Chinese General Practice

Interpretation of SGLT-2 Inhibitors or GLP-1 Receptor Agonists for Adults with Type 2 Diabetes：a Clinical Practice Guideline　

AN Kang, LI Sheyu

2021, 24(26): 3269-3275. DOI: 10.12114/j.issn.1007-9572.2021.01.103

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With a comprehensive review of the latest evidence，the BMJ Rapid Recommendations released a clinical practice guideline entitled SGLT-2 inhibitors or GLP-1 receptor agonists for adults with type 2 diabetes，thoroughly introducing the selection of the two novel anti-diabetic drugs in adults living with type 2 diabetes. This guideline adopts a risk-based decision-making strategy instead of that based on glycemia or glycosylated hemoglobin control. It provides a visualized summary for both evidence and recommendations to facilitate quick check and shared-decision making for general practitioners.

Interpretation of Guidelines for the Rational Use of Antiviral Drugs in Children with Respiratory Viral Infectious Diseases　

HUANG Huan，ZHANG Fangxia，DUAN Miao，HUANG Bo

2021, 24(26): 3276-3280. DOI: 10.12114/j.issn.1007-9572.2021.01.208

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Many recent studies have reported the rational use of common antiviral drugs mostly for viral infectious diseases，yet there is no study comprehensively elaborating appropriate use of such drugs for respiratory viral infectious diseases in children. In 2020，the Chinese Hospital Association，united with National Center for Children's Health，National Medical Quality Control Center Infectious Disease，National Clinical Research Center for Respiratory Disease and other academic institutions jointly formulated the "Guidelines for the Rational Use of Antiviral Drugs in Children with Respiratory Viral Infectious Diseases "，whose publication has important guiding significance for the treatment of children with respiratory viral infectious diseases. This article interprets the guideline from the aspects of diagnosis and pathogenic testing，infection control，selection and use of antiviral drugs，etc，and aims to provide help for domestic pediatric colleagues to understand the guideline.

Temporal Trend of Prevalence of Depressive Symptoms and Associated Factors among Chinese Older Adults：an Analysis Based on the CHARLS Panel Data　

HU Yi，LI Bei

2021, 24(26): 3281-3287. DOI: 10.12114/j.issn.1007-9572.2021.01.207

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Background　Older adults are at high risk of depressive symptoms，which can cause a heavy disease burden. The prevalence of depressive symptoms in this population has been reported in many studies，but its temporal trend has been rarely studied by large-sample studies. Objective　To investigate the temporal trend of prevalence of depressive symptoms and associated factors among Chinese older adults. Methods　From September to October 2020，from participants（≥ 60 years old） of 2011（n=6 609），2013（n=7 158），2015（n=8 231） CHARLS with complete data，including prevalence of depressive symptoms，demographics （gender，age，education level，self-rated health），individual behaviors （smoking，alcohol consumption，sleep duration），social support （marital status），socioeconomic characteristics （hukou type，employment status），and other factors （ medical insurance，pension insurance）. Panel data matching was performed based on the above-mentioned cross-sectional data，and 11 055 cases with fully recorded follow-up data were obtained for three period，constituting a balanced short panel data set with n=3 685 and T=3. The prevalence and temporal trend of depressive symptoms were calculated by the cross-sectional data and follow-up data. A random-effects Logit model with a panel dichotomous choice model was used to explore the factors influencing depressive symptoms prevalence. Results　In 2011，2013，and 2015，the prevalence of depressive symptoms in older adults calculated based on cross-sectional data was 41.6% （2 747/6 609），32.6% （2 333/7 158），and 35.5% （2 919/8 231），respectively，showing no statistically significant trend of change （APC=-3.890，P=0.557）. The prevalence of depressive symptoms in older adults calculated based on the panel data was 38.4%
（1 414/3 685），30.2%（1 114/3 685），and 35.3% （1 301/3 685），respectively，demonstrating no statistically significant trend of change （APC=-2.080，P=0.776）. The results of the random effects Logit model showed that male 〔OR=0.463，95%CI（0.377，0.569）〕，having a spouse 〔OR=0.659，95%CI（0.549，0.792）〕，higher level of education 〔OR=0.756，95%CI（0.661，0.867）〕，having pension insurance 〔OR=0.862，95%CI（0.767，0.969）〕 were associated with decreased prevalence of depressive symptoms，while poor self-rated health 〔OR=2.564，95%CI（2.276，2.890）〕，smoking 〔OR=1.249，95%CI（1.032，1.513）〕，abnormal sleep duration 〔OR=2.069，95%CI（1.838，2.332）〕，and rural hukou 〔OR=2.047，95%CI（1.658，2.529）〕 were associated with increased prevalence of depressive symptoms. Conclusion　The prevalence of depressive symptoms in Chinese older adults was high in general. To reduce the prevalence to ensure healthy aging，more efforts should be made to deliver interventions for the prevention and control of depressive symptoms to women，individuals with poor self-rated health，smoking，abnormal sleep duration，no spouse，low education level，rural hukou，or no pension insurance.

Cardiopulmonary Coupling Analysis in Patients with Depressive Disorders Associated with Moderate to Severe Obstructive Sleep Apnea Syndrome　

