2016 Vol. 7, No. 3

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Ovarian Aging Column
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  Objective  To investigate the changes of serum sex hormone levels and ovary size in ovarian aging in women living in a Beijing community.  Methods  A total of 418 healthy women aged 30 to 68 years who could be staged by STRAW+10 staging system were recruited from a Beijing community and prospectively followed-up for 5 years. Menstrual diary was recorded by every woman during the research. Serum estradiol(E2) and follicle stimulating hormone (FSH) levels were tested at baseline and 5 years later. Pelvic ultrasonography was performed for measurement of ovary size.  Results  According to STRAW+10 stage, E2 began to decrease in early postmenopausal stage, which further decreased in late postmenopausal stage. FSH increased significantly from the beginning of late menopausal transition stage, remaining at a high level after menopause. The length, width, and area of the ovary all reduced after menopause. Hormone levels and ovary size changed with some rules in the 5-year follow-up even when the STRAW+10 stage did not change. In women with staging progressed after 5 years of follow-up, E2 and FSH levels, and length, width, and area of the ovary were significantly different (all P < 0.01) when progressing from early or late menopausal transition stage to early postmenopausal stage. Ovarian no-echo cyst (diameter ≥ 1.4 cm and < 2.5 cm) was the most common in late menopausal transition stage both at baseline and after 5 years, with an incidence of 6.5% and 12.1%, respectively.  Conclusions  When the STRAW+10 stage changes from menopausal transition to early postmenopausal stage, E2 decreases and FSH increases significantly with obvious ovarian atrophy. Reproductive aging has more influence on hormone levels and ovary size than aging does. STRAW+10 staging system could be applied for women in Beijing.
Original Contributions
Abstract:
  Objective  To compare the efficacy and safety of intravitreal injections of dexamethasone implants (DEX) with anti-vascular endothelial growth factor (VEGF) in the treatment of macular edema (ME)secondary to retinal vein occlusion (RVO).  Methods  The databases of Cochrane Library, PubMed, EMBASE, Ovid Medline, and ClinicalTrial.gov between January 1948 and June 2015 were searched for studies comparing DEX with anti-VEGF for the treatment of ME caused by RVO with key words "retinal vein occlusion", "macular edema", "anti-VEGF", "pegaptanib", "Macugen", "bevacizumab", "Avastin", "ranibizumab", "Lucentis", "aflibercept", "Trap-eye", "Ozurdex", "dexamethasone invitreal implant", and "clinical trial". We evaluated the quality of selected studies using Cochrane or Newcastle-Ottawa scale. Data were extracted and analyzed by RevMan 5.3 for Meta-analysis.  Results  The mean difference in the mean changes of best corrected visual acuity (BCVA) in Early Treatment Diabetic Retinopathy Study (ETDRS) letters comparing DEX with anti-VEGF was 0.04[95% confidence interval (CI):-2.07~2.15; P=0.97] at 1 month, -6.98(95% CI:-10.39~-3.58; P < 0.0001) at 3 months, -12.18(95% CI:-20.34~-4.03; P=0.003) at 4 months, and -11.84(95% CI:-19.66~-4.02; P=0.003) at 6 months. A greater reduction of central retinal thickness at 6 months was observed in the anti-VEGF group than in the DEX group (mean difference 135.86 μm; 95% CI:57.07~214.64 μm; P=0.0007). The incidence of intraocular pressure increase in the DEX group was significantly higher than that in the anti-VEGF group (OR=3.54, 95% CI:1.64~7.66, P=0.001).  Conclusions  Anti-VEGF showed better effect than DEX in improving BCVA, reducing ME, and less influence on intraocular pressure for ME secondary to RVO. Therefore, anti-VEGF may have higher efficacy and safety than DEX for this condition.
