Volume 98  ·  Issue 24  ·  2018

New gastric cancer patients in my country account for about 40% of the world. According to 2015 statistics, there are 873,000 gastric cancer patients in my country^[1]。 Compared with other countries with high incidence of gastric cancer, the outstanding feature of gastric cancer patients in China is that the proportion of advanced gastric cancer is relatively high, and about 30% ~40% belong to incurable advanced gastric cancer, that is, clinical stage IV. The efficacy of these patients is extremely poor. With the popularization and application of standardized tumor treatment, early and mid-stage gastric cancer has received great attention, and the curative effect has been significantly improved. However, advanced gastric cancer, as the "last highland" in the field of gastric cancer treatment, always lacks effective treatment. This article summarizes the clinical characteristics of advanced gastric cancer in China, and puts forward the diagnosis and treatment strategies for advanced gastric cancer, hoping to be helpful for the clinical diagnosis and treatment of advanced gastric cancer in China.

At present, socialism with Chinese characteristics has entered a new era, and the main social contradiction has undergone historical new changes, which has been transformed into "the contradiction between the people's increasing demand for a better life and unbalanced and inadequate development"^[1]。 In the field of medical services, the needs of patients have also changed. New needs have developed in terms of function, quality, experience, etc., which affect medical satisfaction and doctor-patient relationship. It is a new problem faced by the field of medical services. It is of great practical significance to carry out in-depth research.

Obstructive sleep apnea (OSA) is a kind of sleep breathing disorder with sleep snoring with apnea and daytime sleepiness as the main clinical manifestations. The prevalence is 2% ~4%^[1]。 The disease can cause intermittent hypoxia, hypercapnia and disorder of sleep structure, and can lead to multiple organ and system damage such as hypertension, coronary heart disease, arrhythmia, cerebrovascular disease, cognitive dysfunction and type 2 diabetes^[2,3]。 Studies have shown that untreated patients with severe OSA have a 3.8-fold higher mortality rate than the general population^[4]。 Data from 20 domestic hospitals confirmed that the prevalence of hypertension in OSA patients in China is 49.3%, while OSA patients account for 83% of patients with refractory hypertension. Treatment of OSA has a positive effect on the reduction of blood pressure in these patients^[5]。 In addition, the OSA population was 4.33 times more likely to have stroke and 1.98 times more likely to have mortality^[6]。 OSA can cause damage to multiple systems in the body and is a veritable systemic disease^[7]。 Therefore, physicians, patients and the whole society should pay attention to the widespread and serious harm of OSA to the body.

Oral fiuoropyrimidine S-1 contains tegafur, gimeracil, oteracil. Tegafur is the major active prodrug, which is metabolized to 5-Fu by cytochrome P4502A6 (CYP2A6). This research investigated the association between CYP2A6 polymorphisms and treatment outcomes of adjuvant S-1 in gastric cancer patients.

A total of 200 patients diagnosed pathological stage Ⅱ-Ⅲ gastric cancer were included in this study, who were received adjuvant S-1 chemotherapy regimens after curative surgery (40 mg/m^2, bid, d1-28, rest 2 weeks, every 6 weeks one cycle). Additionally, the wild-type allele (CYP2A6*1) and four variant alleles (CYP2A6*4, *7, *9, *10) were genotyped.

A total of 200 patients were enrolled in this study with a median follow-up of 46.5 months. The 3-year recurrence free survival rates were 95.9% for W/W (n=49), 83.1% for W/V (n=94), and 72.5% for V/V (n=57), with significant difference (P=0.032). Grade ≥3 hematologic toxicities of three genotype groups were without difference (10.2% vs 14.9% vs 10.5%, P=0.628).

CYP2A6 genotypes correlate with the survival of S-1 chemotherapy. And its polymorphism detection can provide individualized guidance for adjuvant chemotherapy options in patients with gastric cancer.

To investigate the association between chemotherapy-induced leucopenia and patients′ disease-free survival in gastric cancer patients who received radical gastrectomy.

The clinical data of 273 gastric cancer patients who received radical gastrectomy and postoperative adjuvant chemotherapy between January, 2010 and December, 2015 in PLA 309^th hospital was reviewed retrospectively.

