Table of Content

20 February 2023, Volume 26 Issue 06

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Guide·Consensus

Clinical Practice Guideline for Chinese Medicine in the Treatment of Idiopathic Membranous Nephropathy (2021)

Nephrology Branch of China Association of Chinese Medicine, Nephrology Committee of Guangdong Provincial Association of Chinese Medicine, YANG Lihong, SU Peiling, BAO Kun

2023, 26(06):  647-659.  DOI: 10.12114/j.issn.1007-9572.2022.0758

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In China, idiopathic membranous nephropathy (IMN) accounts for 24.9% of glomerular diseases, the second highest share, and is increasing year by year. Chinese medicine has been widely used in the clinical practice of IMN. However, there are no evidence-based practice guidelines for the treatment of IMN with Chinese medicine. This guideline followed the methods and steps of the guideline development manual. The level of the body of the evidence was assessed by the GRADE. An outline of the clinical questions was formulated through interviews with leading Chinese medicine experts and a review of relevant clinical guidelines. Based on the results of a systematic review of authoritative textbooks and clinical research literature, a clinical question list, a clinical outcome assessment index for IMN, and a list of types of Chinese medicine syndromes were developed, and a national expert survey was conducted to identify the clinical questions included in this guideline. A consensus meeting was held to finalize 10 recommendations for treating IMN with Chinese medicine. This guideline focuses on the clinical practice of Chinese medicine in the treatment of IMN, and is applicable to all levels of Chinese medicine and integrated Chinese and Western medicine institutions, as well as medical institutions and healthcare workers who provide Chinese medicine services.

Original Research

Predictive Value of Remnant Lipoprotein-cholesterol and Atherogenic Index of Plasma for First-time Acute Myocardial Infarction in Young Adults

DENG Yifan, ZHU Mixue, LIU Juan, NIE Ri, HE Shenghu, ZHANG Jing

2023, 26(06):  659-664.  DOI: 10.12114/j.issn.1007-9572.2022.0564

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Background

Acute myocardial infarction (AMI) can be found in some patients with normal serum lipids although abnormal lipid metabolism is a major risk of AMI. The association of AMI with two unconventional lipid parameters, namely residual lipoprotein-cholesterol (RLP-C) and atherogenic index of plasma (AIP), has been studied rarely, and the predictive value of RLP-C and AIP for first-time AMI in young adults still needs to be explored.

Objective

To assess the value of RLP-C and AIP in predicting first-time AMI in young adults.

Methods

A total of 1 201 inpatients aged 18-45 years old with an initial diagnosis of coronary heart disease (CHD) were selected from Northern Jiangsu People's Hospital from November 2014 to November 2021, including 627 with first-time AMI and 574 without. General demographics, triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and other indicators were collected, and RPL-C and AIP were calculated according to the formula for statistical analysis. Logistic regression analysis was used to explore the influencing factors of first-time AMI. Receiver operating characteristic (ROC) analysis was used to evaluate the predictive value of RLP-C and AIP for first-time AMI.

Results

CHD patients with and without first-time AMI had significant differences in male ratio, smoking history, hypertension history, and average levels of TG, TC, HDL-C, LDL-C, RLP-C and AIP (P<0.05). Multivariate Logistic regression analysis showed that smoking history〔OR=2.541, 95%CI (1.824, 3.538) 〕, TC≥5.17 mmol/L〔OR=2.787, 95%CI (1.405, 5.531) 〕, RLP-C≥0.6 mmol/L〔OR=3.786, 95%CI (2.648, 5.413) 〕 and AIP≥0.2〔OR=3.427, 95%CI (2.106, 5.576) 〕independently increased the risk for first-time AMI (P<0.05), while HDL-C≥1.19 mmol/L〔OR=0.049, 95%CI (0.025, 0.093) 〕independently decreased the risk of first-time AMI (P<0.05). In ROC analysis, the performance of RLP-C and AIP predicting first-time AMI was as follows: RLP-C had an AUC of 0.851〔95%CI (0.830, 0.873) 〕, with 0.535 mmol/L as the optimal cut-off value, 0.848 sensitivity and 0.699 specificity; AIP had an AUC of 0.813〔95%CI (0.789, 0.837) 〕, with 0.122 as the optimal cut-off value, 0.852 sensitivity and 0.660 specificity.

Conclusion

The risk of first-time AMI in young adults may be increased by smoking history, TC≥5.17 mmol/L, RLP-C≥0.6 mmol/L and AIP≥0.2, and decreased by HDL-C≥1.19 mmol/L. RLP-C and AIP may partially predict first-time AMI.

Analysis of Influencing Factors of the Nutritional Status in Stoke Patients Hospitalized at Different Time Points

WANG Ruobing, WANG Liugen, LI Heping, ZENG Xi

2023, 26(06):  665-671.  DOI: 10.12114/j.issn.1007-9572.2022.0553

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Background

Malnutrition is frequently observed in stroke patients. Most of the previous studies focused on their nutritional status at the time of admission, but there is a lack of studies on the nutritional status in different periods of hospitalization.

Objective

To investigate the influencing factors of nutritional status in stroke patients at different time points (admission, the 7th day and discharge) .

