Table of Content

15 June 2024, Volume 27 Issue 17

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Guidelines·Consensus

Expert Recommendations on the Diagnosis, Treatment, and Care of Post-COVID-19 Conditions for Primary Health Services: Guangdong Province

Primary Healthcare and Health Education Committee of the Guangdong Provincial Health Management Association, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine

2024, 27(17):  2045-2063.  DOI: 10.12114/j.issn.1007-9572.2023.0874

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Post-COVID-19 condition is defined as the presence of symptoms that cannot be explained by other diagnoses, lasting for at least 2 months, occurring three months after a possible or confirmed SARS-CoV-2 infection. It is the result of a complex interplay of biological, psychological, and sociocultural factors, characterized by a high number of affected individuals, complex pathogenesis, diverse symptoms, and a significant need for long-term care. The diagnosis is considered exclusionary and can be classified into six subtypes, including non-severe COVID-19 multiorgan sequelae, pulmonary fibrosis sequelae, myalgic encephalomyelitis or chronic fatigue syndrome, postural orthostatic tachycardia syndrome, post-intensive care syndrome, and medical or clinical sequelae. Based on comprehensive evaluation, treatment and care can be provided through a multidisciplinary approach involving medication, diet, exercise, psychological interventions, patient education, and other methods.

USPSTF Recommendations Interpretation（5）

Interpretation of the U.S. Preventive Clinical Services Guidelines Workgroup's Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults without Cardiovascular Disease Risk Factors: Behavioral Counseling Interventions

YANG Xu, YAO Mi

2024, 27(17):  2064-2069.  DOI: 10.12114/j.issn.1007-9572.2024.0029

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In 2022, the U.S. Preventive Services Task Force (USPSTF) updated its recommendations, reviewing the evidence of the benefits and harms of behavioral counseling interventions aimed at promoting healthy behaviors in adults without cardiovascular disease risk factors. The conclusions of this review align with the 2017 guidelines. Behavioral counseling interventions in adults without cardiovascular disease risk factors result in minimal net benefits. Therefore, it is recommended that clinicians make individualized decisions on whether to provide or recommend behavioral counseling interventions to adults without cardiovascular disease risk factors to promote a healthy diet and physical activity (Grade C). This article provides a comprehensive interpretation of the guidelines in the context of the current status of cardiovascular disease prevention in China, offering valuable insights into cardiovascular disease prevention practices among Chinese adults.

Original Research

Association between Cumulative Episodes of C-reactive Protein Elevations and Somatic/Non-somatic Depressive Symptoms among Chinese Middle-aged and Older Adults: Prospective Cohort Study

ZHAO Ningxuan, JIANG Lin, HU Meijing, YAO Qiang, MAO Yineng, ZHU Cairong

2024, 27(17):  2070-2076.  DOI: 10.12114/j.issn.1007-9572.2023.0869

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Background

Whether considering the cumulative effect of sustained C-reactive protein (CRP) and distinguishing different aspects of depressive symptoms may be the reasons for the inconsistent conclusions of previous studies on the association between CRP and depressive symptoms among middle-aged and older adults. The relationship between cumulative effects of CRP elevations and different aspects of depressive symptoms in middle-aged and older adults in China is not well understood.

Objective

This study aims to examine the relationship between cumulative episodes of CRP elevations over two successive determinations and depressive symptoms, as well as somatic and non-somatic retardation, among Chinese middle-aged and older adults.

Methods

This study used public data from the 2011-2018 Chinese Health and Retirement Longitudinal Study (CHARLS) and included 3 868 subjects. They were categorized based on the frequency of CRP elevations over two consecutive measurements: "elevated on zero occasion" (n=2 918), "elevated on one occasion" (n=763), and "elevated on two occasions" (n=187). Depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CESD-10) in 2011, 2015, and 2018, capturing both somatic and non-somatic dimensions. Multiple linear was used to explore the associations between cumulative episodes of CRP elevations over two successive determinations with depressive symptom scores in 2018, as well as the scores of somatic and non-somatic components separately. Multivariate Logistic regression was used to investigate the effects of cumulative episodes of CRP elevations on the risk of depressive symptoms in 2018.

Results

The results of multiple linear regression analysis showed that after adjusting for all covariates, elevated on two occasions compared with elevated on zero occasion, which was an influential factor for the total score of depressive symptoms (β=1.22, P<0.05), the score of somatic depressive symptoms (β=0.51, P<0.05) and the score of non-somatic symptoms (β=0.71, P<0.05). Logistic regression analysis showed that after adjusting for all covariates, elevated on two occasions were associated with a higher risk of depressive symptoms than elevated on zero occasion (OR=1.64, 95%CI=1.18-2.29) .

Conclusion

Among Chinese middle-aged and older adults, there is a positive association between cumulative effects of CRP elevations and depressive symptoms, encompassing both somatic and non-somatic retardation. Addressing chronic inflammation and treating chronic inflammatory diseases promptly may help mitigate depression risk.

Effects of Threshold Inspiratory Muscle Training Combined with Continuous Positive Airway Pressure on Sleep and Respiratory Function in Stroke Patients with Obstructive Sleep Apnea-hypopnea Syndrome: a Randomized Controlled Trial

LIU Yihan, ZHU Ning, XUE Mengzhou

2024, 27(17):  2077-2082.  DOI: 10.12114/j.issn.1007-9572.2023.0842

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Background

There is a close association between obstructive sleep apnea-hypopnea syndrome (OSAHS) and stroke. The coexistence of the two diseases not only affects the rehabilitation process of patients, prolongs their hospitalization time, but also may increase the risk of death. At present, there is still a lack of clinical research on continuous positive airway pressure (CPAP) combined with respiratory training for stroke patients with OSAHS.

