Chinese General Practice

Interpretation of the Updates in 2018 NICE Guideline for the Diagnosis and Management of Chronic Heart Failure in Adults　

XU Dingli，MA Zhuang

2019, 22(17): 2015-2019. DOI: 10.12114/j.issn.1007-9572.2019.00.065

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Heart failure is the terminal stage of various heart diseases.It is a complex syndrome with different etiologies，pathogenesis and pathological processes.In 2018，the National Institute for Health and Care Excellence （NICE） published its guideline on the diagnosis and management of chronic heart failure in adults，which is a updated edition of the 2010 one.The major updates in the 2018 edition are multidisciplinary cooperation in the management of heart failure，diagnosis and treatment of heart failure，management，monitoring and rehabilitation of heart failure.

Treatment of Chronic Kidney Disease with Hyperuricemia：Current Situation and Challenges　

ZHANG Xiongfeng，LI Zhengsheng，ZHONG Qin，LIU Zhengqi，XIE Juan，CAO Yuepeng

2019, 22(17): 2020-2024. DOI: 10.12114/j.issn.1007-9572.2019.00.028

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Chronic kidney disease is commonly associated with hyperuricemia.Hyperuricemia is an independent risk factor for the progression of chronic kidney disease.Decreased glomerular filtration rate and increased adverse drug reactions can affect the choice of urate-lowering therapies for patients with chronic kidney disease.In this paper，with referencing to the related guidelines，we reviewed the current situation and progress of commonly used urate-lowering drugs，and put forward ways for overcoming the challenges in the application of new drugs for lowering uric acid and the management of uric acid，gout，tophus in chronic kidney disease with hyperuricemia.

Research Advance of Urate-lowering Therapy on Kidney Protection　

XIN Lei，LIANG Jingjing，GAO Ying，XU Xia，ZHAO Dongbao

2019, 22(17): 2025-2029. DOI: 10.12114/j.issn.1007-9572.2018.00.286

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Patients with gout often have some complications，such as cardiovascular diseases，chronic kidney diseases，and metabolic syndrome.Some studies suggested that hyperuricemia and gout increased the risk of chronic kidney diseases.Therefore，it is important to research on the effect of urate-lowering therapy on chronic kidney disease.At present，the effect of urate-lowering therapy on chronic kidney disease is not yet clear.Some randomized controlled studies have found that allopurinol can slow down the deterioration of renal function.The current research on febuxostat is controversial and we are lack of high quality research of benzbromarone in treatment of chronic kidney diseases.In the future，more studies are still needed on kidney protection by urate-lowering therapy.

Research Progress of Obesity-related Glomerulopathy　

ZONG Huimin，WANG Xia，LIU Chunbei

2019, 22(17): 2030-2035. DOI: 10.12114/j.issn.1007-9572.2019.00.011

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The increase of obesity-related glomerulopathy （ORG） parallels to the global epidemic of obesity. And the clinical feature of ORG shows different degrees of proteinuria，with some patients reaching end-stage renal failure. However，the pathogenesis，including hemodynamic abnormalities，renin-angiotensin-aldosterone system activation，insulin resistance，lipid metabolism disorder，adipose factor disorder，inflammation，is not clear. Its treatments include weight loss，blood pressure reduction，metabolic regulation and others. In this article，we reviewed the new progress in pathogenesis and therapies of ORG，including the targeted therapy.

Indications of Bare Metal Stent Implantation in Patients with Acute Coronary Syndrome　

LIU Ruifang，XU Fangxing，ZHOU Yujie，LIU Tongku，MA Hongyan，XU Lihua，GU Ming，DING Fuxiang，ZHAO Dongming，SUN Feng

2019, 22(17): 2036-2041. DOI: 10.12114/j.issn.1007-9572.2019.00.142

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Background　 At present，the proportion of bare metal stents （BMS） implantation in China is less than 5%，which is much lower than that of 30%-40% in the United States and European countries.The reason is that there are few reports on the indications of BMS implantation，and the understanding of BMS is still in its infancy.The indications，efficacy and safety of BMS are questioned in China.Objective　To explore the indications，long-term efficacy and safety of BMS implantations in patients with acute coronary syndrome （ACS）．Methods　A total of 1 203 patients with ACS registered with BMS implantation or drug-eluting stents （DES） were followed up from 2001 to 2010 in Heart Center，Affiliated Hospital of Beihua University，including 491 patients in BMS group and 712 in DES group.All patients were followed up by coronary angiography （CAG） in hospital or CT angiography （CTA） in outpatient department.The follow-up time was（12 to 175）months，with an average follow-up of （71.4±36.4） months.The difference of endpoint events and restenosis rates between the two groups with different pathological types （A，B1，B2，C） were compared.Results　There were no significant differences in the incidence of heart failure，target vessel reconstruction （TVR），and coronary artery bypass grafting （CABG） between the BMS group and the DES group （P>0.05）．The rates of the all-cause death，total major adverse cardiovascular events （MACE） and target lesions revascularization （TLR） in BMS group were significantly higher than those in DES group，and the incidences of recurrent non-fatal myocardial infarction and stent thrombosis （ST） in BMS group were lower than those of DES group （P<0.05）．The rates of the all-cause death，total MACE，recurrent non-fatal myocardial infarction，heart failure，target lesion revascularization （TLR），TVR，ST in patients with coronary type A lesions were not statistically significant between the two groups （P>0.05）．In patients with coronary type B1，B2 and C lesion，all-cause death，total MACE，and TLR in BMS group were significantly higher than those in DES group （P<0.05）．There were no significant differences in the incidence of in-stent restenosis，in-segment restenosis，in-stent restenosis and/or in-segment restenosis between the two groups of patients with coronary type A，B1 lesion （P>0.05）．There was no significant difference in the incidence of in-segment restenosis between the two groups with coronary type B2 and C lesion （P>0.05）．The incidences of in-stent restenosis，in-stent restenosis and/or in-segment restenosis in BMS group were higher than those in DES group with coronary type B2 and C lesion （P<0.05）．Conclusion　The incidence of long-term all-cause death，total MACE，TLR and restenosis in patients with ACS with type A lesion is similar to that of patients with DES.The long-term effect is good and the safety is high.Therefore，ACS with type A lesion can be used as the indication of BMS implantation.

