Volume 100 ·  Issue 10 ·  2020

In early 2020, the outbreak of novel coronavirus pneumonia (COVID-19 for short) is affecting all walks of life across the country, and it is also affecting the normal treatment of cancer patients. When clinicians face patients, they need to take into account the influence of multiple factors such as epidemic prevention and control, disease treatment and allocation of medical resources. How to reasonably adjust the best is also testing clinicians. Therefore, according to the clinical diagnosis and treatment guidelines, combined with expert experience, and according to the different stages and molecular typing of patients, we put forward our own views on ten hot issues in the diagnosis and treatment of breast cancer under the COVID-19 epidemic situation, for reference and criticism by peers.

At present, the epidemic of novel coronavirus (COVID-19 for short) makes the elderly and patients with chronic diseases with poor basic nutritional status more critical after infection, highlighting the importance of nutritional therapy. In order to further promote patient recovery, improve treatment effect, and reduce mortality, the Parenteral Enteral Nutrition Branch (CSPEN) of the Chinese Medical Association has put forward the following 10 expert suggestions for medical nutrition therapy for patients with COVID-19. Now, the nutritional therapy principles, methods, energy, protein, fat, non-protein energy supply ratio, liquid volume, micronutrients, immunonutrients, and monitoring of effects are interpreted, so as to facilitate clinicians' application in the treatment of COVID-19.

Since December 2019, cases of Novel Coronavirus Pneumonia (NCP) have been detected in Wuhan, Hubei Province. With the spread of the epidemic, such cases have been found in other parts of China and abroad. According to the Law of the People's Republic of China on the Prevention and Control of Infectious Diseases, China has classified the disease as a Class B infectious disease, and adopted prevention and control measures for Class A infectious diseases. The National Health and Health Commission has also successively promulgated relevant diagnosis and treatment plans to guide clinical diagnosis and treatment^[1]。 According to the current epidemic data analysis, severe and critical patients account for about 10% of all confirmed cases, and the most important transmission modes are droplet transmission through respiratory tract and contact transmission, while the transmission routes such as aerosol and digestive tract remain clear^[1]At present, there have been many incidents of infection of medical staff. Standardization of airway management techniques and procedures is crucial for preventing cross-infection and infection of medical staff. Therefore, the Respiratory Critical Care Medicine Group of Respiratory Medicine Branch of Chinese Medical Association and the Critical Care Medicine Working Committee of Respiratory Physicians Branch of Chinese Medical Doctors Association organized experts who fought in the front line of fighting the epidemic in Wuhan or the local area, and specially formulated this recommendation based on the actual situation and literature basis to standardize the airway management of patients with severe NCP.

The most important mechanism of resistance to beta-lactam antibiotics in gram-negative bacteria and a few gram-positive bacteria is the production of various beta-lactamases. β-lactamase inhibitors can inhibit some β-lactamases and prevent β-lactam antibiotics from being hydrolyzed and inactivated. Therefore, β-lactam antibiotic/β-lactamase inhibitor compound preparation (abbreviated as β-lactamase inhibitor compound preparation) is an important choice for clinical treatment of β-lactamase-producing bacterial infection. There are many types and specifications of β-lactamase inhibitor compound preparations in clinical use in China. Clinical workers have uneven understanding of the characteristics of these preparations, and the problem of irrational clinical use is more prominent. Expert Consensus on Clinical Application of β-Lactam Antibiotics/β-Lactamase Inhibitor Mixtures prepared by this writing team in 2015^[1], has played an important role in guiding and standardizing the rational use of such antimicrobial drugs in clinical practice. With the change of bacterial drug resistance and the application of many new enzyme inhibitor compound preparations in clinic, in order to further standardize the clinical application of β-lactamase inhibitor compound preparations and delay the occurrence and development of bacterial drug resistance, the expert group has specially updated the consensus.

To study the characteristics and clinical significance of pulmonary function test and kerbs von den lungen 6 (KL-6) in anti-synthetase syndrome related interstitial lung disease (ASSD-ILD) and idiopathic pulmonary fibrosis (IPF).

