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15 October 2024, Volume 27 Issue 29

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USPSTF Recommendations Interpretation（6）

Interpretation of the 2023 Recommendation Statement by the U.S. Preventive Services Task Force on the Screening for Hypertensive Disorders of Pregnancy

ZHANG Peng, LIU Lidi, YANG Ziyu, YANG Rong, LYU Yao, ZHOU Yiheng, FANG Xiang, LEI Yi, DAI Hua, LIAO Xiaoyang

2024, 27(29):  3581-3586.  DOI: 10.12114/j.issn.1007-9572.2024.0149

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Hypertensive disorders of pregnancy (HDP) is one of the leading causes of maternal and perinatal mortality worldwide, with increasing incidence and mortality year by year. In 2023, the U.S. Preventive Services Task Force (USPSTF) updated the recommendation statement on screening for hypertensive disorders of pregnancy by evaluating the latest research evidence and analyzing the benefits and harms of screening for HDP. The recommendation, compared with the 2017 version, further affirms the importance of blood pressure measurement in screening for HDP, affirms substantial net benefit, and recommends blood pressure measurement throughout pregnancy to screen for HDP. This article explores and analyzes the key points of this recommendation based on the RIGHT statement for introductions and interpretations of guidelines in Chinese (RIGHT for INT) and its implications for guiding general practitioners in China.

Original Research·Research of Specific Population·Female Health

Title Vaginal Microbiota Changes of Gestational Diabetes Mellitus Pregnant Women at Different Gestational Weeks and the Impact on Pregnancy Outcome: a Prospective Cohort Study

YANG Xinhui, PENG Xiaoxiao, MA Lili, ZHAO Guoyu, MA Xiuhua, GUO Jing

2024, 27(29):  3587-3594.  DOI: 10.12114/j.issn.1007-9572.2024.0191

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Background

Gestational diabetes mellitus (GDM) is a common complication of pregnancy, and previous studies have shown that pregnant women with GDM have a higher risk of developing infectious diseases of the reproductive tract than healthy pregnant women, but relevant cohort studies are rare.

Objective

To investigate the variation characteristics of vaginal microbiota in pregnant women with GDM at different gestational weeks, to compare the differences of vaginal microbiota between GDM and non-GDM women, and to observe the effects of vaginal microbiota changes on pregnancy outcomes.

Methods

In this study, we used a consecutive sampling method to recruit pregnant women who established their records and regulated health care at Daxing Teaching Hospital of Capital Medical University from March 2022 to March 2023. They underwent 75 g oral glucose tolerance test (OGTT) at 24-28 weeks of gestation to diagnose GDM. The GDM group was matched 1∶1 with the non-GDM group using propensity score matching method (PSM). Sample of vaginal secretions were collected at 24-28 weeks (stage A), 32-35 weeks (stage B) and 37-40 weeks (stage C) for three vaginal microecological examination, respectively. Based on the results, participants were further divided into the GDM normal vaginal flora subgroup, GDM abnormal vaginal flora subgroup, non-GDM normal vaginal flora subgroup and non-GDM abnormal vaginal flora subgroup, and were followed up until 7 d after delivery to assess pregnancy outcome.

Results

A total of 426 participants were initially enrolled in this study, and GDM occurred in 141 cases. After PSM mathing, the GDM and non-GDM groups were successfully matched in 122 pairs. In this study, because 9 women with GDM and 5 women without GDM had preterm birth (<37 weeks of gestation), 113 women with GDM and 117 women without GDM ended up in stage C. The proportion of the dominant vaginal flora of Lactobacillus was higher in stage A than in stage C. Moreover, the vaginal pH, the incidence of vaginal flora abnormalities, and the incidence of BV and VVC were lower than those in stage C (P<0.05). The proportion of dominant bacteria as Lactobacillus in the GDM group was higher than that in the non-GDM group, and the incidence of abnormal vaginal flora and VVC was lower than that in the non-GDM group in stage A (P<0.05). In contrast, the proportion of the dominant bacterium Lactobacillus was lower in the GDM group than in the non-GDM group, and the incidence of abnormal vaginal flora was higher than in the non-GDM in stage C (P<0.05). The incidence of adverse pregnancy outcomes was higher in the GDM abnormal vaginal flora subgroup (n=65) than in the GDM normal vaginal flora subgroup (n=57) (P<0.05). In more details, the risk of adverse pregnancy outcomes in the GDM abnormal vaginal flora group was 1.830 times higher than that in the GDM normal vaginal flora group (RR=1.830, 95%CI=1.293-2.590, P<0.001) .

Conclusion

Compared with non-GDM pregnant women, GDM pregnant women had a lower incidence of vaginal flora abnormalities at 24-28 weeks of gestation and an increased risk of vaginal flora abnormalities after 37 weeks of gestation. GDM pregnant women with abnormal flora have higher risk of adverse pregnancy outcomes, so we recommend enhanced testing and management of vaginal microecology during pregnancy.

Isolated Maternal Hypothyroxinemia in the First Trimester Increases the Risks of Macrosomia and Large for Gestational Age During Pregnancy: a Retrospective Cohort Study

WEI Zhanchao, WANG Jia, LIU Cheng, ZHENG Wei, LI Guanghui

2024, 27(29):  3595-3601.  DOI: 10.12114/j.issn.1007-9572.2024.0024

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Background

Thyroid hormones are very important for normal growth and development of fetus. Hypothyroidism during pregnancy and Graves' hyperthyroidism in pregnancy are well-known risk factors for small for gestational age (SGA). However, the influence of isolated maternal hypothyroxinemia (IMH) in the first trimester during pregnancy on birthweight is less analyzed and controversial.

Objective

To examine the correlation of IMH in the first trimester during pregnancy with birthweight.

