[Successful treatment of high-risk pulmonary embolism with low-dose anticoagulation: a case report]

Reperfusion is considered as the cornerstone of the treatment of high-risk pulmonary embolism (PE). However, when thrombolysis is contraindicated and surgery or interventional therapy is not available, the treatment of high-risk PE becomes very difficult. To our knowledge, there are no reports of successful treatment of high-risk PE with low-dose anticoagulation. On November 30, 2021, a 56-year-old male patient with subarachnoid hemorrhage was admitted to the emergency department of the First Affiliated Hospital of Chongqing Medical University. On the second day of admission, the patient suddenly went into shock during aneurysm clipping. After implementing D-dimer, markers of myocardial injury, echocardiography and computed tomography pulmonary angiography, a high-risk PE was diagnosed. Due to the contraindication of thrombolysis and the refusal of endovascular treatment, he was eventually cured with low-dose anticoagulation combined with vasopressors.

[Surgical treatment and prognosis analysis of hilar cholangiocarcinoma]

Objective: To investigate the surgical treatment effect and prognostic factors of hilar cholangiocarcinoma. Methods: This is an ambispective cohort study. From August 2005 to December 2022,data of 510 patients who diagnosed with hilar cholangiocarcinoma and underwent surgical resection at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively collected. In the cohort,there were 324 males and 186 females,with an age of (M (IQR)) 63(13)years (range:25 to 85 years). The liver function at admission was Child-Pugh A (343 cases,67.3%) and Child-Pugh B (167 cases,32.7%). Three hundred and seventy-two(72.9%) patients had jaundice symptoms and the median total bilirubin was 126.3(197.6) μmol/L(range: 5.4 to 722.8 μmol/L) at admission. Two hundred and fourty-seven cases (48.4%) were treated with percutaneous transhepatic cholangial drainage or endoscopic nasobiliary drainage before operation. The median bilirubin level in the drainage group decreased from 186.4 μmol/L to 85.5 μmol/L before operation. Multivariate Logistic regression was used to identify the influencing factors for R0 resection,and Cox regression was used to construct multivariate prediction models for overall survival(OS) and disease-free survival(DFS). Results: Among 510 patients who underwent surgical resection,Bismuth-Corlett type Ⅲ-Ⅳ patients accounted for 71.8%,among which 86.1% (315/366) underwent hemi-hepatectomy,while 81.9% (118/144) underwent extrahepatic biliary duct resection alone in Bismuch-Corlett type Ⅰ-Ⅱ patients. The median OS time was 22.8 months, and the OS rates at 1-,3-,5-and 10-year were 72.2%,35.6%,24.8% and 11.0%,respectively. The median DFS time was 15.2 months,and the DFS rates was 66.0%,32.4%,20.9% and 11.0%,respectively. The R0 resection rate was 64.5% (329/510), and the OS rates of patients with R0 resection at 1-,3-,5-and 10-year were 82.5%, 48.6%, 34.4%, 15.2%,respectively. The morbidity of Clavien-Dindo grade Ⅲ-Ⅴ complications was 26.1%(133/510) and the 30-day mortality was 4.3% (22/510). Multivariate Logistic regression indicated that Bismuth-Corlett type Ⅰ-Ⅲ (P=0.009), hemi-hepatectomy and extended resection (P=0.001),T1 and T2 patients without vascular invasion (T2 vs. T1:OR=1.43 (0.61-3.35),P=0.413;T3 vs. T1:OR=2.57 (1.03-6.41), P=0.010;T4 vs. T1, OR=3.77 (1.37-10.38), P<0.01) were more likely to obtain R0 resection. Preoperative bilirubin,Child-Pugh grade,tumor size,surgical margin,T stage,N stage,nerve infiltration and Edmondson grade were independent prognostic factors for OS and DFS of hilar cholangiocarcinoma patients without distant metastasis. Conclusions: Radical surgical resection is necessary to prolong the long-term survival of hilar cholangiocarcinoma patients. Hemi-hepatectomy and extended resection,regional lymph node dissection and combined vascular resection if necessary,can improve R0 resection rate.

Moral sensitivity and caring behavior in nursing interns: the mediating role of empathy

Background

The main purpose of this study is to analyze the relationship between moral sensitivity, empathy, and caring behaviors and to explore the mediating effect of empathy on moral sensitivity and caring behaviors of nursing interns.

Methods

A cross-sectional survey was conducted from August to September 2022 in which 261 nursing interns from two Grade 3A Hospitals in Xi'an participated. The questionnaires used in the survey include the General Information Questionnaire (GIQ), the Moral Sensitivity Questionnaire-Revised Version translated into Chinese (MSQ R-CV), the Chinese version of the Jefferson Empathy Scale (JSE), and the Chinese version of the Caring Behavior Inventory (C-CBI). The obtained data were analyzed through descriptive statistics, a one-way analysis of variance (ANOVA), and Pearson's correlation coefficient, and the mediating effect of empathy was tested through structural equations.

Results

The overall mean of moral sensitivity of nursing interns in two Grade 3A Hospitals in Xi'an is 40.84 ± 8.73, the overall mean of empathy is 100.51 ± 21.56, and the overall mean of caring behavior is (113.81 ± 21.05). Statistical analysis showed that there is a positive correlation between moral sensitivity and caring behavior of nursing interns (r = 0.376, p < 0.01), between their empathy and moral sensitivity (r = 0.336, p < 0.01), and between their empathy and caring behavior (r = 0.394, p < 0.01). The empathy of nursing interns has a mediated effect on the relationship between moral sensitivity and caring behavior. The mediated effect value was 0.14, accounting for 31.82% of the total effect.

Conclusion

The moral sensitivity of nursing interns can have a direct impact on predicting the caring behavior and indirect influences their caring behaviors mediated by empathy, with the latter effect being mediated by empathy. Therefore, nursing educators and hospital administrators should adopt targeted interventions to improve the moral sensitivity and empathy of nursing interns, which can further prove to be beneficial in improving their caring behaviors, leading to enhanced quality of nursing care and reduced nurse-patient conflicts and finally to a stabilized nursing team.

[Preliminary clinical application of novel magnetic navigation and ultrasound-guided percutaneous transhepatic cholangiography drainage through the right liver duct for malignant obstructive jaundice]

Objective: To analyze the clinical application value of a novel magnetic navigation ultrasound (MNU) combined with digital subtraction angiography (DSA) dual-guided percutaneous transhepatic biliary drainage (PTCD) through the right hepatic duct for the treatment of malignant obstructive jaundice. Methods: Randomized controlled trial. The clinical data of 64 patients with malignant obstructive jaundice requiring PTCD through the right hepatic duct at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province People's Hospital) from December 2018 to December 2021 were retrospectively analyzed. The MNU group (n=32) underwent puncture guided by a novel domestic MNU combined with DSA, and the control group (n=32) underwent puncture guided by traditional DSA. The operation time, number of punctures, X-ray dose after biliary stenting as shown by DSA, patients' tolerance of the operation, success rate of the operation, pre- and post-operative total bilirubin, and incidence of postoperative complications were compared between the two groups. Results: The operation time of the MNU group was significantly shorter than that of the control group [(17.8±7.3) vs. (31.6±9.9) min, t=-6.35,P=0.001]; the number of punctures in the MNU group was significantly lower [(1.7±0.6) vs. (6.3±3.9) times, t=-6.59, P=0.001]; and the X-ray dose after biliary stenting as shown by DSA in the MNU group was lower than that in the control group [(132±88) vs. (746±187) mGy, t=-16.81,P<0.001]; Five patients in the control group were unable to tolerate the operation, and two stopped the operation, however all patients in the MNU group could tolerate the operation, and all completed the operation, with a success rate of 100% (32/32) in the MNU group compared to 93.8%(30/32) in the control group; the common complications of PTCD were biliary bleeding and infection, and the incidence of biliary bleeding (25.0%, 8/32) and infection (18.8%, 6/32) in the MNU group was significantly lower than that in the control group, 53.1% (17/32) and 28.1% (9/32), respectively. Conclusion: Magnetic navigation ultrasound combined with DSA dual-guided PTCD through the right biliary system for the treatment of malignant obstructive jaundice is safe and feasible.

[Clinical characteristics of programmed cell death-1 inhibitor-associated hypophysitis]

Objective: To explore the clinical features of programmed cell death-1 (PD-1) inhibitor-associated hypophysitis and improve the understanding of the disease. Methods: For the present retrospective case series study, the clinical data of patients with PD-1 inhibitor-associated hypophysitis who were treated at the Affiliated Hospital of Hebei University and the 3rd Hospital of Hebei Medical University from January 2020 to May 2023 were collected for analysis of clinical manifestations and prognosis. Results: Fifteen cases of PD-1 inhibitor-induced hypophysitis were included, with 13 males and 2 females. The mean age of onset was (62.1±7.5) years, and the median time of onset was 6.5 (4.7, 11.6) cycles of PD-1 inhibitor. At diagnosis, 14 patients complained of gastrointestinal symptoms, and 12 patients complained of fatigue. There were 12, 1, 1, 5, and 1 cases of hyponatremia, hypokalemia, hypoglycemia, hypotension, and fever, respectively. Secondary adrenocortical insufficiency occurred in all cases. Moreover, four patients had secondary hypothyroidism, and two patients had secondary hypogonadism. Posterior pituitary hypofunction was not found. Pituitary MRI showed one case each of vacuolar sella turcica, pituitary cystic lesion, pituitary stalk slightly shifted to the left, high metabolism in the sella turcica, and pituitary abnormal signal, while no abnormalities were found in 11 cases. The follow-up time was (47.66±11.93) weeks. At the last follow-up, one patient's serum levels of adrenocorticotropic hormone and cortisol returned to normal. Conclusions: Hypophysitis associated with PD-1 inhibitors occurs later, and gastrointestinal symptoms and fatigue are the most common clinical manifestations. PD-1 inhibitor-associated hypophysitis mainly manifests as adrenocortical hypofunction, and some cases manifest as hypothyroidism and hypogonadism. In addition, patients with PD-1 inhibitor-associated hypophysitis show no obvious imaging changes in the pituitary gland.

