Volume 99 ·  Issue 08 ·  2019

At the initial diagnosis, 5% to 10% of solid tumors are accompanied by thrombocytopenia, and the incidence of thrombocytopenia increases during the subsequent disease course and treatment, resulting in delayed treatment or even life-threatening. The mechanism of its occurrence is complex, involving many factors such as immune and non-immune. Early identification of the clinical pathophysiology of thrombocytopenia and improvement of clinical diagnosis rate can improve the chances of treatment and reduce mortality. This article comprehensively expounds the clinical characteristics of solid tumor-related thrombocytopenia in recent years, and broadens the idea of clinical diagnosis and treatment.

The concept of day surgery was first proposed by Scottish pediatric surgeon James Nicoll, and in 1995 the International Association of Day Surgery (IAAS) was established. In recent years, day surgery has developed rapidly by virtue of its own advantages, and has become a relatively mature surgical management mode. Pediatric day surgery has also received widespread attention and development in China.

acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is one of the most common acute and critical diseases in clinic. Chinese Journal of Internal Medicine, Chinese Journal of Medicine, Chinese Journal of Digestion, Chinese Journal of Digestive Endoscopy and the Digestive Endoscopy Branch of Chinese Medical Association organized experts from gastroenterology, digestive endoscopy, general surgery and acute and critical care medicine in Nanchang at the end of 2015 to conduct special discussions, and jointly formulated and promulgated the Guidelines for the Diagnosis and Treatment of acute Non-variceal upper gastrointestinal bleeding (2015, Nanchang)^[1]This guideline has played a very good guiding role in the clinical diagnosis and treatment of ANVUGIB in my country. In the past three years, with the rapid development of technology in various disciplines, there has been new understanding and progress in the diagnosis and treatment of ANVUGIB. Therefore, the Digestive Endoscopy Committee of Endoscopist Branch of Chinese Medical Doctors Association, together with Chinese Journal of Internal Medicine, Chinese Medical Journal, Chinese Journal of Digestion and Chinese Journal of Digestive Endoscopy, organized experts in related fields again in 2018. Combined with high-quality clinical evidence at home and abroad in recent years and reference to relevant guidelines, the guidelines promulgated in 2015 were revised as follows.

Hepatocellular carcinoma (hereinafter referred to as liver cancer) ranks 6th in the global incidence of malignant tumors. More than half of new cases and deaths of liver cancer every year occur in China^[1]。 The latest data from registered tumor areas in China show that the incidence of liver cancer ranks 4th among malignant tumors and the mortality ranks 3rd among malignant tumors^[2]。 With the development of modern medical science and technology, the treatment of liver cancer has made great progress. Because the clinical symptoms of early liver cancer are not obvious, 70% ~80% of patients have advanced disease at the time of consultation. At present, the overall prognosis of liver cancer treatment is still not ideal.

To explore the association of platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR) with protein energy wasting (PEW) in maintenance hemodialysis (MHD) patients.

A multicenter cross-sectional study was conducted in eleven hemodialysis centers of Guizhou province from June to August, 2017. Clinical data, physical parameters, body composition data and laboratory values of MHD patients were collected. PLR and NLR were calculated according to routine blood test. All patients were divided into four groups (Q1-Q4) according to the median and quartile of PLR and NLR. Multivariate logistic regression models were applied to analyze the relationships between PLR, NLR and PEW. The comparison of predictive power of PLR and NLR for PEW was evaluated by receiver operating characteristic curve (ROC).

A total of 936 MHD patients were enrolled (519 males, 417 females), with a mean age of (55.6±15.6) years. The prevalence of PEW was 46.2% (432/936). Multivariate logistic regression analysis showed that patients in group PLR Q3 and Q4 were 2.07 (95%CI: 1.03-4.13, P=0.014) and 2.73 (95%CI: 1.58-4.74, P<0.001) times more likely to have PEW, compared with those in group PLR Q1 in unadjusted models. PLR was significantly associated with the development of PEW after adjusting age, sex, history of hypertension, diabetes and hemoglobin. Patients in Group PLR Q3 and Q4 were 2.82 times (95%CI: 1.42-5.60, P=0.003) and 2.93 times (95%CI: 1.50-5.73, P=0.002) times more likely to have PEW than those in Group PLR Q1. The ROC showed that only PLR can predict the development of PEW with a diagnostic threshold of 144.09 [area under curve (AUC)=0.61, 95%CI: 0.56-0.66, P<0.001], with a sensitivity and specificity of 61% and 58%, respectively, while the AUC of NLR is 0.55 (P=0.091).

For MHD patients, only PLR could be a relevent factor of PEW and it showed the predictive power of PEW rather than NLR.

