Volume 104 · Issue 12 · 2024

Mobility limitation is an age-related geriatric syndrome that is affected by multiple factors such as aging, multimorbidity, nutritional status, chronic pain, psychological and social factors, which increases the risk of adverse events such as pressure ulcers, venous thrombosis, constipation, frailty, disability, falls and death in older adults. Early identification of mobility limitation and individualized comprehensive management are of great significance to maintain the functional status and quality of life of older adults. However, the understanding of the importance of mobility limitation prevention and treatment in older adults is insufficient, and there is a lack of standardized diagnosis and treatment standards for mobility limitation. Based on evidence-based medicine, this consensus expert group integrated the latest research progress, guidelines and consensus recommendations on mobility limitation and proposed 20 recommendations containing screening, assessment, intervention and comprehensive management, emphasizing the multidisciplinary decision-making model of "screening-comprehensive assessment-multiple interventions-joint management". We aimed to provide guidance and suggestions for the standardized management of mobility limitation in older adults.

Panvascular disease is a systemic condition with vascular lesions (95% of which are atherosclerosis) as the common pathological feature, which can be manifested as coronary artery disease, cerebrovascular disease, peripheral artery disease, etc., or a combination of two or more vascular bed diseases that is called multivascular disease. The burden of panvascular diseases in China is heavy, and improvement of patient prognosis is urgently needed. Although the management of panvascular diseases belongs to different disciplines, they often share common risk factors and pathophysiological mechanisms that warrant standardized treatment strategies. Antithrombotic therapy for panvascular diseases mainly includes antiplatelet and anticoagulant therapy. For patients with different ischemic and bleeding risks and different stages of the disease, there is currently a lack of unified guidance from various disciplines. Given the crucial role of standardized antithrombotic therapy in the treatment of panvascular disease, Chinese College of Cardiovascular Physicians led the organization of a consensus working group consisting of 33 senior experts in the fields of cardiology, vascular surgery, neurology, and endocrinology. "Chinese expert consensus on antithrombotic therapy of panvascular diseases (2024 edition)" was developed based on specific treatment needs of panvascular diseases in China, combined with published clinical research evidence, specialized guidelines and consensus, as well as the recommendations from the consensus expert group. The primary objective of this consensus is to standardize the application of antithrombotic therapy in panvascular diseases, thereby optimizing clinical outcomes, improving patients prognosis, and mitigating the economic and societal burden associated with panvascular disease.

In order to improve the awareness and understanding of hydropic ear disease, the Vertigo Committee of the Chinese Medical Education Association established an expert group and formed the expert recommendation on clinical diagnosis and treatment pathway of hydrochloric ear disease after repeated discussions, based on the existing medical evidence and clinical experience of experts. The article included the understanding process, characteristics, medical history collection and physical examination, diagnosis and clinical pathway of various treatment and rehabilitation methods in hydrochloric ear disease, aiming to promote standardized clinical work and research on hydropic ear disease.

To explore the association between waist-to-height ratio (WHtR) and sarcopenic obesity (SO) in maintenance hemodialysis (MHD) patients with normal body mass index (BMI).

A multicenter and cross-sectional study that included adult patients undergoing MHD was conducted in 20 hemodialysis centers from June 1^st to August 30^th, 2021. Body composition was evaluated by body composition monitor based on bioimpedance spectroscopy. According to the quartiles of WHtR, patients were divided into four groups: Q1, Q2, Q3 and Q4 group. The association of WHtR with SO was determined by multiple logistic regression models, stratified analyses, interactive analyses, and receiver operating characteristic (ROC) analyses, respectively.

