2020 Vol. 11, No. 5

Editorials
Abstract:
Acute respiratory distress syndrome (ARDS) was destined to have an extraordinary life at the beginning of its birth, because ARDS not only originated from a new concept, but also brought the misunderstandings in clinical treatment. From pre-diseases to the real causes, from the ventilator as the main therapeutic method to becoming an important etiology, from focusing on ventilation function to disregarding pulmonary blood flow, from isolated lung disease to other organ injuries as the common components, and so on, physicians have to look back on these detours but not simply to repeat these mistakes again, and effectively to identify the road ahead.
Abstract:
Till 2020, parenteral and enteral nutrition in China has moved from Translation 1 (T1), and then Translation 2 (T2), to Translation 3 (T3) now. The T3 transfer requires the evaluation of medical services' quality and cost-effectiveness research. After learning from international published articles, the multicenter cooperative database group of Chinese Society for Parenteral and Enteral Nutrition (CSPEN) on Nutritional risk, Undernutrition, Support, Outcome, and Cost-effectiveness ratio (NUSOC) (abbreviated to CSPEN-NUSOC Cooperative Group) has made efforts to promote health economics research in the field of parenteral and enteral nutrition in China. This paper reviewed the translational medical research of parenteral and enteral nutrition in China. At present, clinical studies toward the goal of "reasonable use to benefit patients"should be conducted in parenteral and enteral nutrition field in China, such as clinical effectiveness study of nutritional risk screening 2002 and Global Leadership Initiative on Malnutrition criteria, or health economics study on nutritional drug.
Specialist Forum
Abstract:
Computerized tomography (CT) is the gold standard of imaging technique for lung injury. During the early outbreak of COVID-19 in Wuhan, China, lung CT played an important role in screening and classification. With the development of COVID-19, patients' lung CT presents different lesion types and ranges. Correspondingly, Lung ultrasonography can help to quickly screen for the potential causes of respiratory failure in COVID-19 patients, which takes advantages of convenience, high-accuracy, non-radiation, and fewer transmission in hospital. Moreover, lung ultrasonography is useful for continuous and dynamic management of COVID-19. It dynamically monitors the disease progression; evaluates the effectiveness of the prone position ventilation; and guides ventilation settings, weaning, and extracorporeal membrane therapy. However, lung ultrasonography has limitations on identifying over-inflation, operator dependence, and so on. Clinicians should take advantages of lung CT and ultrasonography and make each modality complementary to the other for promoting precise strategic treatment of COVID-19 patients.
Abstract:
The core management for COVID-19 patients with acute respiratory distress syndrome (ARDS)is hemodynamic therapy, including adjustment to the distribution of blood flow in the lungs and to the changes of blood flow in the right heart-lung circulation. These patients not only have the hemodynamic characteristics of traditional ARDS, but also have special features of COVID-19. Multiple monitoring based on critical care ultrasonography is helpful to describe these features in detail and advance precise treatment that depends on the adjustment to the distribution of pulmonary blood flow-right heart-left heart.
Abstract:
Mortality rate of acute respiratory distress syndrome (ARDS) remains high despite the rapid development of treatment in the past fifty years. It is gradually discovered that not only lung injury but also circulatory changes in ARDS patients lead to right-ventricular (RV) failure and acute cor pulmonale (ACP). Short-term hypoxemia is not an independent risk factor. Pulmonary vascular dysfunction has been reported as an independent predictor of death in ARDS patients. As a result, core therapy in ARDS is gradually changed from lung protection to RV protection. In this paper, the characteristics of RV change and the strategies for RV protection in ARDS are reviewed. The existing problems with RV protection scheme are put forward. The concept of preemptive protection is proposed to provide new ideas for the treatment of ARDS in the future.
