Volume 135 · Issue 24 · 2022

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.

肝细胞癌（HCC）是中国60岁以下成年男性癌症相关死亡的主要原因。^[1]肝移植（LT）被普遍认为是终末期肝病最有效的治疗方法之一。HCC LT指南于2014年首次推出，并于2018年更新。最近，需要进一步更新，以适应中国LT的新情况，并继续推进建议。（完整版本见补充文件，http://links.lww.com/CM9/B362）。

严重的术中出血限制了复杂腹腔镜脾切除术（LS）的应用，包括腹腔镜全脾切除术（LTS）和腹腔镜脾部分切除术（LPS）。因此，降低复杂LS的出血风险已成为人们感兴趣的主要课题【补充图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.

致编辑：“狮身人面像之谜”的答案是“人”，人的形象既有消极的一面，也有积极的一面。它经常被用来比喻复杂、神秘和不可理解的问题。随着现代生活环境的恶化和应激的加重，肿瘤的发病率呈上升趋势。过度或长期的应激可导致急性或慢性器官功能障碍和代谢紊乱。研究表明，肿瘤患者往往处于长期的不良应激状态。慢性精神应激通过激活体内应激相关的转录调节因子和信号通路来改变肿瘤细胞的存活、增殖和转移。随着它们在应激下肿瘤发展中的重要作用的证明，相关途径或细胞因子可以被拮抗或抑制以改变肿瘤发展的轨迹。本文探讨了慢性精神应激如何通过影响脑源性神经营养因子的表达来影响肿瘤细胞的存在（BDNF）、胰岛素样生长因子2/胰岛素样生长因子1受体（IGF2/IGF1R）、C反应蛋白（CRP）等癌症患者的可能途径。

致编辑：外上髁痛，其发生率约为1.3%，不仅发生在网球运动员身上（网球运动员仅占5%^[1]），但也与吸烟、社会支持差、体力劳动重有关。保守治疗6个月后失败时应考虑手术治疗，这种情况发生在10%的外侧上髁痛病例中。^[2]关节镜下肘关节囊内手术（关节囊内法）是指选择关节囊自然腔作为手术空间的手术。囊内法因其微创性、安全性和与开放手术相比的直视特征而很快成为主流手术方法。但囊内法需要损伤关节囊，囊内手术可能造成术中神经血管损伤等并发症。鲁本塔勒等人^[3]探索了一种在肘关节囊外进行关节镜治疗外侧上髁痛的新方法。进一步研究^[4]考察了本院临床上开展不久的这种关节囊外术（简称“囊外法”）的疗效和具体手术方案。

致编辑：在乳腺癌中，是转移明确区分了生与死。^[1,2]然而，针对转移的有效治疗仍然是未满足的临床需求。^[2,3]越来越多的证据表明，转移的一个重要步骤是肿瘤细胞获得运动性。^[2]此外，上皮-间充质转化（EMT）通过赋予肿瘤细胞更大的运动性和侵袭性来启动肿瘤细胞扩散的早期步骤。^[1,4]粘着斑激酶（FAK）控制负责侵袭和粘附的细胞间充质特征，使其自身成为调节各种癌细胞中EMT的关键分子。^[4]

致编辑：高钾血症是婴儿晚期慢性肾脏病（CKD）常见的危及生命的并发症。为了控制高钾血症，饮食钾摄入限制是最方便、安全和有效的治疗方法。肾脏疾病结局质量倡议（KDOQI）指南建议一般限钾为40~120 mg·kg^-1·日^-1对于婴儿和30至40 mg·kg^-1·日^-1对于患有慢性肾病的年龄较大的儿童。^[1]因此，作为婴儿的主要替代营养来源的商业婴儿配方奶粉不适合患有CKD的婴儿，因为它们的高钾含量可能引发或进一步加重他们的高钾血症。聚苯乙烯磺酸钠（SPS）作为一种非选择性树脂已在临床上广泛使用超过60年，并在减少成人CKD患者的钾摄入量方面显示出良好的有效性。^[2]然而，口服SPS不适合患有CKD的婴儿，这可能增加坏死性小肠结肠炎的风险。用SPS保留灌肠也是不可行的，因为婴儿的胃肠道不成熟，肠道运动较慢。^[2]

