Higher-level Hospitals Research Articles

Preferences of Individuals With Obesity for Online Medical Consultation in Different Demand Scenarios: Discrete Choice Experiments.

Obesity is a unique chronic disease, with China having the largest number of people living with overweight and obesity in the world. There has been little research from the demand perspective for online medical consultation (OMC) by individuals living with obesity. With the growing demand for obesity OMC, especially due to the emergence of new pharmacotherapies, such as glucagon-like peptide-1 receptor agonists, individuals living with obesity are seeking both advice on obesity management and the prescription of obesity drugs. Therefore, our demand scenarios defined 2 OMC motivations to manage obesity: "For-Drugs" use and "For-Advice" use. This study aims to assess and compare the preferences for For-Drugs and For-Advice OMC among individuals living with obesity in China. Following the International Society for Pharmacoeconomics and Outcomes Research's checklist and comprising 400 participants assigned to the For-Drugs scenario and 400 to the For-Advice scenario, the For-Drugs and For-Advice preferences were estimated through discrete choice experiments. The groups in the 2 scenarios followed a similar distribution, and the 2 different demand scenarios shared the same discrete choice experiment design, comprising 16 choice sets with 6 representative attributes. Mixed logit modeling was used to estimate the willingness to pay and relative importance scores. Doctors with well-known and general expert titles, versus ordinary doctors; doctors from high-level, provincial, tertiary, and municipal hospitals, versus lower-level county hospitals; less waiting time; and lower OMC fees were preferred in both the For-Drugs and For-Advice scenarios. The differences between the 2 scenarios lay in the consultation format, consultation duration, and the relative importance of consultation duration versus waiting time. The For-Advice group preferred telephone consultations, while the For-Drugs group did not; the For-Drugs group preferred longer consultation duration (β=.029), while the For-Advice group preferred shorter consultation duration (β=-.030); and the For-Drugs group rated consultation duration higher than waiting time, while the For-Advice group rated the waiting time as more important than consultation duration. Combined with our qualitative research, the differences can be explained by the different consultation needs in the 2 scenarios, where longer patient consultations were preferred by the For-Drugs patients who sought detailed advice on drug side effects, while quick and direct responses were preferred by the For-Advice participants. By revealing user preferences on costs, doctors' titles and hospital level, wait time, and consultation duration and format, our research informs OMC platforms, OMC regulators, and doctors on market segmentation and service differentiation strategies.

Research-Oriented Hospitals in China: A Bibliometric and Visualization Analysis Based CiteSpace.

Research-oriented hospitals represent the primary direction for the future development of large-scale, high-level hospitals in China. Research-oriented hospitals, increasingly highlighted in domestic policies, lacks a comprehensive analysis of existing research outcomes. Bibliometric evaluates scientific research endeavors and trends in disciplines by statistically analyzing literature data. Citespace is a widely used bibliometric software that helps researchers visualize research hotspots and trends in a specific field by measuring and modeling literature data from that area. This study employs CiteSpace software to conduct a bibliometric analysis and visualization analysis of the literature in the field of research-oriented hospitals, spanning publications from 2003 to 2023 and sourced from databases including the China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu (VIP). Findings indicate rapid publication growth from 2010 to 2016, followed by fluctuations characterized by alternating declines and increases. In terms of the distribution of authors and institutions, the study observes a relatively modest level of collaboration among highly productive researchers and research institutions, suggesting room for enhanced interdisciplinary and institutional partnerships. Moreover, research hotspots in the field of research-oriented hospitals can be categorized into hospital development strategy, hospital management, and technological innovation. Considering the limitations of current research and the evolution of social needs, this study suggests that future research should focus more on clarifying the essence of research-oriented hospitals, developing targeted development strategies, and addressing the numerous obstacles faced during the hospital innovation process. In conclusion, this bibliometric analysis provides a snapshot of the current research status and trend. The insights gained from this research not only aim to inform future studies but also to inspire relevant stakeholders such as policy makers, hospital managers, and scholars to strengthen practical actions, enhance the construction and operation of research-oriented hospitals, thereby improving healthcare outcomes for populations.

Association of long-term exposure to ozone with cardiovascular mortality and its metabolic mediators: evidence from a nationwide, population-based, prospective cohort study

