NCCN癌症相关性静脉血栓栓塞症防治指南（2020版）解读

2020年4月,美国国家综合癌症网络（NCCN）发布了癌症相关性静脉血栓栓塞性疾病（VTE）指南2020年第1版。指南主要对住院及门诊癌症患者如何进行VTE的预防和治疗提供了指导建议。笔者重点将2020版与2019版NCCN指南内容进行对比,同时结合临床实际问题,对更新的VTE风险评估方法和防治措施的内容进行解读,以期相关医务工作者能更好地理解和遵循指南。     

美国国家综合癌症网络临床实践指南:胃癌(2020V2)更新要点和解读

2020年5 月,美国国家综合癌症网络(NCCN )发布了《NCCN临床实践指南:胃癌2020.V2》(以下简称指南)[1].相比于NCCN胃癌临床指南2019.V4 版和2020.V1 版,新版指南对胃癌诊断评估、系统治疗(内镜、手术、放化疗、靶向/免疫治疗等)、遗传风险评估等作出全面更新.更新内容及当前热点包含以下...     

《中国髌股关节骨关节炎诊疗指南(2020年版)》要点解读

髌股关节骨关节炎(patellofemoral osteoarthritis,PFOA)是膝关节骨关节炎的一种重要亚型,因人群患病率高、疾病负担重,近年来受到广泛关注。为此,国家老年疾病临床医学研究中心(湘雅医院)、中华医学会骨科学分会关节外科学组以及《中华骨科杂志》编辑部组织并成立了指南制订专家小组,按照指南制订规范,于2020年9月发布了《中国髌股关节骨关节炎诊疗指南(2020年版)》,对我国PFOA临床诊疗实践的规范化具有重要指导意义。指南内容主要包括PFOA的诊断(症状、体征和影像学改变)、非手术治疗(基础治疗和药物治疗)以及手术治疗(修复性手术和重建手术)等管理措施。本文基于《中国髌股关节骨关节炎诊疗指南(2020年版)》,对PFOA诊疗相关的热点问题进行解读。     

2020年版与2018年版中国胰腺癌综合诊治指南比较分析

随着对胰腺癌生物学行为认识的不断深入,中国抗癌协会胰腺癌专业委员会相继在2018年及2020年制定发布了《中国胰腺癌综合诊治指南(2018版)》和《中国胰腺癌综合诊治指南(2020版)》.为此,笔者对比并总结两版指南在胰腺癌的诊疗过程中的差异之处,并对新版指南中提出的新方法、新方案及热点问题等内容通过参考相关研究的最新...     

基于保护动机理论的久坐行为干预方案在 老年冠心病患者中的应用

目的 探讨基于保护动机理论的久坐行为干预方案在老年冠心病患者中的应用效果。方法 以便利抽样法抽取心内科2个病区的60例老年冠心病患者,将入住1病区的30例患者纳入对照组,入住2病区的30例患者纳入观察组。对照组进行常规健康教育,观察组在常规健康教育基础上实施基于保护动机理论的久坐行为干预方案。分别于出院前1 d、出院后1周、1个月、3个月进行效果评价。结果 干预后1个月、3个月两组久坐行为总时间、久坐行为最长持续时间、每日总步数、6 min步行距离、运动自我效能评分比较,差异有统计学意义（均P＜0.05）。结论 基于保护动机理论的久坐行为干预方案的实施可有效降低老年冠心病患者的久坐行为水平,增加身体活动,提高运动耐力,提升运动自我效能感。     

原发性骨质疏松诊疗流程探讨——骨质疏松专家讨论会纪要

骨质疏松症（osteoporosis）是一种以骨量低下,骨微结构损坏,导致骨脆性增加,骨折风险增加为特征的全身性骨病（世界卫生组织,WHO）。中华医学会骨质疏松和骨矿盐疾病分会于2011年就骨质疏松诊治指南进行了更新,就骨质疏松诊断流程进行了标准的指导;2008年中华医学会骨科学分会《骨质疏松骨折诊疗指南》就骨质疏松性骨折的诊疗也有相关诊疗建议。     

