Table of Content

15 April 2025, Volume 28 Issue 11

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Guidelines·Consensus

Chinese Guideline for Diagnosis and Treatment of Co-morbid Insomnia and Obstructive Sleep Apnea (2024)

Chinese Academy Society of Sleep Medicine, Chinese Medical Doctor Association, Sleep Medicine Group, China Neurologist Association

2025, 28(11):  1289-1303.  DOI: 10.12114/j.issn.1007-9572.2024.0483

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When insomnia and obstructive sleep apnea (OSA) coexist, it is referred to as comorbid insomnia and obstructive sleep apnea (COMISA). The prevalence of COMISA in the general population ranges from 0.6% to 19.3%. It is primarily characterized by difficulty falling asleep, frequent nighttime awakenings, early morning awakening, poor sleep quality, snoring or apnea during sleep, unrefreshing or nonrestorative sleep, excessive daytime sleepiness, fatigue, attention impairment, memory impairment, emotional disorders, and impaired quality of life. COMISA can lead to adverse outcomes in multiple systems and increase all-cause mortality. Therefore, it is significant to establish a guidline for the diagnosis, differential diagnosis, and standardized treatment of COMISA. The guideline was organized by the Chinese Academy Society of Sleep Medicine, Chinese Medical Doctor Association and Sleep Medicine Group, China Neurologist Association. It was formed by reviewing domestic and international COMISA diagnosis and treatment practices, through literature evidence review, and after extensive discussion. The guideline summarized the epidemiology, etiology and risk factors, pathophysiological mechanisms, clinical manifestations, assessment methods, diagnosis, differential diagnosis, and treatment studies of COMISA, providing a basis for decision-making in the diagnosis and treatment of COMISA for clinician.

Multimorbidity Section

Analysis of Depression Status and Influencing Factors in Middle-aged and Elderly Patients with Chronic Diseases in China: an Empirical Analysis Based on CHARLS Data

WEI Xuan, WANG Ning, WEI Ying, CHEN Qilin, ZHAO Yang

2025, 28(11):  1303-1308.  DOI: 10.12114/j.issn.1007-9572.2024.0022

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Background

There are a large number of middle-aged and elderly patients with chronic diseases. However, there is currently limited research on the depression status and influencing factors of middle-aged and elderly patients with chronic diseases nationwide.

Objective

By exploring the depression status and influencing factors of middle-aged and elderly patients with chronic diseases in China, to provide a reference for improving their mental health status.

Methods

According to the fifth round of national survey data conducted by the China Health and Retirement Longitudinal Study (CHARLS) in 2020, a total of 12 551 middle-aged and elderly patients with chronic diseases were selected as the study objects. The depression status of the study objects was measured using the Center for Epidemiologic Studies Depression Scale (CES-D), and the main factors affecting the depression status of middle-aged and elderly patients with chronic diseases were analyzed using the chi-square test and multivariate Logistic regression.

Results

Among middle-aged and elderly patients with chronic diseases, the proportion of those with depressive symptoms was 40.7% (5 111/12 551). The results of multivariate Logistic regression analysis showed that: gender (male: OR=0.613, 95%CI=0.553-0.680), age (65-<75 years old: OR=0.862, 95%CI=0.769-0.965; ≥75 years old: OR=0.604, 95%CI=0.510-0.716), presence of spouse/partner living together or not (have OR=0.730, 95%CI=0.648-0.822), places of residence (rural: OR=1.515, 95%CI=1.387-1.654), educational levels (junior high school: OR=0.727, 95%CI=0.657-0.805; senior high school and above: OR=0.561, 95%CI=0.488-0.646), social status (1 item: OR=0.870, 95%CI=0.793-0.956; ≥ 2 items: OR=0.866, 95%CI=0.779-0.963), satisfaction with child relationships (satisfaction: OR=0.266, 95%CI=0.218-0.324), smoking (OR=1.131, 95%CI=1.014-1.263), alcohol consumption (OR=0.873, 95%CI=0.795-0.959), nighttime sleep duration (6-<8 h: OR=0.539, 95%CI=0.493-0.590; ≥8 h: OR=0.443, 95%CI=0.396-0.495), BADL (damaged: OR=1.875, 95%CI=1.692-2.077), IADL (damaged: OR=2.251, 95%CI=2.030-2.496), number of chronic diseases (2 types: OR=1.202, 95%CI=1.076-1.342; 3 types: OR=1.452, 95%CI=1.289-1.636; ≥ 4 types: OR=1.954, 95%CI=1.749-2.183) were the influencing factors of depression symptoms in middle-aged and elderly patients with chronic diseases (P<0.05) .

Conclusion

The incidence of depressive symptoms in middle-aged and elderly patients with chronic diseases is 40.7%, and the situation is not optimistic. Their depression is influenced by various factors. Healthcare institutions and policymakers should pay attention to their mental health and take targeted measures from personal, family, community, and other aspects to improve.

Influencing Factors for Medication Experience and Medication Adherence in Elderly Patients with Chronic Diseases

GAO Min, LI Xiaona, SHI Yongli, LI Ziyuan, DONG Ping, FENG Zhiqiang, MA Dongping, YIN Wenqiang, CHEN Zhongming

2025, 28(11):  1309-1314.  DOI: 10.12114/j.issn.1007-9572.2024.0137

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Background

With the accelerated population aging, the number of elderly patients with chronic diseases is growingly elevated. Adherence to medication regimens is pivotal for the health outcomes of chronic diseases. Existing research mainly analyzed influencing factors for medication adherence and the outcome of medication adherence by interventions. A single analysis of medication adherence from the aspect of medication experience is one-sided.

Objective

To understand the current situations of medication experience and medication adherence in elderly patients with chronic diseases, and to explore the influence of medication experience at multiple dimensions on medication adherence, thus proposing countermeasures to improve medication adherence in elderly patients with chronic diseases.

Methods

From September 2023 to December 2023, a total of 2 432 residents of three cities in Shandong Province were selected by stratified random sampling according to the economic level and social development. Elderly patients (>60 years of age) with chronic diseases and long-term medications were screened according to the inclusion and exclusion criteria. A self-designed Medication Experience Scale, consisting of 7 dimensions and 28 items was used to investigate the medication experience. A Chinese version of 4-item Medication Adherence Scale was used to investigate the medication adherence. Current status of patients' medication experience and medication adherence were described. Multiple linear regression was performed to analyze the dimensions of medication experience that greatly influenced medication adherence.