Previous studies about chronic effects of ozone (O3) on cardiovascular mortality are scarce and inconclusive. We aimed to investigate the association between cardiovascular mortality and a broad range of long-term O3 exposure levels. This analysis included 3,206,871 participants aged 35-75 years enrolled in the ChinaHEART study. Participants were recruited from the 31 provinces of the Chinese mainland between January 2015 and December 2020. The five-year average O3 concentrations before baseline visits were calculated to represent long-term exposure. Over a median follow-up period of 4.7 (interquartile range: 3.7-6.2) years, 35,553 (1.1%) participants died from cardiovascular diseases (CVD). Following multivariable adjustment, nonlinear relationships were identified between O3 concentrations and CVD and ischemic heart disease (IHD) mortality, with inflection points at 85.44 and 88.15μg/m3, respectively. Above these points, a 10.0μg/m3 increase in the O3 level was associated with a 13.9% (hazard ratio [HR]: 1.139, 95% confidence interval [CI]: 1.096-1.184) and 25.0% (HR: 1.250, 95% CI: 1.151-1.357) greater risk of CVD and IHD mortality, respectively. Conversely, O3 exposure exhibited a linear relationship with ischemic stroke mortality. Moreover, the metabolic factors explained more than half of the association between O3 exposure and CVD mortality. Substantial influences of long-term O3 exposure on CVD mortality were identified, with notable mediation proportions attributed to metabolic factors. These findings could facilitate the air quality standard revisions and risk reduction strategy making in the future. This study was supported by the CAMS Innovation Fund for Medical Science (2021-1-I2M-011), the CAMS Innovation Fund for Medical Science (CIFMS, 2022-I2M-C&T-A-010), the National High Level Hospital Clinical Research Funding (2022-GSP-GG-4), the Ministry of Finance of China and National Health Commission of China, the 111 Project from the Ministry of Education of China (B16005).

Global burden of dementia in younger people: an analysis of data from the 2021 Global Burden of Disease Study

Dementia among younger people is rapidly emerging as a global health concern; however, comprehensive research on its shifting burden trends remains insufficient. Data on the prevalence, incidence, mortality, and disability-adjusted life years (DALYs) associated with dementia occurring in individuals <70 years were extracted from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021. Average annual percentage changes (AAPCs) were calculated to assess trends in age-specific rates (ASRs), including age-specific prevalence rates (ASPRs), age-specific incidence rates (ASIRs), age-specific mortality rates (ASMRs), and age-specific DALY rates (ASDRs) while young-onset dementia (YOD) burden trends were analyzed. The correlation between ASR/AAPC and the sociodemographic index (SDI) was evaluated. In 2021, the global prevalence of dementia in individuals <70 years increased by 122.33%, with a 128% increase in new cases since 1990. Concurrently, deaths and DALYs of individuals <70 years with dementia rose by 119.28% and 119.77%, respectively. The AAPCs of YOD ASRs during 1990-2021 initially increased and then decreased with increasing SDI levels, with the highest AAPCs of ASPR (2.20 [95%CI: 2.08-2.32] per 100,000), ASIR (2.25 [95%CI: 2.06-2.45] per 100,000), ASMR (2.04 [95%CI: 1.93-2.15] per 100,000), and ASDR (2.06 [95%CI: 1.99-2.13] per 100,000) observed in middle-SDI levels. Additionally, females <70 years bore a higher burden of dementia globally, and gender differences are still widening. The growth rate of YOD is accelerating, particularly in the middle to high SDI region with females bearing a disproportionately higher burden of YOD. This work was supported by grants from the National High level Hospital Clinical Research Funding, CAMS Innovation Fund for Medical Sciences, and the National Natural Science Foundation of China.

Gut microbiome metabolites, molecular mimicry, and species-level variation drive long-term efficacy and adverse event outcomes in lung cancer survivors

The influence of the gut microbiota on long-term immune checkpoint inhibitor (ICI) efficacy and immune-related adverse events (irAEs) is poorly understood, as are the underlying mechanisms. We performed gut metagenome and metabolome sequencing of gut microbiotas from patients with lung cancer initially treated with anti-PD-1/PD-L1 therapy and explored the underlying mechanisms mediating long-term (median follow-up 1167 days) ICI responses and immune-related adverse events (irAEs). Results were validated in external, publicly-available datasets (Routy, Lee, and McCulloch cohorts). The ICI benefit group was enriched for propionate (P=0.01) and butyrate/isobutyrate (P=0.12) compared with the resistance group, which was validated in the McCulloch cohort (propionate P<0.001, butyrate/isobutyrate P=0.002). The acetyl-CoA pathway (P=0.02) in beneficial species mainly mediated butyrate production. Microbiota sequences from irAE patients aligned with antigenic epitopes found in autoimmune diseases. Microbiotas of responsive patients contained more lung cancer-related antigens (P=0.07), which was validated in the Routy cohort (P=0.02). Escherichia coli and SGB15342 of Faecalibacterium prausnitzii showed strain-level variations corresponding to clinical phenotypes. Metabolome validation reviewed more abundant acetic acid (P=0.03), propionic acid (P=0.09), and butyric acid (P=0.02) in the benefit group than the resistance group, and patients with higher acetic, propionic, and butyric acid levels had a longer progression-free survival and lower risk of tumor progression after adjusting for histopathological subtype and stage (P<0.05). Long-term ICI survivors have coevolved a compact microbial community with high butyrate production, and molecular mimicry of autoimmune and tumor antigens by microbiota contribute to outcomes. These results not only characterize the gut microbiotas of patients who benefit long term from ICIs but pave the way for "smart" fecal microbiota transplantation. Registered in the Chinese Clinical Trial Registry (ChiCTR2000032088). This work was supported by Beijing Natural Science Foundation (7232110), National High Level Hospital Clinical Research Funding (2022-PUMCH-A-072, 2023-PUMCH-C-054), CAMS Innovation Fund for Medical Sciences (CIFMS) (2022-I2M-C&T-B-010).

