Volume 100 ·  Issue 08 ·  2020

The pathogenesis of chronic subdural hematoma needs to be further elucidated, the surgical outcome is not satisfactory, and there is still a lack of recognized effective drug treatment. The Neurosurgery Branch of Chinese Medical Association guided the Department of Neurosurgery, General Hospital of Tianjin Medical University to set up the Oriental Neurosurgery Evidence-Based Research Collaborative Group, which carried out mechanism research and clinical research on low-dose long-course atorvastatin treatment, confirmed that the new therapy was effective and obtained Grade I evidence of evidence-based medicine, which has been widely used in China and is changing the treatment mode of this disease.

With blood transfusion medicine becoming a secondary discipline of clinical medicine, the construction of blood transfusion outpatient clinics is an urgent need to promote the development of the discipline, a realistic requirement for a smooth diagnosis and treatment process, and an inevitable choice to improve the diagnosis and treatment effect. Strengthening the outpatient construction of blood transfusion department is not only conducive to optimizing the talent structure of blood transfusion professionals, but also can provide a solid platform for the training of blood transfusion medical talents, effectively improve the professional level and comprehensive quality, and improve the "voice" and influence of blood transfusion medicine. Studying the theoretical logic and practical path of outpatient clinic construction and talent team construction in blood transfusion department has an important role in promoting the level of blood transfusion medicine.

chronic subdural hematoma (CSDH) is a chronic space-occupying lesion formed by blood gathering between the arachnoid and the dura mater. It often forms after 3 weeks of head trauma. The incidence rate of CSDH is 1/10~13.1/100,000 population. With the aging of the population, the incidence rate of CSDH continues to increase, and the annual incidence rate of CSDH in the elderly over 80 years old can reach 127/100,000 people^[1,2]。 CSDH is generally believed to be caused by trauma, but about 50% of patients deny a history of trauma^[3,4]。 In addition to trauma, common risk factors associated with the onset, malabsorption, or recurrence of CSDH include: (1) long-term use of anticoagulants and antiplatelet drugs; (2) Repeated or sudden increase in thoracic and abdominal pressure (such as dystocia and constipation); (3) Craniotomy; (4) Blood diseases.

In recent years, for the clinical implementation of nutritional support treatment for critically ill patients, international guidelines developed by the American Critical Care Association (SCCM), the American Association for Parenteral and Enteral Nutrition (ASPEN, 2016), and the European Association for Parenteral and Enteral Nutrition (ESPEN, 2018) have issued clear recommendations. However, patients with critical respiratory illness have their own particularities in disease metabolism and treatment modes, and there is no unified consensus and guideline recommendation on nutritional support treatment strategies for critical respiratory illness. With the rapid development of clinical nutrition, there are increasing researches at home and abroad on whether patients with critical respiratory illness can improve survival rate, shorten ICU stay and improve patients' quality of life through nutritional support therapy. In order to standardize the nutritional support treatment of respiratory critical patients, domestic respiratory critical care and nutrition experts systematically retrieved, screened and evaluated relevant evidence-based medical evidence, including high-quality systematic review, meta-analysis and related RCT studies. Multiple rounds of discussion were conducted on 22 issues that medical staff paid most attention to during the implementation of nutritional support treatment for respiratory critical patients, and 24 recommendations were finally determined by expert voting and scoring.

To analyze the detection of CYP21A2 gene mutations in 21-hydroxylase deficiency (21-OHD) patients, so as to determine the accuracy of clinical diagnosis.

Totally, 514 patients with 21-OHD who visited Peking Union Medical College Hospital from January 2015 to January 2018 were enrolled and their clinical and biochemical data were collected. DNAs were extracted from peripheral blood leukocytes and CYP21A2 mutations were detected by Sanger sequencing and multiple ligation probe amplification (MLPA) technique. We divided 514 patients into three groups: two mutations of CYP21A2 alleles (group A), one mutation of CYP21A2 (group B), and no mutation of CYP21A2 (group C).

