Study on the association of multimorbidity with sleep and diet in young and middle-aged adults in Chongqing region,China

Background:The prevalence of multimorbidity is increasing,with a notable shift towards younger age groups.Methods:Convenience sampling was employed to select 15,988 young and middle-aged adults in Chongqing as the study population.The Apriori algorithm was used to identify the multimorbidity patterns within this population,while an unordered binary logistic regression model was applied to assess the association between sleep,diet and the risk of multimorbidity.Results:The study population had an average age of 39.2±10.1 years.Apriori association rules revealed that the most prevalent binary chronic disease multimorbidity pattern was dyslipidaemia+hypertension(14.78%),while the most common ternary chronic disease multimorbidity pattern was diabetes+dyslipidaemia+hypertension(9.66%).The logistic regression analysis revealed that a lower rating of sleep quality was associated with an elevated risk of multimorbidity(odds ratio(OR)=1.17,95%confidence interval(CI):1.01,1.36).Individuals who adhere to a meat-based diet(OR=1.45,95%CI:1.25,1.68)and those with elevated salt intake(OR=1.22,95%CI:1.01,1.47)were also observed to have an increased risk of multimorbidity.Additionally,a greater likelihood of multimorbidity was observed among those following a spicy diet(OR=1.3,95%CI:1.11,1.52)and consuming more oil(OR=1.16,95%CI:1.01,1.33).Conclusion:A poor sleep quality and a dietary preference for meat-based,salt,spicy and oils were found to be associated with an increased risk of multimorbidity progression among young and middle-aged populations.It is recommended that young and middle-aged adults should pay attention not only to sleep duration but also to sleep quality and improve dietary habits to reduce the likelihood of multimorbidity.

Research Progress of Minimally Destructive Medicine Applied to Multimorbidity

Objective:To review the research status and progress of minimally disruptive medicine(MDM)with a view and to provide a theoretical basis for reducing the treatment burden of patients with multimorbidity.Methods:"Minimal Destructive Medicine"was used as searching term in HowNet Database and Wanfang Database,and"Minimally Disruptive Medicine"was used as searching term in PubMed database.The literature was reviewed for a review of the concepts of minimally destructive medicine(MDM),four basic principles,care models,and tools and strategies for clinical implementation.Results:MDM was developed for the coexistence burden of chronic diseases.It had formed a detailed and detailed application of basic principles and care models.The tools and strategies developed by MDM have been applied in clinical practice with good Results.Conclusion:MDM has a positive effect on reducing the burden of treatment for the multimorbidity and it is worthy of further research and promotion.

Studying host genetic background effects on multimorbidity of intestinal cancer development,type 2 diabetes and obesity in response to oral bacterial infection and high-fat diet using the collaborative cross(CC)lines

Background:Multimorbidity of intestinal cancer(IC),type 2 diabetes(T2D)and obesity is a complex set of diseases,affected by environmental and genetic risk factors.High-fat diet(HFD)and oral bacterial infection play important roles in the etiology of these diseases through inflammation and various biological mechanisms.Methods:To study the complexity of this multimorbidity,we used the collaborative cross(CC)mouse genetics reference population.We aimed to study the multimorbidity of IC,T2D,and obesity using CC lines,measuring their responses to HFD and oral bacterial infection.The study used 63 mice of both sexes generated from two CC lines(IL557 and IL711).For 12 weeks,experimental mice were maintained on specific dietary regimes combined with co-infection with oral bacteria Porphyromonas gingivalis and Fusobacterium nucleatum,while control groups were not infected.Body weight(BW)and results of a intraperitoneal glucose tolerance test(IPGTT)were recorded at the end of 12 weeks,after which length and size of the intestines were assessed for polyp counts.Results:Polyp counts ranged between 2 and 10 per CC line.The combination of HFD and infection significantly reduced(P<.01)the colon polyp size of IL557 females to 2.5 cm 2,compared to the other groups.Comparing BW gain,IL557 males on HFD gained 18 g,while the females gained 10 g under the same conditions and showed the highest area under curve(AUC)values of 40000-45000(min mg/dL)in the IPGTT.Conclusion:The results show that mice from different genetic backgrounds respond differently to a high fat diet and oral infection in terms of polyp development and glucose tolerance,and this effect is gender related.

