2019 Vol. 10, No. 6

Editorial
Abstract:
The introduction of enhanced recovery pathways has led to a considerable shift in the paradigm of perioperative care, which are now widely implemented in a variety of surgical specialties with large positive results. The principles of enhanced recovery are promoting recovery of normal functions, comprehensive perioperative interventions, multidisciplinary involvement and education, and evidence-based intervention. Enhanced recovery pathways were initially introduced in colorectal and cardiac surgery, and have been adopted amongst orthopedics, urology, obstetrics and gynecology, and other surgical specialties. Limitations for older or more frail patients, or patients undergoing emergent surgeries should be considered, and the pathways could be modified for those patients. In this review, we discussed the principles and status of enhanced recovery pathways as well as the room for further development.
Specialist Forum
Abstract:
Reducing surgical injury is always the determinant factor of enhanced recovery after surgery (ERAS), which has not received sufficient appreciation in current ERAS studies, especially in complex surgeries such as gynecologic oncology. The main resolving strategies include the respect for learning curves, comprehensive surgical plans, timely summary of setback experiences, and carrying out prospective researches. In this article, the effect of surgical injury on enhanced recovery after gynecological oncology surgery and possible improvement measures were discussed.
Guideline and Consensus
Abstract:
The definition of ambulatory surgery by the China Ambulatory Surgery Alliance refers to an operation (excluding outpatient surgery) completed within one day (24 h). For the patients with special conditions who have to prolong hospital stays, the length of hospital stays should not exceed 48 h.Enhanced recovery after surgery (ERAS) is a series of optimized perioperative treatments with evidence-based medicine that can reduce perioperative stress and inflammatory responses, promote rapid recovery, and improve patients' perioperative safety and comfort. Ambulatory surgery has the advantages of short hospital stay and high rate of bed rotation. Based on these characteristics, optimized anesthesia management under the concept of ERAS can enhance the safety, comfort, and efficacy of ambulatory surgery.
Guideline Interpretation
Abstract:
The fast development of day-case surgery and the continuous advancement of enhanced recovery after surgery(ERAS)are all aimed at improving the quality of recovery after surgery so that patients can go through the perioperative period more smoothly and safely. The publication of Guidelines for Day-case Surgery 2019:Guidelines from the Association of Anaesthetists and the British Association of Day Surgery, as important guidance for clinicians to safely perform day-case surgery, will help us to better understand the clinical practice and the perioperative management pathway of day-case surgery. The interpretation made a deeply evidence-based exploration in the updated contents of the guidelines, and further disclosed the development direction of day-case surgery from the perspective of ERAS.
Abstract:
The concept of enhanced recovery after surgery (ERAS) can effectively accelerate the recovery of patients after surgery, improve prognosis, reduce hospitalization costs, and thus get better medical results. According to the latest literature at home and abroad, a group of international experts on the surgical management of esophageal cancer systematically assessed the evidence level and overall recommendation of all parts based on the evaluation system. Finally, a total of 39 parts of the Guidelines for Perioperative Care in Esophagectomy:Enhanced Recovery after Surgery Society Recommendations were formulated. This is the first guidance on ERAS of esophagectomy, with a view to promoting the standardization of clinical practice of ERAS in the perioperative medical modality. This paper interprets the guidelines and explains the hot issues.
Abstract:
Enhanced Recovery After Surgery (ERAS) is now firmly established as a global initiative for the improvement of surgical quality, which results in both clinical improvements and cost benefits to the healthcare system. The ERAS Gynecologic/Oncology guidelines were first published in February 2016. It had been updated in February 2019, representing the joint efforts of the ERAS? Society (www.erassociety.org) and the authors from the international ERAS Gynecology chapters, to present an updated consensus review of perioperative care for gynecologic/oncology surgery based on the best current evidence. There are six new items for 2019 guidelines, including prehabilitation, surgical site infection reduction bundles, patient-reported outcomes, pelvic exenteration and hyperthermic intraperitoneal chemotherapy, discharge pathways, and audit and reporting. Compared with the 2016 guidelines, the currently updated guidelines have ten items with differences in the quality of evidence and recommendation grade and five items with no change. This updated ERAS guidelines aim to further disclose the direction of the perioperative clinical practice of gynecologic/oncology.
