2020年 · 第133卷第23期

To eliminate the public health threat of the global human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) epidemic by 2030, the Joint United Nations Programme on HIV/AIDS launched 90-90-90 control targets in 2014 to help end the spread of HIV. China has responded actively by scaling up and expanding HIV testing and implementing early antiretroviral therapy (ART). In progressing towards achieving the 90-90-90 targets, China, in 2018, achieved higher percentages on the second (83.4%vs. 79.5%) and third (94.2%vs. 79.9%) "90" targets than the average global levels but a lower percentage on the first "90" target (69.3%vs. 79.9%), the aim of which is to have 90% of all people living with HIV (PLWHIV) knowing their HIV status. At the same time, the estimated number of PLWHIV in China increased from 0.81 million in 2013 to 1.25 million in 2018. In addition, while AIDS ranked third for the number of cases of nationally notifiable legal infectious diseases in 2019, it ranked first for the number of deaths resulting from such diseases. The above evidence indicates that overreliance on HIV testing and early ART is far from sufficient to control HIV completely. It is necessary to move forward with direct prevention and control strategies that reduce the risk of HIV infection in key populations. HIV pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP) are just two of the measures that need to be fully utilized in this effort.

Since its first isolation in 1983, human immunodeficiency virus (HIV) has caused nearly 50 million deaths and affected millions of people worldwide. Combination antiretroviral therapy (ART) has been universally recommended for HIV infection owing to its beneficial effects on the replication and transmission control of HIV.^[1]The World Health Organization eliminated the traditional CD4-based ART eligibility requirements in late 2015. Thus, ART is now recommended for all people living with HIV (PLWH) regardless of the CD4 level or clinical stage. Global declarations called for a 75% reduction in new HIV infections and acquired immunodeficiency syndrome (AIDS) deaths between 2010 and 2020 and an end to the HIV/AIDS epidemic by 2030 through achieving the 90-90-90 targets (90% of PLWH are diagnosed, of whom 90% are on treatment, of whom 90% are virally suppressed) set for 2020 by the Joint United Nations Programme on HIV/AIDS.^[2]Although positive progress toward achieving these targets was observed in 2019, substantial gaps remain. It was estimated that globally 79% (67%-92%) of all PLWH know their status, 78% (69%-82%) of those who know their status are undergoing treatment, and 86% (72%-92%) of those on treatment have suppressed viral loads. Globally, an estimated 37.9 million (32.7-44.0 million) PLWH, with 1.7 million (1.4-2.3 million) new infections and 770,000 (570,000 to 1.1 million) AIDS-related deaths in 2018. A series of government-sponsored, multi-center studies have been performed over the years to guide the optimization of the HIV/AIDS treatment approach for HIV/AIDS patients, and some new advances have emerged.^[2]

Human immunodeficiency virus (HIV) prevalence among student men who have sex with men (MSM) in college is more than 5.0% and keeps on increasing in China. This study aims to clarify the proportion of HIV recent infection, its propeller and the source among college student MSM.

We conducted a multicenter cross-sectional study in seven major Chinese cities during 2012-2013. HIV recent infections (≤168 days) and incidence was measured and estimated by BED HIV-1 capture enzyme immunoassay (BED-CEIA) testing strategy. HIV-related behaviors and transmitted drug resistance (TDR) were investigated and compared between the college student MSM, < 25-year-old non-student youth MSM (NSYM), and ≥25-year-old non-student non-youth MSM (NSNYM), using structured survey, and analyses of drug resistance.

Overall, 4496 (4496/4526, 99.3%) were eligible for enrollment, comprising 565 college student MSM, 1094 NSYM, and 2837 NSNYM. The proportion of HIV recent infection were 70.3% (26/37), 50.8% (65/128) and 35.1% (95/271), the HIV incidence rate were 10.0 (95% CI: 6.2-13.9)/100 person-year (PY), 12.9 (95% CI: 9.8-16.1 )/100PY, 6.8 (95% CI: 5.4-8.2)/100 PY, and TDR prevalences were 7.4% (2/27), 2.0%, (2/98) and 4.9% (11/226), among student MSM, NSYM, and NSNYM, respectively. Among HIV positive student MSM with age <21 years, the proportion of HIV recent infection is 90.9% (10/11). Factors independently associated with HIV recent infection in student MSM was usage of recreational drug in the past 6 months (adjusted odds ratio [aOR]: 2.5; 95% CI: 1.0-5.8).

