Volume 104 · Issue 25 · 2024

Neuromodulation techniques have gradually evolved from electrical or chemical methods to various physical stimulation techniques including electricity, magnetism, sound, light, heat, and more. However, the clinical efficacy and mechanisms of each stimulation technique or paradigm vary greatly. To facilitate the understanding of the therapeutic effects and mechanisms of different neuromodulation techniques, combined with current clinical practice, the author takes the classification of non-invasive transcranial electrical stimulation as an example and proposes the idea of using energy magnitude as the primary classification and different media/stimulation routes as the secondary classification. This classification emphasizes the energy essence of various physical stimuli, followed by the transmission carriers of physical stimuli. This classification method helps to guide and design neuromodulation paradigms for different target symptoms in various brain disorders, which is beneficial for better serving clinical diagnosis and treatment. The Expert Forum also discusses the advantages and disadvantages of various neuromodulation technologies and their clinical applications.

Insomnia disorder is the most common sleep disorder. It not only increases the risk of multiple somatic and mental disorders, but also carries a heavy social health economic burden. Currently, there is a lack of diagnosis and treatment standards for insomnia disorder in primary medical institutions at home and abroad. To this end, the Chinese Sleep Research Society organized domestic sleep medical experts in sleep medicine to develop this consensus based on the latest research on insomnia disorder. The current consensus elaborates on the pathophysiological mechanism, epidemiology, diagnosis, screening assessment, prevention and control measures and basic management, and has established a total of 15 recommendations. These recommendations aim to provide comprehensive and standardized references and guidelines for the diagnosis and treatment of insomnia disorder.

The interleukin-6 (IL-6) pathway plays a crucial role in various rheumatic diseases. Tocilizumab, a biologic targeting IL-6 receptor, has been widely used in clinical practice, though it′s officially approved in China for only three indications. To address clinical challenges associated with the off-label use of tocilizumab in treating rheumatic diseases, the Committee of Chinese Primary Health Care Foundation for Rheumatologists and Immunologists engaged multidisciplinary experts and highlight 12 related clinical issues. We aggregated the drug specifications, the guidelines for clinical management of rheumatic diseases and the evidence from clinical research. Recommendations were formed through voting with the consensus conference method incorporating the Oxford evidence-based medicine criteria to evaluate the strength of evidence and recommendations. We have formulated 10 recommendations for off-label use of tocilizumab related to giant cell arteritis, polymyalgia rheumatica, Takayasu arteritis, systemic sclerosis, adult-onset Still′s disease, rheumatoid arthritis, and juvenile idiopathic arthritis. This consensus aims to provide references for the rational use of tocilizumab in clinical practice and enhance pharmacovigilance monitoring.

To investigate the effectiveness and safety of multimodal analgesia in patients with end-stage head and neck cancer in open gastrostomy surgery.

This was a randomized controlled trial. From June to December 2023, 50 patients with end-stage head and neck cancer who underwent elective open gastrostomy surgery in Beijing Tongren Hospital Affiliated to Capital Medical University were prospectively selected. The patients were divided into multimodal analgesia group and local anesthesia group using the random number table method according to different anesthesia methods, with 25 cases in each group. In multimodal analgesia group, a multimodal analgesia regimen was adopted: ultrasound-guided abdominal wall nerve block (rectus sheath block and transverse abdominis plane block)+intravenous injection of oxycodone+intravenous injection of flurbiprofen axetil and dexamethasone. In local anesthesia group, local infiltration anesthesia with ropivacaine was adopted. The main outcome measure was the incidence of intraoperative pain numeric rating scale (NRS) score>3 points in the two groups. The secondary observation indicators included NRS score and hemodynamic indexes [mean arterial pressure (MAP) and heart rate (HR)] at various time points during surgery [before anesthesia (T0), at the time of incision (T1), 10 minutes after surgery (T2), during gastric body traction (T3), and at the end of surgery (T4)], incidence of adverse reactions, postoperative patient satisfaction score, as well as the NRS scores at rest and activity (coughing) within 24 hours after surgery.