Original Contributions
Abstract:
  Objective  The aim of this study was to observe the effect of carbohydrate consumption 2hours before surgery on the gastric volume of elderly patients undergoing gastrointestinal surgery with the technique of point-of-care gastric ultrasound, and further assess the risk of reflux misabsorption.  Methods  Elderly patients (> 65 years) undergoing abdominal operation were prospectively recruited in Sichuan Provincial People's Hospital between December 2017 and October 2018 and were randomly divided into experimental and control groups.The patients in the experimental group fasted for 8 hours and drank 200 ml carbohydrate 2 hours before surgery; those in the control group were required of 8-hour food fasting and 4-hour liquid fasting before the operation. The gastric antrum of each patient was scanned in the position of 45° semi-sitting and right lateral decubitus. The anterior-posterior diameter and cranial-caudal diameter of the gastric antrum were measured at the above two positions before induction of anesthesia.Then the distal cross-sectional area (CSA), gastric volume (GV), and gastric volume/weight (GV/W) were calculated. Correlation of the semi-quantitative GV score and GV/W grading with the risk of reflux misaspiration were assessed.  Results  A total of 69 patients meeting the inclusive and exclusive criteria were enrolled in this study, 33 in the experimental group and 36 in the control group. The two groups showed similar demographic characteristics, surgical category, and classification of the American Society of Anesthesiologists (all P>0.05). In the semi-sitting position, the GV/W was (0.57±0.23)ml/kg and (0.44±0.21)ml/kg in the experimental and the control groups, respectively; in the right lateral decubitus position, CSA was (578.8±71.5)mm2 in the experimental group vs. (513.3±53.2)mm2 in the control group, GV(21.2±11.1)ml vs. (12.9±6.8)ml, GV/W(0.36±0.17)ml/kg vs. (0.20±0.11)ml/kg, respectively; the above all showed statistically significant between the two groups (all P < 0.05). The semi-quantitative GV score showed 0 in 17 patients(51.5%, 17/33), 1 in 15(45.5%, 15/33), 2 in 1(3.0%, 1/33) in the experimental group and 0 in 25(69.4%, 25/36), 1 in 11(30.6%, 11/36), 2 in 0(0, 0/33) in the control group (P>0.05). The risk assessment of reflux misabsorption showed that very low risk was 81.8%(27/33) in the experimental group vs. 94.4%(34/36) in the control group, low risk 18.2%(6/33) vs. 5.6%(2/36), and no high risk in both groups (P > 0.05).  Conclusion  Although preoperative carbohydrate consumption might increase the GV in elderly patients with gastrointestinal surgery, the risk of reflux misabsorption does not increase.
