2019 Vol. 10, No. 2

Editorials
Abstract:
Hypertension is the top chronic disease in both the world and China, and its complications of cardiovascular and cerebrovascular diseases are the leading cause of death in our country. Recently, plenty of foreign researches have suggested that the community-based mode of the prevention and treatment of hypertension is an effective way to improve the control rate. In the 20th century, China conducted research on community intervention, focusing on health education, which have achieved remarkable results but not been widely promoted. Since the beginning of the 21st century, China has also carried out many studies on the prevention and treatment of hypertension. However, there are still many shortcomings in the management of hypertension. Therefore, to improve the control rate of hypertension in China, we should actively explore the modes of prevention and treatment suitable for China's national condition.
Abstract:
In recent years, minimally invasive laparoscopic surgery has been widely used in early-stage cervical cancer. Previous retrospective studies have shown that minimally invasive surgery is associated with less intraoperative blood loss, a shorter length of hospital stay, and a lower risk of postoperative complications than the abdominal approach, and yet does not affect survival. But a prospective multicenter randomized controlled clinical trial and a retrospective epidemiological study, which were published in the New England Journal of Medicine on October 30, 2018, showed that minimally invasive surgery in patients with cervical cancer was associated with a higher rate of recurrence and a lower rate of disease-free survival. We can't completely negate the role of laparoscopy in the treatment of cervical cancer. But these results cause our attention and reflection. The choice of the surgical path depends on the characteristics of the patient, disease and personal technology.
Specialist Forum
Abstract:
Hypertension is the most important risk factor for stroke, which is not well controlled in China. The rates of awareness, treatment, and control of hypertension are low. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults redefines hypertension, setting the threshold of hypertension at 130/80 mm Hg(1 mm Hg=0.133 kPa). By this standard, new therapeutic targets and management strategies for hypertension were formulated. The guideline is based on the results of Systolic Blood Pressure Intervention Trial (SPRINT), which indicate that intensive antihypertensive therapy reduces the incidence of cardiovascular events and all-cause mortality compared with the standard blood pressure control. But at the same time, this standard increases the number of patients with hypertension and affects the treatment measures in most people including the elderly and the weakened population. It increases the economic burden while increasing the adverse reactions in special populations, which is not conductive to the prevention and individualized treatment of hypertension. Therefore, by this hypertension standard, according to the existing medical evidence, it is suggested that strategies of stroke prevention, especially primary prevention, should be changed in China.
Abstract:
Recently, ACC/AHA has proposed the new diagnostic criteria of hypertension as130/80 mm Hg (1 mm Hg=0.133 kPa), which is different from other guidelines. The core goal of antihypertensive therapy is the protection of target organs. Therefore, the issues related to intensive antihypertensive therapy and the prevention of cerebral small vessel disease have attracted more attention in recent years. Current findings suggest that the antihypertensive program may have a positive effect on secondary prevention of lacunar stroke and white matter lesions. The exact target blood pressure (BP) has not been determined yet. BP and clinical outcomes may present a J-type relationship, indicating that too low or too high BP may both be harmful, and the ideal target BP is to be further explored.
Abstract:
With the acceleration of population aging in China, the number of older people with hypertension is increasing year by year. In general, elderly is defined as ≥65 years old. Compared to middle-aged and young patients, the elderly with hypertension have their own particularity and the cardiovascular events significantly increase. Older patients are more likely to have isolated systolic hypertension, raised pulse pressure, an obvious variation of blood pressure(BP), and associated complications. Therefore, BP control in the elderly presents more difficulties than in younger people. Antihypertensive treatment for older patients should aim to protect target organs and reduce the incidence of cardio-cerebrovascular events. The benefits of BP treatment in older patients will be influenced by the patients' tolerance to treatment and potentially harmful effects of BP-lowering treatment. In order to attain a safe and steady BP-lowering, it is especially important to take individualized treatment strategies based on complete clinical evaluation and careful monitoring of patients. The target BP < 150/90 mm Hg (1 mm Hg=0.133 kPa) is recommended in older hypertensive patients.
