BACKGROUND:Promoting skin wound healing is a huge challenge facing global public health.To promote faster and higher-quality wound healing,it is necessary to explore more advantageous dressings to address this problem.OBJECTIVE:To investigate the hemostatic properties of acellular dermal matrix hydrogel and its effect on skin wound healing.METHODS:(1)Acellular dermal matrix hydrogel was prepared,and the differences in microscopic morphology and main components between it and acellular dermal matrix were analyzed.(2)Acellular dermal matrix hydrogel and chitosan hydrogel were used to cover the femoral artery puncture site of rats,and the bleeding quality and coagulation time were recorded.Acellular dermal matrix hydrogel and chitosan hydrogel were mixed with rat anticoagulated blood,and the coagulation index within 30 minutes was detected.(3)A full-thickness skin defect model with a diameter of 12 mm was made on the back of 18 SD rats,and they were randomly divided into 3 groups,with 6 rats in each group:the model group used PBS to clean the wound,and the control group and the experimental group used chitosan hydrogel and acellular dermal matrix hydrogel to cover the wound,respectively.The hydrogel dressing was changed every day,and the treatment was continued for 14 days,and the wound healing was observed.On day 3 after modeling,immunofluorescence staining of inducible nitric oxide synthase(M1 macrophages)and CD206(M2 macrophages)was performed on the wound surface.On day 14 after modeling,hematoxylin-eosin staining,Masson staining,and CD31 immunohistochemical staining were performed on the wound surface.RESULTS AND CONCLUSION:(1)Scanning electron microscopy revealed that the acellular dermal matrix hydrogel had a porous structure,and the Fourier transform infrared spectrum showed that it had the same main components as the acellular dermal matrix.(2)Both acellular dermal matrix hydrogel and chitosan hydrogel had obvious hemostatic ability in vivo.In the in vitro coagulation experiments,the coagulation index of acellular dermal matrix hydrogel was significantly higher than that of chitosan hydrogel.(3)In the rat skin full-thickness defect model,both acellular dermal matrix hydrogel and chitosan hydrogel could improve the wound healing rate.Hematoxylin-eosin and Masson staining results showed that acellular dermal matrix hydrogel could reduce the infiltration of inflammatory cells in the center of the wound.Both acellular dermal matrix hydrogel and chitosan hydrogel could decrease scar width and increase collagen deposition rate.CD31 immunohistochemical staining results showed that both hydrogels could promote angiogenesis in the wound site.Immunofluorescence staining results showed that both hydrogels could reduce the proportion of M1 macrophages and increase the proportion of M2 macrophages,and the effect of acellular dermal matrix hydrogel was stronger than that of chitosan hydrogel.(4)The results show that the acellular dermal matrix hydrogel has good hemostatic properties and the ability to promote wound healing.

BACKGROUND:Promoting skin wound healing is a huge challenge facing global public health.To promote faster and higher-quality wound healing,it is necessary to explore more advantageous dressings to address this problem.OBJECTIVE:To investigate the hemostatic properties of acellular dermal matrix hydrogel and its effect on skin wound healing.METHODS:(1)Acellular dermal matrix hydrogel was prepared,and the differences in microscopic morphology and main components between it and acellular dermal matrix were analyzed.(2)Acellular dermal matrix hydrogel and chitosan hydrogel were used to cover the femoral artery puncture site of rats,and the bleeding quality and coagulation time were recorded.Acellular dermal matrix hydrogel and chitosan hydrogel were mixed with rat anticoagulated blood,and the coagulation index within 30 minutes was detected.(3)A full-thickness skin defect model with a diameter of 12 mm was made on the back of 18 SD rats,and they were randomly divided into 3 groups,with 6 rats in each group:the model group used PBS to clean the wound,and the control group and the experimental group used chitosan hydrogel and acellular dermal matrix hydrogel to cover the wound,respectively.The hydrogel dressing was changed every day,and the treatment was continued for 14 days,and the wound healing was observed.On day 3 after modeling,immunofluorescence staining of inducible nitric oxide synthase(M1 macrophages)and CD206(M2 macrophages)was performed on the wound surface.On day 14 after modeling,hematoxylin-eosin staining,Masson staining,and CD31 immunohistochemical staining were performed on the wound surface.RESULTS AND CONCLUSION:(1)Scanning electron microscopy revealed that the acellular dermal matrix hydrogel had a porous structure,and the Fourier transform infrared spectrum showed that it had the same main components as the acellular dermal matrix.(2)Both acellular dermal matrix hydrogel and chitosan hydrogel had obvious hemostatic ability in vivo.In the in vitro coagulation experiments,the coagulation index of acellular dermal matrix hydrogel was significantly higher than that of chitosan hydrogel.(3)In the rat skin full-thickness defect model,both acellular dermal matrix hydrogel and chitosan hydrogel could improve the wound healing rate.Hematoxylin-eosin and Masson staining results showed that acellular dermal matrix hydrogel could reduce the infiltration of inflammatory cells in the center of the wound.Both acellular dermal matrix hydrogel and chitosan hydrogel could decrease scar width and increase collagen deposition rate.CD31 immunohistochemical staining results showed that both hydrogels could promote angiogenesis in the wound site.Immunofluorescence staining results showed that both hydrogels could reduce the proportion of M1 macrophages and increase the proportion of M2 macrophages,and the effect of acellular dermal matrix hydrogel was stronger than that of chitosan hydrogel.(4)The results show that the acellular dermal matrix hydrogel has good hemostatic properties and the ability to promote wound healing.

