[Emphasizing the homogenization of mastoscopy]

As a major development in breast surgery, mastoscopy has been proven safe and been involved in almost all breast surgery operative procedures. Its extensive development has cultivated a group of positively young and middle-aged academic backbones, at the same time nurtured high-level breast subject leaders, providing innovative ideas and useful reference for the high-quality development of breast specialty. However, due to the relatively weak breast specialty, uneven technical treatment ideas, insufficient promotion of endoscopic technology, unique learning curve, and inhomogeneous technical aspects, the development of mastoscopy technology is uneven and the level of homogenization is low. It should be started from four aspects, including strategic focus, treatment idea, endoscopic technical training, and mastoscopic operation. Multiple measures should be taken to comprehensively improve the homogenization of mastoscopic level.

[Participation rate and detection of colorectal neoplasms based on multi-round fecal immunochemical testing for colorectal cancer screening in the Chinese population]

Objective: To evaluate the participation rate and detection of colorectal neoplasms based on annual fecal immunochemical testing (FIT) for three consecutive years in a population-based colorectal cancer screening program in China. Methods: Based on a population-based colorectal cancer screening program conducted from May 2018 to May 2021 in 6 centers in China, 7 793 eligible participants aged 50-74 were included and offered free FIT and colonoscopy (for those who were FIT-positive on initial screening). At baseline, all participants were invited to receive FIT. In subsequent screening rounds, only FIT-positive participants who did not undergo colonoscopy or FIT-negative participants were invited to have repeated FIT screening. FIT-positive participants were recommended to undertake colonoscopy and pathological examination (if abnormalities were found during colonoscopy). An overall of three rounds of annual FIT screening were conducted. The primary outcomes of the study were the participation rate of FIT screening, the compliance rate of colonoscopy for FIT-positive participants, and the detection rate of colorectal neoplasms. Results: Among the 7 793 participants included in this study, 3 310 (42.5%) were male, with age of (60.50±6.49) years. The overall participation rates for the first, second and third round of FIT screening were 94.0%(7 327/7 793), 86.8% (6 048/6 968) and 91.3% (6 113/6 693), respectively. Overall, 7 742 out of 7 793 participants (99.3%) attended at least one round of screening, and 5 163 out of 7 793 participants (66.3%) attended all three rounds of screening. The positivity rate was significantly higher in the first (14.6%, 1 071/7 327) round compared with the second (5.6%, 3 41/6 048) and third (5.5%, 3 39/6 113) screening rounds (P<0.001). The overall compliance rates of colonoscopy examination among FIT-positive subjects were over 70% in three rounds, which were 76.3% (817/1 071), 75.7% (258/341) and 71.7% (243/339), respectively. In a multivariate logistic regression model considering factors including sex, education background, smoking, alcohol drinking, previous colonoscopy examination, colonic polyp history and family history of colorectal cancer among first-degree relatives, gender and smoking status were related factors affecting the participation rate of FIT screening, with higher rate in males and non-smokers. In addition, logistic regression analysis also found that age was negatively correlated with the compliance rate of colonoscopy in FIT positive patients. The detection rate of advanced tumors (colorectal cancer + advanced adenoma) declined from the first round to subsequent rounds [1st round: 1.15% (90/7 793); 2nd round: 0.57% (40/6 968); and 3rd round: 0.58% (39/6 693)], however, the positive predictive value for advanced neoplasms increased round by round, and was 11.02% in the first screening round, 15.50% in the second screening round, and 16.05 % in the third screening round. In each screening round, the detection rate for advanced neoplasms was higher in men than that in women, and increased with age. Conclusions: Annual repeated FIT screening has high acceptance and satisfying detection rates in the Chinese population. To optimize and improve the effectiveness of colorectal cancer screening, multi-round repeated FIT screening should be implemented while ensuring high participation rates.

[Value of fecal immunochemical test in colorectal cancer screening]

Screening and early diagnosis and treatment have been proven effective in reducing the incidence and mortality of colorectal cancer. Colonoscopy combined with pathological examination is the gold standard for colorectal cancer screening. However, due to the invasiveness, high cost and the need for professional endoscopists of colonoscopy, it is not feasible to directly use this method for mass population screening. Fecal immunochemical test (FIT) is one of the screening techniques recommended by authoritative international guidelines for colorectal cancer screening, and has been widely used in population-based colorectal cancer screening programs in countries around the world. This paper elaborates on the value of FIT in colorectal cancer screening from different aspects, such as the technical principles, the screening efficiency, the screening strategies, and the population effects and benefits. Additionally, it describes the current situation of colorectal cancer screening in China and summarizes the challenges faced in colorectal cancer screening in order to optimize the FIT-based colorectal cancer screening strategies in the population and provide theoretical reference for effective colorectal cancer screening.

[Research on applying genetic and environmental risk score in risk-adapted colorectal cancer screening]

