Volume 95  ·  Issue 13  ·  2015

Spinal surgery requires extensive manipulation of bone tissue around nerve vessels. In the past, spinal surgeons often used bone knives, bone-biting forceps, curettes, annular saws and other instruments to treat spinal bones. However, because the spinal bone tissue is irregular and adjacent to important neurovascular tissues, the operation is difficult and dangerous. Using the above tools is easy to cause important structural damage and tissue trauma due to the great vibration impact on bone tissue. With the increasing demand for the precision and safety of spinal surgery, grinding drill is gradually used more and more widely in spinal surgery. As a characteristic tool of contemporary spinal surgery, grinding drills bring greater kinetic energy, faster speed and more delicate operation to surgery. Micro-drill grinding technology is widely used in spinal surgery, which greatly increases the safety of surgery and reduces tissue trauma. In the 21st century, a lot of research has been carried out in ultrasonic grinding, and different ultrasonic grinding drills have appeared. Because of the selectivity of ultrasonic grinding drills to tissue grinding, the surgical safety has been increased, and it is considered to be an ideal tool to replace traditional surgical instruments^[1]。

To explore the influencing factors of pedicle screw instrumentation and provide theoretical rationales for decreasing facet joint violation rate by radiological evaluations of superior-segment facet joint violation after pedicle screw instrumentation in transforaminal lumbar interbody fusion (TLIF).

A retrospective study was conducted for 101 patients undergoing lumbar fusion after failed conservative treatment between December 2011 and December 2013. According to the Seo classification, computed tomography was used for evaluating the position of pedicle screw with superior segment facet joint. And χ ² test was used to examine the associations between superior segment facet joint violation and gender, age, construct level, fusion length and transpedicular screw side.

A total of 202 screws were evaluated. There were grade 0 (n=154, 76.2%), grade 1 (n=43, 21.3%) and grade 2 (n=5, 2.5%). In all screws, facet joint violation occurred in L5 segment more frequently than in any other segment (P<0.05), left-side facet joint violation was more common than right-side one (P<0.05). No statistical associations existed between violation rates and gender, age and fusion length.

During TLIF, there is a higher incidence of facet joint violation at right side and in L5 segment compared with other lumbar segments.

To evaluate the clinical outcomes and operative techniques of microsurgical resection of lumbar intraspinal tumors through paraspinal approach by percutaneous tubular retractor system.

A retrospective study was conducted to analyze 21 patients with lumbar intraspinal tumors between November 2011 and February 2014, including Schwannoma (n=19) and meningioma (n=2) without lumbar instability on preoperative images. The length of tumors was 0.6-2.0 cm. Tracheal intubation anesthesia was performed prior to microsurgery using percutaneous tubular retractor system through paraspinal approach. Operative duration, blood loss volume, postoperative wound pain duration and hospital stay were analyzed. Creatine phosphokinase (CPK-MM) level was recorded at 1 day preoperatively, 1 day, 3 days and 5 days postoperatively. The scores of Japanese Orthopedic Association (JOA) and visual analog scale (VAS) were analyzed at 1 day preoperatively, 1, 3, 5 days and 6 months postoperatively to evaluate the function status of spinal cord. Computed tomography (CT) three-dimensional reconstruction of lumbar vertebrae was performed at 1 week postoperatively. Magnetic resonance imaging (MRI) plain scan and enhanced scan of lumbar vertebrae were conducted preoperatively, 1 week and 6 months postoperatively.

Complete removal of tumors was achieved in all patients without the injuries of spinal cord or nerve root. Postoperative scores of JOA and VAS improved versus preoperative ones (P<0.05). Level of CPK-MM increased 1 day postoperatively and declined to preoperative level at 5 days postoperatively. And the difference was not statistically significant (P<0.05). Neither residual tumor nor tumor recurrence was detected by MRI plain and enhanced scans. No postoperative spinal instability was identified by CT three-dimensional reconstruction. And no spinal deformity occurred during a follow-up period of 6-28 months.

