Objective To analyze the molecular epidemiological characteristics of norovirus (NoV) outbreaks in Qingdao between 2014 and 2016.Methods Stool samples were collected from NoV outbreaks between January 2014 and December 2016 and detected by real-time RT-PCR.NoV open reading frame 1 (ORF1) and ORF2 were partially amplified by RT-PCR.The amplified products were further analyzed by gene sequencing and genotyping.Phylogenetic analysis was conducted by using MEGA 6.0 software package.Results A total of 23 NoV outbreaks, involving 260 cases, were reported during 2014 to 2016.Of all collected stool samples, 128 were positive for NoV including 6 of genogroupⅠ (GⅠ) and 122 of genogroupⅡ (GⅡ).All positive samples were genotyped into 6 genotypes, which were GⅡ.P17-GⅡ.17, GⅡ.P12-GⅡ.3, GⅡ.P7-GⅡ.6、GⅡ.P2-GⅡ.2, GⅠ.Pb-GⅠ.6 and GⅡ.Pg-GⅡ.12.The 23 outbreaks included both single infections and mixed genotype infections, which were 11 of GⅡ.17 single infection, 4 of GⅡ.3 single infection, 3 of GⅡ.17 and GⅡ.3 mixed infection, 2 of GⅡ.17 and GⅡ.6 mixed infection, 1 of GⅠ.6 single infection, 1 of GⅡ.17 and GⅡ.2 mixed infection and 1 of GⅡ.17 and GⅡ.12 mixed infection.Conclusion NoV was an important pathogen responsible for viral diarrhea outbreaks in Qingdao.Several different genotypes were detected.The newly variant GⅡ.P17-GⅡ.17 was the predominant epidemic strain causing norovirus outbreaks in Qingdao during 2014 to 2016.

Objective To investigate influence of mirtazapine on polysomnograpy (PSG) of depression dysphylaxia patient and treatment effect.Methods 22 dysphylaxia patients and 22 healthy contrast persons were detected by PSG.The group of dysphylaxia patients were re-detected PSG 6 weeks later after treatment by Mirtazapine.In order to evaluate the patient' symptoms of depression and early awakening,the scale of HAMD was utilized at the time before and after 2 weeks,6 weeks treatment by mirtazapine.To compare changes of PSG index,HAMD scores and dysphylaxia scores before and after treatment.Results Compared with healthy controls,there existed much deviation with dysphylaxia patients on PSG index.6 weeks after mirtazapine treatment,the PSG showed the sleeping latency had shortened to ( 16.9 ± 6.6) min,sleep efficiency had improved ( 85.4 ± 6.7 ) ％,awake time had shortened (27.7 ± 10.4)min,sleep maintenance rate had risen (87.9 ±5.3)％,decrease (9.7±4.1 )％ of the S1 sleeping stage percentage,S2 had increased ( 148.0 ±30.7)％,REM density had decreased (56.1 ±3.8)％.the difference was significant (P＜0.05).The scores of HAMD and early awakening after treatment were significantly lower than before treatment,the difference was significant (P＜0.01 ).Correlation analysis showed there was no significant correlation between the HAMD,dysphylaxia reduced rate and changes of PSG all indicators(P ＞ 0.05 ).Conclusion It may be one of the biological markers for dysphylaxi in shortened of REM sleep latency,prolonged of REM sleep time and increased of REM activity and density.There is no correlation between post-treatment changes of PSG.

Objective: To analyze the molecular epidemiology of Norovirus(NoV) infection among sporadic hospitalized adults with diarrhea in Qingdao, 2015. Methods: Four hundred and nine stool samples were collected from hospitalized adults with diarrhea and detected by Real-time RT-PCR. For genotyping, ORF1 and ORF2 were partially amplified by RT-PCR and sequenced. Results: 18.1%(74/409) of stool samples were positive for NoV genogroup I(GI) (10/74) and genogroup II(G II) (64/74). Fifty-three positive samples of GII were sequenced and divided into 4 genotypes, including GII.Pe-GII.4(26/53), GII.P17-GII.17(19/53), GII.P12-GII.3(7/53) and GII.P16-GII.13(1/53). All GII.4 strains were the variants of GII.4-Sydney-2012. From May to Aug in 2015, GII.4 only accounted for 5.3%(1/19) and GII.17 were the major epidemic strains(68.4%, 13/19). But from Sept to Dec in 2015, GII.17 decreased substantially to 10.9%(6/55) and GII.4 became the most predominated strains (45.5%, 25/55). Conclusions NoV is an important pathogen responsible for viral diarrhea among adults in Qingdao. GII.4-Sydney-2012 and the newly variant GII.P17-GII.17 were the predominant epidemic strains in Qingdao, 2015.

