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2023 Vol. 14, No. 4

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Editorials
Current Status and Future Prospects of Theranostics with Radiopharmaceuticals
LUO Yaping, LI Fang
2023, 14(4): 669-672. doi: 10.12290/xhyxzz.2023-0236
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Nuclear medicine is a novel technique of theranostics that uses radiopharmaceuticals. Nuclear medicine dated back to a century ago. Owing to the development of nuclear medicine devices and radiopharmaceuticals, increasing clinical demand, government support, and global cooperations, nuclear medicine has witnessed a rapid development. Nowadays, nuclear medicine has played an important and unique role in diagnosis and therapy. There are opportunities and challenges in future development of nuclear medicine, and more progress will be made in nuclear medicine imaging, radionuclide therapy, and artificial intelligence.
Parallel Doctors and Parallel Hospitals: Impact and Perspective of ChatGPT-like AIGC and AGI on Medicine and Medicare
WANG Feiyue
2023, 14(4): 673-679. doi: 10.12290/xhyxzz.2023-0220
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Issues related to the impact of ChatGPT-like artificial intelligence generated content (AIGC) and artificial general intelligence (AGI) technologies on medicine and medicare have been presented and discussed. We believe that advances in medical foundation models, scenarios engineering, and medical operations with operating systems would lead to parallel doctors in parallel hospitals, i.e., digital, robotic, and human doctors working in parallel within cyber-physical-social spaces under three modes: autonomous, parallel, and expert/emergency operations. Under decentralized/distributed autonomous organizations/operations (DAO) and DeSci, as well as DeMed and DeHospitals, the vision for individual patients with her/his personalized digital hospital could be a reality in the future.
Specialist Forum
Advances in Synergistic Antitumor Effects of Radiopharmaceuticals Combined with Immune Checkpoint Inhibitors
ZENG Xinying, WEN Xuejun, GUO Zhide, ZHANG Xianzhong
2023, 14(4): 680-690. doi: 10.12290/xhyxzz.2023-0159
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Targeted radionuclide therapy (TRT) provides an immunogenic microenvironment for immune checkpoint inhibitor (ICI) therapy by inducing DNA double-strand break, activating the cGAS-STING, NF-κB/IRF3 and STAT1/3-IRF1 pathways, up-regulating the expression of PD-L1, and increasing the infiltration of pro-inflammatory cytokines, CD8+ T cells and CD4+ T cells in tumors. The combined therapy could increase the infiltration of memory effector T cells, M1 macrophages and dendritic cells which positively regulate immune response, and downregulate immunosuppressive regulatory T cells, M2 macrophages and myeloid-derived suppressor cells. Partial complete remission and immune memory were achieved in tumor-bearing mice treated with combined therapy. It is worth noting that radiodiagnostic agent 2-[18F]FDG combined with anti-PD-L1 mAb could also reprogram the immune microenvironment and significantly improve therapeutic effect. This review presents typical combination therapy strategies, emphasizes the time window of combination therapy and different combinations of therapy that may improve the therapeutic effect, and proposes that radiodiagnostic agents combined with tumor immunotherapy are expected to become a new paradigm and a direction for further research in the future.
Recent Advance in SPECT Myocardial Perfusion Imaging and Their Clinical Application Values
MA Tianyu, ZHANG Debin, WANG Rui, CHENG Li
2023, 14(4): 691-697. doi: 10.12290/xhyxzz.2023-0172
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Myocardial perfusion single photon emission computed tomography (SPECT) imaging is an important routine diagnostic modality for coronary artery disease. In recent years, there have been continuous advancements in cardiac SPECT imaging instrument technology and image algorithm techniques, with a growing focus on quantitative assessment of myocardial blood flow, a research hotspot that integrates technical and clinical research. This article provides an overview of the development path of cardiac SPECT systems in terms of detector technology, system structure, collimation techniques, as well as SPECT image reconstruction algorithms and myocardial blood flow quantification methods. We briefly discuss the recent research hotspots and progress, highlighting the clinical value enhancement made possible by advancements in instrument technology.
Principles and Clinical Applications of Boron Neutron Capture Therapy
LIU Zhikai, CHENG Weishi, WU Wangsuo, LIANG Tianjiao, XING Qingzi, ZHANG Zizhu, LIU Zhibo, LIU Yuanhao, PAN Jianji, ZHU Shaihong, LI Qingnuan, ZHANG Fuquan, QIU Jie, HUO Li
2023, 14(4): 698-705. doi: 10.12290/xhyxzz.2023-0120
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Boron neutron capture therapy (BNCT) is an advanced radiation therapy technique that is rapidly developing in the field of cancer treatment. This technique, an atomic-level binary targeted therapy, kills cancer cells by causing a 10B(n, α)7Li nuclear reaction within the cancer cells, and its clinical implementation requires professional technology and device support. The core elements of BNCT include appropriate neutron sources and neutron capture drugs. Compared with traditional radiotherapy techniques, BNCT shows outstanding advantages in treating locally recurrent tumors, such as central nervous system tumors and head and neck tumors. Furthermore, it can better protect normal organs, especially for tumors that have already significantly invaded surrounding organs, demonstrating its promising future prospects. This article mainly elaborates on the technical principles, core elements, and clinical applications of BNCT, in hope of providing reference for clinical diagnosis and treatment.
The Standard for Diagnosis and Treatment of Chinese Colorectal Cancer（2023 Version）
General Office of National Health Commission of the People's Republic of China, Oncology Branch of the Chinese Medical Association
2023, 14(4): 706-733. doi: 10.12290/xhyxzz.2023-0315
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Guideline and Consensus
2023 Chinese Expert Consensus Statement for Prevention and Management of Perioperative Hypothermia
National Center for Quality Assurance of Anesthesia
2023, 14(4): 734-743. doi: 10.12290/xhyxzz.2023-0266
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The 2023 Chinese Expert Consensus Statement for Prevention and Management of Perioperative Hypothermia is an update of the 2017 Chinese Expert Consensus Statement for Prevention and Management of Perioperative Hypothermia. It is intended to provide patient-centric recommendations for clinicians to prevent and manage inadvertent hypothermia. It offers advice on assessing patient's risk of hypothermia, measuring and monitoring temperature as well as preventing patients from hypothermia before, during and after surgery. It also provides new evidence on hypothermia and adverse outcomes, and temprature management for special patients care considerations including pediatric, pregnancy, trauma, liver transplantation and sepsis.