[Research progress in associations between dental caries and systemic diseases]

Dental caries is a bacteria-mediated, multifactorial, chronic progressive disease that results in the phasic demineralization and remineralization of dental hard tissues. In recent years, amounts of studies have focused on the association between dental caries and systemic diseases. This paper reviews the researches about associations between caries and systemic diseases. An electronic search was conducted in PubMed and Web of Science for articles published from 2003 to 2022 in the English language. Studies were included in the following ten categories of systemic diseases: cardiovascular diseases, metabolic disorders, respiratory diseases, autoimmune rheumatic diseases, neurologic diseases, gastrointestinal diseases, kidney diseases, skin diseases, iron deficiency anaemia and tumors. This review discusses the relationship between dental caries and systemic diseases, as well as the potentially involved mechanisms, providing new ideas for disease prevention, diagnosis, and treatment strategies for dentists and other clinicians.

[Prevalence of Helicobacter pylori infection and risk factors among family members in Qinghai Province, China]

Objective: To investigate the prevalence of Helicobacter pylori infection among family members, and analyze associated risk factors. Methods: The current investigation was a cross-sectional study. The Qinghai region was stratified into urban areas, agricultural areas, and pastoral areas. The urban areas of Xining City, the agricultural areas of Haidong City, and the pastoral areas of Haibei Tibetan Autonomous Prefecture were selected. A total of 396 resident families (1 131 people) who underwent health checkups from 2021 to 2022 in the above areas were included in the survey study. Questionnaires were administered and H. pylori infection was detected using the 13C-urea breath test. Numerical data were expressed as cases and percentages, and the Chi-square test was used to compare differences in H. pylori infection rates in the populations and families in each group. Multifactorial logistic regression was used to analyze risk factors for H. pylori infection, and P<0.05 was considered statistically significant. Results: The prevalence of H. pylori infection in Qinghai province was 52.8% (597/1 131) and the prevalence of H. pylori infection in households was 80.6% (319/396). In H. pylori-positive households with at least 1 infected spouse, 40.4% (36/89) had only 1 infected spouse, and in 59.6% (53/89) both spouses were infected. In analysis of children infected by parents with H. pylori, 20.0% (9/45) of households had fathers and children infected, 48.9% (22/45) had mothers and children infected, and 31.1% (14/45) had both parents and children infected. In univariate analysis there was a statistically significant difference in the overall comparison of H. pylori infection rates among families with different numbers of people living together (χ2=11.12, P=0.004), and between-group comparisons suggested that H. pylori infection rates were higher in families with 4 or 5 people and more than 5 people living together than in families with 2 or 3 people living together. The H. pylori infection rate was higher in families that did not use serving chopsticks and spoons during family meals than in families that did use serving chopsticks and spoons (χ2=6.12, P=0.013). In multifactorial logistic regression analyses the number of people living together in a family and whether or not serving chopsticks and spoons were used at family meals were associated with H. pylori infection (P<0.05). Conclusion: The H. pylori infection rate in families in Qinghai Province is high, and there is a clear association with family aggregation. It is more common for both members of a couple to be infected, and H. pylori infection of a mother has a greater effect on the children's infection status than H. pylori infection of a father. The infection rate of H. pylori was lower in families that used serving chopsticks and spoons during dinner gatherings, and the fewer the number of people living together in the family, the lower the H. pylori infection rate.

[Analysis of the efficacy and influencing factors of sodium channel blockers in the treatment of focal epilepsy in infants under 6 months of age]

Objective: To analyze the efficacy and safety of the sodium channel blockers (SCB) antiseizure medication in the treatment of focal epilepsy in infants under 6 months of age. Methods: This was a case series study. Infants with focal epilepsy with onset within 6 months of age and treated with SCB attending the Department of Neurology of Beijing Children's Hospital from June 2016 to April 2022 were collected. The clinical data, auxiliary examinations, SCB application, efficacy, adverse reactions, and prognosis were analyzed retrospectively. Patients were grouped according to type of seizure and epileptic syndrome, age of onset and etiology. Chi square test and Fisher exact test were used to analyze the differences between groups statistically. Results: A total of 118 infants were enrolled, 65 males and 53 females, with an age of epilepsy onset of 56 (4, 114) days. Developmental and epileptic encephalopathy was diagnosed in 60 infants, 39 had self-limited neonatal and (or) infantile epilepsy, and 19 had non-syndromic focal epilepsy. Application of SCB: 106 used oxcarbazepine, 2 used lacosamide, 9 switched from oxcarbazepine to lacosamide or a combination of 2 SCB, and 1 used oxcarbazepine, lacosamide, and lamotrigine successively; oxcarbazepine was the first choice in 46 cases. The age at which SCB was applied was 103 (53, 144) days. The children were followed up for 6 months to 6 years. SCB was effective in 89 cases (75.4%), including 70 cases (59.3%) who achieved seizure freedom. The seizure-free rate was higher in the focal epilepsy only group than in the group with other seizure types (64.4% (65/101) vs. 4/17, χ²=9.99, P<0.05). The responder and seizure-free rates were all higher in the group with the onset age of >3-6 months than the group >1-3 months (84.4% (38/45) vs. 62.5% (20/32), 73.3% (33/45) vs. 46.9% (15/32), χ²=4.85 and 5.58, both P<0.05). With the exception of variants in the PRRT2 gene, those with variants in sodium or potassium channels had higher responder and seizure-free rates than those with variants in other genes(86.2% (25/29) vs. 45.5% (10/22), 62.1% (18/29) vs. 22.7% (5/22), χ²=9.65 and 7.82,both P<0.05). The most common adverse event was transient hyponatremia, which happened in 66 cases (55.9%). There were 9 cases of rash, which subsided in 6 cases after discontinuing oxcarbazepine and switching to lacosamide, and 7 cases of electrocardiogram abnormalities, which improved after withdrawing oxcarbazepine and changing to lacosamide in 1 case. Conclusion: SCB are effective and tolerable in the treatment of focal epilepsy in infants under 6 months of age, with better efficacy in patients with genetic variants of the sodium or potassium channel, focal seizures only, and seizure onset >3-6 months of age.

Comparison of Supraclavicular Surgery plus Radiotherapy vs. Radiotherapy Alone in Breast Cancer Patients with Synchronous Ipsilateral Supraclavicular Lymph Node Metastasis: A Multicenter Retrospective Study

PURPOSE/OBJECTIVE(S)

To evaluate and compare the outcomes of supraclavicular lymph node dissection (SLND) plus radiotherapy (RT) and RT alone for patients with synchronous ipsilateral supraclavicular lymph node metastasis (sISLM).

MATERIALS/METHODS

In all, 293 patients with sISLM across three centers were included. Of these, 85 (29.0%) received SLND plus RT and 208 (71.0%) received RT alone. All patients received preoperative systemic therapy followed by mastectomy or lumpectomy and axillary dissection. Supraclavicular recurrence-free survival (SCRFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated by using the Kaplan-Meier method and multivariate Cox models. Multiple imputation was used for missing data.

RESULTS

The median follow-up duration of the RT and SLND+RT groups were 53.7 and 63.5 months, respectively. For the RT and SLND+RT groups, the 5-year SCRFS rates were 91.7% vs. 85.5% (P = 0.522), LRRFS rates were 79.1% vs. 73.1% (P = 0.412), DMFS rates were 60.4 vs. 58.8% (P = 0.708), DFS rates were 57.6% vs. 49.7% (P = 0.291), and OS rates were 71.9% vs. 62.2% (P = 0.272), respectively. There was no significant effect on any outcome when comparing SLND+RT versus RT alone in the multivariate analysis. Based on four risk factors of DFS, patients were classified into three risk groups: the intermediate- and high-risk groups had significantly lower survival outcomes than the low-risk group. SLND+RT did not improve outcomes of any risk group compared with RT alone.

CONCLUSION

Patients with sISLM may not benefit from SLND. Distant metastasis remained the major failure pattern, especially for intermediate- and high-risk groups with sISLM may not benefit from SLND. Distant metastasis remained the major failure pattern, especially for intermediate- and high-risk groups.

The Lyman Normal Tissue Complication Probability Model and Risk Prediction for Temporal Lobe Injury after Re-Irradiation in Patients with Recurrent Nasopharyngeal Carcinoma

PURPOSE/OBJECTIVE(S)

The risk of temporal lobe injury (TLI) in recurrent nasopharyngeal carcinoma (rNPC) patients with intensity-modulated radiation therapy (IMRT) is high. We aimed to construct the normal tissue complication probability (NTCP) model for TLI of rNPC and establish a risk predictive model.

MATERIALS/METHODS

We retrospectively analyzed 103 patients with rNPC who had received two courses of IMRT in our institution. The 206 temporal lobes (TLs) of these patients were randomly divided into a training (n = 144) and validation group (n = 62). We determined the mean value of the following parameters to construct the Lyman NTCP model: TD50(1) (the dose with a 50% probability of complications to an organ when all volumes are irradiated), m [steepness of the dose-response at TD50(1)], and n (the parameter related to volume effect). The most predictive dosimetric parameter and clinical variables were integrated in Cox proportional hazards models. A nomogram was developed for predicting risk of TLs.

RESULTS

The parameters of the fitted NTCP model were TD50(1) = 107.84 Gy (95% confidence interval (CI), [97.15, 118.54]), m = 0.16 (95% CI, [0.14, 0.19]), and n = 0.04 (95% CI, [0.01, 0.06]). The cumulative dose delivered to 0.1 cm3 of temporal lobe volume (D0.1cc-c) was the most predictive dosimetric parameter for TLI. The Kaplan-Meier curves showed a significant difference in 2-year TLI-free survival among different risk groups according to the total score of nomograms.

CONCLUSION

The TD50(1) of TLI in patients with rNPC is 107.84 Gy in Lyman NTCP model. The nomogram model can accurately predict the risk of TLI for individual.

Lymphocyte Count Kinetics and the Effect of Different Radiotherapy Techniques on Radiation-Induced Lymphopenia in Patients with Breast Cancer Receiving Hypofractionated Postmastectomy Radiotherapy

PURPOSE/OBJECTIVE(S)

Radiation-induced lymphopenia (RIL) is associated with poor prognosis in solid tumors. This study aimed to describe the lymphocyte kinetics in patients with breast cancer receiving hypofractionated postmastectomy radiotherapy (RT) and to investigate the association of different RT techniques with RIL.