Single cell atlas reveals multilayered metabolic heterogeneity across tumour types

Metabolic reprogramming plays a pivotal role in cancer progression, contributing to substantial intratumour heterogeneity and influencing tumour behaviour. However, a systematic characterization of metabolic heterogeneity across multiple cancer types at the single-cell level remains limited. We integrated 296 tumour and normal samples spanning six common cancer types to construct a single-cell compendium of metabolic gene expression profiles and identify cell type-specific metabolic properties and reprogramming patterns. A computational approach based on non-negative matrix factorization (NMF) was utilised to identify metabolic meta-programs (MMPs) showing intratumour heterogeneity. In-vitro cell experiments were conducted to confirm the associations between MMPs and chemotherapy resistance, as well as the function of key metabolic regulators. Survival analyses were performed to assess clinical relevance of cellular metabolic properties. Our analysis revealed shared glycolysis upregulation and divergent regulation of citric acid cycle across different cell types. In malignant cells, we identified a colorectal cancer-specific MMP associated with resistance to the cuproptosis inducer elesclomol, validated through in-vitro cell experiments. Furthermore, our findings enabled the stratification of patients into distinct prognostic subtypes based on metabolic properties of specific cell types, such as myeloid cells. This study presents a nuanced understanding of multilayered metabolic heterogeneity, offering valuable insights into potential personalized therapies targeting tumour metabolism. National Key Research and Development Program of China (2021YFA1300601). National Natural Science Foundation of China (key grants 82030081 and 81874235). The Shenzhen High-level Hospital Construction Fund and Shenzhen Basic Research Key Project (JCYJ20220818102811024). The Lam Chung Nin Foundation for Systems Biomedicine.

Method for Enhancing AI Accuracy in Pressure Injury Detection Using Real and Synthetic Datasets

Pressure injuries pose significant health risks, especially for the elderly, immobile individuals, and those with sensory impairments. These injuries can rapidly become chronic, making initial diagnosis important. Due to the difficulty of transporting patients from local health facilities to higher-level general hospitals for treatment, it is essential to utilize telemedicine tools, such as chatbots, to ensure rapid initial diagnosis. Recent advances in artificial intelligence have demonstrated potential for medical imaging and disease classification. Ongoing research in the field of dermatological diseases focuses on disease classification. However, the assessment accuracy of artificial intelligence is often limited by unequal class distributions and insufficient dataset quantities. In this study, we aim to enhance the accuracy of artificial intelligence models by generating synthetic datasets. Specifically, we focused on training models for Pressure Injury assessment using both real and synthetic datasets. We used PI data at a domestic medical university. As part of our supplementary research, we established a chatbot system to facilitate the assessment of pressure injuries. Using both constructed and synthetic data, we achieved a top-1 accuracy of 92.03%. The experimental results demonstrate that combining real and synthetic data significantly improves model accuracy. These findings suggest that synthetic datasets can be effectively utilized to address the limitations of small-scale datasets in medical applications. Future research should explore the use of diverse synthetic data generation methods and validate model performance on a variety of datasets to enhance the generalization and robustness of AI models for Pressure Injury assessment.

Area-level socioeconomic inequalities in mortality in China: a nationwide cohort study based on the ChinaHEART project

Socioeconomic status is a key social determinant of health. Compared with individual-level socioeconomic status, the association between area-level socioeconomic status and mortality has not been well investigated in China. We aimed to assess associations between area-level socioeconomic status and all-cause mortality and cause-specific mortality in China, as well as the interplay of area-level and individual-level socioeconomic status on mortality. In this nationwide cohort study, residents aged 35-75 years from 453 districts and counties were included in the China Health Evaluation and Risk Reduction Through Nationwide Teamwork (ChinaHEART) Study. The composite value of area-level socioeconomic status was generated from national census data and categorised into tertiles. Mortality rates and their 95% CIs were calculated using the Clopper-Pearson method. Cox frailty models were fitted to calculate adjusted hazard ratios and 95% CIs for area-level socioeconomic status with the risk of all-cause mortality and cause-specific mortality and their disparities across different population. We also assessed the roles of multiple individual factors as potential mediators. Between December, 2015, and December, 2022, 1 119 027 participants were included, for whom the mean age was 56·1 (SD 9·9) years and 672 385 (60·1%) were female. 24 426 (5·24 [95% CI 5·18-5·31] per 1000 person-years) deaths occurred during the median 4·5-year follow-up. Compared with high area-level socioeconomic status, low area-level socioeconomic status was significantly associated with an increased risk of all-cause (hazard ratio 1·11, 95% CI 1·07-1·16), cardiovascular disease (1·38, 1·29-1·48), and respiratory disease (1·44, 1·22-1·71) mortality. The stronger associations were observed in people older than 60 years, females, and participants with lower individual-level socioeconomic status. The individual-level socioeconomic, behavioural, and metabolic factors mediated 39·5% of the association between area-level socioeconomic status and mortality, of which individual-level socioeconomic status made the largest contribution. There are substantial area-level socioeconomic status-related inequalities in mortality in China. Individual-level socioeconomic, behavioural, and metabolic factors had mediating effects. Actions to improve area-level circumstances and individual factors are needed to improve health equity. The Chinese Academy of Medical Sciences Innovation Fund for Medical Science, the National High Level Hospital Clinical Research Funding, the Ministry of Finance of China, and the National Health Commission of China. For the Chinese translation of the abstract see Supplementary Materials section.