Expert Consensus for the Diagnosis and Treatment of Bartter Syndrome in China(2023)
Chinese Society of Rare Diseases, Rare Diseases Society of Chinese Research Hospital Association, National Rare Diseases Committee, Beijing Rare Disease Diagnosis, Treatment and Protection Society
2023, 14(4): 744-757. doi: 10.12290/xhyxzz.2023-0207
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Bartter syndrome (BS) is a rare inherited salt-losing renal tubular disorder characterized by secondary hyperaldosteronism with hypokalemia and hypochloremic metabolic alkalosis, and normal or low blood pressure. In severe cases, preterm delivery, hypovolemia, ventricular arrhythmia, rhabdomyolysis, renal failure, growth failure and sensorineural deafness may occur. In recent years, research on BS has made significant progress. The Bartter Syndrome Consensus Working Group has performed a systematic literature review, and based on evidence-based medicine, summarized aspects related to BS, including clinical manifestations and classification, diagnosis, treatment strategies, and management of complications. This consensus provides an important reference for the better diagnosis and treatment of BS.
Original Contributions
Relationship Between Pharmacokinetic Parameters and Imaging Duration in Dynamic 11C-Acetate Cardiac PET/CT
GONG Tan, SHANG Fei, TANG Xiaoying, HUO Li, LIU Shuai
2023, 14(4): 758-765. doi: 10.12290/xhyxzz.2023-0121
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  Objective  To evaluate the effect of imaging time on the pharmacokinetic parameters calculation of dynamic 11C-acetate cardiac positron emission tomography (PET) scan and to investigate the feasibility of shortening the imaging time in clinical practice.  Methods  This study was a retrospective analysis and 46 subjects who underwent 11C-acetate PET/CT cardiac imaging at Peking Union Medical College Hospital (from a clinical study assessing myocardial tissue and metabolic characteristics in men with alcohol consumption) were included. Each subject was injected with 740 MBq 11C-acetate before a 40-minute PET/CT scan, and time-activity curve in the left ventricle was collected as input function. Pharmacokinetic parameters (K1 and k2) calculated from the 40-minute dynamic data (53 frames) was regarded as the reference standard. The number of included dynamic image frames was sequentially reduced from the last frame, and the corresponding pharmacokinetic parameters of 11C-acetate were calculated. Correlation, consistent analysis of trends and the relative differences on pharmacokinetic parameters between shortened data and reference standard were evaluated. The shortest acceptable scan time was determined based on the criterion that the R2 of linear regression models was higher than 0.9 in all myocardial segments.  Results  The R2 between 11C-acetate pharmacokinetic parameters and the reference standard was higher than 0.9 in all myocardial segments at scan time ≥17 min (37 frames) for both K1 and k2. The regression coefficients of K1 values calculated from the shortened data and the reference standard in myocardium were distributed in the range of 0.982-1.007, and the regression coefficients of k2 values calculated from the shortened data and the reference standard were distributed in the range of 0.783-1.000. When the scan time was reduced to 17 min (37 frames), the K1 and k2 values of left anterior descending branch, right coronary artery and left circumflex branch perfusion regions were significantly different from the reference standard (all P < 0.05). Left anterior descending branch perfusion region had the highest relative difference (RD) [K1: (3.93±1.98)%; k2: (13.79±6.40)%], while right coronary perfusion region had the lowest RD [K1: (2.84±1.89)%; k2: (9.74±5.62)%].  Conclusions  For the male population with alcohol consumption or are healthy, shortening the scan time to 17 min (37 frames) during dynamic 11C-acetate PET/CT cardiac imaging can obtain tracer pharmacokinetic parameters consistent with the reference standard, which can provide references for optimizing clinical image acquisition time.
Integrin αvβ3 Targeted Radiopharmaceutical 99mTc-RGD Combined with Anti-PD-L1 mAb to Enhance the Anti-tumor Effect in Tumor Immunotherapy
WEN Xuejun, ZHOU Wuhao, GUO Zhide, ZHANG Xianzhong
2023, 14(4): 766-773. doi: 10.12290/xhyxzz.2023-0155
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  Objective  To investigate the effect of 99mTc-labeled RGD peptide (99mTc-RGD) on regulating the tumor immune microenvironment and enhancing the anti-tumor effect of immunotherapy when combined with anti-programmed death-ligand 1 (PD-L1) antibody.  Methods  The expression of PD-L1 on tumor cells was detected by flow cytometry, and the distribution of 99mTc-RGD in MC38 tumor mice was evaluated using single photon emission computed tomography(SPECT) imaging. The combination therapy was performed to monitor the anti-tumor effect.  Results  The expression of PD-L1 on CT26, MC38, 4T1 and B16F10 tumor cells was upregulated after being induced by 99mTc-RGD, and there was a statistical significance between 99mTc-RGD treated and untreated groups. Subsequently, SPECT imaging was performed by injecting 99mTc-RGD into MC38 tumor-bearing mice, and significant tumor uptake was observed. Based on this, the combination of 99mTc-RGD and anti-PD-L1 antibody in MC38 tumor mice was studied, and the results showed that different doses and time windows had significant effects on the efficacy of the combination therapy. The combination of 18.5 MBq or 37 MBq 99mTc-RGD with an anti-PD-L1 antibody led to the best therapeutic effect at 4 h intervals.  Conclusions  99mTc-RGD could induce the upregulation of tumor PD-L1 expression, and when combined with an anti-PD-L1 antibody, it could enhance the anti-tumor effect.