Methods

This was a retrospective cohort study involving singleton pregnant women with medical files and receiving prenatal examination, delivery or termination of pregnancy in the Beijing Obstetrics and Gynecology Hospital, Capital Medical University from January 2016 to October 2020. According to the 2.5th and 97.5th percentiles of free thyroxine (FT₄) and thyroid stimulating hormone (TSH), participants were assigned into IMH group (n=344) and control group (n=19 426). Binary Logistic regression was used to analyze the correlation of IMH in the first trimester during pregnancy with birthweight. Then according to the pre-pregnancy body mass index (PPBMI), participants were assigned into the overweight/obesity group (PPBMI≥24.0 kg/m², 69 cases in IMH group and 3 376 cases in control group) and non-overweight/obesity group (PPBMI<24.0 kg/m², 275 cases in IMH group and 16 050 cases in control group). The pregnancy outcomes of different groups were compared and the relationship between IMH and pregnancy outcomes was compared.

Results

The results of multivariate Logistic regression analysis showed that, the incidence of macrosomia and large for gestational age (LGA) in the IMH group was 1.627 times (OR=1.627, 95%CI=1.103-2.399, P=0.014) and 1.681 times higher than the control group (OR= 1.681, 95%CI=1.288-2.196, P<0.001), respectively. However, there were no significant differences in the incidences of low birth weight (LBW) and SGA between the two groups (P>0.05). Among participants with PPBMI<24.0 kg/m² (non-overweight/obesity group), the incidence of macrosomia and LGA in the IMH group was 2.021 times (OR=2.021, 95%CI=1.320-3.093, P=0.001) and 1.788 times (OR=1.788, 95%CI=1.322-2.418, P<0.001) higher than the control group, respectively. Among participants with PPBMI≥24.0 kg/m² (overweight/obesity group), there were no significant differences in the incidences of macrosomia, LBW, LGA and SGA between the two groups (P>0.05) .

Conclusion

IMH in the first trimester increases the risks of macrosomia and LGA during pregnancy, especially in pre-pregnancy non-overweight/obese women. Among pre-pregnancy overweight /obese women, IMH in the first trimester does not increase the risks of macrosomia and LGA. However, the incidences of LBW and SGA are comparable in the total cohort, women with pre-pregnancy overweight/obese or those without pre-pregnancy overweight/obese.

The Relationship between Body Composition in Early Pregnancy and Gestational Diabetes Mellitus in a Population of Normal BMI Pregnant Women

XU Lili, ZHENG Wei, YUAN Xianxian, MA Kaiwen, ZHANG Puyang, LI Guanghui

2024, 27(29):  3602-3607.  DOI: 10.12114/j.issn.1007-9572.2024.0023

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Background

Gestational diabetes mellitus (GDM) is closely related to the short-term and long-term health outcomes of the mothers and offspring. Pre-pregnancy BMI is strongly associated with GDM, nevertheless, it does not distinguish between body fat content and fat distribution. Only using it to assess obesity is flawed. Normal weight obesity (normal BMI but body fat percentage above 30%) and normal weight with central obesity (normal BMI but visceral fat area above 80 cm²) show different degree of metabolic dysregulation. However, those population are usually overlooked in clinical practice and there is a paucity of research on those population and GDM.

Objective

To explore the correlation between body composition in early pregnancy and GDM in a population of normal pre-pregnancy BMI, and to investigate the relationship between fat distribution and GDM.

Methods

We performed a study that included 1 938 singleton pregnant women registered in the obstetric out-patient clinic of Beijing Obstetrics and Gynecology Hospital, Capital Medical University from October 2018 to October 2022. They voluntarily underwent nutritional assessment in early pregnancy and had regular pregnancy check-ups until 24-28 weeks of gestation, who underwent body composition testing in early pregnancy (6-16 weeks) and oral glucose tolerance test (OGTT) at 24-28 weeks. According to the OGTT results, the study population were divided into the GDM group (n=382) and the normal group (n=1 556). We estimated the relationship between body composition and fat distribution with GDM in early pregnancy with binary Logistic regression.

Results

Body fat mass (BFM), visceral fat area (VFA), percentage body fat (PBF), and fat mass index (FMI) in the GDM group were higher than in the normal group (P<0.05). BFM, VFA, PBF, FMI (OR=1.044, 95%CI=1.012-1.078; OR=1.007, 95%CI=1.002-1.012; OR=1.041, 95%CI=1.012-1.070; OR=1.138, 95%CI=1.043-1.241) (P<0.05) and central obesity (VFA≥80 cm²) (OR=1.396, 95%CI=1.101-1.770, P<0.05) associated with a significant increased risk for GDM with binary Logistic regression analysis. Spearman rank correlation analysis showed that BFM, VFA, PBF, FMI and blood glucose of the OGTT test were positively correlated (P<0.05) .

Conclusion

Among normal pre-pregnancy BMI women, BFM, VFA, PBF, and FMI in early pregnancy were the risk factors of GDM. Central obesity (VFA≥ 80 cm²) could independently predict the development of GDM. It is necessary to pay attention to fat distribution during pregnancy check-ups and to strengthen the pregnancy management for central obesity women.

The Relationship between Gestational Weight Gain and Pregnancy Outcomes in Patients with Type 2 Diabetes

JIA Jianrui, YAN Xin, ZHANG Lirui, ZHENG Wei, LI Guanghui

2024, 27(29):  3608-3615.  DOI: 10.12114/j.issn.1007-9572.2024.0027

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Background

Given the increased risk of adverse pregnancy outcomes in pregnant women with type 2 diabetes, in addition to glycemic control, it is crucial to understand the relationship between gestational weight gain and adverse pregnancy outcomes.

Objective

To investigate the gestational weight gain in pregnant women with type 2 diabetes and its relationship with pregnancy outcomes.

Methods

A retrospective analysis was conducted on 691 cases of pregnant women with type 2 diabetes who underwent prenatal care and delivery at Beijing Obstetrics and Gynecology Hospital, Capital Medical University, from 2012 to 2020. According to the Chinese "Standard of Recommendation for Weight Gain during Pregnancy Period", the participants were categorized into the inadequate weight gain group (n=143), appropriate weight gain group (n=289), and excessive weight gain group (n=259). The gestational weight gain characteristics, maternal outcomes, and neonatal outcomes were compared among the three groups. Multivariate Logistic regression analysis was employed to explore the impact of gestational weight gain on pregnancy outcomes.

