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2024 Vol. 15, No. 1

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Editorial
Palliative Care: Understanding and Responsibility
LANG Jinghe
2024, 15(1): 1-2. doi: 10.12290/xhyxzz.2023-0469
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Abstract:
Palliative care is in the ascendant, but the clinical understanding of it is still shallow and may have significant biases. This article introduces the origin of palliative care and explains its connotation and importance, in order to deepen the understanding of medical workers on palliative care and promote the implementation of relevant concepts in clinical practice.
Specialist Forum
Palliative Care: From the Perspective of Clinical Oncology
SUN Yan
2024, 15(1): 3-6. doi: 10.12290/xhyxzz.2023-0521
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The concept of modern palliative care originated in the 1960s. It has been highly valued by the World Health Organization, and promoted globally with the "three-step analgesic ladder" as the starting point. China introduced the "three-step analgesic ladder" in 1990, which has been in practice for more than 30 years. This has brought clinical oncology closer to palliative care, thus promoting the progress of palliative care in China. Further development of palliative care in China is expected to significantly improve the survival time and quality of life of cancer patients.
How to Respond Responsibly to Suffering of Others? Rethinking Palliative Care for China
Krakauer Eric L.
2024, 15(1): 7-11. doi: 10.12290/xhyxzz.2023-0613
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The Cartesian medical model is leading to overmedicalization all over the world. Modern palliative care, derived from a reflection on the Cartesian medical model, aims to relieve the suffering of critically ill patients and their caregivers. It also focuses on the unnecessary harm of medical technology itself. This paper presents some issues from a case and inspires further thinking and profound understanding of China's palliative care by reviewing the history of relieving suffering, the views and shortcomings of the Cartesian medical model, and the application of life-sustaining treatment and good death.
China's Healthcare System Urgently Needs the Integration of Palliative Care
NING Xiaohong, YAN Ge
2024, 15(1): 12-17. doi: 10.12290/xhyxzz.2023-0599
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With the rapid development of medical technology, human dying process has been technicalized and medicalized, but the pain caused by ageing and terminal disease remains widespread. However, Palliative care can alleviate this kind of pain and improve the quality of life for end-stage patients.Over the years, China has introduced a series of policies and laws to include hospice care in the national health system from the legislative level, most healthcare providers, however, are incompetent and unable to understand and deliver palliative care, resulting in the poor quality of death in China. Integration of palliative care into the health system needs to be gradually implemented, by unifying definitions and principles, advocating palliative care practice in clinical work, initiating education in medical students, developing palliative care networks in primary healthcare system, formulating national-level development indicators, and emphasizing localized development, with the hope of avoiding futile or inappropriate treatments at the end of life.
Good Life and Good Death: Palliative Pursuit of Chinese Life Culture
HE Renfu
2024, 15(1): 18-23. doi: 10.12290/xhyxzz.2023-0631
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Chinese traditional life culture, based on the unity of life and death, has a set of cultural narrative of "Peace" at the end of life. In terms of the fundamental concept, it argues that "Death" is more important than "Health care", and "Good death" is the pursuit of human happiness. In terms of the strategic path, it advocates to abide by the "Etiquette system" and specially designs a set of deathbed etiquette to help people reach a "Good end". In terms of the goal value, it states that "Knowing life" helps "Knowing death" and living well can lead to dying well, thus realizing the immortality of life value. In terms of spiritual beliefs, it emphasizes the acceptance of "Life and death are destined", and transforms "Life limit" into "Mission", thus sublimating the recognition of "Destiny" and accepting death in the belief that "Life never ends".
Ethical Issues in Palliative Care
ZHANG Di, BI Kejia, XU Shiting
2024, 15(1): 24-31. doi: 10.12290/xhyxzz.2023-0578
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With the transformation of medical philosophy, palliative care has become a fundamental component of end-of-life care for patients with life-threatening illnesses, meanwhile ethical issues involved in palliative care are becoming more prominent. This article, through a comprehensive review of both domestic and international ethical research, articulates five crucial ethical issues inherent to palliative care: truth-telling, advance care planning, the use of life-sustaining interventions, palliative sedation, and the relationship between euthanasia, assisted dying, and palliative care. The objective is to offer an ethical perspective for palliative care, help professionals in palliative care to address the critical ethical issues in practice, improve the quality of care for patients and their families, and to inform the development of related legal, regulatory, and policy frameworks.
The Reversal of Policy Environment and Operation Mechanism of Palliative Care Service
GAO Shan
2024, 15(1): 32-36. doi: 10.12290/xhyxzz.2023-0633
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This paper, from the "dichotomy" phenomenon of good policy environment and obstruction of actual operation in the development of palliative care service in China, introduces the current laws and regulations and system construction of palliative care service, and analyzes the causes, paths and behaviors of the underlying operation mechanism of China's medical and health care system that objectively hinders the development of palliative care service. It also presents how medical institutions of different natures respond differently to palliative care service. We believe that with the reform of China's health care payment method, the original mechanism will change accordingly and promote the development of palliative care service in many ways.
Opinions
Controversies About Palliative Care
YU Shiying
2024, 15(1): 37-41. doi: 10.12290/xhyxzz.2023-0537
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There are two controversies about palliative care. One is whether the scope of palliative care should be expanded, and the other is whether the timing of palliative care intervention should be advanced. Regarding the research progress of palliative care, there are currently two consensuses: the target population of palliative care should be expanded to all patients of all ages who suffer from serious illness and serious health-related suffering, palliative care interventions should be integrated into the whole treatment process of serious illness early. However, the expansion of the scope of palliative care targets and the advancement of the timing of intervention have brought new challenges, and there is an urgent need to formulate a new strategic plan and implement it, so as to accelerate the exploration of the development of palliative care that suits China's national conditions. A new understanding of the target group of palliative care and the timing of intervention will help accelerate the development of palliative care in China. This article analyzes and discusses the history, research progress, definition updates, and existing evidence of palliative care, as well as the clinical needs, aiming to provide a reference for the practice of palliative care in China.
