2022年 · 第135卷第24期

Helicobacter pylori (H. pylori) infection is an infectious disease with a prevalence rate of up to 50% worldwide. It can cause indigestion, gastritis, peptic ulcer, and gastric cancer. H. pylori eradication treatment can effectively control disease progression and reduce the risk of the above conditions. However, the escalating trend of antibiotic resistance presents a global challenge for H. pylori eradication. We aim to provide guidance on pharmacological treatment of H. pylori infection.

This clinical practice guideline is developed following the World Health Organization’s recommended process, adopting Grading of Recommendations Assessment, Development and Evaluation in assessing evidence quality, and utilizing Evidence to Decision framework to formulate clinical recommendations, minimizing bias and increasing transparency of the clinical practice guideline development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and The Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guides to ensure the guideline’s completeness and transparency.

Though decreasing in developed countries, the prevalence of H. pylori remains high in developing countries, causing a major public health burden. This clinical practice guideline contains 12 recommendations concerning pharmacological treatment for H. pylori eradication. Among them, it is worth highlighting that bismuth preparations are inexpensive, safe, and effective, consequently making bismuth quadruple therapy a preferred choice for initial and rescue treatment. In empirical treatment, high-dose dual therapy is equally effective compared with bismuth quadruple therapy.

The 12 recommendations in this clinical practice guideline are formed with consideration for stakeholders’ values and preferences, resource use, feasibility, and acceptability. Recommendations are generalizable to resource limited settings with similar antibiotic resistance pattern as China, and lower middle-income countries facing comparable sociological and technical challenges.

Guidelines International Network (GIN) website, https://guidelines.ebmportal.com/node/69996.

Hepatocellular carcinoma (HCC) is the main cause of cancer-related deaths in adult men under the age of 60 years in China.^[1]Liver transplantation (LT) is generally recognized as one of the most effective therapeutic approaches for end-stage liver diseases. LT guidelines for HCC were firstly launched in 2014 and were updated in 2018. Recently, further updates are required to adapt to the new situation of LT in China and to continue advancing the recommendations. (Full version in Supplementary file, http://links.lww.com/CM9/B362).

Severe intra-operative bleeding has limited the application of complex laparoscopic splenectomy (LS), including laparoscopic total splenectomy (LTS) and laparoscopic partial splenectomy (LPS). Therefore, reducing bleeding risk in complex LS has become a subject of major interest [Supplementary Figure 1, http://links.lww.com/CM9/B377].

The pharmacokinetic and clinical behaviors of many proton pump inhibitors (PPIs) in peptic ulcer treatment are altered by CYP2C19 genetic polymorphisms. This non-inferiority study evaluated the efficacy and safety of the novel PPI anaprazole compared with rabeprazole. We also explored the influence of Helicobacter pylori (H. pylori) infection status and CYP2C19 polymorphism on anaprazole.

In this multicenter, randomized, double-blind, double-dummy, positive-drug parallel-controlled, phase III study, Chinese patients with duodenal ulcers were randomized 1:1 to receive rabeprazole 10 mg + anaprazole placebo or rabeprazole placebo + anaprazole 20 mg once daily for 4 weeks. The primary efficacy endpoint was the 4-week ulcer healing rate assessed by blinded independent review. Secondary endpoints were the proportion of patients with improved overall and individual duodenal ulcer symptoms at 4 weeks. Furthermore, exploratory subgroup analysis of the primary endpoint by H. pylori status and CYP2C19 polymorphism was conducted. Adverse events were monitored for safety. Non-inferiority analysis was conducted for the primary endpoint.

The study enrolled 448 patients (anaprazole, n = 225; rabeprazole, n = 223). The 4-week healing rates were 90.9% and 93.7% for anaprazole and rabeprazole, respectively (difference, -2.8% [95% confidence interval, -7.7%, 2.2%]), demonstrating non-inferiority of anaprazole to rabeprazole. Overall duodenal ulcer symptoms improved in 90.9% and 92.5% of patients, respectively. Improvement rates of individual symptoms were similar between the groups. Healing rates did not significantly differ by H. pylori status or CYP2C19 genotype for either treatment group. The incidence of treatment-emergent adverse events was similar for anaprazole (72/220, 32.7%) and rabeprazole (84/219, 38.4%).