Results

The results of multivariate Logistic regression analysis showed that compared to the appropriate weight gain group, the excessive weight gain group had increased risks of cesarean section (aOR=1.626, 95%CI=1.110-2.382), preeclampsia (aOR=1.997, 95%CI=1.071-3.677), macrosomia (aOR=1.948, 95%CI=1.175-3.230), and large for gestational age (LGA) (aOR=2.090, 95%CI=1.321-3.306), while reducing the rate of vaginal delivery (aOR=0.617, 95%CI=0.415-0.918). The inadequate weight gain group was associated with a reduced risk of delivering LGA (aOR=0.497, 95%CI=0.255-0.970), with no impact on small for gestational age (SGA) (P>0.05). Further stratified analysis revealed that excessive weight gain group with pre-pregnancy BMI≥24.0 kg/m² increased the risks of cesarean section, preeclampsia, LGA [aOR and 95%CI were 1.673 (1.082-2.587), 1.961 (1.022-3.761), 2.031 (1.221-3.379), respectively], while reducing the rate of vaginal delivery (aOR=0.589, 95%CI=0.372-0.933). The inadequate weight gain group with pre-pregnancy BMI≥24.0 kg/m² showed a decreased risk of delivering LGA (aOR=0.487, 95%CI=0.237-0.999). Excessive weight gain during early, middle, and late pregnancy was identified as a risk factor for macrosomia [aOR and 95%CI were 1.07 (1.00-1.15), 1.16 (1.03-1.31), and 1.16 (1.06-1.27), respectively] and LGA [aOR and 95%CI were 1.08 (1.01-1.16), 1.13 (1.02-1.26), and 1.16 (1.07-1.26), respectively]. Excessive weight gain during late pregnancy was associated with gestational hypertension and preeclampsia (aOR=1.13, 95%CI=1.02-1.24; aOR=1.14, 95%CI=1.03-1.26), while excessive weight gain during middle and late pregnancy was a risk factor for cesarean section (aOR=1.11, 95%CI=1.02-1.21; aOR=1.09, 95%CI=1.02-1.17) .

Conclusion

Excessive gestational weight gain increases the risk of adverse pregnancy outcomes such as LGA, macrosomia, preeclampsia, and cesarean section in women with type 2 diabetes during pregnancy. Inadequate gestational weight gain reduces the risk of LGA, but does not increase the risk of SGA. There is a clear correlation between gestational weight gain during different stages of pregnancy and adverse pregnancy outcomes. Therefore, optimizing blood glucose levels during pregnancy in patients with type 2 diabetes should be accompanied by enhanced education and interventions on weight gain management from preconception and early pregnancy stages.

Original Research

Study on the Relationship between Inter-arm Blood Pressure Difference and Mild Cognitive Impairment in Rural Elderly People

WU Qingyue, CHEN Xiaoling, ZHOU Xunqiong, YANG Jingyuan, ZHOU Quanxiang, YANG Xing

2024, 27(29):  3616-3622.  DOI: 10.12114/j.issn.1007-9572.2024.0088

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Background

Previous studies have found that inter-arm blood pressure difference (IAD) and mild cognitive impairment (MCI) are both associated with cardiovascular risk factors, but it is unclear whether there is an association between IAD and MCI.

Objective

To explore the relationship between IAD and MCI in rural elderly persons and to provide a scientific basis for clarifying the mechanisms of cognitive decline in elderly persons.

Methods

From July to August 2019, the rural elderly residents aged 60 years and older were selected using the multi-stage cluster sampling method from 5 townships in 2 counties (districts) of Guizhou Province, and questionnaire surveys, general physical examinations, cognitive function assessments, and bilateral arm blood pressure measurements were carried out among them. Cognitive function was evaluated using the Mini-mental State Examination (MMSE) scale, and activities of daily living were assessed using the Activities of Daily Living Scale (ADL). Spearman rank correlation analysis and binary Logistic regression model were used to investigate the association between IAD and MCI in the elderly persons.

Results

A total of 1 795 questionnaires were distributed, and data from 1 088 participants were finally included in the study after excluding subjects with incomplete information on the questionnaires, those who did not undergo blood pressure measurements, and those who did not undergo blood tests. Among the 1 088 rural elderly residents, 138 patients (12.68%) with MCI, 99 patients (9.10%) with systolic inter-arm blood pressure difference (sIAD) ≥10 mmHg, and 80 patients (7.35%) with diastolic inter-arm blood pressure difference (dIAD) ≥10 mmHg were detected. Individuals with IAD ≥10 mmHg had a higher prevalence of MCI and lower MMSE scores, orientation scores, language scores, and delayed recall scores compared to those with IAD <10 mmHg (P<0.05). The results of correlation analysis showed that the sIAD was significantly negatively associated with the total MMSE score (r_s=-0.094), orientation score (r_s= -0.082), verbal ability score (r_s=-0.065) and delayed recall score (r_s=-0.104) ; and the dIAD was significantly negatively associated with the total MMSE score (r_s=-0.080), orientation score (r_s=-0.094), and attentional calculation score (r_s= -0.063) (all P<0.05). Multivariate Logistic regression analysis showed that the risk of MCI increased by 8.80% for each 1 mmHg increase in sIAD (OR=1.088, 95%CI=1.046-1.131, P<0.001) ; sIAD≥10 mmHg (OR=2.169, 95%CI=1.262-3.728, P<0.05) and dIAD ≥10 mmHg (OR=1.926, 95%CI=1.047-3.542, P<0.05) were the influencing factors for the occurrence of MCI in the elderly.

Conclusion

The prevalence of MCI in rural elderly is 12.68%, and their elevated IAD is associated with an increased risk of MCI. And the risk of MCI is higher in elderly with IAD ≥10 mmHg than in those with IAD <10 mmHg.

Association of Monounsaturated Fatty Acid Intake with Nonalcoholic Fatty Liver Disease Risk in Chinese Han Adults: a Retrospective Case-control Study

FU Wei, CHENG Guobin, LYU Linya, DING Yao, WANG Yao, ZHAO Junlong

2024, 27(29):  3623-3628.  DOI: 10.12114/j.issn.1007-9572.2024.0147

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Background

While the connection between monounsaturated fatty acid (MUFA) intake and non-alcoholic fatty liver disease (NAFLD) has received attention, research in Chinese populations remains scarce.

