Chinese General Practice

Emergency expert consensus on diagnosis and treatment of hypertriglyceridemic acute pancreatitis

Expert group of emergency expert consensus on diagnosis and treatment of hypertriglyceridemic acute pancreatitis

2021, 24(30): 3781-3793. DOI: 10.12114/j.issn.1007-9572.2021.02.028

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Latest Developments in Natural History and Tumor Growth Rate of Breast Cancer　

GAO Ying，WEI Wei，ZHANG Peng，ZHANG Qing

2021, 24(30): 3794-3798. DOI: 10.12114/j.issn.1007-9572.2021.02.002

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In developed countries，early screening for breast cancer is already part of health services. The screening effect is greatly affected by the screening interval，which is determined by the natural history and tumor growth rate of breast cancer in the target population. In this review，we systematically reviewed the previous global studies on natural history of breast cancer，analyzed the most important parameter of tumor progression，namely，tumor growth rate，and its influencing factors，and summarized that most natural history progression models of breast cancer are multi-phased，usually covering four-phases of non-detectable，pre-clinical，clinical and death，with more potentially associated tumor characteristic parameters incorporated；the growth rate of breast tumor is assessed by pre-clinical sojourn time and doubling time；tumor growth rate is influenced by age，BRCA1/2 gene mutation，family history of breast cancer，other traditional breast cancer risk factors，tumor histopathology features，other clinical information and so on. Understanding the growth pattern of breast cancer and its influencing factors will help to formulate the optimal screening strategy and improve early screening effects. As tumor growth rate is associated with the survival of breast cancer patients，effective assessment of tumor growth will give support to develop new treatment strategies and personalized screening interval.

Influencing Factors of Benign Breast Nodules Growth in Women　

FAN Na，GAO Ying，WEI Wei，LI Shu，TAO Fengran，JIANG Yunwen，ZHANG Qing

2021, 24(30): 3799-3805. DOI: 10.12114/j.issn.1007-9572.2021.02.003

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Background　The incidence of benign breast nodules is increasing in recent years，but studies about the factors affecting the growth of benign breast nodules measured by ultrasound（BI-RADS 2 or 3） are very limited. Objective　To identify factors associated with the growth of benign breast nodules. Methods　A total of 1 399 women with newly detected benign breast nodules by annual ultrasound screening for breast were selected from Health Management Center of Tianjin Medical University General Hospital between January 2013 and January 2019. Basic demographics，blood lipids，blood glucose，tumor markers and routine blood parameters were analyzed. Ultrasonic imaging characteristics such as the location，number，size，echo，composition，margin，morphology，calcification，blood flow，ductal dilatation，and presence of nodules in the contralateral breast were analyzed at baseline and during follow-up. Multivariate Cox proportional hazards model was used to identify the factors associated with the growth of benign breast nodules. Results　The mean age of the participants was （45.7±9.3）years，and the median follow-up time was 1.08 years. Up to the study's completion time，654 cases （46.7%） showed an increase in the diameter of the nodules measured by ultrasound. Multivariate Cox proportional hazards regression analysis results revealed that，age <50 years old 〔HR=1.25，95%CI（1.05，1.50）〕，platelet count >252×109/L 〔HR=1.19，95%CI（1.01，1.40）〕，maximum diameter of nodules <8 mm 〔HR=1.62，95%CI（1.35，1.95）〕，and multiple nodules〔HR=1.23，95%CI（1.03，1.47）〕 were all independent risk factors for the growth of benign breast nodules. Conclusion　Increased risk of growth of benign breast nodules in women was independently associated with younger age，elevated platelet count，smaller maximum diameter of breast nodules initially measured by ultrasound，and prevalence of multiple nodules. Therefore，clinical priority should be given to the monitoring of breast nodules and shorten the follow-up interval in female individuals with one of the above-mentioned risk factors，to achieve timely control and effective management of nodules.

Invasive Lobular Carcinoma of Breast：Clinicopathological Features，Current and Prospective Diagnosis and Treatment　

FAN Ziyu，FANG Xuan，ZHANG Sheng

2021, 24(30): 3806-3813. DOI: 10.12114/j.issn.1007-9572.2021.00.596

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Breast cancer is the highest prevalent malignant tumor worldwide，with a variety of histological types，among which invasive lobular carcinoma（ILC）of breast is the second most common histologic type，accounting for about 5%-15% of invasive tumors，showing an increased prevalence in the past 30 years. The major characteristic of ILC of breast is the loss of E-cadherin，which leads to the absence of adhesion between cells. The special diffuse infiltration and growth of ILC of breast pose some challenges to clinical physical and imaging examinations. Even if most patients with ILC of breast are hormone-receptor positive and sensitive to endocrine therapy，the problem of treatment resistance is inevitable in clinical applications. In addition，recent studies have found that the prognosis of ILC of breast is not as good as previously reported，and the principle of treatment based only on tumor stage and molecular typing does not seem to be fully applicable. It is possibly necessary to study ILC of breast as an independent clinical entity. In this paper，we reviewed the epidemiological and clinical characteristics，pathological and molecular characteristics，diagnosis，treatment，prognosis，and future treatment of ILC of breast，so as to better clinicians' understanding of clinical diagnosis and individualized treatment of ILC of breast.