The multimodal analgesia group included 21 males and 4 females, aged (61.4±9.9) years. There were 19 males and 6 females in the local anesthesia group, aged (58.6±10.8) years. The incidence of intraoperative NRS score>3 points and the incidence of salvage analgesia in the multimodal analgesia group were both 12.0% (3/25), which were lower than 60.0% (15/25) in the local anesthesia group, and the differences were statistically significant (all P<0.001); The NRS score [M (Q₁, Q₃)] at T3 in the multimodal analgesia group was 2 (2, 3) points, which were lower than 5 (3, 6) points in the local anesthesia group (P<0.05). There were smaller variabilities in MAP and HR in the multimodal analgesia group than those in the local anesthesia group (all P<0.05). The incidence of intraoperative tachycardia, surgical traction reaction, and nausea in the multimodal analgesia group was lower than that in the local anesthesia group (all P<0.05). The postoperative satisfaction score of patients in the multimodal analgesia group was (9.25±0.71) points, which were higher than (7.33±0.87) points in the local anesthesia group (P<0.001). NRS score during postoperative activity within 24 hours in the multimodal analgesia group were (2.36±0.75) points, which were lower than (3.03±0.81) points of the local anesthesia group (P=0.005). No adverse reactions such as urinary retention, nausea, vomiting and dizziness occurred in both groups.

Compared with local anesthesia, the multimodal analgesic strategy could provide better analgesic effect and longer duration, better hemodynamic stability, and fewer intraoperative adverse reactions in patients with end-stage head and neck cancer undergoing open gastrostomy.

To analyze the efficacy and safety of pulsed radiofrequency (PRF) for the treatment of thoracic postherpetic neuralgia (PHN) in elderly patients with different pain phenotypes.

A total of 201 elderly thoracic PHN patients, including 110 males and 91 females aged (72.2±6.9) years who received high-voltage, long-duration PRF at the dorsal root ganglion at Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine from January 2020 to December 2022, were retrospectively included. The neuropathic pain symptom inventory (NPSI) was used to evaluate the five different pain phenotypes, which included superficial spontaneous pain, deep spontaneous pain, paroxysmal pain, evoked pain, and paresthesia/dysesthesia, and to analyze the distribution of the five pain phenotypes. The numerical rating scale (NRS) and NPSI scores of all patients were compared before treatment and three months after treatment to evaluate the efficacy and safety of PRF for different pain phenotypes and pain phenotype combinations.

All patients had two or more pain phenotypes, and 50.2% (101/201) of the patients had five pain phenotypes at the same time. Compared with those before treatment, three months after treatment, the NPSI scores for superficial spontaneous pain, deep spontaneous pain, paroxysmal pain, evoked pain and paresthesia/dysesthesia decreased (all P<0.05), and the scores decreased by［M（Q₁，Q₃）］3.0 (2.0, 4.0), 1.5 (0.5, 2.5), 3.0 (2.5, 4.0), 2.3 (1.0, 4.0), and 1.0 (0.5, 2.0) points, respectively, the differences were statistically significant (P<0.001). The decrease in the NPSI score in patients with paroxysmal pain was greater than that in patients with the other 4 pain phenotypes (all P<0.05). After treatment, the NRS score decreased by 4.0 (3.0, 5.0), 4.0 (3.0, 5.0), 4.0 (3.0, 5.0) and 5.0 (4.0, 6.0) points in patients with 2, 3, 4 and 5 pain phenotypes, respectively, and the difference was statistically significant (P<0.001). The decrease in the NRS score was greater in patients with a combination of 5 pain phenotypes than that in patients with a combination of 3 and 4 pain phenotypes (all P<0.05). No complications, such as pneumothorax, haematoma or infection, occurred in any of the patients during treatment.

PRF has different therapeutic effects on PHN patients with different pain phenotypes, it has the best effect on paroxysmal pain, and the treatment is safe.

To investigate the risk factors of venous thrombosis in patients with polycythemia vera (PV) and establish a prediction model for venous thrombosis.

PV patients with JAK2^V617F gene mutation positive in the Second Hospital of Tianjin Medical University from September 2017 to November 2023 were retrospectively included. The patients were divided into groups according to whether they had venous thrombosis. After matching age and gender factors with propensity scores, 102 patients were included in the venous thrombosis group [46 males, 56 females, with a median age M (Q₁, Q₃) of 52 (44, 60) years] and 204 cases were included in the group without venous thrombosis [92 males, 112 females, with a median age of 52 (44, 59) years]. The clinical and laboratory characteristics, disease progression and incidence of gene mutation were compared between the two groups. The follow-up cohort ended on November 20, 2023, with a median follow-up [M (Q₁, Q₃)] of 11 (1, 53) years. Multivariate Cox risk model was used to analyze the influencing factors of venous thrombosis in PV patients, and establish a scoring system for the venous thrombosis risk factor prediction model of PV patients. Receiver operating characteristic (ROC) curve was used to evaluate the predictive efficiency of the model.