Objective:To improve the understanding of patients with diffuse large B-cell lymphoma (DLBCL) with pulmonary cryptococcosis.Methods:The clinical data of 1 DLBCL patient with pulmonary cryptococcosis in the Central Hospital of Fengxian District of Shanghai in May 2023 were retrospectively analyzed, and the relevant literatures were reviewed.Results:This 75-year-old female patient was asymptomatic after 2 cycles of R-CHOP chemotherapy. The high-resolution CT of lung showed that lung nodules were progressively enlarged. Antibacterial treatment was ineffective. Pulmonary cryptococcosis was confirmed by bronchoalveolar lavage fluid (BALF) targeted high-throughput sequencing (tNGS) and cryptococcus capsular antigen (CrAg) detection. The central nervous system was not involved. And the long-term adequate-dose fluconazole was prescribed for 6 months, and the treatment against lymphoma was given synchronously. The lung nodule lesions reduced after antifungal therapy for 1 month. The lung nodules disappeared after the follow-up of 6 months after completion of final chemotherapy. The evaluation of lymphoma indicated complete remission.Conclusions:Pulmonary cryptococcosis occurs insidiously and shows no specific symptoms; its imaging manifestations are variable and routine anti-infection is ineffective. Immunochemotherapy for lymphoma patients is a high-risk factor for cryptococcal infection. tNGS and CrAg testing for BALF are effective methods of the confirmed diagnosis. The early and long-term adequate-dose antifungal treatment is the key to preventing the recurrence or progression.

Objective:To explore the movement patterns and factors influencing lung tumors tracked using the M6 cyberknife stereotactic radiotherapy(SRT)system and to provide a reference for the implementation of precise stereotactic radiotherapy for lung tumors.Method:A retrospective analysis was conducted on 29 patients with lung tumors who were treated using x-sight lung tracking technology and the M6 cyberknife SRT system at Tianjin Medical University Cancer Institute&Hospital,from January 2022 to August 2024.The tumor location and volume,irradiation dose,isodose line,and number of divisions were recorded.Lung tumor location and SPSS 26.0 software were used to analyze the movement amplitude of tumors in the left and right(LFT/RGT,LR)directions,the anterior-posterior(ANT/POS,AP)direction,and the superior-inferior(SUP/INF,SI)direction.The results are expressed as the mean±standard deviation((x)±s)mm,and a t-test was used for inter-group comparisons.Multiple linear regression was used to analyze the effects of factors such as age,gender,tumor location(upper and lower lungs),and tumor volume on the amplitudes of the lung tumor movements.Result:The average motion amplitudes in the LR direc-tions,AP direction,and SI direction of the tumor target areas were(3.5±1.8)mm,(5.3±1.7)mm,and(7.3±5.4)mm for the upper lung,based on 19 cases,and(3.1±1.6)mm,(4.5±2.2)mm,and(12.2±4.4)mm for the lower lung,based on 10 cases,respectively.There was a statistic-ally significant difference(P=0.015 3)in the amplitude of movements between the lower and upper lung tumors in the SI direction.The lung tumor movement amplitude in the SI direction was influenced by tumor location(P=0.035),and the movement amplitudes in the LR direc-tions and the AP direction were not related to factors such as gender,age,tumor location,and tumor volume.Conclusions:The lung tumor movement amplitudes for the different locations varied depending on the respiratory movement shown by the patient.In the SI direction,the movement amplitude of the lower lung tumors was greater than that of upper lung tumors,and this was due to tumor location effects.The movement amplitudes of the lower and upper lung tumors were similar in the LR directions and AP directions.Furthermore,movement amplitude was not affected by gender,age,tumor location,and tumor volume.