Objective: To evaluate the effectiveness of a risk-adapted colorectal cancer screening strategy constructed utilizing genetic and environmental risk score (ERS). Methods: A polygenic risk score (PRS) was constructed based on 20 previously published single nucleotide polymorphisms for colorectal cancer in East Asian populations, using 2 160 samples with MassARRAY test results from a multicenter randomized controlled trial of colorectal cancer screening in China. The ERS was calculated using the Asia-Pacific Colorectal Screening Score system. Logistic regression was used to analyze the association between PRS alone and PRS combined with ERS and colorectal neoplasms risk, respectively. We also designed a risk-adapted screening strategy based on PRS and ERS (high-risk participants undergo a single colonoscopy, low-risk participants undergo an annual fecal immunochemical test, and those with positive results undergo further diagnostic colonoscopy) and compared its effectiveness with the all-acceptance colonoscopy strategy. Results: The high PRS group had a 26% increased risk of colorectal neoplasms compared with the low PRS group (OR=1.26, 95%CI: 1.03-1.54, P=0.026). Participants with the highest PRS and ERS were 3.03 times more likely to develop advanced colorectal neoplasms than those with the lowest score (95%CI: 1.87-4.90, P<0.001). As the risk-adapted screening simulation reached the third round, the detection rate of the PRS combined with ERS strategy was not statistically different from the all-acceptance colonoscopy strategy (8.79% vs. 10.46%, P=0.075) and had a higher positive predictive value (14.11% vs. 10.46%, P<0.001) and lower number of colonoscopies per advanced neoplasms detected (7.1 vs. 9.6, P<0.001). Conclusion: The risk-adapted screening strategy combining PRS and ERS helps achieve population risk stratification and better effectiveness than the traditional colonoscopy-based screening strategy.

[Therapeutic efficacy of hematopoietic stem cell transplantation for Wiskott-Aldrich syndrome in 60 children]

Objective: To evaluate the therapeutic efficacy of hematopoietic stem cell transplantation (HSCT) for Wiskott-Aldrich syndrome (WAS), and to analyze the factors related to the outcomes. Methods: The clinical data of 60 children with WAS received HSCT in Shanghai Children's Medical Center from January 2006 to December 2020 were retrospectively analyzed. All cases were treated with a myeloablative conditioning regimen with busulfan and cyclophosphamide, and a graft-versus-host disease (GVHD) prevention regimen based on cyclosporine and methotrexate. Implantation, GVHD, transplant-related complications, immune reconstitution and survival rate were observed. Survival analysis was performed by Kaplan-Meier method, and Log-Rank method was used for univariate comparison. Results: The 60 male patients had main clinical features as infection and bleeding. The age at diagnosis was 0.4 (0.3, 0.8) years, and the age at transplantation was 1.1 (0.6, 2.1) years. There were 20 cases of human leukocyte antigen matched transplantation and 40 mismatched transplantation; 35 patients received peripheral blood HSCT, and 25 cord blood HSCT. All cases were fully implanted. The incidence of acute GVHD (aGVHD) was 48% (29/60) and only 2 (7%) developed aGVHD of grade Ⅲ; the incidence of chronic GVHD (cGVHD) was 23% (13/56), and all cases were limited. The incidence of CMV and EBV infection was 35% (21/60) and 33% (20/60) respectively; and 7 patients developed CMV retinitis. The incidence of sinus obstruction syndrome was 8% (5/60), of whom 2 patients died. There were 7 cases (12%) of autoimmune hemocytopenia after transplantation. Natural killer cells were the earliest to recover after transplantation, and B cells and CD4⁺T cells returned to normal at about 180 days post HSCT. The 5-year overall survival rate (OS) of this group was 93% (95%CI 86%-99%), and the event free survial rate (EFS) was 87% (95%CI 78%-95%). EFS of non-CMV reactivation group is higher than that of CMV reactivation group (95% (37/39) vs.71% (15/21), χ²=5.22, P=0.022). Conclusions: The therapeutic efficacy of HSCT for WAS is satisfying, and the early application of HSCT in typical cases can achieve better outcome. CMV infection is the main factor affecting disease-free survival rate, which can be improved by strengthening the management of complications.

[Clinical analysis of 60 children with anaplastic large cell lymphoma in a single center]

Objective: To summarize the clinical features, treatment outcome and prognostic factors of childhood anaplastic large cell lymphoma (ALCL). Methods: Clinical data of 60 newly diagnosed and biopsy-proven ALCL pediatric patients (≤18 years of age) at Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine from January 2010 to December 2018 were collected. All patients were treated with the Chinese Children Cancer Group-B cell-non-Hodgkin Lymphoma 2010 (CCCG-BNHL-2010) regimen. Overall survival (OS), event free survival (EFS) and progression free survival (PFS) rates were calculated by the Kaplan-Meier method. Univariate analysis was performed with Log-Rank test to find factors of poor prognosis. Results: Among 60 ALCL patients included in the current study, 39 were males and 21 females, the age of onset was 7.9 (1.2-16.7) years. Among all cases, 43 (72%) had B syndrome (any of the following: fever, drenching, weight loss). Forty-nine (82%) cases had lactate dehydrogenase (LDH) levels<2 times upper limit of normal (ULN) and 11 (18%) cases had LDH levels 2-<4 times ULN. The distribution of stages was stage Ⅰ,Ⅱ,Ⅲ, and Ⅳ in 2% (1/60), 5% (3/60), 92% (55/60), and 2% (1/60) of patients, respectively. Of 58 cases who had results of anaplastic lymphoma kinase (ALK) immunohistochemical staining, 53 (91%, 53/58) cases were positive. Visceral involvement was observed in 12 patients (20%). The 4-year OS and EFS rates were (88±4)% and (76±6)% for the entire group, respectively. Univariate analysis for gender, B symptoms, LDH level, ALK expression, clinical stage and visceral involvement showed that only LDH level correlated with an inferior OS rate (χ²=6.571, P=0.010) while not correlated with EFS rate. No independent risk factor for disease progression or recurrence was found by Logistic regression. Up to the last follow-up, 44 cases were continuously at complete remission state, and their follow-up time was 50 (13-119) months. Of 13 (23%) cases experienced disease progression or relapse, 3 cases abandoned treatment, 2 cases progressed to death, 8 cases received second line or salvage treatment (6 survived at last follow-up). For post progression or relapse cases, the 2-year OS and PFS rates were (60±16)% and (16±14)%, respectively. The treatment related death occurred in 3 cases (5%) and all of them were due to severe infection during the chemotherapy. Conclusions: The efficacy of CCCG-BNHL-2010 regimen in the treatment of children with ALCL was good. However, the safety needs to be improved as the treatment-related mortality in the present study was slightly higher. Efficient second line or salvage treatment can achieve cure in pediatric patients post progression or recurrence. LDH ≥2 times ULN was associated with worse prognosis.

