Comparison of aspirin treatment strategies for primary prevention of cardiovascular diseases: A decision-analytic Markov modelling study / 北京大学学报(医学版)

OBJECTIVE@#To compare the expected population impact of benefit and risk of aspirin treatment strategies for the primary prevention of cardiovascular diseases recommended by different guidelines in the Chinese Electronic Health Records Research in Yinzhou (CHERRY) study.@*METHODS@#A decision-analytic Markov model was used to simulate and compare different strategies of aspirin treatment, including: Strategy ①: Aspirin treatment for Chinese adults aged 40-69 years with a high 10-year cardiovascular risk, recommended by the 2020 Chinese Guideline on the Primary Prevention of Cardiovascular Diseases; Strategy ②: Aspirin treatment for Chinese adults aged 40-59 years with a high 10-year cardiovascular risk, recommended by the 2022 United States Preventive Services Task Force Recommendation Statement on Aspirin Use to Prevent Cardiovascular Disease; Strategy ③: Aspirin treatment for Chinese adults aged 40-69 years with a high 10-year cardiovascular risk and blood pressure well-controlled (< 150/90 mmHg), recommended by the 2019 Guideline on the Assessment and Management of Cardio-vascular Risk in China. The high 10-year cardiovascular risk was defined as the 10-year predicted risk over 10% based on the 2019 World Health Organization non-laboratory model. The Markov model simulated different strategies for ten years (cycles) with parameters mainly from the CHERRY study or published literature. Quality-adjusted life year (QALY) and the number needed to treat (NNT) for each ischemic event (including myocardial infarction and ischemic stroke) were calculated to assess the effectiveness of the different strategies. The number needed to harm (NNH) for each bleeding event (including hemorrhagic stroke and gastrointestinal bleeding) was calculated to assess the safety. The NNT for each net benefit (i.e., the difference of the number of ischemic events could be prevented and the number of bleeding events would be added) was also calculated. One-way sensitivity analysis on the uncertainty of the incidence rate of cardiovascular diseases and probabilistic sensitivity analysis on the uncertainty of hazard ratios of interventions were conducted.@*RESULTS@#A total of 212 153 Chinese adults, were included in this study. The number of people who were recommended for aspirin treatment Strategies ①-③ was 34 235, 2 813, and 25 111, respectively. The Strategy ③ could gain the most QALY of 403 [95% uncertainty interval (UI): 222-511] years. Compared with Strategy ①, Strategy ③ had similar efficiency but better safety, with the extra NNT of 4 (95%UI: 3-4) and NNH of 39 (95%UI: 19-132). The NNT per net benefit was 131 (95%UI: 102-239) for Strategy ①, 256 (95%UI: 181-737) for Strategy ②, and 132 (95%UI: 104-232) for Strategy ③, making Strategy ③ the most favorable option with a better QALY and safety, along with similar efficiency in terms of net benefit. The results were consistent in the sensitivity analyses.@*CONCLUSION@#The aspirin treatment strategies recommended by the updated guidelines on the primary prevention of cardiovascular diseases showed a net benefit for high-risk Chinese adults from developed areas. However, to balance effectiveness and safety, aspirin is suggested to be used for primary prevention of cardiovascular diseases with consideration for blood pressure control, resulting in better intervention efficiency.

Application of discrete event simulation model in analysis on cost-effectiveness of epidemiology screening / 中华流行病学杂志