基于指南的卒中患者运动康复推荐意见总结

目的总结国内外指南有关卒中患者运动康复的推荐意见,为制定科学的运动康复锻炼方案提供参考。方法系统检索相关指南网站及数据库有关卒中康复的指南,由4名专家采用AGREEⅡ对指南质量进行评价。结果共纳入8部质量为A级或B级的指南;从卒中后运动康复时间、频率、强度和形式等总结推荐意见。结论指南对卒中后运动康复的意见也未达成一致,还需更多循证证据对卒中后患者的运动康复提供支持。     

成人烧伤营养支持指南

2006年中华医学会肠外肠内营养学分会参照世界卫生组织(world Health Organization,WHO)和AGREE协作网(Appraisal of Guideline Research and Evaluation,http://www.agreecollaboration.org/instrument/)发展的临床指南编写方法学原则,结合我国肠外肠内营养实践现状,建立了指南制定的方法学原则 [1-2].     

成人烧伤营养支持指南

2006年中华医学会肠外肠内营养学分会参照世界卫生组织(world Health Organization,WHO)和AGREE协作网(Appraisal of Guideline Research and Evaluation,http://www.agreecollaboration.org/instrument/)发展的临床指南编写方法学原则,结合我国肠外肠内营养实践现状,建立了指南制定的方法学原则 [1-2].     

成人烧伤营养支持指南

2006年中华医学会肠外肠内营养学分会参照世界卫生组织(world Health Organization,WHO)和AGREE协作网(Appraisal of Guideline Research and Evaluation,http://www.agreecollaboration.org/instrument/)发展的临床指南编写方法学原则,结合我国肠外肠内营养实践现状,建立了指南制定的方法学原则 [1-2].     

The “Goldilocks Day” for Children's Skeletal Health: Compositional Data Analysis of 24-Hour Activity Behaviors

Optimization of children's activity behaviors for skeletal health is a key public health priority, yet it is unknown how many hours of moderate to vigorous physical activity (MVPA), light physical activity (LPA), sedentary behavior, or sleep constitute the best day—the “Goldilocks Day”—for children's bone structure and function. To describe the best day for children's skeletal health, we used data from the cross-sectional Child Health CheckPoint. Included participants (n = 804, aged 10.7 to 12.9 years, 50% male) underwent tibial peripheral quantitative CT to assesses cross-sectional area, trabecular and cortical density, periosteal and endosteal circumference, polar moment of inertia, and polar stress–strain index. Average daily time-use composition (MVPA, LPA, sedentary time, and sleep) was assessed through 8-day, 24-hour accelerometry. Skeletal outcomes were regressed against time-use compositions expressed as isometric log-ratios (with quadratic terms where indicated), adjusted for sex, age, pubertal status, and socioeconomic position. The models were used to estimate optimal time-use compositions (associated with best 5% of each skeletal outcome), which were plotted in three-dimensional quaternary figures. The center of the overlapping area was considered the Goldilocks Day for skeletal health. Children's time-use composition was associated with all skeletal measures (all p ≤ 0.001) except cross-sectional area (p = 0.72). Days with more sleep and MVPA, less sedentary time, and moderate LPA were beneficially associated with skeletal measures, except cortical density, which was adversely associated. The Goldilocks daily time-use composition for overall skeletal health was center (range): 10.9 (10.5 to 11.5) hours sleep; 8.2 (7.8 to 8.8) hours sedentary time; 3.4 (2.8 to 4.2) hours LPA, and 1.5 (1.3 to 1.5) hours MVPA. Estimated optimal sleep duration is consistent with current international guidelines (9 to 11 hours), while estimated optimal MVPA exceeds recommendations of at least 60 min/d. This first study to describe optimal durations of daily activities for children's skeletal health provides evidence to underpin guidelines. © 2020 American Society for Bone and Mineral Research (ASBMR).     

