Guangdong Provincial People's Hospital

Increasing quantitative data generated from transcriptomics and proteomics require integrative strategies for analysis. Here, we present an R package, clusterProfiler that automates the process of biological-term classification and the enrichment analysis of gene clusters. The analysis module and visualization module were combined into a reusable workflow. Currently, clusterProfiler supports three species, including humans, mice, and yeast. Methods provided in this package can be easily extended to other species and ontologies. The clusterProfiler package is released under Artistic-2.0 License within Bioconductor project. The source code and vignette are freely available at http://bioconductor.org/packages/release/bioc/html/clusterProfiler.html.

The outbreak of the novel coronavirus disease (COVID-19) quickly spread all over China and to more than 20 other countries. Although the virus (severe acute respiratory syndrome coronavirus [SARS-Cov-2]) nucleic acid real-time polymerase chain reaction (PCR) test has become the standard method for diagnosis of SARS-CoV-2 infection, these real-time PCR test kits have many limitations. In addition, high false-negative rates were reported. There is an urgent need for an accurate and rapid test method to quickly identify a large number of infected patients and asymptomatic carriers to prevent virus transmission and assure timely treatment of patients. We have developed a rapid and simple point-of-care lateral flow immunoassay that can detect immunoglobulin M (IgM) and IgG antibodies simultaneously against SARS-CoV-2 virus in human blood within 15 minutes which can detect patients at different infection stages. With this test kit, we carried out clinical studies to validate its clinical efficacy uses. The clinical detection sensitivity and specificity of this test were measured using blood samples collected from 397 PCR confirmed COVID-19 patients and 128 negative patients at eight different clinical sites. The overall testing sensitivity was 88.66% and specificity was 90.63%. In addition, we evaluated clinical diagnosis results obtained from different types of venous and fingerstick blood samples. The results indicated great detection consistency among samples from fingerstick blood, serum and plasma of venous blood. The IgM-IgG combined assay has better utility and sensitivity compared with a single IgM or IgG test. It can be used for the rapid screening of SARS-CoV-2 carriers, symptomatic or asymptomatic, in hospitals, clinics, and test laboratories.

BACKGROUND: ) mutation-positive advanced non-small-cell lung cancer (NSCLC). The efficacy and safety of osimertinib as adjuvant therapy are unknown. METHODS: mutation-positive NSCLC in a 1:1 ratio to receive either osimertinib (80 mg once daily) or placebo for 3 years. The primary end point was disease-free survival among patients with stage II to IIIA disease (according to investigator assessment). The secondary end points included disease-free survival in the overall population of patients with stage IB to IIIA disease, overall survival, and safety. RESULTS: A total of 682 patients underwent randomization (339 to the osimertinib group and 343 to the placebo group). At 24 months, 90% of the patients with stage II to IIIA disease in the osimertinib group (95% confidence interval [CI], 84 to 93) and 44% of those in the placebo group (95% CI, 37 to 51) were alive and disease-free (overall hazard ratio for disease recurrence or death, 0.17; 99.06% CI, 0.11 to 0.26; P<0.001). In the overall population, 89% of the patients in the osimertinib group (95% CI, 85 to 92) and 52% of those in the placebo group (95% CI, 46 to 58) were alive and disease-free at 24 months (overall hazard ratio for disease recurrence or death, 0.20; 99.12% CI, 0.14 to 0.30; P<0.001). At 24 months, 98% of the patients in the osimertinib group (95% CI, 95 to 99) and 85% of those in the placebo group (95% CI, 80 to 89) were alive and did not have central nervous system disease (overall hazard ratio for disease recurrence or death, 0.18; 95% CI, 0.10 to 0.33). Overall survival data were immature; 29 patients died (9 in the osimertinib group and 20 in the placebo group). No new safety concerns were noted. CONCLUSIONS: mutation-positive NSCLC, disease-free survival was significantly longer among those who received osimertinib than among those who received placebo. (Funded by AstraZeneca; ADAURA ClinicalTrials.gov number, NCT02511106.).

Spatially resolved transcriptomic technologies are promising tools to study complex biological processes such as mammalian embryogenesis. However, the imbalance between resolution, gene capture, and field of view of current methodologies precludes their systematic application to analyze relatively large and three-dimensional mid- and late-gestation embryos. Here, we combined DNA nanoball (DNB)-patterned arrays and in situ RNA capture to create spatial enhanced resolution omics-sequencing (Stereo-seq). We applied Stereo-seq to generate the mouse organogenesis spatiotemporal transcriptomic atlas (MOSTA), which maps with single-cell resolution and high sensitivity the kinetics and directionality of transcriptional variation during mouse organogenesis. We used this information to gain insight into the molecular basis of spatial cell heterogeneity and cell fate specification in developing tissues such as the dorsal midbrain. Our panoramic atlas will facilitate in-depth investigation of longstanding questions concerning normal and abnormal mammalian development.