A total of 195 (71.4%) patients experienced at least one time of leucopenia, while it was absent in the other 78 (28.6%) patients. The median disease-free survival of patients with or without leucopenia was 49.7 and 44.0 months respectively (P=0.009), leucopenia was an independent factor influencing patients′ disease-free survival (HR=2.758, P=0.022), but there was no statistical difference between the disease-free survival of patients with different degrees and frequency of leucopenia (P=0.446, 0.123).

Chemotherapy-induced leucopenia is a predictor of good prognosis for gastric cancer patients who receive radical gastrectomy.

To analyse the risk factors for periportal lymphnode (No.12p LN) in advanced gastric cancer.

A retrospective analysis of 183 patients with advanced gastric cancer from January 2005 to December 2010, and all patients were underwent D2 lymphadenectomy in addition to No. 12p LN dissections. Potential clinicopathological factors that could influence No. 12p LN metastasis were statistically analyzed.

There were 18 cases (9.8%) with periportal lymphnode metastasis. A logistic regression analysis suggested that the Borrmann type (Ⅲ/Ⅳ versus Ⅰ/Ⅱ, P=0.008), tumor size (≥6 cm vs <6 cm, P=0.001), and depth of invasion (pT4 vs pT2/pT3, P=0.049) were associated with 9.5-, 8.5-, and 3.2-fold increases, respectively, for risk of No. 12p LN metastasis. A logistic regression analysis also showed that No. 5 (P=0.002) and No. 12a (P=0.002) LN metastasis were associated with 7.5- and 7.3-fold increases, respectively, for risk of No. 12p LN metastasis. In addition, significant differences in 5-year survival of patients with and without No. 12p LN metastasis were observed (11.1% vs 32.7%, P=0.042).

Borrmann type, tumor size and depth of invasion are significant factors for identifying patients with No. 12p LN metastasis. Patients with No. 5 or No. 12a LN metastasis should be higher possibility of No.12p LN metastasis.

To explore the safety and reliable of low pressure laparoscopy in old patients, and the advantage over conventional pressure laparoscopy.

Sixty-six patients(≥70 year) with gastric cancer from 2014.4 to 2017.4 were enrolled, and they were divided into three groups randomly. The value of Ejection Fraction (EF), central venous pressure (CVP), B-type natriuretic peptide (BNP), O₂ pressure, CO₂ pressure, complications of three groups were compared and analysis.

There was no differences between low-pressure laparoscopic group, conventional laparoscopic group and laparotomy group in age, gender, EF, oxygen pressure, CVP (P>0.05). But the postoperative BNP, intraoperative carbon dioxide pressure of low-pressure laparoscopic group were significantly better than those of the other two groups. Compared with the conventional laparoscopic group and the laparotomy group, the low-pressure laparoscopic group has fewer postoperative complications (P=0.027, <0.05), especially in postoperative pulmonary infection ( P=0.044, <0.05).

The low pressure laparoscopy has decreased the stimulation of surgery to old patients, and reduced the postoperative complications. All this results demonstrate that the low pressure laparoscopy to old patients is safety and reliable.

To investigate current status and problems of internal quality control (IQC) of complete blood count in China so as to perform IQC normally.

The IQC data of complete blood count for five parameters were collected from laboratories participating in national external quality assessment during 2012-2017 (totally 12 times), including WBC, RBC, Hb, Hct and PLT. After confirmation of all data, data for the 12 times were analyzed as follows.The proportions of using different levels of quality control materials were calculated.The 25th, 50th, 75th, 90th percentiles CV of data collected for the 12 times were calculated respectively and the trends of CV were observed over time.The difference of CV among laboratories running three control levels was compared.The CV of each parameter in 2017 was compared with precision requirements based on biological variation, health standards and German Medical Association Directive; The proportions of laboratories using different control rules were calculated.

