协和医学杂志

Principles, Techniques and Advances of the Lateral Skull Base Surgery

GAO Zhiqiang

2021, 12(6): 819-824. doi: 10.12290/xhyxzz.2021-0575

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The primary goal of the lateral skull base surgery is to radically resect tumors, as well as to reduce mortality and improve quality of life, on the basis of guaranteeing life safety of patients. Following surgical principles and mastering necessary operative skills are essential to ensure the safety and therapeutic effects of the surgery. With the advances of medical science, the lateral skull base surgery has stepped into a new stage, encountering new opportunities as well as challenges. This article summarized the fundamental principles and techniques of lateral skull base surgery, and briefly looked forward to the future in this field.

The PUMCH Classification of Carotid Body Tumor

GU Guangchao, ZHENG Yuehong

2021, 12(6): 825-828. doi: 10.12290/xhyxzz.2021-0568

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Carotid body tumor is a rare neoplasm located at the bifurcation of the carotid artery. Surgical excision is the main treatment but carries a high risk of bleeding, nerve injury and vascular injury. Shamblin's classification is based on the relationship between tumor and carotid arteries, which has limitations. Including both the horizontal relationship to carotid arteries and vertical extension of the tumors, PUMCH (Peking union medical college hospital) classification can better predict surgical complications and guide the surgery and thus might help to improve the surgical outcomes of the lesions.

Digital Doctors and Parallel Healthcare: From Medical Knowledge Automation to Intelligent Metasystems Medicine

WANG Feiyue

2021, 12(6): 829-833. doi: 10.12290/xhyxzz.2021-0586

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This paper proposes the concept of digital doctors and their roles in parallel healthcare for the digital transformation of medical services based on atificial intelligence and intelligent technology. By integrating complexity medicine, transdisciplinary medicine, and systematized intelligent medicine, we outline an ACP-based parallel healthcare and federated hospitals for preventive, proactive, precise, and personalized medical services.

Establishment of the Program for Hierarchical Prevention and Control of Sudden Infectious Diseases Based on the Coronavirus Disease 2019: Experience of Peking Union Medical College Hospital

SUN Fangyan, LIANG Shuang, WANG Lixue, GUO Qin, WANG Ai, CHAI Wenzhao, XU Mei

2021, 12(6): 834-839. doi: 10.12290/xhyxzz.2021-0589

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In the current situation of coronavirus disease 2019, "to prevent import from abroad and to defend internal rebound" is the general principle. Facing the changes in the epidemic situation, especially the winter and spring epidemics, it is a huge challenge to carry out a scientific, precise and flexible program for the prevention and control of healthcare-associated infections so that to ensure the safety of healthcare workers and patients. After more than one year of anti-epidemic work, Peking Union Medical College Hospital has summarized and formulated a four-level retractable and releasable hierarchical program of prevention and control. It is dynamically adjusted according to the responsive level of public health emergencies in Beijing and the relevant regulations of epidemic prevention and control. All departments can also respond quickly to ensure the resumption of work. This program provides reference for the prevention and control of coronavirus disease 2019 and other sudden infectious diseases.

A Combined Transcranial-Transtemporal-Transcervical Approach to Complex Lateral Skull Base Tumors

YANG Shiming, SHEN Weidong, WU Nan

2021, 12(6): 840-843. doi: 10.12290/xhyxzz.2021-0647

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Skull base anatomy is complicated. There are numerous diseases related to skull base, and surgical approaches to them are diverse. Although existing surgical approaches can manage most cases, a combined approach is required for transregional lesions. This article introduces a transcranial-transtemporal-transcervical approach to manage complex skull base tumors.

Otological Surgery of Acoustic Neuroma

XIA Yin, WANG Pu

2021, 12(6): 844-848. doi: 10.12290/xhyxzz.2021-0551

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Acoustic neuroma is the most common benign tumor in the internal auditory canal and cerebellopontine region.Its common clinical symptoms include unilateral sensorineural hearing loss, tinnitus and so on.Surgical resection is the predominant treatment of acoustic neuroma. The common approaches dominated by otologists include translabyrinthine approach, enlarged translabyrinthine approach, transotic approach, modified transotic approach, and middle cranial fossa approach; the approach dominated by neurosurgeons is retrosigmoid (suboccipital) approach. For small tumors with intact hearing, it is recommended to choose the middle cranial fossa approach. Those with large tumors who wish to preserve their hearing can adopt the suboccipital retrosigmoid approach; those who do not consider retaining hearing and have medium or small acoustic neuromas can adopt the translabyrinthe approach or through the transotic approach. With the development of microsurgical technology and the wide application of intraoperative nerve monitoring equipment, the retention rate of facial/cochlear nerve function for surgery of small and medium-sized acoustic neuroma has been significantly improved. In the future, more patients with acoustic neuroma are expected to be completely cured on the basis of preserving facial/cochlear nerve function.

Patient-centric Clinical Trials: A New Paradigm for Drug Development

XIE Jing, WANG Huanling

2021, 12(6): 849-853. doi: 10.12290/xhyxzz.2021-0056

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With the acceleration of innovative drugs launched in the market, clinical trials have become increasingly complex and costly. Integration of patients' perspective and engagement into the clinical research process is essential to the success of the trials, which leads to the emergence of the concept of patient-centric clinical trials. Compared to the conventional paradigm of clinical trials, patient-centric clinical trials have the potential to increase the feasibility of study protocol, to speed recruitment and execution, and to promote the success of trials. It calls for the institutions and investigators of clinical trials to be aware of and adapt to patient-centric initiatives. In this article, we highlight technologies and actions that can be used to enhance patients' engagement in the entire process of drug development, covering protocol development, trial conduction, and result publication.