Results

A total of 2 432 questionnaires were distributed in this survey, and 2 415 were retrieved. After excluding samples with missing data on the main variables, a total of 1 544 samples were included in this study. The mean score of medication experience of elderly patients with chronic diseases was (4.31±0.39) point, with the highest score in the dimension of life influenced by medication (4.72±0.58) points, and lowest in the dimension of convenience (3.86±0.49) points. The mean score of medication adherence in elderly patients with chronic diseases was (3.48±0.62) points. A total of 698 (45.2%) patients were identified as a poor adherence. The most common cause for non-adherence was 'forgetting to take medication' (77.1%, 538/698). Medication adherence scores were significantly lower in female elderly, or elderly patients with two or more chronic diseases than those of counterparts (P<0.05). The results of multivariate linear regression showed that medication adherence was worse in female elderly patients (β=-0.056) and elderly patients with two or more chronic diseases (β=-0.053) (P<0.05). Among the dimensions of the Medication Experience Scale, the dimensions of effectiveness (β=0.083), and affordability (β=0.135) positively predicted patients' medication adherence (P<0.05) .

Conclusion

The proportion of elderly patients with poor medication adherence to chronic diseases in Shandong Province is 45.2%, among whom, female patients and elderly patients with two or more chronic diseases have a worse medication adherence. The effectiveness and affordability dimensions of the medication experience are positive predictors of medication adherence. Relevant departments should focus on continuously reducing the price of chronic disease medicines, and doctors should strengthen the pharmacy guidance service provided to female patients and elderly patients with two or more chronic diseases.

Analysis of Health Literacy Levels and Influencing Factors of Chronic Disease Patients under Active Health Perspective

LI Wanyu, FU Qiangqiang, JIN Hua, YU Dehua

2025, 28(11):  1315-1319.  DOI: 10.12114/j.issn.1007-9572.2024.0365

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Background

With the aging of the population, chronic diseases have become a significant public health challenge. Enhancing health literacy among individuals with chronic diseases can foster a proactive approach to health management, leading to improved health outcomes.

Objective

This study aims to examine the current status of health literacy and its influencing factors among patients with chronic diseases in Shanghai, with the goal of providing theoretical support for future health promotion strategies and chronic disease management programs.

Methods

From February to May 2023, a multi-stage stratified random sampling method was employed. Based on the resident population size and the number of community health service centers in each administrative district of Shanghai, 1 to 4 community health service centers were randomly selected from 16 districts, totaling 28 centers. A questionnaire survey was administered to chronic disease patients visiting these centers. A general information questionnaire was used to collect demographic and clinical data, and a health literacy scale was applied to assess the health literacy levels of the respondents.

Results

Of the 768 chronic disease patients surveyed, 13 questionnaires with incomplete data were excluded, resulting in a final sample of 755 patients, with an effective response rate of 98.3%. Among the respondents, 435 (57.62%) exhibited good health literacy. In terms of specific dimensions, 664 patients (87.95%) demonstrated the ability to obtain information, 618 (81.85%) expressed willingness to provide economic support, 559 (74.04%) showed communication and interaction skills, and 646 (85.56%) were willing to improve their health. Binary logistic regression analysis revealed that female gender (OR=1.549, 95%CI=1.148-2.091) and family doctor contracting (OR=1.634, 95%CI=1.162-2.299) were significant influencing factors for health literacy among chronic disease patients (P<0.05). Furthermore, the proportion of patients with stable disease control in the past year was significantly higher among those with adequate health literacy compared to those without (P<0.05) .

Conclusion

The overall health literacy of chronic disease patients in Shanghai requires improvement. Gender and contracting with a family doctor are key factors influencing health literacy levels. Targeted interventions are recommended to expand the coverage and enhance the quality of family doctor services, thereby improving health literacy. These findings provide valuable insights for promoting proactive health management in chronic disease care.

Effectiveness of Individualized Health Education Interventions on Middle-aged and Elderly Patients with Chronic Diseases in the Community: a Cluster Randomized Controlled Trial

LI Xiaoze, SUN Guoqiang, SHEN Qiang, SONG Yan, WANG Hufeng

2025, 28(11):  1320-1328.  DOI: 10.12114/j.issn.1007-9572.2024.0241

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Background

The high incidence of chronic diseases is associated with the inadequate knowledge of health and disease risks. At the national level, traditional health education remains popular in community health services. The health education conducted by primary healthcare providers are often limited, and lacks specificity in the content. Additionally, community residents generally show a low enthusiasm for participating in health education. The quality and effectiveness of health education for chronic disease patients need an improvement.

Objective

To explore the effectiveness of individualized health education interventions generated through the application of an information-based knowledge base model on middle-aged and elderly patients with chronic diseases in the community. The findings are expected to provide insights to further enhance the management of community-based chronic diseases.

Methods

In 2021, a total of 7 390 patients at the age of 50-70 years with the chronic diseases of hypertension, diabetes, coronary heart disease, and stroke in Beijing Dongcheng District Community Health Service Center were selected as study subjects. A one-year cluster randomized controlled trial was conducted. Patients in both groups received routine follow-up management strategies for chronic diseases, with the preservation of the existing basic public health services for chronic diseases. Those in the intervention group were additionally given individualized health education programs generated through an information-based knowledge base model, including health education prescriptions and individualized health management. Follow-up visits and interventions were conducted every three months, for a total of 12 months. An end-point survey was conducted one year after recruitment. The primary outcome measures were the differences between the baseline and end-point results of the knowledge awareness of chronic diseases, self-management attitudes, self-efficacy, medication adherence, and acceptance of health information technology.