Objective

This study aims to evaluate the association between daily MUFA intake and the prevalence of NAFLD in a Chinese population and to estimate the probable threshold of MUFA intake for NAFLD risk.

Methods

This case-control study employed data from the Dryad database (https://doi.org/10.5061/dryad.8nn2j46), complying with Dryad's terms of service. We collected data from 534 NAFLD patients and 534 healthy controls who underwent medical tests at the First Hospital of Nanping Affiliated to Fujian Medical University between April 2015 and August 2017. A semi-quantitative food frequency questionnaire (SQFFQ) was used to collect individuals' typical food consumption information, and daily MUFA intake was computed. A thorough analytical technique, including baseline characteristics, multivariate statistics, non-linear relationship analysis, and subgroup research, was applied to study the correlation between daily MUFA intake and NAFLD prevalence. Multiple confounding factors, such as age, sex, lifestyle, and other dietary components, were evaluated to estimate the theoretical threshold of MUFA intake for NAFLD risk.

Results

In the adjusted model, daily MUFA intake was a significant risk factor for NAFLD (OR=1.04, 95%CI=1.02-1.07, P<0.001). After transforming daily MUFA intake into a categorical variable, the adjusted model demonstrated an increased trend of NAFLD risk with increasing daily MUFA intake (P_trend<0.001). At 39.04 g/d, non-linear analysis revealed a significant change in the relationship between daily MUFA intake and NAFLD risk. When daily MUFA intake was <39.04 g/d, the risk of NAFLD was 1.08 (95%CI=1.04-1.11, P<0.001). Subgroup analysis revealed significant interactions between sex, age, daily engery intake, and NAFLD risk (P_interaction<0.05) .

Conclusion

Increased daily MUFA intake was related to a greater risk of NAFLD, demonstrating a non-linear relationship after a certain threshold (39.04 g/d). This finding shows the need for evaluating both the quality and quantity of dietary fat in NAFLD management.

Correlation between Body Composition and Cardiopulmonary Exercise Capacity in Patients with Chronic Obstructive Pulmonary Disease

YU Chunyan, DONG Fen, LEI Jieping, YANG Ting, XIA Jingen, QUMU Shiwei, YANG Tianyi, LI Xiaopan

2024, 27(29):  3629-3634.  DOI: 10.12114/j.issn.1007-9572.2024.0095

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Background

Cardiopulmonary exercise testing (CPET) is essential for assessing the maximal exercise capacity of patients with chronic obstructive pulmonary disease (COPD) and for developing rehabilitation prescriptions. Body composition has been shown to be associated with CPET results, which is complex, time-consuming, contraindicated, and risky, and cannot be performed in some COPD patients, whereas body composition analysis is simple and fast.

Objective

This paper focuses on the correlation between body composition and CPET in patients with COPD, and provides a basis for predicting maximal exercise capacity, formulating rehabilitation prescriptions, and rational nutritional support for patients with COPD who are unable to complete cardiopulmonary exercise testing.

Methods

Stable COPD patients were enrolled in the outpatient respiratory clinic of China-Japan Friendship Hospital between July 2021 and March 2022, and were sequentially subjected to body composition measurements and CPET with continuous incremental loading, and the test results were analyzed to assess the relationship between body composition and CPET results, and to analyze the value of the body composition indexes in predicting the results of CPET.

Results

Seventy-seven eligible patients with stable COPD completed body composition measurement and exercise cardiopulmonary exercise testing. Correlation analysis showed that body fat percentage (BFP) was negatively correlated with peak metabolic equivalents (peakMETs) (P<0.01) ; skeletal muscle mass index (SMI) was positively correlated with peak oxygen uptake (peakVO₂), peak load, peak ventilation volume (peakVE), maximum heart rate (peakHR), peak oxygen pulse (peakO₂pulse), and oxygen uptake efficiency slope (OUES) at the highest exercise state were positively correlated (P<0.01) ; and the fat free mass index (FFMI) was positively correlated with peakVO₂, peakLoad, peakVE, peakO₂pulse, and OUES (P<0.01). The results of multivariable linear regression analysis showed that SMI and FFMI were independently and positively correlated with peakLoad, peakVE, peakO₂pulse, and OUES in patients with COPD (P<0.05). BFP was independently and negatively correlated with peakMETs in patients with COPD (P<0.05). SMI had better predictive ability than FFMI for the results of the CPET trial in COPD patients peakLoad, peakVE, peakO₂pulse, and OUES.

Conclusion

Muscle content is positively correlated with the exercise capacity of COPD patients, and the results of body composition measurement can be used as an important criterion for predicting the exercise capacity of COPD patients, guiding the rehabilitation exercise and rational nutritional support therapy.

Correlation between Systemic Immune-inflammation Index and Erythropoietin Hypo-responsiveness in Patients with Maintenance Hemodialysis

NIU Di, CHEN Ruifang, PANG Xinxin, XIAO Mingzhi, ZHANG Junshao, ZHANG Xiaowei

2024, 27(29):  3635-3640.  DOI: 10.12114/j.issn.1007-9572.2023.0788

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Background

Erythropoietin (EPO) hypo-responsiveness is one of the main reasons for the low compliance rate of renal anemia in maintenance hemodialysis (MHD) patients, and it is also an independent risk factor for death in MHD patients. Early identification and early intervention is the key to improve prognosis. Blood inflammatory markers may be associated with EPO hypo-responsiveness in MHD patients.

Objective

To explore the correlation between systemic immune-inflammation index (SII) and EPO hypo-responsiveness in MHD patients.