Objective

To examine the impact of threshold inspiratory muscle training (TIMT) in conjunction with CPAP on sleep status, pulmonary function, and respiratory muscle strength in stroke patients with OSAHS.

Methods

Sixty-nine patients with stroke and OSAHS who met the enrollment criteria were selected from the Second Affiliated Hospital of Zhengzhou University from April 2022 to August 2023. The patients were divided into experimental group (n=35) and control group (n=34) by random number table method. The control group received CPAP and conventional treatment, and the experimental group received TIMT on this basis for 6 weeks. The sleep status, lung function and respiratory muscle function of the two groups were compared before and after intervention.

Results

Six weeks after the intervention, the mean blood oxygen saturation (SpO₂), proportion of deep sleep (proportion of N3 sleep in total sleep time), minimum arterial oxygen saturation (LSaO₂), forced expiratory volume in the first second (FEV₁), forced vital capacity (FVC), one-second rate (FEV₁/FVC), maximum expiratory pressure (MEP) and maximum inspiratory pressure (MIP) were all higher than those before intervention in the 2 groups (P<0.05) ; After 6 weeks of intervention, SpO₂, proportion of deep sleep (proportion of N3 sleep in total sleep time), LSaO₂, FEV₁, FVC, FEV₁/FVC, MEP and MIP in experimental group were higher than those in control group (P<0.05). Sleep apnea hypopnea index (AHI), oxygen loss index (ODI), arousal index and Epworth lethargy scale (ESS) scores in the 2 groups were lower than those before intervention (P<0.05). After 6 weeks of intervention, the ODI, arousal index and ESS scores of experimental group were lower than those of the control group (P<0.05) .

Conclusion

TIMT combined with CPAP can significantly improve the sleep disorder of stroke patients with OSAHS, and improve arterial oxygen partial pressure, respiratory muscle strength and pulmonary function.

Current Status and Influencing Factors of Dysphagia among the Elderly in Communities: a Cross-sectional Study

XU Su, CAI Wenwei, LI Chenyi, WANG Guanghui, XU Youduan

2024, 27(17):  2083-2090.  DOI: 10.12114/j.issn.1007-9572.2023.0832

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Background

Dysphagia, a prevalent geriatric syndrome, has been witnessing an upward trend in incidence rates, potentially leading to severe complications like aspiration pneumonia and asphyxia. Despite its significance, research on the prevalence and determinants of dysphagia among community-dwelling elderly remains scarce.

Objective

This study aims to ascertain the prevalence of dysphagia among Shanghai's elderly community by identifying influencing factors and analyzing occurrence rates and determinants across different age brackets.

Methods

Employing a cross-sectional survey approach, the study was conducted from July 2022 to May 2023. Using convenience sampling, the study involved 358 individuals aged 60 and above, selected from the outpatient and home care services of five community health service centers in Huangpu, Baoshan and Fengxian Districts of Shanghai. Demographic data were collected, and measurements of the Appendicular Skeletal Muscle Index (ASMI), grip strength, and walking speed were taken. The Eating Assessment Tool-10 (EAT-10) was utilized to assess the risk of dysphagia among the elderly.

Results

Out of the 358 community-dwelling elderly individuals surveyed, 80 (22.3%) exhibited symptoms of dysphagia (EAT-10≥3) (dysphagia group). Multivariate Logistic regression analysis identified advanced age (≥80 years) (OR=18.484, 95%CI=3.571-95.679), depressive state (OR=4.135, 95%CI=1.280-13.364), and a history of choking (OR=13.650, 95%CI=4.345-42.877) as significant risk factors for dysphagia (P<0.05). Conversely, a high Barthel Index (OR=0.891, 95%CI=0.832-0.953) and a robust ASMI (OR=0.330, 95%CI=0.199-0.547) emerged as protective factors (P<0.05). When stratified by age, the prevalence rates of dysphagia were 5.0% (6/119), 11.1% (16/144), and 61.1% (58/95) for the age groups 60-69, 70-79, and ≥80 respectively, with statistically significant differences (P<0.05). Significant disparities were noted between dysphagia and non-dysphagia groups in terms of BMI, ASMI, and depression status for ages 60-69 (P<0.05), grip strength, calf circumference, depression, Barthel Index, and choking history for ages 70-79 (P<0.05), and ASMI, grip strength, walking speed, Barthel Index, MMSE scores, and choking history for ages ≥80 (P<0.05). Within the dysphagia cohort, ASMI and grip strength in the 70-79 and ≥80 age groups were lower compared to the 60-69 age group (P<0.05). The walking speed of individuals aged ≥70 was reduced relative to those aged 60-69 (P<0.05). Additionally, individuals aged ≥80 showed a higher choking incidence and scored lower on the Barthel Index and MMSE than those aged 60-79 (P<0.05) .

Conclusion

The prevalence of dysphagia among community-dwelling elderly in Shanghai is notably high and progressively increases with age, with a corresponding rise in influencing factors. It is imperative to intensify dysphagia screening, particularly among the elderly with depressive symptoms or a history of choking. Enhancing muscle mass and self-care capabilities, coupled with age-specific preventive measures, can substantially alleviate the disease burden and improve prognoses.

Risk Factors Analysis of Long-term Prognosis in Patients with D2 Radical Surgery for Stage Ⅲ Gastric Cancer after Adjuvant Chemoradiotherapy: Based on the Data of 10-year Follow-up

MA Guifen, ZHANG Qian, LIU Juan, SUN Jing, LIN Genlai

2024, 27(17):  2091-2097.  DOI: 10.12114/j.issn.1007-9572.2023.0673

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Background

Locally advanced gastric cancer mainly includes stage Ⅲ gastric cancer, which is mainly treated with comprehensive therapy. Postoperative recurrence is a key factor affecting the prognosis of patients.

