[Therapeutic strategy for totally thoracoscopic repeat mitral valve surgery under moderate hypothermia-induced ventricular fibrillation]

Objective: To examine the therapeutic strategy and its impacting factors by analyzing the perioperative outcomes of total thoracoscopic repeat mitral valve surgery under moderate hypothermia-induced ventricular fibrillation with cardiopulmonary bypass. Methods: This study is a retrospective case series. Totally 63 patients who underwent repeat mitral valve surgery by the same surgeon from January 2021 to December 2023 in Department of Cardiovascular Surgery, the First Medical Center of People's Liberation Army General Hospital were retrospectively enrolled. There were 28 males and 35 females with an age of (58.3±15.9) years (range: 13 to 84 years). Surgery was performed using a totally thoracoscopic approach under moderate hypothermia-induced ventricular fibrillation. Mitral valvuloplasty was completed in 32 cases and mitral valve replacement in 31 cases. Preoperative baseline data and perioperative outcomes of the patients were collected and Logistic regression was used to analyze independent influencing factors of premature ventricular contractions in the early postoperative period. Results: The intraoperative cardiopulmonary bypass time was (191.5±50.9) minutes (range: 95 to 286 minutes), and the hypothermic ventricular fibrillation time was (99.0±39.8) minutes (range: 34 to 203 minutes). The anal temperature before the start of cardiopulmonary bypass was (36.3±0.5) ℃ (range: 35.2 to 38.0 ℃), the lowest intraoperative anal temperature was (27.3±1.3) ℃(range: 23.7 to 30.1 ℃), and the anal temperature at the time of the cessation of cardiopulmonary bypass was (36.3±0.4) ℃ (range: 35.2 to 37.0 ℃), and excessive rewarming was observed in 33 cases. Six cases applied the artificial heart assist device. Seventeen cases developed premature ventricular contractions in the early postoperative period. Two cases developed neurologic complications. Five cases developed respiratory complications. One case developed urological systemic complications. Six cases were mechanically ventilated for more than 3 days, and the duration of ICU stay in 16 cases was more than 3 days and the postoperative discharge time of (M(IQR)) 8.0 (3.5) days (range: 3 to 26 days). Two cases died or were discharged voluntarily. Logistic regression results showed that persistent preoperative atrial fibrillation (OR=11.424, 95%CI: 1.477 to 144.564, P=0.033) and excessive rewarming (OR=15.249, 95%CI: 1.357 to 279.571, P=0.038) were independent risk factors for the appearance of premature ventricular contractions in the early postoperative period. Conclusions: The technique of total thoracoscopic surgery under induced moderate hypothermic ventricular fibrillation with cardiopulmonary bypass could be applied to repeated mitral valve surgeries with less trauma and faster recovery. Persistent preoperative atrial fibrillation and excessive rewarming are independent risk factors for the occurrence of premature ventricular contractions in the early postoperative period.

[Reappraisals of biological behaviors of PDGFRA mutant gastrointestinal stromal tumor]

Objective: To investigate the biological behavior spectrum of platelet-derived growth factor alpha receptor (PDGFRA)-mutant gastrointestinal stromal tumor (GIST), and to compare the clinical values of the Zhongshan method of benign and malignant evaluation with the modified National Institutes of Health (NIH) risk stratification. Methods: A total of 119 cases of GIST with PDGFRA mutation who underwent surgical resection at Zhongshan Hospital, Fudan University from 2009 to 2020 were collected. The clinicopathological data, follow-up records, and subsequent treatment were reviewed and analyzed statistically. Results: There were 79 males and 40 females. The patients ranged in age from 25 to 80 years, with a median age of 60 years. Among them, 115 patients were followed up for 1-154 months, and 13 patients progressed to disease. The 5-year disease-free survival (DFS) and overall survival (OS) were 90.1% and 94.1%, respectively. According to the modified NIH risk stratification, 8 cases, 32 cases, 38 cases, and 35 cases were very-low risk, low risk, intermediate risk, and high risk, and 5-year DFS were 100.0%, 95.6%, 94.3%, and 80.5%, respectively. There was no significant difference in prognosis among the non-high risk groups, only the difference between high risk and non-high risk groups was significant (P=0.029). However, the 5-year OS was 100.0%, 100.0%, 95.0% and 89.0%, and there was no difference (P=0.221). According to the benign and malignant evaluation Zhongshan method, 43 cases were non-malignant (37.4%), 56 cases were low-grade malignant (48.7%), 9 cases were moderately malignant (7.8%), and 7 cases were highly malignant (6.1%). The 5-year DFS were 100.0%, 91.7%, 77.8%, 38.1%, and the difference was significant (P<0.001). The 5-year OS were 100.0%, 97.5%, 77.8%, 66.7%, the difference was significant (P<0.001). Conclusions: GIST with PDGFRA gene mutation shows a broad range of biological behavior, ranging from benign to highly malignant. According to the Zhongshan method, non-malignant and low-grade malignant tumors are common, the prognosis after surgery is good, while the fewer medium-high malignant tumors showed poor prognosis after surgical resection. The overall biological behavior of this type of GIST is relatively inert, which is due to the low proportion of medium-high malignant GIST. The modified NIH risk stratification may not be effective in risk stratification for PDGFRA mutant GIST.