Methods

A total of 180 patients who underwent regular MHD at the hemodialysis center of Henan Province Hospital of Traditional Chinese Medicine from June 2022 to June 2023 were selected as the study objects. EPO resistance index (ERI) was used to evaluate the EPO reactivity of the patients, and they were divided into EPO hypo-responsiveness group and non-EPO hypo-responsiveness group according to the ERI value. The general data and laboratory index data of the two groups were compared. Pearson correlation analysis and Spearman rank correlation analysis were used to assess the correlation of ERI with other various indicators. Multivariate Logistic regression analysis was used to explore the independent correlation factors of EPO hypo-responsiveness in MHD patients. The predictive value of SII for EPO hypo-responsiveness in MHD patients was analyzed using receiver operating characteristic (ROC) curves.

Results

A total of 180 patients with MHD were included, including 104 males (57.8%) and 76 females (42.2%), aged (56.1±8.6) years. There were 52 cases (28.9%) in EPO hypo-responsiveness group and 128 cases (71.1%) in non-EPO hypo-responsiveness group. There were significant differences in dialysis age, post-dialysis body weight, weekly rHuEPO dosage, white blood cells, neutrophils, lymphocytes, red blood cells, hemoglobin, platelets, albumin, parathyroid hormone, triglyceride, ERI, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and SII between EPO hypo-responsiveness group and non-EPO hypo-responsiveness group (P<0.05). Correlation analysis results showed that ERI in MHD patients was positively correlated with weekly rHuEPO dosage, white blood cells, neutrophils, platelets, blood uric acid, blood phosphorus, serum ferritin, NLR, PLR and SII [r (r_s) =0.486, 0.355, 0.348, 0.294, 0.198, 0.270, 0.167, 0.258, 0.302, 0.317, P<0.05] ; It was negatively correlated with body weight, erythrocyte, hemoglobin and albumin [r (r_s) =-0.407, -0.502, -0.627, -0.342, P<0.05]. Multivariate Logistic regression analysis showed that SII was one of the independent correlation factors for EPO hypo-responsivenes in MHD patients (OR=1.003, 95%CI=1.001-1.004, P<0.001). ROC curve analysis showed that the AUC of SII for predicting EPO hypo-responsiveness in MHD patients was 0.745 (95%CI=0.660-0.831), sensitivity was 61.5%, specificity was 79.7%, and the best cutoff value was 650.61.

Conclusion

SII is an independent correlation factor of EPO hypo-responsiveness in MHD patients, and has high clinical value in predicting EPO hypo-responsiveness in MHD patients.

Analysis of Gastrointestinal Core Symptoms and Influencing Factors in Postoperative Chemotherapy Patients with Gastric Cancer

ZOU Yanling, WANG Xiaoqing, LI Xun, ZHANG Ziyan, LI Yi, YANG Lihua, GAO Juan, GUAN Huiyun, DUAN Peibei

2024, 27(29):  3641-3647.  DOI: 10.12114/j.issn.1007-9572.2023.0576

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Background

Gastrointestinal symptoms in gastric cancer patients treated with postoperative chemotherapy are diverse and interconnected, without effective intervention targets. In recent years, network analysis has emerged as a prominent approach to identify intervention targets.

Objective

To construct a network of gastrointestinal symptoms in gastric cancer patients treated with postoperative chemotherapy, identify core symptoms and analyze the factors influencing core symptoms, so as to provide a reference for precise symptom management.

Methods

Postoperative chemotherapy patients with gastric cancer were selected in the medical oncology and surgical oncology department of four tertiary A-level Chinese medicine hospitals (Jiangsu Provincial Hospital of Traditional Chinese Medicine, Suzhou Hospital of Traditional Chinese Medicine, Wuxi Hospital of Traditional Chinese Medicine, and Xuzhou Hospital of Traditional Chinese Medicine) in South, Central, and North of Jiangsu Province, from March to December 2022 via convenience sampling method, as the study subjects. The MD Anderson Symptom Inventory Gastrointestinal Cancer (MDASI-GI) was used for evaluating gastrointestinal symptoms and their severity among patients receiving postoperative chemotherapy for gastric cancer, as well as assessing the classification of traditional Chinese medicine constitution among patients. The network of gastrointestinal symptoms was constructed using an R package to identify the centrality indexes. The univariate analysis and multiple linear regression analysis were conducted to investigate factors influencing core gastrointestinal symptoms in patients undergoing postoperative chemotherapy for gastric cancer.

Results

A total of 362 electronic questionnaires were collected, 355 were valid, with a valid recovery rate of 98.1%. The highest incidence of gastrointestinal symptoms in patients with postoperative chemotherapy for gastric cancer was lack of appetite (83.1%), taste alteration (81.7%) and nausea (71.0%), and the top three in terms of severity were lack of appetite (2.77 points), taste alteration (2.50 points) and nausea (2.27 points). Network analysis showed that taste alteration had the highest intensity (r_S=1.27) and the highest tight centrality (r_C=1.50) ; vomiting had the highest betweenness centrality (r_B=1.76). The results of multiple linear regression analysis showed that gender (B=0.809, 95%CI=0.319-1.298), smoking history (B=0.706, 95%CI=0.185-1.228) and phlegm-damp constitution (B=1.703, 95%CI=0.538-2.868) were the factors influencing the severity of taste alteration symptoms in patients with gastric cancer after chemotherapy (P<0.05) .

Conclusion

Taste alteration is the core symptom of gastrointestinal symptoms in gastric cancer patients undergoing postoperative chemotherapy. Gender, smoking history, and phlegm-damp constitution are influential factors contributing to taste alteration. Nursing staff can develop intervention strategies based on these core symptoms and their influencing factors to enhance the efficacy of managing gastrointestinal symptoms during chemotherapy in gastric cancer patients.

The Relationship between Sleep Characteristics and Emotions and Behavior in School-age Children: a Study on the Mediating Effect of Executive Function

MA Ning, ZHAO Yang, LYU Shaobo, ZHANG Haodong, WANG Changming, MENG Jie

2024, 27(29):  3648-3653.  DOI: 10.12114/j.issn.1007-9572.2024.0164

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Background

The sleep characteristics of school-age children have a crucial impact on the development of emotional and behavioral problems. Sleep characteristics also play a role in the development of executive function in school-age children. There is a close relationship between the emergence of emotional and behavioral problems and the development of executive function in these children. Currently, there are few studies on the mediating effect of the relationship between sleep characteristics, executive function, and emotional and behavioral problems in school-age children.

