2020 Vol. 11, No. 1

Editorials
Abstract:
Magnetic resonance-guided focused ultrasound(MRgFUS) is a new technique of tumor thermal ablation that has appeared in recent years. It is a kind of treatment that can use the ultrasonic beam to focus on the target after passing through soft tissue so that the target area produces a high temperature instantaneously and makes coagulating necrosis in the tissue. The range and temperature change of the treatment area are monitored by MR synchronously. This technology is completely non-invasive and non-ionizing with no anesthesia, no hospitalization, but only a small amount of sedatives required. At present, this treatment method is widely used in uterine fibroids/adenomyosis, bone tumors, prostate cancer, functional neural diseases, breast cancer, and so on. MRgFUS has become a hot topic of research and clinical application.
Specialist Forum
Abstract:
The diagnosis of resistant hypertension is made when a patient's blood pressure(BP)is not under control after taking appropriate lifestyle measures and treatment with optimal or best-tolerated doses of 3 antihypertensive medications (a diuretic should be 1 component) for at least 4 weeks or 4 drugs are required to control BP. The inadequate BP control is confirmed by BP measurements of office and out-of-office (ambulatory BP monitoring and Home BP monitoring). Resistant hypertension lacks effective treatment. As a treatment method of resistant hypertension, the pathophysiology of renal sympathetic denervation(RDN) has been confirmed by basic research. Although early studies using the first-generation came to different conclusions, recent clinical trials have reached a positive result with a radiofrequency ablation system of the second-generation.However, the evaluation method for the activity of the renal sympathetic nerve is not clear so that it is hard to accurately screen out the patients who are appropriate for RDN. The clinical application of RDN is still controversial.
Guideline Interpretation
Abstract:
For years, the cervical cancer staging of the International Federation of Gynecology and Obstetrics (FIGO) are of clinical staging. However, with the development of diagnostic techniques, advances in surgical procedures, and a deeper understanding of the prognosis of cervical cancer, the old FIGO staging has not been able to well predict the prognosis of cervical cancer and to help the choice of treatment. Therefore, on the basis of the cervical cancer staging in 2009, FIGO introduced new progress in the diagnosis and treatment of cervical cancer in the past 10 years and formed the new staging of cervical cancer in 2018. The new staging system mainly reflects a more detailed stratification of the tumor size and the inclusion of lymph node metastasis. This article explains the changes in the cervical cancer staging of FIGO 2018 and its clinical significance.
Original Contributions
Abstract:
  Objective  The aim of this study was to investigate the value of CT texture analysis for volumetric changes of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR).  Methods  Clinical and imaging data of patients with AAA undergoing CT angiography (CTA) at the 3rd and 12th months after EVAR in the Department of Radiology, Peking Union Medical College Hospital between July 2014 and June 2019 were retrospectively collected. Using the traditional measurement as the grouping basis, patients were divided into increased and no-increased groups according to the volume changes during the follow-up. Segmentation software was used to manually outline the maximum axial sections of all aneurysms and extract the texture features of the thrombus. The grey level co-occurrence matrix (GLCM), the grey level run length matrix(GLRLM), and the grey level difference matrix(GLDM) were calculated to analyzed their relationship with the enlargement of the aneurysm volume.  Results  A total of 70 patients meeting the inclusive and exclusive criteria were enrolled in this study, 29 cases (41.4%, 29/70) in the increased group and 41 (58.6%, 41/70) in the non-increased group. The areas under the ROC curve of GLCM, GLRLM, and GLDM for the diagnosis of increased volumes were 0.892, 0.888, and 0.800, respectively. The best prediction efficiency was shown in GLCM with the sensitivity and specificity of 86.2% and 85.4% respectively. GLDM had the worst pridiction efficiency with a sensitivity of 86.2% and a specificity of 68.3%.  Conclusion  CT texture analysis might predict the volumetric change of AAA after EVAR.
