Volume 99 ·  Issue 33 ·  2019

At present, total endoscopic spinal surgery has played an important role in the surgical treatment of lumbar disc herniation, lumbar spinal stenosis and cervical spondylotic radiculopathy, showing good curative effect and high safety. The use of total endoscopic thoracic spine surgery is rarely reported and controversial, and its efficacy and safety have been criticized by the industry. Combined with previous literature and own clinical experience, the author analyzes the technique of total endoscopic thoracic decompression surgery and related controversies.

In recent years, endoscopic lumbar spine surgery has evolved from simple decompression to being able to achieve decompression and fusion simultaneously. Although satisfactory short-term results have been achieved, at the same time, high complication rate and uncertain long-term clinical efficacy are still existing problems. This paper discusses the existing problems, key technologies and principles of this technique, so as to provide reference for surgeons who are committed to this technique.

To analyze the changes of growth and development of normal fetal ventricles and cisterna magna with gestational age(GA) and the correlation with fetal gender in the second and third trimester,and establish the MR prenatal diagnosis reference standards.

A total of 633 fetuses (mean GA (27.0±4.1) weeks (18.9-40.6 weeks))without central nervous system abnormalities were retrospectively collected from the Obstetrics and Gynecology Hospital of Fudan University from June 2012 to August 2017. The lateral ventricle trigonometric width (LVTW), third ventricle width (TVW), fourth ventricle width (FVW), anterior-posterior diameter of the fourth ventricle(APDFV), cavum septum pellucidum width (CSPW) and cisterna magna width (CMW) were obtained in the standard measure planes on MR image.The correlation between the biometrics and GA and the correlation between the biometrics and fetal gender were analyzed respectively, and the normal reference values of the biometrics were calculated. Spearman correlation analysis, Pearson correlation analysis,linear regression analysis, independent samples t-test and paired samples t-test were used for statistic analysis.

(1)Fetal LLVTW,RLVTW,TVW,CSPW and CMW in second and third trimesters were correlated with GA at medium and low levels(the correlation coefficient r were 0.311, 0.277, 0.207, 0.226, 0.295, respectively, all P<0.01). FVW and APDFV were statistically correlated with GA, and the linear regression equations were as follows: y=0.022×GA-0.043 (adjusted R²=0.642); y=0.018×GA-0.159 (adjusted R²=0.690). (2)Fetal LLVTW,RLVTW,FVW,APDFV and CSPW were not correlated with fetal gender in second and third trimesters(r=-0.078,-0.057,-0.087,-0.004 and 0.024, P=0.124,0.258,0.085,0.931 and 0.618, all P>0.05). TVW and CMW were statistically correlated with fetal gender(r=-0.310, -0.180, P=0.000, 0.006, all P<0.05). (3) The mean values of LLVTW and RLVTW were (0.71±0.13) cm and (0.68±0.13) cm, respectively, and significant difference was found between them(t=3.180, P=0.002). The mean value of CSPW was (0.59±0.15) cm. And the mean values of male and female fetuses for TVW and CMW were (0.17±0.05) cm, (0.16±0.06) cm and (0.68±0.15) cm, (0.58±0.15) cm, respectively. The corresponding prenatal MRI diagnostic criteria were as follows: LLVTW 1.1 cm, RLVTW 1.0 cm, CSPW 1.0 cm, TVW 0.3 cm, CMW (male 1.1 cm, female 1.0 cm).

The normal fetal ventricles and cisterna magna are increased with the GA in the second and third trimesters. TVW and CMW are related to fetal gender. The establishment of normal reference values of fetal ventricles and cisterna magna based on GA and fetal gender are conducive to enhance the accuracy of MRI prenatal diagnosis.

To explore the value of contrast-enhanced CT combined with texture analysis in differentiating pancreatic cancer from mass-forming pancreatitis in pancreatic head.

