Volume 102 ·  Issue 15 ·  2022

Persistent cerebrospinal fluid leakage can affect a patient's daily life, and may also cause serious complications and increase the risk of death. Perioperative prevention is the focus of cerebrospinal fluid leak management; In addition, early accurate diagnosis of cerebrospinal fluid leakage and the choice of appropriate treatment are the keys to improve the prognosis of patients. Therefore, domestic experts in neurosurgery and other related fields learned from domestic and foreign guidelines and relevant evidence-based evidence, repeatedly discussed the diagnosis, treatment and prevention of cerebrospinal fluid leakage, and collected expert suggestions through the improved Delphi method to form clinical consensus recommendations, which provided scientific and practical guidance and suggestions for clinicians to standardize the management of cerebrospinal fluid leakage.

Primary brainstem hemorrhage (PBSH) is the most fatal subtype of cerebral hemorrhage, with a rapid onset, high disability and fatality rate, which poses a challenge to existing treatment methods. Due to the lack of relevant evidence-based medicine research, there is no relevant expert consensus and guidelines at home and abroad. This article gathers the experiences of experts and their units from the two major cerebrovascular surgery groups of domestic medical associations and medical doctors associations, and reaches the following consensus of Chinese experts. From the perspectives of risk factors, epidemiology, pathogenesis, diagnosis and evaluation, treatment, prognosis, prevention and intervention, different treatment methods were classified and expounded, aiming at providing reference and suggestions for clinical diagnosis and treatment of PBSH.

In recent years, new rheumatoid arthritis (RA) treatment drugs have been continuously launched. At the same time, new evidence-based medical evidence and constantly updated domestic and foreign guidelines suggest that more drugs can be used for RA patients in special periods such as pregnancy preparation, pregnancy, and lactation. However, the update of drug instructions is relatively lagging behind. To this end, the author organized domestic experts in rheumatology, pharmacy and obstetric reproductive medicine to summarize 12 expert consensus on the treatment of RA beyond the instructions, involving three off-instructions uses, such as super-indication, over-administration route and super-population, aiming to provide a basis for clinicians to treat RA beyond the instructions, and further standardize the clinical practice of RA beyond the instructions.

To explore the value of enhanced magnetic resonance imaging nomogram model in the prediction of dual-phenotype hepatocellular carcinoma(DPHCC).

Data of 116 patients of hepatocellular carcinoma (HCC) confirmed by postoperative pathology, who underwent preoperative enhanced MRI between January 2016 and March 2021 in the First Affiliated Hospital of Soochow University were retrospectively evaluated, of these, there are 87 males and 28 females, aged 30-79 (59±10) years, including 31 patients with DPHCC and 85 patients with non-DPHCC. The patients were randomly divided into training set(51 cases of non-DPHCC,19 cases of DPHCC)and validation set(34 cases of non-DPHCC, 12 cases of DPHCC) in a ratio of 6∶4, according to random number table,clinical and imaging characteristics of the two groups were compared. The statistically significant parameters were included in multivariate logistic regression to identify the independent predictors and for the establishment of the nomogram model. The receiver operating characteristic curves were used to evaluate the prediction ability of the models, the corrected curve was used to validate the model.

In the training group, the proportions of rim arterial phase hyperenhancement in the DPHCC was significantly higher than that of the non-DPHCC [47.4%(9/19)vs 7.8%(4/51),P<0.001]. Rim arterial phase hyper-enhancement and enhanced capsule were significant predictors for DPHCC[OR=10.17(1.70-60.80),0.17(0.03-0.93),all P<0.05]. In the training group, the area under curve (AUC), sensitivity and specificity of the nomogram were 0.888 (95%CI: 0.806-0.969), 78.9% and 86.3%. In the validation group, the above three indicators were 0.811(95%CI: 0.655-0.968), 75.0% and 82.4%.

Enhanced MRI nomogram model has certain value in prediction of DPHCC, with high sensitivity and specificity.