After invalid data was excluded from those IQC data of laboratories for the 12 times external quality assessment (up to 2 402, as low as 1 449) from 2012 to 2017, the residual data (up to 2 332, as low as 1 431, accounting for 96.0%-99.2%) was used for analysis. 61.9%-66.1%, 18.2%-23.6% and 14.3%-17.3% of laboratories ran one, two and three control levels respectively, and the proportions of laboratories running more than two control levels increased from 33.9% to 38.1%. The decrease trend of the 75th, 90th percentiles CV of WBC, RBC, Hb, Hct for three levels, PLT for normal level and the 90th percentiles CV of PLT low level had statistically significance over time (P<0.05); the decrease trend of the 75th percentilesCV of PLT low level and 75th, 90th percentiles CV of PLT high level had no statistically significance over time. The CV had significant difference between low and normal, low and high control level for WBC and PLT, while there were no difference between normal and high control levels. There were no significant difference of CV among three control levels for RBC, Hb, and Hct. Except for the CV of Hct low, normal level and PLT low level, 85% of laboratories for the other parameters could meet the minimum precision requirements based on biological variation; more than 85% laboratories met the requirements of health standards; except for the CV of PLT low level, more than 80% laboratories met the requirements of German Medical Association Directive. The proportion of laboratories using 1_3s/2_2s quality control rules increased from 59.2% to 76.0%.

During the past 6 years, the CV for IQC has shown a decrease trend over time. However, the control level and quality control rules used by some laboratories do not meet management requirements. The CV of Hct and PLT in a few laboratories do not meet the minimum requirements of the health standards, and need to implement quality improvements fatherly.

To compare the efficacy and safety of anatomic hepatectomy and non-anatomic hepatectomy in the treatment of single small Hepatocellular carcinoma with MVI.

The clinical data of 84 patients with single small Hepatocellular carcinoma with MVI in Beijing Chaoyang Hospital between January 2008 and December 2013 were retrospectively analyzed. Patients undergoing anatomical hepatectomy were enrolled in the AR group, and the patients undergoing non-anatomic hepatectomy were enrolled in the NR group. The efficacy and survival rate of the two groups were compared.

(1) Operation time, numbers of patients with volume of intraoperative blood loss ≥300 ml and number of patients with blood transfusion were (170±41)minutes, 8, 7 in the AR group and (148±35)minutes, 19, 18 in the NR group, respectively, with statistically significant differences between the 2 groups (P<0.05). (2) The 1-year, 2-year and 3-year overall survival rate were 85.7%, 68.6%, 57.1% in the AR group and 79.6%, 53.1%, 42.9% in the NR group, respectively. The 1-year, 2-year and 3-year progression-free survival rate were 80.0%, 62.9%, 51.4% in the AR group and 71.4%, 49.0%, 38.8%, in the NR group, respectively. There were statistically significant differences between the 2 groups both in the overall survival rate and the progression-free survival rate (P<0.05). (3) Prognostic factors analysis of HCC patients with MVI: result of univariate analysis showed that maximum diameter of tumor and surgical procedures were relative factors affecting overall survival and progression-free survival of HCC patients with MVI, AFP level was relative factors affecting progression-free survival of HCC patients with MVI, with statistically significant differences (P<0.05). Result of multivariate analysis showed that maximum diameter of tumor between 3.0 and 5.0 cm and non-anatomic liver resection were independent factors affecting poor overall survival and progression-free survival of HCC patients with MVI, and AFP≥20 μg/L and total bilirubin ≥20 μmol/L were independent factors affecting poor progression-free survival of HCC patients with MVI, with a statistically significant differences (P< 0.05).

Anatomic hepatectomy for patients with single small hepatocellular carcinoma with microvascular invasion has better clinical efficacy and safety.

To analyze the clinical applications of high frequency jet ventilation(HFJV) in cryotherapy of the trachea and bronchial neoplasms by the rigid bronchoscope.

The clinical data of 35 patients who were treated with tracheal neoplasms cryotherapy by the rigid bronchoscopy under HFJV were collected in China-Japan Friendship Hospital from August 2008 to February 2015.Under general anesthesia, HFJV was used in all patients. The mean arterial pressure (MAP), heart rates (HR), pulse oxygen saturation (SpO₂), results of arterial blood gas analysis and the incidence of complications during the procedure were recorded.

In the 35 patients, one case had multiple operations experience, he had an airway spasm after HFJV 40 min during his second operation, and severe hypoxemia after HFJV 5 min during his third operation, endotracheal intubation was performed immediately. The patient has a serious accumulation of carbon dioxide (CO₂) whose partial pressure of carbon dioxide in the artery (PaCO₂) was up to 71 mmHg(1 mmHg=0.133 kPa). Other patients had stable hemodynamics and no severe CO₂ accumulation.

High frequency jet ventilation can provide satisfactory ventilation effect in cryotherapy of the trachea and bronchial end-stage neoplasms by the rigid bronchoscope.