Clinical Practice Guidelines for Immune Checkpoint Inhibitor Therapy in Gynecological Tumors

Gynecological Oncology Society of Chinese Medical Association

2021, 12(6): 854-880. doi: 10.12290/xhyxzz.2021-0683

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Immune checkpoint inhibitors (ICI) have shown efficacy for some patients with gynecological tumors, which are mainly used to treat persistent, recurrent, or metastatic patients. Immunotherapy with ICI has shown good objective responses and survival benefit in patients with endometrial cancer. However, the rate of response to immunotherapy in patients with ovarian cancer remains modest. Some patients with recurrent or resistant gestational trophoblastic neoplasia benefit from ICI. ICI often has optimal duration of response. Accurately evaluating the indications and responses, recognizing and managing immune-related adverse events are essential to ICI treatment. With regards to ICI, the clinical benefit of monotherapy is limited; however, combinations of ICI with other therapies may have clinical benefit.

Clinical Practice Guidelines on Platinum Therapy in Gynecological Tumors

Gynecological Oncology Society of Chinese Medical Association

2021, 12(6): 881-901. doi: 10.12290/xhyxzz.2021-0690

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Platinum drugs have a wide spectrum of activity and remarkable therapeutic effects. Platinum-based chemotherapy is a widely recommended regimen for gynecology oncology. Carboplatin/paclitaxel is the "standard" combination of the first choice of therapy for patients with ovarian cancer. Cisplatin is preferred for cervical cancer. Preventing and mitigating adverse events and drug reactions are an important part of platinum treatment. For platinum-resistant disease, non-platinum-based agents or regimens are preferred. Platinum resistance remains an urgent challenge for the treatment of gynecological tumors. In order to standardize the clinical management of platinum therapy, we organized experts and scholars to discuss many times, and finally formed this consensus.

Expert Consensus for the Diagnosis and Treatment of Gitelman Syndrome in China (2021)

Rare Diseases Society of Chinese Research Hospital Association, National Rare Diseases Committee, Beijing Rare Disease Diagnosis, Treatment and Protection Society, Gitelman Syndrome Consensus Working Group

2021, 12(6): 902-912. doi: 10.12290/xhyxzz.2021-0555

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In recent years, research on the clinical phenotypes, new classifications, modified functional tests, biomarkers and management experience for patients with Gitelman syndrome (GS)has made a lot of progress in China. Based on evidence-based medicine, this consensus summarizes aspects related to GS, including clinical manifestations and classification, diagnosis, treatment strategies, and management of chronic complications and comorbidity. This consensus provides an important reference for the diagnosis and treatment of GS.

Establishing AKI Warning System in Peking Union Medical College Hospital from a Machine Learning Approach: A Single-center Research Protocol

ZHENG Hua, ZHANG Meng, ZHAO Ze, LIN Jianfeng, GUO Xiuzhi, XIA Peng, REN Fei, QIU Ling, ZHOU Jiong, CHEN Limeng

2021, 12(6): 913-921. doi: 10.12290/xhyxzz.2021-0519

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Background and Objective In-hospital acute kidney injury (AKI) has a significant negative impact on patients' outcome and the length of hospital stay. It is significantly important to use the early warning of electronic medical records (EMR) to identify and intervene AKI in a timely manner so as to reduce the severity of AKI and to improve the prognosis of patients. At present, AKI-related research based on the EMR system mainly uses traditional statistical methods for retrospective analysis, mainly for inpatients in single-disciplinary wards, and there is still a lack of early warning models of AKI risk based on artificial intelligence technology in large-scale multi-disciplinary wards with time-sensitive information and further prospective research. This study aims to develop a multiple-ward AKI prediction model tailored for general hospitals in China based on machine-learning algorithms and big data acquired by the EMR system. Methods This single-center study consists of both a retrospective observational study and a prospective study. All hospitalized adult patients admitted in Peking Union Medical College Hospital (PUMCH) between 2016 and 2020 were included in the retrospective study. Logistic regression, naive Bayes, random forest, support vector machine, gradient boosting and recurrent neural network will be used for modeling based on demographics, clinical feature, vital signs, imaging, lab results and hospitalized medical records, which aims to predict AKI 24-48 h in advance and will be internally validated. The prospective study intends to include all adult inpatients in PUMCH for 12 consecutive months. Among them, all adult hospitalized patients within 6 months before the AKI early warning system is launched will be of the control group, and all adult hospitalized patients within 6 months after the AKI early warning system is launched will be of the intervention group. In the intervention group, the AKI early warning system will be embedded in the EMR, and all patients hospitalized for more than 24 hours will be assessed for AKI risk in the next 48 hours in real time every 6 hours. Early intervention will be carried out for high-risk patients. The control group does not have above-mentioned high-risk and alarm prompts of AKI, and no corresponding intervention measures. The incidence of AKI and AKI grade 3, AKI remission rate, end-stage renal disease progression rate, mortality during hospitalization, length of stay, hospitalization expenses and other indicators will be compared between the two groups. Expected Results An estimated number of 127 000 in-hospital patients will be included in the retrospective study, among which 14 605 patients suffer from AKI. The prediction model is expected to predict AKI 24-48 h in advance and the aim for area under receiver operating characteristics curve should be > 0.80. In the prospective study, 34 748 inpatients will be enrolled, including 17 374 in both the intervention group and the control group. The duration time of renal replacement therapy and length of hospital stay in the intervention group should be shorter than those in the control group (P < 0.05); the proportion of renal replacement therapy, the incidence of AKI and AKI 3, the rate of progression of end-stage renal disease, the mortality rate during hospitalization, and the hospitalization cost should be lower than those in the control group (P < 0.05), and the AKI remission rate should be higher than that in the control group (P < 0.05). Expected conclusion EMR-based multi-ward AKI prediction model will predict AKI risk 24-48 h in advance, which will lower AKI incidence and severity, and improve clinical outcomes.