Abstract:
  Objective  The aim of this study was to primarily explore the value of CT angiography (CTA), transesophageal echocardiography (TEE), and intraoperative digital subtraction angiography (DSA) in measuring the orifice diameter of the left atrial appendage for selecting the appropriate size of a closure device.  Methods  Clinical data of patients with non-valvular atrial fibrillation who underwent percutaneous left atrial appendage closure from December 1, 2015 to March 31, 2019 in The First Medical Center of People'sLiberation Army General Hospital were retrospectively collected. The orifice diameters of left atrial appendage were measured by CTA, TEE, and DSA simultaneously; the size of the device was recorded. The relationship between the measurement result of either method and the device size was analyzed using Pearson's correlation, and the Bland-Altman analysis was used to assess the concordance between the measurement of each method and the device size.  Results  Totally 102 patients meeting the inclusive and exclusive criteria were enrolled in this study. All patients received successful implantation of left atrial appendage device, with the mean age of (70.1±9.8)years, the CHA2DS2-VASc score (estimatiing the stroke risk for nonvalvular atrial fibrillation in adults) of 5.11±1.43, and the HAS-BLED score (assessing the bleeding risk) of 3.61±1.18. There was no significant difference in the diameter measurement of the left atrial appendage orifice between CTA and DSA[(22.51±3.55)mm vs. (22.22±3.73)mm, q=0.81, P=0.12]; while both measurements were greater than that of TEE[(20.82±3.63)mm, both P < 0.01]. There were good correlations between the CTA, DSA, TEE, and device size (r=0.93, 0.87, 0.83, respectively, all P < 0.01). In the Bland-Altman plots, the narrowest limits of agreement were shown in the correlation of the device size and CTA measurements (-7.83 mm, -2.56 mm), the difference was (-5.19±1.35)mm, and the 95% confidence interval was (-5.46 mm, -4.93 mm); while the widest was in the correlation of the device size and TEE measurements (-11.00 mm, -2.77 mm), the difference was (-6.88±2.10)mm, and the 95% confidence interval was (-7.29 mm, -6.47 mm).  Conclusion  s For the selection of WATCHMAN closure device, CTA, DSA, and TEE might provide valuable reference measurements. Among the three imaging modalities, the relevance and concordance of CTA measurements are the best.
Abstract:
  Objective  To analyze the features of rectal stromal tumors in the endorectal ultrasonography and contrast enhanced ultrasonography (CEUS).  Methods  The clinical data of patients with rectal stromal tumors who were admitted in the Cancer Hospital, Chinese Academy of Medical Sciences from February 2013 to February 2019 were analyzed retrospectively, including clinical manifestations, CT, MRI, colonoscopy, rectalendorectal ultrasound, and CEUS. According to the consensus on the classification system of National Institutes of Health (NIH), the patients were divided into high-risk, intermediate-risk, low and very low-risk groups. The imaging features of different groups were compared to each other, and the accuracy of different examination methods in the diagnosis of rectal stromal tumors were analyzed.  Results  A total of 12 patients were included:8 males and 4 females with a median age of 54.0(50.5, 65.25)years. There were 6 cases in very low/low-risk group and 6 cases in intermediate/high-risk group. All of the tumors showed an extroluminal growth pattern, 58.3%(7/12) appearing as oval-shaped, 41.7%(5/12) as lobulated, 91.7%(11/12) with distinct borders, 91.7%(11/12) with heterogeneous echogenicity, 41.7%(5/12) of large tumors with cystic regions, and 91.7%(11/12) with abundant internal blood flow signals. The enhancing mode showed hyper-enhanced with a "fast in and slow out" pattern; the average rise time was (8.10±4.03)s; the average time to peak was (25.54±12.16)s. A total of 5 (83.3%) patients in the intermediate/high-risk group showed inhomogeneous enhancement, centripetal enhancement, perfusion defects. Only one (16.7%) patient in the very low/low-risk group showed similar CEUS feature, and all 6 (100%) patients showed diffuse enhancement. The ratio of correct diagnosis was 60.0% in CT, 66.7% in MRI, 0 in colonoscopy, and 100% in rectal endorectal ultrasound combined with CEUS.  Conclusion  s The combination of endorectal ultrasonography and CEUS with coupling gel filling the rectum could clearly show the original layer and distribution pattern of rectal stromal tumors, which is helpful for the diagnosis of rectal stromal tumor and accurate risk stratification of the rectal stromal tumor.
