Volume 101 ·  Issue 30 ·  2021

Just over a decade ago, it was widely accepted that intrapleural instillation of fibrinolytics was ineffective in treatment of pleural infection. Due to the accumulation of clinical study evidence, an expert team from several countries developed an international consensus and recommended that tissue plasminogen activator and deoxyribonuclease should be instilled intrapleurally at the same time as the initial treatment, or as a follow-up treatment after surgery for pleural infection. The recommended dosages are as follows: tissue plasminogen activator 10 mg, twice a day, deoxyribonuclease 5 mg, twice a day. The future researches should focus on optimizing the tissue plasminogen activator and deoxyribonuclease schemes and developing more effective fibrinolytics.

Infection of pancreatic necrosis is the most frequent cause of late mortality in severe acute pancreatitis(SAP). Most clinical guidelines of acute pancreatitis recommended that prophylactic antibiotics should be avoided. Prophylactic antibiotics can not reduce the pancreatic infection rate or mortality in patients with SAP ornecrotizing pancreatitis. Definitive infection is the only indication for rational use of antibiotics in SAP patients. Broad-spectrum antibiotics for treatment should cover enteric bacteria, and the bacteriology and antibiotic pharmacokinetics of SAP should be considered when selecting antibiotics.

Severe acute pancreatitis (SAP) is one of the most common acute and critical diseases. SAP is often accompanied by necrosis of the pancreas and surrounding tissues.When necrosis is co-infected, it often means high mortality. With the development of endoscopic technology, endoscopic intervention in the treatment of necrotizing pancreatitis has achieved good results, which has the advantages of minimal-invasiveness, effectiveness, and safety, and could significantly improve the prognosis of patients with SAP. This article aims to review the research progress of endoscopic treatment of necrotizing pancreatitis.

Severe acute pancreatitis can induce systemic and local complications, with infectious pancreatic necrosis and sepsis leading to the second death peak. Enterogenous infection caused by intestinal failure is considered to be an important mechanism of secondary infection of pancreatic or peripancreatic necrosis. Therefore, the prevention and treatment of intestinal failure is the key point in the treatment of severe acute pancreatitis and has an important influence on the course and prognosis of the disease. Individualized treatment should be selected according to the advantages of treatment centers and the characteristics of patients.

Fluid resuscitation is the cornerstone in the early treatment of severe acute pancreatitis(SAP). The endpoints of fluid therapy should be closely monitored early in the disease course by different methods, such as clinical status, pressure indicators, volume indicators, the maintain of microcirculation and the tissue oxygenation. To avoid volume overload that may lead to complications such as pulmonary edema and abdominal hypertension, it is critical to adjust the ratio of crystalloid-colloid and the speed of the liquid timely according to the dynamically assessment of fluid responsiveness and tolerance, the perfusion of macrocirculation and microcirculation and the stage of the fluid resuscitation, so as to improve the efficacy and safety of early fluid resuscitation in the treatment of SAP.

Traumatic pancreatitis(TP) is an acute non-infectious inflammation secondary to pancreatic injury.TP can be masked by analgesia or other organ damage after pancreatic injury. So it is difficult to diagnosis in the early stage, easy to missed and misdiagnosis, subsequently prone to infection of pancreatic necrosis (IPN).At present, the treatment of TP is advocated as a step-by-step treatment strategy, which takes minimally invasive surgery as the guidance and takes into account of the principles of multiple injury treatment, inflammation control, infection and necrosis clearance, which runs through the two important links of pancreatic injury and IPN management.

To investigate the diagnostic value of PET/MRI for malignant pleural effusion (MPE), and compare its diagnostic difference with PET/CT.