Results

A total of 7 390 patients with the four types of chronic diseases were included in the study, involving 3 673 patients in the intervention group and 3 717 in the control group. There were no significant differences in the age distribution, gender, education level, and employment status between groups (P>0.05). However, there was a significant difference in the type of medical insurance coverage between groups (P<0.05). After the intervention, patients in the intervention group demonstrated significantly higher correct awareness rates of overall disease knowledge, basic knowledge of chronic diseases, diabetes knowledge, coronary heart disease knowledge, and stroke knowledge compared to pre-intervention levels (P<0.05), while that of hypertension knowledge was not statistically significant (P>0.05). In the control group, there were no significant changes in the correct awareness rates of overall disease knowledge, basic knowledge of chronic diseases, hypertension knowledge, diabetes knowledge, or coronary heart disease knowledge before and after the intervention (P>0.05). However, the correct awareness rate of stroke knowledge in the control group was significantly lower after the intervention compared to pre-intervention levels (P<0.05). The scores of the self-management attitude questionnaire, self-efficacy questionnaire, medication adherence questionnaire, and health information acceptance questionnaire in the intervention group were significantly higher than those of the control group after the intervention (P<0.05). Additionally, in the intervention group, the scores on the self-management attitude questionnaire, self-efficacy questionnaire, medication adherence questionnaire, and health information acceptance questionnaire after the intervention were significantly higher compared to pre-intervention levels (P<0.05). In the control group, the scores of the self-efficacy questionnaire and medication adherence questionnaire improved significantly after the intervention compared to pre-intervention levels (P<0.05), while no significant changes in the scores of the self-management attitude questionnaire and health information acceptance questionnaire were detected (P>0.05) .

Conclusion

Knowledge awareness of chronic diseases, self-management attitude, and health information acceptance are more significantly improved in the intervention group than the control group. Both groups showed improvements in self-efficacy and medication adherence following the intervention, especially in the intervention group. Overall, an individualized health education based on an information-based knowledge base model is beneficial for enhancing the health literacy of patients with chronic diseases.

Original Research

The Impact of Lifestyle on the Relationship between the Duration of Cardiovascular Metabolic Diseases and Mild Cognitive Impairment

LI Yiqing, CHENG Guirong, XU Lang, HU Chenlu, LI Chunli, LI Luhan

2025, 28(11):  1329-1335.  DOI: 10.12114/j.issn.1007-9572.2024.0225

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Background

With the aggravation of population aging, the prevalence of cognitive disfunction is increasing year by year. Cardiovascular metabolic diseases, as an important influencing factor, are closely related to cognitive function. At present, there are few studies on the association between duration of cardiovascular metabolic diseases and mild cognitive impairment (MCI), which lack comprehensive consideration of lifestyle factors and large-scale surveys of elderly people in Chinese communities. The comprehensiveness and reliability of the research need to be further verified.

Objective

To explore the association between the duration of cardiovascular metabolic diseases and MCI in the elderly, and to evaluate the potential role of lifestyle factors in MCI, so as to provide scientific basis for the prevention and intervention of MCI.

Methods

The data from Hubei Memory and Aging Cohort Study (HMACS), a cluster sampling method was used to select the elderly aged 65 and over in 3 communities and 48 villages in Dawu County, Wuhan City, Hubei Province from 2018 to 2023. The standardized scale was used to evaluate the cognitive function. Six factors including smoking, drinking, eating habits, physical exercise, intellectual activity and body mass index (BMI) were used for lifestyle assessment to analyze the prevalence of MCI and its influencing factors. Multivariate Logistic regression analysis was used to analyze the correlation between the duration of cardiovascular metabolic diseases and MCI, the effect of lifestyle on the correlation between the duration of disease and MCI .

Results

A total of 8 635 subjects were included, and the prevalence of MCI was 26.9%. Multivariate Logistic regression analysis showed that among hypertension (OR=1.263, 95%CI=1.093-1.458, P=0.002), diabetes (OR=1.907, 95%CI=1.476-2.463, P<0.001), coronary heart disease (OR=1.550, 95%CI=1.173-2.047, P=0.002), cerebrovascular disease (OR=2.129, 95%CI=1.627-2.786, P<0.001) the duration of illness was influencing factors for MCI in the elderly. Duration of hypertension >10 years (General: OR=1.367, 95%CI=1.086-1.720, P=0.008; Unhealthy: OR=2.377, 95%CI=1.560-3.623, P<0.001), diabetes duration >10 years (General: OR=1.688, 95%CI=1.134-2.514, P=0.010; Unhealthy: OR=2.083, 95%CI=1.035-4.194, P=0.040) duration of coronary heart disease≤10 years (General: OR=1.495, 95%CI=1.030-2.169, P=0.034; Unhealthy: OR=2.062, 95%CI=1.155-3.682, P=0.014), life style was the influencing factor of MCI. In patients with diabetes duration ≤10 years, general lifestyle (OR=1.611, 95%CI=1.065-2.437, P=0.024) was the influencing factor for MCI. Duration of coronary heart disease >10 years (OR=2.859, 95%CI=1.118-7.307, P=0.028), duration of cerebrovascular disease ≤10 years (OR=1.778, 95%CI=1.079-2.930, P=0.024), duration of cerebrovascular disease >10 years (OR=2.589, 95%CI=1.056-6.345, P=0.038), unhealthy lifestyle was the influencing factor for MCI.

Conclusion

The longer the duration of cardiovascular disease in the elderly, the higher the risk of MCI and the unhealthy lifestyle exacerbates this risk. It is recommended to reduce the incidence of MCI early by improving lifestyle and effectively managing chronic cardiovascular disease.

A Retrospective Cohort Study of the Chinese Visceral Adiposity Index and Risk of Fatty Liver

XU Hao, FANG Da, ZHOU Weihong, BI Yan, GU Tianwei

2025, 28(11):  1336-1341.  DOI: 10.12114/j.issn.1007-9572.2024.0408

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Background

Obesity is an important risk factor for the development of fatty liver. The current diagnostic indexes of obesity cannot effectively reflect the role of adipose tissue distribution in the development of fatty liver.

Objective

To assess the correlation of the baseline visceral adiposity index (VAI) and the Chinese visceral adiposity index (CVAI) with the risk of fatty liver.

Methods

This was a retrospective cohort study involving 17 086 adults receiving physical examination at the Health Management Center of Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, from February 2018 to November 2021. Physical examination records were reviewed by the electronic information system of the Health Management Center, and baseline characteristics, physical examination findings, laboratory testing and equipment inspection data were collected. Fatty liver was determined by follow-up abdominal ultrasound and computed tomography (CT). Follow-up was ended in December 2022, and follow-up events were recorded as the interval from non-occurrence of fatty liver at baseline to the first onset of fatty liver or at the end of the follow-up. Subjects were divided into fatty liver group and non-fatty liver group. Baseline VAI and CVAI were compared between groups. They were further divided into four groups based on the quartiles of baseline VAI and CVAI, and the incidence of fatty liver was compared. The correlation of VAI and CVAI with fatty liver was identified by Cox regression. The potential of VAI and CVAI in predicting fatty liver was assessed by the receiver operating characteristic (ROC) curves. Differences in the area under the curve (AUC) between VAI and CVAI were compared by the Delong's test.