Value of S-Detect in Differential Diagnosis between Benign and Malignant Thyroid Nodules：a Meta-analysis　

CHEN Jingtai，HOU Lingmi，TANG Yunhui，QIAN Shuangqiang，PU Hongyu，GAO Yanchun

2021, 24(30): 3814-3820. DOI: 10.12114/j.issn.1007-9572.2021.02.029

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Background　S-Detect is a new computer aided diagnostic technique，which can automatically analyze the ultrasound images qualitatively and quantitatively，helping doctors to identify benign and malignant thyroid modules，but there is no reliable evidence-based practice to verify its differential diagnostic value. Objective　To evaluate the value of S-Detect in differential diagnosis between benign and malignant thyroid nodules. Methods　We did a literature review of PubMed，EMBase，Web of Science，the Cochrane Library，Wanfang Data，CNKI，VIP and SinoMed databases to identify studies published as of January 6，2021 in which the value of S-Detect in differentially diagnosing thyroid nodules was investigated. Two reviewers independently screened the literature，extracted data，and evaluated the risk of bias and quality of the included studies. Meta-analysis was conducted using Meta-Disc 1.4 and Stata 15. The pooled indicators include：sensitivity and specificity，positive likelihood ratio，negative likelihood ratio，diagnostic odds ratio and area under the curve（AUC）. Results　Sixteen studies were included，in which the reported pooled sensitivity，specificity，positive likelihood ratio，negative likelihood ratio，diagnostic odds ratio and AUC of S-Detect in differential diagnosis between benign and malignant thyroid nodules were 0.84〔95%CI（0.81，0.86），P=0.003 6〕，0.71〔95%CI（0.69，0.73），P<0.000 1〕，3.31〔95%CI（2.45，4.47），P<0.000 1〕，0.22〔95%CI（0.17，0.29），P=0.000 6〕，15.93〔95%CI（9.85，25.78），P<0.000 1〕，and 0.89〔95%CI（0.84，0.94）〕，respectively. Conclusion　The current evidence shows that S-Detect significantly contributes to distinguishing benign and malignant thyroid nodules，which may be used as an effective auxiliary tool for usual ultrasound examination.

A Multimodal Ultrasound-based Decision-making Tree Model for the Diagnosis of Papillary Thyroid Carcinoma：Development and Efficacy Evaluation　

LI Ning，KAN Yanmin，LI Xiaosong，WANG Yihua，ZHANG Man，MENG Jian，MA Lin

2021, 24(30): 3821-3827. DOI: 10.12114/j.issn.1007-9572.2021.02.006

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Background　The detection rate of papillary thyroid carcinoma（PTC）is increasing in recent years，which may be due to advances in various ultrasonic imaging technologies and residents’ increased awareness of participating in the screening for PTC. The development of a decision-making tree model is helpful for identifying and diagnosing PTC timely. Objective　To develop a multimodal ultrasound-based decision-making tree model for the diagnosis of PTC，and to assess its efficacy. Methods　One hundred and eighty inpatients with excision of thyroid nodules were recruited from North China University of Technology Affiliated Hospital from January 2018 to October 2020. One hundred and eighty-six thyroid nodules were found in them，and 87 of which were malignant（PTC group），and other 99 were benign（non-PTC group）. The results of routine ultrasound，shear wave elastography（SWE），and contrast-enhanced ultrasound（CEUS）of PTC and non-PTC groups were compared. And the imaging parameters of PTC detected by routine ultrasound，SWE，CEUS，and the combination of routine ultrasound，SWE and CEUS（hereinafter referred to as “multimodal ultrasound”）were used to develop a decision-making tree model，respectively，then the efficacies of these four models were evaluated. Results　There were significant differences in nodule echo，aspect ratio，edge，focal hyperecho，maximum elasticity（Emax），minimum elasticity（Emin），mean elasticity（Emean），standard deviation of elasticity（Esd），elasticity ratio to normal surrounding tissue（Eratio），enhancement degree，enhancement characteristics，contrast medium distribution，contrast medium arrival time，contrast medium subsidence time，peak concentration（Peak），area under the time-intensity curve（AUCt）and mean transit time（MTT）between PTC and non-PTC groups（P<0.05）. Root nodes of decision-making tree models based on imaging parameters of PTC measured by routine ultrasound，SWE，CEUS and multimodal ultrasound were focal hyperecho，Emax，AUCt and Emax，respectively. Ten-fold cross-validation test showed that，misdiagnosis rates of decision-making tree models for PTC based on routine ultrasound，SWE，CEUS and multimodal ultrasound were 33.9%，19.4%，37.6% and 7.0%，respectively. The sensitivity，specificity，accuracy rate，positive likelihood ratio，negative likelihood ratio and Kappa value of multimodal ultrasound-based decision-making tree model for PTC were 88.5%，99.0%，94.1%，88.5，0.12 and 0.880，respectively. And it had higher diagnostic efficiency than other three models. Conclusion　We successfully constructed the multimodal ultrasound-based decision-making tree model for PTC with relatively high diagnostic efficiency. Moreover，it contributes to the improvement of diagnostic accuracy of PTC，which may be considered as a new approach to diagnosing PTC.