Discrete event simulation (DES) model is based on individual data, by which discrete events over time are simulated to reflect disease progression. The effects of individual characteristics on disease progression could be considered in the DES model. Moreover, unlike state-transition models, DES model without setting of fixed cycle can contribute to more accurate estimation of event time, especially in the evaluation of the long-term effectiveness of screening strategies for complex diseases in which time dimension needs to be considered. This article introduces the general principles, construction steps, analytic methods and other relevant issues of the DES model. Based on a research case of estimating the cost-effectiveness of screening for abdominal aortic aneurysms in women aged 65 years and above in the United Kingdom, key points in applications of the DES model in analysis on effectiveness of complex disease screening are discussed in detail, including model construction and analysis and interpretation of the results. DES model can predict occurring time of discrete events accurately by establishing the distribution function of their occurring time and is increasingly used to evaluate the screening strategies for complex diseases in which time dimension needs to be considered. In the construction of DES model, it is necessary to pay close attention to the clear presentation of model structure and simulation process and follow the relevant reporting specification to conduct cost-effectiveness analysis to ensure the transparency and repeatability of the research.

Research progress on the correlation between circadian rhythm and clock genes and the pathogenesis of diabetic retinopathy / 国际眼科杂志(Guoji Yanke Zazhi)

Diabetic retinopathy(DR)is the most common microvascular complication of patients with diabetes mellitus, and it has become one of the leading causes of visual impairment among working-age people worldwide. The pathogenesis of DR is complicated with multiple mechanisms. Plenty of studies have indicated that circadian rhythm and clock genes are closely related to the pathogenesis of DR. Circadian rhythm is a physiological process regulated by clock genes, which takes 24h as a cycle and is consistent with the changes of light and dark outside. Circadian rhythm regulates various physiological activities of the body. The disturbance of circadian rhythm induces DR by affecting the blood glucose level and the physiological homeostasis of the eye in patients with diabetes mellitus, and clock genes may be involved in the pathogenesis of DR by regulating oxidative stress response, inflammatory response, retinal autophagy rhythm, mitochondrial dysfunction and endothelial progenitor cell function. This paper will introduce the generation and regulation mechanism of circadian rhythm, as well as the internal circadian rhythm of retina, and further discuss the influence of circadian rhythm and clock genes on the occurrence and development of DR, aiming to provide a reference for the prevention and treatment of DR.

Effectiveness of statin treatment strategies for primary prevention of cardiovascular diseases in a community-based Chinese population: A decision-analytic Markov model / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the effectiveness of statin treatment strategies based on risk assessment for the primary prevention of cardiovascular diseases by the Western guidelines in a community-based Chinese population from economically developed areas using data from the Chinese electronic health records research in Yinzhou (CHERRY) study.@*METHODS@#A Markov model was used to evaluate the effectiveness of the following statin treatment strategies, including: (1) usual care without cardiovascular risk assessment(Strategy 0); (2) using the World Health Organization (WHO) non-laboratory-based risk charts with statin treatment for high-risk group (risk ≥ 20%) (Strategy 1); (3) using the WHO laboratory-based risk charts with statin treatment for high-risk group (risk ≥ 20%) (Strategy 2); and (4) using the Prediction for Atherosclerotic cardiovascular disease Risk in China (China-PAR) model with statin treatment for high-risk group (risk ≥ 10%, Strategy 3). According to the guidelines, adults in the medium-risk group received lifestyle intervention, and adults in the high-risk group received life-style intervention and statin treatment under these strategies. The Markov model simulated different strategies for ten years (cycles) using parameters from the CHERRY study, published data, meta-analyses and systematic reviews for Chinese. The number of cardiovascular events or deaths, as well as the number need to treat (NNT) with statin per cardiovascular event or death prevented, were calculated to compare the effectiveness of different strategies. One-way sensitivity analysis on the uncertainty of incidence rate of cardiovascular diseases, and probabilistic sensitivity analysis on the uncertainty of hazard ratios of interventions were conducted.@*RESULTS@#Totally 225 811 Chinese adults aged 40-79 years without cardiovascular diseases at baseline were enrolled. In contrast to the usual care without risk assessment-based statin treatment strategy, Strategy 1 using the WHO non-laboratory-based risk charts could prevent 3 482 [95% uncertainty interval (UI): 2 110-4 661] cardiovascular events, Strategy 2 using the WHO laboratory-based risk charts could prevent 3 685 (95%UI: 2 255-4 912) events, and Strategy 3 using the China-PAR model could prevent 3 895 (95%UI: 2 396-5 181) events. NNTs with statin per cardiovascular event prevented were 22 (95%UI: 14-54), 21 (95%UI: 14-52), and 27 (95%UI: 17-67), respectively. Strategy 3 could prevent more cardiovascular events, while Strategies 1 and 2 required fewer numbers need to treat with statin per cardiovascular event prevented. The results were consistent in the sensitivity analyses.@*CONCLUSION@#The statin treatment strategies based on risk assessment for the primary prevention of cardiovascular diseases recommended by the Western guidelines could achieve substantive health benefits in adults from developed areas of China. Using the China-PAR model for cardiovascular risk assessment could prevent more cardiovascular diseases while using the WHO risk charts seems more efficient.