Clinical Values of 99mTc-MIBI Pinhole Dual-phase and Parallel-hole SPECT/CT for Preoperative Localization in Patients with Primary Hyperparathyroidism
LIU Yimin, CHEN Libo, LIU Yu, WANG Zhenghua, HU Nan, LI Congxin, ZHU Shikun, ZHANG Zheng, JING Hongli, HUO Li
2023, 14(4): 774-780. doi: 10.12290/xhyxzz.2023-0164
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  Objective  To evaluate the clinical values of preoperative 99mTc-methoxyisobutylisonitrile (MIBI) pinhole collimator duplex imaging versus parallel-hole collimator single photon emission computed tomography (SPECT)/CT tomography fusion imaging in the preoperative localization of primary hyperparathyroidism (PHPT).  Methods  In this diagnostic test, the patients with suspected PHPT in Peking Union Medical College Hospital from July 2021 to February 2022 were retrospectively analyzed. With postoperative histopathology as the gold standard, the sensitivity, accuracy, and positive predictive value of 99mTc-MIBI pinhole collimator duplex imaging and parallel-hole collimator SPECT/CT tomographic fusion imaging for the detection of PHPT lesions were calculated, and the effect of parathyroid hormone (PTH) on the detection of PHPT lesions by these two diagnostic methods was analyzed.  Results  A total of 135 patients with suspected PHPT on 99mTc-MIBI parathyroid imaging were enrolled. A total of 149 lesions were detected on 99mTc-MIBI pinhole collimator diachronic imaging (including 1 ectopic lesion) and 148 lesions were detected on parallel-hole collimator SPECT/CT tomographic fusion imaging (including 11 ectopic lesions; 1 true positive lesion was a fusion of 2 lesions that could not be distinguished by this method). The sensitivity (79.9% vs. 74.8%, P=0.326), accuracy (79.2% vs. 75.7%, P=0.490) and positive predictive value (98.3% vs. 100%, P=0.499) of the two methods for detecting PHPT lesions were not significantly different. In the subgroups with PTH≤150 ng/L and PTH>150 ng/L, the sensitivity (79.1% vs. 80.5%, P=0.838), accuracy (77.5% vs. 80.8%, P=0.688), and positive predictive value (96.4% vs. 100%, P=0.219) of 99mTc-MIBI pinhole collimator diachronic imaging in detecting PHPT lesions were not significantly different; the sensitivity (71.6% vs. 77.6%, P=0.445), accuracy (73.2% vs. 77.9%, P=0.567), and positive predictive value (100% vs. 100%, P> 0.999) of SPECT/CT fusion imaging were also not significantly different.  Conclusions  Both 99mTc-MIBI pinhole collimator parathyroid duplex imaging and parallel-hole collimator SPECT/CT tomographic fusion imaging have good diagnostic ability for PHPT and are not significantly affected by changes in PTH levels. Due to the high resolution of 99mTc-MIBI pinhole collimator parathyroid duplex imaging, it is still an important basis for preoperative localization and diagnosis of PHPT, while parallel-hole collimator SPECT/CT tomographic fusion imaging has obvious advantages for the diagnosis of ectopic PHPT and is recommended in some special cases.
Characteristics of 99mTc-MDP Whole-body Bone Scintigraphy in Erdheim-Chester Disease
MA Yanru, NIU Na, CAO Xinxin, LI Yi, JING Hongli, LIU Yu, CHEN Libo
2023, 14(4): 781-786. doi: 10.12290/xhyxzz.2023-0162
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  Objective  To summarize the features of 99mTc-methylene diphosphonate (MDP) whole-body bone scintigraphy (WBBS) in Erdheim-Chester disease (ECD) patients and to provide insights for clinical diagnosis and treatment.  Methods  Retrospective analysis was performed in ECD patients with bone lesion who underwent 99mTc-MDP WBBS at Peking Union Medical College Hospital from January 2015 to December 2022.The bone involvement sites and characteristic features in99mTc-MDP WBBS were summarized, and the correlation between bone lesion scores and bone metabolic biomarkers was analyzed.  Results  A total of 44ECD patients with bone involvement were included in the study.According to the 99mTc-MDP WBBS, the most commonly affected sites were the bones of the extremities (100%, 44/44), skull and maxillofacial bones (84.1%, 37/44), and appendicular bones (65.9%, 29/44), while involvement of the ribs and sternum (38.6%, 17/44) and spine (29.5%, 13/44) were less frequent.Bilateral and symmetric change of the lesions was an important feature of 99mTc-MDP WBBS in ECD.The proportion of patients with bilateral and symmetric bone lesions in the extremities, maxillofacial area, and clavicle was relatively high, particularly in the lower extremities (100%).In extremity bone lesions, there was mostly joint involvement of diaphysis and metaphysis, and 81.8%(36/44) patients demonstrated the typical scintigraphic characteristic: bilateral and symmetrical increased uptake in the distal femur and proximal tibia.The maxillofacial lesions mainly presented with focal uptake increase in the region of the paranasal sinuses, with or without diffuse increased uptake in the mandible-Lincoln sign (61.1%, 22/36).Spearman correlation analysis revealed that the bone metabolic biomarkers such as blood calcium, blood phosphate, alkaline phosphatase, and parathyroid hormone were not linearly correlated with bone lesion scores (all P>0.05).  Conclusions  ECD can cause multiple bone lesions, with involvement typically observed in the extremities, particularly in the lower extremities.Lesions in the skull and maxillofacial area are also frequently observed.Bilateral and symmetric uptake increase in the distal femur and proximal tibia is the most pathognomonic manifestation of 99mTc-MDP WBBS, providing valuable information for diagnosing and differentiating ECD.