The data of 57 patients with suspected MPE admitted into Union Hospital of Tongji Medical College of Huazhong University of Science and Technology from October 2017 to January 2020 was analyzed. A total of 53 patients were included in the prospective study, and the whole body PET/CT and thoracic PET/MRI were performed on them respectively. Two physicians used a blind method to evaluate the morphological features of PET/CT and PET/MRI images, delineate the region of interest (ROI), obtain the maximum standard uptake value (SUVmax) of the ROI in the PET/CT and PET/MRI images. The target-to-background ratio (TBR) of the lesion was calculated. The diffusion-weighted imaging (DWI) characteristics of the pleura in PET/MRI images were analyzed. Taking pathological diagnosis as the gold standard, the diagnostic effect of PET/CT and PET/MRI on MPE were evaluated.

The 53 patients who were finally included were (62.8±1.7) years old, consisting of 31 males. Pathological results showed that 41 cases were MPE and 12 cases were benign pleural effusion (BPE). There were no statistical differences in age, gender and smoking history between the two groups (P>0.05). Bland-Altman analysis showed that the SUVmax of pleural lesions by PET/MRI was higher than that by PET/CT (6.4±0.6 vs 5.3±0.5,P<0.001). The TBR of PET/MRI was higher than that of PET/CT (2.2±0.2 vs 1.8±0.2,P<0.001). The sensitivity, specificity, and accuracy of PET/MRI in the diagnosis of MPE by combining imaging features such as SUVmax and DWI of pleural lesions were 75.6%, 100%, and 81.1%, respectively. The sensitivity, specificity, and accuracy of PET/CT combined with SUVmax and imaging features of pleural lesions in the diagnosis of MPE were 85.4%, 83.3%, and 77.4%, respectively. There was no statistically significant difference between PET/MRI and PET/CT in the area under the curve (AUC) for diagnosing MPE (0.934 vs 0.873,P>0.05).

PET/MRI and PET/CT have the equivalent diagnostic efficiency for MPE. However, PET/MRI shows higher SUVmax and TBR for pleural lesions, and has specific pleural DWI imaging characteristics, which is worthy of further clinical research.

To evaluate the efficacy and safety of giant emphysematous bulla (GEB) volume reduction via medical thoracoscope.

This was a prospective, single-arm study conducted between July 2018 and September 2020 in Ri Zhao Hospital of Traditional Chinese Medicine. Patients who met the inclusion criteria were treated with GEB volume reduction via medical thoracoscope and were followed up to evaluate the efficacy and safety of the technique. According to comparison of preoperative and postoperative chest CT results, the self-designed evaluation criteria of imaging efficacy were as follows: complete or nearly complete disappearance of GEB (GEB volume reduction ≥90%), significant reduction of GEB (75%≤GEB volume reduction<90%), reduction of GEB (50%≤GEB volume reduction<75%) and no change (GEB volume reduction<50%).

A total of 47 patients were included, among whom 43 were males, with an ageM (Q₁, Q₃) of 63.0 (55.0, 67.0). The CT results showed complete or nearly complete disappearance of GEB in 43 patients, significant reduction of GEB in 3 patients and reduction of GEB in 1 patient before discharge. The degree of dyspnea improved significantly (P<0.05). Arterial partial pressure of carbon dioxide (PaCO₂) decreased from (48.2±8.4)mmHg (1 mmHg=0.133 kPa) to (45.4±7.3)mmHg (P<0.05). The 6-minute walk test (6MWT) increased from (245.6±162.4)m to (283.5±152.2)m (P<0.05). Six-month postoperative follow-up was completed in 24 patients, and CT results showed that the efficacy of volume reduction was continuous compared with that before discharge. GEB was further reduced or even disappeared in 3 of the cases. Besides, the degree of dyspnea, 6MWT (384.4±148.2)m and PaCO₂ (42.7±6.6)mmHg were improved significantly (P<0.05). The oxygenation index (356.86±61.21)mmHg was significantly higher than that before surgery (295.20±67.16)mmHg and before discharge (294.50±76.69)mmHg (P<0.05). No perioperative deaths occurred.

GEB volume can be completely eliminated or significantly reduced by this innovative technique, while PaCO₂, the degree of dyspnea and exercise endurance can be significantly improved after operation. The 6-month follow-up after surgery showed that the above benefits continued, and that the oxygenation index improved significantly.

To explore the composition of ascites lymphocytes in high-grade serous ovarian carcinoma (HGSOC) and its correlation with clinical features.

