Naoxueshu Oral Liquid Accelerates Post-Craniotomy Hematoma Absorption in Patients: An Open-Label, Multicenter, and Randomized Controlled Trial.

OBJECTIVE: To investigate whether Naoxueshu Oral Liquid (NXS) could promote hematoma absorption in post-craniotomy hematoma (PCH) patients. METHODS: This is an open-label, multicenter, and randomized controlled trial conducted at 9 hospitals in China. Patients aged 18-80 years with post-craniotomy supratentorial hematoma volume ranging from 10 to 30 mL or post-craniotomy infratentorial hematoma volume less than 10 mL, or intraventricular hemorrhage following cranial surgery were enrolled. They were randomly assigned at a 1:1 ratio to the NXS (10 mL thrice daily for 15 days) or control groups using a randomization code table. Standard medical care was administered in both groups. The primary outcome was the percentage reduction in hematoma volume from day 1 to day 15. The secondary outcomes included the percentage reduction in hematoma volume from day 1 to day 7, the absolute reduction in hematoma volume from day 1 to day 7 and 15, and the change in neurological function from day 1 to day 7 and 15. The safety was closely monitored throughout the study. Moreover, subgroup analysis was performed based on age, gender, history of diabetes, and etiology of intracerebral hemorrhage (ICH). RESULTS: A total of 120 patients were enrolled and randomly assigned between March 30, 2018 and April 15, 2020. One patient was lost to follow-up in the control group. Finally, there were 119 patients (60 in the NXS group and 59 in the control group) included in the analysis. In the full analysis set (FAS) analysis, the NXS group had a greater percentage reduction in hematoma volume from day 1 to day 15 than the control group [median (Q1, Q3): 85% (71%, 97%) vs. 76% (53%, 93%), P<0.05]. The secondary outcomes showed no statistical significance between two groups, either in FAS or per-protocol set (P>0.05). Furthermore, no adverse events were reported during the study. In the FAS analysis, the NXS group exhibited a higher percentage reduction in hematoma volume on day 15 in the following subgroups: male patients, patients younger than 65 years, patients without diabetes, or those with initial cranial surgery due to ICH (all P<0.05). CONCLUSIONS: The administration of NXS demonstrated the potential to promote the percentage reduction in hematoma volume from day 1 to day 15. This intervention was found to be safe and feasible. The response to NXS may be influenced by patient characteristics. (Registration No. ChiCTR1800017981).

Ganoderma lucidum Exerts an Anticancer Effect on Human Osteosarcoma Cells via Suppressing the Wnt/ß-Catenin Signaling Pathway.

Background: Current treatment of osteosarcoma is limited in part by side effects and low tolerability, problems generally avoided with traditional Chinese medicine. Ganoderma lucidum, a traditional Chinese medicine with antitumor effects, offers a potential alternative, but little is known about its molecular mechanisms in osteosarcoma cells. Objective: To investigate the effect of G lucidum on osteosarcoma cells and its mechanism. Methods: Osteosarcoma MG63 and U2-OS cells were treated with G lucidum, followed by assays for cell proliferation (Cell Counting Kit-8), colony formation, and apoptosis (Alexa Fluor 647-Annexin V/propidium iodide, flow cytometry). Migration and invasion of cells were assessed by wound healing and Transwell invasion assays, and the effect of G lucidum on Wnt/ß-catenin signal transduction was studied by real-time quantitative polymerase chain reaction, western blot, and dual-luciferase assay. Results:G lucidum inhibited the proliferation, migration, and invasion, and induced apoptosis of human osteosarcoma MG63 and U2-OS cells. Dual-luciferase assay showed that G lucidum suppressed the transcriptional activity of T-cell factor/lymphocyte enhancer factor in the Wnt/ß-catenin signaling pathway. Moreover, G lucidum blocked Wnt/ß-catenin signaling by inhibiting the Wnt co-receptor LRP5 and Wnt-related target genes, such as ß-catenin, cyclin D1, C-Myc, MMP-2, and MMP-9. At the same time, when Wnt/ß-catenin was inhibited, the expression of E-cadherin was upregulated. Conclusions: Our results suggest that G lucidum broadly suppresses osteosarcoma cell growth by inhibiting Wnt/ß-catenin signaling.

Stenosing tenosynovitis : Evaluation of percutaneous release with a specially designed needle vs. open surgery.