SONG Suqi，ZHANG Kai，ZHOU Xiaoqin，LIU Huanzhong

2021, 24(26): 3288-3294. DOI: 10.12114/j.issn.1007-9572.2021.00.533

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Background　Obstructive sleep apnea syndrome（OSAS）can perpetuate depression throughout the course of the disorder，altering the clinical presentation of depression，affecting the efficacy and prognosis，and increasing the risk of relapse. However，there are few reports on the influencing factors of depressive disorder associated with OSAS. Objective　To comparatively analyze the sleep quality of depressive disorder patients with and without moderate to severe OSAS，and to examine associated factors for moderate to severe OSAS in depressive disorders. Methods　Inpatients with depressive disorders were recruited from Department of Psychosomatic Diseases，Chaohu Hospital of Anhui Medical University from June 2017 to September 2019 by two senior attending psychiatrists using structured interviews. The sex，age，BMI，course of depression and the number of depressive episodes were collected through a survey with a questionnaire（compiled by us on the basis of reviewing available related clinical studies）. The Pittsburgh Sleep Quality Index（PSQI）was used to evaluate the subjective sleep quality in the month prior to the study. Hamilton Depression Scale-17（HAMD-17）was used to evaluate the degree of depression. Cardiopulmonary coupling（CPC）was used to estimate sleep quality，and sleep parameters were collected，including total sleep time（TST），deep sleep time，light sleep time，REM sleep time，awakening time，duration of first stage of deep sleep，sleep efficiency，and apnea-hypopnea index（AHI）. AHI≥15 times per hour was defined as moderate to severe OSAS. Person correlation analysis was used to examine the correlation of CPC sleep parameters with demographic information，PSQI and 17-item Hamilton Rating Scale for Depression（HAMD-17）scores. The factors associated with moderate to severe OSAS in depressive disorders were identified through binary logistic regression analysis. Results　Altogether，102 cases were included，accounting for 64.7% of the total inpatients admitted during the period. There were 31 patients with moderate to severe OSAS and 71 patients without moderate to severe OSAS. Compared to patients without moderate to severe OSAS，those with moderate to severe OSAS had higher mean PSQI score，total score and scores of four subscales（anxiety somatic，insomnia，depressed mood，retardation）of HAMD-17，longer mean light sleep time and shorter mean deep sleep time（P<0.05）. TST was negatively correlated with PSQI score（r=-0.28）（P<0.05）. Light sleep time was negatively correlated with PSQI score（r=-0.71），HAMD-17 total score（r=-0.28），suicide score（r=-0.20），depressed mood score（r=-0.23）and retardation score（r=-0.30）（P<0.05）. Deep sleep time was positively correlated with PSQI score（r=0.34）and HAMD-17 total score（r=0.22）（P<0.05）. REM sleep time was negatively correlated with BMI（r=-0.24），and positively correlated with PSQI score（r=0.30），HAMD-17 total score（r=0.21）and suicide score（r=0.21）（P<0.05）. Awakening time was positively correlated with PSQI score（r=0.29）（P<0.05）. The duration of first stage of deep sleep was negatively correlated with anxiety somatic score（r=-0.21）（P<0.05）. Sleep efficiency was negatively correlated with PSQI score（r=-0.29）（P<0.05）. AHI was positively correlated with PSQI score（r=0.48），HAMD-17 total score（r=0.38），anxiety somatic score（r=0.24），insomnia score（r=0.20），depressed mood score（r=0.22）and retardation score（r=0.31）（P<0.05）. Binary Logistic regression analysis showed that PSQI total score 〔OR=2.11，95%CI（1.23，3.63）〕，HAMD-17 total score 〔OR=1.45，95%CI（1.11，1.91）〕 and light sleep time〔OR=22.65，95%CI（3.75，136.68）〕 were the influencing factors of moderate to severe OSAS in depressive disorder（P<0.05）. Conclusion　Depression disorder patients with moderate and severe OSAS had sleep abnormalities，such as longer light sleep time and shorter deep sleep time. PSQI score，HAMD-17 total score，and light sleep time were influencing factors for depression disorder with moderate to severe OSAS. It is necessary to screen these depressive patients using CPC.

Changes of Gut Microbial Metabolism and Blood Lipid Level on Schizophrenia at Different Stages　

YAO Lihui，MENG Xiaojing，WANG Zhongxian，CHEN Yuanyuan，CHENG Peng，SHI Li，LI Jingwei，SU Hong，ZHANG Xulai

2021, 24(26): 3295-3301. DOI: 10.12114/j.issn.1007-9572.2021.00.561

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Background　Intestinal microorganisms play a significant role in regulating host metabolism and dietary lipid metabolism.Recent studies have showed that schizophrenia is associated with lipid metabolism disorders and gut microbial dysbiosis to some degree.However，rare studies in China are focused on the characteristics of gut microbial metabolism and serum lipid metabolism in patients with schizophrenia at different stages. Objective　To study the changes of serum lipid and gut microbial metabolism in patients with schizophrenia，and further explore their influence on the disease. Methods　Forty-two schizophrenic patients in acute stage（acute group），41 schizophrenic patients in remission stage（remission group）and 40 healthy volunteers（healthy control group）were recruited from Anhui Mental Health Center from November 2018 to July 2019.General demographic information including gender，age，height，weight，BMI，and duration of schizophrenia were collected.Clinical symptoms of schizophrenia were assessed by the Positive and Negative Syndrome Scale（PANSS）. The blood sample was collected to measure the levels of total cholesterol（TC），high-density lipoprotein（HDL），triglyceride（TG），apolipoprotein A1（APOA1），apolipoprotein B1（APOB1）. The stool sample was collected to detect the characteristics of microbial metabolism by using the liquid chromatography-mass spectrometry.And the association of microbial metabolism and blood lipid levels with schizophrenia was explored. Results　The average scores of cognitive，excitement，and depression factors，positive and negative subscales and PANSS scale in acute group were higher than those in remission group（P<0.05）.The healthy control group had higher average levels of HDL and APOA1 than both remission and acute groups（P<0.05）.The average level of TG in remission group was higher than that in acute group or healthy control group（P<0.05）.There was a negative correlation between TC level and depression factor score in acute group（P<0.05）. There was a negative correlation between HDL level and negative subscale score in remission group（P<0.05）. The APOA1 level was positively correlated with the positive subscale score（P<0.05），and negatively correlated with the negative subscale score（P<0.05）.Compared with the control group，both acute and remission groups showed significantly changed overall microbial metabolic composition，and notably different lipid metabolism pathways such as steroid hormone synthesis，sphingolipid metabolism，cortisol synthesis and secretion，ovarian steroid production and regulation of fat metabolism in adipocytes（P<0.05）. Moreover，acute group also demonstrated abnormal biosynthesis of unsaturated fatty acid，linoleic acid metabolism and arachidonic acid metabolism pathway. Conclusion　Some abnormal changes in blood lipid and microbial metabolism were found in both acute and remission schizophrenic patients，of which dyslipidemia may be associated with schizophrenic symptoms，and the abnormal lipid metabolism of microorganisms may further affect the lipid metabolism process of the host，both of them are high risk factors for schizophrenia and should be valued in further research and diagnosis and treatment.