Microsurgical resection of lumbar intraspinal tumors using percutaneous tubular retractor system through paraspinal approach minimizes the injuries of paraspinal muscles, facet joint, spinous process and ligaments. This technique offers the advantages of mini-invasiveness, shorter hospital stay, rapid recovery and preserved postoperative spinal stability.

To explore the effects on degenerative single segmental lumbar spinal stability after posterior graded laminectomy and facetectomy by a finite element method.

A finite element model of L3-S1 segments with a single segmental degeneration at L4-5 level was established. Different models of L4-L5 segmental instability after posterior graded laminectomy and facetectomy were established. And interior 1/3, 1/2, 2/3 of laminar and bilateral facet joints were resected. Physical loads were applied to the models and the changes of range of motion (ROM) at L4-5 level in different models were recorded during flexion, extension, lateral bending and rotation.

As compared to preoperative model, after resecting 1/3 bilateral facet joints at L4-5 level, L4-5 segmental ROM increased 18% during flexion, 27% during extension and 45% during torsion. And the increased degree of ROM became more obvious along with a greater resection range of bilateral facet joints. No significant difference existed in L4-5 segmental ROM during lateral bending in all models.

Facet joints play vital roles in lumbar segmental stability. And segmental instability may occur when 1/3 bilateral facet joints are resected.

To employ three-dimensional finite element modeling and biomechanical simulation for evaluating the stability and stress conduction of two postoperative internal fixed modeling-multilevel posterior instrumentation (MPI) and MPI with anterior instrumentation (MPAI) with neck-thoracic vertebral tumor en bloc resection.

Mimics software and computed tomography (CT) images were used to establish the three-dimensional (3D) model of vertebrae C5-T2 and simulated the C7 en bloc vertebral resection for MPI and MPAI modeling. Then the statistics and images were transmitted into the ANSYS finite element system and 20N distribution load (simulating body weight) and applied 1N·m torque on neutral point for simulating vertebral displacement and stress conduction and distribution of motion mode, i. e. flexion, extension, bending and rotating.

With a better stability, the displacement of two adjacent vertebral bodies of MPI and MPAI modeling was less than that of complete vertebral modeling. No significant differences existed between each other. But as for stress shielding effect reduction, MPI was slightly better than MPAI.

From biomechanical point of view, two internal instrumentations with neck-thoracic tumor en bloc resection may achieve an excellent stability with no significant differences. But with better stress conduction, MPI is more advantageous in postoperative reconstruction.

To explore the risk factors, treatment and outcomes of biloma after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

A total of 481 patients with a diagnosis of HCC underwent TACE at our hospital from January 2011 to December 2013. Biloma was tracked by the follow-ups of computed tomography or magnetic resonance imaging (CT/MRI). Retrospective analyses were conducted for their clinical features, treatments and prognosis. The statistically significant factors for univariate analysis were introduced into Logistic regression models for multivariate analysis to obtain the risk factors of biloma post-TACE.

There were 43 cases of complicated biloma after TACE. And 38 patients (88.4%) developed biloma at 0.5-3 months post-TACE while another 5 (9.7%) did so at 3-5 months. The multivariate analysis showed that bile duct dilation, a history of hepatectomy prior to TACE, use of polyvinyl alcohol (PVA) particles and nonsuperselective embolization were the risk factors of biloma formation after TACE. Among 9 symptomatics, there were jaundice (n=2) and fever (n=7). The diameter of bilomas was (8.07±3.53) cm for 9 symptomatics and (2.81±1.26) cm for 35 asymptomatics. And the difference was statistically significant (P<0.01). Nine symptomatic patients underwent percutaneous drainage with tube and biloma diminished (n=7) and even vanished (n=2). Only conservative treatment was offered for 35 asymptomatics. During the follow-ups, it showed no change (n=24), diminishing (n=8) and disappearance (n=2). One case died from a greatly enlarged biloma due to hepatic failure and septic shock via a rupture into abdominal cavity and choleperitonitis.