College student MSM had higher proportion of HIV recent infection and TDR than the youth and older MSM in China during 2012-2013. The HIV infections were more likely to happen during the early year of college life among student MSM.

Cryptococcal meningitis (CM) is one of the most common opportunistic infections caused by Cryptococcus neoformans in human immunodeficiency virus (HIV)-infected patients, and is complicated with significant morbidity and mortality. This study retrospectively analyzed the clinical features, characteristics, treatment, and outcomes of first-diagnosed HIV-associated CM after 2-years of follow-up.

Data from all patients (n = 101) of HIV-associated CM hospitalized in Shanghai Public Health Clinical Center from September 2013 to December 2016 were collected and analyzed using logistic regression to identify clinical and microbiological factors associated with mortality.

Of the 101 patients, 86/99 (86.9%) of patients had CD4 count <50 cells/mm³, 57/101 (56.4%) were diagnosed at ≥14 days from the onset to diagnosis, 42/99 (42.4%) had normal cerebrospinal fluid (CSF) cell counts and biochemical examination, 30/101 (29.7%) had concomitant Pneumocystis (carinii) jiroveci pneumonia (PCP) on admission and 37/92 (40.2%) were complicated with cryptococcal pneumonia, 50/74 (67.6%) had abnormalities shown on intracranial imaging, amongst whom 24/50 (48.0%) had more than one lesion. The median time to negative CSF Indian ink staining was 8.50 months (interquartile range, 3.25-12.00 months). Patients who initiated antiretroviral therapy (ART) before admission had a shorter time to negative CSF Indian ink compared with ART-naïve patients (7 vs. 12 months, χ² = 15.53, P < 0.001). All-cause mortality at 2 weeks, 8 weeks, and 2 years was 10.1% (10/99), 18.9% (18/95), and 20.7% (19/92), respectively. Coinfection with PCP on admission (adjusted odds ratio [AOR], 3.933; 95% confidence interval [CI], 1.166-13.269, P= 0.027) and altered mental status (AOR, 9.574; 95% CI, 2.548-35.974, P = 0.001) were associated with higher mortality at 8 weeks.

This study described the clinical features and outcomes of first diagnosed HIV-associated CM with 2-year follow-up data. Altered mental status and coinfection with PCP predicted mortality in HIV-associated CM.

Numerous studies have focused on lymphoma among patients infected with human immunodeficiency virus (HIV). However, little is known about the treatment options and survival rate of lymphoma in the Chinese people living with HIV (PLHIV). Our study aimed to investigate the prognosis and compare outcome of dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (DA-EPOCH-R) with standard cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab(R-CHOP) as front line therapy for PLHIV with diffuse large B-cell lymphoma (DLBCL) receiving modern combined antiretroviral therapy (cART).

A retrospective analysis evaluating PLHIV with DLBCL was performed in Shanghai Public Health Clinical Center from July 2012 to September 2019. The demographic and clinical data were collected, and overall survival (OS) and progression-free survival (PFS) analyses of patients receiving R-CHOP or DA-EPOCH-R therapy were performed by Kaplan-Meier analysis. Additionally, a Cox multiple regression model was constructed to identify related factors for OS.

A total of 54 eligible patients were included in the final analysis with a median follow-up of 14 months (interquartile range [IQR]: 8-29 months). The proportion of high international prognostic index (IPI) patients was much larger in the DA-EPOCH-R group (n = 29) than that in the R-CHOP group (n = 25). The CD4 cell counts and HIV RNA levels were not significantly different between the two groups. The 2-year OS for all patients was 73%. However, OS was not significantly different between the two groups, with a 2-year OS rate of 78% for the DA-EPOCH-R group and 66% for the R-CHOP group. Only an IPI greater than 3 was associated with a decrease in OS, with a hazard ratio of 5.0. The occurrence of grade 3 and 4 adverse events of chemotherapy was not significantly different between the two groups.

Outcomes of R-CHOP therapy do not differ from those of DA-EPOCH-R therapy. No HIV-related factors were found to be associated with the OS of PLHIV in the modern cART era.