[Efficacy and safety of hepatitis B re-vaccination in children after completion of chemotherapy and(or) hematopoietic stem cell transplantation]

Objective: To assess the anti-hepatitis B surface antibody (HBsAb) titers in children after completion of chemotherapy and (or) hematopoietic stem cell transplantation (HSCT), evaluate the efficacy and safety of the current hepatitis B re-vaccination schedule. Methods: A total of 239 children who completed their chemotherapy and (or) HSCT and visited the vaccination clinic of Shanghai Children's Medical Center from March 2017 to July 2019 were enrolled in this study. According to the previous diseases, patients were divided into leukemia group (85 cases), lymphoma group (30 cases), solid tumor group (49 cases) and non-malignant hematological disease group (75 cases). According to the treatment of previous diseases, the patients were divided into chemotherapy group (126 cases), HSCT group (89 cases) and chemotherapy plus HSCT group (24 cases). HBsAb titers were assessed both at the time of diagnosis and after completion of treatment and some children who were HBsAb seronegative were re-vaccinated with 3 doses of hepatitis B vaccine, the vaccine-related adverse reactions were monitored. HBsAb titers were measured again one month after the completion of inoculation. HBsAb titers were defined as negative at levels <10 U/L and positive at ≥ 10 U/L. Chi-square test or Fisher exact test was used to compare the difference of negative conversion rate of hepatitis B antibody between groups, and Logistic regression was used to explore the risk factors of hepatitis B antibody negative conversion. Results: Among 239 patients, there were 143 males and 96 females. At the time of diagnosis, 179 patients (74.9%) were HBsAb seropositive and 60 patients (25.1%) were HBsAb seronegative. After completion of chemotherapy and (or) HSCT, 133 of 179 children with HBsAb seropositive (74.3%) at diagnosis became HBsAb seronegative. Univariate analysis showed significant differences at the negative conversion rates of HBsAb between different disease groups (χ²=10.211，P=0.015), different treatments groups (χ²=14.899，P<0.01) and different HBsAb titers groups before treatment (χ²=32.117，P<0.01). Logistic regression showed that HSCT (chemotherapy group as the reference, odds ratio (OR）=2.999, 95% confidence interval (CI) 1.276-7.050，P=0.012) and HBsAb titers<328.2 U/L before treatment (HBsAb titers≥328.2 U/L group as the reference, OR=6.397， 95% CI3.159-12.954，P<0.01) were risk factors for negative conversion of HBsAb. Among 48 patients whose HBsAb was seronegative after completion of chemotherapy and (or) HSCT and re-vaccinated with hepatitis B vaccine, 47 (97.9%) cases became HBsAb seropositivie. No serious adverse effects or complications were reported among these patients. Conclusions: After completion of chemotherapy and (or) HSCT, most children completely lose their protective humoral immunity against hepatitis B. Hepatitis B re-vaccination schedule can be efficiently and safely applied in those patients.

[Oncologic outcomes of early stage cervical cancer performed operation by different laparoscopic surgical procedures: analysis of clinical data from mutiple centers]

Objective: To evaluate the oncologic outcomes of different laparoscopic radical hysterectomy. Methods: From January 2011 to December 2014, the laparoscopic operation cases of cervical cancer at stage Ⅰb1, Ⅰb2, Ⅱa1 and Ⅱa2, including the histologic subtypes of squamous-cell carcinoma, adenocarcinoma and adenosquamous carcinoma, were collected in five clinical centers. The data were divided into two groups according to the surgical procedures, that is, modified laparoscopic-vaginal radical hysterectomy (mLVRH) and total laparoscopic radical hysterectomy (TLRH). The overall survival rate (OS), disease-free survival rate (DFS) at 5 years were retrospectively analyzed in this study. Results: There were 674 cases in total, including 377 cases of mLVRH, 297 cases of TLRH. (1) The OS at 5 years: the mLVRH was 96.1% and the TLRH was 92.0%, and the mLVRH was higher than that of TLRH （P=0.010）. Stratify analysis， including stage of disease （Ⅰb1 and Ⅱa1）， histologic subtypes （squamous-cell carcinoma, adenocarcinoma）， lymph node metastasis， revealed that, ① Stage of disease: in stage Ⅰb1, the OS at five years of mLVRH was higher than that in TLRH group （98.6% vs 93.6%, P=0.012）. In stage Ⅱa1, there was significant difference between the two groups, the OS at five years of mLVRH and TLRH were 93.6% and 77.6% （P=0.007）. ② Histologic subtypes: for the OS at five years of squamous-cell carcinoma, mLVRH and TLRH were 96.1% and 92.3%, and there was significant difference （P=0.046）； for adenocarcinoma, the OS at five years were 91.0% and 88.6%， and there was no difference between two groups （P=0.230）. ③ Lymph node metastasis： the mLVRH and TLRH with lymph node metastasis, the OS at five years were 98.6% and 96.4%; the mLVRH and TLRH without lymph node metastasis, the OS at five years were 89.3% and 80.8%. There were no significant differences between the two groups,respectively (P=0.156， P=0.093）. (2) The DFS at 5 years: there was no significant difference between mLVRH and TLRH (94.1% vs 90.9%, P=0.220). Stratify analysis for stage of disease, the mLVRH group was higher than that in the TLRH group in stage Ⅰb1 (97.0% vs 92.8%, P=0.039). However, for stage Ⅱa1, there was no significant difference between mLVRH and TLRH group （88.2% vs 75.8%, P=0.074）. Conclusions: The results of this retrospective study indicated that different laparoscopy surgical procedures had diverse oncologic outcomes. The OS at 5 years of the mLVRH is superior to the TLRH. The DFS at 5 years in Ⅰb1 stage, the mLVRH is higher than the TLRH. Therefore, the modified laparoscopy is still an alternative surgery for early cervical cancer patients when following the principle of no-tumor-exposure.