Can we improve cognitive function among adults with osteoarthritis by increasing moderate-to-vigorous physical activity and reducing sedentary behaviour? Secondary analysis of the MONITOR-OA study

Background

Preliminary evidence suggests osteoarthritis is a risk factor for cognitive decline. One potential reason is 87% of adults with osteoarthritis are inactive, and low moderate-to-vigorous physical activity and high sedentary behaviour are each risk factors for cognitive decline. Thus, we investigated whether a community-based intervention to increase moderate-to-vigorous physical activity and reduce sedentary behaviour could improve cognitive function among adults with osteoarthritis.

Methods

This was a secondary analysis of a six month, proof-of-concept randomized controlled trial of a community-based, technology-enabled counselling program to increase moderate-to-vigorous physical activity and reduce sedentary behaviour among adults with knee osteoarthritis. The Immediate Intervention (n?=?30) received a Fitbit® Flex? and four bi-weekly activity counselling sessions; the Delayed Intervention (n?=?31) received the same intervention two months later. We assessed episodic memory and working memory using the National Institutes of Health Toolbox Cognition Battery. Between-group differences (Immediate Intervention vs. Delayed Intervention) in cognitive performance were evaluated following the primary intervention (i.e., Baseline – 2?Months) using intention-to-treat.

Results

The intervention did not significantly improve cognitive function; however, we estimated small average improvements in episodic memory for the Immediate Intervention vs. Delayed Intervention (estimated mean difference: 1.27; 95% CI [??9.27, 11.81]; d?=?0.10).

Conclusion

This small study did not show that a short activity promotion intervention improved cognitive health among adults with osteoarthritis. However, the effects of increased moderate-to-vigorous physical activity and reduced sedentary behaviour are likely to be small and thus we recommend subsequent studies use larger sample sizes and measure changes in cognitive function over longer intervals.

Trial registration number

ClinicalTrials.gov Protocol Registration System: NCT02315664; registered 12 December, 2014; https://clinicaltrials.gov/ct2/show/NCT02315664?cond=NCT02315664&rank=1

     

Moderate‐to‐Vigorous Physical Activity But Not Sedentary Time Is Associated With Musculoskeletal Health Outcomes in a Cohort of Australian Middle‐Aged Women

Associations between physical activity and time spent sedentary and musculoskeletal outcomes remain unclear in middle‐aged adults. This study aimed to describe associations between objectively‐measured physical activity and sedentary time and musculoskeletal health outcomes in middle‐aged women. This cross‐sectional study from a population‐based sample of 309 women (age 36 to 57 years) examined associations of total physical activity (accelerometer counts/min of wear time), and time spent sedentary, in light physical activities and moderate‐to‐vigorous physical activities (MVPA) (by Actigraph GT1M accelerometer) with lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) (by dual‐energy X‐ray absorptiometry), lower limb muscle strength (LMS), and functional mobility and balance tests (timed up and go test [TUG], functional reach test [FRT], lateral reach test [LRT], and step test [ST]) using linear regression. Total physical activity was beneficially associated with FN BMD (values are β; 95% CI) (0.011 g/cm²; 95% CI, 0.003 to 0.019 g/cm²), LMS (2.13 kg; 95% CI, 0.21 to 4.06 kg), and TUG (–0.080 s; 95% CI, –0.129 to –0.030 s), after adjustment for confounders. MVPA was also beneficially associated with FN BMD (0.0050 g/cm²; 95% CI, 0.0007 to 0.0094 g/cm²), LMS (1.48 kg; 95% CI, 0.45 to 2.52 kg), ST (0.12 steps; 95% CI, 0.02 to 0.23 steps), and TUG (–0.043 s; 95% CI, –0.070 to –0.016 s). Associations between MVPA and LMS, TUG and ST persisted after further adjustment for sedentary time. Only TUG was associated with sedentary time, with a detrimental effect (0.075 s; 95% CI, 0.013 to 0.137 s) and this did not persist after further adjustment for MVPA. Light physical activity was not associated with any outcome. MVPA appears more important than light physical activity or sedentary time for many musculoskeletal outcomes in middle‐aged women. This needs to be considered when developing interventions to improve habitual physical activity that aim to improve musculoskeletal health. © 2016 American Society for Bone and Mineral Research.     