Objective

To explore the influencing factors of long-term prognosis in patients with stage Ⅲ gastric cancer undergoing D2 radical surgery and adjuvant chemotherapy.

Methods

Gastric cancer patients who underwent D2 radical surgery and adjuvant chemoradiotherapy were collected from the Department of Radiotherapy at Zhongshan Hospital affiliated to Fudan University from 2009 to 2014. They were pathologically diagnosed with stage Ⅲ gastric cancer according to the International Union of Cancer (UICC) and American Cancer Federation (AJCC) 8th edition TNM staging system for gastric cancer. All postoperative patients were followed up every 3 months in the first year, every 6 months for the following 2 years, and once a year thereafter. The deadline for follow-up is December 15, 2021. Survival rates of subgroups were compared using Log-rank tests.The influencing factors of overall survival (OS) and disease-free survival (DFS) were compared using Cox proportional hazards regression analysis, and the prediction of clinicopathological features were analyzed by Nomogram. Comparison of survival differences among patients with different pTNM stagings, age, metastatic lymph node radios (LNR), and gastrectomy methods using Kaplan-Meier method.

Results

A total of 135 qualified patients were included, with a median follow-up time of 10.48 years. Within 5 years, there were 70 cases of recurrence and 62 deaths. The 5-year DFS rate and OS rate were 48.1% (65/135) and 54.1% (73/135), respectively; Within 10 years, there were 74 cases of recurrence and 74 deaths. The 10-year DFS rate nd OS rate were both 45.2% (61/135). The Log-rank test results showed that there was a statistically significant difference in 5-year survival rates among patients with different pTNM stagings, pT stagings, LNRs, cancer nodules, tumor locations, and gastrectomy methods (P<0.05). The 10-year survival rates of patients with different pTNM stagings, pT stagings, LNRs, nerve infiltrations, and gastrectomy methods were compared, and the differences were statistically significant (P<0.05). The results of multivariate Cox proportional hazards regression analysis showed that pTNM staging (Stage ⅢA, OS: HR=0.40, 95%CI=0.19-0.83; DFS: HR=0.40, 95%CI=0.19-0.92), LNR (>50%, OS: HR=1.74, 95%CI=1.03-2.94; DFS: HR=1.73, 95%CI=1.02-2.94), and gastrectomy method (total gastrectomy, OS: HR=2.07, 95%CI=1.22-3.50; DFS: HR=2.02, 95%CI=1.20-3.41) were independent influencing factors for OS and DFS in patients with stageⅢ gastric cancer undergoing D2 radical surgery with adjuvant chemotherapy (P<0.05), while age (≤ 40 years, HR=2.19, 95%CI=1.06-4.53) was an independent influencing factor for OS. Moreover, nomogram indicated that age, pTNM staging, LNR, and gastrectomy method have good predictive effects on the prognosis. For recurrence, 10 cases (7.4%) experienced local recurrence (recurrence of anastomotic sites and lymph nodes within the radiation field), 35 cases (25.9%) experienced abdominal and pelvic dissemination of implants, and 37 cases (27.4%) experienced distant metastasis (including lung, liver, bone, brain and other organs) ; Some patients had two or more types of recurrence. The postoperative survival curves of stageⅢ gastric cancer patients with different pTNM stagings, age, LNRs, and gastrectomy methods were compared, and the differences were statistically significant (P<0.05) .

Conclusion

Most patients with stageⅢ gastric cancer who undergo adjuvant chemoradiotherapy after D2 radical surgery experience recurrence or death within 5 years. pTNM staging, LNR, and gastrectomy method are factors that affect the prognosis of these patients.

Deep Transcranial Magnetic Stimulation Combined with Escitalopram Oxalate in the Treatment of Depression: a Randomized Controlled Trial

PANG Lan, LI Peifan, ZHU Xiaogang, YANG Zaihong, ZHENG Lei

2024, 27(17):  2098-2103.  DOI: 10.12114/j.issn.1007-9572.2023.0555

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Background

Depression is a common psychiatric disorder with limited treatment options. Deep transcranial magnetic stimulation (dTMS), as a new non-invasive neuromodulation technique, has been utilized in the treatment of major depressive disorder (MDD), but there is less evidence from clinical studies.

Objective

To explore the clinical efficacy of dTMS combined with escitalopram oxalate (Esc) in the treatment of depression, and provide further reliable data reference for dTMS in the treatment of depression patients.

Methods

A total of 73 patients with depression who attended Department of Psychiatry, Affiliated Hospital of Guizhou Medical University from December 2021 to January 2023 were selected as the study subjects and divided into the control group (n=35) and combined treatment group (n=38) according to the random number table. Patients in the control group were given Esc ( 10 mg per day in the first week and 20 mg per day from the second week for 2 consecutive weeks). The combined treatment group received the treatment of dTMS (left DLPFC as the stimulation target, 18 Hz, 120%MT, 1 980 times per day for 2 weeks, 10 times in total) based on the same treatment for the control group. The depressive symptoms and cognitive improvement of patients in the two groups were evaluated before and after the two weeks of treatments by Hamilton depression scale (HAMD), Beck Scale for Suicide Ideation (BSS), Montreal Cognitive Assessment Scale (MoCA) and the mean oxygenated hemoglobin (oxy-Hb) concentration in the prefrontal cortex measured by functional near-infrared spectroscopy (fNIRS) based on the verbal fluency text (VFT) task.