Analysis and Summary: Reconstructive Methods of Lateral Skull Base Defects after Radical Tumor Resection in 62 Cases

ZHU Zhihui, HOU Yingzi, ZHAO Ruiqi, WU Limeng, LEI Zhenghui, FENG Guodong, GAO Zhiqiang, ZHANG Tao

2021, 12(6): 922-932. doi: 10.12290/xhyxzz.2021-0565

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Objective To explore the methods for the reconstruction of lateral skull base defects after radical tumor resection. Methods Patients who underwent lateral skull base radical tumor resection and reconstruction from January 1, 2012 to December 31, 2019 in the Department of Stomatology and Otorhinolaryngology in Peking Union Medical College Hospital, were enrolled in this retrospective study. These patients were divided into three subgroups depending on the type of defects. Group I, patients without skin defects; Group Ⅱ, patients with skin defects; Group Ⅲ, patients with larger jaw defects. Different reconstructive methods were applied for the three groups. Results Sixty-two patients (63 procedures of defect repair) were enrolled in this study. The survival rate of tissue flap was 98.41%(62/63), and the primary wound healing rate was 90.48% (57/63). There were 34 patients in Group I. Among them, 6 cases received free fat transplantation; 14 cases were repaired with fat transplantation combined with local flaps; 13 cases were repaired with sternocleidomastoid muscle flap or combined temporal muscle flap; 1 case was repaired with temporal muscle flap combined with submandibular gland flap. Among them, two patients had postoperative cerebrospinal fluid leakage and delayed healing after dressing change. All patients had no postoperative infection and fat liquefaction, and the wounds healed by primary intention. The survival rate of tissue flap was 100%, and 94.12% (32/34) of the wounds healed by primary intention. There were 23 patients in Group Ⅱ. Five patients whose skin defects were less than 3 cm were reconstructed with local tissue flaps combined with advancement flaps; all flaps survived completely and the wounds healed by primary intention. The survival rate of tissue flap was 100%, and the primary wound healing rate was 100%. For those skin defects greater than 3 cm, free anterolateral thigh flaps were applied in 8 patients, pedicle flaps such as pectoralis flaps in 6 patients, 2 cases used forearm flap combined with pedicle skin flap or local tissue flap, 2 cases had pectoralis major myocutaneous flap or combined cervical and facial propulsion skin flap and submandibular gland flap, 1 case had rectus abdominis skin flap. One of the patients who had undergone high-dose radiotherapy developed venous embolism 3 days after repair with the anterolateral thigh myocutaneous flap, which was later repaired with pectoralis major myocutaneous flap rescue, and the remaining flaps survived completely; 1 patient with anterolateral thigh flap transplantation developed recipient hematoma on the second postoperative day, and the wound recovered after hematoma evacuation. One patient with rectus abdominis muscle repair developed cerebrospinal fluid leakage after surgery, and the skin lesions had delayed healing after dressing change. Two cases were repaired with pectoralis major myocutaneous flap and other pedicle skin flaps, and there was a small area of necrosis at the distal end. The wounds had delayed healing after dressing change. The wounds of the remaining patients healed at first stage; the first-stage wound-healing rate was 84.21% (16/19), and the flap survival rate was 94.74%(18/19). There were 5 patients in Group Ⅲ; 2 cases were reconstructed with fibular flap; 2 cases were reconstructed with free rib graft combined with temporal flap; 1 patient underwent femur-anterolateral thigh osteomyocutaneous free flap reconstruction. There were 10 patients whose tumors invaded the bones of the skull base and caused intracranial and external communication after surgery. Seven of them had no postoperative complications, and the remaining three had post-operative cerebrospinal fluid leakage, which delayed healing after dressing changes. There were 24 patients received simultaneous facial nerve reconstruction, including 12 cases reconstructed with greater auricular nerve transplantation, 8 cases with hypoglossal nerve, 3 cases with masseter nerve (+/-) greater auricular nerve, and 1 case with lateral femoral cutaneous nerve. Thirteen patients were followed up, and all had varying degrees of recovery of facial nerve function. Conclusions Different reconstruction regimens should be taken according to different types of defects after radical tumor resection. The patients without skin defects can be reconstructed with the temporal muscle flap combined with autologous fat grafting or local tissue flaps. The patients with skin defects smaller than 3 cm can be reconstructed with the cervicofacial advancement flap combined with local tissue flaps. The most reliable free flap for lateral skull base reconstruction is the anterolateral thigh flap for the patients with skin defects larger than 3 cm. For those patients who were not suitable for microsurgical reconstructive operation, the pectoralis major muscle flap repair should be selected. If the defect is above the zygomatic arch, it is better to choose the pectoralis major muscle flap combined with cervicofacial advancement flap or local tissue flaps. The bone defect should be reconstructed appropriately if the patients presented with a large jaw defect. If conditions permit, the facial nerve defect reconstruction should be applied simultaneously.

