Volume 97  ·  Issue 31  ·  2017

tumor ablation is a non-vascular interventional therapy, which is a local therapy that directly applies chemicals or energy to a tumor lesion to eradicate or substantially destroy the tumor: including chemical ablation and energy-based ablation. The former mainly uses absolute ethanol, acetic acid, etc. to destroy tumors, while the latter includes radio-frequency ablation (RFA), microwave ablation (MWA), cryoablation (Cryo-A), laser ablation (LA), ultrasound ablation (ultrasound ablation) and irreversible electroporation (IRE) that inactivates tumors by non-thermal effects^[1,2]。

Tumor ablation technique refers to the local treatment technique that directly destroys the tumor by physical methods, including radiofrequency, microwave, freezing, ultrasound, laser, irreversible electroporation, etc^[1]Therapeutic approaches include percutaneous, laparoscopic and open surgery under direct vision. After decades of development and exploration, tumor ablation has been paid more and more attention by clinicians, and has become another important means for treating solid tumors besides surgical treatment, radiotherapy and chemotherapy. Although the tumor ablation treatment technology has exact safety and effectiveness, it is still in the initial stage of treatment for many solid tumors due to its late start, and it has high requirements for the service ability of medical institutions and the technical level of medical staff. Therefore, it belongs to the medical technology that needs limited conditions. At the same time, at present, medical institutions at all levels in China are carrying out or planning to carry out clinical and scientific research on tumor ablation treatment, but the development level of each institution is uneven, and a unified standardized management model has not yet been formed.

Primary liver cancer is one of the common malignant tumors in China, and the liver is also the second most common metastatic organ of tumors in other parts of the body. The treatment methods of liver tumors include surgical resection, liver transplantation, local ablation, transcatheter hepatic artery chemoembolization (TACE), radiotherapy, etc. In recent years, with the promotion of minimally invasive concept, local ablation methods represented by radiofrequency ablation (RFA) have developed rapidly. Because of its advantages such as positive therapeutic effect, few complications and low cost, local ablation has gradually been widely used in the treatment of liver tumors. In order to standardize the clinical application of tumor ablation technology, the National Health and Family Planning Commission of the People's Republic of China has formulated the Technical Management Standards for Tumor Ablation Treatment (2017 edition) (hereinafter referred to as the Standards), which makes specific requirements for medical institutions and personnel qualifications, technical management and personnel training that carry out tumor ablation, so as to ensure the quality and medical safety of ablation treatment. This article discusses the standardized application of ablation technique in surgical treatment.

The International Society for Medical Shockwave Treatment (ISMST) held an enlarged meeting of ISMST Standing Committee members in Naples, Italy on October 12, 2016, and once again focused on updating and revising the indications and contraindications of extracorporeal Shockwave, which became a weather vane to guide the clinical application of ISMST members' Shockwave technology in the new era, and laid an important foundation for China to expand the application scope and operating specifications of Shockwave technology. We interpret this revision accordingly, in order to promote the clinical application and popularization of shock wave technology.

In order to standardize the clinical application of tumor ablation treatment technology and ensure medical quality and medical safety, the National Health and Family Planning Commission organized domestic experts in the field of tumor ablation treatment and set up an expert group headed by Professor Zheng Jiasheng to formulate this specification. This specification is the minimum requirement for medical institutions and their medical staff to carry out tumor ablation treatment technology. The tumor ablation treatment technology mentioned in this specification refers to the local treatment technology that directly damages the tumor by physical methods, including radio frequency, microwave, freezing, ultrasound, laser, irreversible electroporation and other treatment technologies. The treatment approaches include percutaneous, endoscopic and open surgery.

The quality control indicators of clinical application of tumor ablation therapy technology are as follows.

