Clinical assessment and management of liver fibrosis in nonalcoholic fatty liver disease

Non-alcoholic fatty liver disease(NAFLD)is among the most frequent etiologies of cirrhosis worldwide,and it is associated with features of metabolic syndrome;the key factor influencing its prognosis is the progression of liver fibrosis.This review aimed to propose a practical and stepwise approach to the evaluation and management of liver fibrosis in patients with NAFLD,analyzing the currently available literature.In the assessment of NAFLD patients,it is important to identify clinical,genetic,and environmental determinants of fibrosis development and its progression.To properly detect fibrosis,it is important to take into account the available methods and their supporting scientific evidence to guide the approach and the sequential selection of the best available biochemical scores,followed by a complementary imaging study(transient elastography,magnetic resonance elastography or acoustic radiation force impulse)and finally a liver biopsy,when needed.To help with the selection of the most appropriate method a Fagan′s nomogram analysis is provided in this review,describing the diagnostic yield of each method and their post-test probability of detecting liver fibrosis.Finally,treatment should always include diet and exercise,as well as controlling the components of the metabolic syndrome,+/-vitamin E,considering the presence of sleep apnea,and when available,allocate those patients with advanced fibrosis or high risk of progression into clinical trials.The final end of this approach should be to establish an opportune diagnosis and treatment of liver fibrosis in patients with NAFLD,aiming to decrease/stop its progression and improve their prognosis.

Clinical and Sonographic Assessment of Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

The purpose of this study was to assess the differences in clinical and sonographic features of papillary thyroid carcinoma（PTC） between cervical lymph node metastatic（CLNM） and nonmetastatic groups.Clinical data of PTC patients（414 patients with 624 malignant nodules） who underwent a preoperative ultrasonography and surgery between June 2010 and March 2015 at Renmin Hospital of Wuhan University were retrospectively analyzed.Clinical factors,preoperative ultrasound features and the final pathological findings were obtained.The differences in the sonographic features of PTC between the CLNM group and the non-CLNM group were analyzed.There were 187 CLNM and 227 non-CLNM patients.The median age at the diagnosis of this cohort was 45.4 years old（ranging from 18 to 77 years）.Ultrasonographic parameters that were significantly associated with CLNM [OR=2.569（1.502,4.393）,P〈0.001）] were as follows：the mulifocality of the nodules,size over 2 cm,the presence of microcalcifications,the distance ratio（DR） pattern showing the contact of the nodules with the thyroid capsule,and the extracapsular spread of the nodules.No significant differences in age,gender,thyroid stimulating hormone（TSH） levels and other ultrasonography parameters were found between the CLNM and the non-CLNM groups.Therefore,our results suggest that a larger size,microcalcifications,mulifocality,and the DR pattern showing the contact of the nodules with the thyroid capsule and extracapsular spread are significantly more indicative of CLNM in PTC.

Clinical nursing competency assessment:a scoping review

Objective:To ensure that only competent graduates are licensed to practice nursing,councils conduct licensing examinations,which may include among others clinical competency assessment.This review explored current practices in clinical competency assess­ment of nursing students as part of a larger study aimed at developing an evidence-based,context-specific framework for clinical competency assessment in a sub-Saharan African(SSA)country.Methods:A scoping guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews(PRISMA-ScR)was conducted.Results:Findings from 28 out of 1151 studies identified from Scopus,PubMed,CINAHL,Wiley Online Library,and ProQuest were included and synthesized.Results show that a good assessment system must be valid,reliable,transparent,feasible,fair,objective,and must provide feedback and continually improve to have an educational impact.Clinical competency assessment systems must be developed on sound empirical evidence,pilot tested,and involve thorough training and evaluation of the examiners.Continuous evaluation of the assessment system is also essential to ensure the quality and relevance of the assessment system.Only one of the included studies was conducted in Africa.Conclusions:The paucity of clinical competency assessment research in sub-Saharan Africa may lead to benchmarking assessment systems on research conducted outside the context.Sub-Saharan Africa has a set of circumstances that demand a context-specific clinical competency assessment framework to guide clinical competency assessment.