To compare the differences of brain functional damage of subtypes of patients with Cushing′s syndrome (CS).

A total of 11 adrenocorticotropic hormone (ACTH)-dependent CS patients and 29 ACTH-independent CS patients were recruited from Chinese PLA General Hospital between September 2015 and March 2017 with confirmed CS. The psychiatric scales and brain task functional magnetic resonance imaging (fMRI) were evaluated.

A total of 40 patients (34 females, 6 males) with a mean age of (39.20±12.10) years and a median education level of 12 (9, 16) years were enrolled. ACTH-dependent patients had significantly worse performance than the ACTH-independent patients in response to the depression evaluation (64.6±6.1 vs 56.2±12.8, P=0.008), positive emotion (17.8±4.2 vs 24.3±7.2, P=0.008) and CS life quality [31(29,33) vs 42(29,51), P=0.040]. In the reaction to positive target pictures, ACTH-dependent CS patients showed stronger activation in left superior temporal gyrus compared with patients in ACTH-independent group, while the activation degree of their bilateral dorsal anterior cingulate cortex, bilateralsuperior frontal gyrus and left middle frontal gyrus was much worse. In the reactions to negative target pictures, ACTH-dependent CS patients had weaker activation in bilateral cerebellum, left superior frontal gyrus, left middle frontal gyrus, left precuneus and right postcentral gyrus, compared with patients in the ACTH-independent CS group (P<0.01, AlphaSim corrected). The activation degree of some regions whose brain function was different between the two groups was correlated to the cortisol level, ACTH level, 24 h urinary free cortisol (UFC) level, depression evaluation and negative emotion assessment (all P<0.05).

The severity of the depression and the life quality of patients in ACTH-dependent group are worse than ACTH-independent CS patients. The brain function of ACTH-dependent CS patients is much weaker.

To evaluate the diagnosis of interferon gamma release assay (IGRA) combined with tumor marker carbohydrate antigen-125 (CA-125) in active pulmonary tuberculosis (PTB).

One hundred and three patients with active PTB (48 definite and 55 clinical diagnosed), 646 patients with non-PTB pulmonary disease and 60 normal controls hospitalized in Beijing Tongren Hospital, Capital Medical University between January 2014 and December 2016 were retrospectively investigated. Blood samples were collected to determine the IGRA and CA-125 level by enzyme-linked immunosorbent assay and electrochemiluminescence, respectively. The CA-125 level of patients with active PTB, non-PTB pulmonary disease and normal controls were compared. Subsequently, the best cut-off value of CA-125 for diagnosing PTB was calculated based on 60 active PTB cases and 60 normal controls. Methodological evaluation of IGRA, CA-125 and combination of these two tests (both positive) for active PTB diagnosing were performed based on 43 active PTB cases and all the non-PTB pulmonary disease cases.

The median values of CA-125 among definite and clinical diagnosis groups of active PTB were 55.00 (25.35, 156.90) U/ml and 81.50 (39.40, 138.00) U/ml, respectively. There was no difference between the two groups (U=1 093.00, P>0.05). And the CA-125 level of male and female PTB patients were also undifferentiated (U=1 124.00, P>0.05). There were statistically significant differences in CA-125 levels between the active PTB group and all other non-PTB groups (all P<0.001), including those who had ever closely contacted with TB patients. The area under the ROC curve constructed by CA-125 for diagnosing active PTB was 0.933. And the best cut-off value of CA-125 was 22.00 U/ml. Based on this cut-off value, the accuracy, sensitivity and specificity of CA-125 for diagnosing active PTB were 70.5% (486/689), 86.0% (37/43) and 69.5% (449/646). The accuracy, sensitivity and specificity of IGRA for diagnosing active PTB were 73.3% (480/689), 90.7% (39/43) and 68.3%(441/64). The accuracy, sensitivity and specificity of IGRA combined with CA-125 for diagnosing active PTB were 90.6% (624/689), 76.7% (33/43), 91.5% (591/646). Both of the accuracy and the false positive ratio of this combinational method (8.5%, 55/646) were significantly lower than two indexes individually used (χ²=94.461, 88.261, P<0.001). However, the false negative ratio was increased to 23.3% (10/43) by combinational method.

IGRA combined with CA-125 has a certain clinical value in diagnosis of active PTB, especially when the evidences of bacterial is not available.

To evaluate the efficacy and safety of rituximab combined with the modified NHL-BFM-90 protocol in childhood and adolescence with Burkitt′s lymphoma (BL).

A retrospective analysis of 67 untreated childhood and adolescence patients with BL was made. All patients were treated with the modified NHL-BFM-90 protocol with or without rituximab.