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  Objective  To evaluate the effect of intravenous dexmedetomidine on intraoperative sedation and adverse events in parturients undergoing Cesarean section using combined spinal-epidural anesthesia.  Methods  Fifty singleton parturients at term scheduled for Cesarean section under combined spinal-epidural anesthesia were allocated to two groups using random numbers:dexmedetomidine group(study group, n=25) and normal saline group(control group, n=25). All the parturients received 0.5% hyperbaric bupivacaine 8 mg intrathecally following subarachnoid puncture. After delivery of the baby, the study group received dexmedetomidine 1 μg/kg intravenous bolus infusion for 10 minutes followed by 0.5 μg/(kg·h) continuous infusion until the end of surgery, whereas the control group was infused with equivalent amount of normal saline. Ramsay scores were recorded every 30 minutes during the surgery. The incidence of intraoperative adverse events and adverse drug reactions were also recorded, as well as 1-minute and 5-minute Apgar scores of the newborns.  Results  Ramsay score of the study group was significantly higher than that of the control group (3.4±0.7 vs. 2.2±0.4, P=0.001). Incidences of shivering (0 vs. 16%, P=0.001), nausea and vomiting (8% vs. 36%, P=0.019), abdominal discomfort upon surgical traction (12% vs. 48%, P=0.006) in the study group were all significantly lower than those in the control group. In terms of adverse drug reactions, incidence of bradycardia in the study group was higher than that in the control group (24% vs. 0, P=0.011), while incidences of hypotension, oversedation, and respiratory depression showed no significant difference between the two groups. Apgar scores of the two groups also showed no significant difference.  Conclusions  Intravenous dexmedetomidine could improve intraoperative sedative effect in parturients undergoing Cesarean section under combined spinal-epidural anesthesia and reduce the incidence of intraoperative adverse events with little adverse reaction and no influence on neonates.
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  Objective  To evaluate the clinical features and explore the prognostic factors of acute necrotic collection (ANC) and walled-off pancreatic necrosis (WOPN) following acute pancreatitis.  Methods  A retrospective study was conducted to analyze the clinical data of 164 patients with moderate to severe acute pancreatitis treated in Peking Union Medical College Hospital from October 2013 to October 2015. Clinical and laboratory indexes were compared between ANC and non-ANC, WOPN and non-WOPN patients.  Results  The proportions of systemic complications and infection were significantly higher in patients with ANC following acute pancreatitis (respiratory failure 47.1% vs. 30.2%, cardiovascular failure 14.7% vs. 5.2%, renal failure 38.2% vs. 15.6%, infection 19.1% vs. 6.3%, all P < 0.05). Within 48 hours of admission, higher levels of heart rate, high-sensitive C-reactive protein, glucose, serum creatinine, urea, and lower level of PaO2 were observed in patients with ANC compared with patients without ANC (all P < 0.05). Among ANC patients, higher proportions of infection, intervention therapy and surgery were found in patients with WOPN (infection 40.7% vs. 4.9%, P < 0.001; intervention 29.6% vs. 7.3%, P=0.020; surgery 22.2% vs. 0, P=0.003); these patients also had longer hospital stay[29.0(15.0, 56.0)d vs. 13.0(4.5, 26.3)d, P=0.005] and higher total costs[72 818.3(27 805.1, 168 932.9)RMB vs. 28 155.2(6057.6, 51 259.1)RMB, P=0.015]. Within the first 1-2 weeks after onset, a higher temperature, heart rate, breathe rate, counts of white blood cells, counts of neutrophils, and a lower level of blood calcium were shown in patients with WOPN compared with patients whose necrotic materials were absorbed.  Conclusions  ANC and WOPN are associated with more severe clinical manifestations, higher risk of infection, higher proportion of intervention therapy and surgery, longer hospital stay and increased cost. Laboratory tests are useful in the prediction and monitoring of local complications in acute pancreatitis.
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  Objective  To investigate the diagnostic value of three-vessel and tracheal (3VT) view in fetal aortic arch anomalies.  Methods  Ultrasound findings of 17 fetuses with aortic arch anomalies diagnosed in Peking Union Medical College Hospital between May 2010 and May 2014 were reviewed and compared with the findings of postnatal ultrasonography and pathological examinations to analyze the ultrasound features of aortic arch anomalies of different types, focusing on the importance of 3VT view.  Results  In all 17 cases the 3VT view was abnormal. 3 cases were aortic coarctation, mainly manifested as reduced diameter of the aortic arch; 7 cases were interrupted aortic arch, in which there was discontinuity between the thinning aortic arch and the descending aorta; 5 cases were right aortic arch (RAA) with aberrant left subclavian artery, with a 'U'-shaped vascular loop around the trachea; and 2 cases were RAA with mirror-image branching, with the aortic arch situated to the right of the trachea and not forming a V- or U-shaped confluence with the ductus.  Conclusions  The 3VT view is avery sensitive view to effectively diagnose fetal aortic arch anomalies. Meticulous ultrasound examination focusing on this view during second trimester may disclose the presence of such anomalies and help provide the appropriate genetic counselling.
