2022年 · 第135卷第16期

Zhaoet al^[1]from Shanghai, China, have undertaken a detailed clinical study in a cohort of 206 asymptomatic patients with type 2 diabetes utilizing advancedin vivonerve imaging with corneal confocal microscopy (CCM-Heidelberg HRT III RCM) and continuous glucose monitoring (CGM-iPro2 system) over 7 days. The study provides important insights into the relationship between relatively short-term glucose perturbation over 7 days and corneal nerve loss in diabetic neuropathy. Furthermore, it reinforces the role of CCM in detecting early sub-clinical nerve loss, as almost one-third of asymptomatic patients had corneal nerve fiber loss, which was independently associated with glucose time in range (TIR) (percentage of time within the glucose range of 3.9–10.0 mmol/L) but not with quartiles of hemoglobin A1c (HbA1c), an established measure of long-term glycemic control. Indeed, each 10% increase in TIR was associated with a 28.2% (95% CI: 0.595–0.866,P= 0.001) decrease in the risk of abnormal corneal nerve fiber length (CNFL). This supports recent studies showing that TIR is associated with other long-term complications of diabetes, including symptomatic diabetic neuropathy in patients with nephropathy^[2]and diabetic retinopathy.^[3]

This consensus focuses on severe and critical coronavirus disease 2019 (COVID-19) mainly based on the consideration that mortality of severe and critical cases is higher than mild and moderate cases of COVID-19. Severe patients usually developed dyspnea and/or hypoxemia in a short period of time, and in some cases progressively developed respiratory failure, septic shock, coagulation disorders, and multi-organ dysfunction.^[1,2,3]To better standardize and guide the diagnosis and treatment of severe and critical COVID-19 patients and improve the treatment success rate, the frontline medical experts across China first identified the problems relevant to the diagnosis and treatment of severe and critical COVID-19, then defined the clinical problems using the population, interventions, comparisons, and outcomes framework to guide the literature search. The databases searched included PubMed, Web of Science, and Embase. The keywords searched included severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), novel coronavirus, nCoV, COVID-19, critically ill, severely ill, diagnosis, treatment, novel coronavirus pneumonia, severe and critical, and management. The keywords were searched in combination with free terms. The time period searched was from the date the databases were established to June 2022. All search results were pooled, including systematic reviews, meta-analyses, randomized, controlled studies, cohort studies, case reports, and guidelines. Publications not in English or Chinese and publications where full text was not available and the authors could not be reached were excluded. Based on a comprehensive review (analysis, consolidation, and summarization) of the treatment protocols, management consensuses, and relevant literature on COVID-19 and the experience gained from the diagnosis and treatment of severe and critical COVID-19 patients during the fight against the pandemic in China, a draft of this consensus was produced. The draft was subsequently discussed at face-to-face and online video expert workshops, underwent several rounds of revision (including repeated searching and updating of references), and finally formulated the current statement based on a consensus reached using the Delphi method. This consensus comprises 49 recommendations. The expert consensus involves etiology, pathology, pathophysiology, clinical features, classification, diagnostic criteria, early warning, clinical monitoring and treatment, traditional Chinese medicine, rehabilitation therapy, patients transfer, protection of health care workers, and vaccine. This expert consensus is expected to provide valuable suggestions for the treatment of severe and critical COVID-19 [Supplementary files, http://links.lww.com/CM9/B253].

Hypertrophic cardiomyopathy (HCM) is an underdiagnosed genetic heart disease worldwide. The management and prognosis of obstructive HCM (HOCM) and non-obstructive HCM (HNCM) are quite different, but it also remains challenging to discriminate these two subtypes. HCM is characterized by dysmetabolism, and myocardial amino acid (AA) metabolism is robustly changed. The present study aimed to delineate plasma AA and derivatives profiles, and identify potential biomarkers for HCM.

Plasma samples from 166 participants, including 57 cases of HOCM, 52 cases of HNCM, and 57 normal controls (NCs), who first visited the International Cooperation Center for HCM, Xijing Hospital between December 2019 and September 2020, were collected and analyzed by high-performance liquid chromatography–mass spectrometry based on targeted AA metabolomics. Three separate classification algorithms, including random forest, support vector machine, and logistic regression, were applied for the identification of specific AA and derivatives compositions for HCM and the development of screening models to discriminate HCM from NC as well as HOCM from HNCM.

