2020 Vol. 11, No. 2

Editorials
Abstract:
Thrombotic diseases are common in clinical practice, and thrombolytic agents play a key role in the treatment during the acute period. Thrombolytic agents have developed rapidly since the discovery of streptokinase in 1933. The efficacy and safety of thrombolysis have been improved significantly as the agents progressed from the early generation without fibrin specificity to the current generation of gene recombinant drugs. With continuous exploration in clinical practice, thrombolytic agents that are used widely in the treatment during the acute period of thrombotic diseases are the key to reduce disability and mortality. However, current existing thrombolytic agents still have disadvantages such as severe bleeding, limited recanalization, short half-life, immunogenicity, high price, and so on. It still needs to explore new breakthroughs in the future.
Abstract:
Thrombolytic revascularization therapy still remains an important method in the treatment of ST-segment elevation myocardial infarction (STEMI). Recent clinical studies confirmed the status of thrombolytic therapy in 3 clinical situations:estimated long delay(>2 hours) in primary percutaneous coronary intervention (PCI), pharmco-invasive thrombolytic therapy with estimated PCI delay(1 hour), a large thrombus treated with intra-coronary use of low dose thrombolytic therapy during primary PCI. Above 3 conditions should be fully considered during clinical application.
Abstract:
Systemic lupus erythematosus(SLE) is a complicated autoimmune disease characterized by aberrant B cell activation. Belimumab is a human monoclonal antibody, which can reduce active B cells through binding to the B-cell-activating factor of the tumor necrosis factor family(BAFF). In 2011, the US Food and Drugs Administration approved belimumab as a new drug option for SLE patients. This article mainly discusses the mechanism and relevant clinical trials of belimumab and looks forward to its future.
Specialist Forum
Abstract:
Thrombolysis is an important treatment in critical patients with acute pulmonary embolism (PE). Although meta-analysis has shown that acute PE patients benefit from thrombolysis, the mortality is not reduced when thrombolysis is applied in patients with PE of intermediate risk due to the increased bleeding risk. Guidelines recommend that thrombolysis should be applied in high-risk PE with cardiac arrest, obstructive shock, or persistent hypotension. The most important risk of thrombolysis is bleeding, especially cranial bleeding, which restricts the wide use of thrombolysis. Recombinant tissue-type plasminogen activator is the most widely used thrombolytic agent, which is superior to urokinase and streptokinase. Some studies on reduced-dose thrombolysis achieved advantageous results, but more large-scale studies are needed. Ultrasound-assisted thrombolysis is a widely studied catheter-directed thrombolytic technique, and can be applied in some specific patients.
Controversy
Abstract:
Cerebral venous sinus thrombosis(CVST) is rare and accounts for less than 1% of strokes. The mainstay treatment for CVST is systemic anticoagulation with heparin, but 9%-13% of patients have a poor outcome. In patients who show signs of rapid deterioration, endovascular treatment(ET) is technically feasible and has shown benefit with good recanalization rates in different case series and prospective cohorts. However, it remains unknown whether it improves the clinical outcome of the ET subgroup compared with anticoagulation alone. Therefore, whether acute CVST requires endovascular therapy remains controversial.