Results

The actual completion of the trial was 30 cases in the control group and 31 cases in the combined treatment group. After treatment, the HAMD and BSS scores of the combined treatment group were lower than those of the control group, and the MoCA score was higher than that of the control group (P<0.05). After treatment, the HAMD and BSS scores of patients in the two groups were lower than those before treatment, and the MoCA score was higher than that before treatment (P<0.05). There was no significant activation of the prefrontal cortex after treatment in both groups. The improvement of depression symptoms and cognitive function in the combined treatment group was better than that in the control group.

Conclusion

The combination of dTMS and Esc can improve the depressive symptoms and cognitive function better than Esc treatment alone in depression patients.

The Assessment Value of Systemic Inflammation Response Index in Evaluating the Severity of Acute Pancreatitis

LI Sisi, HE Qiang, XU Youqing

2024, 27(17):  2104-2108.  DOI: 10.12114/j.issn.1007-9572.2023.0547

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Background

Acute pancreatitis (AP) is one of the common gastrointestinal emergencies, and the disease progression of moderately severe and severe AP is rapid. Early and accurate identification is crucial for effective intervention and prognosis assessment. there is still a lack of effective and simple predictive indicators.

Objective

To investigate the early dynamic changes and predictive value of the systemic inflammation response index (SIRI) in patients with AP.

Methods

A total of 221 AP patients who met the inclusion and exclusion criteria at the Department of Gastroenterology, Beijing Tiantan Hospital, Capital Medical University, were included as study subjects from August 2020 to March 2023. According to the revised 2012 Atlanta criteria, patients were categorized into mild group (MAP group, mild acute pancreatitis) and non-mild group (non-MAP group, including moderate severe and severe acute pancreatitis). The SIRI values (SIRI 0 h, SIRI 48 h) and C-reactive protein (CRP) levels (CRP 0 h, CRP 48 h) during admission and within 48 hours of admission for the patients were collected by reviewing cases. The receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated to analyze the predictive value of SIRI for non-MAP and compare it with CRP as a common clinical indicator of inflammation.

Results

A total of 221 AP patients were finally included, 102 with MAP and 119 with non-MAP. SIRI 0 h and SIRI 48 h were higher in patients in the non-MAP group than in the MAP group (P<0.001). The ROC curve showed that the AUC for SIRI 0 h and SIRI 48 h in predicting non-MAP were 0.685 (95%CI=0.615-0.756) and 0.753 (95%CI=0.689-0.816), respectively, with no significant difference with CRP [0.607 (95%CI=0.533-0.681) and 0.752 (95%CI=0.687-0.817) ] during the corresponding time intervals (Z=1.67, P=0.095; Z=0.02, P=0.981). The optimal cut-off value for SIRI 48h to predict non-MAP was 2.49, with sensitivity, specificity, positive predictive value, and negative predictive value of 81.51%, 58.82%, 69.78%, and 73.17%, respectively.

Conclusion

SIRI is an affordable and readily available test that can be used as an indicator for assessing the severity of early-stage AP.

Analysis of Adverse Reactions in the Assessment of Coronary Microvascular Disease by Adenosine Load and Adenosine Disodium Triphosphate Load

ZHAO Hui, LI Wenhao, CHENG Gong, CHEN Liang, LIANG Chenyuan, WANG Yiyang, JIANG Hongying, JIANG Ruijia

2024, 27(17):  2109-2112.  DOI: 10.12114/j.issn.1007-9572.2023.0526

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Background

The treatment of coronary microvascular disease (CMVD) has always been the focus of non-coronary obstructive ischemic heart disease. Adenosine injection and adenosine disodium triphosphate (ATP) injection, which are common clinical loading drugs to determine coronary flow reserve (CFR) and evaluate CMVD, are related but significantly different. ATP is the precursor of adenosine, with low price and similar vasodilatory mechanism to adenosine, and is often substituted for adenosine in clinical practice, but its potential adverse effects are ignored.

Objective

To compare the incidence of adverse reactions in the assessment of coronary microvascular disease by adenosine load and adenosine disodium triphosphate load.

Methods

A total of 170 patients who visited the Department of Cardiology of Shaanxi Provincial People's Hospital for typical angina pectoris and underwent coronarography/Coronary CT angiography (CTA) to determine the residual stenosis diameter of each branch coronary artery <50% during June 2019 to July 2020 were selected and divided into the adenosine group (n=88) and ATP group (n=82) based on random number table method. CFR was determined by adenosine injection loading in the adenosine group and by ATP loading in the ATP group. Blood pressure, heart rate, scanning time and adverse reactions of patients were recorded during the detection process.

Results

The incidence of adverse reactions of chest tightness [61.0% (50/82) vs 20.4% (18/88) ], dizziness [72.0% (59/82) vs 31.8% (28/88) ], headache [68.3% (56/82) vs 11.4% (10/88) ], gastrointestinal discomfort [13.4% (11/82) vs 4.5% (4/88) ], palpitation [69.5% (57/82) vs 5.7% (5/88) ], shortness of breath [40.2% (33/82) vs 2.3% (2/88) ], profuse sweating [28.0% (23/82) vs 3.4% (3/88) ], hot flush [19.5% (16/82) vs 2.3% (2/88) ] and facial flushing [13.4% (11/82) vs 4.5% (4/88) ] in patients in the ATP group were higher than those in the adenosine group (P<0.05). There was no significant difference in the incidence of neuroticism, tinnitus, dry throat and neck discomfort between the two groups (P>0.05) .

Conclusion

Compared with ATP loading, adenosine loading has a lower incidence of adverse reactions determine CFR.