Effectiveness of different screening strategies for type 2 diabete on preventing cardiovascular diseases in a community-based Chinese population using a decision-analytic Markov model / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the effectiveness of different screening strategies for type 2 diabetes to prevent cardiovascular disease in a community-based Chinese population from economically developed areas based on the Chinese electronic health records research in Yinzhou (CHERRY) study.@*METHODS@#A Markov model was used to simulate different systematic diabetes screening strategies, including: (1) screening among Chinese adults aged 40-70 years recommended by the 2020 Chinese Guideline for the prevention and Treatment of Type 2 Diabetes (Strategy 1); (2) screening among Chinese adults aged 35 to 70 years recommended by the 2022 American Diabetes Association Standard of Medical Care in Diabetes (Strategy 2); and (3) screening among Chinese adults aged 35-70 years with overweight or obesity recommended by the 2021 United States Preventive Services Task Force Recommendation Statement on Screening for Prediabetes and Type 2 Diabetes (Strategy 3). According to the guidelines, individuals who were screened positively (fasting plasma glucose ≥ 7.0 mmol/L) would be introduced to intensive glycemic targets management (glycated hemoglobin < 7.0%).The Markov model simulated different screening scenarios for ten years (cycles) with parameters mainly from the CHERRY study or published literature. Number of cardiovascular disease events or deaths could be prevented and number needed to screen (NNS) were calculated to compare the effectiveness of the different strategies. One-way sensitivity analysis on the sensitivity of screening methods and probabilistic sensitivity analysis on uncertainties of diabetes incidence, the sensitivity of screening methods, and intensive glycemic management effects were conducted.@*RESULTS@#Totally 289 245 Chinese adults aged 35-70 years without cardiovascular diseases or diagnosed diabetes at baseline were enrolled. In terms of the number of cardiovascular disease events could be prevented, Strategy 1 for systematic diabetes screening among the adults aged 35-70 years was 222 (95%UI: 180-264), Strategy 2 for systematic diabetes screening among the adults aged 40-70 years was 227 (95%UI: 185-271), and Strategy 3 for systematic diabetes screening among the adults aged 35-70 years with obesity or overweight (body mass index ≥ 24 kg/m2) was 131 (95%UI: 98-164), compared with opportunistic screening. NNS per cardiovascular disease event for the strategies 1, 2 and 3 were 1 184 (95%UI: 994-1 456), 1 274 (95%UI: 1 067-1 564) and 814 (95%UI: 649-1 091), respectively. Compared with Strategy 1, NNS per cardiovascular disease event for Strategy 2 increased by 90 (95%UI: -197-381) with similar effectiveness of cardiovascular prevention; however, NNS per cardiovascular disease event for Strategy 3 was reduced by 460 (95%UI: 185-724) in contrast to the Strategy 2, suggesting that the Strategy 3 was more efficient. The results were consistent in multiple sensitivity analyses.@*CONCLUSION@#Systematic screening for diabetes based on the latest guidelines in economically developed areas of China can reduce cardiovascular events and deaths. However, merely lowering the starting age of screening from 40 to 35 years seems ineffective for preventing cardiovascular disease, while screening strategy for Chinese adults aged 35-70 years with overweight or obesity is recommended to improve efficiency.