Hearing Preservation in the Middle Fossa Approach for Vestibular Schwannoma

CHEN Jiyue, MA Xiaoyan, DING Zhiwei, ZHANG Chi, CAO Wei, WANG Fangyuan, WU Nan, WANG Guojian, HAN Weiju, DAI Pu, HAN Dongyi, SHEN Weidong, YANG Shiming

2021, 12(6): 933-939. doi: 10.12290/xhyxzz.2021-0570

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Objective To discuss the middle fossa approach (MFA) for vestibular schwannoma (VS) and hearing preservation (HP). Methods Retrospectively analyze the database of HP in patients that underwent MFA for intracanalicular VS from May 2006 to May 2021. Examinations of preoperative hearing and craniocerebral imaging were performed to evaluate whether the patients met the criterion of HP. The function of the cochlear nerve was evaluated with American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification; the facial nerve function was evaluated with House-Brackmann (HB) grading. Different clinical characteristics regarding HP were summarized. Results A total of 22 patients with VS that met the inclusion and exclusion criteria were included in this study. Facial nerve function was HB grade Ⅰ in 21 patients, grade Ⅲ in 1 patient. The preoperative serviceable and usable HP rate were 77.3%(17/22, 95% CI: 58.3%-96.3%) and 86.4%(19/22, 95% CI: 70.8%-100%), respectively. Seventeen patients met the criterion of hearing preservation, and the other 5 got their residual hearing reserved. The tumor was completely removed in 22 patients with VS and without postoperative complications, such as cerebrospinal fluid (CSF) leakage, epidural hematoma or infection. The rates of postoperative serviceable and useful HP were 52.9%(9/17, 95% CI: 26.5%-79.4%) and 73.7%(14/19, 95% CI: 51.9%-95.5%), respectively. In the patients present and those absent of CSF cap, the rates of postoperative serviceable HP were 60.0% (3/5, 95% CI: 23.1%-96.9%), 50.0% (6/12, 95% CI: 16.8%-83.2%), and the rates of useful HP were 80.0% (4/5, 95% CI: 24.5%-100%), and 71.4% (10/14, 95% CI: 44.4%-98.5%), respectively. In the tumor originating from the superior vestibular nerve, the rates of postoperative serviceable HP and useful HP were 33.3% (2/6, 95% CI: 0-87.5%) and 57.1% (4/7, 95% CI: 7.7%-100%), respectively. Whereas in patients with tumors originating from the inferior vestibular nerve, the rates of serviceable HP and useful HP were 55.6% (5/9, 95% CI: 14.0%-96.1%) and 80.0% (8/10, 95% CI: 49.8%-100%), respectively. For the patients in the presence and those in the absence of adhesion between the tumor and the cochlear nerve, the rates of serviceable HP were 41.7%(5/12, 95% CI: 8.9%-74.4%), 80.0% (4/5, 95% CI: 24.5%-100%), and the rates of useful HP were 66.7% (8/12, 95% CI: 35.4%-98.0%), 85.7% (6/7, 95% CI: 50.8%-100%), respectively. The median follow-up was 4.9 years. None of the patients had tumor recurrence. Postoperatively, the facial nerve function was HB grade Ⅰ in 21 patients and grade Ⅳ in 1 patient. Conclusions The preoperative hearing classification and the features of imaging should be considered for complete excision of the tumor with the middle fossa approach and HP. As well, sufficient surgical skills need to be grasped in the condition of different nerve origin and the degree of adhesion between the tumor and cochlear nerve to preserve the anatomy and function of the cochlear nerve.

The Clinical Effects of Modified Infratemporal Fossa Approach Type A for Glomus Jugulare Tumors in 39 Patients

ZHANG Wenyang, XUE Yubin, YE Ting, QU Xiaopeng, YAN Xukun, WANG Pu, LIU Qiang, XIA Yin

2021, 12(6): 940-945. doi: 10.12290/xhyxzz.2021-0564

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Objective To analyze the clinical effects of modified infratemporal fossa type A approach for glomus jugulare tumors. Methods The clinical data of patients with glomus jugulare tumors who received modified infratemporal fossa approach type A from May 2014 to December 2019 were retrospectively collected in the Beijing Tiantan Hospital, Capital Medical University. Modified infratemporal fossa approach type A was performed and improved on two aspects: anterior transfer of facial nerve and management of sigmoid sinus. CT was performed 6 hours after surgery to exclude intracranial hemorrhage. MRI was reviewed 2 weeks after surgery to define residual tumor, and every year to determine recurrence. Follow-up was conducted to assess the facial nerve function. Results A total of 39 patients were included in this study. Patients' grades of preoperative facial nerve function according to House-Brackmann (HB) were as following: grade Ⅰ in 12 patients, grade Ⅱ in 6 cases, grade Ⅲ in 8 cases, grade Ⅳ in 9 cases, grade Ⅴ in 3 cases, and grade Ⅵ in 1 case. All 39 patients successfully completed surgery, and there were no deaths and no severe complications such as hemiplegia, or intracranial infections. Cerebrospinal fluid leakage occurred in 1 case and drainage was performed. There was no intracranial hemorrhage in the CT exam 6 hours after surgery. Total resection was performed in 37 cases (94.9%) and nearly total resection in 2 cases (5.1%). The postoperative facial function after 1 year was HB grade Ⅰ in 8 patients, grade Ⅱ in 16 cases, grade Ⅲ in 9 cases, grade Ⅳ in 4 cases, grade Ⅴ in 2 cases. The facial function was improved after the surgery(P < 0.05). One year after surgery, tumor recurrence occurred in 1 patient and radiotherapy was performed. There was no significant tumor enlargement during follow-up. Conclusions The modified infratemporal fossa approach type A keeps the advantage of classical approach. By adjusting the anterior transfer of the facial nerve, the preservation of facial nerve function was improved. By compressing the sigmoid sinus instead of ligation, the occurrence of brain injury and cerebrospinal fluid leakage were reduced.