Abstract:
  Objective  The aim of this study was to summarize the integrated program of enhanced recovery after surgery (ERAS) in the perioperation of adolescent idiopathic scoliosis (AIS) and to evaluate its impact on the recovery.  Methods  Among the continuous cohort of AIS patients who underwent the orthopedic surgery in Peking Union Medical College Hospital from January 2007 to January 2017, the initial 100(Cases 1-100, traditional group) and the last 100 cases (Cases 1193-1292, ERAS group) were enrolled in this study. The preoperative, intraoperative, and postoperative enhanced recovery managements were performed in the ERAS group. The related recovery indicators were compared between the two groups, including the length of stay, the postoperative length of stay, allogeneic blood transfusion, pain scores at the discharge, the incidence of complications within 30 days, and the incidence of unplanned reoperation within 1 year.  Results  There was no statistical difference in gender, age, body mass index, surgical segment, and the incidence of unplanned reoperation within 1 year between the two groups. The length of stay and the postoperative length of stay in the traditional group were significantly longer than those in the ERAS group[Length of stay:traditional group (17.18±2.67)days, ERAS group (11.35±1.49)days, P < 0.05; Postoperative length of stay:traditional group (9.34±0.52)days, ERAS group (7.19±0.71)days, P < 0.05]. The percentage and volume of allogeneic blood transfusion in the traditional group were both higher than those in the ERAS group[Percentage:traditional group 41%(41/100), ERAS group 20%(20/100), P < 0.05; Volume:traditional group (1.43±0.39)U, ERAS group (0.59±0.12)U, P < 0.05]. The pain scores at the discharge of the traditional group[(3.40±0.63) points] was slightly higher than that of the ERAS group[(3.00±0.47) points] without the statistical significance.  Conclusion  Proposal formulation of ERAS program for the surgical treatment of AIS might reduce hospital stay and blood transfusion, and accelerate recovery without increasing complications and reoperation.
Abstract:
  Objective  The aim of this study was to investigate the effect of intraoperative intravenous lidocaine infusion on pain control and the recovery of gastrointestinal function after abdominal pelvic surgery.  Methods  Clinical data of patients who underwent abdominal pelvic surgery under general anesthesia from January 2017 to May 2019 in Peking Union Medical College Hospital were retrospectively collected and analyzed. The patients of the control group received traditional general anesthesia, while those of the experimental group received the intravenous infusion of lidocaine based on general anesthesia. The total amount of sufentanil within the postoperative 24 h, pain visual analogue score (VAS), the number of deliveries, incidence of nausea andvomiting, the propertion of patients with intestinal passing gas were compared.  Results  The amount of sufentanil and the number of deliveries in the experimental group were lower than those in the control group[(0.0372±0.0137)μg/(kg·h) vs. (0.0498±0.0447)μg/(kg·h), t=-2.190, P=0.030; 7.4±6.7 vs. 11.1±10.6, t=-2.257, P=0.027]. Compared with that in the control group, the proportion of the pain VAS ≤ 3 at rest and active state in the experimental group were higher(97.0% vs. 85.5%, χ2=3.938, P=0.047; 68.7% vs. 47.3%, χ2=5.710, P=0.017), as well as the proportion of patients with intestinal passing gas(26.9% vs. 5.5%, χ2=9.717, P=0.002); there was no statistical difference in the incidence of nausea and vomiting.  Conclusion  Intraoperative intravenous lidocaine infusion may be helpful to optimize postoperative pain control and enhance the recovery of gastrointestinal function after surgery.
Abstract:
  Objective  The aim of this study was to evaluate the potential diagnostic value of metagenomic next-generation sequencing(mNGS) for cryptococcus infection in the central nervous system(CNS).  Methods  The clinical data of 6 patients with cryptococcal meningitis diagnosed with mNGS in Peking Union Medical College Hospital from January 2014 to December 2016 were retrospectively collected, including the routine examinations, the culture of cerebrospinal fluid (CSF), biochemical and cytologic tests, India Ink stain methods, and the sequencing results using BGISEQ-100 sequencing platform to identify the pathogenic microorganisms of CSF.  Results  The 6 patients'median age was 51 years (range from 26 to 53 years), 4 males and 2 females. None of them had immunodeficiency disease. All had the headache and meningeal irritation, five with fever, and two with diplopia. Lumbar puncture revealed increased opening pressure, slightly increased pleocytosis and protein content, and normal/slightly decreased glucose in all cases. CSF India ink stain was positive in five patients. The antigen of cryptococcal meningitis was positive in 4 patients and the isolation by culture was positive in 2.Cryptococcus specific sequences were detected in all the six patients by mNGS, 5 patients infected with Cryptococcus neoformans and one with Cryptococcus gattii. The identified reads corresponding to Cryptococcus neoformans and Cryptococcus gattii ranged from 108 to 25 361 with genomic coverage rates from 0.19% to 29.00%.  Conclusion  mNGS may be beneficial to make the diagnosis of cryptococcus infection in CNS, especially for the differential diagnosis of Cryptococcus gattii.