Physical Activity and Sedentary Behavior in an Ethnically Diverse Group of South African School Children

Few studies have examined physical activity and inactivity levels in an urban South African setting across 12 years of formal schooling. This information is important for implementing strategies to curb increasing trends of physical inactivity and related negative consequences, especially in low to middle income countries facing multiple challenges on overburdened health care systems. We examined levels of physical activity and sedentary behaviour cross-sectionally over 12 school years from childhood to adolescence in Black, White and Indian boys and girls. The aim of our study was to describe gender and race related patterns of physical and sedentary activity levels in a sample of South African children and to determine whether there were associations between these variables and body mass status. Physical activity questionnaires, previously validated in a South African setting, were used to gather information about activity and sedentary behaviours among 767 Black, White and Indian children (5-18 years of age) across the 12 grades of formal schooling. Body mass and height were also measured. Time spent in moderate-vigorous physical activity declined over the school years for all race groups and was consistently lower for girls than boys (p = 0.03), while time spent in sedentary activity increased with increasing grade (p < 0.001) for boys and girls and across all race groups. Associations between physical activity and body mass were observed for White children (r = -0.22, p < 0.001), but not for Black and Indian children (p > 0.05) whereas time spent in sedentary activities was significantly and positively correlated with body mass across all race groups: Indian (r = 0.25, p < 0.001), White (r = 0.22, p < 0.001) and Black (r = 0.37, p = 0.001). The strength of the associations was similar for boys and girls. Black and Indian children were less physically active than their white peers (p < 0.05), and Black children also spent more time in sedentary activity (p < 0.05). Additionally, Black children had the highest proportion of overweight participants (30%), and Indian children the most number of underweight children (13%). Regardless of ethnicity, children who spent more than 4 hours per day in front of a screen were approximately twice as likely to be overweight (OR, 1.96 [95%CI: 1.06-3.64, p = 0.03]). Regardless of race, inactivity levels are related to body mass. Ethnic and gender disparities exist in physical activity and sedentary activity levels and this may echo a mix of biological and cultural reasons.

Key points

• Regardless of race, inactivity levels are related to body mass.
• In an ethnically diverse urban group of South African school children, there exists an age related decline in physical activity and increase in time spent in front of a screen.
• Ethnic and gender disparities exist in physical activity and sedentary activity levels and this may echo a mix of biological and cultural reasons.

Key words: South African children, ethnicity, screen time, physical activity     

Tri-Axial Accelerometer-Determined Daily Physical Activity and Sedentary Behavior of Suburban Community-Dwelling Older Japanese Adults

Knowledge regarding accelerometer-derived physical activity (PA) and sedentary behavior (SED) levels is scarce for Japanese older adults. The aims of this study were therefore to 1) describe levels of PA and SED in Japanese community-dwelling older adults, using tri-axial accelerometer; 2) examine the variation of PA and SED with respect to sex, age, and body mass index (BMI). Participants of this study were from the baseline survey of the Sasaguri Genkimon Study, who were 65 years or older and not certified as those requiring long-term care. PA was assessed objectively for seven consecutive days using tri-axial accelerometer. A total of 1,739 participants (median age: 72 years, men: 38.0%) with valid PA data were included. Overall, participants in the present study spent 54.5% of their waking time being sedentary and 45.5% being active, of which 5.4% was moderate-to-vigorous physical activity (MVPA). Women accumulated more minutes of light physical activity (LPA) and MVPA compared with men. In contrast, men spent more time being sedentary. Mean steps per day did not differ between sexes. Furthermore, participants with higher BMI (BMI ≥25) had lower PA levels, and longer SED compared with those with lower BMI (BMI <). PA levels were lower and SED was longer with age. The present study is the first to demonstrate that the levels of PA and SED differed by sex, age, and BMI in Japanese community-dwelling older adults. In particular, women were more active compared with men, providing unique insight into the current level of PA in older adults. Data presented in the study will enable further investigation of additional determinants of PA and SED in order to develop effective population-based intervention strategies to promote PA and reduce prolonged SED in the Japanese population and possibly other rapidly aging societies.