The efficacy of anaprazole is non-inferior to that of rabeprazole in Chinese patients with duodenal ulcers.

ClinicalTrials.gov, NCT04215653.

Colorectal cancer (CRC) still ranks the top in morbidity and mortality of cancers worldwide, posing a huge threat and burden to the society. We aimed to determine the age-standardized incidence, mortality, and disability-adjusted life years (DALYs) of CRC and explore potential changes in the temporal trends of the CRC burden in Shanghai during 2002 to 2016.

The cancer statistics and demographics were obtained from the Cancer Registry and the Statistics Bureau of Pudong New Area, respectively. Data from 2002 to 2016 were included and analyzed retrospectively. DALYs were calculated using DisMod and the age-standardized rates (ASRs) were obtained according to Segi world standard population. Joinpoint regression was used to measure the trends in CRC incidence and to estimate the annual percent change.

The increasing trend of CRC ASR incidence halted after 2014, coinciding with the introduction of the Shanghai CRC screening program. The ASRs of mortality and DALYs increased, at 0.42% (P < 0.05) and 4.07% (P < 0.001) per year, respectively, which were mainly driven by men and individuals aged above the CRC screening program target.

The disease burden of CRC in Shanghai remains serious, especially among men, and individuals aged >74 years. The benefits of the screening program have been partially proven by the ASRs of CRC incidence, providing important insights into better and wider application of screening programs.

Cholangiocarcinoma (CCA) is a malignant biliary tract tumor with an extremely poor prognosis. There is an urgent demand to explore novel therapeutic strategies. L-fucose has been confirmed to participate in anti-inflammation and antitumor activities. However, the effect of L-fucose on the progression of CCA has not been well investigated. This study aimed to determine whether L-fucose induced the inhibition of CCA and its possible mechanism.

The anti-growth activity was determined using Cell Counting Kit-8 assay, colony formation assays, Annexin V-fluorescein isothiocyanate/propidium iodide (FITC/PI) assay, and cell cycle analysis. The anti-metastasis activity was determined by wound healing, transwell, and invasion assays. The anti-angiogenesis activity was determined by tube formation and transwell assays. MicroRNAs that may be involved in the L-fucose-induced CCA inhibition was analyzed using bioinformatics methods. The preclinical therapeutic efficacy was mainly estimated by ultrasound in xenograft nude mouse models. Differences were analyzed via Student’s t test or one-way analysis of variance.

L-Fucose induced apoptosis and G0/G1 cell cycle arrest, inhibited cell epithelial-mesenchymal transition of CCA cells, and additionally inhibited tube formation of human umbilical vein endothelial cells (HUVECs) in a dose-dependent manner, leading to a decrease in cell proliferation, metastasis, and angiogenesis. Mechanistically, L-fucose induced microRNA-200b (miR-200b) upregulation, and mitogen-activated protein kinase 7 (MAPK7) downregulation was found to be targeted by miR-200b, with decreased cell proliferation and metastasis. Additionally, phosphorylated signal transducer and activator of transcription 3 was found to be downregulated after L-fucose treatment. Finally, in vivo experiments in CCA xenograft models also confirmed the antitumor properties of L-fucose.

L-Fucose inhibited the progression of CCA via the miR-200b/MAPK7 and signal transducer and activator of transcription 3 signaling pathways.

The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement (TAVR) for symptomatic severe aortic stenosis (AS), and the impact of sizing strategies and related procedural outcomes.

Patients with severe AS who underwent TAVR were consecutively enrolled from 2012 to 2019. The anatomy and morphology of the aortic root were assessed. "Downsize" strategy was preformed when patients had complex morphology. The clinical outcomes of patients who performed downsize strategy were compared with those received annular sizing strategy. The primary outcome was device success rate, and secondary outcomes included Valve Academic Research Consortium-3 clinical outcomes variables based on 1-year follow-up.