Disparity in healthcare seeking behaviors between impoverished and non-impoverished populations with implications for healthcare resource optimization

Globally, poverty and illness are linked, attracting widespread attention. In China, illness contributes to about 40% of rural poverty. This study sought to investigate how healthcare-seeking behavior differs between impoverished and non-impoverished populations within the same Chinese healthcare delivery system. It also sought to understand how differences should be considered when assessing spatial accessibility to provide more accurate recommendations for healthcare resource optimization and promote village revitalization and health equity in China. Methodologically, a survey conducted in May 2019 in Enshi Prefecture (a national impoverished region in Hubei Province, China) collected data on healthcare resource utilization regarding the inpatient and outpatient needs of both impoverished and non-impoverished populations. A Chi-square test compared their respective healthcare-seeking behaviors in three respects (e.g., preference for healthcare institution type, transportation mode, and travel time). Baidu Map data with healthcare institution locations and real-life travel times were then incorporated to assess spatial access to different types of healthcare institutions. Results showed that in Enshi, the most widespread village clinics (low-level) were generally the most utilized healthcare institutions for outpatient visits, with patients usually walking for about 30 min. The middle-level Township Health Centers (THCs) and high-level public hospitals were the most used for inpatient visits, with patients willing to drive up to 30 min to THCs and 60 min to hospitals. Comparatively, the impoverished have more frequent service demands but tend to choose lower-level healthcare institutions, with longer travel times and limited transportation modes. Although 75% of Enshi’s area was covered within 30 min by village clinics and 51% of the villages were within 60 min’ drive to hospitals, considerable areas remain under-served compared with the shortest travel time targets in China. In conclusion, spatial access to healthcare resources in Enshi must be further improved, especially by strengthening the service capacity of primary healthcare institutions to address the healthcare needs of Enshi’s impoverished population. The disparity in healthcare-seeking behavior between different population groups should be fully considered to effectively allocate limited healthcare resources to promote health equity for vulnerable populations as proposed in international and domestic policies.

Machine-learning-derived online prediction models of outcomes for patients with cholelithiasis-induced acute cholangitis: development and validation in two retrospective cohorts

Cholelithiasis-induced acute cholangitis (CIAC) is an acute inflammatory disease with poor prognosis. This study aimed to create machine-learning (ML) models to predict the outcomes of patients with CIAC. In this retrospective cohort and ML study, patients who met the both diagnosis of 'cholangitis' and 'calculus of gallbladder or bile duct' according to the International Classification of Disease (ICD) 9th revision, or met the diagnosis of 'calculus of bile duct with acute cholangitis with or without obstruction' according to the ICD 10th revision during a single hospitalization were included from the Medical Information Mart for Intensive Care database, which records patient admissions to Beth Israel Deaconess Medical Center, MA, USA, spanning June 1, 2001 to November 16, 2022. Patients who were neither admitted in an emergency department nor underwent biliary drainage within 24h after admission, had an age of less than 18, or lost over 20% of the information were excluded. Nine ML methods, including the Logistic Regression, eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting Machine, Adaptive Boosting, Decision Tree, Gradient Boosting Decision Tree, Gaussian Naive Bayes, Multi-Layer Perceptron, and Support Vector Machine were applied for prediction of in-hospital mortality, re-admission within 30 days after discharge, and mortality within 180 days after discharge. Patients from Zhongda Hospital affiliated to Southeast University in China between January 1, 2019 and July 30, 2023 were enrolled as an external validation set. The area under the receiver operating characteristic curve (AUROC) was the main index for model performance assessment. A total of 1156 patients were included to construct models. We performed stratified analyses on all patients, patients admitted to the intensive care unit (ICU) and those who underwent biliary drainage during ICU treatment. 13-16 features were selected from 186 variables for model training. The XGBoost method demonstrated the most optimal predictive efficacy, as evidenced by training set AUROC of 0.996 (95% CI NaN-NaN) for in-hospital mortality, 0.886 (0.862-0.910) for re-admission within 30 days after discharge, and 0.988 (0.982-0.995) for mortality within 180 days after discharge in all patients, 0.998 (NaN-NaN), 0.933 (0.909-0.957), and 0.988 (0.983-0.993) in patients admitted to the ICU, 0.987 (0.970-0.999), 0.908 (0.873-0.942), and 0.982 (0.971-0.993) in patients underwent biliary drainage during ICU treatment, respectively. Meanwhile, in the internal validation set, the AUROC reached 0.967 (0.933-0.998) for in-hospital mortality, 0.589 (0.502-0.677) for re-admission within 30 days after discharge, and 0.857 (0.782-0.933) for mortality within 180 days after discharge in all patients, 0.963 (NaN-NaN), 0.668 (0.486-0.851), and 0.864 (0.757-0.970) in patients admitted to the ICU, 0.961 (0.922-0.997), 0.669 (0.540-0.799), and 0.828 (0.730-0.925) in patients underwent biliary drainage during ICU treatment, respectively. The AUROC values of external validation set consisting of 61 patients were 0.741 (0.725-0.763), 0.812 (0.798-0.824), and 0.848 (0.841-0.859), respectively. The XGBoost models could be promising tools to predict outcomes in patients with CIAC, and had good clinical applicability. Multi-center validation with a larger sample size is warranted. The Technological Development Program of Nanjing Healthy Commission, and Zhongda Hospital Affiliated to Southeast University, Jiangsu Province High-Level Hospital Construction Funds.

