2021年 · 第134卷第14期

出版日期 2021-07-20电子版￥0.00元

Consensus Statements

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Yue-Tian Yu, Jiao Liu, Bo Hu, Rui-Lan Wang, Xiang-Hong Yang, Xiu-Ling Shang, Gang Wang, Chang-Song Wang, Bai-Ling Li, Ye Gong 等

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001661

摘要

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识别乳腺癌高危女性的风险评估临床实践指南：中国乳腺外科学会（CSBrS）实践指南2021

Fei Wang, Xue-Ning Duan, Rui Ling, Zhi-Gang Yu, Chinese Society of Breast Surgery

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001502

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导管内乳头状瘤临床实践指南：中国乳腺外科学会（CSBrS）实践指南2021

Di Wu, Ai-Ping Shi, Ai-Lin Song, Zhi-Min Fan, Chinese Society of Breast Surgery

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001533

摘要

Review Article

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含趋化因子样因子MARVEL跨膜结构域家族对抗磷脂综合征的可能作用

Ying-Ying Ge, Hong-Ji Duan, Xiao-Li Deng

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001449

摘要

Meta Analysis

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新辅助化疗与手术治疗的比较vs局部晚期胃癌单纯手术治疗的荟萃分析

Jian-Hong Yu, Zao-Zao Wang, Ying-Chong Fan, Mao-Xing Liu, Kai Xu, Nan Zhang, Zhen-Dan Yao, Hong Yang, Cheng-Hai Zhang, Jia-Di Xing 等

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001603

摘要

Perspective

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中药单体对脊髓损伤后神经功能恢复的潜在治疗机制

Tao Zhang, Kai Gao, Ting-Zhen Yan, Cheng-Wei Lyu, Chao-Liang Lyu

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001476

摘要

Viewpoint

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中国重症医学大数据平台现状及未来展望

Long-Xiang Su, Sheng-Jun Liu, Xiang Zhou, Mei-Li Duan, Jian Liu, Bin Ouyang, Bing-Yu Qin, Hong-Liang Wang, Xue Wang, Lei Xu 等

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001366

摘要

“大数据”一词起源于第11届电子材料大会世界年会上，原指技术应用产生的大量数据。^[1]医疗大数据不仅包括患者住院期间积累的病史和检查数据，还包括来自门诊、急诊、医保结算部门以及临床实验中心的患者相关随访数据、预后数据。迄今为止，它在医学的各个专业都有深刻的应用。^[2,3,4]然而，重症监护医学（ICU）不同于其他医疗领域。与临床实践数据相比，ICU医疗数据具有以下特点：规模大、生产快、维度多样、不准确性、异质性、不完整性、复杂性和隐私问题。^[5]事实上，在国内和全球各大ICU数据库的建设过程中，都对这些数据库进行了大篇幅的优化。以异构为例，医疗数据可能的格式包括文本类型、数字类型和图像类型。基于文本的数据包括人口统计学特征、药物使用、病史和症状。数字数据包括各种实验室检测结果、生命体征、监测仪器数据。图像类型数据包括各种成像评估，例如B型超声、计算机断层扫描、磁共振成像、X射线和其他检查。在数据库的形成中，需要文本类型数据的标准化格式。对于数字化数据，强调采集的时效性，并考虑治疗方法和各种指标的趋势。对于图像数据，除了常规的成像报告之外，还可以通过结合诊断和图像特征来建立人工智能图像读取模型。到目前为止，中国在重症医学领域尚未达成行业标准共识。中国卫生信息与健康医疗大数据学会重症医学分会成立于2019年3月，旨在建立和推广重症医疗大数据应用。经过全面调查，发现ICU数据库建设数量和质量有限。应该做出更多的努力来改善这种情况。我们坚信，中国重症数据库的发展将充分利用大数据平台，为患者提供更好的诊断和治疗流程，为管理决策者提供准确客观的诊断，为医学研究人员提供更高质量的数据。

Original Article

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肺部计算机断层扫描中孤立性肺结节恶性肿瘤的风险评估：一项多变量预测模型研究

Hai-Yang Liu, Xing-Ru Zhao, Meng Chi, Xiang-Song Cheng, Zi-Qi Wang, Zhi-Wei Xu, Yong-Li Li, Rui Yang, Yong-Jun Wu, Xiao-Ju Zhang