Effectiveness of Combined Application of Shock Index and Early Warning Scoring System in Patients with Acute Gastrointestinal Hemorrhage

Objective:To explore the effect of the combined application of the Shock Index(SI)and the Early Warning Score(EWS)in patients with acute gastrointestinal bleeding.Methods:Seventy patients with acute gastrointestinal bleeding admitted to a hospital from June 2022 to May 2024 were selected and randomly divided into two groups:the control group and the observation group,with 35 patients in each group.The control group received conventional emergency care measures,while the observation group received SI combined with NEWS emergency care measures.The treatment effects in both groups were compared.Results:The observation group had shorter waiting times for consultation(4.45±1.59 minutes),intravenous access establishment(6.79±2.52 minutes),hemostasis time(4.41±1.52 hours),and hospital stays(8.39±2.13 days)compared to the control group,which had times of 5.46±1.34 minutes,8.41±2.16 minutes,5.16±1.47 hours,and 10.26±2.98 days,respectively.The differences were statistically significant(P<0.05).Before management,there were no significant differences in the levels of hemoglobin,prealbumin,and serum protein between the two groups(P>0.05).However,after systematic emergency management,the serum indexes in both groups significantly improved,with the observation group showing greater improvement than the control group,and these differences were statistically significant(P<0.05).In the observation group,only one case of cardiovascular complications occurred during the rescue period,with an incidence rate of 2.86%.In contrast,the control group experienced eight cases of complications,including hemorrhagic shock,anemia,multi-organ failure,cardiovascular complications,and gastrointestinal rebleeding,with an incidence rate of 22.85%.The difference between the groups was statistically significant(P<0.05).Conclusion:The application of SI combined with EWS emergency care measures in patients with acute gastrointestinal hemorrhage can effectively improve serum indexes,shorten resuscitation time and hospital stay,and reduce the risk of complications such as hemorrhagic shock,anemia,infection,multi-organ failure,cardiovascular complications,acute renal failure,and gastrointestinal rebleeding.This approach has positive clinical application value.

Comparison of four clinical scores for the predicting lower limb deep venous thrombosis in Chinese patients

Objective：To evaluate Wells, Kahn, St.Andr 6 and Constans scores for the prediction of deep venous thrombosis in Chinese patients. Methods：One hundred and seventy-two patients, prospectively, blinded referred for evaluation with four clinical-score systems for suspected deep venous thrombosis, were examined by ultrasonography. Sensitivity, specificity, positive predictive value, negative predictive value and receiver operation curves were calculated for four clinical scores. The difference between areas of the ROC curve for each of the scores was compared with others and reference line. Results：Forty-six of 172 patients had deep venous thrombosis proven by sonography. The sensitivity, specificity, positive predictive value and negative predictive value for Wells score was 91.3%, 57.1%, 43.8% and 94.7%, respectively, for Kahn score; 65.2%, 71.4%, 45.5% and 84.9%, respectively, for St.Andr 6 score; 63%, 38.9%, 27.4% and 74.2% respectively, for Constans score; 95.7%, 34.9%, 34.9% and 95.7% respectively. Area under ROV curve of Constans score was 0.814, which was similar to that of Wells score, then followed by Kahn score and that of St.Andr 6 score was no difference with the reference line. Conclusion：Based on the results of our study, the sensitivity, negative prediction value and area under ROC curve are larger for Constans score and Wells score in Chinese hospitalized patients than that of Kahn score or St.Andr 6 score. Considering the aim of the clinical assessment, Constans score and Wells score are more efficient for Chinese hospitalized patients.

