Table of Content

20 March 2022, Volume 25 Issue 09

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Special Report

Research Agenda for General Practice/Family Medicine and Primary Health

Care in Europe. European General Practice Research Network，Maastricht

2009.

Eva Hummers-Pradier, Martin Beyer, Patrick Chevallier, Sophia Eilat-Tsanani, Christos Lionis, Lieve Peremans, Davorina Petek, Imre Rurik, Jean Karl Soler, Henri E.J.H. Stoffers, Pinar Topsever, Mehmet Ungan, Paul van Royen

2022, 25(09):  1027-1039.  DOI: 10.12114/j.issn.1007-9572.2022.02.006

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Evidence for Optimization

Quality Assessment of Guidelines forVascular Cognitive Impairment Using the AGREEⅡ

MA Huaping, HAN Zhenyun, CHANG Ze, WANG Yuchun, HU Yuli, ZHANG Dingding

2022, 25(09):  1039-1046.  DOI: 10.12114/j.issn.1007-9572.2021.02.127

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As the second primary type of cognitive impairment worldwide, vascular cognitive impairment (VCI) is closely associated with cerebrovascular risks, which imposes a heavy burden on the society and families. Early diagnosis and treatment are important for intervening and reversing VCI. And formulating high-quality clinical guidelines is an effective way to improve diagnosis and treatment levels of VCI.

To assess the quality of guidelines for VCI, aiming at offering support for making clinical decisions for VCI.

From August to November 2021, we searched literature databases and websites in China and abroad to identify guidelines for VCI, and assessed them using the Appraisal of Guidelines for Research & Evaluation (AGREE) Ⅱ.

A total of 18 guidelines were enrolled, 12 of which are Chinese guidelines and 6 are foreign guidelines; 9 of which are evidence-based guidelines, and the other 9 are not. The intraclass correlation coefficient was 0.935, indicating a high degree of agreement between raters. The overall quality of these guidelines was relatively low, since in the six domains, only the average score of Clarity of Presentation was greater than 60% (64.04%) , and the average scores of Scope and Purpose (52.31%) and Editorial Independence (42.01%) were between 30% and 60%, and those for other three domains, Stakeholder Involvement (27.24%) , Rigor of Development (20.05%) and Applicability (13.83%) , were all less than 30%. The grade of recommendation for 6 guidelines was B, and that for other 12 guidelines was C.

The overall quality of the included guidelines was rated relatively low, especially their average score for each of the three domains, Stakeholder Involvement, Rigor of Development, and Applicability, was below the average level. It is suggested to enhance the quality of VCI guidelines via improving the details of guidelines strictly under the evidence-based principle.

Best Evidence Summary for Perioperative Blood Glucose Management in Patients Undergoing Pancreatectomy

CUI Lei, LIU Linglong, WANG Jianjian, YU Huiping, SUN Qingmei, MIAO Yi, FANG Xiaoping

2022, 25(09):  1047-1053.  DOI: 10.12114/j.issn.1007-9572.2021.02.096

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Blood glucose disorder is a common perioperative problem in patients with pancreatectomy. However, current perioperative blood glucose management for pancreatic resection patients in China is mostly based on experience and lack of evidence-based basis.

To summarize the best evidence for perioperative blood glucose management in patients undergoing pancreatectomy.

A systematic literature search of BMJ Best Practice, Up to Date, Guideline International Network, International Diabetes Federation, World Health Organization, National Guideline Clearinghouse, American Diabetes Association, the National Institute for Health and Care Excellence, New Zealand Guidelines Group, Canadian Diabetes Association, Australian Diabetes Society, Scottish Intercollegiate Guidelines Network, PubMed, Web of Science, EMBase, CINAHL Database, Cochrane Library, the Joanna Briggs Institute Evidence-based Health Care Center, Medlive.cn, Wanfang Data, CNKI, and Chinese Biomedical Database was conducted to screen the literature on perioperative blood glucose management in patients with pancreatectomy published from inception to December 2020. The AGREE Ⅱ scale updated in 2009 by the International AGREE Collaboration Organization was used to assess the quality of guidelines. The quality assessment of the expert consensus used the 2017 version of the expert consensus evaluation standard of the Australian JBI Evidence-based Health Care Center. The Jadad scale was used to assess the quality of randomized controlled trials (RCTs) .

A total of 6 637 studies were retrieved, and 13 of them were finally included, of which 7 were clinical practice guidelines, 4 were expert consensus, and 2 were RCTs. The results of quality assessment showed that 3 of the 7 clinical practice guidelines were rated grade A, and the remaining 4 were rated grade B. In assessing the quality of the 4 expert consensuses, the answers of raters for all items were "yes" , except that their answers for the item "Is there a reasonable explanation for the point of view inconsistent with other literature?" were "unclear" . Both the two RCTs were rated high. A total of 62 pieces of best evidence were collected, mainly related to perioperative organization and management, admission evaluation and treatment, blood glucose control goals, blood glucose monitoring, preoperative, intraoperative and postoperative blood glucose management strategies, management of emergency conditions, and discharge guidance.

Clinical medical workers can develop individualized and holistic perioperative blood glucose management plans for patients with pancreatectomy, based on the above-mentioned 9 aspects of best evidence.

Article

Reducing the Risk of Adverse Events in Patients with Type 2 Diabetes Who are Poorly Treated with Metformin Combined with Acarbose：Dipeptidyl Peptidase-4 Inhibitor is Better Than Insulin

SU Peng, LIU Yukun, LIANG Xiaohua, LIU Xin, YU Yaohui, HUANG Pengfei, BAI Yuru, HE Xiaoyan, SHEN Zhihong, MA Dong

2022, 25(09):  1054-1061.  DOI: 10.12114/j.issn.1007-9572.2022.02.022

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Clinically, when metformin (Met) combined with acarbose (Aca) cannot achieve the ideal hypoglycemic effect, a third drug will be usually added, such as insulin (Ins) or dipeptidyl peptidase-4 inhibitor (DPP-4i) etc., but there are few reports on the effect of triple therapy on complications related to type 2 diabetes (T2DM) .

