Volume 103 ·  Issue 27 ·  2023

To standardize the prevention and clinical management of lung cancer, improve patients′ survival outcomes, and offer professional insight for clinicians, the Oncology Society of Chinese Medical Association has summoned experts from departments of pulmonary medicine, oncology, thoracic surgery, radiotherapy, imaging, and pathology to formulate the Chinese Medical Association Guideline for Clinical Diagnosis and Treatment of Lung Cancer in China (2023 edition) through consensus meetings. Updates in this edition include 1) cancer screening: deletion of high-risk traits of lung cancer based on epidemiological investigations in the Caucasian population, while preserving features confirmed by research on the Chinese population. Advice on screening institutions is also added to raise awareness of the merits and demerits of lung cancer screening through detailed illustrations. 2) Principles of histopathologic evaluation: characteristics of four types of neuroendocrine tumors (typical carcinoid, atypical carcinoid, large cell carcinoma, and small cell carcinoma) are reviewed. 3) Surgical intervention: more options of resection are available for certain peripheral lesions based on several clinical studies (CALGB140503, JCOG0802, JCOG1211). 4) neoadjuvant/adjuvant therapy: marked improvement in the prognosis of non-small cell lung cancer (NSCLC) patients receiving neoadjuvant immunotherapy are reviewed; more options for consolidation immunotherapy after radiochemotherapy have also emerged. 5) Targeted and immune therapy: tyrosine kinase inhibitors of sensitive driver mutations such as EGFR and ALK as well as rare targets such as MET exon 14 skipping, RET fusion, ROS1 fusion, and NTRK fusion have been approved, offering more treatment options for clinicians and patients. Furthermore, multiple immune checkpoint inhibitors have been granted for the treatment of NSCLC and SCLC, resulting in prolonged survival of late-stage lung cancer patients. This guideline is established based on the current availability of domestically approved medications, recommendations of international guidelines, and present clinical practice in China as well as integration of the latest medical evidence of pathology, genetic testing, immune molecular biomarker detection, and treatment methods of lung cancer in recent years, to provide recommendations for professionals in clinical oncology, radiology, laboratory, and rehabilitation.

Spinal muscular atrophy (SMA) is a common degenerative neurological disease characterized by progressive muscle weakness and atrophy. In recent years, disease-modifying therapies have emerged and changed the natural course of SMA, with pre-symptomatic diagnosis and treatment being superior to post symptom treatment. Therefore, in order to standardize and guide the current newborn screening work of SMA, we organized national experts from related fields across the country to reach the following consensus: the SMA newborn screening process and related issues, the SMA post-screening diagnosis process and related issues, and the disease management of screened and confirmed SMA newborns, etc.

Chinese society is progressively aging, and more and more patients suffer from spinal diseases in advanced age patients (>75 years). Surgery is still the most effective solution for patients who have failed conservative treatment or who present with progressively worsening symptoms. Excluding surgical and anesthetic technical failures, the key factors affecting the incidence of postoperative complications are the stress response to surgery and the increased demands on organ function after surgery. Late old patients generally have a poor ability to withstand surgical shock, the implementation of enhanced recovery after surgery (ERAS) to reduce surgical stress response is more important for late old patients undergoing spinal surgery. Specific measures to familiarize more spinal surgeons with older spinal ERAS. On the basis of evidence-based medicine, experts from the Geriatric Group of Orthopaedic Branch of Beijing Medical Association, Geriatric Anesthesiology Group of Anesthesiology Branch of Chinese Medical Association reached the following expert consensus through multiple discussions and votes based on the existing clinical experience and published relevant data, for the reference of academic colleagues.

To investigate the expression levels of thymocyte selection related high mobility group proteins (TOX) and different inhibitory receptors in peripheral blood CD8⁺T cells of patients with aplastic anemia (AA), and to conduct correlation analysis.

From September 2019 to November 2020, 27 AA patients in the Department of Hematology, General Hospital of Tianjin Medical University were retrospectively selected, including 21 males and 6 females, with a median age [M (Q₁, Q₃)] of 48 (30, 72) years. Thirty-three healthy controls, included 17 males and 16 females, with a median age of 46 (27, 69) years. The expression levels of TOX, programmed cell death receptor-1 (PD-1), T-cell immunoglobulin and mucin domain 3 (TIM-3), cytotoxic T-lymphocyte associated antigen-4 (CTLA-4), T-cell immune receptor with immunoglobulin (Ig) and immunoreceptor tyrosine-based inhibitory motif (ITIM) domain (TIGIT), perforin and granzyme B in peripheral blood CD8⁺T cells from AA patients and healthy controls were detected by flow cytometry. The correlation between TOX expression levels and different inhibitory receptors was analyzed using Pearson correlation analysis.