A retrospective study collected 21 patients with pancreatic head mass-forming pancreatitis confirmed by surgery or biopsy and 47 patients with pancreatic ductal adenocarcinoma confirmed by surgery. The patients visited the Affiliated Hospital of Nanjing University of Chinese Medicine and the First Affiliated Hospital of Wannan Medical College between January 2014 and December 2017. Gender, age and CT findings were collected. The parenchymal phase was selected for texture analysis. The minimum absolute shrinkage and selection operator (LASSO) method was applied for dimensionality reduction.Two independent sample t-tests or Mann-Whitney U test were used for continuous variables based on the Shapiro-Wilks normality test results. Categorical variables were tested by Chi-square or Fisher test. By multivariable regression analysis, CT findings, CT texture analysis, CT findings combined with texture analysis prediction models were established. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance of individual indicators and each prediction model. The Delong test was used to compare the area under the curve (AUC) of each model.

The CT findings prediction model consisted of CT value of lesion on pancreatic parenchymal phase and pancreatic duct penetrating sign. The texture analysis prediction model consists of root mean square and low grey level run emphasis_angle135. The AUC of them were not statistically different (Z=0.150,P>0.05). The combined predictive model had the better diagnostic performance (AUC 0.944, sensitivity 83.0%, specificity 95.2%, +LR 17.43, -LR 0.18) than CT sign prediction model (Z=2.008, P<0.05) and texture analysis prediction model(Z=2.236, P<0.05) were significantly different.

The CT findings model and the texture analysis model have equivalent diagnostic performance in the differentiation of mass-forming pancreatitis and pancreatic cancer. The enhanced CT combined with texture analysis model has the best diagnostic efficiency and can further improve the diagnostic ability.

To explore clinical application value of prognostic nutrition index(PNI) and apparent diffusion coefficient(ADC) in treating hepatic arterial chemoembolization (TACE) of patients with hepatic cell carcinoma (HCC).

A total of 77 patients with HHC of BCLC B were retrospectively analyzed in Dalian Medical University Affiliated Second Hospital who were diagnosed for the first time and received TACE treatment from October 2017 to December 2018, of whom 64 Males, 13 females, mean age was 54±13 years.At 1 month after surgery, TACE efficacy was evaluated according to revised solid tumor evaluation criteria (mRECIST), the enrolled patients were divided into TACE effective group (41 cases, 53.2%) and TACE ineffective group (36 cases, 46.8%) to compare ability of PNI and ability of ADC alone or in combination in evaluating efficacy of TACE and the relationship between these two groups.

Overall postoperative PNI of enrolled patients was decreased compared with preoperative PNI, 47.7±6.6 vs 48.3±5.9 (P<0.05), preoperative and postoperative PNI of TACE effective group were all higher than that of TACE ineffective group (49.9±6.0 vs 46.6±5.3, 50.6±5.4 vs 44.4±5.1,all P<0.05), there was no significant difference in PNI between the treatment groups (P>0.05). The value of ADC in postoperative tumor region increased compared with that in preoperative tumor region ((1.43±0.15) ×10^-3 vs (1.28±0.08) ×10^-3 mm²/s, P<0.05), the difference between postoperative tumor region ADC value and postoperative normal liver parenchyma had no statistical significance(P>0.05). Overall postoperative PNI and tumor region ADC value of enrolled patients had linear correlation (P<0.05).Threshold value of PNI and ADC value in preoperative prediction were 51.05 and 1.32×10^-3 mm²/s; postoperative evaluation threshold value were 50.11 and 1.41×10^-3 mm²/s.Postoperative combination of PNI and ADC had the highest value in evaluating TACE efficacy.

TACE postoperative PNI and tumor region ADC are related. PNI and tumor region ADC could be used in predicting and evaluating TACE efficacy in HCC patients, combination of these two could further increase the efficiency.

To evaluate the value of ultrasound contrast agent with enteral nutrition suspension as mixed medium in locating indwelling nasointestinal tube in critically ill patients.

