2023年 · 第136卷第01期

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new virus, still full of surprises. As of September 2022, there have been over 605 million confirmed cases of coronavirus disease 2019 (COVID-19), including 6.5 million deaths reported to the World Health Organization (WHO).^[1]SARS-CoV-2 is a bad virus, which often produces new variants that scape natural immunity and sometimes vaccines [Figure 1].^[2]

Data on the immunogenicity and safety of heterologous immunization schedules are inconsistent. This study aimed to evaluate the immunogenicity and safety of homologous and heterologous immunization schedules.

Multiple databases with relevant studies were searched with an end date of October 31, 2021, and a website including a series of Coronavirus disease 2019 studies was examined for studies before March 31, 2022. Randomized controlled trials (RCTs) that compared different heterologous and homologous regimens among adults that reported immunogenicity and safety outcomes were reviewed. Primary outcomes included neutralizing antibodies against the original strain and serious adverse events (SAEs). A network meta-analysis (NMA) was conducted using a random-effects model.

In all, 11 RCTs were included in the systematic review, and nine were ultimately included in the NMA. Among participants who received two doses of CoronaVac, another dose of mRNA or a non-replicating viral vector vaccine resulted in a significantly higher level of neutralizing antibody than a third CoronaVac 600 sino unit (SU); a dose of BNT162b2 induced the highest geometric mean ratio (GMR) of 15.24, 95% confidence interval [CI]: 9.53-24.39. Following one dose of BNT162b2 vaccination, a dose of mRNA-1273 generated a significantly higher level of neutralizing antibody than BNT162b2 alone (GMR = 1.32; 95% CI: 1.06-1.64), NVX-CoV2373 (GMR = 1.60; 95% CI: 1.16-2.21), or ChAdOx1 (GMR = 1.80; 95% CI: 1.25-2.59). Following one dose of ChAdOx1, a dose of mRNA-1273 was also more effective for improving antibody levels than ChAdOx1 (GMR = 11.09; 95% CI: 8.36-14.71) or NVX-CoV2373 (GMR= 2.87; 95% CI: 1.08-3.91). No significant difference in the risk for SAEs was found in any comparisons.

Relative to vaccination with two doses of CoronaVac, a dose of BNT162b2 as a booster substantially enhances immunogenicity reactions and has a relatively acceptable risk for SAEs relative to other vaccines. For primary vaccination, schedules including mRNA vaccines induce a greater immune response. However, the comparatively higher risk for local and systemic adverse events introduced by mRNA vaccines should be noted.

PROSPERO; https://www.crd.york.ac.uk/PROSPERO/; No. CRD42021278149.

Whether high cut-off (HCO) membranes are more effective than high-flux (HF) membranes in patients requiring renal replacement therapy (RRT) remains controversial. The aim of this systematic review was to investigate the efficacy of HCO membranes regarding the clearance of inflammation-related mediators, β2-microglobulin and urea; albumin loss; and all-cause mortality in patients requiring RRT.

We searched all relevant studies on PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure, with no language or publication year restrictions. Two reviewers independently selected studies and extracted data using a prespecified extraction instrument. Only randomized controlled trials (RCTs) were included. Summary estimates of standardized mean differences (SMDs) or weighted mean differences (WMDs) and risk ratios (RRs) were obtained by fixed-effects or random-effects models. Sensitivity analyses and subgroup analyses were performed to determine the source of heterogeneity.

