Quality Assessment of Guidelines forVascular Cognitive Impairment Using the AGREEⅡ
MA Huaping，HAN Zhenyun，CHANG Ze，WANG Yuchun，HU Yuli，ZHANG
Background As the second primary type of cognitive impairment worldwide, vascular cognitive impairment (VCI) is closely associated with cerebrovascular risks, which imposes a heavy burden on the society and families. Early diagnosis and treatment are important for intervening and reversing VCI. And formulating high-quality clinical guidelines is an effective way to improve diagnosis and treatment levels of VCI.
What This Study Found The overall quality of these guidelines was relatively low, since in the six domains, only the average score of Clarity of Presentation was greater than 60% (64.04%) , and the average scores of Scope and Purpose (52.31%) and Editorial Independence (42.01%) were between 30% and 60%, and those for other three domains, Stakeholder Involvement (27.24%) , Rigor of Development (20.05%) and Applicability (13.83%) , were all less than 30%. The grade of recommendation for 6 guidelines was B, and that for other 12 guidelines was C.
Implications The overall quality of the included guidelines was rated relatively low, especially their average score for each of the three domains, Stakeholder Involvement, Rigor of Development, and Applicability, was below the average level. It is suggested to enhance the quality of VCI guidelines via improving the details of guidelines strictly under the evidence-based principle
Best Evidence Summary for Perioperative Blood Glucose Management in Patients Undergoing Pancreatectomy
CUI Lei，LIU Linglong，WANG Jianjian，YU Huiping，SUN Qingmei，MIAO Yi，FANG Xiaoping
Background Blood glucose disorder is a common perioperative problem in patients with pancreatectomy. However, current perioperative blood glucose management for pancreatic resection patients in China is mostly based on experience and lack of evidence-based basis.
What This Study Found In assessing the quality of the 4 expert consensuses, the answers of raters for all items were "yes" , except that their answers for the item "Is there a reasonable explanation for the point of view inconsistent with other literature?" were "unclear" . Both the two RCTs were rated high. Mainly related to perioperative organization and management, admission evaluation and treatment, blood glucose control goals, blood glucose monitoring, preoperative, intraoperative and postoperative blood glucose management strategies, management of emergency conditions, and discharge guidance.
Implications Clinical medical workers can develop individualized and holistic perioperative blood glucose management plans for patients with pancreatectomy, based on the above-mentioned 9 aspects of best evidence.
Reducing the Risk of Adverse Events in Patients with Type 2 Diabetes Who are Poorly Treated with Metformin Combined with Acarbose：Dipeptidyl Peptidase-4 Inhibitor is Better Than Insulin
SU Peng，LIU Yukun，LIANG Xiaohua，LIU Xin，YU Yaohui，HUANG Pengfei，BAI Yuru，HE Xiaoyan，SHEN Zhihong，MA Dong
Background Clinically, when metformin (Met) combined with acarbose (Aca) cannot achieve the ideal hypoglycemic effect, a third drug will be usually added, such as insulin (Ins) or dipeptidyl peptidase-4 inhibitor (DPP-4i) etc., but there are few reports on the effect of triple therapy on complications related to type 2 diabetes (T2DM) .
What This Study Found Compared with the Met+Aca+Ins group, the incidences of comprehensive outcome events (6.53/100 person-per year) , non-fatal cardiovascular disease (5.03/100 person-years) , all-cause death (0.73/100 person-per year) , and severe hypoglycemic (0.73/100 person-er year) were lower in the Met+Aca+ DPP-4i group. The multivariate Cox proportional hazards regression model analysis showed that the risk of comprehensive outcome events in the Met+Aca+DPP-4i group was 67% lower than the Met+Aca+Ins group, the risk of composite non-fatal cardiovascular disease decreased by 52% compared with the Met+Aca+Ins group, and the risk of all-cause mortality was higher than the Met+Aca group. The Met+Aca+Ins group group decreased by 81%, and the risk of severe hypoglycemia decreased by 80% compared with the Met+Aca+Ins group. The survival curve was drawn with the comprehensive outcome events as the outcome event. The results of Log-rank test showed that the survival rate of Met+Aca+DPP-4i group was higher than the Met+Aca+Ins group (χ2=32.849, P<0.001) . The results of covariate interaction analysis showed that in patients with adequate sleep (>7 h/d) , non-smoking, and no family history of cardiovascular disease, Met+Aca+DPP-4i treatment reduced the incidence of comprehensive outcome events in T2DM patients compared with Met+Aca+Ins treatment (P values were 0.008, 0.031, and 0.042, respectively) .