To investigate the application value of relaxation time quantitative technique from synthetic magnetic resonance imaging (MRI) in the diagnosis and invasion assessment of prostate cancer.

A total of 119 patients with prostate diseases [122 regions of interest(ROI)] who underwent routine MRI scan and magnetic resonance image compilation (MAGiC) sequence of prostate from March 2020 to March 2021 in General Hospital of Ningxia Medical University were retrospectively collected, they were divided into prostate cancer group(58 cases, 61 ROI) and non-prostate cancer group(61 cases, 61 ROI) according to the pathological results. In the prostate cancer group, those patients with an age of 48 to 85(69.8±5.9) years, and further divided into two subgroups according to the location of occurrence: peripheral zone cancer group (43 cases, 45 ROI) and transitional zone cancer group (15 cases, 16 ROI). The non-prostate cancer group consisted of patients with benign prostatic hyperplasia or complicated with chronic prostatitis, with an age of 41 to 81(68.6±7.0) years, and they were further divided into two subgroups according to the location of occurrence: non-cancerous peripheral zone group (45 cases, 45 ROI) and transitional zone benign prostatic hyperplasia group(16 cases, 16 ROI). Prostate cancer lesions were classified as low risk (Gleason score ≤6) or intermediate/high risk (Gleason score ≥7). After the post-processing of MAGiC images, T₁, T₂ and proton density(PD) values of prostate cancer group and non-prostate cancer group were obtained. At the same time, relevant software were used for image post-processing to generate apparent diffusion coefficient (ADC) value, the data between the two groups were analyzed by the Independent sample t-test or Mann-Whitney U-test, and the diagnostic effectiveness of each quantitative parameter in diagnosing prostate cancer and discriminating low risk prostate cancer from intermediate/high risk prostate cancer was analyzed by using receiver operating characteristic curve (ROC) analysis, the correlation between each quantitative parameter and Gleason score were assessed by Spearman correlation analysis.

The T₁ value and T₂ value of the peripheral zone cancer group were lower than those in non-cancerous peripheral zone group [1 201.3 (1 103.5, 1 298.2) ms vs 2 274.0 (1 620.9, 2 776.5) ms; 78.0 (74.0, 83.8) ms vs (160.6±54.9) ms] (all P<0.001), there was no statistically significant in PD value between the two groups (P>0.05). The T₁ value and T₂ value of the transitional zone cancer group were lower than those in transitional zone benign prostatic hyperplasia group [1 073.3 (1 003.9, 1 164.9) ms vs 1 340.8 (1 208.5, 1 502.8) ms; 76.9 (74.8, 82.8) ms vs 95.1(82.8, 103.4) ms] (all P<0.001), there was no statistically significant in PD value between the two groups (P>0.05). The area under the curve (AUC) of T₂ value was similar with the ADC value in discriminating peripheral zone cancer group from non-cancerous peripheral zone group(0.963 vs 0.991, P=0.105), while in discriminating transitional zone cancer group from transitional zone benign prostatic hyperplasia group, the AUC of T₂ value、T₁ value and ADC value were similar(0.867, 0.930 vs 0.938, all P>0.05). ADC value, T₂ value all were negatively correlated with Gleason score (r=-0.747,-0.453, all P<0.001). T₂ value and ADC value demonstrated equivalent diagnostic performance in discriminating low risk from intermediate/high risk prostate cancer, and there were no statistically significant (AUC: 0.787 vs 0.943, P=0.069).

Quantitative relaxation time T₁ and T₂ values derived from synthetic MRI can discriminate prostate cancer from other benign pathologies, and T₂ value have the equivalent diagnostic performance compared to ADC value. Synthetic MRI has high clinical application value, and T₂ value can distinguish low risk prostate cancer from intermediate/high risk prostate cancer.

To explore the risk factors associated with septic cardiomyopathy and establish a predictive model of the disease based on left ventricular global longitudinal strain (LV GLS).