致编辑：C先天性心脏病（CHD）是最常见的严重先天性畸形，威胁胎儿健康，是胎儿宫内死亡的主要原因。严重冠心病的产前检测可降低新生儿死亡率和发病率。产前超声检查检出率为25.0%~59.7%。^[1]我们需要确定新的策略来提高产前冠心病的检出率。基于深度学习（DL）的计算机辅助诊断（CAD）近年来得到了高度和快速的发展。DL的发展可以改善诊断，降低医疗保健成本，优化临床工作流程。^[2]神经网络也用于产科超声的标准平面检测，以及自动成像和标记，但较少用于胎儿心脏的筛查和诊断。在本研究中，我们选择四腔视图（4CV）中胎儿心脏的2D超声图像，并应用CAD方法来识别主要元素并自动筛查CHD。我们采用simple方法获得4CV，旨在提高胎儿心脏基础训练和CHD筛查。

致编辑：血浆致动脉粥样硬化指数(AIP)由甘油三酯(TG)与高密度脂蛋白胆固醇(HDL-C)的比率的对数转换得出。综合反映血浆脂质稳态。据报道，在基于人群的研究中，AIP与心血管疾病（CVD）有关，^[1]并被认为是临床实践中CVD风险的潜在独立预测因子。目前，中国关于AIP值特征的数据有限。我们基于多民族中国人口数据检查了各民族之间AIP值的差异。建立了中国成人AIP的参考值，并确定了其随年龄的变化趋势。

致编辑：急性肾损伤（AKI）是世界范围内常见的公共卫生问题，可对患者的生活质量产生不利影响，甚至导致死亡。^[1]学术医院在收治AKI患者和为其提供治疗方面发挥着重要作用，但关于县级地方医院患者特征的数据有限。作为国际肾脏病学会“0 by 25”项目（到2025年消除所有与未经治疗的AKI相关的死亡）的一部分，我们的研究小组于2013年在中国22个省级地区启动了一项全面调查，以调查AKI的疾病负担及其相关风险因素和预后。我们发现地方医院AKI的检出率显著低于学术医院（1.66%vs.2.20%).^[2]此外，医院所在地区的经济发展水平是AKI认识不足的独立危险因素。因此，在本研究中，我们旨在进一步描述在当地医院专门检测到的AKI患者的特征，并基于上述中国全国范围的调查确定经济发展是否与AKI的预后相关。

致编辑：根据世界卫生组织（WHO）2022年7月12日发布的数据，全球已有5个地区和35个国家报告了约1010例病因不明的儿童急性肝炎病例；这些报告包括自2021年10月1日以来的新病例和回顾性发现的病例。大多数患者表现为急性重型肝炎和转氨酶水平显著升高；最常见的症状和体征是恶心或呕吐（60%）、黄疸（53%）、全身无力（52%）和腹痛（50%），这些都是急性重型肝炎的典型症状。在可能的情况下，5%（n=46）的儿童需要移植，而2%（n=22)的死亡报告给世卫组织。^[1]虽然过去几个月的病例增长率呈下降趋势，但实际病例数可能被低估了。

致编辑：近端胃切除术（PG）是早期食管胃结合部腺癌（AEG）的传统治疗方法。内镜黏膜下剥离术（ESD）和内镜黏膜下隧道剥离术（ESTD）新概念的超级微创手术（SMIS）具有与传统手术相同的疗效，优点是不在解剖学上改变消化道。^[1]随着该疗法成功率的提高，健康相关生活质量（HRQoL）已成为一个重要的结局参数。我们旨在比较早期AEG SMIS和PG后HRQoL的差异，为临床决策提供参考。

在最初的文章发表之后，^[1]作者告知我们以下错误：图5提交不正确，而正确的图5应提交如下。