Talking About Palliative Care Recipients From the Perspective of Promoting Living Wills
WANG Bo, JIANG Wei, LUO Yuping
2024, 15(1): 42-44. doi: 10.12290/xhyxzz.2023-0617
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At present, all countries and regions providing palliative care service regard living wills and similar documents expressing personal wishes as the legal premise for carrying out this medical service. Defining the population receiving palliative care involves not only ethics or professional skills, but also constant revisions and changes with the development of economy and civilization. Meanwhile, the concept and promotion methods of living wills have also undergone rounds of updates. The nature of hospice and palliative care is respect for individuals, and it is the product of re-understanding the nature of life in the era of technological expansion. As a social organization promoting the concept of living will and death with dignity, we earnestly and confidently expect that hospice and palliative care become a basic right enjoyed by everyone in the near future.
China Healthcare Big Data
Current Situation, Challenges and Suggestions for the Development of Primary Health Care Services in China in the Post Pandemic Era
KE Dandan, JIA Nan, CUI Puan, HE Zhong
2024, 15(1): 45-51. doi: 10.12290/xhyxzz.2023-0290
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Primary health care institutions should be the main force of China's medical and health service system and the cornerstone of the national health care system. During the COVID-19 pandemic, China's primary health care institutions played a critical role, but many deficiencies and weaknesses were also highlighted. Through systematic literature search and analysis, this article finds that China's primary health care institutions have some problems such as low demand for patient care, weak integration of the health system, weak service foundation, and insufficient emergency response capacity for public health emergencies. Accordingly, we put forward a strategy for the construction of primary health care institutions based on the "Three Forces Theory", which aims to improve the primary medical and health care service system, upgrade the capacity of primary medical and health care services, and better fulfill the strategic goal of "Healthy China 2030".
Guideline Interpretation
Interpretation on Management of Dyspnea in Advanced Cancer: ASCO Guideline
JIA Zhimeng, Rebecca Colman, NING Xiaohong
2024, 15(1): 52-57. doi: 10.12290/xhyxzz.2023-0517
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Dyspnea, the subjective sensation of breathlessness, is a common source of distress for patients living with advanced cancer. Effective assessment and management of dyspnea among patients living with advanced cancer represents core competencies for front-line clinicians and professional caregivers. However, there is still a lack of standardized procedures for handling dyspnea in China. Based on evidence-based medicine, the American Society of Clinical Oncology practice guidelines for management of dyspnea in advanced cancer was released, which outlines assessment and management of dyspnea among patients living with advanced cancer. This article aims to provide detailed interpretation of key clinical content to guide China's clinical practice.
Interpretation on the Consensus on Targeted Drug Therapy for Spondyloarthritis
YANG Xiaoxi, TIAN Xinping, LI Mengtao, LENG Xiaomei, ZHAO Yan, ZENG Xiaofeng
2024, 15(1): 58-67. doi: 10.12290/xhyxzz.2023-0391
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Spondyloarthritis (SpA) is a group of chronic inflammatory diseases which predominantly involve spine and/or peripheral joints. SpA can be disabling and seriously affect the quality of life and function of patients. With the increasing clinical use of targeted drug therapy, precise and standardized use becomes the focus. China's first Consensus on Targeted Drug Therapy for Spondyloarthritis was developed by National Clinical Research Center for Dermatologic and Immunologic Diseases using international norms for consensus development. The consensus addresses 13 important clinical questions, ranging from principles, patient eligibility, pre-treatment screening, treatment initiation, drug selection and switch, co-medication, to adverse event monitoring of targeted drug therapy in SpA, and recommends treatment for specific patients, playing a key role in guiding clinical practices.
Interpretation on the Consensus Recommendations of Enhanced Recovery for Liver Transplantation by the International Liver Transplantation Society
YU Huan, WANG Xiaomei, WANG Rui, PENG Guoqing, GONG Liyun
2024, 15(1): 68-76. doi: 10.12290/xhyxzz.2023-0357
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Liver transplantation, the only effective treatment for end stage liver disease, is characterized by complicated surgery, long surgery time, and high trauma. Patients may experience a variety of difficulties following surgery, including infection, abdominal bleeding and rejection, all of which directly affect the quality of rehabilitation. Enhanced Recovery After Surgery (ERAS), a novel perioperative management strategy, can effectively promote postoperative recovery of patients and has been extensively implemented in various fields of surgery. However, there are no scientific and universal ERAS protocols in the fields of liver transplantation in China. The first Consensus Recommendations of Enhanced Recovery for Liver Transplantation was issued by the International Liver Transplantation Society in December 2022, offering recommendations about ERAS strategies for liver transplantation recipients who receive deceased and living organ donations, and for living donors of liver transplantation. This paper provides a detailed interpretation of the key points to offer a practical reference for domestic liver transplantation perioperative ERAS management.