Readiness for non-communicable disease service delivery in Ethiopia: an empirical analysis

BackgroundEthiopia’s health system is overwhelmed by the growing burden of non-communicable diseases (NCDs). In this study, we assessed the availability of and readiness for NCD services and the interaction of NCD services with other essential and non-NCD services.MethodsThe analysis focused on four main NCD services: diabetes mellitus, cardiovascular diseases, chronic respiratory diseases, and cancer screening. We used data from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. As defined by the World Health Organization, readiness, both general and service-specific, was measured based on the mean percentage availability of the tracer indicators, such as trained staff and guidelines, equipment, diagnostic capacity, and essential medicines and commodities needed for delivering essential health services and NCD-specific services, respectively. The survey comprised 632 nationally representative healthcare facilities, and we applied mixed-effects linear and ordered logit models to identify factors affecting NCD service availability and readiness.ResultsOnly 8% of facilities provided all four NCD services. Availability varied for specific services, with cervical cancer screening being the least available service in the country: less than 10% of facilities, primarily higher-level hospitals, provided cervical cancer screening. General service readiness was a strong predictor of NCD service availability. Differences in NCD service availability and readiness between regions and facility types were significant. Increased readiness for specific NCD services was significantly associated with increased readiness for communicable disease services and interacted with the readiness for other NCD services.ConclusionNCD service availability has considerable regional variation and is positively associated with general and communicable disease services readiness. Readiness for specific NCD services interacted with one another. The findings suggest an integrated approach to service delivery, focussing holistically on all disease services, is needed. There also needs to be increased attention to reducing resource allocation variation between facility types and locations.

Hand Surgery Training Structure in Germany - Evaluation of an Online Questionnaire

The duration of the training for hand surgery in Germany was reduced from three to two years in 2020, while other European Countries introduced hand surgery as a separate surgical specialty. Therefore, the structure of hand surgery training in Germany is under intense, ongoing discussion. This study aimed to evaluate the current situation of hand surgery training in Germany. Two separate online questionnaires were developed for self-assessment of residents and teachers in German hand surgery services. The questionnaire contained 29 questions for residents and 24 questions for teachers. Demographic data, educational tools, surgical training parameters and satisfaction were assessed from May to July 2023. The survey was based on the former training time of three years. The online questionnaire was sent to the members and associate members of the German Society for Hand Surgery via email. 148 participants answered the questionnaire, including 54 residents and 94 teachers. Overall, more female residents were assessed, whereas the majority of teachers was male. Hand surgery training is mostly conducted in high-level hospitals (tertiary care p=0.012, quaternary care p<0.001). Residents use digital teaching media significantly more often than teachers do (p<0.001). In contrast, teachers use journals (p=0.006) and clinical visits (p=0.024) significantly more often for their training than residents do. Trainers and trainees mostly agreed about time points of surgical milestones during surgical training that should be performed independently. Both trainers and trainees were largely satisfied with the practical and theoretical training in hand surgery. The importance of digital media in hand surgery training will increase in the near future. Therefore, digital media should be more frequently included in hand surgery training protocols. The study revealed that the majority of residents as well as teachers would appreciate the introduction of an independent hand surgery specialty, which would most likely improve the hand surgery competence in Germany.

Abstract P105: Comparative Effectiveness between Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors on Mortality: a Nationwide, Population-based, Prospective Cohort Study in China

Background: Contemporary evidence comparing the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) versus angiotensin II receptor blockers (ARBs) on long-term outcomes in patients with hypertension is sparse and inconsistent. The aim is to compare the effectiveness of ACEI monotherapy versus ARB monotherapy on all-cause death and cardiovascular death. Methods: Based on a nationwide, population-based prospective cohort project, which covered 318 study sites from 2014 to 2021 in China. Detailed information was collected by questionnaire, physical measurement, and blood test. Participants aged 35-75 years with hypertension and taking ACEI or ARB monotherapy once daily, and with good medication adherence at baseline were included. Information on mortality was followed up until 31 December 2021. Stabilized inverse probability treatment weighting (IPTW) was applied to compare the effectiveness. Results: 68 771 (49326 ARB, 19445 ACEI) participants were finally included, with a mean age of 59.9±8.3 years and 40.2% being female. During a median follow-up time of 44 months, 785 cardiovascular deaths and 1657 deaths were recorded. Compared with ACEI monotherapy, ARB monotherapy was associated with a quarter relative risk reduction of cardiovascular death (IPTW rates: 0.95 % Vs 1.43%, HR =0.73 [ 95%CI , 0.62-0.87]) and one-fifth relative risk reduction of all-cause death (IPTW rates: 2.13% Vs 2.84%, HR =0.80 [ 95%CI , 0.71-0.89]). These differences remained consistent after further adjusting for blood pressure and with differences more pronounced in patients with controlled and newly onset hypertension. Sensitive analysis and subgroup analysis yielded consistent results. Conclusions: Attention should be paid that ARB can be preferred to ACEI in patients with hypertension in terms of long-term health outcomes. Funding: This work was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Science (2021-I2M-1-011), and the National High Level Hospital Clinical Research Funding (2022-GSP-GG-4, NCRCSZ-2023-016). Keywords: Hypertension, Angiotensin receptor blocker, Angiotensin-converting enzyme inhibitor, Mortality, Comparative effectiveness