[Predictive value of aMAP risk score for early recurrence of small hepatocellular carcinoma after microwave ablation]

Objective: To explore the value of the aMAP risk score (age, male, albumin-bilirubin, and platelets) to predict early recurrence within one year after microwave ablation in patients with small hepatocellular carcinoma. Methods: This was a retrospective study that enrolled 142 patients diagnosed with hepatocellular carcinoma who were treated with microwave ablation in the Department of Hepatology Unit of Nanfang Hospital, Southern Medical University from July 2016 to July 2021. The cohort enrolled 121 male and 21 female patients, including 110 patients that were <60 years old. All the patients were followed-up after microwave ablation to evaluate residual tumor and recurrence of tumor by computed tomography or magnetic resonance imaging. The observation indices mainly included general data and imaging data of patients. Using the X-tile tools, patients were divided into two groups: a high aMAP score group and a low aMAP score group. Multivariate Cox regression analysis was conducted for comparison of independent risk factors. Results: Multivariate Cox regression showed that high aMAP score, maximum tumor diameter >20 mm, and high AFP were the independent risk factors of early recurrence (all P<0.05). Kaplan-Meier survival curves showed that the median recurrence-free survival was 25.5 months in the low aMAP score group and 6.1 months in the high aMAP score group (P=0.001). Conclusions: The aMAP score could predict the early recurrence within 1 year of small hepatocellular carcinoma after microwave ablation. Patients with high aMAP score should undergo rigorous postoperative follow-up evaluations..

Diagnostic performance of gadoxetic acid-enhanced abbreviated magnetic resonance imaging protocol in small hepatocellular carcinoma (≤2 cm) in high-risk patients

BACKGROUND

Biannual Ultrasound showed insufficient sensitivity in detecting small or early-stage hepatocellular carcinoma (HCC). Abbreviated magnetic resonance imaging (A-MRI) protocols with fewer sequences demonstrated higher HCC detection sensitivity than ultrasound with acceptable cost and examination time.

PURPOSE

To compare the diagnostic performance of gadoxetic acid-enhanced A-MRI with a full sequence MRI (F-MRI) protocol for small HCC (≤2 cm) in cirrhotic or hepatitis B virus-infected high-risk patients.

MATERIAL AND METHODS

Two hundred and four consecutive patients with 166 pathologically confirmed small HCC who underwent preoperative gadoxetic acid-enhanced MRI were retrospectively included. A-MRI set comprised T1-weighted hepatobiliary phase imaging, T2-weighted imaging, diffusion-weighted imaging and apparent diffusion coefficient mapping. Two independent radiologists blinded to clinical data assessed the A-MRI set and F-MRI set. Per-patient HCC and per-lesion HCC diagnostic performance were compared.

RESULTS

Per-patient HCC detection sensitivity of A-MRI set was 93.8% and 91.2% for observer 1 and observer 2, and, for the F-MRI set, the per-patient HCC detection sensitivity was 96.6% and 95.2%, respectively. There was no significant difference in per-patient sensitivity, specificity and per-lesion HCC detection sensitivity between the two imaging sets for both readers. (P = 0.06-0.25) The A-MRI set showed higher sensitivity on HCC without arterial phase hyperenhancement, and the F-MRI set demonstrated with higher sensitivity on HCC with arterial phase hyperenhancement (P < 0.05).

CONCLUSION

A-MRI using diagnostic criteria including hypointensity on hepatobiliary phase plus mild to moderate hyperintensity on T2-weighted imaging or restricted diffusion demonstrated comparable sensitivity and specificity for small HCC compared to the F-MRI protocol in high-risk patients.

Diagnostic Performance of Contrast Enhanced CT Alone or in Combination with (Non-)Enhanced MRI for Colorectal Liver Metastasis

RATIONALE AND OBJECTIVES

To compare the diagnostic performance of contrast enhanced CT (CE-CT), CE-CT combined with non-enhanced MRI (NE-MRI) or contrast enhanced MRI (CE-MRI) for colorectal liver metastasis (CRLM).

MATERIALS AND METHODS

Sixty-six colorectal cancer patients with 198 focal liver lesions who underwent preoperative abdominal CE-CT and MRI examinations were included respectively. The images were assessed independently by two readers in three protocols (1: CE-CT, 2: CE-CT+NE-MRI, 3: CE-CT+CE-MRI). The diagnostic performance of each protocol was analyzed by receiver operating characteristic (ROC) curve and the areas under ROC (AUCs) were calculated and compared.

RESULTS

The detection rates of protocol 2 were 90.9%-92.9% for liver lesions and 86.4%-89.6% for CRLM, and both significantly higher than protocol 1 of 82.8%-85.4% and 76.8%-80.8% (p<0.001-0.001), whereas similar to protocol 3 of 91.9%-94.4% and 87.2%-91.2% (p 0.250-1.000). The AUCs of protocol 2 were greater than protocol 1 for all lesions (0.914-0.934 vs. 0.779-0.799, p<0.001) and lesions < 10mm (0.726-0.776 vs. 0.528-0.561, p<0.001), and were not inferior to that of protocol 3 (0.929-0.949 in all lesions and 0.754-0.821 in lesion < 10mm, p 0.053-0.162).