Correlation between CYP2C19 Gene Polymorphism and Clinical Prognosis of Patients with Atherosclerotic Stroke after Oral Clopidogrel Treatment in Different Age Groups

QIN Yiren，WANG Dapeng，ZHAO Hongru，FANG Qi

2021, 24(26): 3302-3309. DOI: 10.12114/j.issn.1007-9572.2021.01.012

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Background　As a classic platelet aggregation inhibitor，clopidogrel has been widely used in secondary prevention and treatment of patients with ischemic stroke. However，some patients with clopidogrel treatment still have ischemic stroke，which might be attributed to CYP2C19 gene polymorphisms，but it remains controversial whether CYP2C19 gene polymorphisms are independently associated with increased risk of stroke in different age groups of patients. Objective　To explore the correlation between CYP2C19 polymorphisms and clinical outcomes in different age groups of patients with minor stroke caused by large-artery atherosclerosis（LAA）. Methods　A total of 479 inpatients with minor stroke due to LAA（169 cases≤60 years old，and 310 cases>60 years old） and one-year oral administration of clopidogrel were selected from Department of Neurology，the First Affiliated Hospital of Soochow University from April 2015 to April 2018. Baseline data were collected，including age，gender，NIHSS score，blood glucose，high-density lipoprotein（HDL），low-density lipoprotein（LDL），total cholesterol（TC），triacylglycerol（TG），white blood cell count，prevalence of diabetes，hypertension，CYP2C19 LOF alleles，smoking，and drinking. Recurrence of stroke or death within three months after stroke was obtained during follow-up. One-year clinical outcome was evaluated using the Modified Rankin Scale（mRS）（mRS score ≤2 indicating good outcome，and mRS score >2 indicating poor outcome）. The homogeneity test was used to analyze the heterogeneity of the results in different age groups. Multivariate Logistic regression was used to analyze the potential predictors of outcome in different age groups. Results　In patients aged ≤60 years old，significant differences in average NIHSS score，blood glucose，LDL，and white blood cell count，as well as prevalence of diabetes，hypertension，CYP2C19 LOF，smoking between good and poor outcome cases（P<0.05）. In patients aged>60 years，there were statistically significant differences in gender ratio，average blood glucose，HDL，LDL，and TG，as well as prevalence of diabetes，and hypertension between good and poor outcome cases（P<0.05）. Breslow-Day test found that there was an interaction effect between age and correlation of CYP2C19 LOF allele carriage with clinical outcome （χ2=6.352，P=0.012）. Tarone test also demonstrated that there was an interaction effect between age and correlation of CYP2C19 LOF allele carriage and clinical outcome（χ2=6.351，P=0.012）. The size of the interaction effect analyzed using binary Logistic regression showed that the difference in the size of the interaction effect was statistically significant〔P=0.013，OR=3.63，95%CI（1.31，10.07）〕. In addition，there was no heterogeneity in the correlation between CYP2C19 LOF alleles and stroke recurrence or death 3 months after stroke in patients of different age groups（P>0.05）. CYP2C19 LOF allele carriers had higher rate of stroke recurrence or death within 3 months after stroke than non-carriers（P=0.023）. Multivariate Logistic regression analysis showed that in patients ≤60 years old，CYP2C19 LOF alleles carriage，hypertension，diabetes，smoking，and elevated LDL may be independent predictors of clinical outcome（P<0.05）. Among those aged >60 years old，hypertension，diabetes，drinking，male，elevated blood glucose and HDL may be independent predictors of clinical outcome（P<0.05）. After controlling for confounding factors，such as CYP2C19 LOF alleles，hypertension，diabetes，smoking，drinking，gender，NIHSS score，blood glucose，TC，TG，LDL，HDL，and white blood cell count，it is still not certain whether CYP2C19 LOF was the independent predictor of stroke recurrence or death three months after stroke（P>0.05）. Conclusion　The correlation between CYP2C19 polymorphisms and long-term clinical outcome might be stronger in younger patients with minor stroke due to LAA treated with clopidogrel.

Analysis of Risk Factors of Lung Cancer Patients Combined with Sarcopenia and Their Correlation with Clinical Prognosis　

LI Zhouhua，JI Shuang，HU Xianwei，YOU Qinghai，FEI Guanghe

2021, 24(26): 3310-3315. DOI: 10.12114/j.issn.1007-9572.2021.00.599

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Background　Patients with lung cancer often suffer from sarcopenia，but the relationship between sarcopenia and quality of life，emotional status is unclear. Objective　To investigate the incidence of sarcopenia in lung cancer patients，analyze its risk factors and their impact on the clinical prognosis including emotional status，quality of life，etc，so as to provide evidence for the overall improvement of the clinical prognosis of lung cancer patients. Methods　87 patients with lung cancer who attended the Department of Respiratory and Critical Care Medicine，the First Affiliated Hospital of Anhui Medical University from December 2019 to July 2020 were recruited，and their age，gender，education level，smoking status，tumor pathological type，PS score，length of illness，treatment status，comorbidities，body mass index（BMI）were collected，their hemoglobin，lactate dehydrogenase，prealbumin，albumin were measured. The body composition analyzer was used to measure the muscle mass of the limbs and calculate skeletal muscle mass index （SMI），and the patients were divided into sarcopenia group（46 cases）and no sarcopenia group（41 cases）according to the diagnostic criteria of the Asia Working Group on Sarcopenia in Older People（AWGSOP）. The Nutritional Risk Screening 2002（NRS2002）was used to evaluate the patients' malnutrition risk，the Quality-of-Life Questionnaire-Core 30（QLQ-C30）was used to evaluate the quality of life of the patients，and the Hospital Anxiety and Depression Scale（HADS）was used to evaluate the emotional state of the patients. Binary logistic regression analysis was used to explore the influencing factors of lung cancer combined with sarcopenia，and Pearson correlation analysis was used to explore the correlation between sarcopenia and quality of life，emotional status. Results　The prevalence of sarcopenia in lung cancer patients was 52.9%. Age，proportion of long-term smoking，Charlson comorbidity index，NRS2002 score，and risk of malnutrition in the sarcopenia group were higher than the non-sarcopenia group，while BMI，limb muscle mass，and SMI were lower than the non-sarcopenia group（P<0.05）. The results of binary logistic regression analysis showed that long-term smoking history〔OR=5.515，95%CI（1.234，24.646）〕，duration of illness〔OR=1.132，95%CI（1.007，1.272）〕，BMI 〔OR=0.676，95%CI（0.519，0.880）〕，NRS2002 score 〔OR=1.773，95%CI（1.012，3.108）〕 are the influencing factors of lung cancer combined with sarcopenia. The scores of anxiety scale，depression scale，fatigue，pain，shortness of breath，and loss of appetite in the sarcopenia group were higher than the no sarcopenia group（P<0.05）. The total score of QLQ-C30，the scores of physical function，role function，emotional function，and social function in sarcopenia group were lower than the no sarcopenia group（P<0.05）. Pearson correlation analysis results showed that sarcopenia was positively correlated with the scores of anxiety，depression，fatigue，pain，shortness of breath，and appetite loss（P<0.05），but negatively correlated with the scores of global quality of life，role functioning，physical functioning，emotional functioning，social functioning（P<0.05）. Conclusion　Longer disease duration，long term smoking history，higher NRS2002 score and lower BMI has higher risk for developing sarcopenia. Sarcopenia is significantly associated with poorer quality of life，and anxiety and depressive symptoms in patients with lung cancer.

