协和医学杂志

2024, 15(2): 237-238.

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Postoperative Patient-controlled Analgesia: Thirty Years of Clinical Experience in Peking Union Medical College Hospital

ZHAO Lin, REN Liying, NIE Weihua, CHEN Yaqi, ZHANG Jie, ZHANG Shengjie, WANG Yingli, DIAO Cuicui, MA Huiying, ZHANG Zheng, ZHOU Li, SHEN Le, WANG Huizhen, HUANG Yuguang

2024, 15(2): 239-245. doi: 10.12290/xhyxzz.2023-0600

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Postoperative pain seriously affects the recovery process of patients, resulting in prolonged hospital stay and increased care costs. Appropriate application of patient-controlled analgesia devices can effectively relieve perioperative acute pain. In 1994 patient-controlled analgesia began to be used in Peking Union Medical College Hospital, and the Acute Pain Service Working Group was established in 2004. With the cooperation of anesthesiologists and specialist nurses, the group jointly has implemented the whole process and standardized management based on patient-controlled analgesia, and constantly improved and innovated working methods, laying a solid foundation for the development of postoperative pain management. This paper systematically reviews and summarizes the work from the aspects of clinical focus, nursing management experience, promotion and dissemination of pain treatment concepts, and development of acute pain service model under the new situation, with the hope of providing valuable reference for comprehensively strengthening pain management in the process of diagnosis and treatment, and enhancing patients' satisfaction with perioperative analgesia services.

Epidural Labor Analgesia: Comfort and Safety Run in Parallel, with Teaching and Quality Control Complementing Each Other

ZHANG Yu, ZHAO Mengyun, PEI Lijian, GONG Yahong, RUAN Xia, ZHANG Yuguan, XIA Di, LU Zhilong, ZHANG Zhanjie, ZHOU Jiong, FU Chenwei, GAO Jinsong, HUANG Yuguang

2024, 15(2): 246-250. doi: 10.12290/xhyxzz.2024-0026

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Epidural labor analgesia aims to provide effective medical services to alleviate labor pain in parturients, while adhering to the principles of voluntary participation and clinical safety. In 2018, Peking Union Medical College Hospital(PUMCH)became one of the first pilot units for labor analgesia in China, and has achieved satisfactory results in high-quality development of labor analgesia. This article mainly introduces the achievements and experience of labor analgesia at PUMCH, including: (1) prioritizing maternal and infant safety, arranging personnel rationally, and developing standardized treatment processes through multidisciplinary collaboration to ensure safe and comfortable childbirth; (2) leveraging the hospital's comprehensive capabilities in emergency treatment, and improving collaborative rescue plans for critically ill parturients and newborns; (3) implementing advanced teaching methods to effectively train and conduct simulated drills for labor analgesia and rescue of critically ill parturients; (4) conducting patient education and informative lectures to help parturients acquire a scientific understanding of labor analgesia. We hope that this experience can provide reference and inspiration for other hospitals.

Development and Translation of Super Long-acting Analgesics

HE Yumiao, LI Mohan, MA Chao, HUANG Yuguang

2024, 15(2): 251-257. doi: 10.12290/xhyxzz.2023-0574

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Pain management, listed as the fifth vital sign, has gained increasing attention from clinicians. Conventional analgesics have limited duration, leading to intense monitor and frequent dosing during the early phase in order to prevent the progression of chronic pain. Thus, prolonging the duration of analgesics has become one focus of the pain research. Several strategies, such as adding adjuvants, producing derivatives, and applying extended-release carriers, make it possible for super long-acting analgesics to come into reality. This review briefly introduces the strategies and development of the super long-acting analgesics, including the successful translation and commercialization of the present products of super long-acting analgesics. It also summarizes the application and translation of extended-release drug carriers, providing invaluable reference for the future research on the field of super long-acting analgesics.

Baroreflex in Pain Regulation: Pathogenic Mechanism and Clinical Application

CUI Quexuan, CHE Lu, XU Li

2024, 15(2): 258-264. doi: 10.12290/xhyxzz.2023-0552

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The baroreceptor reflex is an essential mechanism for the autonomic nervous system in cardiovascular homeostasis and is closely related to pain regulation. Baroreflex sensitivity (BRS) is an indicator for quantitative evaluation of baroreflex reflex function. Pain sensitivity is negatively correlated with BRS, therefore, BRS has potential application prospects in pain risk prediction and therapeutic efficacy assessment. Vagus nerve stimulation, capable of activating the baroreceptor reflex, has been widely used in acute or chronic pain patients in recent years. This article reviews the mechanism and clinical application progress of the baroreceptor reflex in pain regulation, with the hope of providing reference for further exploring treatment to regulate baroreceptor reflex function in pain treatment.

Progress in Diagnosis and Treatment of Central Post-stroke Pain

SONG Shujia, SUN Chen, PEI Lijian, XU Weihai, HUANG Yuguang

2024, 15(2): 265-271. doi: 10.12290/xhyxzz.2023-0591

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Central post-stroke pain (CPSP), a neuropathic pain syndrome occurring after a cerebrovascular accident, is characterized by pain or paraesthesia in the part of the body dominated by the area of the brain where blood vessels are injured. CPSP patients are often accompanied by anxiety, depression and other emotional disorders, which have a serious negative impact on patients' quality of life. However, the pathogenesis of CPSP has not been fully elucidated, the clinical diagnosis rate is not high, and the commonly used treatment methods are not effective. This article reviews the clinical features, epidemiology, pathogenesis and treatment of CPSP in order to provide reference for the elucidation of CPSP mechanism and effective treatment.