Mutation was detected in each allele of CYP21A2 gene in 401 (78.0%) patients, ninety (17.5%) had only one mutant allele and 23 (4.5%) had no mutation. There was no significant difference between the patients with different clinical phenotypes and the number of CYP21A2 gene mutations detected. In male, the cortisol of the patients with simple virilizing 21-OHD in group A [0.04 (0.02, 0.20) nmol/L] was lower than that of group B [0.24 (0.17, 0.28) nmol/L] and the difference was statistically significant (P=0.014). In female, 17-hydroxyprogesterone (17-OHP) of patients with salt wasting 21-OHD in group A [153.7 (90.1, 204.5) nmol/L] was higher than that of group B [38.2 (31.0, 183.3) nmol/L] and C [42.6 (27.8, 48.1) nmol/L] and the differences were statistically significant (bothP<0.05). The progesterone of patients with simple virilizing 21-OHD in group C [23.0 (8.6, 33.2) nmol/L] was lower than that of gourp A [57.8 (34.4, 110.2) nmol/L] and B [63.6 (31.4, 110.8) nmol/L] and the difference were statistically significant (bothP<0.05). The 17-OHP of patients with non-classical 21-OHD in group C [24.5 (20.4, 54.2) nmol/L] was lower than that of group A [158.7 (59.1, 187.6) nmol/L] and B [147.8 (131.9, 179.3) nmol/L]. The difference were statistically significant (bothP<0.05).

Mutations of two alleles have not been found in all patients with clinically diagnosed 21-OHD. Other congenital adrenal hyperplasia (CAH) types which can cause similar changes in 17-OHP and other hormones may be misdiagnosed as 21-OHD. Therefore, 21-OHD cannot be diagnosed with help of 17-OHP level only, and gene detection plays a vital role in the differential diagnosis of different CAH types.

To investigate the factors influencing the efficacy of CD19 chimeric antigen receptor T (CAR-T) cells in the treatment of patients with relapsed refractory B cell lymphoma and to provide evidence for further improvement of CAR-T efficacy.

A total of 34 patients with relapsed and refractory B-cell lymphoma were recruited from the Department of Hematology of Tianjin First Central Hospital from February 2017 to January 2019. All patients received CD19 CAR-T cell therapy. These patients were evaluated for efficacy, factors with poor efficacyand adverse effects.

The overall response rate was 58.8% (20/34) and the complete remission rate was 41.2% (14/34) after infusion of CD19 CAR-T cells in 34 patients with relapsed refractory B cell lymphoma. According to the efficacy of CAR-T cells, patients were divided into two groups, 20 in the effective group and 14 in the poorly effective group. The median am ount of CD19 CAR-T cell infusions in these two groups were 8.6 (5.0-12.7)×10⁶/kg and 9.7 (5.8-15.0) × 10⁶/kg, respectively, and the difference was not statistically significant (P=0.654). The percentage of CD19 CAR-T cells in the effective group and the poorly treated group was 10.28% (3.92%-44.16%) and 4.05% (0.92%-28.63%), respectively.The effective group had a higher proportion of CAR-T cells than the poorly treated group, but the difference was not statistically significant (P=0.371).The presence of massive mass was an unfavorable factor affecting the efficacy of CD19 CAR-T cells and the difference was statistically significant (P=0.001). Logistic regression multivariate analysis showed that the characteristics of massive tumors were still independent prognostic factors for poor efficacy of CD19 CAR-T cells (P=0.005, OR=0.039). Of all 34 patients, there were 70.6% (24/34) who showed varying degrees of adverse reactions after the infusion of CD19 CAR-T cells, mainly cytokines release syndrome (CRS). The median time of occurrence of fever was on the third day after infusion (0-11th) day. 16 patients were with grade 1 CRS, 7 with grade 2, and 1 with grade 3. After glucocorticoids and support treatment, they all showed improvements.

CD19 CAR-T cell therapy has achieved a certain effect in CD19⁺B cell lymphoma, but has poor efficacy on some patients. Large mass tumors may be an adverse factors to CAR-T cell treatment.