Methods

The study comprised 177 patients with the diganosis stroke admitted to the Department of Rehabilitation Medicine of the First Affiliated Hospital of Zhengzhou University between January and December 2021. According to the nutritional status, the patients were divided into nutritional normal and malnutrition groups at different time points. General data of the patients were being collected, including gender, age, hypertension, diabetes, post-stroke pneumonia, post-stroke anxiety and depression, obstructive sleep apnea hypoventilation syndrome (OSAHS), history of smoking and alcohol consumption, and mode of nutritional support〔oral feeding only, nasogastric tube only (NGT), intermittent oral to esophageal tube feeding only (IOE), combined parenteral nutrition (PN) 〕. Assessment of patients′ swallowing function using the Water Swallow Test (WST), and the degree of neurological deficits can be evaluated by the National Institutes of Health Stroke Scale (NIHSS). Univariate and multifactorial Logistic regression analyses were used to determine the factors influencing the nutritional status of stroke inpatients at different time points.

Results

The incidence of malnutrition in stroke patients at admission, the 7th day and discharge were 11.9%, 32.2% and 19.8%, respectively. The rate of malutrition on the 7th day of admission was higher than admission and discharge (P<0.05). At the time of admission, between the normal nutrition group (n=156) and the malnutrition group (n=21) in the age, smoking and drinking history, nutritional support mode, and WST score, there were significantly different (P<0.05). On the 7th day of hospitalization, the normal nutrition group (n=120) was significant differences in age, post-stroke pneumonia, nutritional support mode, WST score and NIHSS score compared with malnutrition group (n=57) (P<0.05). At the time of discharge, the differences were statistically significant in nutrition support mode, WST score and NIHSS score between the normal nutrition group (n=142) and malnutrition group (n=35) (P<0.05). At the time of admission, WST score〔OR=2.118, 95%CI (1.390, 3.226), P<0.001〕was the influencing factor of malnutrition. On the 7th day, age〔OR=1.035, 95%CI (1.001, 1.070), P=0.028〕, combined-PN〔OR=19.206, 95%CI (3.188, 115.707), P=0.001〕and NIHSS score〔OR=1.108, 95%CI (1.029, 1.194), P=0.007〕were influencing malnutrition. Only-NGT〔OR=13.518, 95%CI (1.783, 102.493), P=0.012〕and combined-PN〔OR=18.445, 95%CI (2.870, 118.531), P=0.002〕are the influencing factors at the time of discharge.

Conclusion

The incidence of malnutrition is higher in stroke patients at admission, the 7th day and discharge. WST score is an influential factor for malnutrition at the time of admission. On the 7th day, the age, PN, and NIHSS score are influencing factors relevant to malnutrition. At the time of discharge, only-NGT and combined-PN are meaningful factors for malnutrition.

Correlation of Body Fat Composition and Metabolic Indicators with Metabolic-associated Fatty Liver Disease in a Non-obese Population

WANG Yingjie, CHENG Haoran, ZHOU Weihong

2023, 26(06):  672-680.  DOI: 10.12114/j.issn.1007-9572.2022.0573

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Background

The prevalence of metabolic-associated fatty liver disease (MAFLD) has increased rapidly. And there is no conclusion on body fat composition, characteristics of metabolic indicators, and their predictive values for MAFLD in non-obese populations.

Objective

To identify the risk factors for MAFLD by comparing body fat composition and key metabolic indicators (blood lipids, blood sugar, uric acid) between obese and non-obese MAFLD patients, and to assess their associations with MAFLD as well as their predictive values for MAFLD in non-obese patients.

Methods

Physical examinees with and without liver B-ultrasound-detected fatty liver were recruited from Health Management Center, Nanjing Drum Tower Hospital from January 2018 to January 2019 after excluding those with non-MAFLD, and divided into obese group (including 129 cases with MAFLD, and 129 without fatty liver) and non-obese group (including 129 without fatty liver cases, and 129 with MAFLD) by BMI. The body fat composition and metabolic indices in non-obese MAFLD cases were compared with those of the other three subgroups. The correlation of each index with MAFLD in non-obese cases was analyzed. The independent risk factors of MAFLD in non-obese cases were identified by using Logistic regression. The predictive value of each index for MAFLD in non-obese was assessed using the receiver operating characteristic (ROC) curve.

Results

(1) Comparison of body fat composition and metabolic indicators: compared with non-obese without fatty liver cases, non-obese cases with MAFLD had greater average BMI, body fat (BF), body fat ratio (BFR), visceral fat area (VFA), waist circumference (WC), waist-hip-ratio (WHR), total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), uric acid (UA), alanine transaminase (ALT) and gamma-glutamyl transpeptidase (GGT), and lower high-density lipoprotein cholesterol (HDL-C) (P<0.05). In comparison with obese cases with MAFLD, non-obese cases with MAFLD had lower average BMI, BF, VFA, WC, WHR, fasting plasma glucose (FPG), and glycosylated hemoglobin (HbA_1c) (P<0.05). Non-obese cases with MAFLD had lower average BMI, BF and WC, and higher average TG, UA, ALT and GGT than obese cases without fatty liver (P<0.05). Non-obese female cases with MAFLD had greater average age, BF, BFR and VFA and lower WC, VA, GGT than non-obese male cases with MAFLD (P<0.05). (2) Kendall's rank correlation analysis showed that the risk of MAFLD in non-obese cases increased with the growth of BFR, VFA, WHR, TC, TG, LDL-C, UA, ALT, and GGT (r=0.099, 0.092, 0.136, 0.095, 0.176, 0.092, 0.114, 0.125, 0.142, P<0.05), but decreased with the growth of HDL-C (r=-0.112, P<0.05). (3) Multivariate Logistic regression analysis showed that TG, ALT, UA, BFR and VFA were risk factors of MAFLD in non-obese cases. (4) The results of ROC analysis of the performance of five indicators predicting MAFLD in non-obese cases were as follows: BFR had an AUC of 0.853〔95%CI (0.807, 0.898) 〕, with 0.789 sensitivity, 0.770 specificity when 22.30% was chosen as the optimal cut-off value; VFA had an AUC of 0.938〔95%CI (0.906, 0.970) 〕, with 0.852 sensitivity, 0.904 specificity when 61.45 cm² was chosen as the optimal cut-off value; TG had an AUC of 0.807〔95%CI (0.754, 0.860) 〕, with 0.822 sensitivity, 0.713 specificity when 1.02 mmol/L was chosen as the optimal cut-off value; UA had an AUC of 0.665〔95%CI (0.599, 0.731) 〕, with 0.605 sensitivity, 0.682 specificity when 356.00 μmol/L was chosen as the optimal cut-off value; ALT had an AUC of 0.752〔95%CI (0.692, 0.812) 〕, with 0.814 sensitivity, 0.770 specificity when 18.35 U/L was chosen as the optimal cut-off value.