MATERIALS/METHODS

We assessed 607 patients who received hypofractionated postmastectomy RT for breast cancer in our prospective clinical database from 8 hospitals. All patients received irradiation to the chest wall and supraclavicular fossa. RT techniques included integrated RT with the photon-based intensity modulated techniques to irradiate all target volumes (integrated RT) and a hybrid approach combining photon irradiation to supraclavicular nodes and electron irradiation to the chest wall (hybrid RT). Peripheral lymphocyte counts (PLC) were tested prior to RT (baseline), weekly during RT, at 1, 2 weeks, 3, 6 months after RT, and then every 6 months. Grade 3+ RIL was defined as PLC nadir during RT of <0.5 ×103/ml. Mean PLC was compared by the t test. Univariate, multivariate, and propensity score matching (PSM) analyses were used to evaluate the effect of different RT techniques on grade 3+ RIL.

RESULTS

During RT, 121 (19.9%) of patients had grade 3+ RIL. The PLC started to recover at 1 week and reached baseline levels 1 year after RT. A greater proportion of the patients treated with the integrated RT (90/269, 33.5%) developed grade 3+ PLC compared with those receiving hybrid RT (31/338, 9.2%, P < 0.001). After conducting PSM, multivariate analyses showed lower baseline PLC (HR = 0.15, P<0.001) and RT technique (the integrated RT vs. hybrid RT, HR = 4.76, P<0.001) were independent risk factors for grade 3+ RIL. The PLC in patients receiving the integrated RT after RT were higher than that in those receiving hybrid RT (p<0.05).

CONCLUSION

RT technique affect the risk of and recovery from RIL, which may impact survival. Choosing appropriate RT technique to minimize RIL might be considered to benefit their outcomes.

Quality Assurance in a Phase III, Multicenter, Randomized Trial of POstmastectomy radioThErapy in Node posiTive Breast Cancer with or without Internal mAmmary nodaL Irradiation (POTENTIAL): A Planning Dummy Run

PURPOSE/OBJECTIVE(S)

To report the planning dummy run results of the POstmastectomy radioThErapy in Node posiTive breast cancer with or without Internal mAmmary nodaL irradiation (POTENTIAL) trial-a multicenter, randomized, phase 3 trial-to evaluate postmastectomy radiotherapy, with or without internal mammary nodal irradiation, for patients with high-risk breast cancer.

MATERIALS/METHODS

All participating institutions were provided the contours of the dummy run case, and they generated radiotherapy (RT) plans per protocol guidelines. The plans were reviewed and feedback were provided by the quality assurance team, after which the institutions resubmitted revised plans. The information on beams arrangement, skin flash, inhomogeneity corrections, and protocol compliance was assessed both in the primary and final submission.

RESULTS

Theplans from 26 institutions were included in the analysis. A number of major deviations were found in the primary submission, such as less strict constraint on organs at risk (OARs) V5Gy, and no application of chest wall skin flash. The protocol compliance rates of the dose coverage for the planning target volume of the chest wall (PTVcw), PTV of supra/infraclavicular fossa plus axilla levels I, II, III (PTVsc+ax), and PTV of the IMN region (PTVim) were all significantly improved in the final submission compared with those in the primary submission, which were 96.2% vs. 69.2%, 100% vs. 76.9%, and 88.4% vs. 53.8, respectively. For OARs, the protocol compliance rates of heart Dmean, left anterior descending coronary artery V40Gy, ipsilateral lung V5Gy, and stomach V5Gy were significantly improved.

CONCLUSION

All major deviations were corrected and protocol compliance was significantly improved and of high level in the final submission. Moreover, the variations were reduced. Therefore, a planning dummy run was essential to guarantee good RT plan quality and inter-institutional consistency for multicenter trials.

[Comparison of efficacy and safety of transurethral thulium laser vapoenucleation of prostate and transurethral thulium laser enucleation of prostate in the treatment of benign prostatic hyperplasia]

Objective: To compare early outcomes between transurethral thulium laser vapoenucleation of prostate and transurethral thulium laser enucleation of prostate for the treatment of benign prostatic hyperplasia (BPH). Methods: Retrospective analysis was conducted on the clinical data of 1 638 BPH patients admitted to the Department of Urology of Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine from January 2018 to December 2021. There were 916 patients underwent transurethral thulium laser vapoenucleation of prostate (ThuVEP group) and 722 patients underwent transurethral thulium laser enucleation of prostate (ThuLEP group). The operation time, eliminated tissue weight, surgical complications, duration of post-operative catheter implantation were compared between the two groups. The improvement of International Prostate Symptom Score (IPSS), Quality of Life Index (QoL), maximum uroflow rate (Qmax) and post-void residual urine volume (PVR) at 1 month after operation was compared between the two groups. Results: There were no significant differences in age, preoperative and 1-month postoperative prostate volume, IPSS score, QoL score, Qmax, and PVR between the ThuVEP and ThuLEP group (all P>0.05). There were no significant differences in perioperative indicators such as operation time, cutting or enucleation time, tissue crushing time, tissue weight, hemoglobin change, catheter indwelling time, and postoperative hospital stay between ThuVEP group and ThuLEP group (all P>0.05). The incidence of minor gross hematuria after extubation in the ThuVEP group was 7.8% (56/916), which was lower than 9.4% (65/722) in the ThuLEP group (P=0.026); the incidence of temporary incontinence at 1 month after surgery was 5.2% (38/916) in ThuVEP group, lower than 11.9% (86/722) in ThuLEP group (P<0.001). A total of 3 patients (0.4%) in ThuLEP group required operative intervention for severe post-operation bleeding, but none of ThuVEP group suffered from this kind of surgical complications. Conclusions: ThuVEP has similar efficacy with ThuLEP for the treatment of BPH. ThuVEP can significantly reduce the incidence of post-operation temporary urine incontinence, and has much superiority in stanching bleeding.

[Clinical characteristics of patients with colon complications after necrotizing pancreatitis: a retrospective cohort study]

Objective: To investigate the clinical characteristics of colon complications in patients with necrotizing pancreatitis(NP). Methods: The clinical data of 403 patients with NP admitted to the Department of General Surgery,Xuanwu Hospital, Capital Medical University from January 2014 to December 2021 were retrospectively analyzed. There were 273 males and 130 females,aged (49.4±15.4) years(range: 18 to 90 years). Among them,there were 199 cases of biliary pancreatitis,110 cases of hyperlipidemic pancreatitis,and 94 cases of pancreatitis caused by other causes. A multidisciplinary diagnosis and treatment model was used to diagnose and treat patients. Depending on whether the patients had colon complications,they were divided into colon complications group and noncolon complications group. Patients with colon complications were treated with anti-infection therapy,parental nutritional support,keeping the drainage tube unobstructed,and terminal ileostomy. The clinical results of the two groups were compared and analyzed using a 1∶1 propensity score match(PSM) method. The t test,χ² test, or rank-sum test was used to analyze data between groups,respectively. Results: The incidence of colon complications was 13.2%(53/403),including 15 cases of colon obstruction,23 cases of colon fistula,and 21 cases of colon hemorrhage. After PSM,the baseline and clinical characteristics at admission of the two groups of patients were comparable (all P>0.05). In terms of clinical outcome,compared to patients with NP without colon complications,the number of patients with colon complications who received minimally invasive intervention(88.7%(47/53) vs. 69.8%(37/53),χ²=5.736,P=0.030),the number of minimally invasive interventions (M(IQR))(2(2) vs. 1(1), Z=4.638,P=0.034),the number of patients with multiple organ failure(45.3%(24/53) vs. 32.1%(17/53),χ²=4.826,P=0.041),and the number of extrapancreatic infections(79.2%(42/53) vs. 60.4%(32/53),χ²=4.476,P=0.034) increased significantly. The time required for enteral nutrition support(8(30)days vs. 2(10) days, Z=-3.048, P=0.002), parental nutritional support(32(37)days vs. 17(19)days, Z=-2.592, P=0.009),the length of stay in the ICU(24(51)days vs. 18(31)days, Z=-2.268, P=0.002),and the total length of stay (43(52)days vs. 30(40)days, Z=-2.589, P=0.013) were also significantly prolonged. However,mortality rates in the two groups were similar(37.7%(20/53) vs. 34.0%(18/53),χ²=0.164,P=0.840). Conclusions: Colonic complications in NP patients are not rare,which can lead to prolonged hospitalization and increased surgical intervention. Active surgical intervention can help improve the prognosis of these patients.

Choroid Plexus Calcification Correlates with Cortical Microglial Activation in Humans: A Multimodal PET, CT, MRI Study

BACKGROUND AND PURPOSE

The choroid plexus (CP) within the brain ventricles is well-known to produce cerebrospinal fluid (CSF). Recently, the CP has been recognized as critical in modulating inflammation. MRI-measured CP enlargement has been reported in neuroinflammatory disorders like MS as well as with aging and neurodegeneration. The basis of MRI-measured CP enlargement is unknown. On the basis of tissue studies demonstrating CP calcification as a common pathology associated with aging and disease, we hypothesized that previously unmeasured CP calcification contributes to MRI-measured CP volume and may be more specifically associated with neuroinflammation.

MATERIALS AND METHODS

We analyzed 60 subjects (43 healthy controls and 17 subjects with Parkinson's disease) who underwent PET/CT using 11C-PK11195, a radiotracer sensitive to the translocator protein expressed by activated microglia. Cortical inflammation was quantified as nondisplaceable binding potential. Choroid plexus calcium was measured via manual tracing on low-dose CT acquired with PET and automatically using a new CT/MRI method. Linear regression assessed the contribution of choroid plexus calcium, age, diagnosis, sex, overall volume of the choroid plexus, and ventricle volume to cortical inflammation.

RESULTS

Fully automated choroid plexus calcium quantification was accurate (intraclass correlation coefficient with manual tracing = .98). Subject age and choroid plexus calcium were the only significant predictors of neuroinflammation.

CONCLUSIONS

Choroid plexus calcification can be accurately and automatically quantified using low-dose CT and MRI. Choroid plexus calcification-but not choroid plexus volume-predicted cortical inflammation. Previously unmeasured choroid plexus calcium may explain recent reports of choroid plexus enlargement in human inflammatory and other diseases. Choroid plexus calcification may be a specific and relatively easily acquired biomarker for neuroinflammation and choroid plexus pathology in humans.