The univariate analysis showed that the serine, glycine, proline, citrulline, glutamine, cystine, creatinine, cysteine, choline, and aminoadipic acid levels in the HCM group were significantly different from those in the NC group. Four AAs and derivatives (Panel A; proline, glycine, cysteine, and choline) were screened out by multiple feature selection algorithms for discriminating HCM patients from NCs. The receiver operating characteristic (ROC) analysis in Panel A yielded an area under the ROC curve (AUC) of 0.83 (0.75–0.91) in the training set and 0.79 (0.65–0.94) in the validation set. Moreover, among 10 AAs and derivatives (arginine, phenylalanine, tyrosine, proline, alanine, asparagine, creatine, tryptophan, ornithine, and choline) with statistical significance between HOCM and HNCM, 3 AAs (Panel B; arginine, proline, and ornithine) were selected to differentiate the two subgroups. The AUC values in the training and validation sets for Panel B were 0.83 (0.74–0.93) and 0.82 (0.66–0.98), respectively.

The plasma AA and derivatives profiles were distinct between the HCM and NC groups. Based on the differential profiles, the two established screening models have potential value in assisting HCM screening and identifying whether it is obstructive.

Changes in thyroid hormone levels are commonly recognized characters among the elderly, which were reported to potentially influence incident frailty. Therefore, we examined the cross-sectional associations of thyroid hormones (THs) with frailty as well as the five components characterizing frailty (fatigue, resistance, ambulation, number of illnesses, and loss of weight) among the oldest-old.

Four hundred and eighty-seven community-dwelling oldest-old from a local community in Haidian District, Beijing, participated in our recruitment campaign between April 2019 and May 2020. The primary outcomes were a definitive diagnosis of frailty according to the FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, Loss of weight) and a positive score for each frailty subdomain. Demographic information (age, sex, marital status, and educational status), comorbidities, and details on the participants’ lifestyles were recorded. Serum THs including free triiodothyronin (fT3), triiodothyronine (T3), free thyroxine (fT4), and thyroxine (T4) and thyroid stimulating hormone (TSH) levels were also measured at the beginning of our study. Logistic regressions were conducted to screen for potential risk factors for frailty and its subdomains.

Among the total 487 subjects at enrollment, 60 (12.23%) of them were diagnosed with subclinical hypothyroidism and 110 (22.59%) of the total population scored positive for frailty. Logistic regression analyses adjusted for all potential confounders, showed that frailty was significantly associated with the serum TSH concentration (odds ratio [OR]: 1.06), fT3 concentration (OR: 0.54), and subclinical hypothyroidism score (OR: 2.18). The association between fT4 and frailty was absent in our observational study. The fT3/fT4 ratio characterizing peripheral hormone conversion was also tested to be correlated with frailty.

Subclinical hypothyroidism, higher TSH level, lower fT3 level, and decreased fT3/fT4 ratio were all associated with frailty assessed by the FRAIL scale among the community-dwelling oldest-old, suggesting a relevant role of thyroid function in aging. Future longitudinal studies are warranted to determine the casual relationship between thyroid dysfunction and frailty in the oldest-old.

The fetal growth charts in widest use in China were published by Hadlock >35 years ago and were established on data from several hundred of American pregnant women. After that, >100 fetal growth charts were published around the world. We attempted to assess the impact of applying the long-standing Hadlock charts and other charts in a Chinese population and to compare their ability to predict newborn small for gestational age (SGA).

For this retrospective observational study, we reviewed all pregnant women (n = 106,455) who booked prenatal care with ultrasound measurements for fetal biometry at the Shenzhen Maternity and Child Healthcare Hospital between 2012 and 2019. A fractional polynomial regression model was applied to generate Shenzhen fetal growth chart ranges for head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC), and femur length (FL). The differences between Shenzhen charts and published charts were quantified by calculating the Z-score. The impact of applying these published charts was quantified by calculating the proportions of fetuses with biometric measurements below the 3rd centile of these charts. The sensitivity and area under the receiver operating characteristic curves of published charts to predict neonatal SGA (birthweight <10th centile) were assessed.

Following selection, 169,980 scans of fetal biometry contributed by 41,032 pregnancies with reliable gestational age were analyzed. When using Hadlock references (<3rd centile), the proportions of small heads and short femurs were as high as 8.9% and 6.6% in late gestation, respectively. The INTERGROWTH-21st standards matched those of our observed curves better than other charts, in particular for fat-free biometry (HC and FL). When using AC<10th centile, all of these references were poor at predicting neonatal SGA.

Applying long-standing Hadlock references could misclassify a large proportion of fetuses as SGA. INTERGROWTH-21st standard appears to be a safe option in China. For fat-based biometry, AC, a reference based on the Chinese population is needed. In addition, when applying published charts, particular care should be taken due to the discrepancy of measurement methods.