Abstract:
Acute respiratory distress syndrome(ARDS) is a kind of respiratory failure caused by a series of etiologies, with high mortality in critically ill patients. According to different insults, there are pulmonary ARDS and extra-pulmonary ARDS. Pulmonary ARDS damages epithelial cells and alveolar membrane directly, while extra-pulmonary ARDS damages alveolar endothelial cells and causes increased permeability, interstitial edema, and collapsed alveoli. Pulmonary and extra-pulmonary insults usually co-exist in critically ill ARDS patients so that we couldn't differentiate them according to etiology, clinical characteristics, biomarkers or mortality. In this article, the differences in risk factors, clinical features, and mortality of pulmonary ARDS and extra-pulmonary ARDS are compared, and we comb the pathogenesis, clinical manifestations, treatment and prognosis of ARDS which are extremely important. It enables intensive care physicians to have a more comprehensive understanding of the pathogenesis of ARDS, and can standardize and systematically initiate the precise assessment and treatment of ARDS, thereby reducing the mortality rate of ARDS patients.
Abstract:
Pituitary adenomas (PAs) are a kind of neuroendocrine neoplasm(NEN)and mostly benign. However, the hyper function of adenohypophysis and the compression to surrounding tissues and organs are often seriously presented in macroadenomas. The standardized diagnosis and treatment of PAs by multidisciplinary team is important. In 2017, the World Health Organization (WHO) revised the pathological diagnosis classification of PAs for the fourth time. High risk PAs and refractory PAs are still challenge in clinical diagnosis and treatment. The mechanism and potential therapeutic target of PAs need to be further revealed. The pathogenesis and clinical diagnosis and treatment of pituitary adenomas were reviewed.
Abstract:
Superior mesenteric artery aneurysm (SMAA) is a rare vascular disease entity with high risk of rupture and mortality. Patients are treated either with surgical intervention or conservative observation. Traditional open surgery includes simple ligation, aneurysmectomy with reconstruction of the mesenteric artery, and simultaneous bowel resection. Endovascular treatment is considered less invasive and preferred in patients with complex comorbidities or branch aneurysms. Embolization and endovascular stenting are the major choices of endovascular treatment. Given the knowledge on the management of SMAA is relatively limited, clinical decisions should be made with great caution, regarding the etiology, pathophysiology of SMAA, and the risk of perioperative and long-term complications.
China Healthcare Big Data
Abstract:
At present, research and application of medical big data are more and more extensive. But inevitably, medical big data is of some deception, and in many scenarios, it can result in wrong conclusions and influence. In this paper, firstly we analyze the causes of medical big data deception from the data deception per se and pitfalls of machine learning. Then, we introduce how to avoid data pitfalls in statistics and analyze the strategies to tackle attacks on models. The importance and methods achieving model interpretability in the medical area are also mentioned.
Guideline and Consensus
Abstract:
In order to improve the overall treatment level of pancreatic cancer in China, Study Group of Pancreatic Surgery in China Society of Surgery of Chinese Medical Association and Pancreatic Disease Committee of China Research Hospital Association have formulated the guideline for neoadjuvant therapy of pancreatic cancer in China (2020 edition). Based on the Grading of Recommendations Assessment, Development and Evaluation system, the guideline has conducted a discussion on the indication, regimen selection, therapeutic effect evaluation, pathological diagnosis and surgery strategy, etc. This guideline has quantified the evidence level of the current clinical researches and provided recommendations for the clinical practice in the neoadjuvant therapy of pancreatic cancer. The guideline has highlighted the role of multiple disciplinary team and represented the conversion of treatment concept in pancreatic cancer. Neoadjuvant therapy has prolonged the survival of the part of pancreatic cancer patients. However, more high-quality clinical researches are in urgent need to improve the level of evidence, optimize the clinical practice and improve the survival of patients.