To explore the risk of adverse events of DPP-4i combined with Met and Aca, Ins combined with Met and Aca in the treatment of T2DM patients, in order to provide help for the choice of drugs for clinical T2DM treatment.

In the retrospective cohort study, patients diagnosed with T2DM and treated with Met+Aca+ DPP-4i or Met+Aca+Ins in Shijiazhuang Second Hospital from November 1, 2017 to August 1, 2020 were selected as the study subject. Telephone follow-up was conducted from November 20, 2017 to August 4, 2020, the follow-up wasn't terminated until a preset outcome occurred, then that was recorded. The three prespecified outcome events were non-fatal cardiovascular disease, death from all causes, and severe hypoglycemic events. The comprehensive outcome events including all-cause death, or composite non-fatal cardiovascular events, or severe hypoglycemic events. Propensity score matching (1∶1 ratio for data matching, caliper value set to 0.02) was used, and multivariate Cox proportional hazards regression model was used to analyze the risk of comprehensive outcome events in T2DM patients after drug treatment. Stratified analysis was performed on the effect of each covariate on the risk of comprehensive outcome events in patients treated with different drugs.

Finally, 1 570 patients with T2DM were enrolled, including 1 089 patients who received Met+Aca+Ins treatment (Met+Aca+Ins group) and 481 patients who received Met+Aca+DPP-4i treatment (Met+Aca+DPP-4i group) . There were 434 cases in both groups after propensity score matching. Compared with the Met+Aca+Ins group, the incidences of comprehensive outcome events (6.53/100 person-per year) , non-fatal cardiovascular disease (5.03/100 person-years) , all-cause death (0.73/100 person-per year) , and severe hypoglycemic (0.73/100 person-er year) were lower in the Met+Aca+ DPP-4i group. The multivariate Cox proportional hazards regression model analysis showed that the risk of comprehensive outcome events in the Met+Aca+DPP-4i group was 67% lower than the Met+Aca+Ins group 〔HR=0.34, 95%CI (0.23, 0.50) , P<0.001〕, the risk of composite non-fatal cardiovascular disease decreased by 52% compared with the Met+Aca+Ins group 〔HR=0.48, 95%CI (0.30, 0.77) , P=0.002〕, and the risk of all-cause mortality was higher than the Met+Aca group. The Met+Aca+Ins group group decreased by 81% 〔HR=0.19, 95%CI (0.07, 0.56) , P=0.003〕, and the risk of severe hypoglycemia decreased by 80% compared with the Met+Aca+Ins group 〔HR=0.20, 95%CI ( 0.07, 0.59) , P=0.003〕. The survival curve was drawn with the comprehensive outcome events as the outcome event. The results of Log-rank test showed that the survival rate of Met+Aca+DPP-4i group was higher than the Met+Aca+Ins group (χ²=32.849, P<0.001) . The results of covariate interaction analysis showed that in patients with adequate sleep (>7 h/d) , non-smoking, and no family history of cardiovascular disease, Met+Aca+DPP-4i treatment reduced the incidence of comprehensive outcome events in T2DM patients compared with Met+Aca+Ins treatment (P values were 0.008, 0.031, and 0.042, respectively) .

After failure treatment of Met and Aca in T2DM patients, the supplementation of DPP-4i was associated with a lower risk of comprehensive outcome events, cardiovascular disease, all-cause mortality, and severe hypoglycemia compared with the Ins addition, particularly in patients with adequate sleep, no smoking, and without family history of cardiovascular disease.

Efficacy of Modified Bismuth Triple Regimen in Eradicating Helicobacter Pylori Infection

HUANG Hongyu, LEI Tiantian, LIU Jiahuan, ZHAO Ying, YANG Jinlin, MA Hongsheng

2022, 25(09):  1062-1069.  DOI: 10.12114/j.issn.1007-9572.2021.02.124

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The antibiotic resistance rate of Helicobacter pylori (H.pylori) is increasing while its eradication rate is decreasing year by year. So it is urgent to explore more effective treatment regimens.

To explore the clinical efficacy of a modified bismuth triple regimen in eradicating H.pylori infection.

A total of 360 eligible patients with H.pylori infection were selected from the Gastroenterology & Hepatology Clinic, West China Hospital of Sichuan University from April 2019 to December 2020. They were equally randomized into a modified bismuth triple regimen group〔EBA group, esomeprazole 40 mg/time, colloidal bismuth pectin capsules 300 mg/time, and amoxicillin 1 g/time, twice a day for 14 days) , and a standard bismuth quadruple regimen group〔EBAT group, esomeprazole (strength: 20 mg, produced by AstraZeneca) 20 mg/time, colloidal bismuth pectin capsules 300 mg/time, amoxicillin 1g/time, and tetracycline 750 mg/time, twice a day for 14 days〕. The ¹³C- or ¹⁴C-urea breath test was performed 4-8 weeks after the treatment, and the negative result was defined as successful eradication treatment of H.pylori infection. The eradication rate of H.pylori infection and the improvement of related symptoms were compared between two groups.