Original Contributions
Cognition of Palliative Care and Experience of Palliative Sedation in Chinese Anesthesiologists: A National Cross-sectional Survey
YU Jiawen, LIU Hongju, XU Yingying, BAO Yanping, SHI Jie, LIU Zhimin, ZHANG Yuelun, NING Xiaohong, HUANG Yuguang
2024, 15(1): 77-83. doi: 10.12290/xhyxzz.2023-0158
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Abstract:
  Objective  This study aimed to investigate Chinese anesthesiologists' comprehension of palliative care and their experiences with palliative sedation for patients in the end-stage of life.  Methods  From October to December 2021, a national cross-sectional survey was conducted among anesthesiologists in China distributed by the Chinese Society of Anesthesiology, Chinese Medical Association with convenient sampling. The survey questionnaire encompassed general information, professional experience, familiarity with palliative care, emotional responses to end-stage cases, experience with sedation for critically ill or end-stage patients, and preferences for sedation medication.  Results  A total of 2536 anesthesiologists from 29 provinces in China completed valid questionnaires. Among them, 572 anesthesiologists(22.6%, 572/2536) reported familiarity with palliative medicine. Male anesthesiologists, as well as those with prior experience in caring for critically ill or end-stage patients, involved in pain management and practicing in hospitals with established institutional palliative care teams, demonstrated greater familiarity with palliative care concepts(all P<0.05). Over 40% of respondents felt powerless, helpless, and indecisive when confronted with end-stage patients. Anesthesiologists knowledgeable about palliative care exhibited greater confidence in managing critically ill or end-stage patients(9.8% vs. 4.4%, P=0.001). Among the anesthesiologists surveyed, 734 had administered sedation to end-stage patients, with 151 of them(20.6%, 151/734) inappropriately relying solely on opioids for sedation.  Conclusions  The understanding of palliative care and palliative sedation medication choice among anesthesiologists in China is still very limited. The establishment of palliative care teams, provision of education and training in palliative care, and enhancement of familiarity with palliative principles may bolster anesthesiologists' confidence when encountering critically ill or end-stage patients and subsequently enhance the quality of care for patients in the terminal stages of life.
Changes in the Death Status of End-of-life Patients After Concept Promotion and Practice of Palliative Care
DAI Xiaoyan, YAN Jing, WANG Youpei, NING Xiaohong
2024, 15(1): 84-88. doi: 10.12290/xhyxzz.2023-0648
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  Objective  The International Medical Services Department of Peking Union Medical College Hospital (PUMCH) has gradually promoted the concept and practice of palliative care since 2016. This study aims to analyze the death status of end-of-life patients before and after the promotion endeavor, in order to evaluate the impact of palliative care on the death quality.  Methods  All clinical data from end-of-life patients who died at the International Medical Services Department of PUMCH in 2013 and 2019 were retrospectively collected, and their diagnosis and treatment details before death were compared.  Results  A total of 36 end-of-life patients who died in 2013 and 37 end-of-life patients who died in 2019 met the inclusion and exclusion criteria. In 2013, there were 19 males and 17 females, with an average age of (72.1±14.0) years, and 19 cases had advanced cancer. In 2019, there were 19 males and 18 females, with an average age of (70.8±15.3) years, and 27 cases had advanced cancer. Compared to patients who died in 2013, a lower proportion of the patients in 2019 who were transferred to the ICU before death(0 vs. 22.2%, P=0.008), received cardiopulmonary resuscitation (0 vs. 16.7%, P=0.011), had tracheal intubation(5.4% vs. 36.1%, P=0.001), invasive mechanical ventilation(2.7% vs. 33.3%, P=0.001), and total parenteral nutrition(32.4% vs. 61.1%, P=0.014), while a higher proportion received palliative care consultations(29.7% vs. 0, P<0.001), and humanistic care(40.5% vs. 16.7%, P=0.024). In 2019, compared to the patients who did not receive palliative care consultations, those who received palliative care consultations had a higher proportion of humanistic care(90.9% vs. 19.2%, P<0.001).  Conclusions  After concept promotion and practice of palliative care, the proportion of end-of-life patients receiving invasive treatments before death in the International Medical Services Department of PUMCH has significantly decreased, the proportion receiving humanistic care has significantly increased, and the quality of death has been improved to a certain extent.
Establishment and Validation of A Prediction Model for the Occurrence of Acute Kidney Disease in Patients with Liver Cirrhosis
OUYANG Jing, CHANG Hong, YANG Mengjiao, ZHANG Meng, TIAN Meng, ZHENG Ya, WANG Yuping, CHEN Zhaofeng
2024, 15(1): 89-98. doi: 10.12290/xhyxzz.2023-0394
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  Objective  To establish a model that can predict the occurrence of acute kidney disease (AKD) in liver cirrhotic patients and evaluate its performance.  Methods  Liver cirrhotic patients who hospitalized in the department of gastroenterology of the First Hospital of Lanzhou University from January 2017 to January 2022 were retrospectively included. They were divided into AKD and non-AKD groups according to whether they were combined with AKD during hospitalization, and were randomized into training and validation sets in a 7∶3 ratio. The clinical data of patients in the two groups were collected, and LASSO regression and multifactorial Logistic regression were used to screen the influencing factors for the occurrence of AKD in patients with liver cirrhosis and to establish a prediction model. The model was then evaluated by using the receiver operating characteristic curve, the calibration curve and the clinical decision curve.  Results  A total of 796 cases of liver cirrhotic patients who met the inclusion and exclusion criteria were enrolled. Among them, 103 cases were in the AKD group and 693 cases were in the non-AKD group; 561 cases were in the training set and 235 cases were in the validation set. The results of LASSO regression and multifactorial Logistic regression showed that a history of diabetes (OR=2.922, 95% CI: 1.290-6.564, P=0.009), hepatic encephalopathy (OR=6.210, 95% CI: 2.278-17.479, P < 0.001), gastrointestinal bleeding (OR=2.501, 95% CI: 1.236-5.073, P=0.011), ascites (OR=3.219, 95% CI: 1.664-6.539, P < 0.001), male (OR=0.477, 95% CI: 0.254-0.879, P=0.019), hemoglobin (OR=0.987, 95% CI: 0.975-0.999, P=0.044), albumin (OR=0.952, 95% CI: 0.911-0.991, P=0.023), and prothrombin time (OR=0.865, 95% CI: 0.779-0.920, P < 0.001) were the independent influences on the occurrence of AKD in liver cirrhotic patients, and were used to construct a prediction model. The area under the curve of the model in the training set and validation set for predicting the occurrence of AKD in liver cirrhotic patients was 0.895 (95% CI: 0.865-0.925) and 0.869 (95% CI: 0.807-0.930), respectively. The calibration curves showed that the model had good fit and consistency and the clinical decision curves showed that the use of the model for predicting the risk of AKD could benefit liver cirrhotic patients overall.  Conclusions  A prediction model for the occurrence of AKD in liver cirrhotic patients was established based on eight influencing factors, including gender, history of diabetes, and hepatic encephalopathy. It was validated to have good discrimination, calibration, and clinical utility, and is expected to assist in the clinical early screening and identification of liver cirrhosis-associated AKD.