PURPOSE The phase III PACIFIC trial compared durvalumab with placebo in patients with unresectable, stage III non–small-cell lung cancer and no disease progression after concurrent chemoradiotherapy. Consolidation durvalumab was associated with significant improvements in the primary end points of overall survival (OS; stratified hazard ratio [HR], 0.68; 95% CI, 0.53 to 0.87; P = .00251) and progression-free survival (PFS [blinded independent central review; RECIST v1.1]; stratified HR, 0.52; 95% CI, 0.42 to 0.65; P &lt; .0001), with manageable safety. We report updated, exploratory analyses of survival, approximately 5 years after the last patient was randomly assigned. METHODS Patients with WHO performance status 0 or 1 (any tumor programmed cell death-ligand 1 status) were randomly assigned (2:1) to durvalumab (10 mg/kg intravenously; administered once every 2 weeks for 12 months) or placebo, stratified by age, sex, and smoking history. Time-to-event end point analyses were performed using stratified log-rank tests. Medians and landmark survival rates were estimated using the Kaplan-Meier method. RESULTS Seven hundred and nine of 713 randomly assigned patients received durvalumab (473 of 476) or placebo (236 of 237). As of January 11, 2021 (median follow-up, 34.2 months [all patients]; 61.6 months [censored patients]), updated OS (stratified HR, 0.72; 95% CI, 0.59 to 0.89; median, 47.5 v 29.1 months) and PFS (stratified HR, 0.55; 95% CI, 0.45 to 0.68; median, 16.9 v 5.6 months) remained consistent with the primary analyses. Estimated 5-year rates (95% CI) for durvalumab and placebo were 42.9% (38.2 to 47.4) versus 33.4% (27.3 to 39.6) for OS and 33.1% (28.0 to 38.2) versus 19.0% (13.6 to 25.2) for PFS. CONCLUSION These updated analyses demonstrate robust and sustained OS and durable PFS benefit with durvalumab after chemoradiotherapy. An estimated 42.9% of patients randomly assigned to durvalumab remain alive at 5 years and 33.1% of patients randomly assigned to durvalumab remain alive and free of disease progression, establishing a new benchmark for standard of care in this setting.

BACKGROUND: In adults with active lupus nephritis, the efficacy and safety of intravenous belimumab as compared with placebo, when added to standard therapy (mycophenolate mofetil or cyclophosphamide-azathioprine), are unknown. METHODS: , and no use of rescue therapy). The time to a renal-related event or death was assessed. RESULTS: A total of 448 patients underwent randomization (224 to the belimumab group and 224 to the placebo group). At week 104, significantly more patients in the belimumab group than in the placebo group had a primary efficacy renal response (43% vs. 32%; odds ratio, 1.6; 95% confidence interval [CI], 1.0 to 2.3; P = 0.03) and a complete renal response (30% vs. 20%; odds ratio, 1.7; 95% CI, 1.1 to 2.7; P = 0.02). The risk of a renal-related event or death was lower among patients who received belimumab than among those who received placebo (hazard ratio, 0.51; 95% CI, 0.34 to 0.77; P = 0.001). The safety profile of belimumab was consistent with that in previous trials. CONCLUSIONS: In this trial involving patients with active lupus nephritis, more patients who received belimumab plus standard therapy had a primary efficacy renal response than those who received standard therapy alone. (Funded by GlaxoSmithKline; BLISS-LN ClinicalTrials.gov number, NCT01639339.).

Mesenchymal stromal cells (MSCs), also known as mesenchymal stem cells, have been intensely investigated for clinical applications within the last decades. However, the majority of registered clinical trials applying MSC therapy for diverse human diseases have fallen short of expectations, despite the encouraging pre-clinical outcomes in varied animal disease models. This can be attributable to inconsistent criteria for MSCs identity across studies and their inherited heterogeneity. Nowadays, with the emergence of advanced biological techniques and substantial improvements in bio-engineered materials, strategies have been developed to overcome clinical challenges in MSC application. Here in this review, we will discuss the major challenges of MSC therapies in clinical application, the factors impacting the diversity of MSCs, the potential approaches that modify MSC products with the highest therapeutic potential, and finally the usage of MSCs for COVID-19 pandemic disease.

Background: The accurate assessment of individual risk can be of great value to guiding and facilitating the prevention of atherosclerotic cardiovascular disease (ASCVD). However, prediction models in common use were formulated primarily in white populations. The China-PAR project (Prediction for ASCVD Risk in China) is aimed at developing and validating 10-year risk prediction equations for ASCVD from 4 contemporary Chinese cohorts. Methods: Two prospective studies followed up together with a unified protocol were used as the derivation cohort to develop 10-year ASCVD risk equations in 21 320 Chinese participants. The external validation was evaluated in 2 independent Chinese cohorts with 14 123 and 70 838 participants. Furthermore, model performance was compared with the Pooled Cohort Equations reported in the American College of Cardiology/American Heart Association guideline. Results: Over 12 years of follow-up in the derivation cohort with 21 320 Chinese participants, 1048 subjects developed a first ASCVD event. Sex-specific equations had C statistics of 0.794 (95% confidence interval, 0.775–0.814) for men and 0.811 (95% confidence interval, 0.787–0.835) for women. The predicted rates were similar to the observed rates, as indicated by a calibration χ 2 of 13.1 for men ( P =0.16) and 12.8 for women ( P =0.17). Good internal and external validations of our equations were achieved in subsequent analyses. Compared with the Chinese equations, the Pooled Cohort Equations had lower C statistics and much higher calibration χ 2 values in men. Conclusions: Our project developed effective tools with good performance for 10-year ASCVD risk prediction among a Chinese population that will help to improve the primary prevention and management of cardiovascular disease.