The 64 patients (95.52%) achieved complete remission (CR), 3 patients (4.48%) partial remission (PR), and the overall response rate (CR+PR) was 100%. 67 patients were followed up for a median of 44 (3-89) months. The 3 and 5-year overall survival (OS) were 92.54% and 88.98%, respectively. The 3 and 5-year progression-free survival (PFS) were all 90.34%. The 5-year OS were 100%,91.7% and 80.0% in low risk, moderate risk and high risk group, respectively, and the difference was statistically significant (P=0.048). Of the 67 patients, 55 patients (82.09%) were treated with rituximab plus chemotherapy. Compared with the 5-year OS and PFS of 74.3% and 78.6% in the chemotherapy group, the 5-year OS and PFS in the rituximab plus chemotherapy group were 95.2% and 95.5%, respectively, and the difference was statistically significant (P value was 0.021, and 0.036, respectively). Major toxicity was myelosuppression and mucositis. No treatment related death was found.

Rituximab combined with the modified NHL-BFM-90 protocol was highly effective for children and adolescents with BL, and significantly improved long-term survival.

To investigate the correlation between the proportion of CTL and Th1 cells in peripheral blood of liver transplant recipients and the success of hepatitis B vaccination.

The subjects of this study were liver transplantation recipients with chronic HBV-related liver diseases in Organ transplantation institute of the third medical center of PLA general hospital. Subjects were randomly divided into two groups for prospective study. In the rapid group, one dose of 40 μg hepatitis B vaccine was administered at 0, 1, 2and 3 months, and one dose of 20 μg hepatitis B vaccine was administered at 4, 5 and 6 months. In the rapid-enhanced group, one dose of 40 μg hepatitis B vaccine was administered at 0, 1, 2 and 3 months, and one dose of 60 μg hepatitis B vaccine was administered at 4, 5 and 6months. Compare and analyze the success rate of inoculation, the titer of hepatitis B surface antibody (anti-HBs), the proportion of CTL cells in CD8 ⁺T cells and Th1 cells in CD4⁺T cells. Correlation analysis was performed for CTL and Th1 cells and anti-HBs, Observe the safety of vaccination.

The inoculation success rate, anti-HBs growth rate, CTL cell percentage increase and Th1 cell percentage increase in the rapid enhancement group were all higher than those in the rapid enhancement group, and the differences were statistically significant, they were 38.3% (23/60) vs 21.7% (13/60) (P=0.046), 91.3(72.5,124.2) vs 22.1(12.4, 31.6) (P=0.001), 1.4(0.8,1.9) vs 0.4(0.2,1.4) (P=0.001) and 7.4±2.6 vs 5.6±3.7 (P=0.001) respectively. The percentage increase of CTL cells and Th1 cells in the successful group was greater than that in the non-successful group, and the difference was statistically significant. They were 1.9(1.4,2.5) vs 0.1(0.0,1.1) (P=0.024) and 9.6±3.1 vs 2.4±2.0 (P<0.001). There was no significant correlation between anti-HBs increase (105.5±37.1) and CTL increase 1(0,3) (P=0.099), while there was significant positive correlation with Th1 increase 7(2,11) (P<0.001). No rejection reaction occurred during the study period, and there was no special abnormal change in the safety index.

Reasonable increase of vaccine dose can up-regulate Th1 cell expression and promote the generation of anti-HBs

To explore the effect and mechanism of Rafkinase inhibitor protein (RKIP) on proliferation and migration of malignant melanoma cells in vitro.

The RKIP overexpression and down-regulated stable transfected strains of mouse malignant melanoma cell line B16 were constructed by recombinant lentiviral transfection technique and established as RKIP overexpression group and RKIP down-regulation group, the mouse malignant melanoma B16 cells without any treatment were used as a blank control group, and the proliferation activity and migration ability of each group were detected by cell counting kit-8 (CCK-8) and cell scratch test. The relative expression levels of CyclinD1, Calcium-dependent cell adhesin, Ki-67, Matrix metalloproteinase (MMP)-9, MMP-13, MMP-2 and Phosphatidylethanolamine binding protein (PEBP-1) were detected by quantitative real-time polymerase chain reaction (qPCR). Western blot was used to detect the difference of RKIP expression and the protein expression level of nuclear factor-kappa B (NF-κB) signaling pathway in each group.