Human Papillomavirus Genotype Prevalence and Attribution in Patients with Cervical Intraepithelial Neoplasia and Cancer　

ZHANG Lei，BI Qingqing，CHEN Wen，MU Xiaofeng

2019, 22(17): 2042-2046. DOI: 10.12114/j.issn.1007-9572.2019.00.246

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Background　Globally，cervical cancer ranks second in terms of both incidence and mortality among women，only to breast cancer.Persistent infection with high risk human papillomavirus （HPV） is a necessary cause of malignant cervical lesion.Accurate evaluation of the regional distribution of HPV genotypes is essential for the development of screening and vaccine preventative strategies for cervical cancer.Objective　The aim of this study was to investigate HPV genotype prevalence and attribution in patients with cervical intraepithelial neoplasia （CIN） and cancer.Methods　A total of 1 664 patients 〔including 376 with CIN1，408 with CIN2，336 with CIN3，440 with cervical squamous cell carcinoma （SCC），104 with adenocarcinoma of the uterine cervix （AUC）〕 from Qingdao Central Hospital and Qingdao Cancer Hospital were enrolled from 2012 to 2015.Samples of cervical exfoliated cells were collected and HPV genotypes in them were detected using polymerase chain reaction and reverse dot blot hybridization.23 HPV genotypes were characterized and genotype prevalence and attribution rates in the participants were calculated.Results　HPV positive ratio，rate of single genotype infection，and rates of 2，3 and 4 or more genotypes infection differed significantly in patients with different cervical lesions （P<0.05）．In CIN1 patients，the top 3 prevalent HPV genotypes were as follows：HPV52 （19.1%），HPV16 （17.4%），and HPV58 （8.7%）．In CIN2/3 patients，the top 5 prevalent HPV genotypes were as follows：HPV16，HPV52，HPV31，HPV33 and HPV58.In cervical SCC patients，the top 4 prevalent HPV genotypes were as follows：HPV16（43.1%），HPV52 （16.3%），HPV31（8.9%），and HPV58（7.3%）．In AUC patients，the top 3 prevalent HPV genotypes were as follows：HPV18 （57.1%），HPV16 （28.6%），and HPV52（14.3%）．30.7% of CIN2 and 43.3% of CIN3 were attributed to HPV16；49.1% of cervical SCC and 65.1% of AUC were attributed to HPV16 and HPV18.CIN and cervical cancer were attributable to HPV16 the most，followed by HPV52.Conclusion　The HPV vaccination program and cervical cancer prevention strategies in Qingdao should also focus on HPV52，HPV31，HPV58 and HPV33 while focusing on HPV16 and HPV18.Exploring HPV genotype prevalence and attribution analysis are helpful for clinical targeted treatment.

Pathological Characteristics of Renal Biopsy Tissue in Elderly People with Renal Disease：a Ten-year Comparative Analysis　

BAI Peijin，LIN Mengjie，CHEN Jian，ZHANG Yanlin，HE Jinxuan，ZHONG Hongbin，ZHANG Yong

2019, 22(17): 2047-2051. DOI: 10.12114/j.issn.1007-9572.2019.00.186

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Background　The incidence of kidney disease in the elderly population is increasing each year.This disease in older people presents special clinical pathological types and manifestations.And its pathological types vary substantially according to race and geographical region，and also change over time.Objective　To explore the pathological changes of renal biopsy tissues in elderly people with kidney disease in recent 10 years.Methods　A total of 652 kidney disease inpatients aged ≥60 years from Department of Nephrology，the 900th Hospital of Joint Logistic Support Force，PLA，the First Affiliated Hospital of Xiamen University，and Zhongshan Hospital，Xiamen University during 2008 to 2017 were enrolled，including 284 treated between 2008 and 2012，and 368 treated between 2013 and 2017.Both groups underwent pathological examination of renal biopsy tissues，and the detected pathological types，as well as sex，age，and major clinical manifestations were analyzed comparatively.Results　Both groups showed no significant differences in sex and age （P>0.05）．The most common clinical manifestation in both groups was nephrotic syndrome 〔45.2%（295/652）〕，followed by acute kidney injury 〔23.3%（152/652）〕.The incidence rates of nephrotic syndrome，nephritis syndrome，occult nephritis，and chronic renal failure were similar in both groups （P>0.05）．Those treated between 2013 and 2017 were found to have a much higher incidence rate of acute kidney injury （P<0.05）．The percentage and types of primary glomerular diseases differed significantly between the groups （P<0.05）.In particular，those treated between 2013 and 2017 were identified with a significantly higher percentage of membranous nephropathy （χ2=12.224，P<0.001）．Two groups showed significantly different percentages of secondary glomerular diseases （P<0.05），but the types of secondary glomerular diseases were similar （P>0.05）.Conclusion　Nephrotic syndrome is still the most common clinical manifestation in elderly patients with kidney disease，but the incidence rate of acute kidney injury is higher than before.Primary glomerular disease is still the main pathological type，but its proportion has decreased.The evolution of renal pathology in this population may be correlated with variations in actual morbidity and the improvement of diagnostic ability.