Total of 45 critically ill patients had nasointestinal tube indwelled were collected from June 1,2018 to April 1,2019 in the Intensive Care Unit of Zhejiang Provincial People′s Hospital, including 30 males and 15 females, with an average age of (63±17) years.Enteral nutritional suspension Peptisorb Liquid was used as research medium,with the ultrasonic imaging performance of it confirmed by in vitro and in vivo experiments.The optimal mixing ratio of microbubble ultrasound contrast agent and Peptisorb Liquid was confirmed by in vitro experiment, then the mixture was quietly placed and its stability was dynamically observed. The nasointestinal tube was confirmed in the digestive tract by conventional ultrasound and then the ultrasound contrast mode turned on. Ultrasound contrast agent with Peptisorb Liquid as mixed medium was injected into the nasointestinal tube and the tube direction and end position were observed and recorded in real time. Abdominal X-ray examination or CT was used as the gold standard for verifying the location of the nasointestinal tube and the same result represented successful positioning.

The in vitro and in vivo experiments showed that Peptisorb Liquid had good ultrasound imaging uniformity and penetrating power, which could clearly show the range and boundary of the filling intestine cavity; the in vitro experiment showed that the ultrasound contrast agent prepared with the microbubble ultrasound contrast agent and Peptisorb Liquid by the ratio of 1∶1 000 and 1∶500 which had the best imaging effect and the best distribution uniformity, with the best stability within 10 minutes after quietly placed. Nasointestinal tubes were successfully located by using ultrasound contrast agent with enteral nutritional suspension as mixed medium in 95.6%(43/45) of the patients collected in this study,including success at one attempt in 39 cases, the operating time was (1.6±0.5) minutes and 4 cases were successfully located after multiple operations with (5.1±0.5) minutes, the tube bent in the stomach in one case and flexed back into the stomach from the descending duodenum in another. The operation failed in 2 cases (4.4%). No significant complications occurred during the examination.

The ultrasound contrast agent with enteral nutritional suspension as mixed medium has the advantages of both, which can conveniently, safely and effectively locate the direction and end position of nasointestinal tube in critically ill patients.

To investigate the clinical features, imaging findings and prognosis of idiopathic intracranial hypertension (IIH) patients complicated with iron deficiency anemia (IDA).

A total of 307 cases of IIH patients hospitalized in Beijing Tongren Hospital were retrospectively screened between January 1, 2011 and February 28, 2018. There were 49 anemia cases (15.96%) and 45 IDA cases (14.66%), respectively. Finally, 36 IDA patients were enrolled. The clinical characteristics, imaging findings, treatment and prognosis of these patients were analyzed.

IIH combined with IDA was more common in women of childbearing age (34/36). There were 30 obese and overweight cases (83.33%), with multiple subacute or chronic course of disease. The visual symptoms in the early IIH patients were first diagnosed in the Department of Ophthalmology. The first symptom was headache with/without visual symptoms (27 cases (75%)). Head MRI detected empty sella or partial empty sella, and 2 cases of venous sinus thrombosis were found in DSA examination. Of the 34 female patients, 24 had simple menometrorrhagia or menstrual disorder. All patients were given methyl acetate to reduce the intracranial pressure and iron therapy. Five patients received low molecular weight heparin-warfarin sequential treatment, 5 cases underwent gynecologic surgery and 2 male cases received hemorrhoid operation. There were 7 cases underwent lumbar cisterna-peritoneal shunt for visual impairment. During the follow-up, intracranial pressure decreased and visual function of patients improved significantly.

IIH is frequently found in obese or overweight women at childbearing age and IDA may be an important cause of IIH. IIH can cause serious irreversible visual impairment. Therefore, early identification and active treatment should be performed. Correction of anemia can significantly improve the clinical symptoms of IIH. Operation should be employed for IIH patients with poor visual function or rapid progress, in order to reduce intracranial pressure and improve prognosis as soon as possible.

To study the operative method, special technique and curative effect of complete neuroendoscopic microvascular decompression(MVD) related to vertebrobasilar artery compression.

Thirteen patients with functional cranial nerve disease caused by vertebrobasilar artery as direct or indirect responsible vessel accepted complete endoscopic MVD, including 11 patients with hemifacial spasm and 2 patients with trigeminal neuralgia. The procedure and curative effect of endoscopic surgery were analyzed retrospectively.