Original Contributions
Abstract:
  Objective  This study aimed to identify the possible short-term risk factors associated with the mortality of patients with acute pulmonary embolism after thrombolytic therapy.  Methods  We retrospectively collected the patients with acute pulmonary embolism who were diagnosed by computed tomography pulmonary angiography (CTPA) or echocardiography (ECHO) and received thrombolytic therapy with recombinant tissue-type plasminogen activator (rt-PA) in Peking Union Medical College Hospital from January 2014 to November 2017. The collection of clinical data including comorbidities, course of the disease, clinical features, laboratory tests, imaging findings, simplified pulmonary embolism severity index (sPESI), treatment, outcomes, etc. were used to analyze the prognostic factors of disease 7 days, 14 days and 30 days after thrombolytic therapy.  Results  A total of 23 patients, 5 males and 18 females, were included in the study with an average age of (57.3 ±14.0) years. Sixteen patients survived (69.6%, 16/23) and 7 died (30.4%, 7/23); the 7-day, 14-day and 30-day mortality was 26.1% (6/23), and 30.4%(7/23), 30.4%(7/23), respectively. Compared to the survival group, patients in the death group had higher sPESI[3(2, 3)vs 2(1, 2), P=0.008], lower systolic pressure[(79.3±25.4)mm Hg vs (108.7±18.1)mm Hg, P=0.005], less platelets[(135.1±58.3)×109/L vs (223.2±89.4)×109/L, P=0.012], lower calcium concentration[(1.9±0.2)mmol/L vs(2.1±0.2)mmol/L, P=0.030], higher N-terminal pro-B-type natriuretic peptide (NT-proBNP)[6372(1637, 17 228)pg/ml vs 1166(343, 1821)pg/ml, P=0.035], and more frequent cardiopulmonary resuscitation (100% vs 12.5%, P=0.000). Survival analysis indicated that patients who had a heart rate>110 beats/min (P=0.012), systolic blood pressure < 90 mm Hg(P=0.000), cardiopulmonary resuscitation(P=0.000), or NT-proBNP >6000 pg/ml (P=0.001) had a lower 14-day survival rate. Factors such as the absence of malignant tumors or chronic cardiopulmonary disease, arterial oxygen saturation ≥ 90%, platelets ≥ 200×109/L, and blood calcium ≥ 2.00 mmol/L made no difference in the improvement of 14-day survival.  Conclusions  In patients with acute pulmonary embolism after thrombolytic therapy, hypotension, cardiopulmonary resuscitation, elevated heart rate and NT-proBNP may indicate a higher risk of short-term mortality. Whether hypocalcemia and thrombocytopenia can be used as short-term prognostic factors requires further researches.
Abstract:
  Objective  This study aimed to investigate the expression of rhomboid domain-containing protein 1(RHBDD1)in the tissue of gastric cancer, and to evaluate its relationship with the occurrence and development of gastric cancer.  Methods  We retrospectively collected the clinical data of patients with gastric cancer, precancerous lesions, or chronic superficial gastritis(CSG)admitted in the Department of Gastroenterology, Beijing Hospital from January 2015 to January 2018. The histopathological diagnosis of the lesions was reinterpreted. According to the type of pathological diagnosis, the lesions were divided into groups of CSG, low-grade gastric intraepithelial neoplasia(LGIN), high-grade gastric intraepithelial neoplasia(HGIN), early gastric cancer(EGC), and advanced gastric cancer(AGC). The positive rate of the expression of RHBDD1 in the gastric tissue was analyzed.  Results  A total of 76 patients with 152 lesions were enrolled in this study, including CSG 17, LGIN 21, HGIN 54, EGC 44, and AGC 16. The expression of RHBDD1 in chronicgastritis was significantly lower than that in other gastric lesions, including LGIN, HGIN, EGC, and AGC(P=0.001). The general trend of positive RHBDD1 expression in gastric mucosal lesions increased gradually with the severity[CSG(35.3%)→precancerous lesions(LGIN+HGIN)(74.7%)→EGC(75.0%)→AGC(87.5%)].  Conclusion  The expression of RHBDD1 in the gastric tissue may provide a useful clue for the differentiation between benign and malignant gastric diseases.
Abstract:
  Objective  This study aimed to evaluate the potential influence of culture conditions, incubation time, and the interpreting cut-off value(COV) in the identification of filamentous fungi by matrix-assisted laser desorption ionization-time of flight mass spectrometry(MALDI-TOF MS).  Methods  Seventy-eight isolates of filamentous fungi were cultivated in sabouraud dextrose agar(SDA) or potato dextrose agar(PDA) media with an incubation temperature of 28℃ or 35℃ separately, namely four different culture conditions.MALDI-TOF MS identification was carried out at different time including the 2nd, 3rd, 4th, 5th and 7th days of incubation of the isolates. Differences in identification capacities of MALDI-TOF MS under the tested parameters were analyzed to determine the optimal culture condition and incubation time of filamentous fungi. The influence of lowered interpreting COV in MALDI-TOF MS identification of filamentous fungi was also evaluated.  Results  No significant difference was detected between the SDA and PDA culture media in the identification capacities of MALDI-TOF MS(χ2=0.467, P=0.792). The identification capacity of MALDI-TOF MS with the incubation temperature of 28℃ was superior to that of 35℃(χ2=7.195, P=0.027). Higher identification rates of species level(40.3%, 34.3%) and genus level(44.8%, 46.3%) were achieved in isolates incubated for 2 and 3 days. The identification rate of species level was increased significantly from 32.1% to 85.9%(χ2=40.119, P < 0.01) without increasing the false identification rate after adjusting the interpreting COV from score > 2.0 to > 1.7.  Conclusion  The performance of MALDI-TOF MS in the identification of filamentous fungi could be improved by applying the optimal culture condition of incubating in SDA or PDA media under the temperature of 28℃ for 2 to 3 days and by adjusting the interpreting COV of the species level with a score > 1.7.