The risk factors of biloma formation after TACE for HCC are bile duct dilation, a history of hepatectomy before TACE, use of PVA particles and nonsuperselective embolization. For symptomatics, drainage must be performed timely and the prognosis is fair. For asymptomatics, regular imaging follow-ups are needed. Drainage must be performed timely when the diameter of biloma increased significantly during the follow-ups.

To investigate the clinical characteristic and drug resistance of decompensated cirrhosis patients bloodstream infections causing by Escherichia coli, and determine risk factors for mortality among patients with bloodstream infections.

The clinical data and drug susceptibility of decompensated cirrhosis patients Escherichia coli bloodstream infections from 2009 to 2012 in 302 hospital of PLA were retrospectively analyzed. Univariable and multivariable Logistic regression was used to identify independent risk factors for all-cause mortality.

A total 211 strains of E. coli were isolated from decompensated cirrhosis inpatients, 80 strains ESBLs detecting were positive, positive rate was 37.9%. Most of infection source were uncertain. The drug resistance of ESBLs positive strains was higher than ESBLs negative strains, but no statistical difference existed in age, sex, basic disease, infection source, peak temperature, white blood cell count, the percentage of neutrophils between ESBLs positive strains and negative strains. 154 patients were survived and 57 patients were died after treatment, with a mortality of 27.01%. On multivariate analysis, independent risk factors for in-hospital mortality were old age[odds ratio (OR)=2.429], abnormal pulse (OR=2.977), liver failure (OR=11.159), hepatic encephalopathy (OR=2.524), septic shock (OR=8.837), acute kidney injury (OR=3.758), gastrointestinal bleeding (OR=4.118). Body temperature of > 39 ℃ ( OR=0.301) had protective effect to lower mortality. A Logistic probobility model was created by adding points for each independent risk factor, and had a c-statistic of 0.898.

Due to decompensated cirrhosis patients Escherichia coli bloodstream infection severity and bad prognosis, early effective antimicrobial therapy and severe complication prevention should be taken to reduce mortality.

To investigate the Lactobacillus species in the vaginas of vulvovaginal candidiasis and to assess the prevalence of each Lactobacillus species in vulvovaginal candidiasis.

154 vaginal samples were analyzed, 92 of which were from fertile healthy women, and 62 of which were from women with vulvovaginal candidiasis; and species-specific PCR showed the prevalence of each Lactobacillus species Species-specific PCR was used to investigate the prevalence of each Lactobacillus species in healthy Chinese women and the women with vulvovaginal candidiasis.

In women with vulvovaginal candidiasis: L. iners(6.5%), L. cripatus(79.0%), L. gasseri(37.1%), L. jensenii(74.2%), L. acidophilus(16.1%), L. brevis(19.4%), L. plantarum(1.6%), L. johnsonii(51.6%), L. fermentum(8.1%), L. salivarius(9.7%), L. reuter(1.6%), L. paracasei(8.1%), L. delbrueckii(3.2%); More than two different Lactobacillus species coexisted in 98% of women with vulvovaginal candidiasis, and no anyone species existed in 2% of them; In fertile women: L. iners(82.6%), L. cripatus(70.7%), L. gasseri(67.4%), L. jensenii(40.2%), L. acidophilus(39.1%), L. brevis(23.9%), L. plantarum(5.4%), L. rhamnosus(1.1%), L. paracasei(1.1%), L. reuter(1.1%)i, L. johnsonii(3.3%), L. fermentum(2.2%), L. salivarius(2.2%); More than two different Lactobacillus species coexisted in 97% of fertile women, and only one species existed in 3% of fertile women.