Opinions
Abstract:
Hypertension is the top modifiable cause for the incidence and mortality of cardiovascular disease in China. Because the etiology of hypertension is not clear in most of the patients, the current antihyperten-sive strategy focuses on its treatment rather than the prevention. The main goals are to increase the awareness rate, treatment rate, and control rate for patients with hypertension. Because of the lack of effective strategies to prevent the occurrence of hypertension, the prevalence rate of hypertension has been increasing in all age groups of adults in China, especially in young and middle-aged Chinese. Many studies show that people who have so-called prehypertension with systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg have the highest risk of future hypertension. It is the first time in the world that the 2017 ACC/AHA hypertension guideline redefined hypertension by including prehypertension as stage 1 hypertension and recommended early lifestyle modification as the priority strategy for these patients. This article discussed the motivation and rationale of the new definition of hypertension issued by 2017 ACC/AHA, and analyzed the potential significance and positive impact on the development of the prevention and treatment of hypertension in China.
Abstract:
The 6th World Symposium on Pulmonary Hypertension was held in Nice between February 28 and March 1, 2018. The major progress in chronic thromboembolic pulmonary hypertension (CTEPH) in the past 5 years was reviewed by the experts of Task Force 11. The definition, classification, pathologic mechanisms, epidemiology, diagnosis, and treatment were updated based on available evidence. Chronic thromboembolic disease (CTED) was defined and the difference between CTED and CTEPH was summarized. All CTEPH patients should be evaluated by a multidisciplinary team. Balloon pulmonary angioplasty (BPA), with improved efficacy and safety, plays an important role in CTEPH therapy. An ongoing study investigates patients with CTEPH who are not eligible for pulmonary endarterectomy and are randomized into medicine therapy or balloon pulmonary angioplasty (BPA), and compares the effects of the two therapies. The combination therapy for CTEPH needs the evidence of a long-term follow-up.
Original Contributions
Abstract:
  Objective  To study the correlation between 24-hour urinary sodium excretion and the controlling status of office blood pressure (BP) and home blood pressure monitoring (HBPM) in patients with resistant hypertension (RH).  Methods  A cross-sectional study was performed based on the RH patient database in Peking Union Medical College Hospital. All RH patients treated in the Cardiology Clinic, Peking Union Medical College Hospital from October 2017 to March 2018 were enrolled. Twenty-four-hour urinary sodium excretion (24h-UNa) was examined to estimate daily sodium intake. Office BP, HBPM (4 measurements daily: before medicine in the morning, 10 a.m., 4 p.m., and before sleeping at night, respectively), and the types of antihypertensive drugs were recorded. Based on the quartile method for 24h-UNa excretion, all enrolled patients were stratified into four groups: low 24h-Una, low-mid 24h-UNa, mid-high 24h-UNa, and high 24h-Una groups. Multiple Logistic regression analysis was used to analyze the correlation of independent factors with the rate of BP control.  Results  Totally 202 subjects were recruited, 107 men, 95 women, aged (59.87±16.30) years, and the 24h-UNa was (198.92±96.59) mmol. Patients with higher urine-sodium excretion were younger and with a higher body mass index (P < 0.001). The number of antihypertensive drugs increased significantly with the increase of urinary sodium level (P=0.001). High urine sodium excretion was associated with the reduced BP control rate for HBPM in the morning and at 10 a.m.. Multivariate Logistic regression analysis showed that 24h-UNa was independently associated with the target achievement of office BP (OR=2.356, 95% CI:1.004-5.533, P=0.049), morning HBPM (OR=2.408, 95% CI:1.026-5.650, P=0.030), and 10 a.m. HBPM (OR=2.299, 95% CI:1.031-5.129, P=0.033), while not with the 4 p.m. and night HBPM.  Conclusions  24h-UNa is an independent risk factor for the control rates of office BP and morning HBPM in RH patients. Restriction of sodium salt intake plays an important role in reducing BP fluctuation and improving BP control.