CONCLUSION

CE-CT combined with NE-MRI offered superior diagnostic performance for CRLM compared to CE-CT alone and showed comparable performance to CE-CT combined with CE-MRI.

Tumor Radiomic Features on Pretreatment MRI to Predict Response to Lenvatinib plus an Anti-PD-1 Antibody in Advanced Hepatocellular Carcinoma: A Multicenter Study

Introduction

Lenvatinib plus an anti-PD-1 antibody has shown promising antitumor effects in patients with advanced hepatocellular carcinoma (HCC), but with clinical benefit limited to a subset of patients. We developed and validated a radiomic-based model to predict objective response to this combination therapy in advanced HCC patients.

Methods

Patients (N = 170) who received first-line combination therapy with lenvatinib plus an anti-PD-1 antibody were retrospectively enrolled from 9 Chinese centers; 124 and 46 into the training and validation cohorts, respectively. Radiomic features were extracted from pretreatment contrast-enhanced MRI. After feature selection, clinicopathologic, radiomic, and clinicopathologic-radiomic models were built using a neural network. The performance of models, incremental predictive value of radiomic features compared with clinicopathologic features and relationship between radiomic features and survivals were assessed.

Results

The clinicopathologic model modestly predicted objective response with an AUC of 0.748 (95% CI: 0.656-0.840) and 0.702 (95% CI: 0.547-0.884) in the training and validation cohorts, respectively. The radiomic model predicted response with an AUC of 0.886 (95% CI: 0.815-0.957) and 0.820 (95% CI: 0.648-0.984), respectively, with good calibration and clinical utility. The incremental predictive value of radiomic features to clinicopathologic features was confirmed with a net reclassification index of 47.9% (p < 0.001) and 41.5% (p = 0.025) in the training and validation cohorts, respectively. Furthermore, radiomic features were associated with overall survival and progression-free survival both in the training and validation cohorts, but modified albumin-bilirubin grade and neutrophil-to-lymphocyte ratio were not.

Conclusion

Radiomic features extracted from pretreatment MRI can predict individualized objective response to combination therapy with lenvatinib plus an anti-PD-1 antibody in patients with unresectable or advanced HCC, provide incremental predictive value over clinicopathologic features, and are associated with overall survival and progression-free survival after initiation of this combination regimen.

Prognostic value of preoperative CT features for disease-free survival in patients with primary gastric gastrointestinal stromal tumors after resection

PURPOSE

Tumor size is an important prognostic factor without consideration of the necrotic and cystic components within tumor for patients with gastrointestinal stromal tumors (GISTs). We aimed to extract the enhancing viable component from the tumor using computed tomography (CT) post-processing software and evaluate the value of preoperative CT features for predicting the disease-free survival (DFS) after curative resection for patients with primary gastric GISTs.

METHODS

132 Patients with primary gastric GISTs who underwent preoperative contrast-enhanced CT and curative resection were retrospectively analyzed. We used a certain CT attenuation of 30 HU to extract the enhancing tissue component from the tumor. Enhancing tissue volume and other CT features were assessed on venous-phase images. We evaluated the value of preoperative CT features for predicting the DFS after surgery. Univariate and multivariate Cox regression analyses were performed to find the independent risk factor for predicting the DFS.

RESULTS

Of the 132 patients, 68 were males and 64 were females, with a mean age of 61 years. The median follow-up duration was 60 months, and 28 patients experienced disease recurrence and distant metastasis during the follow-up period. Serosal invasion (p < 0.001; HR = 5.277) and enhancing tissue volume (p = 0.005; HR = 1.447) were the independent risk factors for predicting the DFS after curative resection for patients with primary gastric GISTs.

CONCLUSION

Preoperative contrast-enhanced CT could be useful for predicting the DFS after the surgery of gastric GISTs, and serosal invasion and enhancing tissue volume were the independent risk factors.

Prognostic model for predicting outcome and guiding treatment decision for unresectable hepatocellular carcinoma treated with lenvatinib monotherapy or lenvatinib plus immunotherapy

Background

Lenvatinib monotherapy and combination therapy with immune checkpoint inhibitors (ICI) were widely applied for unresectable hepatocellular carcinoma (uHCC). However, many patients failed to benefit from the treatments. A prognostic model was needed to predict the treatment outcomes and guide clinical decisions.

Methods

304 patients receiving lenvatinib monotherapy or lenvatinib plus ICI for uHCC were retrospectively included. The risk factors derived from the multivariate analysis were used to construct the predictive model. The C-index and area under the receiver-operating characteristic curve (AUC) were calculated to assess the predictive efficiency.

Results

Multivariate analysis revealed that protein induced by vitamin K absence or antagonist-II (PIVKA-II) (HR, 2.05; P=0.001) and metastasis (HR, 2.07; P<0.001) were independent risk factors of overall survival (OS) in the training cohort. Herein, we constructed a prognostic model called PIMET score and stratified patients into the PIMET-low group (without metastasis and PIVKA-II<600 mAU/mL), PIMET-int group (with metastasis or PIVKA-II>600 mAU/mL) and PIMET-high group (with metastasis and PIVKA-II>600 mAU/mL). The C-index of PIMET score for the survival prediction was 0.63 and 0.67 in the training and validation cohort, respectively. In the training cohort, the AUC of 12-, 18-, and 24-month OS was 0.661, 0.682, and 0.744, respectively. The prognostic performances of the model were subsequently validated. The AUC of 12-, 18-, and 24-month OS was 0.724, 0.726, and 0.762 in the validation cohort. Subgroup analyses showed consistent predictive value for patients receiving lenvatinib monotherapy and patients receiving lenvatinib plus ICI. The PIMET score could also distinguish patients with different treatment responses. Notably, the combination of lenvatinib and ICI conferred survival benefits to patients with PIMET-int or PIMET-high, instead of patients with PIMET-low.

