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缓和医疗:一门“柔性”学科

北京协和医学院“4+4”医学试点班2021级 李一林

缓和医疗的兴起不仅是医疗体系发展所需,更是对每一个生命的敬畏和尊重。医学有时代无法突破的技术局限性,医生和患者面对无法治愈的疾病时常常存在无力感。而此时,缓和医疗作为一种选择,提醒着我们,医学的使命不仅仅是对患者的施救,还包括对患者痛苦的细微体察和人文关怀。正如特鲁多墓志铭所阐述的那样——有时是治愈,常常是帮助,总是去安慰。

为展现本期主题“缓和医疗理论与实践”的丰富内涵,封面设计最终采用写意与写实结合的方式呈现。画面主体以医护人员双手紧握因疾病消耗而骨瘦嶙峋的患者之手,传达对患者的安慰和关爱,这是临床工作中经常用到的肢体语言,借此展现缓和医疗的理念和本源:以患者为中心,医护主动参与的帮助、照护和关怀。画面背景以一条常青藤环绕,是抽象的蛇杖形象,柔韧的藤蔓展现出缓和医疗中的“柔性”。藤蔓从左至右分别生长着春、夏、秋、冬四个季节的代表性花朵和叶子,可入中药的辛夷代表疗愈,向日葵代表希望,雏菊代表健康长寿与淡然祥和的心态,霜雪中傲然盛开的腊梅象征生命的坚忍,串联起来既代表时间的变换、生命的周期,也代表疾病的历程,同时象征着缓和医疗在疾病不同阶段丰富多元的实践形式。

希望本期封面可以增进更多医务人员和大众对缓和医疗丰富内涵的认识,从而更好地将理念付诸实践,提高患者的生命质量!

Vol. 15, No. 1 30 01 2024
Chinese Bimonthly CN 11-5882/R ISSN 1674-9081
Articles in press have been peer-reviewed and accepted, which are not yet assigned to volumes /issues, but are citable by Digital Object Identifier (DOI).
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Abstract: 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. Patient-controlled analgesia has been used in Peking Union Medica College Hospital since 1994, and the Acute Pain Service Working Group has been established since 2004. Under the cooperation of anesthesiologists specialist nurses, the group jointly implemented the whole process and standardized management based on patient-controlled analgesia, and constantly improved and innovated working methods, which has laid 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 a view of providing valuable references for comprehensively strengthening the pain management in the process of diagnosis and treatment, and enhancing patients' satisfaction with perioperative analgesia services. more>
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Abstract: Objective To investigate the expression and significance of cell surface receptor signaling lymphocyte activation molecule receptor 7 (SLAMF7) in normal intestinal tissues and intestinal inflammatory tissues of mice. Methods Five C57BL/6J wild-type male mice aged 8-10 weeks were taken and fed normally. Lamina propria lymphocytes (LPLs) and intestinal epithelial cells (IECs) were extracted, and total cell RNA was extracted by Trizol reagent. The mRNA expression of SLAMF7 in cells was detected by reverse transcription polymerase chain reaction (RT-PCR) and real-time fluorescent quantitative polymerase chain reaction (RT-qPCR). Ten C57BL/6J wild-type male mice aged 8-10 weeks were randomly divided into control group (n=5) and model group (n=5). The control group was fed with normal drinking water for 5 days, the model group was fed with 2.5% dextran sodium sulfate (DSS) drinking water for 5 days to establish a model of ulcerative colitis(UC), and the mice in both groups were killed on the 5th day. Flow cytometry was used to detect the expression of SLAMF7 in immune cell subpopulations in the control group and the model group. Results Compared with colonic IECs, the expression of SLAMF7 was higher in colonic LPLs (P=0.017). After DSS induced enteritis, the expression of SLAMF7 was up-regulated in neutrophils (P=0.001), but had no significant changes in CD4+T cells, CD8+T cells, B cells, macrophages and conventional dendritic cell (all P>0.05). Conclusion SLAMF7 may play a certain role in the occurrence and development of UC through neutrophilrelated pathways. more>
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Abstract: Adaptive design, with advantages such as dynamically adjusting trial plans, reducing resource waste, and improving trial efficiency, has broken through the competitive situation of new drug development and gradually met the needs of clinical research. In recent years, the use of adaptive design in platform trials as an innovative research model has added impetus to new drug development. This article briefly outlines the research progress , content and characteristics, common design types, statistical analysis, and case interpretation of adaptive design, introduces the concept, types, and applications of adaptive platform trials, in the hope to provide scientific references for further exploration of clinical trials and new drug development. more>
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Abstract: Gastric cancer is one of the most common malignant tumors in the world. Patients with gastric cancer often use surgery, radiotherapy, chemotherapy and immunotherapy, but the clinical efficacy and prognosis are poor. As an important member of ADAMs family, the expression of a disintegrin and metalloprotease 17 (ADAM17) in gastric cancer is significantly higher than that 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 is expected 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. more>
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Abstract: National health standards are 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, within the scope of responsibilities for matters that need to be regulated uniformly across the country. The establishment of health standards in China should align with the country's 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 the 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 involved, and proposes reflections and recommendations. more>
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Abstract: In April 2023, the 《Circulation Journal》 published the paper titled “JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis”, which aims to provide clinicians with recommendations for the diagnosis and treatment of myocarditis. The definition and classification, epidemiology, pathophysiology, diagnosis, diagnostic process, treatment, and management of myocarditis are interpreted in a new way. In view of the lack of guidelines on myocarditis in China recently, this article intends to interpret the main points of the 2023 JCS guidelines based on the latest research progress on myocarditis, hoping to attract the attention of clinicians interested in myocarditis in China and improve the level of diagnosis and treatment of myocarditis. more>
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Abstract: Immune checkpoint inhibitors (ICIs) have been approved for the treatment of uroepithelial carcinoma, 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 pathways. and may affect the clinical efficacy of ICIs through different pathways, making it difficult for patients to derive clinical benefit or 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 uroepithelial carcinoma, with a view to providing a reference for the application of individualised treatment strategies of ICIs in patients with advanced UC. more>
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Abstract:

Missing data commonly occur in clinical trials due to various reasons. The occurrence of missing data will cause information loss of the original data, and reduce the robustness and validity of the research results. Therefore, how to adequately deal with missing data should be considered with caution in clinical trials. This article introduces the causes and types of missing data, as well as several common methodological approaches to addressing missing data, aiming to promote researchers’ understanding and improve the quality of handling missing data in trials. Nevertheless, the best way to deal with missing data is to prevent or reduce the occurrence of data being missing in clinical trials, rather than relying on post hoc statistical analyses.

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Abstract: 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 quantitatively evaluating baroreflex reflex function. Pain sensitivity is negatively correlated with BRS, and BRS has potential application prospects in pain risk prediction and therapeutic efficacy assessment. Vagus nerve stimulation (VNS) can activate the baroreceptor reflex and 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 a view to providing references for further exploring treatment to regulate baroreceptor reflex function in pain treatment. more>
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Abstract: Objective To explore the mechanism of Wnt5a on keratinocyte involved in the peripheral sensitization of complex regional pain syndrome type-1 by regulating the expression of MMP9, and thus to search for potential therapeutic strategies. Methods 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 has been established to mimic the pathophysiological process of CRPS-1, Box5(20) group and Box5(40) group were treated with intraplantar injection of 20 mol/L and 40 μmol/L Box5 100μL, respectively. Cultured HaCaT cells were treated with oxygen glucose deprivation/reoxygenation (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 (20umol/L, 40umol/L) on MMP9 were explored. 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 After OGD/R treatment, the mitochondrial atrophy was observed in OGD/R group under transmission electron microscope and the average fluorescence intensity of MMP9 increased 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). 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 number of inflammatory cell infiltration in the dermis and excessive keratosis in the epidermis, 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. Conclusion Peripheral ischemia reperfusion injury leads to overexpression of MMP9 on keratinocytes, resulting in CRPS-1 type peripheral sensitization. Targeted inhibition of Wnt5a/MMP9 pathway can reverse pain behavior in rat model of CPIP, and thus providing a strategy for clinical treatment of chronic pain. more>
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Abstract: Systematic reviews are the basis of evidence-based medical research, and high-quality systematic reviews represent the highest level of evidence for evaluating treatment effects. Traditional systematic reviews are mainly done manually, especially the reading and screening of massive literature requires a lot of energy and time for clinicians, and the efficiency is low, which cannot meet the needs of rapid decision-making. This article systematically sorts out existing automated tools for systematic review literature screening, and analyzes their respective performance, characteristics, and usage to understand the current development status of this field and provide reference for related research and applications. more>
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Abstract: Objective To explore the clinical effect, safety and effectiveness of ultrasound-guided rhomboid intercostal and subserratus plane (RISS) block for postoperative analgesia after minimally invasive McKeown esophagectomy (MIE-McKeown), and provide new ideas for the selection of postoperative analgesia programs for minimally invasive esophageal cancer surgery patients. Methods: A prospective randomized controlled study design was used to collect 96 patients undergoing MIE-McKeown in the Department of cardiothoracic surgery of Fuling Hospital of Chongqing University from March 2022 to June 2023 were prospectively collected as research objects, They were divided into three groups by random number table method: Group A: continuous RISS plane block+patient controlled intravenous analgesia (PCIA), Group B: single RISS plane block+PCIA, Group C: control group, simple PCIA, with 32 cases in each group. The outcome indicators of each group were recorded and compared: ①Analgesic effect [visual analogue scale (VAS) pain score for rest and cough at 2, 6, 12, 24, and 48 hours after surgery], ②Postoperative use of analgesics [the amount of sufentanil used within 24 hours after surgery, the number of effective presses of the analgesia pump and the number of additional rescue analgesia], ③Adverse reactions during postoperative analgesia [dizziness, lethargy, postoperative nausea and vomiting(PONV), hypotension, respiratory