Corneal confocal microscopy (CCM) is a noninvasive technique to detect early nerve damage of diabetic sensorimotor polyneuropathy (DSPN). Time in range (TIR) is an emerging metric of glycemic control which was reported to be associated with diabetic complications. We sought to explore the relationship between TIR and corneal nerve parameters in asymptomatic patients with type 2 diabetes (T2DM).

In this cross-sectional study, 206 asymptomatic inpatients with T2DM were recruited. After 7 days of continuous glucose monitoring, the TIR was calculated as the percentage of time in the glucose range of 3.9 to 10.0 mmol/L. CCM was performed to determine corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length (CNFL). Abnormal CNFL was defined as ≤15.30 mm/mm².

Abnormal CNFL was found in 30.6% (63/206) of asymptomatic subjects. Linear regression analyses revealed that TIR was positively correlated with CCM parameters both in the crude and adjusted models (all P < 0.05). Each 10% increase in TIR was associated with a 28.2% (95% CI: 0.595–0.866, P = 0.001) decreased risk of abnormal CNFL after adjusting for covariates. With the increase of TIR quartiles, corneal nerve fiber parameters increased significantly (all P for trend <0.01). The receiver operating characteristic curve indicated that the optimal cutoff point of TIR was 77.5% for predicting abnormal CNFL in asymptomatic patients.

There is a significant independent correlation between TIR and corneal nerve fiber loss in asymptomatic T2DM patients. TIR may be a useful surrogate marker for early diagnosis of DSPN.

The screening of periprosthetic joint infection (PJI) in patients with inflammatory diseases before revision arthroplasty remains uncertain. Serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen (FIB), monocyte/lymphocyte ratio, and neutrophil/lymphocyte ratio (NLR) can help screening PJI, but their values in patients with inflammatory diseases have not been determined.

Patients with inflammatory diseases who underwent revision hip or knee arthroplasty at West China Hospital, Sichuan University, from January 2008 to September 2020 were divided into infected and non-infected groups based on the 2013 International Consensus Meeting criteria. Sensitivity and specificity of the tested biomarkers for diagnosing infection were determined based on receiver operating characteristic (ROC) curves, and optimal cutoffs were determined based on the Youden index. The diagnostic ability of these biomarkers was re-assessed after combining them with each other.

A total of 62 patients with inflammatory diseases were studied; of them 30 were infected. The area under the ROC curve was 0.813 for CRP, 0.638 for ESR, 0.795 for FIB, and 0.656 for NLR. The optimal predictive cutoff of CRP was 14.04 mg/L with a sensitivity of 86.2% and a specificity of 68.7%, while FIB had a sensitivity of 72.4% and a specificity of 81.2% with the optimal predictive cutoff of 4.04 g/L. The combinations of CRP with FIB produced a sensitivity of 86.2% and specificity of 78.1%.

CRP with a slightly higher predictive cutoff and FIB are useful for screening PJI in patients with inflammatory diseases, and the combination of CRP and FIB may further improve the diagnostic values.

ChiCTR.org.cn, ChiCTR2000039989

Anorexia nervosa (AN) is a psychological disorder, which is characterized by the misunderstanding of body image, food restriction, and low body weight. An increasing number of studies have reported that the pathophysiological mechanism of AN might be associated with the dysbiosis of gut microbiota. The purpose of our study was to explore the features of gut microbiota in patients with AN, hoping to provide valuable information on its pathogenesis and treatment.

In this cross-sectional study, from August 2020 to June 2021, patients with AN who were admitted into Peking University Third Hospital and Peking University Sixth Hospital (n = 30) were recruited as the AN group, and healthy controls (HC) were recruited from a middle school and a university in Beijing (n = 30). Demographic data, Hamilton Depression Scale (HAMD) scores of the two groups, and length of stay of the AN group were recorded. Microbial diversity analysis of gut microbiota in stool samples from the two groups was analyzed by 16S ribosomal RNA (rRNA) gene sequencing.