Study on the Effect of Baseline Blood Lipid Level on the Prognosis of Patients with Non-triple-negative Breast Cancer　

WU Wenxia，ZHANG Meng

2021, 24(26): 3316-3322. DOI: 10.12114/j.issn.1007-9572.2021.01.009

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Background　Dyslipidemia is one of high risk factors of breast cancer. Current studies have found that the level of blood lipid metabolism may also be closely related to the stage，pathology，overall survival（OS） and disease free survival（DFS） of breast cancer，but the results were stil controversial. Objective　To explore the effect of baseline blood lipid metabolism on the prognosis of non-Triple Negative Breast Cancer（TNBC）. Methods　Retrieved from January 2019 to March 2021 in Sun Yat-sen memorial Hospital from January 2016 to March 2017 in the electronic medical record system，202 cases of non-triple-negative breast cancer patients were included. All the patients had no history of diabetes，dyslipidemia，cardiovascular or cerebrovascular disease. The clinical general information including age，menopausal status，history of hypertension，body mass index（BMI），fasting blood glucose，blood lipids〔including total cholesterol（TC），triacylglycerol（TG），low-density lipoprotein cholesterol（LDL-C），high-density lipoprotein cholesterol（HDL-C），apolipoprotein A1（APOA1），apolipoprotein B（APOB），apolipoprotein E（APOE）〕，high-sensitivity C-reactive protein （hsCRP），uric acid，pathological results 〔including tumor size（T stage），lymph node metastasis（N stage），ER，PR，HER-2，Ki-67，tissue grade〕were collected. The OS and DFS time until three years of diagnosis were recorded. The patients were divided into two groups according to the breast cancer stage. Group 1was stage Ⅰ-Ⅱ and group 2 was stage Ⅲ. Kaplan-Meier curves were used to determine OS and DFS rates. Log rank-tests were performed to compare differences in survival curves. Multivariable Cox proportional hazards regression models were used to study the associations between pre-diagnostic lipids and DFS，OS of non-TNBC. Results　The TG level of group 2 was higher than that of group 1，while the level of HDL-C was lower than that of group 1
（P<0.05）. The optimal cutoff values of the TG level and HDL-C were determined to be 1.39 mmol/L〔AUC=0.626，95%CI（0.562，0.690）〕 and 1.14 mmol/L〔AUC=0.599，95%CI（0.531，0.668）〕，respectively. The proportion of stage Ⅲ was higher in patients with TG≥1.39 mmol/L or HDL-C<1.14 mmol/L than TG<1.39 mmol/L or HDL-C≥1.14 mmol/L（P<0.05）. Patients with TG≥1.39 mmol/L had higher proportion of lymph node metastasis than with TG<1.39 mmol/L. Patients had more advanced T stage in group with HDL-C<1.14 mmol/L than HDL-C≥1.14 mmol/L. Patients with HDL-C≥1.14 mmol/L had higher OS（98.1%）and DFS（89.8%） than HDL-C<1.14 mmol/L，which was 90.9% and 77.4% respectively（χ2=4.669，P=0.031；χ2=3.859，P=0.049）. After adjusting for menopausal status，BMI，blood pressure and blood glucose levels，baseline HDL-C<1.14 mmol/L is considered recurrence，metastasis〔HR=2.907，95%CI（1.024，8.255），P=0.045〕 and death〔HR=8.718，95%CI （1.148，66.198），P=0.036〕 influencing factors. Conclusion　HDL-C<1.14 mmol/L might be an influencing factor for the poor clinical prognosis of non-triple-negative breast cancer.

Viral Spectrum and Clinical Features in Adult Inpatients with Community-acquired Pneumonia and Respiratory Viral Infection　

HE Yanchao，ZHANG Jing，FENG Jingjing，MEI Zhoufang，QIAN Ling，HUANG Qihui，JIE Zhijun

2021, 24(26): 3323-3329. DOI: 10.12114/j.issn.1007-9572.2021.00.588

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Background　It is unclear whether there is a difference in clinical therapies for adults with community-acquired pneumonia（CAP） complicated with respiratory virus infection（RVI） and CAP alone. This study tried to explore the issue by analyzing the viral spectrum of adults with CAP with RVI，and comparing their clinical features with those with CAP alone. Objective　To investigate the viral spectrum and clinical features of adults with CAP and RVI. Methods　Nasopharyngeal swab samples of 223 CAP patients who were admitted to the inpatient department of Shanghai Fifth People's Hospital from June 2017 to May 2019 were collected. Nested multiplex RT-PCR technique was adopted to detect the 8 species（10 common types） of respiratory viruses in throat swabs，and according to the results，patients were divided into virus-positive and virus-negative groups，and clinical features of virus-positive group were analyzed. ELISA was used to detect the concentration of 6 cytokines（IL-6，IL-8，IL-10，IFN-γ，IP-10，TNF-α） in serum samples of 24 virus-positive CAP patients，24 virus-negative CAP patients and 24 community healthy controls. Results　 Sixty-one（27.35%） were detected positive for respiratory viruses in throat swabs，3 of whom had multiple virus infection，and the other 58（26.01%） had single virus infection，including 22 cases（9.87%） of influenza A virus（Flu A），14 cases（6.28%） of rhinovirus（RhV），9 cases（4.03%） of influenza B virus（Flu B），5 cases（2.24%） of adenovirus，2 cases（0.90%） of coronavirus，2 cases（0.90%） of respiratory syncytial virus A，2 cases（0.90%） of metapneumovirus，1 case（0.45%） of bokavirus，and 1 case（0.45%） of respiratory syncytial virus B. There was no significant difference in virus detection rate between non-elderly group（≤65 years old） and elderly group（>65 years old）（P>0.05）. Patients were infected throughout the four seasons，with a high incidence in winter，and the infected viruses mainly included Flu A，RhV and Flu B. Virus-positive group had statistically higher death rate than virus-negative group（P<0.05）. And all deceased cases in virus-positive group had got the influenza infection. Further analysis found that the LDH level was higher in those with influenza infection（including Flu A and Flu B） than in those without（P<0.05） in virus-positive group. And those with influenza infection in virus-positive group had higher death rate than virus-negative group（P<0.05）. In imaging features analysis，bilateral lung lesions，multiple lobe lesions and patchy exudation presented more frequently in virus-positive group（P<0.05）. Serum concentrations of IL-10 of virus-positive group were significantly higher than those of virus-negative group（P<0.05）. Conclusion　 RVI was common in CAP patients in Shanghai's Minhang District，and the viruses detected were mainly Flu A，RhV and Flu B. Clinical features of CAP virus-positive patients lacked specificity. Influenza virus infection may increase the mortality of CAP. CAP virus-positive patients showed bilateral lung lesions，multiple lung lobe lesions and patchy exudation frequently in chest image，and presented a significant increase in the serum IL-10 levels. These results may provide certain reference values for the management of CAP complicated with RVI.