PSMA and 18F-FDG PET Imaging in the Treatment of Metastatic Prostate Cancer with 223Ra: Initial Application and Experience
HU Guilan, TIAN Jian, LI Yongqiang, JI Zhigang, HUO Li, CHEN Yonghui
2023, 14(4): 787-794. doi: 10.12290/xhyxzz.2023-0152
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  Objective  To share our experience of the use of prostate specific membrane antigen (PSMA) and/or 18F-fluoroodexyglucose (18F-FDG) positron emission tomography (PET) in the setting of radium-223 dichloride (223Ra) in treatment of bone metastases of prostate cancer in order to broaden the know-ledge of application of 223Ra in China.  Methods  Retrospective analysis was conducted for the patients with advanced prostate cancer treated with 223Ra in Peking Union Medical College Hospital between September 2021 to January 2023.The treatment outcomes and survival status were recorded.Characteristics of bone scans and PET imaging (including PSMA PET and/or 18F-FDG PET) before and after treatment were summarized.  Results  Nine patients were enrolled (2 additional patients were excluded for the reason of visceral metastases confirmed by pretreatment PET imaging), among whom 8 patients had metastatic castration resistant prostate cancer and 1 had metastatic hormone-sensitive prostate cancer.In total the 9 patients received 36 doses of 223Ra, and the numbers of patients receiving 6, 5, 4, 2, and 1 doses were 3, 1, 2, 2, and 1, respectively.At the middle or end of treatment, there was 1 case of partial remission, 1 case of stable disease, 6 cases of progressive disease, and 1 case was switched to endocrine therapy after 1 shot of 223Ra treatment so that the efficacy was not evaluated.At the time of the last follow-up (March 15, 2023), among the 9 patients, 4 died (1 due to heart failure and 3 due to disease progression) and 5 survived.For patients who died or with progressive disease, there was an inconsistency between the metastases shown on baseline PET images and bone scans, with the former modality revealing more bone metastases.PET imaging especially PSMA PET was more accurate than bone scan in assessing response and could avoid bone scintillation.  Conclusions  PSMA PET and/or 18F-FDG PET could help detect visceral metastases and assist in patient screening.The inconsistency between baseline PET images and bone scan images suggests a worse outcome of 223Ra treatment.During the efficacy evaluation process, PSMA and/or 18F-FDG PET (especially PSMA PET) also outperforms bone scan.
SPECT/CT in Localization of Sentinel Lymph Node of Skin Tumors
ZHU Shikun, ZHANG Shu, LUO Yaping
2023, 14(4): 795-801. doi: 10.12290/xhyxzz.2023-0170
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  Objective  Sentinel node lymphoscintigraphy and biopsy is an essential procedure in theranostics of skin tumors.The aim of this study is to determine the role of SPECT/CT in localization of sentinel lymph node of skin tumors.  Methods  This study retrospectively reviewed the sentinel node lymphoscintigraphy and biopsy data in patients with skin tumors diagnosed in Peking Union Medical College Hospital from April 2019 to February 2023, and analyzed the role of SPECT/CT in sentinel lymphoscintigraphy.  Results  Thirty-seven patients were retrospectively enrolled.The primary skin tumor included melanoma (32 patients), squamous cell carcinoma (3 patients), and basal cell carcinoma (2 patients).The sentinel nodes localized in inguinal (23 patients), popliteal (2 patients), axilla (8 patients), trochlea (2 patients), and parotid/periauricular regions (2 patients).Sentinel lymph nodes were localized by SPECT/CT in 36 cases (one patient only underwent planar dynamic imaging).SPECT/CT detected multiple focus in the lymphatic drainage in 16 patients, and in 13 patients they were confirmed to be local retention of the tracer in the lymphatic duct instead of the sentinel lymph node, suggesting false positive uptake.Thirty-four patients underwent sentinel node biopsy 1-4 h after localization, and localization of the sentinel node was consistent with preoperative sentinel node lymphoscintigraphy.Sentinel node biopsy found nodal metastasis in 6 patients (all of them had melanoma in the foot or lower limb).  Conclusions  Sentinel node lymphoscintigraphy is an important step for localization before sentinel node biopsy.SPECT/CT can help improve the accuracy of localizing sentinel lymph node.
Preliminary Efficacy of Combined Laparoscopy and Cystoscopy in the Treatment of Bladder Diverticula
WEI Mengchao, WANG Wenda, WANG Shijun, ZHANG Zhijun, WEN Jin
2023, 14(4): 802-807. doi: 10.12290/xhyxzz.2023-0044
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  Objective  To exploratively analyze the efficacy and safety of combined laparoscopy and cystoscopy in the treatment of bladder diverticula.  Methods  Clinical data of patients who received bladder diverticulectomy in Peking Union Medical College Hospital from March 2007 to September 2022 were retrospectively collected.The patients were divided into open/laparoscopy alone group and combined laparoscopy and cystoscopy group based on surgical approach.Surgery-related outcomes and complication rates were compared.  Results  A total of 11 patients with bladder diverticula who met the inclusion and exclusion criteria were enrolled in thestudy, including 6 patients in the open/laparoscopy alone group and 5 patients in the combined laparoscopy and cystoscopy group.The median maximum diameter of diverticula in the open/laparoscopy alone group and combined laparoscopy and cystoscopy group were 7.5(4.5, 11.5) cm and 5.2(5.0, 7.9) cm, respectively, and the median diameter of diverticula neck were 1.1(1.0, 1.6) cm and 1.5(1.1, 1.8) cm, respectively.Operations were successfully performed in both two groups and the patients had normal urination after drawing the catheter.No recurrence of bladder diverticulum at 6 to 60 months of follow-up.The median operative time[150.0(142.5, 180.0) min vs. 160.0(108.8, 300.0) min], blood loss[50.0(35.0, 50.0) mL vs. 50.0(45.0, 62.5) mL]and indwelling time of drainage tube[5.0(3.5, 5.5) d vs. 4.5(4.0, 6.8) d]were similar between the two group.Compared to the open/laparoscopy alone group, the combined laparoscopy and cystoscopy group had a shorter postoperative hospital stay[6.0(6.0, 8.5) d vs. 9.5(7.0, 16.0) d]and longer indwelling time of urinary catheter[14.0(10.5, 14.0) d vs. 11.5(6.5, 13.3) d].No complications occurred in the combined laparoscopy and cystoscopy group.In the open/laparoscopy alone group, 2 patients underwent postoperative complications, including 1 patient with deep vein thrombosis of the lower extremities and 1 patient with hyperpyrexia.  Conclusion  Preliminary results show that cystoscopy combined with laparoscopic resection for bladder diverticula can achieve similar outcomes as open surgery alone or laparoscopic surgery, and with greater safety and faster postoperative patient recovery.