Allogeneic natural killer (NK) cell immunotherapy is recognized as a promising anti-tumor strategy, but whether it plays a role in poor CD4 recovery among human immunodeficiency virus type 1 (HIV-1) infected patients is unknown. This study aimed to investigate the safety and effectiveness of allogeneic NK cells immunotherapy on HIV-1 immunological non-responders (INRs) receiving antiretroviral therapy (ART).

From February to April 2018, a prospective, randomized, controlled, open-label clinical trial, which enrolled 20 HIV-1 INRs following specific inclusion criteria, was conducted at Nankai University Second People’s Hospital. Participants were randomly allocated (simple randomization 1:1) to either the combined treatment (NK + ART) group (n = 10) or the control (ART) group (n = 10). The allogenic highly activated NK cells from killer cell immunoglobulin-like receptor (KIR)/human leukocyte antigen (HLA)-Cw mismatched healthy donor were prepared (10⁸ cells in each injection) and intravenously infused to each recruited patient of NK+ART group in three courses. Key immune parameters (CD4 count, CD8 count, CD4/CD8 ratio), laboratory tests (count of blood cells, biochemistry panel) and symptoms at baseline and at month 1, 3, 6, 9, 12, and 24 were measured/collected to analyze the safety and efficacy of the therapy. Comparisons were between the seven time-points of both groups using repeated measurement analysis of variance (ANOVA) test. Generalized estimating equations (GEE) model was performed to evaluate the overall effect of the NK+ART group vs. the ART group.

From baseline to 24 months, we noted a mean CD4 count augmentation (139 to 243 cells/μL) in the NK + ART group and (144 to 176 cells/μL) in the ART group (difference, 67; 95% CI, 10 to 124; P = 0.024). Our estimations revealed that NK+ART group could improve CD4 level (β = 54.59, P= 0.006) and CD8 level (β = 322.47, P= 0.010) on average among the six measurements compared with the ART group. Only two (2/10, 20%) participants in the NK+ART group developed a transient mild fever after the first course.

This preliminary study informs that HIV-1 INRs, allogenic NK cells immunotherapy is safe and could significantly improve CD4 recovery but not CD4/CD8 ratio. The practical effects, however, need long-term follow-up observations. Further study on the potential underlying mechanism is warranted.

www.chictr.org.cn/showproj.aspx?proj=34912 (No. ChiCTR1900020634).

Lipid abnormalities are prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and contribute to increasing risk of cardiovascular events. This study aims to investigate the incidence of dyslipidemia and its risk factors in PLWH after receiving different first-line free antiretroviral regimens.

PLWH who sought care at the Third People’s Hospital of Shenzhen from January 2014 to December 2018 were included, and the baseline characteristics and clinical data during the follow-up were collected, including total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). The risk factors of dyslipidemia after antiretroviral therapy were analyzed with the generalized estimating equation model.

Among the 7623 PLWH included, the mean levels of TC, HDL-C and LDL-C were 4.23 ± 0.85 mmol/L, 1.27 ± 0.29 mmol/L and 2.54 ± 0.65 mmol/L, respectively, and the median TG was 1.17 (IQR: 0.85-1.68) mmol/L. Compared with that in PLWH receiving tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) + ritonavir-boosted lopinavir (LPV/r), zidovudine (AZT) + 3TC + efavirenz (EFV), and AZT + 3TC + LPV/r, the incidence of dyslipidemia was lower in PLWH receiving TDF + 3TC + EFV. In multivariate analysis, we found that the risks of elevations of TG, TC, and LDL-C were higher with TDF + 3TC + LPV/r (TG: odds ratio [OR] = 2.82, 95% confidence interval [CI]: 2.55-3.11, P < 0.001; TC: OR = 1.24, 95% CI: 1.14-1.35, P < 0.001; LDL: OR = 1.06, 95% CI: 1.00-1.12, P = 0.041), AZT + 3TC + EFV (TG: OR = 1.41, 95% CI: 1.28-1.55, P < 0.001; TC: OR = 1.43, 95% CI: 1.31-1.56, P < 0.001; LDL: OR = 1.18, 95% CI: 1.12-1.25, P < 0.001), and AZT + 3TC + LPV/r (TG: OR = 3.08, 95% CI: 2.65-3.59, P < 0.001; TC: OR = 2.40, 95% CI: 1.96-2.94, P < 0.001; LDL: OR = 1.52, 95% CI: 1.37-1.69, P < 0.001) than with TDF + 3TC + EFV, while treatment with TDF + 3TC + LPV/r was less likely to restore HDL-C levels compared with TDF + 3TC + EFV (OR = 0.95, 95% CI: 0.92-0.97, P < 0.001). In addition to antiretroviral regimens, antiretroviral therapy duration, older age, overweight, obesity and other traditional factors were also important risk factors for dyslipidemia.