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001507

摘要

Background: Computed tomography images are easy to misjudge because of their complexity, especially images of solitary pulmonary nodules, of which diagnosis as benign or malignant is extremely important in lung cancer treatment. Therefore, there is an urgent need for a more effective strategy in lung cancer diagnosis. In our study, we aimed to externally validate and revise the Mayo model, and a new model was established. Methods: A total of 1450 patients from three centers with solitary pulmonary nodules who underwent surgery were included in the study and were divided into training, internal validation, and external validation sets (n = 849, 365, and 236, respectively). External verification and recalibration of the Mayo model and establishment of new logistic regression model were performed on the training set. Overall performance of each model was evaluated using area under receiver operating characteristic curve (AUC). Finally, the model validation was completed on the validation data set. Results: The AUC of the Mayo model on the training set was 0.653 (95% confidence interval [CI]: 0.613-0.694). After re-estimation of the coefficients of all covariates included in the original Mayo model, the revised Mayo model achieved an AUC of 0.671 (95% CI: 0.635-0.706). We then developed a new model that achieved a higher AUC of 0.891 (95% CI: 0.865-0.917). It had an AUC of 0.888 (95% CI: 0.842-0.934) on the internal validation set, which was significantly higher than that of the revised Mayo model (AUC: 0.577, 95% CI: 0.509-0.646) and the Mayo model (AUC: 0.609, 95% CI, 0.544-0.675) (P < 0.001). The AUC of the new model was 0.876 (95% CI: 0.831-0.920) on the external verification set, which was higher than the corresponding value of the Mayo model (AUC: 0.705, 95% CI: 0.639-0.772) and revised Mayo model (AUC: 0.706, 95% CI: 0.640-0.772) (P < 0.001). Then the prediction model was presented as a nomogram, which is easier to generalize. Conclusions: After external verification and recalibration of the Mayo model, the results show that they are not suitable for the prediction of malignant pulmonary nodules in the Chinese population. Therefore, a new model was established by a backward stepwise process. The new model was constructed to rapidly discriminate benign from malignant pulmonary nodules, which could achieve accurate diagnosis of potential patients with lung cancer.

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序贯喂养与连续喂养对危重患者血糖的影响：一项非劣效性随机对照试验

Chang-Jie Ren, Bo Yao, Miao Tuo, Hui Lin, Xiang-Yu Wan, Xu-Feng Pang

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001684

摘要

Background: Glucose control is an important aspect in managing critically ill patients. The goal of this study was to compare the effects of sequential feeding (SF) and continuous feeding (CF) on the blood glucose of critically ill patients. Methods: A non-inferiority randomized controlled trial was adopted in this study. A total of 62 patients who were fed enteral nutritional suspension through gastric tubes were enrolled. After achieving 80% of the nutrition target calories (25 kcal·kg-1·day-1) through CF, the patients were then randomly assigned into SF and CF groups. In the SF group, the feeding/fasting time was reasonably determined according to the circadian rhythm of the human body as laid out in traditional Chinese medicine theory. The total daily dosage of the enteral nutritional suspension was equally distributed among three time periods of 7 to 9 o’clock, 11 to 13 o’clock, and 17 to 19 o’clock. The enteral nutritional suspension in each time period was pumped at a uniform rate within 2 h by an enteral feeding pump. In the CF group, patients received CF at a constant velocity by an enteral feeding pump throughout the study. Blood glucose values at five points (6:00/11:00/15:00/21:00/1:00) were monitored and recorded for seven consecutive days after randomization. Enteral feeding intolerance was also recorded. Non-inferiority testing was adopted in this study, the chi-square test or Fisher test was used for qualitative data, and the Mann-Whitney U test was used for quantitative data to determine differences between groups. In particular, a repeated measure one-way analysis of variance was used to identify whether changes in glucose value variables across the time points were different between the two groups. Results: There were no significant demographic or physiological differences between the SF and CF groups (P > 0.050). The average glucose level in SF was not higher than that in CF (8.8 [7.3-10.3] vs. 10.7 [9.1-12.1] mmol/L, Z = -2.079, P for non-inferiority = 0.019). Hyperglycemia incidence of each patient was more common in the CF group than that in the SF group (38.4 [19.1-63.7]% vs. 11.8 [3.0-36.7]%, Z = -2.213, P = 0.027). Hypoglycemia was not found in either group. Moreover, there was no significant difference during the 7 days in the incidence of feeding intolerance (P > 0.050). Conclusions: In this non-inferiority study, the average blood glucose in SF was not inferior to that in CF. The feeding intolerance in SF was similar to that in CF. SF may be as safe as CF for critically ill patients.