Objective To analyze the role and mechanism of Xiaoqinglong decoction in alleviating the pathological process of pulmonary arterial hypertension(PAH),and to observe the effect of Xiaoqinglong decoction on endothelial-mesenchymal transition(EMT)in human pulmonary arterial endothelial cell(HPAEC)and the involvement of the Toll-like receptor/nuclear factor-κB/hypoxia-inducible factor-1α(TLR/NF-κB/HIF-1α)pathway in this mechanism.Methods Thirty-six male Sprague Dawley(SD)rats and HPAEC were randomly divided into control group,model group,Xiaoqinglong decoction plus Earthworm group,Bosentan tablet group,dimethyl sulfoxide(DMSO)group,and monophosphoryl lipid A(MPL)group.PAH rat models and HPAEC models were established by hypoxic exposure.The Xiaoqinglong decoction plus Earthworm group received intragastric administration Xiaoqinglong decoction plus Earthworm(5 g·kg-1·d-1)or cultured with 10%corresponding drug serum,the Bosentan group received Bosentan(100 mg·kg-1·d-1)by gavage or cultured with 10%corresponding drug serum,the MPL group received 1 μg MPL,and the DMSO group received an equivalent volume of the DMSO and corn oil mixed solvent as a negative control for the MPL group.The hemodynamic parameters,including mean pulmonary arterial pressure(mPAP),right ventricular systolic pressure(RVSP),and the maximum rate of right ventricular pressure(+dp/dt max),were measured via right heart catheterization.After euthanasia,lung and heart tissues were collected to assess the right ventricular hypertrophy index(RVHI);hematoxylin-eosin(HE)staining was used to observe the degree of right ventricular cardiomyocyte hypertrophy and to calculate the average intima-media thickness(IMT)in small pulmonary arteries;Western blotting was used to detect the protein expression levels of proliferating cell nuclear antigen(PCNA),CD68,TLR4,NF-κB,HIF-1α,vascular endothelial cadherin,and vimentin;cell counting kit-8(CCK-8),Transwell,and scratch assays were used to observe cell proliferation and migration;Enzyme-linked immunosorbent assay(ELISA)was used to measure the levels of interleukins(IL-8,IL-6),tumor necrosis factor-α(TNF-α),endothelin-1(ET-1),and nitric oxide(NO).Results Compared with the model group,the Xiaoqinglong decoction plus Earthworm group showed significant reductions in mPAP,RVSP,RVHI,and IMT in PAH rats[mPAP(mmHg,1 mmHg≈0.133 kPa):22.17±1.94 vs.42.00±4.90,RVSP(mmHg):34.67±3.20 vs.52.83±3.76,RVHI:0.402±0.057 vs.0.822±0.101,IMT:(37.85±2.49)%vs.(62.06±4.52)%,all P<0.05],and a significant increase in+dP/dT max(mmHg/s:2 730.83±137.89 vs.1 718.33±148.36,P<0.05).Western blotting and ELISA results showed that compared with the model group,the Xiaoqinglong decoction plus Earthworm group had significantly lower protein expression of PCNA and CD68 in lung tissue,and levels of inflammatory factors(IL-6,IL-8,TNF-α)in rat serum[lung tissue:PCNA protein expression(PCNA/GAPDH)was 1.56±0.08 vs.2.20±0.26,CD68 protein expression(CD68/GAPDH):1.46±0.09 vs.2.60±0.23;serum:IL-8(ng/L)was 39.67±6.28 vs.149.17±7.49,IL-6(ng/L):81.00±6.63 vs.211.00±25.31,TNF-α(ng/L):213.17±24.86 vs.799.50±43.51,all P<0.05].In vitro experiments,compared with the model group,Xiaoqinglong decoction plus Earthworm inhibited abnormal proliferation(A value:2.052±0.087 vs.2.242±0.057,P<0.05)and migration[number of migrating cells(per field):101.33±12.01 vs.226.67±17.56,P<0.05]of HPAEC,and reversed the EMT process,manifested as upregulation of vascular endothelial cadherin protein expression levels(vascular endothelial cadherin/GAPDH:0.39±0.06 vs.0.12±0.03,P<0.05)and downregulation of vimentin protein expression(vimentin/GAPDH:4.96±0.33 vs.7.89±0.44,P<0.05).Western blotting results indicated that compared