[Genotype-environment interaction on arterial stiffness: A pedigree-based study]

OBJECTIVE

To utilized the baseline data of the Beijing Fangshan Family Cohort Study, and to estimate whether the association between a healthy lifestyle and arterial stiffness might be modified by genetic effects.

METHODS

Probands and their relatives from 9 rural areas in Fangshan district, Beijing were included in this study. We developed a healthy lifestyle score based on five lifestyle behaviors: smoking, alcohol consumption, body mass index (BMI), dietary pattern, and physical activity. The measurements of arterial stiffness were brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI). A variance component model was used to determine the heritability of arterial stiffness. Genotype-environment interaction effects were performed by the maximum likelihood methods. Subsequently, 45 candidate single nucleotide polymorphisms (SNPs) located in the glycolipid metabolism pathway were selected, and generalized estimated equations were used to assess the gene-environment interaction effects between particular genetic loci and healthy lifestyles.

RESULTS

A total of 6 302 study subjects across 3 225 pedigrees were enrolled in this study, with a mean age of 56.9 years and 45.1% male. Heritability of baPWV and ABI was 0.360 (95%CI: 0.302-0.418) and 0.243 (95%CI: 0.175-0.311), respectively. Significant genotype-healthy diet interaction on baPWV and genotype-BMI interaction on ABI were observed. Following the findings of genotype-environment interaction analysis, we further identified two SNPs located in ADAMTS9-AS2 and CDH13 might modify the association between healthy dietary pattern and arterial stiffness, indicating that adherence to a healthy dietary pattern might attenuate the genetic risk on arterial stiffness. Three SNPs in CDKAL1, ATP8B2 and SLC30A8 were shown to interact with BMI, implying that maintaining BMI within a healthy range might decrease the genetic risk of arterial stiffness.

CONCLUSION

The current study discovered that genotype-healthy dietary pattern and genotype-BMI interactions might affect the risk of arterial stiffness. Furthermore, we identified five genetic loci that might modify the relationship between healthy dietary pattern and BMI with arterial stiffness. Our findings suggested that a healthy lifestyle may reduce the genetic risk of arterial stiffness. This study has laid the groundwork for future research exploring mechanisms of arterial stiffness.

Development of a novel piezoelectric-driven non-resonant elliptical vibrator with adjustable characteristics

Aiming at the fabrication of a micro-textured surface, a novel piezoelectric-driven non-resonant elliptical vibrator is proposed in this paper; the output characteristics could be adjusted by the length change of the tool holder. The flexible mechanism is the primary structure of the vibrator, which includes a lever type mechanism, an enhanced Scott-Russell mechanism, and a T-shaped mechanism. The former two mechanisms are used to enlarge the output of the piezoelectric actuator, and the T-shaped mechanism is applied to transfer the parallel movements to the elliptical trajectory. The theoretical models including the elliptical trajectory, output stiffness, and resonant frequencies are established to investigate the impacts of the tool holder and controlling signals on the output characteristics of the vibrator, which are further validated using the finite element analysis method. A prototype is developed by integrating the non-resonant elliptical vibrator assembly and controlling system. Some experiments are carried out to verify the basic performance and the adjustable properties of the vibrator.

[Hepatic pathological characteristics and factors influencing alanine transaminase value below twice the upper limit of normal in patients with chronic hepatitis B]

Objective: To analyze the hepatic pathological characteristics and factors influencing an alanine transaminase value below twice the upper limit of normal in patients with chronic hepatitis B (CHB) and further explore the optimal ALT threshold strategy for initiating antiviral therapy. Methods: Clinical data of treatment-naïve CHB patients who underwent liver biopsies from January 2010 to December 2019 were retrospectively collected. Multiple regression models were used to explore the ALT levels and significant risk of hepatic histological changes (≥G2/S2). Receiver operating characteristic curve was used to evaluate the value of different models in diagnosing liver tissue inflammation≥G2 or fibrosis ≥ S2. Results: A total of 447 eligible CHB patients, with a median age of 38.0 years and 72.9% males, were included. During ALT normalization, there was significant liver inflammation (≥G2) and fibrosis (≥S2) in 66.9% and 53.0% of patients, respectively. With an ALT rise of 1-2×ULN, the proportions of liver inflammation≥G2 and fibrosis≥S2 were 81.2% and 60.0%, respectively. After adjusting for confounding factors, higher ALT levels (> 29 U/L) were found to be associated with significant liver inflammation (OR: 2.30, 95% CI: 1.11 ~ 4.77) and fibrosis (OR: 1.84, 95% CI: 1.10 ~ 3.09). After the measurement of glutamyltransferase-platelet ratio (GPR), the proportion of CHB patients with≥G2/S2 was significantly reduced under different treatment thresholds of ALT standards, and in particular, the erroneous evaluation of liver fibrosis≥S2 was significantly improved (33.5% to 57.5%). Conclusion: More than half of CHB patients have a normal ALT or one within 2 × ULN, regardless of whether or not there is apparent inflammation and fibrosis. GPR can significantly improve the precise assessment of different conditions of treatment thresholds for the ALT value in CHB patients.

[Current status and future perspectives on the methods of prognosis evaluation for intrahepatic cholangiocarcinoma]

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary malignant tumor in the liver after hepatocellular carcinoma. Its incidence and mortality rates have increased worldwide in recent years. Surgical resection is the best treatment modality for ICC;however,the overall prognosis remains poor. Accurate evaluatiion of post operative prognosis allows personalized treatment and improved long-term outcomes of ICC. The American Joint Commission on Cancer TNM staging manual is the basis for the standardized diagnosis and treatment of ICC;however,the contents of stage T and stage N need to be improved. The nomogram model or scoring system established in the analysis of commonly used clinicopathological parameters can provide individualized prognostic operative and improve prediction accuracy;however,more studies are needed to validate the results before clinical use. Meanwhile,imaging features exhibit great potential to establish the post operative prognosis evaluation system for ICC. Molecular-based classification provides an accurate guarantee for prognostic assessment as well as selection of populations that are sensitive to targeted therapy or immunotherapy. Therefore,the establishment of a prognosis evaluation system,based on clinical and pathological characteristics and centered on the combination of multidisciplinary and multi-omics,will be conducive to improving the long-term outcomes of ICC after surgical resection in the context of big medical data.

[The role of the high-level public health school in the development of the Center for Disease Control and Prevention]

The Ministry of Education and other four departments jointly issued the Notice on the Construction of high-level schools of public Health, proposing that "it will take ten years to build a number of high-level schools of public health, and form a high-quality education development system to adapt to the construction of modern public health system". At present, the construction of high-level public health schools in various universities in China is in full swing. The high-level School of Public Health and the CDC have played an important role in constructing the national public health system and the human health community. The high-level public health schools are of strategic significance and important value to the development of the CDC. The review presents reflections and insights on the role of high-level public health schools in the development of the CDC and the challenges they might face.

[Progress in research of risk prediction of non-syndromic oral clefts using genetic information]

Non-syndromic oral cleft (NSOC), a common birth defect, remains to be a critical public health problem in China. In the context of adjustment of childbearing policy for two times in China and the increase of pregnancy at older childbearing age, NSOC risk prediction will provide evidence for high-risk population identification and prenatal counseling. Genome-wide association study and second generation sequencing have identified multiple loci associated with NSOC, facilitating the development of genetic risk prediction of NSOC. Despite the marked progress, risk prediction models of NSOC still faces multiple challenges. This paper summarizes the recent progress in research of NSOC risk prediction models based on the results of extensive literature retrieval to provide some insights for the model development regarding research design, variable selection, model-build strategy and evaluation methods.

[Associations between 24-hour urinary sodium excretion and all-cause mortality in adults living in north China]

Objective: To investigate the associations between 24-hour urinary sodium excretion (24hUNaE) and all-cause mortality in adult Northern Chinese population. Methods: Data from this study were derived from the prospective urban and rural epidemiology (PURE) study in north China. Baseline information of all participants were obtained by face to face interview through trained research staffs based on questionnaires, and morning fasting urine samples of participants were collected to estimate 24hUNaE and 24-hour potassium excretion (24hUKE). Multivariable frailty Cox regression models were used to explore the association between 24hUNaE (<3.00, 3.00-3.99, 4.00-4.99, 5.00-5.99 and ≥6 g/d) and all-cause death. Results: A total of 27 310 participants were included in this study. The mean 24hUNaE was (5.84±1.73) g/d. After a median follow-up of 8.8 years, 1 024 participants died (3.7%), including 390 cardiovascular related deaths and 591 non-cardiovascular related deaths. The cause of death of the remaining patients could not be determined. Using 24hUNaE level of 4.00-4.99 g/d as the reference group, after fully adjustment, 24hUNaE ≥6.00 g/d was associated with an increased risk of all-cause death (HR=1.24, 95%CI: 1.02-1.49) and cardiovascular related death (HR=1.39, 95%CI: 1.02-1.88). 24hUNaE<3.00 g/d was associated with increased risk of all-cause mortality (HR=1.38, 95%CI: 0.96-1.99). There was no significant association between 24hUNaE and non-cardiovascular related death. Furthermore, using the combination of 24hUNaE 4.00-4.99 g/d and 24hUKE≥2.11 g/d as the reference group, the highest risk occurred in participants with the combination of low sodium (<3.00 g/d) and low potassium (<2.11 g/d). Conclusion: 24hUNaE equal or higher than 6 g/d or lower than 3 g/d is associated with increased risk of all-cause mortality and cardiovascular related death in Northern Chinese population. Besides, moderate sodium intake in combination with increased potassium intake might reduce the risk of all-cause death.

[Family-based association tests for rare variants]

Next-generation sequencing has revolutionized family-based association tests for rare variants. As the lower power of genome wide association study for detecting casual rare variants, methods aggregating effects of multiple variants have been proposed, such as burden tests and variance component tests. This paper summarizes the methods of rare variants association test that can be applied for family data, introduces their principles, characteristics and applicable conditions and discusses the shortcomings and the improvement of the present methods.