The clinical data of 43 patients with ASSD-ILD (ASSD-ILD group) from May 2015 to May 2017 were collected retrospectively, including 12 males and 31 females, and 34 patients with IPF (IPF group) treated in the First Affiliated Hospital of Zhengzhou University during the same period, including 28 males and 6 females, were also included. The basic information, and the value of pulmonary function test [pulmonary function parameters included the forced vital capacity expressed as percent predicted (FVC%pred), the forced expiratory volume in 1 second expressed as percent predicted (FEV₁%pred), the ratio of FVC to FEV₁ (FVC/FEV₁), the peak expiratory flow expressed as percent predicted (PEF%pred), the forced expiratory flow at 25%, 50%, 75% of FVC as percent predicted (FEF₂₅%pred, FEF₅₀%pred, and FEF₇₅%pred), the maximum mid-expiratory flow as percent predicted (MMEF% pred), and the diffusing capacity for carbon monoxide as percent predicted (DLCO% pred)], and serum KL-6 level in ASSD-ILD and IPF were compared.

The FEV₁%pred, FEF₅₀%pred, FEF₇₅%pred, and MMEF%pred values in ASSD-ILD group were significantly lower than those in IPF group (all P<0.05), while the FVC% pred, FVC/FEV₁, PEF% pred, FEF₂₅%pred, and DLCO% pred values in ASSD-ILD group had no significant difference compared with IPF group (all P>0.05). There was no significant difference in serum KL-6 level between ASSD-ILD group and IPF group [(1 169±911) vs (1 210±908) U/ml, t=0.62, P=0.463]. Follow-up analysis showed that the serum KL-6 level of ASSD-ILD patients who died within two years was significantly higher than that of survivors [(2 060±1 168) vs (1 042±858) U/ml, t=2.93, P=0.041]. The serum KL-6 level of patients who died within two years of IPF patients was also significantly higher than that of patients who survived [(1 767±865) vs (1 089±894) U/ml, t=2.53, P=0.026]. The serum KL-6 level in ASSD-ILD group was negatively correlated with FVC%pred (r=-0.43, P=0.004), FEV₁%pred (r=-0.39, P=0.010) and DLCO% pred (r=-0.41, P=0.006). There was no correlation between serum KL-6 level and pulmonary function test indexes in IPF group (all P>0.05).

There is difference in pulmonary function test between ASSD-ILD patients and IPF patients. High serum KL-6 level will be predictive of poor prognosis.

To investigate the clinical and immunological features of cardiac involvement in patients with dermatomyositis (DM).

Data of 271 adult patients with DM diagnosed in the Department of Rheumatology and Immunology, Peking University People′s Hospital from 2003 to 2018 were collected retrospectively and analyzed statistically.

The occurrence of cardiac involvement in DM was 15.9% (43/271). Main feature of cardiac involvement in DM was elevated cardiac troponin I (cTnI). The most common abnormalities of ECG were T wave abnormality (27.9%, 12/43), sinus tachycardia (16.3%,7/43), ST-T change (14%, 6/43) and right bundle branch block (7%, 3/43). The common manifestations of echocardiography were left ventricular diastolic dysfunction (23.3%, 10/43) and pericardial effusion (23.3%, 10/43). As compared with DM patients without cardiac involvement, DM patients with cardiac damage were more likely to have rapidly progressive interstitial lung disease (ILD), skin damage, anemia, elevated creatine kinase, decreased C3 and serum albumin (P<0.05). Positive anti-Ro-52 antibody and Jo-1 antibody were detected more common in DM with cardiac involvement(P<0.05).

Cardiac damage is common complication of DM. Manifestations of cardiac damaging are varied. Rapid progressive ILD and positive Jo-1 and Ro-52 antibodies are more common in this group. Clinicians should improve the awareness of cardiac involvement in DM patients.

To investigate the correlations of serum total 25-hydroxyvitamin D (T-25 (OH) D) levels with serum cytokine levels including interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor α (TNF-α) and Crohn′s disease activity index (CDAI) in patients with Crohn′s disease (CD).

A total of 60 patients with CD admitted in Peking Union Medical College Hospital from April 2014 to March 2019 who completed the tests for serum T-25 (OH) D and cytokines (IL-6, IL-8 and/or TNF-α) were retrospectively enrolled. Clinical data were collected for analysis.