Objective

To explore the relationship between sleep characteristics, executive function, and emotional and behavioral problems in school-age children, and to examine the mediating role of executive function in the relationship between sleep characteristics and emotional and behavioral problems.

Methods

From August 21 to October 8, 2021, a convenience sampling method was used to select 516 school-age children from grades 1 to 6 in Xiwu Primary School and the Fourth Experimental Primary School in Shexian County, Handan City, Hebei Province. The Children's Sleep Habits Questionnaire (CSHQ), the Strengths and Difficulties Questionnaire (SDQ), and the Behavior Rating Inventory of Executive Function (BRIEF) were used to assess the sleep characteristics, emotional and behavioral problems, and executive function of the school-age children, respectively. Correlation analysis, regression analysis, and mediation analysis were conducted using SPSS 27.0 and the PROCESS 4.1 plugin.

Results

A total of 516 questionnaires were distributed, and 496 valid questionnaires were recovered, with an effective recovery rate of 96.1%. Correlation analysis showed that the total score of the CSHQ was negatively correlated with the Behavioral Regulation Index (BRI), Metacognition Index (MI), inhibition, shifting, emotional control, task initiation, working memory, planning, organization, and monitoring factors of the BRIEF (P<0.001). The total score of the SDQ was positively correlated with the BRI, MI, inhibition, shifting, emotional control, task initiation, working memory, planning, organization, and monitoring factors of the BRIEF (P<0.001). Forced entry method results showed that sleep characteristics negatively predicted emotional and behavioral problems (B=-0.15, t=-5.33, P<0.01), while executive function positively predicted emotional and behavioral problems (B=0.13, t=20.88, P<0.01). Mediation analysis showed that when executive function, BRI, and MI were used as mediating variables, there was a complete mediating effect between sleep characteristics and emotional and behavioral problems in children. The 95%CI for both the main effect and the indirect effect did not include 0 (P<0.001), and the 95%CI for the direct effect included 0 (P>0.05) .

Conclusion

There is a close relationship between sleep characteristics, executive function, and emotional and behavioral problems in school-age children. Executive function has a complete mediating effect on the relationship between sleep characteristics and emotional and behavioral problems. This finding emphasizes the importance of good sleep for the behavioral and emotional well-being of school-age children and provides new perspectives and intervention approaches for enhancing executive function and overall development in school-age children.

Functional Analysis of Macrophages in the Progression of Liver Cirrhosis and Liver Cancer

REN Lingxuan, LU Ziqi, QI Wei, FENG Zhijie

2024, 27(29):  3654-3663.  DOI: 10.12114/j.issn.1007-9572.2023.0596

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Background

Hepatic macrophages play a vital role in the defense mechanisms and maintaining the internal environment stability of body, and are also major cellular components involved in liver injury and repair. Macrophages derived from hematopoietic stem cells exhibit distinct gene regulation patterns compared to resident macrophages in the liver. More than 90% of primary liver cancer occurs on the basis of cirrhosis, and the dynamic changes of macrophages in the progression of cirrhosis to hepatocellular carcinoma are worth exploring.

Objective

To analyze the transcriptomic differences of hepatic macrophages originating from diverse sources, analyze the dynamic pattern of macrophage changes in liver cirrhosis and liver cancer progression, and explore potential strategies for preventing the progression of liver cancer.

Methods

In this study, single-cell transcriptomics data of healthy, cirrhotic and hepatocellular carcinoma (HCC) tissues were obtained from the Gene Expression Omnibus (GEO) database. The healthy and liver fibrosis data were obtained from the GSE136103 dataset of the GEO database, which included samples from five healthy liver tissues and five liver cirrhosis tissues. The HCC data were obtained from the GSE149614 dataset of the GEO database, which consisted of 21 samples from ten HCC patients. Utilizing the Seurat package, a clustering analysis was conducted on the transcriptomic data derived from liver fibrosis and HCC samples to identify distinct cell types. Notably, three distinctive clusters of macrophage subtypes were identified within the fibrosis samples, from which the top 200 marker genes were extracted. Metascape online analysis software was applied to functionally analyze each subcluster-specific expressed gene. Subgroup-specific expressed genes in liver fibrosis were extracted, and the function of macrophages in cirrhosis was explored by KEGG functional analysis. The CellChat software package was utilized to analyze intercellular interactions within liver fibrosis and HCC single-cell transcriptome data, differences in macrophage communication between cirrhosis and HCC samples were compared. Additionally, normal, fibrotic and cancerous macrophages were extracted, and batch effect correction was performed using the Harmony package. Subsequently, the Monocle package was employed for pseudo-time analysis to construct the developmental trajectory of macrophages spanning from a healthy state to fibrosis and eventually to the HCC microenvironment. The limma package was utilized to find genes that are continuously up-regulated and down-regulated during the evolution of macrophages from healthy state to cirrhotic state and finally to HCC, and functional enrichment analysis was performed.

Results

Unsupervised clustering was performed, and a total of three macrophage subclusters (designated as Mac1, Mac2, Mac3) were identified based on the expression patterns of marker genes. Mac1 originates from tissue-resident macrophages (Kupffer cells). Mac2 and Mac3 derived from blood monocytes and their numbers were significantly increased in cirrhotic tissue. Mac1 in cirrhotic tissue showed up-regulation of adaptive immune system-related functions. Mac2 and Mac3 subgroups show down-regulation of phagosome-related functions and antigen presentation functions. There were significant differences in communication between macrophages and other cell types in cirrhotic tissue and HCC tissue. Certain intercellular communication occurs only in cirrhotic macrophages, including cell communication of signaling pathways such as IFN-Ⅱ and CD40. After batch effect correction, pseudo-time series analysis was performed on macrophages from healthy liver, liver cirrhosis and HCC, the results suggest that there is a specific temporal relationship between the three groups of macrophages. This study identified 81 genes that were continuously down-regulated during the process, however, no genes were identified that were continuously up-regulated during the evolution of healthy-cirrhotic-HCC macrophage. Functional analysis suggested that the continuously down-regulated genes are functionally enriched for immune responses to bacteria.