Advances of Virtual Reality in the Field of Pain Treatment

WU Chen, ZHANG Li, MA Chao, LIU Hongju, LIU Xuming, ZHANG Kepu, WANG Tengti

2024, 15(2): 272-278. doi: 10.12290/xhyxzz.2023-0519

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Pain not only affects the physical and mental health of individuals, but also imposes a huge burden on society as a whole. Traditional pain management measures are diverse, but each has its limitations. Therefore, there is an urgent need for new tools. Digital therapies are booming, and virtual reality (VR) has been widely used, especially in the field of pain management. VR uses assistive tools, such as headsets, to build a three-dimensional virtual world with the participation of multiple senses, including vision, hearing, and smell, so that it can make user feel being there. This review aims to summarize the application and mechanism of VR in the field of pain management, with the hope of making VR a new choice for pain management.

Prospects of Digital Medicine in Postoperative Pain Management in Children

CHEN Fei, ZHANG Yuguan, ZHU Bo

2024, 15(2): 279-284. doi: 10.12290/xhyxzz.2023-0429

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In recent years, with the gradual and extensive application of digital medical treatment in the field of medica anesthesia, its role in the postoperative pain management of children has attracted increasing attention. It provides new ideas for the preoperative prediction, postoperative monitoring and evaluation, and treatment management of postoperative pain in children, as well as a new scheme for anesthesiologists to formulate the best postoperative pain management strategy for children. This article reviews digital medical treatment and its application in clinical anesthesia, and reviews the application prospects of this therapy in postoperative pain in children, in order to deepen clinicians' knowledge.

2024 Consensus Guidelines on Spinal Cord Stimulation for Chronic Pain Management Among Practicing Pain Physicians in China and the United States

2024 Consensus Working Group on Chronic Pain Management Through Spinal Cord Electrical Stimulation in China and the United States

2024, 15(2): 285-293. doi: 10.12290/xhyxzz.2024-0033

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In recent years, Spinal Cord Stimulation (SCS) has emerged as a pivotal intervention in chronic pain management. The judicious utilization of SCS is paramount for effective clinical outcomes. The 2024 Consensus Working Group on SCS Management of Chronic Pain, spanning experts from China and the United States, undertook a comprehensive literature review guided by the RIGHT framework. This review addressed SCS's role in chronic pain management, focusing on indications and contraindications, patient selection processes, education, considerations during trial and implantation phases, and strategies for managing complications. Leveraging the United States Preventive Services Task Force's grading guidelines, this consensus offers evidence-based recommendations aimed at enhancing SCS application in chronic pain management. This guideline seeks to equip pain physicians across all levels with the most current evidence, thereby refining SCS practices for optimal patient outcomes.

2024 Consensus Guidelines on Lumbar Facet Interventions Among Practicing Pain Physicians in China and the United States

2024 Consensus Working Group on Lumbar Facet Interventions in China and the United States

2024, 15(2): 294-302. doi: 10.12290/xhyxzz.2024-0076

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Lumbar facet interventions, including facet joint injections, medial nerve blocks, and radiofrequency ablation (RFA), are prevalent treatments for low back pain (LBP). Despite their widespread use, debates persist regarding various aspects of these procedures. The 2024 Consensus Working Group on Lumbar Facet Interventions, composed of practicing pain physicians from both China and the United States, conducted an extensive review of the literature on the use of lumbar facet interventions in chronic pain management. Following the U.S. Preventive Services Task Force grading guidelines, this consensus provides an evidence-based, patient-centered guideline tailored for pain physicians at all expertise levels for the management of chronic lower spinal pain. The guideline offers detailed recommendations on the identification of facetogenic pain, criteria for patient selection, the application of lumbar facet blocks and RFA techniques, and strategies for the prevention and management of intervention-related complications.

Management Standard on Perioperative Prophylactic Use of Antibiotics in Peking Union Medical College Hospital (2023)

Editorial Committee on Management Standard on Perioperative Prophylactic Use of Antibiotics in Peking Union Medical College Hospital

2024, 15(2): 303-311. doi: 10.12290/xhyxzz.2023-0593

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To standardize the use of antibiotics for surgical prophylaxis, ensure patient safety, improve medical quality, and combat bacterial resistance, the editorial committee at Peking Union Medical College Hospital for the management of antibiotics for surgical prophylaxis has formed management practice of perioperative prophylactic use of antibiotics. The management practice, based on the Guideline Principles for the Clinical Application of Antimicrobial Drugs (2015 edition) issued by the National Health Commission of People's Republic of China, also reviews the authoritative literature at home and abroad and combines with our hospital's antimicrobial drugs catalog and characteristics of bacterial resistance, with the hope of promoting the rational use of antibiotics.

Interpretation on the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guidelines for the Management of Patients with Chronic Coronary Disease

LIANG Yan

2024, 15(2): 312-319. doi: 10.12290/xhyxzz.2024-0043

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In July 2023, the American Heart Association (AHA), the American College of Cardiology (ACC), and four other professional societies jointly released the updated version of the AHA/ACC/ACCP/ASPC/NLA/PCNA Guidelines for the Management of Patients with Chronic Coronary Artery Disease. This guideline emphasizes a patient-centered and team-based approach to the overall management of chronic coronary artery disease (CCD), highlights the impact of lifestyle improvements on the prognosis of CCD patients, and provides new insights into risk assessment for major adverse cardiovascular events (MACE) and recommendations for novel medications. These updates hold significant guiding value for health care professionals in China to provide high-quality management for CCD patients.

Interpretation of JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis

ZHANG Song, QIU Luhong, LIU Yingxian, XU Xiqi

2024, 15(2): 320-327. doi: 10.12290/xhyxzz.2023-0630

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JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis offers a new perspective on the definition, classification, epidemiology, pathophysiology, diagnosis, diagnostic, treatment and management of myocarditis. It also provides recommendations to clinicians on the diagnosis and treatment of myocarditis which are more suitable for clinical practice. Given that no myocarditis guidance document has recently been issued in China, this article provides a comprehensive interpretation of the key points of this guideline combined with the latest research, so as to provide reference for the diagnosis and treatment of myocarditis in our country.