[Epidemiological analysis on bud-events of Norovirus-associated infectious diarrhea in Shanghai, 2018]

Objective: To analyze the epidemiological characteristics related to Norovirus-associated infectious diarrhea bud events in Shanghai, and to discuss the value of bud events surveillance, so as to help Norovirus-associated infectious diarrhea control, prevention and to improve the surveillance system on bud events. Methods: Data related to 142 Norovirus-associated infectious diarrhea bud events were gathered from 16 districts of Shanghai areas in 2018 and were analyzed. Results: There were 2 peaks, April and November for 142 Norovirus-associated infectious diarrhea bud events reported in 2018. 98.59% (140/142) of the bud events occurred in schools and kindergartens. 80.28% (114/142) of the bud events would involve 6-19 cases per each event. The median time duration between the onset date of the first case and the reporting date of the event was 2 days and the median event duration was 7 days. The bud event scale and regional incidence of bud events as well as the reporting timelines were influential factors on the duration of the bud events. Conclusions: Two peaks, spring and winter bud events of the Norovirus-associated infectious diarrhea were seen in Shanghai in 2018. Schools and kindergartens were to be prioritized locations for control and prevention of Norovirus-associated infectious diarrhea bud events. Surveillance system was proved to have contributed to the early detection, reporting and control of bud events.

[Alternative donor HSCT for 109 children with acquired severe aplastic anemia: a single center retrospective analysis]

目的

了解替代供者（AD）移植一线治疗儿童再生障碍性贫血（AA）的疗效及安全性。

方法

回顾性分析2010年4月1日至2016年12月31日在上海儿童医学中心一线接受AD移植治疗的AA患儿临床资料，统计分析总生存（OS）率、植入成功率、移植物抗宿主病（GVHD）发生率等指标。

结果

共纳入109例患者，极重型AA（VSAA）32例，重型AA（SAA）64例，非重型AA（NSAA）伴输血依赖13例，中位年龄6（0.8~18）岁，其中44例患者接受全相合无关供者（MUD）移植，44例接受8–9/10位点不全相合无关供者（MMUD）移植，21例接受不全相合亲缘供者（MMRD）移植，所有患者均接受以外周血干细胞（PBSC）为主的移植，≥3个位点不合的单倍型移植加第三方脐血（UCB）一份。所有患者移植前均未接受过抗胸腺细胞球蛋白（ATG）治疗，并排除活动性感染。106例（97.2%）获造血重建，中性粒细胞中位重建时间为13（9~19）d，血小板中位重建时间为16（10~81）d。死亡13例，5年OS率为88.1%（95%CI 81.1%~91.4%），MUD、MMUD及MMRD三组患者OS率差异无统计学意义（P=0.361）。总体急性GVHD（aGVHD）及Ⅱ~Ⅳ度aGVHD发生率分别为74.3%和39.4%，总体慢性GVHD（cGVHD）和中度cGVHD发生率分别为30.7%和9.9%，无一例患者发生重度cGVHD。

结论

对于无同胞全相合供者的SAA/VSAA患儿，早期一线接受AD移植可能是一个选择，但需要进一步探索更有效的预防及治疗GVHD的措施。

[General plan of Shanghai Diet and Health Survey]

Shanghai Diet and Health Survey (SDHS) was designed to prospectively access local residents' food consumption, energy and nutrient intake, related chemical contaminant exposure, and the seasonal change trend to explore the relationship of diet with health. Data from SDHS can be used as fundamental information and scientific evidences for the development of local nutrition and food safety policies.

Changes in flowering functional group affect responses of community phenological sequences to temperature change

Our ability to predict how temperature modifies phenology at the community scale is limited by our lack of understanding of responses by functional groups of flowering plants. These responses differ among species with different life histories. We performed a reciprocal transplant experiment along four elevation gradients (e.g., 3,200, 3,400, 3,600 and 3,800 m) to investigate the effects of warming (transferred downward) and cooling (transferred upward) on plant flowering functional groups (FFGs) and community phenological sequences (i.e., seven phenological events). Warming significantly decreased early-spring-flowering (ESF) plant coverage and increased mid-summer-flowering plant (MSF) coverage, while cooling had the opposite effect. All community phenological events were advanced by warming and delayed by cooling except for the date of complete leaf-coloring, which showed the opposite response. Warming and cooling could cause greater advance or delay in early-season phenological events of the community through increased coverage of MSF species, and warming could delay late-season phenological events of the community by increased coverage of ESF species. These results suggested that coverage change of FFGs in the community induced by temperature change could mediate the responses of the community phenological events to temperature change in the future. The response of phenological events to temperature change at the species level may not be sufficient to predict phenological responses at the community-level due to phenological compensation between species in the community.