Clinical Application of Follicular Unit Extraction in Androgenetic Alopecia
WANG Fang, CHEN Ying, LEI Huibin, ZHANG Huifeng, HE Jie, LI Meng, LEI Ting, ZHANG Wei
2023, 14(4): 808-813. doi: 10.12290/xhyxzz.2022-0716
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  Objective  To explore the clinical application of follicular unit extraction (FUE) hair transplantation in male androgen alopecia (AGA).  Methods  From August 2016 to September 2018, male AGA patients operated with FUE hair transplantation in the First Affiliated Hospital of Xi'an Medical University were retrospectively analyzed.At one year after transplantation, clinical curative effect was evaluated by the survival hair density and follicles rate of FUE transplantation, meanwhile surgical complications, patient satisfaction rate and life quality score were measured and analyzed.  Results  A total of 126 male AGA patients who met the inclusion and exclusion criteria were included, with average age was (37±9.05) years and average disease course was (10±2.76) years.According to the Hamilton-Norwood grade standard, there were 5 grade Ⅱpatients, 55 grade Ⅲ patients, 54 grade Ⅳ patients, 10 grade Ⅴ patients, and 2 grade Ⅵ patients.At one year after transplantation, viable hair density on the anterior hairline and the top of the head was (65±7) FUs/cm2 and (43±4) FUs/cm2, respectively.The survival rate of hair follicles was more than 90%, even more than 95% among the 107 AGA patients.The effective rate was 100%(126/126), no serious complications occurred, and the satisfaction rate of patients was 97.6%(123/126).Besides, the scores of physical function, psychological function, social function and material life status of 126 AGA patients were significantly increased than those before transplantation (all P < 0.01).  Conclusions  FUE hair transplantation has significant clinical effect, and is highly safe and effective.With the potential to dramatically improve life quality, it can be widely applied in treatment of AGA.
Comparison of the Risk of Perioperative Blood Loss in Hemophilic Arthritis and Initial Total Hip Arthroplasty for Femoral Head Necrosis under Multimodal Blood Management Measures: A Retrospective Cohort Study
CHEN Bo, XU Yimin, PENG Huiming, FENG Bin, LIU Guanmo, WANG Xueqing, WENG Xisheng
2023, 14(4): 814-819. doi: 10.12290/xhyxzz.2023-0009
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  Objective  To compare the perioperative blood loss and risk of allogeneic transfusion between hemophilia arthritis (HA) patients and osteonecrosis of the femoral head (ONFH) patients undergoing unilateral total hip arthroplasty (THA) under multimodal blood management measures.  Methods  Clinical data of HA patients treated with unilateral THA from January 2010 to June 2022 and ONFH patients matched 1:3 by gender were retrospectively collected at Peking Union Medical College Hospital, and the differences in indicators related to perioperative blood loss and complication rates were compared between the two groups.  Results  A total of 26 patients with HA and 76 patients with ONFH who met the inclusion and exclusion criteria were enrolled.Compared with ONFH patients, the total blood loss[(1927.08±956.59) mL vs.(1475.88±924.43) mL, P=0.036], major bleeding rate (38.46%vs. 14.47%, P=0.009), allogeneic transfusion rate (15.38%vs. 3.95%, P=0.046), and complication rate (34.62%vs. 7.89%, P=0.000) in HA patients were higher, and postoperative day 3 hemoglobin[(112.94±12.26) g/L vs.(117.40±11.17) g/L, P=0.000]and hematocrit[(29.44±7.96)%vs.(32.80±5.52)%, P=0.019]were lower.  Conclusion  The risk of perioperative blood loss and allogeneic transfusion is higher in HA patients treated with unilateral THA than in ONFH-THA patients, and further optimization of blood management strategies is needed.
Occupational Factors Associated with Breastfeeding Continuation after Maternity Leave Among Female Anesthesia Residents in China
XU Xiaohan, ZHANG Jiao, YU Xuerong, LI Xu, HUANG Yuguang
2023, 14(4): 820-825. doi: 10.12290/xhyxzz.2023-0165
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  Objective  To analyze the current status and occupational factors associated with breastfeeding continuation after maternity leave among female anesthesia residents in China.  Methods  Our study was based on a nationwide survey "Breastfeeding and Work/Family Balance Among Female Anesthesiologists" conducted by Chinese Society of Anesthesiology, which was targeted to female anesthesia residents giving birthsince January 1, 2015.An anonymous online questionnaire was developed to collect basic information, breastfeeding practices and workload.The inclusion variables were screened using the akaike information criterion (AIC), with the event defined as "termination of breastfeeding".Occupational factors that may affect breastfeeding were included as explanatory variables and non-occupational related factors that may affect breastfeeding were also included in the model to adjust for potential confounding effects.Schoenfeld were used to assess whether the variables were satisfied for each explanatory variable, and for those that were not, the time-dependent covariate for that variable was added to the model, occupational factors affecting breastfeeding duration were analyzed using stepwise Cox regression.  Results  A total of 436 anesthesia residents from 29 provinces were included.According to the survey, 372(85.3%, 372/436) terminated breastfeeding, of which 268(72.0%, 268/372) ended breastfeeding early due to work, 419(96.1%, 419/436) significantly reduced breast milk after work, and 133(30.5%, 133/436) had no opportunity to breastfeed at work.Their median breastfeeding duration was 10(8, 12) months.Longer work experience at childbirth was associated with a higher risk of discontinuing breastfeeding (HR=1.09, 95% CI: 1.03-1.15, P=0.004).The following occupational factors were associated with a longer breastfeeding duration: prolonged maternity leave (HR=0.85, 95% CI: 0.78-0.93, P < 0.001), tertiary hospital (HR=0.56, 95% CI: 0.43-0.73, P < 0.001), more opportunities for breast pumping during worktime (HR=0.02, 95% CI: 0-0.08, P < 0.001) and reduced workload during the breastfeeding period (HR=0.47, 95% CI: 0.26-0.86, P=0.014).  Conclusion  Hospital administrators can make efforts to offer prolonged maternity leave, modified rotation plan, breastfeeding rooms, and breastfeeding breaks, which are beneficial to both maternal and fetal health.