A total of 293 patients were enrolled. Among them, 95 patients (32.4%) had bicuspid aortic valve. The calcium volume (Hounsfield Unit-850) of aortic root was 449.90 (243.15-782.15) mm³. Calcium is distributed mostly on the leaflet level. Downsize strategy was performed in 204 patients (69.6%). Compared with the patients who performed annular sizing strategy, those received downsize strategy achieved a similar device success rate (82.0% [73] vs. 83.3% [170], P= 0.79). Aortic valve gradients (downsize strategy group vs. annular sizing group, 11.28 mmHg vs. 11.88 mmHg, P = 0.64) and percentages of patients with moderate or severe paravalvular regurgitation 2.0% (4/204) vs. 4.5% (4/89), P = 0.21) were similar in the two groups at 30 days after TAVR. These echocardiographic results were sustainable for one year.

Chinese TAVR patients have more prevalent bicuspid morphology and large calcium volume of aortic root. Calcium is distributed mostly on the leaflet level. Compare with annular sizing strategy, downsize strategy provided a non-inferior device success rate and transcatheter heart valve hemodynamic performance in self-expanding TAVR procedure.

The heavy metals cadmium (Cd) and mercury (Hg) are known to be widespread environmental contaminants and high occupational exposure adversely affects the risk of chronic kidney disease (CKD). However, evidence from epidemiological studies linking low Cd and Hg exposure (or non-industrial) to the risk of progression to CKD are conflicting. This study aimed to explore the association of low Cd and Hg exposure with the risk of CKD in Chinese adults aged ≥80 years.

The participants were recruited for the Healthy Aging and Biomarkers Cohort Study in 2017, an ongoing perspective survey conducted in longevity areas in China initially involving 3016 older adults. We used logistic regression models to estimate odds ratios (ORs) with 95% confidence intervals of CKD setting Cd and Hg as categorical variables. Logistic regression with restricted cubic spline was used to characterize a dose-response relationships between Cd or Hg concentrations and the risk of CKD in the study population.

The ORs for the risk of CKD comparing the fourth to the first quartile of blood Cd, blood Hg, urine Cd, and urine Hg were 1.77, 1.57, 2.03, and 1.50, respectively. Restricted cubic spline models showed that blood Cd and urine Hg were significantly linearly correlated with the risk of CKD, while blood Hg and urine Cd were non-linearly correlated with the risk of CKD with a steeper slope at concentrations <2.30 μg/L and 3.30 μg/g creatinine.

Our findings suggest that even low Cd and Hg exposure (or non-industrial) were associated with increased risk of CKD in Chinese oldest old, although we did not find a significant multiplicative and additive interaction between Cd and Hg levels in relation to the risk of CKD.

Patients with pneumoconiosis have an elevated risk of contracting pulmonary tuberculosis (PTB) and need particular attention. However, extensive population-based studies on the prevalence of PTB in patients with pneumoconiosis have not been reported in China since 1992. This study aimed to investigate the epidemiological characteristics of PTB in patients with pneumoconiosis based on its social determinants and risk factors in China.

Based on the Commission on Social Determinants of Health (CSDH) framework, data were obtained from a questionnaire survey of patients with pneumoconiosis from China’s 27 provinces (autonomous regions, municipalities) from December 2017 to June 2021. By chi-square and multivariate logistic regression analyses, the epidemiological characteristics of PTB in the patients were identified based on its prevalence and odds ratio (OR) and associated social determinants and risk factors. The population attributable fractions (PAFs) of significant risk factors were also calculated.

The prevalence of PTB in patients with pneumoconiosis (n = 10,137) was 7.5% (95% confidence interval [CI]: 7.0-8.0%). Multivariate logistic regression analysis showed that risk factors included in-hospital exposure to patients with PTB (OR = 3.30, 95% CI: 2.77-3.93), clinically diagnosed cases (OR = 3.25, 95% CI: 2.42-4.34), and northeastern regions (OR = 2.41, 95% CI: 1.76-3.31). In addition, lack of work-related injury insurance (WRII), being born in a rural area, being unemployed, living in western regions, household exposure to patients with PTB, smoking, being underweight, complications of pulmonary bullae or pneumothorax, hospitalization history, and former drinkers among the rural patients were also statistically significant risk factors. Being born in a rural area, lack of WRII and in-hospital exposure to patients with PTB had higher PAFs, which were 13.2% (95% CI: 7.9-18.5%), 12.5% (95% CI: 8.3-16.7%), and 11.6% (95% CI: 8.8-14.3%), respectively.