Conclusion

Compared with non-obese people without fatty liver, non-obese people with MAFLD had increased BF and visceral fat, abnormal lipid metabolism, elevated levels of UA and transaminase. The risk of MAFLD in non-obese people increased with the increase in TG, ALT, UA, BFR and VFA, but decreased with the increase in HDL-C. BFR, VFA, TG, UA and ALT could partially predict and diagnose MAFLD in non-obese people, providing evidence for the delivery of interventions as soon as possible.

Total Deep Medullary Veins Score in Cerebral Small Vessel Disease: Association with Imaging Markers and Factors Related to Its Elevation

ZHANG Sen, BAI Hongying, LI Qianqian, LI Caixia

2023, 26(06):  681-686.  DOI: 10.12114/j.issn.1007-9572.2022.0543

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Background

Deep medullary veins (DMV) are small veins distributed perpendicularly to the lateral ventricles, which may have a potential role in the pathogenesis or progression of cerebral small vessel disease (CSVD) .

Objective

To investigate the correlation between DMVs sign and various scores of imaging markers in CSVD, and to analyze the factors related to elevated total DMVs score.

Methods

A retrospective design was used. Participants were 86 cases of CSVD who were selected from Neurology Department, the Second Affiliated Hospital of Zhengzhou University and Public People's Hospital of Xinzheng from January 2021 to May 2022. Their DMVs scores were assessed using a visual scoring method based on susceptibility-weighted imaging. Then the CSVD patients werer divided into mild DMVs group (n=39) and severe DMVs group (n=47) by the median total DMVs score. Imaging markers of CSVD and total CSVD burden were assessed using the common scoring method. Spearman rank correlation analysis was performed to investigate the correlation between the total score of DMVs and several imaging markers. Factors associated with elevated total score of DMVs were explored by multivariate Logistic regression analysis.

Results

The Spearman correlation analysis showed that total score of DMVs was positively correlated with the score of lacunes, white matter hyperintensity, deep matter hyperintensity, total white matter hyperintensity, cerebral microbleeds, enlarged perivascular spaces, or total CSVD burden (r_s values were 0.386, 0.419, 0.437, 0.469, 0.562, 0.415, 0.664; P<0.05). Multivariate Logistic regression analysis showed that the history of acute cerebral stroke〔OR=5.462, 95%CI (1.387, 21.502), P=0.015〕, elevated levels of serum uric acid 〔OR=1.013, 95%CI (1.004, 1.022), P=0.005〕and hemoglobin 〔OR=1.056, 95%CI (1.006, 1.109), P=0.028〕were associated with increased total score of DMVs.

Conclusion

DMVs may play a rolein the development and progression of CSVD. The history of acute cerebral stroke and elevated levels of serum uric acid and hemoglobin may be related to increased total score of DMVs.

Plasma Cytokine Level and Influencing Factors of Depression in Stable Schizophrenia Patients

SUN Liang, LIU Zhiwei, ZHANG Yulong, ZHANG Dapeng, LI Wenzheng, YAO Xianhu, LIU Huanzhong

2023, 26(06):  687-691.  DOI: 10.12114/j.issn.1007-9572.2022.0440

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Background

A large body of literature suggests that plasma cytokine levels are associated with symptoms in patients with schizophrenia, but the relationship of plasma cytokines with depressive symptoms, which often occur in the late stage of schizophrenia, still needs to be explored.

Objective

To explore the relationship between plasma cytokine levels and depressive symptoms in schizophrenic patients.

Methods

Patients with stable schizophrenia were selected from Department of Psychiatry of three hospitals (Chaohu Hospital Affiliated to Anhui Medical University, Hefei Fourth People's Hospital, and Maanshan Fourth People's Hospital) from May to December 2018. The Calgary Depression Scale for Schizophrenia (CDSS) was used to evaluate the depressive symptoms, and the total score of CDSS≥5 was defined as depression. The plasma levels of interleukin (IL) -1β, IL-2, IL-6 and IL-17A were detected by flowcytometry. Spearman rank correlation analysis and multiple linear regression analysis were used to analyze the relationship between plasma cytokine and depression in stable schizophrenia.

Results

A total of 111 patients with stable schizophrenia were included, with depression prevalence of 28.83% (32/111). Spearman rank correlation analysis showed that the total score of CDSS was positively correlated with the level of plasma IL-1β, IL-2 or IL-17A (r_s=0.507, 0.466, 0.374, P<0.05). Multiple linear regression analysis showed that higher level of plasma IL-17A was associated with decreased of risk of depression in stable schizophrenia (B=-0.125, P<0.05), and longer duration of schizophrenia was associated with increased of risk of depression in stable schizophrenia (B=0.343, P<0.05) .

Conclusion

Higher level of IL-17A and longer duration of schizophrenia may be correlated with depression in stable schizophrenia.