Epicardial Fat Thickness and Severity of Obstructive Sleep Apnea-hypopnea Syndrome in Obese and Nonobese Patients　

MA Xiao，LU Ying，CHEN Qianhua

2019, 22(17): 2052-2057. DOI: 10.12114/j.issn.1007-9572.2019.00.143

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Background　Obesity is an important predisposing factor for the development and progression of obstructive sleep apnea-hypopnea syndrome （OSAHS）．Most OSAHS patients have central obesity and increased visceral fat.Epicardial fat thickness （EFT） is a new tool for measuring visceral fat.And its relationship with the severity of OSAHS has been rarely reported.Objective　To investigate the relationship between EFT and severity of OSAHS in obese and nonobese patients.Methods　A total of 197 OSAHS patients diagnosed by polysomnography （PSG） and 50 physical examinees （healthy controls） were enrolled from Aviation General Hospital from October 2015 to October 2017，among whom 111 OSAHS patients and 14 controls were obese，and 86 OSAHS patients and 36 controls were nonobese （obesity was defined as BMI≥28.0 kg/m2）．By the apnea-hypopnea index （AHI） per hour，OSAHS patients were stratified into mild OSAHS subgroup （5≤AHI <15），moderate OSAHS subgroup （15≤AHI <30），and severe OSAHS subgroup （AHI≥30）．Baseline and PSG characteristics of OSAHS patients were collected.EFT data of all the participants were obtained by echocardiography.Results　Compared with nonobese OSAHS patients，obese OSAHS patients showed similar mean age，AHI，oxygen desaturation index （ODI），mean oxygen saturation （MSaO2），lowest oxygen saturation （LSaO2） and EFT （P>0.05），but demonstrated higher female ratio，greater mean BMI，mean neck circumference，and waist circumference，and higher percentage of total sleep time with oxygen saturation <90% （Ts90%）（P<0.05）．Mean neck circumference，and waist circumference，AHI，Ts90%，ODI，MSaO2 and LSaO2 differed significantly between obese controls and obese patients with different severity of OSAHS （P<0.05）．Sex ratio，mean neck circumference，AHI，Ts90%，ODI，MSaO2，LSaO2，and EFT varied significantly between nonobese controls and nonobese patients with different severity of OSAHS（P<0.05）．Correlation analysis showed that EFT was positively correlated with BMI，AHI and ODI in obese OSHAS patients （P<0.05）．In nonobese OSHAS patients，it was positively correlated with BMI，neck circumference，AHI，Ts90%，and ODI，but negatively correlated with LSaO2 （P<0.05）．Multiple linear regression analysis suggested that neck circumference 〔β=0.747，95%CI（-0.106，1.820）〕，and EFT〔β=3.375，95%CI（-1.783，7.938）〕were independent predictors of AHI in obese OSHAS patients （P<0.05）．EFT 〔β=4.346，95%CI（-0.081，8.771）〕was an independent predictor of AHI in nonobese OSHAS patients （P<0.05）．Conclusion　EFT is different among nonobese patients with different severity of OSAHS，and it showed a positive correlation with BMI，AHI and OHI.EFT may be a valuable parameter in the objective evaluation of OSAHS severity，especially in nonobese patients.

Correlation of Serum β2-microglobulin Level with Disease Activity of Systemic Lupus Erythematosus and Degree of Lupus Nephritis　

ZHANG Zongwei，CHEN Cheng，WANG Huiming，DING Guohua

2019, 22(17): 2058-2063. DOI: 10.12114/j.issn.1007-9572.2018.00.310

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Background　Systemic lupus erythematosus （SLE） can lead to lupus nephritis （LN），which greatly affects the survival rate of patients with SLE.β2-microglobulin （β2-MG） is a small-molecule protein which exists on human nucleated cell membranes.The correlation betweenβ2-MG and the disease activity of SLE and lupus kidney damage is still unclear.Objective　 To investigate the relationship between serum β2-MG and disease activity of SLE and degree of lupus nephritis，so as to provide reference for clinical evaluation of SLE disease activity and lupus kidney damage.Methods　 A total of 260 SLE patients admitted to Dermatological Department and Nephrology Department of Renmin Hospital of Wuhan University from January 2016 to January 2018 were enrolled.General data，laboratory tests and scores of Systemic Lupus Erythematosus Disease Activity Index（SLEDAI）were collected.According to SLEDAI score，118 cases were in mild activity group（SLEDAI score 0-9），76 cases in moderate activity group（SLEDAI score 10-14），and 66 cases in severe activity group（SLEDAI score≥15）.According to estimated glomerular filtration rate（eGFR），patients were divided into normal renal function group（177 cases），mild abnormal renal function group（45 cases），moderate abnormal renal function group（23 cases），severe abnormal renal function group（9 cases） and extremely severe abnormal renal function group（6 cases）.Multivariate Logistic regression was used to analyze the influencing factors of renal function and disease activity in patients with SLE.Results　There were significant differences in age，percentage of LN，β2-MG，platelet count（PLT），hemoglobin（Hb），albumin（ALB），serum creatinine（Scr），eGFR，anti-Sm antibody，positive rate of anti-dsDNA antibody，C3 and C4 and 24-hour urinary total protein（UTP） in different disease activity groups（P<0.05）；there were significant differences in age，course of disease，LN percentage，β2-MG，Hb，PLT，ALB，Scr，C3，and SLEDAI scores among different renal function groups（P<0.05）.Correlation analysis showed that β2-MG was positively correlated with age，LN，Scr，anti-dsDNA antibody，UTP，SLEDAI score，and negatively correlated with Hb，PLT，ALB，eGFR and C3（P<0.05）；eGFR was positively correlated with LN，Hb，PLT，ALB，anti-RNP antibody and C3，and negatively correlated with age，β2-MG，Scr，BUN，anti-dsDNA antibody，and SLEDAI score（P<0.05）；SLEDAI score was positively correlated with LN，β2-MG，Scr，anti-Sm antibody，anti-dsDNA antibody，anti-RNP antibody and UTP，and negatively correlated with age，Hb，PLT，ALB，eGFR，C3 and C4（P<0.05）.Results of multivariate Logistic regression analysis showed that β2-MG 〔OR=1.197，95%CI（1.004，1.427）〕，PLT 〔OR=0.992，95%CI（0.984，0.999）〕，eGFR 〔OR=0.983，95%CI（0.968，0.998）〕 and anti-dsDNA antibody 〔OR=2.239，95%CI（0.801，6.256）〕 were influencing factors of disease activity in patients with SLE（P<0.05），and LN 〔OR=9.687，95%CI（1.004，93.500）〕，β2-MG 〔OR=1.407，95%CI（0.797，2.481）〕，Scr 〔OR=1.248，95%CI（1.154，1.351）〕 and anti-RNP antibody 〔OR=5.149，95%CI（1.028，25.785）〕 were influencing factors of renal function in patients with SLE（P<0.05）.Conclusion　 Serum β2-MG level is closely related to SLE disease activity and renal function，and can be used as one of the serological indicators for evaluating disease activity and renal damage in SLE patients.

