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Journal: Zhonghua nei ke za zhi

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The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy (HE) in cirrhosis based on the published evidences and panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy (OHE) emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and prompt treatment are essential to improve the prognosis of HE. The principles of treatment mainly consist of eliminating precipitating factors, treating hyperammonemia to improve acute neuropsychiatric abnormalities rapidly, primary and secondary prophylaxis.

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To establish the experts consensus on the use of methotrexate in the treatment of rheumatic diseases. A consensus development panel was established. The panel of consensus was composed of 45 experts in rheumatology from the group of Chinese Association of Rheumatology and Immunology Physicians. The consensus development panel developed 7 recommendations, including the clinical status and application principles of methotrexate in the treatment of rheumatoid arthritis, optimal dosage and route, dosage adjustment, monitoring, long-term safety and management in the perioperative period and before/during pregnancy. This consensus was intended to standardize the use of methotrexate in rheumatic diseases and improve the management of rheumatoid arthritis and other rheumatic diseases.

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Objective: Abnormalities of lipid profile were considered as risk factors of hemorrhage after ischemic stroke. We aimed to determine the relationship between lipid levels and bleeding in minor stroke or transient ischemic attack (TIA) patients receiving antiplatelet therapy. Methods: Serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglyceride were tested in a subgroup of 3 044 consecutive patients from Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial. Patients were randomized to clopidogrel plus aspirin group or single aspirin group. The primary endpoint was any bleeding within 90 days. The secondary endpoint was severe bleeding according to the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) definition. Cox proportional hazards models were used to assess the associations of lipid levels and outcomes. Results: A total of 59 (1.9%) bleeding events occurred at 90 days. High-density lipoprotein cholesterol (adjusted HR=2.16; 95%CI 1.17-4.00, P=0.014) and age (adjusted HR=1.04; 95%CI 1.01-1.06, P=0.006) were significantly associated with any bleeding. High-density lipoprotein cholesterol was also associated with severe bleeding (adjusted HR=3.05; 95%CI 1.39-6.68, per 1 mmol/L increase). No correlations between outcomes and levels of total cholesterol, low-density lipoprotein cholesterol and triglyceride were found. There was no interaction of any lipid component level with randomized antiplatelet therapy. Conclusions: Elevated high-density lipoprotein cholesterol is independently associated with any bleeding and severe bleeding in the patients with acute minor stroke or high-risk TIA on antiplatelet therapy.

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Objectives: To evaluate the effectiveness of cognitive behavior therapy for insomnia (CBT-i) in chronic insomnia patients in terms of the improvements of psychological and sleep diary parameters. Methods: Patients who met the diagnostic criteria of chronic insomnia, were divided into primary group or comorbid group. Both groups received standard CBT-i interventions. Psychological scales and sleep diaries were used to evaluate participants' severity of insomnia and psychological conditions related to insomnia at four time points: before intervention (baseline), immediate after intervention, 4 weeks and 16 weeks after intervention. Results: Both groups achieved significant improvements after intervention on psychological measurements and sleep diary parameters. Such improvements were maintained at 4-week and 16-week follow-ups. The sleep diary data indicated that by the end of the intervention, there were significant differences on sleep onset latency (51.72 min to 10.53 min in primary group, P<0.01; 59.26 min to 15.67min in comorbid group, P<0.01) and sleep efficiency (71% to 95% in primary group, P<0.01; 68% to 90% in comorbid group, P<0.01). There were differences on sleep onset latency (10.00 min vs. 13.93 min, P<0.05), total sleep time (355.71 min vs. 327.85 min, P<0.05) and sleep efficiency (95% vs. 91%, P<0.01) in primary group and comorbid group respectively. No differences were found on wake after sleep onset in the two groups. Conclusions: Chronic insomnia patients with or without comorbidities both have improvements after CBT-i. Sleep diary parameters rather than psychological measurements are different in two groups. Thus, CBT-i is an effective non-pharmaceutical therapy inpatients with chronic insomnia.