259 newly treated patients with H.pylori infection (138 in EBA group and 121 in EBAT group) and 101 retreated patients (42 in EBA group and 59 in EBAT group) were included. The treatment completion rate of EBA group was 83.3% (150/180, including 112 cases of newly treated, and 38 retreated) , and that of EBAT group was 86.7% (156/180, including 104 newly treated patients and 52 retreated) . No statistical difference in completion rate was found between the two groups (χ²=0.784, P=0.376) . Intention-to-treat analysis revealed that, the eradication rate of H.pylori infection in newly treated patients in EBA group was not statistically different from that of those in EBAT group〔69.6% (96/138) vs 80.2% (97/121) 〕 (χ²=4.313, P=0.116) . Furthermore, per-protocol analysis found that, the eradication rates in newly treated patients in EBA group and EBAT group were 85.7% (96/112) and 93.3% (97/104) , respectively, demonstrating no statistically significant intergroup difference (χ²=3.235, P=0.072) .For retreated patients, intention-to-treat analysis indicated that, the eradication rates for those in EBA group and EBAT group were 54.8% (23/42) , and 72.9% (43/59) , respectively, showing no statistically significant intergroup difference (χ²=5.678, P=0.058) . However, based on the per-protocol analysis, the eradication rates for those in EBA group and EBAT group were 60.5% (23/38) and 82.7% (43/52) , respectively, manifesting statistically significant intergroup difference (χ²=5.516, P=0.019) . The rates of symptom improvements in newly treated patients with pre-treatment symptoms in EBA and EBAT groups showed no statistically significant difference〔88.3% (83/94) vs 92.0% (80/87) 〕 (χ²=0.897, P=0.639) . And the rates of symptom improvements in retreated patients with pre-treatment symptoms in EBA and EBAT groups also showed no statistically significant difference〔88.6% (31/35) vs 75.0% (33/44) 〕 (χ²=2.353, P=0.308) .

For newly treated patients with H.pylori infection, the modified bismuth triple regimen had effects similar to those of the standard bismuth quadruple regimen in terms of eradication rate of H.pylori infection and symptoms improvement rate, which could be used as a new treatment option. However, this modified triple regimen was not suitable for retreated patients, although the symptoms improvement rate was similar to that of the quadruple regimen, the eradication rate of H.pylori infection was too lower.

Progression and Reversion of Mild Cognitive Impairment：a Study Using Data from the Uniform Data Set

HAN Hongjuan, QIN Yao, CHEN Durong, AN Jianhua, YU Hongmei

2022, 25(09):  1070-1076.  DOI: 10.12114/j.issn.1007-9572.2021.02.103

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Mild cognitive impairment (MCI) has highly variable cognitive trajectories. Approximately 10% to 15% of MCI patients progress to dementia, and nearly 24% revert to normal cognition each year. There are few studies on the progression and reversion of MCI, especially there version of MCI to normal cognition.

To construct a multi-class classification model of MCI outcomes (reversion, stabilization and progression) and to explore the possible associated factors of these outcomes.

Data were collected from the National Alzheimer's Disease Coordinating Center Unified Data Set, involving 397 patients who were initially diagnosed with MCI during 2005—2019 with at least two follow-ups and complete clinical and follow-up data. Patients' demographic information, physical examination, disease history, and measurement results by assessment scales in MCI were selected for analysis. Boruta was used for feature selection. Random forest was used for supporting the classification of MCI outcomes. A stepwise multinomial logistic regression was used to explore the associated factors of different MCI outcomes.

Of the 397 cases, 124 (31.23%) reverted to normal cognition, 77 (44.58%) were in stable condition, and 96 (24.18%) progressed to dementia. In the multi-classification task, the accuracy of direct three-class classification was 67.58%. In multiple binary classifications, the accuracies of reversion and stabilization, and reversion and progression were above 90%. Among the hierarchical three-class classification, the accuracy based on stabilization→ reversion → progression was 84.38%. Stepwise multinomial Logistic regression analysis showed that age ≥80 years 〔OR=0.260, 95%CI (0.117, 0.574) 〕, self-reported cognitive impairment 〔OR=0.295, 95%CI (0.139, 0.623) 〕, and decreased Clinical Dementia Rating (CDR) scores〔OR=0.220, 95%CI (0.092, 0.525) 〕 were associated with decreased risk of MCI progressing to dementia, while history of stroke 〔OR=2.896, 95%CI (1.370, 6.122) 〕, fecal incontinence 〔OR=6.556, 95%CI (1.787, 24.047) 〕, and higher Functional Activities Questionnaire score〔OR=1.048, 95%CI (1.003, 1.095) 〕were associated with increased risk of MCI progressing to dementia. Decreased probability of reversion from MCI to normal cognition was related to age ≥80 years 〔OR=0.289, 95%CI (0.091, 0.914) 〕, obesity 〔OR=0.236, 95%CI (0.075, 0.740) 〕, self-reported cognitive impairment 〔OR=0.289, 95%CI (0.111, 0.757) 〕, and higher CDR scores 〔OR=0.015, 95%CI (0.003, 0.089) 〕, while increased probability of reversion from MCI to normal cognition was related to higher MMSE score 〔OR=1.708, 95%CI (1.428, 2.043) 〕 and higher numbers of correct naming of animals 〔OR=1.139, 95%CI (1.046, 1.240) 〕.

The outcome of MCI patients is affected by multiple factors. Advanced age, obesity, history of stroke, fecal incontinence, self-reported cognitive impairment and reduced functional activity were important factors influencing MCI progression and reversion.

Ultrasound-based Thyroid Nodule Malignancy Risk Stratification in Differentiating Benign and Malignant Thyroid Nodules：a Comparative Analysis between the C-TIRADS and ATA Guidelines

LI Jian, YIN Yanhua, QI Jianguo, WANG Zhou, REN Yongfeng, WANG Shanshan, ZHANG Weili, WANG Xiaojun, TANG Kun

2022, 25(09):  1077-1081.  DOI: 10.12114/j.issn.1007-9572.2021.02.026

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The 2020 Chinese guidelines for ultrasound malignancy risk stratification of thyroid nodules: the C-TIRADS (C-TIRADS for short) put forward a method for stratifying the malignancy risk of thyroid nodules, but there are few studies about its value in differentiating benign and malignant thyroid nodules.

To compare the value of ultrasound-based thyroid nodule malignancy risk stratification in differentiating malignant and benign thyroid nodule between C-TIRADS and 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer (ATA guidelines for short) .

A total of 336 inpatients who underwent surgery and ultrasound examination in Bozhou People's Hospital from January 2019 to May 2021 were selected as participants. Four ultrasonologists with a title higher than attending physician were equally randomized into groups A and B for evaluating ultrasonic examination results according to ultrasound-based thyroid nodule malignancy risk stratification in C-TIRADS and ATA guidelines, respectively. The accuracies of ultrasound-based thyroid nodule malignancy stratification in the two guidelines in differentiating malignant and benign thyroid nodules were assessed using intraoperative or postoperative pathological findings (gold standard for diagnosis) , and were further analyzed using ROC analysis.

