National Medical Journal of China
Volume 100 · Issue 36 · 2020
Natl Med J China
Cushing's syndrome is a rare disease with various etiologies. How to apply glucocorticoids rationally during perioperative period is a controversial clinical issue. According to the pharmacological properties of glucocorticoids, intravenous hydrocortisone is the first choice for perioperative stress state, and hydrocortisone, prednisone or prednisolone are the choices for long-term maintenance replacement therapy. Patients with ectopic corticotropic hormone syndrome had the fastest recovery of adrenal function after surgery, followed by Cushing's disease, and unilateral adrenal adenoma had the slowest recovery. The time of withdrawal can be determined based on the early morning blood cortisol and adrenocorticotropic hormone (ACTH) stimulation test to judge the recovery of adrenal function.
This paper comprehensively analyzed the relevant research at home and abroad, and put forward the influencing factors of delayed treatment on the prognosis of breast cancer patients: (1) the delayed time of seeking medical treatment: ≥12 weeks affects the prognosis of patients; (2) Operation time: Surgical treatment within 4 weeks after pathological diagnosis and no more than 8 weeks after neoadjuvant chemotherapy will not affect the prognosis of patients; (3) Chemotherapy time: neoadjuvant chemotherapy within 8 weeks after diagnosis and adjuvant chemotherapy within 4 weeks after surgery will not shorten the survival time of patients; (4) Targeted therapy time: the delay of targeted therapy for HER2-positive breast cancer patients should not exceed 4 months after the diagnosis of breast cancer; (5) Radiotherapy time: Radiotherapy for breast-conserving patients within 8 weeks of surgery or chemotherapy does not affect the local recurrence rate.
Patients with obstructive sleep apnea (OSA) actually perform a series of Valsava actions during apnea at night, which can cause the embolus of the right heart system to enter the left heart system and even the brain through the patent foramen ovale. This mechanism plays an important role in the pathogenesis of unexplained cerebral embolism, paradoxical embolism, transient cerebral ischemia and migraine. In-depth study of patent foramen ovale occurring in patients with OSA is of great significance for further study of OSA and various cerebrovascular diseases.
Rational application of antimicrobial drugs is the core of the treatment of bacterial infectious diseases. In recent years, the resistance rate of clinical isolates to commonly used antimicrobial drugs in China has been increasing continuously, and multi-drug resistant bacteria are becoming more and more common[
To evaluate the changes and diagnostic value of serum dehydroepiandrosterone sulfate (DHEAS) in Cushing′s syndrome (CS) with different etiologies.
The study retrospectively recruited patients diagnosed as CS in Drum Tower Hospital affiliated to Nanjing University Medical School between January 2012 and June 2019, including 36 patients (8 males, 28 females, with an average age of 44 years) with Cushing disease (CD) and 64 patients (6 males, 58 females, with an average age of 39 years) with adrenal CS (ACS). Meanwhile, 97 patients diagnosed as nonfunctional adrenal adenoma (NFA) were also included as controls. Clinical characteristics, laboratory data, adrenocorticotropic hormone (ACTH), serum DHEAS level and sex-and age-adjusted DHEAS ratio of the three groups were collected. The sensitivity and specificity of DHEAS and its ratio in differential etiology diagnosis of CS were compared using receiver operating characteristic (ROC) curve analysis.
Compared to NFA group, ACS patients had lower DHEAS levels [0.39 (0.39, 0.63) μmol/L vs 2.96 (1.92, 4.60) μmol/L, P<0.01] and lower DHEAS ratio [0.58 (0.27, 0.98) vs 3.95 (3.08, 6.83), P<0.01]. DHEAS [6.49 (4.32, 11.63) μmol/L] and DHEAS ratio [9.17 (4.49, 15.41)] in CD patients were significantly higher compared to those in NFA and ACS patients (all P<0.01). There were 53 ACS patients (82.8%) with suppressed ACTH level (<2.2 pmol/L) and 11 patients (17.2%) with normal/high ACTH level (≥2.2 pmol/L). The level of 24 hour urine free cortisol in normal/high ACTH level group was lower than the suppressed ACTH group [(1 299±511) nmol/24 h vs (1 972±876) nmol/24 h,P=0.04]. No significant differences were found in the DHEAS and DHEAS ratio between the two groups. ROC analysis showed that the area under the curve of serum DHEAS and DHEAS ratio in diagnosing ACS from CD was 0.997 and 0.990, respectively. The optimal cut-off values for DHEAS and its ratio were 2.06 μmol/L and 2.10, respectively. The diagnostic sensitivity and specificity of DHEAS were 97.5% and 100%, and those of DHEAS ratio were 95.0% and 100%, respectively.
