Volume 98  ·  Issue 20  ·  2018

Pituitary adenomas are common benign tumors in the cranium, most of which show the expansive growth characteristics of benign tumors, and most of them can be cured by surgery or drugs. However, a small number of pituitary adenomas are insensitive to conventional surgery, radiotherapy and drug therapy, and the tumor continues to grow in size. This part of the tumor is called refractory pituitary adenoma^[1,2]。 Further subarachnoid metastasis or distant metastasis is pituitary adenocarcinoma^[3]。 Whether it is refractory pituitary adenoma or pituitary adenocarcinoma, its diagnosis and treatment are very difficult. The tumor seriously affects the quality of life of patients, even threatens life, and the prognosis is extremely poor. In January 2018, the European Endocrinology Society issued the Guidelines for the Diagnosis and Treatment of Refractory Pituitary Adenomas and Pituitary Adenocarcinoma (hereinafter referred to as the Guidelines)^[4], aiming to provide standardized clinical guidance for the diagnosis, treatment and follow-up of refractory pituitary adenomas and pituitary adenocarcinomas. Summarize the important recommendations provided in the guidelines, including: (1) the diagnosis and treatment of patients with refractory pituitary adenoma and pituitary adenocarcinoma should be the responsibility of multidisciplinary collaborative (MDT) multidisciplinary teams; (2) tumor specimens need histopathological analysis, including pituitary hormones and proliferation markers, and if necessary, staining for transcription factors for correct tumor classification; (3) Temozolomide monotherapy is the first-line treatment for refractory pituitary adenoma and pituitary adenocarcinoma; The efficacy can be evaluated after 3 cycles; (4) In patients with temozolomide sensitivity, continuous treatment is recommended for at least 6 months. In addition, the guidelines provide detailed treatment recommendations for patients who relapse after temozolomide treatment, patients who are insensitive to temozolomide, and patients with systemic metastases. The interpretation and comments of the guide in this article are as follows.

Sleep apnea hypopnea syndrome (SAHS) is a common and chronic disease. In recent years, many new understandings have emerged about SAHS in the elderly, which has important guiding value for the clinical management of this type of patients^[1,2]。 First of all, sleep dyspnea in the elderly has many characteristics different from young and middle-aged patients in etiology and clinical manifestations, and its identification and clinical diagnosis and treatment are special. Secondly, does sleep breathing disorders in the elderly lead to a series of serious clinical consequences like young and middle-aged patients? Do they all require active treatment? These are uncertain. Thirdly, the occurrence of sleep breathing disorder is closely related to the life process of aging. So is sleep breathing disorder in elderly patients a continuation of the disease of young patients, or is it an independent, age-related life phenomenon? The understanding of these problems is briefly explained below.

Evidence-based practice guidelines are guiding recommendations (recommendations) based on a systematic review (body of evidence) and balancing the pros and cons of different interventions to provide the best health care for patients. In view of its importance in clinical decision-making and wide application, the formulation of guidelines has become a hot topic in medical circles at home and abroad. World Health Organization (WHO)^[1]International Guide Alliance (G-I-N)^[2]National Institute for Clinical Optimization (NICE)^[3]Rules and Guidelines Research and Evaluation Tools for the Development of Guidelines have been published (Appraisal of Guidelines Research and Evaluation in Europe, AGREE) Ⅱ^[4]Evaluate the published guidelines to recommend good quality guidelines for clinical use.

In the past 20 years, both physicians and patients have recognized the importance of clinical practice guidelines, so the number of guidelines has increased year by year. From 1993 to 2016, a total of 664 guideline articles were published in domestic medical journals, but most of them were consensus of experts, and there were few evidence-based guidelines based on systematic reviews; The average number of references for domestic guidelines is 36, compared to 400 for international guidelines; Conflict of interest is a serious problem, with 88% of guidelines having no conflict of interest statements^[1]So the quality of domestic guidelines is generally low. Moreover, there are multiple guidelines for the same problem, and the recommendations of multiple guidelines may be different, so doctors don't know how to choose. Therefore, it is very important to establish an evaluation system for the quality of guidelines, which helps clinicians to choose high-quality guidelines to guide clinical practice, and also helps guidelines formulators to formulate guidelines in a standardized way.