Clinical Study of in Situ Arteriovenous Fistula Reconstruction for Occlusion of Internal Arteriovenous Fistulas in Hemodialysis Patients　

LIN Mingzeng，XU Liyun，FAN Jiani，ZHENG Youmao，CAI Luqian

2019, 22(17): 2064-2068. DOI: 10.12114/j.issn.1007-9572.2018.00.307

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Background　Loss of arteriovenous fistula function is inevitable for patients undergoing long-term hemodialysis.In order to save vascular resources，current studies mostly focus on reconstructing arteriovenous internal fistula on the basis of original blood vessels by Fogarty balloon catheter extraction and anastomotic dilation.Although its recanalization rate is high，its long-term recanalization rate is not satisfied.It is necessary to find a method that can not only save vascular resources but also prolong the service life of internal fistula.Objective　To explore the value of in situ arteriovenous fistula reconstruction applied to the treatment of internal arteriovenous fistula occlusion in hemodialysis patients.Methods　Totaled 92 maintenance hemodialysis patients with arteriovenous fistula occlusion were recruited from Taizhou Enze Medical Center of Zhejiang Province from March 2015 to March 2017.They were equally divided into the study group and control group by using a random number table，receiving in situ arteriovenous fistula reconstruction，fistula embolectomy and angioplasty with Fogarty balloon embolectomy catheter，respectively.Data concerning surgery，inflammatory factors，indicators of renal function，blood lipid，protein and so on before and after treatment（obtained by measuring peripheral venous blood） were compared between the groups.The incidence of surgical complications was recorded.Results　The study group demonstrated shorter mean duration of surgery and mean incision length，lower mean surgery cost，and higher 6-month and 12-month patency rates of the arteriovenous fistula and more blood flow through the arteriovenous fistula compared with the control group（P<0.05） although mean intraoperative blood loss and success rate of surgery were similar in the two groups（P>0.05）.Similar mean serum levels of Scr，BUN，hs-CRP，IL-6，TNF-α，total cholesterol，triacylglycerol，total protein，albumin and β2 microglobulin were found in both groups before treatment（P>0.05）.After treatment，all of them decreased except total protein and albumin increased significantly in both groups（P<0.05）.Pairwise comparison showed hs-CRP，IL-6，TNF-α，total cholesterol and triacylglycerol were obviously lower in the study group than in the control group（P<0.05） but other 5 indicators were still similar in both groups（P>0.05）.Two groups showed no significant difference in the incidence of complications 〔15.2%（7/46） vs 10.9%（5/46）〕（χ2=0.383，P=0.536）.Conclusion　In situ arteriovenous fistula reconstruction is strongly recommended for clinical use，for it is easy to operate and inexpensive，and has high success rate and can achieve a stable and favorable outcome.

Bioinformatic Analysis of Toll-like Receptor Signaling Pathway and Coronary Heart Disease　

LI Ziqing，YAN Yuqing，ZHANG Nianping，BAI Chunyang，FANG Qingli

2019, 22(17): 2069-2074. DOI: 10.12114/j.issn.1007-9572.2018.00.404

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Background　Coronary heart disease （CHD） is a serious health issue among middle-aged and elderly people.Inflammation and immune response plays a vital role in occurrence，progression and prognosis of CHD.Toll-like receptors （TLRs） are known to mediate innate and acquired immune responses.Previous studies have shown that TLR2 and TLR4 receptor pathways are associated with CHD，while the relationship between TLRs pathways and other TLRs subtypes and CHD remains to be further studied.Objective　To identify the relationship between TLRs pathways and other TLRs subtypes and CHD，so as to identify the role of TLRs signaling pathway in the process of CHD and find new CHD-related protein.This study would provide a new candidate target for the treatment of CHD.Methods　We used the semantic similarity method based on GO database，and performed functional analysis between the gene sets from March 2016 to February 2018.First，we found the relationship of TLRs signaling pathways with CHD and then followed protein-protein interaction network to analyze the function of targeted proteins.Further，we determined the relationship of TLRs subtypes with CHD based on the number of known CHD-related proteins interacting with the tested proteins.Results　Study results showed that the similarity score of immune system was the highest in seven system pathways of KEGG database.Functional similarity score of TLRs signaling pathway gene set and CHD gene set was higher than that of random gene set （P<0.05）．In fourteen immune system pathways，the functional similarity score of TLRs signaling pathway was the highest.We also observed close interaction between TLR10 and disease-related proteins using analysis of protein-protein interaction network besides TLR2 and TLR4.Conclusion　TLRs signaling pathway plays a crucial role in the process of CHD and the TLRs family may be a new target for the prevention and treatment of CHD.TLR10 could be a new CHD-related protein.