with the model group,the protein expression levels of TLR4,the ratio of phosphorylated p65 to total p65,and HIF-1α in both lung tissue and HPAEC were significantly reduced in the Xiaoqinglong decoction plus Earthworm group[lung tissue:TLR4 protein expression(TLR4/GAPDH)was 3.13±0.20 vs.4.38±0.30,p-p65/p65 ratio:7.11±0.81 vs.12.73±1.80,HIF-1α protein expression(HIF-1α/GAPDH):2.37±0.32 vs.4.45±0.34;HPAEC:TLR4 protein expression(TLR4/GAPDH)was 1.42±0.03 vs.2.43±0.05,p-p65/p65 ratio:6.01±1.84 vs.11.28±1.06,HIF-1α protein expression(HIF-1α/GAPDH)was 3.24±0.17 vs.5.50±0.44,all P<0.05],accompanied by upregulated vascular endothelial cadherin protein expression(vascular endothelial cadherin/GAPDH:0.66±0.03 vs.0.49±0.03,P<0.05)and downregulated vimentin protein expression(vimentin/GAPDH:1.81±0.12 vs.2.47±0.10,P<0.05),indicating that Xiaoqinglong decoction plus Earthworm inhibits the EMT process in endothelial cells by suppressing the activation of the TLR/NF-κB/HIF-1α pathway.Experiments with a TLR agonist further confirmed that activation of the TLR pathway reverses the protective effects of Xiaoqinglong decoction plus Earthworm,as shown by the MPL group compared to the DMSO group having significantly increased protein expression of the p-p65/p65 ratio and HIF-1α[p-p65/p65 ratio:2.17±0.35 vs.1.08±0.14,HIF-1α/GAPDH:3.96±0.25 vs.1.03±0.10,both P<0.05],further decreased vascular endothelial cadherin protein expression(vascular endothelial cadherin/GAPDH:0.66±0.04 vs.0.99±0.02,P<0.05),further increased vimentin protein expression(vimentin/GAPDH:1.53±0.12 vs.0.93±0.07,P<0.05),along with enhanced cell migration capacity[number of migrating cells(per field):176.67±17.50 vs.107.00±11.14;cell migration rate in scratch assay:(34.32±2.82)%vs.(22.71±2.49)%,both P<0.05]and increased proliferation activity(48 hours A value:2.156±0.044 vs.1.810±0.088,P<0.05).Conclusions Xiaoqinglong decoction combined with Pheretima not only significantly reduces pulmonary artery pressure,improves cardiac function and mitigates pulmonary vascular fibrosis in PAH rats,but also alleviates pulmonary vascular remodeling by inhibiting inflammatory responses and EMT.It can further decrease the content of ET-1,increase the level of NO,and ameliorate vascular stenosis.This result further indicates that exterior-relieving medicines exert a significant dilating and supporting effect on the narrowed meridians and collaterals.

Postoperative infection of internal fixation of closed fractures the lower limbs in adults represents a devastating complication, characterized by diagnostic challenges, prolonged treatment duration and high disability rates. Current management of these infections faces multiple challenges, such as difficulties in early accurate diagnosis, and various controversies about the treatment plan, leading to poor overall diagnosis and treatment results. To address these issues, based on evidence-based medicine and principles with emphasis on scientific rigor, clinical applicability and innovation, the Trauma Branch of the Chinese Medical Association, Orthopedic Branch of the Chinese Medical Doctor Association, Orthopedics Branch of the Chinese Medical Association, and Trauma Orthopedics and Polytrauma Group of the Resuscitation and Emergency Committee of the Chinese Medical Doctor Association have collaboratively organized a panel of relevant experts to develop the Guideline for diagnosis and treatment of infection after internal fixation of closed lower limb fractures in adults ( version 2025). The guideline proposed 10 recommendations, aiming to provide a foundation for standardized diagnosis and treatment of postoperative infection in adults with closed lower limb fractures.

