Wound healing is a sequester program that involves diverse cell signalling cascades. Notwithstanding, complete signal transduction pathways underpinning acidic milieu derived from cancer cells is not clear, yet. MTT (3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide) assay, fluorescein diacetate/propidium iodide staining, and cell cycle flow cytometry revealed that acidic media decreased cell viability and cell number along with enhanced dead cells and S‐phase arrest in normal fibroblasts. Notably, the trends of intracellular reactive oxygen species production and lactate dehydrogenase release significantly increased with time. It seems the downregulation of Klf4 is in part due to acidosis‐induced DNA damage. It promoted cells towards S‐phase arrest and diminished cell proliferation. Klf4 downregulation had a direct correlation with the P53 level while acidic microenvironment promotes cells towards cell death mechanisms including apoptosis and autophagy. Noteworthily, the unchanged levels of Rb and Mlh1 indicated in those genes had no dominant role in the repairing of DNA damage in fibroblasts treated with the acidic microenvironment. Therefore, cells owing to not entering to mitosis and accumulation of DNA damage were undergone cell death to preserve cell homeostasis. Since acidic media decreased the level of tumour suppressor and DNA repair genes and altered the normal survival pathways in fibroblasts, caution should be exercised to not lead to cancer rather than wound healing.
The aim of this study was to translate into Mexican Spanish, cross‐culturally adapt and validate the wound‐specific quality of life (QoL) instrument Cardiff wound impact schedule (CWIS) for Mexican patients. This instrument went through the full linguistic translation process based on the guidelines of Beaton et al (Beaton DE, Bombardier C, Guillemin F, Ferraz MB, Guidelines for the process of cross‐cultural adaptation of self‐report measures, Spine Phila Pa, 1976, 2000, 318‐391). We included a total of 500 patients with chronic leg ulcers. The expert committee evaluated the Face validity and they agreed unanimously that the instrument was adequate to assess the QoL of these patients, covering all relevant areas presented by them. The content validity index obtained was of 0.95. The construct validity demonstrated moderately significant correlations between related sub‐scales of CWIS and SF‐36 (P = .010 to P < .001). The instrument was able to discriminate between healed and unhealed ulcers. The instrument obtained an overall Cronbach's alpha of .952, corresponding to an excellent internal consistency (.903‐.771 alpha range for domains). The CWIS can be appropriately used to assess the health‐related QoL of Mexican patients with chronic leg ulcers.
The objective of this study is to investigate the mechanism whereby innate immune molecule surfactant protein D (SP‐D) attenuates sepsis‐induced acute kidney injury (AKI) through modulating apoptosis and nuclear factor kappa‐B (NFκB)‐mediated inflammation. In the present study, a mouse sepsis model was established by cecal ligation and puncture in SP‐D knockout (KO) mice and wild‐type (WT) mice. A sham‐operated group was included as the control. The experimental materials were extracted 6 and 24 hours postoperatively. The plasma levels of tumour necrosis factor alpha (TNF‐α) and MCP‐1 were determined by enzyme‐linked immunosorbent assay (ELISA). Apoptosis was measured by double staining with Annexin V/propidium iodide and flow cytometry. The levels of NFκB in renal tissues were measured by ELISA and Western blotting assay. Apoptosis was detected by TUNEL assays. There were no significant differences in plasma TNF‐α levels between the WT sham group and the KO sham group at 6 and 24 hours postoperatively (P < .05), but the levels of TNF‐α in the WT sepsis and KO sepsis groups were significantly higher than those in controls (P < .05). The levels of TNF‐α in the KO sepsis group were significantly higher than those of the WT sepsis group (P < .05). TNF‐α levels in the WT sepsis group and the KO sepsis group at 24 hours postoperatively were significantly higher than those at 6 hours postoperatively (P < .05). The levels of MCP‐1 in the WT sepsis group and the KO sepsis group at 6 and 24 hours postoperatively were significantly higher than those in the control group (P < .05), and MCP‐1 levels in the KO sepsis group were significantly higher than those in the WT sepsis group (P < .05). MCP‐1 levels in the WT sepsis group and the KO sepsis group at 24 hours postoperatively were significantly higher than those at 6 hours postoperatively (P < .05). The expression of SP‐D in WT kidneys was significantly lower at 6 and 24 hours postoperatively (P < .05). The number of TUNEL‐positive cells in the kidneys from septic SP‐D KO mice was significantly higher (P < .05). The levels of NFκB in septic mice were significantly increased at 6 and 24 hours after induction of sepsis compared with the sham‐operated group compared with those of septic SP‐D KO mice and WT mice (P < .05). Innate immune molecule SP‐D significantly decreased plasma levels of inflammatory cytokines in mice and attenuated sepsis‐induced AKI by inhibiting NFκB activity and apoptosis.