2019, 10(6): 612-614. doi: 10.3969/j.issn.1674-9081.2019.06.011
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2019, 10(6): 698-704. doi: 10.3969/j.issn.1674-9081.2019.06.025
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2019, 10(6): 710-712. doi: 10.3969/j.issn.1674-9081.2019.06.027
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Abstract:
Reviews
Abstract:
Enhanced recovery after surgery (ERAS) has been applied in some kinds of surgery, which improves patients' satisfaction and utilization efficiency of medical resources. However, the application of ERAS in the perioperative period of neurosurgery is still at the exploratory stage in China. In this review, we briefly introduce the concept of ERAS and summarize recent research progression in the enhanced recovery of neurosurgical patients in order to improve perioperative anesthesia management in neurosurgical patients and promote ERAS in the rehabilitation after surgery.
Abstract:
Enhanced recovery after surgery (ERAS) aims at reducing surgical stress and accelerating patients' postoperative recovery by optimizing perioperative management, which has been widely applied in multiple fields such as colorectal surgery, orthopedics, and urology, and has gained attention from gynecologists over the last decade. It has been showed that ERAS can reduce postoperative pain, bring down the incidence of postoperative nausea and vomiting, promote the recovery of bowel function, save hospitalization expenses, and improve patient satisfaction in both benign and malignant gynecological conditions. The successful implementation of ERAS requires close collaboration among multiple disciplines as well as rigorous and scientific prospective study providing high-quality evidence support, so as to promote the continuous improvement of ERAS program and bring maximum benefits to patients.
Abstract:
Highly effective antiretroviral therapy (ART) can greatly reduce the fatality rate in patients with human immunodeficiency virus infection and enable them to achieve long-term survival. Medication adherence is one of the key factors to achieve viral suppression and delay disease progression. Current methods of measuring adherence can be divided into indirect and direct methods. The factors affecting adherence can be roughly divided into four categories:individual levels, drug treatment programs, interpersonal relationship problems, and structural problems. Strategies to improve adherence include short message alert, treatment guidance and planning, real-time adherence monitoring, and application of long-acting antiviral agents. Although there have been many studies on adherence, there are still major challenges in obtaining effective and scalable adherence monitoring and improvement tools.
Abstract:
Venous thromboembolism (VTE), comprised of deep vein thrombosis and pulmonary thromboembolism, is a severe complication with a high incidence after major lower limb joint surgery, which has been drawing more of orthopedic surgeons' attention to the preventive treatment. With the development and application of the guidelines of anticoagulant treatment, the risk and the mortality of VTE have been decreased dramatically, and the consensus that anticoagulation is routinely applied to these patients has been reached among orthopedic surgeons. However, controversies remain in the aspects encompassing the choice of specific regimen, short or long course of anticoagulant treatment, the necessity of drug combination, and the anticoagulant plans for those with complex comorbidities. Therefore, the anticoagulant medications, the selection of prophylactic regimen, the risks and complications of anticoagulation, and the optimal anticoagulant plans for complex cases are discussed in the current review.
Abstract:
Venous thromboembolism is a serious complication after orthopedics arthroplasty, which could result in significant loss of patients' satisfaction with the artificial joint. In some extreme cases, it also could lead to the death from respiratory and circulatory failure. The most important and effective method to prevent this complication is preoperative anti-coagulation therapy that could greatly reduce the incidence of venous thromboembolism after arthroplasty. Anticoagulant drugs, such as low molecular weight heparin, Xa factor inhibitors, are the first choices for anti-coagulation therapy after arthroplasty. These drugs have certain effectiveness and low risk of postoperative bleeding, but there are still some deficiencies, including expensiveness, parenteral administration, and so on. Aspirin is a historical antiplatelet drug. Now some guides and researches suggest it also can be a choice for the prevention of venous thromboembolism after arthroplasty. In these researches, aspirin was found to have similar prophylactic effect and safety compared to anticoagulant drugs in the prevention of venous thromboembolism after arthroplasty. Aspirin is cheaper and economical. It can be administered orally, which is convenient for patients. Some researchers also believe aspirin has a lower bleeding rate compared with anticoagulant drugs. In terms of drug dose, low-dose aspirin has a sufficient preventive effect for venous throm-boembolism, which could reduce the side effect of gastrointestinal adverse reactions. In conclusion, aspirin is a new choice for the prevention of venous thromboembolism after arthroplasty.