Among 60 CD patients, there were 46 male patients, and the age was (34±13) years. There were 16 patients (26.7%) in remission and 44 cases (73.3%) in active status. The T-25(OH)D level was (16.0±7.7)μg/L. The prevalence of vitamin D sufficiency, insufficiency and deficiency was 26.7%, 40.0% and 33.3%, respectively. Correlation analysis showed that serum T-25 (OH) D level was negatively correlated with CDAI (r=-0.363,P=0.004), IL-6 level (r=-0.360,P=0.007), hsCRP level(r=-0.272, P=0.043) and ESR level(r=-0.293, P=0.024), while positively correlated with serum Alb level(r=0.372, P=0.003)、Hb(r=0.330, P=0.010) and BMI(r=0.276, P=0.033).Twenty-three cases (52.3%) of active CD patients accompanied with infection had a lower level of serum T-25 (OH) D than those without infection [(12.55±7.17) vs (17.41±6.49)μg/L,P=0.023].

Serum T-25 (OH) D level was negatively correlated with CDAI, serum IL-6 level and inflammatory markers in patients with CD, and it was lower in active CD patients with infection than those without infection.

To investigate the wave variations of the electroretinography (ERG), and explore the clinical value of using ERG in alkali injury.

A total of 13 patients with alkali burns who were treated in the Department of Ophthalmology of Peking University Third Hospital from May 2018 to October 2019 were selected, including 12 males and 1 female. The age ranged from 19 to 60 years old. A total of 15 injured eyes were used as the alkali burn group, meanwhile, another 15 contralateral eyes with mechanical unilateral trauma were used as the healthy controls. ERG examination was performed to compare the amplitudes of 6 activation-induced responses between the two groups.

Compared with control group, b-wave amplitude of dark adaption 0.01 ERG in alkali injury group decreased [(137±23) μV vs (348±14) μV, P<0.001]. Compared with control group [(335±17) μV and (368±19) μV], a-wave amplitude of dark adaption 3.0 ERG and 10.0 ERG in alkali injury groups [(172±20) μV and (220±21) μV] were decreased (both P<0.001). As for b-wave amplitude of dark adaption 3.0 ERG and 10.0 ERG, compared with control group [(610±20) μV and (612±19) μV], those of alkali injury groups [(359±21) μV and (384±21) μV] were decreased (both P<0.001). In terms of oscillatory potentials (OPs) amplitude of dark 3.0 ERG adaption, compared with control group [(209±8) μV], that of alkali injury group [(94±13) μV] was decreased ( P<0.001). Compared with normal group [(58±3) μV], a-wave amplitude of light adaption 3.0 ERG in alkali injury group [(40±4) μV] was decreased ( P<0.001). As for b-wave amplitude of light adaption 3.0 ERG, compared with control group [(146±6) μV], that of alkali injury group [(90±11) μV] was decreased ( P<0.001). In terms of photopic 3.0 flicker 30 Hz of light adaption, compared with control group [(166±10) μV], that of alkali injury group [(93±11) μV] was decreased ( P<0.001).

Alkali injury can cause ocular surface morphological changes, meanwhile, it leads to the alternations of the visual function.

To investigate the significance of quantitative fecal immunochemical test (FIT) for opportunistic screening of colorectal neoplasia, and to propose the most optimal thresholds to improve the screening level of early colorectal neoplasia.

The opportunistic screening participants were recruited from the Department of Gastroenterology & GI Endoscopy Center of the Seventh Medical Center of PLA General Hospital, and stool sample was collected before colonoscopy and the quantitative FIT was analyzed by OC-MICRO analysator for each patient. We assessed test performance in detecting colorectal neoplasia (advanced adenoma and CRC)with different thresholds on sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

A total of 1 448 objects were enrolled in this study, including 714 male (49.3%)and 734 female (50.7%).All participants were classified according to the result of colonoscopy and pathology, and 242 cases of colorectal neoplasia were found, containing 157 advanced adnoma and 85 colorectal cancer. The FIT threshold increased from 50 μg/L to 200 μg/L, while the positivity rate dropped from 11.5% to 8.6% and the sensitivity in detecting colorectal neoplasia dropped from 47.9% to 38.8%. However, the specificity increased from 96.8% to 98.2% and the positive predictive value increased from 82.3% to 87.0%.The miss rate of colorectal cancer increased from 11.8% ( n=10) to 17.6% (n=15) along with the increase in FIT thresholds, but the miss rate of 100 μg/L and 150 μg/L was the same as 12.9% ( n=11).