Diabetic neuropathy is defined as the presence of symptoms and signs of peripheral nerve dysfunction in diabetics. The aim of this study is to develop a predictive logistic model to identify the risk of losing protective sensitivity in the foot. This descriptive cross‐sectional study included 111 patients diagnosed with diabetes mellitus. Participants completed a questionnaire designed to evaluate neuropathic symptoms, and multivariate analysis was subsequently performed to identify an optimal predictive model. The explanatory capacity was evaluated by calculating the R 2 coefficient of Nagelkerke. Predictive capacity was evaluated by calculating sensitivity, specificity, and estimation of the area under the receiver operational curve. Protective sensitivity loss was detected in 19.1% of participants. Variables associated by multivariate analysis were: educational level (OR: 31.4, 95% CI: 2.5‐383.3, P = .007) and two items from the questionnaire: one related to bleeding and wet socks (OR: 28.3, 95% CI: 3.7‐215.9, P = .001) and the other related to electrical sensations (OR: 52.9, 95% CI: 4.3‐643.9, P = .002), which were both statistically significant. The predictive model included the variables of age, sex, duration of diabetes, and educational level, and it had a sensitivity of 81.3% and a specificity of 95.5%. This model has a high predictive capacity to identify patients at risk of developing sensory neuropathy.
For optimal wound bed preparation, wound debridement is essential to eliminate bacterial biofilms. However, it is challenging for clinicians to determine whether the biofilm is completely removed. A newly developed biofilm detection method based on wound blotting technology may be useful. Thus, we aimed to investigate the effect of biofilm elimination on wound area decrease in pressure ulcers, as confirmed using the wound blotting method. In this retrospective observational study, we enrolled patients with pressure ulcers who underwent sharp debridement with pre‐ and post‐debridement wound blotting. Biofilm was detected on the nitrocellulose membrane using ruthenium red or alcian blue staining. Patients were included if the test was positive for biofilm before wound debridement. Percent decrease in wound area after 1 week was calculated as an outcome measure. We classified the wounds into a biofilm‐eliminated group and a biofilm‐remaining group based on the post‐debridement wound blotting result. Sixteen wound blotting samples from nine pressure ulcers were collected. The percent decrease in wound area was significantly higher in the biofilm‐eliminated group (median: 14.4%, interquartile range: 4.6%‐20.1%) than in the biofilm‐remaining group (median: −14.5%, interquartile range: −25.3%‐9.6%; P = .040). The presence of remaining biofilms was an independent predictor for reduced percent decrease in wound area (coefficient = −22.84, P = .040). Biofilm‐based wound care guided by wound blotting is a promising measure to help clinicians eliminate bacterial bioburden more effectively for wound area reduction.
Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post‐surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African‐American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence.
Exact data regarding the clinical role of maggot debridement therapy (MDT) for wound care in a specific country are not available. Thus, we analysed the use of MDT in hospitalised patients in Germany. Detailed lists of all hospitalised cases treated with MDT in Germany for the years 2011 to 2016 were provided by the Federal Statistical Office as well as the lists of the 15 most frequent principal and additional diagnoses, respectively, and the 10 most frequent procedures documented with MDT in 2016. Within the 6‐year time period of the study, the number of cases treated with MDT increased by 11% from 4513 in 2011 to 5.017 in 2016. Lower leg and foot were the most frequent anatomic sides of treatment counting up to 83.9% of all cases. In addition, MDT procedures for temporary soft tissue coverage including negative pressure wound therapy were often performed: for treatment of large areas in 36.7% and small areas in 6.2%. 41.3% of all cases treated with MDT had infection with Escherichia coli and 35.9% of all cases with Bacillus fragilis. Our analysis shows a limited use of MDT with a small increase only in the last 6 years in German hospitals. MDT is predominately used to treat foot or leg ulcers.