Health economics evidence during guideline development^[21,22]Is advocating for reporting. From the current situation, there is still a lack of health economics research results on TUPKP itself and comparison of TUPKP with other surgical treatments; At the same time, there is a lack of real RCT or high-quality RCT between laser surgery such as DiLEP. Therefore, future research in this area is needed. Furthermore, the current state advocates the localization of recommended diagnosis and treatment equipment^[23]At present, there is still a lack of evidence on the efficacy and safety of domestic TUPKP equipment in the treatment of BPH and comparison with imported TUPKP equipment in the treatment of BPH. This is also the research direction that needs to be carried out in the future. Third, the current evidence results from domestic and foreign populations suggest that TUPKP in the treatment of BPH is particularly relevant to the clinical experience of physicians. The more clinically experienced physicians will have better results with TUPKP. Although our country has been doing fruitful work in the training of physician skills, there is still a lack of relevant research results reports on the physician population in our country. Fourthly, patient values/preferences are one of the three elements of evidence-based decision-making. The development of this guideline did not conduct a survey of patient values/preferences. Next, the team developing this guideline will conduct a survey of preferences and values of patients who have undergone TUPKP surgery to prepare for the update of this guideline. Fifth, for the high cardiovascular risk/elderly population, there is currently a lack of research on comparing TUPKP with other surgical treatments; There is still a lack of relevant research on people taking anticoagulants, which is also a work that needs to be carried out in the future.

The 2017 edition of the World Health Organization (WHO) pituitary tumor classification has been released recently^[1]In addition to the typing supplement of pituitary adenoma by emphasizing the mechanism of pituitary differentiation, the most important point is the abolition of "atypical pituitary adenoma" (APA) and the proposal of "refractory pituitary adenoma" (refractory pituitary adenoma). At present, there is no clear definition at home and abroad for the incidence, diagnostic criteria, treatment methods and follow-up of refractory pituitary adenoma and pituitary adenocarcinoma. The European Journal of Endocrinology published the Guidelines for the Diagnosis and Treatment of Refractory Pituitary Adenomas and Pituitary Adenocarcinomas of the European Endocrinology Association in Issue 1, 2018^[2]The aim is to provide clinical guidelines for the diagnosis and treatment of clinically refractory pituitary adenoma and pituitary adenocarcinoma.

To explore the diagnostic value of cardiopulmonary coupling analysis in the screening of obstructive sleep apnea (OSA).

A total of 44 participants with sleep disorders from Sleep Medicine Center of West China Hospital in May 2016 were included in the study. All participants were monitored with cardiopulmonary coupling while undergoing polysomnography (PSG). The sleep parameters detected by cardiopulmonary coupling and PSG were compared and the correlation between respiratory disturbance index (RDI) of cardiopulmonary coupling and sleep parameters of PSG were analyzed. Using PSG as "golden standard" , the sensitivity, specificity, positive predictive value, negative predictive value and the corresponding areas under the receiver operating characteristic (ROC) curves were calculated for cardiopulmonary coupling.

There were 44 participants included in the study (37 males and 7 females) with a mean age of (46.3±12.5) years old and a mean body mass index of (25.6±3.7) kg/m². And there were 33 subjects diagnosed with OSA. There were no significant difference between respiratory disturbance index (RDI) derived from cardiopulmonary coupling and apnea-hypopnea index (AHI) derived from PSG. Correlation analysis showed that the RDI, low frequency coupling monitored by cardiopulmonary coupling was positively correlated with AHI detected by PSG (r=0.849, 0.850, both P<0.001); and the high frequency coupling was significantly negatively correlated with AHI (r=-0.767, P<0.001). For AHI ≥5/h, ≥10/h, ≥15/h, ≥20/h and ≥30/h respectively according to PSG, sensitivity was 0.82, 0.93, 0.96, 0.96, 0.77, specificity was 0.50, 0.75 0.72, 0.80, 0.86, positive predictive value was 0.85, 0.87, 0.83, 0.85, 0.85, negative predictive value was 0.55, 0.86, 0.93, 0.94, 0.79 for cardiopulmonary coupling. The corresponding areas under the ROC curves were 0.868, 0.892, 0.915, 0.942, 0.921 respectively. In addition, when the RDI derived from CPC was higher than 20.4/h, the patients were more likely suffering from OSA, and the sensitivity was 0.79 and the specificity was 0.91.