Abstract:
Polymyxin was an important antimicrobial agent against resistant Gram-negative bacilli. In 2020, the American Clinical and Laboratory Standards Institute changed the clinical breakpoints of polymyxin, eliminating the "susceptible" interpretive category, and only reporting intermediate (I≤2 mg/L) and resistant(R≥4 mg/L) ones. However, the European Committee on Antimicrobial Susceptibility Testing recommended the use of susceptible (S≤2 mg/L), resistant (R > 2 mg/L) as the clinical breakpoints. The international disunity of clinical breakpoints of polymyxin brings great trouble to the domestic clinical staffs. Therefore, how to accurately carry out the susceptibility test of polymyxin and standardize the interpretation of its report is an urgent problem to be solved in the field of antibacterial drug application and anti-infection in China. To this end, we organized experts in related fields to normalize and interpret the susceptibility test of polymyxin and its results, and put forward corresponding suggestions of experts for reference.
Abstract:
Uterine fibroid is the most common benign tumor in women of a childbearing age. MR-guided focused ultrasound (MRgFUS) is a new non-invasive method for the treatment of uterine fibroids. Guided by MRI, the ultrasound can focus on the fibroid tissue accurately, producing a high temperature(65-85 ℃)to inactivate protein, induce apoptosis and coagulate necrosis of tumor cells. MRgFUS can accurately ablate fibroid tissue and avoid damage to normal tissue outside the treatment area. In order to further improve the level of MRgFUS treatment of uterine fibroid in China, reduce and avoid the occurrence of complications, and provide safe, effective and standardized treatment to patients, the Minimally Invasive Therapeutics Group of MRI Application Committee of China Medical Equipment Association organized relevant experts to formulate the "China consensus on MR-guided focused ultrasound for uterine fibroids".
Original Contributions
Abstract:
  Objective  To compare the difference of acute pain after joint replacement in patients with knee osteoarthritis (KOA) with or without diabetes.  Methods  Clinical data of patients with total knee arthroplasty (TKA) who underwent surgery at Beijing Chaoyang Hospital, Capital Medical University from October 2017 to February 2018 were prospectively collected and analyzed. They were divided into the diabetes group and the non-diabetes group according to whether they had diabetes or not. Patients of the two groups were given subarachnoid anesthesia combined with single femoral nerve block anesthesia. After the operation, patient controlled intravenousanalgesia (PCIA) was applied. If the visual analogue scale (VAS) score exceeded 4 in the resting state, the patients would take 5 mg of Oxycodone analgesia orally. VAS scores of resting pain/exercise pain, drug dosage in postoperative analgesia pump, and oral oxycodone dose were compared between the two groups before, 4 h, 1 d, 2 d, 3 d, 4 dand 5 d after the operation. The occurrence of adverse reactionsduring the use of narcotic drugs was recorded.  Results  A total of 117 KOA patients meeting the inclusion and exclusion criteria were included in this study, including 49 in the diabetic group and 68 in the non-diabetic group. VAS scores of rest pain/exercise pain were not significantly different between the two groups before, 4 h, and 1 d after the operation (all P > 0.05). VAS scores of rest pain/exercise pain were significantly higher in the diabetic group than in the non-diabetic group 2 d, 3 d, 4 d, and 5 d after the operation (all P < 0.05). There was no statistically significant difference between the two groups in term of the dosage of analgesia pump 4 h after the operation and the dosage of oral oxycodone 1 d after the operation (all P > 0.05). The dosage of oral oxycodone 2 d, 3 d, 4 d and 5 d after the operation and the dosage of oral oxycodone 24 h and 48 h after the operation of the diabetes group were higher than that of the non-diabetes group (all P < 0.05). There was no statistical difference in the incidence of nausea, vomiting, and dizziness during applying PCIA between the two groups (all P > 0.05).  Conclusion  Diabetes can aggravate acute pain in KOA patients after TKA (2-5 d after TKA) and increase the use of opioid analgesics in the early stage.
