Intersphincteric resection following robotic-assisted versus laparoscopy-assisted total mesorectal excision for middle and low rectal cancer: a multicentre propensity score analysis of 1571 patients.

BACKGROUND: Robotic-assisted total mesorectal excision (RaTME) may be associated with reduced conversion to an open approach and a higher rate of complete total mesorectal excision (TME); however, studies on its advantages in intersphincteric resection (ISR) are inadequate. MATERIALS AND METHODS: This retrospective multicenter cohort study enroled consecutive patients who underwent RaTME and laparoscopy-assisted total mesorectal excision (LaTME) at four medical centres between January 2020 and March 2023. Propensity score matching (PSM), inverse probability of treatment weight (IPTW), and multivariate logistic regression analyses were performed. The primary outcome was the ISR rate. Secondary outcomes were coloanal anastomosis (CAA), conversion to open surgery, conversion to transanal TME, abdominoperineal resection, postoperative morbidity and mortality within 30 days, and pathological outcomes. RESULTS: Among the 1571 patients, 1211 and 450 underwent LaTME and RaTME, respectively, with corresponding ISR incidences of 5.3% and 8.4% ( P =0.024). After PSM and IPTW, RaTME remained associated with higher ISR rates (4.5% versus 9.4%, P =0.022 after PSM; 4.9% versus 9.2, P =0.005 after IPTW). This association remained in multivariate analysis after adjusting for other confounding factors. RaTME was further associated with a higher CAA rate, longer operating time, and higher hospitalization expenses. CONCLUSIONS: RaTME may facilitate ISR in middle and low rectal cancers, showing an independent association with a higher ISR incidence, with pathological outcomes and complications comparable to those of LaTME. However, it may also require a longer operating time and incur higher hospitalization expenses.

Assessment of surrogate models for flood inundation: The physics-guided LSG model vs. state-of-the-art machine learning models.

Hydrodynamic models can accurately simulate flood inundation but are limited by their high computational demand that scales non-linearly with model complexity, resolution, and domain size. Therefore, it is often not feasible to use high-resolution hydrodynamic models for real-time flood predictions or when a large number of predictions are needed for probabilistic flood design. Computationally efficient surrogate models have been developed to address this issue. The recently developed Low-fidelity, Spatial analysis, and Gaussian Process Learning (LSG) model has shown strong performance in both computational efficiency and simulation accuracy. The LSG model is a physics-guided surrogate model that simulates flood inundation by first using an extremely coarse and simplified (i.e. low-fidelity) hydrodynamic model to provide an initial estimate of flood inundation. Then, the low-fidelity estimate is upskilled via Empirical Orthogonal Functions (EOF) analysis and Sparse Gaussian Process models to provide accurate high-resolution predictions. Despite the promising results achieved thus far, the LSG model has not been benchmarked against other surrogate models. Such a comparison is needed to fully understand the value of the LSG model and to provide guidance for future research efforts in flood inundation simulation. This study compares the LSG model to four state-of-the-art surrogate flood inundation models. The surrogate models are assessed for their ability to simulate the temporal and spatial evolution of flood inundation for events both within and beyond the range used for model training. The models are evaluated for three distinct case studies in Australia and the United Kingdom. The LSG model is found to be superior in accuracy for both flood extent and water depth, including when applied to flood events outside the range of training data used, while achieving high computational efficiency. In addition, the low-fidelity model is found to play a crucial role in achieving the overall superior performance of the LSG model.

The pan-Canadian Tiered Pricing Framework and Chinese National Volume-Based Procurement: A comparative study using Donabedian's structure-process-outcome framework.