Correlation between Bcl-2 Expression and the Efficacy of Bcl-2 Inhibitors in Patients with Myelodysplastic Syndromes

WU Jiafei, WANG Jun, WANG Yijing, ZHENG Boyue, WANG Yu, JIANG Chuanyan, DONG Dandan, LI Hui

2024, 27(17):  2113-2118.  DOI: 10.12114/j.issn.1007-9572.2023.0191

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Background

The heterogeneity of myelodysplastic syndromes (MDS) is strong, with poor efficacy of existing therapeutic regimens and large individual differences in patient prognosis. B-cell lymphomato-2 (Bcl-2) protein is highly expressed in patients with myeloid tumors, which has been proved by previous to be associated with disease progression, chemotherapy resistance, and shortened overall survival. The Bcl-2 inhibitor Veneckla (VEN) is approved for elderly patients with newly diagnosed acute myeloid leukemia (AML) who are not eligible for intensive therapy, and there is less data on its use in MDS patients. The difference in Bcl-2 expression in MDS patients and its correlation with the efficacy and prognosis of VEN therapy haven't been reported.

Objective

To analyse the expression of Bcl-2 protein in MDS patients and assess its correlation with the efficacy and prognosis of VEN treatment.

Methods

The clinical data of 71 patients with MDS admitted to Sichuan Academy of Medical Sciences·Sichuan Provincial People's Hospital from July 2018 to December 2022 were retrospectively analyzed. Baseline data of patients including gender, age, blood routine, blood biochemistry, bone marrow hemocytology, flow cytometry, chromosome karyotype, myeloid gene mutation, fusion gene mutation and MDS-EB typing were collected. The expression of Bcl-2 protein was detected by immunohistochemical staining. According to the modified International Prognostic Score System (IPSS-R), the patients were divided into 5 risk levels of very low risk (0 case), low risk (1 case), medium risk (7 cases), high risk (40 cases) and very high risk (23 cases). Patients with bone marrow Bcl-2 positivity≥10% were defined as Bcl-2 positive and<10% as Bcl-2 negative. Patients were divided into the positive group (n=38) and negative group (n=33). Of 63 patients with high-risk and very high-risk MDS, 38 were treated and evaluated for efficacy, including 28 patients who received VEN combined with azacitidine (VA combination regimen) and 10 patients who received hypomethylated drugs (HMA, including azacitidine or decitabine) as monotherapy. The patients were followed up until 2022-12-30. Kaplan-Meier curve was plotted to analyze the overall survival time (OS) of different patients, and Log-rank test was used for comparison. Univariate Cox regression model was used to analyze the influencing factors of patients' OS.

Results

The proportions of fusion gene mutation and nuclear myeloid phosphoprotein 1 (NPM1) gene mutation in the positive group were higher than those in the negative group, and the difference was statistically significant (P<0.05). Of the 10 patients who received HMA monotherapy, 1 was Bcl-2 negative and 9 were Bcl-2 positive, after 14 days of treatment, 4 of them (40.0%) achieved composite complete response (CR/mCR). Of the 28 patients receiving the VA combination regimen, 12 were Bcl-2 negative and 16 were Bcl-2 positive, and after 14 days of treatment, 20 (71.4%) patients receiving the VA combination regimen achieved CR/mCR. There was no significant difference in CR/mCR ratio between the two treatment regimens (P=0.087). The median overall survival time (mOS) for patients with VA combination therapy was 6.9 months, with a mOS of 2.9 months for Bcl-2 negative patients and 7.4 months for Bcl-2 positive patients. There was no significant difference in survival rate between Bcl-2 positive patients and Bcl-2 negative patients (χ²=2.075, P=0.150). The mOS of Bcl-2 positive patients receiving HMA monotherapy was 4.3 months, and there was no significant difference in the survival rate comparing with Bcl-2 positive patients receiving VA combination regimen (χ²=0.824, P=0.364). Univariate Cox regression model analysis showed that age, Bcl-2 protein expression, mutant gene number, chromosome karyotype, MDS-EB typing, IPSS-R risk, and efficacy were not the influencing factors for OS in patients treated with VA combination regimen (P>0.05) .

Conclusion

Bcl-2 protein contributes to MDS fusion gene mutation and myeloid gene mutation; Bcl-2 positive expression was not associated with the survival of MDS patients. There was no difference in survival rate between Bcl-2 positive and Bcl-2 negative patients who received the VA combination regimen.

Original Research·Multimorbidity Section

Study on the Health Management Service Pathway for Multimorbidity of Middle-aged and Older Adults in the Community

ZHENG Xiao, ZHANG Chichen, TIAN Feng, XUE Benli, LI Xinru, XIAO Shujuan, CHEN Yiming

2024, 27(17):  2119-2123.  DOI: 10.12114/j.issn.1007-9572.2023.0664

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Multimorbidity has become an important characteristic of chronic diseases, jeopardizing the health of middle-aged and older adults, and posing new challenges to health management of chronic disease. There is a lack of guidelines and intervention programs for multimorbidity in China. In this study, we initially formulated a health management service pathway for multimorbidity among middle-aged and older adults in the community through the literature research method and focus group discussion method. Then, the constructed service pathway was evaluated and revised through the expert consultation method. Finally, a health management service pathway for the multimorbidity of middle-aged and older adults in the community with behavioral change techniques as the core. The pathway optimizes the implementation of multimorbidity health management, and standardizes its health monitoring, assessment and intervention process, providing a theoretical and practical guidance for primary care providers in the health management of multimorbidity.