External appearance is the main aesthetic outcome in patients who undergo surgical procedures. Scars located in exposed areas, such as the neck and face, are important for patients. There are at least eight instruments that are used to evaluate postoperative scars, but few fulfil standard methodological conditions. The Patient Scar Assessment Questionnaire (PSAQ) was designed and validated using psychometric methodology. However, this scale has not been translated or validated in the Spanish language. The aim of this study was to undergo a cross‐cultural adaptation and psychometric validation of the PSAQ scale to the Spanish language in patients who underwent head and neck surgery. We followed The Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for the translation and validation of health‐related scales. Forward and back translations were made by independent translators. We included adult patients who underwent thyroidectomy, parathyroidectomy, parotidectomy, and neck dissection. For the psychometric validation, we used a principal axis exploratory factor analysis with oblimin rotation. A reliability test involving Cronbachs alpha and the item‐total correlation was performed and for the convergent/concurrent validity, we selected the Spanish version of the Vancouver Scar Scale. A total of 180 patients were recruited. Factor analysis showed a five‐factor solution. Cronbachs alpha for the subscales was >0.7. The comparison between the PSAQ appearance subscale and the VSS demonstrated a high correlation (rho = − 0.89). In a sample of 62 patients, the test‐retest evaluation showed high correlation (0.74‐0.99). Our study supports the Spanish version of the PSAQ as a valid, reliable, and reproducible tool to assess the perception and impact of neck scars in Spanish‐speaking patients who undergo head and neck surgery.
Early reliable, valid screening, diagnosis, and treatment improve peripheral arterial disease outcomes, yet screening and diagnostic practices vary across settings and specialties. A scoping literature review described reliability and validity of peripheral ischaemia diagnosis or screening tools. Clinical studies in the PUBMED database January 1, 1970, to August 13, 2018, were reviewed summarising ranges of reliability and validity of peripheral ischaemia diagnostic and screening tools for patients with non‐neuropathic lower leg ischaemia. Peripheral ischaemia screening and diagnostic practices varied in parameters measured such as timing, frequency, setting, ordering clinicians, degree of invasiveness, costs, definitions, and cut‐off points informing clinical and referral decisions. Traditional ankle/brachial systolic blood pressure index <0.9 was a reliable, valid lower leg ischaemia screening test to trigger specialist referral for detailed diagnosis. For patients with advanced peripheral ischaemia or calcified arteries, toe‐brachial index, claudication, or invasive angiographic imaging techniques that can have complications were reliable, valid screening, and diagnostic tools to inform management decisions. Ankle/brachial index testing is sufficiently reliable and valid for use during routine examinations to improve timing and consistency of peripheral ischaemia screening, triggering prompt specialist referral for more reliable, accurate Doppler, or other diagnosis to inform treatment decisions.