Conclusion

The PIMET score comprising metastasis and PIVKA-II could serve as a helpful prognostic model for uHCC receiving lenvatinib monotherapy or lenvatinib plus ICI. The PIMET score could guide the treatment decision and facilitate precision medicine for uHCC patients.

Circulating immune index predicting the prognosis of patients with hepatocellular carcinoma treated with lenvatinib and immunotherapy

Background

Immune checkpoint inhibitor (ICI)-based combination therapy has opened a new avenue for the treatment of multiple malignancies including hepatocellular carcinoma (HCC). However, considering the unsatisfactory efficacy, biomarkers are urgently needed to identify the patients most likely to benefit from ICI-based combination therapy.

Methods

A total of 194 patients undergoing ICI-based combination therapy for unresectable HCC were retrospectively enrolled and divided into a training cohort (n = 129) and a validation cohort (n = 65) randomly. A novel circulating immune index (CII) defined as the ratio of white blood cell count (×10⁹/L) to lymphocyte proportion (%) was constructed and its prognostic value was determined and validated.

Results

Patients with CII ≤ 43.1 reported prolonged overall survival (OS) compared to those with CII > 43.1 (median OS: 24.7 vs 15.1 months; 6-, 12-, 18-month OS: 94.2%, 76.7%, 66.1% vs 86.4%, 68.2%, 22.8%, P = 0.019), and CII was identified as an independent prognostic factor for OS (hazard ratio, 2.24; 95% confidence interval, 1.17-4.31; P = 0.015). These results were subsequently verified in the validation cohort. Additionally, patients with low CII levels had improved best radiological tumor response (complete response, partial response, stable disease, progressive disease: 3%, 36%, 50%, 11% vs 0%, 27%, 46%, 27%; P = 0.037) and disease control rate (89% vs 73%; P = 0.031) in the pooled cohort and better pathologic response (pathologic complete response, major pathologic response, partial pathologic response, no pathologic response: 20%, 44%, 28%, 8% vs 0%, 0%, 40%, 60%; P = 0.005) in the neoadjuvant cohort. Detection of lymphocyte subsets revealed that an elevated proportion of CD4+ T cells was related to better OS, while the proportion of CD8+ T cells was not.

Conclusions

We constructed a novel circulating immune biomarker that was capable of predicting OS and therapeutic efficacy for HCC patients undergoing ICI and lenvatinib combination therapy.

[Predictive value of hemoglobin glycation index for chronic kidney disease]

Objective: To investigate the influence of hemoglobin glycation index (HGI) on the risk of incident chronic kidney disease (CDK) among nondiabetic patients. Methods: Prospective cohort study. At baseline, a total of 7 407 nondiabetic patients without a history of CKD from Pingguoyuan Community of the Shijingshan District in Beijing were included from December 2011 to August 2012, who were then divided into three groups according to the tertiles of their baseline HGI levels. The CKD incidence rate was compared among the different HGI groups at last follow-up. Cox multivariable regression was applied to evaluate whether HGI measures predicted CKD risk. Test for trend across tertiles were examined using ordinal values in separate models. Results: The mean age of the subjects was (56.4±7.5) years, and 4 933 (66.6%) were female. At mean follow-up of 3.23 years, 107 (1.4%) individuals developed CKD. The incidence of CKD was gradually increasing from the low to high HGI groups [1.1% (28/2 473) vs. 1.2% (31/2 564) vs. 2.0% (48/2 370), P=0.016]. In the multivariate Cox regression analysis, after adjustment for potential confounders, the high HGI group had a 68.5% increased risk of CKD compared with the low HGI group (HR=1.685, 95%CI 1.023 to 2.774). CKD risk increased with increasing HGI tertiles (P for trend=0.028). Conclusion: High HGI is associated with an increased risk for CKD in the nondiabetic population, indicating that HGI may help identify individuals at high risk for CKD.

Hepatobiliary phase images of gadoxetic acid-enhanced MRI may improve accuracy of predicting the size of hepatocellular carcinoma at pathology

BACKGROUND

Gadoxetic acid-enhanced magnetic resonance imaging (MRI) has been widely used in clinical practice. However, scientific evidence is lacking for recommending a particular sequence for measuring tumor size.

PURPOSE

To retrospectively compare the size of hepatocellular carcinoma (HCC) measured on different gadoxetic acid-enhanced MRI sequences using pathology as a reference.