[Effectiveness, safety and cost of urinary follicle stimulating hormone in controlled ovarian stimulation in China: multi-center retrospective cohort study of 102 061 in vitro fertilization cycles]

Objective: To explore the effectiveness, safety and cost between urinary follicle stimulating hormone (uFSH) and recombinant follicle stimulating hormone (rFSH) in controlled ovarian stimulation (COS) in China. Methods: Data were collected from 16 reproductive centers in China covering oocytes collection time from May 1, 2015 to June 30, 2018. Eligible patients were over 18 years old, adopting COS with uFSH (uFSH group) or rFSH (rFSH group) as start gonadotropins (Gn), and using in vitro fertilization (IVF) and (or) intracytoplasmic sperm injection for fertilisation, excluding frozen embryo recovery cycle. Generalised estimating equation was used to address the violation of independency assumption between cycles due to multiple IVF cycles for one person and clustering nature of cycles carried out within one center. Controlling variables included age, body mass index, anti-Müllerian hormone level, cause of infertility, ovulation protocol, type of fertilisation, number of embryos transferred, number of days of Gn use. Results: Totally 102 061 cycles met eligibility criteria and were included in the analyses. In terms of effectiveness, after controlling relevant unbalanced baseline characteristics, compared with rFSH group, the high oocyte retrieval (>15 oocytes was considered high retrieval) rate of uFSH group significantly decreased in gonadotropin-releasing hormone agonist protocol (OR=0.642, P<0.01) and in gonadotropin-releasing hormone antagonist protocol (OR=0.556, P=0.001), but the clinical pregnancy rate per transfer cycle and the live birth rate per transfer cycle significantly increased (OR=1.179, OR=1.169, both P<0.01) in both agonist and antagonist protocols. For safety, multiple analysis result demonstrated that in the agonist protocol, compared with rFSH group, the incidence of moderate to severe ovarian hyperstimulation syndrome of uFSH group significantly decreased (OR=0.644, P=0.002). The differences in ectopic pregnancy rate and multiple pregnancy rate between the uFSH and rFSH groups were not significant (P=0.890, P=0.470) in all patients. In terms of cost, compared with rFSH group, the uFSH group had lower total Gn costs for each patient (P<0.01). Conclusion: For patients who underwent COS, uFSH has better safety, and economic profiles over rFSH in China.

[Efficacy and safety of neoadjuvant immunotherapy for hepatocellular carcinoma]

Objective: To study the surgical safety and efficacy of preoperative neoadjuvant therapy with immune checkpoint inhibitors combined with anti-angiogenic drugs in patients with China liver cancer staging(CNLC)-Ⅱb and Ⅲa resectable hepatocellular carcinoma. Methods: The data of 129 patients with Ⅱb and Ⅲa hepatocellular carcinoma who underwent surgery at the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2020 were analyzed. All patients were divided into two groups: the neoadjuvant therapy group(n=14,13 males and 1 female,aged (55.4±12.6)years(range:34 to 75 years)) received immune combined targeted therapy before surgery,immune checkpoint inhibitor camrelizumab was administered intravenously at a dose of 200 mg each time,every 2 weeks for 3 cycles,anti-angiogenesis drug apatinib was taken orally and continuously with a dose of 250 mg for 3 weeks and the conventional surgery group(n=115,103 males and 12 females,aged (55.8±12.0)years(range:21 to 83 years)) did not receive antitumor systemic therapy before surgery. There were 3 patients with CNLC-Ⅱb,11 with CNLC-Ⅲa in the neoadjuvant group;28 patients with CNLC-Ⅱb,87 with CNLC-Ⅲa in the conventional group. Student's t test or rank-sum test was used to compare the differences between two groups for quantitative data, Fisher's exact probability method was used to compare the differences of proportions between two groups, and Log-rank test was used to compare survival differences between two groups. Results: The 1-year recurrence rate in the neoadjuvant group was 42.9%,and the 1-year recurrence rate in the conventional group was 64.0%,with a statistically significant difference between the two groups(χ²=3.850,P=0.050);The 1-year survival rate in the neoadjuvant group was 100% and that in the conventional group was 74.2%,with a statistically significant difference between the two groups(χ²=5.170,P=0.023). According to the stratified analysis of the number of tumors,for single tumor,the 1-year recurrence rate in the neoadjuvant group was 25.0%,and that in the conventional surgery group was 71.0%,and the difference between the two groups was statistically significant(χ²=5.280, P=0.022). For multiple tumors, the 1-year recurrence rate in the neoadjuvant group was 66.7%,and the 1-year recurrence rate in the conventional surgery group was 58.9%,with no significant difference between the two groups(χ²=0.110,P=0.736). The operative time,intraoperative blood loss,and postoperative hospital stay in the neoadjuvant group were similar to those in the conventional group,and their differences were not statistically significant. Conclusions: Immune checkpoint inhibitors combined with anti-angiogenic targeted drugs as a neoadjuvant therapy for resectable hepatocellular carcinoma can reduce the 1-year recurrence rate and improve the 1-year survival rate,especially for those with solitary tumor. Limited by the sample size of the neoadjuvant group,the safety of immune combined targeted therapy before surgery cannot be observed more comprehensively,and further studies will be explored.

[Development of a Ranking Tool for Scientificity, Transparency and Applicability of Clinical Practice Guidelines]

Objective: To address the limitations of existing methods and tools for evaluating clinical practice guidelines, we aimed to develop a comprehensive instrument focusing on the three main dimensions of guideline development: scientificity, transparency, applicability. We will use it to rank the guidelines according to the scores. We abbreviated it as STAR, and its reliability, validity and usability were also tested. Methods: A multidisciplinary expert working group was set up, including methodologists, statisticians, journal editors, medical professionals, and others. Scoping review, Delphi methods and hierarchical analysis were used to determine the final checklist of STAR. Results: The new instrument contained 11 domains and 39 items. Intrinsic reliability of each domain was indicated by Cronbach's α coefficient, with a average value of 0.646. The Cohen's kappa coefficients for methodological evaluators and clinical evaluators were 0.783 and 0.618. The overall content validity index was 0.905. The R2 for the criterion validity analysis was 0.76. The average score for usability of the items was 4.6, and the mean time spent to evaluate each guideline was 20 minutes. Conclusion: The instrument has good reliability, validity and evaluating efficiency, and can be used for evaluating and ranking guidelines more comprehensively.

VLCAD inhibits the proliferation and invasion of hepatocellular cancer cells through regulating PI3K/AKT axis

PURPOSE

Very-long-chain acyl-CoA dehydrogenase (VLCAD) is an essential mediator in fatty acid metabolism. The progression of human hepatocellular carcinoma (HCC) is closely associated with the disorder of energy supply. Here, we aimed to investigate the role and underlying molecule mechanism of VLCAD in pathological process of HCC.

METHODS

In this study, VLCAD was induced silencing and overexpression using small hairpin RNA (shRNA) and lentiviral-mediated vector in HCC cell lines. The proliferation of HCC cells was determined using CCK-8 assay. Transwell assay and lung metastasis were performed to analysis cell metastasis in vitro and in vivo. ECAR and OCR were used to evaluate the activity of glycolysis and mitochondrial oxidative phosphorylation.

RESULTS

Our data indicated that VLCAD was downregulated in human HCC tissues and cells. VLCAD overexpression strongly suppressed the proliferation and metastasis of HCC cells associating with the decrease of ATP accumulation and glycolysis activity. Importantly, the PI3K/AKT inhibitor LY294002 strongly abolished the role of shVLCAD in HCC cells. Our results suggested that VLCAD suppressed the growth and metastasis in HCC cells by inhibiting the activities of glycolysis and mitochondrial oxidative phosphorylation metabolism via PI3K/AKT pathway.

CONCLUSIONS

Together, present findings not only demonstrated the protective role of and molecular network of VLCAD in HCC cells but also indicated its and potential use as a target in the therapy of HCC.

[Analysis of clinical and genetic characteristics of epilepsy associated with chromosome 16p11.2 microdeletion]

Objective: To investigate the clinical and genetic characteristics of epilepsy associated with chromosome 16p11.2 microdeletion. Methods: The patients (n=10) with 16p11.2 microdeletion found in children with epilepsy treated in Beijing Children's Hospital Affiliated to Capital Medical University from January 2018 to January 2021 were collected. The clinical manifestations, gene variations and prognosis were analyzed retrospectively. Results: A total of 10 children's data were collected, including 5 male and 5 female. The onset age of epilepsy was 4.5 (4.1,5.0) months. Regarding the seizure types, 7 cases had focal seizures with secondary generalization, 2 cases had generalized seizures, and 1 case had tonic seizures and spasms. Nine cases had cluster seizure attacks and 3 cases had status epilepticus. Seven cases had focal or multifocal epileptiform discharges in interictal electroencephalogram (EEG), 3 cases had borderline or normal EEG. Brain magnetic resonance imaging showed polymicrogyria in 1 case, paraventricular leukomalacia in 1 case, delayed myelination of white matter in 3 cases, and no obvious abnormalities in the other 5 cases. The patients were followed up for 0.5-3.5 years, with 1-3 kinds of antiepileptic drugs taken orally. The case with polymicrogyria still had seizures, however the other 9 cases had seizures controlled. The age of the last seizure attack was 8 (6, 12) months. There were 6 cases with mental and motor developmental delay before epilepsy onset. During the follow-up, 7 cases were retarded to varying degrees, while 3 cases had normal development. Regarding the genetic detection methods, 7 cases underwent whole exome sequencing, 2 cases underwent whole genome copy number variation detection, and 1 case underwent whole genome sequencing. The length of the 16p11.2 deletion in 10 cases ranged from 525 to 951 kb, and all contained the PRRT2 gene intact. Six cases were de novo variants, 1 case was inherited from the mother who had a history of convulsions in early childhood, and the source of variant was not verified in 3 cases, none of whose parents had relevant phenotype. Conclusions: The epilepsy associated with 16p11.2 microdeletion is mainly induced by the heterozygous deletion of PRRT2 gene in this region, however the phenotype is usually severe, and often combined with developmental and epileptic encephalopathy. Detection of copy number variation should be emphasized in children whose etiology is considered genetic but second-generation sequencing result is negative.