Esketamine Improves Working Memory Impairment in Neuropathic Mice Through Hippocampal BDNF-TrkB Pathway

JIANG Yubin, WANG Xingming, ZHANG Yue, ZHOU Zhiqiang, YANG Jianjun

2024, 15(2): 328-334. doi: 10.12290/xhyxzz.2023-0581

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Objective To explore the effect of esketamine on working memory impairment in neuropathic mice and its underlying mechanism. Methods Fifty clean grade male C57BL/6J mice (2 months) were divided into 5 groups by random number table method: sham+saline (SN group), CCI+saline (CN group), CCI+esketamine(CE group), CCI+ANA-12 (CA group), CCI+ANA-12+esketamine (CAE group), with 10 mice in each group. Chronic constriction injury (CCI) was employed to establish a neuropathic pain model. On the 16th day after modeling, CE group and CAE group were administered ketamine (10 mg/kg), CAE group received ANA-12 (0.5 mg/kg) half an hour before ketamine injection, CA group was only given ANA-12, and SN group and CN group received an equivalent volume of saline. The administration was done through intraperitoneal injection for 5 consecutive days. The open-field test (OFT), paw withdrawal threshold (PWT), paw withdrawal latency (PWL) and Y-maze test were performed from day 21 after surgery. Bromo-2-deoxyUridine (BrdU) was dissolved in saline and intraperitoneally injected into the mice on days 21 to 23 after the surgery. Western blot was performed to determine the expression of Brain-derived neurotrophic factor(BDNF) in hippocampus, the immunofluorescence was performed to determine the number of BrdU and doublecortxin (DCX) positive cells in the dentate gyrus (DG) area of hippocampal. Results Compared with SN group, the other four groups showed significant reductions in both PWT and PWL on day 21 after surgery (all P<0.05); There was no significant difference in the total distance travelled by the 5 groups of mice (P=0.142); In the Y maze test, compared to SN group, the accurate percentage of spontaneous alternation in CN group showed significant reductions (P<0.001), which was reversed by esketamine administration (P<0.001); compared with CE group, there was a significant reduction of the accurate percentage of spontaneous alternation in CAE group (P=0.004). The expression of BDNF protein in CN group was lower than that in SN group (P=0.021) and CE group (P=0.030), and compared with CE group, the expression of BDNF was significant decreased in CEA group (P=0.043). The number of BrdU positive and DCX positive cells significantly reduced in the DG area of the hippocampus in CN group compared to SN group (P=0.025) and CE group (P=0.003). The number of BrdU positive and DCX positive cells in CAE group significantly reduced in the DG region of the hippocampus compared to CE group (P=0.014). Conclusion Esketamine maybe improve working memory impairment in neuropathic mice and the neurogenesis in dentate gyrus area of hippocampal through the BDNF-TrkB pathway.

Mechanism of Wnt5a on Keratinocyte Regulating MMP9 for CRPS-Ⅰ Peripheral Sensitization

ZHU He, WEN Bei, XU Li, HUANG Yuguang

2024, 15(2): 335-343. doi: 10.12290/xhyxzz.2023-0551

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Objective To explore the mechanism of Wnt5a on keratinocyte involved in the peripheral sensitization of complex regional pain syndrome type-Ⅰ (CRPS-Ⅰ) by regulating the expression of MMP9, and search for potential therapeutic strategies. Methods Cultured HaCaT cells were treated with oxygen glucose deprivation/re-oxygenation (OGD/R). The early stage of mitochondrial damage and membrane potential changes after OGD/R and the effects of Box5 (Wnt5a inhibitor) at different concentrations (20 μmol/L, 40 μmol/L) on MMP9 were explored. Adult male Sprague-Dawley rats were divided into Control group(n=8), CPIP group (n=8), Box5 (20) group (n=8) and Box5 (40) group (n=8). The rat chronic post-ischemia pain (CPIP) model was established to mimic the pathophysiological process of CRPS-Ⅰ. Box5 (20) group and Box5 (40) group were treated with intraplantar injection of 20 μmol/L and 40 μmol/L Box5 100 μL, respectively. The changes of mechanical withdrawal threshold and thermal withdrawal latency were measured within two weeks, and the skin inflammatory infiltration and keratosis were observed by HE staining. The expression of MMP9 was observed by immunofluorescence, and the levels of IL-1β and TNF-α in dorsal root ganglion of different groups were detected by ELISA. Results Vitro experiment: After OGD/R treatment, the mitochondrial atrophy was observed in OGD/R group under transmission electron microscope and the average fluorescence intensity of MMP9 was found to increase significantly (P<0.001). Compared with Control group, the mitochondrial membrane potential in OGD/R group decreased significantly by JC-1 detection (P=0.027). Compared with OGD/R group, only Box5 (40) group had a statistically significant increase in mitochondrial membrane potential (P=0.046). Animal experiment: Behavioral tests showed that the mechanical pain threshold and thermal pain threshold of CPIP group were significantly decreased at each time point (D1, D2, D4, D10, D14) (all P<0.05). HE staining indicated that there was a large-scale infiltration of inflammatory cell in the dermis and excessive keratosis in the epidermis, and the thickness of stratum granulosum and stratum spinosum increased significantly (P < 0.001). Immunofluorescence analysis showed that the expression of MMP9 in CPIP group was significantly increased (P<0.001). Compared with CPIP group, the fluorescence intensity of MMP9 in Box5 (20) group (P=0.002) and Box5 (40) group (P<0.001) were significantly decreased. ELISA results showed that the concentrations of IL-1β (P=0.048) and TNF-α (P=0.002) in CPIP group were significantly increased. Compared with CPIP group, the concentrations of IL-1β (P=0.047) and TNF-α (P=0.047) were significantly decreased in Box5 (40) group. Conclusions Peripheral ischemia reperfusion injury leads to overexpression of MMP9 on keratinocytes, resulting in CRPS-Ⅰ peripheral sensitization. Targeted inhibition of Wnt5a/MMP9 pathway can reverse pain behavior in rat model of CPIP, thus providing a strategy for clinical treatment of chronic pain.