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基于随机生存森林模型的急慢性肝衰竭患者个体死亡风险预测系统

Zhi-Qiao Zhang, Gang He, Zhao-Wen Luo, Can-Chang Cheng, Peng Wang, Jing Li, Ming-Gu Zhu, Lang Ming, Ting-Shan He, Yan-Ling Ouyang 等

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001539

摘要

Background: The basis of individualized treatment should be individualized mortality risk predictive information. The present study aimed to develop an online individual mortality risk predictive tool for acute-on-chronic liver failure (ACLF) patients based on a random survival forest (RSF) algorithm. Methods: The current study retrospectively enrolled ACLF patients from the Department of Infectious Diseases of The First People’s Hospital of Foshan, Shunde Hospital of Southern Medical University, and Jiangmen Central Hospital. Two hundred seventy-six consecutive ACLF patients were included in the present study as a model cohort (n = 276). Then the current study constructed a validation cohort by drawing patients from the model dataset based on the resampling method (n = 276). The RSF algorithm was used to develop an individual prognostic model for ACLF patients. The Brier score was used to evaluate the diagnostic accuracy of prognostic models. The weighted mean rank estimation method was used to compare the differences between the areas under the time-dependent ROC curves (AUROCs) of prognostic models. Results: Multivariate Cox regression identified hepatic encephalopathy (HE), age, serum sodium level, acute kidney injury (AKI), red cell distribution width (RDW), and international normalization index (INR) as independent risk factors for ACLF patients. A simplified RSF model was developed based on these previous risk factors. The AUROCs for predicting 3-, 6-, and 12-month mortality were 0.916, 0.916, and 0.905 for the RSF model and 0.872, 0.866, and 0.848 for the Cox model in the model cohort, respectively. The Brier scores were 0.119, 0.119, and 0.128 for the RSF model and 0.138, 0.146, and 0.156 for the Cox model, respectively. The nonparametric comparison suggested that the RSF model was superior to the Cox model for predicting the prognosis of ACLF patients. Conclusions: The current study developed a novel online individual mortality risk predictive tool that could predict individual mortality risk predictive curves for individual patients. Additionally, the current online individual mortality risk predictive tool could further provide predicted mortality percentages and 95% confidence intervals at user-defined time points.

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淀粉样蛋白和tau阳性轻度认知障碍：痴呆进展的临床和生物标志物特征

Hong-Chun Wei, Bing Li, Kok Pin Ng, Qing-Xi Fu, Sheng-Jie Dong, Mao-Wen Ba, Min Kong

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001496

摘要

Background: According to the amyloid, tau, neurodegeneration research framework classification, amyloid and tau positive (A+T+) mild cognitive impairment (MCI) individuals are defined as prodromal Alzheimer disease. This study was designed to compare the clinical and biomarker features between A+T+MCI individuals who progressed to progressive MCI (pMCI) and those who remained stable MCI (sMCI), and to identify relevant baseline clinical biomarker and features that could be used to predict progression to dementia within 2 years. Methods: We stratified 197 A+T+MCI individuals into pMCI (n = 64) and sMCI (n = 133) over 2 years. Demographics and cognitive assessment scores, cerebrospinal fluid (CSF), and neuroimaging biomarkers (18F-florbetapir positron emission tomography mean standardized uptake value ratios [SUVR] and structural magnetic resonance imaging [MRI]) were compared between pMCI and sMCI at baseline, 12- and 24-month follow-up. Logistic regression models then were used to evaluate clinical baseline and biomarker features that predicted dementia progression in A+T+MCI. Results: pMCI individuals had higher mean 18F-florbetapir SUVR, CSF total-tau (t-tau), and p-tau181P than those in sMCI individuals. pMCI individuals performed poorer in cognitive assessments, both global and domain specific (memory, executive, language, attention, and visuospatial skills) than sMCI. At baseline, there were significant differences in regions of interest of structural MRI between the two groups, including bilateral amygdala, hippocampus and entorhinal, bilateral inferior lateral ventricle, left superior and middle temporal, left posterior and caudal anterior cingulate (P < 0.05). Baseline CSF t-tau levels and cognitive scores of Montreal cognitive assessment, functional assessment questionnaire, and everyday cognition by the patient’s study partner language domain could predict progression to dementia in A+T+MCI within 2 years. Conclusions: In future clinical trials, specific CSF and cognitive measures that predict dementia progression in A+T+MCI might be useful risk factors for assessing the risk of dementia progression.