Results

The mean age, BMI and follow-up period of the subjects were (44.3±13.2) years old, (23.2±2.6) kg/m², and (2.7±1.1) years, respectively. By the end of follow-up, fatty liver was detected in 2 523 (14.8%) subjects. The incidence of fatty liver was significantly higher in men than women [19.4% (1 837/9 461) vs. 9.0% (686/7 625), P<0.001]. The VAI and CVAI of the fatty liver group were significantly higher than those of the non-fatty liver group (P<0.05). Trend testing showed that the incidence of fatty liver significantly increased with the increasing baseline VAI (χ²_trend=1 034.9) and CVAI (χ²_trend=1 334.8) (both P<0.001). Multivariate Cox regression showed that the risk of fatty liver in the VAI-Q4 group and CVAI-Q4 group was 2.579 times (95%CI=2.088-3.186) and 3.375 times (95%CI=2.488-4.576) that of the VAI-Q1 group, respectively. The ROC curve showed that the AUC of CVAI in predicting fatty liver was greater than that of VAI (0.737 vs. 0.708, P<0.001). Stratified analysis showed that CVAI was significantly correlated with the occurrence of fatty liver in gender, age and BMI subgroups (P<0.001) .

Conclusion

Baseline CVAI is significantly correlated with fatty liver development, and superior to VAI in predicting fatty liver.

The Real Experience of Elderly People in Rural Areas Who Witnessed Acute Cardiovascular and Cerebrovascular Events: a Qualitative Study

KONG Xiaoqian, WANG Jingyi, WANG Li, MAO Ting, XIA Wenjing, SHI Yan

2025, 28(11):  1342-1346.  DOI: 10.12114/j.issn.1007-9572.2024.0361

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Background

First aid in mountainous areas is the key and difficult point in the construction of the basic emergency rescue network in China. As the main resident population in mountainous areas, the elderly in mountainous rural areas have a high mortality and disability rate of cardiovascular and cerebrovascular emergencies and understanding the real experience of this group when witnessing acute cardiovascular and cerebrovascular diseases is an important supplement to the relevant research on mountain first aid literacy.

Objective

To analyze the real experience of elderly people in rural areas under the witness situation of acute cardiovascular and cerebrovascular events to deeply understand the first-aid literacy level of elderly people in rural areas and to provide practical reference for the management of cardiovascular and cerebrovascular diseases in mountainous areas for grass-roots public health service personnel.

Methods

From January to February 2024, purpose sampling was used to select rural elderly people in Zunyi Mountain area of Guizhou Province as the research objects for face-to-face and semi-structured in-depth interviews. The directed content analysis method was used to analyze the data based on the knowledge-attitude-practice (KAP) theory.

Results

Three themes and eight sub-themes were summarized: (1) Personal first aid knowledge and skills: serious lack of first aid knowledge, weak ability of information screening, information support needs exist. (2) Beliefs and attitudes towards rescue in emergency situations: negative response to life first aid, lack of confidence in the role of rescue, more rescue concerns. (3) Specific behavior in emergent situations: poor response to illness, wrong rescue behavior.

Conclusion

The problems of low first aid literacy, poor treatment level, and insufficient rescue initiative among elderly people in mountainous rural areas who witness acute cardiovascular and cerebrovascular events have become prominent. Grassroots health service organizations should focus on improving the relevant work of this group's ability to treat acute cardiovascular and cerebrovascular diseases.

The Relationship between Remnant Cholesterol and Maternal Depression and Pregnancy Stress in the Second Trimester

CHEN Hongxu, WANG Denglan, CHEN Yuanyuan, SHEN Juanjuan, SONG Chun, WANG Fan, KONG Tiantian

2025, 28(11):  1347-1353.  DOI: 10.12114/j.issn.1007-9572.2024.0429

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Background

Limited research currently exists on the relationship between remnant cholesterol (RC) and maternal depression as well as pregnancy stress.

Objective

To explore the relationship between factors such as RC and maternal depression and pregnancy stress in the second trimester, providing a scientific foundation for clinical identification and intervention strategies.

Methods

Pregnant women in early pregnancy (6 to 13⁺⁶ weeks of gestation) who attended regular prenatal check-ups at the Obstetrics Department of the Second Affiliated Hospital of Xinjiang Medical University from June 2020 to April 2024 were recruited as study participants. A longitudinal study design was adopted to collect baseline data and blood lipid indicators of pregnant women, followed up until the second trimester, and used the Edinburgh Postpartum Depression Scale (EPDS) and Pregnancy Pressure Scale (PPS) to evaluate the depression and stress of pregnant women. Multi-factor Logistic regression analysis was used to construct a prediction model for maternal depression and pregnancy stress. In order to further determine the factors that have the greatest impact on the outcome, the random forest (RF) algorithm was used to build the model again, and the SHAP tool was used to visually analyze the RF model results.

Results

This study followed 403 pregnant women from the first trimester to the second trimester, with 323 valid responses collected, resulting in a follow-up loss rate of 19.9%. After excluding inaccurate baseline data, 279 pregnant women were included in the final analysis. Results indicated that the incidence of depression was 38.7% (108/279), and the incidence of pregnancy stress was 20.8% (58/279). RC levels were significantly higher in pregnant women with depression and pregnancy stress than in those without (P<0.05). Multivariate Logistic regression identified pregnancy planning (OR=0.441, 95%CI=0.251-0.775), breakfast frequency (OR=5.086, 95%CI=2.105-12.270), and RC (OR=2.759, 95%CI=1.157-6.580) as significant factors influencing depression during the second trimester (P<0.05). Additionally, taking a midday rest (OR=0.513, 95%CI=0.276-0.953) and RC (OR=3.747, 95%CI=1.519-9.246) were significant factors associated with pregnancy stress (P<0.05). The SHAP analysis indicated that RC was the most influential factor affecting maternal depression and pregnancy stress in the second trimester.