Comparison of RKIP overexpression group and blank control group shown cell proliferation and migration were significantly inhibited in RKIP overexpression group (0.794±0.038 vs 1.200±0.081) (P<0.001). However, there was no significant difference in cell proliferation between RKIP down-regulation group and blank control group (1.077±0.084 vs 1.200±0.081) (P>0.05), and the cell migration ability of RKIP down-regulation group was significantly higher than that of the blank control group (P<0.001). In addition, there was no significant difference between the RKIP down-regulation group and the blank control group in PEBP-1 expression (P>0.05), while the expression levels of the remaining genes in the RKIP overexpression group were significantly lower than those in the blank control group, and the expression levels in the RKIP down-regulation group were significantly higher than those in the blank control group (P<0.001). Furthermore, the protein level of phosphorylated P65 (p-P65) in RKIP overexpression group was significantly lower than that in blank control group (0.080±0.000 vs 0.236±0.000), and RKIP down-regulation group was significantly higher than that in blank control group (1.139±0.001 vs 0.236±0.000) (both P<0.001).

RKIP overexpression can inhibit the proliferation and migration of malignant melanoma cells, which may be related to the regulation of NF-κB signaling pathway-related protein p-P65.

Allergic bronchopulmonary aspergillosis (ABPA) is an allergic disease mediated by fungal sensitization IgE. The increase of serum total IgE is its main clinical feature, and targeted anti-IgE therapy has become a new therapeutic hotspot. Foreign studies have shown that omalizumab treatment of ABPA can significantly reduce asthma symptoms, improve lung function, reduce systemic hormone demand, and reduce the risk of acute exacerbation. Referring to the results of foreign studies, omalizumab was added to the treatment of this patient, and remarkable clinical results were achieved.

Adrenal sarcomatoid carcinoma (ASC) is clinically rare, highly malignant and has a poor prognosis. A male patient complained that "physical examination found that the left adrenal gland occupied space for 1 month". CT showed a space-occupying lesion of the left adrenal gland, and the tumor size was 7.7 cm ×6.3 cm ×6.7 cm. Transabdominal left adrenal tumor resection was performed. Postoperative pathology showed left ASC. Adjuvant chemotherapy was performed for one course. Postoperative follow-up was performed for 6 months. At present, there was no tumor recurrence and systemic metastasis.

This paper reports a rare case of adult sacrococcygeal mature teratoma with carcinoid tumors. Mature teratoma is a germ cell tumor, composed of mature cells in one or more germ layers. Malignant tumors in mature teratoma are rare, which is called teratoma combined with malignant transformation. Malignant transformation mostly occurs in teratomas derived from gonadal organs, and malignant transformation of teratomas derived from extragonadal organs is rare.

Venous thromboembolism (VTE) is a complex disease caused by the combination of genetic predisposition factors and acquired risk factors. In European and American populations, coagulation factor V Leiden and prothrombin G20210A mutations were found to be characteristic susceptibility genes closely related to the development of VTE. There are currently many known acquired risk factors for VTE. It was found that the interaction between genetic and acquired risk factors can increase the risk of VTE, but the results lack consistency. The research on VTE-related susceptibility genes in China started late, and it is still in the stage of fragmentation and small sample. Moreover, the influence of the interaction between genetic and acquired risk factors on the risk of VTE in Chinese population remains to be clarified.

Obesity has become a global health threat, and the imbalance between energy intake and consumption is the main cause of obesity. Hormones secreted by classical endocrine organs, such as thyroid hormone, growth hormone, gonadal hormone, regulate energy metabolism and play an important role in weight control and improving body fat distribution. This article will review the role of endocrine hormones in energy metabolism and weight control, and explore the significance of endocrine hormone balance in the prevention and treatment of obesity.

This paper describes the advantages of intraperitoneal hyperthermia infusion chemotherapy (HIPEC) combined with hyperthermia and intraperitoneal chemotherapy, and discusses its inhibition of CD133⁺CXCR4⁺Growth of pancreatic cancer stem cell population, prolonging survival mechanism of pancreatic cancer patients. The literature recommends the use of cytotoxic drugs for HIPEC treatment during operation and early postoperative period (within 24-48 h). At the same time, HIPEC is relatively safe in the treatment of pancreatic cancer and does not increase the incidence of related complications. The application of "HIPEC +" treatment model significantly improves the prognosis of pancreatic cancer patients, and has a good clinical application prospect.

Idiopathic pulmonary fibrosis a chronic progressive interstitial lung disease. Acute exacerbation can occur in some patients during the course of the disease, resulting in a sharp deterioration of the patient's condition or even death. The definition and diagnostic criteria of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) are constantly updated with the progress of research. The causes and pathogenesis of its occurrence are still unclear, which may be induced by external factors or related to the imbalance of internal environment of the body. This article reviews the definition and diagnostic criteria of AE-IPF, the possible etiology and risk factors, and the principles of prevention and treatment.