The weight (AN vs. HC, [39.31 ± 7.90] kg vs. [56.47 ± 8.88] kg, P < 0.001) and body mass index (BMI, AN vs. HC, [14.92 ± 2.54] kg/m²vs. [20.89 ± 2.14] kg/m², P < 0.001) of patients with AN were statistically significantly lower than those of HC, and HAMD scores in AN group were statistically significantly higher than those of HC. For alpha diversity, there were no statistically significant differences between the two groups; for beta diversity, the two groups differed obviously regarding community composition. Compared to HC, the proportion of Lachnospiraceae in patients with AN was statistically significantly higher (AN vs. HC, 40.50% vs. 31.21%, Z = –1.981, P = 0.048), while that of Ruminococcaceae was lower (AN vs. HC, 12.17% vs. 19.15%, Z = –2.728, P = 0.007); the proportion of Faecalibacterium (AN vs. HC, 3.97% vs. 9.40%, Z = –3.638, P < 0.001) and Subdoligranulum (AN vs. HC, 4.60% vs. 7.02%, Z = –2.369, P = 0.018) were statistically significantly lower, while that of Eubacterium_hallii_group was significantly higher (AN vs. HC, 7.63% vs. 3.43%, Z = –2.115, P = 0.035). Linear discriminant effect (LEfSe) analysis (LDA score >3.5) showed that o_Lachnospirales, f_Lachnospiraceae, and g_Eubacterium_hallii_group (o, f and g represents order, family and genus respectively) were enriched in patients with AN. Microbial function of nutrient transport and metabolism in AN group were more abundant (P > 0.05). In AN group, weight and BMI were significantly negatively correlated with the abundance of Bacteroidota and Bacteroides, while positively correlated with Subdoligranulum. BMI was significantly positively correlated with Firmicutes; HAMD scores were significantly negatively correlated with Faecalibacterium.

The composition of gut microbiota in patients with AN was different from that of healthy people. Clinical indicators have correlations with the abundance of gut microbiota in patients with AN.

Worldwide, the volume and availability of digestive endoscopy have undergone dramatic development in recent years, with increasing attention on quality assurance. We investigated the utilization and quality of digestive endoscopy in China from 2015 to 2019 and developed a quantitative quality evaluation tool for medical institutions.

We invited all tertiary/secondary hospitals in Chinese mainland to participate in the survey annually. The questionnaires included the personnel, annual volume, and quality indicators of endoscopy. An endoscopy quality index (EQI) was developed based on recorded quality indicators using principal component analysis to determine the relative weight.

From 2015 to 2019, 806, 1412, 2644, 2468, and 2541 hospitals were respectively enrolled in this study. The average annual volume of endoscopy increased from 12,445 to 16,206 (1.30-fold) and from 2938 to 4255 (1.45-fold) in tertiary and secondary hospitals, respectively. The most obvious growth was observed in diagnostic colonoscopy (1.44-fold for all hospitals after standardization). The proportion of early cancer among all esophageal and gastric cancers during diagnostic esophagogastroduodenoscopy increased from 12.3% (55,210/448,861) to 17.7% (85,429/482,647) and from 11.4% (69,411/608,866) to 16.9% (107,192/634,235), respectively. The adenoma detection rate of diagnostic colonoscopy increased from 14.9% (2,118,123/14,215,592) to 19.3% (3,943,203/20,431,104). The EQI model included 12 quality indicators, incorporating 64.9% (7.792/12) of the total variance into one comprehensive index. According to the EQI measurements, the quality of endoscopy was higher in tertiary hospitals and hospitals in developed areas with higher volume or more endoscopists than that in other hospitals.

Digestive endoscopy in China has developed considerably in recent years in terms of both volume and quality. The EQI is a promising tool to quantify the quality of endoscopy at different hospitals.

To the Editor: Behcet’s disease is a chronic vascular inflammatory disease that involves multiple systems of the body. Although the incidence of pulmonary damages is low in Behcet’s disease, most of them are serious. The initial pulmonary damages of Behçet’s disease are mainly manifested with mild cough, chest pain, and slight hemoptysis, which are easily misdiagnosed as pulmonary embolism, pneumonia, or other diseases. Although some studies have reported the cases of pulmonary damage in Behcet’s disease, few studies have summarized the results of its specific pulmonary imaging. In this study, we described the diagnosis and treatment of eight cases of Behcet’s disease-related pulmonary damage. Especially, we reviewed their clinical symptoms, especially pulmonary imaging data, to improve the understanding of this disease.

To the Editor: Air pollution is a rapidly developing environmental problem worldwide. A large number of studies have indicated that ambient air pollutants have effects on mortality and morbidity of respiratory diseases. Remarkably, paramount attention should be paid to the impact on respiratory diseases associated with air pollution from a public health standpoint. Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory disease characterized by partially irreversible chronic airflow limitation that may lead to disability and impaired quality of life.^[1,2]The most recent national survey in China reports that the overall prevalence of COPD patients aged ≥40 years has reached 13.7% in 2012 to 2015.^[3]Obstructive sleep apnea (OSA), one of the common complications of COPD, is characterized by repetitive episodes of partial or complete upper airway obstruction during sleep, leading to sleep apneahypopnea, hypoxemia, and sleep fragmentation.