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老年髋部骨折患者服用氯吡格雷早期手术的安全性：中国120例患者的回顾性病例对照研究

Ming-Hui Yang, Bo Li, Dong-Chen Yao, Yan Zhou, Wen-Chao Zhang, Geng Wang, Ping Zhang, Shi-Wen Zhu, Xin-Bao Wu

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001668

摘要

Background: Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal. Methods: Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student’s t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables. Results: Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0-120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups. Conclusions: Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.

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经颅超声在帕金森病与其他运动障碍鉴别诊断中的应用

Li-Shu Wang, Teng-Fei Yu, Bin Chai, Wen He

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001503

摘要

Background: Reports evaluating the efficacy of transcranial sonography (TCS) for the differential diagnosis of Parkinson disease (PD) and other movement disorders in China are scarce. Therefore, this study aimed to assess the application of TCS for the differential diagnosis of PD, multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and essential tremor (ET) in Chinese individuals. Methods: From 2017 to 2019, 500 inpatients treated at the Department of Dyskinesia, Beijing Tiantan Hospital, Capital Medical University underwent routine transcranial ultrasound examination. The cross-sections at the midbrain and thalamus levels were scanned, and the incidence rates of substantia nigra (SN) positivity and the incidence rates of lenticular hyperechoic area were recorded. The echo of the SN was manually measured. Results: Of the 500 patients, 125 were excluded due to poor signal in temporal window sound transmission. Among the 375 individuals with good temporal window sound transmission, 200 were diagnosed with PD, 90 with ET, 50 with MSA, and 35 with PSP. The incidence rates of SN positivity differed significantly among the four patient groups (χ2 = 121.061, P < 0.001). Between-group comparisons were performed, and the PD group showed a higher SN positivity rate than the ET (χ2 = 94.898, P < 0.017), MSA (χ2 = 57.619, P < 0.017), and PSP (χ2 = 37.687, P < 0.017) groups. SN positivity showed a good diagnostic value for differentiating PD from the other three movement diseases, collectively or individually. The incidences of lenticular hyperechoic area significantly differed among the four patient groups (χ2 = 38.904, P < 0.001). Next, between-group comparisons were performed. The lenticular hyperechoic area was higher in the PD group than in the ET (χ2 = 6.714, P < 0.017) and MSA (χ2= 18.680, P < 0.017) groups but lower than that in the PSP group (χ2 = 0.679, P > 0.017). Conclusion: SN positivity could effectively differentiate PD from ET, PSP, and MSA in a Chinese population.

Clinical Observation

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脓毒症患者血清微管相关蛋白轻链3 II型水平与病情恶化和多器官功能障碍相关

Wei Huang, Da-Wei Liu, Guang-Jian Wang, Hong-Min Zhang, Gao-Sheng Zhou, Jing-Jing Liu, Xiao-Ting Wang

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001640

摘要

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重症监护病房获得性碳青霉烯类耐药肺炎患者继发血流感染的临床特征及相关危险因素肺炎克雷伯菌

Xin-Yun Zhu, Hong-Bin Wang, Ye-Han Zhu, Yan-Bin Chen, Bei-Lei Zhang, Cheng Chen

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001444

摘要

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血小板计数是横纹肌溶解症致急性肾损伤的独立危险因素

Di Wang, Wei Guo, Xiao-Gen Tao, Ting-Ting Zhang, Jin-Quan Wang

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001651

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中国2152个家系人类白细胞抗原（HLA）A-C-B-DRB1-DQB1单倍型分离分析及与期望最大化算法结果的比较

Yang Li, Lu-Yao Chen, Teng-Teng Zhang, Xiao-Ni Yuan, Xiao-Jing Bao, Jun He

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001458

摘要

Correspondence

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贫血与ICU结局的关系

Xuan Song, Xin-Yan Liu, Huai-Rong Wang, Xiu-Yan Guo, Kianoush B. Kashani, Peng-Lin Ma

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001669

摘要

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基于中国医疗质量重症监护病房数据的生存脓毒症运动指南3小时和6小时依从性影响因素分析

Lu Wang, Xu-Dong Ma, Huai-Wu He, Long-Xiang Su, Yan-Hong Guo, Guang-Liang Shan, Xiang Zhou, Da-Wei Liu, Yun Long, China National Critical Care Quality Control Center group

中华医学杂志英文版2021年 134卷 14期

DOI: 10.1097/CM9.0000000000001362

摘要