depression, urinary retention, etc.], ④Intraoperative hemodynamic indicators [mean arterial pressure (MAP) and heart rate (HR) at different time points], ⑤Analgesia satisfaction. ①②③ were the primary outcome indicator, and ④⑤were the secondary outcome indicator. Results: Group A patients had lower resting and cough VAS scores at 2, 6, 12, 24, and 48 hours after surgery compared to Group C. Group A had lower resting VAS scores at 2, 24 hours after surgery and lower cough VAS scores at 12, 24 hours after surgery compared to Group B. Group B patients had lower resting VAS scores at 2, 6, 12 hours after surgery and lower cough VAS scores at 2, 6, 12, 24, and 48 hours after surgery compared to Group C, with statistically significant differences (P<0.05). The dosage of sufentanil, the number of effective compressions of the analgesic pump, and the additional number of remedial analgesia gradually increased between groups A, B, and C within 24 hours after surgery, with statistical differences (P<0.05). The incidence of dizziness and PONV in Group C was higher than that in Groups A and B, respectively (P<0.05). There were no statistically significant differences in MAP and HR among the three groups of patients before anesthesia induction (T0), immediately after skin incision (T1), 5 minutes after skin incision (T2), and 5 minutes after extubation (T3) (P>0.05). The satisfaction with pain relief in Group A, Group B, and Group C decreased sequentially. Conclusion: Ultrasound guided RISS block can provide good postoperative analgesia for MIE-McKeown surgery. As an active exploration of multimodal analgesia, continuous RISS has better analgesic effects, is safe and effective, and is worthy of further clinical promotion and use. more>
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Abstract: “Target trial emulation” (TTE), as a new framework in real-world research, was formally established in recent years and 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 emulate a corresponding randomized controlled trial (RCT) using real-world data, following the principles of an RCT, to draw conclusions about the causal relationship between interventions and outcomes. The main implementation tips of TTE can be summarized as “3-7-2”: formulating the causal question, designing the emulation plan, and emulating the target study; considering the design elements including eligibility criteria, treatment strategies, intervention allocation, follow-up period, outcome, causal contrast of interest, and analysis plan; and controlling immortal time bias and prevalent user bias. In this article, we provide 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. more>
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Abstract: Objective This study aims to analyze the research trends and cutting-edge hot spots in the field of multimorbidity in older adults from 2000 to 2023. Methods We conducted a search in the Web of Science Core Collection database, specifically looking for articles or reviews in English literature on multimorbidity in older adults published between January 1, 2000, and October 24, 2023. VOSviewer 1.6.18 software was used to extract the content in the literature and to draw the cooperative network diagram of countries(regions) and institutions and the timeline diagram of keyword co-occurrence relationship. CiteSpace 6.1.R6 software was used to co-occur and cluster analyse the information of authors, research institutions and countries(regions). The "bibliometrix" package in R was used to analyse the evolution of keywords in the literature. Results A total of 2590 documents were obtained, consisting of 2230 Articles and 360 Reviews. The worldwide publication count has significantly increased since 2000. Among the countries(regions), the United States has the highest number of publications (907 articles, accounting for 35.02% of the total) and total citations (31,343 times) in this field. In terms of institutions, the University of Toronto stands out with 67 articles (2.59%) as the top contributor. McMaster University's author, Jenny Ploeg is recognized as the most prolific authors, having published 32 articles (1.24%). When it comes to journals, BMC Geriatrics has the highest amount of literature related to multimorbidity (99 articles). The key areas of research in this field include multimorbidity, older adults, frailty, aging, and polypharmacy. Notably, there is growing interest in studying the relationship between multimorbidity and aging in older adults, as well as the impact of frailty and polypharmacy on multimorbidities. Conclusions In recent years, research on multimorbidities in the elderly has primarily centered around examining the correlation between comorbidities and aging, as well as exploring the impact of frailty and polypharmacy on individuals with multimorbidities. Future research could potentially delve into the significance of primary health care and comprehensive geriatric assessment in effectively managing comorbidities among older adults, while also emphasizing the importance of maintaining their overall quality of life. more>