COVID-19 and hepatorenal syndrome

Coronavirus disease 2019(COVID-19)is a highly infectious disease which emerged into a global pandemic.Although it primarily causes respiratory symptoms for affected patients,COVID-19 was shown to have multi-organ manifestations.Elevated liver enzymes appear to be commonly observed during the course of COVID-19,and there have been numerous reports of liver injury secondary to COVID-19 infection.It has been established that patients with pre-existing chronic liver disease(CLD)are more likely to have poorer outcomes following COVID-19 infection compared to those without CLD.Co-morbidities such as diabetes,hypertension,obesity,cardiovascular and chronic kidney disease frequently co-exist in individuals living with CLD,and a substantial population may also live with some degree of frailty.The mechanisms of how COVID-19 induces liver injury have been postulated.Hepatorenal syndrome(HRS)is the occurrence of kidney dysfunction in patients with severe CLD/fulminant liver failure in the absence of another identifiable cause,and is usually a marker of severe decompensated liver disease.Select reports of HRS following acute COVID-19 infection have been presented,although the risk factors and pathophysiological mechanisms leading to HRS in COVID-19 infection or following COVID-19 treatment remain largely unestablished due to the relative lack and novelty of published data.Evidence discussing the management of HRS in highdependency care and intensive care contexts is only emerging.In this article,we provide an overview on the speculative pathophysiological me-chanisms of COVID-19 induced HRS and propose strategies for clinical diagnosis and management to optimize outcomes in this scenario.

Significance of Evidence-based Medicine in the Assessment of Chinese Medicine Clinical Efficacy

Evidence-base dmedicine （EBM） requires the integration of the best research evidence with our clinical expertise and our patient＇s unique values and circumstances. Thebest evidence is valid and clinically relevant, especially from patient-centered clinical research. The clinical expertise means the ability to use our clinical skills and past experiences to rapidly identify each patient＇s unique health state and diagnosis, their individual risks,

The Application of Assessment of the Quality of Life in the Clinical Efficacy Evaluation System and the Selection of Questionnaires of Chinese Medicine Treating Tumors

In China, CM has been applied to treat almost every cancer patient, especially during the observation period after surgery, routine radiotherapy and chemotherapy. Several decades of CM treatment results have shown that CM treatment could be helpful in improving patients＇ physical rehabilitation, relieving symptoms and strengthening immunity. CM also could aid in the decline of rates of recurrence and metastasis, prolong the survival time, and especially, have significant effects on relieving symptoms such as relieving fatigue, improving syndromes caused by conventional therapies （surgery, radiotherapy, chemotherapy and biological treatment）, and indescribable discomforts caused by the unknown reason. It has been found in several studies that conventional medical treatment combined with CM could significantly improve QOL, and reduce treatment-related and disease-related symptoms. Patients treated with CM and Western medicine have higher scores in the fields of psychology, society,

Phenobarbital Use as Adjunct to Benzodiazepines in the Treatment of Severe Alcohol Withdrawal Syndrome

Severe AWS （alcohol withdrawal syndrome） and AWD （alcohol withdrawal associated delirium） are common indications for intensive care unit admissions. Approximately 25% of patients with severe alcohol withdrawal require prolonged critical care hospital courses, often complicated by respiratory failure, need for mechanical ventilation due to administration of sedative continuous infusions and development of nosocomial infections. Although benzodiazepines are the mainstay of therapy for alcohol withdrawal, some patients exhibit benzodiazepine-refractory alcohol withdrawal. The use of phenobarbital as adjunct to benzodiazepines has been shown in studies to be effective in enhancing therapeutic responsiveness to benzodiazepines and reducing the need for mechanical ventilation. The objective of this study is to evaluate whether severe alcohol withdrawal treatment based on combining symptom-triggered benzodiazepine therapy with adjunctive phenobarbital will result in decreased mechanical ventilation rates, decreased use of continuous sedative infusions, decreased time to withdrawal symptom resolution and decreased length of stay in the intensive care unit. Chart reviews were utilized to determine total amount of benzodiazepine and phenobarbital use, need for mechanical ventilation, requirement of continuous lorazepam, dexmedetomidine or propofol infusions, average intensive care unit length of stay and incidence of adverse effects.