The prevalence of PTB in pneumoconiosis remains high in China; it is basically in line with the CSDH models and has its characteristics.

To the Editor: The answer to the "Riddle of Sphinx" is "human" , whose image is both negative and positive. It is often used as a metaphor for complex, mysterious, and incomprehensible problems. With the deterioration of modern living environment and the aggravation of stress, the incidence of the tumor is on the rise. Excessive or prolonged stress can lead to acute or chronic organ dysfunction and metabolic disorders. Studies have shown that tumor patients are often under long-term adverse stress states. Chronic mental stress alters tumor cell survival, proliferation and metastasis by activating stress-related transcriptional regulators and signaling pathways in the body. With the demonstration of their important role in tumor development under stress, related pathways or cytokines could be antagonized or inhibited to change the trajectory of the tumor development. This article explores how chronic mental stress affects the presence of tumor cells by influencing the expression of brain-derived neurotrophic factor (BDNF), insulin-like growth factor 2/insulin-like growth factor 1 receptor (IGF2/IGF1R), C-reactive protein (CRP) and other possible pathways in cancer patients.

To the Editor: Lateral epicondylalgia, whose incidence rate is approximately 1.3%, not only occurs in tennis players (tennis players only account for 5%^[1]), but is also related to smoking, poor social support, and heavy physical labor. Surgical treatment should be considered when conservative treatment fails after 6 months, which occurs in 10% of lateral epicondylalgia cases.^[2]Arthroscopic intra-capsular elbow surgery (the intra-capsular method) refers to an operation that selects the natural cavity of joint capsule as operating space. The intra-capsular method soon became the mainstream surgical method because of its minimally invasive nature, safety, and direct-vision feature compared with open surgery. However, the intra-capsular method requires damage to the joint capsule, and intra-capsular operation may cause intraoperative neurovascular injury and other complications. Rubenthaleret al^[3]explored a new approach to arthroscopic treatment for lateral epicondylalgia, which was performed outside of the elbow joint capsule. Further study^[4]investigated the efficacy and specific surgical scheme of this extra-capsular arthroscopy (referred to as the "extra-capsular method" ), which was soon launched in our clinical practice.

To the Editor:In breast cancer, it is the metastasis that makes a clear distinction between life and death.^[1,2]However, effective treatment targeted against metastasis remains an unmet clinical need.^[2,3]Accumulating evidence suggests that an essential step in metastasis is tumor cell acquisition of motility.^[2]Furthermore, epithelial-mesenchymal transition (EMT) initiates the early steps of tumor cell spread by endowing them with greater motility and invasiveness.^[1,4]Focal adhesion kinase (FAK) controls cell mesenchymal characteristics responsible for invasiveness and adhesion, placing itself as a critical molecule in regulating EMT in various cancer cells.^[4]

To the Editor:Hyperkalemia is a common life-threatening complication of advanced chronic kidney disease (CKD) in infants. To manage hyperkalemia, dietary potassium intake restrictions is the most convenient, safe, and effective treatment. Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommends that the general restriction of potassium is 40 to 120 mg·kg^-1·day^-1for infants and 30 to 40 mg·kg^-1·day^-1for older children with CKD.^[1]Thus, commercial infant formulas as the main alternative source of nutrition for infants are not suitable for infants with CKD, because of their high potassium content, which may initiate or further aggravate hyperkalemia of them. Sodium polystyrene sulfonate (SPS) as a non-selective resin has been widely used in the clinic for >60 years and has shown good effectiveness to decrease potassium intake in adult patients with CKD.^[2]However, oral administrating of SPS is not suitable for an infant with CKD, which may increase the risk for necrotizing enterocolitis. It is also not feasible to retention enema with SPS, because of infants’ immature gastrointestinal tracts and slower gut motility.^[2]