Different Medications for Preventing 131I-induced Salivary Gland Damage in Thyroid Cancer Patients：a Network Meta-analysis　

MA Dan，YIN Xinbo，LIU Jiahui，FANG Qunyao，HE Qiu，XIONG Yu，GONG Fanghua

2021, 24(30): 3828-3836. DOI: 10.12114/j.issn.1007-9572.2021.02.017

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Background　Although 131I adjunctive therapy can significantly improve the survival rate of patients with thyroid cancer，its induced salivary gland damage seriously affects the quality of life. Currently，there are a variety of drugs for the prevention and treatment of 131I-induced salivary gland damage，but it needs to conduct a network Meta-analysis to fill the gap of comparison of these medications. Objective　To perform a network Meta-analysis of different medications for preventing 131I-induced salivary gland damage in thyroid cancer patients. Methods　Randomized controlled trials（RCTs） or non-RCTs about different medications for preventing 131I-induced salivary gland damage in thyroid cancer patients were searched in databases of Cochrane Central Register of Controlled Trials，Web of Science，PubMed，and EMBase，VIP，CNKI，Wanfang Data and SinoMed from inception to January 2021. Literature screening and data extraction were performed by two researchers，separately. The literature quality was evaluated using the risk of bias assessment tool in the Cochrane Handbook for Systematic Reviews of Interventions（Version 5.1.0） and MINORS. Consistency test，publication bias analysis and graph drawing were carried out using Stata 16.0. OpenBUGS 3.2.3 was used for network Meta-analysis. Results　A total of 11 articles were included，involving 7 intervention schemes：amifostine，vitamin C，amifostine with vitamin C，citric acid，vitamin E，selenium and propylthiouracil. Network Meta-analysis revealed that in terms of preventing 131I-induced loss of salivary excretion fraction in the parotid gland，amifostine with vitamin C was superior to citric acid and propylthiouracil，so was amifostine（P<0.05）. Amifostine was also superior to the regular treatment（P<0.05）. The SUCRA score for the schemes in preventing 131I-induced loss of salivary excretion fraction in the parotid gland ranked from highest to lowest was：amifostine with vitamin C> amifostine > vitamin C>regular treatment > vitamin E> selenium >citric acid > propylthiouracil. In terms of preventing 131I-induced loss of salivary excretion fraction in the submandibular gland，propylthiouracil was inferior to vitamin E，amphostine with vitamin C，amphostine and regular treatment（P<0.05）. The SUCRA score for the schemes in preventing 131I-induced loss of salivary excretion fraction in the submandibular gland ranked from highest to lowest was：vitamin E>amphostine with vitamin C> amphostine>selenium> vitamin C> citric acid> regular treatment > propylthiouracil. The funnel plot of comparing different medications for preventing 131I-induced loss of salivary excretion fraction in the parotid gland or submandibular gland was obviously symmetrical. Conclusion　Amphostine with vitamin C may be the best intervention for preventing 131I-induced loss of salivary excretion fraction in the parotid gland. And vitamin E may be the best scheme for preventing 131I-induced loss of salivary excretion fraction in the submandibular gland，followed by amphostine with vitamin C. Due to limitations of this study，these results should be taken with caution，which still need to be verified by more large-sample，high-quality clinical studies.

Study on the Influencing Factors and Prognosis of Liver Injury in Patients with Newly Diagnosed Pulmonary Tuberculosis and Hepatitis B Co-infection during Anti-tuberculosis Treatment　