A total of 59 newly-diagnosed HGSOC patients, aged (58±11) years old, who were treated at the Department of Obstetrics and Gynecology of Peking University Third Hospital from July 2019 to December 2020 were included, collecting ascites and peritoneal irrigation fluid respectively. Detect the proportion of T, B, NK cell and its subpopulations by flow cytometry, and analyze its correlation with the clinical characteristics of patients.

Among 59 patients, 48 patients (81.4%) had ascites, and 11 patients (18.6%) had no ascites. Compared with the peritoneal irrigation fluid, the CD3⁺T (70.2%±15.6% vs 78.1%±6.7%, P=0.014), CD8⁺T (38.3%±11.2% vs 47.7%±10.1%, P=0.014) and CD16^-CD56^bright NK [2.0% (0.8%, 3.6%) vs 4.2% (1.5%, 7.1%), P=0.026] cells were significantly decreased in the ascites, while the CD16⁺CD56^dim NK cells was significantly increased [6.8% (2.8%, 15.7%) vs 2.6% (1.6%, 4.3%), P=0.008]. In patients with ascites volume ≥1 000 ml, CD16^-CD56^bright NK cells were significantly increased than those ascites volume<1 000 ml [3.1% (1.2%, 3.9%) vs 0.8% (0.4%, 2.3%),P=0.002]. Age was significantly positively correlated with the level of CD4⁺T cells (r=0.332, P=0.021) and the ratio of CD4⁺T/CD8⁺T (r=0.379, P=0.008) in ascites. In ascites from patients with poor response to treatment, the proportion of CD4⁺T cells was increased significantly than those with better response (64.7%±4.2% vs 48.3%±11.7%, P=0.002).

The formation of ascites in newly diagnosed high-grade serous epithelial ovarian cancer patients would affect the lymphocyte composition in the abdominal cavity microenvironment, which is related to the patient′s age, cancer progression and treatment response.

To investigate the effect of axillary lymph node status on the prognosis of different types of invasive breast cancer.

Patients with invasive breast cancer of different molecular subtypes diagnosed in the breast cancer prevention and treatment center of Beijing Cancer Hospital from January 2000 to July 2011 were collected as a historical cohort, and the influence of lymph node status on the prognosis of different types of breast cancer was analyzed.

A total of 4 269 female breast cancer patients with molecular subtypes [aged (50.8±11.2) years] information and 3 824 female breast cancer patients with complete axillary lymph node status information [aged (50.5±10.9) years] were included in the study, including 3 135 cases with both molecular subtypes and lymph node status information. The 10-year event free survival (EFS) rates of hormone receptor (HR)⁺/human epidermal growth factor receptor-2(HER2)^-, HR^-/HER2^-and HER2⁺were 82.2%, 79.0% and 76.8%, respectively; the 10-year overall survival (OS) rates were 88.1%, 83.1% and 84.4%, respectively, and the differences of 3 molecular subtypes in EFS and OS were statistically significant (both P<0.001). The 10-year EFS rate of lymph node positive and negative patients was 68.8% and 88.2%, respectively; the 10-year OS rate was 76.7% and 92.5%, respectively, and the differences of lymph node status in EFS and OS were statistically significant (bothP<0.001). In lymph node negative subgroup, 3 subtypes showed similar EFS and OS rate (bothP>0.05); In lymph node positive subgroup, 3 subtypes showed significantly different EFS and OS (bothP<0.05). No modification effect was detected of lymph node status on the correlation of molecular subtypes and EFS, DDFS and OS(allP_interactive>0.1).

Different molecular subtypes of breast cancer have different prognosis. Compared with molecular subtype, lymph node status may be a more important prognostic factor.

To analyze the effect of triple-induction regimen including all-trans retinoic acid(ATRA), arsenic trioxide(ATO) plus anthracyclines and double-induction regimen including ATRA and ATO for adults with non-high-risk acute promyelocytic leukemia(APL).