Conclusion

Elevated RC levels may increase the risk of depression and stress-related events in pregnant women during the second trimester. Future research involving larger cohort studies or clinical trials is necessary to confirm these findings and elucidate causal relationships.

The Effect of Type 2 Diabetes Mellitus and Obesity on FIB-4 Index Screening for Early Hepatic Fibrosis in Nonalcoholic Fatty Liver Disease

ZHUO Lili, QU Huanjia, ZHANG Qiuling

2025, 28(11):  1354-1360.  DOI: 10.12114/j.issn.1007-9572.2024.0234

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Background

With the prevalence of obesity, the incidence of non-alcoholic fatty liver disease (NAFLD) is increasing, the risk of liver fibrosis and liver cancer is also increasing. Screening for early fibrosis is of great significance. International guidelines recommend fibrosis-4 (FIB-4) index as an indicator for screening hepatic fibrosis. However, it is unclear whether FIB-4 index screening is affected by type 2 diabetes and BMI in screening for early fibrosis.

Objective

To evaluate whether the effectiveness of FIB-4 index in primary care screening is affected by type 2 diabetes and BMI.

Methods

A total of 110 patients diagnosed with NAFLD by liver biopsy in the Affiliated Hospital of Hangzhou Normal University from 2013 to 2023 were selected as the study objects. They were divided into type 2 diabete (T2DM) group and non-T2DM group according to T2DM. According to BMI, they were divided into normal weight group, overweight group and obesity group. According to the liver biopsy results, they were divided into F0-F1 group and F2-F4 group. FIB-4 index was calculated and the differences among each group were compared. Spearson correlation was used to analyze the correlation between FIB-4 index and various indexes. The accuracy of FIB-4 index was evaluated via receiver operating characteristics (ROC) curves. The area under ROC curve (AUC) was calculated and Delong test was used to compare AUC differences between groups.

Results

The comparison results of FIB-4 index showed that the T2DM group was higher than non-T2DM group, and F0-F1 group was lower than F2-F4 group with statistical significance (P<0.05). There was no significant difference in FIB-4 index among normal weight group, overweight group and obesity group (P>0.05). Correlation analysis showed that FIB-4 index was positively correlated with age, aspartate aminotransferase, fasting glucose and fibrosis (P<0.05), and negatively correlated with platelet count (P<0.05). The AUC of FIB-4 index in the diagnosis of NAFLD was 0.77 (95%CI=0.68-0.86, P<0.001) and the AUC of FIB-4 index in the diagnosis of NAFLD with T2DM was 0.85 (95%CI=0.72-0.98, P<0.001). The AUC of FIB-4 index in the diagnosis of NAFLD without T2DM was 0.71 (95%CI=0.58-0.84, P=0.006). Delong test results showed that there was no significant difference in AUC between the T2DM group and the non-T2DM group (Z=1.509, P=0.131). The AUC of FIB-4 index in the diagnosis of NAFLD was 0.91 (95%CI=0.76-1.00, P=0.029) in the normal group, 0.65 (95%CI=0.46-0.83, P=0.125) in the overweight group, and 0.82 (95%CI=0.70-0.94, P<0.001) in the obese group. The AUC of the normal group was higher than that of the overweight group, and the difference was statistically significane (Z=2.037, P=0.042). There was no significant difference in AUC between the obese group and the normal group or the overweight group (Z=0.876, P=0.381; Z=1.452, P=0.146) .

Conclusion

FIB-4 is not affected by T2DM in the assessment of early fibrosis in NAFLD patients, but has a certain relationship with BMI.

Application of Random Forest Algorithm in Pregnancy Prediction after Fallopian Tube Recanalization

LIU Feiran, CHEN Minghuang, ZHAO Shuaihong, BAI Wenpei

2025, 28(11):  1361-1366.  DOI: 10.12114/j.issn.1007-9572.2023.0697

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Background

Protecting female fertility stands as a central goal and vision in a fertility-friendly society, and fallopian tube recanalization offers the possibility of pregnancy for patients with tubal infertility.

Objective

This study aims to accurately identify the influencing factors affecting successful pregnancy after fallopian tube recanalization and explore the application of the random forest algorithm in screening and predicting pregnancy influencing factors in such patients.

Methods

The study collected and analyzed data from 170 patients who underwent laparoscopic combined with hysteroscopic fallopian tube recanalization at Capital Medical University Affiliated Beijing Shijitan Hospital between 2016 and 2018. Based on whether the patients achieved successful natural pregnancy within 2 years after the surgery, they were divided into the pregnancy and non-pregnancy groups. Using the R software, a random forest model for predicting pregnancy risk after tube recanalization was established on the training data set (108 cases, 63.2% of cases, extracted via Bootstrap method), and its prediction accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve (AUC) were evaluated on the verification data set.

Results

The study comprised 82 cases in the pregnancy group and 88 in the non-pregnancy group, with a spontaneous pregnancy rate of 48.2% post-surgery. The random forest algorithm, trained on the training set, demonstrated robust predictive capability upon validation, with an accuracy of 87.1%, sensitivity of 93.1%, specificity of 81.8%, positive predictive value of 81.8%, negative predictive value of 93.1%, and an AUC of 0.921. The random forest algorithm was employed to rank the importance of factors influencing pregnancy following fallopian tube recanalization by using variable importance scores. The analysis identified the top three significant predictor variables: duration of infertility, history of previous pregnancies, and patient age.

Conclusion

The random forest algorithm emerges as a viable tool for predicting factors influencing pregnancy after fallopian tube recanalization. The predictive model, predicated on infertility duration, history of prior pregnancies, and age, exhibits notable discrimination and accuracy. Early identification of key factors post-recanalization allows for timely and effective interventions. We recommend that patients presenting risk factors consider utilizing assisted reproductive technology to improve pregnancy rates.

Original Research·Combination of Chinese and Western Medicine

Acupoint Application with Tianjiu Powder for Pre-asthma: a Randomized Controlled Trial

GUO Xin, ZHOU Mingjuan, FAN Feiting, XIAO Jingmin, CHI Yihe, WU Lei, LIN Lin, CHEN Yuanbin

2025, 28(11):  1367-1375.  DOI: 10.12114/j.issn.1007-9572.2024.0044

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Background

Pre-asthma is a pre-disease state of asthma. However, effective interventions against pre-asthma at currently scant.