Thermal ablation of liver tumors refers to a local treatment method for in situ inactivation of liver tumors by thermal effects, including radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (Cryo-A), laser ablation (LA), ultrasound ablation, and the like. Percutaneous puncture is mostly performed under the guidance of images, which has the advantages of simple operation, minimally invasive, precise and accurate curative effect. It can also be performed under laparoscopy or open surgery, and its clinical application is increasingly widespread. Tumor ablation is a medical technology with limited clinical application in China. In order to standardize the operation of thermal ablation technology for liver tumors and ensure medical safety, the National Health and Family Planning Commission entrusted the Chinese Medical Doctors Association to organize multidisciplinary experts in the field of tumor ablation treatment in China to participate and carefully discuss, and finally form this consensus. This consensus is represented by radiofrequency ablation, which is also suitable for microwave ablation, and can provide reference for other ablation treatment methods.

The objective was to assess the relationship between early response and later response to antipsychotics, and the relationship between antipsychotics and early response.

Data were retrospectively analyzed from patients with schizophrenia and they were hospitalized in the Second Affiliated Hospital of Xinxiang Medical College from May, 2013 to September, 2015.The patients were divided into theearly response group (PANSS total score improvement ≥20% at week 2) and early nonresponse group.General information, the use of drug and the Positive and Negative Syndrome Scale (PANSS) on before and 2, 4, 6 weeks after treatment were compared between the two groups.The relation between early response and late response and the effect of drug selection on early response were analyzed by correlation analysis and regression analysis.

Relative to early nonresponders, early responders were significantly more likely to have lower PANSS scores (total scores on 2, 4, 6 weeks after treatment 66.2±11.8 vs 84.5±10.9, 55.9±13.2 vs 70.9±13.7, 48.9±13.1 vs 60.6±14.9, all P<0.05) and higher PANSS scores improvement at 2, 4, 6 weeks after treatment (total scores improvement on 2, 4, 6 weeks after treatment (37±14)%vs (9±7)%, (56±19)% vs (32±18)%, (68±20)% vs (49±21)%, all P<0.05). The correlation coefficient between PANSS total score improvement at week 2 and at week 4, 6 were 0.730 and 0.541, respectively (allP<0.05). Olanzapine had more PANSS total score improvement than aripiprazole, quetiapine and ziprasidone (2 weeks after treatment (29±19)%vs (19±16)%, (18±15)%, (17±15)%, 4 weeks after treatment (51±21)% vs (37±25)%, (39±18)%, (37±22)%, all P<0.05). The protective factor for early response was olanzapine (P<0.05).

Early responders are associated with faster and greater improvement in symptoms, the type of antipsychotic has impacts on early response, early non-responders can benefit from adjustment of treatment.

To investigate the value of magnetic resonance imaging (MRI) in predicting the type and severity of placenta accreta (PA).

The clinical data of 67 PA cases in Peking University Third Hospital from January, 2015 to November, 2016 were analyzed retrospectively.Cases were classified according to the direct and indirect MRI signs.Chi-square test was applied to disclose the difference between different PA types and MRI signs.MRI signs with statistical significance were further calculated by the area under ROC curve (AUC) value analysis to reveal the correlation between specific signs and the type/severity of PA.

Among the 67 cases, 24 cases were of mild PA and 43 cases were of severe PA.Statistical difference was found between the two PA groups in some signs such as placenta tissues invading the uterus myometrium, placenta tissues extending beyond the uterus outline, the uniformity of placental signal, abnormal vessel imaging in the placenta basilar part, Bladder Tent Sign and the discontinuity of low signal zone in the gap between bladder and placenta.AUC analysis showed that the above MRI signs had the stronger correlations between the type/severity of PA, compared with other signs.

Not only can MRI be used to predict the type of PA, but also it can be used to predict the location and severity of PA, which has an important reference value for clinical works.

To explore the clinical efficacy of prevention strategy for acute intraoperative encephalocele of patients with severe traumatic brain injury (sTBI).

A total of 173 patients with sTBI, who treated in Emergency Neurosurgery Department of Shandong University Qilu Hospital from January, 2011 to September, 2015 were collected and divided into research group and control group, according to their therapeutic strategy.The clinical data during hospitalization and prognosis 1 year after injury was analyzed retrospectively to clarify the effect of acute encephalocele prevention strategy.