Data from sepsis patients without a history of cardiac dysfunction who were treated in the Critical Care Department of the Northern Jiangsu People′s Hospital from September, 2019 to January, 2021 were included in the analysis. The LV GLS was measured by echocardiography within 72 hours and the patients were divided into a septic myocardiopathy group (LV GLS>-17%) and a normal cardiac function group (LV GLS≤-17%). Clinical data from two groups of patients were collected for univariate analysis. The receiver operating characteristic (ROC) curves of the factors that were statistically different were drawn for exploring the diagnostic and cut-off values. The continuous variable was converted to a dichotomous variable according to the cut-off value. Multivariate logistic regression analysis of sepsis cardiomyopathy was performed to screen the risk factors and create a predictive model. The predictive model was evaluated by ROC curve analysis and the Bootstrap method and shown as a nomograph.

Patients in the sepsis cardiomyopathy group had higher levels of high sensitive troponin I (Hs-TnI), procalcitonin (PCT), lactate (Lac), N-terminal pro-brain atriuretic peptide (NT-proBNP), vasopressor dosing intensity (VDI) and sequential organ failure assessment (SOFA) when compared to those in the normal cardiac function group (all P<0.05). The multivariate logistic regression analysis showed that Hs-TnI≥0.131 μg/L (OR=6.71, 95%CI:2.67-16.88, P<0.001), PCT≥40 μg/L (OR=3.08, 95%CI:1.10-8.59, P=0.032), Lac≥4.2 mmol/L (OR=2.80, 95%CI:1.02-7.69, P=0.045), NT-proBNP≥3 270 ng/L (OR=2.67, 95%CI:1.06-6.74, P=0.038) were independent risk factors for septic myocardiopathy. The area under the ROC curve of the predictive model based on the four indexes up-mentioned was 0.838 (95%CI:0.766-0.910), and the C-index was 0.822 (95%CI:0.750-0.894) which indicated the utility of the nomogram. The model had a good predictive ability, accuracy and discrimination.

Hs-TnI≥0.131 μg/L, PCT≥40 μg/L, Lac≥4.2 mmol/L and NT-proBNP≥3 270 ng/L are independent risk factors for septic myocardiopathy, and the septic cardiomyopathy predictive model constructed based on these factors has a good diagnostic performance.

To investigate the effect of continuous intravenous infusion of subanesthetic dose of esketamine intraoperatively on postoperative opioid consumption in patients undergoing thoracoscopic surgery.

A total of 71 patients with elective thoracoscopic lung surgery in the First Affiliated Hospital of Zhengzhou University from December 2020 to December 2021 were selected. Patients who were classified as grade Ⅰ or Ⅱ by the American Society of Anesthesiologists (ASA) and aged 18-70 years were included, including 32 males and 39 females, with a body mass index (BMI) of 18.5-30.0 kg/m². The patients were randomly divided into three groups: (1) Control group (group C, n=24): continuous intravenous infusion of normal saline at the same rate during surgery; (2) Subanesthetic dose of esketamine 0.125 mg·kg^-1·h^-1 group (group ES1, n=23): continuous intravenous infusion of esketamine at a rate of 0.125 mg·kg^-1·h^-1 during surgery; (3) Subanesthetic dose of esketamine 0.250 mg·kg^-1·h^-1 group (group ES2, n=24): continuous intravenous infusion of esketamine at a rate of 0.250 mg·kg^-1·h^-1 during surgery. The main outcome measures were the total consumptions of hydromorphone of 3 groups within 24 and 48 hours after surgery. The secondary outcome measures were the extubation time, length of postanesthesia care unit (PACU) stay, the time of first feeding, and the incidences of adverse effects within 24 h after surgery in 3 groups.