Deletion of the lmna gene induces growth delay and serum biochemical changes in C57BL/6 mice

The A-type lamin deficient mouse line (Lmna^−/−) has become one of the most frequently used models for providing insights into many different aspects of A-type lamin function. To elucidate the function of Lmna in the growth and metabolism of mice, tissue growth and blood biochemistry were monitored in Lmna-deficient mice, heterozygous (Lmna^+/−) and wide-type (Lmna^+/+) backcrossed to C57BL/6 background. At 4 weeks after birth, the weight of various organs of the Lmna^−/−, Lmna^+/− and Lmna^+/+ mice was measured. A panel of biochemical analyses consisting of 15 serological tests was examined. The results showed that Lmna deficient mice had significantly decreased body weight and increased the ratio of organ to body weight in most of tissues. Compared with Lmna^+/+ and Lmna^+/− mice, Lmna^−/− mice exhibited lower levels of ALP (alkaline phosphatase), Chol (cholesterol), CR (creatinine), GLU (glucose), HDL (high-density lipoprotein cholesterol) and higher levels of ALT (alanine aminotransferase) (p<0.05). Lmna^−/− mice displayed higher AST (aspartate aminotransferase) values and lower LDL (lowdensity lipoprotein cholesterol), CK-MB (creatine kinase-MB) levels than Lmna^+/+ mice (p<0.05). There were no significant differences among the three groups of mice with respect to BUN (blood urea nitrogen), CK (creatine kinase), Cyc C (cystatin C), TP (total protein), TG (triacylglycerols) and UA (uric acid) levels (p>0.05). These changes of serological parameters may provide an experimental basis for the elucidation of Lmna gene functions.

Heterotopic central nervous system tissue arising in the palatopharyngeal region associated with cleft palate: case report

We present a rare case of heterotopic central nervous system tissue that arose in the palatopharyngeal region in a 4-year girl with a cleft palate.

A retrospective study of pulmonary infarction in patients with systemic lupus erythematosus from southern Taiwan

Since large-scale reports of pulmonary infarction in systemic lupus erythematosus (SLE) are limited, a retrospective study was performed for this manifestation in 773 hospitalized patients in southern Taiwan from 1999 to 2009. Pulmonary infarction was defined as the presence of pulmonary embolism, persistent pulmonary infiltrates, and characteristic clinical symptoms. Demographic, clinical, laboratory, and radiological images data were analyzed. There were 12 patients with pulmonary embolism and 9 of them had antiphospholipid syndrome (APS). Six patients (19 to 53 years, average 38.2 ± 12.6) with 9 episodes of lung infarction were identified. All cases were APS and four episodes had coincidental venous thromboembolism. There were four episodes of bilateral infarction and seven episodes of larger central pulmonary artery embolism. Heparin therapy was routinely prescribed and thrombolytic agents were added in two episodes. Successful recovery was noted in all patients. In conclusion, there was a 0.8% incidence of pulmonary infarction in patients with SLE, all with the risk factor of APS. Differentiation between pulmonary infarction and pneumonia in lupus patients should be made; they have similar chest radiography with lung consolidation but require a different clinical approach in management. Although this report is a retrospective study with relatively small numbers of lupus patients with lung infarcts, our observation might provide beneficial information on the clinical features and radiological presentations during the disease evolution of pulmonary infarction in SLE with APS.

Estrogen enhances the functions of CD4(+)CD25(+)Foxp3(+) regulatory T cells that suppress osteoclast differentiation and bone resorption in vitro

Cross-talk has been shown to occur between the immune system and bone metabolism pathways. In the present study, we investigated the impact of CD4(+)CD25(+)Foxp3(+) regulatory T (Treg) cells on osteoclastogenesis and bone resorption. Treg cells that were isolated and purified from peripheral blood mononuclear cells (PBMCs) of healthy adults inhibited both the differentiation of osteoclasts (OCs) from human embryo bone marrow cells (BMCs) and the pit formation in a dose-dependent manner. In cell cocultures, the production levels of both interleukin-10 (IL-10) and transforming growth factor-beta 1 (TGF-β1) were proportionally upregulated as the ratio of Treg cells to BMCs was increased, and the inhibition of OC differentiation and bone resorption by Treg cells was completely reversed by anti-IL-10 and anti-TGF-β1 antibodies. Treatment of BMC and Treg cell cocultures with 17β-estradiol (E2) at concentrations between 10⁻⁷ and 10⁻⁹ mol/l suppressed OC differentiation and bone resorption more efficiently than it did in cultures of BMCs alone; this enhanced suppression occurred via the stimulation of Treg cell IL-10 and TGF-β1 expression. These data suggest that Treg cells suppress OC differentiation and bone resorption by secreting IL-10 and TGF-β1. E2 enhances the suppressive effects of Treg cells on OC differentiation and bone resorption by stimulating IL-10 and TGF-β1 secretion from these cells. Therefore, Treg cell-derived IL-10 and TGF-β1 are likely involved in the regulation of E2 on bone metabolism and represent potential therapeutic targets for the treatment of postmenopausal osteoporosis (PMO).

Systemic steroid pretreatment improves cerebral protection after circulatory arrest

BACKGROUND

This study evaluates whether systemic steroid pretreatment enhances neuroprotection during deep hypothermic circulatory arrest (DHCA) compared with steroid in cardiopulmonary bypass (CPB) prime.

METHODS

Four-week-old piglets randomly placed into two groups (n = 5 per group) were given methylprednisolone (30 mg/kg) into the pump prime (group PP), or pretreated intravenously 4 hours before CPB (group PT). All animals underwent 100 minutes of DHCA (15 degrees C), were weaned off CPB, and were sacrificed 6 hours later. Postoperative changes in body weight, bioimpedance, and colloid oncotic pressure (COP) were measured. Cerebral trypan blue content, immunohistochemical evaluation of transforming growth factor-beta1 (TGF-beta1) expression, and caspase-3 activity were performed.