There are significant differences in serum DHEAS level and DHEAS ratio between ACS and CD patients, which might be used as indicators for the identification of the two main CS etiologies, especially in the identification of ACS patients without plasma ACTH suppression from CD patients.
To analyze and summarize the clinical characteristics of primary aldosteronism (PA) with concurrent adrenal Cushing′s syndrome (ACS).
The clinical, imaging and pathological data of 87 patients with PA admitted to Peking University First Hospital from January 1st, 2013 to December 31th, 2016 were reviewed. There were 45 males (51.7%) and 42 females (48.3%) with an average age of (52.7±10.5) years (range: 15-70 years). According to whether they were diagnosed with ACS, the patients were divided into PA with concurrent ACS group (n=11) and pure PA group (n=55). The clinical characteristics of PA with concurrent ACS were summarized.
Ten of the eleven patients in PA with concurrent ACS group were diagnosed with subclinical ACS. Compared with these in pure PA group, the patients in PA with concurrent ACS group were older [(55.6±9.1) years vs (48.4±10.2) years, P=0.033], with larger diameters of adrenal tumors [(2.3±1.6) cm vs (1.4±0.6) cm, P=0.015], higher serum cortisol levels in the circadian rhythm [158 (92, 217) nmol/L vs 71 (43, 128) nmol/L at 0∶00, P=0.004], lower plasma adrenocorticotropic hormone (ACTH) levels in the circadian rhythm [0.80 (<0.22, 1.45) pmol/L vs 4.40 (2.58, 5.93) pmol/L at 8∶00,P<0.001; 0.25 (<0.22, 0.91) pmol/L vs 2.03 (0.74, 3.69) pmol/L at 16∶00,P<0.001;<0.22 (<0.22, 0.44) pmol/L vs 1.27 (<0.22, 2.66) pmol/L at 0∶00,P<0.001], and higher serum cortisol levels after 1 mg overnight dexamethasone suppression test [95 (73, 142) nmol/L vs 30 (22, 41) nmol/L, P<0.001]. Unilateral adrenalectomy was performed in 31 patients, of whom 3 patients in PA with concurrent ACS group (3/8) and 3 patients in pure PA group (3/23) presented with adrenal insufficiency and received glucocorticoid replacement therapy after adrenalectomy.
PA with concurrent ACS is not rare in PA patients, which are mainly complicated with subclinical ACS and easily misdiagnosed. It is recommended that elderly PA patients with large adrenal tumors should be screened for ACS by means of cortisol and ACTH circadian rhythm and 1 mg overnight dexamethasone suppression test. Postoperative adrenal insufficiency is prone to occur in those patients, who should be followed up closely after adrenalectomy, and receive glucocorticoid replacement therapy in time.
To examine the clinical characteristics and metabolic features of subclinical Cushing′s syndrome (SCS), and determine the effects of surgical or conservative approaches on the hormone levels and metabolic comorbidities in patients with SCS, thereby providing the evidence for decision-making in SCS management.
A total of 56 consecutive SCS patients were selected in Drum Tower Hospital Affiliated to Nanjing University Medical School between 2010 and 2018, with 41 patients undergoing surgical treatment and 15 patients receiving conservative therapy. Meanwhile, 56 and 68 cases of sex-and age-matched patients diagnosed as nonfunctional adrenal adenoma (NFA) and adrenal Cushing′s syndrome (CS) were included respectively. Clinical characteristics of patients in different groups were compared. Hormone levels and metabolic comorbidities were also observed during follow-up.