Chronic Postsurgical Pain Among Patients with Preoperative COVID-19: An Ambispective Cohort Study

CHE Lu, YU Jiawen, JIN Di, BAI Xue, WANG Yi, ZHANG Yuelun, XU Li, SHEN Le, HUANG Yuguang

2024, 15(2): 344-350. doi: 10.12290/xhyxzz.2023-0556

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Objective To investigate the occurrence of chronic postsurgical pain (CPSP) among patients with preoperative COVID-19, and further analyze the risk factors for CPSP. Methods This study was a ambispective cohort study, with subjects from a completed cohort study with follow-up. We included the clinical data of the patients with preoperative COVID-19 who underwent surgery at Peking Union Medical College Hospital from December 1, 2022 to February 28, 2023. Follow-up was conducted up to 6 months postoperatively, with the primary outcome being CPSP. Multivariate Logistic regression analysis was used to analyze the correlation between COVID-19-related exposure indicators and CPSP. Results A total of 4117 surgical patients were included, all of whom had preoperative COVID-19. Among them, 4002 cases had mild symptoms during the acute phase, 62 cases had severe symptoms, and 53 cases were critically ill. At 6th month postoperatively, 1298 cases (31.53%) had long COVID-19 syndrome, and the incidence of CPSP was 5.59% (95% CI: 4.88%-6.28%). After adjusting for confounding factors including age, gender, comorbidities, anesthesia method, and type of surgery, multivariate Logistic regression analysis revealed that critically ill COVID-19 during the acute phase (aOR=3.35, 95% CI: 1.48-7.62, P < 0.001) and presence of long COVID-19 syndrome postoperatively (aOR=2.50, 95% CI: 1.90-3.29, P < 0.001) were associated with CPSP. Conclusions It is clear for the first time that critically ill COVID-19 during the acute phase and the presence of long COVID-19 syndrome postoperatively are the risk factors for CPSP among patients with preoperative COVID-19.

Association Between Coffee Consumption and Pain: A Cross-sectional Study Based on American National Health and Nutrition Examination Survey

WEN Bei, ZHU He, XU Li, HUANG Yuguang

2024, 15(2): 351-358. doi: 10.12290/xhyxzz.2023-0553

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Objective To elucidate whether coffee consumption and caffeine intake was associated with various subtypes of pain based on extensive data from publicly accessible databases. Methods The information was extracted from three cycles of the American National Health and Nutrition Examination Survey (1999—2000, 2001—2002, 2003—2004), encompassing data on coffee consumption, pain information, and 11 covariates (including age, gender, race, etc.). Multinomial logistic regression in three models were utilized for analysis. Results A total of 13 428 participants were included in this study, with a mean age of (49.79±19.06)years and a male-to-female ratio of 0.9∶1. Daily coffee intake: non-drinker 7794(58.0%), > 0-2 cups 2077(15.5%), > 2 cups 3557(26.5%); daily caffeine intake: without intake 7794(58.0%), > 0-200 mg 3152(23.5%), > 200 mg 2482(18.5%); pain situation: no pain or pain duration < 24 h 10 202(76.0%), acute pain 910(6.8%), subacute pain 369(2.7%), chronic pain 1947(14.5%). After weighting, 13 428 participants were expected to represent 190 million(190 709 157) U.S. citizens aged ≥20 years, and the overall prevalence of acute, subacute, and chronic pain in the U.S. population during that period was estimated to be 8%, 3%, and 16%, respectively. Without adjusting for covariates, individuals who consumed more than 2 cups of coffee or 200 mg of caffeine per day exhibited an elevated risk of chronic pain compared to non-coffee/caffeine drinkers, with an odds ratio of 1.354(95% CI: 1.187-1.544) and 1.372(95% CI: 1.185-1.587), respectively. After adjusting for partial covariates including age, sex, and race, individuals who consumed more than 2 cups of coffee or more than 200 mg of caffeine per day still demonstrated an increased risk of chronic pain with an odds ratio of 1.243(95% CI: 1.083-1.427) and 1.249 (95% CI: 1.072-1.456), respectively. However, after all covariates were adjusted, there was no significant association between coffee/caffeine consumption and chronic pain. Furthermore, the number of cups of coffee consumed or caffeine intake showed no significant correlation with acute and subacute pain. Conclusions Compared with nondrinkers, heavy daily coffee drinkers may be more likely to have chronic pain, but it is affected by multiple factors. Basic research and prospective clinical studies are needed to further determine the causality in this association.