Abstract:
  Objective  The aim of this study was to evaluate the quality of life in patients with pulmonary thromboembolism (PTE) by the SF-36 questionnaire and to investigate the determinants of the quality of life.  Methods  PTE patients who had discharged from Peking Union Medical College Hospital or had visited the Department of Respiratory Medicine between May 2016 and November 2017 were invited to fill the SF-36 question- naire. The  Results  were compared with the normal Chinese population. Demographic (gender, age, and obesity)and clinical data (the interval from PTE to questionnaire, locations of thrombus, deep vein thrombosis, cancer, chronic heart/pulmonary disease, provoked PTE, transient risk factor, and permanent risk factor) were collected and determinants were analyzed with the univariate and multivariate regression.  Results  Eighty-eight patients finished the SF-36 questionnaire. PTE patients had lower subscale scores of SF-36 compared with normal Chinese people: physical functioning, 59.8±27.4 vs. 87.6±16.8; role-physical, 30.4±41.9 vs. 83.0±20.7; bodily pain, 67.4±23.6 vs. 83.3±19.7; general health, 43.0±23.1 vs. 68.2±19.4; vitality, 57.3±23.5 vs. 70.1±16.8; social functioning, 60.1±29.9 vs. 84.8±16.6; role-emotional, 44.7±43.1 vs. 85.3±17.7; and mental health, 58.7±21.5 vs. 78.8±15.4 (all P < 0.01). The life quality scores of PTE that occurred more than one year before were higher than those of PTE within one year in every subscale except mental health. Multivariate regression analysis showed that: Age and provoked PTE were associated with general health; the interval from the diagnosis of PTE to questionnaire was associated with bodily pain; the transient risk factor was associated with role-physical, vitality, social functioning, health transition; and the permanent risk factor was associated with mental health.  Conclusions  The quality of life in PTE patients is generally lower than that in normal Chinese population; age, interval, provoked PTE, transient risk factor, and permanent risk factor are associated with their quality of life.
Abstract:
  Objective  Intraoperative blood salvage (IBS) is a commonly used technique of blood protection in the clinic. However, salvaged blood may contain muscle relaxant and lead to repression of the functional recovery of muscle and respiratory after surgery. Cis-atracurium besilate (Cisa) is a new type of muscle relaxant. The aim of this study was to investigate the safety of Cisa in patients receiving IBS.  Methods  Fifty patients with lumbar disc herniation who received lumbar decompression and internal fixation under general anesthesia in the Department of Spine, Beijing Jishuitan Hospital from March to June 2017 were prospectively and sequentially enrolled. The first 25 patients were included in the experimental group and the last 25 in the control group. Cisa was used as the muscle relaxant during general anesthesia. In both groups, the IBS technique was used to collect and wash the autologous blood from the surgical field. In the post anesthesia care unit, train-of-four stimulation (TOF) was monitored every 5 min for 40 min after extubation to evaluate the recovery of muscle function. The salvaged blood was one-timely re-transfused after extubation in the experimental group and 40 min later in the control group. The arterial partial pressure of oxygen (PaO2) and the partial pressure of carbon dioxide in the artery (PaCO2) were assessed before anesthesia and immediately after observation to evaluate the respiratory function.  Results  All patients in both groups finished the whole observation. There were 25 men and 25 women with average age of (55.1±11.1)years and weight of (72.7±9.8)kg. The basic data between two groups were matched. An upward trend of TOF was shown with time, while the increase of TOF at the 40-min point showed no statistical difference between the two groups [(9.6±7.3)% vs. (9.5±8.1)%, P=0.963]. Patients in both groups underwent respiratory insufficiency by the end of observation, but there was no statistical difference in PaCO2-incr[4.4(2.0, 8.0)mm Hg vs. 4.8(0, 7.1)mm Hg, P=0.312](1 mm Hg=0.133 kPa) and PaO2-decr[3.2(-2.4, 7.9)mm Hg vs. 7.2(-1.6, 13.0)mm Hg, P=0.133] between groups.  Conclusion  Cisa is safe as a muscle relaxant for patients receiving IBS under general anesthesia.