According to intraoperative or postoperative pathological findings, the participants had 367 thyroid nodules in total, including 253 benign nodules and 114 malignant nodules. The nodules were classified as follows according to the TI-RADS in the C-TIRADS by ultrasonologists in group A: (1) 253 benign nodules: 2 were in TI-RADS 5 category, 23, 30, and 80 were in categories 4c, 4b, and 4a, respectively, 103 were in 3 category, and 15 were in 2 category; (2) 114 malignant nodules: 24 were in TI-RADS 5 category, 59 were in 4c category, 22 were in 4b category, 6 were in 4a category and 3 were in 3 category. And the classification of nodules according to the ATA guideline by ultrasonologists in group B was: (1) 253 benign nodules: 13, 53, 47, 118 were high, intermediate, low, and very low suspicion pattern for malignancy, respectively, and 22 were benign pattern; (2) 114 malignant nodules: 76, 24, 8, 6 were high, intermediate, low, and very low suspicion pattern for malignancy, respectively. ROC analysis showed that, AUCs of ultrasound-based thyroid nodule malignancy risk stratification in differentiating malignant and benign thyroid nodules between C-TIRADS and ATA guidelines were 0.890〔95%CI (0.815, 0.918) 〕and 0.780〔95%CI (0.750, 0.876) 〕, with significant difference (Z=13.62, P<0.05) . The TI-RADS in the C-TIRADS showed 92.11% sensitivity, 78.26% specificity, 82.56% accuracy, with Youden index of 0.70 in differentiating 4b category benign and malignant nodules, and demonstrated 97.37% sensitivity, 46.64% specificity, 62.40% accuracy with Youden index of 0.44 in differentiating 4a category benign and malignant nodules. The ultrasound-based thyroid nodule malignancy risk stratification in ATA guideline showed 87.72% sensitivity, 67.98% specificity, 74.11% accuracy, with Youden index of 0.56 in differentiating intermediate suspicion pattern for malignancy, and demonstrated 94.74% sensitivity, 44.66% specificity, 60.22% accuracy with Youden index of 0.39 in differentiating low suspicion pattern for malignancy.

The ultrasound-based thyroid nodule malignancy risk stratification in C-TIRADS has higher value in differentiating malignant and benign thyroid nodules than that in ATA guidelines, and the optimal performance of which may be manifested in differentiating malignant and benign thyroid nodules of TI-RADS 4b category.

Relationships of Skin AGEs and Serum CN-1 with Microvascular Complications in Type 2 Diabetes Mellitus

YANG Guang, XU Xin, ZHANG Yu, XU Juan, JIANG Shujuan, XIA Li, ZHANG Yang, WANG Yikun, LI Zhongsheng, ZHANG Shiqi

2022, 25(09):  1082-1087.  DOI: 10.12114/j.issn.1007-9572.2021.02.134

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Hyperglycemia plays a significant role in the development and progression of diabetic complications. While carnosine is a putative scavenger of advanced glycation end products (AGEs) , its availability in tissue is limited by the activity of serum carnosinase-1 (CN-1) . So far, the correlations of skin AGEs and serum CN-1 concentration with type 2 diabetes mellitus (T2DM) , and microvascular complications in T2DM are still unclear.

To investigate the relationships of skin AGEs, and serum CN-1 with microvascular complications in T2DM to evaluate the predictive values of skin AGEs and serum CN-1 for diabetic complications.

A total of 134 inpatients with T2DM were recruited from the Department of Endocrinology, the First Affiliated Hospital of Anhui Medical University between January and March 2021.Their clinical data were collected. Pearson correlation analysis and Spearman rank correlation analysis were used to examine the correlation between skin AGEs and serum CN-1, and the correlations of skin AGEs and serum CN-1 with demographic and serological data, diabetic microvascular complications and other diseases. The influencing factors of skin AGEs and serum CN-1 were investigated by multiple linear regression analysis.

Out of all subjects, there were 13 (9.7%) cases of diabetic retinopathy (DR) , 38 (28.4%) cases of diabetic nephropathy (DN) , 56 (41.8%) cases of diabetic peripheral neuropathy (DPN) , and 79 (59.0%) cases of diabetic peripheral vascular disease. The skin AGEs level was (80.2 ±10.6) and serum CN-1 concentration was (6.9±3.4) μg/L on average. Correlation analyses demonstrated that gender, age, and DR were positively correlated with skin AGEs (P<0.05) , but estimated glomerular filtration rate (eGFR) and CN-1 were negatively correlated with skin AGEs (P<0.05) . Multiple linear regression analysis revealed that gender (B=7.630) , age (B=0.408) and DR (B=7.183) were associated with skin AGEs (P<0.05) . Correlation analyses showed that serum CN-1 was increased with age or with the increase in diastolic blood pressure (DBP) (P<0.05) , while it decreased with the decline of skin AGEs (P<0.05) .

Both skin AGEs and serum CN-1 may have no obvious correlation with most diabetic microvascular complications, such as DN, DPN and diabetic peripheral vascular disease. But different from serum CN-1, skin AGEs may significantly correlated with DR.

External Validation of Risk Prediction Models for Postpartum Stress Urinary Incontinence

ZHANG Danli, HU Fengxin, WANG Jia, CHEN Ling, LIU Sha, CAI Wenzhi

2022, 25(09):  1088-1092.  DOI: 10.12114/j.issn.1007-9572.2021.02.129

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Our research team developed two prediction models of postpartum stress urinary incontinence (PSUI) , one for primiparas, and the other for multiparae, aiming at early identifying women at high risk of PSUI, and providing effective interventions, but they have not yet been externally validated.

To externally validate the risk prediction models of PSUI previously developed by us to assess their clinical applicability.