The expression levels of TOX, PD-1, TIM-3, CTLA-4, TIGIT, perforin, and granzyme B in peripheral blood CD8⁺T cells of AA patients were 47.33%(41.47%, 56.61%), (30.61±12.37)%, (39.94±10.84)%, (6.21±3.40)%, (51.45±20.21)%, (71.32±22.46)%, and (52.39±23.99)%, respectively, which were higher than those of healthy controls 27.32%(21.64%, 46.96%), (21.29±10.01)%, (21.11±3.00)%, (1.31±0.34)% (30.80±13.40)%, (46.72±22.53)%, (21.75±16.43)% (all P<0.05). The expression level of TOX in CD8⁺T cells was positively correlated with the expression levels of PD-1, TIM-3, CTLA-4, TIGIT, perforin, and granzyme B (r=0.49, 0.65, 0.70, 0.54, 0.58, 0.48, all P<0.05).

The expression levels of TOX and different inhibitory receptors on peripheral blood CD8⁺T cells in AA patients are higher than those in the healthy control group, and the expression levels of TOX and different inhibitory receptors are positively correlated.

To evaluate the efficacy of CT-guided partial radiofrequency ablation of bilateral responsible cranial nerves in the treatment of Meige syndrome.

The Clinical data of 56 patients with Meige syndrome in the Department of Pain Medicine, Affiliated Hospital of Jiaxing University from June 2019 to January 2023 were retrospectively analyzed [19 males and 37 females, aged 42-76 (58.6±8.3) years], including 51 cases of blepharospasm, 3 cases of oromandibular dystonia and 2 cases of blepharospasm concomitant with oromandibular dystonia. CT-guided partial radiofrequency ablation of bilateral responsible cranial nerves was performed on different types of Meige syndrome. And the efficacy and complications of the technique were observed.

Fifty-one patients with blepharospasm Meige syndrome underwent CT-guided radiofrequency of facial nerve through bilateral stylomastoid foramen punctures, the symptoms of blepharospasm disappeared completely, leaving bilateral mild and moderate facial paralysis symptoms. Three patients with oral-mandibular dystonia underwent CT-guided radiofrequency therapy by bilateral foramen ovale puncture of mandibular branches of trigeminal nerve, masticatory muscle spasm disappeared, the patients had no difficulty opening the mouth, and the skin numbness in bilateral mandibular nerve innervation area was left. Two cases of Meige syndrome with blepharospasm concomitant with oromandibular dystonia were treated by radiofrequency of facial nerve and mandibular branch of trigeminal nerve, and all symptoms disappeared. The patients were followed up for 1-44 months after the operation, and the symptoms of mild and moderate facial paralysis disappeared at (3.2±0.8) months after the operation, but the numbness did not disappear. Three patients with blepharospasm recurred at the 14, 18 and 22 months after the operation, respectively, while the rest cases did not recur.

According to different types of Meige syndrome, CT-guided partial radiofrequency ablation of responsible cranial nerves can effectively treat the corresponding type of Meige syndrome. The complications are only mild and moderate facial paralysis which can be recovered, and/or skin numbness in the mandibular region.

To investigate the value of contrast-enhanced ultrasound in detecting endoleak after endovascular repair of infrarenal abdominal aortic aneurysm (EVAR).

The postoperative follow-up data of 102 patients with infrarenal abdominal aortic aneurysm treated with EVAR in Tianjin Medical University General Hospital from August 2015 to December 2021 were retrospectively analyzed. There were 79 males and 23 females, aged 50-91 (69.6±7.6) years old. Using CT angiography (CTA) as the gold standard for diagnosing endoleaks, the effectiveness of contrast-enhanced ultrasound and CDUS in detecting endoleaks was evaluated by paired design chi-square test, and the Kappa value was calculated for consistency test. Patients were divided into groups according to body mass index (BMI), and the number of false-negative endoleaks detected by contrast-enhanced ultrasound in each group was calculated, and its ratio to the actual number of endoleaks was calculated to evaluate whether BMI was related to false-negative ultrasound-enhanced ultrasound.