The Effect of Elderly Care and Medical Services Integration Model on Quality of Life in Elderly People：a Meta-analysis　

LUO Jing，LIU Yao，LUO Yuru，JU Mei

2019, 22(17): 2075-2083. DOI: 10.12114/j.issn.1007-9572.2019.00.009

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Background　According to the latest world population aging data released by the United Nations Population Division，the proportion of people aged over 60 years has risen from 8.5% in 1980 to 12.7% in 2017，which is expected to double by 2050. In China，the population aged 60 years and over accounts for 16.2% in 2017，which is estimated to reach 35.1% in 2050，posing a extremely grim aging trend. To achieve healthy aging，China has proposed a model of combination of elderly care and medical services. However，compared with the abundant and mature old-age care models in western developed countries，the benefit and content of the combination of medical and health care model should be further verified and improved. Objective　Domestic and foreign randomized controlled trials （RCT） on the effect of elderly care and medical services integration model were systemically retrieved to evaluate its effect on improving the quality of life among the elderly，so as to provide reliable reference for the exploration and development of elderly care and medical services integration model. Methods　The systematic evaluation method provided by Cochrane Collaboration Network was used systemically and comprehensively to retrieve databases，including Cochrane Library，Web of knowledge，Medline，EMBase，Chinese Biological Medical Literature Database （CBM），CNKI，Wanfang Data Knowledge Service Platform，and VIP．Meanwhile，references cited in literature were also screened，and relevant periodicals and gray literature were manually retrieved until 30th December，2017，so as to enroll RCT on providing elderly care and medical services integration model for the elderly. The methodological quality of enrolled literature was evaluated by two reviewers independently using Cochrane Interventions Systematic Review Manual，and the RevMan 5.3 software was used for meta-analyses. Results　A total of 15 studies involving 2 958 subjects were enrolled. According to the Cochrane evaluation tool，two of them were of grade B，and thirteen were of grade C. Results of meta-analysis suggested that PF score，RP score，BP score，GH score，VT score，SF score，RE score，MH score and ADL score in intervention group were higher than those in control group〔MD=7.07，95%CI （4.89，9.25），P<0.000 01；MD=11.73，95%CI （6.98，16.48），P<0.000 01；MD=6.69，95%CI （0.26，13.12），P=0.04；MD=6.38，95%CI （3.13，9.62），P=0.000 1；MD=6.51，95%CI （3.62，9.40），P<0.000 01；MD=6.59，95%CI （4.08，9.10），P<0.000 01；MD=6.64，95%CI （2.19，11.09），P=0.003；MD=5.21，95%CI （1.35，9.08），P=0.008；MD=1.95，95%CI （0.16，3.73），P=0.03〕. Besides，difference in the CES-D score and MMSE score between intervention group and control group were not statistically significant〔MD=-0.93，95%CI （-3.07，1.21），P=0.40；MD=0.18，95%CI （-0.55，0.92），P=0.63〕. Moreover，the meta-analysis results were relatively stable by changing the effect model of meta-analysis and removing high-weight literature. Conclusion　Existing clinical researches have proven that elderly care and medical services integration model is more effective than traditional care in terms of improving the quality of life in elderly people. However，due to late development of this model in China and low quality and small sample size of existing research，more high-quality studies are needed for further research and exploration.

Cognitive Behavioral Therapy for Relieving Depression or Anxiety in Parkinson's Disease：a Meta-analysis　

ZHANG Xingxing，ZHOU Chen，DUAN Hongwei，WANG Xiaoxiao，WANG Aihong

2019, 22(17): 2084-2090. DOI: 10.12114/j.issn.1007-9572.2018.00.356

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Background　Depression，anxiety and other symptoms are common psychiatric symptoms in patients with Parkinson's disease，ranking the top 5 among all the symptoms.Depression and anxiety not only cause different degrees of functional damage，but also seriously affect patients’ quality of life.However，traditional medicines have many side effects and are addictive，while psychotherapies have fewer adverse reactions and reduce economic costs.Cognitive behavioral therapy （CBT） is widely used，and a large number of studies have confirmed its effectiveness in patients with Parkinson's disease.Objective　To systematically evaluate the effect of CBT on the symptoms of depression and anxiety and the quality of life in patients with Parkinson's disease（PD）.Methods　We searched the databases of PubMed，EMBase，Web of Science，Cochrane Library，Science Direct，CNKI，VIP，Wanfang Data Knowledge Service Platform and CBM.And randomized controlled trials（RCT）related to using CBT to relieve depression and anxiety in patients with PD included since the inception to May 2018 were collected.RCT were screened，data extraction was performed and qualities of eligible RCT were assessed.Meta-analysis was implemented with RevMan 5.3.Results　Nine RCT with 401 patients were included.Meta-analyses of depression symptom score 〔SMD
=-1.15，95%CI（-2.18，-0.13），P=0.03〕，anxiety symptom score 〔SMD=-0.80，95%CI（-1.40，-0.21），P=0.008〕 and general psychological health 〔SMD=-1.27，95%CI（-1.96，-0.59），P=0.000 3〕 after treatment showed the superiority of the experimental group over the control group.However，there was no significant difference in post-treatment quality of life between the groups（P>0.05）.Subgroup analyses showed that CBT had a poor effect on depression and anxiety after treatment immediately（P>0.05）.However，follow-up results showed that it significantly relieved the symptoms of depression and anxiety （P<0.05）.Conclusion　CBT helps to relieve the symptoms of depression and anxiety in PD.And long-term use of it can bring significant effect.However，its short-term effect and its effect on improving the quality of life need to be verified by further clinical studies.

Efficacy and Safety of Jinghua Weikang Combined with Triple or Quadruple Therapy in the Treatment of Helicobacter Pylori Associated Chronic Gastritis or Peptic Ulcer：a Meta-analysis　