To the Editor: Congenital heart disease (CHD) is the most common severe congenital malformation which threatens the health of the fetus and the primary factor of intrauterine death. Prenatal detection of severe CHD could reduce the neonatal mortality and morbidity. The detection rate ranges between 25.0% and 59.7% in the prenatal ultrasonographic examination.^[1]We need to identify new strategies to improve detection rates of CHD prenatally. Deep-learning (DL)-based computer-aided diagnosis (CAD) has been highly and rapidly developed in recent years. The development of DL could improve diagnosis, reduce health care cost, and optimize clinical workflow.^[2]Neural network is also used in standard plane detection in obstetrics ultrasound, as well as in automated imaging and tagging, but less in screening and diagnosis of the fetal heart. In this study, we selected the 2D ultrasound images of the fetal heart in four-chamber view (4CV) and applied CAD methodology to identify the main elements and screen CHD automatically. We used the simple method to obtain 4CV, aiming to improve the fetal heart basic training and CHD screening.

To the Editor: The atherogenic index of plasma (AIP) is derived from the logarithmic conversion of the ratio of triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C). It comprehensively reflects plasma lipid homeostasis. AIP has been reported to be related to cardiovascular disease (CVD) in population-based studies,^[1]and is regarded as a potential independent predictor for CVD risk in clinical practice. Currently, there are limited data on the characteristics of AIP values in China. We examined the differences in AIP values among ethnic groups based on multiethnic Chinese population data. The reference values of AIP in Chinese adults were established, and their variation tendencies according to age were identified.

To the Editor:Acute kidney injury (AKI) is a common public health problem worldwide, which can adversely affect patients’ quality of life and even lead to death.^[1]Academic hospitals play an important role in admitting and providing treatment for patients with AKI, but limited data exist regarding the characteristics of patients in county-level local hospitals. Our research group initiated a comprehensive survey as part of the International Society of Nephrology’s "0 by 25" project (eliminating all deaths related to untreated AKI by 2025) for investigating the disease burden of AKI and its associated risk factors and prognosis through 22 province-level regions of China in 2013. We found that the detection rate of AKI in local hospitals was significantly lower than that in academic hospitals (1.66%vs.2.20%).^[2]In addition, the level of economic development of the region where a hospital was located was an independent risk factor for the under-recognition of AKI. Therefore, in this study, we aim to further describe the characteristics of the patients detected with AKI specifically in local hospitals and determine whether economic development was associated with the prognosis of AKI based on the above-mentioned nationwide survey in China.

To the Editor: According to the data released by the World Health Organization (WHO) on July 12, 2022, around 1010 cases of children with acute hepatitis of unknown etiology have been reported in five regions and 35 countries globally; these reports include new and retrospectively identified cases since October 1, 2021. Most patients presented with acute severe hepatitis and significantly high transaminase levels; the most common symptoms and signs were nausea or vomiting (60%), jaundice (53%), general weakness (52%), and abdominal pain (50%), which are typical symptoms of acute severe hepatitis. Among the possible cases, 5% (n= 46) of children required transplantation, while 2% (n= 22) of deaths were reported to the WHO.^[1]Although the case growth rate in the past months showed a downward trend, the actual number of cases might have been underestimated.

To the Editor: Proximal gastrectomy (PG) is the traditional treatment for early-stage adenocarcinoma of the esophagogastric junction (AEG). The new concept of super minimally invasive surgery (SMIS) by endoscopic submucosal dissection (ESD) and endoscopic submucosal tunnel dissection (ESTD) has the same curative effect as traditional surgery, with the advantage of not anatomically changing the digestive tract.^[1]With the higher success rate of this therapy, health-related quality of life (HRQoL) has become an important outcome parameter. We aimed to compare differences in HRQoL after SMIS and PG for early-stage AEG to provide a reference for clinical decision-making.

Following the original article’s publication,^[1]the authors informed us of the following errors: The Figure 5 was submitted incorrectly, while correct Figure 5 should be submitted as following.