Satisfaction about Patient-centeredness and Healthcare System among Patients with Chronic Multimorbidity

The aim of the present study was to measure the prevalence of multimorbidity in Bangladesh,India and China,and to assess the relationship between multimorbidity and patient's opinion regarding their involvement in healthcare decision-making and overall satisfaction of healthcare system.Cross-sectional data on 18696 men and women aged 18 and above were collected from the World Health Survey of World Health Organization(WHO).Outcome variables were subjective rating of(1)healthcare system's ability to involve patients in decision-making,and(2)satisfaction with the way healthcare system runs in the country.Self-reported chronic conditions were used to measure the prevalence of multimorbidity.Out of 9 chronic conditions,back pain,arthritis,and chronic cough appeared to be the most prevalent ones among majority of the participants.About one-third of the participants in China(30.7%)and two-thirds in Bangladesh(66.1%)and India(66.6%)reported having at least one chronic illness.Prevalence of multimorbidity was highest in India(34.3%)followed by Bangladesh(28.8%)and China(14.3%).In Bangladesh,India and China,respectively 70.5%,41.7%,61.3%women and 54.5%,42.8%and 58.8%men expressed dissatisfaction regarding the way healthcare system runs in their country.In Bangladesh and India,men who were living with multimorbidity were more likely to rate the patient-centeredness as"bad"than those who had no disease illness.This study suggests that the prevalence of multimorbidity was remarkably high especially in Bangladesh and India.Higher likelihood of dissatisfaction about healthcare system among multimorbid patients might be indicative of inadequacy in the provision of care in qualitative and quantitative terms.

The prevalence of depression amongst outpatients with multimorbidity

Objectives: Depression may be under-diagnosed and under-treated amongst older adults with multiple chronic illnesses. The current study explores the prevalence of depression diagnosis and Geriatric Depression Scale (GDS) symptoms amongst older multimorbid outpatients, and agreement between GDS scores and doctor-diagnosed depression. Method: Deidentified data from the files of 452 patients aged over 64, with chronic conditions present in two or more organ domains, were extracted from the clinical database of a tertiary referral hospital multidisciplinary outpatient clinic in South Australia between 2005 and 2011. Frequency calculations determined the prevalence of depression diagnosis and GDS categories. Logistic regression, cross-tabulation, kappa and ROC graphs explored relationships between variables. Results: A depression diagnosis had been recorded for 71 (15.7%) patients. Using the recommended cut-off scores for the GDS, 225 (49.8%) patients met criteria for mild-severe depressive symptoms, and 96 (21.3%) met criteria for moderate-severe symptoms. Poor agreement was found between doctor diagnosis of depression and a positive screen for depression using a GDS cut-off score of either 5, k = 0.112 (p = 0.001), or 9, k = 0.189 (p < 0.001), although logistic regression found an association between severity of depression and depression diagnosis, OR = 1.15, p < 0.001 (CI = 1.08 - 1.22). Con-clusion: A much higher proportion of patients with multimorbidities reported threshold level depression symptoms than had a recorded diagnosis of depression, suggesting that although likelihood of diagnosis increases with symptom severity, depression often goes undetected in this population. Depressions’ negative impact on prognosis calls for further investigation of the barriers to screening and diagnosis of depression in multimorbid patients.

Thoughts about Person-Centered Care for the Adult Population with Multimorbidity

Patients with multimorbidity are becoming the norm rather than the exception. The management of patients with several chronic diseases is now the most important challenge facing health care systems in developed countries. Based on the actual medical records of ambulatory care visits, this study investigated the prevalence and patterns of multimorbidity in 55 and older population. Among a cohort comprised of 300,000 beneficiaries selected randomly from the National Health Insurance Research Database of Taiwan in 2001, 42,441 were eligible. These were followed longitudinally 10 years. The prevalence of chronic disease rose from 62.3% to 79.8% and multimorbidity rose from 57.4% to 75.7%. Multimorbidity patterns were found fell in-to four clusters: metabolic diseases, cardiac diseases, mental joints and gastrointestinal tract disorders. Hypertension and diabetes mellitus, as well as hyperplasia of the prostate in men, were the most common chronic diseases. The prevalence of chronic disease increased with age, especially high at age 75 - 79. Thought about the health care system for an ageing society is necessary. Applying the concept of customer experience and strengthening people-centered management in an integrated model of health care, enhancing knowledge and skills in the long-term management of chronic disease, revising clinical guidelines and training professionals in caring for the elderly, reinforcing preventive health services, especially in men’s health, modifying the materials for health education, and planning for health manpower resources will provide a better model to ensure the health care for people with multimorbidity.