Nineteen RCTs involving 710 participants were included in this systematic review. Compared with HF membranes, HCO membranes were more effective in reducing the plasma level of interleukin-6 (IL-6) (SMD -0.25, 95% confidence interval (CI)-0.48 to -0.01, P = 0.04, I² = 63.8%); however, no difference was observed in the clearance of tumor necrosis factor-α (TNF-α) (SMD 0.03, 95% CI -0.27 to 0.33, P = 0.84, I² = 4.3%), IL-10 (SMD 0.22, 95% CI -0.12 to 0.55, P = 0.21, I² = 0.0%), or urea (WMD -0.27, 95% CI -2.77 to 2.23, P = 0.83, I² = 19.6%). In addition, a more significant reduction ratio of β₂-microglobulin (WMD 14.8, 95% CI 3.78 to 25.82, P = 0.01, I² = 88.3%) and a more obvious loss of albumin (WMD -0.25, 95% CI -0.35 to-0.16, P < 0.01, I² = 40.8%) could be observed with the treatment of HCO membranes. For all-cause mortality, there was no difference between the two groups (risk ratio [RR] 1.10, 95% CI 0.87 to 1.40, P = 0.43, I² = 0.0%).

Compared with HF membranes, HCO membranes might have additional benefits on the clearance of IL-6 and β2-microglobulin but not on TNF-α, IL-10, and urea. Albumin loss is more serious with the treatment of HCO membranes. There was no difference in all-cause mortality between HCO and HF membranes. Further larger high-quality RCTs are needed to strengthen the effects of HCO membranes.

Managing acute postoperative pain is challenging for anesthesiologists, surgeons, and patients, leading to adverse events despite making significant progress. Patient-controlled intravenous analgesia (PCIA) is a recommended solution, where oxycodone has depicted unique advantages in recent years. However, controversy still exists in clinical practice and this study aimed to compare two drugs in PCIA.

We performed a literature search in PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, Wanfang, and VIP databases up to December 2020 to select specific randomized controlled trials (RCTs) comparing the efficacy of oxycodone with sufentanil in PCIA. The analgesic effect was the primary outcome and the secondary outcome included PCIA consumption, the Ramsay sedation scale, patients’ satisfaction and side effects.

Fifteen RCTs were included in the meta-analysis. Compared with sufentanil, oxycodone showed lower Numerical Rating Scale scores (mean difference [MD] = -0.71, 95% confidence interval [CI]: -1.01 to -0.41; P < 0.001; I² = 93%), demonstrated better relief from visceral pain (MD = -1.22, 95% CI: -1.58 to -0.85; P < 0.001; I² = 90%), promoted a deeper sedative level as confirmed by the Ramsay Score (MD = 0.77, 95% CI: 0.35-1.19; P < 0.001; I² = 97%), and resulted in fewer side effects (odds ratio [OR] = 0.46, 95% CI: 0.35-0.60; P < 0.001; I²= 11%). There was no statistical difference in the degree of patients' satisfaction (OR = 1.13, 95% CI: 0.88-1.44; P = 0.33; I² = 72%) and drug consumption (MD = -5.55, 95% CI: -14.18 to 3.08; P= 0.21; I²= 93%).

Oxycodone improves postoperative analgesia and causes fewer adverse effects, and could be recommended for PCIA, especially after abdominal surgeries.

PROSPERO; https://www.crd.york.ac.uk/PROSPERO/; CRD42021229973.

The gastrointestinal (GI) tract is a unique organ that has its own nervous system called enteric nervous system (ENS) and also termed "little brain." The ENS has 200 to 600 million neurons and can function independently without inputs from the brain. It communicates with the brain via the autonomic nervous system that is composed of sympathetic and parasympathetic nervous systems. The parasympathetic system consists of the vagus nerve and the sacral nerve.

Maturity-onset diabetes of the young (MODY) is the most common monogenic diabetes. The aim of this study was to assess the prevalence of MODY in phenotypic type 2 diabetes (T2DM) among Chinese young adults.

From April 2015 to October 2017, this cross-sectional study involved 2429 consecutive patients from 46 hospitals in China, newly diagnosed between 15 years and 45 years, with T2DM phenotype and negative for standardized glutamic acid decarboxylase antibody at the core laboratory. Sequencing using a custom monogenic diabetes gene panel was performed, and variants of 14 MODY genes were interpreted as per current guidelines.