Effect of Intraoperative Multimodal Analgesia on the Early Postoperative Quality of Recovery in End-stage Head and Neck Cancer Patients Undergoing Open Gastrostomy: A Prospective Randomized Controlled Study

HU Chunhua, ZHAO Xiaoyan, WU Lili, CHEN hongya, XU Xin, WANG Guyan

2024, 15(2): 359-365. doi: 10.12290/xhyxzz.2024-0072

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Objective To evaluate the effect of intraoperative multimodal analgesia on the early postoperative quality of recovery in end-stage head and neck cancer patients undergoing open gastrostomy surgery. Methods This was a prospective, parallel, randomized controlled study. The research subjects were end-stage head and neck cancer patients who underwent elective open gastrostomy at Beijing Tongren Hospital affiliated to Capital Medical University from November 2022 to May 2023. The patients were randomly divided into local anesthesia group and multimodal analgesia group at a 1∶1 ratio. For local anesthesia group, 0.25% ropivacaine 20-30 mL was administered for local infiltration anesthesia. For multimodal analgesia group, the anesthesia method was nerve block + intravenous analgesia: ultrasound-guided left transverse abdominis plane block (0.25% ropivacaine 0.3 mL/kg)+bilateral rectus abdominis sheath block (0.25% ropivacaine 0.3 mL/kg per side)+intravenous injection of oxycodone 0.1 mg/kg, flurbiprofen 1 mg/kg, and dexamethasone 0.2 mg/kg. The primary outcome measure was the quality of requirements-15 (QoR-15) score at postoperative 24 h, while the secondary outcome measures were the QoR-15 score at postoperative 48 h, the numerical rating scale (NRS) and Bruggemann comfort scale (BCS) scores at different time points after the surgery, the first time of rescue analgesia, the first time of off-bed activity and intestinal exhaust, as well as the incidences of adverse reactions within postoperative 48 h. Results A total of 46 patients with end-stage head and neck cancer who underwent open gastrostomy and met the inclusion and exclusion criteria were ultimately enrolled, with 23 patients in multimodal analgesia group and 23 patients in local anesthesia group. There was no statistically significant difference in preoperative QoR-15 scores between the two groups (P > 0.05). Multimodal analgesia group had higher QoR-15 scores at 24 h postoperatively[(81.77±8.91) vs. (71.46±7.61), P < 0.05] and 48 h postoperatively[(86.26±7.92) vs. (80.13±6.98), P < 0.05], and the difference in QoR-15 scores at 24 h postoperatively was clinically significant. Compared with local anesthesia group, at 6 h and 24 h after surgery, the multimodal analgesia group showed a decrease in NRS scores at rest and during exercise, while the comfort BCS score increased (all P < 0.05). Multimodal analgesia group also had a delayed time for the first rescue analgesia, a reduced incidence of rescue analgesia within 48 h after surgery, an earlier time for first postoperative off-bed activity and intestinal exhaust (all P < 0.05). The incidence of adverse reactions in multimodal analgesia group and local anesthesia group was 8.70% and 13.04%, respectively, but the difference was not statistically significant (P > 0.05). Conclusion Intraoperative multimodal analgesia can effectively alleviate postoperative pain, increase the comfortable degree, shorten the first time of postoperative off-bed activity and intestinal exhaust, and accordingly improve the quality of early postoperative recovery in patients undergoing open gastrostomy.

Risk Factors for Postoperative Nausea and Vomiting in Surgical Patients Undergoing Patient Controlled Intravenous Analgesia

WU Juelun, TIAN Yuan, NIE Weihua, ZHANG Yuelun, SHEN Le

2024, 15(2): 366-374. doi: 10.12290/xhyxzz.2023-0579

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Objective To identify the risk factors for postoperative nausea and vomiting (PONV) in surgical patients undergoing patient controlled intravenous analgesia (PCIA). Methods Our study was a retrospective cohort study, including patients who underwent surgery at Peking Union Medical College Hospital from July 1 to October 31, 2023 and received PCIA after surgery. Patient characteristics, medical history, surgical information, intraoperative medication information, postoperative analgesia follow-up information were obtained through the electronic medical record system. The patients were divided into PCIA-PONV group and non-PCIA-PONV group, depending on the occurrence of PONV during PCIA, and all patients were also divided into PCIA-POV group and non-PCIA-POV according to whether postoperative vomiting (POV) occurred. Multivariate Logistic regression analysis was used to identify the risk factors for PCIA-PONV and PCIA-POV. Results A total of 1373 patients were included in this study, with 676 cases in PCIA-PONV group. The incidence of PCIA-PONV was 49.2%. There were 285 patients in PCIA-POV group, and the incidence of PCIA-POV was 20.8%. The results of multivariate Logistic regression analysis showed that female (OR=2.134, 95% CI: 1.590-2.865, P < 0.001) and abdominal surgery (OR=1.655, 95% CI: 1.253-2.186, P < 0.001) were risk factors for PCIA-PONV, whereas the increase of age (OR=0.990, 95% CI: 0.982-0.998, P=0.019) and the increase of BMI (OR=0.961, 95% CI: 0.932-0.991, P=0.012) were protective factors for PCIA-PONV. Female (OR=2.646, 95% CI: 1.754-3.992, P < 0.001), history of general anesthesia (OR=1.372, 95% CI: 1.042-1.806, P=0.024), and intraoperative use of high-dose opioids (OR=1.607, 95% CI: 1.206-2.142, P=0.001) were risk factors for PCIA-POV, whereas no intraoperative use of neuromuscular blocking antagonists (OR=0.393, 95% CI: 0.237-0.651, P < 0.001) was protective factor for PCIA-POV. Conclusions Our study reveals the risk factors for PONV in surgical patients undergoing PCIA, and shows that comprehensive preoperative assessment and reasonable perioperative management strategies are significant in the prevention of PCIA-PONV.