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  Objective  To discuss the clinical manifestations, surgery-based therapy of neuroendocrine tumors of the thymus (NETT) and the potential prognostic factors.  Methods  We selected 26 consecutive cases diagnosed, treated, and confirmed as NETT by postoperative pathology between December 2004 and December 2013 in Peking Union Medical College Hospital, including 18 males and 8 females. Their clinical manifestations, imaging findings, surgery-based therapy, perioperative complications, and follow-up were retrospectively analyzed.  Results  The median age of the 26 cases was 46(13-75)years and the median duration of disease was 3.5(1-84)months. Early detection of NETT was difficult due to occult onset and nonspecific clinical manifestations. Seven cases were complicated with Cushing's syndrome and 1 case with multiple endocrine neoplasia type 1. Thoracic contrast-enhanced computed tomography showed mass in the region of thymus. All the cases received thoracotomy and 22 cases got macroscopically radical resection, with 3 cases developing complications and no perioperative death. Sixteen cases received adjuvant therapy after the surgery. Pathologically, there were 20 well differentiated cases (8 typical carcinoids and 12 atypical carcinoids), and 6 poorly differentiated cases (5 small cell and 1 large cell neuroendocrine tumors). There were 4 Masaoka-Koga stage Ⅰ cases, 3 stage Ⅱ cases, 12 stage Ⅲ cases, and 7 stage Ⅳ cases. After long-term follow-up, the median survival was 51.0 months, and 3- and 5-year survival rates were 71.0% and 44.6%, respectively. Multivariate analysis showed that degree of tumor differentiation (P=0.039) and staging (P=0.012) had impact on prognosis.  Conclusions  NETT is a rare malignancy with tremendous aggressiveness. Early confirmed diagnosis and therapy is still a big challenge due to nonspecific clinical manifestations. Thoracic contrast-enhanced CT could help detect the tumor and evaluate the possibility of surgery. Stage and differentiation of the tumor might be major prognostic factors.
Abstract:
  Objective  To investigate the clinical effectiveness of lymphaticovenular anastomosis in secondary extremity lymphedema.  Methods  Fifteen patients with secondary extremity lymphedema treated with lymphaticovenular anastomosis between September 2013 and August 2014 at Peking Union Medical College Hospital were included in this study, of whom 12 were unilateral, and 3 were bilateral. Indocyanine green lymphography was used before the operation to evaluate the severity of lymphedema and the patency of lymphatic vessels. Microsurgery was applied to determine the site and number of anastomosis. The circumference of the involved limb was measured before and after the operation at the same level to calculate the reduction of circumference.  Results  Lymphaticovenular anastomosis was successfully conducted in all the 15 patients. The follow-up period ranged from 6 to 10 months (mean 8.3 months), and the average circumference reductions in upper and lower limbs were 33.7% and 20.0%, respectively. None of the patients suffered recurrent lymphangitis after the operation.  Conclusion  Lymphaticovenular anastomosis is an effective treatment for early pitting extremity lymphedema, especially for the cases with patent lymphatic vessels without fibrosis as confirmed by preoperative lymphography.
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  Objective  To study the short-term impact of cleft palate repair surgery on hearing and middle ear function in infants.  Methods  Thirty-three infants with cleft palate who received cleft palate repair surgery from January 2013 to November 2014 in Peking Union Medical College Hospital were included in this study, including 22 male infants and 11 female infants. They were examined using distortion product otoacoustic emission (DPOAE), auditory brainstem response (ABR), 226 Hz probe-tone tympanometry before surgery and 1-24 months after surgery.  Results  The mean age of the 33 infants (66 ears) at the time of surgery was 17 months (8.5-25 months). Sixty-four ears were examined with preoperative DPOAE, with 7 ears (10.9%) passed; postoperative DPOAE was performed in 56 ears, with 19 ears (33.9%) passed. The passing rate was significantly improved after operation (P < 0.01). In the 54 ears for which both preoperative and postoperative DPOAE were conducted, 16 ears (29.6%) showed improved hearing. Sixty-three ears were examined with preoperative ABR, showing a mean hearing threshold of (43.73±13.65)dB nHL; 62 ears were examined with postoperative ABR, showing a mean hearing threshold of (35.65±13.75)dB nHL, significantly improved compared with the preoperative threshold (P < 0.01). In the 53 ears which received both preoperative and postoperative ABR, 29 ears(54.7%) showed reduced hearing thresholds. There was no significant difference in 226 Hz probe-tone tympanometry between preoperative and postoperative examinations(P>0.05).  Conclusion  In infants with cleft palate, short-term hearing improvement may be observed after repair surgery, while middle ear function may show no obvious improvement.