All procedures of complete neuroendoscopic MVD were successfully completed.Intraoperative observation by endoscope showed that 6 cases were oppressed directly by vertebral artery, 2 cases were oppressed directly by basilar artery, 5 cases were combined oppressed by displaced basilar artery and other vessels (1 case was superior cerebellar artery and 4 cases were anterior inferior cerebellar artery). During the operation, Teflon sheets was placed directly into the compression point in 2 cases, the "Pre-placed" technique was used to place Teflon sheets in 7 cases, and the "Set up bridge" technique was used to place Teflon sheets in 4 cases. Follow-up for 8-38 months,the symptoms disappeared completely in 12 cases and improved in 1 case. No deaths and severe complications occurred, such as postoperative bleeding, cerebellar infarction and intracranial infection.

MVD related to vertebrobasilar artery compression can be performed by complete neuroendoscopic technique, which can achieve sufficient decompression effect and curative effect.Flexible use of the special technology of placing Teflon sheets by single-hand under endoscope, such as the "Pre-placed" and "Set up bridge" technique, is an important technical guarantee for the successful completion of endoscopic MVD.

To analysepregnancy outcome of intrauterine insemination(IUI) after three different trigger methods.

A retrospective study was designed, included 341 couples seeking for their first or second IUI cycle from 2016.7 to 2018.6 in women′s hospital, school of medicine, zhejiang university. Ovulation was trigger by HCG 10 000 IU in 154 cases named HCG group, by 0.1/0.2 mg triptorelinin 94 cases called GnRHa group, by HCG combined with triptorelinin in 93 cases defined as dual trigger group. The primary outcome was clinical pregnancy rate and ongoing pregnancy rate beyond 28 gestational weeks,second outcome which contains biochemical pregnancy, miscarriagerate, ectopic pregnancy rateand multiple pregnancy rate were also observed in three groups.

Pregnancy outcomeshowed no significant difference among three groups.

The study suggested that all this three methods(HCG trigger, GnRHa trigger, HCG combined with GnRHa dual trigger) couldinduced ovulation, their effects on IUI pregnancyout come were similar.

To observe the effects of intravenous granisetron and acupuncture point injection at PC6(Neiguan) with 0.9% sodium chloride on postoperative nausea and vomiting (PONV) after gynecological laparoscopic surgery.

Qualified cases were collected according to prospective randomized controlled clinical trial design. 94 cases patients undergoing gynecological laparoscopic surgery without postoperative intravenous analgesia were selected from February 2017 to November 2018 in Beijing Aerospace General Hospital and The Affiliated Hangzhou Hospital of Nanjing Medical University. The patients were randomly divided into three groups: bilateral PC6 sham injection of 0.9% sodium chloride+ intravenous granisetron(group A, n=31); bilateral acupuncture point injection at PC6 of 0.9% sodium chloride+ intravenous 0.9% sodium chloride(group B, n=33); bilateral acupuncture point injection at PC6 of 0.9% sodium chloride+ intravenous granisetron(group C, n=30). The indexes including age, body mass index(BMI), type of surgery, surgery time, anesthesia time, liquid intake and output volume, the time from the completion of the operation to the removal of the tracheal catheter, the time from the completion to follow the instruction, respiratory depression, restlessness, arrhythmias and other adverse reactions during anesthesia recovery were recorded. Evaluated the nausea and vomiting according to the visual analogue scales (nausea visual analog scale, NVAS) 12 hours after the operation. Not only the dose and the related frequency of antiemetic drugs for rescue, but also the time of the first anal exsufflation and the pain 24 hours after the operation were recorded. Detected the concentration of motilin (MTL), when the operation started/awake after extubation/12 hours after the operation

The incidence of nausea and vomiting 12 hours after the operation in group A, B and C was 35.5%, 33.3%, 10.0%. The difference was statistically significant (χ²=0.654, P<0.05). The motilin after 12 hours of operation in group A, B and C was (564±76),(559±84),(472±69) ng/L. The difference was statistically significant (F=14.033, P<0.05). The incidence of nausea and vomiting and the motilin after 12 hours of operation in group C were lower than group A and B. The time for the first anal exsufflation in group A, B and C was (19±8),(19±7),(14±8)h.The difference was statistically significant (F=4.523, P<0.05). The time for the first anal exsufflation in group C was earlier than group A and B.