To analyze the clinical features of ulcerative colitis associated colorectal cancer (UC-CRC).

A total of 869 inpatients with Ulcerative Colitis (UC) in Peking Union Medical Hospital from January 1998 to January 2018 were continuously enrolled. Clinical data and the outcome of colorectal cancer (CRC) were collected via medical records and telephone follow-up. Chi-square test and logistic regression model were used to analyze the data.

There were 16 patients in 869 UC inpatients who were diagnosed with CRC during a period of 7 548 person years and the incidence rate of UC-CRC was 1.84%. Compared to UC inpatients without CRC, a longer course of disease (OR=1.087, 95% CI:1.046-1.129) , a lower usage rate of 5-Aminosalicylic Acid(5-ASA) (OR=0.218, 95% CI:0.052-0.915) and a higher incidence rate of intestinal stenosis (OR=16.533, 95% CI:3.824-71.478) were found in UC inpatients with CRC.

A long disease course is a risk factor for UC patients developing CRC, while 5-ASA therapy can reduce the risk of suffering from CRC. For UC patients with intestinal stenosis, CRC should be warned for occurring.

To explore the methods and appliaction value for self-constructing brainstem fiber bundles by neurosurgeon through 3D-Slicer software in neurosurgical preoperative planning.

The DCIOM format imaging data of 31 patients with neurosurgical brainstem lesions were collected who admitted to Neurosurgery Department at the First Affiliated Hospital of Chongqing Medical University from June 2018 to May 2019 and imported into the 3D-Slicer software system. The neurosurgery specialists independently constructed the fiber bundles to generate two-dimensional Fraction Anisotropy maps, Directionally Encoded Color maps and three-dimensional fiber bundle tracing maps. Building a preopertive virtual pathological anatomical imaging system and understanding the three-dimensional pathological anatomical relationship between lesions and brain stem fiber bundles to develop an accurate surgical approach and simulate surgicalprocedures before surgery.

All cases were reconstructed by neurosurgeon, and the self-constructed 3D virtual images were used to develop the surgical plan. All the operations were successfully completed under the assistance of microsurgical techniques and neuroendoscopy while avoiding fiber bundles as much as possible, and the total or subtotal tumor was achieved without damage to the fiber bundle. After operation, the symptoms of new brainstem fiber bundle injury were mild. 31 patients were followed up 3 months after operation without obvious symptoms of brainstem fiber bundle injury, and 31 patients were followed up 6 months after operation without obvious symptoms of brainstem fiber bundle injury.

Constructing brainstem fiber bundles by neurosurgeon can accurately and purposefully reconstruct the shape of brainstem fiber bundles, so that neurosurgeons can more accurately understand the three-dimensional pathological anatomical relationship between tumor and brain stem fiber bundles. In order to formulate the surgical plan in a more reasonable way, choose the optimal surgical approach, understand the location of the "relative safe area" , and be more confident to avoid damage to the brain stem fiber bundle while achieving subtotal or total resection of the tumor,also the nerve function of the patient is preserved as much as possible.

To investigate the causes of misdiagnosis of suprasellar arachnoid cysts, analyze its characteristics and put forward the diagnostic basis and differential points.

The clinical data fo 97 cases of suprasellar arachnoid cysts diagnosed and treated in the neurosurgery department of Beijing Tiantan Hospital and Hebei General Hospital from March 2015 to March 2019 were analyzed retrospectively. All patients underwent CT and MRI scans with obstructive hydrocephalus. 13 cases were misdiagnosed, including 7 males and 6 females. First visit age 1-31 years old, with an average age of 6.3 years. There were 10 patients younger than 6 years old. The remaining 15-year-old patients, 31-year-old patients and 26-year-old patients each have one case. 11 cases were misdiagnosed as obstructive hydrocephalus, 2 cases as cystic craniopharyngioma.