Primary gastric diffuse large B-cell lymphoma (PG-DLBCL) is the most common non-Hodgkin lymphoma (NHL) of extranodal origin. Most patients with PG-DLBCL had localized disease (stage Ⅰ or Ⅱ) at presentation, and will achieve complete response (CR) after induction chemotherapy. However, there has been little consensus regarding whether optimal treatment is provided by chemotherapy alone or chemotherapy plus radiotherapy, nor the treatment outcome from the addition of rituximab in localized-stage PG-DLBCL.

Patients with Stage ⅠE and ⅡE PG-DLBCL were retrospectively analyzed. Patients have not undergone surgery, have received at least 3 cycles of R-CHOP or CHOP-like chemotherapy as initial therapy, and achieved CR or partial response (PR) were enrolled.

A total of 91 patients were studied. The median age was 51 years, included 47 males and 44 females. Fifty-two patients were at Stage ⅠE and 39 at Stage ⅡE, 64 (70.3%) patients received R-CHOP-like regimens, and 27 (29.7%) received CHOP-like regimens, the median chemotherapy cycle was 6 (3-8). Among the 91 patients, 80 (87.9%) patients achieved CR from induction chemotherapy, 11(12.1%) was evaluated PR. Of CR patients, 48 patients (60%) underwent consolidating radiotherapy and 32 patients (40%) did not receive radiotherapy; all PR patients received salvage radiotherapy. CR patients with and without radiation therapy had 4-year progression-free survival (PFS) rates of 96.4% and 96.7%, respectively (χ² = 0.546, P=0.46); 7/11 (63.6%) PR patients achieved CR after radiotherapy, with a median follow-up of 41 months, they were all disease free. For patients treated with R-CHOP or CHOP-like regimens, the 4-year PFS was 93.2% and 89.7%, respectively (χ²=0.096, P=0.757).

Consolidation radiotherapy failed to improve the outcome for early-stage PG-DLBCL, while for PR patients, salvage radiotherapy increased CR rate and improved survival. The addition of rituximab to CHOP did not improve the efficacy.

To explore the effect of metformin on murine model of bleomycin (BLM)-induced lung injury and fibrosis.

A total of 30 mice were divided into 3 groups: control, BLM, and BLM with metformin, in accordance with the random number table and each group had 10 mice. To induce the pulmonary fibrosis model, a concentration of 2 mg/ml bleomycin was intratracheally administered in the BLM group and BLM with metformin group with a volume of 1.75 μl/g, while the control group accepted saline with the same volume. Metformin (200 mg/kg) was given to the mice orally once a day from the day before intratracheal instillation of bleomycin to day 14. The daily survival condition of mice was recorded during 14 days. At day 14, HE-staining was used to assess the severity of fibrosis according to the method proposed by Ashcroft. Total lung collagen content was determined by hydroxyproline assay and Masson′s trichrome staining. To examine the expression of fibronectin we used the method of immunohistochemistry staining. The changes of Transforming Growth Factor beta 1 (TGF-β ₁) in plasm, bronchoalveolar lavage fluid (BALF) and lung were measured by ELISA.

The survival rates of control group, BLM group and BLM with metformin group at day 14 were 10/10, 4/10 and 7/10 respectively. According to the method proposed by Ashcroft the score of metformin treated mice was significantly lower than that of the bleomycin model mice[(3.82±0.58) vs (7.79±0.06), (P<0.05)]. The hydroxyproline level in lung tissue were markedly attenuated in metformin treated mice compared with bleomycin model mice [(0.40±0.05) vs (0.73±0.10) μg/mg, (P<0.05)]. The level of TGF-β₁ in plasma, BALF and lung tissue were also decreased in mice treated with metformin compared with bleomycin model mice [(2.32±0.68) vs (4.59±0.45) ng/ml, (0.81±0.09) vs (1.40±0.06) ng/ml, (17.12±0.83) vs (21.25±0.69) ng/mg, all P<0.05].

Metformin can reduce the severity of pulmonary fibrosis in mice induced by bleomycin.

To observe the effect of knockdown A20 gene expression on the proliferation, invasion and metastasis of human nasopharyngeal carcinoma cell in vivo and in vivo.