Objective To investigate the molecular characteristics of coxsackievirus A12 ( CV-A12) and to understand the clinical manifestations of severe hand, foot and mouth disease (HFMD) caused by CV-A12 in Qingdao. Methods Throat swabs of HFMD, herpangina and influenza-like cases from 2011 to 2016 were detected for enteroviruses ( EVs) in Qingdao. Human rhabdomyosarcoma ( RD) and human la-ryngeal carcinoma (Hep-2) cells were used for virus proliferation and CV-A12 strains were identified through a semi-nest RT-PCR. The full-length of VP1 gene of CV-A12 strains was sequenced and phylogenetically an-alyzed using MEGA7. 0 software package. Clinical data of severe HFMD cases positive for CV-A12 were col-lected and analyzed. Results CV-A12-positive HFMD, herpangina and influenza-like cases accounted for 0. 3％(18/6798), 1. 2％(2/169) and 0. 1％(1/676) in Qingdao, respectively. Most of the HFMD caused by CV-A12 in children were mild before 2013 (84. 6％, 11/13), while hospitalized severe cases with neurological symptoms (100％, 5/5) became more common after 2013. Phylogenetic analysis of the VP1 region revealed that CV-A12 strains worldwide could be divided into two genotypes, A and B. All of the CV-A12 strains successfully sequenced in Qingdao from 2011 to 2016 belonged to genotype B, and 88. 9％(16/18) of them belonged to subgenotype B2. All hospitalized severe cases of CV-A12-caused HFMD after 2013 were associated with strains in branch B2b of subgenotype B2. Conclusion CV-A12 was one of the pathogens causing HFMD, herpangina and influenza-like illness in children in Qingdao. Strains of genotype B2 were the predominant CV-A12 strains circulating in Qingdao in recent years. CV-A12-caused HFMD might complicated by nervous system damage.

Objective:To evaluate the dosimetric properties of intensity-modulated proton therapy (IMPT) plans for simulated treatment planning in patients with ventricular tachycardia (VT) using stereotactic ablative body radiotherapy (SABR), in comparison with the volumetric-modulated arc therapy (VMAT).Methods:A total of 25 gross target volume (GTV) of the apical, anterior, septal, inferior and lateral wall of the left ventricle (LV) were delineated on the CT simulation images of 5 patients with complete data. An additional 5 mm GTV margin was added to the internal target volume (ITV), and an additional 3 mm ITV margin was added to the planning target volume (PTV). VMAT and IMPT plans were designed in each target area. Dose prescription was 25 Gy (RBE) in a single fraction. The dosimetric differences of ITV and organ at risk (OAR) were compared between VMAT and IMPT.Results:The median volume of ITV was 45.40 cm 3(26.72-67.59 cm 3). All plans had adequate target coverage(V 95%Rx≥99%). Compared with the VMAT plans, IMPT reduced the D mean of whole heart, pericardium and non-target cardiac tissues (relative difference) by 44.52%, 44.91% and 60.16%, respectively, which also reduced D 0.03 cm 3 of the left anterior descending artery by 17.58%( P<0.05). After stratified analysis according to the lesion sites, IMPT could still reduce the dose of most OAR. However, the D 0.03 cm 3 of LAD and LCX for the lesions in the anterior wall of LV, the D 0.03 cm 3 of LCX in the inferior wall and D 0.03 cm 3 of LAD in the apical wall did not significantly differ (both P>0.05). Conclusions:Both VMAT and IMPT plans can meet the clinical dosimetric requirements when SABR is simulated in patients with VT. However, IMPT can lower the dose of normal heart tissues, which has the potential benefit of reducing the risk of complications, such as ischemic heart disease, pericarditis/pericardial effusion, etc.