by Yewande T. Nejo, David O. Olaleye, Georgina N. OdaiboBackground
Persistent infections with high-risk genital Human papillomavirus (HPV) especially types 16 and 18, are associated with cervical cancer. However, distribution of HPV types varies greatly across geographical regions and the available vaccines target only few types. This study was designed to determine the HPV types circulating in Southwestern Nigeria, thereby providing necessary information for effective control of the virus.Methods
Endocervical swab samples were collected from a total of 295 consenting women attending routine cervical cancer screening, STI clinics and community-based outreach programme. Viral DNA was extracted from the samples and the consensus region of the HPV DNA was amplified by PCR using GP-E6/E7 primers. Type-specific nested multiplex PCR and Sanger sequencing were used to genotype the HPV isolates.Results
In this study, 51 (17.3%) individuals were positive for HPV DNA using consensus primers that target the E6/E7 genes but only 48 (16.3%) were genotyped. A total of 15 HPV types (HPV-6, 16, 18, 31, 33, 35, 42, 43, 44, 52, 58, 66, 74, 81, 86) were detected, with HPV-31 being the most predominant (32.8%), followed by HPV-35 (17.2%) and HPV-16 (15.5%). Two rare HPV types; 74 and 86 were also detected. The HPV-74 isolate had three nucleotide (CCT) insertions at E7 gene that translated into amino acid proline. Highest nucleotide substitutions (n = 32) were found in HPV-44 genotype. Among positive individuals, 20.8% had dual infections and 86.2% had High-risk HPV types.Conclusions
Multiple Human papillomavirus types co-circulated in the study. Most of the circulating Human papillomavirus are high-risk type with type 31 being the most predominant. Although the implication of HPV-74 with proline insertion detected for the first time is unknown, it may have effect on the transformation potential of the virus. Polyvalent HPV vaccine will be more effective for the infection control in Nigeria.
by Jesse Burk-Rafel, Ricardo W. Pulido, Yousef Elfanagely, Joseph C. KolarsIntroduction
The United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) are important for trainee medical knowledge assessment and licensure, medical school program assessment, and residency program applicant screening. Little is known about how USMLE performance varies between institutions. This observational study attempts to identify institutions with above-predicted USMLE performance, which may indicate educational programs successful at promoting students’ medical knowledge.Methods
Self-reported institution-level data was tabulated from publicly available US News and World Report and Association of American Medical Colleges publications for 131 US allopathic medical schools from 2012–2014. Bivariate and multiple linear regression were performed. The primary outcome was institutional mean USMLE Step 1 and Step 2 CK scores outside a 95% prediction interval (≥2 standard deviations above or below predicted) based on multiple regression accounting for students’ prior academic performance.Results
Eighty-nine US medical schools (54 public, 35 private) reported complete USMLE scores over the three-year study period, representing over 39,000 examinees. Institutional mean grade point average (GPA) and Medical College Admission Test score (MCAT) achieved an adjusted R2 of 72% for Step 1 (standardized βMCAT 0.7, βGPA 0.2) and 41% for Step 2 CK (standardized βMCAT 0.5, βGPA 0.3) in multiple regression. Using this regression model, 5 institutions were identified with above-predicted institutional USMLE performance, while 3 institutions had below-predicted performance.Conclusions
This exploratory study identified several US allopathic medical schools with significant above- or below-predicted USMLE performance. Although limited by self-reported data, the findings raise questions about inter-institutional USMLE performance parity, and thus, educational parity. Additional work is needed to determine the etiology and robustness of the observed performance differences.
by Linh V. Nguyen, Quang V. Ta, Thao B. Dang, Phu H. Nguyen, Thach Nguyen, Thi Van Huyen Pham, Trang HT. Nguyen, Stephen Baker, Trung Le Tran, Dong Joo Yang, Ki Woo Kim, Khanh V. DoanCatecholamine excess reflecting an adrenergic overdrive of the sympathetic nervous system (SNS) has been proposed to link to hyperleptinemia in obesity and may contribute to the development of metabolic disorders. However, relationship between the catecholamine level and plasma leptin in obesity has not yet been investigated. Moreover, whether pharmacological blockade of the adrenergic overdrive in obesity by the third-generation beta-blocker agents such as carvedilol could help to prevent metabolic disorders is controversial and remains to be determined. Using the high fat diet (HFD)-induced obese mouse model, we found that basal plasma norepinephrine, the principal catecholamine as an index of SNS activity, was persistently elevated and highly correlated with plasma leptin concentration during obesity development. Targeting the adrenergic overdrive from this chronic norepinephrine excess in HFD-induced obesity with carvedilol, a third-generation beta-blocker with vasodilating action, blunted the HFD-induced hepatic glucose over-production by suppressing the induction of gluconeogenic enzymes, and enhanced the muscular insulin signaling pathway. Furthermore, carvedilol treatment in HFD-induced obese mice decreased the enlargement of white adipose tissue and improved the glucose tolerance and insulin sensitivity without affecting body weight and blood glucose levels. Our results suggested that catecholamine excess in obesity might directly link to the hyperleptinemic condition and the therapeutic targeting of chronic adrenergic overdrive in obesity with carvedilol might be helpful to attenuate obesity-related metabolic disorders.