Species of lactobacillus in women with vulvovaginal candidiasis did not significantly reduced compared with healthy women. Lactobacillus inert may be a marker of the change of vaginal microenvironment; Lactobacillus crispatus is a dominant lactobacillus in the vaginal of fertile healthy women, pregnant women and women with vulvovaginal candidiasis.

To assess the perfusion changes in brains of patients with varying levels of generalized anxiety disorder (GAD).

A total of 38 GAD outpatients of Department of Psychiatry at our hospital from February to August, 2014 and 10 healthy controls received a ^99mT_C-ECD SPECT/CT scan with scenium analysis. Differences between brain perfusion and anxiety levels were analyzed by SPSS 16.0 with one-way ANOVA, Pearson's Chi-square,t test and Spearman's correlation.

They were grouped according to the levels of anxiety severity, i. e. mild (n=11), moderate (n=16) and severe (n=11). They had significantly lower blood flow in right superior frontal medial gyrus, right precuneus, right putamen, bilateral paracentral lobule and bilateral supplementary motor area (t=-2.19, -2.14, -2.22, -2.34, -2.08, -3.26, -2.72, P<0.05). Individuals had significantly greater blood flow in mild group than those of control group in right olfactory (t=2.09, P=0.05). Individuals of moderate group had significantly lower blood flow than those of control group in left superior frontal gyrus medial orbital, right superior frontal gyrus medial orbital and left supplementary motor area, but greater in right olfactory (t=-2.16, -2.24, -2.49, 2.17, P=0.04, 0.04, 0.02, 0.04). Individuals had lower blood flow in severe group than those of control group in left frontal lobe, right putamen, left paracentral lobule, right paracentral lobule, left precuneus, right precuneus, left parietal lobe, left precentral, right precentral, right postcentral, left rolandic operculum, left supplementary motor area, right supplementary motor area and left central region (t=-2.32, -2.11, -3.16, -2.61, -2.39, -2.18, -2.32, -2.67, -2.14, -2.11, -2.25, -4.38, -3.54, -2.38, P=0.03, 0.05, 0.01, 0.02, 0.03, 0.04, 0.03, 0.02, 0.05, 0.05, 0.04, 0.00, 0.00, 0.03). Statistical differences existed in right middle frontal gyrus orbital part (mild: 0.96±0.07, moderate: 1.03±0.06, severe: 0.98±0.08, P=0.04) and left paracentral (mild: 0.91±0.07, moderate: 0.93±0.04, severe: 0.87±0.07, P=0.02). There was a tendency of negative correlation between perfusion in right middle cingulate and paracingulate gyri, left precuneus, right precuneus and left thalamus and anxiety scores by Spearman's correlation analysis (r=-0.28, -0.28, -0.27, -0.29, P=0.09, 0.09, 0.10, 0.07).

Scenium software provides quantitative measurements for diagnosis of GAD in different anxiety levels. Also larger samples are required for confirming the results in further studies.

To investigate the imaging features of humerus, radius and ulna rare malformation.

A retrospective analysis of the clinical data and image of 40 cases of humerus and the radius and ulna rare developmental deformity andadmitted to hospital affiliated to 1958-2014 years in The Affiliated Hospital of Hangzhou Normal University and the Third Hospital of Hebei Medical University. Take the Swanson classification as the basis, the image changes of different types of malformations are classified and summarized.

40 cases of humerus, radius and ulna rare malformation in 19 males and 21 females, age 18 days to 51 years, mean age (11.6 ± 11.5) years; a total of 10 kinds of deformities to Swanson classification, radius and ulna: failure of formation of parts 9 cases, for radial defect; failure of differentiation are congenital radioulnar synostosis 6 cases, Madelung's deformity 12 cases, congenital radial head dislocation 4 cases; duplication 2 cases, for double ulna syndrome; overgrowth 2 cases, as long ulna short radial deformity; undergrowth 1 case, for the micromelia. Humerus and ulna bony involvement: failure of differentiation 1 case, for brachial radial synostosis; failure of formation of parts 1 case, for amelia. There is still one kind of deformity can not be accurately classified as patella cubiti 2 cases.