Research Progress of ADAM17 in Gastric Cancer

YANG Mengjiao, YUAN Hao, ZHENG Ya, WANG Yuping, GUO Qinghong

2024, 15(2): 375-381. doi: 10.12290/xhyxzz.2023-0383

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Gastric cancer is one of the most common malignant tumors in the world. Patients with gastric cancer are often treated by surgery, radiotherapy, chemotherapy or immunotherapy, but the clinical efficacy and prognosis are poor. As an important member of ADAMs family, a disintegrin and metalloprotease 17 (ADAM17) is significantly more highly expressed in gastric cancer than in adjacent tissues. It participates in the occurrence and development of gastric cancer by mediating EGFR, TNF-α, TGF-β/Smad, Notch and Wnt, FoxM1-ADAM17 and EGFR/ERK/SP1. The high expression of ADAM17 is also closely related to the poor prognosis of gastric cancer, suggesting that ADAM17 can be used as a biological index to predict the development and prognosis of gastric cancer and has great potential to become a new therapeutic target for gastric cancer. In this paper, the mechanism, treatment and prognosis of ADAM17 in the development of gastric cancer are reviewed, in order to provide new ideas for clinical diagnosis and treatment of gastric cancer.

Obstructive Sleep Apnea-induced Gut Dysbiosis and Ischaemic Stroke: Mechanism and Research Progress

LIU Miaomiao, YUE Hongmei, LI Yating, XU Jinhui, WU Xingdong, ZHU Haobin

2024, 15(2): 382-386. doi: 10.12290/xhyxzz.2023-0452

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Ischemic stroke, a cerebrovascular disease with high incidence, high mortality, high disability rate and high recurrence rate, is an important cause of death and disability of middle-aged and elderly people in China, and imposes a huge burden to society and families. Therefore, it is essential to identify the risk factors associated with ischemic stroke and effectively prevent them. Studies have shown that obstructive sleep apnea is an independent risk factor for ischemic stroke. However, the exact pathological mechanism of their association has not been clarified. With the development of next-generation sequencing technology, more and more studies have focused on intestinal microbiota. They have found that obstructive sleep apnea can cause intestinal microbiota changes, and intestinal microbiota may be closely related to ischemic stroke. Therefore, this paper attempts to investigate the relationship between intestinal flora and ischemic stroke, so as to reveal the potential pathological mechanism of ischemic stroke caused by obstructive sleep apnea.

Application Status and Research Advances of Artificial Intelligence in Pancreatobiliary Endoscopy

LAI Xinxiu, WANG Xiang

2024, 15(2): 387-393. doi: 10.12290/xhyxzz.2023-0524

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Traditional pancreatobiliary endoscopy surgery is limited by the fact that capturing image information is time-consuming, inefficient, and susceptible to the level of the practitioner. Artificial intelligence, however, provides an efficient and accurate method of automatic image recognition for pancreaticobiliary endoscopic surgery, thus assisting clinicians to achieve rapid and accurate clinical predictions and guiding clinical decision-making. Moreover, artificial intelligence has great potential for applications in many aspects such as quality control and training of procedure. This paper provides an overview of the current status and research progress in the application of artificial intelligence in pancreatic and biliary endoscopic techniques, with the hope of offering new ideas and methods for improving the current clinical diagnosis and treatment pattern and realizing precision medicine for pancreatobiliary diseases.

Research Progress on the Effect of Clinical Concomitant Medication on Efficacy of Immune Checkpoint Inhibitors in Urothelial Carcinoma

LYU Zhengqin, ZHAO Yuhao, GUO Yuanyuan, LIU Beibei, LIU Jianmin

2024, 15(2): 394-399. doi: 10.12290/xhyxzz.2023-0488

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Immune checkpoint inhibitors (ICIs) have been approved for the treatment of urothelial carcinoma(UC). However, the use of antibiotics, proton pump inhibitors, corticosteroids, beta-blockers, metformin, and statin concomitant medications in some patients due to complications during the treatment process may affect the clinical efficacy of ICIs through different pathway, making it difficult for patients to derive clinical benefit or making it more likely to develop drug resistance. In this paper, we present a review of the effects of the above concomitant drugs on ICIs in the treatment of patients with advanced UC, with a view to provide reference for the application of individualized treatment strategies of ICIs in patients with advanced UC.

Research Status and Application Prospect of Bone Age Assessment by Ultrasonography

ZHAO Zeqing, PAN Hui, ZHANG Li, WANG Fengdan, CHEN Shi, YANG Xiao, LI Jianchu

2024, 15(2): 400-405. doi: 10.12290/xhyxzz.2023-0270

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Bone age, the most commonly used and effective indicator for understanding children's growth and development, plays an important role in the diagnosis and efficacy evaluation of various growth and development disorders. Clinically, X-rays of the left hand and wrist are mostly taken for bone age assessment, but there is a certain radiation risk. Ultrasound can clearly display the epiphysis and secondary ossification center, and conveniently perform multi-site scanning and dynamic measurement without radiation. In recent years, great progress has been made in the research and clinical application of ultrasound in bone age assessment. This article, by reviewing the latest literature, discusses the value of musculoskeletal ultrasound and quantitative ultrasound in bone age assessment, raises the problems in the study of ultrasound assessment of bone age, and suggests direction for improvement.

Cronkhite-Canada Syndrome Combined with Asymptomatic Novel Coronavirus Infection: A Case Report

ZHANG Ning, YANG Chenhao, ZHOU Liangrui, SUN Xiaohong, LIU Xiaohong, KANG Lin, LI Ji, LI Hailong

2024, 15(2): 406-412. doi: 10.12290/xhyxzz.2023-0476

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This article presents a case study of a patient who had Cronkhite-Canada syndrome in combination with an asymptomatic novel coronavirus infection. The patient exhibited clinical symptoms of loss of appetite, hair and nail loss, and skin pigmentation. Digestive endoscopy revealed widespread and varying-sized polypoid changes in the mucosa of the stomach, duodenum, and colon. During the course of the illness, the patient tested positive for novel coronavirus nucleic acid. Treatment with moderate doses of prednisone resulted in the patient's hair regrowth and decreased skin hypopigmentation. The article provides a summary of the patient's diagnosis and treatment and a review of relevant literature, with the aim of enhancing clinicians' understanding of the disease.