Conclusion

Cirrhotic macrophages can be divided into three subgroups, of which Mac1 derived from liver-resident Kupffer cells and Mac2 and Mac3 derive from blood monocytes. Many immune-related cell communications in liver cirrhosis, such as IFN-Ⅱ and CD40 pathways, disappear in HCC. There is a continuous down-regulation of immune responses to bacteria in the evolution of healthy -cirrhotic-HCC macrophages, which may exacerbate the destructive effect of portal hypertension-induced gut microbiota displacement. For patients with liver cirrhosis, early treatment of portal hypertension-induced intestinal leakage (leaky gut) may be an important treatment strategy.

Evidence-based Medicine

Psychological Resilience Scale for Cancer Patients: a Systematic Review Based on COSMIN Guidelines

ZHANG Yasi, ZHANG Jing, XU Chen, SUN Yujing, BAI Yinjie

2024, 27(29):  3664-3671.  DOI: 10.12114/j.issn.1007-9572.2023.0717

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Background

The assessment of psychological resilience can facilitate an understanding of how patients utilize internal and external resources to adapt to adversities, traumas, significant life stressors, and disease treatment. At present, the unity of self-reported scales for assessing the psychological resilience of cancer patients remains controversial. Furthermore, it lacks the integration and standardized evaluation of scale measurement properties, and the selection of evaluation tools lacks evidence-based evidence.

Objective

To systematically assess the measurement properties of a psychological resilience evaluation tool for cancer patients and critically examine the study's methodological quality, therefore to provide a reference for healthcare professionals in selecting a high-quality assessment tool.

Methods

A systematic search of databases like PubMed, Embase, Web of Science, Cochrane Library, CINAHL, CNKI, VIP, CBM, and Wanfang Data was conducted for literature related to the evaluation of the measurement properties of the Cancer Psychological Resilience Scale. The search was done within the time frame of the database's creation to 2023-02-14. All identified articles were rated by two independent assessors following the COSMIN guidelines.

Results

Thirteen studies were included, and among the nine cancer psychological resilience tools were the 10-item Connor-Davidson Resilience Scale (CD-RISC-10), the Resilience Scale Specific to Cancer (RS-SC), the 10-item Resilience Scale Specific to Cancer (RS-SC-10), the 14-item Resilience Scale (RS-14), the Brief Resilient Coping Scale (BRCS), the SV-RES Resilience Scale (SV-RES), the Ego-Resiliency Scale (ER89-R12), the Pain Resilience Scale (PRS), and the Shift and Persist Questionnaire. All scales—aside from the RS-SC-10, which suggested a "C" because of its poor cross-cultural validity—were rated "B" because of their ambiguous content validity and differing levels of evidence.

Conclusion

This systematic review provides an overview of psychological resilience assessment tools used in cancer patients. The RS-SC stands out as being one of the most robust instruments for measuring psychological resilience in patients. Evidence needs to be generated and used in the clinical setting.

Roland-Morris Disability Questionnaire Measurement Performance Evidence in Chinese Patients with Low Back Pain: a Systematic Review Based on COSMIN Guidelines

GAO Yixuan, WANG Xiyou, CHEN Qianji, YANG Xiaoming, GUO Junming, ZI Yilu, WENG Zhiwen, MA Jingyi, ZHANG Naiwen, LIU Eryang, SHAO Hui, SUN Yanan, YU Changhe

2024, 27(29):  3672-3678.  DOI: 10.12114/j.issn.1007-9572.2023.0519

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Background

The global prevalence of low back pain is gradually increasing, and it is the main cause of disability, sick leave, and unemployment, posing a heavy burden on individuals and society. Assessing the degree of disability in patients with chronic low back pain is crucial for evaluating the efficacy of clinical interventions and clinical epidemiology. The Roland-Morris Disability Questionnaire (RMDQ) is currently the main tool for evaluating disability in patients with low back pain, but the applicability of its measurement performance in the Chinese population remains unclear.

Objective

To evaluate the applicability of RMDQ in the Chinese population with low back pain and provide evidence for clinical practice and research application.

Methods

CNKI, Wanfang Data Knowledge Service Platform, SinoMed, PubMed, Embase and Web of Science were searched from inception to 2023-10-01, to establish a literature base for the performance of the low back pain scale, and then select research on the measurement performance of RMDQ from it. The measurement performance of the RMDQ scale was evaluated according to the COSMIN system evaluation guidelines, and the evidence evaluation level was used to grade the evidence.

Results

A total of six RMDQ documents were included, with insufficient methodological quality for RMDQ content validity and adequate measurement performance. The quality of internal consistency methodology was very good with uncertainty and measurement performance was adequate; the methodological quality of retesting was uncertain, and the measurement performance was sufficient; the methodological quality of measurement error was uncertain, and the measurement performance was sufficient; the methodological quality of criterion validity was uncertain, and the measurement performance was insufficient; hypothesis testing methodological quality was very good with uncertain, and the measurement performance was sufficient and uncertain; the quality of reactivity methodology was very good, with sufficient and insufficient, while the measurement performance was sufficient with insufficient. According to the GRADE evidence quality rating results, there is low quality evidence to prove uncertainty in content validity, and moderate quality evidence to prove sufficient retesting reliability and internal consistency; there is sufficient evidence of low quality to prove the measurement error and reactivity. There is very low quality evidence of insufficient calibration validity when using the Oswestry Dysfunction Index (ODI) and the Visual Analog Scale (VAS) as calibrators; hypothesis testing had moderate quality evidence of uncertainty.

Conclusion

The methodological quality of the RMDQ scale is not high, with acceptable measurement performanceand low quality of evidence, and needs to be used cautiously in clinical practice or trials of low back pain in China. Although there is sufficient evidence of moderate quality to prove the reliability and internal consistency of retesting, the research content and methods are not standardized. In future research, attention should be paid to standardization to more accurately assess its applicability in the Chinese population.