Human nasopharyngeal carcinoma cell 5-8F-H3 was transfected with A20-specific shRNA Tet-on inducible plasmid vectors, and A20 silenced cells were screened by Puromycin. Quantitative RT-PCR and Western blot analysis were used to detect the mRNA level and protein of A20. The cell proliferation was detected by cell counting kit-8 (CCK8) and plate colony formation assays. The cell cycle and apoptosis were measured by flow cytometry. And the ability of cell invasion was measured using Boyden chamber assay in vivo. Subcutaneous tumor formation and liver metastasis in vivo were examined with whole-body fluorescence imaging system to observe the influence of silencing A20 gene expression in nude mice.

The stable A20 inducible silencing cells line 5-8F-H3/A20-shRNA was established successfully. Down-regulation of A20 mRNA and protein expression were observed in 5-8F-H3/A20-shRNA cells treated with DOX(both P<0.01). The results of CCK-8 assay (F=18.542, P=0.003), clone formation experiment (F=40.080, P<0.001) and flow cytometry analysis (F=7.398, P=0.024) in vivo showed that the cell proliferation of 5-8F-H3 was remarkably inhibited by down-regulation of A20 gene expression. The results of Boyden chamber assay showed that A20 gene silencing could inhibit the cell invasion ability (F=26.157, P<0.001). Silencing of A20 inhibited tumorigenesis and metastasis via subcutaneous tumor formation and liver metastasis experiments in nude mice.

A20 gene is closely related to the malignant biological behaviors of nasopharyngeal carcinoma, and it may serve as a potential molecular target for the treatment of nasopharyngeal carcinoma.

Precise renal puncture is an essential but challenging step for successful percutaneous nephrolithotomy. We evaluated the efficiency of a novel real-time navigation system using Mixed Reality(MR) technology for human phantom kidney puncture.

One human kidney phantom underwent MR-assisted percutaneous collecting system puncture. Two punctures were performed by each of 6 surgeons in the randomize selected upper, middle or lower calyces. Outcome measurements were the number of attempts for renal puncture, the time needed to evaluate the trajectory and to perform percutaneous puncture.

A total of 12 punctures were performed successfully using MR-Assisted Guidance. Median evaluation time and renal puncture time for the selected calyces was 13 (range 11 to 19) and 19 seconds (range 15 to 44), respectively. One or Two attempts were needed to achieve a successful renal puncture for all of the surgeons.

The proposed MR-assisted guidance solution for renal collecting system puncture proved to be accurate, simple and quick. The inherent limitations of traditional X - ray and ultrasonic technology can be overcome.

A 56-year-old female was admitted to Peking Union Medical College Hospital on July 19, 2017 due to fear of cold for 10 years and polyuria for 6 years. Since 2007, the patient has been sensitive to cold without inducement, accompanied by edema of face, hands and feet, and fatigue. There was no fever or change in urine output. In September 2008, thyroid stimulating hormone (TSH) was 5.55 mU/L (reference range: 0.38~4.34 mU/L), free triiodothyronine (FT₃) 4.70 pmol/L (reference range: 2.76-6.30 pmol/L), free thyroxine (FT₄) 16.9 pmol/L (reference range: 10.5-24.4 pmol/L); 24 h urine free cortisol (24 h UFC) was in a normal range without special treatment. Since 2011, polyuria, polydipsia and polydipsia have occurred without trigger, and they have gradually worsened. The daily water consumption and urine volume are about 7 L, the urine volume at night is about 4 L, and nocturia is 5 to 6 times. Check blood sugar is normal; TSH 10.4 mU/L, FT₃FT₄Normal range, positive for thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb); Thyroid ultrasound showed that the thyroid was enlarged, the internal echo was rough and grid-like, and the blood flow signal was abundant. Levothyroxine sodium was administered orally, gradually increasing the dose from 12.5 μ g/time, once/d to 100 μ g/time, once/d, and TSH decreased to normal after re-examination. In July 2017, the urine specific gravity was 1.005; Serum sodium 147 mmol/L (reference range: 135-145 mmol/L); erythrocyte sedimentation rate 22 mm/1 h (reference range: 0-20 mm/1 h); Enhanced magnetic resonance imaging (MRI) of the sellar region showed thickening of the pituitary stem and disappearance of short T1 signals in the posterior pituitary lobe (Figure 1)； The results of water-prohibition test are consistent with diabetes insipidus; Whole body bone imaging revealed abnormal radioactive concentration at the top of the left skull. The patient's urine output was reduced to 2~2.5 L/d and nocturia was performed once after the oral administration of desmopressin (0.05 mg/time, twice/d). Admitted for further diagnosis and treatment. Past history, personal history, marriage and childbirth history are no different, 49 years old menopause. Family history: Two older brothers suffered from autoimmune hepatitis and nephritis respectively, and one sister suffered from systemic lupus erythematosus.