Implications After failure treatment of Met and Aca in T2DM patients, the supplementation of DPP-4i was associated with a lower risk of comprehensive outcome events, cardiovascular disease, all-cause mortality, and severe hypoglycemia compared with the Ins addition, particularly in patients with adequate sleep, no smoking, and without family history of cardiovascular disease.
Efficacy of Modified Bismuth Triple Regimen in Eradicating Helicobacter Pylori Infection
HUANG Hongyu，LEI Tiantian，LIU Jiahuan，ZHAO Ying1，YANG Jinlin，MA Hongsheng
Background The antibiotic resistance rate of Helicobacter pylori (H.pylori) is increasing while its eradication rate is decreasing year by year. So it is urgent to explore more effective treatment regimens.
What This Study Found The treatment completion rate of EBA group was 83.3%, and that of EBAT group was 86.7%. No statistical difference in completion rate was found between the two groups . Intention-to-treat analysis revealed that, the eradication rate of H.pylori infection in newly treated patients in EBA group was not statistically different from that of those in EBAT group . Furthermore, per-protocol analysis found that, the eradication rates in newly treated patients in EBA group and EBAT group were 85.7% and 93.3% , respectively, demonstrating no statistically significant intergroup difference.For retreated patients, intention-to-treat analysis indicated that, the eradication rates for those in EBA group and EBAT group were 54.8% , and 72.9%, respectively, showing no statistically significant intergroup difference. However, based on the per-protocol analysis, the eradication rates for those in EBA group and EBAT group were 60.5% and 82.7% , respectively, manifesting statistically significant intergroup difference. The rates of symptom improvements in newly treated patients with pre-treatment symptoms in EBA and EBAT groups showed no statistically significant difference. And the rates of symptom improvements in retreated patients with pre-treatment symptoms in EBA and EBAT groups also showed no statistically significant difference.
Implications For newly treated patients with H.pylori infection, the modified bismuth triple regimen had effects similar to those of the standard bismuth quadruple regimen in terms of eradication rate of H.pylori infection and symptoms improvement rate, which could be used as a new treatment option. However, this modified triple regimen was not suitable for retreated patients, although the symptoms improvement rate was similar to that of the quadruple regimen, the eradication rate of H.pylori infection was too lower.
Progression and Reversion of Mild Cognitive Impairment：a Study Using Data from the Uniform Data Set
HAN Hongjuan，QIN Yao，CHEN Durong，AN Jianhua，YU Hongmei
Background Mild cognitive impairment (MCI) has highly variable cognitive trajectories. Approximately 10% to 15% of MCI patients progress to dementia, and nearly 24% revert to normal cognition each year. There are few studies on the progression and reversion of MCI, especially there version of MCI to normal cognition.
What This Study Found In multiple binary classifications, the accuracies of reversion and stabilization, and reversion and progression were above 90%. Among the hierarchical three-class classification, the accuracy based on stabilization→ reversion → progression was 84.38%. Stepwise multinomial Logistic regression analysis showed that age ≥80 years , self-reported cognitive impairment, and decreased Clinical Dementia Rating (CDR) scores were associated with decreased risk of MCI progressing to dementia, while history of stroke, fecal incontinence , and higher Functional Activities Questionnaire score were associated with increased risk of MCI progressing to dementia. Decreased probability of reversion from MCI to normal cognition was related to age ≥80 years , obesity, self-reported cognitive impairment, and higher CDR scores , while increased probability of reversion from MCI to normal cognition was related to higher MMSE score and higher numbers of correct naming of animals.