Predictive Value of Albumin-Bilirubin Score Combined with Liver Function Index and CEA for Liver Metastasis of Colorectal Cancer
FAN Wanli, HE Dong, ZHANG Shuze, CHEN Gang, ZHAO Bin, CHENG Zhibin
2024, 15(1): 99-108. doi: 10.12290/xhyxzz.2023-0261
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  Objective  To investigate the predictive value of albumin-bilirubin (ALBI) score combined with liver function index and carcinoembryonic antigen (CEA) for liver metastasis of colorectal cancer.  Methods  We retrospectively analyzed the clinical data of patients with colorectal cancer who underwent surgical treatment in the Second Hospital & Clinical Medical Hospital, Lanzhou University from January 2016 to July 2021 and were followed up for 24 months. According to the follow-up results, the enrolled patients were divided into liver metastasis group and non-liver metastasis group, and were randomly divided into modeling group and validation group by a ratio of 2∶1. The risk factors of liver metastasis in the patients with colorectal cancer were analyzed. Lasso-Logistic regression was used to construct the prediction model. Bootstrap method was used for internal verification. Receiver operating characteristic curve, calibration curve and clinical decision curve were used to evaluate the reliability of the prediction model. Finally, a nomogram was drawn to show the prediction results.  Results  A total of 195 patients who met the inclusion and exclusion criteria were enrolled, including 130 in the modeling group and 65 in the validation group. Through Lasso regression variable screening and Logistic regression analysis, the results showed that ALBI score(OR=8.062, 95% CI: 2.545-25.540), alanine transaminase (ALT) (OR=1.037, 95% CI: 1.004-1.071) and CEA (OR=1.025, 95% CI: 1.008-1.043) were independent predictors of liver metastasis in colorectal cancer. The area under curve (AUC) of the combined prediction of liver metastasis of colorectal cancer in the modeling group was 0.921, the sensitivity was 78%, the specificity was 95%, the C-index was 0.921, the H-L fitting curve χ2=0.851, P=0.654, and the slope of the calibration curve was close to 1, suggesting that the accuracy of the model was high, and the DCA curve showed that the model had good clinical application value. For the data of the modeling group, the Bootstrap method was used for internal verification of 1000 resamplings. The accuracy was 0.869, the kappa consistency was 0.709, and the AUC was 0.913. When ALBI score, ALT and CEA were used to diagnose liver metastasis of colorectal cancer alone, the AUC of CEA was the largest (0.897), and the combination of the three had the highest efficacy in the diagnosis of liver metastasis of colorectal cancer. In the validation group, the AUC, sensitivity, specificity, C-index of the combined prediction of liver metastasis of colorectal cancer were 0.918, 85.0%, 95.6%, 0.918, respectively, and H-L fitting curve χ2=0.586, P=0.746.  Conclusions  ALBI score, ALT and CEA have certain predictive value for liver metastasis of colorectal cancer. The combined diagnosis of liver metastasis of colorectal cancer has high efficacy, and the risk prediction model constructed has a good predictive effect.
Establishment and Validation of Prediction Models for Non-curative Resection After ESD for Early Gastric Cancer
DONG Na, MA Ganqing, WANG Lulu, SHI Ronghui, FENG Jie, HUANG Xiaojun
2024, 15(1): 109-116. doi: 10.12290/xhyxzz.2023-0442
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  Objective  To establish a prediction model for non-curative resection in patients with early gastric cancer (EGC) who underwent endoscopic submucosal dissection (ESD), and to evaluate its predictive value.  Methods  Clinical data of EGC patients in the Second Hospital & Clinical Medical School, Lanzhou University from January 2014 to July 2023 were retrospectively collected. According to the postoperative pathological results of ESD, the patients were divided into curative resection group and non-curative resection group. Multifactorial Logistic regression analysis was used to screen the risk factors for non-curative resection after ESD surgery and establish a prediction model, and the model was evaluated using receiver operating characteristic(ROC) curves, calibration curves and clinical decision curve analysis.  Results  A total of 479 EGC patients who underwent ESD were included, with 60 cases in the non-curative resection group and 419 cases in the curative resection group. The results of multifactorial Logistic regression analysis showed that the lesion diameter > 2 cm (OR=3.017, 95% CI: 1.483-6.136, P=0.002), flat lesion morphology (OR=2.712, 95% CI: 0.774-9.497, P=0.043), undifferentiated/mixed histologic type (OR= 4.199, 95% CI: 1.621-10.872, P=0.003), and submucosal infiltration (OR=30.329, 95% CI: 13.059-70.436, P < 0.001) were independent risk factors for non-curative resection after ESD in EGC patients. The area under the curve of ROC validated within the column-line graph prediction model constructed accordingly was 0.867 (95% CI: 0.811-0.923), the calibration curve showed that the model had good calibration, and decision curve analysis showed the model had a good clinical usefulness.  Conclusions  The prediction model constructed based on lesion diameter, lesion morphology, histologic type, and depth of mucosal infiltration has good differentiation, calibration, and clinical utility. This model is expected to assist in the early clinical screening of the population at high risk for noncurative resection after ESD in patients with EGC, and to provide a basis for the development of optimal clinical decisions.