Implementation Evaluation of Clinical Practice Guidelines for Integrative Medicine

YE Ziying, TIAN Chen, YAN Yilong, LI Qiaofeng, NING Jinling, LI Tingting, GE Long

2024, 15(2): 413-421. doi: 10.12290/xhyxzz.2023-0198

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Objective To systematically assess the applicability of the clinical practice guidelines (CPGs) integrating Chinese and western medicine, thereby providing reference for enhancing their future usability. Methods PubMed, Web of Science, Embase, SinoMed, WanFang Data, and CNKI databases were searched for guidelines for the integration of Chinese and western medicine. Supplementary searches of Chinese Medical Association, Chinese Medicine Administration, MedSci websites, Website of China Association of Chinese Medicine, Medlive, Website of Dangdang, Chinese Association of Integrative Medicine and World Federation of Traditional Chinese Medicine Societies were conducted. The search time frame was from inception of the databases to December 31, 2022. Four reviewers independently evaluated the implementability of clinical practice guidelines by using "Clinical Practice Guideline (CPG) implementation evaluation tool". Results A total of 61 integrative Chinese and western medicine guidelines were included. Of the guidelines assessed, 9 guidelines(14.75%) exhibited strong implementability, 40(65.57%) demonstrated average implementability, and 12 (19.67%) demonstrated poor implementability. Among the 5 domains, the dimensions of "accessibility" and "implementability" were found to be of high quality, while those of "communication", "ease of identification" and "applicability" were relatively poor. Notably, compared to guidelines published between 2006—2016, those published between 2017—2022 showed improvements in the areas of "identification" and "application". Conclusions The implementabilityof the existing clinical practice guidelines of the integrative Chinese and western medicine is average and needs to be improved. In the future, emphasis should be placed on the integration of medical education and research, publicity of the guidelines, continuous medical education and training, a more concise form of recommendations, application of the guidelines by clinicians, and the implementability of the integrative Chinese and western medicine guideline.

Novel Framework (Target Trial Emulation) in Observational Causal Inference Research Based on Real-world Data and Its Application Prospects in Traditional Chinese Medicine

LU Cuncun, CHEN Zijia, WANG Zhifei

2024, 15(2): 422-428. doi: 10.12290/xhyxzz.2023-0398

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"Target trial emulation" (TTE), as a new framework in real-world research, has been formally established in recent years. It can be used to guide the evaluation of the effectiveness and safety of medical interventions based on real-world data for observational causal inference. The core idea of this framework is to follow the principles of randomized controlled trial (RCT), emulate a corresponding RCT using real-world data, and then draw conclusions about the causal relationship between interventions and outcomes. The main implementation tips of TTE can be summarized as "3-7-2": 3 implementation steps including formulating the causal question, designing the emulation plan, and emulating the target study; 7 design elements including eligibility criteria, treatment strategies, intervention allocation, follow-up period, outcome, causal contrast of interest, and analysis plan; and control of 2 critical biases including immortal time bias and prevalent user bias. In this article, we present an overview of the development, current status, implementation steps, classic examples, advantages and limitations of TTE, and its application prospects in traditional Chinese medicine (TCM). It is hoped that this article can assist researchers in TCM to utilize this method for real-world research and contribute to the construction of a clinical evaluation system with distinctive features of TCM.

Methodology of Scientific, Transparent and Applicable Rankings for Chinese Guidelines and Consensus Related Literature Published in the Medical Journals: ample Identification and Speciality Assignment

LIU Hui, YANG Nan, SHI Qianling, LUO Xufei, ZHANG Hairong, TIAN Jinhui, JIN Yinghui, CHEN Yaolong, Methodology and Technology Specialisation Committee of the STAR Working Group

2024, 15(2): 429-434. doi: 10.12290/xhyxzz.2024-0112

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With the development of the Scientific, Transparent and Applicable Rankings tool for clinical practice guidelines(STAR), the publication of evaluation and ranking for scientificity, transparency and applicability of Chinese guidelines and consensus published in the medical journals in 2021and 2022, as well as the publication of the STAR evaluation and ranking for some specialities, the STAR evaluation and ranking has received widespread attention in the medical community. In order to further enhance its scientificity and transparency, Methodology and Technology Specialization Committee of the STAR Working Group presents this article to introduce sample identification and speciality assignment in the evaluation and ranking process.

Reflections on Developing Health Standards Based on Evidence-based Concept

SU Renfeng, LIU Hui, SHI Qianling, LUO Xufei, YANG Nan, ZHAO Junxian, TIAN Qiannan, ZHANG Juanjuan, WU Liqun, CHEN Yaolong

2024, 15(2): 435-441. doi: 10.12290/xhyxzz.2023-0433

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National health standards involve all kinds of technical requirements formulated and numbered in accordance with the procedures and formats stipulated in the standardisation system for the implementation of national health and hygiene laws, regulations and policies, and the protection of human health. The establishment of health standards in China should align with our legal framework, including laws, regulations, departmental rules, and health and hygiene policies. During the development of these standards, a comprehensive approach is advocated, encompassing in-depth investigations, rigorous demonstrations, and extensive stakeholder engagement. However, the process of standard formulation may suffer from insufficient research evidence. The evidence-based concept emphasizes the significance of evidence. Therefore, integrating evidence-based concept into the process of developing health standards can enhance the quality and scientific basis of these standards. This article systematically elucidates the current status and development process of health standards in China, explores the necessity and feasibility of incorporating evidence-based concept into the development of these standards, analyzes the challenges and opportunities, and presents reflections and suggestions.