Background: Generic drugs have been seen as a potentially powerful way to alleviate the financial burden on patients and health care systems. Two strategies for achieving rational prices of generic drugs are tiered pricing framework and pooled purchasing power. We compare the pan-Canadian Tiered Pricing Framework (TPF) and the Chinese National Volume-Based Procurement (NVBP) as comparators to explore the similarities and differences between the two mechanisms and summarise lessons for other jurisdictions. Methods: This comparative study applies Donabedian's structure-process-outcome framework to systematically analyse the macro contexts, procedures, and long- and short-term results of each pricing mechanism, and the interactions between them. Results: Structure: TPF is an upstream initiative aimed at lowering the prices of generic drugs and increasing coverage and price consistency. NVBP is a downstream national initiative prioritised for reducing drug prices to achieve value-based purchasing. Process: By associating the number of manufacturers with price cuts, TPF leaves the choice to manufacturers to decide if they want to enter a specific market. In contrast, the Chinese government determines NVBP list and has the authority to choose manufacturer(s) with the lowest price(s). TPF provides clear price information to potential suppliers with unclear order quantity. The NVBP drug price is determined by tendering, while procurement volume is clear and massive. Outcome: The effectiveness of TPF and NVBP is similar, with both achieving a 53% price cut. Both TPF and NVBP experienced efficiency improvement since their establishment, with 98 and 86 drugs priced per year. By comparing 60 drugs covered by both programmes, the NVBP price is 57% of that of the TPF counterpart on average (1.1 to 301.6%), by purchase power parity. Conclusions: The tiered pricing scheme is feasible in regions with a stable and mature pharmaceutical market, typically seen in high-income countries, while tendering is more workable in low- and middle-income countries where the pharmaceutical market is weak and unstable. Experience in the two countries shows that a coordinated pricing mechanism involves many piecemeal interactive problems, which a sophisticated system with a robust long-range plan may address better.

Improving access to medicines and beyond: the national volume-based procurement policy in China.

Since 2019, the Chinese central government has taken significant steps to centralize national purchasing power and has implemented a pooled procurement system. In this paper, we provide an in-depth analysis of China's National Volume-Based Procurement (NVBP) policy, which represents a unique approach to pooled procurement within the pharmaceutical sector. The primary objectives of the NVBP are to reduce drug prices, enhance access to affordable medications, and improve the overall functioning of the pharmaceutical industry in China. Our analysis delves into the key features of the NVBP, including its centralized procurement system, volume-based procurement approach, and the guaranteed procurement volumes allocated to winning bidders. We also address the challenges and implications associated with the NVBP, such as its impact on the pharmaceutical industry, the sustainability of price reductions, and the importance of striking a balance between price reduction and industry sustainability. Through a comparative analysis, we shed light on the distinct characteristics of China's approach to pooled procurement and its potential ramifications for healthcare policies and practices. By examining the NVBP within the broader context of China's evolving healthcare landscape, we aim to contribute to a deeper understanding of the implications and effectiveness of this unique policy initiative.

Assessment of vasa vasorum on coronary plaques in patients with acute coronary syndromes using intravascular ultrasound and iMap analysis: A retrospective cohort study.

Studies have revealed that vasa vasorum (VV) neovascularization is vital for the progression and vulnerability of coronary atherosclerotic plaques. The correlation between VV, plaque constituents, and the no-reflow phenomenon (NRP) in percutaneous coronary intervention (PCI) remains elusive. We explored plaque constituents in iMap-intravascular ultrasound (iMap-IVUS) and NRP during PCI for VV lesions. We studied 166 coronary lesions in 166 patients with acute coronary syndromes (ACS) (118 lesions with VV) undergoing pre-intervention intravascular ultrasound (IVUS). We evaluated the diversity in plaque morphological status and post-PCI results based on the presence or absence of VV. The lesions with VV group had significantly higher high-sensitivity C-reactive protein (hs-CRP) levels than the lesions without VV group (8.41 ± 4.98 vs 4.19 ± 3.69 mg/L, P < .001). The frequency of after-stent deployment thrombolysis in myocardial infarction (TIMI) flow grades 0, 1, and 2 was remarkably greater in lesions with VV than in those without VV (22.9% vs 10.4%, P < .001). Plaques at the minimum lumen, necrotic core (1.26 ± 0.64 vs 0.92 ± 0.61 mm2, P < .001; 20.95 ± 7.19 vs 13.34% ± 6.54%, P < .001), and fibrous areas (4.23 ± 1.32 vs 3.92 ± 1.01 mm2, P = .006; 61.01 ± 9.41 vs 56.92% ± 11.42%, P = .001) were considerably larger in the lesions with VV than in those without VV. In addition, densely calcified plaques (0.41 ± 0.26 vs 0.81 ± 0.59 mm2, P < .001; 3.63 ± 2.19 vs 7.18% ± 2.01%, P < .001) were considerably smaller in the lesions with VV than in those without VV. Multivariate analyses revealed that VV and plaque volume were independent predictors of NRP after stent deployment (odds ratio [OR]: 5.13, 95% confidence interval [CI]: 1.19-15.32, P = .002; OR: 4.79, 95% CI: 1.08-9.01, P = .005). Lesions with VV exhibited considerable plaque vulnerability in patients with ACS, and they displayed more NRP during PCI. VV and plaque volume were independent predictors of NRP after stent deployment.