The 24 h postoperative consumption of hydromorphone in group C, ES1 and ES2 was (5.4±1.0) mg, (4.5±1.5) mg and (4.0±0.8) mg, respectively. Likewise, the 48 h postoperative consumption of hydromorphone was (9.7±2.2) mg, (9.0±3.0) mg and (7.7±1.8) mg, respectively. Compared with group C, the 24 h postoperative hydromorphone consumptions were significantly reduced in group ES1 and ES2 (both P<0.05). The extubation time, length of PACU stay and the time of first feeding after surgery in group C were (23±10) min,(70±12) min,(17±3) h,in group ES1 were (22±4) min,(69±11) min,(14±5) h,in group ES2 were (16±8) min,(58±12) min,(14±3) h, respectively. Compared with group C and group ES1, both of the extubation time and length of PACU stay were shortened in group ES2 (both P<0.05). Compared with group C, the first postoperative feeding time of group ES1 and ES2 was shortened (both P<0.05). There were no differences in the incidences of adverse effects at postoperative 24 h among 3 groups (all P>0.05).

Continuously intravenous infusion of subanesthetic esketamine at a rate of 0.250 mg·kg^-1·h^-1 can significantly reduce the postoperative opioid consumption and improve the patient′s outcomes.

To investigate the methods and quality assurance of metagenomic next-generation sequencing (mNGS) to detect the microbial cfDNA (mcfDNA) from blood samples in different laboratories across China.

In October 2020, questionnaires about detecting mcfDNA in blood samples with mNGS were distributed to 80 laboratories across the country. The questionnaire included four parts: pre-analysis, during analysis, post-analysis, and carrying out of performance validation for mNGS. (1) Pre-analysis: the requirements for samples quality, such as collection, storage, the transportation conditions of samples; (2) During analysis: the extraction workflows of mcfDNA, the quality requirements of the library, the application of the sequencing platforms and the bioinformatics analysis pipelines; (3) Post-analysis: the standard of interpretation results for mNGS; (4) Carrying out of performance validation: the minimum detection limit for various pathogens. All laboratories are required to fill in the questionnaire according to the actual situation. The feedback data were summarized and analyzed.

The 80 laboratories included 20 medical centers and 60 independent medical laboratories. There were 80.0% (64/80) of laboratories indicated that both plasma and serum samples were used to detect mcfDNA in blood, and the rest of the laboratories (16/80, 20.0%) only used plasma samples. The sequencing platforms used by mNGS laboratories involved in the survey included illumina (49), Beijing Genomics Institute (16), Ion Torrent (13) and Nanopore sequencing (2). There were 87.5% (70/80) of laboratories used the integrated analysis tools built by the third-party laboratories, and other laboratories (12.5%, 10/80) independently built the analysis platform by open-source software. The interpretation criteria of mNGS results varied between laboratories, among which the normalized number of pathogen-specific sequences, relative abundance, genome coverage rate, and the detection of the microorganism in the negative control were the main factors considered by laboratories. Most laboratories (76.3%, 61/80) had carried out the performance validation for the mcfDNA mNGS workflows. The limit of detection of the laboratories-developed mNGS workflows for Gram-positive bacteria, Gram-negative bacteria, fungi, parasites, and other pathogens were mainly distributed at 10-100 copies/ml, DNA virus was mainly distributed at 500-1 000 copies/ml.

The mNGS workflows of various laboratories are very different. In order to ensure timely and accurate testing results, every laboratory needs to actively optimize the mNGS testing procedures, improve quality assurance measures, and carry out performance validation before mNGS is widely used in clinical settings.

The clinical data and follow-up results of 27 paraspinoid aneurysms treated by Willis covered stent (WCS) in Department of Neurosurgery, Army Medical University from May 2014 to January 2021 were retrospectively analyzed. Among them, 17 cases (63.0%) were treated with WCS alone, and 10 cases (37.0%) were assisted with coiling embolization. During the follow-up, postoperative internal leakage occurred in 2 patients(7%), of which 1(type Ⅰ) wasself-healing and the other 1 (type Ⅲ) was cured by WCS implantation again. The remaining patients had no aneurysm recurrence, unobstructed parent artery, stent displacement and internal stenosis. 92.6% (25/27) of the improved mRS scores were good. WCS is a safe and effective method for the treatment of parabedinal aneurysms.