Prevalence and risk factors of training-related abdominal injuries: A multicenter survey study

PurposeThis study aims to identify the prevalence and risk factors of military training-related abdominal injuries and help plan and conduct training properly. MethodsThis questionnaire survey study was conducted from October 2021 to May 2022 among military personnel from 6 military units and 8 military medical centers and participants’ medical records were consulted to identify the training-related abdominal injuries. All the military personnel who ever participated in military training were included. Those who refused to participate in this study or provided an incomplete questionnaire were excluded. The questionnaire collected demographic information, type of abdominal injury, frequency, training subjects, triggers, treatment, and training disturbance. Chi-square test and t-test were used to compare baseline information. Univariate and multivariate regression analyses were used to explore the risk factors associated with military training-related abdominal injuries. ResultsA total of 3058 participants were involved in this study, among which 1797 (58.8%) had suffered training-related abdominal injuries (the mean age was 24.3 years and the service time was 5.6 years), while 1261 (41.2%) had no training-related abdominal injuries (the mean age was 23.1 years and the service time was 4.3 years). There were 546 injured patients (30.4%) suspended the training and 84 (4.6%) needed to be referred to higher-level hospitals. The most common triggers included inadequate warm-up, fatigue, and intense training. The training subjects with the most abdominal injuries were long-distance running (589, 32.8%). Civil servants had the highest rate of abdominal trauma (17.1%). Age ≥ 25 years, military service ≥ 3 years, poor sleep status, and previous abdominal history were independent risk factors for training-related abdominal injury. ConclusionMore than half of the military personnel have suffered military training-related abdominal injuries. Inadequate warm-up, fatigue, and high training intensity are the most common inducing factors. Scientific and proper training should be conducted according to the factors causing abdominal injuries.

The implementation of the guideline for the management of pediatric off-label use of drugs in China: a cross-sectional study.

Previously, we developed the Guidelines for the Management of Pediatric Off-Label Use of Drugs in China in addressing the need for standardization of pediatric off-label drug use. As the implementation of recommendations in Guidelines among healthcare professionals is weak, it is important to identify barriers to guideline implementation for developing appropriate strategies for specific settings and target groups. This study aimed to assess the difficulty and urgency in implementing the recommendations in the Guideline, identifying the factors affecting the implementation of these recommendations to realize the clinical translation of the Guideline. A cross-sectional study was conducted from March 1 to June 17, 2022. Pediatricians, pharmacists, and health managers from all 31 mainland Chinese provinces were involved. The electronic questionnaires were distributed nationwide by The Clinical Pharmacology Group of the Pediatric Society of the Chinese Medical Association and the National Clinical Research Center for Child Health. Data analysis, including frequency, percentages, averages, and standard deviations was performed using Microsoft Excel 16.54. Chi-squared tests, multi-factor logistic regression, and linear regression were analyzed in SPSS 23.0. A Sankey diagram was constructed using R software. A total of 869 valid questionnaires were collected from 491 participating organizations. More than half of the recommendations were implemented, and 12 recommendations were implemented more in tertiary hospitals than in secondary hospitals. The mean urgency scores of all 21 recommendations were over 5. The mean difficulty scores of all 21 recommendations were over 4. The percentage of the most urgent was 44.33%, and the least urgent was 1.45%. The most difficult portion was 12.03%, and the least difficult was 5.74%. Factors impacting the urgency and difficulty of guideline implementation were different, with common influences including the position, education level of clinicians and hospital level. The recommendations in the Guideline for the Management of Pediatric Off-Label Use of Drugs are considered highly urgent for implementation in China. Nevertheless, the study revealed challenges in applying all 21 recommendations within clinical practice. The key factors affecting implementation include the position, education, experience, and hospital level of healthcare professionals. It is recommended to facilitate implementing the recommendations by sharing experience across various hospital levels, starting from high-level hospitals and extending to primary healthcare settings. Moreover, adjustments to the professional structure within hospitals are needed to enhance the management of off-label drug use in pediatric patients.