YANG Jiahui，LIANG Yu，LUO Peipei，HE Shuixiang

2019, 22(17): 2091-2098. DOI: 10.12114/j.issn.1007-9572.2019.00.017

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Background　Helicobacter pylori （Hp） infection is closely related to chronic gastritis and certain types of peptic ulcer，and eradication of Hp is a key link in the treatment of related diseases.However，due to the increasing drug resistance rate of antibody treatment and the effective bactericidal and bacteriostatic effect of some traditional Chinese medicine，whether the combination of traditional Chinese medicine and western medicine can improve the eradication rate of Hp is increasingly concerned.Objective　To systematically evaluate the efficacy and safety of Jinghua Weikang combined with triple or quadruple therapy compared with standard quadruple therapy in the treatment of Hp related chronic gastritis or peptic ulcer.Methods　The databases，such as CNKI，VIP，Wanfang Data Knowledge Service Platform，CBM，PubMed and Ovid-EMBase were retrieved.They were searched from the establishment of databases to April 2018 to identify the randomized controlled trials （RCTs） of Jinghua Weikang capsules combined with triple or quadruple therapy compared with quadruple therapy in the treatment of Hp-associated chronic gastritis or peptic ulcer.Then studies were identified according to predefined inclusion and exclusion criteria，and their quality was evaluated by two researchers separately.The meta-analysis was performed using RevMan 5.2 and STATA 14.0 software.Results　Twenty-one studies involving 2 974 patients were included.The results of meta-analysis showed that there was no significant difference in Hp eradication rate between the experimental group of Jinghua Weikang combined with triple regimen and control group of quadruple therapy 〔RR=0.98，95%CI（0.94，1.02），P=0.35〕；the incidence of adverse reactions in the experimental group was lower than that in the control group 〔RR=0.39，95%CI（0.26，0.58），P<0.000 01〕；the improvement of digestive tract-related symptoms in the experimental group was higher than that in the control group 〔RR=1.31，95%CI（1.14，1.51），P=0.000 2〕.The eradication rate of Hp in the experimental group of Jinghua Weikang combined with quadruple therapy was higher than that in the control group of quadruple therapy 〔RR=1.16，95%CI（1.08，1.24），P<0.000 1〕；the incidence of adverse reactions in the experimental group was lower than that in the control group 〔RR=0.36，95%CI（0.15，0.82），P=0.02〕.There was no significant difference in the improvement of digestive tract-related symptoms between the experimental group and the control group 〔RR=1.15，95%CI（0.97，1.36），P=0.12〕.Conclusion　The Hp eradication rate of Jinghua Weikang combined with triple therapy was comparable to that of standard quadruple therapy，with better symptom improvement and reduced adverse reactions.Compared with the single quadruple therapy，Jinghua Weikang combined with quadruple therapy has better efficacy in eradicating Hp，and the improvement of symptoms is comparable，but the adverse reactions are significantly reduced.Our study could provide reference for clinical medication.

Common Causes of Poor Efficacy of Immune Checkpoint Inhibitors in Special Populations　

ZHU Yue，SUN Gengyun

2019, 22(17): 2099-2105. DOI: 10.12114/j.issn.1007-9572.2019.00.041

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Recently，treatment with immune checkpoint blockers （ICB） for advanced non-small cell lung cancer （NSCLC） has progressed very rapidly.It is one of the most popular cancer treatments，and has even been listed as a first-line treatment in the latest NCCN guidelines for driver gene mutation negative patients.The recent approval of ICB by China Food and Drug Administration has brought a new treatment concept for cancer treatment and new hopes for lung cancer patients，indicating that it has a broad prospect of clinical use.However，clinical use of ICB faces many problems，such as the associations of response to ICB with steroid hormones used before ICB treatment，cumulative antibiotic use，brain metastases in NSCLC，and tobacco exposure，and efficacy of ICB in combination with local-brain radiation therapy.Along with these problems being solved successively，anti-PD-1/PD-L1 monoclonal antibodies will bring survival benefits to more special populations.

Analysis of 41 Medical Disputes Cases Related to Drug Misuse　

NING Chao，ZHU Ping，SU Tianzhao，WANG Ying

2019, 22(17): 2105-2110. DOI: 10.12114/j.issn.1007-9572.2018.00.424

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Background　Drugs play an important role in the process of clinical treatment，and medical disputes are caused by improper use of drugs. Paying attention to medical disputes related to improper use of drugs is an vital measure to ensure medical quality and promote harmony between doctors and patients. Objective　To guide the safety management of clinical rational drug use by analyzing medical disputes cases related to drug misuse.Methods　We selected and analyzed documents of 41 legal precedents caused by drug misuse from China Judgments Online （http：//wenshu.court.gov.cn/） through advanced search in July 2018，extracted the year of filing，district，hospital level，medical accident，accident grade，lawsuit reason，appraisal method，degree of responsibility （participation），judgment result，amount of claim，amount of compensation，cause of improper drug use，and calculated trial time，compensation coefficient，participation and proportion of compensations.Results　Among 41 cases of drug misuse，22 cases were sentenced in the court of first instance and 19 cases in the court of second instance.Among them，the appraisements of medical damage were applied for 72 times and average 1.76 times per case.Four cases were judged to be medical accidents and 34 cases were identified as fault participation.The mean compensation of the total 41 cases was 704 220.60 yuan，the mean compensation of 37 cases was 211 865.10 yuan，and the proportion of compensations was 30.1%.Twenty-nine medical disputes were directly caused by drug misuse，including 25 cases of medication errors，2 cases of adverse drug reactions and 2 cases of unclear cause.There were frequent misuse of antibiotics，hormones，sedatives，analgesics and antidotes in dosage，time，combination of drugs and treatment adjustment.Conclusion　The situation of medical disputes related to drug misuse is not optimistic.The safety of clinical pharmacy should be strengthened through informatization，institutionalization and process management.At the same time，the procedures of identification and compensation for disputes should be further clarified to protect the legitimate rights and interests of both doctors and patients.