Policy Suggestions on Procurement of Basic Infusion Against the Background of Volume Procurement

Objective To evaluate the clinical value of basic infusion packaging materials for providing suggestions on formulating basic infusion volume procurement policies.Methods Combined with market data,questionnaire surveys were used to rank different basic infusion packaging materials.Pharmacists,nurses,and experts in the field of packaging respectively assess the safety,compatibility,effectiveness,convenience,and environmental friendliness of the materials.Results and Conclusion Products with the best clinical value have a lower market share than other products with average clinical value.The best three packaging materials only account for 15%of the market share.The order of clinical value from good to bad is inner-sealed polypropylene infusion bag(BFS)>soft aseptic bag with double valves and layers>upright polypropylene infusion bag>non-PVC soft bag>plastic bottle>glass bottle.The order of market share is non-PVC soft bag>soft aseptic bag with double valves and layers>plastic bottle>vertical polypropylene infusion bag>inner-sealed polypropylene infusion bag(BFS)>glass bottle.Therefore,the clinical values of various basic infusion packaging materials are different.The following countermeasures are put forward such as separating bidding for basic infusions with different packaging materials,combining volume and price with procurement,and priority procurement of packaging materials with better clinical values.

Identification of Expression Pattern and Clinical Significance of the Small Cajal Body-specific RNA SCARNA16 in Hepatocellular Carcinoma

Background and Aims:For high morbidity and mortality,hepatocellular carcinoma(HCC)becomes a major health issue worldwide.Nowadays,numerous non-coding RNAs(ncRNAs)are known to regulate the occurrence and patho-genesis of tumors.Some ncRNAs have also been developed as tumor biomarkers and therapeutic targets.However,the potential function of the small Cajal body-specific RNA(scaRNA)SCARNA16,a newly identified ncRNA,remains to be explored in HCC.Methods:In both HCC cell lines and specimens from 120 enrolled patients,the expression val-ues of SCARNA16 were detected.We divided patients into SCARNA16 high and low expression subgroups,and then analyzed the difference of various clinical characteristics and prognosis data between subgroups.Results:Compared to paired controls,SCARNA16 was significantly down-regulated in HCC cell lines and clinical specimens(p<0.01).Besides,HCC patients with lower SCARNA16 expression commonly presented with larger and more tumor lesions,more ves-sel carcinoma emboli,more capsular invasion and higher TNM stages(p<0.05).Moreover,SCARNA16 expression was negatively correlated with postoperative prognosis of HCC patients in 5-year follow-up,including tumor-free survival(TFS)(median time of low vs.high subgroups:14 vs.48 months,p=0.006)and overall survival(OS)(median time of low vs.high subgroups:39 vs.52 months,p=0.001).Besides,SCARNA16 acted as an independent prognostic bio-marker in TFS(hazard ratio[HR]:0.578,95%CI:0.345-0.969,p=0.038)and OS(HR:0.366,95%CI:0.178-0.752,p=0.006).Conclusions:Low expression patterns of SCAR-NA16 remarkably associated with severe clinical status and poor survival of patients,suggesting that SCARNA16 pos-sesses potency as a novel biomarker for HCC.

Impact of Residual SYNTAX Score and Its Derived Indexes on Clinical Outcomes after Percutaneous Coronary Intervention：Data from a Large Single Center