This study was conducted between July and September 2020. Participants were 6-month postpartum women (validation group) who were selected from the electronic medical record system of Shenzhen Hospital of Southern Medical University, and the University of Hong Kong-Shenzhen Hospital. Information about age, height, pre-pregnancy weight, abortion history, and delivery history was collected from the electronic medical record system of the two hospitals. A telephone follow-up was conducted to investigate the incidence of stress urinary incontinence within 6-month postpartum. The area under the receiver operating characteristic curve (AUC) was computed to estimate the value of the predictive models in discriminating PSUI. Hosmer-Lemeshow goodness-of-fit test was used to examine the calibration of the prediction models.

A total of 298 cases were included, and 203 of them (68.1%) were primiparas (158 with PSUI, and other 45 without) , other 95 (31.9%) were multiparae (72 with PSUI, and other 23 without) . The AUC of the risk prediction model for PSUI in primiparas was 0.719〔95%CI (0.643, 0.795) 〕, and that of the risk prediction model for PSUI in multiparae was 0.833〔95%CI (0.738, 0.928) 〕. Hosmer-Lemeshow goodness-of-fit test suggested that the PSUI risk prediction model for primiparas had poor calibration (χ²=34.11, P<0.001) , while that for multiparae had satisfactory calibration (χ²=9.62, P=0.293) .

The PSUI risk prediction model for primiparas could effectively distinguish PSUI, but its applicability needs to be further improved. The PSUI risk prediction model for multiparae had acceptable performance, which may be used and promoted as an evaluation tool for early pelvic floor rehabilitation in multiparae.

Correlations of BMI and Blood Lipids with Diabetes in an Elderly Health Check-up Population of Luzhou：a Longitudinal Study

ZHANG Wenxin, FAN Song, LIU Xia, LI Xinping, LEI Zhi, LI Ailing

2022, 25(09):  1093-1097.  DOI: 10.12114/j.issn.1007-9572.2021.02.114

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A number of studies have shown that obesity, overweight and dyslipidemia have various strength of correlation with diabetes, but there is a lack of longitudinal studies to verify this issue.

To perform a longitudinal study of diabetes prevalence, and the strength of correlationof body mass index (BMI) and blood lipid with diabetes in an older health check-up population of Luzhou during 2016 to 2019, providing a scientific basis for the formulation of diabetes prevention and treatment strategies for the elderly.

A longitude study design was used. Health check-up data of Luzhou older adults (≥64 years old) in four consecutive years (from 2016 to 2019) were retrospectively collected, including gender, age, BMI, smoking and alcohol consumption, total cholesterol (TC) , triglyceride (TG) , low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) . Generalized estimating equation was used to analyze the strength of correlation of BMI, TC, TG, LDL-C and HDL-C with diabetes.

The prevalence of diabetes in the participants during 2016—2019 was 10.5% (15 893/151 132) , 11.5% (17 375/151 132) , 11.9% (18 019/151 132) and 13.5% (20 394/151 132) , respectively. After controlling for gender, age, smoking and alcohol consumption, the analysis using generalized estimating equation revealed that obesity〔OR=2.610, 95%CI (2.523, 2.700) 〕, overweight〔OR=1.749, 95%CI (1.710, 1.790) 〕, increased TC〔OR=1.073, 95%CI (1.040, 1.106) 〕, marginally increased TG〔OR=1.151, 95%CI (1.126, 1.177) 〕, increased TG〔OR=2.091, 95%CI (2.042, 2.140) 〕, marginally increased LDL-C〔OR=1.208, 95%CI (1.178, 1.240) 〕, increased LDL-C〔OR=1.264, 95%CI (1.219, 1.310) 〕, and decreased HDL-C〔OR=1.552, 95%CI (1.506, 1.599) 〕 were correlated with increased risk of diabetes (P<0.01) . Slightly underweight〔OR=0.763, 95%CI (0.73, 0.798) 〕 and marginally increased TC 〔OR=0.868, 95%CI (0.850, 0.886) 〕were correlated with decreased risk of diabetes (P<0.01) .

The prevalence of diabetes was relatively high in the elderlyhealth check-up population of Sichuan's Luzhou, which may be closely correlated with overweight / obesity and dyslipidemia. In view of this, it is suggested to lose weight and lower blood lipids to reduce diabetes prevalence and to prevent diabetes in this group.

Probability of Premature Mortality Caused by Major Non-communicable Diseases in Pudong New Area of Shanghai，2002—2020

CHEN Yichen, CHEN Hua, ZHOU Yi, QU Xiaobing, SUN Lianghong, CHEN Hanyi, LI Xiaopan, YANG Chen, XIAO Shaotan

2022, 25(09):  1098-1104.  DOI: 10.12114/j.issn.1007-9572.2021.02.074

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Non-communicable diseases (NCDs) pose a major threat to population health. Probability of premature mortality is an index recommended by WHO for the evaluation of the threat of NCDs.

To explore the mortality and probability of premature mortality caused by four major NCDs (cardiovascular and cerebrovascular diseases, cancer, diabetes and chronic respiratory disease) in Pudong New Area of Shanghai from 2002 to 2020, providing a reference for the development of measures to the target of reducing the probability of premature mortality due to these four major NCDs in the Health China 2030 plan.

This analysis was conducted in May 2021 based on data collected from Pudong New Area's Residents Death Surveillance Database, involving registered residents of Pudong New Area who died of cardiovascular and cerebrovascular diseases, cancer, diabetes and chronic respiratory disease between 2002-01-01 and 2020-12-31. Crude mortality, age-standardized mortality and probability of premature mortality were used for analyzing deaths due to the four above-mentioned NCDs. The annual percent change (APC) was adopted to analyze the temporal trend of mortality and probability of premature mortality.