Oral Anticoagulation Therapy Increased the Incidence of Abnormal Uterine Bleeding in Patients with Thrombophilia: A Single-center Retrospective Study
ZHANG Wenjing, ZHU Tienan, LI Kuixing
2024, 15(1): 117-123. doi: 10.12290/xhyxzz.2023-0265
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  Objective  To investigate the incidence and adverse effects of abnormal uterine bleeding (AUB) during oral anticoagulation therapy in women with thrombophilia.  Methods  The female patients with thrombophilia who received oral anticoagulation therapy with rivaroxaban or warfarin in the Department of Hematology of Peking Union Medical College Hospital from January 2013 to May 2023 were selected as the study subjects. Their demographic characteristics, disease related data and AUB before and after anticoagulant therapy were retrospectively collected. The patients were divided into rivaroxaban treatment group and warfarin treatment group according to anticoagulant drugs. The generalized estimating equation was used to analyze the difference in the incidence of AUB before and after anticoagulant therapy, and explore the effect of different anticoagulant therapy on AUB.  Results  A total of 106 female patients with thrombophilia were included, and we found that oral anticoagulation significantly increased the incidence of AUB (56.6% vs. 26.4%, P < 0.001), predominantly characterized by excessive menstruation (48.1%) and prolonged periods (21.7%). Rivaroxaban was more likely to cause AUB than warfarin (OR=3.3, 95% CI: 1.5-7.4, P=0.003). Of the patients who experienced excessive menstruation and prolonged periods, 72.2%(39/54) required intervention, with suspension of anticoagulants during menstruation as the main intervention (37.0%). The patients taking rivaroxaban were more likely to stop taking them during menstruation compared to those taking warfarin (OR=10.4, 95% CI: 1.2-87.2, P=0.019).  Conclusions  Oral anticoagulation therapy significantly increased the incidence of AUB in women with thrombophilia and the risk of AUB associated with rivaroxaban was significantly higher than that with warfarin.
Pelvic Obliquity During Standing and Walking in Adolescent Idiopathic Scoliosis with Lumbar Curvature
SHI Weihong, CHEN Lixia, YUAN Wangshu, ZHANG Yuhang, ZHANG Houqiang, ZHANG Huiling, YANG Yuying, LU Jiandong
2024, 15(1): 124-129. doi: 10.12290/xhyxzz.2023-0447
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  Objective  To evaluate the severity and features of pelvic coronal plane tilt in individuals with adolescent idiopathic scoliosis (AIS) who had lumbar curvature during the gait cycle.  Methods  AIS patients with lumbar curvature and patients with microcurvature (Cobb Angle less than 10 degrees) treated in Peking Union Medical College Hospital from September 2020 to February 2023 were retrospectively included. According to PUMC conservative classification system and Spinal Full-length Standing X-ray, AIS patients with lumbar curvature were enrolled. The bilateral iliac crest was used as the bony marker of the pelvic coronal surface, and the bilateral iliac crest height and its changes were measured during the standing position and walking cycle, so as to evaluate the degree of pelvic coronal tilt in AIS patients with lumbar curvature.  Results  A total of 209 AIS patients with lumbar curvature and 36 patients with microcurvature who met the inclusion and exclusion criteria were enrolled. The proportion of AIS patients with lumbar curvature who had a "congruent" relationship between the higher iliac crest and the convex side of the spine in standing position (iliac crest lower on the convex side than on the concave side) was significantly higher in AIS patients with lumbar curvature than patients with microcurvature(58.9% vs. 30.6%, P=0.002). AIS patients with lumbar curvature had statistically different bilateral iliac crest height change values throughout the gait cycle (including minimum, maximum, swing phase minimum, and swing phase maximum) (all P < 0.001), and the iliac crest height change values on the convex side were significantly higher than those on the concave side (all P < 0.05), whereas the patients with microcurvature did not have any statistically significant bilateral iliac crest height change values throughout the gait cycle (all P > 0.05).  Conclusion  The height of the iliac crest on the convex side of the lumbar spine is lower than that on the concave side in the standing position of AIS patients with lumbar curvature, and the value of the change of the iliac crest on the convex side of the pelvis is greater than that on the concave side in walking to maintain the balance of the body, which may provide a new direction for the intervention in the clinical rehabilitation treatment of AIS patients with lumbar curvature.
Reviews
Early Efficacy Assessment of Targeted Therapy for Crohn's Disease by Ultrasound
QIN Jing, ZHU Qingli
2024, 15(1): 130-134. doi: 10.12290/xhyxzz.2023-0306
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Crohn's disease (CD) is a chronic inflammatory bowel disease with complicated pathogenesis and prolonged condition. In recent years, with the development of targeted therapy, biological agents have been widely used in the treatment of CD, which has significantly improved the prognosis of CD patients. If the efficacy evaluation can be carried out at the early stage of targeted therapy, it may help to figure out the patients who can benefit from the treatment and optimize the treatment plan for the ineffective patients in time. In the evaluation of CD activity and efficacy, ultrasound has the advantages of high accuracy, no radiation and high patient acceptance, and therefore has potential clinical application value in the early efficacy evaluation of CD targeted therapy. This article reviews the research progress to provides a reference for optimizing the treatment plan for CD patients.