Abstract:
  Objective  To investigate the correlation of 25-hydroxy vitamin D [25-(OH)D] and lipopro- tein-associated phospholipase A2(LP-PLA2) with diabetic retinopathy(DR).  Methods  From May 2014 to January 2017, data of patients with type 2 diabetes mellitus from the Department of Endocrinology of Cangzhou Central Hospital were retrospectively analyzed and selected for the study. Patients were divided into three groups according to the Results of fundus photography:type 2 diabetes mellitus without retinopathy (NDR group), background type 2 diabetic retinopathy(BDR group), and proliferative stage 2 diabetic retinopathy (PDR group), and healthy subjects who took a medical examination were selected as the control group. Relative biochemical indexes were compared among the four groups.Pearson correlation analysis and multiple Logistic regression were carried out to analyze the correlated and independent risk factors.  Results  Three hundred and forty type 2 diabetic patients (NDR group:125 cases, BDR group: 118 cases, PDR group: 97 cases) and 100 healthy controls were selected for this study. There was no significant difference in sex, age, body mass index, systolic blood pressure, diastolic blood pressure, total cholesterol, triglyceride, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and fasting blood glucose among the four groups (all P > 0.05). The course of the NDR group was shorter than that of the BDR group, and the later was shorter than that of the PDR group (P < 0.05). Compared with the control group, glycated hemoglobin A1c(HbA1c), glycated albumin (GA), serum cystatin C (Cys-C), and LP-PLA2 were significantly higher, and 25(OH)D was significantly lower in NDR group, BDR group, and PDR group(all P < 0.05). Among the BDR group, PDR group, and NDR group, HbA1c, GA, Cys-C, LP-PLA2, and 25(OH)D also had significant differences (all P < 0.05). After Pearson correlation analysis, the course of the disease, HbA1c, GA, Cys-C, and LP-PLA2 were positively correlated with DR (all P=0.000), and 25(OH)D had a negative correlation with DR(P=0.000). After Logistic regression analysis, the course of the disease, HbA1c, Cys-C, and LP-PLA2 were independent risk factors of DR, and 25(OH)D was the protective factor of DR(all P < 0.05).  Conclusions  25(OH)D and LP-PLA2 levels are closely related to the occurrence and development of DR. 25(OH)D is the protective factor, and LP-PLA2 is a risk factor.
Reviews
Abstract:
In the past decade, the emergence of targeted therapy has provided an exciting option for the treatment of renal cell carcinoma. There were 9 targeting agents approved for the treatment of unresectable or metastatic renal carcinoma by the American Food and Drug Administration(FDA). The promise of renal carcinoma immunotherapy was officially validated in December 2015 when the FDA approved Nivoliumab for the treatment of metastatic renal carcinoma. There are an increasing number of clinical trials on immune checkpoint inhibitors alone or combined with targeting agents that are now being identified and used for renal carcinoma immunotherapy. In this review, we present a brief overview of current treatments and discuss major clinical trials and data on renal carcinoma.
Abstract:
Diagnostic vitrectomy is a procedure that can obtain vitreous, retina or choroid specimens from patients with intraocular inflammation or malignant tumors of obscured etiology or irresponsive to treatments. An accurate diagnosis could be obtained from vitrectomy specimens by using related laboratory diagnostic technologies. Diagnostic vitrecomy with micro-incision and the developed laboratory diagnostic technology increase the specificity and sensitivity of disease diagnosing. The review summarized the surgical indications of diagnostic vitrectomy, specimen collection and process, methods of laboratory diagnostic technology, and the development of diagnostic vitrectomy.
Abstract:
Cutaneous T cell lymphoma(CTCL) are mostly indolent, which slowly progress. The patients usually get a definite diagnosis in the early stage. Topical medication and physical therapy are the mainstays in the treatment of CTCL, including topical corticosteroids, immunosuppressive agents, retinoids, radiation therapy, and phototherapy. In recent years, the efficacy and safety of traditional methods has been further evaluated. Meanwhile, some new strategies of topical medication and physical therapy such as topical tazarotene, topical resiquimod, ultraviolet A plus new photosensitizer, and photodynamic therapy have been employed for CTCL. This article reviewed the research progress of topical medication and physical therapy for CTCL.
Complocated and Rare Disease
Abstract:
Birt-Hogg-Dubé(BHD)syndrome is a rare autosomal dominant genetic disease that results from the mutation of folliculin gene and commonly affects lungs, kidneys, and skin. In China, only a few families affected by this syndrome were reported. Pulmonary cysts and pneumothorax are common clinical manifestations of this disease, while skin lesions and kidney tumors are relatively rare. Here we reported a case of BHD syndrome with renal hybrid oncocytic/chromophobe tumors, analyzed its clinical features, laboratory examinations, family history, diagnostic methods, and treatment, and reviewed the relevant literature. Clinical attention should be paid to the diagnosis of BHD syndrome. The treatment principle for patients with renal tumors is early detection and to carry out nephron sparing surgery.