Quantitative FIT,which is simple and fast,with the threshold of 100 μg/L for opportunistic screening, has a high sensitivity and specificity for the diagnosis of colorectal neoplasia,and is an important index in screening and diagnosis of colorectal neoplasia.

To explore the association between serum brain-derived neurotrophic factor and clinical stage and dysmenorrhoea of endometriosis.

A total of 82 patients were studied with laparoscopically diagnosed endometriosis between June 2017 and June 2019, and 75 healthy women with reproductive age were selected as the control group during the same period. The endometriosis patients were scored by visual analogue scale(VAS)according to their preoperative dysmenorrhoea.And endometriosis was staged and scored according to the score of Revised American Fertility Society(r-AFS).Enzyme-linked immunosorbent assay (ELISA) was used to determine preoperative BDNF level in serum, and the correlation between BDNF level with clinical stage as well as dysmenorrhea of endometriosis were analysed.

The serum BDNF level in endometriosis patients was (1 082±43) ng/L, significantly higher than that in the normal control [(649±30) ng/L], there was statistical difference between the two groups(P<0.001). The BDNF expression in patients with r-AFS stage Ⅲ-Ⅳ was higher than that in patients with Ⅰ-Ⅱ stage [(1 164±389) ng/L vs (791±218)ng/L, P<0.001]. BDNF level in serum was closely correlated with the degree of dysmenorrhea (r=0.682), and the BDNF level in patients with moderate or severe dysmenorrhea was significantly higher than that in patients without dysmenorrhea and patients with mild dysmenorrhea [(1 292±43) ng/L vs(718±36) ng/L, P<0.001].

The serum BDNF level in endometriosis patients is positively correlated with clinical stage and dysmenorrhea.

To investigate the effect of modified tubal resection or ligation on the incidence of interstitial pregnancy during the re-pregnancy.

Patients who underwent tubal resection or ligation in our hospital from June 2017 to June 2019 were selected as research subjects and randomly divided into observation group and control group, with 43 cases in each group.The observation group received modified tubal resection or ligation, while the control group received traditional tubal resection or ligation, and the occurrence of re-gestation interstitial pregnancy was followed up.

A total of 86 subjects were included, with an average age of (32.3±2.6) years old, 2-5 pregnancies, and 2-4 births. There was no statistical difference in general data between the two groups.The success rate of operation in both groups was more than 95%, with 6.98% (3/43) patients in the observation group having temporary fever and other discomforts after operation, and 9.30%(4/43) patients in the control group having good outcomes.In the observation group and the control group, 36 and 34 patients underwent in vitro fertilization and embryo transfer three months after the operation, respectively, and 23 pregnancies were successful in each group. All pregnancies in the observation group were intrauterine, and no ipsilateral tubal interstitial pregnancy occurred; in the control group, 19 were intrauterine pregnancies, and 4 cases of ipsilateral tubal interstitial pregnancy occurred.Ipsilateral tubal interstitial pregnancy after modified tubal ligation was significantly lower than that after traditional tubal resection or ligation (χ²=4.195, P=0.041).

Modified tubal ligation and resection can effectively reduce the occurrence of interstitial pregnancy during the re-pregnancy.

To investigate the mechanism of epoxyeicosatrienoic acids (EET) on renal ischemia/reperfusion (I/R).

Thirty 10-week male C57BL6 mice were randomly divided into five groups: sham goup, I/R group, I/R with EET group, I/R with toll-like receptor 4 (TLR4) inhibitor (TAK242) group, I/R with EET and TAK242 group. Blood urea nitrogen (BUN) and serum creatinine (Scr) as well as renal pathological changes were observed 24 h after reperfusion. The protein expression of NOD-like receptor pyrin domain containing 3 (NLRP3), cysteinyl aspartate specific proteinase 1 (caspase-1), interleukin-1β (IL-1β), TLR4 and myeloid differentiation factor 88 (MyD88) were evaluated using Western blot.