Differences in Health-related Behaviors and Quality of Life among Older Adults with Multimorbidity Based on Latent Class Analysis

LIAO Yanming, ZHENG Xiao, XUE Yaqing, XIAO Shujuan, XUE Benli, LI Xinru, CHEN Yiming, ZHANG Mengjie, ZHANG Chichen

2024, 27(17):  2124-2129.  DOI: 10.12114/j.issn.1007-9572.2023.0822

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Background

The severe trend of the aging population, the rapid increase in the prevalence of chronic diseases among older adults, and the greater prominence of multimorbidity have posed challenges to the prevention and treatment of chronic diseases in China. Adverse health-related behaviors are modifiable risk factors for chronic diseases. Exploring the latent classes of health-related behaviors in older adults with multimorbidity and their associations with quality of life will help identify the characteristics of their health-related behaviors and uncover risk behaviors affecting the quality of life, providing references for precise health management to improve the quality of life of older adults.

Objective

To explore the latent classes of health-related behaviors in older adults with multimorbidity and the differences in the quality of life among the different classes.

Methods

Based on the baseline data from the Community Health and Behavior of the Elderly Panel Study (CHBEPS) conducted by our team in 2021, a total of 1 395 older adults aged 60 years and above with multimorbidity were included as study participants. A self-designed questionnaire was used to collect basic information, including disease status, smoking status, alcohol consumption, and dietary preferences of the participants. The Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short-Chinese Version (IPAQ-S-C), and Lubben Social Network Scale-6 (LSNS-6) were used to assess staying up late, physical activity, and social network of the participants, respectively. The EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) was used to measure the quality of life of the participants. Latent class analysis of health-related behaviors among older adults with multimorbidity was conducted using Mplus 8.3 software. Based on the fitted model, the different latent classes of health-related behaviors among older adults with multimorbidity were used as groups, and the Kruskal-Wallis and Wilcoxon rank-sum tests were performed using SPSS 26.0 software to analyze the differences in quality of life among these groups.

Results

Four latent classes of health-related behaviors were identified among older adults with multimorbidity, which are named the health behavior group (n=280), risk behavior group (n=366), comprehensive behavior group (n=173), and adverse behavior group (n=576). There were statistically significant differences in quality of life among the four latent classes (P<0.05). Specifically, the quality of life in the health behavior group was higher than that in the risk behavior group and adverse behavior group (P<0.05) .

Conclusion

When implementing precise health management for older adults with multimorbidity, the characteristics of their health-related behaviors should be taken into account. Special attention should be given to those with a higher probability of behaviors such as smoking, alcohol consumption, and a preference for sweet, spicy, and salty tastes, as well as those with a lower probability of behaviors such as a balanced diet, regular consumption of vegetables and fruits, and social networks. Additionally, measures targeted at addressing common issues such as insufficient physical activity should be implemented to improve the effectiveness of health management and the quality of life of older adults with multimorbidity.

Path Study of Social Networks in the Older Adults on Multimorbidity: the Mediating Effects of Physical Activity and Sleep

ZHANG Mengjie, ZHENG Xiao, LIAO Yanming, TIAN Feng, QIAN Juan, ZHOU Jiexing, ZHANG Chichen

2024, 27(17):  2130-2137.  DOI: 10.12114/j.issn.1007-9572.2023.0669

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Background

In recent years, in the context of global aging, the number of patients with chronic diseases in China has increased significantly, and the the coexistence of multiple diseases has become more and more common, which seriously threatens the life safety and quality of life of the older adults in China.

Objective

To investigate the status of multimorbidity of older adults, and explore the relationship and pathways of action between sleep, physical activity, social network and multimorbidity of older adults, providing ideas for the effective prevention of multimorbidity and health improvement of older adults.

Methods

Elderly people aged≥60 years in the Community Health and Behavior of the Elderly Panel Study (CHBEPS) established by our team in 2021 were selected as the subjects of the survey, a questionnaire was used to investigate the study population, the research objects were investigated by questionnaire, and the general situation was collected by self-designed basic information collection form, IPAQ-S-C, LSNS-6 and PSQI were used to assess the physical activity, social network and sleep of the subjects. AMOS 28.0 statistical software was used to set up the structural equation model.

Results

A total of 3 392 valid questionnaires were collected from 3 531 people over 60 years old, with an effective recovery rate of 96.06%. The average score of physical activity was 2 426.42 (495.00, 3 060.00) MET-min/w, the average score of social network was (15.91±6.43), and the average score of sleep was (5.49±3.53). There were 788 (23.23%) older adults with insufficient social network and 353 (10.41%) older adults with fair or very poor sleep quality. The prevalence of multimorbidity among the survey respondents was 41.13% (1 395/3 392). The results of correlation analysis showed that social network was negatively correlated with sleep level (r_s=-0.113, P<0.01) and multimorbidity (r_s=-0.049, P<0.01), and was positively correlated with physical activity (r_s=0.073, P<0.01). Multivariate Logistic regression analysis showed that physical activity of 0-600 MET-min/w (OR=0.576, 95%CI=0.342-0.970) and good sleep quality (OR=0.409, 95%CI=0.209-0.803) were protective factors for multimorbidity (P<0.05). The results of structural equation modeling showed that social networks could affect physical activity and sleep quality (standardized path coefficient=0.096, t=4.982, P<0.001; standardized path coefficient=-0.043, t=-5.981, P<0.001), physical activity and sleep quality could affect multimorbidity (standardized path coefficient=0.023, t=5.280, P<0.001; standardized path coefficient=0.111, t=9.409, P<0.001). Social network had no direct effect on multimorbidity, but an indirect effect on it through two mediators of physical activity and sleep. The indirect effect of social network on multimorbidity through physical activity accounted for 10% of the total effect, and the indirect effect of social network on multimorbidity through sleep accounted for 36.5% of the total effect.