Analysis of the Effect of Facial Nerve Processing in the Surgery of Paraganglioma of the Lateral Skull Base Area

ZHANG Liqin, ZHAO Yang, TIAN Xu, GAO Zhiqiang, FENG Guodong

2021, 12(6): 946-951. doi: 10.12290/xhyxzz.2021-0576

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Objective To summarize the key points of the operation related to the facial nerve function after surgery of paraganglioma involving the jugular foramen in the lateral skull base. Methods We retrospectively analyzed the clinical data of patients with lateral skull base paraganglioma involving jugular foramen that were diagnosed and treated in Peking Union Medical College Hospital from August 2015 to January 2021. According to the relationship between the tumor and the facial nerve, the facial nerve was treated in different ways during the operation. The postoperative facial nerve function of patients with different treatments is summarized. Results A total of 30 patients with lateral skull base paraganglioma in the jugular foramen area were included. The Fisch classification of these patients was as followed: C1(n=3), C2(n=6), C2De1(n=2), C2Di1(n=2), C3De1(n=7), C3Di1(n=5), C3Di2(n=3), C4De1(n=1), C4Di1(n=1). Preoperative facial nerve function assessed by House-Brackmann (HB) grade: grade Ⅰ-Ⅱ (n=22), grade Ⅲ (n=2), grade Ⅳ (n=3), grade Ⅴ(n=2), grade Ⅵ(n=1). All tumors were completely resected, which was verified by post-operational MRI. No recurrence was observed during the medium follow-up of 886 days. All of the postoperative nerve function refers to the results of the last follow-up. Anterior facial nerve rerouting was performed in 15 cases whose tumor did not invade the facial nerve. The postoperative facial nerve function was HB grade Ⅰ-Ⅱ in 13 cases and HB grade Ⅲ in 2 cases. The tumors were adhesive to the facial nerve in 2 cases. The tumors and the facial nerve were successfully separated in both cases; one achieved HB grade Ⅰ-Ⅱ, while the other was HB grade Ⅰ-Ⅱ postoperatively. In 13 cases, the tumor wrapped the facial nerve. Among those patients, the tumor was separated from the facial nerve in 1 case, with the postoperative facial nerve function of HB grade Ⅲ. In the remaining 12 cases, the facial nerve was resected together with the tumor. Facial nerve reconstruction was performed in 3 cases in the same or the second surgery. The postoperative facial nerve function was HB gradeⅠ-Ⅱ in 1 case and HB grade Ⅲ in the other 2 cases. The postoperative facial nerve function in the remaining 9 cases that did not receive facial nerve reconstruction was HB grade Ⅵ. Conclusions In patients with lateral skull base paraganglioma, anterior facial nerve rerouting has a slight effect on the function of facial nerve, if the tumor does not invade the facial nerve. It is difficult to separate the tumor and the facial nerve, if the facial nerve is wrapped by the tumor, and the rate of postoperative facial nerve paralysis is higher in these cases.

Relationship between the Enhanced MRI Features of Preoperative Brain Volume Imaging and Surgical Methods of the Glomus Jugulare Tumor

CHEN Yu, FENG Guodong, SU Tong, MAO Mingyang, TIAN Xu, XU Zhentan, ZHOU Hailong, FANG Hongying, ZHANG Zhuhua, GAO Zhiqiang, JIN Zhengyu

2021, 12(6): 952-957. doi: 10.12290/xhyxzz.2021-0574

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Objective To investigate the relationship between the enhanced MRI features of preopera-tive brain volume imaging (BRAVO) and surgical methods in patients with glomus jugulare tumor (GJT). Methods The imaging data of enhanced BRAVO sequence and surgical methods of patients with GJT confirmed by surgery and pathology from February 2015 to March 2021 in Peking Union Medical College Hospital were analyzed retrospectively. According to the surgical mode, the patients were divided into the groups of single infra-temporal fossa approach (IFA) group and combined infratemporal fossa approach (CIFA) group. Both groups of patients underwent MRI examination before operation, and the Fisch classification of tumor was determined based on the characteristics of enhanced BRAVO sequential images, and the consistency was compared with the Fisch classification determined during the operation. The maximum diameter of the tumor in the transverse axis, the longest diameter in the coronal plane, the width diameter of meningeal invasion and the depth diameter of meningeal invasion were measured and compared between two groups. Results A total of 25 patients were included. Among them, 16 cases were in the IFA group (surgical approach was infratemporal fossa type A), and 9 cases in the CIFA group (surgical approach was infratemporal fossa type A + type B). The classification of image C includes 1 case of C1 type, 10 cases of C2 type, 12 cases of C3 type, and 2 cases of C4 type. The classification of image D includes 8 cases of De1 type, 6 cases of Di1 type, and 5 cases of Di2 type. Except for one patient in the IFA group who was evaluated as C3 preoperatively based on imaging, and confirmed as C2 postoperatively, the image classification of C and D of the other patients were consistent with those of surgical classification of C and D (Kappa=0.934, P < 0.001;Kappa=1.000, P < 0.001). Image classification of C (P=0.029) and D (P=0.006) had significant differences between the two groups. The maximum diameter(P=0.013), depth(P=0.003) and width of meningeal invasion(P=0.011) in the CIFA group were greater than those in the IFA group. There was no significant difference in the longest diameter of the coronal plane (P=0.125) between the two groups. Conclusions Enhanced BRAVO sequence can be used for preoperative evaluation of Fisch classification of GJT. The enhanced image features based on BRAVO sequence showed differences between the two different surgical approaches.