Objective To examine the changing prevalence and antimicrobial resistance profiles of Burkholderia cepacia in 52 hospitals across China from 2015 to 2021.Methods A total of 9 261 strains of B.cepacia were collected from 52 hospitals between January 1,2015 and December 31,2021.Antimicrobial susceptibility of the strains was tested using Kirby-Bauer method or automated antimicrobial susceptibility testing systems according to a unified protocol.The results were interpreted according to the breakpoints released in the Clinical & Laboratory Standards Institute(CLSI)guidelines(2023 edition).Results A total of 9 261 strains of B.cepacia were isolated from all age groups,especially elderly patients.The proportion was 11.1％(1 032 strains)in children,significantly lower than the proportion in adults.About half(46.5％,4 310/9 261)of the strains were isolated from patients at least 60 years old and 42.3％(3 919/9 261)of the strains were isolated from young adults.Most isolates(71.1％)were isolated from sputum and respiratory secretions,followed by urine(10.7％)and blood samples(8.1％).B.cepacia isolates were highly susceptible to the five antimicrobial agents recommended in the CLSI M100 document(33rd edition,2023).B.cepacia isolates showed relatively higher resistance rates to meropenem and levofloxacin.However,the resistance rates to ceftazidime,trimethoprim-sulfamethoxazole,and minocycline remained below 8.1％.The percentage of B.cepacia strains resistant to levofloxacin was the highest compared to other antibiotics in any of the three age groups(from 12.4％in the patients＜18 years old to 20.6％in the patients aged 60 years or older).Conclusions B.cepacia is one of the clinically important non-fermenting gram-negative bacteria.Accurate and timely reporting of antimicrobial susceptibility test results and ongoing antimicrobial resistance surveillance are helpful for rational prescription of antimicrobial agents and proper prevention and control of nosocomial infections.

Clinically,the incidence of chronic musculoskeletal pain is relatively high,and it is one of the main causes of disability in Chinese residents,causing a heavy health and economic burden to the society.There are limited treatments available for patients who are ineffective to conservative treatment and whose disorders are inoperable.Recently,transcatheter embolization(TCE)has become a potential treatment method for such patients.Chronic musculoskeletal pain,such as knee osteoarthritis,adhesive capsulitis of the shoulder(frozen shoulder),tendinopathy,and neck/back muscle pain,can induce pathological neovascularization and inflammatory reactions.TCE of abnormal neovasculature can improve patient's pain and limb function.So far,there are relatively few studies on the TCE of chronic musculoskeletal pain in China,and there are no large-scale high-quality clinical studies abroad.This paper aims to make a comprehensive review about the TCE for chronic musculoskeletal pain,focusing on its basic principles,operative techniques,and latest clinical achievements.

Objective To understand the changing composition and antibiotic resistance of bacterial species in the clinical isolates from outpatient and emergency department(hereinafter referred to as outpatients)and inpatient children over time in various hospitals,and to provide laboratory evidence for rational antibiotic use.Methods The data on clinically isolated pathogenic bacteria and antimicrobial susceptibility of isolates from outpatients and inpatient children in the CHINET program from 2015 to 2021 were collected and analyzed.Results A total of 278 471 isolates were isolated from pediatric patients in the CHINET program from 2015 to 2021.About 17.1％of the strains were isolated from outpatients,primarily group A β-hemolytic Streptococcus,Escherichia coli,and Staphylococcus aureus.Most of the strains(82.9％)were isolated from inpatients,mainly SS.aureus,E.coli,and H.influenzae.The prevalence of methicillin-resistant S.aureus(MRSA)in outpatients(24.5％)was lower than that in inpatient children(31.5％).The MRSA isolates from outpatients showed lower resistance rates to the antibiotics tested than the strains isolated from inpatient children.The prevalence of vancomycin-resistant Enterococcus faecalis or E.faecium and penicillin-resistant S.pneumoniae was low in either outpatients or inpatient children.S.pneumoniae,β-hemolytic Streptococcus and S.viridans showed high resistance rates to erythromycin.The prevalence of erythromycin-resistant group A