There were no statistically significant differences in sex, age, preoperative Glasgow coma scale score and imaging type of lesion between patients from the two groups.The highest intraoperative intracranial pressure in the research group and control group were (35.71±4.13) mmHg and(34.85±3.81) mmHg, respectively.The acute encephalocele incidence of the research group (7 cases, 6.5%) was significantly lower than that of the control group (13 cases, 19.7%) (P<0.01). Subgroup analysis showed that the incidence of acute encephalocele in patients with only unilateral lesions was low (1.3%), while higher (19.4%) in patients with both unilateral lesions and other secondary lesions or diffuse brain swelling.The prognosis of the patients was evaluated by Glasgow Outcome Scale according to the follow-up 1 year after injury, and it was suggested that the percentage of patients with good outcome in the research group (62 cases, 57.9%) was remarkably higher than that in the control group (26 cases, 39.4%) (P=0.018).

For sTBI patients with high risk of acute encephalocele, prevention strategy was found to be able to retard the progression of delayed hematoma and diffuse brain swelling, prevent the acute encephalocele during operation, and then significantly improve the prognosis.

To explore the association between gene mutations and clinical characteristics in Chinese patients with epilepsy.

A total of twenty-three patients with idiopathic epilepsy admitted to the Xuanwu Hospital of Capital Medical University from January 2014 to July 2016 were included.The age at onset of epilepsy ranged from 8 months to 31 years.All patients were screened for mutations by next-generation of sequencing (NGS), using a targeted capture panel of epilepsy and related seizures to screen forgene causative for or related to epilepsy.Some mutations were verified for inheritance by Sanger sequencing of two generations in the family.The differences in clinical characteristics among different mutation carriers were compared.

A total of 38 mutations were identified in 23 patients.Most of the patients presented with tonic-clonic seizures, and most were not accompanied by mental retardation.Causative genes were dominated by those encoding ion channel, enzyme and proteins with special functions.Although mutation carriers for genes encoding ion channel proteins and those with special functions were not significantly different in age at onset, types of seizure, family history or complications(P>0.05), patients presenting with tonic-clonic seizures had higher frequency of mutations in genes encoding ion channel (15/15)than those encoding proteins with special function(16/20)(P=0.066).

NGS is a useful technology in detecting mutations in patients with various types of epilepsy and aiding in etiological diagnosis of the disease.Tonic-clonic seizures may correlate with mutations in genes encoding ion channel.

To investigate the relationship between the proximal femur geometry and elderly osteoporotic hip fractures.

From May 2015 to December 2015, 137 patients with elderly osteoporotic hip fractures were involved.69 cases were in the fracture group and 68 cases were in the control group.CT scan were performed on all patients and the proximal femur geometry parameters were measured, including the neck width (NW), neck length (NL), neck shaft angle (NSA), femur head diameter (FHD), head height (HH) and Offset.Statistical analysis was performed between two groups.

The results of single factor analysis showed that age, sex, NL, FHD, NSA and Offset had significantly differences between two groups (P<0.05). The multipleLogistic regression analysis showed that age, sex, NL and NSA were independent risk factor for the hip fractures.The ROC curve analysis showed that area under curve (AUC) were 0.818, 0.818 and 0.725, respectively.

The patients with older age, longer NL and larger NSA might be prone to hip fracture and it was an effective and feasible method to reconstruct and measure the CT data of the proximal femur with Mimics software.

This study explored the preoperative prognostic factors of patients with glioblastoma multiforme (GBM) in order to propose a preoperative prognosis estimation model.