Abstract:
  Objective  To evaluate the use status and influencing factors of nutrition supplements among early pregnant women in China.  Methods  Data was from the Concorde project of the Chinese Pregnant Women Cohort study (CPWCS). The project recruited pregnant women in the first trimester of pregnancy from July 25th, 2017 to July 24th, 2018. An online questionnaire was used to investigate the use of nutritional supplements in pregnant women, including whether they used supplements and the types of supplements used. Multivariate logistic regression was used to analyze the influencing factors of the use of various nutritional supplements.  Results  A total of 7931 pregnant women who met the inclusion criteria were included in the study. The number of pregnant women using nutrient supplements was 7431, the utilization rates of various nutrient supplements from high to low were folic acid (88.7%, 7034/7931), multivitamin (43.5%, 3451/7931), calcium (29.0%, 2297/7931), vitamin D (23.8%, 1891/7931), probiotics (22.4%, 1778/7931), iron(21.9%, 1739/7931), dietary fiber (18.9%, 1497/7931) and docosahexaenoic acid (DHA) (17.0%, 1350/7931). The number of pregnant women who used two or more nutrient supplements was the highest (60.0%, 4678/7931), followed by who used one nutrient supplement (34.7%, 2753/7931) and who did not use any nutrient supplement (6.3%, 500/7931). The multivariate logistic regression analysis showed that the age of pregnant women and the educational level of pregnant women and their spouse were the main factors influencing the use of nutrient supplements.  Conclusions  The use of nutrient supplements is universal among early pregnant women; folic acid and multivitamin are the main types. But the phenomenon of using multiple nutrient supplements at the same time exists. Socioeconomic status survey of pregnant women and their spouses were related to the use of nutrient supplements.
Reviews
Abstract:
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract. They originate from interstitial cells of Cajal (ICC) or their homologous stem cells. Most of them are related to mutations in KIT or PDGFRA genes. The incidence, drug resistance rate of targeted therapy, and recurrence rate are increasing year by year, which greatly affect the prognosis of patients. The treatment of GISTs is facing bottlenecks, and searching for new treatment methods has become a current research hotspot of GISTs. ETV1 is a member of the transcription factors of ETS family, which can stimulate the transcription of KIT gene. KIT proteins enhance the expression of ETV1 through MEK-MAPK signaling pathway. The synergistic regulation of ETV1 and KIT positive feedback leads to continuous activation of intracellular signaling pathways in ICC/GISTs, thus promoting the proliferation of tumors. FOXF1 is highly expressed in GISTs, which may be an upstream regulator of KIT and ETV1 and promotes the expression of genes specific to ICC/GISTs. FOXF1 and ETV1 may provide new ideas and directions for the treatment of GISTs. This article reviews the relationship between ETV1, FOXF1 gene expression, and GISTs.
Abstract:
Helicobacter pylori is one of the most common pathogenic bacteria of the digestive tract, which is involved in the etiology of acute gastroenteritis, peptic ulcer, gastrointestinal tumor and Parenteral diseases. The epidemiological relationship between Helicobacter pylori and preeclampsia has been confirmed currently. Even tighter association has been found between preeclampsia and infection of cytotoxin-associated gene A (cagA) positive strains of Helicobacter pylori. The anti-caga antibody induced by Helicobacter pylori can have an immune reaction with trophoblast cells, leading to abnormal trophoblast infiltration. In addition, the inflammation and abnormal lipid metabolism caused by Helicobacter pylori can cause abnormal vascular endothelial function, leading to the onset of preeclampsia and the generation of long-term complications. This article reviews the relationship between Helicobacter pylori and preeclampsia and the latest research progress.
Abstract:
In the interferon era, cytoreductive nephrectomy was recommended for the treatment of patients with good performance status that were diagnosed with metastatic renal cell carcinoma. In recent years, in spite of the wide application of targeted therapy, cytoreductive nephrectomy is still an important part of the treatment of metastatic renal cell carcinoma. With the publication of two prospective studies, CARMENA and SURTIME, the role of cytoreductive nephrectomy in the management of metastatic renal cell carcinoma should be revalued. Based on the results and related considerations of above two studies, we reviewed recent progress in the application of cytoreductive nephrectomy in metastatic renal cell carcinoma.