The survey determined 18 patients having genetic variants causing MODY (6 HNF1A, 5 GCK, 3 HNF4A, 2 INS, 1 PDX1, and 1 PAX4). The prevalence of MODY was 0.74% (95% confidence interval [CI]: 0.40-1.08%). The clinical characteristics of MODY patients were not specific, 72.2% (13/18) of them were diagnosed after 35 years, 47.1% (8/17) had metabolic syndrome, and only 38.9% (7/18) had a family history of diabetes. No significant difference in manifestations except for hemoglobin A1c levels was found between MODY and non-MODY patients.

The prevalence of MODY in young adults with phenotypic T2DM was 0.74%, among which HNF1A-, GCK-, and HNF4A-MODY were the most common subtypes. Clinical features played a limited role in the recognition of MODY.

Post-operative pneumonia (POP) is a common complication of lung cancer surgery, and muscular tissue oxygenation is a root cause of post-operative complications. However, the association between muscular tissue desaturation and POP in patients receiving lung cancer surgery has not been specifically studied. This study aimed to investigate the potential use of intra-operative muscular tissue desaturation as a predictor of POP in patients undergoing lung cancer surgery.

This cohort study enrolled patients (≥55 years) who had undergone lobectomy with one-lung ventilation. Muscular tissue oxygen saturation (SmtO₂) was monitored in the forearm (over the brachioradialis muscle) and upper thigh (over the quadriceps) using a tissue oximeter. The minimum SmtO₂ was the lowest intra-operative measurement at any time point. Muscular tissue desaturation was defined as a minimum baseline SmtO₂ of <80% for >15 s. The area under or above the threshold was the product of the magnitude and time of desaturation. The primary outcome was the association between intra-operative muscular tissue desaturation and POP within seven post-operative days using multivariable logistic regression.The secondary outcome was the correlation between SmtO₂ in the forearm and that in the thigh.

We enrolled 174 patients. The overall incidence of muscular desaturation (defined as SmtO₂ < 80% in the forearm at baseline) was approximately 47.1% (82/174). The patients with muscular desaturation had a higher incidence of pneumonia than those without desaturation (28.0% [23/82] vs. 12.0% [11/92]; P = 0.008). The multivariable analysis revealed that muscular desaturation was associated with an increased risk of pneumonia (odds ratio: 2.995, 95% confidence interval: 1.080-8.310, P = 0.035) after adjusting for age, American Society of Anesthesiologists status, Assess Respiratory Risk in Surgical Patients in Catalonia score, smoking, use of peripheral nerve block, propofol, and study center.

Muscular tissue desaturation, defined as a baseline SmtO₂ < 80% in the forearm, may be associated with an increased risk of POP.

No. ChiCTR-ROC-17012627.

Synovectomy has been introduced into total knee arthroplasty (TKA) with the aim of relieving pain and inflammation of the synovium. However, there are no long-term, comparative data to evaluate the effect of synovectomy in TKA. This study was aimed at assessing pain, function, and complications in patients undergoing synovectomy during TKA for osteoarthritis (OA) at long-term follow-up.

This was a prospective randomized controlled trial of 42 consecutive patients who underwent staged bilateral TKA. Patients undergoing the first-side TKA were allocated to receive TKA with or without synovectomy followed by a 3-month washout period and crossover to the other strategy for the opposite-side TKA. The overall efficacy of both strategies was evaluated by determination of blood loss, the Knee Society score (KSS), and knee inflammation conditions during a 3-month postoperative period. The postoperative pain, range of motion (ROM), and complications were sequentially evaluated to compare the two groups until 10 years after surgery.

At the 10-year follow-up, both groups had a similarly significantly improved ROM (114.88 ± 9.84° vs. 114.02 ± 9.43°, t = 0.221, P = 0.815) and pain relief with no differences between the two groups (1.0 [1.0] vs. 1.0 [1.5], U = 789.500, P = 0.613). Similar changes in total blood loss, KSS, and knee inflammation were found in both groups during 3 months postoperatively (P > 0.05). Additionally, there was no significant difference regarding complications and satisfaction between the two groups (P > 0.05).