Validity and Reliability of the Chinese Version of FACIT-F and BRAF-MDQ in Rheumatoid Arthritis Patients　

GAO Lei，ZHONG Biliu，YU Chunyan，ZHANG Lin，LIU Qin

2019, 22(17): 2111-2115. DOI: 10.12114/j.issn.1007-9572.2018.00.358

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Background　Fatigue is an important indicator of disease status in patients with rheumatoid arthritis （RA）.The Functional Assessment of Chronic Illness Therapy-Fatigue （FACIT-F）and the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire （BRAF-MDQ） are currently used abroad to assess the fatigue of RA patients.Therefore，understanding the fatigue status of RA patients in China and exploring effective assessment tools are of great significance for the comprehensive treatment of RA and the improvement of clinical symptoms.Objective　To assess the validity and reliability of the Chinese version of FACIT-F and Chinese version of BRAF-MDQ in patients with RA.Methods　A total of 281 outpatients and inpatients with RA who were treated in the First People's Hospital of Huizhou，Guangdong Province from July 2017 to March 2018 were enrolled using convenience sampling.A set of questionnaires comprised of Socio-demographic Questionnaire，Chinese version of FACIT-F，Chinese version of BRAF-MDQ，Chinese version of SF-36 Physical Functioning subscale （SF-36 PF） and fatigue-VAS （fatigue-VAS），and pain-VAS （pain-VAS） were used to collect data.The reliability and validity of both Chinese version of FACIT-F and Chinese version of BRAF-MDQ were evaluated by item analysis，exploratory factor analysis，correlation analysis，criterion-related validity and reliability analysis.Results　Item analysis showed that the mean total scores of both Chinese version of FACIT-F and Chinese version of BRAF-MDQ were much higher in the top 27% （high score group） compared with the bottom 27% （low score group）（P<0.05）.One common factor was extracted from the Chinese version of FACIT-F，which explained 71.40% of the total variance，achieving factor loadings of 0.563-0.941，while two common factors were extracted from the Chinese version of BRAF-MDQ，which explained 73.53% of the total variance and the factor loadings obtained were 0.565-0.804.The total score of Chinese version of FACIT-F was positively correlated with the total score of SF-36 PF，but negatively correlated with the total score of pain-VAS and fatigue-VAS （P<0.05）.The total score of the Chinese version of BRAF-MDQ and scores of its two domains of physical fatigue，cognitive-emotional fatigue were negatively correlated with the score of SF-36 PF，whereas positively correlated with that of pain-VAS and fatigue-VAS （P<0.05）.The Cronbach's α （measuring the internal consistency），and intraclass correlation coefficient （ICC） of the Chinese version of FACIT-F were 0.965，0.967，respectively.The Cronbach's α and ICC were 0.956，0.962，respectively for the Chinese version of BRAF-MDQ，0.929，0.968，respectively for the physical fatigue domain，and 0.948，0.954 respectively for the cognitive-emotional fatigue domain. Conclusion　Both the Chinese version of FACIT-F and BRAF-MDQ have statistically acceptable levels of reliability and validity for assessing fatigue in patients with RA.Healthcare providers can choose the appropriate scale to assess the fatigue level of RA patients according to the clinical needs.

Development of Health Education Competency Scale of Community Nurses and Its Reliability and Validity Test　

NIU Geng，SU Ye，LI Yuying，SUN Yumei

2019, 22(17): 2116-2120. DOI: 10.12114/j.issn.1007-9572.2018.00.296

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Background　Community health education is an important part of the health promotion system.As the main player in health education，the competency of community health nurses directly influences the effect of healthy education.Therefore，it is particularly important to evaluate the health education competency of community health nurses.However，there is no assessment tool for this at home and abroad.Objective　To develop Health Education Competency Scale of Community Nurses and test its reliability and validity.Methods　Literature review，expert consultations and pilot survey were used to develop the draft of the scale.A total of 614 community nurses were selected from Nanshan District，Longhua District Louhu District，Baoan District，Dapeng New District，Longgang District，Futian District in Shenzhen，Guangdong Province during March to June 2017 for investigation to test the reliability and validity.Results　Four dimensions and 29 items were finally contained in the scale.The exploratory factor analysis identified 4 principal factors：assessment ability，planning ability，implementation and evaluation ability，and communication and learning ability，and explained for 66.256% variance.The r value of Pearson linear correlation analysis between the 4 dimensions was from 0.672 to 0.810.The r value of dimension score and the total score of the scale was from 0.854 to 0.936.The scale content validity index（S-CVI） was 0.933 and the item content validity index （I-CVI）ranged from 0.857 to 1.000.The Cronbach's α coefficient of the scale was 0.968.The Cronbach's α coefficients of 4 dimensions were 0.887，0.907，0.943 and 0.906，respectively.Conclusion　The Health Education Competency Scale of Community Nurses has been proved to be reliable and valid，and can be used to evaluate the competency of community nurses in health education.

The Short Term Effect of Different Oxygen Therapies in Non-surgical Critically Ill Patients after Extubation　

SUN Bo，ZHANG Tianqing，HU Xuezhong，JIANG Mingming，SONG Liqing，SUN Qin

2019, 22(17): 2121-2124. DOI: 10.12114/j.issn.1007-9572.2018.00.291

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Backgroud　Heated humidified high flow nasal cannula（HFNC）is a safe，efficient and comfortable new oxygen therapy method，which has been applied widely in the field of respiratory therapy. However，the optimal population for HFNC is still unclear. Objective　To investigate the short term effect of HFNC and conventional oxygen therapy （COT） applied to non-surgical critically ill patients after extubation in ICU.Methods　A prospective analysis of 87 patients with endotracheal intubation admitted to the Department of Critical Care Medicine，Cixi Hospital Affiliated to Wenzhou Medical University from September 2016 to February 2018 was performed.Patients who were ready for planned extubation were randomized （random number） to receive HFNC（HFNC group） or COT（COT group） sequentially after extubation.Oxygenation index （PaO2/FiO2），arterial partial pressure of carbon dioxide （PaCO2），respiratory rate and heart rate were compared between two groups 24 hours after extubation.The main observation result was re-intubation rate within 48 hours after extubation.Secondary observations included duration of ICU stay，duration of hospitalization，and in-hospital mortality.Results　A total of 82 patients who met the inclusion criteria were enrolled in the study，with 42 cases in HFNC group and 40 cases in COT group.The oxygenation index of HFNC group was higher than that of COT group 24 hours after extubation，and the respiration rate and heart rate of HFNC group were lower than those of COT group 24 hours after extubation（P<0.05），but there was no significant difference of PaCO2 between two groups（P>0.05）．The re-intubation rate 48 hours after extubation，duration of ICU stay and duration of hospitalization in HFNC group were significantly lower than those in COT group（P<0.05），but there was no significant difference of in-hospital mortality between two groups（P>0.05）．Conclusion　Compared to COT，HFNC sequentially applied to non-surgical critically ill patients has an advantage in term of oxygenation index after extubation.Furthermore，HFNC can reduce re-intubation rate 48 hours after extubation，duration of ICU stay and duration of hospitalization .Therefore，HFNC could be used as a preferred treatment in non-surgical critically ill patients after extubation in ICU.