The clinical data of adult patients with non-high-risk APL who were first diagnosed and admitted to the Henan Provincial People′s Hospital from January 2009 to December 2019 were retrospectively analyzed. All patients were divided into triple-induction group and double-induction group according to the treatment. The general data of patients, blood routine, coagulation function changes and blood transfusions during the induction period were collected, and the complete remission rate, early mortality and prognosis of two groups were analyzed.

A total of 164 patients were enrolled, including 86 males and 78 females, and the M(Q₁,Q₃) of their age was 41(18, 70) years. Among them, 75 were in triple-induction group and 89 in double-induction group. The white blood cell(WBC) counts of triple-induction group on day 7th and 14th after induction were (9.49±6.10)×10⁹/L and (5.43±3.97)×10⁹/L, while those in double-induction group were (15.17±17.06)×10⁹/L and (13.37±12.59)×10⁹/L, the differences were statistically significant (both P<0.05). In addition, the peak of WBC in the triple-induction group was lower than that in the double-induction group [13.8(6.3,89.7)×10⁹/L vs 19.2(3.8,112.8)×10⁹/L, P=0.019]. On day 7th after induction, the platelet(PLT) counts in the triple-induction group was lower than that in the double-induction group [27(11,147)×10⁹/L vs 45(8, 183)×10⁹/L, P=0.014]. However, the difference was not statistically significant in PLT counts between the two groups on day 14th, 21st and 28th, or in PLT transfusions during induction (all P>0.05). After treatment, it was observed only in a few patients of two groups that the prothrombin time(PT) elongation ≥3 s and/or activated partial thromboplastin time(APTT) elongation ≥10 s, and the difference was not statistically significant (allP>0.05). The incidence of induced differentiation syndrome in the triple-induction group was lower than that in the double-induction group (2.7% vs 12.4%,P=0.022) The early mortality rate was lower than that in the double-induction group (1.3% vs 5.6%), but the difference was not statistically significant (P>0.05). There were no statistically significant differences in the early complete remission rate, genetic remission rate, molecular remission rate, relapse rate, overall survival (OS) rate and disease-free survival (DFS) rate between the two groups.

For adults with non-high-risk APL, the triple-induction therapy can reduce the counts and peaks of WBC, and reduce the incidence of induced differentiation syndrome.

To investigate the relationship between urinary sodium excretion and fluid overload (FO) in non-dialysis patients with chronic kidney disease (CKD).

Patients with CKD stage 1-4 who underwent bioelectrical impedance (BIA) in the Department of Nephrology, Jiangsu Province Hospital from December 2019 to January 2021 were recruited. All enrolled patients were categorized into two groups according to whether or not they develop FO. Further, clinical parameters were compared between the two groups. Spearman correlation analysis was used to investigate the association between over hydration/extracellular water (OH/ECW) and clinical characteristics. Multivariate logistic regression analysis was performed to evaluate the relationship between urinary sodium excretion and FO (FO was defined as OH/ECW≥7%).

A total of 385 patients with CKD stage 1-4 were finally included in the study, with a mean age of (46±15) years. There were 216 male cases (56.1%), and 150 cases (39.0%) existed FO. Spearman correlation analysis indicated that OH/ECW positively correlated with urinary sodium excretion (r=0.147, P=0.004), urinary protein excretion (r=0.555, P<0.001) and systolic blood pressure (r=0.241, P<0.001), but inversely related to estimated glomerular filtration rate (eGFR) (r=-0.111, P=0.030) and serum albumin (r=-0.659, P<0.001). After adjusting for confounding factors including age, systolic blood pressure, diabetes, urinary protein excretion, serum albumin, serum sodium, serum chlorine, urinary calcium excretion, urinary phosphorus excretion and use of diuretics, multivariate logistic regression analysis demonstrated that higher level of urinary sodium excretion was associated with increased risk of FO in patients with CKD (OR=1.005, 95%CI: 1.000-1.011, P=0.048).

High urinary sodium excretion is independently associated with fluid FO in non-dialysis patients with CKD.

To investigate the value of serum cystatin C for the evaluation of renal function damage in patients with proliferative diabetic retinopathy (PDR).