Hemoglobin concentration, the ratio of hematopoietic volume≥55%, neutrophil to lymphocyte ratio≥5, hypertension, subcostal spleen≥5 cm and secondary myelofibrosis in venous thrombosis group were higher than those in non-venous thrombosis group (all P<0.05). In addition, the proportion of history of thromboembolism, V617F gene mutation load (V617F%)≥50%, diabetes mellitus, ASXL1 mutation and secondary reticular silver staining≥3 in the venous thrombosis group were higher than those in the non-venous thrombosis group (all P<0.05). The proportion of PV patients with 3 or more gene mutations was 44.1% (45/102) in venous thrombosis group, which was higher than that of PV patients without venous thrombosis 29.9% (61/204) (P=0.014). The proportion of ASXL1 gene mutation in venous thrombosis group was 17.6% (18/102), which was higher than the 4.9% (10/204) in non-venous thrombosis group (P<0.001). Multivariate Cox risk model analysis showed that previous thromboembolism history (HR=2.031, 95%CI: 1.297-3.179, P=0.002), V617F%≥50% (HR=2.141, 95%CI: 1.370-3.347, P=0.001), ASXL1 mutation (HR=4.632, 95%CI: 1.497-14.336, P=0.008), spleen subcostal≥5 cm (HR=1.771, 95%CI: 1.047-2.996, P=0.033) are the risk factors of venous thrombosis in PV patients. According to HR values, a score system for predicting risk of venous thrombosis in PV patients was established: previous history of thromboembolism, V617F%≥50% and spleen subcostoal≥5 cm were assigned 1 point respectively, and ASXL1 mutation was assigned 2 points. Low risk group: score 0, medium risk group: score 1-2, high risk group: score≥3. The ROC curve analysis of the model for predicting venous thrombosis in PV patients showed that the area under the curve (AUC) was 0.807 (95%CI: 0.755-0.860), with the sensitivity of 88.2% and the specificity of 59.8% when the Youden index was 0.48.

Previous thromboembolism history, V617F%≥50%, ASXL1 mutation, spleen subcostoal≥5 cm are risk factors of venous thrombosis in PV patients. The established prediction model has good prediction efficiency.

To explore the menopause status of patients with rheumatoid arthritis (RA) and clinical characteristics of perimenopausal RA patients.

A cross-sectional study. Female RA patients were recruited retrospectively in the Sun Yat-Sen Memorial Hospital from August 2015 to August 2023. Clinical data were collected, including onset age, disease duration, RA disease activity indicators, functional assessment, and radiographic scores. According to menopausal status, the patients were categorized as pre-menopausal, perimenopausal and post-menopausal groups to explore their menopausal and clinical characteristics.

A total of 1 151 female patients were enrolled, with a mean age of (50.2±13.0) years. At enrollment, there were 470 (40.8%), 140 (12.2%) and 541 (47.0%) patients in pre-menopause, perimenopause and post-menopause status, respectively. The mean age of menopause was (49.0±4.2) years. Compared with pre-menopausal group, perimenopausal RA patients had higher disease activity indicators [clinical disease activity index (CDAI) 17 (6, 26) vs 10 (3, 19) ], higher levels of inflammation [erythrocyte sedimentation rate (ESR) 35 (21, 65) vs 26 (14, 44) mm/1h, C-reactive protein (CRP) 6.2 (3.2, 16.8) vs 3.3 (3.2, 13.6) mg/L], and a higher proportion of functional limitation [25.0%(35/140) vs 10.4%(49/470)] (all P<0.016 7); while there was no significant differences in disease activity[M(Q₁, Q₃)] [CDAI 17 (6, 26) vs 14 (6, 25)], levels of inflammation [ESR 35(21, 65) vs 42 (23, 72) mm/1h, CRP 6.2 (3.2, 16.8) vs 6.2 (3.3, 23.9) mg/L] and functional limitation [25.0%(35/140) vs 28.8%(156/541)] when compared with those in post-menopausal group (all P>0.016 7). In RA patients during the perimenopausal period, 49 cases (35.0%) developed RA during this period. Compared with patients with RA onset during reproductive age, patients with RA onset during the perimenopausal period had higher numbers of 28-joint tender joints [7 (2, 10) vs 4 (0, 8)], higher CDAI [20 (12, 29) vs 14 (4, 24)], and higher ESR [45 (25, 72) vs 32 (18, 56) mm/1h] (all P<0.05).

Perimenopausal patients with RA have severe disease activity and functional limitation.