by Seokhun Yang, Soongu Kwak, Jeong-Hoon Lee, Shinae Kang, Seung-Pyo LeeAims
The relationship between nonalcoholic fatty liver disease and incident metabolic syndrome in metabolically healthy subjects is unknown. We aimed to investigate whether nonalcoholic fatty liver disease is a predictor of future metabolic syndrome in metabolically healthy subjects.Materials and methods
Subjects who underwent health evaluation at least twice between 2009 and 2015 from the National Health Insurance Service-National Sample Cohort in South Korea were included. Patients without obesity who had no metabolic syndrome components were finally analyzed (n = 28,880). The definition of nonalcoholic fatty liver disease was based on both the hepatic steatosis and fatty liver indices. The incidence of metabolic syndrome, prediabetes/type 2 diabetes, hypertension, and dyslipidemia was compared between the subjects with and without nonalcoholic fatty liver disease.Results
The presence of nonalcoholic fatty liver disease was associated with a higher risk of incident metabolic syndrome, prediabetes/type 2 diabetes, hypertension, and dyslipidemia in the entire cohort (metabolic syndrome: adjusted hazard ratio, 2.10; 95% confidence interval, 1.18–3.71; prediabetes/type 2 diabetes: adjusted hazard ratio, 1.42; 95% confidence interval, 1.06–1.90; hypertension: adjusted hazard ratio, 2.36; 95% confidence interval, 1.35–4.12; dyslipidemia: adjusted hazard ratio, 1.49; 95% confidence interval, 1.07–2.06). A similar finding was observed in the age-, sex-, smoking status-, and body mass index-based 1:5 propensity score-matched cohort of 1,092 subjects (metabolic syndrome: adjusted hazard ratio, 3.56; 95% confidence interval, 1.79–7.07; prediabetes/type 2 diabetes: adjusted hazard ratio, 1.97; 95% confidence interval, 1.04–3.73; hypertension: adjusted hazard ratio, 2.57; 95% confidence interval, 1.35–4.88; dyslipidemia: adjusted hazard ratio, 1.61; 95% confidence interval, 1.12–2.32).Conclusions
Nonalcoholic fatty liver disease is an early predictor of metabolic dysfunction even in metabolically healthy populations.
by David M. Markowitz, Jeffrey T. Hancock, Jeremy N. Bailenson, Byron ReevesThis preregistered study examined the psychological and physiological consequences of exercising self-control with the mobile phone. A total of 125 participants were randomly assigned to sit in an unadorned room for six minutes and either (a) use their mobile phone, (b) sit alone with no phone, or (c) sit with their device but resist using it. Consistent with prior work, participants self-reported more concentration difficulty and more mind wandering with no device present compared to using the phone. Resisting the phone led to greater perceived concentration abilities than sitting without the device (not having external stimulation). Failing to replicate prior work, however, participants without external stimulation did not rate the experience as less enjoyable or more boring than having something to do. We also observed that skin conductance data were consistent across conditions for the first three-minutes of the experiment, after which participants who resisted the phone were less aroused than those who were without the phone. We discuss how the findings contribute to our understanding of exercising self-control with mobile media and how psychological consequences, such as increased mind wandering and focusing challenges, relate to periods of idleness or free thinking.