Abstract:
Further understanding of the sagittal curvature of the cervical spine plays an important role in the study of the pathogenesis of cervical spondylosis and adjacent spondylosis, as well as in improving the surgical effect. In the past literature, there have been many studies on the relationship between the thoracolumbar curvature and patients' quality of life or functional status, while there are few studies related to cervical curvature, So it is necessary to carry out prospective studies with a large number of cases. This article reviews the measurement method of cervical curvature, the normal curvature of the cervical spine, the relationship of cervical curvature with cervical spondylosis and clinical effects, etc., so as to provide a reference for spine surgeons to understand and treat cervical spondylosis.
Abstract:
Hypersecretion of catecholamines from pheochromocytoma and paraganglioma(PPGL) is associated with high morbidity and mortality, even when the tumors are benign. Up to 25% of PPGL are associated with germline mutations in susceptible genes. About one-quarter is metastatic, defined by the presence of distant metastases. Treatment options for unresectable metastatic disease, including chemotherapy, 131I-MIBG, and radiation, can offer limited tumor and hormone control, although none are curative. Over the past 10 years, substantial progress has been made toward understanding the clinical aspects and molecular origins of PPGL. Nevertheless, predicting and managing malignancy remains the biggest challenge in clinical practice. The natural history of patients with metastatic PPGL has not yet been described, and their prognosis varies. Currently, the diagnosis of metastatic PPGL relies on the presence of metastases, and by then, the disease is usually advanced. A better understanding of the clinical and molecular characteristics of patients with metastatic PPGL has spurred several prospective clinical trials. A deeper understanding of the alteration of the specific molecular pathways causing metastatic PPGL might hopefully lead in the future to the development of radiotherapy and multiple molecular-targeted therapies to treat it successfully.
Abstract:
Gestational diabetes(GDM) is one of the most common complications during pregnancy, which seriously threatens the health of mothers and infants. Therefore, blood glucose monitoring and control during pregnancy are essential. Glycated albumin(GA) is the indicator of short-term glycemic control that reflects the mean blood glucose level in prior 2-3 weeks. Compared with other methods monitoring blood glucose, the application of GA in GDM is more advantageous. GA can be used as a good indicator for monitoring blood glucose during pregnancy and predict complications for mother and infants. However, there are few studies of GA in pregnant women, and the reference range of its normal value in pregnant women has not been defined. This review is about the progress in research on glycosylated albumin in gestational diabetes.
Abstract:
Non-small cell lung cancer (NSCLC) has become one of the leading causes of death by cancer in the world. Research on the treatment of lung cancer has become a hot spot. The incidence of fibroblast growth factor receptor (FGFR) gene mutation and anaplastic lymphoma kinase gene fusion in NSCLC is low, and the curative effect of corresponding targeted drug treatment is not satisfactory. FGFR1 is a common abnormal gene in non-small cell lung cancer. Recent study gradually found its abnormal amplification in various tumors, and also found that various related molecular-targeting drugs have an inhibitory effect on the corresponding tumor. This paper reviews the expression of FGFR1 in non-small cell lung cancer, its relationship with the clinical characteristics of NSCLC, and current research progress in targeted drug therapy.