Complaint and current medical history: The patient was a 59-year-old male who went to Peking University First Hospital on April 1, 2017 due to "repeated low back pain for 1.5 years and fever for 2 days". The patient had sudden left low back pain with fever 1.5 years ago. No abnormalities were found in urine routine, renal function, blood culture, kidney B-ultrasound and other examinations in the local hospital. He was considered "perirenal infection" and improved after symptomatic analgesic and anti-infective treatment. Three months later, abdominal B-ultrasound showed that the left kidney was atrophied. The serum creatinine fluctuated from 57 to 104 μ mol/L in the past 1 year, and the serum creatinine was 76 μ mol/L in the last re-examination 1 week ago. Two days ago, the patient suddenly experienced dull pain in the right middle and lower abdomen after taking a long-distance train, without nausea, vomiting, diarrhea, frequent urination, urgency, painful urination, etc. The pain did not relieve after defecation and lasted for about 1 h to relieve spontaneously. Two hours later, the patient developed persistent distension and pain in the right lower back, voluntary decrease in urine output (specificity unknown) and fever (maximum body temperature 39.2℃). Visit the outpatient clinic of our hospital, blood test routine: white blood cells 10.14×10⁹/L ↑ (3.5-9.5×10⁹/L), neutrophils 7.8×10⁹/L ↑ (1.8-6.3×10⁹/L), monocytes 1.39×10⁹/L ↑ (0.1-0.6×10⁹/L), hemoglobin 114 g/L↓ (130-175 g/L), platelets 181×10⁹/L (125-350×10⁹/L); Urinary routine: urinary protein 2+, urinary red blood cells 2~4/HP, white blood cells 1~3/HP, granular tube type 2~4/LP; Biochemical examination showed: serum creatinine 346 μ mol/L↑, urea nitrogen 9.3 mmol/L↑, serum creatinine 3.8 mmol/L, lactate dehydrogenase 696 IU/L↑ (100-240 IU/L); Coagulation indicators showed: prothrombin time 13.8 s ↑ (9.0~11.5 s), activated partial thromboplastin time (APTT) 36.2 s (26.9~37.9 s), fibrinogen quantitation (FIB) 4.57 g/L↑ (2~4 g/L), D-dimer 1.73 mg/L↑ (<0.24 mg/L), fibrinogen degradation products (FDP) 11.5 mg/L↑ (0-5 mg/L). Abdominal B-ultrasound showed very hypoechoic nodules on the right kidney and atrophy of the left kidney. Abdominal CT scan showed multiple slightly lower density foci in the parenchyma of the right kidney, the nature of which was to be determined, and the left kidney atrophy. Admitted to hospital for further treatment. Since the onset of the disease, the patient's urine output has decreased significantly, and there is no significant change in spirit, sleep, appetite and weight.

The 25-year-old female was seen in the emergency department of ophthalmology department of our hospital on November 30, 2016 because she did not see for 2 days after hyaluronic acid injection in her right forehead. The patient contacted the online "plastic surgeon" 2 days ago to perform hyaluronic acid injection on the right forehead in the local hotel. The hyaluronic acid injection equipment, injection dosage and injection technique were unknown. Complete ptosis of the right eye appeared immediately after the injection, which was not paid attention to by the patient. Two days later, the patient found that his right eye was invisible and his eyeball rotation was impaired, so he went to the emergency department of ophthalmology department of our hospital.

Community-acquired pneumonia (CAP) is characterized by high morbidity and mortality in immunocompromised hosts (ICH), and empirical antimicrobial therapy is usually recommended with limited efficacy. So far, there have been few studies on ICH-CAP, and almost all prospective clinical studies of CAP have excluded this population^[1,2]； Treatment recommendations for this group of patients are also not included in guidelines for the management of CAP by the American Society of Infectious Diseases and the Chest Association^[3]。 The relevant research is systematically reviewed and summarized as follows.