Abstract:
Single-cell sequencing is characterized by precise analysis of genome, transcriptome, epigenomics, and multi-omics of cancer cells at the single-cell level, which promotes understanding of evolution and dynamic changes in cancer niches. Yet, intra- and extra-tumor heterogeneity of brain tumors can make it difficult to obtain a full-view landscape in bulky tumor assessment. Based on single-cell sequencing, genomic instability, biomarker, signaling pathway and immune responses in the tumor environment of a brain malignant tumor can be uncovered, which provides a novel opportunity for assessment, diagnosis, classification and management of brain malignant tumors. In this article, we review the progress of single-cell sequencing and the prospect in the management of brain malignant tumor in the future.
Clinical Practice Guidelines
Abstract:
The combination of traditional Chinese medicine(TCM) and western medicine is one of the characteristics of Chinese health system. Clinical practice guidelines of western medicine and TCM all are meaningful and valuable for guiding Chinese clinical practice. Thus, we discuss the current development, differences and relationship between western clinical practice guidelines and TCM clinical practice guidelines, and give consideration and suggestions for how to promote mutual learning between western clinical practice guidelines and TCM guidelines, and in order to improve the quality of healthcare in China.
Breast Cancer
Abstract:
Whether menopausal hormone therapy (MHT) increases the risk of breast cancer has been controversial. In September 2019, the famous medical journal, the Lancet, published a meta-analysis that has gathered the worldwide evidence of MHT and incidence of breast cancer, showing that in addition to vaginal estrogen, all type of MHTs increased the risk of breast cancer, and the risk increased steadily with the duration of MHT use. The risk was greater for oestrogen-progestagen therapy; the excess risk persisted after the drug was stopped for more than 10 years. Low doses of MHT or natural progesterone do not prevent the risk of breast cancer. This article interprets the meta-analysis and emphasizes that MHT should be taken into account of increasing the risk of breast cancer, and the risks and benefits should be fully evaluated.
Drug Therapy for Tumors
Abstract:

Nasopharyngeal carcinoma is mainly associated with Epstein-Barr virus(EBV) infection. The treatment of early nasopharyngeal carcinoma has a good prognosis, but the treatment options for recurrent/metastatic nasopharyngeal carcinoma are limited and the prognosis is poor. In recent years, there have been extensive studies on immunotherapy in advanced nasopharyngeal carcinoma, among which immune-checkpoint inhibitors are effective and causing clinical concern. Programmed death-ligand 1 expression status, tumor mutation burden and circulating EBV-DNA level may be biomarkers for predicting the efficacy of immune-checkpoint inhibitors. The applications of immune-checkpoint inhibitors in recurrent/metastatic nasopharyngeal carcinoma will be reviewed in this article.

History of Medicine
Abstract:
The 3rd edition of Formulary of Peking Union Medical College Hospital pressed in 1927 was the earliest collection in our hospital. It was revealed that those common references in English including United States Pharmacopoeia, British Pharmacopoeia, National Formulary (United States), etc., were the most of the bases for the enrollment and quality standard of medications used in our hospital. Both useful and economic characteristics were given priority to the formulary in order to promote the teaching of rational drug therapy, to secure the economy compatible with the welfare of patients, and to limit the number and cost of drugs in stock. It also reflected the unique pharmacy administration, medication-supply system and the pace kept with the international advanced medical level in our hospital nearly a hundred years ago. Its objects, frame, enrolled principles and contents were briefly introduced here.
Clinical Ethics
Abstract:
Clinical ethical thought has always been developing for thousands of years. However, clinical ethics as a discipline is just in the early stage. In the New Era, both medical humanists and clinicians ought to work together to identify and solve ethical issues and build up its own concepts and the ethical framework in clinical settings, in order to contribute to the growth of clinical ethics.