MATERIAL AND METHODS

A total of 217 patients with single HCC who underwent gadoxetic acid-enhanced MRI before surgery were included. The size of the HCC was measured by two abdominal radiologists independently on the following sequences: T1-weighted; T2-weighted; b-500 diffusion-weighted imaging (DWI); and arterial, portal venous, transitional, and hepatobiliary phases. Tumor size measured on MRI was compared with pathological size by using Pearson correlation coefficient, independent-sample t test, and Bland-Altman plot. Agreement between two readers was evaluated with intraclass correlation coefficient (ICC).

RESULTS

Correlation between the MR images and pathology was high for both readers (0.899-0.955). Absolute error between MRI and pathologic assessment was lowest on hepatobiliary phase images for both readers (reader 1, 2.8±4.2 mm; reader 2, 3.2±3.4 mm) and highest on arterial phase images for reader 1 (4.9±4.4 mm) and DWI phase images for reader 2 (5.1±4.9 mm). Absolute errors were significantly different for hepatobiliary phase compared with other sequences for both readers (reader 1, P≤0.012; reader 2, P≤0.037). Inter-reader agreements for all sequence measurements were strong (0.971-0.997).

CONCLUSION

The performance of gadoxetic acid-enhanced MRI sequences varied with HCC size, and the hepatobiliary phase may be optimal among these sequences.

[Effect and influence factors of cardiopulmonary resuscitation in children with congenital heart disease in pediatric intensive care unit]

Objective: To investigate the prognostic factors of children with congenital heart disease (CHD) who had undergone cardiopulmonary resuscitation (CPR) in pediatric intensive care unit (PICU) in China. Methods: From November 2017 to October 2018, this retrospective multi-center study was conducted in 11 hospitals in China. It contained data from 281 cases who had undergone CPR and all of the subjects were divided into CHD group and non-CHD group. The general condition, duration of CPR, epinephrine doses during resuscitation, recovery of spontaneous circulation (ROSC), discharge survival rate and pediatric cerebral performance category in viable children at discharge were compared. According to whether malignant arrhythmia is the direct cause of cardiopulmonary arrest or not, children in CHD and non-CHD groups were divided into 2 subgroups: arrhythmia and non-arrhythmia, and the ROSC and survival rate to discharge were compared. Data in both groups were analyzed by t-test, chi-square analysis or ANOVA, and logistic regression were used to analyze the prognostic factors for ROSC and survival to discharge after cardiac arrest (CA). Results: The incidence of CA in PICU was 3.2% (372/11 588), and the implementation rate of CPR was 75.5% (281/372). There were 144 males and 137 females with median age of 32.8 (5.6, 42.7) months in all 281 CPA cases who received CPR. CHD group had 56 cases while non-CHD had 225 cases, with the percentage of 19.9% (56/281) and 80.1% (225/281) respectively. The proportion of female in CHD group was 60.7% (34/56) which was higher than that in non-CHD group (45.8%, 103/225) (χ²=4.00, P=0.045). There were no differences in ROSC and rate of survival to discharge between the two groups (P>0.05). The ROSC rate of children with arthythmid in CHD group was 70.0% (28/40), higher than 6/16 for non-arrhythmic children (χ²=5.06, P=0.024). At discharge, the pediatric cerebral performance category scores (1-3 scores) of CHD and non-CHD child were 50.9% (26/51) and 44.9% (92/205) respectively. Logistic regression analysis indicated that the independent prognostic factors of ROSC and survival to discharge in children with CHD were CPR duration (odds ratio (OR)=0.95, 0.97; 95%CI: 0.92~0.97, 0.95~0.99; both P<0.05) and epinephrine dosage (OR=0.87 and 0.79, 95%CI: 0.76-1.00 and 0.69-0.89, respectively; both P<0.05). Conclusions: There is no difference between CHD and non-CHD children in ROSC and survival rate of survival to discharge was low. The epinephrine dosage and the duration of CPR are related to the ROSC and survival to discharge of children with CHD.

Utility of preoperative computed tomography features in predicting the Ki-67 labeling index of gastric gastrointestinal stromal tumors

PURPOSE

To evaluate the value of preoperative computed tomography (CT) features including morphologic and quantitative features for predicting the Ki-67 labeling index (Ki-67LI) of gastric gastrointestinal stromal tumors (GISTs).

METHODS

We retrospectively included 167 patients with gastric GISTs who underwent preoperative contrast-enhanced CT. We assessed the morphologic features of preoperative CT images and the quantitative features including the maximum diameter of tumor, total tumor volume, mean total tumor CT value, necrosis volume, necrosis volume ratio, enhanced tissue volume, and mean CT value of enhanced tissue. Potential predictive parameters to distinguish the high-level Ki-67LI group (>4%, n = 125) from the low-level Ki-67LI group (≤4%, n = 42) were compared and subsequently determined in multivariable logistic regression analysis.

RESULTS

Growth pattern (p = 0.036), shape (p = 0.000), maximum diameter (p = 0.018), total tumor volume (p = 0.021), mean total tumor CT value (p = 0.009), necrosis volume (p = 0.006), necrosis volume ratio (p = 0.000), enhanced tissue volume (p = 0.027), and mean CT value of enhanced tissue (p = 0.004) were significantly different between the two groups. Multivariate logistic regression analysis indicated that lobulated/irregular shape (odds ratio [OR] = 3.817; p = 0.000) and high necrosis volume ratio (OR = 1.935; p = 0.024) were independent factors of high-level Ki-67LI.