Managing the Needs of Older Patients with Multimorbidity—A Systematic Review of the Challenges Faced by the Healthcare Services

Research fails to provide an overview of the challenges involved in caring for older patients with multimorbidity. Multimorbidity is defined as the presence of two or more chronic conditions in the same person, leading to a high risk of care dependency. The aim of this review was to illuminate the challenges faced by the healthcare services in managing the needs of older patients with multimorbidity. A systematic review was performed, a total of 1,965 abstracts were read and nine quantitative studies included. Data were analysed by thematic synthesis, revealing six themes: A frequent problem in older female patients;High healthcare expenditure and costs, Medication management problems, Social inequities, Complex healthcare and consultation needs and High mortality. The study highlights that healthcare professionals struggle to obtain suitable guidelines for the care of patients with multimorbidity while trying to respond to their needs. Patient-centred integration across settings and coordination in clinical practice are necessary. The healthcare system today does not seem to focus on patient safety and preventing harm. Older patients should be reviewed by a healthcare professional responsible for coordinating their care. To ensure safe and effective care for elderly persons with multimorbidity, the healthcare services should abandon the current focus on managing innumerable individual diseases and conditions.

Association between Chinese visceral adiposity index and risk of cardiometabolic multimorbidity in middle-aged and elderly Chinese population:Evidence from a national longitudinal study

Background There are several surrogate indicators of abdominal fat deposition,including tri-ponderal mass index(TMI),lipid accumulation product(LAP),and the Chinese visceral adiposity index(CVAI).In spite of this,it remains unclear whether these indices have a longitudinal relationship with the prevalence of cardiometabolic multimorbidity(CM),a pressing global health issue.This research investigated the association between CVAI and CM compared to other indicators of visceral obesity.Methods 6638 participants(aged>45)from the China Health and Retirement Longitudinal Study(CHARLS)were analyzed for incident CM.Cox proportional models were adopted to explore whether the level of CVAI was correlated with the risk of CM.Harrell's concordance statistic(C-statistic)was applied to compare predictive values.Sensitivity and subgroup analyses were implemented for the steadiness of the results.Results Over 4 years,266(4.01%)participants developed CM.A 1-standard deviation(SD)increase in the levels of CVAI,body mass index(BMI),LAP,and TMI was associated with greater CM risk after adjusting for confounders[hazard ratios(HRs):2.20,95%confidence interval(CI):1.88-2.57,1.92(95%CI:1.55-2.38),1.20(95%CI:1.12-1.27),and 1.50(95%CI:1.35-1.66),respectively].CVAI outperformed other indices in predictive performance.Subgroup analysis revealed younger participants or those living alone were more prone to developing CM.Results were potent after finishing all sensitivity analyses.Conclusions The study highlighted a positive correlation between the level of CVAI and CM risk.CVAI's superior predictive performance positions it as a reliable indicator for identifying individuals at heightened CM risk.

The Impact of Multimorbidity on Healthcare Utilization and Expenditure:Evidence from China

Objective To investigate the impact of multimorbidity on China’s healthcare utilization and expenditure.Methods A two-part model was used to analyze the outpatient cares based on the data from CHARLS 2015 wave.Results and Conclusion As the prevalence of multimorbidity was 36.6%among 15523 middle-aged and elderly respondents in China,the multimorbidity increased the likelihood of outpatient service,while the total outpatient expenditure did not increase significantly as well as the OOP expenditure.Secondly,although there was a similar probability of outpatient visit,the patients with multimorbidity excluding diabetes and(or)hypertension,had not been concerned by China’s Chronic Condition Management Programs(CCCMP)yet.Thirdly,the patients with multimorbidity increased the outpatient visits to different types of hospitals.Under CCCMP intervention,the patients did not switch from the county/city hospital to primary healthcare centers and township hospital.A costeffective strategy for providing services to patients with multimorbid conditions is needed,the focus of CCCMP should be switched from the single chronic disease to the multimorbidity.