To investigate the role and underlying mechanisms of intercellular adhesion molecule-1 (ICAM-1) in the adhesion and migration of mesenchymal stem cells (MSCs) in patients with ankylosing spondylitis (AS).

Bone marrow and ligament tissues were collected during surgery from patients with AS and thoracolumbar fractures (as controls, HC) treated from October 2021 to October 2022 at Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital. MSCs were isolated and cultured from the bone marrow using the Ficoll separation method. Cell morphology was observed under high-resolution microscopy, and differences in the cytoskeletal features between AS-and HC-MSCs were analyzed through immunofluorescence staining. The expression of ICAM-1 was quantified in both groups using real-time quantitative polymerase chain reaction (RT-qPCR) and flow cytometry. Transwell migration assays and wound healing experiments were conducted to evaluate the differences in migration rates between the two groups of MSCs.

The interspinous ligament and bone marrow was acquired in AS (2 males and 1 female; 33, 37, 32 years old, respectively) and no-AS patients (2 males and 1 female; 35, 32, 38 years old, respectively). AS-MSCs exhibited broader cell morphology compared to HC-MSCs under bright field and fluorescence microscopy. Immunofluorescence staining of the interspinous ligament showed higher expression of ICAM-1 (68.38±3.42 vs 48.31±2.43) and CD105 (37.97±2.16 vs 23.36±2.06) in AS patients (both P<0.001). Western blot and RT-qPCR analysis revealed significantly stronger protein expression and transcription levels of ICAM-1 in AS-MSCs when compared to those in HC-MSCs (both P<0.001). Flow cytometry confirmed greater mean fluorescence intensity of ICAM-1 in AS-MSCs than in that in HC-MSCs (924.30±54.99 vs 636.47±40.03, P=0.002). Regarding cell adhesion efficiency, it showed no significant difference between AS-MSCs and HC-MSCs in the early stage of adhesion (0.5 h: 1 496±213 vs 1 205±163, P=0.133), but they were all significantly higher in AS-MSCs in the later stage (1 h: 2 894±172 vs 1 908±155, P=0.002; 2 h: 4 540±286 vs 3 334±188, P=0.004; 3 h: 5 212±281 vs 4 208±303, P=0.014). Finally, cell migration experiments demonstrated a stronger migration capability of AS-MSCs compared to HC-MSCs (5 449±172 vs 4 016±155, P<0.001), and the inhibition efficiency of A-205804 on the migration rate of AS-MSCs was stronger than that on HC-MSCs (2 145±239 vs 3 539±316, P=0.004).

The aberrant expression of ICAM-1 markedly influences the adhesion and migration dynamics of MSCs. Elevated ICAM-1 levels in MSCs derives from patients with AS significantly enhance their migratory capabilities.

This article reports that a 26-year-old young woman was seen in Peking Union Medical College Hospital on November 18, 2022 due to "intermittent abdominal pain for 6 months, diarrhea and fever for 4 months". The patient was diagnosed with "Crohn's disease" in another hospital, and the short-term infliximab treatment was not effective. Auxiliary examination showed elevated inflammatory indexes, gastroscopy showed shortened duodenal villi, capsule enteroscopy showed shortened small intestinal villi, intermittent mucosal multiple small ulcers, some deep ulcers, rough and uneven surface, erosion. Pathology showed that small intestinal villi were low and flat, Pan's cells and goblet cells were reduced, apoptotic bodies were seen, and no intraepithelial lymphocytes were increased, and the diagnosis of "autoimmune enteropathy" was made. Glucocorticoid treatment was effective, and abdominal pain and diarrhea improved. However, the symptoms worsened in the process of trying to overtake oral glucocorticoids, and enterogenic infection occurred. After multidisciplinary discussion, the slow reduction of intravenous hormone combined with tacrolimus for maintenance, the current condition improved. Follow-up until March 2024, during which the patient formed soft stools once a day, and the duodenal villi shortening improved compared with the previous after reexamination by gastroscopy.

This paper reports the diagnosis and treatment of a female patient with unnamed aneurysm rupture and right scapular sarcoma. The 62-year-old patient underwent endovascular repair and carotid-carotid bypass due to "recurrent chest pain for half a month" and unnamed aneurysm rupture on CT angiography (CTA). Chest pain was still felt after operation, and the mass shadow of mediastinal aorta on CTA was gradually enlarged. After 7 months, ascending aorta replacement and aortic semi-arch replacement were performed. Still intermittent chest and back pain after operation, CTA showed bone destruction of right scapula, bone puncture pathology showed the possibility of right scapular sarcoma, currently treated with oral targeted drug anlotinib.