CONCLUSIONS

Higher necrosis volume ratio in combination with lobulated/irregular shape could potentially predict high expression of Ki-67LI for gastric GISTs.

[Perioperative safety and feasibility of simultaneous off-pump coronary artery bypass grafting with non-cardiac surgical procedures of moderate-to-severe severity]

Objective: To examine the perioperative safety and feasibility of simultaneous off-pump coronary artery bypass grafting (OPCAB) with non-cardiac surgical procedures of moderate-to-severe severity. Methods: The perioperative results of 54 patients underwent simultaneous OPCAB with non-cardiac surgical procedures from September 2013 to January 2019 at Department of Cardiac Surgery, Peking University First Hospital were assessed retrospectively. There were 46 males and 8 females, aging (65.8±8.8) years (range: 41 to 85 years). All simultaneous non-cardiac surgical procedures, including vascular (n=1), thoracic (n=26), general (n=12) and urologic surgical procedures (n=15), were assessed to be of moderate-to-severe grade by operative severity scoring system. Perioperative results were compared between the OPCAB patients who underwent simultaneous non-cardiac surgical procedures (n=54) and 1∶2 matched patients who underwent isolated OPCAB performed most recently by the same cardiac team with similar procedures accordingly (n=108), using t test, Mann-Whitney U test, χ² test or Fisher exact test. Results: All baseline factors were matched between the two groups, with no significant difference on European system for cardiac operative risk evaluation (EuroSCORE) Ⅱ (1.185(0.758)% vs. 1.215(0.905)%, Z=‒0.036, P=0.972). No perioperative death was observed in the two groups. Although patients underwent simultaneous non-cardiac surgical procedures showed prolonged operation duration time ((324.9±97.1) minutes vs. (166.7±36.7) minites, t=11.564, P<0.01) and increased intraoperaive blood loss ((462.2±269.6) ml vs. (304.5±177.8) ml, t=3.866, P<0.01), primary postoperative complications, including perioperative myocardial infarction, atrial fibrillation, perioperative stroke, acute renal failure, wound infection, and bleeding reoperation did not show significant differences between the two groups (all P>0.05), while total blood transfusion volume, mechanical ventilation time and intensive care unit residence time also showed no significant differences between the two groups (all P>0.05). Conclusion: Simultaneous OPCAB with non-cardiac surgical procedures of moderate-to-severe severity in patients with operative indications are safe and feasible, and are not associated with increased postoperative risks when compared with isolated OPCAB.

CT-detected extramural venous invasion is corelated with presence of lymph node metastasis and progression-free survival in gastric cancer

OBJECTIVE

This study aimed to investigate if CT-detected extramural venous invasion (ctEMVI) was associated with the presence of lymph node metastasis (LNM) and survival outcomes in patients with gastric cancer.

METHODS

We retrospectively reviewed 105 patients with pathologically proved gastric cancer who underwent pre-operative CT examinations and received radical gastrectomy with extended lymphadenectomy. Differences in CT characteristics between the LNM-positive and -negative groups were assessed by two observers. Binary logistic regression analysis was performed to determine the risk factors of lymph node metastasis in gastric cancer. Progression-free survival analysis was performed by Kaplan-Meier method.

RESULTS

Two observers reached good inter-reader agreements in ctEMVI and ctN status with κ values of 0.711 and 0.751, respectively. The frequency of ctEMVI-positive status was 58.1% (61/105) in patients with gastric cancer. The LNM-positive group showed higher possibility of ctEMVI-positive status (81.7% vs 26.7%, p＜0.001), larger tumor volume (mean volume, 40.77 vs 22.09 mL, p＜0.001), poor tumor margin (45.0% vs 26.7% , p = 0.054) and high enhancement on arterial phase (43.3% vs 26.7%, p = 0.023) and venous phase (60.0% vs 44.4%, p = 0.048), than LNM-negative group. In multivariate analysis, ctEMVI status and tumor volume were identified as independent risk factors for lymph node metastasis with odds ratio (OR) of 9.804 (95% CI, 3.076－31.246; p＜0.001) and 1.030 (95% CI, 1.001－1.060; p = 0.044). CT-detected EMVI presented better diagnostic efficiency for lymph node metastasis than CT-defined N status, with sensitivity (81.7% vs 70.0%), specificity (73.3% vs 71.1%), accuracy (78.1% vs 70.5), PPV (80.3% vs 76.4%), and NPV (75.0% vs 64.0%), respectively. Kaplan-Meier curves showed that patients with positive ctEMVI findings has lower PFS rate than patients with negative ctEMVI findings (Log-rank test, p = 0.007).

CONCLUSION

CT-detected EMVI was significantly associated with lymph node metastasis and progression free survival in patients with gastric cancer. Compared to CT-defined N status, ctEMVI provided superior diagnostic performance to predict pathologic Nstatus.

ADVANCES IN KNOWLEDGE

Our study proved that CT-detected EMVI is a promising imaging marker to predict lymph node metastasis and poor prognosis, which may contribute to the precise evaluation of gastric cancer before surgery.

[Does age affect the hidden blood loss of elderly intertrochanteric fracture patients fixed with combined external fixator?]