LI Jinghong，WU Yuqing，LIAO Yongmei，LIU Zhou

2021, 24(30): 3837-3842. DOI: 10.12114/j.issn.1007-9572.2021.00.566

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Background　There are both high burden of tuberculosis and hepatitis B in China，and tuberculosis combined with hepatitis B is very common. Therefore，in principle，anti-HBV treatment or optimization of anti-tuberculosis programs should reduce the occurrence of liver injury for patients with tuberculosis and HBV infection. Objective　To explore the influencing factors of liver injury in patients with newly diagnosed pulmonary tuberculosis and hepatitis B co-infection during anti-tuberculosis treatment，and analyze the influencing factors of death in patients with liver injury. Methods　230 cases of patients admitted to Jiangxi Chest Hospital，Nanfeng County People's Hospital，Duchang County Second People's Hospital，and Gongqingcheng People's Hospital from June 2015 to June 2019 with newly diagnosed pulmonary tuberculosis and hepatitis B co-infection combined with liver injury during anti-tuberculosis treatment were collected（recorded as the liver injury group），and matched 1∶1 to 230 cases of newly diagonsed pulmonary tuberculosis patients with pulmonary tuberculosis and HBV infection who completed anti-tuberculosis treatment in four hospitals without liver injury according to gender，age and source（recorded as control group）. Medical records of all the enrolled patients were retrospectively collected and the influencing factors of liver injury during anti-tuberculosis treatment of patients with newly diagnosed pulmonary tuberculosis and hepatitis B co-infection were analyzed. According to the prognosis of the patients，the patients were divided into death subgroups and improvement subgroups，and the influencing factors of death after liver injury in patients with newly diagnosed pulmonary tuberculosis and hepatitis B co-infection during anti-tuberculosis treatment were analyzed. Results　There was a statistically significant difference in the level of education，history of alcohol abuse，hepatitis B e antigen（HBeAg），HBV-DNA level，whether rececived preventive anti-HBV treatment，anti-tuberculosis treatment plan，and whether rececived preventive liver protection treatment between the two groups（P<0.05）. The results of multivariate Logistic regression analysis showed that preventive anti-HBV treatment 〔OR=1.88，95%CI（1.55，3.04）〕 and anti-tuberculosis treatment rograms〔OR=5.16，95%CI（1.90，14.02）〕were influencing factors for patients with newly diagnosed pulmonary tuberculosis and hepatitis B co-infection during anti-tuberculosis treatment（P<0.05）. Among the 230 newly treated pulmonary tuberculosis patients with hepatitis B co-infection，214 improved and 16 died. There was a statistically significant difference between the two subgroups of patients with hepatitis B co-infection on serum albumin level at the time of liver injury，preventive anti-HBV treatment，and the interval from onset of gastrointestinal symptoms to stopping anti-tuberculosis treatment（P<0.05）. The results of multivariate logistic regression analysis showed that preventive anti-HBV treatment 〔OR=1.61，95%CI（1.13，2.28）〕，the interval from onset of gastrointestinal symptoms to stopping anti-tuberculosis treatment〔OR=3.07，95%CI（1.45，6.49）〕 were independent influencing factors of death after liver injury in patients with newly diagnosed pulmonary tuberculosis and hepatitis B co-infection（P<0.05）. Conclusion　Preventive anti-HBV treatment and anti-tuberculosis treatment programs are the factors affecting liver injury during anti-tuberculosis treatment for patients with pulmonary tuberculosis and HBV infection，while preventive anti-HBV treatment，the interval from onset of gastrointestinal symptoms to stopping anti-tuberculosis treatment are the influencing factors of death after liver injury in patients with pulmonary tuberculosis and HBV infection.

Impact of Alanine Aminotransferase Level on Liver Stiffness Measured by Fibrotouch in Patients with Chronic Hepatitis B　

WANG Wenling，ZHANG Xinyuan，YE Song，LI Rongkuan

2021, 24(30): 3842-3847. DOI: 10.12114/j.issn.1007-9572.2021.00.535

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Background　A number of studies have shown that elevated alanine aminotransferase（ALT）level may result in increase of liver stiffness measurements，but few studies have explored the association of liver stiffness measurements with elevated ALT，especially mildly elevated ALT，in patients with chronic hepatitis B（CHB）. Objective　To explore the impact of ALT level on liver stiffness measured by FibroTouch in patients with CHB. Methods　A total of 145 CHB patients were recruited from Inpatient Ward of Infectious Disease Department，the Second Hospital of Dalian Medical University during May 2016 to March 2019. All of them performed ALT blood test，measured liver stiffness by FibroTouch，and assessed liver fibrosisby liver biopsy. Liver stiffness measured by FibroTouch was compared by ALT level〔ALT<1×ULN（upper limit of normal）（group A，n=46），1×ULN≤ALT<2×ULN（ group B，n=64），2×ULN≤ALT<5×ULN（group C，n=35）〕and by liver fibrosis assessed by liver biopsy using the METAVIR scoring system〔score F1（mild liver fibrosis），score F2-F3（obvious liver fibrosis）and score F4（cirrhosis）〕. ROC analysis was used to assess the accuracy of FibroTouch in measuring liver stiffness，with the results of liver biopsy serving as the gold standard of reference. Results　Groups A and B had lower mean liver stiffness measured by FibroTouch than group C（P<0.05）. Patients with mild liver fibrosis（n=16）in group A had lower mean liver stiffness measured by FibroTouch than those（n=6）in group C，so did those（n=14）in group B（P<0.05）. Patients with obvious liver fibrosis（n=22）in group A showed lower mean liver stiffness measured by FibroTouch than those（n=22）in group C，so did those（n=44）in group B（P<0.05）. Patients with cirrhosis（n=8）in group A demonstrated lower mean liver stiffness measured by FibroTouch than those（n=7）in group C，so did those（n=6）in group B（P<0.05）. In groups A，B and C，the mean liver stiffness measured by FibroTouch successively increased with the aggravation of liver fibrosis severity assessed by liver biopsy（P<0.05）. Spearman rank correlation analysis found that，liver stiffness measured by FibroTouchwas positively correlated with degree of liver fibrosis assessed by liver biopsy in groups A，B and C，respectively（rs=0.81，0.71，and 0.73，respectively，P<0.001）. ROC analysis showed that，the AUC of FibroTouch in staging F2-F3 in all participants，and groups A，B and C was 0.904，0.933，0.914 and 0.897，respectively，and the AUC of which in staging F4 in all participants，and groups A，B and C was 0.942，0.954，0.989 and 0.949，respectively（P<0.001）. Conclusion　Liver stiffness measured by FibroTouch may not be affected in CHB patients with ALT<2×ULN，but it may be overestimated in those with ALT≥2×ULN，which may not be the real degree of liver fibrosis.