Key points

• Accelerometer, that is capable to assess PA more precisely in large scale epidemiological studies, provides opportunity for improving understanding of daily PA in older adults.
• This study first demonstrated that the levels of PA and SED differed by sex, age, and BMI in Japanese community-dwelling older people.
• Women were more active compared with men, in terms of more minutes of MVPA.

Key words: Tri-axial accelerometer, physical activity, sedentary behavior, community-based study, older adults     

Frequent walking,but not total physical activity,is associated with increased fracture incidence: A 5‐year follow‐up of an Australian population‐based prospective study (AusDiab)

Current public health physical activity (PA) guidelines recommend that older adults accumulate ≥ 2.5 hours per week of moderate‐ to vigorous‐intensity PA to optimize health. The aim of this study was to examine (1) whether adults who meet the current PA guidelines are at reduced risk of fracture, (2) whether fracture risk varies by PA type/intensity and frequency, and (3) whether prolonged TV viewing, as a marker of sedentary behavior, is associated with fracture risk. This national, population‐based prospective study with a 5‐year follow‐up included 2780 postmenopausal women and 2129 men aged 50 years or older. Incident nontraumatic clinical fractures were self‐reported. Overall, 307 (6.3%) participants sustained at least one incident low‐trauma fracture (women 9.3%, men 2.3%). Multivariate logistic regression, adjusting for age, body mass index (BMI), physical function, previous fracture history, smoking, and dietary calcium and serum 25‐hydroxyvitamin D levels, showed that women who walked more than 3 hours per week or completed at least 6 weekly bouts of walking had a 51% and 56% increased fracture risk, respectively, compared with women who did no walking [odds ratio (OR) time = 1.51, 95% confidence interval (CI) 1.01–2.24; OR frequency = 1.56, 95% CI 1.07–2.27]. However, total and moderate to vigorous PA time and the accumulation of 2.5 hours per week or more of PA and TV viewing time were not associated with incident fractures. In men, there also was an increased fracture risk for those who walked more than 3 hours per week (OR = 2.30, 95% CI 1.06‐4.97) compared with those who reported no walking. In conclusion, older adults who adhered to the current PA guidelines were not protected against fragility fractures, but more frequent walking was associated with an increased fracture risk. © 2011 American Society for Bone and Mineral Research.     

Anesthetic concerns for pediatric patients in the era of COVID‐19

After a novel human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was reported in China in December 2019, the disease quickly reached pandemic level. On January 30, 2020, the World Health Organization (WHO) declared that the SARS‐CoV‐2 outbreak constituted a Public Health Emergency of International Concern. The caseload has increased exponentially, with WHO reporting 182 000 global cases by March 17, 2020, and over 2.6 million by 23 April. The clinical situation is complex, with children presenting different clinical features compared to adults. Several articles with recommendations on the anesthetic management of adult patients with COVID‐19 have been published, but no specific recommendations for pediatric anesthesiologists have been made yet. This article addresses specific concerns for the anesthetic management of the pediatric population with COVID‐19.     

Physical Activity - A Neat Solution to An Impending Crisis

Childhood obesity is arguably the most significant global public health threat, yet effective strategies to contain or prevent the disease are not available. This review examines the physical activity patterns of children and the role physical activity plays in daily energy expenditure. The prevailing focus on moderate to vigorous activity in childhood means there is limited objective information on either sedentary behaviour or non-exercise activity thermogenesis (NEAT), the energy expended during the activities of daily living. Most strategies targeting the prevention of childhood obesity have focused upon adding moderate to vigorous activity and have not been particularly successful. The low efficacy of more purposeful activity is perhaps not surprising because of the small variance in children’s physical activity levels explained by moderate to vigorous activity. Subtle changes in NEAT have in contrast been shown to account for differences in fat-mass gain or resistance in adults. Theoretically, manipulating a child’s living environment to enhance NEAT would create a positive gain in TDEE, a gain that could lead to the prevention of excess fat-mass. More careful consideration of the specific aspects of physical activity that are most influential in the maintenance of body weight in childhood is a priority. Appreciating the role NEAT may play in the variation of total daily energy expenditure in children is a future challenge for physical activity research.