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

BACKGROUND: Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor that stimulates erythropoiesis and regulates iron metabolism. Additional data are needed regarding the effectiveness and safety of roxadustat as compared with standard therapy (epoetin alfa) for the treatment of anemia in patients undergoing dialysis. METHODS: In a trial conducted in China, we randomly assigned (in a 2:1 ratio) patients who had been undergoing dialysis and erythropoiesis-stimulating agent therapy with epoetin alfa for at least 6 weeks to receive roxadustat or epoetin alfa three times per week for 26 weeks. Parenteral iron was withheld except as rescue therapy. The primary end point was the mean change in hemoglobin level from baseline to the average level during weeks 23 through 27. Noninferiority of roxadustat would be established if the lower boundary of the two-sided 95% confidence interval for the difference between the values in the roxadustat group and epoetin alfa group was greater than or equal to -1.0 g per deciliter. Patients in each group had doses adjusted to reach a hemoglobin level of 10.0 to 12.0 g per deciliter. Safety was assessed by analysis of adverse events and clinical laboratory values. RESULTS: A total of 305 patients underwent randomization (204 in the roxadustat group and 101 in the epoetin alfa group), and 256 patients (162 and 94, respectively) completed the 26-week treatment period. The mean baseline hemoglobin level was 10.4 g per deciliter. Roxadustat led to a numerically greater mean (±SD) change in hemoglobin level from baseline to weeks 23 through 27 (0.7±1.1 g per deciliter) than epoetin alfa (0.5±1.0 g per deciliter) and was statistically noninferior (difference, 0.2±1.2 g per deciliter; 95% confidence interval [CI], -0.02 to 0.5). As compared with epoetin alfa, roxadustat increased the transferrin level (difference, 0.43 g per liter; 95% CI, 0.32 to 0.53), maintained the serum iron level (difference, 25 μg per deciliter; 95% CI, 17 to 33), and attenuated decreases in the transferrin saturation (difference, 4.2 percentage points; 95% CI, 1.5 to 6.9). At week 27, the decrease in total cholesterol was greater with roxadustat than with epoetin alfa (difference, -22 mg per deciliter; 95% CI, -29 to -16), as was the decrease in low-density lipoprotein cholesterol (difference, -18 mg per deciliter; 95% CI, -23 to -13). Roxadustat was associated with a mean reduction in hepcidin of 30.2 ng per milliliter (95% CI, -64.8 to -13.6), as compared with 2.3 ng per milliliter (95% CI, -51.6 to 6.2) in the epoetin alfa group. Hyperkalemia and upper respiratory infection occurred at a higher frequency in the roxadustat group, and hypertension occurred at a higher frequency in the epoetin alfa group. CONCLUSIONS: Oral roxadustat was noninferior to parenteral epoetin alfa as therapy for anemia in Chinese patients undergoing dialysis. (Funded by FibroGen and FibroGen [China] Medical Technology Development; ClinicalTrials.gov number, NCT02652806.).

PURPOSE: We assessed the efficacy and safety of camrelizumab [an anti-programmed death (PD-1) mAb] plus apatinib (a VEGFR-2 tyrosine kinase inhibitor) in patients with advanced hepatocellular carcinoma (HCC). PATIENTS AND METHODS: This nonrandomized, open-label, multicenter, phase II study enrolled patients with advanced HCC who were treatment-naïve or refractory/intolerant to first-line targeted therapy. Patients received intravenous camrelizumab 200 mg (for bodyweight ≥50 kg) or 3 mg/kg (for bodyweight <50 kg) every 2 weeks plus oral apatinib 250 mg daily. The primary endpoint was objective response rate (ORR) assessed by an independent review committee (IRC) per RECIST v1.1. RESULTS: Seventy patients in the first-line setting and 120 patients in the second-line setting were enrolled. As of January 10, 2020, the ORR was 34.3% [24/70; 95% confidence interval (CI), 23.3-46.6] in the first-line and 22.5% (27/120; 95% CI, 15.4-31.0) in the second-line cohort per IRC. Median progression-free survival in both cohorts was 5.7 months (95% CI, 5.4-7.4) and 5.5 months (95% CI, 3.7-5.6), respectively. The 12-month survival rate was 74.7% (95% CI, 62.5-83.5) and 68.2% (95% CI, 59.0-75.7), respectively. Grade ≥3 treatment-related adverse events (TRAE) were reported in 147 (77.4%) of 190 patients, with the most common being hypertension (34.2%). Serious TRAEs occurred in 55 (28.9%) patients. Two (1.1%) treatment-related deaths occurred. CONCLUSIONS: .

BACKGROUND: Roxadustat (FG-4592) is an oral inhibitor of hypoxia-inducible factor (HIF) prolyl hydroxylase that stimulates erythropoiesis and regulates iron metabolism. In phase 2 studies involving patients with chronic kidney disease, roxadustat increased levels of endogenous erythropoietin to within or near the physiologic range, along with increasing hemoglobin levels and improving iron homeostasis. Additional data are needed regarding the efficacy and safety of roxadustat for the treatment of anemia in patients with chronic kidney disease who are not undergoing dialysis. METHODS: In this phase 3 trial conducted at 29 sites in China, we randomly assigned 154 patients with chronic kidney disease in a 2:1 ratio to receive roxadustat or placebo three times a week for 8 weeks in a double-blind manner. All the patients had a hemoglobin level of 7.0 to 10.0 g per deciliter at baseline. The randomized phase of the trial was followed by an 18-week open-label period in which all the patients received roxadustat; parenteral iron was withheld. The primary end point was the mean change from baseline in the hemoglobin level, averaged over weeks 7 through 9. RESULTS: During the primary-analysis period, the mean (±SD) change from baseline in the hemoglobin level was an increase of 1.9±1.2 g per deciliter in the roxadustat group and a decrease of 0.4±0.8 g per deciliter in the placebo group (P<0.001). The mean reduction from baseline in the hepcidin level (associated with greater iron availability) was 56.14±63.40 ng per milliliter in the roxadustat group and 15.10±48.06 ng per milliliter in the placebo group. The reduction from baseline in the total cholesterol level was 40.6 mg per deciliter in the roxadustat group and 7.7 mg per deciliter in the placebo group. Hyperkalemia and metabolic acidosis occurred more frequently in the roxadustat group than in the placebo group. The efficacy of roxadustat in hemoglobin correction and maintenance was maintained during the 18-week open-label period. CONCLUSIONS: In Chinese patients with chronic kidney disease who were not undergoing dialysis, those in the roxadustat group had a higher mean hemoglobin level than those in the placebo group after 8 weeks. During the 18-week open-label phase of the trial, roxadustat was associated with continued efficacy. (Funded by FibroGen and FibroGen [China] Medical Technology Development; ClinicalTrials.gov number, NCT02652819.).