Perioperative Application of Infrared Therapy Combined with Air Wave Pressure Treatment on Open Reduction and Internal Fixation for Calcaneal Fracture　

XIONG Bin，ZHOU Yun，ZHAN Junfeng，HUANG Jingjing，LI Kai，WANG Yongzhao，JING Juehua，WU Jianxian

2019, 22(17): 2125-2129. DOI: 10.12114/j.issn.1007-9572.2018.00.288

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Background Open reduction and internal fixation of calcaneal fracture during the perioperative period of ankle swelling and wound healing has always been the focus of surgeons. Clinicians have also been trying to shorten the waiting period for surgery and reduce infected incision.Objective　To investigate perioperative effect of infrared therapy combined with air wave pressure treatment in patients of open reduction and internal fixation for calcaneal fracture.Methods　A total of 40 patients with open calcaneal fracture，who received internal fixation surgery in the Second Hospital of Anhui Medical University from January 2016 to January 2017，were randomly divided into observation group and control group，each with 20 cases.The control group was treated with perioperative routine rehabilitation，including correct posture management，ice compress and exercise therapy．The observation group had infrared therapy and air wave pressure treatment based on the treatment in control group．The time required for positive skin folding test，postoperative incision recovery，swelling，ankle circumference difference，pain，average duration of hospitalization and hospitalization expenses were compared between the two groups.Results　The time needed for positive skin folding test in observation group was （6.4±0.7） days，which was lower than that in control group of（8.2±1.2）days （t=-5.794，P<0.001）．The cure rate of incision in observation group was 70%（14/20），which was higher than that in control group of 35%（7/20）（χ2=4.912，P=0.027）．The incidence of grade Ⅱ swelling in observation group was lower than that in control group （χ2=5.584，P=0.018）．On the fifth day after admission and the fifth day after operation，the difference of ankle circumference in observation group was smaller than that in control group （P<0.05），and the visual analogue score （VAS） of observation group was lower than that of control group （P<0.05）．The average duration of hospitalization and average expenses in observation group were less than those in control group （P<0.05）．Conclusion　The treatment of infrared therapy combined with air wave pressure on patients undergoing open reduction and internal fixation for calcaneal fracture has obvious curative effect on relieving swelling and pain，promoting wound healing and reducing average hospitalization duration and expenses.

Cryptococcal Pulmonary and Skin Infections Secondary to Immunosuppressive Agent Treatment for Nephrotic Syndrome：a Case Report and Literature Review　

FENG Zhen，DONG Chunxia，GUO Lan，SHI Yanan，NIU Kai，LIU Bing

2019, 22(17): 2130-2135. DOI: 10.12114/j.issn.1007-9572.2018.00.354

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Invasive fungal infections are common in immunocompromised hosts with difficult diagnosis and high fatality.Nephrotic syndrome patients receiving immunosuppressive agent treatment are probably susceptible to invasive fungal infections due to decreased immune functions caused by the treatment.Cryptococcal infections is a global fungal disease caused by cryptococcus whose incidence rate is rising in recent years.However，nephrotic syndrome with cryptococcal infections is relatively rare，in particular，cryptococcus spreads to the skin via the bloodstream is more rare，which is often misdiagnosed.In this paper，we reported a case of nephrotic syndrome with cryptococcal pulmonary and skin infections following immunosuppressive agent treatment on the basis of reviewing adequate studies pertinent to the case.

Primary Sjogren's Syndrome with Bilateral Pleural Effusion as the Initial Manifestation：a Case Report and Literature Review　

CHEN Aifeng，SHEN Xiaoqiang，XIE Wenjun，RU Chuhui，XU Jianpu

2019, 22(17): 2136-2140. DOI: 10.12114/j.issn.1007-9572.2018.00.211

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Objective　To study the clinical characteristics and treatment of primary Sjogren's syndrome （PSS） with bilateral pleural effusion （BPE） as the initial manifestation.Methods　 We retrospectively analyzed the clinical data of a case of PSS with BPE as the initial manifestation who received inpatient treatment from Respiratory Department，Hangzhou Red Cross Hospital on May 9，2016.Moreover，we reviewed the studies about the treatment for PSS with BPE as the initial manifestation published from 1975 to 2015 collected from the electronic databases of Wanfang Data Knowledge Service Platform，CNKI，PubMed and EMBase by searching with terms “Sjogren's syndrome” and “pleural effusion”.Results　 Our case was a 73-year-old woman，who was admitted to hospital due to suffering from cough and chest tightness after exercise for 2 years，and the symptoms aggravated for 1 month.Clinical manifestations were cough and chest tightness after exercise.B-mode ultrasound assessment of the chest identified BPE.Routine blood test found decreased white blood cell count，antinuclear antibodies，anti-SSA and anti-SSB antibodies.BPE analysis detected antinuclear antibodies anti-SSA and anti-SSB antibodies.After receiving treatment for regulating immune responses and hormone therapy，the BPE was absorbed，and the conditions were improved.12 studies were included after screening based on the inclusion and exclusion criteria.The totaled 13 cases （our case and 12 cases reported by the included studies） include 5 males and 8 females aged 40-73，with fever，cough，chest pain and breathing difficulty as the main manifestations，and lymphocytes accounting for most of the white blood cells.Moreover，most of these cases were found with antinuclear antibodies，anti-SSA and anti-SSB antibodies in serum and pleural effusion.Conclusion　PSS with pleural effusion is rare without specific clinical features，which is mainly treated by immunoregulation and hormone therapies after a definite diagnosis is made.The mechanism of pleural effusion associated with PSS is not clear and requires further exploration.

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