Abstract:
Systemic lupus erythematosus is a multi-systemic autoimmune disease. Interferon-α is a key factor in the systemic lupus erythematosus immune disorder. The mechanism of action and signaling pathways further reveal the pathogenesis of systemic lupus erythematosus and provide a new strategy for the clinical treatment of the disease. Recent studies have found that microRNA plays an important role in the pathogenesis of systemic lupus erythematosus, and abnormal microRNA expression is involved in the regulation of type Ⅰ interferon pathway. This article reviews the regulation of microRNAs on the type Ⅰ interferon pathway and its role in the pathogenesis of systemic lupus erythematosus, which is of great significance for further understanding the pathogenesis of systemic lupus erythematosus.
Clinical Research and Evidence Based Medicine
Abstract:
Evidence-based medicine calls for consideration of the best available evidence and incorporation of patient values and preferences in health care decisions. The rationale of shared decision making is that both physicians and patients are experts, the physicians on medicine and the patients on their own preferences. Thus, it is essential for physicians and patients to exchange their expertise and make decisions together. To realize shared decision making in practice, physicians need to learn how to acquire the best available evidence, and how to use the decision aid to implement the shared decision making.This article compares different decision making approaches, and discusses the theory, practice, and the barriers to shared decision making specifically in China, aiming to support better clinical decision making and improvement of healthcare quality.
Clinical Practice Guidelines
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Conflicts of interest can affect the credibility, independence, and quality of clinical practice guidelines. Guideline developers, users, and researchers are trying to manage and reduce conflicts of interest worldwide. In this article, we analyzed and compared the definition, classification, and management strategies of conflicts of interest of the key national and international guideline developers, and give recommendations on how to address conflicts of interest in clinical practice guidelines in China.
Breast Cancer
Abstract:
  Objective  The clinical and pathological features and the follow-ups of 173 patients with pathological nipple discharge were analyzed to provide the basis for diagnosis and treatment.  Methods  We reviewed the data of the patients who suffered from pathological nipple discharge and as well underwent surgery in Peking Union Medical College Hospital from Jan to Dec 2015. According to the characteristics of nipple discharge, the patients were divided into groups of hemorrhagic and non-hemorrhagic nipple discharge. We compared the clinical and pathological characteristics between the two groups.  Results  A total of 173 patients who met the inclusion and exclusion criteria were enrolled in this study, all of whom were female, with an average age of (45.65±13.48)years and a median course of disease of 3(1, 12)months. Among them, 119 patients (68.8%, 119/173) had hemorrhagic discharge; 54 patients (31.2%, 54/173) had non-hemorrhagic serous discharge. 111 patients (64.2%, 111/173) had lesions detected by ultrasound before surgery. Therewas no significant difference in age, course of the disease, preoperative physical condition, molybdenum target examination results, and the postoperative pathological classification between the two groups (all P>0.05). There were statistically significant differences in preoperative ultrasound examination (whether lesions were found) and postoperative pathological diagnosis (whether breast cancer was found) (P=0.012 and P=0.045). The age of the malignant lesion group was older in patients with hemorrhagic discharge (P=0.014). After a median follow-up of 17 (14, 20) months, none of the patients who were diagnosed with breast cancer had a recurrence, metastasis, or deceased.  Conclusions  Hemorrhagic nipple discharge showed a higher risk of breast cancer, especially for elder patients. Ultrasound revealed more lumps than physical examination and mammography. Since the examinations can not identify the malignant lesions out of the symptoms of nipple discharge, surgery is always needed and the postoperative prognosis is quite good.
History of Medicine
Abstract:
Chu Fu-tang is the founding father of modern pediatrics in China. In his early life in Peking Union Medical College Hospital, he had a close relationship with his teacher Alexander Ashley Weech. By going through the letters of those two and relative people, along with other materials, the author tried to have a better under standing of their interaction and details of Chu Fu-tang's early academic career, from which young pediatricians could acquire academic and professional wisdom and experience. Also, this essay served as a part of the author's preliminary study of the history of pediatrics in China.