RESULTS

Percentage weight gain (group PP 25.0% +/- 10.4% versus group PT 12.5% +/- 4.0%; p = 0.036), and percentage decrease in bioimpedance (PP 37.2% +/- 14.5% versus PT 15.6% +/- 7.9%; p = 0.019) were significantly lower, whereas postoperative COP was significantly higher in group PT versus group PP (PT 15.3 +/- 1.8 mm Hg versus PP 11.6 +/- 0.8 mm Hg; p = 0.003). Cerebral trypan blue (ng/g dry tissue) was significantly lower in group PT (PT 5.6 x 10(-3) +/- 1.1 x 10(-3) versus PP 9.1 x 10(-3) +/- 5.7 x 10(-4); p = 0.001). Increased TGF-beta1 expression and decreased caspase-3 activity were shown in group PT.

CONCLUSIONS

Systemic steroid pretreatment significantly reduced total body edema and cerebral vascular leak and was associated with better immunohistochemical indices of neuroprotection after DHCA.

Application of pusher in mini-invasive patent ductus arteriosus ligation

The possibility of a residual shunt is a major drawback to current minimally invasive procedures for the treatment of patent ductus arteriosus (PDA). From April 1997 to October 1999, 30 patients (10 males, 20 females) underwent PDA ligation by a modified technique that uses a pusher for securing the ligate of PDA via posterolateral minithoracotomy at our hospital. No complication or mortality occurred. Postoperative echocardiography also revealed no residual shunt. In this article, we introduce this simple, safe procedure for PDA ligation.

Brachial plexus injury following coronary artery bypass surgery: a case report

Postoperative brachial plexus injury, often manifesting as a variety of upper extremity neuropathies, is a recognized and not uncommon complication following cardiac surgery that requires a median sternotomy. In general, the vast majority of its neurological symptoms are transient and need no treatment. Nevertheless, in very rare cases, the peripheral neuropathies will persist and cause disability. We treated a 67-year-old male patient complicated by permanent paresthesia and paralysis of the left upper extremity after an eventful coronary artery bypass surgery. The nerve conduction measurements and electromyography all revealed a C5 to T1 lesion. After carefully reviewing the surgical course and referring to the published literature, we tentatively concluded that compression or overstretching produced by wide and prolonged sternal separation of the brachial plexus was the most likely etiology. Asymmetrical traction of the sternal halves during internal mammary artery harvesting might also have contributed to this nerve injury. We surmised, therefore, that brachial plexus injury could be minimized by an exact median sternotomy, a lower position and the smallest possible opening for the sternal retractor, and the avoidance of constant and asymmetrical traction on the sternal halves.

[Determination of three active ingredients in food additive sucrose fatty acid ester by TLC scanning]

A method of separation and quantitation of monoester, diester and triester in food additive sucrose fatty acid esters by TLC with dual-wavelength TLC scanner in the sawtooth scanning mode is described. The detective wavelength was 530 nm and the reference wavelength was 700 nm. A mixture of chloroform, methanol, acetic acid and water (80:10:8:1, V/V) was used as mobile phase. The calibration curve was linear over a range from 4 micrograms to 60 micrograms with correlation coefficients of 0.9949-0.9980. The average recoveries were 96.45%-98.73% (n = 3, RSD = 2.7%-3.2%). This method is accurate, simple and dependable, with a wide range of linearity. It has been applied to the analysis of various samples and can be used for the quality control of the food additive sucrose fatty acid ester.

Comparison of intensive care of injured children between pediatric-based and non-pediatric-based intensive care units in a university hospital in Taiwan

Intensive care management of the injured child requires a multidisciplinary approach and meticulous attention to detail. However, the overwhelming majority of injured children are cared for by surgeons in surgical intensive care units (ICU) that see both adult and pediatric patients. There have been no previous reports of studies comparing the outcome in surgical ICUs (SICU) dealing with patients of all ages versus the outcome in pediatric ICUs (PICU). This study sought to determine differences in the outcome of pediatric intensive care between the SICU and PICU of our hospital. From Jan. 1989 to Aug. 1995, 118 children (68 boys and 50 girls), with an average age of 9.19 years (range: 3 months to 16 years), were admitted to our SICU. During the same period, 65 children (42 boys and 23 girls), with an average age of 5.04 years (range: 2 months to 16 years), were admitted to our PICU. Most of these patients received surgical intervention and were exclusively under surgeons' management. The decision to admit patient to the SICU or PICU was made by surgeon based on the availability of ICU beds. Pediatric risk of mortality (PRISM) score was used as a scoring system to assess disease severity in children. The most common cause for admission in both ICUs was traffic accidents. The average hospitalization duration in the SICU was 4.06 days (range 1 day to 23 days) and 3.34 days (range 1 day to 17 days) in the PICU. The average PRISM score was 7.87 (range 0-41) in the SICU and 6.48 (range 0-35) in the PICU. The overall mortality rate in the SICU was 12.7% (15/118) and 7.7% (5/65) in the PICU. There was a significant difference in patients' age and operative status but no significant difference in admission duration, PRISM score, and mortality rate between the SICU and PICU groups. The regression coefficients of the selected predictor variables and the impact on outcome showed one more score of PRISM would increase 1.5 fold of risk to become poor outcome while operation had lower risk (0.1 fold) to develop poor outcome. In conclusion, disease diversity and severity were similar among PICU and pediatric SICU patients in this study. The outcome was better in PICU patients although the difference was not statistically significant. The PRISM score is a useful measure to predict poor outcome in ICU patients after adjustment with confounders.