Association Analysis of Sleep Quality with School Bullying Victimization Experiences among Junior High School Students in Sanya City　

DUAN Fangfang，WANG Peipei，ZHENG Qinliang，DU Li，YANG Chunju，XIONG Xiaohua，ZHOU Ting，ZHANG Chi，WANG Guanghai

2021, 24(26): 3330-3337. DOI: 10.12114/j.issn.1007-9572.2021.01.011

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Background　Sleep quality is closely related to psychosomatic health in junior high school students. Previous studies suggest that bullying may be associated with sleep quality，but the association between the two in junior high school students has been rarely studied. Objective　To explore the association between sleep quality and bullying victimization experiences in junior high school students in Sanya City. Methods　An online，cross-sectional questionnaire survey was conducted from 2020-03-18 to 2020-04-18 in Sanya City to collect information on demographic characteristics，Pittsburgh Sleep Quality Index（PSQI）score，Insomnia Severity Index （ISI）score，clinical insomnia diagnosis，bullying victimization experiences，and related distresses and injuries. Students from nine public junior high schools in three most populated districts participated in this study：five schools in Tianya District，three schools in Jiyang District and one school in Yazhou District. Descriptive data were presented as two groups：one group with bullying victimization experiences and the other group without. Logistic regression was used to analyze the association between sleep quality and bullying victimization experiences. Results　Among the 3 050 students who participated in the survey，2 727 submitted questionnaires，and 2 167 of them were eligible respondents，including 125 with self-reported bullying victimization experience and 2 042 without，indicating that the survey response rate was 79.5%. Students with and without bullying victimization experiences differed significantly in mean age，gender ratio，grade distribution，and distribution of anxiety and depression levels（P<0.05）. Male students had higher rate of having self-reported bullying victimization experiences than female students（P<0.05）. Higher percentage of grade eight or nine students reported bullying victimization experiences than grade seven students（P<0.05）. Those with anxiety and/or depression had higher rate of experiencing bullying victimization than those without （P<0.05）. There were significant differences in prevalence of poor sleep outcomes，global PSQI score and subscale PSQI scores of subjective sleep quality，sleep latency，sleep duration，sleep disturbances，use of sleeping medication，and daytime dysfunction，ISI total score，prevalence of insomnia symptoms，and prevalence of clinical diagnosed insomnia between students with and without bullying victimization experiences（P<0.05）. Self-perceived bullying severity was positively correlated with global PSQI score（rs=0.166，P<0.001）） and ISI total score （rs=0.151，P<0.001）. After adjusted for age，gender，BMI，grade，ethnic group，being an only child or having siblings，resident status （on/off campus），paternal education，maternal education，and educational performance，bullying victimization experiences remained significantly associated with poor sleep outcomes（global PSQI score >7）（OR=3.54，P<0.001），poor subjective sleep quality（OR=3.47，P<0.001），longer sleep latency（OR=2.28，P<0.001），shorter sleep duration（OR= 1.88，P<0.001），sleep disturbances（OR=2.93，P<0.001），more frequent use of sleeping medication（OR=10.49，P<0.001），worse daytime dysfunction（OR=4.31，P<0.001），insomnia symptoms（OR=4.95，P<0.001），and being diagnosed with insomnia（OR=2.76，P<0.001）. Furthermore，after anxiety and depression being added as cofounders in model 2，bullying victimization experiences remained significantly associated with poor sleep outcomes（global PSQI score >7）（OR=2.45，P=0.001），poor subjective sleep quality（OR=2.71，P<0.001），longer sleep latency（OR=1.92，P=0.002），shorter sleep duration（OR=1.59，P=0.025），sleep disturbances（OR=2.27，P<0.001），more frequent use of sleeping medication（OR=4.75，P=0.039），worse daytime dysfunction（OR=3.19，P<0.001），and or insomnia symptoms （ISI≥8）（OR=3.18，P<0.001）. Conclusion　Bullying victimization experiences might be a risk factor of poor sleep outcomes among junior high school students.

Exploration on the Detection Results of 2019 Novel Coronavirus Antibodies in the Real World　