The incidence of dyslipidemia varies with different antiretroviral regimens, with TDF + 3TC + EFV having lower risk for dyslipidemia than the other first-line free antiretroviral regimens in China.

The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy.

A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed.

There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ± 1.6 vs. 12.1 ± 1.5), immediately postoperatively (14.4 ± 1.1 vs. 13.8 ± 1.3), or at the last follow-up (14.6 ± 1.0 vs. 14.2 ± 1.1) (P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0° ± 7.3° vs. -1.4° ± 7.5°). The Cobb angle significantly improved immediately postoperatively (12.3° ± 4.2° vs. 9.2° ± 3.6°) and at the last follow-up (12.4° ± 3.5° vs. 9.0° ± 2.6°) in both groups compared with their preoperative values (P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group.

Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.

There are an increasing number of patients with oral sensory complaints (OSCs) presenting to our dental clinic. For most dentists, it is difficult to distinguish burning mouth syndrome (BMS) from other oral mucosal diseases that may cause symptoms such as burning mouth. It is beneficial to effectively distinguish OSC patients to reduce misdiagnosis and eliminate burning symptoms as much as possible.

Patients with oral burning sensations in the oral mucosal disease clinic were collected from the Peking University Hospital of Stomatology between September 1, 2014 and December 31, 2018. After excluding oral candidiasis, anemic stomatitis, dental material allergy, and other diseases from patients with oral sensory complaints, basic conditions such as gender, age, education level, job status, hyperglycemia, hypertension, hyperlipidemia, history of brain abnormalities, history of cervical spondylitis, history of thyroid disease, history of thyroid disease and insomnia were obtained. The BMS patients were compared with the control group. The t test and Chi-square test were used for statistical analysis to compare the clinical symptoms of these diseases and explore the risk factors for BMS.

In this case-control study, 395 patients (321 females and 74 males, mean age 55.26 ± 10.51 years) with oral sensory complaints and 391 healthy controls (281 females and 110 males, mean age 47.11 ± 13.10 years) were enrolled, among which, 8.4% (33/395) had oral candidiasis, 1.3% (5/395) had dental material allergy, 0.8% (3/395) had anemic stomatitis and 0.5% (2/395) had lichen planus. A total of 352 patients were eventually diagnosed with BMS. Anxiety and depression were more severe in BMS patients, as were the incidences of sleep disorders and brain abnormalities. Logistic regression analysis showed that age (odds ratio [OR]= 2.79, 95% confidence interval [CI]: 1.61-4.83, P < 0.001), total cholesterol level (OR= 2.92, 95% CI: 1.32-6.50, P = 0.009) and anxiety score (OR = 1.75, 95% CI: 1.01-2.77, P = 0.017) significantly increased the incidence of BMS. Patients with hyperglycemia (OR = 0.46, 95% CI: 0.23-0.89, P = 0.022), low body mass index (BMI: OR = 0.57, 95% CI: 0.34-0.93, P = 0.026) and low education level (OR = 3.43, 95% CI: 1.91-6.15, P < 0.001) were more likely to suffer from BMS.

Oral candidiasis, anemic stomatitis, and dental material allergy with burning symptoms should be excluded from patients with BMS. It is recommended to conduct a questionnaire survey (including anxiety and depression), blood cell analysis, and salivary fungus culture for all patients with an oral burning sensation. It is necessary to conduct a patch test on patients with oral burning sensations and metal restorations.