Abstract:
  Objective  The aim of this study was to investigate the clinical significance of serum amyloid A protein (SAA), soluble triggering receptor expressed on myeloid cell-1(sTREM-1), and D-Dimer in the evaluation of prognosis of sepsis.  Methods  From January 2018 to February 2019, patients with sepsis who were prospectively included in the ICU of Hainan Provincial People's Hospital were tested for the levels of SAA, sTREM-1, D-Dimer, C-reactive protein (CRP), and procalcitonin (PCT).Patients' acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scores were recorded. The patients who died within 28 days after the diagnosis of sepsis were included in the study group (death group), otherwise the septic patients were included in the control group (survival group). The multivariate Logistic regression analysis and the receiver operator characteristic (ROC) curve were used to analyze the correlation of each index with the prognosis of patients and the evaluation value.  Results  A total of 82 patients with sepsis who met the inclusion and exclusion criteria were selected for this study, 51 males and 31 females, with an average age of (68.17±9.94) years. There were 30 cases in the death group and 52 cases in the survival group. There was no significant difference in age, sex, and body mass index between the two groups (all P>0.05). There were significant differences in APACHE Ⅱ scores, SAA, sTREM-1, D-Dimer, CRP, and PCT level between the survival group and the death group on the 1st, 3rd and 7th day after the diagnosis (all P < 0.05). Multivariate Logistic regression analysis showed that SAA (P=0.004), sTREM-1 (P=0.025), CRP (P=0.005), and PCT (P=0.016) were independent predictors for the prognosis of sepsis. It was also found that there was a positive correlation of SAA and sTREM-1 levels with APACHE Ⅱ scores on the 1st, 3rd and 7th day (all P < 0.05), and there was a positive correlation between D-Dimer and APACHE Ⅱ scores on the 3rd and 7th day (all P < 0.05). It was found that the areas under ROC curve of SAA on the 1st, 3rd and 7th day were the largest (0.878, 0.916, 0.954, respectively). On the 3rd and 7th day, the areas under the ROC curve of sTREM-1 were (0.907, 0.929) larger than those of CRP (0.897, 0.927) and PCT (0.892, 0.890). The areas under the ROC curve (0.918, 0.974, 0.984, respectively) of the combined detection of SAA, sTREM-1, and D-Dimer on the 1st, 3rd and 7th day were larger than those of the individual indexes.  Conclusions  The dynamic joint monitoring results of SAA, sTREM-1, and D-Dimer can be used as the prognostic indicators for sepsis, and have a higher predictive value than traditional indicators such as CRP and PCT.
Abstract:
  Objective  The aim of this study was to observe the effects of the scoliosis specific exercise (SSE) on mild adolescent idiopathic scoliosis (AIS).  Methods  Clinical data of patients with mild AIS aged from 10 to 18 years who were treated by SSE in Peking Union Medical College Hospital between January and March, 2016 were retrospectively collected. The Cobb angle, the angle of axial trunk rotation (ATR), and the scales of Scoliosis Research Society Patient Questionnaire-22 (SRS-22) were evaluated before and after the treatment.  Results  Totally 31 patients meeting the inclusive and exclusive criteria were enrolled in this study. After the treatment, the Cobb angle and ATR angle decreased than before (Cobb angle:16.29°±5.05° vs.19.23°±2.85°, t=2.955, P=0.006; ATR angle:5.97°±2.22° vs. 7.16°±1.66°, t=4.799, P=0.000). The satisfaction scale after the treatment was higher than that of before[5.0(4.0, 5.0) vs. 3.0(3.0, 3.0), Z=0.000, P < 0.05].  Conclusion  SSE might delay or even improve the spinal deformity in patients with mild AIS.
Abstract:
  Objective  The aim of this study was to observe the feasibility and effectiveness of iThermonitor for continuous monitoring of the core body temperature during ambulatory surgery.  Methods  The body temperatures of patients who underwent ambulatory surgery in West China Hospital from October 25 to December 8, 2017 were prospectively collected. Each set of data included the esophageal temperature, rectal temperature, and armpit temperature measured by iThermonitor.The esophageal temperature was used as the standard and subtracted from the armpit temperature and rectal temperature, respectively. SAS and R softwares were used for consistent analysis.  Results  A total of 113 patients meeting the inclusive and exclusive criteria were enrolled in this study, and 1451 sets of intraoperative temperature data were collected.The armpit temperature measured by iThermonitor was (0.06±0.26)℃ lower, while the rectal temperature was (0.39±0.23)℃ higher than the esophageal temperature. In terms of the correlation coefficient, iThermonitor temperature (r=0.9331) was closer to the esophageal temperature than the rectal temperature (r=0.8431). In respect of theproportion of falling into the esophageal temperature ±0.5℃, armpit temperature was 94.97% and the rectal temperature was 78.91%.  Conclusion  iThermonitor might be effectively used to monitor the core body temperature of adult patients during ambulatory surgery.