There were 56 SCS patients, including 15 males and 41 females, with an age of (52.0±12.6) years. The circadian rhythms of adrenocorticotropic hormone (ACTH) and cortisol disappeared in CS and SCS groups. Compared to NFA group, patients with SCS were characterized by suppressed plasma ACTH level [2.40 (1.11, 4.33) pmol/L vs 4.23 (2.74, 6.26) pmol/L], elevated midnight cortisol level [(240±121) nmol/L vs (59±8) nmol/L] and increased cortisol level after 1 mg overnight dexamethasone suppression test [(241±130) nmol/L vs (34±12) nmol/L] (allP<0.01). The derangement of ACTH-cortisol axis was more obvious in CS patients compared to SCS patients. The prevalence of hypertension, glucose intolerance, dyslipidemia and osteopenia/osteoporosis were higher in SCS patients compared to NFA patients (75.0% vs 41.1%, 33.9% vs 12.5%, 62.5% vs 28.6%, 35.7% vs 8.9%, all P<0.05). The 24-hour urine free cortisol correlated positively with systolic blood pressure, glycated hemoglobin A1c (HbA1c) and fasting blood glucose in SCS patients (r=0.335, 0.562 and 0.463, respectively, all P<0.05). In the surgical group, body weight, body mass index (BMI) and blood pressure decreased significantly after surgery (all P<0.05). Glucose intolerance/diabetes mellitus improved in 6 of 9 patients, BMI of 4 of 11 overweight/obesity patients normalized, and hypertension in 54.5% of patients (12/22) showed improvement after surgery. However, no alterations of hormone levels and metabolic parameters were observed in conservatively-managed patients.
Patients with SCS are characterized by mild autonomous cortisol secretion and increased risk of metabolic comorbidities. Compared with conservative management, hormone abnormalities were corrected and metabolic abnormalities were improved in some SCS patients after surgery.
To investigate the effect of antipsychotic medicine risperidone on prepulse inhibition of the startle reflex (PPI) and P50 deficit in patients with first-episode and chronic.
Thirty-eight patients with first-episode schizophrenia and 36 patients with chronic schizophrenia, both in acute stage, were enrolled in the study. All patients were treated with risperidone of different doses (2 to 6mg/d). All patients fulfilled the evaluation of PPI and P50 before treatment and 8 weeks after treatment. The psychotic symptoms were assessed with Positive and Negative Syndrome Scale (PANSS), and the therapeutic effects were evaluated with PANSS reduction rate.
(1) There was no significant difference in PPI and P50 parameters between the two groups before treatment (PPI ratio: first group 43%±29%, chronic group 42%±27%, P>0.05; P50 S2/S1 ratio: first group 83%±33%, chronic group 82%±24%, P>0.05). (2) There was no significant correlation between PPI and P50 inhibition parameters and disease course, psychotic episodes and psychiatric symptoms (PANSS total score, positive symptoms score, negative symptoms score and general psychopathology symptoms score) of schizophrenia (P>0.05). (3) Except the group main effect for S2 amplitude (F=5.75, P=0.019), there was no significant change for main effect and interaction of the other P50 and PPI inhibition ratio parameters after treatment (P50 S2/S1 ratio: first group before treatment 83%±33%, after treatment 85%±49%, P>0.05; chronic group before treatment 82%±44%, after treatment 84%±35%, P>0.05. PPI ratio: first group before treatment 43%±29%, after treatment 42%±27%; chronic group before treatment 42%±27%, after treatment 41%±28%,P>0.05). The effect of risperidone on P50 and PPI parameters was not related to the therapeutic effect.
Deficit in sensory gating inhibition exists in both first-episode schizophrenia and chronic schizophrenia, and risperidone is not effective in treating the deficit in sensory gating (PPI and P50) inhibition of schizophrenia.
To investigate the expression levels of programmed death protein 1 (PD-1)、T cell immunoglobulin domain and mucin domain 3(TIM-3)、lymphocyte activating gene 3 (LAG-3) and B and T lymphocyte attenuator (BTLA) in Diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS) and their effects on prognosis.
The paraffin specimens of 30 patients with DLBCL, NOS newly diagnosed in People′s Hospital of Zhengzhou University were stained with immunohistochemistry. The effects of single positive and co-expression of the above molecules on progression-free survival (PFS) phase and overall survival (OS) phase were analyzed.
There was no significant difference in prognosis between PD-1, TIM-3, LAG3, BTLA single positive group and single negative group. The median PFS phase of PD-1 and TIM-3 co-expression group and TIM3 and BTLA co-expression group were 26 and 24 months respectively, which were both lower than the 54 months (P=0.021) and 47 months (P=0.037) in non-co-expression group. The median PFS phase and OS phase of PD-1, TIM-3 and LAG-3 co-expression group were 17 and 25 months respectively, which were significantly lower than the 41 months (P=0.024) and 60 months (P=0.015) of non-co-expression group. The median PFS phase and OS phase of PD-1, TIM-3, LAG-3 and BTLA co-expression group were 18 and 26 months respectively, which were significantly lower than the 40 months (P=0.038) and 57 months (P=0.041) of non-co-expression group.