Acute myeloid leukemia (AML) is a malignant hematological disease, originating from hematopoiesis stem cell differentiation obstruction and clonal proliferation. New reagents or biologicals for the treatment of AML are urgently needed, and exosomes have been identified as candidate biomarkers for disease diagnosis and prognosis. This study aimed to investigate the effects of exosomes from bone marrow mesenchymal stem cells (BMSCs) on AML cells as well as the underlying microRNA (miRNA)-mediated mechanisms.

Exosomes were isolated using a precipitation method, followed by validation using marker protein expression and nanoparticle tracking analysis. Differentially expressed miRNAs were identified by deep RNA sequencing and confirmed by quantitative real-time polymerase chain reaction (qPCR). Cell proliferation was assessed by the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium inner salt method, and cell cycle progression and apoptosis were detected by flow cytometry. Functional gene expression was analyzed by qPCR and Western blotting (WB). Significant differences were determined using Student’s t test or analysis of variance.

BMSCs-derived exosomes effectively suppressed cell proliferation (both P < 0.0001 at 10 and 20 μg/mL) and cell cycle progression (P < 0.01 at G0-G1 stage), and also significantly enhanced cell apoptosis (P < 0.001) in KG-1a cells. There were 1167 differentially expressed miRNAs obtained from BMSCs-derived exosomes compared with KG-1a cell-derived exosomes (P < 0.05). Knockdown of hsa-miR-124-5p in BMSCs abrogated the effects of BMSCs-derived exosomes in regulating KG-1a such as the change in cell proliferation (both P < 0.0001 vs. normal KG-1a cell [NC] at 48 and 72 h). KG-1a cells treated with BMSCs-derived exosomes suppressed expression of structural maintenance of chromosomes 4 (P < 0.001 vs. NC by qPCR and P < 0.0001 vs. NC by WB), which is associated with the progression of various cancers. This BMSCs-derived exosomes effect was significantly reversed with knockdown of hsa-miR-124-5p (P < 0.0001 vs. NC by WB).

BMSCs-derived exosomes suppress cell proliferation and cycle progression and promote cell apoptosis in KG-1a cells, likely acting through hsa-miR-124-5p. Our study establishes a basis for a BMSCs-derived exosomes-based AML treatment.

Although the global human immunodeficiency virus (HIV) epidemic has been effectively curbed, preventing and managing HIV infection in high-risk populations remains challenging.^[1]In China, HIV is primarily transmitted through sexual contact.^[1,2]Pre-exposure prophylaxis (PrEP) is a new and effective method for preventing HIV infection using antiretroviral drugs^[3]; data from multiple clinical trials worldwide have shown that using antiretroviral drugs for PrEP can limit HIV transmission.^[4,5,6,7]The World Health Organization (WHO) issued guidelines in 2015 recommending PrEP in populations with an HIV incidence above 3/100 person-years (PY) and in individuals engaging in high-risk behaviors.^[3]According to existing studies, the HIV incidence among key populations in China was 5.6/100 PY for men who have sex with men (MSM),^[8]1.6/100 PY for intravenous drug users (IDUs),^[9]and 1.4/100 PY for female sex workers.^[10,11]As of July 2020, 54 countries and regions have issued PrEP guidelines for adults to prevent HIV infection, and 36 of these have also published guidelines for children and adolescents. However, there are no PrEP guidelines or related consensus statement in China. As such, there is a strong need for standardized guidance on the implementation of PrEP pertaining to medical selection criteria, PrEP timing, drug safety, and consultation and testing programs. Here we present the consensus statement on the implementation of PrEP in China based on the opinions and suggestions of health policy-makers, scientists, clinical experts, community-based organizations of key populations, and the latest reports in PrEP researches.

It has been found that some patients with coronavirus disease 2019 (COVID-19) have clinically relevant heart injuries, and the incidence of myocarditis among patients with COVID-19 was reported to be 12% in hospitals and 32% in intensive care units in Wuhan, China.^[1]Acute myocardial injuries or myocarditis is a very important clinical issue due to the risk of rapid disease progression to severe arrhythmia, heart failure, cardiac shock, etc.^[2,3]The bedside echocardiography examination is the first-line preferential imaging option for the evaluation of myocarditis and other complications, such as acute right heart failure specially due to pulmonary artery embolism, stress cardiomyopathy, acute myocardial infarction and coexisting fundamental chronic cardiovascular disease.^[4,5,6,7]