Reviews
Advances in the Pathogenesis of Type Ⅰ Autoimmune Pancreatitis
LIU Yixiao, YANG Yingyun, YANG Aiming
2023, 14(4): 826-832. doi: 10.12290/xhyxzz.2022-0517
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Type Ⅰ autoimmune pancreatitis (AIP) is a type of pancreatitis with a predominantly inflammatory and fibrotic nature and is an IgG4-related disease. The pathogenesis of type Ⅰ AIP is still poorly understood, but it is generally believed that it is the result of a combination of genetic, environmental, and immune factors. In recent years, many advances have been made in the cellular and molecular mechanisms of the pathogenesis of type Ⅰ AIP. Therefore, this article aims to review the research progress of the pathogenesis of this disease from the immunological perspective.
Relationship and Potential Mechanism Between Helicobacter Pylori Infection and Non-alcoholic Fatty Liver Disease
CHEN Danni, WANG Shiling, LU Hong, ZHENG Ya, WANG Yuping, REN Qian
2023, 14(4): 833-838. doi: 10.12290/xhyxzz.2022-0710
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Since people's lifestyles have changed, non-alcoholic fatty liver disease (NAFLD) has emerged as the most prevalent liver condition globally. It can progress to cirrhosis and hepatocellular carcinoma (HCC), both of which pose major risks to people's health. Currently, the treatment of NAFLD is still based on lifestyle modification, glycemic and lipid control, and other risk factors, and there are no effective therapeutic drugs. Therefore, it is important to study the pathogenesis of NAFLD. Recent studies have shown that Helicobacter pylori (HP) infection is associated with the development of NAFLD, and HP infection may contribute to the development of NAFLD by inducing insulin resistance, altering the lipid profile, promoting oxidative stress, changing intestinal permeability, and regulating gene expression. Therefore, this paper reviews the correlation between HP infection and NAFLD and the potential pathogenesis of NAFLD due to HP infection, with the aim of providing new ideas for the diagnosis and treatment of NAFLD.
Research Progress of Prostate Cancer Somatic Mutation and Treatment
WU Liyi, YAN Weigang
2023, 14(4): 839-843. doi: 10.12290/xhyxzz.2022-0717
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Prostate cancer, one of the most common male malignancies in the world, seriously threatens the health of middle-aged and elderly men. The clinical manifestations and prognosis of prostate cancer patients have individual differences. Most low-risk patients have a slow disease course and a low risk of death, while intermediate- and high-risk patients have a poor prognosis and a high risk of death. Current studies have shown that prostate cancer genes have complex genetic heterogeneity associated with clinical manifestations and somatic mutation is an important part of prostate cancer genome variations. With the development of high-throughput sequencing technology, related research is increasing. This article reviews the research progress on somatic mutations in prostate cancer and treatment to provide reference for prognosis prediction and drug treatment of the disease.
Excitatory-inhibitory Imbalance and Autism Spectrum Disorder: Mechanism and Treatment Progress
SHI Yue, ZHU Bo, HUANG Yuguang
2023, 14(4): 844-849. doi: 10.12290/xhyxzz.2023-0174
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Autism spectrum disorder (ASD) is becoming one of the fastest growing neurodevelopmen-tal disorders around the world, yet its clinical treatment still faces challenge due to the heterogeneity in etiology and symptom phenotypes. It is believed that excitatory-inhibitory (E-I) imbalance in the central nervous system may play an important role in the pathogenic mechanisms of ASD. E-I imbalances in synaptic transmission and neural circuits are frequently observed in different animal models of ASD, and the corresponding reversion normalizes the autism-like behaviors in these animals. Some E-I modulators have been tested for their therapeutic potential on ASD patients with encouraging results. This article expounds the mechanism of E-I imbalance in ASD and E-I imbalance regulators treatment progress, to provide new insights on the therapeutic targets for ASD.
Research Progress of Bathing in Pediatric Atopic Dermatitis
LIU Zhengqiang, YU Hong
2023, 14(4): 850-854. doi: 10.12290/xhyxzz.2022-0427
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Atopic dermatitis (AD) is a common chronic inflammatory skin disease characterized by recurrent eczematous lesions with dry skin and refractory pruritus. The pathogenesis of AD is complex and one of the reasons may be related to the skin microbial environment. Multiple studies have found that bathing may be associated to skin barrier function and different bathing method may affect the severity of AD. This paper focuses on the bathing method of children with AD as well as the cleansers, and reviews relevant guidelines and evidence-based medicine.
Complicated and Rare Disease
Secondary Lymphedema of Both Lower Extremities Complicated with Pretibial Myxedema: A Case Report
HAO Kun, SUN Yuguang, LI Bin, XIN Jianfeng, ZHANG Li, YU Chunkai, WANG Rengui, SHEN Wenbin
2023, 14(4): 855-858. doi: 10.12290/xhyxzz.2022-0671
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Abstract:
This paper reports a case of rare secondary lymphedema with pretibial myxedema, which was diagnosed as secondary lymphedema of both lower extremities by completing a comprehensive examination of the lymphatic system. After partial resection and biopsy were performed on the tumor of the left lower leg, it was initially diagnosed as a fibromyxoid tumor (intermediate type), more likely superficial CD34-positive fibroblastic tumor with myxodegeneration. As the tumor of the left lower leg was rare, after consulting the opinions of some domestic hospitals, and combined with the medical history and hormone treatment effect, our final diagnosis was left anterior tibial myxedema. After more than 10 months of external treatment with halometasone ointment, all nodules became flat, leaving light brown pigmentation spots. This article discusses the differential diagnosis of this disease, with the aim to enhance clinical doctors' understanding of the disease.
Clinical Research and Evidence Based Medicine
Real World Research: Bridging the Gap Between Clinical Practice Guidelines and Clinical Decision Making
SHI Xiuqing, YAN Siyu, HUANG Qiao, LI Xuhui, WANG Yongbo, MA Wenhao, SHANG Hongcai, JIN Yinghui
2023, 14(4): 859-867. doi: 10.12290/xhyxzz.2022-0217
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Clinical practice guidelines are an important basis for clinical decision-making, but there are still many factors that prevent physicians from following the guidelines. One of the problems, the limited external validity of the guidelines, ultimately prevents the guidelines from providing an adequate basis for clinical decision-making, thus forming the gap between the guidelines and clinical decisions. Real-world research can enhance the external validity of the guidelines, provide a basis for clinical decision-making, and offer localized evidence for the guidelines, evidence of cost-effectiveness and other evidence for the guidelines. It can also monitor the implementation of the guidelines and help to make up for the lack of evidence in the formulation of traditional guidelines. Therefore, high-quality real-world studies and real-world evidence may be considered in the guideline development process to facilitate guideline optimization and serve as an aid to guideline quality improvement.
Clinical Practice Guidelines
WHO SMART Guidelines: A New Direction for Guideline Development and Implementation
WANG Qi, LUO Xufei, WANG Zijun, YANG Nan, ZHU Di, LI Zhewei, XIN Xin, YANG Zhenhua, WANG Ling, SHI Qianling, CHEN Yaolong
2023, 14(4): 868-874. doi: 10.12290/xhyxzz.2023-0274
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The quality and methodology of guidelines developed by the World Health Organization (WHO) have been continuously improved after decades of development and reform. However, the implementation of conventional guidelines faces certain challenges, including lengthy timelines, the possible loss of accuracy and consistency of recommendations, and limited capacity of some countries to support guideline adaptation and implement. As a result, the expected effects of guideline recommendations may not be fully achieved. As many countries are investing heavily in digital health systems, both the WHO and its Member States have recognized the importance of digital implementation of guidelines and developed the SMART Guidelines. As a new approach, SMART Guidelines can accelerate the implementation of evidence-based recommendations in the digital age, enhance their compliance and implementability, and improve healthcare quality and population outcomes. This article aims to provide an overview of the background, definition, framework, and knowledge layers of the WHO SMART Guidelines, using antenatal care guidelines as an example for interpretation.
Organizing Patient Panel: Suggestions on Incorporating Patient's Values and Preferences into Guideline Development
GAO Yicheng, XIA Ruyu, CHAI Qianyun, FENG Yuting, WANG Yaqi, LUO Minjing, FEI Yutong
2023, 14(4): 875-880. doi: 10.12290/xhyxzz.2022-0528
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As an emerging international research hotspot, the development of guidelines with patient participation has seen great differences in related methodological research in China and abroad. This paper advocates the establishment of patient panel, and discusses the working methods of patient panel, the source and selection of patient representatives, participation phases, management, and support. Methodological optimization suggestions are also proposed, such as the sustainability of patients, structuring and two-way communication mode made by a consensus expert group involving patients' values and preferences, in order to provide a reference for the development of patient participation guidelines in China.
Medical Supports to Tibet & Xinjiang
Intestinal Microbiota Polymorphism of Epilepsy Patients in Middle and High Altitude Areas: A Case-control Study
ZHENG Meiling, FAN Qingli, ZHONG Lianmei
2023, 14(4): 881-888. doi: 10.12290/xhyxzz.2022-0533
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  Objective  To investigate the composition and distribution characteristics of intestinal flora in patients with epilepsy at middle-high altitude, in order to provide theoretical reference for the etiological study of epilepsy.  Methods  From September 2021 to August 2022, we continuously recruited middle-high altitude epilepsy (MHE) patients (altitude 2200-4500 m) and healthy people at the same altitude as middle- high altitude normal (MHN). MHE were epileptic patients in neurology department of Qinghai Provincial People's Hospital, and MHN were healthy people in physical examination center of Qinghai Provincial People's Hospital which matched 1∶1 with MHE by age and gender. Stool tissue specimens from both groups were collected, and the 16S rDNA V3 to V4 regions of the intestinal flora were sequenced for DNA and analyzed bioinformatically.  Results  A total of 32 cases of MHE and 33 cases of MHN who met the inclusion and exclusion criteria. Alfa diversity analysis showed that ACE index, Shannon index and Chao index in MHE group were lower than those in MHN group (all P < 0.05). Beta diversity analysis showed that there were significant differences in the distribution of intestinal flora between the two groups. In the analysis of intestinal flora composition, MHE group also showed different characteristics from MHN group at phylum level and genus level. The relative abundance of Verrucomicrobiota, Collinsella, Fusobacteriota, Bifidobacterium and other bacteria increased, whereas the relative abundance of Bacteroidota, Bacteroides, Prevotella, Faecalibacterium and other bacteria decreased.  Conclusion  The intestinal flora of epilepsy patients at middle and high altitude has different polymorphisms from that of healthy people at the same altitude, which may be associated with epilepsy.
MDT Case from PUMCH
Anorexia, Jaundice, Hyperglycemia, and Elevated Serum IgG4 Level
ZHANG Ning, WU Juan, SUN Xiaohong, KANG Lin, YUAN Ling, YANG Huaxia, LUO Ling, LU Bo, ZHOU Xiang, ZHANG Wen
2023, 14(4): 889-894. doi: 10.12290/xhyxzz.2023-0004
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In this paper, we report an elderly patient who had been experiencing poor appetite for one month and yellowing of the skin and sclera for two months before visiting the Department of Geriatrics at Peking Union Medical College Hospital. The patient's blood tests revealed significantly elevated levels of serum total bilirubin, direct bilirubin, and blood sugar. The serum IgG4 level nearly tripled. Abdominal imaging examinations revealed diffuse pancreatic lesions, narrowing of the intrapancreatic segment of the common bile duct, and thickening and marked enhancement of the common hepatic duct, left and right hepatic ducts, and branches. Blood glucose was also significantly elevated during the course of the disease. Moreover, nutritional assessment found that the patient was malnourished. After multidisciplinary discussion, a medium dose of oral methylprednisolone was prescribed to the patient due to his advanced age and multiple chronic conditions. The dose was then quickly reduced while the patient simultaneously received low-dose mycophenolate mofetil (MMF) treatment. As a result, the patient's bilirubin level significantly decreased, jaundice subsided, and his body weight returned to normal with improved physical function. Throughout the diagnosis and treatment process, a multidisciplinary team actively participated in discussions and gradually identified the underlying cause. This exemplifies the crucial role of interdisciplinary collaboration in effectively diagnosing and treating complex illnesses in elderly patients.
Technology and Methodology
Total Marrow and Lymphoid Irradiation: A New Technology Assisting in Myeloablating Before Hematopoietic Stem Cell Transplantation
SHEN Jing, LIU Zhikai, GUAN Hui, ZHEN Hongnan, SUN Xiansong, JIANG Fei, ZHANG Yue, YU Lang, ZHANG Jie, ZHANG Fuquan
2023, 14(4): 895-899. doi: 10.12290/xhyxzz.2022-0503
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This paper reports the first case of myelodysplastic syndromes combined with myeloid sarcoma for which the department of radiotherapy used total marrow and lymphoid irradiation (TMLI) to assist in myeloablating. Radiotherapy localization and target area delineation were carried out before treatment and the entire process of TMLI treatment was designed using the TOMO therapy. Radiotherapy was performed successfully for targeted irradiation of the total bone marrow and lymph nodes. The patient felt comfortable during the treatment process and good pretreatment effects were achieved. The treatment time (45 min-1 h per session) was significantly shorter than that during total body irradiation (TBI)(3-4 h per session), the irradiation dose rate (800 cGy/min) was significantly increased compared to TBI (5-30 cGy/min), and oral mucosal inflammation and gastrointestinal reactions were mild after treatment. This article discusses the treatment process of this case and TMLI technology, to provide reference for the whole process design and important parameters for further treatment of more patients.
Teaching and Research
Application of Ultrasonography Visualization Teachingin the Integration Course of Diagnostics and Ultrasonic Medicine for Eight-year Clinical Medicine Program Students
ZHAO Ruina, WANG Ming, WANG Xin, LI Jianchu, FAN Hongwei, HUANG Xiaoming, LI Wenbo, SU Na, WANG Yahong, ZHU Shenling, ZHANG Xiaoyan, WANG Ying, GAO Luying, WANG Ruojiao, YANG Meng
2023, 14(4): 900-904. doi: 10.12290/xhyxzz.2022-0185
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  Objective  To evaluate the effect of ultrasonography visualization teaching in the integration course of diagnostics and ultrasonic medicine for eight-year clinical medicine program students and to provide reference for further optimization of the teaching program.  Methods  The study conducted a questionnaire survey with electronic questionnaire in the eight-year clinical medicine program students from Peking Union Medical College who participated in ultrasonography visualization teaching of neck and abdomen. We adopted self-control study(data from the questionnaires completed by the same student before and after the course) to compare the accuracy of each knowledge point before and after teaching to evaluate the teaching effect, and collected course satisfaction ratings and feedback from the students.  Results  A total of 124 eight-year medical students participated in the survey, with 107 cases eight-year clinical medicine program students in grade 2017, and 17 cases "4+4" pilot class students in grade 2019 from Peking Union Medical College. Altogether 116 valid questionnaires (the response rate was 93.5%, 116/124) were collected for neck ultrasound courses and 101 valid questionnaires (the response rate was 94.4%, 101/107) for abdominal ultrasound courses. After the teaching of neck ultrasound course, the correctness of 68.8%(11/16) and 66.7%(10/15) of the knowledge points was significantly improved for the grade of 2017 and 2019 medicine students, respectively (all P < 0.05); after the teaching of abdominal ultrasound course, the correctness of 80%(4/5) of the knowledge points was significantly improved for both the grade of 2017 and 2019 medicine students (all P < 0.05). Course satisfaction surveys showed that 99.1%(115/116)of the students were very satisfied or satisfied with the cervical ultrasound course, and 0.9%(1/116) were somewhat satisfied. As for the abdominal ultrasound course, 99.0% (100/101) of the students were very satisfied or satisfied and 1.0%(1/101) were somewhat satisfied. Twenty one medical students gave feedback on the evaluation of the course, believing that ultrasound visualization teaching improved learning initiative (52%, 11/21) and learning efficiency (43%, 9/21) and stimulated learning interest (5%, 1/21); 27 medical students made suggestions on the teaching mode, among which "increasing teaching hours" accounted for the highest proportion (56%, 15/27), followed by "recommending reference books" (26%, 7/27).  Conclusion  The ultrasonography visualization teaching improves the learning initiative and efficiency of eight-year clinical medicine program undergraduates, stimulates the learning interest, and promotes their mastery of relevant knowledge.
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