Humerus, radius and ulna although more types of malformations and the incidence rate is not high, only a comprehensive understanding of different deformity classification and characteristics, combined with the typical imaging findings in order to arrive at a correct diagnosis to avoid misdiagnosis.

To evaluate the cortico-cortical evoked potential (CCEP) in exploring the network in epileptics.

Two patients with intractable epilepsy underwent chronic intracranial electrode placement. According to the distribution of icta onset zones and the functional brain mapping, alternating 1 Hz electrical stimuli were delivered to the target electrodes. And CCEPs were recorded by averaging electrocorticograms time-locked to stimuli from subdural electrodes. Then icta onset zones, eloquent areas identified by electrical cortical mapping and CCEP distributions were compared.

Typical CCEP responses were observed. The data of one patient was useful for investigating the connectivity associated with various brain networks while another patient was useful for evaluating the cortical excitability.

The exploration of epileptic network is achieved through cortico-cortical evoked potential by investigating the connectivity associated with various brain networks and cortical excitability.

To explore the diagnostic value of simultaneous electroencephalography/functional magnetic resonance imaging (EEG-fMRI) for epileptic foci in focal epilepsy of normal brain structure.

The normal structural images of EEG-fMRI and resting state-fMRI (RS-fMRI) with 3.0T high-field MR system were performed for 15 focal epileptic patients from April 2013 to July 2014. On EEG-fMRI, epileptiform discharges were regarded as nerve stimulation. And off-line analysis yielded the blood oxygen level-dependent (BOLD) responses related to epileptiform discharges. The relationship was analyzed between BOLD activation reaction and electroencephalography-clinical symptomatology position. And the electroencephalography-clinical symptomatology position was selected as a major indicator of judging the degree of concordance.

The involved lobes were temporal (n=7), frontal (n=5) and frontotemporal (n=3). On EEG-fMRI, all patients demonstrated BOLD responses related to epileptiform discharges. Compared with electroencephalography-clinical symptomatology position, 12 cases (12/15) were fully concordant and 3 cases (3/15) partially concordant. Three patients had BOLD responses in accordance with electroencephalography-clinical symptomatology position on RS-fMRI. And the detection rate of BOLD responses was higher for EEG-fMRI than that for RS-fMRI.

The BOLD responses related to epileptiform discharges may help locate noninvasively the epileptogenic region of focal epilepsy and provide additional useful information for preoperative evaluations of epilepsy.

To explore the diagnosis and treatment of multicentric glioma and discuss its underlying pathological mechanism.

The clinical cases of multicentric glioma at our department were prospectively collected from January 2012 to December 2014. A total of 62 cases, along with the literally reported cases with relative complete data, were studied with Kaplan-Meier and COX regression to identify the prognostic factors of disease.

The median age was 55.3±14.3 (11-78) years. The ratio of male-to-female was 1.27. There were synchronous (n=48) and multichronous (n=13) multicentric gliomas. The median survival time was 8 months and 7 months if calculated from the appearance of new tumor. Kaplan-Meier analysis revealed that the survival time was correlated with age, resection of tumor, radiotherapy and chemotherapy. And COX regression analysis indicated that only resection of tumor(s) and chemotherapy were independently correlated with the prognosis of multicentric glioma.

Multicentric glioma is mainly of high-grade glioma with a very poor prognosis. Total resection and standard chemotherapy yield a better prognosis. Radiotherapy should be prudent if there are signs of intracranial hypertension.

With the discovery of more patients with anti-N-methyl-D-aspartate (anti-NMDAR) encephalitis, frequent clinical relapses pose a new challenge to neurologists.

Retrospective reviews were conducted for 16 hospitalized patients with relapsing anti-NMDAR encephalitis at our hospital from June 2011 until November 2014. Their clinical data including symptoms, cerebrospinal fluid (CSF) profiles, neuroimaging findings and relapsing treatment were compared with those initial episodes.