Either intravenous granisetron or acupuncture point injection at PC6 of 0.9% sodium chloride can effectively reduce the incidence of postoperative nausea and vomiting after gynecological laparoscopic surgery. Intravenous granisetron combined with acupuncture point injection at PC6 of 0.9% sodium chloride has better effect and promotes the first anal exsufflation time, which is conducive to the rapid postoperative recovery of patients.

To analyze the risk factors of catheter-related right jugular venous thrombosis in patients undergoing abdominal surgery.

A total of 125 patients (18-90 years, ASA Ⅰ-Ⅲ) scheduled for abdominal surgery underwent right internal jugular in our study. Ultrasound-guided central venous catheterization were carried out before surgery and Doppler ultrasound examination were conducted daily postoperatively until the catheter was removed. The patients were divided into thrombosis positive or negative group based on the Doppler ultrasound examinations. General clinical data of all patients including name, gender, age, BMI, preoperative Caprini score, bleeding, duration of operation and anesthesia, were also collected. D-dimer test was performed on the third postoperative day.

Of the 125 patients, 16(12.8%) were found to have catheter-related right internal jugular vein thrombosis. There were 16 cases (9 males and 7 females) in the thrombosis positive group, with an average age of (73±7) years old, body mass index (22.8±2.9) kg/m², and preoperative Caprini score (6.1±1.4).In the thrombosis negative group,among whom 72 were men and 37 were women. The average age of these patients was (66±11) years old, BMI was (22.6±2.9)kg/m², and preoperative Caprini score was (5.9±1.3).There was no statistical difference between the two groups regarding age, gender, BMI, preoperative Caprini score (P>0.05).The average operating time, anesthesia time, bleeding amount and D-dimer level on the third postoperative day were (189±46) min, (211±59) min, (288±96) ml,(3.4±1.6) mg/L in thethrombosis positive group, and (139±39) min, (171±46) min, (175±114) ml,(2.0±0.9) mg/L in the thrombosis negative group, respectively. Duration of surgery, bleeding amount and D-dimer level on the third postoperative day significantly affected the occurrence of catheter-related right internal jugular venous thrombosis (U=10.768, 359.000, 390.000, P<0.05), but no statistically significant differences in anesthesia time between the two groups.Logistic regression analysis screened out duration of surgery, bleeding amount and D-dimer level on the third postoperative day as risk factors for catheter-related right jugular venous thrombosis(OR=10.037, 1.011, 3.274, P<0.05).

The high incidence of catheter-related right jugular venous thrombosis in patients undergoing abdominal surgery is closely related to intraoperative blood loss, operation time, D-dimer level on the third postoperative day and other factors.

To explore the clinical features and genetic causes of autism spectrum disorder (ASD) patients with epilepsy.

The clinical data of five patients with ASD and epilepsy admitted to Xuanwu Hospital between September 2017 and September 2018 were collected, including medical history, intelligence level, developmental level, physical examination, neuroimaging and electroencephalogram. High-throughput whole-genome sequencing was applied to five patients and their parents.

Of five patients, four were male and one was female. All five patients had mild mental retardation, and one patient had significant growth retardation and craniofacial deformity. The average epilepsy onset age was 6.3 years old (7 months to 16 years). The main epileptic type was tonic-clonic seizure with abnormal EEG results. All patients have a favorable response to anti-epileptic drugs. Whole-exome sequencing (WES) revealed copy number variation in all 5 patients. Among them, 3 cases were reported to be pathogenic, and 2 cases were not reported (chromosome 16p13.3 duplication and chromosome 21q22.3 deletion).

The results of current study support that autism spectrum disorders with seizures is often associated with copy number variations, such as Williams-Beuren region duplication syndrome, chromosome 15q11.2 duplication syndrome and chromosome 15q11.2 deletion syndrome. We reported two novel copy number variations (chromosome 16p13.3 duplication and chromosome 21q22.3 deletion) in two autism spectrum disorder patients with epileptic seizures.