DAI Juhua，LIN Bozhi，SUN Xinping

2021, 24(26): 3338-3342. DOI: 10.12114/j.issn.1007-9572.2021.01.302

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Background　In the early stage of COVID-19，the colloidal gold method was the first to be approved by the National Medical Products Administration for clinical use，but the interfering factors of false positive antibody test results are still unclear. Objective　To explore how to analyze and interpret the positive results of COVID-19 antibody test in clinical practice. Methods　A total of 8 678 patients simultaneously submitted for SARS-CoV-2 IgM/IgG antibody and nucleic acid in Peking University International Hospital from March to June 2020 for retrospective analysis were included in the inretrospective analysis. The epidemiological history，clinical manifestations and laboratory indicators（including SARS-CoV-2 IgM/IgG antibody and nucleic acid，rheumatoid factor，complement，immunoglobulin）. The colloidal gold method was used to detect the SARS-CoV-2 IgM/IgG antibody，and the positive check of the antibody was performed by the magnetic particle chemiluminescence method. RT-PCR method was adopted to detect SARS-CoV-2 nucleic acid. The heterophilic antibody blocking tube（HBT）was used to process the specimens that were positive by the colloidal gold method，and then the test was performed again. Results　（1）Among the 8 678 patient specimens submitted for examination，8 677 were negative for SARS-CoV-2 nucleic acid detection，of which 25 cases（0.288%）were positive for SARS-CoV-2 IgM antibody detected by colloidal gold method，SARS-CoV-2 -5 patients（0.058%）with IgG antibody positive，and 0 patients with SARS-CoV-2 IgM and SARS-CoV-2 IgG antibodies at the same time.（2）Thirty patients who tested positive for SARS-CoV-2 antibody by colloidal gold method had no epidemiological history，and at the same time，the results of SARS-CoV-2 nucleic acid test were negative. The possibility of SARS-CoV-2 infection or previous SARS-CoV-2 infection was ruled out. Among them，10 patients with positive SARS-CoV-2 IgM antibody were still positive after more than 2 times of dynamic monitoring，and the remaining 20 patients were not clinically active monitored.（3）The false positive rate of SARS-CoV-2 IgM antibody detected by colloidal gold method was 0.288%，and the false positive rate of SARS-CoV-2 IgG antibody was 0.058%. After HBT was used to process the SARS-CoV-2 colloidal gold-positive specimens，among the 25 SARS-CoV-2 IgM antibody-positive specimens，except for 1 case which was still positive，the other results became negative；the results of 5 specimens with positive SARS-CoV-2 IgG antibody were still positive.（4）The rheumatoid factor，complement and immunoglobulin levels of 30 SARS-CoV-2 antibody-positive patients were within the normal reference range. Conclusion　The SARS-CoV-2 antibody test results may have false positives. The majority of SARS-CoV-2 IgM antibody positives are caused by heterophilic antibody interference. Those with SARS-CoV-2 IgG antibody positive may also have other potentially unknown interference factors. Heterophile antibodies interfere with colloidal gold methods more than chemiluminescence methods. Therefore，non-suspected patients or confirmed patients should not be tested for SARS-CoV-2 antibody to guide clinical practice，and the interference factors of the experiment must be considered.

A Follow-up Survey on Mental Health Status of COVID-19 Survivors　

WANG Xixin，CAO Jie，YANG Yanguo，XU Fei，XIA Lei，HU Xiaowen，LIU Huanzhong

2021, 24(26): 3343-3348. DOI: 10.12114/j.issn.1007-9572.2021.01.303

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Background　The "Work Plan for Psychological Counseling of Patients Under Normalization of Prevention and Control of New Coronary Pneumonia" in September 2020 pointed out that it is important to strengthen the follow-up of the psychological status of COVID-19 patients after recovery. At present，cross-sectional studies have found that patients have frequent mental health problems after recovery，but there is still a lack of dynamic follow-up studies. Objective　A dynamic follow-up survey was conducted to investigate the mental health status and its influencing factors of COVID-19 patientstwo weeks and three months after recovery and discharge. Methods　 COVID-19 patients diagnosed in two designated hospitals in Anhui Province from February to April 2020 were selected as the research objects，the thegeneral demographic data were collected，and the Streaming Depression Self-Rating Scale （CES-D），Insomnia Severity Index Scale （ISI），Somatization Symptom Self-rating Scale（SSS） and Post-Traumatic Stress Disorder Checklist（PCL） were used for mental health status evaluation. Results　One hundred and twenty five questionnaires were distributed.The results showed that the incidences of depression，insomnia，PTSD and somatization symptoms in COVID-19 patients at 2 weeks after discharge were 9.92% （12/121），26.45%（32/121），1.65%（2/121） and 4.96%（6/121），respectively. The incidences of depression，insomnia，PTSD and somatization symptoms at 3 months were 36.47%（31/85），83.53%（71/85），8.24%（7/85） and 18.82%（16/85），respectively. There was no significant difference in gender，age，health status，family support，need for psychological assistance and acceptance of psychological assistance between 2 weeks and 3 months after discharge （P>0.05）. There were significant differences in the economic status，physical and mental impairment and care about the views of the people around them at 2 weeks and 3 months after discharge（P<0.05）. The total scores of CES-D，ISI，SSS and PCL at 3 months after discharge were higher than those at 2 weeks after discharge（P<0.05）. In the Multivariate Logistic regression analysis with depression as the dependent variable，age and the need for psychological assistance were the risk factors of depression at 2 weeks after discharge（P<0.05）. Physical and mental impairment was the risk factor of depression at 2 weeks and 3 months after discharge（P<0.05）. The risk factor of depression at 3 months after discharge was caring about the views of the people around them. Patients who cared about the views of others were 3.997 times more likely to suffer from depressive symptoms than those who didn't〔OR （95%CI）=3.997（1.708，9.351），P=0.001〕. In the Multivariate Logistic regression with insomnia as the dependent variable，age，physical and mental impairment and the need for psychological assistance were the risk factors of insomnia at 2 weeks after discharge（P<0.05）. The risk factor of insomnia at 3 months after discharge was caring about the views of the people around them or not. Patients who cared about the views of others were 10.255 times more likely to suffer from insomnia than those who didn't〔OR （95%CI）= 10.255 （2.796，37.611），P<0.001〕.Conclusion　 After recovery and discharge，COVID-19 patients have obvious mental health problems such as depression，insomnia，post-traumatic stress disorder and somatization symptoms，and the longer the follow-up period，the higher the incidence of symptoms. Psychiatric professionals need to carry out psychological crisis intervention as soon as possible.