A total of 2 207 MHD patients (1 341 males and 866 females) were included, and aged [M (Q₁, Q₃)] 57 (44, 68) years. The prevalence of SO was increased with increasing quartiles of WHtR [8.6% (46/533), 22.5% (141/628), 35.4% (215/608), and 44.3% (194/438) for Q1, Q2, Q3, and Q4 group, respectively]. Multivariate logistic regression analysis showed that WHtR was associated with SO. The association remained statistically significant even after adjusting for age, gender, dialysis vintage, BMI, biochemical indicators, and various medical histories. Compared with Q1 group, the odds ratios (OR) were 2.54 (95%CI: 1.69-3.83), 4.30 (95%CI: 2.88-6.42) and 5.18 (95%CI: 3.37-7.96) for Q2, Q3 and Q4 group, respectively. The interaction analysis showed that age, sex and history of diabetes had interactive roles in the association between WHtR and SO (all P<0.05). The association stably existed across subgroups, and it was more obvious in male patients, those with older age and without a history of diabetes（all P<0.05）. Furthermore, the cut-off value of WHtR identifying SO in male patients was 0.49, and the corresponding area under the curve (AUC) was 0.73 (95%CI: 0.70-0.75), with the sensitivity of 72.7% and specificity of 60.3%. In female patients, the cut-off value was 0.51, and the AUC was 0.68 (95%CI: 0.65-0.71), with the sensitivity of 70.1% and specificity of 57.8%.

WHtR could be used as a simple index to evaluate the risk of SO in MHD patients with normal BMI.

To investigate the effect of dual fluorescence imaging in identifying central lymph nodes and parathyroid glands during thyroid cancer surgery.

This study was a cross-sectional study. Patients who underwent surgery for papillary thyroid cancer (PTC) at the Department of Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University between January 2022 and September 2023 were included. All patients underwent thyroid lobectomy or total resection, and central lymph node dissection was performed at the same time. During the operation, tracing injection of mitoxantrone hydrochloride and 785 nm and 660 nm dual fluorescence imaging technique were used to measure the fluorescence intensity (FI) of parathyroid glands, central lymph nodes and background. After correcting to obtain the standardized FI, the paired t-test was used to compare the standardized FI of the parathyroid glands and central lymph nodes, and the Spearman′s rank correlation analysis was used to analyze the relationship between the standardized FI and various clinical indicators.

The study included 30 patients (8 males and 22 females), with a mean age of (41.8±10.4) years. A total of 76 parathyroid glands and 234 central lymph nodes were identified under dual fluorescence imaging, and the standardized FI of parathyroid glands was less than that of central lymph nodes (44.7±16.8 vs 99.5±28.4, P<0.001). The visualization rate, false rate and miscut rate of parathyroid glands under 785 nm wavelength excitation light were 98.7% (76/77), 0 (0/77) and 1.3% (1/77), respectively (one case with no visualization and miscutting parathyroid gland was the encapsulated type). The visualization rate of central lymph nodes under 660 nm wavelength excitation light was 98.7% (234/237). There was no significant correlation between FI and clinical indicators such as gender, age, height, weight, body mass index, preoperative thyroid stimulating hormone, thyroglobulin antibody, thyroid microsomal antibody, serum calcium, parathyroid hormone level and surgical procedure (all P>0.05).

Dual fluorescence imaging of central lymph nodes and parathyroid glands can improve the ability to identify parathyroid gland while assisting central lymph node dissection.

To evaluate the mid-term efficacy of ABO incompatible living donor kidney transplantation (ABOi-KT) based on the results of routine renal biopsy for transplantation.

Retrospective collection of clinical data from 23 pairs of ABOi-KT donors and recipients at the First Affiliated Hospital of Sun Yat-sen University from July 2015 to November 2021. ABOi-KT was performed on recipients after desensitization treatment, and the results of routine kidney transplant biopsy at 1 week, 1 month, 3 months, 6 months, and 12 months after surgery were analyzed. Combined with blood type antibody levels and renal function recovery, the mid-term efficacy of ABOi-KT was evaluated.

Among the 23 recipients, there were 19 males and 4 females; age range from 19 to 47 years old [(29.6±6.7) years old], all underwent ABOi-KT successfully after receiving desensitization treatment. The follow-up time was (44.6±22.4) months, of which 22 cases were followed up for more than 1 year. The incidence rates of rejection reactions at 1 week, 1 month, 3 months, 6 months, and 12 months after surgery were 15.0% (3/20), 11.1% (1/9), 7.7% (1/13), 25.0% (3/12), and 12.5% (1/8), respectively. For receptors with rejection reactions, targeted anti-rejection therapy was performed based on clinical symptoms and various indicators. Borderline T cell mediated rejection (TCMR) can be converted to mild tubular inflammation after anti-rejection treatment. The positive rate of complement C4d in peritubular capillaries was 95.0% (19/20) one week after surgery, and the positive rate of complement C4d was 100% at 3 and 12 months after surgery. The cumulative survival rates at 1, 3, 5, and 7 years after surgery were all 100%. The cumulative survival rates at 1, 3, 5, and 7 years after kidney transplantation were 100%, 93.3%, 84.0%, and 84.0%, respectively. Except for 2 recipients who underwent transplantation in 2017 and experienced kidney failure at 30 and 49 months after surgery, all other transplanted kidneys survived.