Colonic ischemia caused by mesenteric venous lesions is a rare type of colonic ischemic disease with non-specific clinical manifestations, and patients are prone to hypercoagulability. Imaging directly suggests that mesenteric venous thrombosis is rare, but mesenteric vein and its branches are missing or poorly developed, and endoscopic segmental or continuous lesions are more common. Mild to moderate colonic ischemia is mainly treated with conservative medical treatment, while patients with intestinal infarction need surgical intervention. This article focuses on colonic ischemia caused by mesenteric venous lesions, and discusses its etiology, pathogenesis, disease characteristics, diagnosis and differential diagnosis, treatment and prognosis.

The 16-year-old child went to the outpatient clinic of the People's Liberation Army General Hospital for "right hip pain for more than 1 year". One year before admission, I developed right hip pain during sitting and at night, and the symptoms were partially relieved after taking non-steroidal anti-inflammatory drugs and local hot compress. Since the onset of the disease, the pain in the right hip has gradually worsened and the frequency of the disease has increased. The effect of drug and physical therapy has not been good in the past month. The patient's outpatient hip X-ray revealed a lesion on the anteromedial side of the right femoral neck (Figure 1). CT showed that the lesion was located in the cortex bone, with sclerosis of the surrounding bone, a circular low-density shadow inside, and oval sclerotic bone in the center, showing "bull's eye sign" (Figure 2). MRI 2T lipid pressure imaging also showed high-signal annular liquid area in the lesion and low-signal sclerotic bone in the center (Figure 3). It is likely to consider the diagnosis of osteoid osteoma of the femoral neck. He was admitted to the undergraduate department and underwent arthroscopic surgery to completely remove the lesion, and was diagnosed as osteoid osteoma after pathological examination: the bone-like tissue was irregular in shape, and osteoblasts and capillaries were visible in the interstitium. Osteoid osteoma is a single benign tumor that occurs in children and adolescents. It mainly occurs in the long femoral shaft and long bone metaphysis of the limbs. The incidence ratio of male to female is about 2:1. Pain often occurs in the area where the tumor nest is located, and the typical symptom is nocturnal pain, which can be relieved by oral non-steroidal anti-inflammatory drugs. Osteoid osteoma is mainly diagnosed by CT, and the typical "bull eye sign" manifestation can be seen in the cortex of bone. The treatment is to completely remove the tumor nest and its surrounding hardened bone through surgery. The symptoms, imaging and pathological manifestations of this patient were in line with the characteristics of osteoid osteoma of the femoral neck, and the diagnosis was clear and the postoperative effect was good.

A 34-year-old female went to the outpatient clinic of the People's Liberation Army General Hospital for "a mass found in her hip for more than one month". The patient found a buttock mass 2 months ago, about the size of an "egg". There was no pain in the buttock, the mass was inactive when touched, there was no tenderness, and the left lower limb felt numb. Past physical health, no history of chronic diseases such as hypertension and diabetes. Physical examination: A mass about 10 cm ×8 cm in size can be palpable in the left hip, with positive tenderness and tenderness, and numbness in the left lower limb. MRI showed that there was a cystic space-occupying lesion between the gluteus maximus muscle and the quadratus femoris muscle in the left buttock (near the running area of the sciatic nerve), with a maximum diameter of 3.6 cm and a smooth edge, and a flocculate high signal was directly connected to the subcutaneous area through the gluteus muscle, and the surrounding fascial septum was thickened (Figures 1 and 2). After admission, the patient underwent arthroscopic exploration and clearance of left hip joint. Pathological biopsy showed that the tumor size was 4.5 cm ×2.6 cm, the surface envelope was intact, the section was cystic-solid, gray-white and gray-brown, and the texture was soft. Immunohistochemical staining showed tumor cells: CD34 (-), NF (-), S-100 (+ + +) and CD117 (-), and it was diagnosed as peripheral nerve schwannoma of left hip joint. Peripheral nerve schwannoma of the hip joint is a nerve tissue tumor and differentiates from Schwann cells. The clinical manifestation is a painless slowly growing soft tissue mass. Tapping the mass may exhibit a numbness and electric shock sensation. Usually surgical resection, generally speaking, the prognosis is good, but the envelope of schwannoma is a normal nerve sheath tissue, not a part of the tumor body, so the tumor should be completely removed in the envelope to reduce nerve damage and reduce the probability of surgical complications. This patient was diagnosed with peripheral nerve schwannoma of hip joint by combining MRI and surgical pathological biopsy.