Current Status and Prospects of Radiation Therapy Guided by Optical Surface Monitoring Technology
SHEN Jing, CHEN Wanqi, HOU Xiaorong, QIU Jie
2024, 15(1): 135-140. doi: 10.12290/xhyxzz.2023-0287
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Surface guided radiation therapy (SGRT) is a non-radiation, non-invasive technology that provides continuous postural monitoring of patients during radiotherapy. Using advanced 3D optical surface localization and tracking technology, SGRT quickly captures the surface contour information of patients through optical means to generate high-precision 3D surface contours, enabling real-time monitoring of patients during radiotherapy to ensure its accuracy. This image-guided technology has been widely applied in radiotherapy for tumors in different parts of the body, such as breast, intracranial, head and neck, and limbs. SGRT can reduce initial setup errors and provide real-time monitoring during treatment, or be combined with respiratory gating and deep inspiration breath-hold techniques. SGRT can also reduce radiation dose by reducing the use of CBCT, improve patient comfort with the use of immobilization devices, and enhance clinical speed, efficiency, and safety. This review aims to provide an overview of the commonly used technology and clinical applications of SGRT, and discuss its current limitations and future prospects.
Research Progress on the Role of HMGB1 in Regulating the Function of Osteoarthritis Chondrocytes
QI Xin, ZHANG Xiaogang, YU Haiyang, CHEN Xin, AN Wenbo, WANG Zhipeng, WANG Duoxian, LUO Pengfei, CHEN Yixin, MA Jiaojiao, QI Wei, HU Ziyang, LIU Jianjun
2024, 15(1): 141-146. doi: 10.12290/xhyxzz.2023-0269
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Osteoarthritis (OA) is a chronic degenerative joint disease whose main characteristic is the destruction of articular cartilage, causing pain and disability in patients and seriously affecting their quality of life. OA can be induced by a variety of causes, and pathological changes in articular cartilage are considered to be one of the key driving factors for the occurrence of OA. High mobility group box-1 protein (HMGB1), as a non-histone protein in eukaryotic cells, can participate in regulating the inflammation and apoptosis process of OA chondrocytes, thus leading to the occurrence of OA. This article reviews the research on the mechanism of HMGB1 in OA chondrocytes, with a view to providing new ideas for the clinical prevention and treatment of OA.
Research Progress on Emerging Signaling Pathways Related to Muscle Bone Symbiosis
LIU Yandong, DENG Qiang, ZHANG Yanjun, LI Zhongfeng, PENG Randong, GUO Tiefeng, WANG Yurong, CHEN Bo
2024, 15(1): 147-152. doi: 10.12290/xhyxzz.2023-0277
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Osteoporosis is a systemic metabolic bone disease characterized by decreased bone mass, damage to bone tissue microstructure, increased bone fragility, and susceptibility to fractures, while sarcopenia is a syndrome characterized by progressive reduction in overall muscle mass and functional decline. Based on the common pathophysiological mechanism and close correlation between the two, the concept of "osteosarcopenia" has gradually emerged to describe the simultaneous attenuation of muscles and bones. Signaling pathways serve as important signal transmission channels between muscles and bones, and if abnormal, they can lead to osteosarcopenia. The aim of this article, therefore, is to review the signaling pathways related to osteogenesis and myogenesis, such as Hedgehog, Hippo, mTOR, MAPK, in order to provide new ideas for targeted treatment of osteosarcopenia.
Role of Neutrophil Extracellular Traps in Chronic Obstructive Pulmonary Disease
XU Jinhui, YUE Hongmei, LIU Miaomiao, LI Yating, WU Xingdong, ZHU Haobin
2024, 15(1): 153-159. doi: 10.12290/xhyxzz.2023-0396
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Chronic obstructive pulmonary disease (COPD), a respiratory disease characterized by inflammation due to neutrophil infiltration, has become the third leading cause of death worldwide. After the occurrence of COPD, the persistent accumulation of neutrophils can promote the excessive formation of neutrophil extracellular traps (NETs), which plays an important role in local capture and clearance of pathogens, rapid control of infection, and immune regulation. This article mainly introduces the mechanism of COPD occurrence and NETs formation as well as the research progress of NETs in COPD, and summarizes the relevant drug targets for COPD treatment based on NETs, aiming to provide a reference for further research.
Mechanism of Epithelial-mesenchymal Transition Leading to Gastric Cancer Induced by Helicobacter pylori
SUN Zhencan, ZHOU Jukun, XU Yunpeng, WANG Jun, ZHENG Ya, WANG Yuping, JI Rui
2024, 15(1): 160-165. doi: 10.12290/xhyxzz.2023-0341
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Helicobacter pylori (Hp) is a unipolar, microaerobic, multiflagellar, spiral-shaped Gram-negative bacterium that survives and colonizes human gastric mucosa. As a classⅠcarcinogen associated with gastric cancer, long-term stimulation of gastric mucosa by Hp can cause atrophic gastritis, peptic ulcer, gastric cancer and gastric mucosa-associated lymphoid tissue lymphoma. It has been reported that Hp can cause epithelial-mesenchymal transition (EMT) in gastric epithelial cells, thereby inducing gastric cancer. We review the mechanism of Hp-induced EMT in gastric epithelial cells, in order to provide new insights for early diagnosis and targeted therapy of gastric cancer.