There were 11 females and 5 males with a mean onset time of 21.2 (10-34) years. For initial episodes, the mean number of major symptoms was 5.8 and the mean modified Rankin score (mRS) 4.56. And 7 (43.8%) cases were admitted into intensive care unit (ICU). All received first-line immunotherapy and only one case second-line immunotherapy. Ovarian teratoma was detected and resected in only one case of initial episode. Among 32 relapses, 8 cases (50%) had multiple (2-4) relapses. There was a median delay of 5.0 (0.5-18) months for relapses. Relapses were common upon pausing or reducing immunotherapy, usually monotherapy with corticosteroids. Compared with initial episodes, relapses were less severe (mean mRS 2.69, mean number of symptom 2.59) and only 2 cases were admitted into ICU during relapses. Presentation of relapses were partial symptoms of initial episode. However, two patients had new symptoms of brain stem involvement. Brain magnetic resonance imaging (MRI) of 8 cases showed abnormality initially during initial episode and disappearance at relapses while new lesions appeared in 7 patients including 3 cases with CNS demyelinating features of central nervous system (CNS) on MRI. The positivity rate of anti-NMDAR antibody was 100% in CSF and 53.1% in sera during relapses. Anti-AQP4 and NMO-Ig were positive in one case with brain stem involvement. All cases received first-line immunotherapy and 12 chronic second-line immunotherapy. Two cases of ovarian teratoma were detected on reassessment during relapse and then resected.

Inadequacy of second-line and chronic immunotherapy, occult teratoma and potential demyelination may contribute to a relapse of anti-NMDAR encephalitis. And its proper management should follow the recommendations of guidelines.

To explore the effects and activation mechanism of adenosine triphosphate (ATP) on large conductance calcium-activated potassium channel (BK channel) in coronary artery smooth muscle cells.

Coronary smooth muscle cells were isolated by enzyme digestion from Sprague-Dawley rats. And BK currents were recorded by patch clamp technique in whole cell configuration. The effects of ATP on cytosolic calcium concentrations were examined by recording the changes of fluorescence intensity ratios.

BK current densities were (137±13) pA/pF and (179±15) pA/pF before and after a perfusion of 1 mmol/L ATP (P<0.05). The fluorescence ratios were 2.46±0.08 and 4.04±0.21 (P<0.05) before and after 0.5 mmol/L perfusion. After incubating with purine receptor (P2Y1) blocker MRS2179, phospholipase C (PLC) blocker U73122 and inositol triphosphate (IP3) blocker 2-APB, the fluorescence ratios were 2.7±0.06, 2.65±0.12 and 2.69±0.13 respectively. Compared with control group, all fluorescence ratios decreased after incubating with three blockers (P<0.05).

ATP may elevate intracellular calcium concentration via P2Y1-PLC-IP3 pathway consequently activating BK channel.

A 67-year-old female was admitted to Peking Union Medical College Hospital on May 24, 2011 due to sudden retrosternal persistent crushing pain for 2 h. Electrocardiogram: Sinus rhythm, pathological Q wave formation in V8-V9 leads, no ST segment and T wave dynamic changes were observed. Serum creatine kinase 194 U/L, creatine kinase isoenzyme-MB 18.2 μ g/L, troponin I 2.59 μ g/L. "Non-ST segment elevation myocardial infarction" was diagnosed, and the symptoms were relieved by intravenous injection of nitroglycerin and antiplatelet and anticoagulant therapy. Past history: Diagnosis of "hypertension" for 20 years; Diagnosis of "dyslipidemia" for 10 years; Diagnosis of "ischemic stroke" for 10 years; Diagnosis of "left breast cancer" for 7 years, radical left breast cancer surgery; After the diagnosis of "coronary atherosclerotic heart disease" for 4 years, one rapamycin-eluting stent was implanted in each of the anterior descending artery and the posterior descending artery. Physical examination: blood pressure 135/77 mmHg (1 mmHg =0.133 kPa), heart rate 65 beats/min, body mass index 27.4 kg/m²There were no other positive findings.