Reviews
Abstract:
Acute ischemic stroke(AIS), characterized by its high morbidity, high mortality, and high disability, is the most common subtype of stroke. Rapidly recanalizing the occluded arteries to salvage ischemic parenchyma in the early stage is essential to treat AIS, which mainly includes intravenous thrombolysis and endovascular treatment. The reperfusion therapy of AIS has been studied for over thirty years developing from intravenous thrombolysis(IVT) to endovascular treatment. There are three main stages in the evolution of reperfusion therapy:(1)investigating thrombolytic agents, which commenced the era of IVT in treating AIS; (2)investigating the dose and time window of thrombolytic agents to maximize the benefit and minimize the risk of IVT; (3)investigating mechanical thrombectomy for AIS, which contributes to the diversification and individualization of reperfusion therapy. Currently, IVT, bridging therapy, and direct mechanical thrombectomy can be applied to treating AIS according to the duration from the onset, the severity of clinical manifestation, and findings in the imaging examination.
Abstract:
In patients with acute myocardial infarction, mechanical revascularization by percutaneous coronary intervention can effectively reduce mortality. However, a substantial proportion of patients with acute myocardial infarction develop chronic cardiac failure, despite restoration of epicardial vessel patency. It is found that the phenomenon of "no-reflow" caused by coronary microvascular obstruction and the subsequent myocardial hemorrhage are the important factors involved in this process. Understanding of the role of intramyocardial haemorrhage in the no-reflow phenomenon and myocardial injury is crucial to the development of new therapeutic strategies to treat acute myocardial infarction. In this article, we reviewed the latest development in pathophysiology, imaging, clinical significance, and therapeutic strategies of intramyocardial hemorrhage.
Abstract:
Celiac disease is an immune-mediated intestinal disorder characterized by chronic inflammation of the small intestine, triggered and maintained by exposure to gluten in the diet. The rapid development of technology and a better understanding of the mechanism of celiac disease lead to combining the application of new serologic diagnostic tests, certain genetic markers, and histopathologic evaluation to aid the diagnosis of celiac disease. We reviewed the recent progress and debate of the diagnostic techniques for celiac disease.
Abstract:
Generally, total or subtotal pancreatectomy induces an inevitable loss of partial or even all of the pancreas, which brings about impaired glucose tolerance and diabetes mellitus.To protect the pancreatic endocrine function, islet auto-transplantation from the resected pancreatic tissues has gradually been valued. This article reviews the 40-years progress of islet auto-transplantation since 1977 when the first case was reported, including the progress in the techniques of islet isolation, purification, and transplantation, improvement of postoperative insulin independency, and expansion of the indications. We also discuss the current status and the difficulty of islet auto-transplantation, and finally forecast its prospect.
Abstract:
Imprinted genes are epigenetic modifications that make a pair of alleles express only paternal or maternal genes. Most of the imprinted genes exist in the placenta and are very important for placental and embryonic development. Imprinted genes are an indispensable part of the study of the pathogenesis of being small for gestational age. However, relevant research is controversial and has not yet reached a common conclusion. In this paper, recent studies on the relation ofimprinted genes and being small for gestational age are reviewed.
