are the building blocks required for DNA replication and repair .Recent studies have revealed that RR activity is associated with DNA replication in virus , and RR inhibitors have been used for clinical antiviral treatment .This paper reviews research progress on RR and its inhibitors , including the classification , structure and function of RR; the classification, mechanism and clinical application of RR inhibitors in antiviral therapy and the future prospects of RR inhibitors .

Progress on pharmacokinetics/pharmacodynamics of antimicrobial agents / 中华临床感染病杂志

The pharmacokinetics/pharmacodynamics ( PK/PD) of antimicrobials aims to establish and evaluate dose-concentration-response relationship, and subsequently to describe and predict the effect-time courses resulting from a drug dose.Nowadays, PK/PD is playing an important role in dosage regimen optimizing, reducing toxicity and drug tolerance of antibiotics.And it is also of great significance in determining susceptibility breakpoints and development in new drug.This paper reviews the progress on PK/PD studies of antibacterial and antifungal agents to provide theoretical basis for safe and effective individual dosage regimens.

Research progress on correlations between interlukin-28B polymorphism and hepatitis B / 中华临床感染病杂志

Interferon (IFN) is one of the commonly used anti-HBV drug in clinic,in which IFN-λ is a new type of IFN,including IFN-λ1,IFN-λ2 and IFN-λ3 (also called IL-29,IL-28A and IL-28B,respectively).Researches in recent years show that IFN-λ3 (IL-28B) polymorphism seems to be involved in the onset of hepatitis B,the response to antiviral therapy and the outcome of HBV infection.This paper reviews the correlations between IL-28B polymorphism and the spontaneous clearance of HBV,the progression of HBV infection,the occurrence of liver cancer and the therapeutic effect of IFN treatment.

Molecular typing and drug resistance of methicillin-resistant Staphylococcus aureus in Zhejiang province / 中华临床感染病杂志

Objective To investigate molecular types and drug resistance of methicillin-resistant Staphylococcus aureus (MRSA) in Zhejiang province.Methods One hundred and fourty-seven clinical MRSA isolates were collected from 11 grade A tertiary hospitals during January 2009 and December 2010 in Zhejiang province.Minimal inhibitory concentrations (MICs) of 13 antimicrobial agents were determined by agar dilution.Multilocus sequence typing (MLST),staphylococcal cassette chromosome mec (SCCmec) typing and spa typing were used to examine the homology of the strains,and drug resistance patterns were compared among different molecular types.Simpson index was used to determine the discriminatory power of three typing methods.Results Fourteen STs were identified in 147 MRSA isolates,of which ST239 (75 isolates),ST5 (24 isolates) and ST59 (23 isolates) were the most prevalent clones.Four SCCmec types (types Ⅱ to Ⅴ) were identified in 141 isolates,and 6 isolates were not typed.SCCmec type Ⅲ was the predominant type (76 isolates),which was followed by type Ⅳ (32 isolates),type Ⅱ (24 isolates) and type Ⅴ (9 isolates).All MRSA isolates yielded 23 spa types,in which t030 (57 strains),t437 (17 strains),t002 (15 strains) and t037 (12 strains) were the predominant spa types.MRSA strains were sensitive to linezolid,teicoplanin,vancomycin and norvancomycin,but were highly resistant to other antibacterial agents,especially in strains carrying clone ST239 or of SCCmec type Ⅲ.The discriminatory power of MLST,SCCmec and spa typing were 0.6885,0.6577 and 0.8165,respectively.Conclusion The predominant clone of MRSA strains in Zhejiang province was ST239-SCCmec Ⅲ-t030-MRSA,and these strains are highly resistant to most antibacterial agents,so that the surveillance of MRSA in hospital should be strengthened.

The use of modified apnea test in the brain death evaluation / 中华急诊医学杂志

Objective To evaluate the safety and feasibility of the modified apnea test (MAT) for brain death evaluation. Method A prospective, controlled clinical study was carried out. Forty-three patients with suspected brain death underwent a total of 85 MATs. The patient's spontaneous breathing, hemodynamics and oxy genarion were monitored during MAT; arterial blood pH, PaCO2, PaO2 were measured before and after the MAT. Paired t test was used for statistical analysis to determine significant differences in measurements before and after MAT on the same patient. The Wilcoxon Signed-Rank Test was used to determine statistical significance for skew distribution of PaO2 before and after apnea testing. Informed consent was obtained from the kinfolk of all participants and all of the procedures were done in accordance with national and international laws and policies. Results Hemodynamics and oxygenarion were stable in all patients during MAT, and none regained spontaneous respiration. About 89.4% of tests were completed within 4 minutes, and 10.6% within 8 minutes. The mean value of Pa CO2 rise was (23.1 ±4.8), and the average rate of PaCO2 increase was 5.3 mmHg per minute. Conclusions Modified apnea test can be done safely for brain death evaluation and is a useful supplement to the common apnea test.