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Objective: To investigate the change of circulating follicular helper T cells (cTfh) in patients with anti-neutrophil cytoplasmic myeloperoxidase antibody-associated vasculitis (MPO-AAV), and to analyze the relationship between cTfh and disease activity. Methods: Thirty-eight untreated MPO-AAV patients (patient group) and thirty-eight healthy volunteers (control group) were enrolled in this study. cTfh and membrane expression of inducible co-stimulator (ICOS) and programmed cell death protein 1 (PD-1) were detected by flow cytometry (FCM). Serum anti-neutrophil cytoplasmic myeloperoxidase antibody (MPO-ANCA) was measured by ELISA. Disease activity was evaluated by Birmingham vasculitis activity score (BVAS). Results: Compared with those in control group, the proportions of cTfh, ICOS(+)Tfh and PD-1(+) Tfh cells in patient group were significantly higher [(25.9±3.8)% vs. (21.0±5.3)%, P<0.001; (1.8±0.8)% vs. (0.8±0.5)%, P<0.001 and (10.2±2.8)% vs. (8.2±2.2)%, P=0.001, respectively]. Meanwhile, the expression of ICOS and PD-1 on cTfh in patient group was markedly more intensive (59.6±10.0 vs.49.2±6.9, P<0.001 and 532.6±104.2 vs. 485.1±73.4, P=0.025, respectively). In patient group, the proportion of cTfh was positively correlated with the ratio of ICOS(+)Tfh, the expression of ICOS, the level of MPO-ANCA and BVAS (r=0.407, P=0.011; r=0.705, P<0.001; r=0.737, P<0.001 and r=0.663, P<0.001, respectively). The expression intensity of ICOS on cTfh was positively associated with ICOS(+)Tfh ratio, serum MPO-ANCA and BVAS (r=0.388, P=0.016; r=0.645, P<0.001 and r=0.653, P<0.001, respectively). Nevertheless, the expression of PD-1 on cTfh was only positively correlated with the ratio of PD-1(+) Tfh (r=0.473, P=0.003). Conclusions: Enhanced cTfh in patients with MPO-AAV might produce MPO-ANCA, which is related to the aggravation of MPO-AAV. Thus, cTfh and its ICOS could be potentially targeted for the treatment of MPO-AAV.

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Objective: Gut microbiota have been reported to be able to regulate host metabolism and is closely associated to obesity. The purpose of this study was to explore the differences between the diversity of luminal and mucosa-associated microbial communities in obese mice. Methods: Colonic luminal contents and colonic mucosa were separately collected from 10 obese mice fed with high-fat diet for 12 weeks. DNA of gut microbiota was extracted and micro flora populations were analyzed by Illumina sequencing. Species annotation, diversity analysis, and species difference analysis were conducted. Results: The microbial flora from colonic contents had similar richness, evenness and overall structure to those from colonic mucosa (ACE index 250 vs. 285, Chao index 257 vs. 291, Shannon index 3.84 vs. 3.97, Simpson index 0.05 vs. 0.06, all P>0.05). However, there were differences in the microbial composition on specific levels. At the phylum level, colonic contents had higher abundance of Bacteroidetes (56.08% vs. 27.25%, P=3.21×10(-5)), while colonic mucosa had higher abundance of Firmicutes (49.09% vs. 34.27%, P=0.03) and proteobacteria (18.48% vs. 3.62%, P=0.000 9). At the genus level, butyrate-producing bacteria-Lactobacillus was more abundant in colonic content (LDA score=3.89), whereas gram-negative genus Helicobacter, Sphingomonas and Desulfovibrio were relatively abundant in colonic mucosa (LDA score=4.78, 3.59 and 4.11, respectively). Conclusion: There were differences in microbial composition at the phylum and genus levels between microbial flora from colonic contents and colonic mucosa, although they had similar richness, evenness and overall structure.