In Vitro Production of Red Blood Cells: Progress and Challenge
WANG Hui, ZHANG Jinjin, CHEN Lili, XING Yanchao
2024, 15(1): 166-171. doi: 10.12290/xhyxzz.2023-0299
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Although blood protection technologies such as autologous blood transfusion can alleviate to some extent the short supply of clinical blood, red blood cells are still in great demand as the main blood component. This problem can be solved by the safe production of red blood cells in vitro. At present, mature erythrocytes can be differentiated from embryonic stem cells, human induced pluripotent stem cells, umbilical cord blood, peripheral blood, and immortalized erythroid progenitor cell lines. This article reviews the sources and applications of red blood cells produced in vitro, and analyzes the current challenges, in order to provide new insights for blood transfusion therapy.
Clinical Research and Evidence Based Medicine
Multi-evidence Integration Methodology for Traditional Chinese Medicine: the MERGE Framework
LAI Honghao, WANG Zhe, LI Ying, TANG Wenjing, WANG Beibei, SUN Peidong, SUN Mingyao, HUANG Jiajie, XIAO Zhipan, ZHAO Chen, SHANG Hongcai, YANG Kehu, LIU Jie, GE Long
2024, 15(1): 172-182. doi: 10.12290/xhyxzz.2023-0083
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In the era of evidence-based medicine, it is necessary to explore the unique advantages of traditional Chinese medicine (TCM) based on standardized technical methods and operating procedures in order to achieve the modernization and internationalization of TCM and benefit all humanity. The proposal of a three-pronged evidence system combining TCM theory, human experience and experimental evidence marks an important progress in the thinking method of the TCM evaluation system. The multi-evidence body integrated through appropriate methods provides a strong support for the clinical guideline recommendations and evidence-based health decision-making in TCM. Based on the current methodological progress of international evidence synthesis and grading, this paper proposes a novel approach for integrating multi-evidence in TCM: the MERGE framework. The aim is to establish a solid foundation for the development of this methodology and provide guidance for the advancement of evidence-based medicine framework in TCM.
Methods for Developing Rapid and Living Evidence-based Guidelines
TIAN Chen, YANG Qiuyu, SUN Mingyao, LIU Jie, TIAN Jinhui, CHEN Yaolong, YANG Kehu, GE Long
2024, 15(1): 183-191. doi: 10.12290/xhyxzz.2023-0191
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The aims of developing rapid and living guidelines is to keep the recommendations in the guideline up-to-date. Compared with the conventional guideline, the rapid and living guideline can make better use of the existing evidence and apply and transform the evidence in a timely manner. This paper introduces the advantages and usage of rapid and living guidelines, the development process and existing challenges, and offers some insights, in order to provide reference for domestic organizations and scholars engaged in guideline development.
Clinical Practice Guidelines
Analysis of the Current Status of China's Adaptation Guidelines
WANG Ling, REN Yaxuan, LUO Xufei, ZHU Di, LI Zhewei, WANG Ye, WANG Bingyi, ZHANG Huayu, YANG Shu, CHEN Yaolong
2024, 15(1): 192-201. doi: 10.12290/xhyxzz.2023-0545
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  Objective  To analyze the current status of the development of adaptation guidelines in China, as well as their methodological quality and the reporting quality, in order to provide reference for the development of adaptation guidelines.  Methods  We searched and collected adaptation guidelines led by Chinese researchers or institutions from 2015 to 2023 from four electronic databases, China National Knowledge Infrastructure, WanFang Data Knowledge Service Platform, SinoMed and PubMed, extracted the basic information of the adapted guidelines, and assessed their methodological quality and reporting quality using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) Ⅱ and RIGHT-Ad@pt tools.  Results  A total of 14 adaptation guidelines were included, mainly focusing on nursing (42.9%, 6/14), with the most frequently used adaptation method of ADAPTE (71.4%, 10/14), and with reference to pre-existing guidelines mainly from the United States, the United Kingdom, and international organizations. Assessment by the AGREE Ⅱ tool showed that the average methodological quality score of the adapted guidelines was 36.6%. The scores were relatively high in the domains of clarity of expression and rigor of formulation (44.4% and 54.9%), and lowest in the domain of applicability (15.3%). The results of the RIGHT-Ad@pt tool showed that the reporting quality of the adaptation guidelines was relatively good, with the highest reporting rate of 91.2% and the lowest of 35.3%, and the reporting rates of seven articles were higher than 70%.  Conclusions  Adaptation guidelines in China are still in their infancy, with a relatively small number and mainly focusing on the nursing field. The most commonly used adaptation method is the ADAPTE method. The methodological quality and reporting quality of adaptation guidelines need to be further improved, and more research should be conducted on the specific conditions and timing of adaptation guidelines development.
Health Standards
Management and Development of Health-related Standards in Nations and Organizations: An Evidence-based Review
HE Hongfeng, TIAN Qiannan, ZHOU Qi, ZHAO Junxian, SU Renfeng, LI Zhewei, LIU Hui, YANG Nan, CHEN Yaolong, WU Liqun, WANG Xiaohui
2024, 15(1): 202-210. doi: 10.12290/xhyxzz.2023-0449
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  Objective  To promote the development of high-quality health standards in China and summarize the characteristics of global health standards management systems and development processes.  Methods  We conducted a systematic search of relevant databases and the websites of standardization institutions. A descriptive method was used to analyze the basic characteristics of the standard management systems and development processes.  Results  The majority of the investigated countries and organizations primarily implement voluntary standards, with the exception of Chinese and the European Committee for Standardization that enforce compulsory standards. All countries and organizations have health standards at the national, group, and enterprise levels. In China and Japan, standards authorities are subordinate to the government, while in other countries or organizations, they operate as independent civil societies. The development process for health standards generally involves five stages: "Project/Proposal → Draft → Enquiry → Review → Publication". However, the specific steps in the development of health standards vary across different countries and organizations. Furthermore, China ranks high in the number of both standards and health standards issued, but the proportion of health standards is only 2.06%.  Conclusions  There are significant differences between China and other countries in terms of the management system and development process of health standards. To promote the management and development of high-quality health standards in China, we recommend promoting the coordination mechanism for standard development, increasing efforts to publicize standards and evaluate the implementation effect, strengthening the construction of personnel for the development of health standards, optimizing the efficiency of standard development and improving the internationalization level of health standards.