Abstract:
A niche-shaped myometrium defect can be noticed after the cesarean procedure, which is defined as the thickness of the remaining myometrium < 3 mm or < 50% of the adjacent myometrium. The leading symptom of patients with cesarean scar defect is long-lasting spotting following a normal menstrual period; dysmenorrhea and infertility are relatively rare symptoms.Pregnancy in the niche of the cesarean scar and uterine rupture are much more severe complications happening in the conceived patients. The transvaginal sonography is most widely used for diagnosis due to its convenience and accuracy, which along with magnetic resonance imaging or hysteroscope provides more detailed information. The majority of patients have no symptoms and treatment is only indicated when there are symptoms that need to be corrected, particularly the spotting symptom. There are only a few of studies revealing that oral contraceptives could be used as a conservative treatment. Both thermo-ablation andcanalling are effective, but they should not be opted if a future pregnancy is expected. On the contrary, the laparoscopic or transvaginal repair of the defect is more promising. They both provide not only symptom correction but also improvement of the scar thickness.
Abstract:
With the deep application of information technology in the medical field, the number of information technology-related medical adverse events has been increasing. In this paper, the terms, concepts, and research status of medical adverse events related to information technology were reviewed and classified from three aspects:manifestation, system composition, and error causes. And the corresponding definitions and case descriptions were discussed. Based on relevant research in China and abroad, this paper further explored the counter measures for information technology-related medical adverse events, and proposes solutions to enhance attention, encourage reporting, and establish a standardized prevention system. Hopefully, this review will get more attention of medical industry to information technology-related medical adverse events and provide knowledge and reference for relevant research.
Complicated and Rare Disease
Abstract:
This paper reports a case of Castleman disease variant of POEMS syndrome that has no M protein but has several major and minor diagnostic criteria of POEMS syndrome including Castleman disease, vascular endothelial growth factor elevation, organomegaly, endocrinopathy, extravascular volume overload, papilledema, and skin changes. Through analyzing the clinical manifestations, laboratory examination results, and treatment responses of the patients, clinicians' understanding of atypical POEMS syndrome can be enhanced.
Clinical Practice Guidelines
Abstract:
Clinical practice guidelines are guiding documents in medical practices. Timely updated recommendations are important and valuable to guide physicians in making clinical decisions. Guidelines should be developed on the latest research evidence for the best recommendations in clinical practice and updated regularly to remain valid. Based on the discussion about the status quo, methods and procedures, and challenges of updating guidelines, our results showed that the longest update period is 5 years, and the shortest period can be constantly updated. Since there are no standardized methods for guideline updating, we proposed in this article the procedures for Chinese guideline developers, and recommended RIGHT and CheckUp as the reporting checklists. In addition, the related strategies and suggestions to effectively update guidelines were proposed for the guideline managers, developers, researchers, and users.
Clinical Biobank
Abstract:
  Objective  The aim of this study was to present a method for evaluating the comprehensive performance of each platform-based sub-Biobanks of a general hospital in order to provide reasonable advice to new Biobankers.  Methods  We conducted a comprehensive analysis of all these sub-Biobanks from three aspects including specimen incoming, specimen application, and specimen quality as well.We gave different weight of these 3 indicators for comprehensive evaluation(30% for incoming, 30% for application, and 40% for quality).  Results  A total of 77 sub-Biobanks were included in this study, with 22 project-based Biobanks and 55 reserve Biobanks. There was no significant difference in specimen incoming scores between project-based banks and reserve banks (50.7±30.1 vs. 47.6±29.9, P=0.1614). Project-based Biobanks scored significantly better than reserve Biobanks in specimen application[30.3(0, 84.2) vs. 0(0, 31.6), P=0.0327], specimen quality (100.0±0.0 vs. 94.5±22.9, P=0.0444), and comprehensive score (62.5±14.8 vs. 57.9±17.9, P=0.0077).  Conclusion  Project-based Biobanks' comprehensive performance isbetter than that of reserve Biobanks in platform-based Biobanks of general hospitals.