Synovectomy in conjunction with TKA for primary OA does not seem to provide any benefit regarding postoperative pain, ROM, and satisfaction during a 10-year follow-up. In addition, it may not result in more blood loss and increased incidence of long-term complications. Based on our long-term findings, it should not be performed routinely.

Chinese Clinical Trial Registry, ChiCTR-INR-16008245; https://www.chictr.org.cn/showproj.aspx?proj= 13334.

Preliminary studies have indicated that Shexiang Baoxin Pill (MUSKARDIA) has a coronary artery dilation effect and increases the coronary blood flow, relieving the symptoms of angina. This study aimed to evaluate the benefit of MUSKARDIA on patients with stable coronary artery disease (CAD) and diabetes mellitus (DM).

This was a subgroup analysis of a multicenter, randomized, placebo-controlled phase IV trial. CAD patients with a medical history of DM or baseline fasting blood glucose (FBG) ≥7.0 mmol/L were grouped according to the treatment (standard therapy plus MUSKARDIA or placebo). The primary outcome was major adverse cardiovascular events (MACEs), which was the composite outcome of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. The secondary outcome was the composite outcome of all-cause death, non-fatal myocardial infarction, non-fatal stroke, hospitalization for unstable angina or heart failure, and coronary angioplasty.

MACEs occurred in 2.6% (9/340) and 4.8% (18/376) of patients in the MUSKARDIA and placebo groups, respectively (P = 0.192). Secondary composite outcome was significantly less frequent with MUSKARDIA than with placebo (15.3% [52/340] vs. 22.6% [85/376], P = 0.017). Risk of MACEs (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.31-1.57) was comparable between two groups. In patients with uncontrolled DM (≥4 measurements of FBG ≥7 mmol/L in five times of follow-up), the risk of secondary outcome was significantly lower with MUSKARDIA (5/83, 6.0%) than with placebo (15/91, 16.5%) (HR= 0.35, 95%CI: 0.13-0.95).

As an add-on to standard therapy, MUSKARDIA shows a trend of reduced MACEs in patients with stable CAD and DM. Furthermore, MUSKARDIA may reduce the frequency of all-cause death, hospitalization, and coronary angioplasty in this population, especially in those with uncontrolled DM.

ChiCTR.org.cn, ChiCTR-TRC-12003513

No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects.

Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported.

A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001).

The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.

Cytogenetic aberrations (CAs) are vital markers for risk stratification of multiple myeloma (MM). The prognostic significance of the aberration, t(11;14)(q13;q32), in MM has remained controversial over recent years. In addition, studies on the heterogeneity of t(11;14) MM and the impact of additional CAs are rare.^[1]We therefore conducted a retrospective study on relevant data collected at our center in order to further analyze the characteristics of Chinese patients with t(11;14) MM and elaborate on heterogeneity in their genetic profile.

To the Editor: Incretin-based therapies for type 2 diabetes mellitus (T2DM) include incretin mimetics of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and incretin enhancers of dipeptidyl peptidase-4 (DPP-4) inhibitors.^[1]With good hypoglycemic effects of incretin-based drugs that show no weight gain or hypoglycemia risk, these drugs are increasingly used in patients with T2DM. GLP-1 RAs are considered superior to DPP-4 inhibitors in controlling glycosylated hemoglobin, fasting blood glucose, and body weight.^[2]However, the incidence of adverse events, such as adverse gastrointestinal reactions and dizziness caused by GLP-1 RAs, is higher than it is for DPP-4 inhibitors.^[3]Unlike other anti-diabetic agents, safety concerns have been raised regarding the risk for gastrointestinal cancer associated with incretin-based treatments. Both a better understanding of their roles as second-line glucose-lowering treatments and a comprehensive assessment of their benefits and harms could inform the choice of treatment in clinical practice.