Review & Perspectives

Research Progress on Chest CT Features of the Preserved Ratio Impaired Spirometry Population

HUANG Jinhai, LI Yun, GAO Yi

2024, 27(29):  3679-3684.  DOI: 10.12114/j.issn.1007-9572.2023.0370

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Preserved ratio impaired spirometry (PRISm) is a common pulmonary functional impairment, considered a pre-chronic obstructive pulmonary disease stage and has received increased attention from the academic community in recent years. Despite a comprehensive review of the etiology, epidemiology, and risk factors of the PRISm population, there is a lack of systematic review for chest CT imaging. To gain a more comprehensive understanding of this population, this article summarizes the chest CT imaging features of the PRISm population using both visual and quantitative assessment methods, including the characteristic changes of airways, lung parenchyma, and vessels. The article indicates that the reference value of visual assessment of chest CT results for the PRISm population is limited, while quantitative assessment of chest CT, combined with pulmonary function testing, is advantageous in gaining a deeper understanding of the lung structural features of the PRISm population. Future studies are expected to employ a more systematic approach through prospective, large-sample, multi-center cohort studies to elucidate the characteristics of the PRISm population in chest imaging.

Research Progress on the Regulation Mechanism of Senescence-associated Secretory Phenotype in Osteoporosis

YANG Chaofu, TAN Guoqing, XU Zhanwang

2024, 27(29):  3685-3695.  DOI: 10.12114/j.issn.1007-9572.2023.0721

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Senescence-associated secretory phenotype (SASP) is an important feature of cellular senescence and plays an important role in regulating the disease microenvironment. At present, the role of SASP in intervening bone metabolism and inducing bone loss is very limited. Therefore, this paper discusses the regulatory mechanism of SASP in osteoporosis models and summarizes its regulatory characteristics: SASP is fully expressed in senescent bone cells and transmits aging effects to mesenchymal stem cells in an autocrine/paracrine manner, thereby interfering with osteogenic differentiation. SASP activates immune cells and promotes their aging, thus inducing the formation of inflammatory tissue microenvironment and aggravating bone loss. Mitochondrial homeostasis, pathologic hyperglycemia, and obesity-induced fat accumulation all promote SASP expression, thus disrupting microenvironmental homeostasis and transmitting aging effects to bone tissue. To sum up, understanding the role of SASP in osteoporosis lays a solid foundation for us to develop anti-SASP therapy for osteoporosis in the future.

Clinical Study Outcome Indicators for Henoch-Schonlein Purpura Nephritis: a Scoping Review

TONG Jinghan, WU Xiaoming, SUN Yaxin, LI Shuning, LIANG Chen, DONG Heng, CHE Gang, LIU Chang, HU Yan, LIU Yali

2024, 27(29):  3696-3703.  DOI: 10.12114/j.issn.1007-9572.2023.0381

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Background

Henoch-Schonlein purpura is a vascular inflammatory illness that develops in childhood and in some children involves the kidneys, clinically known as Henoch-Schonlein purpura nephritis. Different studies have suggested different interventions, and there is a wide variation in the outcome indicators used for the intervention approaches.

Objective

To investigate and analyze the current status of clinical research outcome indicators for Henoch-Schonlein purpura nephritis in China, so as to provide a reference basis for the establishment of a core set of outcome indicators in this field.

Methods

CNKI, CBM, VIP, Wanfang Data, PubMed, Cochrane Library, Embase and Web of Science were systematically searched to collect publicly available Henoch-Schonlein purpura nephritis studies from January 2010 to June 2021. The Chinese databases were searched using the search strategy of title or keywords combined with subject terms, and the English databases were searched using subject terms combined with free words. Two investigators independently screened the literature and extracted information according to the inclusion and exclusion criteria, processed and analyzed the data on outcome indicators.

Results

A total of 148 randomized controlled trials of Henoch-Schonlein purpura nephritis were included, and the outcome indicators of Henoch-Schonlein purpura nephritis studies were mainly physical and chemical indicators, with fewer symptomatic indicators. The highest frequency of outcome indicators were clinical efficacy (121 times, 81.76%), adverse reactions (74 times, 50.00%), 24-hour urine protein (68 times, 45.95%), urinary red blood cells (43 times, 29.05%), and recurrence rate (20 times, 13.51%). The division between primary and secondary outcome indicators was clearly distinguished in only two articles.

Conclusion

There are several indicators for the research outcomes of Henoch-Schonlein purpura nephritis in China, primarily physical and chemical variables, with significant variation. The research focuses on efficacy measures but ignores adverse reactions. As a result, it is necessary to establish a set of outcome indicators for clinical intervention studies on Henoch-Schonlein purpura nephritis in order to provide a reference basis for selecting outcome indicators and guiding clinical decision-making in future similar studies.

Serial Research：Rare Diseases

Mitochondrial DNA Depletion Syndrome Caused by RRM2B Gene Mutation: Clinical Characteristics and Genetic Analysis of Two Cases with Different Types (8A and 8B)

DENG Lin, LU Jun

2024, 27(29):  3704-3708.  DOI: 10.12114/j.issn.1007-9572.2023.0520

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RRM2B gene mutation-related diseases can be divided into four types according to genetic pattern and clinical phenotype of mitochondrial DNA depletion syndrome 8A (MTDPS8A), mitochondrial DNA depletion syndrome 8B (MTDPS8B), rod-cone dystrophy, sensorineural deafness, and fanconi-type renal dysfunction (RCDFRD), progressive external ophthalmoplegia with mitochondrial and deletions, autosomal dominant 5 (PEOA5). Among them, MTDPS8A and MTDPS8B are both mitochondrial DNA depletion syndromes with the same genetic pattern, and the clinical phenotypes are complex and heterogeneous in the early stage, making it difficult to identify them. This paper systematically reviewed and analyzed the clinical characteristics, genetic test results, diagnosis and treatment process and other case data of two children diagnosed with MTDPS8A and MTDPS8B, and reviewed relevant literature to summarize the genetic characteristics of these two types, so as to provide diagnostic ideas for future suspected cases and further improve the clinical diagnosis rate of RRM2B mutation-related mitochondrial encephalomyopathy, which also helps to assess the prognosis.