Our study was subject to several important limitations. First, we failed to identify a detectable etiology in >50% of cases. This limitation seemed to be common to surveillance studies with similar study designs5,6. Several factors such as the usage of antibiotics or antiviral drugs prior to treatment might offer plausible explanations for these low detection rates. Second, causal relationships cannot be determined merely from the positive detection of pathogens. Especially for bacterial pathogens, the culture on nasopharyngeal aspirate or sputum is likely to be colonization rather than an invasive infection, which was owing to the clinical dilemma that poorly tolerated invasive tests are usually were not prescribed on patients with mild symptoms or children6. Conversely, there is growing evidence showing an association between bacterial colonization levels and future occurrence of ARIs36.
As a matter of fact, it became a dilemma of whether bear bile should be used or not. The usage of bear bile was a problem of history, culture and economy and it might also become a political issue. On the one hand, there was pressure from wild animal protection groups on the Mainland and overseas. On the other hand, bear bile was an important raw material of TCM. No alternative materials could replace its integrative effects of pain-killing and anti-inflammatory for the time being. By far, there were 123 Chinese medicine products made of bear bile and 183 enterprises supported by bear bile powder . Facing these two challenges, if bear farming industry had to be eliminated within China, an alternative for bear bile should be found out and widely promoted for producing Chinese Medicine products.
Despite a universal agreement on the relation of GLM to parity and lactation, possibly reflecting the impact of prolonged estrogen exposure, still it is rarely reported in nulliparous women, young girls, and males, expanding the dilemma about the etiology [22, 23, 33]. It is worth mentioning, however, that in a good percentage of cases reported in the male population, there was suggestion of increased endogenous estrogen to androgen ratio . 2b1af7f3a8