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To explore clinical characteristics, electrophysiological findings and treatment response in diabetic patients with chronic inflammatory demyelinating polyradiculoneuropathy (DM-CIDP). Thirty-six CIDP patients were identified, 10 were DM-CIDP and 26 were non-DM-CIDP. Clinical medical records, electrophysiological data and treatment were retrospectively reviewed. DM-CIDP patients were significantly older than non-DM-CIDP patients [(56.7±10.0) years old vs. (40.4±16.9) years old, P=0.001]. However, clinical characteristics and abnormalities of electrophysiological tests in both groups were comparable. DM-CIDP subjects responded to corticosteroids or intravenous immunoglobulin, thus with better prognosis.

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To explore the impact of gender on presentation of primary hyperparathyroidism (PHPT), clinical data of 150 histopathologically proven PHPT patients were collected and retrospectively analyzed. Most of the patients (72.0%) were parathyroid adenoma (PA), and 9.3% of them were parathyroid carcinoma (PC). In PA patients, albumin-corrected serum calcium levels (TASC) were lower in women than in men [ (2.84±0.28) mmol/L vs. (3.03±0.34) mmol/L, P=0.006]. In all PHPT subjects, serum urea nitrogen, creatinine, uric acid levels were lower in women than in men. Bone pain was more frequent in women over 50 years old than in men (52.33% vs.29.17%, P=0.045). The incidence of PC was higher in men than in women (20.59% vs. 6.03%, P=0.010). In conclusion, there are gender differences in the clinical presentation of PHPT. TASC was high in men with PA compared to women with PA. Bone pain was more common in the woman patients over 50 years old, and PC was more common in men.

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According to the national survey data over the past five years, there are about 50.16 million elderly diabetic patients (≥60 years old) in China. With the increase in the total number of the elderly, this number will be expected to increase. Among the elderly patients, most of them are newly diagnosed, and are associated with a number of risk factors for cardiovascular diseases at the time of initial diagnosis. Those who were with young-onset have a long-term clinical course, and often complicated with diabetic chronic complications and potential organ dysfunctions. Most of the elderly diabetic patients in China are with poor glycemic control. The diabetes-related complications have become one of the major reasons for the senile death. It is well accepted that early diagnosis and reasonable treatment could reduce the occurrence of diabetic complications, and the disability and fatal cardiovascular and cerebrovascular events. Thus, it is recommended, in the consensus, to conduct a comprehensive assessment of the glycemic control, metabolic cardiovascular risk factors, diabetes complications, multiple organ functions of the elderly patients, as well as their intelligence and physical fitness. Personalized control targets on blood glucose, pressure, lipids, uric acid and body weight would be established based on the assessment of each patient and consideration of the balance between benefits and risks in order to achieve the goal of early detection, early diagnosis, early treatment and early target reaching. Moreover, it is also recommended, in the consensus, to focus on the basic treatments (diets, exercises, self-monitoring and management), initiate suitable hypoglycemic drugs with complementary mechanisms when needed, and take into consideration of management of multiple cardiovascular risk factors and drug usage together with the caution of mutual interactions of multiple drugs.

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Dengue is the most prevalent and rapidly spreading mosquito-borne viral disease. As a dengue non-endemic country, China has experienced several dengue outbreaks in recent years. However, dengue patients in China displayed distinct clinical characteristics compared to patients in endemic countries. To standardize the diagnosis and treatment of dengue fever, the experts of the Society of Infectious Diseases, Society of Tropical Medicine and Parasitology of Chinese Medical Association, and the Society of Emergency Medicine, China Association of Chinese Medicine have reached this guideline based on guidelines for diagnosis, treatment, prevention and control of dengue (World Health Organization, 2009); guidelines for diagnosis and treatment of dengue (National Health and Family Planning Commission of the People’s Republic of China, 2014, Edition 2), health industry standard of the People’s Republic of China “diagnosis for dengue fever (WS216-2018)” and systemic reports on dengue. The guideline includes 8 aspects: introduction, terminology, epidemiology and prevention, etiology and pathogenesis, clinical features, diagnosis, treatment and problems to be solved.