Clinical Research and Evidence Based Medicine
Abstract:
A well-conducted randomized controlled trial(RCT) is considered the gold standard for comparing the efficacy and common adverse events of different interventions. However, for China's RCTs, there is still room for the improvement in research design, implementation, selection of effective measures, data analysis, and interpretation of results. In this article, we present six misunderstandings or errors to help clinicians in clarifying the concept of randomization, correctly implementing the process of randomization and concealment of allocation, understanding the baseline imbalance in RCTs, reasonably selecting effective measuers, and correctly interpreting the statistical significance and clinical significance in an effort to produce more RCTs of high-quality and protect clinicians from potentially misleading presentations and interpretations of research findings.
Clinical Biobank
Abstract:
In recent years, research on stem cell has made great progression and widespread clinical application in disease treatments, tissue repair, anti-aging, cosmetology, and other fields. It has become one of the most important researching directions in the field of life science, and has been widely concerned around the world. A high-quality stem cell bank of the clinical grade is not only the precondition for stem cell products to enter clinical practice, but also the key factor for the success of the stem cell industry. Besides, it will provide an indispensable resource for the clinical research of stem cells. Based on the situation of our country and the practice and exploration experience of construction and management of a clinical stem cell bank of East Hospital Affiliated to Tongji University, the article focuses on the planning, construction, and the management of a whole process chain of a stem cell bank of the clinical grade, and covers collection, preparation, testing, cryopreservation, distribution, the establishment of a quality management system, information tracking, and data management of stem cell lifecycle.
2019, 10(2): 178-184. doi: 10.3969/j.issn.1674-9081.2019.02.018
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Abstract:
Case Report
Abstract:
Sarcoidosis is a multi-system inflammatory disorder with the characteristics of non-caseating granulomas, which is most commonly involved in lungs, heart, eyes, skin, and other organs. Symptomatic cardiac involvement is found in about 2%~5% of sarcoidosis patients. However, autopsy studies have detected that approximately 25%~50% of sarcoidosis patients have asymptomatic cardiac involvement with a delayed diagnosis and poor prognosis. We report the clinical manifestations, laboratory examinations, diagnostic methods, and treatment of one sarcoidosis patient with latent cardiac involvement, to remind clinicians to pay attention to the systematic evaluation of sarciodosis.
Teaching and Research
Abstract:
  Objective  To explore the Methods of critical reading based on active learning in clinical teaching.  Methods  A total of 38 students consisting of residents and postgraduates, who participated in both clinical and research work in the Department of Neurology of Peking Union Medical College Hospital, were organized to conduct a critical reading and discussion about literature every 2 weeks. The main process of discussion each time included self-selecting, analyzing, discussing, and raising questions about the literature with the Methods of critical reading, under the supervision of the teachers in case of necessity. Lectures on methodological knowledge were given as supplements. Literature from high-impact journals was suggested in the initial stage. The evaluation was mainly based on the reporting guidance published on the website "http://www.equator-network.org/", including observational, interventional, and diagnostic/prognostic studies, and systematic reviews published in English. Evaluation of the effect of critical reading was performed by questionnaire.  Results  Six sessions have been conducted since October 2017. The selected articles cover four types of study design: randomized controlled trials, cohort studies, diagnostic tests, and case-control studies, encompassing the specialities of cerebrovascular disease, multiple sclerosis, amyotrophic lateral sclerosis, and Parkinson's disease. Two lectures were delivered with topics of "research design and literature search". Feedback was collected anonymously by questionnaire. Eleven students responded that they learned the benefit of critical reading for building their reading habit; eleven students thought it was helpful in learning research methodology; four students considered their statistical knowledge was enhanced during these reading sessions; one student believed that it helped to update the latest progress in Neurology. Feedbacks about how to improve were scattered: five students wished more lectures being given; four students wished to focus more on the study of statistical knowledge during the discussion; three students wished to receive articles earlier; two students wanted more guidance from the teachers.  Conclusions  Generally, the whole design of teaching practice was well accepted among young doctors and medical students, giving us the confidence to improve students' ability of critical reading and conducting their own research in a way with critical thinking.