Epstein-Barr virus-containing T-cell lymphoma and atherosclerotic abdominal aortic aneurysm in a young adult

Malignant lymphoma infiltrating the abdominal aorta and resulting in an aortic aneurysm has never been documented. We report here a case of angiocentric T-cell lymphoma in a 33-year-old man who for months presented intermittent fever, splenomegaly, and an abdominal pulsatile mass. Angiography revealed extensive aneurysmal dilatation of the infrarenal abdominal aorta, bilateral iliac artery, and right common femoral artery. Splenic abscess and infected abdominal aortic aneurysm were initially suspected. An urgent splenectomy and aneurysmectomy with an aortic bifemoral bypass were performed. Pathological examination of the aortic aneurysm showed extensive necrosis, severe atherosclerosis, and lymphoma cell infiltration of the aortic wall. The lymphoid cells in the aorta and spleen were stained positive for CD45RO, CD56, and CD8, but negative for CD4 and CD19. Double-labeling immunohistochemistry and in situ hybridization using EBER1 for Epstein-Barr virus (EBV) revealed positive nuclear staining in the atypical T-lymphoid cells. This is the first definitive proof of peripheral T-cell lymphoma involving the abdominal aorta. Our evidence also supports that the EBV infection of T cells could be responsible for the atherosclerosis and hypertriglyceridemia, and the angiocentricity of the tumor cells apparently results in the presenting atherosclerotic aortic wall destruction, providing an additional causative concept for abdominal aortic aneurysm.

Pulmonary artery leiomyosarcoma

Pulmonary artery leiomyosarcoma is a rare but highly lethal disease, and can be mistaken for pulmonary thromboembolism. We report a case of pulmonary artery leiomyosarcoma managed with surgical resection, chemotherapy, and radiotherapy. A 57-year-old woman was admitted with complaints of aggravated dyspnea. She was initially treated with oxygen therapy and heparinization for a suspected pulmonary embolism. Echocardiography revealed a dilated right atrium and ventricle and severe tricuspid regurgitation, with an estimated systolic right ventricular pressure of 95 mm Hg; a shadow of a mass in the main pulmonary artery was also noted. Right ventriculography revealed a filling defect, and to-and-fro motion of the mass in the main pulmonary artery. The left pulmonary artery was almost totally occluded by the mass. The patient's condition improved dramatically after palliative excision of the mass and patch reconstruction of the outflow tract of the right ventricle with a bicuspid xenograft. Pathologic examination of the mass revealed leiomyosarcoma. Chemotherapy and radiotherapy were subsequently administered and follow-up imaging studies 3 months postoperatively revealed no recurrence of the tumor. The patient remains well, more than 1 year after treatment. This report emphasises that pulmonary artery sarcoma should be considered in the differential diagnosis in cases of suspected pulmonary thromboembolism.

Mitral valve replacement in the presence of massive posterior annular calcification

Replacement of the mitral valve in the presence of extensive calcification of the posterior annulus is a technical challenge. The heavily calcified annulus often results in difficulties of seating the prosthesis and later periprosthetic leakage. A radical calcium debridement may leave a friable and thin annulus that contributes to the risks of prosthesis dehiscence and ventricular perforation. To avoid technical difficulties and associated catastrophic complications, we devised a new technique of mitral valve replacement that allows a surgeon to implant a prosthesis securely. This technique involves inserting a larger single tilting disc mechanical valve (Medtronic Hall disc) with intra-atrial anchorage over the posterior sector of the calcified annulus, orienting the working (major) orifice of the mechanical valve anteriorly, and thereby tilting the lesser occluder segment of the disc upward into the atrium and away from the calcification in diastole. By utilizing this method, we have successfully performed mitral valve replacement in two patients who exhibited massive calcification of the posterior mitral annulus. Postoperative transeosophageal echocardiography showed excellent hemodynamic performance of the implanted valves. We therefore recommend this simple, safe, and time-saving procedure as a feasible method to deal with this surgical dilemma.

Endoscopic saphenous vein harvest decreases leg wound complication in coronary artery bypass grafting patients

BACKGROUND

Coronary artery bypass grafting (CABG) is the most common procedure performed in adult cardiovascular surgery. The most frequently used conduit is the greater saphenous vein. Using traditional methods, the complication rate of the leg is relatively high (up to 24%). To decrease the complication rate, we used the Endo-Path to harvest the greater saphenous vein.

METHODS AND RESULTS

From May 1997 through March 1999, a total of 135 patients received the CABG operation. We excluded the patients who died immediately postoperatively or had concomitant surgical procedures. Sixty patients received the endoscopic saphenous vein harvest procedure (group A), while another 59 patients (group B) did not. No important differences were noted between the two groups in respect to the number of distal anastomoses, length of harvested vein, total surgical time, and length of ICU stay. However, the leg wound complication rate decreased from 20.3% to 5.0% (p < 0.001).

CONCLUSIONS

Although the long-term patency rate needs time to be proven, the endoscopic greater saphenous vein harvest method is an attractive and effective method.