Consistency assessment and visualization of recommendations on gastroesophageal reflux disease: a scoping review of clinical practice guidelines.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder that causes diverse esophageal and extraesophageal symptoms. Many clinical practice guidelines (CPGs) have been issued around the world to provide practical evidence regarding GERD management. However, some of the recommendations discussed in various CPGs are inconsistent across individual documents. OBJECTIVES: We aimed to summarize the evidence from CPGs on GERD and assess the consistency of the recommendations. PATIENTS AND METHODS: In this scoping review, we identified current CPGs on the clinical management of GERD, which were comprehensively searched for in electronic databases and on relevant scientific websites. The recommendations were extracted using the population­intervention­comparison framework and were subsequently categorized into tables. RESULTS: Ultimately, 24 CPGs were identified. They included 86 recommendations, which were classified into 5 categories: definition, epidemiology, diagnosis, treatment, and complications. Among the identified recommendations, 68 were proposed in at least 2 CPGs, and they were assessed for the consistency of direction and strength. Overall, 32.4% of the recommendations (22/68) were consistent in direction and strength, whereas 60.3% (41/68) were consistent in direction but inconsistent in strength. Moreover, 7.4% (5/68) were inconsistent in direction. These referred to the relationship between GERD and tobacco consumption, Helicobacter pylori infection, diagnostic utility of the 2­week proton pump inhibitor test, cessation of special food, and antireflux surgery for GERD with extraesophageal symptoms. CONCLUSIONS: Most CPG recommendations regarding GERD were consistent in direction, except for 5 discrepancies, for which further well­designed, large­scale research is required to explain the inconsistency.

Cost-effectiveness of COVID-19 vaccination: A systematic review.

OBJECTIVE: The COVID-19 vaccination strategy has been widely used to protect population health worldwide. This study aims to summarize the cost-effectiveness evidence of economic evaluation of COVID-19 vaccination strategies to provide evidence supporting the usage of COVID-19 vaccination, especially where the supply of COVID-19 vaccine is limited. METHODS: A systematic literature review was performed by searching both English and Chinese databases, including PubMed, Embase, Science Direct, Web of Science, Medline, Scopus, and CNKI. Articles published from January 1, 2020 to August 1, 2022 (PROSPERO registration number: CRD42022355442). RESULTS: Of the 1035 papers identified, a total of 28 English studies that met the preset criteria were included. COVID-19 vaccination and booster vaccination were cost-effective or cost-saving regardless of the vaccine type; vaccine efficacy, vaccine price, vaccine supply or prioritization, and vaccination pace were the influential factors of cost-effectiveness among different population groups. When supply is adequate, mass vaccination should be encouraged, while when supply is inadequate, prioritizing the high risk and the elderly is more cost-effective. CONCLUSIONS: COVID-19 vaccination strategies are economically favorable in a wide range of countries and population groups, and further research on suitable strategies for booster COVID-19 vaccination is needed.

How to help aortic dissection survivors with recovery?: A health promotion program based on the comprehensive theory of health behavior change and literature review.

For aortic dissection survivors, health promotion can help them recover from the disease, which requires systematic program support. The aim of this study was to construct a health promotion program for aortic dissection survivors. Literature search, group discussion, and expert consultation were used. The Integrated Theory of Health Behavior Change was the theoretical basis of the program. Multiple medical-related databases were searched. Based on a literature search and group discussion, 3 primary items, 8 secondary items, and 34 tertiary items were formed. After 2 rounds of expert consultation (number of experts = 25), 3 primary items, 16 secondary items, and 54 tertiary items were retained. The authority coefficients of the 2 rounds of experts were 0.890 and 0.905, respectively. The Kendall W coefficient of the 2 rounds were 0.210 to 0.370 (P < .05) and 0.221 to 0.378 (P < .05), respectively. The mean importance value and coefficient of variation of each item were >3.5 and <0.25, respectively. The health promotion program constructed in this study was reasonable and scientific, which could provide a reference for clinical work.

Variation in quality of care by medical institute level in China: a systematic review protocol.

INTRODUCTION: Quality variation has been widely witnessed and discussed in China. However, limited evidence reveals quality gaps by the medical institute level, especially between hospitals and primary care institutes. This systematic review will synthesise the available evidence on quality variation between medical institutes at different levels in China. By adopting a quality framework, we will also explore the detailed domains (structure, process and outcomes) and dimensions (safety, effectiveness, timeliness, patient-centredness, efficiency, integration and equity) of quality gaps. METHODS AND ANALYSIS: An extensive literature search will be conducted on eight key electronic databases: MEDLINE, Web of Science, Cochrane Library, Scopus, EMBASE, ProQuest, China National Knowledge Infrastructure and WANFANG database. The Grey Matter Checklist will be used to screen relevant grey literature. The publication time limit should be before 31 December 2022 when we plan to conduct a literature search. All kinds of studies that revealed the quality difference between medical institutes at different levels will be included, no matter if quality improvement intervention is involved. All quality measures and indicators will be recorded and sorted into appropriate domains and dimensions. For those studies that took the completion rate of standard operations to assess the quality, we will also record the name of the clinical pathways, guidelines or checklists used. Two reviewers will independently perform the study selection, data extraction and quality assessment process. A narrative or quantitative synthesis will be performed based on the available data. ETHICS AND DISSEMINATION: Ethics approval is not applicable. The results of this study will be submitted to a widely accepted peer-review journal. The findings will also be used to inform administration about quality gaps by different medical institute levels and, therefore, help them to design policies that will minimise the quality variation. PROSPERO REGISTRATION NUMBER: CRD42022345933.

Evaluation for the spatiotemporal patterns of ecological vulnerability and habitat quality: implications for supporting habitat conservation and healthy sustainable development.

Currently, the rapid socioeconomic development and urbanization around the world have caused the ecological environment on the earth surface to become extremely fragile and destroyed. In addition, the increasing demand of human beings for material also leads to the unsustainable development of resources and environment. However, how to achieve the win-win goal between socioeconomic development and ecological protection in the context of these impacts? It is becoming a major problem for governments and policy makers. To further reveal the contradiction between man and land, taking Wuhan metropolitan area as the study area, this study mainly proposed a framework for the comprehensive optimization of landscape pattern and ecological environment and constructed the ecological vulnerability mixed evaluation model. Then, the integrated valuation of ecosystem services and trade-offs (InVEST) model was employed to evaluate the changes in habitat quality, focusing on the analysis of the impact mechanism of the evolution of ecological environment. This study found that the hybrid model of landscape vulnerability can successfully explore the landscape ecological vulnerability of Wuhan metropolitan area from 2000 to 2020, and its spatiotemporal differentiation pattern was obvious. The InVEST model showed that the habitat quality had obvious spatial differentiation. On the whole, the overall quality of the habitat was low and the degradation degree was high. Furthermore, our study also showed that the change of landscape ecological environment was influenced by the common potential of local nature and social economy, rather than a single factor. Finally, the main purpose of this study is to help scientifically formulate habitat protection and landscape planning strategies through in-depth study of landscape ecological environment, so as to alleviate man-land contradiction and support regional sustainable development.

[Risk Assessment and Attribution Analysis of "Five Toxic" Heavy Metals in Cultivated Land in Lanzhou].

Heavy metals in cultivated soil may migrate and transform through the food chain to harm the ecological environment and human health. At present, the ecological environment and human health risks of heavy metals in cultivated soil in Lanzhou city remain unclear, which impacts the effective management and control of heavy metals. The potential ecological risk hazard index was used to evaluate the ecological environmental risks of As, Cd, Cr, Hg, and Pb in the surface soil of cultivated land in Lanzhou, and the health risk model proposed by USEPA and the recommended standard were used to evaluate their human health risk. The main factors influencing the spatial differentiation of human health risk were explored by using geographic detectors. The risk of heavy metals to the ecological environment of the cultivated land surface soil in the study area was mainly medium (65.25%), and small portions were low (13.80%) and high (20.95%). The low-risk areas were mainly located in the southeast of Yongdeng County, the middle and north of Yuzhong County, and the southwest of Gaolan County. Moderate risk areas were distributed in three counties and five districts. The high-risk areas were located in the north and southeast of Yongdeng County, the south of Chengguan District, the northeast of Qilihe, the east of Xigu District, and the middle of Yuzhong County. The non-carcinogenic and carcinogenic risks of five types of heavy metal exposure pathways were as follows:oral ingestion>skin contact>respiratory ingestion; generally speaking, children were at higher risk than adults. The non-carcinogenic risk in children was higher than that in adults; however, there was no such risk for local residents, as they were all less than 1. At the same time, the carcinogenic risk of As was greater than 1×10-5 (children 2.04×10-5) and less than 1×10-4 (adults 1.91×10-5), respectively. This indicated an acceptable medium risk to the local residents, and the risk to children was again greater than that to adults. Geographical detector analysis showed that average precipitation during the sampling season had the greatest impact on the spatial differentiation of human health risks of As and Cd, GDP had the greatest impact on the spatial differentiation of human health risks of Cr, and distance from the railway had the greatest impact on the spatial differentiation of human health risks of Hg and Pb. Interaction detection showed that all factors were enhanced by double factors. In addition to leading factors, other factors such as pH, slope, and altitude also enhanced the influence of leading factors on the spatial differentiation of heavy metal risk in cultivated soil.

Impact of '4+7' volume-based drug procurement on the use of policy-related original and generic drugs: a natural experimental study in China.

OBJECTIVE: To evaluate the impact of the first round of the National Centralized Drug Procurement pilot (so-called '4+7' policy) on the use of policy-related original and generic drugs. METHODS: A retrospective natural experimental design was adopted. Drug procurement data from the China Drug Supply Information Platform database were used, involving 9 '4+7' pilot cities in intervention group and 12 non-pilot provinces in control group. '4+7' policy-related drugs were selected as study samples, including 25 drugs in the '4+7' procurement list and their alternative drugs that have not yet been covered by the policy. '4+7' List drugs were divided into bid-winning and non-winning products according to the bidding results. Included drugs were sorted into original and generic products. Difference-in-difference method was employed to estimate the net effect of policy impact. RESULTS: After policy intervention, the DDDs (defined daily doses) of '4+7' List original drugs significantly reduced (ß=-39.10, p<0.001), while generic drugs increased (ß=40.43, p<0.01). 17.08% of the original drugs in DDDs were substituted by generic drugs. Prominent reduction was observed in the monthly expenditure of '4+7' List drugs (¥726.40 million) and overall policy-related drugs (¥654.47 million). The defined daily drug cost (DDDc) of bid-winning original and generic drugs, as well as non-winning original drugs, decreased by 44.44%, 79.00% and 15.10% (all p<0.01), while the DDDc of non-winning generic drugs increased by 64.81% (p<0.001). The use proportion of higher-quality drugs raised prominently from 39.66% to 91.93%. CONCLUSIONS: '4+7' policy is conducive to generic substitution, drug price reduction and pharmaceutical cost-containment in China. The overall quality level of drug use of the Chinese population increased after policy intervention, especially in primary healthcare settings. However, the increased DDDc of non-winning generic drugs and alternative drugs should draw the importance of further policy monitoring.

Economic Policy Uncertainty, Social Development, Political Regimes and Environmental Quality.

This paper aims to examine the influence of Economic Policy Uncertainty (EPU) on environmental performance, as well as the moderating effect of social development and the political regimes in EPU's influence on environmental performance. To investigate such essential issues, we conducted Generalized Method of Moments (GMM) estimations by utilizing cross-country data covering 137 countries during the period of 2001-2018, according to the Stochastic Impacts by Regression on Population, Affluence and Technology (STIRPAT) model. Our empirical estimations support that EPU negatively affects environmental performance; this idea was still supported when we conducted an empirical analysis by changing the measurements, employing alternative estimations and constructing new samples. Furthermore, not only would the absolute level of EPU bring worse environmental performance, but so would an increase in EPU. Moreover, higher economic performance, globalization and a high quality of governance can help countries to alleviate the adverse environmental effect of EPU. Additionally, EPU's negative effect on environmental performance is stronger in right-wing countries, autocracies and non-OECD countries, compared to their counterparts. Our study provides substantial policy implications for governments participating in the international treaties of environmental protection, to mitigate environmental degradation.

An integrated approach of logistic-MCE-CA-Markov to predict the land use structure and their micro-spatial characteristics analysis in Wuhan metropolitan area, Central China.

As human interference with the natural environment accelerates, land use has undergone great changes. However, to realize rational land development in the rural-urban ecotone, the micro-spatial (MS) unit is the best scale for the management and planning of sustainable land use. Taking Wuhan metropolitan area as research area, the integrated logistic-multi-criteria evaluation (MCE)-cellular automata (CA)-Markov model was used to simulate land use pattern for 2025. In addition, the 1 km×1 km, 2 km×2 km, 3 km×3 km, and 4 km×4 km and typical sample belt were built to reveal the spatial microcosmic expression of land use structure. The results showed that the kappa coefficient and figure of merit (FoM) were 88.01% and 26.86%, respectively, indicating the integration model has high prediction accuracy. In 2005-2025, the diversification of land use in the Wuhan metropolitan area will be generally above the medium level, and the types of land combinations will be relatively abundant. As human activities increase, the land use degree will show increases continuously, it will expand outward from Wuhan, and there is a positive correlation between cultivated land-rural residential land and urban land-cultivated land. The spatial distribution of land use structure presents regional scale characteristics, and different regions have micro-spatial scale dependence. The selection of MS scales based on local conditions can be a good way to reflect land use internal structure and provide a better reference for the compilation of regional land use optimization.

Does Overseas Investment Raise Corporate Environmental Protection? Evidence from Chinese A-List Companies.

This paper uses the relevant data of China's listed companies from 2010 to 2018 to test the impact of overseas investment on corporate environmental protection and further examines whether the heterogeneity of the company and the heterogeneity of the host country changes this effect. The research results show that the environmental protection of overseas investment companies is significantly higher than that of other companies. The impact of overseas investment on corporate environmental protection is dynamic, and it only helps improve corporate environmental protection after three years of investment. This article is conducive to causally identifying the logical relationship between overseas investment and corporate environmental protection. The policy significance is that the government can rationally guide companies to invest abroad, and oversea investment will help enhance corporate environmental protection.

The Impact of Globalization on Forest Growth: Evidence from Multinational Panel Data.

Even though some existing literature has studied the impact of globalization on forest growth, this research remains inconclusive; moreover, little clarification has emerged as to whether the influence of globalization on forest growth is consistent among different countries. To fill this research gap, we investigated the impact of globalization on forest growth and considered what factors could change the influence of the former upon the latter. To empirically investigate these essential issues, we utilized cross-country data covering 108 countries during the period 1991-2018 to conduct a system generalized method of moment (GMM) estimation. The baseline results confirm the positive impact of globalization on forest growth, which is also supported by several robustness tests, such as changing the measurements and setting new samples. Furthermore, an increase in globalization would bring about higher forest growth. Aside from this, two specific dimensions of globalization, namely economics and trade, can also protect forest growth. Additionally, a higher FDI strengthens the positive impact of globalization on forest growth, while aging, industrial share, and CO2 emissions weaken it. Finally, the impact of globalization on forests is weaker in democracies, emerging markets, and countries with higher fiscal freedoms, while it is stronger in countries with higher political stability. Our study provides substantial policy implications for governments participating in international treaties related to forest growth. The structure of this paper is organized as follows.

Revisited Globalization's Impact on Total Environment: Evidence Based on Overall Environmental Performance Index.

This study aims to examine the impact of globalization on environmental performance by employing panel data for 148 countries from 2001 to 2018, via the indicator of Environmental Performance Index to capture the overall environmental quality and KOF index to measure the multi dimensions of globalization. The empirical results suggest that globalization is critical to environmental performance, which is reliable while we conduct several robustness tests. Furthermore, if globalization increases, it would be beneficial for the environmental performance; moreover, among specific dimensions of globalization, economic globalization, social globalization and political globalization would bring about better environmental performance. Besides, the improvement of globalization, social globalization and political globalization would bring about better environmental performance, while that of economic globalization cannot change the overall environmental performance. Our study offers more insight into the relationship between globalization and environmental performance.

Assessment of Clinicopathological Characteristics and Development of an Individualized Prognostic Model for Patients With Hepatoid Adenocarcinoma of the Stomach.

Importance: Few studies have examined the clinicopathological characteristics and prognoses of patients with hepatoid adenocarcinoma of the stomach (HAS). Objective: To explore the clinicopathological characteristics and prognoses of patients with HAS and develop a nomogram to predict overall survival (OS). Design, Setting, and Participants: This prognostic study involved a retrospective analysis of data from 315 patients who received a diagnosis of primary HAS between April 1, 2004, and December 31, 2019, at 14 centers in China. Main Outcomes and Measures: OS and prognostic factors. Patients were randomly assigned to a derivation cohort (n = 220) and a validation cohort (n = 95). A nomogram was developed based on independent prognostic factors identified through a multivariable Cox mixed-effects model. Results: Among 315 patients with HAS (mean [SD] age, 61.9 [10.2] years; 240 men [76.2%]), 137 patients had simple HAS (defined as the presence of histologically contained hepatoid differentiation areas only), and 178 patients had mixed HAS (defined as the presence of hepatoid differentiation areas plus common adenocarcinoma areas). Patients with simple HAS had a higher median preoperative α-fetoprotein level than those with mixed HAS (195.9 ng/mL vs 48.9 ng/mL, respectively; P < .001) and a higher rate of preoperative liver metastasis (23 of 137 patients [16.8%] vs 11 of 178 patients [6.2%]; P = .003). The 3-year OS rates of patients with simple vs mixed HAS were comparable (56.0% vs 60.0%; log-rank P = .98). A multivariable Cox analysis of the derivation cohort found that the presence of perineural invasion (hazard ratio [HR], 2.13; 95% CI, 1.27-3.55; P = .009), preoperative carcinoembryonic antigen levels of 5 ng/mL or greater (HR, 1.72; 95% CI, 1.08-2.74; P = .03), and pathological node category 3b (HR, 3.72; 95% CI, 1.34-10.32; P = .01) were independent risk factors for worse OS. Based on these factors, a nomogram to predict postoperative OS was developed. The concordance indices of the nomogram (derivation cohort: 0.72 [95% CI, 0.66-0.78]; validation cohort: 0.72 [95% CI, 0.63-0.81]; whole cohort: 0.71 [95% CI, 0.66-0.76]) were higher than those derived using the American Joint Committee on Cancer's AJCC Cancer Staging Manual (8th edition) pathological tumor-node-metastasis (pTNM) staging system (derivation cohort: 0.63 [95% CI, 0.57-0.69]; validation cohort: 0.65 [95% CI, 0.56-0.75]; whole cohort: 0.64 [95% CI, 0.59-0.69]) and those derived using a clinical model that included pTNM stage and receipt of adjuvant chemotherapy (derivation cohort: 0.64 [95% CI, 0.58-0.69]; validation cohort: 0.65 [95% CI, 0.56-0.75]; whole cohort: 0.64 [95% CI, 0.59-0.69]). Based on the nomogram cutoff of 10 points, the whole cohort was divided into high-risk and low-risk groups. The 3-year OS rate of patients in the high-risk group was significantly lower than that of patients in the low-risk group (29.7% vs 75.9%, respectively; log-rank P < .001), and the 3-year prognosis of high-risk and low-risk groups could be further distinguished into pTNM stage I to II (33.3% vs 80.2%; exact log-rank P = .15), stage III (34.3% vs 71.3%; log-rank P < .001), and stage IV (15.5% vs 70.3%; log-rank P = .009). Conclusions and Relevance: This study found that perineural invasion, preoperative carcinoembryonic antigen levels of 5 ng/mL or greater, and pathological node category 3b were independent risk factors associated with worse OS. An individualized nomogram was developed to predict OS among patients with HAS. This nomogram had good prognostic value and may be useful as a supplement to the current American Joint Committee on Cancer TNM staging system.

Progress and challenges of network meta-analysis.

In the past years, network meta-analysis (NMA) has been widely used among clinicians, guideline makers, and health technology assessment agencies and has played an important role in clinical decision-making and guideline development. To inform further development of NMAs, we conducted a bibliometric analysis to assess the current status of published NMA methodological studies, summarized the methodological progress of seven types of NMAs, and discussed the current challenges of NMAs.