Objective

To assess the clinical efficacy and safety of acupoint application with Tianjiu Powder on treating pre-asthma, aiming to develop a traditional Chinese medicine (TCM) preventive therapy regimen for external treatment of pre-asthma.

Methods

This was a randomized, double-blind, placebo-parallel controlled trial. A total of 123 pre-asthma patients treated in the Guangdong Provincial Hospital of Chinese Medicine from August 1, 2016 to December 31, 2019 were recruited and randomly assigned into the treatment group (n=62) and control group (n=61) at a ratio of 1∶1. During the experimental period, 12 cases were dropped off in the treatment group and finally 50 patients who completed the experiments were involved in. In the control group, 38 cases were finally involved in after excluding 22 cases of drop-off and 1 with bronchiectasis. Acupoint application of Tianjiu Powder and placebo was respectively given to patients of the treatment group (n=50) and control group (n=38). After 24 weeks of treatment, patients were followed up for another 24 weeks. Primary and secondary outcomes before the treatment (V1 visit), at 12 weeks (V2 visit), 24 weeks (V3 visit) and 48 weeks of treatment (end of the follow-up, V4 visit) were compared between groups. The primary outcome was the negative conversion rate of the bronchial provocation test (BPT) /bronchial dilation test (BDT). Secondary outcomes included the positive rate of BPT/BDT, forced expiratory volume in one second (FEV₁), small airway function indicators, TCM syndrome score, the 36-item Short-Form (SF-36) score, serum eosinophil cationic protein (ECP), eosinophil percentage (EOS%) and total serum immunoglobulin E (IgE). Adverse events were recorded during treatment.

Results

The negative conversion rate of BPT/BDT at V2 (66.1% vs. 47.5%), V3 (64.5% vs. 44.3%) and V4 (58.1% vs. 36.1%) was significantly higher in the treatment group than that of control group (P<0.05). The main effect of grouping on FEV₁ change was significant in BDT (P_grouping<0.05). The change in FEV₁ of BDT at V4 was significantly less in the treatment group than that of the control group (P<0.05). The changes in the peak expiratory flow (PEF) before and after treatment at V2 and V3 were significantly larger in the treatment group than those of control group (P<0.05). Physical Functioning (PF) and Role Physical (RP) scores of the SF-36 at V4 were significantly higher in the treatment group than those of the control group (P<0.05). The General Health (GH) score of the SF-36 before the treatment was significantly lower in the treatment group than that of control group (P<0.05), but no significant difference after treatment was detected between groups (P>0.05). TCM syndrome scores at V2, V3 and V4 were significantly lower in the treatment group than those of the control group, but no significant differences were detected between the two groups (P>0.05). There was no significant difference in ECP at V1 between the two groups (P>0.05), which, at V3 was significantly higher in the treatment group than control group (P<0.05). There were no significant differences in EOS% and its difference, ECP difference and serum total IgE and its difference at V1 and V3 between the two groups (P>0.05). There was no significant difference in the incidence of adverse events between the two groups (P>0.05) .

Conclusion

Acupoint application with Tianjiu Powder can enhance the rate of negative conversion rate of BPT/BDT, increase PEF, and reduce the change in FEV₁ of BDT. It improves the quality of life and offers a high safety in treating pre-asthma.

Study on the Intervention and Prognosis of Modified Lifting Powder on Acute Kidney Injury and Acute Kidney Disease in Children

ZHANG Pei, YANG Meng, GAO Chunlin, XIA Zhengkun

2025, 28(11):  1376-1382.  DOI: 10.12114/j.issn.1007-9572.2024.0158

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Background

The transition stage from acute kidney injury (AKI) to chronic kidney disease (CKD) is referred to as acute kidney disease (AKD). Currently, there are relatively few studies on the intervention of traditional Chinese medicine in the progression of AKI to AKD in children.

Objective

To explore the intervention effect and impact on prognosis of Modified Shengjiang Powder on AKI and AKD in children.

Methods

A total of 136 children with AKI admitted to the Department of Pediatrics of Jinling Hospital Affiliated to Medical College of Nanjing University from June 2017 to June 2022 were selected and divided into the treatment group (65 cases) and the control group (71 cases) by random number method. The control group was treated with conventional Western medicine, while the children in the treatment group were treated with oral Modified Shengjiang Powder decoction in addition to Western medicine. Laboratory examination indicators were collected from the children at 7 days and 14 days after treatment, and the TCM syndrome score was evaluated at 14 days after treatment. The AKI children were re-evaluated after 7 days of treatment. The children were followed up for 3 to 60 months after treatment. Univariate and multivariate Cox regression analyses were used to explore the risk factors for AKI children progressing to AKD and the risk factors for AKD children progressing to CKD stage 3. The Kaplan-Meier method was used to draw the survival curve of the cumulative survival rate of the children, and the Log-rank test was used for survival curve comparison.

Results

A total of 136 AKI children were included, including 81 boys and 55 girls, with an average age of (12.6±4.5) years. After 7 days of treatment, a total of 67 children progressed to AKD, among which 26 children in the treatment group and 41 children in the control group progressed to AKD. According to the previous AKI grouping and treatment results, the AKD children were divided into the AKD treatment sub-group (26 cases) and the AKD control sub-group (41 cases) again. After treatment, the levels of serum creatinine (Scr), blood urea nitrogen (BUN), uric acid (UA), urinary N-acetyl-β-D-glucosaminidase (NAG) enzyme, urinary retinol-binding protein (RBP), urinary neutrophil gelatinase-associated lipocalin (NGAL), TCM syndrome score, and the proportion of CKD stage 3 in the treatment group were lower than those in the control group, while the estimated glomerular filtration rate (eGFR) and the proportion of complete recovery of AKI were higher than those in the control group (P<0.05). After 14 days of treatment for AKD children, the levels of Scr, urinary NAG enzyme, urinary NGAL, the proportion of CKD stage 3, and end-stage renal disease (ESRD) in the AKD treatment sub-group were lower than those in the AKD control sub-group (P<0.05). The results of multivariate Cox regression analysis showed that urinary NAG enzyme≥9.7 U·g^-1·Cr^-1 was a risk factor for AKI children progressing to AKD (HR=2.724, 95%CI=1.886-4.519, P=0.007), and traditional Chinese medicine treatment was a protective factor for AKI children progressing to AKD (HR=0.482, 95%CI=0.319-0.843, P=0.008) ; stage 3 of AKD was a risk factor for AKD children progressing to CKD stage 3 (HR=2.865, 95%CI=2.213-3.619, P=0.011), and traditional Chinese medicine treatment was a protective factor for AKD children progressing to CKD stage 3 (HR=0.665, 95%CI=0.422-0.953, P=0.040). At the end of the treatment course, the risk of progression to AKD in the AKI treatment group was lower than that in the AKI control group (χ²=5.343, P=0.021) ; at 90 days of follow-up, the risk of progression to CKD stage 3 in the AKI treatment group was lower than that in the AKI control group (χ²=4.623, P=0.032), and the risk of progression to CKD stage 3 in the AKD treatment group was lower than that in the AKD control group (χ²=7.409, P=0.006) ; at the end of the follow-up, the renal survival rate in the AKD treatment group was higher than that in the AKD control group (χ²=8.133, P=0.004) .