β-hemolytic Streptococcus was higher in outpatients than that in inpatient children.The prevalence of β-lactamase-producing H.influenzae showed an overall upward trend in children,but lower in outpatients(45.1％)than in inpatient children(59.4％).The prevalence of carbapenem-resistant Klebsiella pneumoniae(CRKpn),carbapenem-resistant Pseudomonas aeruginosa(CRPae)and carbapenem-resistant Acinetobacter baumannii(CRAba)was 14％,11.7％,47.8％in outpatients,but 24.2％,20.6％,and 52.8％in inpatient children,respectively.The prevalence of multidrug-resistant E.coli,K.pneumoniae,Proteus mirabilis,P.aeruginosa and A.baumannii strains was lower in outpatients than in inpatient children.The prevalence of fluoroquinolone-resistant E.coli,ESBLs-producing K.pneumoniae,ESBLs-producing P.mirabilis,carbapenem-resistant E.coli(CREco),CRKpn,and CRPae was lower in children in outpatients than in inpatient children,but the prevalence of CRAba in 2021 was higher than in inpatient children.Conclusions The distribution of clinical isolates from children is different between outpatients and inpatients.The prevalence of MRSA,ESBL,and CRO was higher in inpatient children than in outpatients.Antibiotics should be used rationally in clinical practice based on etiological diagnosis and antimicrobial susceptibility test results.Ongoing antimicrobial resistance surveillance and prevention and control of hospital infections are crucial to curbing bacterial resistance.

Objective To investigate the changing antibiotic resistance profiles of E.coli isolated from patients in the 52 hospitals participating in the CHINET program from 2015 to 2021.Methods Antimicrobial susceptibility was tested for clinical isolates of E.coli according to the unified protocol of CHINET program.WHONET 5.6 and SPSS 20.0 software were used for data analysis.Results Atotal of 289 760 nonduplicate clinical strains ofE.coli were isolated from 2015 to 2021,mainly from urine samples(44.7±3.2)％.The proportion of E.coli strains isolated from urine samples was higher in females than in males(59.0％vs 29.5％).The proportion of E.coli strains isolated from respiratory tract and cerebrospinal fluid samples was significantly higher in children than in adults(16.7％vs 7.8％,0.8％vs 0.1％,both P＜0.05).The isolates from internal medicine department accounted for the largest proportion(28.9±2.8)％with an increasing trend over years.Overall,the prevalence of ESBLs-producing E.coli and carbapenem resistant E.coli(CREco)was 55.9％and 1.8％,respectively during the 7-year period.The prevalence of ESBLs-producing E.coli was the highest in tertiary hospitals each year from 2015 to 2021 compared to secondary hospitals.The prevalence of CREco was higher in children's hospitals compared to secondary and tertiary hospitals each year from 2015 to 2021.The prevalence of ESBLs-producing E.coli in tertiary hospitals and children's hospitals and the prevalence of CREco in children's hospitals showed a decreasing trend over the 7-year period.The prevalence of CREco in secondary and tertiary hospitals increased slowly.Antibiotic resistance rates changed slowly from 2015 to 2021.Carbapenem drugs(imipenem,meropenem)were the most active drugs amongβ-lactams against E.coli(resistance rate≤2.1％).The resistance rates of E.coli to β-lactam/β-lactam inhibitor combinations(piperacillin-tazobactam,cefoperazone-sulbactam),aminoglycosides(amikacin),nitrofurantoin and fosfomycin(for urinary isolates only)were all less than 10％.The resistance rate of E.coli strains to antibiotics varied with the level of hospitals and the departments where the strains were isolated,especially for cefazolin and ciprofloxacin,to which the resistance rate of E.coli strains from children in non-ICU departments was significantly lower than that of the strains isolated from other departments(P＜0.05).The E.coli isolates from ICU showed higher resistance rate to most antimicrobial agents tested(excluding tigecycline)than the strains isolated from other departments.The E.coli strains isolated from tertiary hospitals showed higher resistance rates to the antimicrobial agents tested(excluding tigecycline,polymyxin B,cefepime and carbapenems)than the strains from secondary hospitals and children's hospitals.Conclusions E.coli is an important pathogen causing clinical infection.More than half of the clinical isolates produced ESBL.The prevalence of CREco is increasing in secondary and tertiary hospitals over the 7-year period even though the overall prevalence is still low.This is an issue of concern.