Risk Factors for Breast Cancer-related Lymphedema in Chinese Women：a Meta-analysis　

ZHANG Hao，LIU Ruirui，ZHU Lin，BO Dingxi，ZHONG Yizhu，LIANG Yun，GAO Jing

2021, 24(26): 3349-3358. DOI: 10.12114/j.issn.1007-9572.2021.01.206

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Background　Breast cancer-related lymphedema （BCRL）is the most common postoperative complication of breast cancer，which cannot be cured clinically at present. Early identification of the risk factors for BCRL may improve the outcome significantly，yet it is still controversial in existing relevant studies，and there is no relevant systematic review in China. Objective　To systematically evaluate the risk factors for BCRL in Chinese women. Methods　We searched the databases of CINAHL，PubMed，EMBase，Web of Science，The Cochrane Library，CNKI，CQVIP，Wanfang Data and SinoMed for articles about the risk factors of BCRL among Chinese women published from inception to June 2020.Two researchers independently screened the studies based on the inclusion and exclusion criteria，extracted data 〔including the first author，time of publication，type of studies，sample size，measurement methods for edema，degree of edema，follow-up time，and BCRL-related factors（age，BMI，hypertension prevalence，lymph node metastasis prevalence，scope of axillary lymph node dissection，having a lymph node dissection，number of lymph nodes dissected，postoperative healing complication，chemotherapy，radiation therapy）〕，and performed risk of bias assessment using the Newcastle-Ottawa Scale. Meta-analysis was performed using RevMan 5.3. Results　31 studies involving 2 618 subjects were included，with moderate or high methodological quality. Meta-analysis showed that older age〔OR=2.59，95%CI（1.95，3.45），P<0.000 01〕，increased BMI〔OR=2.33，95%CI（1.91，2.85），P<0.000 01〕，hypertension〔OR=4.76，95%CI（2.53，8.94），P<0.000 01〕，lymph node metastasis〔OR=1.22，95%CI（1.06，1.39），P=0.005〕，extended axillary lymph node dissection〔OR=2.30，95%CI（1.88，2.81），P<0.000 01〕，having a lymph node dissection〔OR=8.29，95%CI（2.32，29.60），P=0.001〕，number of dissected lymph nodes ≥15〔OR=1.12，95%CI（1.06，1.19），P<0.000 1〕，postoperative healing complication〔OR=4.11，95%CI（3.26，5.17），P<0.000 01〕，chemotherapy〔OR=3.17，95%CI（2.16，4.63），P<0.000 01〕，radiation therapy〔OR=2.69，95%CI（2.32，3.13），P<0.000 01〕were risk factors of BCRL. Conclusion　BCRL among Chinese women may be associated with various risk factors，such as age>40，BMI≥24 kg/m2，hypertension，lymph node metastasis，extended axillary lymph node dissection，having a lymph node dissection，number of dissected axillary lymph nodes ≥15，postoperative healing complication，chemotherapy，and radiation therapy. Due to limited quality and quantity of the included studies，more large-sample prospective cohort studies are required to verify the above conclusion.

Systematic Review of Efficacy and Safety of Rhodiola Wallichiana Injection in Treating Coronary Heart Disease and Angina　

LI Deheng，WANG Tianyuan，ZHANG Huina，FENG Shuo，HU Jing，WANG Hong，LI Bo

2021, 24(26): 3359-3368. DOI: 10.12114/j.issn.1007-9572.2021.01.210

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Background　Coronary heart disease and angina is often encountered clinically，which is mainly caused by insufficient blood supply of coronary artery，impairing the cardiac function，quality of life，and even threatening the life. Existing routine treatment may produce adverse reactions such as hypotension，endothelial function damage，liver damage and myopathy. Rhodiola and its related preparations have been gradually used for cardiovascular disease，but relevant systematic evaluations are not comprehensive enough. Objective　To systematically assess the efficacy and safety of Rhodiola wallichiana injection（RWI）in coronary heart disease and angina. Methods　Databases of PubMed，The Cochrane Library，Embase，CNKI，CQVIP，SinoMed，and Wanfang Data were searched from inception to January 13th，2021 for randomized controlled trials（RCTs）about coronary heart disease and angina patients treated with RWI and routine therapy（experimental group）compared with those treated with routine therapy（control group）. Two researchers separately screened the literature，and extracted data from the included RCTs，including the first author，time of publication，size and age of the sample，interventions，course of treatment，outcome indicators〔angina response to treatment，and electrocardiographic response to treatment，hemorheological indices（whole blood viscosity at high and low shear rates，fibrinogen，D-dimer），oxidative stress markers（SOD，malondialdehyde），C-reactive protein，clinical response rate，and incidence of adverse reactions〕. The Cochrane risk-of-bias tool was used to evaluate the methodology quality. RevMan 5.3 was used for meta-analysis. Results　Altogether，28 RCTs involving 2 475 participants were finally included. The overall quality of the RCTs was rated as relatively low. Meta-analysis showed that compared with the control group，the experimental group had higher angina response to treatment〔RR=1.22，95%CI（1.13，1.31），P<0.000 01〕，higher electrocardiographic response rate to treatment〔RR=1.22，95%CI（1.16，1.29），P<0.000 01〕，greater decrease in whole blood viscosity at a high shear rate〔MD=-1.06，95%CI（-1.20，-0.91），P<0.05〕，and at a low shear rate〔MD=-1.61，95%CI（-1.90，-1.31），P<0.000 01〕，greater improvement in levels of fibrinogen〔MD=-0.36，95%CI（-0.48，-0.24），P<0.000 01〕，D-dimer〔MD=-19.84，95%CI（-45.58，-5.91），P=0.13〕，SOD〔SMD=2.52，95%CI（2.14，2.89），P<0.000 01〕，malondialdehyde 〔SMD=2.56，95%CI（-3.57，-1.56），P<0.000 01〕，and CRP〔MD=-2.15，95%CI（-2.62，-1.68），P<0.000 01〕，as well as higher clinical response rate〔RR=1.24，95%CI（1.17，1.30），P<0.000 01〕. The incidence of adverse reactions was lower in the experimental group〔RR=0.68，95%CI（0.35，1.35），P=0.27〕. Conclusion　Compared to routine treatment alone，its combination with RWI may generate better effect on improving the angina response to treatment，electrocardiographic response to treatment，hemorheological indices，CRP and oxidative stress markers，with lower incidence of adverse reactions.

Latest Advances in Mechanisms of Non-pharmacological Interventions to Improve Multiple Chronic Conditions　

ZHAO Minjun，LI Shuangqing

2021, 24(26): 3369-3376. DOI: 10.12114/j.issn.1007-9572.2021.01.102

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As an important adjuvant therapy or primary treatment for single or multiple chronic conditions，the efficacy of non-pharmacological interventions has been widely recognized，and the potential of them has been valued increasingly，especially when pharmacological interventions constitute a considerable economic burden，but there is a lack of systematic understanding of the possible mechanism of action of non-pharmacological interventions. Considering this，we reviewed mechanisms of actions of current non-pharmacological interventions （involving exercise，diet and psychology） for chronic diseases，which affect the disease development through regulating inflammation-immune responses，and stress responses，modulating glucose and lipid metabolism，gene expression and intestinal microbiota，via each pathway individually or interactively. This review will help to enhance the understanding of the complex pathogenesis of multimorbidity，and the great potential of non-pharmacological interventions against the pathogenesis.