[Summary of tools for assessment of public health emergency response capability]

With the progress of globalization, the public health emergencies represented by major infectious diseases have become a major challenge for the public health management in China. The article briefly describes the emergency response capability assessment tools in China, and introduces two emergency response assessment tools with complete content structure and wide application in the world. Then the advantages and disadvantages of the tools are compared and discussed in order to provide reference for improvement of the assessment tools for public health emergency response capability in China.

[Progress in research of risk factors of iron deficiency and intervention in blood donors]

Long-term repeated regular blood donation may result in the loss and deficiency of iron. Epidemiological studies have indicated that blood donation frequency, demographical characteristics, and genetic factors are associated with iron deficiency. Our review summarizes the progress in research of etiology of iron deficiency in blood donors and intervention measures to provide evidence for the health management of non-remunerated blood donors in China.

[Clinical characteristics and gene analysis of GRIN2B gene related neurological developmental disorders in children]

Objective: To analyse the clinical and gene characteristics of GRIN2B gene related neurological developmental disorders in children. Methods: The data of 11 children with GRIN2B gene related neurological developmental disorders from November 2016 to February 2021 were collected from Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health and analyzed retrospectively. The clinical features, electroencephalogram (EEG), brain imaging and gene testing results were summarized. Results: Among 11 children 6 were boys and 5 were girls. Two of them were diagnosed with developmental and epileptic encephalopathy. The ages of seizures onset were 3 months and 9 months, respectively. Seizure types included epileptic spasm, tonic seizures, tonic spasm and focal seizures, and 1 patient also had startle attacks. EEG showed interictal multifocal epileptiform discharges. Both of them were added with more than 2 anti-seizure drugs, which were partially effective but could not control. They had moderate to severe mental and motor retardation. The phenotype of 9 cases was developmental delay or intellectual disability without epilepsy, age of visit 1 year to 6 year and 4 months of whom 5 cases had severe developmental delay, 2 cases had moderate and 2 cases had mild delay. Multi-focal epileptiform discharges were observed in 3 cases, no abnormality was found in 3 cases, and the remaining 3 cases did not undergo EEG examination. Ten cases underwent brain magnetic resonance imaging (MRI), 6 cases had nonspecific abnormalities and 4 cases were normal. Nine GRIN2B gene heterozygous variants were detected by next-generation sequencing in these 11 patients, 8 cases had missense variants and 1 case had nonsense variant, all of which were de novo and 3 of which were novel. Missense variants were found in 10 patients, among them 6 cases had severe developmental delay, 3 cases had moderate and 1 case had mild developmental delay, but the patient with nonsense variant showed mild developmental delay without epilepsy. Conclusions: The phenotypes of GRIN2B gene related neurological developmental disorders in children are diverse, ranging from mild intellectual impairment without epilepsy to severe epileptic encephalopathy. Patients with epileptic phenotype usually have an onset age of infancy, and spasm and focal seizures are the most common seizure types. And the epiletice episodes are refractory. Most of the patients with missense variants had severe developmental delay.

[Progress of lupus anticoagulant detection in venous thromboembolism]

Lupus anticoagulant is one of the risk factors for venous thromboembolism, and the detection of lupus anticoagulant in patients with venous thromboembolism is important for the choice of treatment options and prognosis of treatment. There was no relevant literature to analyze and summarize the application progress of lupus anticoagulant detection in venous thromboembolism. In order to deepen the understanding of such patients, and help clinicians to conduct reasonable diagnosis, treatment and management of these patients, we reviewed the relevant epidemiology, test precautions, and the value of test results in venous thromboembolism and related treatments.

[Clinical analysis of 15 patients with epileptic spasms and focal seizures as a single ictal event in neonatal period]

Objective: To investigate the phenomenon of epileptic spasms (ES) and focal seizures (FS) in a single ictal event (FS-ES phenomenon) and to study the etiology, manifestations, and prognosis of this phenomenon. Methods: The data of the 15 neonates who had ES and FS in a single ictal event, according to video-electroencephalography (VEEG) recording in Department of Neonatology of Children's Hospital of Fudan University during the period of January 2018 to December 2019, was analyzed retrospectively. Results: Of the 15 neonates, 7 were male and 8 were female. Gestational age was 39 (32-42) weeks. Birth weight was 3 100 (1 825-3 850) g. The initial onset age of convulsions was 2 (1-10) days. The age of the first discovery of FS-ES phenomenon was 25 (14-32) days. The age of seizure-free was 7(1-27) months. All of the initial seizure types were FS. The FS-ES phenomenon of 15 patients started with FS. The FS-ES phenomenon manifested in 2 forms: FS followed by ES (12 cases), ES appeared during an FS without interrupting FS (2 cases). In 1 neonate the spasm occurred in both forms. The etiology included genetic factors (9 cases), intracranial infection (1 case), abnormal brain tissue structure (2 cases), and etiology was unknown in 3 cases. All the neonates had a poor prognosis except one. Conclusions: The FS-ES phenomenon in the neonatal period starts with FS. There are various etiologies. Etiologies of most patients are genetic factors. Most of the patients have a poor prognosis.

[Efficacy of the XEN gel stent on intraocular pressure lowering in glaucoma patients]

Objective: To evaluate the efficacy and safety of the XEN gel implant in the treatment of glaucoma. Methods: It was a retrospective case series study. Eight patients (8 eyes) in the First Affiliated Hospital of Fujian Medical University from January 2020 to September 2020 were included, including six males and two females, aged 29 to 74 years. The patients treated with the XEN gel implanting for glaucoma. After detailed ophthalmic examination, all the patients met the surgical indications for the XEN gel implanting. Preoperative and postoperative intraocular pressure (IOP), anterior segment and fundus examination results, medication, and surgical complications were evaluated. Results: There were seven patients with primary open-angle glaucoma and one patient with glaucomatocyclitic syndrome. Five patients had received anti-glaucoma surgeries, and the remaining three patients had not received surgical treatment. All XEN gel stents were implanted successfully. All patients were followed up for 4 to 12 months. The preoperative maximum IOP ranged from 11 to 44 mmHg (median, 28 mmHg, 1 mmHg=0.133 kPa), and the IOP was 10 to 18 mmHg (median, 13 mmHg) at the last follow-up. Two to 4 types of medication were used for glaucoma preoperatively (median, 3), while 0 to 2 types (median, 0) were used at the last follow-up. During the follow-up, 7 cases were completely successful and only one case failed. Intraoperative hemorrhage occurred in two patients, and after effective treatment, the IOP decreased to below 20 mmHg. One patient was found to have an increased IOP with the XEN luminal obstruction, and the XEN drainage tube was recanalized. The IOP was about 10 mmHg at the last follow-up, and no anti-glaucoma drugs were used, but the surgery was assessed as failure by standard. The remaining patients had no other serious complications. Conclusion: This preliminary study shows that the XEN gel drainage may be a safe and effective treatment for patients with glaucoma. (Chin J Ophthalmol, 2021, 57: 679-684).

[Research of prognostic immunophenotypes in 163 patients of diffuse large B-cell lymphoma]

目的

筛选并分析与弥漫大B细胞淋巴瘤（DLBCL）预后相关的免疫表型，探究其预后价值。

方法

选取天津医科大学肿瘤医院2011年1月至2016年12月收治的163例DLBCL患者，免疫组织化学染色检测DLBCL常见免疫表型，COX模型探索独立于国际预后指数（IPI）影响总生存（OS）与无进展生存（PFS）的免疫表型，并分析其两两联合表达对预后的影响。

结果

多因素分析显示BCL6阴性（PFS：HR＝1.652，95％ CI 1.030～2.649，P＝0.037）、P53阳性（OS：HR＝1.842，95％ CI 1.008～3.367，P＝0.047）、BCL2强阳性（OS：HR＝2.102，95％CI 1.249～3.537，P＝0.005；PFS：HR＝2.126，95％ CI 1.312～3.443，P＝0.002）是DLBCL中独立于IPI的预后不良因素。亚组分析显示，在年龄≤60岁组患者中BCL6阴性（PFS：HR＝2.042，95％CI 1.021～4.081，P＝0.043）、P53阳性（OS：HR＝3.069，95％ CI 1.244～7.569，P＝0.015）和BCL2强阳性（OS：HR＝2.433，95％ CI 1.165～5.082，P＝0.018；PFS：HR＝3.209，95％CI 1.606～6.410，P＝0.001）对预后影响显著；在IPI 0～2分亚组患者中，BCL6阴性（OS：HR＝2.467，95％CI 1.322～4.604，P＝0.005；PFS：HR＝2.248，95％CI 1.275～3.965，P＝0.005）和BCL2强阳性（PFS：HR＝2.045，95％CI 1.119～3.735，P＝0.020）对预后影响显著。BCL6和BCL2强阳性的联合表达与DLBCL的预后相关（P＝0.005和P<0.001），BCL6阳性/BCL2非强阳性（86例）预后最好［3年OS率（71.6±4.9）％，3年PFS率（67.0±5.1）％］，BCL6阴性/BCL2强阳性（10例）预后最差［3年OS率（20.0±12.6）％，3年PFS率（10.0±9.5）％］；BCL6、P53的联合表达与DLBCL的预后差异无统计学意义（P＝0.061和P＝0.089），但生存曲线显示BCL6阳性/P53阴性的病例（98例）预后较好［3年OS率（70.6±4.7）％，3年PFS率（64.6±4.9）％］；BCL2强阳性、P53的联合表达与DLBCL的预后显著相关（P<0.001和P<0.001），BCL2强阳性/P53阳性的病例（5例）预后最差（3年OS率和PFS率均为0）；无论BCL6与P53表达如何，BCL2强阳性的病例预后均比非强阳性病例差。

结论

BCL6阴性、P53阳性、BCL2强阳性三种免疫表型单独及联合表达对DLBCL尤其是年龄≤60岁和IPI 0～2分患者的预后预测具有一定价值。

[Application value of machine learning algorithms for predicting recurrence after resection of early-stage hepatocellular carcinoma]

Objective: To compare the performance of multiple machine learning algorithms in predicting recurrence after resection of early-stage hepatocellular carcinoma(HCC). Methods: Clinical data of 882 early-stage HCC patients who were admitted to the First Affiliated Hospital of Nanjing Medical University from May 2009 to December 2019 and treated with curative surgical resection were retrospectively collected. There were 701 males and 181 females,with an age of (57.3±10.5)years(range:21 to 86 years). All patients were randomly assigned in a 2∶1 ratio, the training dataset consisted of 588 patients and the test dataset consisted of 294 patients. The construction of machine learning-based prediction models included random survival forest(RSF),gradient boosting machine,elastic net regression and Cox regression model. The prediction accuracy of the model was measured by the concordance index(C-index). The prediction error of the model was measured by the integrated Brier score. Model fit was assessed by the calibration plot. The performance of machine learning models with that of rival model and HCC staging systems was compared. All models were validated in the independent test dataset. Results: Median recurrence-free survival was 61.7 months in the training dataset while median recurrence-free survival was 61.9 months in the validation dataset, there was no significant difference between two datasets in terms of recurrence-free survival(χ²=0.029,P=0.865). The RSF model consisted of 5 commonly used clinicopathological characteristics, including albumin-bilirubin grade,serum alpha fetoprotein,tumor number,type of hepatectomy and microvascular invasion. In both training and test datasets,the RSF model provided the best prediction accuracy,with respective C-index of 0.758(95%CI:0.725 to 0.791) and 0.749(95%CI:0.700 to 0.797),and the lowest prediction error,with respective integrated Brier score of 0.171 and 0.151. The prediction accuracy of RSF model for recurrence after resection of early-stage HCC was superior to that of other machine learning models,rival model(ERASL model) as well as HCC staging systems(BCLC,CNLC and TNM staging),with statistically significant difference(P<0.01). Calibration curves demonstrated good agreement between RSF model-predicted probabilities and observed outcomes.All patients could be stratified into low-risk,intermediate-risk or high-risk group based on RSF model;statistically significant differences among three risk groups were observed in both training and test datasets(P<0.01). The risk stratification of RSF model was superior to that of TNM staging. Conclusion: The proposed RSF model assembled with 5 commonly used clinicopathological characteristics in this study can predict the recurrence risk with favorable accuracy that may facilitate clinical decision-support for patients with early-stage HCC.

Half-year follow-up of patients recovering from severe COVID-19: Analysis of symptoms and their risk factors

OBJECTIVES

To understand the sequelae of COVID-19.

METHODS

We followed up 1174 patients with severe coronavirus disease 2019 (COVID-19)who were recovered and discharged for 6 months.

RESULTS

There were 175 cases with clear IgG results 6 months after discharge, of which 82 (46.9%) were IgG (+) and 16 (9.1%) were IgG (dim+). Four hundred and forty-one participants (55.4%) had some kind of sequelae. The most common symptoms were fatigue (25.3%), sleep disorder (23.2%) and shortness of breath (20.4%). In those who had sequelae, 262 (59.4%) had more than one symptom. Critical cases were more likely to have cough (20.5% vs 11.6%, p = 0.023) and hypomnesis (15.1% vs 8.0%, p = 0.041) than severe cases. Furthermore, univariate and multivariate logistic regression analyses revealed that women are more likely to have multiple symptoms (p = 0.002), fatigue (p = 0.009) and sleep disorder (p = 0.008), whereas critical illness was found as independent risk factor for hypomnesis (p = 0.045).

CONCLUSION

Our study demonstrated the duration of antibody and sequelae of COVID-19 and compared the differences amongst different populations.

[The Ophthalmology-centered medical industry in Suzhou in the Ming and the Qing Dynasties - from the Painting Album of Cityscapes and Business]

The Painting Album of Cityscapes and Business was finished in the early Qing Dynasty with realism. This painting album described the prosperity in business and everyday life in Suzhou during the late Ming and the early Qing Dynasties. They were drawn and painted retrospectively, ie, the content of the pictures was based on existing paintings handed down. In the painting album, more than ten medical-related elements were specifically depicted, such as traditional Chinese medicine clinics and pharmacies and seven ophthalmology-related elements including one clinic specialized in ophthalmology, two spectacle shops, two people wearing eyeglasses and three blind people. Up to now, no specialized ophthalmology clinics and spectacle shops have been found in earlier literature and paintings. It can be speculated that the Painting Album of Cityscapes and Business is the earliest album of paintings depicting clinics specialized in ophthalmology and spectacle shops in China. This painting album provides important information for the study of the medical industry in Suzhou in the late Ming and the early Qing Dynasties, particularly, in terms of ophthalmology-related diagnosis and treatment.

[Imaging phenotypes of chronic obstructive pulmonary disease based on biphasic quantitative CT features]

Quantitative analysis was performed on the biphasic CT of 40 patients [43-80 (66.1±9.0) years old, including 37 males] with stable chronic obstructive pulmonary disease (COPD) to measure the percentage of emphysema (Emph%); the percentage of small airway disease (SAD%) and the square root of the wall area of hypothetical airway with internal perimeter of 10 mm (Pi10). Based on the cluster analysis of Emph%, SAD% and Pi10, the patients were divided into five imaging phenotypes including no obvious imaging abnormality type (n=11), small airway disease-dominant type (n=9), bronchial wall thickening-dominant type (n=8), emphysema-dominant type (n=6) and mixed type (n=6). Patients with the same Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade had similar degree of airflow limitation, but the lesion components were not identical. Being different from the traditional imaging classification, even in the cases of mild emphysema, they can be further divided into small airway disease-dominant type and bronchial wall thickening-dominant type according to the difference of airway disease.

[Progress in genetic epidemiology of non-syndromic cleft palate only]

One of the most common birth defects is cleft palate only (CPO) of which non-syndromic cleft palate only (NSCPO) accounts for 50%. NSCPO is a complex disease where multiple genes and environmental factors contribute to its risk. Unlike non-syndromic cleft lip with or without cleft palate (NSCL/P), previous genome-wide association studies only identified a few common genetic variations achieving genome-wide significance. This review summarizes the recent findings on genetic epidemiology of NSCPO. According to the current evidence, the candidate genes are divided into three categories: candidate genes with strong evidence, candidate genes with suggestive evidence, and candidate genes with inadequate evidence. The findings of epigenetic studies, the next generation sequencing studies, interaction analysis on NSCPO are also reviewed.

[The etiology of 340 infants with early-onset epilepsy]

Objective: To investigate the etiology of epilepsy onset before 6 months old and improve clinical understanding. Methods: The medical history, electroencephalogram, brain imaging, genetic examination and other clinical data of 340 patients who were diagnosed with epilepsy with onset under 6 months of age and were hospitalized in the Department of Neurology, Beijing Children's Hospital, Capital Medical University between January 2017 and December 2018 were retrospectively analyzed. Rank sum test was used to compare the ages of onset of different etiologic groups. Results: Of the 340 patients, 196 were males and 144 were females. The age of onset was 90.5 (48.0, 135.5) days. In the 250 (73.5%) underwent genetic test, 103 (41.2%) had pathogenic or likely pathogenic variants, involving 43 single gene variants and 2 chromosomal abnormalities. Seventy-nine patients (23.2%) had genetic etiology, 66 (19.4%) had structural etiology, 19 (5.6%) had metabolic etiology, 13 (3.8%) had multiple etiologies, and 163 (47.9%) had unknown etiology. In the 79 cases with genetic etiology, 30 single gene variants were detected, including 19 cases of PRRT2, 10 cases of KCNQ2, 7 cases of SCN1A, 6 cases of SCN2A, 6 cases of STXBP1, 5 cases of CDKL5, 2 cases of ARX, and 1 case of each of 23 gene variants. Two cases had chromosomal abnormalities which were 21-trisomy and 16p11.2 microdeletion syndrome respectively. Among the 66 cases with structural etiologies, 37 cases had acquired factors such as perinatal brain injury, 28 cases had congenital factors such as cortical malformation and 1 case was perinatal brain injury combined megalencephaly. The onset age of genetic etiology was 95 (26, 128) days, that of structural etiology was 90 (58, 30) days, and that of metabolic etiology was 57 (30, 90) days. The onset age of metabolic etiology was earlier than that of structural etiology (U=436.500, P=0.044). Conclusions: Genetic etiology is the most common defined etiology of infants with early-onset epilepsy aged 0-6 months, and there are certain differences in the age of onset between different etiologies. Proper application of genetic test is helpful to identify the etiology and guide treatment.

[Surgical treatment of primary liver cancer:a report of 10 966 cases]