Challenges and improvement strategies in the hospitalization of chronic multimorbid patients

BACKGROUND Addressing the growing challenge of hospitalizing chronic multimorbid patients,this study examines the strain these conditions impose on healthcare systems at a local level,focusing on a pilot program.Chronic diseases and complex patients require comprehensive management strategies to reduce healthcare burdens and improve patient outcomes.If proven effective,this pilot model has the potential to be replicated in other healthcare settings to enhance the management of chronic multimorbid patients.AIM To evaluate the effectiveness of the high complexity unit(HCU)in managing chronic multimorbid patients through a multidisciplinary care model and to compare it with standard hospital care.METHODS The study employed a descriptive longitudinal approach,analyzing data from the Basic Minimum Data Set(BMDS)to compare hospitalization variables among the HCU,the Internal Medicine Service,and other services at Antequera Hospital throughout 2022.The HCU,designed for patients with complex chronic conditions,integrates a patient-centered model emphasizing multidisciplinary care and continuity post-discharge.RESULTS The study employed a descriptive longitudinal approach,analyzing data from the BMDS to compare hospitalization variables among the HCU,the Internal Medicine Service,and other services at Antequera Hospital throughout 2022.The HCU,designed for patients with complex chronic conditions,integrates a patient-centered model emphasizing multidisciplinary care and continuity post-discharge.CONCLUSION This study demonstrates the effectiveness of the HCU in managing patients with complex chronic diseases through a multidisciplinary approach.The coordinated care provided by the HCU results in improved patient outcomes,reduced unnecessary hospitalizations,and better management of patient complexity.The superiority of the HCU compared to standard care is evident in key outcomes such as fewer readmissions and higher patient satisfaction,reinforcing its value as a model of care to be replicated.

Multimorbidity patterns and association with mortality in 0.5 million Chinese adults

Background:Few studies have assessed the relationship between multimorbidity patterns and mortality risk in the Chinese population.We aimed to identify multimorbidity patterns and examined the associations of multimorbidity patterns and the number of chronic diseases with the risk of mortality among Chinese middle-aged and older adults.Methods:We used data from the China Kadoorie Biobank and included 512,723 participants aged 30 to 79 years.Multimorbidity was defined as the presence of two or more of the 15 chronic diseases collected by self-report or physical examination at baseline.Multimorbidity patterns were identified using hierarchical cluster analysis.Cox regression was used to estimate the associations of multimorbidity patterns and the number of chronic diseases with all-cause and cause-specific mortality.Results:Overall,15.8%of participants had multimorbidity.The prevalence of multimorbidity increased with age and was higher in urban than rural participants.Four multimorbidity patterns were identified,including cardiometabolic multimorbidity(diabetes,coronary heart disease,stroke,and hypertension),respiratory multimorbidity(tuberculosis,asthma,and chronic obstructive pulmonary disease),gastrointestinal and hepatorenal multimorbidity(gallstone disease,chronic kidney disease,cirrhosis,peptic ulcer,and cancer),and mental and arthritis multimorbidity(neurasthenia,psychiatric disorder,and rheumatoid arthritis).During a median of 10.8 years of follow-up,49,371 deaths occurred.Compared with participants without multimorbidity,cardiometabolic multimorbidity(hazard ratios[HR]=2.20,95%confidence intervals[CI]:2.14-2.26)and respiratory multimorbidity(HR=2.13,95%CI:1.97-2.31)demonstrated relatively higher risks of mortality,followed by gastrointestinal and hepatorenal multimorbidity(HR=1.33,95%CI:1.22-1.46).The mortality risk increased by 36%(HR=1.36,95%CI:1.35-1.37)with every additional disease.Conclusion:Cardiometabolic multimorbidity and respiratory multimorbidity posed the highest threat on mortality risk and deserved particular attention in Chinese adults.

Complex multimorbidity and health outcomes in older adult cancer survivors

Objective:To characterize complex multimorbidity among cancer survivors and evaluate the association between cancer survivorship,time since cancer diagnosis,and self-reported fair/poor health,self-rated worse health in 2 years,and 2-year mortality.Methods:We used the 2010-2012 Health and Retirement Study.Cancer survivors were indi-viduals who reported a(nonskin)cancer diagnosis 2 years or more before the interview.We defined complex multimorbidity as the co-occurrence of chronic conditions,functional limitations,and/or geriatric syndromes.In addition to descriptive analyses,we used logistic regression to evaluate the independent association between cancer survivor status and health outcomes.We also examined whether cancer survivorship differed by the number of years since diagnosis.Results:Among 15,808 older adults(age≥50 years),11.8%were cancer survivors.Compared with cancer-free individuals,a greater percentage of cancer survivors had complex multimorbidity:co-occurring chronic conditions,functional limitations,and geriatric syndromes.Cancer survivor-ship was significantly associated with self-reported fair/poor health,self-rated worse health in 2 years,and 2-year mortality.These effects declined with the number of years since diagnosis for fair/poor health and mortality but not for self-rated worse health.Conclusion:Cancer survivor status is independently associated with more complex multi-morbidity,and with worse health outcomes.These effects attenuate with time,except for patient perception of being in worse health.

Major depressive disorders in patients with inflammatory bowel disease and rheumatoid arthritis

BACKGROUND Various immune-mediated inflammatory diseases consisting of inflammatory bowel disease(IBD)and rheumatoid arthritis(RA),are found to have a substantial societal burden,increased healthcare costs,and progressive disability.Studies suggest that patients with vs without comorbid depression have a more significant disability,a lower likelihood of remission,and reduced adherence to therapy.Elevated interleukin(IL)-1β,tumor necrosis factor-α,and IL-6 contribute to developing depression by the impaired physiological responses to stress,resulting in increased pain,fever,fatigue,and lack thereof of interest,and thus poor long-term outcomes.This study emphasizes the timely recognition of the prevalence of major depressive disorder(MDD)in patients with RA and IBD combined,thus preventing disability.AIM To identify the prevalence level and temporal trends of depression in hospitalized IBD-RA patients.METHODS All adult hospitalized patients from January 2000 to December 2019 in the nationwide inpatient sample(NIS)were captured.The study population included all patients with a primary or secondary IBD-RA overlap disease using corresponding international classification of diseases(ICD)-9 and ICD-10 codes.IBD includes Crohn’s disease and ulcerative colitis.The study population was divided into IBD-RA without MDD(controls)and IBD-RA with MDD(cases).For group comparison between MDD vs no MDD,we used Student’s t-test for continuous variables and RaoScott Chi-square tests for categorical variables.For univariate analyses,we used logistic regression,and for multivariate analysis,we used a weighted multi-level mixed-effects model.We attested all hypotheses with two-tailed significance level of 0.05(P<0.05 was considered significant).The outcome is to examine the temporal trends and prevalence of depression in patients with IBD-RA by gender,race,and age.RESULTS A total of 133315 records were identified with IBD-RA overlap,of which 26155 patients(19.62%)had MDD.Among the IBD-RA patients,those who had MDD were younger[mean age of 56 years(SD±15)]to IBD-RA without MDD patients with a P<0.0001,more females(80%among cases vs 73%among controls)than males with a P<0.0001,frequent in the white race(79%among cases vs 73%among controls)than black race.Over the 19 years,the number of patients with MDD in IBDRA increased from 153(the year 2000)to 2880(the year 2019)in weighted NIS,representing a 1782%increase compared to the year 2000 with a P<0.001.Factors associated with higher MDD included younger age,female gender,white race,alcohol,opioids,esophageal disorders,peptic ulcer disease,chronic pancreatitis,paralysis,dementia,menopausal disorders,obesity,nutritional deficiencies,diabetes mellitus with chronic complications,and osteoarthritis.CONCLUSION There is a rise in the prevalence of depression in younger patients with IBD-RA combined compared to their counterparts.These patients are also at higher risk for the increased cost of care and poor treatment compliance.It is crucial to educate the involved clinicians to identify the early signs and symptoms of depression in patients with IBD or RA or IBD-RA combined and treat them to have a better overall prognosis.

Relationships between Chronic Diseases and Depression among Middleaged and Elderly People in China: A Prospective Study from CHARLS