The results of cardiopulmonary coupling are consistent with simultaneous PSG parameters. Cardiopulmonary coupling has a highly diagnostic value for sleep respiratory disorder.

To investigate the effects of continuous positive airway pressure (CPAP) on periodic limb movements during sleep (PLMS) in patients with obstructive sleep apnea (OSA).

The polysomnography (PSG) data of 828 consecutive OSA outpatients from January 2015 to January 2017 who had undergone overnight CPAP titration were analyzed retrospectively. On the basis of changes in periodic limb movements index (PLMI) values (cut off level≥15/h) from baseline PSG (BPSG) to CPAP titration PSG, patients were assigned to one of the following four groups: persistent, CPAP-emergent, CPAP-disappeared, and non-PLMS.

Among 828 patients, 756 (91.3%) were male and 72 (8.7%) were female. The mean age was (45.7±10.7) years old, the mean body mass index (BMI) was (27.6±3.5) kg/m². The rate of patients was 3.9% in the persistent group, 10.3% in the CPAP-emergent group, 7.5% in the CPAP-disappearance group, and 78.4% in the non-PLMS group. Multivariate Logistic regression analysis revealed that female appeared to be associated with the persistent group (P=0.004); older age and higher apnea-hypopnea index (AHI) on BPSG appeared to be associated with the CPAP-emergent group (P=0.012, 0.030). On the other hand, older age was negatively associated with the non-PLMS group (P=0.006).

Elderly patients with higher AHI at BPSG may present with CPAP-emergent PLMS.

To evaluate the clinical value of three questionnaires [Sleep Apnea Clinical Score (SACS), Berlin Questionnaire (BQ), and Epworth Sleepiness Scale (ESS)] in screening obstructive sleep apnea (OSA) in patients with chronic obstructive pulmonary disease (COPD).

A total of 198 patients with COPD were assessed the likelihood of OSA by using the SACS, BQ, ESS, which was confirmed by the overnight polysomnography (PSG). The receiver operating characteristic curve (ROC) and the calculated likelihood ratios were used to compare the values of three scoring systems in predicting OSA in COPD patients.

The patients had an average age of (65.5±9.3) years and 92.9% (184 cases) of which were male, 14 cases (7.1%) were female; 27 cases (13.6%) had a high probability of OSA by SACS assessment, 61 cases (30.8%) had a high probability screened by BQ, and 72 (36.4%) had OSA high probability by ESS. The diagnosis of OSA in 75 patients (37.9%) were confirmed by PSG. OSA did not be accurately predicted by ESS screening in patients with COPD, with a ROC curve area under the curve of 0.592 (95% CI: 0.509-0.674, P=0.053). BQ had an area under the ROC curve of 0.706 (95% CI: 0.626-0.779, P<0.001). However, the prediction of SACS was much better, with an area under the ROC curve of 0.810 (95%CI: 0.737-0.871, P<0.001).

SACS is superior to BQ and ESS in predicting OSA in this group of patients with COPD.

To investigate the treatment acceptance in patients with obstructive sleep apnea (OSA) and its influence factors.

This cross-sectional survey recruited OSA patients diagnosed at sleep center in Guangdong General Hospital from January 2014 to December 2015. By phone follow-up, a pre-designed questionnaire was performed for all adults, which composed of the following sections: treatment or none, treatment method, reason for non-treatment, revisit or none.

From 524 OSA patients with completed contact information, 480 (91.6%) valid questionnaires were collected. The apnea hypopnea index was (36.1±21.4) /h. The mild, moderate, severe OSA patients accounted for 12.5%(60 cases), 33.1%(159 cases), 54.4%(261 cases) respectively. For all 480 included subjects, 200 (41.7%) received treatment and among them 184 (92.0%) were treated by continuous positive airway pressure. The treatment rate was lower in mild OSA, non-obesity, female, and patients without daytime sleepiness. Receiving treatment was negative correlated to difficult falling asleep. The first reason of non-treatment was self-determined behavioral intervention and the second was self-concept of no requirement for treatment. The specialist revisit rate was 3.8%, which was slightly higher in treated patients and those with sudden awakening when feeling asphyxia.