A Prediction Nomogram for High-risk Esophageal Varices in Cirrhosis Patients　

GUO Maodong，HU Liang，CHEN Yanping，SHI Xin，YE Xiaohua，WANG Qunying，ZHANG Yunyun，DING Jin

2021, 24(30): 3848-3855. DOI: 10.12114/j.issn.1007-9572.2021.02.018

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Background　Esophageal variceal bleeding is a fatal complication of cirrhotic portal hypertension. Early diagnosis and treatment of esophageal varices can significantly reduce the mortality. However，there is still a lack of a unified noninvasive model for predicting the risk of esophageal variceal bleeding. Objective　To develop a prediction nomogram for high-risk esophageal varices in cirrhosis patients. Methods　Participants were cirrhosis patients selected from Affiliated Jinhua Hospital，Zhejiang University School of Medicine from January 2018 to October 2020. Laboratory examination indices were collected within 24 hours after admission. Gastroscopy was performed for evaluating the degree of esophageal varices. Enhanced abdominal CT was conducted. The potential predictors subsets of high-risk esophageal varices were screened by LASSO regression and 10-fold cross-validation method，and determined by using multivariate Logistic regression analysis，then were used for developing a prediction nomogram for high-risk esophageal varices using the R software. ROC curve analysis was used to evaluate the predictive ability of the model. Internal validation was performed using a bootstrap method. The discrimination of the nomogram was determined by calculating the average consistency index（C-index）. Calibration curve was used to assess the calibration of the nomogram. Results　A total of 204 cases were enrolled，including 92 with high-risk esophageal varices and 112 with low-risk esophageal varices. The diameter of the left gastric vein〔OR=2.174，95%CI（1.547，3.056），P<0.001〕，platelet count 〔OR=0.970，95%CI（0.950，0.991），P<0.001〕，splenic thickness〔OR=1.061，95%CI（1.003，1.123），P=0.039〕，and ascites〔OR=3.091，95%CI（1.768，5.404），P<0.001〕 were independent predictors for high-risk esophageal varices. The AUC of the nomogram for predicting high-risk esophageal varices was 0.949〔95%CI（0.921，0.978）〕，and the C-index was 0.951 in internal validation. The calibration curve showed that the predictive results were in good consistency with the actual results. Conclusion　This nomogram built based on variables of left gastric vein，platelet，splenic thickness and ascites has good discrimination and accuracy，which may be helpful for screening high-risk esophageal varices in cirrhosis patients.

Association of Helicobacter Pylori Infection with Non-alcoholic Fatty Liver Disease and Related Colorectal Polyps　

YANG Qiujin，ZHENG Jie，YANG Jing，LUO Run，LENG Jiao，JIN Qiu，MA Honglin

2021, 24(30): 3855-3862. DOI: 10.12114/j.issn.1007-9572.2021.00.549

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Background　Non-alcoholic fatty liver disease （NAFLD） has become the most common chronic liver disease worldwide now. Studies have shown that Helicobacter pylori （H.pylori） infection is related to the development of NAFLD，but there is still controversy. Objective　To examine the association of H.pylori infection with NAFLD and related colorectal polyps. Methods　One hundred and eighteen patients diagnosed as NAFLD by transabdominal ultrasound were selected from the Second Affiliated Hospital of Kunming Medical University from December 2018 to May 2020，and were divided into NAFLD with and without H.pylori groups by H.pylori infection prevalence. Demographic data，results of liver fibrosis，fatty liver disease and biochemical tests，as well as colposcopy were collected. The severity of liver steatosis and liver stiffness measured by the FibroTouch test was divided into mild，moderate and severe. Results　Compared to NAFLD patients without H.pylori infection（n=56），those with H.pylori infection（n=62） had higher mean levels of BMI，CAP，E score，ALT，AST，GGT，TBiL，DBiL，TC，TG，LDL，TyG，WBC，NLR，PCT，IL-6，and CRP，and higher mean NFS score and APRI，as well as higher severity of liver steatosis and liver stiffness （P<0.05）.Fifty-one of the 75 cases（37 with H.pylori infection and 38 without ） undergoing colonoscopy were found with colorectal polyps，of whom 26 were H.pylori positive.Those with H.pylori infection had higher prevalence of multiple colorectal polyps or colorectal polyps with a diameter of ≥1 cm than those without （P<0.05）. A total of 41 out of 75 patients undergoing colonoscopy underwent pathological examination of polyps，and the results revealed that those with H.pylori infection had higher prevalence of adenomatous polyps and colorectal intraepithelial neoplasia than those without（P<0.05）. Multivariate logistic regression analysis showed that H.pylori infection was associated with the number of colorectal polyps〔OR=7.547，95%CI（1.467，38.827）〕，colorectal polyps pathology〔OR=8.500，95%CI（1.574，45.916）〕，and colorectal intraepithelial neoplasia〔OR=4.571，95%CI（1.218，17.157）〕in NAFLD patients （P<0.05）. Conclusion　H.pylori infection may increase BMI，and aggravate hypertension，diabetes，liver dysfunction，dyslipidemia，inflammatory response，liver fibrosis，and liver steatosis in NAFLD patients.In addition，it may be associated with the number of colorectal polyps，pathology of colorectal polyps，and colorectal intraepithelial neoplasia.