Past and Present of Implementation Science (PartⅠ)—Origin and Development

XU Dong, CHEN Jiangyun, CAI Yiyuan

2024, 15(2): 442-449. doi: 10.12290/xhyxzz.2024-0023

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Implementation science aims to close the gap between knowledge and practice by fostering the uptake and implementation of evidence-based practices. In Europe and America, implementation science is rapidly evolving and improving. In China, the field is still in its infancy. This paper focuses on the definition, origin, domestic and international development, research hotspots, challenges, and opportunities of implementation science. Although implementation science is still at an early stage in China, it has shown rapid development momentum. Chinese scholars, therefore, should leverage China's distinctive research environment to conduct high-quality and innovation implementation studies in order to excel in implementation science areas and lead globally.

Oral Proactive Healthcare and Obesity

CUI Jing, DU Hanze, ZHAI Wenhao, WEN Linlin, HUANG Lei, CHEN Shi, LI Daowei, PAN Hui

2024, 15(2): 450-455. doi: 10.12290/xhyxzz.2024-0071

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Oral health is closely related to systemic health. Common chronic oral diseases, periodontitis and periapical inflammation for example, not only affect the health of oral soft and hard tissues including the alveolar bone and gums, but may also cause changes in systemic conditions such as chronic low-grade inflammation, elevated oxidative stress levels, and dysbiosis of the microbiota. These changes in systemic health can exacerbate the progression of obesity. Therefore, through proactive oral health interventions such as maintaining good oral hygiene habits, modifying dietary structures, and undergoing oral examinations, it is possible to effectively prevent and alleviate inflammatory oral diseases, and actively intervene in obesity. This article delves into the impact of inflammatory oral diseases on obesity and their underlying mechanisms, defines the concept of "oral proactive healthcare", and systematically summarizes their preventive and therapeutic effects on inflammatory oral diseases, thereby demonstrating the potential of improving obesity through proactive oral health strategies.

Young Female, Fatigue, Hypokalemia, Hyperglycemia

CHEN Rong, WANG Xi, SONG An, WANG Jiajia, LI Wei, CHEN Shi, XING Xiaoping

2024, 15(2): 456-461. doi: 10.12290/xhyxzz.2023-0490

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We report a case of a young female patient with fatigue, hypokalemia, and hyperglycemia. She had past-history of diabetes mellitus, and was admitted to hospital with a history of fatigue and hypokalemia for 5 years. The patient's examination indicated hypokalemia, hypomagnesemia, metabolic alkalosis, hypocalciuria, and SLC12A3 gene pathogenic mutation. The diagnosis was Gitelman syndrome. Potassium and magnesium supplements were given to improve the patient's fatigue. Serum potassium and magnesium were normal. The blood glucose reached standard after treatment with oral hypoglycemic drugs. This article incorporates literature review to sort out the diagnosis and treatment of Gitelman syndrome, in order to provide feasible reference for clinicians.

Explorations of Clinical Teaching and Training Model for Refresher Anesthesiologists

MA Manjiao, MA Lulu, WANG Ruiying, ZHANG Xiuhua

2024, 15(2): 462-465. doi: 10.12290/xhyxzz.2023-0369

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Objective To establish and evaluate the clinical teaching and training model for refresher anesthesiologists. Methods A total of 25 refresher anesthesiologists from the Department of Anesthesiology in Peking Union Medical College Hospital during the period of March to September 2023 were enrolled. They were taught with the clinical teaching and training model, namely "tutorial system-knowledge update-clinical practice". The refresher anesthesiologists completed the same structured pre-designed questionnaire at the beginning and the end of training respectively. The scores were recorded and compared to evaluate the effectiveness of the clinical training model. Feedback from refresher anesthesiologists about the teaching and training model was also collected. Results Altogether 84%(21/25) and 100%(25/25) of questionnaires distributed were completed respectively, and 92% students gave positive feedback. The mean score at the end of training (10.1±1.1) was significantly higher than that at the beginning (5.6±1.8)(P < 0.01). Conclusion The "tutorial system-knowledge update-clinical practice" clinical teaching and training model was significantly useful to elevate the effectiveness of training refresher anesthesiologists and their satisfaction.

"Seminar-CBL-Ideological and Political Education" Innovative Mode in Clinical Pharmacology Teaching

DU Ping, LIU He, AN Zhuoling

2024, 15(2): 466-469. doi: 10.12290/xhyxzz.2023-0202

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Clinical pharmacology is an important discipline that bridges clinical medicine and pharmacology. In the teaching practice, it is necessary to keep up with educational reform and adopt the seminar teaching method combined with case-based learning (CBL), so as to practically improve the benefits of both "teaching" and "learning". The teaching of ideology and politics in the curriculum is the key to cultivate students' high sense of responsibility and noble medical ethics, and realize the goal of moral education. At present, in the teaching of clinical pharmacology of antineoplastic drugs, there are problems such as students' weak basic knowledge of oncology pharmacology, separation of "teaching" and "learning" due to the traditional teaching method, outdated teaching materials, and low motivation of students. Therefore, this paper takes this part of the course teaching as an example to initially explore the role of the innovative model of "Seminar-CBL-Ideological and Political Education " in the teaching practice of clinical pharmacology, with the hope of stimulating the students' interest in learning, cultivating students' correct outlook on the world, life, and values, achieving the goals of "teaching" and "learning", and providing reference for optimizing clinical pharmacology education.

MA Yueh-ch'ing: The First Chinese Anesthesiologist

FAN Xinchen, LI Naishi, HUANG Yuguang

2024, 15(2): 470-476. doi: 10.12290/xhyxzz.2023-0309

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MA Yueh-ch'ing (1906—1984), graduated from Peking Union Medical College in 1934, and became the first Chinese anesthetist hired by Peking Union Medical College Hospital in 1939. Based on the development and historical background of global anesthesiology, this article briefly introduces MA Yueh-ch'ing's personal experience and major achievements in anesthesiology.

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2024, Volume 15, Issue 2