A majority of OSA patients do not receive treatment, primarily as a result of their self-determined behavior intervention and self-concept of no requirement for treatment.

Using clinical "big data" , to investigate the factors that affect the levels of thyroid hormones, and to explore the partitioning criteria for reference intervals (RI) of these hormones.

An observation study was conducted. Information of 107 107 individuals undergoing routine physical examination in Peking Union Medical College Hospital from September 1^st, 2013 to August 31^st, 2016 was collected, thyroid hormone of these subjects were detected. To explore the test results distribution and differences of TSH, FT4 and FT3 by gender and age; according to the seasonal division standard of China Meteorological Administration, the study period was divided into four seasons, and the seasonal fluctuation on TSH was analyzed.To define the appropriate partition by gender, age and season according to significant difference analysis.

In male and female, the distributions of TSH were 1.779(0.578-4.758), 2.023(0.420-5.343)mU/L, respectively, and the level of TSH in female was higher than in male (Z=-37.600, P<0.001). The distributions of FT4 were 0.127(0.098-0.162), 0.117(0.091-0.151) μg/L, the distributions of FT3 were 3.33(2.47-3.74), 3.01(2.35-3.57)ng/L. And the level of FT4, FT3 in female were significantly lower than in male (Z=-94.000, -154.600, all P<0.001). Furthermore, males were divided into two groups by 65 years old and female were divided by 50 years old, respectively, and the distributions of TSH in male and female of older group were 1.818(0.528-5.240), 2.111(0.348-5.735)mU/L, in younger group were 1.778(0.582-4.696), 1.991(0.427-5.316)mU/L. The level of TSH in older group was significantly higher than in younger group (Z=-2.269, -10.400, all P<0.05), and the distribution of TSH in older group was much wider than in younger. The distribution of whole in spring, summer and autumn was 1.869( 0.510-5.042)mU/L, in winter was 1.978(0.527-5.250) mU/L, and the difference between them had statistical significance (Z=-15.000, P<0.001).

Gender and age significantly affect the serum levels of TSH, FT4, and FT3, the distribution of TSH in female and elder group are wider than in male, and that of FT4, FT3 are lower.Seasons significantly affect the serum TSH level, the peak value is observed in winter. There are obviously differences between "rough" RIs and manufacture recommended RIs. Each laboratory should establish reference intervals for thyroid hormones on the premise of appropriate grouping.

To compare and analyze the clinical characteristics and laboratory parameters of central nervous system (CNS) infection caused by different Gram-stained bacteria after craniocerebral surgery, and to provide a preliminary basis for early anti-infection treatment to reduce the use of extended-spectrum antibiotics and the generation of resistant strains.

A single center retrospective study was conducted to investigate the clinical data of patients with intracranial infection after craniocerebral surgery from January 2012 to December 2016 in PLA general hospital. The general conditions, clinical features, laboratory parameters, antibiotic treatments and prognosis were analyzed.

A toal of 813 cases of CNS infection after craniocerebral surgery were found during the 5-year period, with an incidence rate of 5.43% (813/14 986). The positive rate of cerebrospinal fluid (CSF)culture was 9.72% (79/813). According to the criteria, 71 cases were included in the study. Among all the cases, 64.8% (46/71) of which were Gram-positive bacteria (G⁺ ) and 35.2% (25/71) were identified as Gram-negative bacteria (G^-). The duration between surgery and meningitis events, as well as the period of antibiotic treatment for G⁺ bacteria group were 5.0 (4.0, 6.0) days and (18.3±6.8) days, which were shorter than those of the G^- bacteria group 9.0(7.0, 11.0) days and (29.2±9.9) days (Z=-6.184, t=-5.245, both P<0.01) , and the differences were statistically significant. The serum procalcitonin concentration in the G⁺ group was lower than that in G^- group [1.02(0.83, 1.27)μg/L vs 2.68(1.97, 5.07)μg/L,Z=-5.719, P<0.01]. The cerebrospinal fluid glucose content was higher than that of G^- bacteria group[(2.13±1.30) mmol/L vs (1.09±0.95) mmol/L, t=3.512, P<0.01]. The protein level was lower than that of G^- bacteria group [(1 615.93±848.83) mg/L vs (2 480.60±1 105.28) mg/L, t=-3.679, P<0.01]. Serum C-reactive protein concentrations in the two groups did not show any statistical significance [(96.2±46.1) mg/L vs (117.8±46.3) mg/L,t=-1.884, P>0.05]. In addition, the mortality rate of the G^- bacteria group was 16.0% (4/25), and 0 in G⁺ bacteria group.