Conclusion

The prevalence of multimorbidity is high in the older adults (41.13%). The social network of the elderly group should be appropriately expanded to encourage them to maintain a moderate amount of physical activity and a good quality of sleep, alleviate and prevent the occurrence of multimorbidity.

A Decomposition Study of Health Status Disparities among Older Adults with Multimorbidity: a Multiple Level Model Based on Health Double Factors

LI Xinru, CHEN Huiwen, CHEN Yiming, XUE Benli, ZHENG Xiao, SHI Lei, CHEN Yaguang, ZHANG Chichen

2024, 27(17):  2138-2144.  DOI: 10.12114/j.issn.1007-9572.2023.0670

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Background

Currently, research on the factors influencing the health status of older adults with multimorbidity in China is scattered, and it is difficult to give a comprehensive consideration from a holistic perspective, and the contribution of factors leading to health disparities is not explored, resulting in the ineffectiveness of current health management often programs in older adults with multimorbidity.

Objective

By introducing a health bifactor model, this study aims to understand the endogenous and exogenous influencing factors and their contributions to the health of older adults with multimorbidity and provide a practical basis for developing precise health management plans for older adults with multimorbidity.

Methods

In this study, using the China Health and Retirement Longitudinal Survey (CHARLS) 2018 data and introducing the two-factor model of health developed from the Grossman health production function (including both endogenous and exogenous aspects of health determinants). First, the Wilcoxon rank sum test was used to analyze whether there were differences in the health status of older adults with multimorbidity by gender. Secondly, the OLS regression model was used to analyze the mechanism of the two-factor model of health on the health of older adults with multimorbidity. Finally, the Shapley value method was further used to decompose the contribution of health endogenous factors to their health.

Results

The study found that factors such as still drinking alcohol, having no disease control methods, being satisfied with medical services, having a high level of education, having a pension, not using health services, attending free health checks, caring for grandchildren and being satisfied with their children's relationship were more likely to improve the health of older people with multiple chronic conditions. The results of the Shapley decomposition showed that socioeconomic status was the most important factor in the full sample, while family health support, health-related behaviors, and health-related behaviors were the most important factors. Coping strategies was the next most important, and social health resources was the least influential. In the gender subgroup analysis, socioeconomic status remained the most important factor; for older men with multiple chronic illnesses, health-related behaviors were the next most important factor; for older women with multiple chronic illnesses, coping strategies were the next most important.

Conclusion

The health status of older men with multimorbidity is better than that of women, socioeconomic status is the most important factor affecting the health of older adults with multimorbidity, and the remaining four dimensions have different contributions to the health differences between men and women. It is recommended that precise health management should be implemented according to the size of the contribution of each dimension of different health endogenous factors to improve the health status of older adults with multimorbidity with maximum benefit.

Evidence-based Medicine

The Prevalence of Dyslipidemia in Chinese Children and Adolescents: a Meta-analysis

ZHOU Zitong, JIA Yu, YAN Hong, XU Jialan, WEN Jun, WANG Siyu

2024, 27(17):  2145-2154.  DOI: 10.12114/j.issn.1007-9572.2023.0806

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Background

Cardiovascular disease (CVD) is the leading cause of death in China and the world as a whole, and lipid metabolism disorder is the key factor for this disease. A comprehensive understanding of the prevalence of dyslipidemia in children and adolescents can contribute to the early prevention of dyslipidemia in adulthood.

Objective

To systematically evaluate the status quo of the prevalence of dyslipidemia in Chinese children and adolescents.

Methods

Cross-sectional studies on the morbidity rate of dyslipidemia among Chinese children and adolescents and published from January 2015 to July 2023 were retrieved from databases of CBM, CNKI, Wanfang, VIP, Embase, Web of Science and Cochrane Library. Processes of literature screening, data extraction and risk bias analysis were performed by two researchers. A meta-analysis was performed by taking advantage of Stata 17.0.

Results

34 cross-sectional studies were collected and a total of 134 438 children and adolescents were involved. Results of the meta-analysis indicated that the overall morbidity rate of dyslipidemia in Chinese children and adolescents was 19% (95%CI=16%-21%), and the morbidity rates of high cholesterol (TC), high triacylglycerol (TG), high low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C) were 6% (95%CI=5%-7%), 9% (95%CI=6%-12%), 4% (95%CI=3%-5%) and 10% (95%CI=7%-13%) respectively. Regarding time distribution, the detection rate of dyslipidemia was fluctuant and showed a decreasing trend; the detection rate of high TC and high LDL-C showed an increasing trend in general, but it fell slightly in 2023; the detection rate of high TG and low HDL-C fluctuated greatly: the detection rate of high TG gradually decreased from 2018 to 2022 and rebounded slightly in 2023. The results of subgroup analysis showed that, concerning age, the overall morbidity rate of dyslipidemia in children and adolescents and that of high TC showed an ascending tendency with the increasing of age (10% and 2% for those aged from 3 to 6, 17% and 10% for those aged from 7 to 11, and 27% and 14% for those aged from 12 to18), the morbidity rate of lowered HDL-C was higher among 12-to-18-year olds (20%) than among 7-to-11-year olds (9%), and the morbidity rate of high TC among 3-to-6-year olds (9%) was higher than that among 7-to-11-year olds and 12-to-18-year-olds (4% and 3%) (P<0.05). Concerning region, the morbidity rates of low HDL-C were higher in the West (15%) than in the East (7%), and the morbidity rates of high TC and high LDL-C were higher in the East (7% and 6%) than in the West (3% and 2%) (P<0.05). Concerning BMI, the morbidity rates of dyslipidemia, high TG and high LDL-C were higher in obese children and adolescents (48%, 18%, 25%, and 7%) than in overweight (27%, 6%, 9%, and 4%) and normal children and adolescents (15%, 4%, 3%, and 3%) (P<0.05) .