Research Progress in High-risk Infants Follow-up after Discharge　

WANG Peiyue，SHEN Fang，ZENG Lin，HAN Tongyan

2021, 24(26): 3377-3382. DOI: 10.12114/j.issn.1007-9572.2021.00.483

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High-risk neonatal survival rate is obviously increased with the development of technology in Neonatal Intensive Care Unit （NICU），and the number of preterm infants also increases. Compared with normal newborns，high-risk infants are at great risk for developmental problems and poor outcomes. Follow-up of high-risk infants after hospital discharge is of great significance for early detection of developmental delay and early intervention，to improve of long-term prognosis and enhance the life quality. This article introduces the definition and classification of high-risk infants，and the research progress for follow-up of high-risk infants after discharge in China and in the world，so as to provide the information for management of high-risk infants follow-up.
Intensive care，neonatal；High-risk infants；Aftercare；Review；Follow-up studies

YEARS Algorithm：a New Diagnostic Strategy for Suspected Pulmonary Embolism　

WANG Yueyue，XU Qixia

2021, 24(26): 3383-3386. DOI: 10.12114/j.issn.1007-9572.2021.01.007

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Pulmonary embolism is a common pulmonary vascular disease with high rates of misdiagnosis and missed diagnosis. Early identification，diagnosis and treatment are essential to improve the prognosis of patients. Although pulmonary angiography is deemed as the gold standard for the diagnosis of pulmonary embolism，it has been gradually replaced by CT pulmonary angiography due to high cost，invasion and risk of radiation exposure. However，if patients with suspected pulmonary embolism are not effectively evaluated，it may lead to overuse of examinations，and waste of medical resources，as well as an increase in patients' risk of exposure to radiation. There are a variety of scoring models that can be used as assistant tools for effectively ruling out suspected pulmonary embolism. But those using the traditional scoring method are not easily to be promoted due to complexity. In contrast，the YEARS algorithm，a recently emerged model，is simple and mnemonic，which can be used to safely，effectively and rapidly exclude suspected pulmonary embolism，and is easily to be promoted. But its diagnostic value still needs to be verified since studies on its clinical application are limited. This article reviews clinical studies of YEARS algorithm，offering new ideas for pulmonary embolism diagnosis.

The Treatment Value of Taking Twice Abiraterone Acetate for the Metastatic Prostate Cancer　

WANG Hui，ZHAO Shankun，LIU Shixiong，LI Xin

2021, 24(26): 3387-3391. DOI: 10.12114/j.issn.1007-9572.2021.00.505

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Abiraterone acetate（AA），a new antiandrogen，has just recently been introduced into the Chinese market，and used once for most patients. We retrospectively analyzed the diagnosis and treatment process of two cases of metastatic prostate cancer（mPC）treated using a comprehensive treatment scheme including the “sandwich” therapy with AA，and found this scheme may be effective for mPC. Moreover，we also found that the response time of the first AA treatment may be longer if the first AA treatment was stopped as early as possible at the end of the hormone-sensitive period，but that may be shorter if being stopped later in the castrate-resistant period. Furthermore，early discontinuation of the first AA treatment significantly prolonged the overall drug response period and the cancer-specific survival. Therefore，the "sandwich" regimen of AA could be used as a new strategy to improve the efficacy of mPC. And the earlier discontinuation regimen will be more conducive to optimizing the existing sequential treatment of mPC than the later discontinuation regimen.

Recurrent Purulent Meningitis in Children：an Analysis of 15 Cases　

LI Xin，SUN Suzhen，PANG Lingyu，WEN Xin，WANG Weixiu

2021, 24(26): 3392-3396. DOI: 10.12114/j.issn.1007-9572.2021.00.506

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Background　Recurrent purulent meningitis（RPM）is a rare disease in children，which is easily missed due to the complex and insidious etiology. So early detection and diagnosis in time has a positive impact on improving the prognosis. But there are few clinical studies and etiological analyses on RPM in children. Objective　To study the clinical characteristics，possible causes and treatments of RPM. Methods　Clinical data of 15 pediatric inpatients with RPM were collected retrospectively from Hebei Children's Hospital from 2012 to 2018. All cases underwent brain and spinal cord MRI，temporal bone CT scan，hearing screening or immune function test according to different possible causes of RPM，and received normal cerebral therapy（including antibiotic and dehydration treatment and so on），and treatment targeting the possible cause，as well as a post-discharge telephone follow-up ranging from 6 to 36 months. Results　Of the 15 cases，8 were male and 7 female，with an age of first onset of 24 days to 9 years old，and an average age of onset of（3.1±2.6）years old. The time to onset ranged from 4 hours to 7 days，with presentations of fever and poor mental health status in all cases. Headache and jet vomiting were found in older children，while babies had irritability and bulging of the anterior fontanelle. Cerebrospinal fluid culture was positive in 15 cases，and blood culture was positive in 8 cases. The underlying causes of 15 cases of RPM：structural abnormality in 7 cases （46.7%）〔internal ear dysplasia（4 cases），pilonidal sinus（2 cases），discontinuous cortex of skull base ethmoid plate（1 case）〕，purulent meningitis after craniofacial trauma in 3 cases (20.0%)〔brain contusion and laceration（1 case），traumatic cerebrospinal fluid rhinorrhea（1 case），traumatic tympanic membrane perforation with humoral immunodeficiency（1 case）〕，adjacent tissue inflammation in 2 cases (13.3%)〔local inflammation of sphenoid bone caused by cellulitis（1 case），cerebrospinal fluid otorrhea（1 case）〕，serious complications（2 cases）and unknown cause（1 case）. In the acute stage，the anti-infective therapy was used，and then in convalescent stage，stereotactic abscess resection，cerebrospinal fluid rhinorrhea and otorrhea repair，skull base repair，pilonidal sinus resection，regular intravenous immunoglobulin therapy or conservative treatment was used. There was no recurrence in 6 to 36 months of follow-up. Conclusion　The RPM onset in children may occur during neonatal stage to childhood stage，the etiology is complex and diverse，and structural abnormality is a main contributing factor. Timely identifying RPM，and finding and removing the possible cause，may prevent the recurrence of RPM.

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