Implications The outcome of MCI patients is affected by multiple factors. Advanced age, obesity, history of stroke, fecal incontinence, self-reported cognitive impairment and reduced functional activity were important factors influencing MCI progression and reversion.
Ultrasound-based Thyroid Nodule Malignancy Risk Stratification in Differentiating Benign and Malignant Thyroid Nodules：a Comparative Analysis between the C-TIRADS and ATA Guidelines
LI Jian，YIN Yanhua，QI Jianguo，WANG Zhou，REN Yongfeng，WANG Shanshan，ZHANG Weili，WANG Xiaojun，TANG Kun
Background The 2020 Chinese guidelines for ultrasound malignancy risk stratification of thyroid nodules: the C-TIRADS (C-TIRADS for short) put forward a method for stratifying the malignancy risk of thyroid nodules, but there are few studies about its value in differentiating benign and malignant thyroid nodules.
What This Study Found ROC analysis showed that, AUCs of ultrasound-based thyroid nodule malignancy risk stratification in differentiating malignant and benign thyroid nodules between C-TIRADS and ATA guidelines were 0.890〔95%CI (0.815, 0.918) 〕and 0.780〔95%CI (0.750, 0.876) 〕, with significant difference (Z=13.62, P<0.05) . The TI-RADS in the C-TIRADS showed 92.11% sensitivity, 78.26% specificity, 82.56% accuracy, with Youden index of 0.70 in differentiating 4b category benign and malignant nodules, and demonstrated 97.37% sensitivity, 46.64% specificity, 62.40% accuracy with Youden index of 0.44 in differentiating 4a category benign and malignant nodules. The ultrasound-based thyroid nodule malignancy risk stratification in ATA guideline showed 87.72% sensitivity, 67.98% specificity, 74.11% accuracy, with Youden index of 0.56 in differentiating intermediate suspicion pattern for malignancy, and demonstrated 94.74% sensitivity, 44.66% specificity, 60.22% accuracy with Youden index of 0.39 in differentiating low suspicion pattern for malignancy.
Implications The ultrasound-based thyroid nodule malignancy risk stratification in C-TIRADS has higher value in differentiating malignant and benign thyroid nodules than that in ATA guidelines, and the optimal performance of which may be manifested in differentiating malignant and benign thyroid nodules of TI-RADS 4b category.
Relationships of Skin AGEs and Serum CN-1 with Microvascular Complications in Type 2 Diabetes Mellitus
YANG Guang，XU Xin，ZHANG Yu，XU Juan，JIANG Shujuan，XIA Li，ZHANG Yang，WANG Yikun，LI Zhongsheng，ZHANG Shiqi
Background Hyperglycemia plays a significant role in the development and progression of diabetic complications. While carnosine is a putative scavenger of advanced glycation end products (AGEs) , its availability in tissue is limited by the activity of serum carnosinase-1 (CN-1) . So far, the correlations of skin AGEs and serum CN-1 concentration with type 2 diabetes mellitus (T2DM) , and microvascular complications in T2DM are still unclear.
What This Study Found The skin AGEs level was (80.2 ±10.6) and serum CN-1 concentration was (6.9±3.4) μg/L on average. Correlation analyses demonstrated that gender, age, and DR were positively correlated with skin AGEs (P<0.05) , but estimated glomerular filtration rate (eGFR) and CN-1 were negatively correlated with skin AGEs (P<0.05) . Multiple linear regression analysis revealed that gender (B=7.630) , age (B=0.408) and DR (B=7.183) were associated with skin AGEs (P<0.05) . Correlation analyses showed that serum CN-1 was increased with age or with the increase in diastolic blood pressure (DBP) (P<0.05) , while it decreased with the decline of skin AGEs (P<0.05) .