IMPORTANCE: Understanding population-wide trends in prevalence and control of diabetes is critical to planning public health approaches for prevention and management of the disease. OBJECTIVE: To determine trends in prevalence of diabetes and control of risk factors in diabetes among US adults between 1999-2000 and 2017-2018. DESIGN, SETTING, AND PARTICIPANTS: Ten cycles of cross-sectional National Health and Nutrition Examination Survey (NHANES) data between 1999-2000 and 2017-2018 were included. The study samples were weighted to be representative of the noninstitutionalized civilian resident US population. Adults aged 18 years or older were included, except pregnant women. EXPOSURES: Survey cycle. MAIN OUTCOMES AND MEASURES: Diabetes was defined by self-report of diabetes diagnosis, fasting plasma glucose level of 126 mg/dL or more, or hemoglobin A1c (HbA1c) level of 6.5% or more. Three risk factor control goals were individualized HbA1c targets, blood pressure less than 130/80 mm Hg, and low-density lipoprotein cholesterol level less than 100 mg/dL. Prevalence of diabetes and proportion of adults with diagnosed diabetes who achieved risk factor control goals, overall and by sociodemographic variables, were estimated. RESULTS: Among the 28 143 participants included (weighted mean age, 48.2 years; 49.3% men), the estimated age-standardized prevalence of diabetes increased significantly from 9.8% (95% CI, 8.6%-11.1%) in 1999-2000 to 14.3% (95% CI, 12.9%-15.8%) in 2017-2018 (P for trend < .001). From 1999-2002 to 2015-2018, the estimated age-standardized proportion of adults with diagnosed diabetes who achieved blood pressure less than 130/80 mm Hg (P for trend = .007) and low-density lipoprotein cholesterol level less than 100 mg/dL (P for trend < .001) increased significantly, but not individualized HbA1c targets (P for trend = .51). In 2015-2018, 66.8% (95% CI, 63.2%-70.4%), 48.2% (95% CI, 44.6%-51.8%), and 59.7% (95% CI, 54.2%-65.2%) of adults with diagnosed diabetes achieved individualized HbA1c targets, blood pressure less than 130/80 mm Hg, and low-density lipoprotein cholesterol level less than 100 mg/dL, respectively. Only 21.2% of these adults (95% CI, 15.5%-26.8%) achieved all 3. During the entire study period, these 3 goals were significantly less likely to be achieved among young adults aged 18 to 44 years (vs older adults ≥65 years: estimated proportion, 7.4% vs 21.7%; adjusted odds ratio, 0.32 [95% CI, 0.16-0.63]), non-Hispanic Black adults (vs non-Hispanic White adults: estimated age-standardized proportion, 12.5% vs 20.6%; adjusted odds ratio, 0.60 [95% CI, 0.40-0.90]), and Mexican American adults (vs non-Hispanic White adults: estimated age-standardized proportion, 10.9% vs 20.6%; adjusted odds ratio, 0.48 [95% CI, 0.31-0.77]). CONCLUSIONS AND RELEVANCE: Based on NHANES data from US adults, the estimated prevalence of diabetes increased significantly between 1999-2000 and 2017-2018. Only an estimated 21% of adults with diagnosed diabetes achieved all 3 risk factor control goals in 2015-2018.

Mesenchymal stem cells (MSCs) have been extensively investigated for the treatment of various diseases. The therapeutic potential of MSCs is attributed to complex cellular and molecular mechanisms of action including differentiation into multiple cell lineages and regulation of immune responses via immunomodulation. The plasticity of MSCs in immunomodulation allow these cells to exert different immune effects depending on different diseases. Understanding the biology of MSCs and their role in treatment is critical to determine their potential for various therapeutic applications and for the development of MSC-based regenerative medicine. This review summarizes the recent progress of particular mechanisms underlying the tissue regenerative properties and immunomodulatory effects of MSCs. We focused on discussing the functional roles of paracrine activities, direct cell-cell contact, mitochondrial transfer, and extracellular vesicles related to MSC-mediated effects on immune cell responses, cell survival, and regeneration. This will provide an overview of the current research on the rapid development of MSC-based therapies.

Importance: The aging of the population is associated with an increasing burden of fractures worldwide. However, the epidemiological features of fractures in mainland China are not well known. Objective: To assess the prevalence of and factors associated with osteoporosis, clinical fractures, and vertebral fractures in an adult population 40 years or older in mainland China. Design, Setting. and Participants: This cross-sectional study, the China Osteoporosis Prevalence Study, was conducted from December 2017 to August 2018. A random sample of individuals aged 20 years or older who represented urban and rural areas of China were enrolled, with a 99% participation rate. Main Outcomes and Measures: Weighted prevalence of osteoporosis, clinical fracture, and vertebral fracture by age, sex, and urban vs rural residence as determined by x-ray absorptiometry, questionnaire, and radiography. Results: A total of 20 416 participants were included in this study; 20 164 (98.8%; 11 443 women [56.7%]; mean [SD] age, 53 [13] years) had a qualified x-ray absorptiometry image and completed the questionnaire, and 8423 of 8800 (95.7%) had a qualified spine radiograph. The prevalence of osteoporosis among those aged 40 years or older was 5.0% (95% CI, 4.2%-5.8%) among men and 20.6% (95% CI, 19.3%-22.0%) among women. The prevalence of vertebral fracture was 10.5% (95% CI, 9.0%-12.0%) among men and 9.7% (95% CI, 8.2%-11.1%) among women. The prevalence of clinical fracture in the past 5 years was 4.1% (95% CI, 3.3%-4.9%) among men and 4.2% (95% CI, 3.6%-4.7%) among women. Among men and women, 0.3% (95% CI, 0.0%-0.7%) and 1.4% (95% CI, 0.8%-2.0%), respectively, with osteoporosis diagnosed on the basis of bone mineral density or with fracture were receiving antiosteoporosis treatment to prevent fracture. Conclusions and Relevance: In this cross-sectional study of an adult population in mainland China, the prevalence of osteoporosis and vertebral fracture were high and the prevalence of vertebral fracture and clinical fracture was similarly high in men and women. These findings suggest that current guidelines for screening and treatment of fractures among patients in China should focus equally on men and women and should emphasize the prevention of vertebral fractures.

The SARS-CoV-2 Delta variant has spread rapidly worldwide. To provide data on its virological profile, we here report the first local transmission of Delta in mainland China. All 167 infections could be traced back to the first index case. Daily sequential PCR testing of quarantined individuals indicated that the viral loads of Delta infections, when they first become PCR-positive, were on average ~1000 times greater compared to lineage A/B infections during the first epidemic wave in China in early 2020, suggesting potentially faster viral replication and greater infectiousness of Delta during early infection. The estimated transmission bottleneck size of the Delta variant was generally narrow, with 1-3 virions in 29 donor-recipient transmission pairs. However, the transmission of minor iSNVs resulted in at least 3 of the 34 substitutions that were identified in the outbreak, highlighting the contribution of intra-host variants to population-level viral diversity during rapid spread.

INTRODUCTION: In the Phase 3, placebo-controlled PACIFIC trial of patients with unresectable, stage III NSCLC without disease progression after concurrent chemoradiotherapy, consolidative durvalumab was associated with significant improvements in the primary end points of overall survival (OS) (hazard ratio [HR] = 0.68; 95% confidence interval [CI]: 0.53-0.87; p = 0.00251; data cutoff, March 22, 2018) and progression-free survival (PFS) (blinded independent central review; Response Evaluation Criteria in Solid Tumors version 1.1) (HR = 0.52; 95% CI: 0.42-65; p < 0.0001; February 13, 2017) with manageable safety. Here, we report updated analyses of OS and PFS, approximately 4 years after the last patient was randomized. METHODS: Patients with WHO performance status of 0 or 1 (and any tumor programmed death-ligand 1 status) were randomized (2:1) to intravenous durvalumab (10 mg/kg) or placebo, administered every 2 weeks (≤12 months), stratified by age, sex, and smoking history. OS and PFS were analyzed using a stratified log-rank test in the intent-to-treat population. Medians and 4-year OS and PFS rates were estimated by the Kaplan-Meier method. RESULTS: Overall, 709 of 713 randomized patients received durvalumab (n/N=473/476) or placebo (n/N=236/237). As of March 20, 2020 (median follow-up = 34.2 months; range: 0.2-64.9), updated OS (HR = 0.71; 95% CI: 0.57-0.88) and PFS (HR = 0.55; 95% CI: 0.44-0.67) remained consistent with the primary analyses. The median OS for durvalumab was reached (47.5 mo; placebo, 29.1 months). Estimated 4-year OS rates were 49.6% versus 36.3% for durvalumab versus placebo, and 4-year PFS rates were 35.3% versus 19.5% respectively. CONCLUSION: These updated exploratory analyses demonstrate durable PFS and sustained OS benefit with durvalumab after chemoradiotherapy. An estimated 49.6% of patients randomized to durvalumab remain alive at 4 years (placebo, 36.3%), and 35.3% remain alive and progression-free (placebo, 19.5%).

As of March 8, 2020, the novel coronavirus disease 2019 (COVID-19) had caused 80,815 human infections and 3073 deaths in China, including more than 3000 infections among medical staff. Guangdong Second Provincial General Hospital (Guangzhou, Guangdong Province, China), a provincial emergency hospital, has treated more than 35 confirmed cases of COVID-19 and more than 260 suspected cases. Most of nurses' work involves direct contact with patients. As nurses have high vulnerability to COVID-19, it is necessary to establish hospital-specific protocols to reduce the risk of nurses' infection in interactions with COVID-19 patients. Our hospital has maintained a "zero nurse infection" rate while battling SARS in 2003 and during the present COVID-19 epidemic. The following are the key measures implemented in our hospital.