The results of routine renal transplant biopsy show that ABOi-KT has a good mid-term therapeutic effect. The pathological changes of ABOi-KT can be dynamically observed through routine renal transplant biopsy and targeted treatment for rejection reactions can be provided accordingly.

To explore the effectiveness of minimally invasive surgical treatment for pancreatic acinar cell carcinoma (PACC).

Six patients with PACC diagnosed in Peking University Third Hospital from January 2010 to September 2022 were retrospectively selected. Preoperative evaluation was performed on whether the lesions were eligible for surgery, including whether radical resection of liver metastases could be performed. Laparoscopic or Da Vinci robot-assisted resection was performed on six patients, and spleen retention was determined according to the original lesions and the relationship with peripheral blood vessels and tissues, while simultaneous resection was performed on cases of peripheral organ tissue invasion. The patients′ basic information, preoperative general conditions, preoperative diagnosis and tumor stage, minimally invasive surgery methods, postoperative complications, pathological results, tumor stage and follow-up data were collected and analyzed to explore the effectiveness of minimally invasive surgery.

Among the six patients, four were males and two were females, with the age of 25-69 years. Five patients had abdominal pain and distension before surgery, five patients had tumors located at the tail of the pancreatic body, and one patient had tumors located at the head of the pancreas. Preoperative imaging (enhanced CT and MRI) was performed to measure the tumor diameter (2.8-10.0 cm). Tumor markers were elevated in two patients before surgery, and six patients underwent surgery through laparoscopy or robotic platform. No complications such as postoperative pancreatic fistula and bleeding were clinically relevant during and after surgery. There were two cases with concurrent or heterochronous liver metastasis, two cases with lymph node metastasis and nodular metastasis, four cases with tumor invasion of surrounding organs (stomach, spleen or duodenum), and three cases with vascular cancer thrombi. The follow-up time of the six patients was 12 to 165 months, and one patient underwent three operations due to postoperative liver metastasis and residual pancreatic recurrence, and the results were satisfactory. All the six patients survived at the last follow-up.

PACC is prone to invade the surrounding organs, and has a large tumor diameter. Radical surgery for PACC can be completed through minimally invasive surgery, and satisfactory oncology prognosis can be obtained. In addition, some PACC patients with recurrence and metastasis can still be treated by surgery.

To analyze the correlative factors of invasion syndrome in patients with diabetes complicated with Klebsiella pneumoniae liver abscess, and to construct and verify the online nomographic prediction model.

A case control study. The clinical data of 213 diabetic patients with Klebsiella pneumoniae liver abscess admitted to the Third Affiliated Hospital of Soochow University from January 1, 2015 to December 31, 2021 were retrospectively analyzed. The patients were divided into the training set (149 cases) and the test set (64 cases) by stratified random sampling method at a ratio of 7∶3. Synthetic minority over-sampling technique(SMOTE) was used to process the imbalanced data, then Lasso regression was used to screen out the optimal feature variables in the training set and multivariate logistic regression model was used to construct the prediction model of invasion syndrome in patients with diabetes complicated with Klebsiella pneumoniae liver abscess, and verify it in the training set and test set. Receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA) were used to evaluate the prediction efficiency of the model, and the simple and online interactive dynamic web page column graph was constructed.

Among the 213 patients, 60 were males and 153 were females, aged of (61.4±12.0) years. A total of 25(11.74%) diabetic patients with Klebsiella pneumoniae liver abscess developed invasion syndrome, which were included in divided into invasive K.pneumoniae liver abscesses syndrome (IKPLAS) group, and the other 188 cases were in without invasive K.pneumoniae liver abscesses syndrome (NIKPLAS) group. SMOTE algorithm was used for oversampling processing, so that the ratio of positive and negative samples was 1∶1. In the oversampling training set, 5 main risk factors were screened based on Lasso regression, namely fasting blood glucose (λ=0.063), hemoglobin (λ=-0.042), blood urea nitrogen (λ=-0.050), abscess size (λ=-0.025) and sequential organ failure assessment (SOFA) score (λ=0.450), respectively. Multivariate logistic regression model showed that fasting blood glucose (OR=1.20, 95%CI: 0.98-1.48, P=0.006), hemoglobin (OR=0.90, 95%CI: 0.86-0.95, P<0.001), blood urea nitrogen (OR=1.22, 95%CI: 1.03-1.43, P=0.017), abscess diameter (OR=0.76, 95%CI: 0.61-0.94, P=0.010), SOFA score (OR=3.08, 95%CI: 2.18-4.36, P<0.001) were associated with invasion syndrome in patients with diabetes complicated with Klebsiella pneumoniae liver abscess. The area under the curve of ROC in the training set was 0.966 (95%CI: 0.943-0.989), the sensitivity was 90.5%, and the specificity was 91.3%. The area under the curve of the validation set ROC was 0.946 (95%CI: 0.902-0.991), with a sensitivity of 79.6% and a specificity of 88.9%. The calibration curves drawn in the training set and the test set fit well with the ideal curve. DCA showed that the neomorph prediction model had a good clinical net benefit when predicting the risk of IKPLAS in patients with diabetes complicated with Klebsiella pneumoniae liver abscess was 0.10-0.40.

Fasting blood glucose, hemoglobin, urea nitrogen, abscess size and SOFA score are the related factors for invasion syndrome in patients with diabetes complicated with Klebsiella pneumoniae liver abscess. The constructed column graph can effectively predict the risk of invasion syndrome in patients with diabetes complicated with Klebsiae pneumoniae liver abscess.

To investigate the association between positive anti-thyroid peroxidase antibody (TPOAb) and/or anti-thyroglobulin antibody (TgAb) and the occurrence of thyroid immune-related adverse events (irAEs) in patients with malignant tumors who treated with immune checkpoint inhibitors (ICIs).

A case-control study. A total of 116 patients with malignant tumor who received ICIs treatment and underwent thyroid function evaluation at Peking Union Medical College Hospital from January 2017 to April 2023 were enrolled retrospectively, including 77 males and 39 females, with a median age of (M(Q₁, Q₃)) 63.0 (55.0, 70.0) years. The patients were divided into the euthyroid group (n=58) and the thyroid irAEs group (n=58) according to whether thyroid irAEs occurred after ICIs treatment. The clinical characteristics and baseline anti-thyroid antibodies associated with the occurrence of thyroid irAEs after ICIs treatment in patients with malignant tumors were evaluated. Variables with statistical significance in univariate analysis were included in multivariate logistic regression model to analyze the risk factors for thyroid irAEs in patients with malignant tumors who received ICIs treatment.

In irAEs group, therewore 4 (3.4%) cases of clinical thyrotoxicosis, 23(19.8%) cases of subclinical thyrotoxicosis, 23 (19.8%) cases of clinical hypothyroidism, and 8(6.9%) cases of subclinical hypothyroidism. The positive rate of anti-thyroid antibodies at baseline in the thyrioid irAEs group was higher than that in the euthyroid group［16/58（27.6%）vs 3/58（5.2%），P=0.001］. After at least one course of ICIs treatment, the incidence of thyroid irAEs in patients with positive anti-thyroid antibodies at baseline was 84.2% (16/19), whereas it was 43.3% (42/97) in patients with negative anti-thyroid antibodies(P=0.001). Univariate logistic regression analysis showed that gender (OR=2.812, 95%CI:1.257-6.293), baseline thyroid autoantibodies were positive (OR=6.984, 95%CI: 1.909-25.547), baseline TgAb positivity (OR=8.909, 95%CI: 1.923-41.280), and baseline TPOAb positivity (OR=7.304, 95%CI: 1.555-34.308) were associated with thyroid irAEs (all P<0.05). Multivariate logistic regression analysis indicated that baseline TgAb positivity (OR=7.637, 95%CI: 1.617-36.072) was a risk factor for thyroid irAEs (P=0.01).