Growth and Active Health
Proactive Health Model Integrating Sports, Health and Education Is an Important Tool for Chronic Disease Prevention and Control in Adolescents
PAN Hui, ZUO QingYi, YANG Xiao, CHEN Shi, ZHAO Li
2024, 15(1): 211-216. doi: 10.12290/xhyxzz.2023-0658
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Since the convening of the 19th National Congress of the Communist Party of China, public health of the Chinese has significantly improved, but chronic diseases have hindered its further development. Proactive health is a positive approach to health management, with an emphasis on the prevention of diseases through a healthy lifestyle, which is of great significance to chronic disease prevention and control. Chronic diseases are becoming more prevalent among young age groups in China; thus, it is necessary to advance chronic disease prevention to adolescence. The implementation of proactive health has marked effects on chronic disease prevention and health promotion in adolescents. The integration of sports, health and education is an important way to promote the implementation of proactive health in adolescents and facilitate their healthy development. However, the integration is still insufficient, so synergistic development of the three fields is needed to improve relevant measures and optimize the effects of proactive health on adolescents.
Complicated and Rare Disease
Successful Treatment of A Patient with Chronic Myeloid Leukemia Complicated by Cerebral Hemorrhage Manifesting as Platelet Abnormal Elevation
ZHANG Xin, ZHANG Xiao, GUO Yi, FENG Jun, XIAO Zhiyuan, XIE Zhaoxiang, WU Jing, XU Dongrui, WEI Junji, WANG Yu
2024, 15(1): 217-222. doi: 10.12290/xhyxzz.2023-0377
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Platelet elevation is a rare manifestation in the peripheral blood of patients with chronic myeloid leukemia (CML). In this paper, we report for the first time a case of CML combined with cerebral hemorrhage manifested by abnormally elevated platelets. The patient had elevated platelets in the peripheral blood, showed normal coagulation function, and underwent intracranial hematoma removal due to cerebral hemorrhage. After the operation, bleeding from the operated area and other systems occurred, and the patient was diagnosed as having accelerated CML after combining bone marrow biopsy and genetic testing. His condition was controlled after administration of flumatinib through a jejunal tube. Based on this patient's experience, the feasibility ofadministering flumatinib via a jejunostomy tube was determined, which is the first report of its kind in China and abroad.This article summarizes the diagnosis and treatment process of this patient, with the aim of providing a warning and reference for clinicians.
Teaching and Research
Investigation on Clinical Oncology Teaching Among Medical Students
ZHANG Zhiyang, ZHAO Lin, SHAO Yajuan, WANG Xiang, LI Ningning, NING Xiaohong, GE Yuping
2024, 15(1): 223-228. doi: 10.12290/xhyxzz.2023-0103
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  Objective  To investigate the needs of eight-year program clinical medical students for the organization and contents of clinical oncology courses.  Methods  From September to November 2020, a questionnaire survey was conducted among eight-year program clinical medicine students in Peking Union Medical College to find out their knowledge base in oncology, teaching mode preference and course contents of interest.  Results  A total of 122 students participated in the survey, in which 89.3%(109/122) of the students showed interest in basic and clinical research projects related to oncology, 84.4%(103/122) thought it was better to use Simulation-based medical education (SBME), and 91.0%(111/122) hoped to learn throughoff-line discussion. In terms of course contents, eight-year program medical students were more interested in knowledge directly related to clinical context, such as diagnosis, treatment, multidisciplinary comprehensive treatment and evidence-based medicine. In terms of sub-analysis, traditional eight-year students (86%, 92/107) showed a higher acceptance of palliative care than students in the 4+4 reform program(60%, 9/15) and were more willing to act as scriptwriters in SBME(26% vs. 7%, P=0.013). The students in clinical phase gained a better understanding of oncology knowledge through research training and were more inclined to take on the role of scriptwriters in SBME than those in basic phase (27% vs. 11%, P=0.048).  Conclusions  The eight-year program clinical medical students are interested in the clinical oncology course and prefer study in the form of Simulation-based medical education (SBME).
History of Medicine
Introduction and Production Plan of Insulin by Internal Medicine Department of Peking Union Medical College Hospital
GU Xiaoyang
2024, 15(1): 229-232. doi: 10.12290/xhyxzz.2023-0183
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Insulin was introduced to China in 1923. Before it entered China, the Internal Medicine Department of Peking Union Medical College Hospital(PUMCH) had actively introduced insulin and planned to produce the drug in China. On the occasion of the 100th anniversary of the introduction of insulin into China, the author accessed the archives of Peking Union Medical College(PUMC), the medical journals, the annual report of PUMCH, and other historical materials to trace this little-known history. The aim is to enrich the history of medicines, the history of diabetes, and the history of the PUMC and PUMCH.
2024, 15(1): 233-234. doi: 10.12290/xhyxzz.2023-0598
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2024, 15(1): 235-236. doi: 10.12290/xhyxzz.2023-0639
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