As of March 24, 2020, novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been responsible for 379,661 infection cases with 16,428 deaths globally, and the number is still increasing rapidly. Herein, we present four critically ill patients with SARS-CoV-2 infection who received supportive care and convalescent plasma. Although all four patients (including a pregnant woman) recovered from SARS-CoV-2 infection eventually, randomized trials are needed to eliminate the effect of other treatments and investigate the safety and efficacy of convalescent plasma therapy. As of March 24, 2020, novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been responsible for 379,661 infection cases with 16,428 deaths globally, and the number is still increasing rapidly. Herein, we present four critically ill patients with SARS-CoV-2 infection who received supportive care and convalescent plasma. Although all four patients (including a pregnant woman) recovered from SARS-CoV-2 infection eventually, randomized trials are needed to eliminate the effect of other treatments and investigate the safety and efficacy of convalescent plasma therapy. An outbreak of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection first appeared in Wuhan, China,1Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China [published online ahead of print February 28, 2020]. N Engl J Med. https://doi.org/10.1056/NEJMoa2002032.Google Scholar and rapidly spread to 171 countries. As of March 24, 2020, the virus has been responsible for 379,661 confirmed cases and 16,428 deaths worldwide. To date, no specific treatment has been recommended for SARS-CoV-2 infection except for meticulous supportive care.2Chen N. Zhou M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (13646) Google Scholar Numerous therapeutics have been explored or developed during the outbreak. A recent trial showed lopinavir-ritonavir has no treatment benefit for severe illness caused by SARS-CoV-2.3Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19 [published online ahead of print March 18, 2020]. N Engl J Med. https://doi.org/10.1056/NEJMe2005477.Google Scholar Immunotherapy with virus-specific antibodies in convalescent plasma had been used as a last resort to improve the survival rate of patients with serious infectious diseases, such as severe acute respiratory syndrome, middle east respiratory syndrome coronavirus, Ebola virus disease, pandemic influenza A, and avian-origin influenza A.4Chen L, Xiong J, Bao L, et al. Convalescent plasma as a potential therapy for COVID-19 [published online ahead of print February 27, 2020]. Lancet Infect Dis. https://doi.org/10.1016/S1473-3099(20)30141-9.Google Scholar Previous reports have shown treatment with convalescent plasma collated from recovered patients could reduce the hospital stay and mortality of patients.5Soo Y.O. Cheng Y. Wong R. et al.Retrospective comparison of convalescent plasma with continuing high-dose methylprednisolone treatment in SARS patients.Clin Microbiol Infect. 2004; 10: 676-678Abstract Full Text Full Text PDF PubMed Scopus (309) Google Scholar, 6Cheng Y. Wong R. Soo Y.O. et al.Use of convalescent plasma therapy in SARS patients in Hong Kong.Eur J Clin Microbiol Infect Dis. 2005; 24: 44-46Crossref PubMed Scopus (728) Google Scholar, 7Lai S.T. Treatment of severe acute respiratory syndrome.Eur J Clin Microbiol Infect Dis. 2005; 24: 583-591Crossref PubMed Scopus (92) Google Scholar However, the efficacy of convalescent plasma in critically ill patients with SARS-CoV-2 infection remains unclear. Herein, we report the disease course on four critically ill patients infected with SARS-CoV-2 and treated with supportive care and convalescent plasma. Figure 1 shows the clinical course of four critically ill patients infected with SARS-CoV-2. The first case is a 69-year-old woman with a history of hypertension who presented with fever for 2 days and clear sputum for 5 days. On January 30, the patient was admitted to Dongguan Ninth People’s Hospital because of positive reverse transcriptase polymerase chain reaction (RT-PCR) test of throat swab by Dongguan Center for Disease Control (CDC). A chest CT scan revealed bilateral ground-glass opacities primarily distributed along the pleura. Treatment with arbidol (200 mg three times daily), lopinavir-ritonavir (400 mg twice daily), interferon alpha inhalation (50 μg twice daily), and other supportive therapies was started. At 4 pm on February 4, the patient’s Po2 decreased to 56.5 mm Hg with an oxygenation index (OI) (Po2/Fio2) of 94 mm Hg. Significantly increased consolidation was observed in the right lung. The patient was transferred to the ICU of Dongguan People’s Hospital (a designated center for critical illness treatment) on February 5 and received invasive mechanical ventilation. Apart from antiviral drugs (lopinavir-ritonavir, oseltamivir, and interferon alpha), human albumin, zadaxin and immunoglobulin, and antibacterial and antifungal drugs were administrated because of coinfection with bacteria and Aspergillus. At 6:30 pm on February 11, the patient’s Po2 was 58 mm Hg. She experienced septic shock with BP of 89/44 mm Hg 5 h later. Hypohemoglobin (92 g/L) and bloody sputum under bronchoscopy suggested pneumorrhagia. A bedside chest radiograph showed obvious progression of disease. Although the patient was successfully rescued, follow-up chest radiographs showed continuous progression of pneumonia. A total of 900 mL O-compatible convalescent plasma was transfused to the patient in three batches; the first batch was given at 8 am on February 17 (200 mL), the second one was at 8 am on February 27 (400 mL), and the last one was at 8 am on February 28 (300 mL). The virus load of the patient on February 18 was 55 × 105 copies/mL, which significantly decreased to 3.9 × 104 copies/mL on February 28, and further decreased to 180 copies/mL on March 5. The patient was extubated and noninvasion ventilation was given on March 3. Chest CT scans obtained on February 27, March 6, and March 15 showed persistent absorption of consolidation. The results of two repeat RT-PCR tests of oropharyngeal swabs (with at least 1-day interval) performed on March 9 and 11 were negative. The patient was discharged on March 13. The second case was a 55-year-old man with a history of COPD who was admitted to a fever clinic of Xiangtan Central Hospital on February 5, 2020. He had nausea, poor appetite, and cough with clear sputum for 4 days. The results of RT-PCR assay of throat swab were positive for SARS-CoV-2 infection. A chest CT scan obtained on February 6 revealed interlobular septal thickening with honeycombing change in the right upper lung. The patient started to receive antiviral