13 cases were misdiagnosed and mistreated, 11 cases were treated with intraventricular and abdominal shunt, 9 cases were treated with neuroendoscopy and recovered well. One cases of intracranial hematomas underwent craniotomy again, the hematomas were removed again and the bone slise were decompressed. One case had fissured stable after shunt. There were no operative deaths and no complications in this group. After endoscopic reoperation, CT and/or MRI scans showed that the ventricle narrowed in varying degrees, some of them returned to normal size and the flow of cerebrospinal fluid (cerebrospinal fluid) was unobstruct at the end of magnetic resonance cerebrospinal fluid angiography (MRI) fistula after endoscopic reoperation.

The incidence of suprasellar arachnoid cysts is low, it is rare in clinic and it is easy to misdiagnose and mistreate. At present, it is recognized that the best treatment methods are partial resection of endoscope cyst wall, cyst ventricle fistula and third ventricle floor fisthla.

To determine the clinical features and outcomes of pneumocystic pneumonia (PCP) in patients treated with rituximab for autoimmune diseases.

PCP patients with autoimmune diseases as underlying diseases from January 2009 to April 2019 in Peking University First Hospital (male 67 cases, female 35 cases, age 17-79) were retrospectively reviewed. Patients were grouped as rituximab group and non-rituximab group based on the fact if they were treated with rituximab before the onset of PCP. Demographic data, clinical features, and outcomes of the two groups were analyzed.

There were 102 cases altogether, and 7 patients were treated with rituximab before the onset of PCP. Patients in rituximab group were relatively younger than that in non-rituximab group [(32.0±18.7) vs (52.4±14.9) years, P=0.010]. Patients in rituximab group had more CD3⁺, CD4⁺, CD8⁺T lymphocytes in peripheral blood samples than that in non-rituximab group [(1 306±596) vs (546±439)/μl, (674±401) vs (243±232)/μl, (616±249) vs (282±256)/μl, respectively, allP<0.01]. However, the B lymphocyte count and plasma level of IgG and IgM were significantly lower in rituximab group than that in non-rituximab group [0 (0, 0.2) vs 72 (50.0, 124.4)/μl, 4.0 (2.6, 5.8) vs 9.4 (5.3, 12.0) g/L, 0.3 (0.2, 1.0) vs 1.1 (0.6, 1.8) g/L, respectively, allP<0.05]. The incidence of Cytomegalovirus (CMV) pneumonia was significantly lower in rituximab group (0/7 and 57/95, P=0.007). Other demographic data, the use of corticosteroids, the incidence of severe PCP, mechanical ventilation, intubation, pneumothorax and mediastinal emphysema complications, as well as hospital mortality and length of stay in hospital in the two groups were comparable.

In patients treated with rituximab for autoimmune diseases, the number of B lymphocytes in peripheral blood and the plasma level of immunoglobulins but not CD3⁺, CD4⁺, and CD8⁺T lymphocyte counts may play an important role in the pathogenesis of PCP. These patients are not vulnerable to be complicated with CMV pneumonia.

To investigate the neuroprotective effect of facial nerve monitoring on acoustic schwannoma resection and its impact on prognosis.

Eighty patients with acoustic schwannomas were enrolled in our study in the past 2 years and randomly divided into a monitoring group and a non-monitoring group. Tumor size was measured by MRI, and the general condition of the patients were analyzed. The preoperative hearing loss was evaluated, and the facial numbness, post-group related symptoms, and facial paralysis grade were also evaluated before surgery. The monitoring group performed facial nerve monitoring during the operation of auditory schwannomas resection, while the non-monitoring group did not. Both groups decided to perform total or subtotal resection according to the actual conditions during the operation. The hearing status, facial numbness, posterior group related symptoms and facial paralysis grade were evaluated 3 days after surgery, and the prognosis Glasgow outcome score (GOS) was evaluated 1 month after surgery.