A total of 203 follow-up visits met the inclusion criteria. Endoleaks were detected 36 times (17.7%) by CTA, 31 times (15.3%) by contrast-enhanced ultrasound, 16 times (7.9%) by CDUS, and they all detected type Ⅰ, type Ⅱ and type Ⅲ endoleaks. There was no significant difference between contrast-enhanced ultrasound and CTA in endoleak detection rate and determination of endoleak types (endoleak detection rate: 15.3% vs 17.7%; determination of endoleak types: type Ⅰ 4 vs 4, type Ⅱ 26 vs 31, type Ⅲ 1 vs 1; all P>0.05). CDUS and CTA had statistically significant differences in the detection rate of endoleaks and determination of endoleak types (endoleak detection rate: 7.9% vs 17.7%; determination of endoleak types: type Ⅰ 4 vs 4, type Ⅱ 11 vs 31, type Ⅲ 1 vs 1; all P<0.001). Compared with CTA, contrast-enhanced ultrasound has a sensitivity of 83.3%, a specificity of 99.4%, a Youden index of 0.827, a coincidence rate of 96.6%, a positive predictive value of 96.8%, a negative predictive value of 96.5%, and a Kappa value of 0.875(P<0.001). The two showed excellent diagnostic consistency. All 6 endoleaks not detected by contrast-enhanced ultrasound were type Ⅱ endoleak that did not require treatment, and 3(15.8%) occurred in obese patients with a BMI≥32 kg/m². Compared with CTA, CDUS had a sensitivity of 38.9%, a specificity of 98.8%, a Youden index of 0.377, a coincidence rate of 88.2%, a positive predictive value of 87.5%, a negative predictive value of 88.2%, and a Kappa value of 0.482 (P<0.001). The two showed moderate diagnostic agreement. The correlation coefficient of the maximum diameter of aneurysms measured by ultrasound and CT was r=0.873(P<0.001).

Contrast-enhanced ultrasound is accurate in detecting endoleak after infrarenal EVAR, and its sensitivity to endoleak detection in obese patients with BMI≥32 kg/m² will be reduced. CDUS is not suitable for detection of endoleak after infrarenal EVAR, but it can be used to monitor the change of the largest diameter of aneurysm after EVAR.

To investigate the value of histogram parameters in quantifying brain development trajectory at slice of anterior and posterior horns of lateral ventricles on conventional brain MRI in normal children aged 0-5 years.

Routine brain MRI data [apparent diffusion coefficient (ADC) map, T₁-weighted imaging (T₁WI), and T₂-weighted imaging (T₂WI)] were retrospectively collected from 300 children aged 0-5 years who underwent MRI at Children ′s Hospital of Nanjing Medical University from April 2014 to November 2021, 154 males and 146 females, aged [M (Q₁, Q₃) ] 35.57(17.98,50.66)months. According to the random sampling method, they were divided into training set (n=240) and validation set (n=60) in a ratio of 8∶2. The training set was divided into 6 groups according to age:≤0.5 years, 24 persons; >0.5-≤1 years,21 persons; >1-≤2 years,31 persons; >2-≤3 years,44 persons; >3-≤4 years,42 persons; >4-≤5 years,78 persons. MRIcron software was used to delineate the whole brain at the level of the anterior and posterior horns of the lateral ventricles of the three MRI data as the region of interest. Then gray histograms and their parameters [including mean, maximum, minimum, skewness, kurtosis, mode, variance, and percentiles at 5% intervals from 10% to 95%(10th-95th) ]were obtained. Intra-class correlation coefficients (ICC) were used to assess consistency of intra-observer and inter-observer measurement. Representative parameters were selected by Spearman correlation analysis and curve fitting. The linear regression coefficient β represented development rates at different ages. The selected curve regression models were applied to the validation set, and the reliability of the model was evaluated with accuracy.

Intra-observer and inter-observer histogram measurement parameters were generally in good consistency (ICC>0.800, all P<0.001). Histogram parameters ADC 10th-65th, T₁WI 55th-80th and T₂WI 10th-45th were highly correlated with age (∣r∣≥0.700, 0.600 and 0.600 respectively; all P<0.001). ADC 30th and T₂WI 10th had the greatest goodness of fit (R²=0.871, 0.873; both P<0.001). Map of brain development trends showed that ADC 30th and T₂WI 10th decreased with age. ADC 30th changed rapidly before the age of 2 years, most significantly within 6 months, and the rate of decrease slowed down after 2 years old. T₂WI 10th decreased rapidly within 1 year, and moderately after 1 year old. The curve regression models of ADC 30th and T₂WI 10th had higher accuracy in validation set [93% (56/60) and 95% (57/60), respectively].