Investigation on the Clinical Use of 17 Antineoplastic Drugs Passing National Medical Insurance Negotiation in Peking Union Medical College Hospital

SUN Wenjuan, TANG Yan, ZOU Yuzhen, ZHANG Qian, ZHANG Bo, DU Xiaoli

2021, 12(6): 958-964. doi: 10.3969/j.issn.1674-9081.2020.00.018

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Objective The aim of this study is to investigate the clinical use of 17 antineoplastic drugs passing national medical insurance negotiation in Peking Union Medical College Hospital before and after the implementation of national policies about promoting the inclusion of antineoplastic drugs in health insurance, and to provide reference for the optimization and adjustment of hospital formulary. Methods The prescription data of 17 antineoplastic drugs of outpatients and inpatients in our hospital from December 1, 2017 to November 30, 2019(December 1, 2017 to November 30, 2018 for the year 2018, December 1, 2018 to November 30, 2019 for the year 2019) were collected. The basic information of patients, the usage amount and cost, defined daily doses (DDDs), and defined daily cost (DDC) were analyzed. Results A total of 6881 patients used the 17 antineoplastic drugs in 2019. Among them, there were 4713(68.5%) outpatients and 2168(31.5%) inpatients. The proportions of the cost of 17 antineoplastic drugs to that of all antineoplastic drugs and all formulary drugs in our hospital were 16.3% and 3.8%, respectively. The 17 antineoplastic drugs were mainly used for thorax, hematologic, and urologic malignancies. The top three antineoplastic drugs in terms of cost were osimertinib, octreotide acetate microspheres and crizotinib, with good synchronization between drug cost and DDDs. The top three drugs in terms of DDC were vemurafenib, cetuximab and ibrutinib. The total cost and prescription of the six drugs that had already been included in the formulary of our hospital before the implementation of the policy increased by 78.2% and 89.8%, respectively in 2019 compared with those in 2018, and the proportions of the cost of six antineoplastic drugs to that of all antineoplastic drugs and all formulary drugs in the hospital increased by 54.4% and 78.6%, respectively. After the implementation of national policies, the quantity and cost of osimertinib increased significantly, and the drugs increased in quantity but decreased in cost were cetuximab, axitinib, and sunitinib in sequence. Both the quantity and the cost of pegaspargase decreased significantly. Conclusions The national health insurance negotiation policy promoted the use of 17 antineoplastic drugs in the hospital and improved the accessibility of these drugs to patients significantly. At the same time, the total cost of the involved drugs had a sharp rise. It is necessary to strengthen the monitoring and dynamic evaluation of the clinical application of related drugs, so as to promote rational drug use while meeting patients' needs.

Acute Generalized Exanthematous Pustulosis Caused by Proton Pump Inhibitors: A Real-World Pharmacovigilance Study

ZHAO Zhe, WANG Tao, TANG Yan, CHEN Xiaoguang, ZHAO Bin

2021, 12(6): 965-971. doi: 10.12290/xhyxzz.20200262

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Objective To explore and compare the associations of different proton pump inhibitors (PPIs) with acute generalized exanthematous pustulosis (AGEP). Methods Data were obtained from the database of Food and Drug Administration's adverse event reporting system (FAERS) from January 2004 to June 2020. Non-proportional analysis and Bayesian analysis were utilized to analyze the signs of AGEP caused by different PPIs. The onset time and prognosis of PPIs-related AGEP were also analyzed. Results A total of 162 cases of AGEP caused by PPIs were reported. The most frequently used PPI was omeprazole (33.95%, 55/162), followed by esomeprazole (29.63%, 48/162) and pantoprazole (26.54%, 43/162). Pantoprazole showed the strongest correlation with AGEP, followed by omeprazole and lansoprazole, while esomeprazole appeared to have a weaker association with AGEP than other PPIs. The median time to the onset of AGEP was 6 (2, 12) days after PPI treatment, and 60.00%-83.33% of patients developed symptoms within 10 days after the medication (except rabeprazole). PPI-associated AGEP generally led to a fatality of 1.86% (3 cases) and a hospitalization rate of 79.50% (128 cases). The hospitalization rate of AGEP patients caused by omeprazole was the highest (91.49%, 43/47), followed by that of pantoprazole (88.37%, 38/43), lansoprazole (85.71%, 12/44), and omeprazole (61.82%, 34/55). Conclusions Our pharmacovigilance study based on the FAERS database demonstrated in detail the risks and characteristics of AGEP caused by different PPIs, which could provide a theoretical basis for rational clinical drug use.

Preliminary Report of Non-punitive Reporting of Perioperative Adverse Events in Peking Union Medical College Hospital during 2010—2014

ZHU Bo, ZHANG Yu, FENG Xuexin, ZHANG Xiuhua, HUANG Yuguang

2021, 12(6): 972-976. doi: 10.12290/xhyxzz.20200020

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Objective o optimize the system conditions and improve the patients' perioperative surgical safety through feedback learning for adverse events. Methods We retrospectively analyzed the adverse events (AEs) and risks of patients' safety reported by the Department of Anesthesiology, Peking Union Medical College Hospital from January 2010 to December 2014. Fish bone diagram was used to analyze and summarize the root causes, timing, avoidability and injury from adverse events. Results A total of 370 cases of AEs were collected. The root causes of AEs were mainly human factors (43.08%, 224/520), followed by systemic factors (30.96%, 161/520), and patient factors were the lowest (25.96%, 135/520). Forty-four cases (11.89%, 44/370) were emergent operations; 37 cases (10.00%, 37/370) occurred at night; 243 cases (65.68%, 243/370) could be avoided. According to the different occurrence time, the top four incidence rates were intraoperative (28.11%, 104/370), before anesthesia induction (17.30%, 64/370), during anesthesia induction (13.78%, 51/370), and at the end of surgery (12.97%, 48/370). Eighty AEs (21.62%, 80/370) did not cause injury; 262 cases (70.81%, 262/370) caused temporary minor injury; 15 cases (4.05%, 15/370) caused permanent injury; 13 cases (3.51%, 13/270) caused non-anesthesia related death intraoperatively or within 24 hours after the surgery. Compared with avoidable AEs, the proportion of patient factors (60.26% vs. 11.26%, P < 0.001) and that of non-anesthesia related death intraoperatively or within 24 hours after the surgery (8.66% vs. 0.82%, P < 0.001) in the unavoidable group were higher. Conclusions The root causes of perioperative AEs are mainly human factors, most of which can be avoided and cause temporary mild injury to patients. Strengthening feedback learning of AE, improving personnel training and optimizing system conditions might reduce the incidence of AE and promote perioperative safety and quality.