Effectiveness of different screening strategies for cardiovascular diseases prevention in a community-based Chinese population: A decision-analytic Markov model / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the potential effectiveness of different screening strategies for cardiovascular diseases prevention in a community-based Chinese population from economically developed area of China.@*METHODS@#Totally 202 179 adults aged 40 to 74 years without cardiovascular diseases at baseline (January 1, 2010) were enrolled from the Chinese electronic health records research in Yinzhou (CHERRY) study. Three scenarios were considered: the screening strategy based on risk charts recommended by the 2020 Chinese guideline on the primary prevention of cardiovascular diseases in Chinese adults aged 40-74 years (Strategy 1); the screening strategy based on the prediction for atherosclerotic cardiovascular disease risk in China (China-PAR) models recommended by the 2019 Guideline on the assessment and management of cardiovascular risk in China in Chinese adults aged 40-74 years (Strategy 2); and the screening strategy based on the China-PAR models in Chinese adults aged 50-74 years (Strategy 3). According to the guidelines, individuals who were classified into medium- or high-risk groups after cardiovascular risk assessment by the corresponding strategies would be introduced to lifestyle intervention, while high-risk population would take medication in addition. Markov model was used to simulate different screening scenarios for 10 years (cycles), using parameters mainly from the CHERRY study, as well as published data, Meta-analyses and systematic reviews for Chinese populations. The life year gained, quality-adjusted life year (QALY) gained, number of cardiovascular disease events/deaths could be prevented and number needed to be screened (NNS) were calculated to compare the effectiveness between the different strategies. One-way sensitivity analysis on uncertainty of cardiovascular disease incidence rate and probabilistic sensitivity analysis on uncertainty of distributions for the hazard ratios were conducted.@*RESULTS@#Compared with non-screening strategy, QALYs gained were 1 433 [95% uncertainty interval (UI): 969-1 831], 1 401 (95%UI: 936-1 807), and 716 (95%UI: 265-1 111) for the Strategies 1, 2, and 3; and the NNS per QALY in the above strategies were 141 (95%UI: 110-209), 144 (95%UI: 112-216), and 198 (95%UI: 127-529), respectively. The Strategies 1 and 2 based on different guidelines showed similar effectiveness, while more benefits were found for screening using China-PAR models in adults aged 40-74 years than those aged 50-74 years. The results were consistent in the sensitivity analyses.@*CONCLUSION@#Screening for cardiovascular diseases in Chinese adults aged above 40 years seems effective in coastal developed areas of China, and the different screening strategies based on risk charts by the 2020 Chinese guideline on the primary prevention of cardiovascular diseases or China-PAR models by the 2019 Guideline on the assessment and management of cardiovascular risk in China may have similar effectiveness.

Application of quadrant classification in infants with threshold and type 1 prethreshold stage retinopathy of premature / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To explore the possible application of quadrant classification in retinopathy of premature infants at threshold and type 1 pre-threshold stage.<p>METHODS: Thirty-two preterm infants with retinopathy at the threshold and type 1 threshold preterm stage in the Affiliated Eye Hospital of Nanchang University from April 2017 to January 2018 were recruited for retrospective case analysis. The main location and stage of the retinopathy in these premature infants were divided into three categories by the quadrant method: only one quadrant(above the nose, subnasal, supratemporal, and subtemporal)recorded as “1 quadrant”; distributed in two quadrants(supertemporal+infratemporal, supra-nasal+sub-nasal, supra-nasal+super-temporal, sub-nasal+sub-temporal, supra-nasal+sub-temporal, sub-nasal+super-temporal)were recorded as “2 quadrants”; distributed more than two quadrants recorded as “>2 quadrants”. The clinic characteristics of all cases and the responses to intravitreal injection of ranibizumab were observed according to the quadrant method. <p>RESULTS: Totally 32 cases with 62 eyes of premature infants recruited in the study. Only 2 eyes were in 1 quadrant before surgery, and the efficiency of a single injection was 100%. A total of 25 eyes were distributed in 2 quadrants, and with a single injection, the effective rate was 100%. 35 eyes with a distribution “2 quadrants” had a single injection rate of only 74% and a recurrence rate of 26%. <p>CONCLUSION: The main lesions in most cases are distributed in “2 quadrants”(supertemporal+subtemporal). The more of quadrants accumulated for the major lesions and the more severe of the condition; the higher recurrence rate after intravitreous anti-VEGF therapy.