Histogram parameters can quantify brain developmental trajectories at slice of anterior and posterior horns of lateral ventricles on conventional MRI in normal children aged 0-5 years, and obtain the brain development curves reflecting this slice of this age group.

This article reports the case of a 39-year-old male with onset of abdominal pain and then chronic diarrhea with intestinal fistula. "Crohn's disease" was suspected in another hospital and biological treatment was recommended, but the clinical manifestations, laboratory and imaging tests of the patient did not support Crohn's disease. Finally, the patient underwent surgical treatment. During the operation, it was found that the patient had ileal duplication deformity. The duplicate intestinal tube led to fecal stone incarceration, which further led to ileo-sigmoid fistula, and was finally diagnosed as foreign body incarceration. This case is helpful to increase medical workers' understanding of foreign body incarceration, further learn the differential diagnosis of Crohn's disease, and avoid delaying the patient's condition or even misdiagnosis.

A 16-year-old male patient showed progressive muscle weakness, pain, decreased activity endurance and brown urine as the main manifestations, abnormal urine test, and increased serum aminotransferase, creatine kinase and blood ammonia. Detection of increased blood acyl carnitine by tandem mass spectrometry; Gas chromatography was used to detect the increase of glutaric acid in urine. Whole exome sequencing suggests a complex heterozygous mutation in exon 5 c.524G>A (p.R175H) and exon 3 c.250G>A (p.A84T) of the ETFDH gene, which can ultimately diagnose multiple acyl-CoA dehydrogenase deficiencies. After treatment with hydration, alkalization, riboflavin, coenzyme Q10 and L-carnitine, the muscle strength and various biochemical indexes of the children returned to normal. Patients with recurrent or progressive myopathy, rhabdomyolysis, acute metabolic disorders and increased serum creatine kinase should be alert to delayed metabolic myopathy. Early diagnosis and treatment are the key to improve prognosis.

In April 2021, the National Health and Wellness Commission promulgated the health industry standard WS/T 779-2021 "Reference Interval for Blood Cell Analysis of Children". This standard is based on the direct sampling method, and a large sample of healthy children and adolescents aged 28 days to 18 years are screened in multiple centers. Under strict quality control conditions, the blood cell analysis data of venous blood and peripheral blood are obtained at the same time, and the reference interval is formulated according to different ages and genders. This standard reflects the age-dependent trend of blood cell parameters in children and adolescents, and is helpful for the accurate interpretation of children's blood cell analysis results. In order to promote the popularization and application of this standard, this paper interprets the key clauses such as the establishment and verification of reference interval, the analysis of common problems in reference interval application and the treatment suggestions, so as to help pediatric clinical and laboratory staff better understand and apply this standard, and provide evidence-based decision-making basis for children's health assessment, disease diagnosis and treatment effect assessment.

Mutations in the dystrophin gene often lead to a group of fatal X-linked recessive muscle diseases. Among them, Duchenne muscular dystrophy (DMD) is the most common and the clinical phenotype is the most serious. Children with DMD mostly show progressive myasthenia in the early stage, and can progress to dilated cardiomyopathy at about 6 years old. At the end of the disease course, they often die of heart failure or sudden cardiac death. In recent years, with the development and application of gene therapy, the performance of skeletal muscle involvement in children has gradually improved, but targeted therapy of myocardium still faces great challenges. Early effective cardiac therapy will determine children's quality of life and long-term prognosis. This paper reviews the current pathogenesis, clinical phenotype and treatment of heart damage in children caused by this disease, aiming at strengthening the early attention of heart damage in children with dystrophin gene mutation, so as to facilitate the management and treatment of heart in children.

Acute pancreatitis (AP) is one of the most common acute abdominal diseases, and its severity and prognosis are heterogeneous. Of these, up to 20% of AP patients develop severe acute pancreatitis (SAP), which is characterized by persistent organ failure and high mortality. Due to the particularity of the course of AP, there is no predictive system that can accurately judge the severity and clinical outcome of AP at the beginning of the disease. Therefore, this study constructed a machine learning (ML) prediction model by including a multicenter, prospective cohort to predict the severity and outcome of AP.