The clinical data of PDR patients treated in ophthalmic wards of Beijing Tongren Hospital from July 2019 to January 2021 were retrospectively analyzed. The estimated glomerular filtration rate (eGFR) was calculated by the abbreviated Modification of Diet in Renal Disease (MDRD) study equation. Based on the eGFR level, the patients were divided into no obvious renal function damage group [≥ 60 ml·min⁻¹·(1.73 m²)⁻¹] and renal inadequacy group [<60 ml·min⁻¹·(1.73 m²)⁻¹]. The clinical characteristics between the two groups were compared. Multivariate logistic regression analysis was performed to identify the relevant factors of renal inadequacy. The value of cystatin C to predict the renal inadequacy was calculated by the receiver operating characteristic (ROC) curves.

A total of 1 009 patients [593 males and 416 females; mean age: (52±12) years] were finally included in the study, with 192 cases (19.0%) and 817 cases (81.0%) in renal inadequacy group and no obvious renal function damage group, respectively. There were no significant statistically differences in gender, age, diastolic blood pressure, body mass index, fasting blood glucose and low-density lipoprotein between the two groups (all P>0.05). The systolic blood pressure, blood urea nitrogen, creatinine, uric acid, triglyceride, cholesterol and cystatin C were higher in the renal inadequacy group than those of no obvious renal function damage group (allP<0.05). However, the glycosylated hemoglobin, albumin and high-density lipoprotein were lower in the renal inadequacy group (allP<0.05). Multivariate logistic regression analysis showed that serum creatinine (OR=1.189, 95%CI: 1.101-1.284, P<0.001) and cystatin C (OR=3.175, 95%CI: 1.272-7.923, P=0.013) were independent risk factors for renal inadequacy in PDR patients. The ROC curve showed that cystatin C had a predictive value for renal inadequacy, with an area under the curve (AUC) of 0.966 (95%CI: 0.952-0.979). Meanwhile, the cutoff value was 1.315 mg/L, and the Youden index was 0.826, with the sensitivity of 94.3% and specificity of 88.4%.

Serum cystatin C can be used as an important laboratory indicator to evaluate the renal impairment in PDR patients.

To evaluate the cost-effectiveness of government fully-funded quadrivalent influenza vaccination (QIV) program for older adults aged 60 and above in mainland China.

Based on decision tree model in the previous research on the cost-effectiveness analysis of TIV immunization, we extended the structure of model and updated the key parameters such as influenza patients′ healthcare seeking behavior, vaccine cost, vaccine coverage and vaccine efficacy/effectiveness to estimate influenza-associated outpatient consultations, hospitalizations, respiratory disease excess mortality and quality-adjusted life years (QALY) between the QIV and no vaccination or TIV program. And incremental cost and incremental cost-effectiveness ratio (ICER) were evaluated between the QIV and no vaccination or TIV program from the societal perspective. The time frame of the study is one year. All costs were adjusted to 2019 using the consumer price index.

Comparing the fully-funded QIV and no vaccination or TIV for older adults aged 60 and above is separately expected to prevent 45 070 or 2 718 influenza-associated influenza-like illness (ILI) outpatients, 21 451 or 1 294 influenza-associated severe acute respiratory infection (SARI) hospitalizations, 19 346 or 1 167 influenza-associated respiratory excess deaths and avoid 155 234 or 9 363 QALY loss each year. Compared with no vaccination, introducing QIV into National Immunization Program (NIP) is expected to increase the cost of 11.71 billion yuan from the societal perspective. The incremental cost per QALY gained between QIV and no vaccination was 75 325 yuan per QALY, which is higher than willingness-to-pay (WTP) threshold (one-fold gross domestic product per capita is considered as WTP: 70 892 yuan) and means no cost effective. Introducing QIV rather than TIV into NIP will cost 7.98 billion yuan from the societal perspective and the ICER was 852.54 thousand yuan per QALY which is much higher than WTP and means no cost effective as well. The threshold of vaccination cost between QIV and no vaccination or TIV should no more than 113.41 or 6.83 yuan when the two comparators′ scenarios above are all cost effective.