by Craig D. Soutar, John StavrinidesThe Enterobacterial genus Pantoea contains both free-living and host-associating species, with considerable debate as to whether documented reports of human infections by members of this species group are accurate. MALDI-TOF-based identification methods are commonly used in clinical laboratories as a rapid means of identification, but its reliability for identification of Pantoea species is unclear. In this study, we carried out cpn60-based molecular typing of 54 clinical isolates that had been identified as Pantoea using MALDI-TOF and other clinical typing methods. We found that 24% had been misidentified, and were actually strains of Citrobacter, Enterobacter, Kosakonia, Klebsiella, Pseudocitrobacter, members of the newly described Erwinia gerundensis, and even several unclassified members of the Enterobacteriaceae. The 40 clinical strains that were confirmed to be Pantoea were identified as Pantoea agglomerans, Pantoea allii, Pantoea dispersa, Pantoea eucalypti, and Pantoea septica as well as the proposed species group, Pantoea latae. Some species groups considered largely environmental or plant-associated, such as P. allii and P. eucalypti were also among clinical specimens. Our results indicate that MALDI-TOF-based identification methods may misidentify strains of the Enterobacteriaceae as Pantoea.
by Ifeoma D. Ozodiegwu, Mary Ann Littleton, Christian Nwabueze, Oluwaseun Famojuro, Megan Quinn, Richard Wallace, Hadii M. MamuduObjective
Adult women are disproportionately affected by overweight and obesity in Sub-Saharan African (SSA) countries. Existing evidence on the sociocultural context remains unconsolidated. In this qualitative research synthesis, we aggregate research literature on contextual factors that potentially predispose adult women and adolescent girls to overweight and obesity to inform research, policies and programs over the life course.Methods
PubMed, CINAHL, PsychInfo, ProQuest Central, EMBASE, and Web of Science were searched to locate qualitative research articles conducted in SSA countries beginning in the year 2000. After assessment for eligibility and critical appraisal, 17 studies were included in the synthesis. Textual data and quotes were synthesized using meta-aggregation methods proposed by the Joanna Briggs Institute.Results
The synthesized studies were conducted in South Africa, Ghana, Kenya and Botswana. The three overarching themes across these studies were body size and shape ideals, barriers to healthy eating, and barriers to physical activity, with cultural and social factors as cross-cutting influences within the major themes. Culturally, the supposedly ideal African woman was expected to be overweight or obese, and voluptuous, and this was associated with their identity. Although being overweight or obese was not acceptable to adolescent girls, they desired to be voluptuous. Healthy food choices among women and adolescent girls were hampered by several factors including affordability of nutritious foods and peer victimization. Both adult women and adolescent girls experienced ageism as a barrier to physical activity.Significance
This is the first qualitative research synthesis to amplify the voices of women and girls in SSA countries highlighting the challenges they face in maintaining a healthy body weight. Sociocultural, institutional and peer-related factors were powerful forces shaping body size preferences, food choices and participation in physical activity. Our study findings provide insights for the design of contextually appropriate obesity prevention interventions and lay the foundation for further research studies.
by Jiaming Dan, Xueping Zhang, Zhihua Ren, Liqin Wang, Suizhong Cao, Liuhong Shen, Junliang Deng, Zhicai Zuo, Shumin Yu, Ya Wang, Xiaoping Ma, Haifeng Liu, Ziyao Zhou, Yanchun Hu, Hualin Fu, Changliang He, Yi Geng, Xiaobin Gu, Guangneng Peng, Zhijun ZhongGiardia duodenalis is a zoonotic parasitic protist and poses a threat to human and animal health. This study investigated the occurrence of G. duodenalis infection in post-weaned calves from Sichuan province, China. Faecal samples were collected from a total of 306 post-weaned calves (3–12 months old) from 10 farms, including 4 intensive feeding farms and 6 free-ranging farms. The overall infection rate of G. duodenalis was 41.2% (126/306) based on the PCR results at any of the three genetic loci: beta-giardin (bg), triose-phosphate isomerase (tpi) and glutamate dehydrogenase (gdh) genes. Giardia duodenalis assemblages E (n = 115, 91.3%), A (n = 3, 2.4%), and A mixed with E (n = 8, 6.3%) were identified among the 126 positive specimens. Multilocus sequence typing of G. duodenalis revealed 34 assemblage E multilocus genotypes (MLGs), 1 assemblage A MLG and 7 mixed assemblage (A and E) MLGs. The eBURST data showed a high degree of genetic diversity within assemblage E MLGs. The phylogenetic tree revealed that MLG E3 was the primary MLG subtype in Sichuan province and also the most widely distributed in China.