Key points

• Excessive weight gain affects children in both developed and developing countries alike, and results initially from small energy imbalances. Increasing the energy expended in daily living has the potential to re-adjust energy balance and prevent initial excess weight gain.
• Sedentary behaviour and light intensity movement, as opposed to moderate or vigorous movement, dominate a child’s day. We need to understand more about which aspects of activity account for variance in total daily energy expenditure in children.
• Finding innovative and creative ways to increase the daily energy children expend should be a priority.

Key Words: Physical activity, energy expenditure, obesity, children     

Objective features of sedentary time and light activity differentiate people with low back pain from healthy controls: a pilot study

BACKGROUND CONTEXTPhysical inactivity has been described as both a cause and a consequence of low back pain (LBP) largely based on self-reported measures of daily activity. A better understanding of the connections between routine physical activity and LBP may improve LBP interventions.PURPOSEIn this study, we aim to objectively characterize the free-living physical activity of people with low back pain in comparison to healthy controls using accelerometers, and we aim to derive a set of LBP-specific physical activity minutes thresholds that may be used as targets for future physical activity interventions.STUDY DESIGNCross-sectional.PATIENT SAMPLEA total of 22 low back pain patients and 155 controls.OUTCOME MEASURESAccelerometry derived physical activity measures.METHODSTwenty-two people with LBP were compared to 155 age and gender-matched healthy controls. All subjects wore an ActiGraph accelerometer on the right hip for 7 consecutive days. Accelerometry-based physical activity features (count-per-minute CPM) were derived using Freedson's intervals and physical performance intervals. A random forest machine learning classifier was trained to classify LBP status using a leave-one-out cross-validation procedure. An interpretation algorithm, the SHapley Additive exPlanations (SHAP) algorithm was subsequently applied to assess the feature importance and to establish LBP-specific physical activity thresholds.RESULTSThe LBP group reported mild to moderate disability (average ODI=18.5). The random forest classifier identified a set of 8 features (digital biomarkers) that achieved 88.1% accuracy for distinguishing LBP from controls. All of the top distinguishing features were related to differences in the sedentary and light activity ranges (<800 CPM), whereas moderate to vigorous physical activity was not discriminative. In addition, we identified and ranked physical activity thresholds that are associated with LBP prediction that can be used in future studies of physical activity interventions for LBP.CONCLUSIONSWe describe a set of physical activity features from accelerometry data associated with LBP. All of the discriminating features were derived from the sedentary and light activity range. We also identified specific activity intensity minutes thresholds that distinguished LBP subjects from healthy controls. Future examination on the digital markers and thresholds identified through this work can be used to improve physical activity interventions for LBP treatment and prevention by allowing the development of LBP-specific physical activity guidelines.     

Is physical activity a trigger factor for subarachnoid hemorrhage?

IntroductionSubarachnoid hemorrhage (SAH) is a serious pathology, associated with 43% mortality and significant disability. In the absence of relevant guidelines, some teams advocate that patients harboring an unruptured intracranial aneurysm (ICA) abstain from all sports activity, as a prophylactic precaution. The aim of the present study was to evaluate the impact of physical activity as a risk factor for SAH, through a review of the literature.MethodA systematic literature review was performed for the period 2000 to 2020 in accordance with the PRISMA guidelines. Prospective and retrospective articles reporting more than 50 patients whose physical activity was associated with onset of SAH were included. The main end-point was prevalence of SAH occurring after physical activity. For comparison purposes, the prevalences of other circumstances were calculated to establish a range of frequency.ResultsPhysical activity appeared to be quite rarely associated with onset of SAH, with a prevalence of 3%, compared to 30% at rest, 7.3% in association with defecation and 4.5% in association with sexual activity. Age under 60 years, male gender (M/F ratio 1.38) and smoking (67.1%) were associated with onset of SAH during physical activity.ConclusionPhysical activity appears to be a rare trigger factor for SAH. These results are in contrast to the idea that physical activity should, as a precaution, be avoided in patients with unruptured ICA. There is at present no scientific evidence of an association with aneurysmal SAH.