The crude mortality of four major NCDs ascended from 526.82/100 000 in 2002 to 678.84/100 000 in 2020 (APC=1.56%, Z=13.715, P<0.001) . The age-standardized mortality of four major NCDs decreased from 404.05/100 000 in 2002 to 260.87/100 000 in 2020 (APC=-2.09%, Z=-12.428, P<0.001) . The probability of premature mortality caused by four major NCDs decreased from 13.09% in 2002 to 8.45% in 2020 (APC=-2.31%, Z=-15.847, P<0.001) . The probability of premature mortality caused by cardiovascular and cerebrovascular diseases was declined from 3.57% in 2002 to 2.38% in 2020 (APC=-2.21%, Z=-9.739, P<0.001) , and that caused by cancer decreased from 8.36% to 5.49% (APC=-2.24%, Z=-19.476, P<0.001) , and that by chronic respiratory disease reduced from 1.08% to 0.24% (APC=-7.23%, Z=-13.326, P<0.001) . No significant temporal trend for the probability of premature mortality caused by diabetes was found (Z=-0.395, P=0.698) . The probability of premature mortality caused by four major NCDs in males was higher than that in females. According to the annual increase rates during 2015 to 2020, it is estimated that the probability of premature mortality caused by these four major NCDs would be 6.67%.

The crude mortality of the four major NCDs in Pudong New Area ascended during 2002—2020, and both the age-standardized mortality and the probability of premature mortality showed a downward tendency in the same period. Pudong New Area had achieved the goal in the Health China 2020 plan of reducing the probability of premature mortality of four NCDs in 2020. However, according to the present annual increase rates, the task of achieving the Health China 2030 target of the decent of the probability of premature mortality caused by four major NCDs would be daunting. Thus, more measures should be taken to strengthen the containment of such NCDs. Moreover, males should be treated as the key group, and more attention should be paid to the premature death caused by diabetes in males.

Study on the Mediating Effect of Intimate Relationship between Dyadic Coping and Quality of Life in Gynecological Cancer Patients' Couples

YE Huihui, GE Lina, ZANG Shuang, HU Shuang

2022, 25(09):  1105-1112.  DOI: 10.12114/j.issn.1007-9572.2021.02.070

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Dyadic coping are associated with quality of life in gynecologic cancer patients, but the mechanism path of action is still unclear.

To explore the mechanism of intimate relationship between dyadic coping and quality of life in gynecological cancer patients.

By using a convenience-sampling method, 309 hospitalized gynecological cancer patients from Shengjing Hospital of China Medical University from May 2020 to February 2021 were selected as the research objects. The general data questionnaire was used to investigate the general data of patients, the Dyadic Coping Inventory was used to assess the dyadic coping under stress. The Chinese version of the Lock-Wallace Marriage (Love) Relationship Adjustment Scale was used to evaluate the quality of intimate relationships between couples, the The Chinese version of the World Health Organization Quality of Life-BREF Scale (including the four dimensions of physical health, mental health, social relations, and environment) was used to examine the quality of life of patients.

A total of 320 questionnaires were distributed, 11 invalid questionnaires were excluded, and 309 valid questionnaires were returned, with an effective recovery rate of 96.56%. The average score of positive dyadic coping, negative dyadic coping and total score of dyadic coping for 309 patients were (48.2±7.4) , (8.3±1.4) , and (97.9±11.4) , respectively. The Chinese version of Locke-Wallace Marital (love) Adjustment and Prediction Test's mean score was (90.9±19.7) . The average score for the physical domain, psychological domain, social domain, and environment domain were (41.9±14.1) , (49.8±11.9) , (50.6±13.4) , and (47.8±9.9) , respectively. Multiple linear regression analysis showed that the total score of the Lock-Wallace Marital (love) Adjustment and Prediction Scale were significantly correlated with physical domain scores in gynecologic cancer patients (P<0.05) ; The Lock-Wallace Marital (love) Adjustment and Prediction Scale scores were associated with psychological domain scores in gynecologic cancer patients (P<0.05) ; The Lock-Wallace Marital (love) Adjustment and Prediction Scale scores were associated with social domain scores in gynecologic cancer patients (P<0.05) ; The total score of dyadic coping and Lock-Wallace Marital (love) Adjustment and Prediction Scale were significantly correlated with environment domain scores in gynecologic cancer patients (P<0.05) . The results of Structural Equation Model showed that the total score of dyadic coping positively predicted Lock-Wallace Marital (love) Adjustment and Prediction Scale (β=0.931, P<0.001) , Lock-Wallace Marital (love) Adjustment and Prediction Scale scores positively predicted the World Health Organization Quality of Life-BREF Scale scores (β=0.781, P=0.012) , and the total score of dyadic coping exerted no predictive effect on the World Health Organization Quality of Life-BREF questionnaire scores (β=0.112, P=0.688) .The results of the bootstrap sampling method (5 000 replicates) showed that the mediating effect of intimate relationship on the relationship between dyadic coping and quality of life was 0.727, accounting for 86.7% of the total effect.

Gynecological cancer patients may have a relatively low level of dyadic coping, unsatisfactory intimate relationship, and poorer quality of life. The dyadic coping can indirectly predict the quality of life through intimate relationship was verified by structural equation modeling.

Association between Subclinical Hypothyroidism and Cardiac Autonomic Neuropathy in Type 2 Diabetes Mellitus

ZHAO Lei, LI Ruqiang, YUAN Mingxia

2022, 25(09):  1113-1118.  DOI: 10.12114/j.issn.1007-9572.2021.02.128

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Cardiac autonomic neuropathy (CAN) is a common and severe chronic diabetic complication, whose association with thyroid function has rarely been reported.

To investigate the association between subclinical hypothyroidism and CAN in type 2 diabetes mellitus (T2DM) .

We performed a retrospective analysis of 564 outpatients and hospitalized patients with T2DM recruited from Beijing Friendship Hospital, Capital Medical University from October 2019 to October 2020. Baseline characteristics, physical and laboratory examination results were collected. Ewing test was performed to identify CAN. The association between subclinical hypothyroidism and CAN was assessed using the Pearson correlation coefficient and Spearman's rank coefficient of correlation. Factors associated with CAN in T2DM were identified using multivariate, stepwise logistic regression.

One hundred and twenty-nine subjects (22.9%) were found with CAN, and other 435 without. Subclinical hypothyroidism was detected in 84 cases (14.9%) , including 36 with CAN and 48 without. The prevalence of subclinical hypothyroidism in those with CAN〔28.0% (36/129) 〕 was higher than that of those without〔11.0% (48/435) 〕 (χ²=22.346, P<0.001) . For those with CAN, the ratio between maximum and minimum R-R intervals during the Valsalva maneuver demonstrated a negative correlation with the duration of T2DM, glycated hemoglobin, fasting plasma glucose, low-density lipoprotein cholesterol, triacylglycerol, high-sensitivity C-reactive protein, thyroid-stimulating hormone and urine albumin-to-creatinine ratio, while it demonstrated a positive correlation with the diastolic blood pressure (P<0.05) . The multivariate, stepwise logistic regression analysis revealed that subclinical hypothyroidism〔OR=1.717, 95%CI (1.246, 2.365) 〕was independently associated with increased risk of CAN in T2DM (P<0.05) .

In type 2 diabetes patients, the level of TSH may be related to CAN, and subclinical hypothyroidism may be an independent associated factor of CAN.

Associated Risk Factors in Group B Streptococcus Infection During Pregnancy

HUANG Yan, WANG Mingying, FENG Junyan, ZHANG Jie

2022, 25(09):  1118-1122.  DOI: 10.12114/j.issn.1007-9572.2021.02.139

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Group B streptococcus (GBS) infection can give rise to intrauterine infection during pregnancy and postpartum endometritis, and increase the risk of premature birth or stillbirth. So it is essential to improve the detection rate of GBS and to identify risk factors of GBS infection.

To explore the risk factors of GBS infection during pregnancy.

Participants were pregnant women in late pregnancy (n=11 248) who were selected from Department of Obstetrics and Gynecology, Peking University International Hospital from January 2017 to August 2021. All of them underwent screening for GBS infection, 4 479 of them used vaginal swab test (single-swab culture group) , 1 239 used vaginal and rectal swabs tests (double-swab culture group) , and other 5 530 used PCR test of vaginal and rectal swabs (double-swab & PCR group) , and GBS detection rates in the groups were compared. Then, from the double-swab & PCR group, 305 cases who were detected with GBS infection and 2 650 without were selected and compared in terms of information possibly related to GBS infection collected from the medical records, by which potential intrapartum risk factors for GBS infection were identified exploratively. Furthermore, 294 of the above-mentioned 305 cases who also underwent vaginal microbiome test were selected, and compared with a random sample of 367 of the above-mentioned 2 650 cases who also underwent vaginal microbiome test, to analyze the association of vaginal microbiota status with GBS infection.

The GBS detection rates in single-swab culture group, double-swab culture group, and double-swab & PCR group were 5.94% (266/4 479) , 8.07 (100/1 239) , and 10.31% (570/5 530) , respectively. The GBS detection rate was lower in single-swab culture group than that of other two groups (P<0.017) . And double-swab & PCR group had a higher GBS detection rate than did double-swab culture group (P<0.017) . Multiple Logistic regression analysis showed that grade Ⅲ or Ⅳ vaginal cleanliness was closely associated with the prevalence of GBS infection in pregnancy〔OR=3.005, 95%CI (1.220, 7.403) , P=0.017〕.

PCR test of both vaginal and rectal swabs could increase the GBS detection rate. Vaginitis is a major high-risk factor associated with GBS infection during pregnancy, which needs to be addressed in the process of diagnosis and treatment.

Article·Brain Health

Brain White Matter Fiber Bundle Alterations and Severity of Depression in Patients with Post-stroke Depression

QI Jie, ZHANG Lei, DENG Lijun, DUAN Xiaodi, DONG Binbin, SUI Rubo

2022, 25(09):  1123-1129.  DOI: 10.12114/j.issn.1007-9572.2021.02.079

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Post-stroke depression (PSD) , a common complication in stroke patients, may increase the disability and mortality, however, its pathogenesis is unknown yet.

To observe the white matter fiber bundle alterations by diffusion tensor tractography (DTT) , and to explore its correlation with depression in patients with PSD.

Participants were selected from the First Affiliated Hospital of Jinzhou Medical University from September 2019 to September 2020, involving 40 inpatients with first-episode ischemic stroke (20 were found with PSD, and 20 without) , and 20 physical examinees as healthy controls. DTT was performed in all participants, fractional anisotropy (FA) and number of fiber bundles in regions of interest (ROIs) were compared across PSD and non-PSD inpatients and healthy controls. Pearson correlation analysis was performed to analyze the correlations of FA and number of fiber bundles on the side of stroke in the ROIs with 24-item Hamilton Rating Scale for Depression (HAMD-24) in PDS inpatients.

In PSD inpatients, the FA of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle and uncinate fasciculus on the side of the stroke was significantly lower than those on the contralateral side (P<0.05) . And the number of fiber bundle of inferior fronto-occipital fascicles, corticospinal tract and frontopontine tract on the side of the stroke was significantly less than those on the contralateral side (P<0.05) . Compared to non-PSD inpatients or healthy controls, PSD inpatients demonstrated significantly lower FA of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle and uncinate fasciculus, and notable less number of fiber bundles of inferior fronto-occipital fascicles, corticospinal tract and frontopontine tract on the side of the stroke (P<0.05) . Pearson correlation analysis revealed that, the FA of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle or uncinate fasciculus on the side of the stroke was negatively correlated with HAMD-24 score in PSD inpatients (r=-0.469, -0.769, -0.728, -0.801, -0.839, P<0.05) ; the number of fiber bundle of inferior fronto-occipital fascicles, corticospinal tract or frontopontine tract on the side of the stroke was negatively correlated with HAMD-24 score in PSD inpatients (r=-0.858, -0.806, -0.694, P<0.01) .

There were impairment changes of structure of inferior fronto-occipital fascicles, corticospinal tract, frontopontine tract, cingulum bundle and uncinate fasciculus in patients with PSD, and these changes may be significantly correlated with the severity of depression, indicating that some white matter fiber bundle alterations may be involved in the onset of PSD.

Correlation Study between Serum Trimethylamine-N-oxide and the Risk of Acute Ischemic Stroke

LUO Jiaxin, ZHANG Aoqi, GAO Ruijiang, LI Ziru, ZHU Runxiu, YAO Yuan, YUAN Jun

2022, 25(09):  1130-1135.  DOI: 10.12114/j.issn.1007-9572.2021.02.125

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Assessment of the risks of stroke and then initiation of primary prevention are crucial to reducing the incidence rate of stroke. Trimethylamine-N-oxide (TMAO) is a recently discovered intestinal microbial metabolite, whose relationships with the risks of stroke have been rarely reported.

To explore the correlation between serum TMAO levels and the risks of acute ischemic stroke (AIS) .

With the supporting by the project of the National Health Commission (stroke high risk population screening and intervention) , five hundred cases were randomly selected from the stroke screening population in the New Urban Community of Hohhot city of Inner Mongolia from October to December 2020. Finally, 399 cases were included according to the set of standard, and then the 399 cases were divided into normal control group (n=121) , moderate AIS risk group (n=141) , and high AIS risk group (n=137) in accordance with the screening results (score of stroke risk rated using a scoring card) . Demographic and laboratory indices (including serum TMAO detected using ELISA) of all cases were collected. Pearson correlation test and Spearman rank correlation test were conducted to measure the correlation of TMAO with AIS risks. Multinomial and ordinal Logistic regressions were used to explore the influencing factors of AIS risks. ROC analysis was used to estimate the predictive value of TMAO for AIS risk.

Compared with the control group, the serum TMAO level in high-risk group was increased significantly (P<0.05) . Correlation analysis results found that serum TMAO level was negatively associated with increased age, being female, history of hypertension, diabetes history, current smoking and drinking consumption (r=-0.182, r_s=-0.130, -0.262, -0.147, -0.178, -0.140, P<0.05) , but positively associated with lack of exercise and increased BMI (r_s=0.153, r=0.210, P<0.05) .The multinomial and ordinal Logistic regression analyses showed that increased TMAO was independently associated with increased risk of AIS (B=3.084, SE=0.426, P<0.001) . The AUC of serum TMAO in predicting AIS risk was 0.790 〔95%CI (0.737, 0.837) 〕with 62.0% sensitivity and 91.6% specificity when its optimal cut-off value was determined as 3.28 μmol/L.

Serum TMAO level may be independently related to AIS, which could be used as a clinical predictor for AIS.

The Glymphatic System：a New Exploration of Pathological Mechanism in Stroke

YI Ting, JIN Shuoguo, YIN Haiyan, GAO Ping, ZHU Tianmin

2022, 25(09):  1136-1140.  DOI: 10.12114/j.issn.1007-9572.2021.02.107

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The glymphatic system is a system that promotes the exchange and flow of cerebrospinal fluid (CSF) -interstitial fluid (ISF) to maintain the balance of CSF-ISF, and rid the neuropil of toxic proteinaceous metabolites with astroglial water channel aquaporin-4 as the mediator. Increasing evidence has shown that the glymphatic system is strongly related to the pathological changes and outcomes of stroke. Available studies have found that the glymphatic system partially affects post-stroke cerebrospinal fluid circulation and cerebral edema. Different types of strokes include acute ischemic stroke, subarachnoid hemorrhage and intracerebral hemorrhage also have pathological changes in the glymphatic system. This review summarizes the structure and function of the glymphatic system, and the latest developments in its impact on pathological changes of different types of strokes, providing a new direction for the prevention and treatment of stroke.

Review

Research Progress of the Prevention and Treatment of Metabolic Diseases Based on Short Chain Fatty Acids

ZENG Lin, ZHANG Pengxiang, HUANG Qian, WANG Gaoxiang, LI Huilin

2022, 25(09):  1141-1147.  DOI: 10.12114/j.issn.1007-9572.2021.02.135

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Short chain fatty acids (SCFAs) are a class of saturated fatty acids containing 1-6 carbon atoms, which are mainly produced by specific flora in the intestine through the fermentation of dietary fiber, and play an important role in maintaining the homeostasis of the intestinal environment. Recent studies have shown that SCFAs can regulate glucose and lipid metabolism, regulate energy balance, maintain the intestinal barrier and reduce inflammatory responses, eventually participating in the occurrence and development of metabolic diseases such as type 2 diabetes mellitus, obesity, lipid metabolic disorders and nonalcoholic fat liver disease through the above multiple pathways. This article summarizes the mechanism of SCFAs regulating metabolism and the research progress in the prevention and treatment of metabolic diseases, in order to provide more reference materials for the prevention and treatment of metabolic diseases.

Recent Developments in the Prevention and Treatment of Irritable Bowel Syndrome

GAO Lian, HUANG Xiaoming, WU Qingming

2022, 25(09):  1148-1154.  DOI: 10.12114/j.issn.1007-9572.2021.02.138

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Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disease. The clinical symptoms of IBS mainly include abdominal pain and abnormal bowel movements. Clinically, IBS is divided into four types, which are caused by environmental and host factors, but the exact pathogenesis is unclear. Clinical diagnosis, treatment, and prevention of IBS are rather tricky. In contrast to functional diarrhea and constipation, the most notable symptom for diagnosing IBS is abdominal pain. The treatments for IBS include non-drug treatment and/or drug treatment. In general, the non-drug treatment is delivered in accordance with the patient's physiology and psychology, including professional guidance, dietary intervention, and psychological counseling. And drug treatment is implemented depending on the specific condition of the patient. Recent studies have shown that the intestinal flora is also involved in the incidence and progression of IBS, and the use of probiotics and intestinal microbiota transplantation may be effective treatments for IBS. This article reviews the latest developments in pathogenesis, treatments, prevention strategies, and possible future research directions regarding IBS.