Objective: To evaluate the postoperatively hidden blood loss of elderly intertrochanteric fracture patients fixed with combined external fixator, and to explore the correlation between hidden blood loss and age. Methods: A retrospective analysis was conducted on 60 elderly intertrochanteric fracture patients who were admitted to the Department of Orthopedics of Hebei Provincial Hospital from January 2016 to May 2019. All the fractures were fixed with combined external fixators. The patients were divided into two groups according to the age: there were 31 cases in group A (60-80 years old) and 29 cases in group B (≥80 years old). The Gross equation and the Nandler formula were used to evaluate the amount of hidden blood loss based on changes in hematocrit (Hct) at the day preoperatively, 3 days postoperatively and the weight. The data were compared between the two groups by independent-sample t test. Results: The decreased Hct, hemoglobin(Hb) and the dominant blood loss and hidden blood loss in group A and B was 3.4%±1.7%, (13±7) g/L, (25±6) ml, (186±7) ml and 3.8%±1.2%, (13±3) g/L, (24±8) ml, (194±7) ml, respectively. There was no significant differences in the dominant and hidden blood loss between the groups (t=0.309, 0.883, both P>0.05). Conclusion: The age doesn't affect the hidden blood loss in elderly intertrochanteric fracture patients fixed with combined external fixator, which indicated that the operation is safe and reliable for such patients.

Extracapsular dissection versus partial superficial parotidectomy for the treatment of benign parotid tumours

The purpose of this study was to compare the complications of patients treated for a benign parotid tumour (BPT) by extracapsular dissection (ECD) vs. partial superficial parotidectomy (PSP). A comprehensive literature investigation was conducted by searching electronic databases. A systematic review and meta-analysis of comparative studies were performed to assess ECD and PSP for the treatment of BPTs with fixed-effects models. The outcomes analysed were transient or permanent facial nerve injury, Frey syndrome, recurrence rate, infection, and salivary fistula/sialocele. A total of 1641 patients from seven studies (1120 ECD-treated and 521 PSP-treated patients) were included in this meta-analysis. Transient facial nerve injury (odds ratio (OR)=0.28, 95% confidence interval (CI): 0.11-0.71; p=0.008) and Frey syndrome (OR=0.12, 95% CI: 0.03-0.48; p=0.003) were less prevalent in the ECD group. The rates of permanent facial nerve injury (OR=0.77, 95% CI: 0.35-1.70; p=0.520), recurrence rate (OR=0.17, 95% CI: 0.02-1.75; p=0.14), infection (OR=0.70, 95% CI: 0.07-6.67; p=0.76), and salivary fistula/sialocele (OR=0.40, 95% CI: 0.06-2.66; p=0.350) were similar in both groups. Although there was a trend that ECD showed a reduced risk for complications, the present results are not sufficient to conclude that ECD is more beneficial than PSP.

Intermartensitic Transformation and Enhanced Exchange Bias in Pd (Pt) -doped Ni-Mn-Sn alloys

In this work, we studied the phase transitions and exchange bias of Ni_50−xMn₃₆Sn₁₄T_x (T = Pd, Pt; x = 0, 1, 2, 3) alloys. An intermartensitic transition (IMT), not observed in Ni₅₀Mn₃₆Sn₁₄ alloy, was induced by the proper application of negative chemical pressure by Pd(Pt) doping in Ni_50−xMn₃₆Sn₁₄T_x (T = Pd, Pt) alloys. IMT weakened and was suppressed with the increase of applied field; it also disappeared with further increase of Pd(Pt) content (x = 3 for Pd and x = 2 for Pt). Another striking result is that exchange bias effect, ascribed to the percolating ferromagnetic domains coexisting with spin glass phase, is notably enhanced by nonmagnetic Pd(Pt) addition. The increase of unidirectional anisotropy by the addition of Pd(Pt) impurities with strong spin-orbit coupling was explained by Dzyaloshinsky-Moriya interactions in spin glass phase.

Critical role of calcium overloading in cadmium-induced apoptosis in mouse thymocytes

Cadmium (Cd) is a well-known environmental carcinogen and immunotoxin. Currently the direct cytotoxic effects of Cd on thymocytes are largely unexplored. The main objective of the present study was to investigate the apoptogenic property of Cd and the mechanisms involved, using primary cultured mouse thymocytes as a model. Cd-induced apoptosis in thymocytes was studied by TdT-mediated dUTP nick end-labeling assay and DNA gel electrophoresis. The results showed that Cd was able to cause apoptosis in mouse thymocytes in a time- and dose-dependent manner. Moreover, Cd exposure led to a rapid and sustained intracellular calcium (Ca2+) elevation, followed by caspase-3 activation and PARP cleavage, all of which preceded the characteristic DNA fragmentation. BAPTA-AM, a specific intracellular Ca2+ chelator, abolished Cd-induced Ca2+ overloading and subsequently inhibited caspase-3 activation, PARP cleavage, and apoptosis. It is believed that intracellular Ca2+ elevation may trigger caspase-3 activation either through mitochondria or through activation of Ca2+-dependent protease in Cd-treated thymocytes. Results from this study thus provide new information for a better understanding of the immunotoxic and immunomodulatory effects of Cd.

[The retrosigmoid approach surgery of trigeminal never]

OBJECTIVE

To explore the effect of retrosigmoid approach surgery of trigeminal never to treat trigeminal neuralgia.