Implications Both skin AGEs and serum CN-1 may have no obvious correlation with most diabetic microvascular complications, such as DN, DPN and diabetic peripheral vascular disease. But different from serum CN-1, skin AGEs may significantly correlated with DR.
External Validation of Risk Prediction Models for Postpartum Stress Urinary Incontinence
ZHANG Danli，HU Fengxin，WANG Jia，CHEN Ling，LIU Sha，CAI Wenzhi
Background Our research team developed two prediction models of postpartum stress urinary incontinence (PSUI) , one for primiparas, and the other for multiparae, aiming at early identifying women at high risk of PSUI, and providing effective interventions, but they have not yet been externally validated.
What This Study Found The AUC of the risk prediction model for PSUI in primiparas was 0.719, and that of the risk prediction model for PSUI in multiparae was 0.833. Hosmer-Lemeshow goodness-of-fit test suggested that the PSUI risk prediction model for primiparas had poor calibration , while that for multiparae had satisfactory calibration.
Implications The PSUI risk prediction model for primiparas could effectively distinguish PSUI, but its applicability needs to be further improved. The PSUI risk prediction model for multiparae had acceptable performance, which may be used and promoted as an evaluation tool for early pelvic floor rehabilitation in multiparae.
Correlations of BMI and Blood Lipids with Diabetes in an Elderly Health Check-up Population of Luzhou：a Longitudinal Study
ZHANG Wenxin，FAN Song，LIU Xia，LI Xinping，LEI Zhi，LI Ailing
Background A number of studies have shown that obesity, overweight and dyslipidemia have various strength of correlation with diabetes, but there is a lack of longitudinal studies to verify this issue.
What This Study Found The prevalence of diabetes in the participants during 2016—2019 was 10.5%, 11.5%, 11.9% and 13.5%, respectively. After controlling for gender, age, smoking and alcohol consumption, the analysis using generalized estimating equation revealed that obesity, overweight, increased TC, marginally increased TG, increased TG, marginally increased LDL-C, increased LDL-C, and decreased HDL-C were correlated with increased risk of diabetes (P<0.01) . Slightly underweight and marginally increased TC were correlated with decreased risk of diabetes (P<0.01) .
Implications The prevalence of diabetes was relatively high in the elderlyhealth check-up population of Sichuan's Luzhou, which may be closely correlated with overweight / obesity and dyslipidemia. In view of this, it is suggested to lose weight and lower blood lipids to reduce diabetes prevalence and to prevent diabetes in this group.
Study on the Mediating Effect of Intimate Relationship between Dyadic Coping and Quality of Life in Gynecological Cancer Patients' Couples
YE Huihui，GE Lina，ZANG Shuang，HU Shuang
Background Dyadic coping are associated with quality of life in gynecologic cancer patients, but the mechanism path of action is still unclear.
What This Study Found The Chinese version of Locke-Wallace Marital (love) Adjustment and Prediction Test's mean score was. Multiple linear regression analysis showed that the total score of the Lock-Wallace Marital (love) Adjustment and Prediction Scale were significantly correlated with physical domain scores in gynecologic cancer patients (P<0.05) ; The Lock-Wallace Marital (love) Adjustment and Prediction Scale scores were associated with psychological domain scores in gynecologic cancer patients (P<0.05) ; The Lock-Wallace Marital (love) Adjustment and Prediction Scale scores were associated with social domain scores in gynecologic cancer patients (P<0.05) ; The total score of dyadic coping and Lock-Wallace Marital (love) Adjustment and Prediction Scale were significantly correlated with environment domain scores in gynecologic cancer patients (P<0.05) . The results of Structural Equation Model showed that the total score of dyadic coping positively predicted Lock-Wallace Marital (love) Adjustment and Prediction Scale , Lock-Wallace Marital (love) Adjustment and Prediction Scale scores positively predicted the World Health Organization Quality of Life-BREF Scale scores , and the total score of dyadic coping exerted no predictive effect on the World Health Organization Quality of Life-BREF questionnaire scores (β=0.112, P=0.688) .The results of the bootstrap sampling method (5 000 replicates) showed that the mediating effect of intimate relationship on the relationship between dyadic coping and quality of life was 0.727, accounting for 86.7% of the total effect.