The time of onset of intracranial infection, serum PCT concentration, and cerebrospinal fluid glucose and protein content caused by Gram-positive bacteria and Gram-negative bacteria are found to be significantly different, and these findings could serve as a preliminary guide for the selection of antibiotics in early experiential anti-infective treatments without the etiology report.

To analyze clinical feature and treatment outcome of patients with primary diffuse large B cell lymphoma(DLBCL) in reproductive system.

A total of 26 patients with DLBCL in reproductive system were retrospectively analyzed, and the clinical features, laboratory data were included in Kaplan-Meier and prognostic analysis.

In our center, the incidence of primary diffuse large B cell lymphoma in reproductive system was 3.5% in all DLBCL patients, and the median age was 62.0 years. Male are more common with unilateral testicular involvement, and 38.5% patients belong to Ⅲ and Ⅳstage while 84.6% patients belong to non-germinal center B cell-like subgroup. The overall response rate(ORR) for the whole group was 88.5%. The complete response rate was 76.9%. The 3, 5-year progression free survival rate was 70.5% and 62.7% , and the 3, 5-year overall survival rate was 83.5% and 69.6%, respectively. The most common recurrent sites were contralateral testis and central nervous system. Rituximab can improve the survival of patients and combined with contralateral irradiation can furtherly improve progression free survival of patients(P=0.047). Clinical stage, B symptom, IPI, the level of LDH, and CRP, age>60 years, and initial treatment outcome were predictive of overall survival.

Primary diffuse large B cell lymphoma in reproductive system is a rare type of extranodal DLBCL which occurs in older men with aggressive features. The most common sites of recurrence were contralateral testis and central nervous system. Surgery, rituximab , radiotherapy and prophylactic intrathecal injection can improve the survival of patients and may be the first-line treatment.

To investigate the clinical features and management of male patients with adult-onset idiopathic hypogonadotropic hypogonadism (AIHH).

Clinical features and treatment of six patients with AIHH between January 2010 and June 2017 were retrospectively reviewed.

The patients were all male, with an age of 26 (20-35) years old and they experienced complete pubertal development. The main complaints were decreased libido, erectile dysfunction and gynecomastia. Physical examination found that the testicular size was 15 (12-20) ml and they were fully virilized. The serum luteinizing hormone (LH), follicle-stimulating hormone (FSH) and total testosterone was 0.1 (0.1-0.8) U/L, 0.4 (0.1-0.9) U/L and 0.62 (0.10-0.90) nmol/L, respectively. Pituitary MRI and other pituitary hormones were all normal. Testosterone was administrated to three patients and the libido and erectile function returned to normal. Sperm was successfully induced in two patients after combined gonadotropin therapy for 4-6 months. One patient had a reversed hypothalamus-pituitary-testis axis function.

The mechanism of male AIHH is unknown. Compared to those with congenital hypogonadotropic hypogonadism, patients with AIHH may achieve better spermatogenesis after gonadotropin therapy. Small portion of patients may have a reversal of hypothalamus-pituitary-testis axis function.

To evaluated early clinical outcomes of saphenous vein grafts harvested with a No-touch technique in off-pump coronary artery bypass graft (OPCABG) surgery.

A total of 124 patients with three-vessel disease undergoing OPCABG by No-touch technique between June and November 2017 in Beijing An Zhen Hospital were respectively reviewed.