METHOD

Twenty-six patients underwent the selective trigeminal neurectomy, among them 2 cases of surgical removal of the cerebellopontine angle cholesteatoma and 2 cases of trigeminal never branch No. I splitting; four patients underwent microvascular decompression.

RESULT

By 1-7 years of following up, only one case of microvascular decompression recurrence in all successful operations.

CONCLUSION

The effect of retrosigmoid approach surgery of trigeminal never is satisfactory. To know the management of the complications is very important too.

Translocation (12;14) in lipoma: a case report and review of the literature

We report a case of an intramuscular lipoma with the following karyotype: 46,XY,t(12;14) (q14-15;q24). To our knowledge, this is the third report of a t(12;14) as a sole abnormality in a lipoma.

[Effect of NO-like relaxing factor (NO-LRF) in rat tourniquet shock]

On tourniquet shock (ToS) rat model, it was found that the reactivity of isolated perfused aortic ring to noradrenaline was decreased, while the cGMP content of the aortic tissue was increased. These ToS-induced changes could be potentiated or attenuated respectively by perfusion with NO-precursor, L-arginine, or NO-synthesis inhibitor L-NNA independent of the presence of vascular endothelium. Guanylate cyclase inhibitor, methylene blue, could also attenuate the aortic reactivity. All these results suggest that the aortic musculature can produce a NO-LRF factor capable of lowering the vascular reactivity of the ToS animals. That L-arginine can ameliorate while L-NNA can exacerbate ToS, suggest that NO-LRF do play an adaptive role in the protective mechanism of the organism during ToS.

[Role of endothelin in the pathogenesis of rat experimental hypertension produced by aorta narrowing and saline uptake]

Endothelin is a bioactive polypeptide released from vascular endothelium, which has a strong action promoting vascular contraction, proliferation and hypertrophy of vascular smooth muscle cells. The present investigation was performed on the hypertensive rat produced by narrowing abdominal aorta and drinking saline. It was observed that the level of plasma endothelin in the hypertensive rats was doubled (9.70 +/- 0.68 vs. sham group 4.11 +/- 0.33 pg/ml, P < 0.01), and administration of specific endothelin-antiserum into hypertensive rats significantly attenuated the increase in the blood pressure (18.97 + 1.32 vs. 27.33 + 0.09 kPa in untreated hypertensive rats, P < 0.01), and dramatically ameliorated malfunction resulting from myocardial hypertrophy. The results suggest that endothelin is an important factor in the pathogenesis of hypertension, and that inhibition of endothelin action may be a new effective way in prevention and therapy of hypertension.

Renal metastases of choriocarcinoma. A clinicopathological study of 31 cases

From 1949 through 1978, 31 patients with renal metastasis were diagnosed in a total of 448 cases of choriocarcinoma admitted to our hospital, giving an incidence of 6.9%. Renal metastasis was invariably preceded by pulmonary metastases and usually accompanied by other visceral metastases, indicating that renal metastasis is the result of dissemination of tumor cells secondarily from lung metastasis through the general circulation and should be categorized as arterial metastasis. Pyelogram is useful in the presence of medullary invasion by the tumor. Renal metastatic tumors are very sensitive to chemotherapy. Good response to chemical agents may be due to high drug concentration attained in the kidney tissue during excretion. Since successful treatment of renal metastasis by chemotherapy alone may be obtained, patients can be spared a major operation without jeopardizing the prognosis.

Clinical significance of hysterography in the diagnosis of choriocarcinoma and invasive mole

From 1963 through 1988, a total of 194 hysterographies were performed for 111 patients. Three types of abnormalities were observed on the hysterogram: filling defect, intramural invasion of the uterine wall by the contrast medium; and intravasation of the contrast medium into the pelvic veins. The pathology and clinical significance of three types of abnormalities were studied. The results showed that hysterography demonstrated better images than pelvic arteriography and B-scan for the diagnosis of choriocarcinoma and invasive mole, especially when combined with B-scan/or pelvic arteriography, a greater accuracy was achieved.

Pregnancy outcomes after successful chemotherapy for choriocarcinoma and invasive mole: long-term follow-up

In order to preserve the fertility of young patients with choriocarcinoma and invasive mole, chemotherapy alone was given without hysterectomy in 265 cases from 1959 through 1980. By the end of 1985, 205 patients had become pregnant after recovery, with a total of 355 pregnancies. Among these, 23 were terminated by induced abortions, 26 as miscarriages, two as ectopic gestations, two as intrauterine deaths, and three as stillbirths. Among 303 livebirths (including four sets of twins), six infants died neonatally, three of whom were found to have congenital anomalies incompatible with life, and two died during infancy. All the remaining 295 children had normal growth and development, the oldest now being 25 years of age. The rates of fetal wastage, malformations, twin pregnancies, and neonatal and infantile deaths did not deviate from the normal. Cytogenetic study of the peripheral lymphocytes of 94 of the children revealed no increase of chromosomal aberrations. The rates of recurrence of disease and of death caused by recurrence of disease in these were not increased in comparison with those in patients who underwent hysterectomy. These data indicate that treatment of malignant trophoblastic neoplasms with chemotherapy alone is compatible with the preservation of fertility in most women.