Prognostic Value of Prognostic Nutritional Index and a Prognostic Nomogram Developed Based It for Gastric Cancer Patients with Lung Metastasis　

DILINUER·Aierken，ZHANG Hua，ABUDUSHATAER·Kadier，KALIBINUER·Aierken，MAYINUER·Aili

2021, 24(30): 3863-3869. DOI: 10.12114/j.issn.1007-9572.2021.02.019

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Background　Gastric cancer is a common digestive tract cancer worldwide that seriously endangers the life and health of residents. Nutritional status has been reported to be closely related to cancer patients' prognosis，which is assessed by prognostic nutritional index（PNI） in increasing studies to predict long-term prognosis of cancer patients. Objective　To evaluate the prognostic value of PNI in gastric cancer patients with lung metastasis，and to establish a PNI-based prognostic nomogram. Methods　Participants were 245 gastric cancer patients with lung metastasis who were admitted to the First Affiliated Hospital of Xinjiang Medical University from July 2010 to July 2018. By reviewing medical records and test reports，demographic and clinicopathological data were collected，including age，sex，primary lesion，histological grade，T stage，N stage，type of lung metastasis，timing of lung metastasis，chemotherapy status，tumor diameter，prevalence of pleural effusion and intravascular tumor thrombus，primary lesion surgery，serum CEA，serum CA199，number of peripheral lymphocytes and albumin level one week before operation，and calculated PNI. Follow-up data were collected through a telephone or clinic follow-up till April 2019. The influencing factors of PNI and its association with the prognosis were analyzed. A prognostic nomogram was constructed based on potential prognostic factors of gastric cancer patients with lung metastasis. Results　The optimal cut-off value of PNI for predicting 3-year survival in gastric cancer patients with lung metastasis was 46.1 with 71.7% sensitivity and 67.8% specificity. Multivariate Logistic regression analysis showed that age >65 years old〔OR=2.123，95%CI（1.201，3.752）〕，advanced T stage〔OR=2.104，95%CI（1.336，3.313）〕，advanced N stage〔OR=1.876，95%CI（1.286，2.735）〕 and tumor diameter> 5 cm 〔OR=1.839，95%CI（1.054，3.208）〕were independent risk factors for PNI<46.1（P<0.05）. The 1-year，2-year and 3-year survival rates of gastric cancer patients with lung metastasis were 33.3%，15.1% and 4.3%，respectively. The 3-year survival rate of low PNI group（n=114，PNI<46.1） was lower than that of high PNI group（n=131，PNI>46.1）（P=0.001）. Multivariate Cox regression analysis showed that histological grade〔HR=1.414，95%CI（1.059，1.887）〕，type of lung metastasis〔HR=1.647，95%CI（1.213，2.237）〕，chemotherapy〔HR=0.740，95%CI（0.559，0.981）〕，primary lesion surgery 〔HR=0.649，95%CI（0.475，0.886）〕 and PNI〔HR=0.733，95%CI（0.550，0.978）〕 were independent prognostic factors for gastric cancer patients with lung metastasis（P<0.05），and all of which were used to construct the prognostic nomogram to predict the 1-year，2-year and 3-year overall survival with a C-index of 0.755. Conclusion　PNI may be a major prognostic factor for gastric cancer patients with lung metastasis. And the prognostic nomogram based on PNI is helpful for individualized prognosis analysis.

Clinical Characteristic of Anti-Caspr 2 Antibody Autoimmune-associated Encephalitis in Adults　

WU Lanxiang，TIAN Sheng，ZHENG Heqing，LIU Pan，WU Wei

2021, 24(30): 3870-3877. DOI: 10.12114/j.issn.1007-9572.2021.02.023

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Background　Anti-contact protein related protein-2 （Caspr 2） antibody autoimmune-associated encephalitis （AE） is a seldom encountered disease with diverse clinical manifestations，which is difficult to diagnose，and has been rarely studied. Objective　This study was aimed to summarize and analyze the clinical features，auxiliary examinations，treatments，and prognosis of anti-Caspr 2 antibody AE in adults，to improve clinicians' understanding of this disease. Methods　Fourteen patients who were positive for anti-Caspr 2 antibody in the serum or cerebrospinal fluid （CSF） were retrospectively selected from 198 adults with acute or subacute encephalitis symptoms and a definite diagnosis of AE who hospitalized in Department of Neurology，the Second Affiliated Hospital of Nanchang University from April 2016 to December 2020. The clinical features，laboratory test results，imaging results，EEG results，treatments，and follow-up data of these patients were collected. Results　Among the 14 patients〔including 11 men and three women，with a mean age of （47.9±19.6） years〕，mental and behavioral disorders were the most common initial symptoms；during the course of disease，11 showed limbic encephalitis symptoms （nine with mental and behavioral disorders，seven with declined cognitive function，and six with epilepsy），10 showed autonomic dysfunction （eight with hyperhidrosis，six with sinus tachycardia，two with constipation，and one with dysuresia），six had insomnia，and three showed cerebellar symptoms，five showed peripheral nerve hyperexcitability symptoms，four showed neuropathic pain. Laboratory tests found that 13 were positive for serum anti-Caspr 2 antibody，eight were positive for CSF anti-Caspr 2 antibody，and five were concurrently positive for anti-NMDAR antibody. None of the patients were identified with cancer by cancer screening. All patients received first-line immunotherapy，10 of them showed good prognosis，one died，one had recurrence，one was still undergoing treatment（by the end of the follow-up），and one had comlicated with head necrosis. Conclusion　Anti-Caspr 2 antibody AE has diverse clinical manifestations that may involve the central and peripheral neuromuscular systems and autonomic nervous system. Sudden death is possible when arrhythmia occurs，and the patients may be positive for other types of autoantibodies. Immunotherapy is effective for this disease，but recurrence may still occur.