Abstract:
  Objective  This study aimed to explore the feasibility of non-conventional indwelling catheter in enhanced recovery after surgery(ERAS) for postoperative patients with gastric cancer.  Methods  The clinical data of patients undergoing gastric cancer radical surgery with ERAS were analyzed retrospectively in the Department of General Surgery, Nanjing General Hospital of Nanjing Military Region from June 2016 to March 2017. All catheters were inserted in the patients during the anesthesia induction period and removed immediately after surgery. The first time of urination after surgery, the volume, and the proportion of re-catheterization were recordedat the observing start point. The risk factors of the delay of the first urination and the reset of catheters were analy-zed.  Results  In all 137 patients, there were 90 male (65.7%) and 47 female cases (34.3%) with an average age of (58.9±10.1)years. The first time of urination was (5.3±2.1) hours; the volume of the first urination was (298.9±101.3)ml; the incidence of resetting catheters was 11.7%(16/137). Subgroup analysis showed that the automatic urination rate was higher in the robotic surgery group. The induced urination rate, the incidence of resetting the urinary catheter, and the urinary tract irritation of the robotic surgery group were all lower compared with the open surgery group(all P < 0.05). 6-hour was used as the cutting line of the first postoperative urination time. Compared with the ≤ 6 h group, the >6 h group had more intraoperative infusion, urinary volume, and the first time of postoperative urine volume that delayed the first time of mobilization(all P < 0.01).  Conclusion  sIt is feasible for patients with gastric cancer in ERAS to remove the urinary catheter immediately after surgery. Intraoperative control of infusion and multimodal analgesia are the basic conditions for non-conventional indwelling catheters. Robotic surgery is favorable for early postoperative recovery of automatic urination.
Reviews
Abstract:
Magnetic resonance-guided focused ultrasound is an advanced non-invasive therapeutic technique, which has great potential in targeted thermal ablation and blood-brain barrier opening treatment of central nervous system diseases. It has been used in the research and treatment of essential tremor, Parkinson's disease, intracranial tumors, Alzheimer's disease, obsessive-compulsive disorder, neuropathic pain, and other diseases now. Magnetic resonance-guided focused ultrasound therapy may be a potential alternative therapy for many diseases due to its advantages such as precision, non-ionizing radiation, and real-time monitoring of target temperature. In this article, we reviewed the progress of magnetic resonance-guided focused ultrasound therapy in clinical applications and scientific researches.
Abstract:
In recent years, vascular interventional therapy has been widely used in clinical practice due to its less trauma, better curative effect and faster recovery. However, traditional vascular interventional therapy is often guided by radiology such as digital subtraction angiography, which is not suitable for patients with iodine contrast agent allergy or contraindications. Ultrasound-guided vascular interventional therapy can avoid the above defects, and it is low-cost and convenient. At present, this technique is mainly used in the minimally invasive treatment of arterial stenosis or occlusion of the lower extremity, renal artery stenosis, abdominal aortic aneurysm, iatrogenic pseudoaneurysm, Budd-Chiari syndrome, walnut clip syndrome, left iliac vein compression syndrome, great saphenous varicose vein, venous malformation, inferior vena cava filter implantation, catheter contact thrombolization, and so on. The basis and key to the success of the treatment is that the conventional ultrasound image can clearly display the operating pathway and lesion area, and maintain image stability. At the same time, the guidewire and balloon and other intravascular operating instruments can be dis-played clearly on the ultrasound image in real time. Ultrasound-guided vascular interventional therapy can also evaluate the vascular segment of the lesion and estimate the effect of interventional therapy in real time. In addition, intravascular ultrasound can more intuitively display the internal structure of blood vessels, so that the difficult operation guided by conventional ultrasound intervention can be successfully carried out, which broadens the field of ultrasound interventional therapy.
Abstract:
Pelvic actinomycosis is a rare infectious disease involving the female reproductive tract. Most of the patients carry an intrauterine device, having some non-specific clinical symptoms and manifestations such as fever, abdominal pain, discharge, and pelvic mass. The diagnosis of actinomycosis highly depends on discoveries of pathology and microbiology. Drug therapy is a basic choice of treatment. Surgeries were applied to severe necrosis and formation of sinus or fistula. Generally, patients with pelvic actinomycosis have a good prognosis.
Abstract:
Unscheduled bleeding is a common cause of discontinuation during the using of combined oral contraceptives(COC). Compliance can be improved by appropriate counseling about the possibility of unscheduled bleeding, as well as by the necessary prevention and treatment. The mechanisms underlying this kind of bleeding are not fully understood. There is little high-level evidence of clinical strategies to support the management of unscheduled bleeding associated with COC. It is critical to role out gynecological pathology for patients with persistent or new-onset unscheduled bleeding.