Syphilis, a sexually transmitted infection (STI), is caused byTreponema pallidum. Syphilis continues to be a major public health problem worldwide. Positive responses to the treatment of syphilis are indicated by a four-fold decrease in non-treponemal titers or seroreversion post-treatment. Approximately 5% to 41% of patients with syphilis do not respond to treatment and remain serofast^[1,2,3]and only show a less than four-fold (two-dilution) decrease in non-treponemal antibody titers after 6 months in early-stage syphilis and 12 months in late-stage syphilis, or show consistently low titers post-treatment.^[4,5,6]These conditions have been referred to as the serofast state. To date, the pathogenesis of the serofast state is unclear and it is hard to predict serofast occurrence. Therefore, we evaluated factors related to the serofast state.

Syphilis is a sexually transmitted infection caused by the spirocheteTreponema pallidum(T. pallidum) and is of global and historic significance. People living with HIV (PLWH) infection are frequently coinfected with syphilis, because of the overlapping modes of pathogen acquisition. Neurosyphilis can occur at any stage of syphilis infection, and PLWH are at a greater risk of developing neurosyphilis in early and late latent syphilis, including asymptomatic central nervous system (CNS) infection than those without HIV infection. Some patients with neurosyphilis present neurological manifestations such as meningitis, stroke, cranial nerve dysfunction, auditory or ophthalmic abnormalities, and acute changes in mental status. However, some neurosyphilis cases in PLWH lack signs or symptoms of CNS infection. Asymptomatic neurosyphilis is diagnosed in the absence of neurological signs or symptoms and can only be detected in the presence of cerebrospinal fluid (CSF) abnormalities indicative of CNS infection, including mononuclear pleocytosis, increased protein concentration, and/or a reactive CSF venereal disease research laboratory (VDRL) assay. This has raised concerns that a persistent reservoir ofT. pallidumalthough asymptomatic in the CNS, may result in treatment failure and neurological sequelae in PLWH. Neurosyphilis might lead to cranial nerve palsies, syphilitic meningitis, general paresis, and tabes dorsalis even several years after infection. Thus, early intervention may be needed for asymptomatic neurosyphilis in PLWH.

To the Editor:Rasmussen encephalitis (RE) is a chronic inflammatory disease of unknown origin, which usually affects one hemisphere of the brain.^[1]It is an uncommon disease of the nervous system that is usually seen in children. While the cause of RE is unknown, current evidence suggests that autoimmune processes are responsible for the damage to the brain cells. Because of repeated convulsions and progressive neuronal damage, patients often suffer from mental decline and neurological impairment.

Atrial fibrillation (AF) is a growing public health problem in the context of the epidemiologic transition from communicable to non-communicable diseases, and a high prevalence of AF was found in Chinese patients who died in hospital.^[1]Indeed, most understanding of AF is based on findings from clinical trials and observational studies performed in North America and Western Europe,^[2]and some studies have described the characteristics of patients with AF in other regions. These data have highlighted the important differences in the clinical characteristics and treatment of patients with AF in these regions.^[3,4]However, few studies have investigated the characteristics of patients with AF in China. Hence, the aim of this study was to investigate the clinical demographics, management, and outcomes of patients hospitalized for AF using data from a recently registered AF-specific nationwide cohort study in China, the real-world study of Chinese atrial fibrillation (RWS-CAF) registry. The RWS-CAF registry (registration number: ChiCTR1900021250) comprises a multicenter, observational, prospective cohort that includes consecutive patients requiring hospitalization with a diagnosis of AF made according to the Chinese AF guidelines, spanning from November 1, 2017, to October 31, 2018. All of the enrolled hospitals are grade A class three hospitals. Individual patients hospitalized with AF who were aged 18 years or older were recruited.