Eye Movement Desensitization and Reprocessing versus Sertraline in the Treatment of Depressed Adolescents with Childhood Trauma

HU Shuwei, OU Wei, WANG Zhi, PENG Juan

2023, 26(06):  692-698.  DOI: 10.12114/j.issn.1007-9572.2022.0650

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Background

Depressed adolescents with childhood trauma often present with more severe symptoms and are insensitive to drugs. Eye movement desensitization and reprocessing (EMDR) plays a unique role in the treatment of trauma-related mental disorders. It has been gradually used in the treatment of depression and has achieved certain results recently, but there are few related studies in China.

Objective

To assess whether EMDR has better efficacy than sertraline in the treatment of depressed adolescents with childhood trauma using a comparative analysis, providing scientific evidence for further promoting clinical application of EMDR.

Methods

Sixty depressed adolescents with childhood trauma were recruited from Psychological Clinic, Affiliated Hospital of Zunyi Medical University from December 2020 to February 2022, and equally randomized into a sertraline group and an EMDR group. Sertraline group received a eight-week treatment with sertraline: the dose was 50 mg/d in the first week and gradually increased to 100 mg/d in the second week, and could be increased to 200 mg/d at the end of the fourth week if the patients had negative ideas or self-injurious behavior. The EMDR group received EMDR treatment, once a week, for a total of 8 weeks. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Connor-Davidson Resilience Scale (CD-RISC) were used to evaluate the psychological status of the two groups before treatment, four weeks and eight weeks after treatment.

Results

Except for five dropouts, the remaining cases who completed the trial were finally included, including 28 in the sertraline group and 27 in the EMDR group. The treatment type and treatment duration had interactive effects on the BDI, BAI and CD-RISC scores of the two groups (P<0.05). The treatment duration had significant main effects on the BDI, BAI and CD-RISC scores of the two groups (P<0.05). The treatment type had significant main effects on BAI and CD-RISC scores of the two groups (P<0.05), but produced no significant effects on the BDI scores (P>0.05). EMDR group had higher average CD-RISC score than sertraline group at four weeks after treatment (P<0.05). EMDR group had higher average CD-RISC score, and lower average BDI and BAI scores than sertraline group at eight weeks after treatment (P<0.05). In the sertraline group, the average BDI score at eight weeks after treatment was much lower than that at baseline or four weeks after treatment (P<0.05), the BDI score after 4 weeks of sertraline treatment was lower than that before treatment (P<0.05), and the average BAI score at eight weeks after treatment was much lower than that at basetime (P<0.05). In the EMDR group, the average BDI and BAI scores decreased significantly while the average CD-RISC score increased significantly at both four and eight weeks after treatment compared with baseline levels (P<0.05). And compared with four-week treatment, eight-week treatment lowered the average BDI and BAI scores more significantly, and increased the average CD-RISC score more significantly (P<0.05) .

Conclusion

Sertraline could partially improve depression and anxiety in depressed adolescents with childhood trauma, but had no significant improvement of psychological elasticity. In contrast, EMDR could effectively improve the depression and anxiety as well as psychological elasticity, so it could be used as the preferred treatment.

Clinical Features of Hepatic Cirrhosis in Hypopituitarism

SHI Xuexiu, YUN Wenjing, WANG Haixu, ZHAO Yingying, YANG Yanan, SUN Tongwen

2023, 26(06):  699-703.  DOI: 10.12114/j.issn.1007-9572.2022.0591

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Background

Hepatic cirrhosis represents the final stage for a wide variety of chronic liver diseases, which may be induced by numerous causes, and is associated with high mortality when complications arise. The relationships between hormone deficiencies due to hypopituitarism and hepatic cirrhosis have been rarely reported.

Objective

To analyze the clinical characteristics of 8 cases of hepatic cirrhosis secondary to hypopituitarism, and investigate the potential role of hypopituitarism in the development of hepatic cirrhosis.

Methods

Participants were 8 patients with hepatic cirrhosis secondary to hypopituitarism who were recruited from the First Affiliated Hospital of Zhengzhou University from January 2010 to December 2021. A retrospective analysis was conducted on their clinical manifestations, laboratory and imaging test result, treatments and follow-up results.

Results

The age at the diagnosis of hypopituitarism for all cases ranged from 9 to 20 years old, and that at the diagnosis of hepatic cirrhosis was 16 to 24 years old, with an interval of 3 to 14 years old. The causes of hypopituitarism were germ cell tumor surgery (4 cases), craniopharyngioma surgery (2 cases), radiotherapy for nasopharyngeal carcinoma (1 case) and pituitary stalk interruption syndrome (1 case). All cases received no standardized hormone replacement therapy before cirrhosis was diagnosed by biopsy (2 cases) or imaging (6 cases). Fatigue, anorexia, hypoplastic external genitalia, short stature, recurrent upper respiratory tract infection and bleeding were the most common clinical manifestations. All cases had abnormalities in pituitary-thyroid axis, pituitary-gonadal axis, growth hormone, insulin-like growth factor-1, routine blood markers, four markers of hepatic fibrosis and liver imaging results. Moreover, it was found that 7 cases were also with abnormalities in antidiuretic hormone and hepatic function, and 6 cases were with abnormalities in pituitary-adrenal axis, coagulation function and serum lipids. All patients received treatment with desmopress in acetate, thyroid hormone, hydrocortisone and sex hormones as necessary. Four patients also received growth hormone replacement therapy. One-year follow-up indicated that, all cases had significantly improved levels of leukocyte, platelet, aspartate aminotransferase, alkaline phosphatase, total bilirubin, indirect bilirubin, total cholesterol, low-density lipoprotein, high-density lipoprotein, fibrinogen and four markers of hepatic fibrosis after treatment (P<0.05). However, no significant post-treatment improvement was found in the levels of hemoglobin, alanine aminotransferase, gamma-glutamyl transpeptidase, direct bilirubin, triacylglycerol and D-dimer, and in prothrombin time and endogenous prothrombin potential (P>0.05) .