Objective: To summarize the experience of surgical treatment of primary liver cancer. Methods: The clinical data of 10 966 surgically managed cases with primary liver cancer, from January 1986 to December 2019 at Hepatobiliary Center, the First Affiliated Hospital of Nanjing Medical University, were retrospectively analyzed. The life table method was used to calculate the survival rate and postoperative recurrence rate. Log-rank test was used to compare the survival process of different groups, and the Cox regression model was used for multivariate analysis. In addition, 2 884 cases of hepatocellular carcinoma(HCC) with more detailed follow-up data from 2009 to 2019 were selected for survival analysis. Among 2 549 patients treated with hepatectomy, there were 2 107 males and 442 females, with an age of (56.6±11.1) years (range: 20 to 86 years). Among 335 patients treated with liver transplantation, there were 292 males and 43 females, with an age of (51.0±9.7) years (range: 21 to 73 years). The outcomes of hepatectomy versus liver transplantation, anatomic versus non-anatomic hepatectomy were compared, respectively. Results: Of the 10 966 patients with primary liver cancer, 10 331 patients underwent hepatectomy and 635 patients underwent liver transplantation. Patients with liver resection were categorized into three groups: 1986－1995(712 cases), 1996－2008(3 988 cases), 2009‒2019(5 631 cases). The 5-year overall survival rate was 32.9% in the first group(1986－1995). The 5-year overall survival rate of resected primary liver cancer was 51.7% in the third group(2009-2019), among which the 5-year overal survival rates of hepatocellular carcinoma, intrahepatic cholangiocarcinoma and mixed liver cancer were 57.4%, 26.6% and 50.6%, respectively. Further analysis was performed on 2 549 HCC patients with primary hepatectomy. The 1-, 3-, 5-, and 10-year overall survival rates were 88.1%, 71.9%, 60.0%, and 41.0%, respectively, and the perioperative mortality rate was 1.0%. Two hundred and forty-seven HCC patients underwent primary liver transplantation, with 1-, 3-, 5-, and 10-year overall survival rates of 84.0%, 64.8%, 61.9%, and 57.6%, respectively. Eighty-eight HCC patients underwent salvage liver transplantation, with the 1-, 3-, 5-, and 10-year overall survival rates of 86.8%, 65.2%, 52.5%, and 52.5%, respectively. There was no significant difference in survival rates between the two groups with liver transplantation (P>0.05). Comparing the overall survival rates and recurrence rates of primary hepatectomy (2 549 cases) with primary liver transplantation (247 cases), the 1-, 3-, 5-, and 10-year overall survival rates in patients within Milan criteria treated with hepatectomy and transplantation were 96.3%, 87.1%, 76.9%, 54.7%, and 95.4%, 79.4%, 77.4%, 71.7%, respectively (P=0.754). The 1-, 3-, 5-year recurrence rates were 16.3%, 35.9%, 47.6% and 8.1%, 11.7%, 13.9%, respectively(P<0.01). The 1-, 3-, 5-, 10-year overall survival rates in patients with no large vessels invasion beyond the Milan criteria treated with liver resection and transplantation were 87.2%, 65.9%, 53.0%, 33.0% and 87.6%, 71.8%, 71.8%, 69.3%, respectively(P=0.003); the 1-, 3-, 5-year recurrence rate were 39.2%, 57.8%, 69.7% and 29.7%, 36.7%, 36.7%, respectively (P<0.01). The 1-, 3-, 5-, and 10-year overall survival rates in patients with large vessels invasion treated with liver resection and transplantation were 62.1%, 36.1%, 22.2%, 15.0% and 62.9%, 31.8%,19.9%, 0, respectively (P=0.387); the 1-, 3-, 5-year recurrence rates were 61.5%, 74.7%, 80.8% and 59.7%, 82.9%, 87.2%, respectively(P=0.909). Independent prognostic factors for both overall survival and recurrence-free survival rates of HCC patients treated with liver resection included gender, neoadjuvant therapy, symptoms, AST, intraoperative or postoperative blood transfusion, tumor number, tumor size, cirrhosis, macrovascular invasion, microvascular invasion, and pathological differentiation. Propensity score matching analysis of 443 pairs further showed that there was no significant difference in overall survival rate between anatomical liver resection and non-anatomical liver resection(P=0.895), but the recurrence rate of non-anatomical liver resection was higher than that of anatomical liver resection(P=0.035). Conclusions: In the past decade, the overall survival rate of HCC undergoing surgical treatment is significantly higher than before. For HCC patients with good liver function reservation, surgical resection can be performed first, and salvage liver transplantation can be performed after recurrence. The effect of salvage liver transplantation is comparable to that of primary liver transplantation. As for the choice of liver resection approaches, non-anatomical resection can reserve more liver tissue and can be selected as long as the negative margin is guaranteed.

[Clinical characteristics and survival analysis of primary intestinal extranodal NK/T-cell lymphoma, nasal type]

Objective: To retrospectively analyze the clinical features and survival analysis of primary intestinal extranodal NK/T-cell lymphoma nasal type(ENKTL). Methods: Patients with intestinal lymphoma at the First Affiliated Hospital of Air Force Military Medical University were collected from January 2009 to December 2019, and those with primary intestinal ENKTL screened. The general situation, main symptoms, ECOG scale, lactic dehydrogenase(LDH), and β(2)-microglobulin(β(2)-MG)in the serum, lesion site and form, numbers of extranodal invasion, Lugano stage, pathological features, and lifetime and survival outcomes were evaluated. Results: In total, 34 patients with confirmed diagnosis of primary intestinal ENKTL were identified. The incidence rate of primary intestinal ENKTL is 16.2% (34/210). A total of 26 patients were men and 8 were women with the median age at diagnosis of 45 (range, 20-69)years and patients younger than 60 years account for 85.3%. It included abdominal pain (76.5%), diarrhea(20.6%), hematochezia(29.4%), and abdominal mass(2.9%), 85.3% with B-symptoms, and abnormally elevated LDH in the serum(73.5%). The lesion sites included large intestine(52.9%), small intestine(29.4%), and both of them(17.7%). The lesion forms were featured by mass(8.8%), ulcer(32.4%), diffuse infiltration(2.9%), and hybrid(55.9%). Lugano stage included stage Ⅰ/Ⅱ (70.6%)24 patients and stage Ⅳ(29.4%)10 patients. About 94.1% patients were EBER positive. The median survival time was 60 days. The overall survival rate had significant differences on ECOG scale, LDH in the serum, IPI score and complications(P=0.037, 0.009, 0.002, and 0.000, respectively). Conclusion: Primary intestinal ENKTL was commonly observed in men at young or middle age, and the most common symptom was abdominal pain, often with B-symptoms, abnormally elevated LDH in the serum. The most common site was the large intestine. The lesion forms were mainly featured by the hybrid and ulcer. It seemed that patients with IPI low-risk group and without any complication would have longer survival time.

[Practice guideline for patients with osteoporosis]

In recent years, osteoporosis (OP) has become one of the main diseases affecting the health of middle-aged and elderly people in China, and the prevalence of OP has increased significantly. The clinical diagnosis and treatment guidelines for this disease are also constantly updated. The overall principles speciallyemphasise that doctors and patients need to work together to negotiate the details of the diagnosis and treatment guidelines, in order to improve the OP clinical diagnosis and treatment rate. Therefore, patients' knowledge of the disease, understanding of clinical guidelines, and cooperation with doctors to implement diagnosis and treatment plans are very important. In this study, from the most concerned issues of the patients, we established the OP patient practice guideline working group. 14 recommendations, as the OP patient practice guidelines, are proposed in accordance with the relevant principles of the "World Health Organization guidelines development manual" and the international normative process.

[Early onset epileptic encephalopathy caused by mitochondrial arginyl-tRNA synthetase gene deficiency: report of two cases and literature review]

Objective: To summarize the clinical features of two early onset epileptic encephalopathy (EOEE) patients with arginyl-tRNA synthetase (RARS2) gene variations and to review related literature. Methods: The clinical data and genetic features of two pontocerebellar hypoplasia type 6 (PCH6) patients with RARS2 variation diagnosed by the Department of Neurology, Beijing Children's Hospital from January 2017 to December 2018 were analyzed retrospectively. A literature search with "RARS2" "pontocerebellar hypoplasia type 6" and "early onset epileptic encephalopathy" as key words was conducted at China national knowledge infrastructure (CNKI), Wanfang Data Knowledge Service Platform and PubMed (up to May 2020), literature about RARS2 gene variation patients and their complete clinical data were chosen and reviewed. Results: The onset age of the two cases (1 male, 1 female) were 2 months and 29 days respectively and the early onset symptom of them was epileptic encephalopathy. The main symptoms included seizures, development delay, microcephaly and lactic acidosis. In addition to these symptoms, the female also had dyspnea, hypoglycemia and metabolic acidosis after birth. Brain magnetic resonance imaging (MRI) of the two patients were normal at first. Follow up at four-month (case 1) and eight-month (case 2) MRI showed atrophy of cerebral and cerebellar, but the pons was not affected. All four heterozygous variations in RARS2 gene revealed by whole-exome sequencing (p.Arg560His and p.Arg6His from case 1, p.Arg254Trp and p.Phe5Ser from case 2) were novel. No eligible reports were found in Chinese journals, while 17 reports were found in English literature. Excluded cases with incomplete data together with these two cases, a total of 34 patients from 20 families were found. All patients had developmental delay while 94% (32/34) patients showed the initial symptoms within 3 months, 93% (28/30) patients were diagnosed as epilepsy, 89% (25/28) patients had progressively microcephaly and 52% (16/31) cases did not show the pons atrophy on brain MRI. Twenty of 28 cases (71%) were refractory epilepsy. There were 31 types of gene variations and most of them were missense variations (21/31, 68%). Conclusions: The majority of PCH6 cases caused by RARS2 gene variation show the initial symptoms within 3 months, characterized by EOEE, most of them are refractory epilepsy, accompanied by developmental delay, microcephaly and increased lactic acid. Brain MRI indicates progressive cerebral or pontocerebellar atrophy.

[Association of Urinary Phenol Concentration and Blood Biochemical Indices in Coke Oven Workers]

Objective: To explore the association of urinary phenol concentration and blood biochemical indices in coke oven workers. Methods: From April to may 2019, we investigated 771 employing coke oven workers from a coke plant in Taiyuan city, and categorized into benzene-exposed group (n=402) and control group (n=369) based on their benzene exposures in workplace and urophenol concentrations. All subjects were interviewed face-to-face using a questionnaire including name, age (year) , gender, smoking and drinking habits, personal vocational history, working length (year) , and occupational protection, etc. Post-shift urine samples detected using a gas chromatography-hydrogen flame ionization detector. Fasting venous blood was drawn in the morning and centrifuged, the separated serum were detected the following items using an automatic blood biochemistry analyzer. Covariance and multiple linear regression were used to test the association of urinary phenol concentration and the levels of all the blood biochemical indices. Results: The subjects were predominantly males (n=719, 93.3%) , with an average age of (42.3±8.2) years and an average working length of (20.6±8.2) years. Compared with the control group, the benzene-exposed group were significantly different in age, working length of years, gender, smoking and drinking habits (P<0.05) . The median (interquartile interval) concentration of urinary phenol was 6.00 (0.00-33.00) μg/ml in the benzene-exposed group, which was significantly higher than that in the control group (P<0.05) . Covariance analysis indicated that the fasting blood glucose, total cholesterol and high density cholesterol in the benzene-exposed group were significantly reduced compared with the control group, yet the serum creatinine, serum uric acid and triglyceride were significantly increased (P<0.05) . Multiple linear regression showed that, an increase of each natural logarithm (Ln) transformed urinary phenol concentration was significantly associated with increases in serum uric acid level [9.82 (95%CI: 2.18-17.47) μmol/L] and cholesterol level[0.10 (95%CI:0.00-0.20) mmol/L]. An increase of each Ln-transformed accumulated benzene exposure levels was significantly associated with an increase in total cholesterol level[0.09 (95%CI: 0.01-0.17) mmol/L]. Conclusion: Occupational benzene exposure is possibly related to the variation of purine and total cholesterol metabolism in coke oven workers.