Spontaneous esophageal rupture, or Boerhaave syndrome, is a rare but potentially fatal condition with a mortality rate ranging from 20% to 30% in the literature.^[1]In some European countries, the incidence is below 3 to 6/1,000,000 persons.^[2]Nowadays, the treatment of this disease remains a challenge to physicians due to the variable clinical manifestations and lack of consensus or guidelines.^[3]

The John Cunningham (JC) polyomavirus was first discovered in a patient with progressive multifocal leukoencephalopathy (PML) in 1971. The diagnosis for PML includes definite (etiological) diagnosis and presumptive (clinical) diagnosis. The etiological diagnosis consists of cerebrospinal fluid (CSF)-confirmed PML (evidence of JC polyomavirus in the CSF) and tissue-confirmed PML (evidence of JC polyomavirus in brain tissues). The clinical diagnosis of PML is defined as evidence of typical clinical and magnetic resonance imaging (MRI) findings.^[1]

To the Editor:Chronic hepatitis B virus (HBV) infection is common (7.4%) among people living with human immunodeficiency virus (PLWH) globally, with the highest prevalence rate being reported in sub-Saharan Africa and Asia.^[1]Perinatal and horizontal transmission is the major route of HBV infection in these regions. However, human immunodeficiency virus (HIV)/HBV co-infection were more commonly seen among men who have sex with men or injecting drug users in developed countries. On the other hand, the hepatitis C virus (HCV) antibody was found in 6.2% of PLWH, meaning an estimate of 2.3 million out of 36.7 million PLWH globally have serological evidence of past or present HCV co-infection.^[1]

To the Editor:There are 1.25 million people living with human immunodeficiency virus (HIV) (PLWH) in China, with more than 135,000 newly diagnosed cases in 2018.^[1]HIV-positive patients who suffer a fracture have extremely high complication rates following operations, and medical staff frequently experience occupational exposure during the perioperative period. Therefore, surgeons are often worried about operating on HIV-positive patients. To ensure the safety of surgeons and reduce patients’ postoperative complications, we attempted to maximally suppress the viral load (VL) prior to operation. Previous studies have shown that PLWH demonstrated high uptake of highly active antiretroviral therapy (HAART) and rapid VL suppression.^[2]In recent years, more rapid VL suppression has been observed with newly introduced antiretroviral drugs, for example, a combination of the integrase strand transfer inhibitor (INSTI), in a single-tablet regimen (STR) containing elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (E/C/F/TAF) (150/150/200/10 mg).^[3]Studies have shown that STRs have more reliable virus suppression success rates than multiple-tablet regimens (MTRs).^[4]Generally, patients prefer freely available HAART drugs that are available nationally, containing tenofovir disoproxil fumarate, lamivudine, and efavirenz (TDF/3TC/EFV) (400/300/600 mg). In this study, we compared the preoperative effect of E/C/F/TAF and TDF/3TC/EFV regimens in the treatment for HIV-positive patients to reduce VL and improve the immune function in 7 and 10 days.

To the Editor:Kaposi’s sarcoma (KS), a low-grade vascular tumor, is one of the most common neoplasms reported in patients with acquired immunodeficiency syndrome (AIDS). Based on epidemiological and clinical characteristics, four types of KS have been reported: classic KS, endemic KS (in equatorial Africa), AIDS-associated KS (AIDS-KS), and iatrogenic KS. Clinically, the presentation of KS can be variable with dark or brown macules, plaques, or nodules that may bleed or, ulcerate on the skin and mucous membranes. Besides, the lymph nodes and some visceral organs can also be involved in more advanced stages of the disease.

To the Editor:Atrial fibrillation (AF) is one of the leading risk factors for stroke and is associated with a fivefold increase in the incidence of stroke. For years, warfarin has been prescribed to lower the thrombotic risk in patients with AF. However, because of the finicky nature of warfarin (ie,unpredictable pharmacokinetics, frequent international normalized ratio testing, complex food-drug interactions, etc.), it has been incrementally replaced by multiple direct oral anticoagulants (DOACs). Dabigatran, a potent, competitive, and reversible DOAC that directly targets thrombin, was approved by the US Food and Drug Administration in 2010 as an alternative antithrombotic option for nonvalvular AF. While the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial (a noninferiority trial comparing warfarin with dabigatran in patients with AF) showed that dabigatran is as successful as warfarin for preventing stroke or systemic embolism, its adverse effects also need attention.^[1]Accumulating case reports have attracted attention to the issue of dabigatran-induced esophagitis (DIE).^[2,3]Recent studies have found that elderly patients are more likely to develop DIE.^[4]However, herein, we present a case of a younger male who developed DIE after taking dabigatran.