Severe renal tubular epithelial cell injury and decreased renal function [BUN:(10.37±0.53) vs (6.70±0.82)mmol/L, t=9.17, P<0.001; Scr: (83.67±3.88) vs (32.50±3.51)μmol/L,t=23.96, P<0.001] occurred in I/R group. Compared to the sham group, the relative expression of NLRP3 (1.54±0.10 vs 0.71±0.05, t=13.14, P<0.001), caspase-1 (2.35±0.05 vs 0.62±0.02, t=73.77, P<0.001), IL-1β (3.11±0.11 vs 1.26±0.05,t=35.97, P<0.001), TLR4 (1.58±0.03 vs 0.39±0.01, t=86.00, P<0.001), MyD88 (0.94±0.02 vs 0.26±0.01, t=72.61, P<0.001) were significantly increased. Mice pretreated with EET analog featured lower kidney damage and diminished levels of above proteins than I/R group (all P<0.001). Besides, the co-administration of TAK242 and EET analog could even markedly reduced the expression levels of each proteins than those in I/R group and I/R with EET group (all P<0.001).

EET exerts a protective effect on attenuating renal I/R injury possibly through inhibiting TLR4 pathway to regulate the activation of NLRP3-induced pyroptosis.

To analyze the clinical characteristics of patients with retroperitoneal tumor, improve the understanding of retroperitoneal tumor, and avoid misdiagnosis as gynecological tumor. The clinical data, auxiliary examination and pathological diagnosis of 25 patients with retroperitoneal tumors misdiagnosed as gynecological tumors were retrospectively analyzed and summarized. The main clinical manifestations of this group of patients were adnexal area or pelvic mass found by gynecological color ultrasound during health examination, followed by self-palpation and lower abdominal mass, lower abdominal pain, abdominal distension, low back pain, frequent urination and urgency, left lower limb pain, dysmenorrhea and vaginal bleeding. The incidence of retroperitoneal tumors is low, its clinical symptoms are similar to those of gynecological diseases, and it is easy to be misdiagnosed as gynecological tumors.

This paper reports a case of skin pigmentation, increased progesterone and sudden increase in height as the main clinical manifestations. A 6-year-old boy went to the doctor because of dark skin color and sudden increase in height. Auxiliary examination showed that the levels of testosterone, progesterone and 17 α hydroxyprogesterone (17-OHP) were significantly increased, and the bone age was significantly advanced. Genetic detection indicated that there was a compound heterozygous mutation in CYP21A2 gene. The diagnosis of "congenital adrenocortical hyperplasia (CAH), 21-hydroxylase deficiency (21-OHD), peripheral precocious puberty" was clear. Elevated levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) during hydrocortisone treatment suggest gonadal axis initiation and central precocious puberty secondary to peripheral precocious puberty. This case suggests that while 17-OHP is increased in 21-OHD patients, progesterone level is also significantly increased, and there is a good positive correlation between the two. Progesterone can be used as an important indicator of 21-OHD screening, and for primary hospitals where 17-OHP cannot be detected, progesterone can be used as the basis for preliminary screening of 21-OHD.

Patients with carcinoid syndrome and bronchial carcinoid are prone to wheezing, which should be clinically distinguished from asthma. This patient was diagnosed with asthma for 10 years, but it was still uncontrolled after standard asthma treatment. Chest CT examination showed multiple nodules and patches in both lungs. Surgical lung biopsy of intrapulmonary nodules revealed lung carcinoid. After somatostatin analogue treatment, the wheezing symptoms were significantly relieved. Therefore, for asthma patients who cannot achieve good control after using appropriate treatment level and standardized treatment and management, attention should also be paid to screening the possibility of neuroendocrine tumors during clinical differential diagnosis.

Type 1 diabetes mellitus (T1DM) is an organ-specific autoimmune disease resulting in absolute insulin deficiency by selective destruction of islet beta cells mediated by T lymphocytes. Genetic factors and environmental factors interact and participate in the occurrence and development of type 1 diabetes. More than 60 susceptible loci of T1DM have been mapped so far through family linkage analysis, candidate gene association study and genome-wide association study. This paper reviews the research progress in genetics of T1DM, and prospects for the application of susceptibility genes in genetic risk prediction of T1DM.

Erythema nodosum (EN) is the most common type of panniculitis. At present, its etiology and pathogenesis are still unclear, some of which are idiopathic, while the rest may be related to streptococcal or tuberculosis infection, oral contraceptives, inflammatory bowel disease and Behcet's disease. In recent years, more possible causes have been discovered through research, such as other infections besides Streptococcus and Mycobacterium tuberculosis, the use of biological agents and malignant tumors. In this paper, the research progress of secondary EN is reviewed.