Genetics of Head and Neck Paragangliomas

WANG Pu, XIA Yin

2021, 12(6): 977-982. doi: 10.12290/xhyxzz.2021-0588

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Head and neck paragangliomas(HNPGL) are rare neurogenic tumors, in which genetic factors play a certain role. So far, 10 genes related to HNPGL(SDHA, SDHB, SDHC, SDHD, SDHAF2, VHL, HIF2A, RET, NF1 and TMEM127) have been found. The clinical phenotypes of different gene mutations are different. SDHD, SDHC and SDHAF2 gene mutations are almost 100% related to HNPGL. SDHD and SDHAF2 gene mutations tend to form multiple paragangliomas, and its genetic pattern has obviously maternal imprinting. SDHB mutations have sympathetic paraganglioma and malignant tendency. Understanding the molecular mechanism and genotype-phenotypic relationship of paraganglioma can provide significant help for genetic counseling, diagnosis and treatment, and development of follow-up strategies in patients with HNPGL.

Application of Radiomics in Breast Cancer

LUO Yanwen, ZHU Qingli

2021, 12(6): 983-988. doi: 10.12290/xhyxzz.2021-0011

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Breast cancer is the most common malignant tumor in Chinese women. Early diagnosis, treatment, and prognosis assessment are important clinical problems to be solved. Radiomics is a non-invasive method for high-throughput extraction and analysis of lesion features of images to provide more potential information of tumors, and guide precise diagnosis and treatment. Recently, it has been widely concerned and studied in breast cancer, covering every stage in the care of patients with breast cancer. In terms of diagnosis, the research has reached the level of maturity and gradually proceeded to the clinical setting. Regarding efficacy evaluation and prognostic prediction, although in its infancy, radiomics shows promising potential. This paper mainly reviews the application of radiomics in the diagnosis, response evaluation, and prognosis prediction of breast cancer.

Research Progress of Ultrasound Radiomics in Predicting Axillary Lymph Node Metastasis of Breast Cancer

GAO Yuanjing, ZHU Qingli, JIANG Yuxin

2021, 12(6): 989-993. doi: 10.12290/xhyxzz.2021-0187

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Breast cancer, as the most common malignant tumor in women worldwide, has become the focus of global attention. Axillary lymph node tumor burden is an important prognostic indicator of it. Ultrasound is the most commonly used imaging method, but its sensitivity is not high, especially for the diagnosis of small and micro lymph node metastasis. In recent years, the emerging Radiomics in machine learning field has been widely used in the field of medical imaging. Because it can extract high-level information of images that is difficult to be recognized by human eyes, it has been used to establish clinical prediction models. This paper introduced the value of preoperative sonography, sketched Radiomics, and summarized the research progress of this method in predicting lymph node metastasis of breast cancer. This new method is expected to provide a reliable basis for individualized and accurate diagnosis and treatment of breast cancer.

Research Progress on Vitamin D and Gestational Diabetes Mellitus

HUANG Feiling, LIU Yanping, HE Yuan, MA Liangkun

2021, 12(6): 994-998. doi: 10.12290/xhyxzz.2021-0048

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Gestational diabetes mellitus is one of the most common complications during pregnancy and an important factor affecting the health of mothers and babies. The level of vitamin D during pregnancy is related to glucose metabolism, which suggests that vitamin D may be involved in the occurrence and development of gestational diabetes mellitus. This review provides an overview of the correlation between vitamin D and gestational diabetes mellitus, as well as current status of vitamin D in the treatment and prevention for pregnant women in China. Vitamin D deficiency is common in pregnant women. The existing research on this topic is still controversial. High-quality randomized controlled trials with large samples are needed in the future to improve the explanation of clinical trials. The role of vitamin D in the treatment and prevention of gestational diabetes mellitus is worth anticipation.

New Progress in Postoperative Management of Pediatric Ambulatory Surgery

LIU Chaoqun, ZHU Bo, SHEN Le, HUANG Yuguang

2021, 12(6): 999-1003. doi: 10.12290/xhyxzz.20200272

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Pediatric ambulatory surgery can minimize the separation of pediatric patients from their parents, relieve anxiety, and offer care at a reduced cost. However, children are prone to experiencing pain, nausea, vomiting, delirium, and other complications after anesthesia and ambulatory surgery due to their anatomical and physiological characteristics. So, standardized postoperative management is critical to ensure the safety of children and improve the medical quality of pediatric ambulatory surgery. This article reviews new progress in research on common postoperative complications and discharge criteria of pediatric ambulatory surgery.

The Strategy of Facial Nerve Preservation in Acoustic Neuroma Surgery via Suboccipital Retrosigmoid Approach

XU Zhiqin

2021, 12(6): 1004-1008. doi: 10.12290/xhyxzz.2021-0569

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Acoustic neuroma is a common intracranial tumor, with a prevalence of 80-90% in the lesions of cerebellopontine angle. Microsurgical removal remains its main therapy, and the retrosigmoid approach continues to be the most widely employed strategy for the surgical resection of acoustic neuromas, with preservation of facial nerve to be the important goal. In order to preserve the facial nerve, the facial nerve's function should be evaluated accurately before and after the operation. The course of the facial nerve and its variation in cerebellopontine cistern and internal auditory canal should be well understood. Adequate drilling of the posterior wall of the internal auditory canal is necessary. Sufficient decompression of intracranial pressure and the tumor is imperative. The principle of subperineural and bidirectionary dissection should be followed. The use of bipolar coagulation should decrease to the greatest extent, and facial nerve monitoring should be used throughout exposing and removal of the acoustic neuroma.