A transformer-based deep learning model for early prediction of lymph node metastasis in locally advanced gastric cancer after neoadjuvant chemotherapy using pretreatment CT images

Early prediction of lymph node status after neoadjuvant chemotherapy (NAC) facilitates promptly optimization of treatment strategies. This study aimed to develop and validate a deep learning network (DLN) using baseline computed tomography images to predict lymph node metastasis (LNM) after NAC in patients with locally advanced gastric cancer (LAGC). A total of 1205 LAGC patients were retrospectively recruited from three hospitals between January 2013 and March 2023, constituting a training cohort, an internal validation cohort, and two external validation cohorts. A transformer-based DLN was developed using 3D tumor images to predict LNM after NAC. A clinical model was constructed through multivariate logistic regression analysis as a baseline for subsequent comparisons. The performance of the models was evaluated through discrimination, calibration, and clinical applicability. Furthermore, Kaplan-Meier survival analysis was conducted to assess overall survival (OS) of LAGC patients at two follow-up centers. The DLN outperformed the clinical model and demonstrated a robust performance for predicting LNM in the training and validation cohorts, with areas under the curve (AUCs) of 0.804 (95% confidence interval [CI], 0.752-0.849), 0.748 (95% CI, 0.660-0.830), 0.788 (95% CI, 0.735-0.835), and 0.766 (95% CI, 0.717-0.814), respectively. Decision curve analysis exhibited a high net clinical benefit of the DLN. Moreover, the DLN was significantly associated with the OS of LAGC patients [Center 1: hazard ratio (HR), 1.789, P<0.001; Center 2:HR, 1.776, P=0.013]. The transformer-based DLN provides early and effective prediction of LNM and survival outcomes in LAGC patients receiving NAC, with promise to guide individualized therapy. Future prospective multicenter studies are warranted to further validate our model. National Natural Science Foundation of China (NO. 82373432, 82171923, 82202142), Project Funded by China Postdoctoral Science Foundation (NO. 2022M720857), Regional Innovation and Development Joint Fund of National Natural Science Foundation of China (NO. U22A20345), National Science Fund for Distinguished Young Scholars of China (NO. 81925023), Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application (NO. 2022B1212010011), High-level Hospital Construction Project (NO. DFJHBF202105), Natural Science Foundation of Guangdong Province for Distinguished Young Scholars (NO. 2024B1515020091).

Undifferentiated embryonal sarcoma of the liver in children: our experience in four difficult cases and three-dimensional practical exploration

AimsTo explore rare and difficult cases of undifferentiated embryonal sarcoma of the liver (UESL) in children in a single centre, summarize the diagnosis and treatment experience and analyse the role of a computer-assisted surgery system (Hisense CAS), thus providing a new global vision and three-dimensional perspective.MethodsWe retrospectively collected the clinical data including the diagnoses and treatment processes, of children with UESL confirmed by histopathological examination in our hospital from January 2009 to December 2020. The relationship between the tumour volume and important blood vessels and between the liver volume and tumour volume, as well as other three-dimensional characteristics in the reconstructed three-dimensional model were analysed using Hisense CAS. The findings from this analysis can be used to aid in surgical decision-making and preoperative planning.ResultsFour children—3 girls and 1 boy—with UESL were included in the study. The age at onset ranged from 6 to 8 years. All four children presented with symptoms of abdominal discomfort, and abdominal masses were detected during physical examination. Owing to the wishes of their parents and the possibility that the disease was benign, all four children underwent one-stage radical surgery. For patient 1, a three-dimensional reconstruction was created during the initial diagnosis, which made accurate evaluation and planning of the preoperative procedure challenging. In patient 2, the tumour was located in the middle lobe of the liver and involved the first and second hepatic hilum. For patient 3, the pathological diagnosis of the tumour after surgery was challenging, but eventually, the diagnosis was confirmed through histochemistry and consultation with higher-level hospitals. Patient 4 had a giant tumour, which had a preoperative simulated future liver remnant volume (FLV) that was 21.0% of the total volume of the liver and tumour (TLTV). According to the standard liver volume (SLV) for children, the FLV was 77.0% of the SLV, making surgery feasible. All four children underwent complete resection, and only patient 4 experienced recurrence below the diaphragm 19 months after surgery. Currently, the 3-year overall survival rate is 100%, and the 3-year event-free survival rate is 75%.ConclusionUESL in children is rare, and the key to diagnosis and treatment is complete surgical resection. Through individualized three-dimensional surgical planning, accurate and complete resection of difficult and complex UESL in children can be achieved, leading to a favourable prognosis.

Blood pressure response index and clinical outcomes in patients with septic shock: a multicenter cohort study