In patients with DLBCL, NOS, those with PD-1 and TIM-3 co-expression as well as those with TIM-3 and BTLA co-expression have poor PFS phase. Patients with PD-1, TIM-3 and LAG-3 co-expression and patients with PD-1, TIM-3, LAG-3 and BTLA co-expression have poor PFS and OS phase.
To analyze the safety and effectiveness of minimal invasive surgery treating pancreatic neuroendocrine tumors (pNETs), and to summarize surgical characteristics and share experience.
The clinical data of 80 pNETs treated by a single hospital from January 2015 to December 2019 were retrospectively analyzed. The patients were divided into laparoscopic group and robot group. And surgical procedures included pancreaticoduodenectomy (PD), distal pancreatectomy (DP), central pancreatectomy (CP), and tumor enucleation.
Of 80 patients, 76 cases (95%) underwent minimal invasive surgery and 4 cases (5%) changed to open surgery. There were 38 females, with median age of 54.4 (20-80) years and median BMI (17.0-38.0) kg/m2. Among them, 24 patients (31.6%) underwent PD, 36 patients (47.4%) underwent DP, 8 patients (10.5%) underwent CP and 8 patients (10.5%) received tumor enucleation. The postoperative incidence of grade B/C pancreatic fistula was 35.5%, the incidence of abdominal infection was 10.5%, the postoperative bleeding was 7.9%, and the reoperation rate was 6.6%, without perioperative deaths. There was no significant difference in postoperative complications among different surgical methods, including postoperative pancreatic fistula (P=0.396), postoperative bleeding (P=0.297), postoperative abdominal infection (P=0.339) and reoperation (P=0.396).
Surgical resection is an effective treatment for pNETs. pNETs are suitable for minimally invasive surgery with earlier stage and smaller tumor diameter. Minimally invasive surgery for pNETs is safe and feasible, and functional preserving surgery could take into consideration.
To explore the clinical value of robot-assisted laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair.
We performed a retrospective review of 23 consecutive patients who underwent robotic inguinal hernia repair from January 2018 to December 2019 at Beijing United Family hospital. The patients were all male with mean age 48.8 (17-72) years and BMI 25.8 (21.2-32.6)kg/m2. Data examined included perioperative bleeding, operative times, length of stay, pain scale ratings and postoperative complication.
There were no major complications during the surgeries including no significant intraoperative bleeding, injury to the vas deferens or major vascular structures. There were no conversions to open. No patients received prophylactic antibiotics according to our hospital policy. No surgical site infections were found. All patients were discharged home within the 24-hour postoperative period. The mean operating time of 13 cases of unilateral hernia was 121 (82-165) min, and that of 10 cases of bilateral hernia was 166 (100-315) min. The mean intraoperative blood loss was 13.3 ml (5-25 ml). The average pain score in recovery was 0.96 (0-3). The total length of stay was 28.4 (24.2-37.5) h. During a follow-up period of 3-18 months, none of the patients experienced a recurrent hernia. None experienced chronic pain or discomfort in the operative field.
The robotic surgical platform facilitates a new safe, minimally invasive approach to groin hernia. Because of improved ergonomics, visualization and wristed instrumentation, the robotic approach enabled creation of larger peritoneal flaps and had the potential for less injuries. The major advantage to the patient is a shorter hospital stay, and more rapid postoperative recovery and decreased postoperative pain, lower complications and recurrences.
Postoperative delirium is one of the most common postoperative complications in elderly patients, associated with postoperative neurocognitive impairment, prolonged hospital stay, and poor survival. But the relationship between postoperative delirium and long-term activities of daily living and mortality remains unclear. To clarify the effect of postoperative delirium on the long-term decline in activities of daily living and postoperative mortality, the study selected 130 patients over 65 years of age who underwent surgery for internal fixation of fractures under general anesthesia. Delirium was diagnosed by a fuzzy assessment algorithm before surgery and on the 1st, 2nd and 4th postoperative days, activities of daily living were assessed by the Chinese version of the Activities of Daily Living Scale (14 to 56 points), and preoperative cognitive function was assessed by the Brief Mental Status Examination Scale (0 to 30 points). Follow-up assessment was performed 24 to 36 months after surgery, including activities of daily living and mortality. The results showed that 34 (26%) of 130 patients developed delirium on the 1st, 2nd and 4th postoperative days after anesthesia and surgery. Patients with postoperative delirium were older and had more severe preoperative cognitive impairment than those without delirium. Patients with postoperative delirium had a greater decline in activities of daily living and a higher mortality rate at 36 months.