Application of the China-PAR stroke risk equations in a rural northern Chinese population / 北京大学学报(医学版)

OBJECTIVE@#To validate five-year risk prediction models for stroke in a contemporary rural Northern Chinese population.@*METHODS@#Totally 6 483 rural adults aged 40 to 79 years without cardiovascular diseases were enrolled at baseline between June and August 2010, and followed up through January 2017. Expected prediction risk using the China-PAR (prediction for atherosclerotic cardiovascular disease risk in China) stroke risk equations were compared with the new Framingham stroke risk profile (FSRP). The recalibrated models were applied by adjusting the five-year baseline survival rate and the mean score to our rural northern Chinese population, while keeping other coefficient parameters the same as the original models. Kaplan-Meier analysis was used to obtain the observed event (nonfatal or fatal stroke) rate for the five years, and the expected-observed ratios were calculated to evaluate overestimation or underestimation in the cohort. The models were assessed by discrimination C statistic, calibration χ2, and calibration charts and plots for illustration as well.@*RESULTS@#Over an average of (5.83 ± 1.14) years of the follow-up in this validation cohort with 6 483 rural Chinese participants, 438 subjects deve-loped a first stroke event. Recalibrated China-PAR stroke risk equations and FSRP well-performed for predicting five-year stroke risk in men, and had C statistics of 0.709 (95%CI, 0.675 - 0.743) and 0.721 (95%CI, 0.688 - 0.754), with calibration χ2 values being 5.7 (P = 0.770) and 13.6 (P = 0.137), respectively. However, both China-PAR and FSRP overestimated stroke events by 11.6% and 30.0% in women, and had C statistics of 0.713 (95%CI, 0.684-0.743) and 0.710 (95%CI, 0.679-0.740), respectively. Calibration χ2 values in women were 12.5 (P = 0.188) for China-PAR and 24.0 (P = 0.004) for FSRP. In addition, the calibration charts and plots illustrated good agreement between the observations and the predictions only in the China-PAR stroke risk equations, especially for men.@*CONCLUSION@#In this validation cohort of rural northern Chinese adults, the China-PAR models had better performance of five-year stroke risk prediction than the FSRP, indicating that recalibrated China-PAR stroke risk equations might be appropriate tools for risk assessment and primary prevention of stroke in China.

Application of smart phone and supporting set for fundus imaging in primary hospital of rural area / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To describe the application of smart phone and supporting set for acquiring fundus images with slitlamp examination and non-contact lens in primary hospital of the rural area.METHODS:The supporting set for smart phone was purchased from taobao and securely connected to the ocular lens of slitlamp microscopy.The fundus photos were imaged with assistance of non-contact slitlamp lens from Volk.RESULTS:High quality images of various retinal diseases could be successfully taken with smart phone and supporting set by slitlamp examination.The fundus images were send to patients with Wechat as medical records or used for telconsultant.CONCLUSION:High resolution smart phones are wildly used nowadays and supporting sets are very accessible;thus high quality of images could be obtained with minimal cost in rural hospitals.The digital fundus images will be beneficial for medical record and rapid diagnosis with telconsultant.