There were no significant differences between two groups in terms of general condition and preoperative evaluation. There was also no significant difference in surgical methods. But the incidence of facial numbness in monitoring group (42.9%, 15/35) was significantly lower than that in non-monitoring group (86.7%, 39/45) (P<0.001). The facial paralysis grade in monitoring group (17/Ⅰ, 9/Ⅱ, 8/Ⅲ, 1/Ⅳ) was also significantly lower than that of non-monitoring group (1/Ⅰ, 18/Ⅱ, 17/Ⅲ, 9/Ⅳ) (P<0.001). The prognostic score (GOS) in monitoring group (4.60±0.55) was significantly higher than that in non-monitoring group (3.78±0.67)(P<0.001).

Facial nerve monitoring can provide better neuroprotection on acoustic schwannoma resection, avoid facial nerve injury, and improve the prognosis quality of life significantly.

To explore the clinical characteristics, treatment and prognosis of TAFRO syndrome.

All patients diagnosed as Castleman disease in Peking University People′s Hospital between December 2011 and April 2019 were included.Among them,6 patients were diagnosed as TAFRO syndrome. Medical records were studied;the clinical manifestation, laboratory test, pathology, treatment and prognosis were analyzed. Recent related literatures were reviewed.

The average age of six TAFRO syndrome patients (5 males)was 41.5 years(range, 27-59 years). The patients presented as acute or subacute onset, manifested as fever, thrombocytopenia, polyserositis including pleural effusion and ascites, organomegaly, anasarca, and renal insuffciency. One patient was accompanied by hemophagocyticsyndrome, one patient was accompanied by hypothyroidism, six patients′ serum IL-6 was elevated, four patients had received the test of serum VEGF and results were all elevated, six patients′ HIV antibody were negative,four patients had received HHV-8 DNA test and results were all negative. For pathology, threewere plasma cell type, twowere mixed type andonewashyaline vascular type. Renal biopsies were performed in 2 patients, showing that renal thrombotic microangiopathyassociated with subacute tubulointerstitial nephritis and secondary capillary proliferative glomerulonephritis. CHOP chemotherapy wereused in 2 patients, glucocorticoid was used in 1 patient, and glucocorticoid combined with Rituximab or Tocilizumab were used in 3 patients. Among them, one patient died because of disease progression after 5 years, other five patientsare still stable.

TAFRO syndrome is a rare disease, early recognition and appropriate treatment may improvethe prognosis.

The etiology of hypoglycemia is complex, and the diagnosis and treatment are difficult. Among them, congenital hyperinsulinemia (CHI) is an autosomal dominant hereditary disease. At present, more than 10 genes that can cause CHI have been found, including glucose kinase (GCK) gene. In this paper, the clinical characteristics of a patient with hypoglycemia were carefully analyzed, and molecular genetic testing was performed to accurately diagnose a GCK-CHI family. This case suggests that careful family history is very important for the diagnosis of CHI, and GCK-CHI should be considered in patients with persistently low blood glucose after meals.

Extraskeletal Ewing's sarcoma is a rare invasive tumor, often occurring in early childhood and adolescence. It belongs to peripheral primitive neuroectodermal tumor, which rarely occurs in the head and neck area. The most common occurrence sites are the chest wall, paravertebral area and lower limbs, and those occurring in the orbit are even rarer. A case of Ewing's sarcoma in the orbit is reported.

How to promote the application of narrative medicine in the field of general medicine is an important issue to promote the service level of primary medical institutions in China. This article expounds the proposal of narrative medicine, the necessity of its application in the field of general medicine, the development status of narrative medicine abroad and at home, the resistance to the development of narrative medicine at home and the countermeasures, in order to promote the application of narrative medicine in the field of general medicine in China.

Sleep-related painful erection (SRPE) is rare in clinical practice, and its etiology and pathogenesis are still unclear. At present, the treatment mostly depends on clinical experience, and there is a lack of evidence-based medical evidence. Commonly used regimens include rapid eye movement phase sleep inhibitors, anti-male therapy, benzodiazepineClass, antidepressant drugs, etc., short-term treatment is effective, long-term drug resistance is easy, and the treatment effect is not good. Various treatment options lack evidence-based medical evidence, which needs further research.