Relationship between Plasma β-2 Microglobulin Level and Mild Cognitive Impairment in the Elderly　

LI Jiesi，PAN Zimo，CHEN Lingxia，WANG Jingtong

2021, 24(30): 3878-3881. DOI: 10.12114/j.issn.1007-9572.2021.02.034

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Background　Since China entering an aging society，mild cognitive impairment （MCI） in the elderly has become increasingly prevalent. As a new biomarker，β-2 microglobulin （β2M） has gradually gained public attention. However，the role of β2M in aging process and cognitive regulation is still controversial.Objective　To investigate the association between plasma β2M level and MCI in geriatrics. Methods　Two hundred and thirty-three patients hospitalized in Department of Geriatrics，Peking University People's Hospital from June 2018 to June 2019 were selected for the study. According to the score of Montreal Cognitive Assessment （MoCA），the patients were divided into MCI group （n=108） and normal cognitive function group（n=125）. Demographic characteristics，laboratory examination indicators on admission and MoCA score were compared between the two groups. The correlation of MoCA score with age，years of education，and plasma β2M level was analyzed. Binary Logistic regression analysis was applied to explore the influencing factors of MCI in elderly patients. Results　Participants with MCI had greater average age，higher average plasma level of β2M，less average years of education and lower average MoCA score than those with normal cognitive function （P<0.05）. The results of Spearman's rank correlation analysis presented that age（rs=-0.361，P<0.001） and plasma level of β2M （rs=-0.283，P<0.001） were negatively correlated with MoCA score，while years of education was positively correlated with MoCA score （rs=0.305，P<0.001）. After adjusting for age as a covariate，binary Logistic analysis showed that elevated plasma β2M level 〔OR=1.955，95%CI （1.060，3.606）〕 was associated with increased risk of MCI，while longer years of education〔OR=0.860，95%CI （0.777，0.951）〕 was associated with decreased risk of MCI（P<0.05）. Conclusion　Elevated plasma β2M level may be an independent risk factor for MCI in elderly patients. Therefore，early screening for MCI in older people with higher plasma β2M level could contribute to early identification and prevention of MCI.

Clinical，Gut Flora，and Serum Serotonin Responses to Wuyintiaoshen Therapy in Patients with Mild-to-moderate Post-stroke Depression and Liver Qi Stagnation and Spleen Deficiency Syndrome　

LIU Li，DING Yi，WANG Jian，LI Jianfei，ZHANG Tianyu，LI Li

2021, 24(30): 3882-3887. DOI: 10.12114/j.issn.1007-9572.2021.02.025

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Background　Wuyintiaoshen therapy（acupuncture combined with five-element music therapy）has proven to be effective in treating post-stroke depression（PSD），but there is a lack of studies on its clinical response and mechanism of action in PSD patients with liver qi stagnation and spleen deficiency syndrome. Objective　To investigate the clinical，gut flora，and serum serotonin responses to Wuyintiaoshen therapy in mild-to-moderate PSD patients with liver qi stagnation and spleen deficiency syndrome. Methods　Seventy-two mild-to-moderate PSD outpatients and inpatients with liver qi stagnation and spleen deficiency syndrome were recruited from the Rehabilitation Clinic and Ward of the Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine，and equally randomized into control group（routine medical treatment with escitalopram）and experimental group（routine medical treatment with Wuyintiaoshen therapy）. Clinical response，pre- and post-treatment mean Hamilton Rating Scale for Depression（HAMD-17）scores，Gastrointestinal Symptom Rating Scale（GSRS）scores，number of strains of gut floras and serum serotonin levels were compared between the two groups. Results　After treatment，the experimental group had better clinical response，lower mean HAMD-17 and GSRS scores，higher mean number of strains of Bifidobacterium and Lactobacillus，lower mean number of strains of Escherichia coli and Enterococcus，and higher mean serum serotonin level than the control group（P<0.01）. Conclusion　Wuyintiaoshen therapy could effectively reduce the depression level，alleviate gastrointestinal symptoms，and regulate gut flora and serum serotonin level，indicating that the therapy could improve both physical and mental conditions in mild-to-moderate PSD patients with liver qi stagnation and spleen deficiency syndrome.

Characteristics Analysis of Predictive Models of Nonalcoholic Fatty Liver Disease　

GAO Xiaolian，XIAO Mingzhong，TAO Junxiu，AI Yating

2021, 24(30): 3888-3892. DOI: 10.12114/j.issn.1007-9572.2021.00.562

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As a quantitative tool of risk estimate，the disease prediction model is helpful to identify high-risk groups and provide evidence for health management. However，the research on nonalcoholic fatty liver disease（NAFLD） prediction models has not yet attracted sufficient attention in the field of liver disease management in China. Literature review of the NAFLD prediction model was conducted using PubMed，Web of Science，and CNKI databases. Eight NAFLD prediction models were obtained，which are fatty liver index，hepatic steatosis index，percentage of liver fat，Framingham steatosis index，ZJU index，NAFLD Screening Score，Young Jin Park model，and Mika Aizawa model. Modeling methods，performance assessment，expression and application status of the models are summarized in this paper，where Logistic regression is found to be the main modeling method，as the model discrimination is effective and internal validation is mostly adopted. Overall，the NAFLD prediction model is worthy of further exploration.