Visual acuity outcome of cataract surgery in patients with wet age-related macular degeneration / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To evaluate visual acuity outcomes after phacoemulsification and intraocular lens implantation in patients with wet age-related macular degeneration (wAMD).METHODS: We reviewed the medical documents of the patients who underwent phacoemulsification and intraocular lens implantation surgery during June 2013 and January 2016.Totally 61 eyes of 48 patients with wAMD in the stable stage were recruited.The pre-and post-operative vision of selected cases were recorded and compared.RESULTS: After phacoemulsification and intralocular lens implantation, visual acuity changes were as follows: 49 eyes improved, 11 eyes retained, and 1 eye deteriorated.Visual acuity improvement after cataract surger were statistically significant (P<0.001).Visual acuity improvement was not related to age.CONCLUSION: Visual acuity improved in patients with wet AMD after phacoemulcification and intraocular lens implantation.

23G vitrectomy outcomes of macular edema in retinal vein occlusion combined with vitreomacular traction or epiretinal membrane / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To evaluate 23G vitrectomy for macular edema in eyes with retinal vein occlusion (RVO) combined with vitreoretinal traction (VMT) or epiretinal membrane (ERM).METHODS:Totally 22 patients (22 eyes) diagnosed with macular edema of RVO combined with VMT or ERM were retrospectively analyzed.Twelve cases performed with 23G vitrectomy together with peeling of inner limiting membrane (ILM) and/or ERM were considered as the observation group or intervention group.Ten cases without vitrectomy were recruited as control group.The best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, 1, 3 and 6mo were recorded and compared.RESULTS:At baseline, the difference of BCVA and CRT between observation group and control group was not statistically significant (P=0.645, 0.206).After vitrectomy, the BCVA and CRT of RVO patients in observation group were significantly improved compared with baseline at each follow-up (F=2.895, P=0.048;F=16.431, P<0.01).However, the BCVA and CRT in control group remained the same as baseline at every follow-up.Moreover, the BCVA and CRT in observation group were much better than that in control group at both 3 and 6mo after vitrectomy.However, the BCVA and CRT between two groups were not significantly different at 1mo postoperatively.CONCLUSION:The 23G vitrectomy could markedly improve BCVA and reduce CRT in RVO patients with macular edema combined with VMT and/or ERM.

Retrospective analysis of surgical strategies for traumatic lens dislocation in 105 cases / 国际眼科杂志(Guoji Yanke Zazhi)

?AIM: To retrospectively analyze the surgical strategies and outcome of traumatic lens dislocation.?METHODS: Retrospective study. Clinical data of 105 cases ( 105 eyes ) diagnosed with traumatic lens dislocation from April to June 2014 in our hospital were recruited. According to position of dislocated lens and complicated situations, different surgical approaches were performed, including intracapsular lens extraction, phacoemulsification, vitrectomy through pars plana and lensectomy. Meanwhile, vitreo-retinal or anti-glaucoma surgeries were performed in complicated cases. Preoperative and postoperative LogMar ( Logarithm of the Minimum Angle of Resolution ) visual acuity were compared by paired t-test. Perioperative complications including expulsive choroidal hemorrhages and recurrent retinal detachment were recorded and assessed.?RESULTS: All 105 dislocated lenses were removed completely. Visual acuity of 91 eyes ( 86. 7%) were significantly improved postoperatively. The visual acuity of most patients was 0. 1-0. 3 ( 42 eyes, 40. 0%) and 1 patient’s visual acuity with lens subluxation reached more than 0. 8 postoperatively. Expulsive choroidal hemorrhages occurred in 1 eye intraoperatively and 1 eye postoperatively. Recurrent retinal detachment was observed in 2 eyes postoperatively.? CONCLUSION: According to position of the lens dislocation, personalized surgery strategy is critical for therapy of traumatic lens dislocation. Expulsive choroidal hemorrhage is one of most several complications and should be managed properly.