Conclusion

MLD can delay the progression of AKI and AKD, protect renal function and improve prognosis.

Original Research·Evidence-based Medicine

Efficacy and Safety of EGFR-TKI Combined with Chemotherapy for the First-line Treatment of EGFR-mutated Advanced Non-small Cell Lung Cancer: a Meta-analysis

SHI Jian, WANG Yajing, HOU Ran, HUANG Yajie, DUAN Xiaoyang

2025, 28(11):  1383-1394.  DOI: 10.12114/j.issn.1007-9572.2024.0351

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Background

Targeted therapy with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) has become a standardized treatment option for epidermal growth factor receptor (EGFR) mutation-positive advanced non-small cell lung cancer (NSCLC), but clinical findings of unavoidable primary or secondary resistance ultimately lead to disease progression. For this reason, finding markers for early prediction of effective populations and exploring optimized therapeutic regimens to prolong or reverse secondary resistance have become the focus of research at home and abroad.

Objective

To systematically evaluate the efficacy and safety of EGFR-TKI combined with chemotherapy for the first-line treatment of EGFR-mutated advanced non-small cell lung cancer based on data from domestic and international literature.

Methods

Three professionally recognized databases, PubMed, Embase, and Cochrane Library, were searched for randomized controlled trials eligible for the efficacy and safety of EGFR-TKI combination chemotherapy versus single-agent EGFR-TKI for the first-line treatment of patients with EGFR-mutated advanced non-small-cell lung cancer published from the time of construction to November 2023.Data on progression-free survival (PFS), overall survival (OS), objective remission rate (ORR), disease control rate (DCR), and grade≥3 adverse events were collected and analyzed by two investigators who independently screened the literature, extracted the data, and evaluated the risk of bias of the included studies. Subgroup analyses were performed based on baseline clinical characteristics, and data were statistically analyzed using RevMan 5.4.1.

Results

Ten eligible studies with a total of 2 029 patients were included, including 1 049 patients in the experimental group of EGFR-TKI combined with standard chemotherapy; and 980 patients in the control group of EGFR-TKI alone. Meta-analysis showed that compared with EGFR-TKI monotherapy, EGFR-TKI combination chemotherapy prolonged PFS (HR=0.54, 95%CI=0.49-0.60, P<0.000 01) and OS (HR=0.69, 95%CI=0.59-0.79, P<0.000 01). Compared with EGFR-TKI monotherapy, EGFR-TKI combination chemotherapy improved ORR (OR=1.95, 95%CI=1.57-2.42, P<0.000 01) and DCR (OR=1.76, 95%CI=1.13-2.74, P=0.01) in patients with advanced NSCLC with EGFR mutations. In patients with concomitant brain metastases, EGFR-TKI combination chemotherapy prolonged PFS (HR=0.42, 95%CI=0.34-0.52, P<0.000 01) and OS (HR=0.69, 95%CI=0.51-0.94, P=0.02) in patients with EGFR-mutated advanced NSCLC compared with single-agent EGFR-TKI treatment.In patients without brain metastases at baseline, EGFR-TKI combination chemotherapy prolonged PFS compared with single-agent EGFR-TKI treatment in patients with advanced NSCLC with EGFR mutations (HR=0.62, 95%CI=0.53-0.72, P<0.000 01). The incidence of grade ≥3 adverse reactions was higher with EGFR-TKI combination chemotherapy than with single-agent EGFR-TKI treatment in patients with advanced NSCLC with EGFR mutations (OR=4.25, 95%CI=2.74-6.61, P<0.000 01). The incidence of grade ≥3 adverse reactions was higher in the combination therapy group than in the monotherapy group.

Conclusion

EGFR-TKI combination chemotherapy significantly prolongs first-line PFS and OS in EGFR-mutated advanced non-small cell lung cancer, especially in patients with baseline brain metastases. The incidence of adverse events was increased in the combination therapy group, particularly the incidence of grade ≥3 hematologic toxicity, but was overall safe and manageable.

The Suitability of Four Nutritional Screening Tools for Nutritional Screening in Patients with Cirrhosis: a Network Meta-analysis

CHI Xun, LIU Sisi, CHEN Qiao, HU Yue, WANG Weixian

2025, 28(11):  1395-1402.  DOI: 10.12114/j.issn.1007-9572.2024.0196

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Background

Malnutrition has become one of the adverse complications in patients with cirrhosis, and early nutritional screening and early identification of patients with cirrhosis can effectively improve clinical outcomes, however, the types of nutritional screening tools for patients with cirrhosis are varied and not yet standardized, and further research is needed.

Objective

To evaluate the applicability of 4 nutritional screening tools for patients with cirrhosis.

Methods

CNKI, VIP, Wanfang Data, PubMed, Embase, Cochrane Library and Web of Science were searched for diagnostic studies related to nutritional screening tool screens for malnutrition in cirrhotic patients. The search time was limited to December 2023. Two researchers individually read and filtered the literatures, extracted data, and assessed the bias risk of the incorporated researches. RevMan 5.4.1, Meta-DiSc, and StataMP 17.0 were used to perform network meta-analysis. The sensitivity, specificity, positive predictive value and negative predictive value of different nutritional screening tools were ranked by the surface under the cumulative ranking curve (SUCRA) .