Under the condition of current vaccine effectiveness and vaccine cost, comparing fully-funded QIV with no or TIV vaccination program is not cost effective for people aged 60 years or older.

Diabetic nephropathy is a common complication of diabetes, the main cause of end-stage renal disease, and has become a major disease that endangers human health. The sensitivity and accuracy of existing commonly used clinical diagnostic indicators are insufficient, and the mining and application of new biomarkers is urgently needed. Based on proteomics research technology, this paper reviews the application of proteomics in the study of diabetic nephropathy biomarkers from three aspects: diagnosis and prediction, progression and prognosis, and therapeutic targets. As nephrology begins to move towards precision medicine, proteomics technologies will be important graspers to improve diagnosis, treatment, and prognosis using individualized protocols for different patients.

Acromegaly is a chronic systemic disease caused by long-term excessive secretion of growth hormone (GH). More than 95% of patients with acromegaly are caused by pituitary adenomas that secrete GH. Although various methods such as surgery, radiotherapy and drug therapy can be used to help patients achieve biochemical control at present, more and more studies have shown that achieving biochemical standards is not equivalent to improving patients' quality of life, that is, patients with acromegaly who achieve biochemical standards still have many problems of poor quality of life. The mechanisms affecting the quality of life are complex, and the treatment mode, complications, physical symptoms and psychological state may affect the quality of life of patients with acromegaly. It is of great significance to explore the causes of the decline in quality of life of patients with acromegaly, so as to guide clinical decision-making for improving long-term prognosis of patients. This article reviews the research progress related to the quality of life of patients with acromegaly to better guide clinical practice.

Primary liver cancer ranks sixth worldwide in cancer incidence and third in cancer-related deaths. Intrahepatic cholangiocarcinoma (iCCA) and hepatocellular carcinoma (HCC) are the most common primary liver cancers, of which HCC accounts for 80% and iCCA is 10% ~15%. Current evidence suggests that patients with iCCA may have a worse prognosis than those with HCC. Although extensive studies have been conducted on the epidemiology and pathophysiology of these two common liver cancers, differences in demography, clinical characteristics and prognosis between iCCA and HCC patients have not been compared in large-scale population survey studies.

Non-steroidal anti-inflammatory drugs (NSAIDs) are currently important analgesics in the implementation of accelerated rehabilitation surgery (ERAS). Recent evidence suggests that there is an association between postoperative ketorolac use and anastomotic leakage in patients undergoing colorectal surgery, but this association is still under-studied in esophageal cancer resection surgery. With increasing emphasis on non-opioid analgesic regimens and ERAS concepts, it is clinically important to determine the possible association between perioperative ketorolac use and anastomotic leakage. The study retrospectively collected clinical data of patients who underwent esophageal adenocarcinoma resection at the same institution from 2006 to 2018, summarized the occurrence of anastomotic leakage, and queried the institution's pharmacy records to understand the use of ketorolac during the hospitalization of surgical cases; Multivariate logistic regression was used to analyze the relationship between ketorolac application and anastomotic leakage. In the end, a total of 1 019 patients met the inclusion criteria, including 907 (89%) males with a mean age of 62 years. Patients presented mainly with locally advanced lesions and received initial chemoradiotherapy, a total of 686 patients (67%) were treated with ketorolac. During the study period, ketorolac use increased from 49% in 2006 to 92% in 2016. A total of 87 patients (9%) experienced anastomotic leakage, and the incidence of anastomotic leakage decreased over time from 15% (11/72) in 2006 to 2% (2/83) in 2018. The results of multivariate analysis showed that ketorolac administration regardless of whether as a categorical variable (OR=0.99，P=0.958), or use a continuous variable of dose (OR=1.00，P=0.843) were not shown to be associated with the occurrence of anastomotic leakage. This study suggests that the use of ketorolac after esophageal cancer resection has become an important part of the ERAS protocol and does not appear to be associated with anastomotic leakage.