Conclusion

All these 8 patients with hypopituitarism had hormone deficiency for several years before the diagnosis of hepatic cirrhosis, and abnormalities in thyroid hormone, sex hormone, growth hormone, insulin-like growth factor-1, routine blood markers, four markers of hepatic fibrosis and imaging results, with fatigue, anorexia, hypoplastic external genitalia, short stature, recurrent upper respiratory tract infection and bleeding as the most common clinical manifestations. One-year standardized hormone replacement therapy significantly improved the abnormalities in leukocyte, platelets, total cholesterol, high-density lipoprotein, low-density lipoprotein, fibrinogen and four markers of hepatic fibrosis.

Precision Medication·Renal Anemia

Effectiveness and Safety of Roxadustat for Renal Anemia in Dialysis-dependent Chronic Kidney Disease: a Meta-analysis

LI Jiaqing, YANG Qing, YUAN Dunlu, HUANG Jingjing, CHANG Qing, NIE Jingwen, ZHOU Zhu, LI Qing

2023, 26(06):  704-710.  DOI: 10.12114/j.issn.1007-9572.2022.0581

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Background

As the most common clinical manifestation and a major complication in chronic kidney disease, anemia affects the patients' quality of life, increases the risk of renal disease progression and death. Hence, it is important to improve anemia, and monitor and evaluate drug efficacy and safety in the treatment of renal anemia.

Objective

To compare the efficacy and safety between roxadustat and erythropoiesis stimulating agents (ESAs) in treating renal anemia in patients with dialysis-dependent chronic kidney disease.

Methods

We searched PubMed, FMRS, Wanfang Data and ClinicalTrials.gov from inception to January 19, 2022 for randomized controlled trials (RCTs) about maintenance hemodialysis patients with dialysis duraion≥3 months treated with oral roxadustat (experimental group), versus injection of ESAs (control group). Two researchers independently conducted literature screening, data extraction and quality evaluation. Meta-analysis was performed using Review Manager 5.3.

Results

A total of 5 studies with 6 RCTs were included, involving 901 patients (549 in the experimental group and 352 in the control group). Meta-analysis showed that roxadustat was superior to ESAs in improving the levels of serum iron〔MD=2.49, 95%CI (0.82, 4.16), P=0.004〕, transferrin〔MD=0.31, 95%CI (0.17, 0.44), P<0.000 01〕, total iron-binding capacity〔MD=7.51, 95%CI (5.01, 10.01), P<0.000 01〕. The incidence of adverse events did not differ significantly between the two groups〔RR=1.10, 95%CI (0.99, 1.22), P=0.07〕.

Conclusion

Roxadustat demonstrates better effects than ESAs in increasing the levels of serum iron, transferrin and total iron-binding capacity, without increasing the risk of adverse events during a short-term duration of use.

Safety of Weekly Single versus Divided Administration of Moderate-dose Erythropoietin in the Treatment of Maintenance Hemodialysis Patients with Renal Anemia

WU Xiuling, LI Jianjun, YU Ying, XING Rong, WANG Lu, WANG Xuedong, TENG Fubin

2023, 26(06):  711-717.  DOI: 10.12114/j.issn.1007-9572.2022.0542

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Background

From previous studies, the frequency of administration of recombinant human erythropoietin injection (rHuEPO) has no association with its therapeutic effect in renal anemia in chronic kidney disease (CKD), and there is no significant difference in the efficacy between weekly single dosing and divided dosing. Most hemodialysis patients are clinically treated with moderate-dose rHuEPO, but there is a lack of research on the safety of single and divided administration of moderate-dose rHuEPO.

Objective

To compare the safety between weekly single and divided administration of moderate-dose rHuEPO for renal anemia in maintenance hemodialysis patients.

Methods

This study was designed as a randomized, parallel-group controlled, non-inferiority clinical trial. Eighty-eight patients with renal anemia who underwent maintenance hemodialysis at the Hemodialysis Room, Tongzhou Branch, Dongzhimen Hospital, Beijing University of Chinese Medicine from January 2019 to May 2021 were selected and randomly divided into an experimental group and a control group with 44 in each. For comparing the safety and efficacy of weekly single and divided administration of moderate-dose rHuEPO, 29 cases (experimental subgroup 1) and other 15 cases (experimental subgroup 2) in the experimental group received an rHuEPO dose of 6 000 U, and an rHuEPO dose of 4 000 U, once a week, respectively; 30 cases (control subgroup 1) in the control group received a single rHuEPO dose of 2 000 U, three times a week (6 000 U per week in total), and other 14 cases (control subgroup 2) received a single rHuEPO dose of 2 000 U, twice a week (4 000 U per week in total) .

Results

Safety analysis: two-factor repeated-measures ANOVA showed that the type of intervention scheme and duration had no interaction effects on systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pre-dialysis serum potassium between experimental subgroup 1 and control subgroup 1, and between experimental subgroup 2 and control subgroup 2 (P>0.05), and produced no main effects on systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pre-dialysis serum potassium in experimental subgroup 1 and control subgroup 1, and between experimental subgroup 2 and control subgroup 2 (P>0.05). The serum levels of AST, ALT and TBiL were similar between experimental subgroup 1 and control subgroup 1 at baseline and 12 weeks of treatment (P>0.05). Likewise, they were similar between experimental subgroup 2 and control subgroup 2 at baseline and 12 weeks of treatment (P>0.05). No thromboembolic, cardiovascular or cerebrovascular events and gastrointestinal reactions related to rHuEPO occurred in any of the subgroups during the 12-week treatment. Efficacy analysis: the hemoglobin level (reference range was 110-130 g/L) in experimental subgroup 1 〔65.5% (19/29) 〕was similar to that in control subgroup 1 〔73.3% (22/30) 〕at 12 weeks of treatment (χ^2=0.425, P=0.514). The serum levels of hemoglobin were similar between experimental subgroup 2 and control subgroup 2 at 12 weeks of treatment (P>0.05). The levels of red blood cell count, hematocrit, percentage and absolute number of reticulocytes, ferritin and transferrin saturation did not vary between experimental subgroup 1 and control subgroup 1, and between experimental subgroup 2 and control subgroup 2 either at baseline or 12 weeks of treatment (P>0.05) .

Conclusion

Weekly single and divided administration of moderate-dose erythropoietin had no significant difference in medication safety in the treatment of renal anemia in maintenance hemodialysis patients.

Population Health Research

Exploring the Best Sleep Duration for Undergraduates from the Perspective of TCM Constitution by Using Restricted Cubic Spline Model

MA Fanghui, ZHU Yanbo, LIU Wenqiong, WU Xinrui, ZHANG Qian, ZHAO Xinyuan, LI Yuqiong, LONG Liqun, CHEN Pipi

2023, 26(06):  718-724.  DOI: 10.12114/j.issn.1007-9572.2022.0401

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Background

Sleep duration of the undergraduates are closely related to their health, but there is no conclusion about the best sleep duration for undergraduates. And there is a lack of research about the dose-response relationship between sleep duration and Traditional Chinese Medicine (TCM) constitution.

Objective

To explore the relationship between sleep duration and TCM constitution for undergraduates, and to provide reference for their health education about sleep duration.

Methods

This study used a combination of purposeful sampling and snowball sampling methods to conduct on-site questionnaire survey on students from 143 universities including Beijing University of Chinese Medicine, Harbin Institute of Technology (Weihai), Peking University, Northwestern Polytechnical University from January to June 2019. We used the Constitution in Chinese Medicine Questionnaire of 41-item (CCMQ-41) to assess the TCM constitution of undergraduates, and used a self-designed questionnaire to measure socio-demographic information and lifestyle behaviors. This study used the restricted cubic spline fitting multiple linear regression model to analyze the dose-response relationship between sleep duration and TCM constitution with taking sleep duration as the independent variable and TCM constitution score as the dependent variable, and controlling for related confounding variables.

Results

This study collected 1 003 valid questionnaires. The response rate was 98.2%. Pearson correlation analysis showed that the sleep duration was negatively correlated with the score of qi depression (r=-0.067, P=0.034). After controlling for confounders, multiple linear regression analysis showed that there was no linear relationship between sleep duration and TCM constitution scores (P>0.05). The dose-response relationship analysis showed that the highest point of gentleness score and the lowest point of biased constitutions score (except specific diathesis) had a sleep duration of about 8 h. When the sleep duration was >8.5 h, the gentleness score showed a tendency to decrease, and the scores of qi deficiency and qi depression had a tendency to increase (P<0.05) .

Conclusion

Considering the health status of TCM constitutions, the best daily sleep duration for undergraduates is about 8 h. The sleep duration should be restricted to be less than 8.5 h to prevent the possibility of biased constitution.

Association of Sedentary Behavior and Physical Activity with Calcaneal Bone Mineral Density among College Students

LI Shitian, LYU Xiaogang, ZHU Xiaoqi, WANG Jiaye, LU Xiaocui

2023, 26(06):  725-733.  DOI: 10.12114/j.issn.1007-9572.2022.0635

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Background

The association of sedentary behavior and physical activity with bone mineral density (BMD) in Chinese population has been rarely studied in China, and also seldom studied in Asian populations (mainly limited in young children) by foreign countries. Considering there are great discrepancies between foreign populations and Chinese populations in genetics, dietary habits and other aspects, it is necessary to carry out relevant research in China.

Objective

To assess the association of sedentary behavior and physical activity with calcaneal BMD in college students, offering a reference for understanding the bone health status of college students, and for preventing osteoporosis in middle-aged and old people.

Methods

By use of stratified cluster sampling, 781 college students aged 19-25 years (including 518 females and 263 males) of different grades were selected from a medical university in Guangzhou from January 2021 to March 2022. Demographic and anthropometric characteristics (including sex, age, height, weight, fat mass index and fat free mass index) and lifestyle information (including daily sedentary time, time spent on physical activity in one week, frequency of dairy products, carbonated drinks and tea consumption, calcium supplement, smoking status, alcohol use status) were collected. Calcaneal BMD was measured, and compared across college students by physique and lifestyle. Multiple linear regression and binary Logistic regression were used to investigate the association of sedentary behaviors and physical activity with calcaneal BMD.

Results

The prevalence of normal and abnormal calcaneal BMD in all students was 50.3% and 49.7%, respectively. The prevalence of abnormal calcaneal BMD in female college students (59.4%) is higher than that in male college students (30.4%) (χ²=58.849, P<0.001). The prevalence of abnormal calcaneal BMD varied by daily sedentary time and time spent on physical activity in one week in female students (χ²=6.670, 6.559, P<0.05). After controlling for potential confounders, multiple linear regression analysis and test for trend showed that in female students, the T-score value of calcaneal BMD increased with the decrease of daily sedentary time (β=-0.17), and there was an obvious negative linear trend between them (P_trend=0.011). And the T-score value of calcaneal BMD increased with the increase of time spent on physical activity in one week (β=0.15), and there was an obvious positive linear trend between them (P_trend=0.004). Further analysis based on binary Logistic regression models showed that in female students, sedentary time <4 hours per day was associated with lower risk of abnormal calcaneal BMD compared with sedentary time >8 hours per day〔OR=0.17, 95%CI (0.04, 0.68), P<0.05〕, and 90-150 minutes of physical activity in one week was associated with lower risk of abnormal calcaneal BMD compared with less than 90 minutes of physical activity in one week〔OR=0.66, 95%CI (0.44, 1.00), P<0.05〕.

Conclusion

The prevalence of abnormal calcaneal BMD in female college students is higher than that in male college students. Both sedentary behavior and physical activity are associated with calcaneal BMD in female college students, no correlation found among male college students. Daily duration of sedentary behavior <4 hours and 90-150 minutes of physical activity in one week are associated with lower risk of abnormal calcaneal BMD. Furthermore, the shorter time spent on daily sedentary behaviors, the lower the risk of abnormal BMD.

Big Data Research

Past (2000-2019) and Future (2020-2024) Trends of Brain Cancer Mortality in China

DUAN Zhaohui, ZHANG Min, XU Jieru, XIONG Wenjing, CHEN Lei, ZHAO Xiangling, ZHANG Yiyun, RANG Weiqing

2023, 26(06):  734-741.  DOI: 10.12114/j.issn.1007-9572.2022.0630

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Background

There has been a widespread concern over the issue of the negative effects of brain cancer on physical and mental health, but there are few studies on the past and future trends of brain cancer mortality in China.

Objective

To perform an analysis of the trend of crude mortality rate (CMR) of brain cancers in 2000-2019, and that in 2020-2024 in China, providing a reference for formulating prevention and control strategies for brain cancers.

Methods

Data of brain cancer deaths in China from 2000 to 2019 were extracted from the Global Burden of Disease Study 2019, including CMR and age-standardized mortality rate (ASMR, calculated using the age composition of the 2019 world population). The mortality trend was analyzed by Joinpoint regression model. The age, period and birth cohort effects of CMR were estimated by intrinsic estimator (IE) and age-period-cohort model (APC model). GM (1, 1) model was established by R (4.1.3) to predict the CMR of brain cancers in 2020-2024.

Results

The Joinpoint regression analysis the ASMR of brain cancers showed a downward trend in the whole population, male and female populations. The ASMR of brain cancers in the whole population, male and female populations decreased by 0.68%, 0.47%, and 0.87% on average each year, respectively from 2000 to 2019 (P<0.05). The APC analysis revealed that the death risk of brain cancers in both Chinese male and female populations increased with age and period. The death risk of brain cancers in the late birth cohort was lower than that in the early birth cohort, that is, the effect coefficient decreased from 0.62 in the 1904-1908 birth cohort to -1.28 in the 2014-2019 birth cohort in male, and that increased from 0.36 in the 1904-1908 female cohort to 0.57 in the 1929-1933 birth cohort, then it gradually decreased, and hit its lowest point in the 2014-2019 birth cohort (-1.16) in female. GM (1, 1) model predicted that the CMR of brain cancers in China would continue to rise after 2019, reaching 4.34/10⁵ in 2020, 4.39/10⁵ in 2021, 4.44/10⁵ in 2022, 4.49/10⁵ in 2023 and 4.54/10⁵ in 2024.

Conclusion

During 2000 to 2019, the ASMR of brain cancers in China generally showed a downward trend, and the risk of brain cancer death increased with age and year. People who were born earlier had a greater risk of death. The predicted ASMR of brain cancers would continue to rise in 2020-2024. So strong measures should be still carried out to prevent and control brain cancers, such as strengthening the propaganda of prevention and control of brain cancers in high-risk groups, advocating a healthy lifestyle, and reducing the disease burden of brain cancers.

Review & Perspectives

Treatment Strategy of Nonalcoholic Fatty Liver Disease Targeting the Intestinal Microbiota

FU Weiqiang, ZHOU Jianbo, WU Xiongjian, HUANG Caibin

2023, 26(06):  742-748.  DOI: 10.12114/j.issn.1007-9572.2022.0651

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Nonalcoholic fatty liver disease (NAFLD), the most common chronic liver disease, represents a spectrum of nonalcoholic hepatic steatosis, nonalcoholic steatohepatitis, liver cirrhosis and hepatocellular carcinoma. Recent studies have revealed that the gut-liver axis is associated with the development of NAFLD. Intervention measures such as exercise, diet, microecological preparations, antibiotics, fecal microbiota transplantation and bacteriophage can alleviate NAFLD by improving intestinal microbiota. We reviewed recent advances in the relationship and mechanism between intestinal microbiota and NAFLD as well as treatment of NAFLD targeting the intestinal microbiota, and summarized that intestinal microbiota is closely related to NAFLD, and the regulation of intestinal microbiota can be used as a new target for NAFLD treatment, which will provide new ideas and references for clinicians in the diagnosis and treatment of NAFLD.

Review & Perspectives

Effect of Accurate Hierarchical Diagnosis and Treatment for Special Diseases: a Case Study of Chronic Kidney Disease

ZHU Haiyan, WANG Chaoxin, SUN Wanju

2023, 26(06):  749-753.  DOI: 10.12114/j.issn.1007-9572.2022.0643

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As an important measure to improve the supply of essential health services, the implementation of hierarchical medical system has encountered obstacles in different regions. Due to different referral standards in hospitals, temporal and geographical factors during treatment, it is difficult to promote the development of regional medical consortiums. Shanghai Pudong New Area People's Hospital, together with seven community health centers, established a Chuansha Medical Consortium, specifically for treating chronic kidney disease (CKD), using an accurate hierarchical management program for CKD supported by information technology, a hierarchical diagnosis and treatment system designed based on CKD management programs recommended by relevant guidelines, a CKD knowledge base in which medical information and referral criteria are incorporated, and a joint management model integrating hospital and community care. Empirical evaluation indicated that the hierarchical diagnosis and treatment model based on a CKD knowledge base could greatly contributed to accurately identifying vulnerable and high-risk population of CKD, timely screening and assessing patients with early stage CKD, and improving the efficiency of health management and diagnosis and treatment.

Role of Endocrine Function of Adipose Tissue in the Development of Chronic Obstructive Pulmonary Disease: a Review of Recent Advances

WANG Yide, LI Zheng, LI Fengsen

2023, 26(06):  754-759.  DOI: 10.12114/j.issn.1007-9572.2022.0541

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In addition to affecting adjacent tissues and organs through its mechanical characteristics or mechanical functions, adipose tissue participates in the development of a variety of obesity-related diseases by effectively establishing an interaction information network with organs of the respiratory system and other remote organs through signaling pathways of adipokines secreted by adipocytes. As a breakthrough in the field of endocrinology, the endocrine function of adipose tissue has attracted increasing attention in life sciences. A number of recent epidemiological studies have revealed that obesity is an important risk factor for chronic obstructive pulmonary disease and other respiratory impairments. We reviewed recent advances in the role of adiponectin, leptin, endolipin and other adipocytokines in the development of COPD, providing new ideas for the prevention and treatment of COPD from the perspective of endocrine function of adipose tissue.

Medical Information Research

Visualization Analysis of Artificial Intelligence in Global Esophageal Cancer Research, 2000-2022

TU Jiaxin, YE Huiqing, ZHANG Xiaoqiang, LIN Xueting, YANG Shanlan, DENG Lifang, WU Lei

2023, 26(06):  760-768.  DOI: 10.12114/j.issn.1007-9572.2022.0461

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Background

The past nearly 20-year period has seen a sudden increase in the use of artificial intelligence (AI) in esophageal cancer research, and an emergence of many systematic reviews and meta-analyses of the research. However, most of the reviews and meta-analyses only address a single aspect in summary, making it difficult for researchers to gain a comprehensive understanding of the latest developments and research hotspots in the field.

Objective

To perform a bibliometric analysis of the use of AI in esophageal cancer research, and the development, hotspots and emerging trend in this field.

Methods

All literature in English regarding esophageal cancer research using AI included in the Science Citation Index Expanded database of the Web of Science Core Collection was searched from 2000-01-01 to 2022-04-06. Microsoft Excel 2019, CiteSpace (5.8R3-64bit) and VOSviewer (1.6.18) were used to analyze the literature for annual number of publications, country, author, institution, co-citation and keywords.

Results

Nine hundred and eighteen studies were retrieved, with a total of 23 490 times of being cited. The number of studies published between 2000 and 2016 grew slowly (from 6 to 40), but increased rapidly between 2017 and 2022 (from 62 to 216). Sixty countries, 118 institutions and 5 979 authors were involved in the studies. China (306 articles), the United States (238 articles) and the United Kingdom (113 articles) ranked the top three in terms of number of studies published. The top three institutions in terms of intensity of cooperation were University of Amsterdam (TLS=72), Catherine Hospital (TLS=64) and Eindhoven University of Technology (TLS=53). The top three authors in terms of number of publications were Jacques J G H M Bergman from the Netherlands (n=16), Tomohiro Tada from Japan (n=12), and Fons Van Der Sommen from the Netherlands (n=12). There were 39 962 co-cited authors and 42 992 co-cited studies. Thirty-three burst keywords were identified: the major burst keywords were p53 and mutations in 2001-2008 (early stage), and were esophageal cancer classification, new examination techniques (tomography), differentiation, identification and comparison between esophageal cancer and other cancers in 2013-2018 (middle stage), and were deep learning, convolutional neural network, and machine learning in esophageal cancer examination and diagnosis applications in 2019-2022 (late stage). Among which deep learning had the highest burst intensity (burst intensity of 13.89) .

Conclusion

AI application in esophageal cancer research has entered a new phase, moving gradually from genes and mutations toward accurate examination, diagnosis, and treatment. The latest major burst keywords in recent years (2019-2022) are deep learning, convolutional neural network, and machine learning in esophageal cancer examination and diagnosis. The future challenges to the use of AI in esophageal cancer research may include individual data collection, data quality assurance, data processing specifications, AI code reproduction, and reliability assurance of AI-assisted diagnostic decision-making.

Research of Typical Cases

A Case Report of Venous Thromboembolism with Heparin-induced Thrombocytopenia Characterized by Venous Limb Gangrene Treated with Integrated Traditional Chinese and Western Medicine

GONG Rui, ZHANG Yue, CHENG Zhixin, TANG Weihe

2023, 26(06):  769-774.  DOI: 10.12114/j.issn.1007-9572.2022.0531

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Heparin-induced thrombocytopenia (HIT) and venous limb gangrene (VLG) are rare complications of venous thromboembolism (VTE), with high rates of mortality and morbidity once they occur. A case of VTE with HIT characterized by VLG is reported. Relatively satisfactory therapeutic effect has been achieved under the treatment of Integrated Traditional Chinese and Western Medicine, and we hope to provide a reference for clinicians to treat such diseases.