The average age of patients was (60.7±10.3) years, and 80 cases (64.5%) were male, with the average body mass index (BMI)of (25.4±2.5) kg/m^2, the mean preoperative left ventricular ejection fraction (LVEF) of (58.0±7.0%). The operative time was (4.0±0.4) hours, and 16 cases (12.9%) were harvested for whole vein grafts. The number of vein grafts and venous anastomoses was 144 and 284, respectively. There were 16 cases of single bridge NTSVG-LAD, 4 cases of single bridge NTSVG-D, 99 cases of sequential bridge NTSVG-OM-PDA, 5 cases of sequential bridge NTSVG-OM-PLV, 4 cases of sequential bridge NTSVG-OM-RCA, 16 cases of sequential bridge NTSVG-D-OM-PDA. The mean flow volume of No-touch vein grafts was (51.9±2.4) ml/min. There was no death case in hospital. Postoperative re-exploration for hemorrhage of anastomosis happened in 1 case (0.8%), which was caused by pericardial tamponade due to insufficiency of hemostasis in internal mammary bed. There were 1 case of bad wound healing of lower extremity incision (0.8%). A total of 124 cases were followed up after operation, and the follow-up rate was 100%. There was one all-cause death (0.8%) 27 days after the operation.

The short-term clinical observation of the application of No-touch great saphenous vein harvesting technique for OPCABG is safe and effective.

To compare the clinical data, esophageal motility and reflux characteristic in patients with non-erosive reflux disease (NERD) and reflux esophagitis (RE).

A total of 167 patients of NERD were enrolled in the study[60 males, 107 females, mean age(44.1±13.4) years old], and 151 patients of RE were enrolled [74 males, 77 females, mean age(46.5±9.9) years old]. All patients were surveyed by questionnaires to investigate the clinical data. All patients accepted the esophageal highresolution manometry and 24 hours pH+ impedance monitoring to investigate the esophageal motility and reflux characteristic.

The proportion of female patients in group NERD was significantly higher than that in group RE(60/107 vs 74/77, P=0.049). The reflux symptom scores and the proportion of reflux in group NERD were significantly lower than those in group RE[(4.5±2.4) vs (5.6±2.1), 44.91% vs 64.24%, P<0.05). The Demeester score of group NERD was significantly lower than that of group RE[12.54(1.60, 10.80) vs 17.31(3.40, 16.64),P=0.044]. The proportion of Demeester scores positive patients in group NERD was significantly lower than that in group RE(15.1% vs 23.8%, P=0.018). The number of acid reflux in group NERD was significantly lower than that in group RE[17.49(3.00, 22.22) vs 21.69(4.00, 30.00), P=0.042].

There are more female patients in group NERD. The reflux symptoms of the group NERD are less serious than those of group RE.RE patients have more acid reflux events. There is no significant difference in the esophageal motility between the two groups.

To investigate the expression and clinical significance of KIAA1199 in primary hepatocellular carcinoma.

A total of 136 cases of primary hepatocellular carcinoma tissues and paired adjacent tissues were collected. Immunohistochemistry and Western blot were used to detect the expression of KIAA1199 in primary hepatocellular carcinoma tissues and paired adjacent tissues. The relationship between KIAA1199 and clinicopathological parameter of primary hepatocellular carcinoma was analyzed.

The positive rate of KIAA1199 in primary hepatocellular carcinoma was 82.3% (112/136), which was higher than that in paired para-cancerous tissues (14.7%, 20/136). High expression of KIAA1199 was significantly correlated with age, cirrhosis history, tumor size, tumor number, degree of differentiation, TNM staging and microvenous invasion (MVI) (P<0.05), but without gender, drinking alcohol hobby, hepatitis history, family genetic history, tumor location (P>0.05). The Kaplan-Meier survival curves indicated that high KIAA1199 expression was associated with poor survival (P<0.01). In addition, Cox proportional hazards model showed that the expression of KIAA1199 was related to age, cirrhosis history, tumor size, tumor number, degree of differentiation, TNM staging and MVI (P<0.05).

The expression of KIAA1199 is up-regulated in primary hepatocellular carcinoma, which is significantly correlated with the clinicopathological features and prognosis, high expression of KIAA1199 increased the risk of death in patients with primary hepatocellular carcinoma.