A Case of Diabetes Mellitus Type 2 Complicated with Malignant Melanoma Misdiagnosed as Diabetic Foot Ulcer

WU Yaru, ZHAO Yuebin, LIU Shiwei

2021, 12(6): 1009-1015. doi: 10.12290/xhyxzz.2021-0053

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Acral malignant melanoma, as the main type of melanoma in China, is commonly seen in plantar lesions. Due to similar clinical manifestation, it is easy to be misdiagnosed as diabetic foot ulcers. We report a case of diabetes mellitus complicated with malignant melanoma, which was misdiagnosed as diabetic ulcer in the right foot, thus delaying treatment. Therefore, when diabetic foot lesions are characterized by atypical ulcers and the foot ulcers remain unhealed, pathological examination should be performed to exclude the possibility of malignant melanoma.

Investigation and Evaluation of Chinese Clinical Practice Guidelines Published in Medical Journals in 2019: Analysis of the Evidence

LIU Xiao, YANG Nan, WU Shouyuan, GUO Qiangqiang, LIU Hui, SUN Yajia, WANG Jianjian, ZHOU Qi, WANG Zijun, SHI Qianling, ZHAO Siya, LI Qinyuan, LUO Xufei, LYU Meng, SONG Xuping, CHEN Yaolong

2021, 12(6): 1016-1021. doi: 10.12290/xhyxzz.2021-0624

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Objective To investigate the current status of evidence of recommendations contained in Chinese clinical practice guidelines published in journals in 2019, so as to provide reference for the use of evidence for Chinese guidelines in the future. Methods We searched and analyzed information on Chinese guidelines published in 2019 with clear recommendations, grading of evidence quality and corresponding instructions of grading, as well as information on citations supporting the recommendations. Results A total of 31 guidelines (29 Chinese guidelines and 2 English guidelines) containing 568 recommendations and 3126 references were included. Each guideline included an average of 18 recommendations. Of these, 2541 references were presented as evidence in the statements of guideline recommendation(such references are referred to as "evidence" hereafter). The average number of evidence was 82 in each guideline and every recommendation has 4 pieces of evidence. The top three countries where the evidence was from were China (28.8%), the United States (25.9%), and the United Kingdom (7.0%). Only 39.2% (995/2541) of the evidence was published in the last 5 years. The most common type of evidence for guidelines was randomized controlled trials (26.9%). The citation of systematic reviews was only 12.0%. Conclusions Most of the Chinese guidelines published in 2019 did not have clear and unambiguous recommendations. Those guidelines with clear recommendations had incomplete and untimely evidence citations. Guideline developers should strengthen the rational use of currently available research evidence.

Carotid Body Tumor, Cardiac Paraganglioma, Adrenal Pheochromocytoma: A Contest with Hypercatecholamineemia

SUN Juan, LIU Jianzhou, WEN Jin, LI Hanzhong, JI Zhigang, DONG Dexin, YE Zixing, MIAO Qi, TONG Anli, HUANG Yuguang, LONG Yun

2021, 12(6): 1022-1029. doi: 10.12290/xhyxzz.2021-0134

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This patient was an elderly man with left carotid body tumor, cardiac paraganglioma and right adrenal pheochromocytoma at the same time. It was a rare case with a complex condition, and the diagnosis and treatment were difficult. After two rounds of discussion in the multidisciplinary team, our hospital successively removed the lesions of the heart and the right adrenal, and the patient was discharged smoothly after the operations. The diagnosis and treatment of this patient reflects the significance of the multidisciplinary team on the diagnosis and treatment of difficult diseases.

Development and Application of Integrated Intelligent Scheduling Software System

WANG Ying, ZHANG Qing, WEI Yao, WANG Yahong, ZHANG Li, QI Zhenhong, CAI Sheng, LI Jianchu, ZHAO Congpu

2021, 12(6): 1030-1033. doi: 10.12290/xhyxzz.2021-0076

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With the increase of the workload and complexity in the ultrasound department, scheduling is becoming more and more important. In order to improve the efficiency of scheduling, satisfaction of employees, and overall service satisfaction of the department, we developed the software system of integrated intelligent scheduling. Scientific, digital and intelligent scheduling can effectively optimize and integrate the human resources of the department, reduce the cost of staff management, enhance the management of operation, and improve medical practice, teaching, research and management.

Analyze Clinical Ethical Issues in the Treatments of Chronic Renal Failure Based on Four Topics Theory: An Example of a Patient with Chronic Renal Failure Refusing Hemodialysis

BAI Qiong, TANG Wen, WANG Yue

2021, 12(6): 1034-1038. doi: 10.12290/xhyxzz.20200169

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For the treatment of chronic renal failure, nephrologists should avoid the "one-size-fits-all" dialysis program, consider the patients' quality of life, contextual features, respect patients' preference, and recognize the importance of patients' participation in determining the goal and clinical decision. Based on the "Four Topics Theory" of clinical ethics and the medical ethical principles through an example of a patient that refused hemodialysis for chronic renal failure, this article explores the ethical issues related to the choice of treatment for patients with chronic renal failure. The clinical decision should combine the patient's preference and the best quality of medical care, which ultimately achieves a medical model of patient-centered and shared decisionmaking.

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2021 Vol. 12, No. 6

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