Comparison of different surrogate markers of muscle mass for the diagnosis of sarcopenia in patients with colorectal cancer

Background:This study compared the validity of the creatinine-to-cystatin C ratio(CCR),sarcopenia index(SI),and relative skeletalmuscle index(RSMI)as predictors of sarcopenia in patients with colorectal cancer(CRC)and explored their impact on the patient prognosis.Methods:We retrospectively studied patients with CRC who underwent surgical intervention at the Department of Colorectal and Anal Surgery,situatedwithin the First Affiliated Hospital of GuangxiMedical University.The investigation spanned from January 2015 to December 2017,encompassing a cohort of patients subject to surgical management forCRC during this period.Pearson’s correlation analysis was employed to evaluate the relationships between the CCR,SI,RSMI,and skeletal muscle index(SMI)and the patient prognosis.Receiver operating characteristic(ROC)curves were generated to evaluate the predictive precision of these biomarkers and ascertain the optimal cutoff values.Multivariate logistic regression analysis was conducted to pinpoint the independent factors linked with sarcopenia.Survival analyses,contingent on different surrogate markers of muscle mass and sarcopenia,were performed utilizing the Kaplan-Meier method alongside the log-rank test.Results:Weenrolled 815 patientswithCRC(522 male and 293 female patients)whowere eligible for the analysis.In accordancewith the guidelines set forth by the International Consensus on Sarcopenia,sarcopenia was diagnosed in a collective total of 503 patients.A Pearson’s correlation coefficient(r)analysis demonstrated that the CCR,SI,and RSMI were positively correlated with the SMI.In both male and female patients,the RSMI(male:r=0.400,P<0.001;female:r=0.640,P<0.001)was more strongly correlated with the SMI than with the CCR(male:r=0.203,P<0.001;female:r=0.192,P<0.001)or SI(male:r=0.335,P<0.001;female:r=0.285,P<0.001).In male patients,the areas under the ROC curves(AUC)for the CCR,SI,and RSMI were 0.596[(95%confidence interval(CI)=0.545-0.647)],0.648(95%CI=0.599-0.698),and 0.681(95%CI=0.629-0.733),respectively.In female patients,the AUC for the CCR,SI,and RSMI were 0.615(95%CI=0.551-0.680),0.660(95%CI=0.598-0.722),and 0.772(95%CI=0.719-0.825),respectively.A multivariable logistic regression analysis demonstrated that the CCR remained an influential factor for sarcopenia after correcting for confounding[odds ratio(OR)=0.993,95%CI=0.986-1.000,P=0.038].The SI and RSMI also remained influential factors for sarcopenia after correcting for confounding factors(OR=0.983,95%CI=0.972-0.994,P=0.002;and OR=0.401,95%CI=0.320-0.502,P<0.001,respectively).The groups characterized by low CCR and SI demonstrated notably reduced overall survival compared with their counterparts with high CCR and SI(P=0.007 and P=0.001,respectively),whereas the RSMI and sarcopenia did not exhibit a significant correlation with survival(P=0.608 and P=0.062,respectively).Conclusions:The CCR,SI,and RSMI all have predictive value for sarcopenia in patients with CRC.TheRSMI was a better predictor of sarcopenia than either the CCR or SI in both male and female patientswith CRC.However,the RSMI did not have any significant value for predicting the prognosis of patients with CRC.Subsequent prospective investigations are warranted to elucidate a superiormarker or amalgamation thereof,capable of accurately prognosticating sarcopenia and the overall prognosis in individuals diagnosed with CRC.Such studies should aim to meticulously evaluate a comprehensive array of potential markers,considering their individual and collective predictive value in delineating the clinical trajectory of CRC patients.By conducting rigorous prospective analyses,researchers can strive to uncover novel insights into the complex interplay between sarcopenia and CRC outcomes,thereby facilitating the development of more precise prognostic models and tailored therapeutic approaches.

Damage response of conventionally reinforced two-way spanning concrete slab under eccentric impacting drop weight loading

Reinforced concrete(RC)structures are generally designed to carry quasi-static gravity loads through almost indispensable components namely slab,however,it may be subjected to high intense loads induced from the impact of projectiles generated by the tornado,falling construction equipment,and also from accidental explosions during their construction and service lifespan.Impacts due to rock/boulder falls do occur on the structures located especially in hilly areas.Such loadings are not predictable but may cause severe damage to the slab/structure.It stimulates structural engineers and researchers to investigate and understand the dynamic response of RC structures under such impulsive loading.This research work first investigates the performance of 1000×1000×75 mm^(3)conventionally reinforced two-way spanning normal strength concrete slab with only tension reinforcement(0.88%)under the concentric impact load(1035 N)using the finite element method based computer code,ABAQUS/Explicit-v.6.15.The impact load is delivered to the centroid of the slab using a solid-steel cylindroconical impactor(drop weight)with a flat nose of diameter 40 mm,having a total mass of 105 kg released from a fixed height of 2500 mm.Two popular concrete constitutive models in ABAQUS namely;Holmquist-Johnson-Cook(HJC)and Concrete Damage Plasticity(CDP),with strain rate effects as per fib MODEL CODE 2010,are used to model the concrete material behavior to impact loading and to simulate the damage to the slab.The slab response using these two models is analyzed and compared with the impact test results.The strain rate effect on the reinforcing steel bars has been incorporated in the analysis using the Malvar and Crawford(1998)approach.A classical elastoplastic kinematic idealization is considered to model the steel impactor and support system.Results reveal that the HJC model gives a little overestimation of peak displacement,maximum acceleration,and damage of the slab while the predictions given by the CDP model are in reasonable agreement with the experimental test results/observations available in the open literature.Following the validation of the numerical model,analyses have been extended to further investigate the damage response of the slab under eccentric impact loadings.In addition to the concentric location(P1)of the impacting device,five locations on a quarter of the slab i.e.,two along the diagonal(P2&P3),the other two along the mid-span(P4&P5),and the last one(P6)between P3 and P5,covering the entire slab,are considered.Computational results have been discussed and compared,and the evaluation of the most damaging location(s)of the impact is investigated.It has been found that the most critical location of the impact is not the centroid of the slab but the eccentric one with the eccentricity of 1/6th of the span from the centroid along the mid-span section.

RELATION BETWEEN MORPHOMETRIC GRADES OF BLADDER TUMOR AND PROGNOSIS

The relation between morphometric grades (M grading) of 84 cases of bladder tumor and prognoses was evaluated. The results shown that the higher the M grading, the lower the survival rate and the higher the recurrence rate. As the M grade increases, the tumor has partial of total absence of ABO(H) antigens of tumor cell surface and could be accompanied with muscular invasion. When recurring, the tumor has a poor prognosis if M grading increases from lower to higher grades. The morphometric grading system is able to make a quantitative pathologic diagnosis and can predict the biological behavior of bladder tumors.

Synthesis,Characterization and Impedance Analysis of Calcium-Doped Zinc Oxide Nanoparticles

The calcium-doped ZnO nanoparticles,Zn1-xCaxO(x=0,0.025,0.05,0.075)were prepared by the solution combustion meth­od.The synthesized nanoparticles were characterized by various techniques such as XRD,FTIR,Raman,FESEM-EDX,PL,Impedance,and UV-Vis.The Rietveld refinement of the X-ray diffractogram yields the crystalline structure and lattice parameters.Also,the XRD analysis shows that the substitution of Ca into ZnO does not alter the Wurtzite structure of ZnO.The crystallite size of the samples,calculated using the Scherer equation,was found to be between 46 nm and 92 nm.FTIR spectra detect the ZnO-re­lated vibration modes of the samples.The FESEM morphological images suggest the spherical shape of the synthesized nanopar­ticles.The EDAX spectra identify the presence of Zn,Ca,and O atoms in the samples.The Raman active modes of the ZnO phase were identified by Raman spectral analysis.The analysis of Photoluminescence(PL)spectra gives information about the UV emis­sion and other visible bands corresponding to violet,blue,and green emission representing different intrinsic defects in synthesized nanoparticles.Using UV-vis spectroscopy,the optical transparency and band gap values were examined.The energy band gap ob­tained by Tauc’s plot was decreased with the increase in Ca doping.Impedance analysis shows that the grain conductivity increased with the increase in dopant concentration.Contrarily,the total conductivity decreased with the increasing doping concentration due to increased grain boundary resistance.The proposed work demonstrates the changes in microstructure,electrical conductivity,and optical bandgap energy with Ca-doping.These synthesized Ca-doped ZnO nanoparticles could be promising materials for photo­catalytic applications.

Integration of Theory and Practice in Medical Morphology Curriculum in Postgraduate Training:A Flipped Classroom and Case-based Learning Exercise

Objective:The integration of training in theory and practice across the medical education spectrum is being encouraged to increase student understanding and skills in the sciences.This study aimed to determine the deciding factors that drive students'perceived advantages in class to improve precision education and the teaching model.Methods:A mixed strategy of an existing flipped classroom(FC)and a case-based learning(CBL)model was conducted in a medical morphology curriculum for 575 postgraduate students.The subjective learning evaluation of the individuals(learning time,engagement,study interest and concentration,and professional integration)was collected and analyzed after FC-CBL model learning.Results:The results from the general evaluation showed promising results of the medical morphology in the FC-CBL model.Students felt more engaged by instructors in person and benefited in terms of time-saving,flexible arrangements,and professional improvement.Our study contributed to the FC-CBL model in Research Design in postgraduate training in 4 categories:1)advancing a guideline of precision teaching according to individual characteristics;2)revealing whether a learning background is needed for a Research Design course to guide setting up a preliminary course;3)understanding the perceived advantages and their interfaces;and 4)barriers and/or improvement to implement the FC-CBL model in the Research Design class,such as a richer description of e-learning and hands-on practice.Conclusion:Undertaking a FC-CBL combined model could be a useful addition to pedagogy for medical morphology learning in postgraduate training.

Chinese Guideline on the Management of Polypoidal Choroidal Vasculopathy (2022)

Background In China's Mainland,patients with neovascular age-related macular degeneration(nAMD)have approximately an 40%prevalence of polypoidal choroidal vasculopathy(PCV).This disease leads to recurrent retinal pigment epithelium detachment(PED),extensive subretinal or vitreous hemorrhages,and severe vision loss.China has introduced various treatment modalities in the past years and gained comprehensive experience in treating PCV.Methods A total of 14 retinal specialists nationwide with expertise in PCV were empaneled to prioritize six questions and address their corresponding outcomes,regarding opinions on inactive PCV,choices of anti-vascular endothelial growth factor(anti-VEGF)monotherapy,photodynamic therapy(PDT)monotherapy or combined therapy,patients with persistent subretinal fluid(SRF)or intraretinal fluid(IRF)after loading dose anti-VEGF,and patients with massive subretinal hemorrhage.An evidence synthesis team conducted systematic reviews,which informed the recommendations that address these questions.This guideline used the GRADE(Grading of Recommendations,Assessment,Development,and Evaluation)approach to assess the certainty of evidence and grade the strengths of recommendations.Results The panel proposed the following six conditional recommendations regarding treatment choices.(1)For patients with inactive PCV,we suggest observation over treatment.(2)For treatment-na?ve PCV patients,we suggest either anti-VEGF monotherapy or combined anti-VEGF and PDT rather than PDT monotherapy.(3)For patients with PCV who plan to initiate combined anti-VEGF and PDT treatment,we suggest later/rescue PDT over initiate PDT.(4)For PCV patients who plan to initiate anti-VEGF monotherapy,we suggest the treat and extend(TE)regimen rather than the pro re nata(PRN)regimen following three monthly loading doses.(5)For patients with persistent SRF or IRF on optical coherence tomography(OCT)after three monthly anti-VEGF treatments,we suggest proceeding with anti-VEGF treatment rather than observation.(6)For PCV patients with massive subretinal hemorrhage(equal to or more than four optic disc areas)involving the central macula,we suggest surgery(vitrectomy in combination with tissue-plasminogen activator(tPA)intraocular injection and gas tamponade)rather than anti-VEGF monotherapy.Conclusions Six evidence-based recommendations support optimal care for PCV patients'management.

中医药指南制订中共识法应用关键要素的定性研究

目的探索共识法在中医药指南制订中的关键要素,为改善共识的规范性和客观性提供方法学建议,为未来指南制订中规范应用共识法提供新思路。方法采用半结构化定性访谈法,对指南牵头人、工作组及共识组进行访谈,探讨共识可信度的影响因素,以及对共识主体构成和共识过程的看法。结果共访谈了26名专家,对访谈内容进行归纳和整理,形成212条编码,深化为5个领域,分别为组建共识组、患者参与、会议主持人、共识准备及共识影响因素;概括了组建共识组的3个基本步骤,以及共识法应用的17个基本考虑。结论在指南制订过程中,建议增加共识前的方法学培训,方法学家应全程参与,鼓励专家合理看待分歧,重视指南制订方法及证据资料,公开共识组遴选过程、增加患者参与、管理和报告利益冲突,以减少偏倚,提高共识的透明性、可靠性和科学性。

GRADE系统方法学进展

卫生系统中证据推荐分级的评估、制订与评价（TheGrading of Recommendations Assessment，Development and Evaluation，GRADE）系统是循证医学的最新进展，是当前证据质量和推荐强度分级的国际标准之一，适用于临床实践指南、系统评价和卫生技术评估^[1]。GRADE系统被逐渐介绍和引入中国，已有中文的系统评价和临床实践指南采用了GRADE系统。

小于胎龄儿认知发育高危因素与早期干预实践指南(2024)

小于胎龄儿(SGA)儿童追赶生长模式可能是影响后期生命健康的关键因素[1]。但在观察和研究SGA儿童时,临床上常以出生体重低于同胎龄同性别第10百分位数(P10)或低于平均值的两个标准差(-2SDS)作为相对公认的判断标准。SGA病因涉及多方面(母亲因素、孕期因素、产时因素和SGA儿童因素)且相互影响,较难产生设计良好和样本量足够的病例对照研究或队列研究。70%~90%的SGA婴儿在生后早期可出现追赶生长[1],但观察和研究追赶生长的视角也较为复杂,如SGA是足月儿还是早产儿?身长/身高、体重和头围哪个更适合作为追赶生长指标?评价追赶效果的最短追赶生长时间,追赶生长结局到多大年龄适宜?不同追赶生长结局(认知、语言、运动、社交情绪与社会适应、学业和社会成就)的评价工具多种且存在异质性等。追赶生长也不总是如预期那样一定是向好的方向发展,在生命早期的关键或敏感时期,“加速”或过快的增长可能增加代谢综合征的风险。

新生儿经皮二氧化碳分压和经皮氧分压血气分析临床实践指南

危重新生儿,尤其是接受机械通气的新生儿,二氧化碳分压(PCO_(2))和氧分压(PO_(2))处于一个动态及快速变化的状态。采集动脉血或末梢血进行血气分析仅能获得某个时点的PaCO_(2)/PaO_(2)测量结果,具有有创性、不能连续监测等不足,频繁采血也容易导致医源性失血、穿刺部位损伤感染、血流动力学波动、疼痛不适增加和人机对抗等不良后果。无创经皮二氧化碳分压(TcPCO_(2))及经皮氧分压(TcPO_(2))监测技术能对新生儿PCO_(2)/PO_(2)进行连续监测,减少患儿抽血次数,在危重新生儿监护中具有一定的优势[1],尤其有益于极早产儿、极低出生体重儿的临床管理。TcPCO_(2)/TcPO_(2)监测的主要临床问题:①TcPCO_(2)/TcPO_(2)监测结果能否代替有创血气分析的结果;②监测探头的温度和连续监测时长与早产儿皮肤灼伤的关系。针对上述2个临床问题依据WHO指南制定方法,由复旦大学附属儿科医院联合国内3家医院新生儿血气分析专家,邀请复旦大学GRADE中心作为指南方法学指导,制作新生儿TcPCO_(2)/TcPO_(2)临床实践指南(以下简称指南)。

Cr-induced fusion reactions to synthesize superheavy elements

We investigated ^(50,52-54)Cr-induced fusion reactions for the synthesis of the superheavy element in the 104≤Z≤122 range.The cross sections produced in this investigation using ^(54)Cr projectiles were compared with those obtained in prior experiments.The estimated cross sections from this analysis are consistent with the findings of prior studies.From the current study,the predicted cross section was found to be 42fb at 236 MeV for ^(53)Cr+^(243)Am,23.2 fb at 236 MeV for ^(54)Cr+^(247)Cm,95.6 fb at 240 MeV for ^(53)Cr+248Bk,and 1.33 fb at 242 MeV for ^(53)Cr+250Cf.Consequently,these projected cross sections with excitation energy and beam energy will be useful in future Cr-induced fusion reaction investigations.

GRADE新版结果总结表简介及实例解读

2004年,证据推荐分级的评估、制订与评价(Grading of Recommendations Assessment,Development,and Evaluation,GRADE)工作组正式推出GRADE分级方法,随后被广泛地应用于系统评价、临床实践指南和卫生技术评估的制订。2016年,GRADE工作组在旧版SoF表的基础上,通过合并、增加和删减条目研发出新版SoF表。为了验证新旧版So F表的信度和效度差异,GRADE工作组专门开展了一项随机对照试验,招募全球系统评价使用者并随机分组,通过网络问卷形式进行评估,结果:显示在可理解性、信息可及性、满意度和使用者偏好等方面,新版SoF表均优于旧版。本文主要结合这项随机对照试验的结果对新版SoF表进行介绍,同时结合实际案例对新版SoF表的使用进行实例解读,以期促进中国研究者对新版SoF表的了解和使用。

脑卒中中西医结合防治指南(2023版)

近年来我国脑卒中疾病负担仍持续增长,同时目前中西医结合治疗脑卒中领域涌现出许多新的临床证据。为更好地指导中西医结合防治脑卒中的临床实践,本工作组在《中西医结合脑卒中循证实践指南(2019)》的基础上,开展指南更新必要性评估与临床问题遴选,确定了需要更新的12个临床问题,并以《脑卒中中西医结合防治指南》在中华中医药学会申请立项。参考最新的国内外临床实践指南,基于研究证据的系统检索与客观评价,结合我国中西医临床专家的经验,经过工作组的充分讨论及广泛征求意见,最终形成18条推荐意见,以期为各级医疗机构的医务工作者提供科学、具体的指导,促进中西医结合治疗脑卒中的规范应用,从而降低脑卒中的死亡率、复发率、残疾率。

A Protocol for Developing a Clinical Practice Guideline for Therapeutic Drug Monitoring of Vancomycin

This study aimed to develop a guideline for therapeutic drug monitoring（TDM） of vancomycin. We adopted the new guideline definition from the Institute of Medicine（IOM）, adhered closely to the six domains of the Appraisal of Guidelines for Research ＆ Evaluation Ⅱ（AGREE Ⅱ）, and made recommendations based on systematic reviews. We established a Guideline Steering Group and a Guideline Development Group, formulated 12 questions in the form of Population, Intervention, Comparison, Outcome（PICO） and completed a literature search. As far as we know, we will develop the first evidenced-based guideline for vancomycin TDM under the framework of the Grade of Recommendations Assessment, Development and Evaluation（GRADE）.

碳青霉烯类耐药革兰阴性菌感染的诊断、治疗及防控指南

碳青霉烯类耐药革兰阴性菌(CRGNB)的广泛播散是一个全球性的公共卫生问题。CRGNB临床分离株通常呈现广泛耐药或全耐药,对其感染的抗菌治疗方案有限、死亡率高。由感染病临床诊疗、临床微生物、临床药理、医院感染控制及指南方法学等多学科专家组成的指南制定小组,根据现有科学证据制定了本临床实践指南,以解答有关CRGNB检测、抗菌治疗及感染预防控制的系列临床优先问题。本指南聚焦于碳青霉烯类耐药肠杆菌目细菌、碳青霉烯类耐药鲍曼不动杆菌和碳青霉烯类耐药铜绿假单胞菌,从当前临床实践的角度提出16个临床问题,采用人群、干预、对照及预后(population,intervention,comparator,outcomes,PICO)格式转换为研究问题,全面收集和综合分析相关研究证据。采用推荐的分级、评估、制定与评价(grading of recommendations,assessment,development and evaluation,GRADE)方法评估相应干预措施的证据体质量、效益及风险,从而制定推荐意见或建议。随机对照临床试验及系统评价获得的结果被优先用于治疗相关临床问题的推荐证据。在缺乏随机对照临床试验的情况下,观察性研究、非对照研究和专家意见被考虑作为补充证据。推荐意见分为强推荐或弱推荐(有条件推荐)。结合中国的临床实践经验,本指南同时提出实施建议,便于指南推荐意见的临床实施。本指南对耐药菌感染诊疗相关的临床医师等多学科专业人员具有参考价值。

推荐分级的评估、制订与评价(GRADE)方法学家的培训与认证

推荐分级的评估、制订与评价（GRADE）工作组正式成立于2000年,截至2017年初,包含循证医学专家、指南方法学家、系统评价制作人员、医务人员、期刊编辑、卫生决策和管理人员等在内的多学科的成员已超过300多名[1]。GRADE将证据质量分为高（A）、中（B）、低（C）和极低（D）4级[2]。研究的偏倚风险、不一致性、不精确性、间接性和发表偏倚可能会降低证据的质量,大效应量、存在剂量-效应关系和负偏倚可能会升高证据质量.

基于GRADE康复临床实践指南证据质量与推荐强度研究

目的分析康复临床实践指南的GRADE结果。方法在PubMed、EMBASE、中国知网(CNKI)、中国生物医学文献数据库(CBM)和万方等数据库以及指南相关网站检索康复医学临床指南,检索时限均为建库至2020年1月11日。由2名研究员独立筛选采用GRADE系统的指南,并对GRADE分级结果进行提取分析。结果共纳入康复临床实践指南83篇,其中46篇(55.4%)应用分级系统,采用GRADE分级系统的指南仅4篇(4.8%),包含44条推荐意见,其中39条(88.6%)具有明确的证据质量。在推荐意见所引用证据中,低质量证据最多(34.1%);在推荐意见中,弱推荐较多(56.8%)。强推荐支持证据的质量高于弱推荐(χ^2=8.218,P<0.05)。结论康复临床实践指南对GRADE分级系统的应用仍待提高。建议指南制订者进一步掌握指南和GRADE方法学,更有效地改善康复临床实践指南的可靠性和应用性。

《应用GRADE方法结合检验试验准确性结果和患者重要结局制定推荐意见》文献解读

原文出处SCHÜNEMANN H J,MUSTAFA R A,BROZEK J,et al.GRADE guidelines:22.The GRADE approach for tests and strategies-from test accuracy to patient-important outcomes and recommendations.J Clin Epidemiol,2019,111:69-82.原文通讯作者SCHÜNEMANN H J,email:schuneh@mcmaster.ca说明本文解读者根据对原文理解做解读,可能不完全反映原文的思想。

GRADE在卫生技术评估中的应用

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