treatment, including arbidol (200 mg three times daily), lopinavir-ritonavir (500 mg twice daily), and interferon alpha-2b (5 million units twice daily). After 2 days, he complained of shortness of breath and his Po2 decreased to 50 mm Hg with an OI of 135 mm Hg. The patient was therefore diagnosed with ARDS and began to receive noninvasive mechanical ventilation and oxygen therapy through high-flow nasal cannula alternately. However, the conditions of the patient continued to deteriorate despite treatment with pulsed methylprednisolone. His Po2 oscillated between 46 and 83 mm Hg, and symptoms were not improved. Follow-up chest CT scans obtained on February 9 to 16 showed interstitial pneumonia extended to both lungs. At 3 pm on February 16, 200 mL convalescent plasma obtained from a patient recovered from SARS-CoV-2 infection in January 2020 was transfused to the patient. No adverse reactions were observed. One day later, his Po2 increased to 97 mm Hg with an OI of 198 mm Hg. All drugs were discontinued except for methylprednisolone. Chest images obtained on February 17 to 21 showed obvious absorption of interstitial pneumonia. Three repetitive RT-PCR test results were negative from February 20 to 22. The patient recovered and was discharged on February 23. He was asked to continue the quarantine at home for 14 days and receive home oxygen therapy. The third case was a 73-year-old man who was admitted to Dongguan Ninth People’s Hospital on February 2 because of self-reported dry cough for 4 days. He had a history of hypertension and chronic renal failure. On February 3, the patient was confirmed as being infected with SARS-CoV-2 by a virus RNA detection kit. At 11:30 pm, the patient developed acute respiratory failure with Po2 of 53 mm Hg and OI of 124 mm Hg; high-flow oxygen through face mask was given. He was then transferred to the isolation wards of the ICU of Dongguan People’s Hospital for further treatment. A chest radiograph showed bilateral infiltrative shadows. The viral load of the patient was as high as 85 × 105 copies/mL. The patient was treated with arbidol (200 mg three times daily), lopinavir-ritonavir (400 mg twice daily), oseltamivir (75 mg twice daily), and ribavirin and interferon alpha-2b (5 million units twice daily). On February 5, the patient was given tracheal intubation because of dyspnea and consistent decrease of oxygen saturation. On February 11, continuous renal replacement therapy (CRRT) was started on the patient. Laboratory tests obtained on February 14 showed significantly increased WBCs of 33.93 × 109/L and neutrophils of 31.08 × 109/L. He was diagnosed with multiple organ failure by clinical examination. On February 15, the patient developed septic shock and his BP decreased to 90/68 mm Hg with heart rate of 149 beat/min and respiratory rate of 30 breaths/min. A chest radiograph showed bilateral white lung. At 12:55 pm on February 15, the patient started to receive veno-venous extracorporeal membrane oxygenation, whereas the OI was unstable and symptoms were not improved. High-throughput DNA sequencing of sputum suggested Aspergillus infection. The patient was therefore treated with caspofungin and voriconazole. Eight transfusions of B-compatible convalescent plasma (2,400 mL) were given to the patient from February 16 to March 13. On February 21, the patient was confirmed positive for active pneumorrhagia, cystorrhagia, and GI bleeding. Antibody testing on February 27 indicated positive anti-SARS-CoV-2 IgG. The viral load was reduced (detailed values were not available). Follow-up chest radiographs showed absorbed infiltrative lesions but pneumothorax. Two repeat RT-PCR tests of sputum in deep lungs on March 16 and 17 (with at least 1-day interval) were negative and the serum IgM level decreased to the normal range. On March 22, the patient was transferred to the unfenced ICU for further treatment of underlying diseases and multiple organ failure. The fourth case was a 31-year-old pregnant woman (35 weeks and 2 days) who was admitted to Xiaolan People’s Hospital of Zhongshan on February 1 because of pharyngalgia for 4 days and fever (39.3°C) and difficulty breathing for half-day. The patient was confirmed as being infected with SARS-CoV-2 by Zhongshan CDC. A chest CT scan showed opacities in the lower lobe of the left lung. After admission, the patient developed severe ARDS, multiple organ dysfunction syndrome, and septic shock. Invasive ventilation and caesarean section were therefore given to the patient. Unfortunately, the newborn died of endouterine asphyxia. After the conditions turned stable, she was transferred to the Second People’s Hospital of Zhongshan (a designated hospital for SARS-CoV-2 treatment) at 1:04 am on February 2. Amounts of frothy sputum was observed under bronchofiberscope. Cardiac ultrasound suggested left ventricular enlargement with decreased systolic function. The patient received invasive ventilation and CRRT. Treatment with lopinavir-ritonavir (400 mg twice daily) and ribavirin (500 mg every 12 h) was started on February 2. Gram-positive bacteria were detected by blood culture, and imipenem and vancomycin were given to the patient. A chest radiograph showed increased consolidation and extended opacities. Oxygen saturation oscillated between 85% and 92% with an OI between 60 and 75 mm Hg. At 12 am on February 6, the patient started to receive veno-venous extracorporeal membrane oxygenation (flow rate: 3 L/min). Her OI was significantly improved (with a maximum of 200 mm Hg). Follow-up chest radiographs showed partial absorption of opacities. Left ventricular systolic function returned to normal. At 11:30 am on February 19, a 300-mL transfusion of convalescent plasma was given to the patient. On February 27, CRRT and extracorporeal membrane oxygenation (ECMO) were removed. On March 11, trachea cannula was removed and nasal oxygen was given to the patient. On March 6, 8, and 11, anti-SARS-CoV-2 IgM changed from positive to weakly positive to negative, whereas anti-SARS-CoV-2 IgG was persistently positive. Follow-up chest CT scan showed near-complete absorption of opacities. The results of two continual RT-PCR tests of BAL fluid on March 11 and 14 were both negative. The patient recovered from SARS-CoV-2 infection and was discharged on March 17. A recent retrospective review of 72,314 SARS-CoV-2-infected cases by the China CDC showed that 5% of cases were critical illness characterized by respiratory failure, septic shock, and/or multiple organ dysfunction or failure.8Zunyou W, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention [published online ahead of print February 24, 2020]. JAMA. https://doi.org/10.1001/jama.2020.2648.Google Scholar