The incidence of thyroid irAEs is higher in patients who are positive for baseline TPOAb and/or TgAb compared to those who are negative for TPOAb and TgAb. Patients with positive TgAb at baseline are at high risk of developing thyroid irAEs.

This paper reports a case of recurrent polychondritis involving airway with sudden deafness and eye damage. A 35-year-old male was admitted to hospital due to "pain in both eyes, fever, and hearing loss for more than 2 weeks". Chest CT showed diffuse thickening of the great airway, and no typical pathological manifestations of recurrent polychondritis were found in tracheal wall biopsy under bronchoscopy. In the absence of typical clinical manifestations at an early stage with the help of¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission computed tomography (PET/CT) for definitive diagnosis and timely intervention. At first, glucocorticoids combined with immunosuppressants were given to control the disease, but the disease was repeated during the reduction of glucocorticoids, and the disease was relieved by combined tocilizumab treatment. After follow-up, there was no progress in chest CT, no aggravation of symptoms, and the disease was stable.

Dilated cardiomyopathy (DCM) presents with hyposystolic function, ventricular enlargement, and pathological remodeling of the heart, but its underlying molecular etiology remains largely unknown. At present, more than 80 pathogenic genes related to DCM have been discovered. This paper reports a case of DCM caused by a newly discovered truncated mutation of silk protein C (FLNC) gene, aiming at enriching its pathogenic mutation spectrum and providing help for future gene diagnosis.

Hepatocellular carcinoma is a common malignant tumor with high heterogeneity and poor prognosis. Early prediction and treatment are still difficult. However, copper death is a new mechanism of programmed cell death recently discovered, which is mainly related to the instability of iron-sulfur protein induced by copper and the aggregation of lipoylated protein in mitochondria. In recent years, more and more studies have begun to pay attention to the role and mechanism of copper death in hepatocellular carcinoma, trying to explore new predictive markers and therapeutic targets of hepatocellular carcinoma from copper death. This paper reviews the research progress of copper death in hepatocellular carcinoma, mainly involving copper death-related genes and related long chain non-coding RNA, in order to provide reference for follow-up research.

The patient, a 60-year-old female, went to the outpatient department of respiratory and critical care medicine of Peking Union Medical College Hospital for "intermittent shortness of breath for 1 month". In the past month, there was intermittent shortness of breath, no obvious cough, sputum, and no fever; Spontaneous pneumothorax occurred three times in the past 5 years, and there was no history of chronic diseases such as hypertension and diabetes. There are 4 siblings, and the older brother has a history of pneumothorax. CT of the patient's outpatient chest showed multiple thin-walled cystic translucent shadows of different sizes in both lungs (Figures 1, 2), irregular shapes (round, oval and flat shapes can be seen), partially fused, mainly distributed in the middle and lower lungs and the base of both lungs, adjacent to the mediastinum subpleura. Considering the possibility of diagnosis of Birt-Hogg-Dubé syndrome (BHD) syndrome, the diagnosis of BHD syndrome was confirmed after whole exon sequencing of peripheral blood: there is a heterozygous deletion variation of about 2 kb in the copy number of chromosome 17p11.2 region: mainly involving exon 45 of FLCN gene and its adjacent introns. Ultrasound of the urinary tract: small cyst of the left kidney. BHD syndrome is a rare autosomal dominant hereditary disorder characterized by diffuse saccular lesions of the lungs, spontaneous pneumothorax, cutaneous fibropilofolliculoma or trichoma, and kidney tumors; At present, there is no effective treatment for pulmonary cystic lesions, and it is necessary to avoid long-distance flights, breath-holding and weight-bearing in order to reduce the occurrence of spontaneous pneumothorax. In this case, the patient had repeated spontaneous pneumothorax and multiple vesicles with heterogeneous size and shape distributed near the pleura in both lungs. Combined with genetic testing, BHD syndrome was diagnosed.