Results

5 Chinese and 5 English literatures were incorporated, totaling 10, including 1 299 patients; and four nutritional screening tools were included: the Nutritional Risk Screening 2002 (NRS2002), the Royal Free Hospital-Nutritional Prioritization Tool (RFH-NPT), the Malnutrition Universal Screening Tool (MUST), and the Subjective Global Assessment (SGA). The findings of meta-analysis revealed that the combined sensitivity of the four nutritional screening tools was 0.65 (95%CI=0.56-0.73), 0.93 (95%CI=0.89-0.96), 0.77 (95%CI=0.72-0.82), respectively. The combination specificity was 0.87 (95%CI=0.83-0.91), 0.72 (95%CI=0.64-0.79), 0.81 (95%CI=0.68-0.90), and MUST only be studied separately, without the combination sensitivity and combination specificity. The results of network meta-analysis showed the sensitivity and negative predictive value of SGA were lower than that of RFH-NPT (OR=0.03, 95%CI=0-0.55; OR=0.08, 95%CI=0.01-0.81, P<0.05) ; and the sensitivity and negative predictive value of RFH-NPT were higher than that of NRS2002 (OR=44.33, 95%CI=3.94-498.52; OR=17.68, 95%CI=2.13-147.05, P<0.05). The results of the combined subject work characterization curve (SROC) showed that the area under the SROC curve (AUC) for screening for malnutrition in cirrhotic patients was 0.86 for NRS2002, 0.90 for RFH-NPT, and 0.85 for SGA. The SUCRA values of the tools ranked in terms of combined sensitivity from highest to lowest were RFH-NPT (SUCRA=99.5%) >MUST (SUCRA=43.0%) >SGA (SUCRA=39.0%) >NRS2002 (SUCRA=18.5%) ; the SUCRA values of these tools ranked in terms of combined specificity from highest to lowest were: MUST (SUCRA=91.4%) >NRS2002 (SUCRA=49.1%) >SGA (SUCRA=39.8%) >RFH-NPT (SUCRA=19.7%) ; the SUCRA values of these tools ranked in terms of positive predictive value from highest to lowest were MUST (SUCRA=95.2%) >RFH-NPT (SUCRA=37.4%) >NRS2002 (SUCRA=36.1%) >SGA (SUCRA=31.3%) ; the SUCRA values of these tools ranked in terms of negative predictive value from highest to lowest were RFH-NPT (SUCRA=99.1%) >MUST (SUCRA=44.9%) >SGA (SUCRA=39.4%) >NRS2002 (SUCRA=16.7%) .

Conclusion

The current evidence shows that RFH-NPT and MUST are suitable, but this conclusion still needs to be further confirmed by large samples and multiple high-quality studies.

Review & Perspectives

Advances in the Study of Sleep-related Subjective Cognitive Decline

WEN Yining, HUANG Huichang, ZHAO Mingming

2025, 28(11):  1403-1410.  DOI: 10.12114/j.issn.1007-9572.2024.0111

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Subjective cognitive decline (SCD) usually predicts the risk of future cognitive decline, and sleep disturbances are very common in patients with SCD and often precede detectable cognitive changes. Although there is a lack of clarity regarding the relationship between sleep and SCD and the underlying mechanisms of sleep-related cognitive deterioration, studies in recent years have shown a strong link between sleep and cognitive decline. Cognitive decline may be triggered by either sleep deprivation or decreased sleep quality. Therefore, the aim of this review is to provide a comprehensive overview of the research progress on sleep and subjective cognitive decline, and to explore in depth the mechanism of their interaction, with a view to providing new ideas and methods for preventing and delaying cognitive decline, and providing useful references for research and practice in related fields.

Research Progress on Cancer Risk and Its Pathogenesis of Gastric Precancerous Conditions

WANG Yuxin, PENG Wenwan, ZHOU Zheng, HUANG Haiyang, LU Xiaomin, DONG Mingguo

2025, 28(11):  1411-1416.  DOI: 10.12114/j.issn.1007-9572.2023.0884

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The gastric precancerous conditions includes gastric mucosal atrophy and intestinal metaplasia, which is key link in the occurrence and development of gastric cancer, and its prevalence is on the rise in China. This paper details the conceptual difference between gastric precancerous conditions and precancerous lesions, identifies the evaluation methods of patients with high risk of carcinogenesis in gastric precancerous conditions from the aspects of endoscopy, pathological histology, and biomarkers, and summarizes the pathogenesis of gastric precancerous conditions. This paper shows that the cancer risk of gastric precancerous conditions is related to various factors such as the degree, range and subtype of lesions. In the microenvironment of gastric mucosa, imbalance and disorder of oxidation and antioxidant effect, energy metabolism, immune homeostasis, cell proliferation and death are the pathogenesis of gastric precancerous conditions. A comprehensive and prudent assessment of the cancer risk of gastric precancerous conditions is needed in clinical practice, thus providing patients with appropriate surveillance and follow-up programs to improve the detection rate of early gastric cancer. This paper can provide powerful evidence-based medical evidence for high-risk screening and prevention measures of gastric precancerous conditions in China, provide a reference for the in-depth development of mechanism research and new drug development.

Case Study in Public Health

Exploration and Research on Innovative Models for Alleviating Health Poverty in Western China's Child: a Case Study Based on the "Guguding" Medical Science Popularization and Training Program

HE Runxian, LU Wenjie, JIANG Haotian, HU Yan, LIU Qing, GAO Ye, LIU Xu

2025, 28(11):  1417-1420.  DOI: 10.12114/j.issn.1007-9572.2024.0631

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Mitigating child health poverty is an integral part of consolidating the achievements of poverty eradication. This paper conducts an in-depth analysis of the "Guguding" medical science popularization and training program from a public health perspective, leveraging SWOT theory and the McKinsey 7S Model. The analysis reveals that the program's value lies in overcoming challenges faced by current non-profit organizations, such as insufficient credibility, weak cultural atmosphere, limited funding sources, and lack of an effective closed-loop mechanism. By adhering to the "prevention-first" approach in health and wellness work, the program establishes a supporting system for medical hardware and software in underdeveloped regions, thereby achieving primary and secondary prevention of childhood diseases. It enhances one-on-one medical supplementation and fosters a government-oriented mechanism for medical talent retention, ultimately elevating the health standards of low-income school-age children. This endeavor further embodies the pursuit of equity and sustainable health development, serving as a proactive contribution to children, the future, and the global health cause.