Around 48% of patients infected with SARS-CoV-2 had comorbid conditions, commonly cardiovascular diseases and diabetes.9Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published online ahead of print March 11, 2020]. Lancet. https://doi.org/10.1016/S0140-6736(20)30566-3.Google Scholar Older adults with underlying diseases were more likely to have a higher Sequential Organ Failure Assessment score and higher risk of death. The treatment of SARS-CoV-2 infection faces compelling challenges. To date, no therapeutics have yet been proven effective for the treatment of the critical illness except for supportive care, including treatment with antiviral drugs, corticosteroids, immunoglobulins, and noninvasive or invasive mechanical ventilation. The most critically ill patients infected with SARS-CoV-2 have elevated levels of infection-related biomarkers and inflammatory cytokines, indicating potential bacterial coinfection caused by a dysregulated immune system.10Qin C, Zhou L, Hu Z, et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China [published online ahead of print March 12, 2020]. Clin Infect Dis. https://doi.org/10.1093/cid/ciaa248.Google Scholar Antibacterial drugs are therefore given to these patients. Management of critical SARS-CoV-2 infection is not different from management of most viral pneumonia causing respiratory failure. The principal feature of patients with the critical illness is the development of ARDS. ECMO is recommended by World Health Organization interim guidelines to support eligible patients with ARDS, while the use of which is restricted to specialized centers globally and technology challenges.11Ramanathan K, Antognini D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases [published online ahead of print March 20, 2020]. Lancet Respir Med. https://doi.org/10.1016/S2213-2600(20)30121-1.Google Scholar In this study, two patients were treated with ECMO, but the efficacy was mixed. Apart from ARDS, other life-threatening conditions including septic shock and multiple organ dysfunction or failure may occur in a substantial proportion of patients with SARS-CoV-2-related critical illness, the management of which is according to current evidence-based guidelines.12De Backer D. Dorman T. Surviving sepsis guidelines: a continuous move toward better care of patients with sepsis.JAMA. 2017; 317: 807-808Crossref PubMed Scopus (67) Google Scholar In China, if the current therapeutic strategies are not satisfactory for critically ill patients, physicians might turn to convalescent plasma transfusion based on the Pneumonitis Diagnosis and Treatment Program for SARS-CoV-2 infection (Trial Version 7). Convalescent plasma has been used as a last resort to improve the survival rate of patients with severe acute respiratory syndrome infection. Previous evidence has proven that convalescent plasma treatment can significantly reduce the relative risk of mortality of patients,13Hung I.F. To K.K. Lee C.K. et al.Convalescent plasma treatment reduced mortality in patients with severe pandemic influenza A (H1N1) 2009 virus infection.Clin Infect Dis. 2011; 52: 447-456Crossref PubMed Scopus (534) Google Scholar which may be because antibodies from convalescent plasma might suppress viremia. The level of SARS-CoV-2 neutralizing antibodies in donor plasma could be important for the effectiveness of intervention. However, the level of neutralizing antibodies in donor plasma before transfusion cannot be determined. In this study, three patients were tested for either virus load or antibodies IgM and IgG. In the first case, SARS-CoV-2 virus load after convalescent plasma transfusion significantly dropped (from 55 × 105 to 3.9 × 104 to 180 copies/mL). Among the four patients, the time from transfusion to negative RT-PCR test results ranged from 3 to 22 days. The third and fourth cases produced anti-SARS-CoV-2 IgG approximately 14 days after convalescent plasma transfusion. Patients who survive critical illness might mount higher antibody responses, which can persist for longer periods compared with those with nonsevere disease.14Chen J. Zhu H. Horby P.W. et al.Specificity, kinetics and longevity of antibody responses to avian influenza A (H7N9) virus infection in humans.J Infect. 2020; 80: 310-319Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The antibody levels, however, are confounded by other treatments, such as antiviral drugs, steroids, and IV immunoglobulin.15Luke T.C. Kilbane E.M. Jackson J.L. Hoffman S.L. Meta-analysis: convalescent blood products for Spanish influenza pneumonia: a future H5N1 treatment?.Ann Intern Med. 2006; 145: 599-609Crossref PubMed Scopus (487) Google Scholar A recent animal model indicated that antibodies produced from SARS-CoV-2 infection could protect from subsequent exposures.16Bao L, Deng W, Gao H, et al. Reinfection could not occur in SARS-CoV-2 infected rhesus macaques [published online ahead of print March 13, 2020]. bioRxiv. https://doi.org/10.1101/2020.03.13.990226.Google Scholar Our results indicate convalescent plasma might be a potential therapy for critically ill patients infected with SARS-CoV-2. We observed no serious adverse reactions associated with the transfusion of convalescent plasma. However, the relative contributions of supportive care, investigational therapies, and patient’s immune response on survival could not be determined. Whether convalescent plasma and/or supportive care provide any clinical benefit is unknown. The safety and efficacy of convalescent plasma transfusion in patients infected with SARS-CoV-2 should be studied within the context of a well-designed clinical trial.

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic and has claimed over 2 million lives worldwide. Although the genetic sequences of SARS-CoV and SARS-CoV-2 have high homology, the clinical and pathological characteristics of COVID-19 differ significantly from those of SARS. How and whether SARS-CoV-2 evades (cellular) immune surveillance requires further elucidation. In this study, we show that SARS-CoV-2 infection leads to major histocompability complex class Ι (MHC-Ι) down-regulation both in vitro and in vivo. The viral protein encoded by open reading frame 8 (ORF8) of SARS-CoV-2, which shares the least homology with SARS-CoV among all viral proteins, directly interacts with MHC-Ι molecules and mediates their down-regulation. In ORF8-expressing cells, MHC-Ι molecules are selectively targeted for lysosomal degradation via autophagy. Thus, SARS-CoV-2-infected cells are much less sensitive to lysis by cytotoxic T lymphocytes. Because ORF8 protein impairs the antigen presentation system, inhibition of ORF8 could be a strategy to improve immune surveillance.