To investigate the prevalence of Crohn′s disease (CD) among urban employees in 24 provinces (municipalities and autonomous regions) in China in 2013.
The crude annual prevalence of CD among urban employees with medical insurance in 2013 was estimated by using the basic medical insurance database of 24 provinces (municipalities and autonomous regions), as well as the prevalence by sex, age and region. The age-standardized rate based on the 2010 census was also estimated.
The crude prevalence of CD among urban employees in 2013 was 3.2/100 000(95%CI:3.1/100 000-3.3/100 000) , and the sex-specific rate was 3.5/100 000 (95%CI:3.3/100 000-3.6/100 000) and 3.0/100 000 (95% CI:2.8/100 000-3.1/100 000) for male and female, respectively. The crude prevalence in different regions indicated that the highest crude prevalence was in the eastern region [5.6/100 000 (95% CI:5.4/100 000-5.8/100 000) ].
The prevalence of CD in China is still lower than that of the western countries, with difference varied in terms of age, gender and region.
The ultrasonographic characteristics of 9 patients with primary thyroid squamous cell carcinoma (PSCCT) in the First Hospital of Peking University from 1999 to 2019 were retrospectively analyzed. Nine patients with PSCCT, accounting for 0.23% (9/3 920) of primary thyroid cancer in the same period. There were 7 males and 2 females, aged 42-80 years, with a mean age of 57.1 years. A total of 10 masses were found in 8 patients with masses located in unilateral thyroid lobes, 3 of them extended to the isthmus, and 1 patient had one tumor in each lobe of the thyroid gland. The characteristics of PSCCT sonograms are summarized as follows: (1) the masses are large, mostly>2.0 cm (9/10); (2) All of them were hypoechoic in different degrees, with various types of hyperechoic, very hypoechoic areas and irregular vertical stripe attenuation zones mixed in hypoechoic zones, accompanied by calcification in 2 cases; (3) The morphology is irregular, 4 are lobulated, and 3 have an aspect ratio>1; (4) The boundary is blurry or partially unclear (6/10); (5) The rear echo can be enhanced, attenuated or unchanged; (6) Disordered arterial blood flow can be seen inside the mass; (7) Cervical lymph node involvement (4/9).
Acute fatty liver during pregnancy (AFLP) is a rare condition that occurs in the third trimester of pregnancy and has a high mortality rate in pregnant women and fetuses. This article reports a case of a young woman who had sudden hyperthermia at 38+6 weeks of intrauterine pregnancy. The symptoms did not improve after cesarean section. The main manifestations were right pleural effusion, progressive liver enlargement, impaired liver function and abnormal coagulation function. Because of the high proliferation of T lymphocytes found in pleural effusion many times, it was suspected that it was lymphoma. Later, AFLP was diagnosed by liver biopsy. After active anti-inflammatory and symptomatic supportive treatment, the condition improved, the liver function and coagulation function returned to normal, and the severely enlarged liver returned to normal. It is hoped that through this case, clinicians can deepen their understanding of the diagnosis and treatment of AFLP, and early diagnosis and active individualized treatment can improve the prognosis.
This article reports the diagnosis and treatment of a patient with type 1 human immunodeficiency virus (HIV-1) infection in the middle stage (clinical stage II) with severe thrombocytopenia as the first symptom, accompanied by gradual neutrophil decline, infection and hepatic impairment as the main clinical manifestations. It was shown that detection of the expression of HIV-1 core protein P24 on the surface of bone marrow hematopoietic cells can be used as a diagnostic method in the window period of HIV-1 infection.
This article reports two patients with high clinical suspicion of tuberculosis infection, but the disease progressed after quadruple anti-tuberculosis treatment for more than 2 months. Finally, the diagnosis was confirmed by surgical biopsy, and the anti-tuberculosis treatment was adhered to, and the disease improved after prolonging the course of treatment and combined medication.
Cases of intramural accessory spleen are rare in clinical practice. This article reviews the clinical data of a patient with intramural accessory spleen, including gastroscopy, endoscopic ultrasound, CT and other imaging findings. The patient successfully underwent endoscopic submucosal excision (ESE) and was diagnosed with accessory spleen based on intraoperative specimen findings and pathological and immunohistochemical results. This case reminds clinicians that for patients with a history of spleen surgery or trauma, if the gastric submucosal bulging lesions are similar to the spleen under endoscopic ultrasound, the possibility of accessory spleen should be considered to avoid unnecessary surgery.
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