Breast Cancer
Abstract:
  Objective  The aim of this retrospective study was to analyze the distribution of molecular subtypes and its impact on the prognosis of elderly women with breast cancer(BC).  Methods  Elderly women with BC who received an operation between January 1st, 2010 and June 30th, 2016 were reviewed. Information on epidemiological characteristics, operation, pathology, adjuvant therapy, and outcome were collected based on the hospital-based database and routine follow-up. Kaplan-Meier analysis and Cox proportional hazards model were applied to pursue the correlation between molecular subtypes and disease-free survival (DFS)/overallsurvival(OS).  Results  A total of 502 elderly women with BC who met the inclusive and exclusive criteria were enrolled, with an average age of (76.65±4.36)years old, including 401(79.88%) cases of luminal BC, 39(7.77%) of Her-2 rich BC, and 62(12.35%) of triple-negative BC(TNBC). At a median follow-up of 60 months, 8.37%(42/502) of the patients suffered from local recurrence and/or metastasis, and 11 of 50 deaths were of breast cancer. Survival analysis indicated that the molecular subtype had a significant correlation with DFS(P < 0.001) and OS(P=0.040). Compared with the luminal A subgroup, there were more local recurrence or metastasis in the luminal B2(HR=4.306, 95% CI:1.469-12.618, P=0.008), Her-2 rich(HR=3.729, 95% CI:1.418-9.809, P=0.008), and TNBC(HR=2.580, 95% CI:1.045-6.367, P=0.040) subgroups. Compared with the luminal A subgroup, there were more deaths in the Her-2 rich subgroup (HR=3.219, 95% CI:2.762-3.676, P=0.010).  Conclusions  The molecular subtype has a significant correlation with DFS and OS in elderly women with BC. Luminal B2, Her-2 rich, and TNBC subgroups indicate high risk of local recurrence and distant metastasis.
Teaching and Research
Abstract:
Virtual slide technology can transform traditional pathological slices into digital images, which is gradually replacing glass slices and optical microscopes in remote consultation, scientific research, and teaching of pathology because digital images can be preserved longer and easier to obtain. However, its application in the field of nephrology has not been widely carried out. Through literature review and practical experience, this paper expounds the prospect of application of virtual slide technology in clinical practice, scientific research, and teaching of nephrology, emphasizing its potential value on the one hand, and putting forward some suggestions to solve the problems and challenges in the current practical application on the other hand.
Abstract:
  Objective  The aim of this study was to evaluate the training effect of two different simulators of transthoracic echocardiography (TTE).  Methods  Sixty-three residents who received the standardized training and volunteered to participate in this project in the Department of Anesthesiology of Peking Union Medical College Hospital from January 1st to December 31st, 2016 were perspectively enrolled and randomly divided into 3 groups (21 in each group):Heartworks group (using Heartworks simulator), U/S Mentor group (using U/S Mentor simulator), and the control group (traditional teaching method). The evaluation index of teaching effect included the written test scores about the TTE basic knowledge before and after training(the total score was 100 points), the practice examination on volunteer models after the training[including the quality of images (the total score was 25 points) and the ability of identifying cardiac anatomical structures (the total score was 25 points)], and the satisfaction assessment by the participants (3 levels).  Results  The written test scores of the Heartworks, U/S Mentor, and the control groups before training were 41.4±10.6, 40.4±10.9, and 39.8±10.5, respectively; there was no statistical difference among the three groups (P > 0.05). The scores of the above three groups after training were 53.8±12.6, 52.6±13.6, and 43.3±10.8, respectively, which were higher than before (all P < 0.05) in each group, and there was no statistical difference between the Heartworks and the U/S Mentor groups (P>0.05), while both were higher than that of the control group (both P < 0.05). After the training, the scores of image quality of the Heartworks, U/S Mentor, and the control group were 17.1±4.5, 16.0±4.1, and 7.7±3.1, respectively; and the scores of recognition of cardiac anatomical structures were 18.2±6.3, 17.0±6.1, and 11.9±6.9, respectively; there were no statistical difference between the Heartworks and the U/S Mentor groups (P > 0.05), while both groups had higher scores than the control group (both P < 0.05). There was no statistical difference in the satisfaction among the three groups.  Conclusions  The TTE training effect of the Heartworks and U/S Mentor simulators is similar, and both modes are better than the traditional training mode based on the lecture.
Glance Back
Abstract:
ZHONG Shi-fan(1901-1987), a native of Xiamen, Fujian Province and a pioneer in modern clinical pediatrics in China, has a profound impact on virology research. However, his research and introduction are obviously insufficient at present. On the basis of collecting relevant archives, this article introduces his life as well as his role and influence in virology.
2020, 11(2): 238-240. doi: 10.3969/j.issn.1674-9081.20190073
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Abstract: