Volume 104 · Issue 30 · 2024

Pregnancy-associated pulmonary embolism (PE) is a type of venous thromboembolism (VTE) that seriously threatens the lives of pregnant women and has gained more attention in clinical practice. Due to physiological and anatomical characteristics, the incidence of VTE during pregnancy and postpartum is significantly higher than that during non-pregnancy periods. Currently, guidelines widely acknowledge the exploration of appropriate risk assessment models to evaluate the risk of pregnancy-associated VTE and to take corresponding preventive measures from mechanical to medication methods according to different risk levels. For patients suspected of PE, initial assessments can be made based on whether they exhibit clinical manifestations of deep vein thrombosis, with options including vascular compression ultrasonography or chest X-ray examination. Confirmation relies on CT pulmonary angiography or V/Q imaging. For patients with shock, echocardiography can be quickly used for the diagnosis and differential diagnosis of PE. The management of pregnancy-associated pulmonary embolism PE depends on the patient′s hemodynamic status, with options including reperfusion therapy or anticoagulation therapy. Extracorporeal membrane oxygenation may also be beneficial in high risk patients. The overall evidence level for the prevention and management of pregnancy-associated PE is low, and further exploration in clinical practice is still needed to promote the safety of pregnant women.

Thyroid cancer is a malignant tumor originating from thyroid epithelial or parafollicular epithelial cells. It is also the most common malignant tumor in the head and neck. At present, the incidence of thyroid cancer ranks ninth among all common malignant tumors, and has become one of the top ten common malignant tumors. In recent years, with the release of various guidelines, the diagnosis and treatment of thyroid cancer around the world is gradually standardized. Meanwhile, China has also begun to implement quality control of diagnosis and treatment, standardize diagnosis and treatment behavior, and promote the standardization of diagnosis and treatment of thyroid tumors nationwide, in order to ultimately improve patient′s survival rate and quality of life. Based on the current changes in the diagnosis and treatment of thyroid cancer at home and abroad, the article discusses the epidemic situation, diagnosis and treatment status, new concept and progress of standardized diagnosis and treatment of thyroid cancer.

To discuss the efficacy and safety of the dual immunotherapy of nivolumab plus ipilimumab in patients with advanced non-small cell lung cancer (NSCLC) who are double negative for driver gene and programmed death-ligand 1 (PD-L1) expression.

We conducted a retrospective collection of clinical data for 61 patients with advanced NSCLC who were negative for both driver genes and PD-L1 and received dual immunotherapy with nivolumab plus ipilimumab at the First Affiliated Hospital of Guangzhou Medical University from January 2019 to June 2023. Based on treatment conditions, patients were divided into first-line and non-first-line dual immunotherapy groups. Patients were followed up monthly, with the follow-up period ending on October 1, 2023. The efficacy was evaluated using Solid Tumor Response Evaluation Criteria, and adverse reactions were assessed according to the Common Terminology Criteria for Adverse Events developed by the National Cancer Institute in the United States. Survival curves were plotted using the Kaplan-Meier method, and the log-rank test was used to compare the differences in progression-free survival (PFS) and overall survival (OS) between first-line and non-first-line dual immunotherapy patients. The influence factors of PFS were analyzed using a multivariate Cox proportional hazards regression model.

Among the 61 NSCLC patients, 49 were male (80.3%), with an age range of 23-88 years [(65.3±7.4) years]. There were 14 cases (23.0%) classified as stage ⅢC and 47 cases (77.0%) classified as stage Ⅳ according to TNM staging. Forty cases (65.6%) received non-first-line treatment. The objective response rate (ORR) was 24.6% (15/61), and the disease control rate (DCR) was 52.5% (32/61). All 61 patients were followed up, with a median follow-up time of 17.8 months. The median PFS was 6.0 months (95%CI: 5.5-6.4 months), and the median OS was 17.0 months (95%CI: 14.8-19.2 months). For patients receiving first-line dual immunotherapy, the median PFS was longer than for those receiving non-first-line dual immunotherapy [7.0 months (95%CI: 6.0-7.9 months) vs 4.0 months (95%CI: 3.3-4.6 months), P<0.001]; similarly, the median OS for patients receiving first-line dual immunotherapy was longer than for those receiving non-first-line dual immunotherapy [19.0 months (95%CI: 18.1-19.9 months) vs 13.0 months (95%CI: 10.8-15.1 months), P<0.001]. Multivariate Cox risk regression model analysis showed that distant tumor metastasis (HR=1.414, 95%CI: 1.253-1.725), non-first-line dual immunotherapy (HR=1.412, 95%CI: 1.184-1.652), and tumor mutation burden<10 mut/Mb (HR=1.328, 95%CI: 1.151-1.546) were risk factors for PFS, while non-squamous carcinoma (HR=0.917, 95%CI: 0.823-0.984) was a protective factor for PFS. Immune-related adverse reactions occurred in 41 cases (67.2%), including 21 cases (32.8%) of grade 3-4 adverse reactions. Eight cases (13.1%) discontinued treatment, and there were no deaths.

Dual immunotherapy with nivolumab plus ipilimumab can be a treatment option for driver gene and PD-L1 double-negative advanced NSCLC. Distant tumor metastasis, non-first-line dual immunotherapy, and tumor mutation burden<10 mut/Mb are risk factors affecting patients′ PFS, while non-squamous cell carcinoma is a protective factor affecting patients′ PFS.

To explore the association between obesity/overweight and the risk of malignancy in Hürthle cell neoplasms of the thyroid.

The data of patients with complete data who were diagnosed with Hürthle cell neoplasms of the thyroid at the Third Hospital of Peking University from September 2016 to September 2023 were retrospectively collected. Based on postoperative pathological diagnosis, tumors were classified into thyroid Hürthle cell adenoma group and Hürthle cell carcinoma group. Multivariate logistic regression analysis was employed to explore the association between overweight/obesity and the risk of malignancy in Hürthle cell neoplasms of the thyroid.

A total of 102 patients (13 males and 89 females) were included, aged (48.7±13.1) years. There were 22 cases of thyroid Hürthle cell carcinoma and 80 cases of thyroid Hürthle cell adenoma. Univariate analysis showed that the rate of overweight/obesity in the Hürthle cell carcinoma group was higher than that in the adenoma group [73% (16/22) vs 46% (37/80), P=0.050]. Multivariate logistic regression analysis indicated that the overweight/obese patients had a higher risk of malignancy in Hürthle cell neoplasms of the thyroid compared with the non-overweight/obese patients (OR=3.170, 95%CI: 1.126-9.955, P=0.035). Sensitivity analysis excluding individuals with multiple tumors was consistent with the main study results (OR=2.878, 95%CI: 0.922-10.228, P=0.080).

Overweight/obesity may be associated with a higher risk of malignancy in patients with Hürthle cell neoplasms of the thyroid.

To analyse the efficacy and safety of dupilumab in the treatment of moderate to severe atopic dermatitis (AD).

The clinical data of moderate to severe AD patients who received dupilumab therapy in the Department of Dermatology, Xiangya Hospital, Central South University from August 2020 to November 2022 were retrospectively analyzed. The efficacy was evaluated by Eczema Area and Severity Index (EASI), SCORing Atopic Dermatitis (SCORAD), Numerical Rating Scale (NRS), Patient Oriented Eczema Measure (POEM), and Dermatology Quality of Life Index (DLQI) before treatment and 2, 4, 16 and 24 weeks after treatment. Adverse events that occurred during treatment were recorded. Repeated Measures ANOVA and Generalized Estimating Equations were used to compare changes in scores and changes in laboratory indices at different time points before and after treatment.

The age of 259 patients was (35.4±25.9) years, the duration of AD was 4.00 (2.00, 9.00) years, and 64.1% (166 patients) were men patients. The scores of EASI, SCORAD, POEM, DLQI and NRS at 2, 4, 16 and 24 weeks after treatment with dupilumab were significantly lower than those before treatment (all P<0.001). The proportions of EASI50, EASI75, and EASI90 were 91.0% (101/111), 71.2% (79/111), and 40.5% (45/111) at 16 weeks, and 95.0% (76/80), 80.0% (64/80) and 45.0% (36/80) at 24 weeks, respectively. Basal total IgE levels (P=0.005) and EOS counts (P<0.001) at Week 24 were significantly lower than those before treatment. Adverse events occurred in 54 patients (20.9%), mainly manifested as intractable erythema of the face and neck (5.0%, 13 patients) and conjunctivitis (1.9%, 5 patients).

Dupilumab can effectively improve the rash area, rash severity and itchiness of moderate to severe atopic dermatitis, improve the quality of life of patients, and reduce the incidence of adverse effects.

To investigate the effect of increased cardiac output induced by dobutamine on cerebral blood flow (CBF) in healthy volunteers using magnetic resonance 3D-pseudo-continuous arterial spin labeling technology.

A prospective study was conducted on 48 healthy volunteers recruited by handy sampling from June 2021 to January 2022. Physiological parameters before (at rest state) and after (under stress state) dobutamine-induced increase in cardiac output were analyzed. Quantitative CBF maps were generated by using arterial spin labeling difference imaging and proton density weighted reference image processing, and CBF changes under the rest and stress states were compared. Multivariable logistic regression model was used to analyze factors associated with reduced CBF.

A total of 48 subjects were included, with an age [M (Q₁, Q₃)] of 25.0 (24.0, 28.0) years, including 43 men and 5 women. Compared with the rest state, the CBF in the anterior cerebral artery [(36.2±6.9) vs (34.5±6.5) ml·(100 g)^-1·min^-1, P=0.006] and the middle cerebral artery perfusion area [(35.8±6.5) vs (34.1±6.4) ml·(100 g)^-1·min^-1, P=0.006] decreased under the stress state, however there was no statistically significant change in CBF in the posterior cerebral artery and the vertebral-basilar artery perfusion area (all P>0.05). Logistic regression analysis showed that the decrease in CBF in the anterior cerebral artery and middle cerebral artery supply regions during the stress state were correlated with an increase in diastolic blood pressure [OR (95%CI): 0.887 (0.796-0.989) and 0.895 (0.805-0.994), both P<0.05].

Dobutamine-induced increase in cardiac output leads to a decrease in CBF in anterior cerebral circulation but has no effect on posterior circulation. The increase in diastolic blood pressure is associated with decreased CBF under the stress state. Changes in CBF should be considered in the context of increased cardiac output.

To investigate the clinical efficacy of letrozole combined with gonadotropin-releasing hormone antagonists (GnRH-ant) in patients at high risk of ovarian hyperstimulation syndrome (OHSS) who underwent total embryo freezing after oocyte retrieval.

A retrospective analysis was conducted on 348 female patients who underwent in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) at the Reproductive and Genetic Hospital of the First Affiliated Hospital of Zhengzhou University between January and July 2023. Due to their high risk of OHSS, these patients canceled fresh embryo transfer and opted for total embryo freezing. Based on patients′ preferences, those who received GnRH-ant and letrozole after oocyte retrieval were categorized as the intervention group (164 cases), while those who did not receive these medications were categorized as the control group (184 cases). The first luteal phase after oocyte retrieval, OHSS grading, ovarian volume, and estradiol (E₂) levels were evaluated in both groups. A multivariate logistic regression model was used to analyze factors related to moderate-to-severe OHSS among patients at high risk of OHSS who underwent total embryo freezing after oocyte retrieval.

The age of the intervention and control groups was (29.3±3.8) and (29.4±4.1) years, respectively (P=0.821). The duration of the first luteal phase post-oocyte retrieval was shorter in the intervention group [(7.16±1.39) days] compared to that in the control group [(13.88±2.11) days] (P<0.001). The incidences of mild, moderate, and severe OHSS in the intervention group were 75.0% (123 cases), 23.8% (39 cases), and 1.2% (2 cases), respectively, whereas in the control group they were 12.5% (23 cases), 60.9% (112 cases), and 26.6% (49 cases) (P<0.001). E₂ levels on the 2nd and 6th days after oocyte retrieval [M(Q₁,Q₃)] in the intervention group were 1 520.0 (1 213.8, 1 884.8) and 108.5 (45.6, 218.0) ng/L, respectively, which were statistically significantly lower than those in the control group [1 666.0 (508.8, 1 702.0) ng/L] and [1 761.0 (826.0, 2 546.5) ng/L] (P<0.001). The abdominal cavity effusion in the intervention group [M(Q₁,Q₃)] were 19.5 (0, 30) and 0 mm, statistically significantly less than those in the control group [46.0 (0, 61.0) mm] and [54.5 (0, 69.5) mm] (P<0.001). On the 6th day after oocyte retrieval, the bilateral ovarian volumes in the intervention group were smaller than those in the control group (P<0.001). Multivariate logistic regression analysis indicated that no combined treatment with letrozole and GnRH-ant was a risk factor of moderate to severe OHSS. The risk of developing moderate to severe OHSS in the control group was 35.312 times higher than that in the intervention group (OR=35.312, 95%CI: 17.488-71.300).

The administration of letrozole combined with GnRH-ant post-oocyte retrieval in patients at high risk of OHSS can prevent the occurrence of moderate-to-severe OHSS, shorten the first luteal phase, accelerate the reduction of serum E₂ levels, and promote the recovery of ovarian volume and absorption of abdominal fluid.

To investigate the value of serum dehydroepiandrosterone sulfate (DHEAS) in the differential diagnosis of primary bilateral macronodular adrenal hyperplasia (PBMAH) from nonfunctional adenoma tumors (NFA), adrenocortical adenoma (ADA) and Cushing′s disease (CD).

A cross-sectional study. The clinical data of 302 patients with PBMAH, NFA, ADA and CD diagnosed and treated in the First Medical Center of PLA General Hospital from January 2010 to June 2021 were retrospectively analyzed. Among them, 97 were males and 205 were females, aged (45.7±7.2) years. The area under receiver operating characteristic (ROC) curve was used to evaluate the DHEAS ratio (serum DHEAS value divided by the lower limit of normal reference range for the corresponding age and sex) and the 8∶00 adrenocorticotropic hormone (ACTH) level in the differential diagnosis of PBMAH from NFA, ADA and CD. The maximum value of Youden index was cut-off value.

Among the 302 patients, 33 were in PBMAH group, 125 were in NFA group, 67 were in ADA group, and 77 were in CD group. The DHEAS ratio in CD group, NFA group, PBMAH group and ADA group decreased successively, with values of 6.34(4.44, 9.93), 3.37(2.24, 4.79), 1.14(1.04, 2.40) and 0.58(0.27, 1.05), respectively. There was statistical significance among all groups (all P<0.01). The area under the ROC curve for distinguishing PBMAH from NFA, ADA and CD were 0.803, 0.741 and 0.930, and the cut-off value were 2.59, 0.99 and 2.92, respectively. The sensitivity was 66.1%, 64.2% and 87.9%, respectively. The specificity was 81.8%, 81.2% and 85.7%. According to the level of 8∶00 ACTH, PBMAH was divided into ACTH-inhibited group (ACTH<2.2 pmol/L,n=18) and ACTH-non-inhibited group (ACTH≥2.2 pmol/L, n=15).The DHEAS ratio in ACTH-non-inhibited PBMAH group was higher than that in ACTH-inhibited PBMAH group(P<0.01).The area under ROC curve of DHEAS ratio for identifying ACTH-non-inhibited PBMAH and CD was 0.877, the cut-off value was 4.55, the sensitivity was 93.3%, and the specificity was 75.3%. If the DHEAS ratio combined with 8∶00 ACTH was used as a differential diagnostic indicator, the area under the ROC curve for distinguishing ACTH-non-inhibitory PBMAH from CD can reach 0.967, with the sensitivity of 100.0% and the specificity of 81.8%.

DHEAS ratios is different in PBMAH, NFA, ADA and CD patients, which can assist in the differential diagnosis of PBMAH from NFA、ADA and CD patients, especially in the differential diagnosis of ACTH-non-inhibited PBMAH patients and CD patients.

This paper reports a patient with rheumatic heart disease who underwent triple valve repair and simultaneous coronary artery bypass grafting and radiofrequency ablation. The 55-year-old male patient was admitted to the hospital due to "chest tightness and shortness of breath after activity for more than 10 days". After admission, the results of relevant examinations showed that rheumatic heart disease combined with valve damage (involving 3 valves), atrial fibrillation, and 70% of the most severe stenosis of the circumflex artery. On December 19, 2023, he underwent three-valve repair and simultaneous coronary artery bypass grafting and atrial fibrillation radiofrequency ablation under general anesthesia and hypothermic cardiopulmonary bypass. After operation, he was transferred to the intensive care unit of cardiac surgery and the general ward on the second day after operation. He was successfully discharged 9 days after operation, and continued oral warfarin anticoagulation treatment for half a year after discharge. Cardiac color ultrasound examination half a year after operation showed mild regurgitation of the aortic valve, and no obvious abnormalities were found in the remaining valves.

This paper reports a patient with combined thoracic and abdominal injury caused by sharp instruments and rupture of the inferior vena cava in the pericardium, who was treated by the author during the aid period in Africa. Two days later, he had intermittent fever due to malaria infection, and showed shock on the way to the doctor. After admission, he recovered after comprehensive treatment such as anti-shock, anti-malaria and surgery. To summarize the diagnosis and treatment of patients, and explore the treatment experience of similar trauma under simple medical conditions for clinical reference.

Statins are the most widely used lipid-lowering drugs in clinic at present, and can inhibit the occurrence and development of many kinds of malignant tumors including breast cancer. However, there are many kinds of statins and their curative effects on cancer are different. This paper summarizes the research of atorvastatin, a fat-soluble statin, in the field of breast cancer in recent years. At present, it is found that atorvastatin can inhibit the proliferation and migration of breast cancer, increase the sensitivity of breast cancer to radiotherapy and chemotherapy, reduce the adverse reactions caused by radiotherapy and chemotherapy, and can also prevent and monitor the occurrence of breast cancer. Therefore, deepening the understanding of this drug will be beneficial to people to better apply this drug, which has important clinical significance for the treatment of breast cancer.

Calcium plays an important role in nerve conduction, muscle contraction and bone mineralization. The etiology of hypocalcemia is diverse, and it can be divided into two categories: parathyroid hormone-mediated and non-parathyroid hormone-mediated. The clinical manifestations of this disease involve all systems throughout the body, and severe hypocalcemia can be life-threatening, requiring timely identification, rapid evaluation and urgent management. This article introduces the etiology, clinical manifestations of hypocalcemia and the emergency treatment of severe hypocalcemia.

The surgical technique of endovascular treatment of aorta has been accompanied by the development of endovascular grafts, which makes it possible for endovascular treatment to overcome diseases with more complex anatomical structures, and at the same time improves the effect and prognosis of endovascular treatment. However, the existing endovascular aortic grafts at home and abroad still have some problems such as simple design structure and limited material range. Therefore, advanced endovascular graft materials and designs have become an important research direction in the development of vascular surgery nowadays. The emergence of various new stents brings infinite possibilities to the future of endovascular graft. This article makes a comprehensive evaluation of the existing endovascular aortic grafts, focusing on the manufacturing materials and design of metal skeleton and covering, as well as the special design of thoracic aorta, abdominal aorta and branch artery stents. The future development direction of endovascular aortic grafts is prospected and summarized as follows.

The globally accumulated formaldehyde-fixed paraffin-embedded (FFPE) sample bank provides a huge resource base for biomedical research. With the rapid development of sequencing technology, the application of FFPE samples in whole genomics, transcriptomics, proteomics, epigenetics, metabolomics and other omics studies continues to expand, providing a new perspective for the in-depth analysis of disease mechanisms. However, formaldehyde induces cross-linking of biological macromolecules such as nucleic acids and proteins in cells during tissue fixation, which brings challenges to sequencing and analysis. This article reviews the application progress and challenges of FFPE samples in multiomics studies, providing references for future biomedical research.

Esophageal squamous cell carcinoma is one of the most common malignant tumors in China. At initial diagnosis, most of them are unresectable locally advanced esophageal squamous cell carcinoma (LAESCC) with poor prognosis. Concurrent chemoradiotherapy is a standard radical treatment, among which the optimal dose of radiotherapy is still controversial. The clinical target area is more inclined to selective lymph node irradiation. Photon radiotherapy, which is mainly based on intensity modulated radiotherapy, is mostly used in clinical practice, but the potential value of particle radiotherapy should also be actively explored. Different combinations of platinum, paclitaxel and fluorouracil in chemotherapy have achieved good efficacy in the treatment of unresectable LAESCC, but the adverse reactions are different, which should be selected according to the patient's situation. In molecular targeted therapy, the combination of epidermal growth factor receptor inhibitor and vascular endothelial factor receptor inhibitor with concurrent chemoradiotherapy can prolong the survival of patients, and the incidence of adverse reactions is low, which provides a new strategy for the treatment of esophageal cancer. At the same time, the combined efficacy of radiotherapy, chemotherapy and immunotherapy is remarkable, and more and more scholars have carried out related research. New techniques, new concepts and multidisciplinary comprehensive treatment should be the key to the treatment of unresectable LAESCC.

Cervical cancer is one of the most common malignancies in women. Many clinical parameters are used for prognostic prediction in cervical cancer patients, but there are limitations in predictive accuracy, so there is a need to develop a non-invasive detection technique to provide more specific tumor characteristics before or during treatment initiation, enabling clinicians to implement more personalized treatments. Radiomics is a mathematical statistical method to extract information from medical images. It has the potential to predict the stage, histological type, lymph node status, treatment effect, survival and recurrence of cervical cancer patients, and can also enable the assessment of cervical cancer biomarkers and immune microenvironment. This article reviews the latest research progress in the application of radiomics in the diagnosis and prognosis of cervical cancer, and discusses the limitations and challenges of radiomics in current clinical application.

The patient, a 55-year-old female, went to Weifang Second People's Hospital for "chest tightness and right chest pain for 5 days". Physical examination showed that the right lower lung was percussed with turbidity and the right lung was breathing with low sound. Enhanced chest CT showed that the right pleura occupied space, about 88 mm ×90 mm in size, with uneven density, and low-density shadows (Figure 1). Enhanced scan showed obvious enhancement, low-density without enhancement, compression of surrounding tissue, right pleural effusion, incomplete dilation of the right lung (Figure 2), and bone destruction adjacent to the right sixth rib. Color ultrasound showed right pleural effusion of 3.5 cm. Pleural effusion biochemistry suggests exudate. Pathology of pleural tumor biopsy showed that tumor cells were diffusely distributed and abundant in tumor tissue, with spindle-shaped tumor cells, irregular nucleus, deep staining, occasional nuclear division, and not obvious necrosis; Immunohistochemistry: Calcium binding protein antibody (-), WT-1 (-), vimentin (+), desmin (-), insulin-like growth factor II mRNA binding protein 3 (-), signal transduction and transcription activator 6 (+), CD34 (+), B lymphoblastoma-2 gene (+), Ki-67 5%, S-100 (-), diagnosis: consistent with undetermined malignant potential or low-grade malignant spindle cell tumor-solitary fibrous tumor. Clinical diagnosis of solitary fibrous tumor of the pleura (SFTP). SFTP is a tumor originating from dendritic stromal cells in pleural submesothelial tissue. Most of them are benign or borderline, and 10% ~20% are malignant. Common clinical symptoms include cough, chest pain, dyspnea, fever, weight loss, etc. The chest CT findings have certain characteristics. The lesions are mostly single, mostly enveloped, and the boundaries are clear. The malignant signs are unclear boundaries, partial necrosis, and invasion of adjacent tissues. The density of smaller lesions is more uniform, and the mucocystic changes can be seen in larger lesions. The enhanced scan shows "map-like" enhancement, intratumoral staphyloid vessels and peritumoral vascular pedicles.