The clinical data of 416 patients diagnosed with GBM in Beijing Tiantan Hospital affiliated to Capital Medical University from 2008 to 2015 were retrospectively reviewed.A total of nine factors: gender, age, duration of symptoms, preoperative epilepsy, preoperative muscle weakness, preoperative headache, preoperative KPS score, tumor location and tumor diameter were enrolled in the survival analysis.The significant factors identified by Kaplan-Meier plot were further collected in the multivariate Cox regression analysis.On the basis of multivariate analysis results, a preoperative prognosis estimation model was founded.

Univariate analysis showed that Age ≥50 years, without preoperative epilepsy, tumor located in non-frontotemporal lobe, tumor diameter ≥6 cm and preoperative KPS score <70 were prognostic risk factors ( P<0.05). Multivariate analysis revealed that Age ≥50 years, without preoperative epilepsy, tumor located in non-frontotemporal lobe were independent risk factors (P<0.05). The prognostic estimation model based on the independent risk factors divided the whole cohort into three subgroups with different survival (P<0.001).

The more risk factors, the higher score but poorer prognosis. Patients in the high-risk group had lower gross total resection degree but higher rate of postoperative complications, which suggested that aggressive resection was not suitable for high-risk patients.

To compare the difference of hearing loss after microvascular decompression for hemifacial spasm between control and experimental groups, and to explore the possible causes.

A retrospective analysis including 443 patients was performed, including 203 cases of group A (before the operation was improved) and 240 cases of group B (after the operation was improved). Chi-square test was used to compare the rate of hearing loss.

There were 18(8.9%) cases with postoperative hearing loss in group A, including 9 cases of conductive hearing loss and 9 cases of sensorineural hearing loss.While 2 cases of conductive hearing loss and 3 cases of sensorineural hearing loss occurred in group B. Conductive hearing loss and sensorineural hearing loss of two groups had the significant deference (P=0.015 and P=0.04).

The type of hearing loss after microvascular decompression for hemifacial spasm included conductive and sensorineural hearing loss.It could be reduced by early closing of the mastoid air chamber, avoiding continuous traction of the cerebellum, avoiding excessive irrigation and exhaust, and intraoperative auditory brainstem evoked potential monitoring.

To evaluate the feasibility, safety, and preliminary efficacy of percutaneous transcystic papilla balloon dilation for the common bile duct stones.

A total of 11 patients with the common bile duct stones without dilatation of the intrahepatic bile ducts treated with percutaneous transcystic papilla balloon dilation in multiple center from April 2013 to May 2015 were analyzed retrospectively.In these 11 patients, there were 3 males and 8 females.And the average age was 68(52-91) years old.All patients had no obviously dilated intrahepatic bile duct, 6 patients were not suitable for endoscopic treatment or surgery, 4 patients refused endoscopic or surgical treatment and 1 patient had a history of failed endoscopic treatment.The white blood cell count, CA19-9, total bilirubin, direct bilirubin, AST, ALT and serum amylase level were recorded before the procedure, 1 week, and 1 month later.Early complications, such as cholangitis, pancreatitis, hemorrhage, and perforation were evaluated.

Technical success was achieved in all the 11 cases.The level of CA19-9, total bilirubin and direct bilirubin decreased significantly 1 week and 1 month after the procedure.One patient suffered from biliary tract infection.No severe complications, such as perforation of biliary or gastrointestinal tract, occurred during the follow up.Common bile duct stone recurred in 1 patient 2 years after the procedure.

For cases who are not suitable for endoscopic treatment, surgery, or percutaneous transhepatic approach to treat the common bile duct stones, percutaneous transcystic papilla dilation is technically feasible and safe, and seems to be an appropriate alternative strategy.

To assess the feasibility and safety of the irradiation stent system in portal vein on normal beagles.

A portal vein irradiation stent system was composed of an Iodine-125 seeds-carrier and a conventional stent.Twenty beagle dogs were randomly assigned to receive treatment with a conventional stent (5 beagle dogs) or an irradiation stent system (15 beagle dogs in three groups received 11.1, 22.2, 33.3 MBq radioactivity, n=5 in each dose group). Follow-up methods included blood biochemical test, color Doppler sonographyand CT scan at 0, 15, 30, 60, and 120 days after implantation of irradiation stent system.Pathological tissues were obtained from sacrificed beagle dogs on the 120th day.