Surgical experience with Salmonella-infected aneurysms of the abdominal aorta

Five patients, aged between 64 and 75 years with Salmonella-infected abdominal aortic aneurysms were surgically treated between 1993 and 1995 at the National Cheng Kung University Hospital. Cultures of aneurysmal wall tissue and blood yielded Salmonella enteritidis Group B in three patients and Salmonella choleraesuis in the remaining two. All patients presented with fever and abdominal or back pain. Pulsatile masses were noted in only two patients. Infrarenal abdominal infected aneurysms were demonstrated by computed tomography and aortography in each patient. The five patients underwent aneurysmal resection with in situ graft reconstruction from 1 to 20 days after the diagnosis was made. The graft was wrapped with an omental pedicle. Duodenal repair was performed in one patient due to an aortoduodenal fistula found during surgery. He died 19 days after surgery because of duodenal leakage and uncontrolled sepsis. Four patients survived and remained well 11 to 34 months (mean, 25 mo) after surgery. Postoperatively, only one patient developed adhesion ileus and required enterolysis. Parenteral antimicrobial therapy was continued in all patients after surgery for 2 to 4 weeks; only one patient had an additional 4 months of oral antibiotics. Although the number of patients was small, the survival rate was high, at 80%. Our experience suggests that Salmonella-infected aneurysms of the abdominal aorta can be successfully treated by resection of the aneurysm with extensive debridement followed by in situ graft interposition with omentum wrapping. Once diagnosed, the patients should be scheduled for surgery as soon as possible. Antibiotics should be continued parenterally for at least 2 to 4 weeks postoperatively. While long-term suppressive antibiotic therapy is usually recommended, it might not be essential with our surgical approach.

Pulmonary cavernous hemangiomatosis treated with interferon alfa-2a

Pulmonary hemangiomatosis is a rare, usually fatal disorder characterized by diffuse proliferation of blood vessels within the thorax. We describe a 7-year-old boy with cavernous-type pulmonary hemangiomatosis successfully treated with interferon alfa-2a. He presented with respiratory distress and hemoptysis that were alleviated during a 2-year follow-up period.

One-stage repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries by a handmade trifurcated valved conduit

An 18-year-old girl with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (MAPCAs) was reported. Her left-side pulmonary artery was absent, and the blood flow to the left lung was derived from two MAPCAs. One-stage correction, including the left-side thoracotomy and followed by the median sternotomy, was performed. A handmade trifurcated valved conduit was used to connect the right ventricle and the distal pulmonary arteries. The patient was doing well 3 years after the operation.

Modified Senning procedures for simple transposition of the great arteries

From December 1990 to July 1994, 10 infants with simple transposition of the great arteries (TGA) underwent the Senning procedure at National Cheng Kung University Medical College. Their ages ranged from 1 to 8 months (mean, 4.8 +/- 2 months), and their body weight ranged from 3.5 to 7.5 kg (mean, 5.7 +/- 1.2 kg). Four infants were treated with the conventional method by covering the sinoatrial (SA) node with the anterior right atrial flap (group 1). The other six patients had modified procedures, having the suture line across the caval vein, caudal to the SA node (group 2). Three of the group 1 patients experienced junctional rhythm temporarily, another had SA node dysfunction for 1 week postoperatively. In group 2, all patients were in sinus rhythm except one, who returned to sinus rhythm on the second postoperative day. There was one (10%) surgical mortality, a patient in group 1, and one (10%) late mortality, in group 2. The clinical follow-up interval was 6 to 46 months (mean, 28.8 mo). All survivors were in sinus rhythm, and echocardiographic studies demonstrated no difference between the two groups as to conduit obstruction or degree of tricuspid valve regurgitation. In conclusion, in situations that require atrial switch for the correction of TGA, a suture line across the caval vein, caudal to the SA node, may be a useful modification to prevent arrhythmias.

Tetralogy of Fallot with an additional muscular inlet type ventricular septal defect--repair with split patch technique

An 8-year-old girl with tetralogy of Fallot (TF) and double ventricular septal defects (VSDs) was reported. The additional VSD was a muscular inlet type. A split patch technique was used to cover both VSDs during the total correction. Follow-up echocardiogram demonstrated no residual shunt nor significant tricuspid valve regurgitation. The patient is doing well 2 years after operation.

Systemic atrioventricular valve replacement in an infant with corrected transposition of the great arteries

An eight-month-old male infant with corrected transposition of the great arteries and severe systemic atrioventricular valve regurgitation due to "Ebstein-like anomaly" is reported. Through a midline sternotomy and transeptal approach, a 20 mm Medtronic Hall aortic mechanical valve was reversely implanted into the systemic atrioventricular valve. Anti-platelet drugs (acetylsalicylic acid and dipyridamole) were prescribed for prevention of thromboembolism. The patient is doing well three years after operation.

Immunoglobulins from normal sera bind platelet vinculin and talin and their proteolytic fragments

Our previous finding that normal serum immunoglobulins bind to internal platelet proteins on Western blots led us to further identify these proteins and determine the possible significance of autoantibodies against them. A 95-Kd protein reactive with immunoglobulins in most normal sera and easily confused with gpIIIa was shown to be a fragment of vinculin generated by calpain proteolysis. Identity was established by peptide sequencing of the protein purified from platelets stored without specific protease inhibitors. Normal immunoglobulins bound intact vinculin (117 Kd) and metavinculin (152 Kd), and their 105-, 95-, and 80- to 85-Kd proteolytic fragments. IgG in 89%, and IgA and IgM in 100% of normal sera reacted in titers of 10 to 1,000 with purified vinculin. In addition, IgG in 79%, and IgA and IgM in 93% of normal sera reacted in titers of 10 to 5,000 with talin (235 Kd), another cytoskeletal protein, and its 200-Kd proteolytic fragment. IgGs in sera from animals of several different phylogenetic classes also reacted with human vinculin and talin on Western blots. Frequency of occurrence, titers, and classes of antivinculin and antitalin autoantibodies in patients with thrombocytopenia did not differ discernibly from those of normal individuals. These antibodies had no effect on platelet aggregation or clot retraction, and no apparent pathogenic significance, but their widespread presence and the variability in extent of proteolysis of platelet preparations used for Western blots can complicate interpretation of patterns obtained with sera from patients with presumed immune-mediated thrombocytopenias.