A 32-year-old female developed right lumbar pain after climbing stairs more than a month ago, which was persistent dull pain without obvious reflex pain, and the pain resolved spontaneously. Physical examination showed soft abdomen, no tenderness, rebound pain, no muscle guard, no abnormal mass, and negative Murphy's sign. The kidney area was flat and symmetrical, without obvious percussion pain, no vascular murmur, and no tenderness in the bilateral ureteral pathway. Routine urine examination on admission: urine specific gravity: 1.015, urine leukocyte esterase: 2+, urine occult blood: 1+, turbidity: turbidity, 25 red blood cells/μ L, 120 white blood cells/μ L, and 708 bacteria/μ L. MRI examination of upper abdomen showed that a type of round abnormal signal focus was seen in the right adrenal region, T₁WI showed high signal, mixed with patchy flocculate low signal (FIG. 1A), T₂WI – SPAIR showed high signal, mixed with patchy flocculate low signal (FIG. 1B), DWI shows high/low/equal confounding signals (Figure 1C), a fusiform T was seen on the right edge of the lesion₁WI low, T₂WI – SPAIR high, DWI slightly high signal foci; Enhanced scan showed that the cyst wall and septum of the right adrenal area were linear enhancement, but no enhancement was observed in it (Figure 1D), the boundary of the lesion was clear, the size was about 75 mm ×77 mm ×85 mm, the right adrenal gland was unclear, and the adjacent liver, hepatic hilar structure, kidney and inferior vena cava showed compressed migration changes, and the boundary with the lesion was clear. MRI diagnosis of teratoma in the right adrenal region is possible. CT examination of the upper abdomen showed a type of round low-density mass in the right adrenal region, with relatively uniform density on plain scan, and linear separation. The CT value of the fusiform low-density area at the separated right lateral edge was 7-49 HU, with an average CT value of about 23 HU, and the CT value of the round low-density area at the separated left lateral edge was-21-62 HU, with an average CT value of 23 HU, and scattered spotty calcification was also seen (FIG. 2A)； The enhanced scan showed linear enhancement of the cyst wall and septum of the right adrenal region, and no obvious enhancement was observed in it (Figure 2B、Figure 2C、Figure 2D), with clear edges and a size of 75 mm ×80 mm ×90 mm. CT diagnosis of cystic lesions in the right adrenal region is possible. Gross pathology showed cystic lesions of the right adrenal gland, soft and round, with thick cyst wall, hemorrhagic focus and close adhesion to the adrenal gland and surrounding tissues. Pathological diagnosis: right adrenal angioma with hemorrhage and organization (Figure 3)。

A 63-year-old male was admitted to the hospital on 16 April 2014 mainly due to "unresponsiveness with memory loss for 2 weeks". At about 18: 00 pm 12 days before admission, sudden unresponsiveness, dull expression, inability to find their own bed and toilet, memory loss, inability to correctly answer questions and distinguish the surrounding environment, accompanied by dizziness and headache, which lasted for 1 h and improved; Six days before admission, the patient was unresponsive again, unconscious, unclear speech, did not know the door of the home, could not identify the surrounding environment, could not find the door of the toilet, walked unsteadily, and fell; After that, the patient gradually developed increased sleep, sleepiness, less speech and less movement, reduced communication with family members, inability to answer questions correctly, and occasionally incontinence. The outpatient head CT showed "right caudate nucleus head lacunar infarction" and was admitted to the hospital. Previous diabetes for 12 years, silicosis for more than 1 month. He has worked in a cement factory for more than 40 years and smoked for more than 40 years, about 10 cigarettes/d. His father has died of gastric cancer, and his mother has died of cerebral hemorrhage. Physical examination: The mind is clear, the questions can be answered, the answers to the questions are not relevant, the bilateral pathological signs are positive, and the other obvious positive signs are not seen. Medical examination showed no obvious abnormalities in heart, lung and abdomen, and no enlargement of lymph nodes in the whole body.