Establishment of a Rothman-Keller-type Risk Prediction Model for Stress Urinary Incontinence in Adult Women Using Evidence-based Data　

BO Xiaojie，MA Le，YANG Sen

2021, 24(30): 3893-3899. DOI: 10.12114/j.issn.1007-9572.2021.00.584

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Background　As the most common type of female urinary incontinence，stress urinary incontinence（SUI） has an increasing incidence in adult women with the process of aging and lifestyle changes in recent years. Although it is not life-threatening，it seriously affects the performance of work and physical and mental health. Objective　To develop a Rothman-Keller-type model for actively screening for SUI risk in adult women，so as to effectively identify and timely intervene with the high-risk groups. Methods　Observational studies about SUI in adult women were searched from databases of PubMed，EMBase，SinoMed，CNKI and Wanfang Data from January 2005 to December 2020. Review Manager 5.3 software was used for meta-analysis. The establishing principles of the Rothman-Keller model were used for creating a Rothman-Keller-type model for predicting the risk of SUI in adult women，and the threshold of different risks was determined using simulation data sets. The predictive accuracy of the model was verified by using Logistic regression model. Results　Finally，18 articles were included.The 12 risk factors obtained from analysis were：age（≥50 years），BMI（≥24 kg/m2），menopause，urinary system infection，vaginal delivery，and pelvic prolapse，history of pelvic surgery，number of deliveries（≥3 times），constipation，chronic respiratory disease，hypertension，and diabetes. We generated 20 000 simulated individual data based on the risk factors using binomial distribution function，and incorporated them into the Rothman-Keller-type model to plot a curve predicting the SUI risk in adult women，and chose 0.285 5 and 0.429 4 as the threshold for dividing low and intermediate risks，and intermediate and high risks，respectively，according to the curve changes. We incorporated the simulated individual data into a Logistic regression model to plot a curve predicting the SUI risk in adult women，and used 0.261 2 and 0.547 4 as the threshold for dividing low and intermediate risks，and intermediate and high risks，respectively，according to changes in the curve. Validation results of risk prediction for a 60-year-old female：she was predicted to have a high risk for SUI〔P=0.485 6（>0.429 4）〕 by the Rothman-Keller-type model，and was classified into high risk group for SUI 〔P=0.878 6（>0.547 4）〕 according to the prediction using the Logistic regression model，indicating that the predictive results of the two models were consistent. Conclusion　Our model has proved to have strong accuracy and predictability. Our experience may provide ideas for the development of risk prediction models for other chronic diseases.

Congenital Adrenal Hyperplasia Associated with POR Gene Mutation：a Case Report and Literature Review　

QI Qi，HU Honglin，XU Min，WANG Youmin，ZHANG Qiu

2021, 24(30): 3900-3904. DOI: 10.12114/j.issn.1007-9572.2021.00.567

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Congenital adrenal hyperplasia（CAH）is a rare genetic metabolic disorder mainly caused by steroidogenic enzyme gene or cytochrome P450 oxidoreductase（POR）mutations. As its clinical manifestations are similar to those of polycystic ovary syndrome，a differential diagnosis is often needed to distinguish them. We reported a case of CAH associated with POR mutation，who was finally diagnosed with cytochrome P450 oxidoreductase deficiency（PORD）after being detected with homozygous c.1370G>A mutation in exon 12 of POR by gene test. Our study indicates that the key to identifying PORD is comprehensive analysis of results of physical examination，adrenal and sex hormone tests，and in combination with gene analysis for confirmation when necessary，then based on this，delivering precise treatment.

Reversible Posterior Leukoencephalopathy Syndrome Due to Hyponatremia and Combined Injuries Caused by a Traffic Accident：a Case Report and Literature Review　

MAO Zhenlin，YANG Canhong，CAI Zibo，XIE Wenyi，LYU Tianming

2021, 24(30): 3905-3908. DOI: 10.12114/j.issn.1007-9572.2021.00.453

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Reversible posterior leukoencephalopathy syndrom（RPLS），a group of rare neuroimaging syndrome with acute or subacute onset，mainly manifested as headache，dizziness，nausea，vomiting，seizure，visual abnormality，consciousness impairment and disturbance of mental behavior. The typical imaging fingdings of PRLS are reversible and symmetric lesions in white matter of the posterior brain areas. A case of RPLS caused by hyponatremia combined with traffic accident injuries was reported and related literatures were reviewed in this paper，indicating that hyponatremia may be a rare cause of RPLS. Therefore the occurrence of RPLS should be concerned when the hyponatremia caused by various reasons occurred in clinical practice，and early identification and treatment of are essential to prevent permanent neurological sequelae because of the reversibility of RPLS.

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