Conclusion

The morbidity rate of dyslipidemia in Chinese children and adolescents is relatively high and varied across the age, region and BMI of children and adolescents. Due to the limitation of the number and quality of included studies, more high-quality studies are needed to be conducted to further validate these findings.

Efficacy and Safety of Biologics and Small Molecule Drugs in the Treatment of Ulcerative Colitis: a Network Meta-analysis

TAN Shufa, ZHANG Leichang, GAO Qiangqiang, OU Yan, HUANG Shuilan

2024, 27(17):  2155-2166.  DOI: 10.12114/j.issn.1007-9572.2023.0663

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Background

Ulcerative colitis (UC) is a persistent immune-mediated inflammatory bowel disease characterized by chronic relapses and remissions. The management of UC remains a subject of contention, particularly as approximately half of the patients experience a complex disease progression marked by chronic activity or frequent recurrence of common UC symptoms, significantly impacting their quality of life.

Objective

The current landscape presents a growing array of treatment modalities for UC. This study aims to systematically compare the relative efficacy and safety of biologics and small molecule drugs in treating patients with UC.

Methods

Two independent researchers meticulously conducted a search for randomized controlled trials involving biologics and small molecule drugs for UC. The search encompassed PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang Data, and VIP. The intervention group involved either biologics or small molecule drugs, while the control group received a placebo. The quality of the included studies was assessed using the Cochrane Risk of Bias tool and RevMan 5.4. Paired analyses and network meta-analyses were conducted using R Studio. The surface under the cumulative ranking curve (SUCRA) was employed to rank the included drugs based on each outcome indicator, providing a comparative assessment of the clinical efficacy of diverse treatments for UC.

Results

A total of 25 studies including 9 546 patients with ulcerative colitis and 10 intervention regimens (Filgotinib 100 mg, Filgotinib 200 mg, Upadacitinib, Tofacitinib, Etrolizumab, Adalimumab, Vedolizumab, Golimumab 50 mg, Golimumab 100 mg, Infliximab). The results of SUCRA probability ranking of clinical remission effect of each drug showed that Upadacitinib (94.1%) >Vedolizumab (85.1%) >Tofacitinib (74.3%) >Infliximab (72.7%) >Filgotinib 200 mg (51.5%) >Golimumab 100 mg (44.3%) >Golimumab 50 mg (39.3%) >Etrolizumab (38.9%) >Adalimumab (29.8%) >Filgotinib 100 mg (18.7%) >Placebo (0.7%). The results of SUCRA probability ranking of the effect of each drug on clinical response showed that Upadacitinib (98.4%) >Infliximab (84.4%) >Tofacitinib (67.2%) >Vedolizumab (58.4%) >Golimumab 50 mg (53.3%) >Adalimumab (34.6%) >Golimumab 100 mg (30.1%) >Placebo (0.4%). The results of SUCRA probability ranking of the effect of each drug on endoscopic remission showed that Upadacitinib (98.7%) >Tofacitinib (68.6%) >Filgotinib 200 mg (59.6%) >Adalimumab (55.2%) >Etrolizumab (46.0%) >Vedolizumab (45.9%) >Filgotinib 100 mg (23.4%) >Placebo (2.2%). The results of SUCRA probability ranking of the effect of each drug on mucosal healing showed that Upadacitinib (99.7%) >Tofacitinib (77.2%) >Infliximab (65.2%) >Golimumab 50 mg (46.4%) >Vedolizumab (44.4%) >Adalimumab (33.8%) >Golimumab 100 mg (31.9%) >Placebo (1.0%). The results of the SUCRA probability ranking of the risk of adverse events for each drug showed that Golimumab 100 mg (96.7%) >Golimumab 50 mg (92.1%) >Placebo (68.7%) >Tofacitinib (60.8%) >Adalimumab (60.7%) >Etrolizumab (47.2%) >Upadacitinib (42.2%) >Vedolizumab (41.3%) >Infliximab (27.0%) >Filgotinib 200 mg (6.6%) >Filgotinib 100 mg (6.2%) .

Conclusion

Upadacitinib demonstrated optimal efficacy in clinical response, clinical remission, mucosal healing, and endoscopic remission, and Filgotinib 100 mg demonstrating safer outcomes in terms of adverse events.

Consulting Room of General Practitioner

Application of Murtagh Safe Diagnostic Strategy in the General Practice Teaching Clinic: an Example of Rheumatic Polymyalgia

YANG Ling, DU Xueping

2024, 27(17):  2167-2172.  DOI: 10.12114/j.issn.1007-9572.2023.0570

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The Murtagh safe diagnostic strategy proposed by renowned Australian general practitioner John Murtagh has been gradually used by general practitioners in clinical practice for diagnosis and treatment, mainly for initial diagnosis of common diseases, rapid identification of critical and severe diseases, analysis and judgment of the existence of diseases that can be easily overlooked, as well as to understand the patient's concerns and expectations. The general practice teaching clinic is an important training method for developing clinical thinking and enhancing diagnosis and treatment abilities of general practitioners. This article takes a patient with polymyalgia rheumatica (PMR) as a teaching case, applies the Murtagh safe diagnostic strategy to analyze the diagnosis and treatment ideas, analyzes the diagnosis and treatment process in combination with literature, summarizes diagnosis and treatment experience, guides general practitioners to think about disease diagnosis and treatment from multiple dimensions, trains general practice residents' general clinical thinking, improves the diagnosis and treatment level of PMR, so as to achieve the teaching purpose.