Implications Gynecological cancer patients may have a relatively low level of dyadic coping, unsatisfactory intimate relationship, and poorer quality of life. The dyadic coping can indirectly predict the quality of life through intimate relationship was verified by structural equation modeling.
Association between Subclinical Hypothyroidism and Cardiac Autonomic Neuropathy in Type 2 Diabetes Mellitus
ZHAO Lei，LI Ruqiang，YUAN Mingxia
Background Cardiac autonomic neuropathy (CAN) is a common and severe chronic diabetic complication, whose association with thyroid function has rarely been reported.
What This Study Found The prevalence of subclinical hypothyroidism in those with CANwas higher than that of those without. For those with CAN, the ratio between maximum and minimum R-R intervals during the Valsalva maneuver demonstrated a negative correlation with the duration of T2DM, glycated hemoglobin, fasting plasma glucose, low-density lipoprotein cholesterol, triacylglycerol, high-sensitivity C-reactive protein, thyroid-stimulating hormone and urine albumin-to-creatinine ratio, while it demonstrated a positive correlation with the diastolic blood pressure (P<0.05) . The multivariate, stepwise logistic regression analysis revealed that subclinical hypothyroidism was independently associated with increased risk of CAN in T2DM (P<0.05) .
Implications In type 2 diabetes patients, the level of TSH may be related to CAN, and subclinical hypothyroidism may be an independent associated factor of CAN.
Associated Risk Factors in Group B Streptococcus Infection During Pregnancy
HUANG Yan，WANG Mingying，FENG Junyan，ZHANG Jie
Background Group B streptococcus (GBS) infection can give rise to intrauterine infection during pregnancy and postpartum endometritis, and increase the risk of premature birth or stillbirth. So it is essential to improve the detection rate of GBS and to identify risk factors of GBS infection.
What This Study Found The GBS detection rates in single-swab culture group, double-swab culture group, and double-swab & PCR group were 5.94%, 8.07, and 10.31%, respectively. The GBS detection rate was lower in single-swab culture group than that of other two groups. And double-swab & PCR group had a higher GBS detection rate than did double-swab culture group (P<0.017) . Multiple Logistic regression analysis showed that grade Ⅲ or Ⅳ vaginal cleanliness was closely associated with the prevalence of GBS infection in pregnancy.
Implications PCR test of both vaginal and rectal swabs could increase the GBS detection rate. Vaginitis is a major high-risk factor associated with GBS infection during pregnancy, which needs to be addressed in the process of diagnosis and treatment.
Brain White Matter Fiber Bundle Alterations and Severity of Depression in Patients with Post-stroke Depression
QI Jie，ZHANG Lei，DENG Lijun，DUAN Xiaodi，DONG Binbin，SUI Rubo
Background Post-stroke depression (PSD) , a common complication in stroke patients, may increase the disability and mortality, however, its pathogenesis is unknown yet.
What This Study Found And the number of fiber bundle of inferior fronto-occipital fascicles, corticospinal tract and frontopontine tract on the side of the stroke was significantly less than those on the contralateral side. Compared to non-PSD inpatients or healthy controls, PSD inpatients demonstrated significantly lower FA of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle and uncinate fasciculus, and notable less number of fiber bundles of inferior fronto-occipital fascicles, corticospinal tract and frontopontine tract on the side of the stroke. Pearson correlation analysis revealed that, the FA of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle or uncinate fasciculus on the side of the stroke was negatively correlated with HAMD-24 score in PSD inpatients; the number of fiber bundle of inferior fronto-occipital fascicles, corticospinal tract or frontopontine tract on the side of the stroke was negatively correlated with HAMD-24 score in PSD inpatients.