A 49-year-old male, physical examination found that the left occipital region occupied space for more than 3 years, and the lesion was found to be enlarged for more than 1 month. The patient found that the left occipital region occupied space during the physical examination on January 4, 2011. Because the occupied space was small and there was no discomfort, no operation was performed, and he was told to follow-up visit. On November 15, 2011, the lesion was found to be slightly enlarged during the re-examination of MR. After the enhancement, the lesion was significantly enhanced with meningeal tail sign. Meningioma was diagnosed, but no operation was still performed. In recent months, I experienced left occipital discomfort and occasional headache. There were no abnormal manifestations in my scalp and appearance during physical examination. On April 30, 2014, MR was re-examined and the occupied space of the left occipital region was significantly increased. On June 5, 2014, I went to Haikou People's Hospital. Imaging findings: CT on January 4, 2011: Nodular slightly high-density shadow convex into the brain in the left occipital region (FIG. 1A), adjacent to bone resorption destruction (FIG. 1B)； 15-Nov-2011 MR: Left Occipital Nodular Iso-T₁Long T₂Signal, obvious enhancement after enhancement, and meningeal tail sign, adjacent bone destruction (Figure 1C、Figure D、Figure 1E)； 30-Apr-2014 MR: The lesion was significantly enlarged (Figure 1F～Figure 1G)。 On June 9, 2014, the left occipital craniotomy was performed under general anesthesia for tumor resection: during the operation, the tumor was dark red on the convex dura of the left occipital region, the host bone was destroyed, and the occipital lobe was obviously compressed and migrated. Pathological examination: Microscopically, intracellular cavernous angiomatous hyperplasia (FIG. 2A), with bleeding, destruction of the host bone, and new trabecular bone can be seen. Immunohistochemistry: vascular endothelial cells CD31, CD34 (Figure 2B), CD56, Syn and Vimentin (Figure 2C) positive, CgA, CK, CD31, CD34, S-100, SMA, CD138, CD20, desmin, CD79a, CD99 and LCA were all negative, and about 5% of Ki-67 positive cells. Pathological diagnosis: cavernous hemangioma of the skull (left occipital region).

Angiopoietin-like protein family (Angptls) is a new family of secreted glycoproteins discovered in recent years, and its members are Angptls 1~7. As a new family of secreted glycoproteins, the role of Angptls in metabolism and angiogenesis has been widely paid attention to. Among them, there is substantial evidence that ANGPTL3 and ANGPTL4 play an important role in regulating plasma triglyceride levels, including in vivo and in vitro studies in mice and humans^[1,2,3,4]。 In humans, genome-wide association studies have also demonstrated the association of ANGPTL3 and ANGPTL4 with circulating lipid metabolism^[5,6]and the loss of functional mutations in ANGPTL3 in humans may be responsible for low plasma triglyceride levels^[7,8]。 In mice, the effects of ANGPTL3 and ANGPTL4 genes are consistent, that is, both overexpression and deletion of the corresponding genes can increase and decrease the levels of triglycerides in serum, respectively^[9,10]。 Recently, three research groups independently identified and confirmed a new vascular lipid regulator, which was named Lipasin/RIFL/ANGPTL8^[11,12,13]And found that it is a new member of the Angptls family, namely ANGPTL8, and a recent article published in the journal CELL found that this new angiopoietin family member (named betatrophin) can significantly and specifically stimulate the proliferation of β cells in mouse models, which has attracted great attention. In this paper, we will review the related research of this new regulator of glucose and lipid metabolism, in order to better clarify its important role in the regulation of glucose and lipid metabolism, which we collectively call betatrophin here.