2014 Vol. 5, No. 2

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Original Contributions
Abstract:
  Objective  To explore the physical diseases and psychological characteristics of patients with multiple somatic symptoms in the outpatient departments in a general hospital.  Methods  This cross-sectional study was conducted from March to October, 2012. The participants were recruited through convenience sampling from the outpatient departments of Gastroenterology, Traditional Chinese Medicine, and Psychological Medicine in Peking Union Medical College Hospital. Patients in the waiting list were screened continuously by the somatic symptom scale of the Patient Health Questionnaire (PHQ-15). With the cut-off value of 10, patients were divided into the somatic symptom positive (SOM+) group and the control (SOM-) group. With 25patients enrolled for eachgroup from all these three departments, totally 150 patients were included. All the subjects completed seven self-assessment questionnaires including PHD-15, depression scale of the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7-item scale (GAD-7), 12-item Short Form Health Survey (SF-12), Whiteley-7 Index (WI-7), Sense of Coherence scale(SOC-9), and health care used and health status scales, and received semi-structured interviews including the diagnosed physical and psychological illnesses during the past 12 months and the Mini-International Neuropsychiatric Interview (MINI).  Results  The proportions of females and subjects with an education degree below college were significantly higher in SOM+ group than in SOM-group (69.3% vs 53.3%, 54.8% vs 43.2%, respectively; both P < 0.05). While no more physical illness was diagnosed in the past 12 months in the SOM+ group. The prevalence of depression, generalized anxiety disorder, and hypochondriasis and the scores of PHQ-9 and WI-7 were significantly higher in the SOM+ group (P < 0.05). The behavior and daily activities of SOM+ group patients were also more likely to be influenced by their discomforts (P < 0.01). Finally, Logistic regression analysis showed that the high scores of PHQ-9 and WI-7 and unemployment were the influential factors of these manifestations.  Conclusions  Patients with multiple somatic symptoms do not have more physical illnesses that can be clearly diagnosed. However, they have more psychological distress and lower quality of life, and are more likely to be affected by the symptoms. The high degree of depression and anxiety and unemployment were the influential factors for multiple somatic symptoms.
Abstract:
  Objective  To evaluate the transfusion rates and identify perioperative factors associated with allogeneic blood transfusion (AllTx) after primary total knee arthroplasty (TKA) with routine use of low-molecular-weight heparins.  Methods  We retrospectively studied the transfusion rate of 1165 consecutive patients who underwent primary TKA between January 2005 and December 2011. Totally 34 independent variables were analyzed in 617 primary unilateral TKAs without autologous blood predonation for requirement of AllTx. Multiple regression analysis model was used to identify risk factors associated with perioperative blood transfusion.  Results  Overall, 58.2%(678/1165) of patients required AllTx. The median number of units transfused was 2.7 U (range:1 to 13 U). The AllTx rate was 40.0% (278/695) in unilateral TKA procedures and 85.1% (400/470) in one-stage bilateral TKA procedures. Univariate analysis demonstrated the risk of transfusion was independentlypredicted by the patients' age at surgery (P < 0.0001), preoperative hematocrit(P < 0.0001), preoperative hemoglobin concentration (P < 0.0001), American Society of Anesthesiologists (ASA) score ≥ 3 (P=0.004), surgical time (P=0.004), and tourniquet time (P=0.050). Multivariate Logistic regression analysis confirmed significant relationship between allogeneic blood transfusion and age (P < 0.0001), preoperative hemoglobin(P < 0.0001), and surgical time (P < 0.0001).  Conclusions  AllTx rate is high in TKA procedures, especially in one-stage bilateral TKA procedures. Patient's age, preoperative hemoglobin level, and surgical time are helpful in identifying high-risk patients who require postoperative blood transfusion.
Abstract:
  Objective  To evaluate whether the Janus kinase 2(JAK2)/signal transducers and activators of transcription 3 (STAT3)inhibitor WP1066 could be a novel therapeutic target for neuropathic pain and its molecular mechnism.  Methods  Twelve female SD rats weighing 180-200 g were randomly divided into WP1066 group and control group(n=6) using the random number table. Rats in both groups underwent bilateral chronic sciatic nerve constriction injury (bCCI). WP1066 (10 μl, 10 mmol/L in dimethyl sulfoxide) or the equal volume of dimethyl sulfoxide was applied through the intrathecal tube one day before surgery, just before surgery, and 3 and 5 days after surgery in the WP1066 group and control group, respectively. Behavior tests were performed before surgery and 3, 5, 7, 10, and 14 days after the surgery to observe the rats' reactions to mechanical, thermal, and cold stimula-tions. The rats were killed on the 14th postoperative day. The dorsal horn of the spinal cord (L4-L6) was harvested, followed by the reverse transcription polymerase chain reaction (RT-PCR) and Western blotting to investigate the activation of the JAK2/STAT3 pathway.  Results  The pain-related behavior changes were significantly better in the WP1066 group than in the control group. WP1066 significantly inhibited the JAK2, suppressor of cytokine signaling 3(SOCS3), and STAT3 mRNA in rats with bCCI, and significantly decreased the ratio of JAK2, SOCS3 and phosphorylation of STAT3(p-STAT3) protein expression on the 14th postoperative day.  Conclusions  The administration of WP1066 can remarkably improve neuropathic pain in bCCI rats by inhibiting the STAT3 signaling pathway. Therefore, WP1066 may be a novel target for neuropathic pain.
Abstract:
  Objective  To evaluate the diagnostic value of three consecutive qualitative fecal occult blood tests (FOBTs) for colorectal polyps and cancer.  Methods  We retrospectively reviewed patients who underwent three consecutive FOBTs in one week before a standard colonoscopy from August 2006 to April 2013 in Peking Union Medical College Hospital.The sensitivity and specificity of positive FOBT(1, 2, or 3 times) for diagnosing colorectal neoplasms(including polyps and cancer)were calculated. The impacts of colorectal neoplasm's location, amount, size, and histological features on FOBT results were also evaluated.  Results  A total of 303 patients[154 males and 149 females, aged (59.5±15.0)years] were enrolled in this study. Colorectal neoplasms were recognized in 165 patients, in whom 119 patients were diagnosed with colorectal polyps and 46 with cancer. As for colorectal polyps, the sensitivity and specificity of positive FOBT were 71.4% and 52.7% for one time, 41.2% and 67.4% for two times, and 22.7% and 79.9% for three times. As for colorectal cancer, the sensitivity and specificity were 91.3% and 49.4% for one time, 80.4% and 72.0% for two times, and 54.3% and 84.8% for three times. Neoplasms in the left half colon and advanced neoplasms were significantly related to positive FOBTs (P=0.001).  Conclusions  Three consecutive qualitative FOBTs can be used as a screening tool for colorectal polyps and cancer. Location and histological features of polyps may influence FOBT results.
Abstract:
  Objective  To investigate the feasibility of extralevator abdominoperineal excision (ELAPE) under laparoscope.  Methods  We retrospectively analyzed 12 patients with distal rectal cancer who underwent ELAPE in our center from June 2012 to August 2013. During the procedures, the levator ani muscles were cut off laparoscopically at its origin at both sides on the pelvic wall, and its attachment on coccyx was removed posteriorly. The dissection plane was taken along the Denonvillier fascia anteriorly as far as possible to the perineal body. The adjacent organs were removed if invaded by the tumors. The anus and its surrounding tissue were removed by perineal approach without changing patients' positions. The pelvic perinium was closed laparoscopically to prevent the intestine dropping. The operation time, blood loss, retrieval of lymph nodes, radial margin, and postoperative complications were recorded.  Results  The patients aged (65.2±12.5)years and their body mass index was 21.6±3.1. The distance from lower edge of tumor to anal verge was (3.3±0.7)cm. The procedure lasted (176.1±27.5) minutes, with a blood loss of (49.6±38.2)ml. The average number of node retrieval was 18.3±7.8, and no positive radial margin was identified. The postoperative complications included urinary retention in 2 patients. The perineal incision appeared to be class A healing in 9 patients.  Conclusion  By extensively removing the levator ani muscles laterally and posteriorly, ELAPE procedure can be accomplished under laparoscope without changing operative position or flap repair of the pelvic floor.
Abstract:
  Objective  To summarize the clinical features of ankylosing spondylitis (AS) complicated with Takayasu's arteritis (TA).  Methods  We retrospectively analyzed the clinical data of AS complicated with TA patients who had been treated in Peking Union Medical College Hospital from June 2000 to July 2011. AS was diagnosed in accordance with the Modified New York criteria, and TA with American College of Rheumatology classification criteria. All patients had been tested for antinuclear antibody, rheumatoid factor, antineutrophil cytoplasmic antibody, and anticardiolipin antibodies to exclude connective tissue disease and other diseases. Other examinations included tests for erythrocyte sedimentation rate (ESR), C reactive protein, HLA-B27, echocardiography, CT angiography or digital subtraction angiography of aorta and its major branch, color Doppler ultrasound of aorta and its major branch, and X ray and CT of the sacroiliac joint.  Results  Seven patients[4 males and 3 females, with an average age of (29.6±10.6) years (range:18 to 50 years)] during this period were diagnosed as AS complicated with TA. HLA-B27 was positive in 5 patients and negative in 2 patients. The levels of inflammatory markers such as ESR and C reactive protein were high in all patients. The average ESR was 84 mm/h. All patients were first diagnosed as AS, then found to be with TA years later. Before the diagnosis of TA, AS had lasted for (13.9±11.6) years (range:3 to 29 years). The main reason leading to the diagnosis of TA was the symptoms of the involved arteries and the fever caused by inflammation.  Conclusions  AS complicated with TA is not a random phenomenon, in which the inflammatory process may play a crucial role.
Abstract:
  Objective  To investigate the sonographic and clinicopathologic characteristics of the ovarian sclerosing stromal tumor (OSST).  Methods  The clinical, pathological, and sonographic records of 12 patients with pathologically confirmed OSST between March 1996 and September 2013 were retrospectively reviewed, and the sonographic characteristics of the OSSTs were analyzed.  Results  Eight of these 12 patients complained of irregular menstruation. Abnormal hormone levels were observed in 6 patients and elevated CA125 in 4 patients. All OSSTs occurred unilaterally. Under the ultrasound, the tumors manifested as lobulated in 10 patients (83.3%), and all the lesions had a sharp border. The tumors were solid with small cystic structures in 7 patients (58.3%) and purely solid in 4 patients (33.3%). For the solid parts, the tumors were hypo-echoic in 8 cases (66.7%) and heterogeneously echogenic in 12 cases (100%). Thin hyper-echoic strips were seen in 10 cases (83.3%) and posterior attenuation in 11 cases (91.7%). The lesions were hyper-vascularized in 10 cases (83.3%), and spoke-like distribution of the blood flow was a unique feature.  Conclusions  OSSTs have special clinical manifestations, and the ultrasound findings are consistent with their pathological features. Ultrasonography is particularly useful for the preoperative diagnosis of OSSTs.
Abstract:
  Objective  To explore the role of ultrasound in diagnosis of paraganglioma of urinary bladder(PUB).  Methods  The clinical data and urinary bladder sonographic findings of 13 patients(8 females and 5 males, aged 14-76 years) with pathologically confirmed PUB in Peking Union Medical College Hospital from October 2002 to June 2013 were retrospectively analyzed.  Results  Among these 13 patients, 9(69.2%) had headache, palpitation, sweating, and hypertension with micturition, 12(92.3%) had elevated urinary catecholamine, and 4(30.8%) experienced recurrence within 0.5 to 3 years. The diameters of 16 lesions(including 10 solitary lesions and 3 multiple lesions) found in these 13 patients were 1.2-7.5 cm. Nine lesions were morphologically regular and 7(43.8%) were irregular. The margins were well-defined in 9 lesions(56.3%), with continuous bladder mucosa found in 5 lesions(31.3%), and were poorly-defined in 7 lesions(43.8%). All the lesions were hypoechoic, and nest-like structure was seen inside one lesion(6.3%). Color Doppler imaging showed rich blood flow signals in 12 lesions(75%), spot-and strip-like blood flow signals in 2 lesions(12.5%), and no blood flow signal in 2 lesions(12.5%). Involvement of other organs was reported in 4 cases(30.8%).  Conclusions  The sonographic findings of PUB are somehow unique. When combined with clinical features, it is helpful in the differentiation diagnosis, prediction of treatment outcome, and follow-up.
Abstract:
  Objective  To explore the characteristics of abdominal wall endometriosis (AWE) on magnetic resonance imaging (MRI).  Methods  The clinical and MRI data of 7 patients with pathologically confirmed AWE in Peking Union Medical College Hospital from January 2008 to January 2013 were retrospectively collected and analyzed.  Results  Five of the AWE lesions were single and two were multifocal. Ten AWE lesions were found in 7 patients. Seven out of 10 lesions were located in the left, two in the middle, and one in the right. Five lesions were located in the subcutaneous tissue and fascia, the abdominal muscles were invaded in four lesions, and one was located in the subcutaneous tissue, fascia, and muscle. Endometrial invasion from the scar into the abdominal cavity was observed in two patients, with anterior wall and fundus of the uterus for one patient and anterior wall of bladder for another. Nine lesions were solid and mainly showed isointense or hyperintense signal on T1WI and T2WI compared with muscle with foci of higher intensity on T2WI. In one patient, a cystic hyperintense lesion was found on T1WI (including shading on T2WI). Coexistent abnormality was observed in five patients, including adenomyosis in two, uterine malformation in one, adenomyosis and uterine malformation in one, and fibroid in one patient.  Conclusions  MRI manifestations of AWE can provide information on the anatomic locations and the lesion extension. Thus, MRI is an important method for preoperative examination and postoperative follow-up.
Abstract:
  Objective  To investigate the causes of unplanned reoperations of spinal surgery.  Methods  Patients hospitalized in the department of spinal surgery who underwent unplanned reoperations from February 2012 to July 2013 were retrospectively analyzed. The potential causes of unplanned reoperations were summarized. The postoperative outcome, average duration of hospital stay and satisfaction of these inpatients were also analyzed.  Results  A total of 22 patients underwent unplanned reoperations in the department of spinal surgery. Among these 22 patients, unplanned reoperations were performed due to unsatisfied pedicle screw placement in 8 cases, incision problems in 6 cases, and abnormal sensation or muscle strength in 7 cases. Adjustment of screw location, wound debridement, and spinal canal exploration/decompression yielded good outcomes. However, the average duration of hospital stay of these patients was longer than those without unplanned reoperations(25.6 d vs 12.5 d) and the average inpatient satisfaction was lower(85.2 vs 97.7).  Conclusions  Monitoring of unplanned reoperations is particularly important. The specific causes of unplanned reoperations in different departments should be carefully analyzed to inform the improvements.
Abstract:
  Objective  To compare the dosimetric characteristics of preoperative volumetric modulated arc therapy (VMAT) and fixed-field intensity-modulated radiotherapy (FF-IMRT) for rectal cancer.  Methods  The CT images of 15 patients with rectal cancer were transferred into Eclipse planning system. FF-IMRT and VMAT plans were optimized on an Eclipse treatment planning system using beam data generated for Varian Trilogy linear accelerator. Same institutional dose-volume constraints for rectal cancer were used in both techniques. Targets and organs at risk were evaluated.  Results  The target volume coverage could meet the requirement of described dosage in both VMAT plan group and FF-IMRT plan group. Compared with the FF-IMRT plan group, the planning target volume (PTV) 105% (PTV105%) coverage, Dmean, and Dmax significantly increased in the VMAT plan group (P=0.011, P=0.017, and P=0.006, respectively), the radiation conformity index (CI) significantly decreased(P=0.008), and the homogeneity index showed no significant difference (P=0.193). Compared with the FF-IMRT plan group, the V50 of the bladder in the VMAT plan group was increased by about 15% (P=0.009), and the Dmax increased by 0.7 Gy(P=0.003); the V30 of the small intestine decreased by 10%(P=0.004), and the Dmax was increased by 0.9 Gy(P=0.000); the V10, V30, and V40 of the bone marrow reduced by 2%, 10%, and 10% (P=0.000, P=0.000, and P=0.000), and the Dmean reduced by 1.7 Gy (P=0.000); the D5 of the left and right femoral heads reduced by 3.2 Gy and 2.4 Gy (P=0.000, P=0.000); the V10, V20, V30, and V40 of the body also significantly decreased (P=0.003, P=0.000, P=0.000, and P=0.004). The VMAT group also had significantly lower number of monitor units (MU) when compared with the FF-IMRT plan group (P=0.000).  Conclusions  In patients with rectal cancer, preoperative VMAT can achieve equivalent or superior dose distribution compared with the FF-IMRT. In addition, VMAT can increase the number of patients treated per hour and reduce waiting time by shortening treatment time and reducing treatment MU.
Abstract:
  Objective  To summarize the relationship between the transverse dimension of the target volume and the most optimized X jaw size in volumetric modulated arc therapy(VMAT) plan for cervical cancer radiotherapy.  Methods  The VMAT plans were made by modifying X jaw size on CT images in 12 postoperative patients with cervical cancer. On each image, the best X jaw size was identified. The relationship between the best X jaw size and the transverse width of planning target volume (PTV) was determined.  Results  The change in the transverse dimension of the target volume was accompanied with the changes of the optimized X jaw size. The relationship between X jaw size (y) and the PTV's transverse width (x) could be expressed as the following equation:y=-0.0033x2+0.7132x+3.6322.  Conclusions  There is a relationship between X jaw size and PTV's transverse width, which can be used for the postoperative VMAT plan design in patients with cervical cancer.
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Manual of Orthopaedics(7th ed.) (2012)
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Plastic Surgery (3rd ed.) (2013), Vol.1
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