The clinical lesions of 7 patients with rare disease of non-pituitary adenoma in the sellar region were retrospectively analyzed. Among the 7 cases, 1 case of inflammatory lesion, 1 case of malignant tumor and 5 cases of benign tumor were found. The most common clinical manifestations were visual loss in 4 cases, headache in 3 cases and dizziness in 3 cases, without endocrine changes, all of which were treated by surgery. Postoperative headache and dizziness were relieved in 3 cases; One case of visual symptoms was relieved. Serious complications occurred in 3 cases, including pulmonary infection, respiratory failure and electrolyte disorder. Six cases were misdiagnosed before operation. The pathological results showed that 1 case of granulomatous hypophysitis, 1 case of adenoid cystic carcinoma, 1 case of cystic mature teratoma, 1 case of chondroma, 1 case of pigmented schwannoma and 2 cases of cavernous hemangioma.

To investigate the feasibility of small transumbilical incision in laparoscopic surgical specimen removal. This paper retrospectively analyzed 62 patients who underwent laparoscopic surgery in the gynecological ward of Beijing Tongren Hospital from April to December 2018. Small transumbilical incision was used, and the surgical specimens were bagged and removed. All 62 patients underwent laparoscopic surgery were removed smoothly through the small umbilical incision after bagging. There were no rupture, no residual specimens, no other surgical complications, and the umbilical incision healed well after surgery. Transumbilical small incision makes full use of the umbilicus, the only natural scar part of human body, and takes out laparoscopic surgical specimens, which conforms to the principle of minimally invasive, is convenient, effective and easy to master.

This paper reports a case of acute intermittent porphyria in pregnancy with recurrent abdominal pain and intracerebral hemorrhage as clinical manifestations.

Congenital renal arteriovenous malformations are rare in clinical practice and belong to non-neoplastic lesions. This patient was admitted to the hospital with the main complaint of "intermittent full-course macroscopic hematuria for 15 days", and both CT and MRI examinations showed that "space-occupying lesions were not excluded". The source of malignant tumor was excluded by color Doppler ultrasound combined with contrast-enhanced ultrasound, and the diagnosis of congenital renal arteriovenous malformation was confirmed. After conservative treatment, the patient's symptoms disappeared and the kidney morphology returned to normal after 3 months follow-up.

Through clinical data, drug experimental therapy and genetic detection, the clinical manifestations and family history characteristics of a young male patient with Parkinson's disease with clinical manifestations similar to dopa-responsive dystonia were analyzed. The clinical presentation of the patient was similar to dopa-responsive dystonia, and the response to dopaserazine treatment was good. Genetic testing confirmed that the patient had a Parkin gene mutation and was diagnosed with juvenile Parkinson's disease type 2.

A case of Mollaret's meningitis (MM) with pineal cyst in our hospital was retrospectively analyzed. The clinical manifestations included fever, headache, nausea and vomiting, back pain, epilepsy, and transient left lower limb weakness. There were 3 attacks in six months, and the interval between attacks was normal. Cerebrospinal fluid cytology finds characteristic Mollaret cells. MM is rare in clinic but has a good prognosis. For meningitis with recurrent attacks and no residual symptoms, the possibility of this disease should be considered. It is speculated that spontaneous rupture of pineal cyst may lead to the development of MM.

With the 2016 European (ESC) Heart Failure Diagnosis and Treatment Guidelines establishing heart failure with median ejection fraction (HFmrEF) as an independently identified type of heart failure, the related research on HFmrEF has increased significantly, and the understanding has been deepened, but there are still many controversies and unknowns. This paper summarizes the recently published research related to HFmrEF, and analyzes its intrinsic characteristics, current controversies and challenges.

This article reviews the basic and clinical research related to the local adipose tissue of knee joint in recent years, discusses its role in the occurrence and development of knee osteoarthritis (KOA), and discusses the prevention and treatment measures of KOA aimed at improving the understanding of local adipose tissue of knee joint, and probes into the follow-up research direction, so as to better guide clinical practice.