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Abstract: In view of the limitations of traditional pancreatobiliary endoscopy technology, which include capturing image information that is time-consuming, inefficient, and susceptible to endoscopists proficiency, the new diagnosis and treatment pattern of artificial intelligence assisted pancreatobiliary endoscopy has been providing a potential solution. Artificial intelligence technology provides an efficient and accurate method for pancreatobiliary endoscopy to automatically recognize images, which can aid endoscopists to achieve rapid and accurate clinical prediction and guide clinical decision-making. Meanwhile, artificial intelligence has great potential of development 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, hoping to provide new ideas and methods for improving the current clinical diagnosis and treatment pattern and realizing precision medicine for pancreatobiliary diseases. more>
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Abstract: Ischemic stroke is a cerebrovascular disease with high incidence, high mortality, high disability rate and high recurrence rate, which is an important cause of death and disability of middle-aged and elderly people in China, and brings 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, finding 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 related to obstructive sleep apnea, in order to reveal the potential pathological mechanism of ischemic stroke caused by obstructive sleep apnea. more>
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Abstract: Objective To analyze the methodological and reporting quality of systematic reviews of prediction models published in Chinese journals, with the aim of providing references for enhancing the quality of Chinese systematic reviews of prediction models. Methods Chinese systematic reviews of prediction models were electronically searched in CNKI, WanFang Data, CBM, and VIP databases from inception to July 20, 2023. Two independent reviewers screened literature, extracted data, and used the AMSTAR and PRISMA 2020 tools to assess methodological and reporting quality of the included reviews. Results A total of 55 systematic reviews published between 2015 and 2023 were included, with 12 of them being meta-analyses. These reviews encompassed a range of topics, with a primary focus on cardiovascular diseases, stroke, and diabetes. The identified systematic reviews exhibited obvious deficiencies in some areas, including items 1, 4, 5, 6, and 10 of AMSTAR, as well as items 7, 10a, 12, 13a-f, 14, 15, 16a-b, 17, 20b-d, 21, 22, 23d, 24a-c, 25 and 26 of PRISMA 2020. Furthermore, a moderate positive correlation (r = 0.58, P < 0.001) was observed between the methodological and reporting quality. Multiple linear regression analyses revealed: greater number of pages, more recent publications, and funding support were associated with higher methodological quality (P < 0.05). Similarly, greater number of pages, more recent publications, qualitative systematic reviews, and funding support were associated with higher reporting quality, but the number of authors showed a negative association (P < 0.05). Conclusions The current systematic reviews of prediction models published in Chinese journals require enhancement in both methodological and reporting quality. more>
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Abstract: 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. This article briefly introduces MA Yueh-ch’ing’s personal experience and major achievement in anesthesiology based on the development and historical background of global anesthesiology. more>
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Abstract: Objective To establish and evaluate the clinical teaching and training model for refresher anesthesiologists. Methods 25 refresher anesthesiologists from the department of Anesthesiology during the period of March to September 2023 were enrolled. They received the clinical teaching and training model, namely “tutorial system-knowledge update-clinical practice”. The refresher anesthesiologists completed the same structured pre-designed questionnaire before the start 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 21/25 and 25/25 questionnaires distributed were completed before the start and the end of advanced training respectively. The mean score before the start was 5.6±1.8 points. And the mean score before the end of training was 10.1±1.1 points, which was significantly higher than that before the start(P<0.001). 92% students gave positive feedback. Conclusions The “tutorial system-knowledge update-clinical practice” clinical teaching and training model was useful to elevate the effectiveness of training refresher anesthesiologists and their satisfaction. more>
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Abstract: 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 casebased 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 cultivating students' high sense of responsibility and noble medical ethics, and realizing 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. more>
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Abstract:

Bone age is the most commonly used and effective indicator for understanding children's growth and development, and 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 can 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 bone age assessment using ultrasound. This article reviews the latest literature to discuss the value of musculoskeletal ultrasound and quantitative ultrasound in bone age assessment, and puts forward the problems in the study of ultrasound assessment of bone age and improve direction.

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Abstract: Artificial intelligence(AI) empowers the development of the medical industry, providing precise and intelligent assistance for clinical diagnosis, treatment, and rehabilitation.AI has the potential to facilitate shared decision making (SDM). AI interventions used for SDM are currently in their infancy, with new challenges and opportunities. Therefore, this paper describes the application of AI in SDM, explores the problems and challenges of AI-based decision aid used for SDM, and proposes possible solutions, aiming to provide a guide for the development and implementation of AI-based decision aid. more>
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Abstract: Objective This study explores the essential factors during the consensus process in guideline development, aiming to improve the quality of the consensus process by providing methodological suggestions for enhancing standardization. Methods Semi-structured qualitative interviews were used to interview guideline leaders, working groups and consensus groups to explore the relevant factors affecting the credibility of the consensus and their views on the composition and process of the consensus method. Results The researchers interviewed 26 individuals. After summarization, 212 codes were deepened into five areas:establishment of a consensus group, patient participation, meeting moderator, preparation of consensus and the influencing factors of consensus. Summarized the three basic steps of constructing a consensus group and the 17 basic principles of the application of the consensus method. Conclusion In the future guideline development, it is recommended to increase the methodological training before the consensus process and the full participation of methodologists, encourage experts to treat differences reasonably, pay attention to the methodology and evidence materials. The process should involve openly disclosing the selection of consensus group members, increasing patient participation, and managing and reporting conflicts of interest to reduce bias and enhance transparency, reliability, and scientific rigor of consensus outcomes. more>
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Abstract: The development of clinical practice guidelines involves a series of evidencebased decision-making processes, of which the formation of recommendations being a particularly challenging aspect. It demands decision-makers to have a thorough and precise understanding of the evidence, weigh the potential benefits and risks of interventions, and make value judgments and clinical choices. Compared to traditional approaches of presenting evidence information, the use of visualization tools can facilitate the communication and analysis of evidence, simplify information interpretation, and improve the efficiency of decision-making. Based on previous studies, this paper proposes a visualization tool, Vitruvian plot, for summarizing evidence and provides illustrative examples to demonstrate its usage and application effects, aiming to offer valuable guidance for researchers. more>
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Abstract: Objective This study aims to systematically assess the applicability of the clinical practice guidelines (CPGs) integrating Chinese and Western medicine, thereby providing a reference point for enhancing their future usability. Methods PubMed, Web of Science, Embase, SinoMed, WanFang Data, and CNKI databases were searched for guidelines for integration of Chinese and Western medicine, supplemented by searches of the Dangdang, Chinese Medical Association, Chinese Medicine Administration, MedSci websites, Website of China Association of Chinese Medicine, medlive, Chinese Association of Integrative Medicine and World Federation of Traditional Chinese Medicine Societies from inception 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, 39 (63.93%) 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 "communication", "ease of identification" and "applicability" were relatively poor. Notably, compared to guidelines published before 2016, those published between 2017-2022 showed improvements in the areas of “identification” and “application”. Conclusion 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, increasing the publicity of the guidelines, strengthening the application of the guidelines by clinicians, enhancing continuing medical education and training, presenting recommendations in a more concise form, and improving the implementability of the integrative Chinese and Western Medicine guideline. more>
Editorial
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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. more>
Specialist Forum
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Abstract: 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. more>
Specialist Forum
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Abstract: 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. more>
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Abstract: 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. more>
Specialist Forum
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Abstract: 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". more>
Specialist Forum
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Abstract: 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. more>
Specialist Forum
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Abstract: 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. more>
Opinions
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Abstract: 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. more>