To explore the effect of radical TURBT combing with concomitant chemo-radiotherapy for muscle-invasive bladder cancer (MIBC).

From 2010 to 2015, 73 patients were diagnosed as MIBC, in which 28 patients (TMT Group) received tri-modality bladder sparing treatment, including 21 males and 7 females, mean age (68.9±8.9) yr. There were 16 cases of T₂, 12 cases of T₃. 45 patients (RC Group) received radical cystectomy (RC), including 32 males and 13 females, mean age (66.3±9.6) yr. There were 25 cases of T₂, 18 cases of T₃ and 2 cases of T_4a. The effect of two treatment modality and influence for patient′s life quality were retrospective analysis.

The overall survival (OS) rate of TMT group was 64.3%, cancer specific survival (CSS) rate was 78.6%. And the OS rate of RC group was 66.7%, CSS rate was 82.2%. There was no statistical difference between two groups. The life quality of TMT group was better than that of RC group.

In strict control of indication criterion, rigorous postoperative follow-up and timely salvage radical cystectomy, tri-modality therapy can be used as a new option of muscle-invasive bladder cancer.

To investigate the outcome of long-term asthma management of China-Japan Friendship Hospital.

A face-to-face, questionnaire-based survey was carried out in outpatient department in 30 general hospital (including China-Japan Friendship Hospital) from Oct 2015 to May 2016. Data of demographic characteristics, asthma control, asthma management, asthma attacks and self-management, disease perception was collected. Results from China-Japan Friendship Hospital were compared to the national mean level within the same period.

Altogether 150 asthmatic outpatients were recruited from China-Japan Friendship Hospital. Asthma control level was significantly higher than the national asthma control level[56.7% (85/150) vs 28.5% (1 099/3 854), P<0.001]. The rate of hospitalizations due to asthma exacerbations was significantly lower than the national hospitalization rate[13.3% (20/150) vs 26.4% (1 017/3 858),P<0.001]. The rate of peak flow meter (PFM) usage was significantly higher than the national PFM usage rate[50.7% (76/150) vs 10.1% (388/3 837),P<0.001]. For reasons of not using PFM, the proportion of doctors never introduced was lower than the national level[43.3% (65/150) vs 65.2% (2 518/3 860),P<0.001]. As to the choice of anti-asthmatics when symptoms deteriorated, the proportion of inhaled corticosteroid (ICS)+ formoterol was significantly higher than the national level[70.0% (105/150) vs 45.8% (1 776/3 875),P<0.001]. The proportion of the patients that had right perception on disease nature was significantly higher than the national level[78.7% (118/150) vs 69.0% (2 660/3 857),P=0.011]. The proportion of the patients that had right perception on medication choice on daily-used first-line medication for chronic asthma was significantly higher than the national level[70.7% (106/150) vs 60.2% (2 321/3 857), P=0.010].

The level of asthma control, disease management and disease perception in China-Japan Friendship Hospital are much higher than national level due to the conduction of long-term asthma management.

Children with limb bone tumors, pathological fractures and chronic osteomyelitis are increasing year by year. Intramedullary fixation of autologous fibula graft and bone defect filling are considered to be an ideal material and surgical method, and have been widely used in clinical practice; However, partial amputation of fibula may cause different degrees of movement pain of donor ankle joint, weakening of lower limb muscle strength, and even cause ankle deformity and dysfunction. Its long-term effects have been paid more and more attention^[1]。 In this study, 12 patients were surgically treated by modified periosteum-sparing fibula free graft, which is now reported below.