Objective To investigate the molecular epidemiological characteristics of hemaggluti-nin (HA) and neuraminidase (NA) of influenza B viruses (IBV) isolated in Qingdao from 2011 to 2018. Methods A total of 12236 samples of influenza-like cases in Qingdao from 2011 to 2018 were collected to extract viral RNAs. All samples were screened for influenza A viruses ( IAV) and IBV by one-step multiplex real-time RT-PCR. Lineages of IBV were identified. One hundred and eighty-two strains of IBV were select-ed to amplify HA and NA genes by RT-PCR and then analyzed by sequencing. Phylogenetic analysis and variation analysis of genes and amino acids were carried out. Results IBV was detected almost every year in Qingdao from 2011 to 2018. The positive rate was only slightly lower than that of IAV ( 4. 99％ vs 6. 21％). B/Victoria linkage had two prominent epidemic years (2011-2012, 2015-2016), while B/Yama-gata linkage had three (2013-2014, 2014-2015, 2017-2018). Most of the infected people were children un-der 10 years old, and the people infected with the two lineages had similar age characteristics. Phylogenetic analysis of HA genes showed clusters in Victoria clades of 1A and 1B and Yamagata clades of 2 and 3. IBV of Yamagata lineage had more amino acid mutation sites than those of Victoria lineage in HA genes with grea-ter genetic diversity. The B/Yamagata strains had 12 amino acid mutations and the B/Victoria strains had seven in four major epitopes. In the receptor binding sites, two amino acid mutations were detected in the B/Yamagata strains and three in the B/Victoria strains. In Qingdao, 26 strains of IBV were intra-lineage reas-sortments, mostly of the B/Victoria lineage, and 23 strains were inter-lineage reassortments, mostly between HA-B/Yamagata and NA-B/Victoria strains. A possible resistant strain to NA inhibitor was found. Conclu-sions The significance of IBV in seasonal influenza should not be neglected. Amino acid substitution, in-sertion/deletion and gene reassortment were the main strategies for the natural evolution of IBV. Influenza surveillance was of great importance and influenza vaccine strains needed to be updated in time.

Objective:To observe the efficacy of mycophenolate mofetil (MMF) combined with ursodeoxycholic acid (UDCA) for the treatment of primary biliary cholangitis (PBC) with incomplete response to UDCA monotherapy.Methods:This is an open label study. Combination therapy of MMF (0.75-1.5 g/d) and UDCA (13-15 mg·kg -1·d -1) were applied to PBC patients with incomplete response to UDCA alone according to Barcelona Criteria. The expected observation duration of treatment were at least 12 months. The levels of serum alanine amiotransferase (ALT), aspartate transaminase (AST), total bilirubin (TBil), albumin (Alb), alkaline phosphatase (ALP), γ-glutamyltranspeptidase (GGT), immunoglobulin (Ig)M, IgG, IgA were mea-sured at different time points before and after treatment. The biochemical response rates were evaluated with reference to formerly reported criteria including Barcelona criteria and so on. Paired student's t-test and wilcoxon matched-pairs signed rank test were used to compare differences between groups before and after treatment. Mann-Whitney U test was used to compare differences between the two independent groups with abnormal distribution. A two-sided P<0.05 was considered statistically significant. Results:Seventeen of 29 patients included were treated with combination therapy for at least 1 year. The levels of serum ALP were significantly decreased after 3 months [(369±184) U/L vs (309±148) U/L, t=2.149, P=0.045] but not afterwards. GGT levels were significantly decreased at 6 months [266.5(205.5, 414.0) U/L vs 217.5(173.8, 391.8) U/L, Z=-2.334, P=0.018] and the significance continued to 1 year. IgM, IgG and IgA levels had a significant decrease at 3, 6 and 12 months but not AST, Tbil or Alb levels. The biochemical response rates were between 9.5%-23.5%. Conclusion:Overall, the biochemical response rate of combination therapy of MMF and UDCA is low in incomplete responders to UDCA alone. Early recognition of incomplete responders is of great im-portance and high quality researches are needed to confirm the effectiveness of the combined therapies.

Objective To investigate the expression of programmed death receptor-1 (PD-1) in CD8+ T cells and FoxP3+CD4+ cells in patients with primary biliary cholangitis (PBC).Methods The peripheral blood and clinical data of 69 PBC patients in Peking Union Medical College Hospital and 58 health controls (HC) were collected.They were divided into initial treatment group and follow-up group according to whether they were treated or not.Patients in the treatment group were further divided into the refractory group and stable group according to treatment response.Flow cytometry was used to detect the expression of PD-1 in CDS+T cells and FoxP3+CD4+ cells.T-test and Person correlation analysis were used for data analysis.Results The PD-1 expression in peripheral blood mononuclear cells (PBMCs) of 69 PBC patients (12±9)％ was lower than that of HC (20±12)％ (t=-3.687,P＜0.01).The percentage of PD-1+ in FoxP3+ CD4+T cells was significantly increased in PBC (5.6±3.7)％ than HC (7.4±2.4)％ (t=2.048,P＜0.01).The proportion of CD8+T cells,PD-1 expression in CD8+T cells and the proportion of FoxP3+CD4+ cells weren't correlated with clinical parameters (P＞0.05).There was a negative correlation between the expression of PD-1 cells in FoxP3+CD4+ cells and GLOBE score (r=-0.307,P＜0.05).Conclusion The expression of PD-1 in peripheral CD8+T lymphocytes of PBC patients is lower than that of HC,and decreases more significantly in the refractory group.The expression of PD-1 on FoxP3+CD4+T cells is higher than that in HC,and is negatively correlated with the prognostic GLOBE score.It suggests that PD-1/PD-L1 pathway participates in the immune mechanism of PBC.