Implications There were impairment changes of structure of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle and uncinate fasciculus in patients with PSD, and these changes may be significantly correlated with the severity of depression, indicating that some white matter fiber bundle alterations may be involved in the onset of PSD.
Correlation Study between Serum Trimethylamine-N-oxide and the Risk of Acute Ischemic Stroke
LUO Jiaxin，ZHANG Aoqi，GAO Ruijiang，LI Ziru，ZHU Runxiu，YAO Yuan，YUAN Jun
Background Assessment of the risks of stroke and then initiation of primary prevention are crucial to reducing the incidence rate of stroke. Trimethylamine-N-oxide (TMAO) is a recently discovered intestinal microbial metabolite, whose relationships with the risks of stroke have been rarely reported.
What This Study Found Compared with the control group, the serum TMAO level in high-risk group was increased significantly . Correlation analysis results found that serum TMAO level was negatively associated with increased age, being female, history of hypertension, diabetes history, current smoking and drinking consumption, but positively associated with lack of exercise and increased BMI.The multinomial and ordinal Logistic regression analyses showed that increased TMAO was independently associated with increased risk of AIS. The AUC of serum TMAO in predicting AIS risk was 0.790 with 62.0% sensitivity and 91.6% specificity when its optimal cut-off value was determined as 3.28 μmol/L.
Implications Serum TMAO level may be independently related to AIS, which could be used as a clinical predictor for AIS.
Correlation Study between Serum Trimethylamine-N-oxide and the Risk of Acute Ischemic Stroke
LUO Jiaxin，ZHANG Aoqi，GAO Ruijiang，LI Ziru，ZHU Runxiu，YAO Yuan，YUAN Jun
Background Assessment of the risks of stroke and then initiation of primary prevention are crucial to reducing the incidence rate of stroke. Trimethylamine-N-oxide (TMAO) is a recently discovered intestinal microbial metabolite, whose relationships with the risks of stroke have been rarely reported.
What This Study Found Compared with the control group, the serum TMAO level in high-risk group was increased significantly . Correlation analysis results found that serum TMAO level was negatively associated with increased age, being female, history of hypertension, diabetes history, current smoking and drinking consumption, but positively associated with lack of exercise and increased BMI.The multinomial and ordinal Logistic regression analyses showed that increased TMAO was independently associated with increased risk of AIS. The AUC of serum TMAO in predicting AIS risk was 0.790 with 62.0% sensitivity and 91.6% specificity when its optimal cut-off value was determined as 3.28 μmol/L.
Implications Serum TMAO level may be independently related to AIS, which could be used as a clinical predictor for AIS.
The Glymphatic System：a New Exploration of Pathological Mechanism in Stroke
YI Ting，JIN Shuoguo，YIN Haiyan，GAO Ping，ZHU Tianmin
The glymphatic system is a system that promotes the exchange and flow of cerebrospinal fluid (CSF) -interstitial fluid (ISF) to maintain the balance of CSF-ISF, and rid the neuropil of toxic proteinaceous metabolites with astroglial water channel aquaporin-4 as the mediator. Increasing evidence has shown that the glymphatic system is strongly related to the pathological changes and outcomes of stroke. Available studies have found that the glymphatic system partially affects post-stroke cerebrospinal fluid circulation and cerebral edema. Different types of strokes include acute ischemic stroke, subarachnoid hemorrhage and intracerebral hemorrhage also have pathological changes in the glymphatic system. This review summarizes the structure and function of the glymphatic system, and the latest developments in its impact on pathological changes of different types of strokes, providing a new direction for the prevention and treatment of stroke.