The portal vein irradiation stent systems and the conventional stents were successfully deployed into the targeted portal vein segment in all beagles, none was dislodged during the deployment or the follow-up period.Differences of blood biochemical indexes and portal vein flow volume measured by color Doppler sonography were not significant (P>0.05). Stent systems were morphologically intact and patent.None of the peripheral organs had hemorrhage, necrosis or perforation.Pathological tissues revealed that the systems were surrounded by fibrous tissues and a few inflammatory cells, but with no significant differences in all groups.

It indicates that portal veinirradiation stent system is safe in all dose groups, and it is feasible to design a special irradiation stent system for each patient according to the size of the portal vein tumor thrombus.

To investigate the effect of DNA dependent protein kinase catalytic subunit (DNA-PKcs) on glioma proliferation, invasion and temozolomide sensitivity, and also to explore the potential mechanisms.

Human glioma cell lines H4 and U87 were chosen to carry out RNA interference transfection, and then divided into negative control group (blank group) and siRNA group (test group). The knockdown efficacy of DNA-PKcs siRNA was tested by quantitative PCR and Western blot. The MTS assay and Transwell assay were used to investigate the effect of DNA-PKcs knockdown on glioma cell growth and invasion, respectively. We also used MTS assay to investigate the IC₅₀ value of temozolomide in negative control group and siRNA groups.

Compared with blank group, DNA-PKcs specific siRNA significantly downregulated both mRNA and protein level of DNA-PKcs. MTS assay results demonstrated that 72-hours proliferation of test group were only 52.48%, 54.70% (H4) and 52.98%, 50.45% (U87) of the blank group′s counterpart. Transwell assay results showed that the invasiveness abilities of blank and test groups were 1.00±0.03, 0.41±0.05, 0.39±0.04 (H4) and 1.00±0.02, 0.28±0.04, 0.27±0.04 (U87). Moreover, knockdown of DNA-PKcs significantly decreased the temozolomide IC₅₀ value (H4: 249±27, 97±39, 88±35; U87: 485±41, 86±49, 73±38). Further we applied the Western blot to reveal the mechanism of inhibitory effect of DNA-PKcs knockdown on glioma malignancies and temozolomide sensitivity. We found that downregulation of DNA-PKcs reduced the activity of AKT signal and the expression of its downstream effectors, such as c-Myc, MMP9, and Survivin.

RNA interference targeting DNA-PKcs could inhibit glioma malignancies and enhance temozolomide sensitivity. The inhibitory effect of DNA-PKcs knockdown on those biological activities were mainly through inhibition of AKT signal and its downstream effectors.

The patient was a 45-year-old female. He was admitted to hospital in August 2016 with paroxysmal headache for more than 1 month as the main complaint. One month ago, the patient developed paroxysmal headache without obvious trigger, which was dull pain. One week ago, the pain worsened, and I went to a local hospital. CT of the head showed a space-occupying lesion at the top of the left forehead. I came to the First Affiliated Hospital of Zhengzhou University for further diagnosis and treatment. Physical examination: There was no obvious abnormality in nerve reflex, and the muscle strength was normal. Brain MRI: Plain scan showed that the space-occupying lesions at the left frontal top were found in T₁Mixed slightly lower signal on WI (FIG. 1A), at T₂There was mixed high signal on WI, with thick vascular flow empty signal shadows around it, and small patches of higher signal necrosis areas inside it (FIG. 1B), DWI high b value (b =1 000 s/mm²) showed a slightly higher signal (Figure 1C), the lesion showed uneven and obvious enhancement on enhancement scan, and the dura mater immediately adjacent to the lesion was compressed and showed linear enhancement (Figure 1D), the lesion pushes the surrounding brain parenchyma. CT of the brain showed a mixed isodensity mass at the top of the left forehead, with a maximum cross-sectional diameter of about 8.0 cm ×5.9 cm, and multiple calcified high-density shadows, with a CT value of 460 HU (Figure 1E，Figure 1F), the boundary of the mass is clear, the bone of the adjacent skull is destroyed, and a ring-shaped bone-like density shadow can be seen around the mass. Surgical and pathological findings: The left frontal and roof space-occupying lesion was resected under general anesthesia. During the operation, it was seen that the tumor had eroded part of the skull to the whole thickness subcutaneously. The tumor was located outside the dura, gray-red, soft in texture and rich in blood supply. The tumor and its attached dura were removed in blocks. Immunohistochemistry: Cytokeratin (CK), epithelial membrane antigen (EMA), glial fibrillary acidic protein (GFAP), S-100 protein, B lymphocytoma gene (Bcl-2), signaling and transcriptional activator (STAT6), smooth muscle actin (SMA), CD117, DOG-1, oligo-2, PR, CD99 negative, cell proliferation index (Ki-67) (about 20%), Vimentin, CD31, CD34, ERG, F-VIII positive. The pathological diagnosis was: epithelioid hemangioendothelioma (Figure 2)。

repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuroelectrophysiological technique developed on the basis of transcranial magnetic stimulation (TMS). Because of its non-invasive, safe and simple operation, it is widely used in the research and treatment of depression, schizophrenia, Parkinson's disease, epilepsy and other mental and neurological diseases. The research status of rTMS in the treatment of depression in recent years is reviewed.

long QT syndrome (LQTS) is a group of clinical syndromes caused by the reduction of the number of functional potassium ion channels on the cell membrane, which causes the abnormal repolarization of action potential stage III due to the weakening of IKr. There are many reasons for LQTS caused by weakening IKr, mainly including two categories: one is acquired long QT syndrome (aLQTS), which causes aLQTS: electrolyte disorder, hypoxia and different drugs blocking HERG potassium channels. In the past, many approved marketed drugs have been eliminated or their application has been restricted due to the risk of TdP caused by aLQTS, such as probucol, terfenadine, astemizole, etc. This not only greatly increases the cost of drug development, but also increases the risk and burden of serious adverse reactions for patients^[1]； The other type is hereditary long QT syndrome (hLQTS), which is mostly caused by gene mutations. It has been confirmed that most HERG gene mutations mainly affect the protein transport process, and some aLQTS can also cause LQTS due to abnormal HERG potassium channel transport. Therefore, the research on abnormal HERG potassium channel transport has attracted more and more attention.

The pathophysiological basis of hypoxia is diffuse alveolar infiltration, and the causes of hypoxia are diverse, including right-to-left shunt, disproportionate ventilatory blood flow, and diffusion disorders. Right-to-left shunt includes intracardiac shunt and intrapulmonary shunt^[1]。 Intracardiac right-to-left shunt is mainly patent foramen Ovale (PFO)^[2]。 Intrapulmonary shunt includes anatomical shunt and functional shunt, which in turn includes physiological anatomical shunt and open arteriovenous short circuits and dilated capillaries under pathological conditions. Functional shunt mainly refers to capillary shunt and shunt-like effects. Whether it is intracardiac shunt or intrapulmonary shunt, after insufficiently oxygenated blood enters the left heart, it will lead to hypoxemia, and hypoxemia itself will promote the formation and progression of intracardiac shunt and intrapulmonary shunt; On the contrary, right-to-left shunt will aggravate hypoxemia, and the two interact and promote each other^[3]Forming a vicious circle. It can be seen that assessing the presence of shunt in patients is crucial to the overall condition assessment and prognosis of patients. Critical ultrasound technology, due to its non-invasive, safe and convenient, is widely used in the evaluation of critically ill patients. Combined cardiopulmonary ultrasound can be used for rapid differential diagnosis of hypoxemia^[4], combined with saline microbubble angiography experiments, can help assess the presence of shunt in patients^[5]。