Abstract:
  Objective  To explore the hepatic function factors related to renal function in patients with malignant obstructive jaundice undergoing percutaneous self-expanding metal biliary stents (SEMS) implantation to restore internal drainage.  Methods  We reviewed the clinical data of 91 consecutive patients with malignant obstructive jaundice who received SEMS implantation to restore internal biliary drainage in Peking Union Medical College Hospital between January 2005 and May 2014. They were all preoperatively confirmed cases of inoperable malignant biliary obstruction, including 38 men and 53 women, with the mean age of (67.25±13.41) years and mean hospital stay of (12.02±9.96) days. Renal function was assessed by creatinine clearance rate, glomerular filtration rate (GFR) estimated using the Modification of Diet in Renal Disease (MDRD) formula, and blood urea nitrogen and electrolytes (Na, K, Ca, Cl) levels. Hepatic function was assessed by measuring levels of total bilirubin (TB), direct bilirubin (DB), alanine aminotransferase (ALT), aspartate aminotransferase(AST), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), total protein (TP), and albumin (Alb). The data were all obtained with fully automatic biochemical analyzer before SEMS implantation, and before discharge. Quantile regression analysis was used to analyze hepatic functional factors related with GFR change.  Results  The hepatic function indicators significantly decreased after SEMS implantation in these patients(all P < 0.05), among which TB, DB, ALT, AST, GGT, ALP, TP, and Alb decreased by 23%, 24%, 36%, 40%, 59%, 32%, 25%, and 10%, respectively. While the renal function indicators showed no significant change after SEMS implantation. Quantile regression analysis showed that only serum DB/TB ratio was significantly correlated with GFR (P=0.0034).  Conclusions  DB/TB ratio in malignant obstructive jaundice may be associated with renal dysfunction. Early "one-step" percutaneous SEMS implantation is therefore recommended for patients with high DB/TB ratio to restore internal drainage.
Abstract:
  Objective  To evaluate the performance of fluorescence immunochromatography kit in detecting procalcitonin.  Methods  According to the Clinical and Laboratory Standards Institute(CLSI) EP5-A and EP6-A, the performance of fluorescence immunochromatography kit (TEBSUN) in detecting procalcitonin was evaluated in the aspects of precision, linearity, methodology comparison, relative sensitivity, and relative specificity.  Results  The fluorescence immunochromatography kit showed high precision, the coefficients of variation (CV) of low and high concentration samples were 8.3% and 4.7%, respectively. Result of liner verification test showed good linear correlation within the indicated test range (r=0.9989).In methodology comparison tests, the fluorescence immunochromatography kit had good consistency with VIDAS enzyme-linked immunofluorescence kit (r=0.9770).The relative sensitivity and specificity of the fluorescence immunochromatography kit compared with the enzyme-linked immunofluorescence kit were both higher than 86% at 0.5 ng/ml and 2.0 ng/ml level. The total consistency of the two diagnostic kits was 93.75%.  Conclusion  The fluorescence immunochromatography kit has good performance in precision, linearity, methodology comparison, relative sensitivity, and relative specificity, suggesting that it meets the requirements of clinical tests.
2016, 7(3): 212-215. doi: 10.3969/j.issn.1674-9081.2016.03.011
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2016, 7(3): 216-219. doi: 10.3969/j.issn.1674-9081.2016.03.012
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2016, 7(3): 220-223. doi: 10.3969/j.issn.1674-9081.2016.03.013
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2016, 7(3): 224-230. doi: 10.3969/j.issn.1674-9081.2016.03.014
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