Objective To investigate the health related quality of life score [primary biliary cholangitis (PBC)-40] in patients with PBC,and the relationship between PBC-40 and clinical presentations.Methods The PBC-40 score and clinical presentations in PBC patients (n=65) were adapted in this study.Patients were divided into the untreated group and the treated group,and the treated group was further divided into ursodesoxycholic acid (UDCA) response group and UDCA non-response group.PBC-40 scores of different groups were analyzed by t-test and the relationship between PBC-40 and clinical presentations were analyzed with Pearson's test.Results Dimensions of PBC-40 scores of this group of patients were as follows:symptoms were (15.8±4.1) points,itch was (4.9±2.8) points,atigue was (23.8±8.9) points,cognitive dysfunction score was (11.4±4.7) points,social activity score was (17.0±7.5) points,and the emotion score was (6.5±3.1) points.The untreated group had higher emotion scores than the treated group (t=2.024,P=0.045).Compared with the UDCA response group,UDCA non-response group had higher scores in cognitive,social and emotion dimension (t =2.126,2.309,2.062,respectively,P=0.039,0.025,0.045,respectively).Itch score was significantly correlated with total bilirubin (TBil),direct bilirubin (DBil),alkaline phosphatase (ALP) and total bile acid (TBA) (r=0.349,0.345,0.324,0.427,respectively,P＜0.01),while the social scores were correlated with TBil,DBil,aspartate aminotransferase (AST) and TBA (r=0.361,0.383,0.316,0.331,P＜0.01) and emotion scores were associated with ALT,TBil,GGT,ALP,AST and TBA (r=0.332,0.430,0.265,0.326,0.297,0.353,P＜0.05).ConclusionPBC-40 can be used as a health-related quality of life assessment for PBC patients inChinese population.Itch,social and emotion dimensions are correlated with clinical activity indicators.Hyperbilirubin,ALP and TBA can predict low health quality of life in PBC patients.Conclusion PBC-40 can be used as a health-related quality of life assessment for PBC patients in Chinese population.Itch,social and emotion dimensions are correlated with clinical activity indicators.Hyperbilirubin,ALP and TBA can predict low health related quality of life in PBC patients.

Objective:Partial stereotactic ablative boost radiotherapy(P-SABR)is a method to deliver SABR boost to the gross tumor boost volume(GTVb), followed by conventionally fractionated radiotherapy to the whole tumor area(GTV). GTVb is the max volume receiving SABR while ensuring the critical organ-at-risk(OAR)falloff to 3 GyE/f. We investigated the potential advantage of proton therapy in treating bulky non-small cell lung cancer(the tumor length greater than 8 cm).Methods:Nine patients with bulky NSCLC treated with photon P-SABR in our institute were selected. For the treatment planning of proton therapy, the GTVb target area was gradually outwardly expanded based on the photon GTVb target area until the dose to critical OARs reached 3 GyE/f. The GTV and CTV areas remained the same as photon plan. A proton intensity-modulated radiation treatment plan(proton-IMPT), a photon intensity-modulated radiation treatment plan(photon-IMRT)and a photon volumetric modulated arc therapy(photon-VMAT)were created for each patient, respectively. The dosimetric parameters of different treatment plans were compared.Results:The volume ratio of GTVb-photon and GTVb-proton to GTV was(25.4±13.4)% and(69.7±30.0)%,respectively( P<0.001). In photon-IMRT, photon-VMAT, and proton-IMPT plan groups, the mean dose of CTV was(76.1±4.9)Gy, (78.2±3.6)Gy, and(84.7±4.9)Gy, respectively; the ratio of tumor volume with Biologic Effective Dose(BED)≥ 90 Gy to GTV volume was(70.7±21.7)%, (76.8±22.1)%,and(97.9±4.0)%,respectively. The actual dose and BED to the tumor area of the proton-IMPT plan group were significantly higher than those of the photon plan group(both P<0.05). Besides, the OARs dose was significantly decreased in the proton-IMPT group, with(49.2±22.0)%, (56.8±19.0)% and(16.1±6.3)% of the whole lung V5 for photon-IMRT, photon-VMAT and proton-IMPT, respectively(all P<0.001). Conclusions:Larger GTV boost target volume, higher BED and reduced OARs dose can be achieved in proton plans compared with photon plans. Proton P-SABR is expected to further improve the local control rate of bulky NSCLC with fewer adverse effects.