Background： Residual SYNTAX score （rSS） and its derived indexes including SYNTAX revascularization index （SRI） and clinical rSS had been developed to quantify and describe the extent of incomplete revascularization. This study was conducted to explore the utility of the three scores among real-world patients alter percutaneous coronary intervention （PCI）. Methods： From January 2013 to December 2013, patients underwent PCI treatment at Fuwai Hospital were included. Tile primary endpoints were all-cause death and major adverse cardiovascular and cerebrovascular events. The secondary endpoints were myocardial infarction, revascularization, stroke, and stent thrombosis. Kaptan-Meier methodology was used to determine the outcomes. Cox multivariable regression was to test the associations between scores and all-cause mortality. Results： A total of 10,344 patients were finally analyzed in this study. Kaplan-Meier survival analysis indicated that greater residual coronary lesions quantified by rSS and its derived indexes were associated with increased risk of adverse cardiovascular events. However, atier multivariate analysis, only clinical rSS was an independent predictor of 2-year all-cause death （hazard ratio： 1.02, 95% confidence interval： 1.01-1.03, P 〈 0.01）. By receiver operating characteristic （ROC） curve analysis, clinical rSS had superior predictability of 2-year all-cause death than rSS and SRI （area under ROC curve [AUC]： 0.50 vs. 0.56 vs. 0.56, all P 〈 0.01 ）, whereas rSS was superior in predicting repeat revascularization than clinical rSS and SRI （AUC： 0.62 vs. 0.61 vs. 0.61： all P 〈 0.01）. When comparing the predictive capability of rSS 〉8 with SRI 〈70%, their predictabilities were not significantly different.

Assessing the Quality of the First Batch of Evidence-Based Clinical Practice Guidelines in Traditional Chinese Medicine

Objective: To assess the quality of the first batch of Chinese evidence-based clinical practice guidelines (CPGs) in Traditional Chinese Medicine (TCM) using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Methods: Evidence-based CPGs in TCM supported by the World Health Organization Western Pacific Regional Office (WHO/WPRO) and whose development was organized by the China Academy of Chinese Medical Sciences were identified and manually retrieved. CPGs were assessed using the AGREE instrument, and the data in each CPG were analyzed in terms of the six domains in the AGREE instrument: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence. Results: Twenty-eight CPGs were identified, of which 26 were included in the study. The AGREE instrument rated the 26 CPGs in terms of the six domains. The assessment results showed the following average scores: for editorial independence, 84.16%; for rigor of development, 80.95%; for scope and purpose, 79.96%; for clarity and presentation, 70.88%; for stakeholder involvement, 61.28%; for applicability, the average score was only 27.09%. In summary, nine CPGs were rated as "strongly recommended", six as "recommended with provision or alternation", and 11 as "unsure". Conclusion: Most of the first batch of Chinese evidence-based CPGs in TCM had significant shortcomings in applicability. It is suggested that special attention be paid to enhancing the quality of applicability when developing evidence-based CPGs in TCM.

Controversies on the Values for Health Instruments of Chinese Medicine

Currently, there are increasing debates on the necessity of health instruments in Chinese medicine（CM） emerging in China. This study aims to reevaluate its status and values. Analyzing the causes, limits, advantages, and properties characters of health instruments in CM, it is found that weak fundamental research, incomplete self-awareness, and complicated social factors are the primary causes of debates. A comprehensive analysis showed health instruments in CM have health evaluation benefits to people from a dominant Chinese culture, meet the requirements of cultural background, and bring long-term value to Chinese instrument researches. However, its values and status should be treated differently depending on various subtypes. Although little theoretical and practical evidences proved that patients-reported health instruments in CM should be proposed independently, the doctors- and nurses-reported questionnaires are necessary. With this in mind, the study group proposes the ＇Chinese cultural instruments（CCIs）＇ and ＇health-related CCIs＇. The latter one aims to evaluate the health status of people in a dominant Chinese culture. The CCIs theory represents Chinese instrument researches on a larger regional and higher level, and resolves the debates on instruments between CM and Western medicine in China. Health instruments in CM bring more scientific and social benefits for Chinese instrument researches. However, it does not include cultural demands, and lacks scientific significance. CCIs have all its virtues, and add solutions to the latter＇s theory bottleneck and scientific debates, thus bringing increased benefits to clinical assessment in complementary and alternative medicine researches.