To the Editor:Thymic malignancies refer to a group of malignant tumors that originated from the thymic gland, including thymoma, thymic carcinoma, thymic carcinoid, and malignancies from other uncommon histological origins.

To the Editor:Given the high rates of pre-diseases and various initiating causes, critical illnesses have become the most heterogeneous group in clinical practice, which multiplies treatment challenges. Despite different types of injurious "hit," this response to various acute critical conditions is relatively homogenous and may eventually progress to a critical illness.

To the Editor: Iliac vein compression syndrome (IVCS) is a well-documented anatomic abnormality characterized by the compression of iliac veins from the adjacent artery and vertebra. Depending on whether deep vein thrombosis was co-existing, IVCS could be classified into thrombotic and nonthrombotic lesions. Endovascular procedures have become the mainstream treatment for nonthrombotic IVCS.^[1]In most cases, balloon dilation is insufficient to treat nonthrombotic IVCS because the venous wall is easily recoiled. Stenting for iliac vein lesion is therefore necessary for keeping enlargement of the venous lumen. However, stent implantation may bring side effects such as in-stent thrombosis and restenosis. In-stent restenosis (ISR) caused by intimal hyperplasia remains a major drawback of stenting in arterial diseases. However, the evidence about the occurrence and predictors of ISR in nonthrombotic IVCS is limited. We therefore conducted this research to identify the incidence of ISR and explore the potential predictors of ISR in patients with non-thrombotic IVCS.

To the Editor:Cancer has been the leading cause of death worldwide and in China since 2010.^[1]As advances are made in the treatment of cancer, the survival rate of cancer improves; at the same time, many cancer patients and cancer survivors suffer from cardiovascular disease (CVD) as a result of intense anticancer treatment.^[2,3,4]To prevent and treat cardiovascular problems mediated by cancer treatments, a new medical discipline called cardio-oncology was established. Although the field of cardio-oncology has existed for 20 years,^[5]its development in China is still in the early stages.

To the Editor:Fibrosis is a long duration wound healing process triggered by complex cellular and molecular responses that contributes to tissue or organ reconstruction.^[1]Bladder fibrosis is initiated by pathological pressure such as hydrostatic pressure, stretching force, and fluid shear stress. Increased pressure leads to a bladder inflammatory microenvironment, smooth muscle hypertrophy, and fibrosis. To date, two common etiological factors of bladder fibrosis are mechanical obstruction (partial bladder outlet obstruction [pBOO]) and chronic cystitis.^[2]

To the Editor:Osteosarcoma (OS), a disease seriously endangering the health of young people, is the eighth most common primary malignant bone tumor affecting children and adolescents. Typically occurring in the metaphysis of long tubular bone, OS develops from mesenchymal cells and accounts for 20% of primary bone tumors. About 70% to 80% of patients are 8 to 9 years, and the annual incident cases are around 1 to 3 million people.^[1]

To the Editor:Chronic thromboembolic pulmonary hypertension (CTEPH) is a chronic progressive disease in which pulmonary artery pressure (PAP) increases and eventually leads to right heart failure and death. Balloon pulmonary angioplasty (BPA) is a new and effective treatment for CTEPH patients who are unsuitable for surgery or who develop recurrent or persistent pulmonary hypertension after pulmonary endarterectomy (PEA). In recent years, major medical centers at home and abroad have been gradually developing and improving BPA, but overall, a unified treatment process and complication control strategy is lacking.

In the article "Salvianolic acid B decreases interleukin-1β-induced colitis recurrence in mice" which appeared in vol.133, issue 12, page 1436-1444 ofChinese Medical Journal,^[1]the third hematoxylin and eosin (HE) image of Figure 3 contains identical image with the fourth HE image of Figure 7 incorrectly. The authors admitted that they misplaced the pictures when they organized the figure. The error does not affect the results and conclusions of the article. The updated and correct Figure 3 is shown below. The authors deeply apologize for any inconvenience caused.