Given the rapid increase in the prevalence of chronic diseases in aging populations,this prospective study including 17707 adults aged≥45 years from China Health and Retirement Longitudinal Study was used to estimate the associations between chronic discase,multimorbidity,and depression among middle-aged and elderly adults in China,and explore the mediating factors.Depressive symptoms were assessed using the 10-item Centre for Epidemiological Studies Depression Scale(CES-D-10)questionnaire.Twelve chronic physical conditions,including hypertension,diabetes,dyslipidemia,cancer,chronic lung disease,liver disease,heart failure,stroke,kidney disease,arthritis or rheumatism,asthma,digestive disease were assessed.The prevalence rates for physical multimorbidity and depression(CES-D-10≥10)were 43.23%and 36.62%,respectively.Through multivariable logistic models and generalized estimating equation(GEE)models,we found all 12 chronic physical conditions,and multimorbidity were significantly associated with depression.Both mobility problems and chronic pain explained more than 30%of the association for all chronic conditions,with particularly high percentages for stroke(51.56%)and cancer(51.06%)in mobility problems and cancer(53.35%)in chronic pain.Limited activities of daily living(ADL)explained 34.60%of the stroke-cancer relationship,while sleep problems explained between 10.15%(stroke)and 14.89%(chronic lung disease)of the association.Individuals with chronic diseases or multimorbidity are significantly more likely to be depressed.Functional symptoms involving limitations of ADL and mobility difficulties mediated much of the association between chronic diseases and incident depression.These symptoms could be targeted for interventions to ameliorate the incidence of depression among individuals with chronic conditions.

Social isolation and health-promoting behaviors among older adults living with different health statuses:A cross-sectional study

Objectives:To describe the characteristics and relationships of social isolation and health promoting behaviors of Chinese older adults with different health statuses.Methods:Totally 485 older adults were recruited.They were divided into three groups based on their health status:healthy group(n=72),group with one disease(n=183)and group with multimorbidity(n=230).Lubben Social Network Scale-6 and Health-Promoting Lifestyle Profile II were used to measure their social isolation and health-promoting behaviors,respectively.Results:Among the aged with one disease or multimorbidity,30.6%(56/183)and 31.7%(73/230)were socially isolated,respectively,based on the score of the Lubben Social Network Scale-6.The three groups differed significantly in health-promoting behaviors and scores on several subscales.The group with multimorbidity exhibited more social isolation and fewer health-promoting behaviors than other groups.Social isolation was among the factors adversely affecting health-promoting behaviors in older adults.Conclusions:Health care providers should help older adults with multimorbidity preserve the remaining abilities to improve health-promoting behaviors.Meanwhile,it is important to support healthy older adults to increase self-responsibility to achieve healthy aging.

Health care service usage and costs for high-needs elderly patients with heart failure

Heart failure(HF)has been defined as global disease of pandemic proportions,since it affects around 26 million people worldwide.[1]According to a recent study,age is the most important factor influencing the prevalence of HF,as it is for most other chronic conditions.[2]This means that,with the predicted aging of the population(the proportion of the world’s population aged 60 years and over will nearly double from 2015 to 2050),[3]there will be a growth in the total burden of HF,and a rise in the number of comorbidities in HF patients.According to a recent study,almost 86%of adults with HF have two or more comorbid conditions.[4]Comorbidity,defined as the co-existence of one or more additional conditions in individuals with a specified index medical condition,[5]adds to the complexity of treating elderly patients with HF.

Understanding and Promoting Clinical Reasoning in Chronic and Multimorbid Conditions: A Call for GPs and Healthcare Professionals

Multimorbidity, defined as 2 or more chronic diseases, is of increasing importance for health professionals. Many factors are at play when it comes to multimorbidity, but we still know very little about how clinicians actually weigh up the different factors—medical, social, and psychological—to reach a particular course of action. Further research is therefore required to explore the ways in which clinical reasoning processes are involved in the follow up of patients suffering from multimorbidities, to highlight their potential risks of errors. A better understanding of these clinical processes will also enrich supervision of trainees and collaboration between healthcare professionals involved in primary care.

Reality of evidence-based practice in palliative care

There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine(EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard' randomised controlled trials(RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient's physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle(noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach' are likely to pose the correct clinical questions and derive evidencebased yet clinically relevant outcomes.

Development trends of etiological research contents and methods of noncommunicable diseases

1|BACKGROUND Noncommunicable diseases(NCDs)are a significant public concern,greatly impacting the economic and social development in China.In 2019,NCDs accounted for a staggering 88.5%of total deaths in China,with cardiovas-cular diseases,cancer,chronic respiratory diseases,and diabetes—the four major chronic diseases—contributing to a premature mortality rate of 16.5%[1].The complexity of NCDs arises from the involvement of multiple genetic and environmental factors that interact in intricate ways.The complexity is characterized by a multitude of interactions among genes,proteins,and metabolic path-ways throughout the various stages of life.