Sepsis is a leading cause of mortality in intensive care units and vasoactive drugs are widely used in septic patients. The cardiovascular response of septic shock patients during resuscitation therapies and the relationship of the cardiovascular response and clinical outcome has not been clearly described. We included adult patients admitted to the ICU with sepsis from Peking Union Medical College Hospital (internal), Medical Information Mart for Intensive Care IV (MIMIC-IV) and eICU Collaborative Research Database (eICU-CRD). The Blood Pressure Response Index (BPRI) was defined as the ratio between the mean arterial pressure and the vasoactive-inotropic score. BRRI was compared with existing risk scores on predicting in-hospital death. The relationship between BPRI and in-hospital mortality was calculated. A XGBoost's machine learning model identified the features that influence short-term changes in BPRI. There were 2139, 9455, and 4202 patients in the internal, MIMIC-IV and eICU-CRD cohorts, respectively. BPRI had a better AUROC for predicting in-hospital mortality than SOFA (0.78 vs. 0.73, p=0.01) and APS (0.78 vs. 0.74, p=0.03) in the internal cohort. The estimated odds ratio for death per unit decrease in BPRI was 1.32 (95% CI 1.20-1.45) when BPRI was below 7.1 vs. 0.99 (95% CI 0.97-1.01) when BPRI was above 7.1 in the internal cohort; similar relationships were found in MIMIC-IV and eICU-CRD. Respiratory support and latest cumulative 12-h fluid balance were intervention-related features influencing BPRI. BPRI is an easy, rapid, precise indicator of the response of patients with septic shock to vasoactive drugs. It is a comparable and even better predictor of prognosis than SOFA and APS in sepsis and it is simpler and more convenient in use. The application of BPRI could help clinicians identify potentially at-risk patients and provide clues for treatment. Fundings for the Beijing Municipal Natural Science Foundation; the National High Level Hospital Clinical Research Funding; the CAMS Innovation Fund for Medical Sciences (CIFMS) from Chinese Academy of Medical Sciences and the National Key R&D Program of China, Ministry of Science and Technology of the People's Republic of China.

Evidence of being cured for nasopharyngeal carcinoma: results of a multicenter patient-based study in China

The survival rates of patients with nasopharyngeal carcinoma (NPC) have improved significantly, but there is no consensus on whether they can be considered cured. We aimed to determine whether a statistical cure could be achieved for patients with NPC in the contemporary therapeutic landscape. This retrospective multicenter study enrolled 6315 patients with nonmetastatic NPC from nonendemic and endemic regions of China from 2007 to 2020. We applied mixture and nonmixture cure models to estimate the cure probabilities and cure times by incorporating background mortality for the general population, matching by gender, age, and diagnosed year. With death as the uncured event, the probability of patients with NPC achieving a life expectancy at par with the general population was 78.1%. Considering progression as the uncured event, the likelihood of patients attaining a life expectancy without progression equivalent to that of the general population was 72.4%. For individuals, the probabilities of achieving cure were conditional and time-dependent, requiring approximately 7.1 and 4.7 years with 95% certainty, respectively. The corresponding cure times for uncured patients were 8.9 and 6.8 years, respectively. The cure probability was correlated with age, Eastern Cooperative Oncology Group score, TNM staging, Epstein-Barr virus DNA copies, and lactate dehydrogenase. The correlation was excellent between 5-year overall survival/progression-free survival and cure fractions. Statistical cure is potentially achievable among patients with NPC undergoing contemporary treatment modalities. The results hold significant potential implications for both clinical practice and patient perspectives. National High Level Hospital Clinical Research Funding; Beijing Xisike Clinical Oncology Research Foundation; Beijing hope run fund.

Cultural competence and associated factors among nurses working in public hospitals of South Wollo zone, Northeast Ethiopia: a multi-center cross-sectional study

BackgroundEnhancing cultural competence stands as a cornerstone in the realm of clinical nursing. Consequently, nurses engaging with culturally diverse communities encounter significant challenges. In Ethiopia, nurses providing care often prioritize physical well-being, the therapeutic journey, and medical interventions, while overlooking the critical cultural dimensions of patient care. Therefore, this study aims to assess the level of cultural competence and its determining factors among nurses employed in public hospitals located in the South Wollo Zone of northeastern Ethiopia.MethodsA multicenter, institution-based cross-sectional study was conducted, involving 629 nurses employed in public hospitals across northeastern Ethiopia. Participants were selected using a simple random sampling method. Data were gathered using a structured, self-administered English version of the Nurse Cultural Competence Scale Questionnaire (NCCSQ), and subsequently entered into Epi-data 4.6 for analysis. Statistical analysis was performed using SPSS version 26, employing multiple linear regression analysis to identify determining factors.ResultThe participants’ overall mean score for cultural competence was 3.198 [95% CI: 3.161, 3.234]. Specifically, factors such as being a female nurse (β = 0.089, CI: 0.019–0.159), having a diploma level of education (β = -0.084, CI: -0.101 to -0.007), having 11–20 years of work experience (β = 0.412, CI: 0.090–0.815), a 1:15 nurse-to-patient ratio (β = 0.081, CI: 0.010–0.162), experience with caring for culturally and ethnically diverse patients (β = 0.362, CI: 0.248–0.476), comprehensive hospital level (β = 0.699, CI: 0.496–0.903), and attending cultural training (β = 0.002, CI: 0.234–0.931) were predictors of the mean score for cultural competence.ConclusionIn this study, the level of cultural competence was found to be at a moderate level and need more effort. Factors such as gender, years of work experience, nurse-to-patient ratio, experience in caring for culturally and ethnically diverse patients, hospital level, educational attainment, attendance of cultural training, and the presence of a feedback system for cultural competence were identified as predictors of cultural competence level. Sharing experiences from higher-level hospitals to lower-level ones and strengthening cultural competence training sessions for nurses can significantly enhance cultural competence within clinical settings.