A 36-year-old female, primary school teacher, was admitted to the Department of Endocrinology of Peking Union Medical College Hospital on May 11, 2015 due to "face turning round and red for 4 years and menstrual disorder for 1 year". In May 2011, the patient's face became rounded and red, waist circumference increased, weight increased by 10 kg (44 kg to 54 kg) within one year without obvious inducement, accompanied by broad purple lines on the abdomen and inner thighs, vellus hair on the back, small beard on the lips, and ecchymosis easily appeared when the skin bumped. In February 2014, the patient developed menstrual disorders (menarche 12 years old, menstrual days 5-7 days, menstrual cycle 28-30 days), menstruation 1-2 days, low menstrual flow, and the cycle prolonged to 40-60 days. In April 2015, the patient visited the outpatient clinic of our hospital, and 24-hour urinary free cortisol (24-hour UFC) was checked at 2 677.09 nmol/24 h, and was admitted to our hospital for further diagnosis and treatment. Since the onset of the disease, the patient is mentally tired, his skin color is deeper than before, his diet is normal, his sleep is good, his defecation is normal, his weight has increased by 2.5 kg in the past 1 year, and his height has not become significantly shorter. There were no special findings in the remaining medical history.

The patient was admitted to the hospital on September 11, 2017, 16 hours after birth, because "the muscle tone of the limbs was increased for 16 hours". The child is the 3rd and 2nd birth, gestational age 39^＋5Zhou was delivered by vaginal delivery at 17:03 on 10 September 2017, with a birth weight of 3 450 g; Apgar score: 1 min score: 9 points (1 point deducted for crying), 5 min score: 10 points; Amniotic fluid is clear, the amount is normal, there is no umbilical cord around the neck, and there is no premature rupture of membranes; After birth, the child presented with persistent increased muscle tone of the limbs. The parents of the child are from Guizhou Province, both of Dong nationality, and they are not married by close relatives. The pregnant mother had a history of threatened abortion at 4 months of pregnancy, low risk of Down's syndrome screening, and no obvious abnormalities were found in fetal three-dimensional ultrasound; The father is in good health and has a history of smoking and drinking; The mother is in good health and has two marriage history. The first marriage has a healthy 7-year-old girl, and she had one induced abortion in 2016. The child is the first child of the mother after remarriage. Physical examination of the child: body temperature (T) 37 ℃, heart rate (P) 140 beats/min, breathing (R) 50 beats/min, blood pressure 74/38 mmHg (1 mmHg =0.133 kPa); Body mass 3 320 g, percutaneous oxygen saturation (SpO₂) 95%, head circumference 32.5 cm, body length 50 cm; Sleepiness, irritability, smooth breathing, rosy skin, normal head shape; A 3 cm ×5 cm mass can be palpable on the left top, with a clear boundary, does not cross the suture, and has a fluctuating feeling when touched; The anterior fontanel is flat and soft, about 0.5 cm ×0.5 cm in size; Facial appearance without deformity; There were no abnormalities in the heart, lungs, abdomen and external genitals. Increased muscle tone, rated as grade 4 according to the modified Ashworth classification (stiffness): hands clenched in fist shape, thumb adducted, index finger flexed tightly inside, upper limbs flexed against the chest, lower limbs rigid, and toes flexed in hook shape. The sucking reflex is weak, and the foraging and hugging reflexes are not elicited.

The latest data from the National Cancer Center show that China is a country with a high incidence of gastric cancer, and the morbidity and mortality rate rank second among all cancers^[1]The number of morbidities and deaths accounts for about 50% of the world's total. An epidemiological survey of more than 20,000 cases of gastric cancer shows that the 5-year survival rate (OS) of gastric cancer in China is only 27.4%^[2]While data from the SEER database in the United States show that the participation of postoperative adjuvant chemoradiotherapy prolongs the survival of patients with stage II to IV operable non-metastatic gastric cancer^[3]。 At present, the status of radiotherapy in the adjuvant treatment of gastric cancer in China is still controversial. Some domestic scholars believe that gastric cancer surgery in the United States has not generally reached the level of D2 radical resection, but the proportion of D2 radical resection in INT-0116 study, which established the status of adjuvant radiotherapy and chemotherapy after gastric cancer surgery, is 9.6%^[4]。 However, although D2 radical resection is recommended as the standard surgical procedure for local advanced gastric cancer in China, judging from many published articles, even in the best gastric cancer diagnosis and treatment centers in China, the proportion of actual acceptance of standard D2 radical resection in clinical practice is only about 50%. Therefore, it is very urgent to clarify the scientificity and necessity of adjuvant radiotherapy after radical gastrectomy in China.