This paper reports a patient who underwent elective radical resection of esophageal cancer with mild sleep apnea syndrome. Recurrent laryngeal nerve injury is considered because the patient has hoarseness, upper respiratory tract obstruction, and large decrease in blood oxygen saturation after extubation. Immediately give measures such as lifting the mandible, inserting the oropharyngeal airway, and pressurizing the mask to supply oxygen, and the patient's blood oxygen saturation returned to normal. Subsequently, a muscle relaxation monitor was used, suggesting that the patient had a residual muscle relaxation (muscle relaxation), and the residual muscle relaxation was rapidly antagonized with sugamentose sodium. In the end, the patient did not have upper respiratory tract obstruction and other events again, the respiratory rate and tidal volume were normal, and the blood oxygen saturation reached 100%.

This paper reports a case of atypical intracranial teratoid/rhabdoid tumor in young people, which is extremely rare in clinical practice. A 22-year-old male was admitted to the hospital with "headache for 2 months and blurred vision for 1 month". Conventional MRI, enhanced MRI and magnetic resonance spectroscopy examination showed malignant tumor of the corpus callosum. After surgical resection, atypical teratoid/rhabdoid tumor was diagnosed by postoperative pathology. After surgical treatment, the patient was in poor condition and did not receive adjuvant chemoradiotherapy. The postoperative survival time was 20 days.

A 69-year-old female patient showed progressive hearing loss and loss, fever, headache, unclear speech, dysphagia, choking and coughing after drinking water, weakness in chewing, lifting neck and limbs. Perinuclear anti-neutrophil cytoplasmic antibody (target antigen myeloperoxidase), anti-acetylcholine receptor antibody, neostigmine test and repeated low-frequency electrical stimulation attenuation test were all positive. Electrophysiology suggested peripheral nerve damage. After shock therapy with glucocorticoids, mycophenolate mofetil, pyridostigmine bromide and intravenous immunoglobulin, the patient was discharged from hospital with confusion of speech, dysphagia, choking and cough after drinking water, chewing and neck lifting.

Patients with locally advanced non-small cell lung cancer are at high risk of recurrence after resection. Although platinum-based adjuvant chemotherapy has become standard treatment, the role of postoperative radiotherapy (PORT) has been controversial for many years. For patients with incomplete resection, despite the lack of randomized evidence, postoperative radiotherapy should be strongly recommended on a consensus basis. In patients with fully resected (R0) NSCLC, a meta-analysis showed a poorer prognosis for PORT in the absence of mediastinal involvement (pN0 and pN1). In pN2 patients, the role of PORT is unknown and needs further investigation. But this meta-analysis included trials with older radiological techniques and poorer surgical quality compared to today's standards, and patient selection was not based on positron emission tomography. Updated retrospective and non-randomized studies, as well as subgroup analyses of randomized trials evaluating adjuvant chemotherapy, suggest that PORT can provide survival benefits for PN2R0 patients. Two recent randomized trials (Lung ART and PORT-C) evaluated the advantage of conformal PORT versus non-PORT for disease-free survival in stage IIIA-N2 patients, although PORT significantly reduced mediastinal recurrence rates. PORT had no effect on survival, probably due to the high rate of distant recurrence and the additional risk of cardiopulmonary toxicity. Ongoing and future analyses are planned in Lung ART to identify patients for whom PORT can be recommended. In neoadjuvant and/or adjuvant therapy settings, new systemic therapies (immune checkpoint inhibitors or targeted therapies for oncogene-dependent patients) are being incorporated. In future studies, it is necessary to better identify patients at high risk of disease recurrence by analyzing circulating tumor cell DNA on the basis of detecting minimal (or molecular) residual disease after surgery.