Abstract:
Respiratory manifestations of connective tissue diseases include interstitial lung diseases, diffuse alveolar injury, alveolar hemorrhage, pulmonary vascular lesions, pleural lesions and airway disease. Their clinical symptoms were not specific. Pulmonary function test and chest computed tomography come to be the most frequently applied examinations. Different connective tissue diseases involving respiratory system have not only common features but also characteristic imaging patterns. In this paper, imaging manifestations of respiratory diseases associated with connective tissue diseases were reviewed, so as to improve readers' recognition of the diseases and guide clinical practice.
Abstract:
Osteoarthritis (OA), the most common chronic joint disease in the elderly population, is mainly characterized by the degeneration of articular cartilage and its pathogenesis is not fully understood yet. Long non-coding RNAs(lncRNAs)are of a new class of regulatory non-coding RNAs with a length longer than 200 nucleotides. They lack open reading frames and have no potential capacity forprotein translation. Increasing evidence indicates that LncRNAs can be differentially expressed in the normal articular cartilage and OA cartilage. Moreover, some lncRNAs have been shown to be involved in multiple pathological processes of OA, including extracellular matrix degradation, inflammatory responses, apoptosis, angiogenesis, autophagy, the response of chondrocytes to mechanic stress, etc. In this review article, we will focus on the function of lnc-RNAs in the development and progression of OA and the potential new targets that might be used for the diagnosis and treatment of OA.
Complicated and Rare Disease
Abstract:
The clinical presentation of primary adrenal lymphoma(PAL) is comprised of major general symptoms. Although adrenal insufficiency is very common in patients with bilateral involvement, it has not been systematically tested. Positron emission tomography is an efficient examination to visualize extra-adrenal locations. The preliminary results of magnetic resonance imaging to distinguish between PAL and adrenocortical carcinoma should be confirmed. Further studies are needed to establish an optimal strategy for the management of patients with PAL. At present, it is unclear whether the adjunction of rituximab (R) and CHOP(cyclophosphamide, doxorubicin, vincristine, prednisone) can cure patients with high-risk aggressive lymphoma. It is also unknown whether the prolonged complete response was due to R-CHOP alone. It is necessary to emphasize that early diagnosis of PAL before the appearance of adrenal insufficiency contributes to decreasing the patients' morbidity and mortality.
Clinical Research and Evidence Based Medicine
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New diagnostic methods must be evaluated by rigorously designed diagnostic accuracy studies before clinical implementation. Designing a diagnostic accuracy study includes 8 procedures:constructing the research question with the PICOS (P:Patient; I:Intervention; C:Comparison; O:Outcome; S:Study design)framework, identifying an appropriate gold standard, choosing a representative patient sample, estimating the sample size, interpreting results of diagnostic tests and the gold standard blind to the other, setting up the optimal threshold, evaluating the diagnostic accuracy, and finally drafting a report according to the standards for reporting diagnostic accuracy. The accuracy of diagnostic tests includes sensitivity, specificity, predictive value (PV), and likelihood ratio (LR). The LR estimated by diagnostic tests can move clinicians from the pretest probability to a posttest probability. If the clinical setting is similar to that of the study and the patient meets all eligibility criteria of the study, the LR may facilitate the diagnostic process in clinical practice.
Clinical Practice Guidelines
Abstract:
Guideline adaptation is not only an effective approach for low-income countries lacking the ability to develop and obtain high-quality guidelines, but also for middle- and high-income countries or coun-tries with guideline-developing capacity, to reduce work of duplication and fully integrate the existing resources. Thus, the purpose of this paper is to analyze the current situation, the theoretical framework, and challenges, and then put forward some thoughts and suggestions on the application of adapting guidelines.
2020, 11(1): 109-114. doi: 10.3969/j.issn.1674-9081.20190116
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2020, 11(1): 119-120. doi: 10.3969/j.issn.1674-9081.20190206
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Teaching and Research
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This article focuses on explicating the core competencies required for clinical and translational medicine mentors from a case scenario. To discuss "how to give a feedback on the evaluation of mentees", first of all, we present problems involved in the case and the connotation of mentorship reflected by the case; after that, each problem is analyzed in depth and solutions are proposed to reflect the core competence of mentors. The core competencies required by a mentorship are skills of communication, management, psychosocial support, career planning, etc.