PURPOSE: The purpose of this study was to evaluate the effectiveness of conventional open surgery and percutaneous release with a specially designed needle for treating stenosing tenosynovitis in terms of cure, relapse and complication rates. METHODS: In this study 89 fingers from 76 patients were randomly assigned and allocated to one of the treatment groups. A total of 37 patients were treated with open surgery in group 1 and 39 patients with percutaneous release using a specially designed needle in group 2. A patient-based 4-inch visual analogue scale (VAS), Quinnell grading (QG), disability of arm shoulder and hand (DASH) score and finger total joint range of motion (FTROM) score were evaluated before treatment and after 7, 30 and 180 days. When finger QG scores were equal or greater than 2 points at follow-up at 180 days this was defined as recurrence.. RESULTS: There were no significant differences between the two groups (P > 0.05) in terms of VAS, DASH and QG scores and the degree of FTROM. At 7 days all the data were significantly different (p < 0.05) compared with preoperative data, 30 days was significantly different (p < 0.05) compared with 7 days while at 180 days no significant differences could be found (p > 0.05) compared with 30 days. The recurrence rate in group 1 was 4.65% and 6.55% in group 2. CONCLUSION: The percutaneous release and open surgery methods displayed similar effectiveness regarding the cure and recurrence of trigger finger disorder. The use of a specially designed needle for release is a safe and reliable method.

Reliability, Validity, and Responsiveness of the Chinese Version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in Patients with Anterior Cruciate Ligament Reconstruction in Mainland China.

OBJECTIVE: The aim of this study was to perform a cross-cultural adaption of the KOOS into Chinese and to evaluate its psychometric properties in patients with anterior cruciate ligament reconstruction (ACL reconstruction) in mainland China. DESIGN: A cross-sectional study. SETTING: Patients completed the Chinese version of the KOOS and the SF-36 questionnaire three times. We evaluated the reliability, checked the validity, and assessed the responsiveness. PARTICIPANTS: A total of 42 patients who had undergone ACL reconstruction. MAIN OUTCOME MEASURES: The results of the questionnaire survey. RESULTS: The Chinese version of the KOOS was well accepted, with ideal test-retest reliability and internal consistency. The test-retest reliability was significant, with high ICC values ranging from 0.888 to 0.941. Additionally, we found that the internal consistency was adequate, with Cronbach's alpha coefficient ranging from 0.740 to 0.975. All a priori hypotheses were supported by a high correlation between the KOOS and SF-36. Furthermore, responsiveness was demonstrated since the ES and SRM between subscales following ACL reconstruction was found in the expected pattern. CONCLUSIONS: The Chinese version of the KOOS showed psychometric properties demonstrating acceptable reliability and validity similar to the original version. We conclude that the Chinese version is a reliable and valid instrument for research and clinical assessments of ACL reconstruction patients in mainland China.

Connexin 43 Modulates Osteogenic Differentiation of Bone Marrow Stromal Cells Through GSK-3beta/Beta-Catenin Signaling Pathways.

BACKGROUND/AIMS: Bone marrow stromal cells (BMSCs) are multipotent precursors that give rise to osteoblasts, and contribute directly to bone formation. Connexin 43 (Cx43) is the most ubiquitous gap junction protein expressed in bone cell types, and plays crucial roles in regulating intercellular signal transmission for bone development, differentiation and pathology. However, the precise role and mechanism of Cx43 in BMSCs are less known. Here, we investigate the function of Cx43 in osteogenic differentiation of BMSCs in vitro. METHODS: BMSCs were isolated by whole bone marrow adherent culture. Knock down of Cx43 was performed by using lentiviral transduction of Cx43 shRNA. BMSCs were induced to differentiate by culturing in a-MEM, 10% FBS, 50 µM ascorbic acid, 10 mM beta-glycerophosphate, and 100 nM dexamethasone. Alkaline phosphatase (ALP) activity and alizarin red S staining were used to evaluate osteogenic differentiation in calcium nodules. Target mRNAs and proteins were analyzed by using real-time quantitative PCR (qPCR) and western blotting. RESULTS: Cx43 expression markedly increased during osteogenic differentiation. Osteogenic differentiation was suppressed following lentiviral-mediated knockdown of Cx43 expression, as judged by decreased levels of Runt-related transcription factor 2 (Runx2), bone sialoprotein (BSP), osteocalcin (Bglap), Osterix (Osx), alkaline phosphatase (ALP) activity and the number of calcium nodules in response to osteogenic differentiation stimuli. Knock down of Cx43 reduced the level of phosphorylation of GSK-3beta at Ser9 (p-GSK-3beta), resulting in decreased beta-catenin expression and activation. Furthermore, treatment of Cx43-knockdown cells with lithium chloride (LiCl), a GSK-3beta inhibitor, reduced osteogenic differentiation and decreased GSK-3beta levels, as well as partially rescued levels of both total and activated beta-catenin. CONCLUSION: These findings indicate that Cx43 positively modulates osteogenic differentiation of BMSCs by up-regulating GSK-3beta/beta-catenin signaling pathways, suggesting a potential role for Cx43 in determining bone mass and bone mineral density by modulating osteogenesis.

RACK1 Silencing Induces Cell Apoptosis and Inhibits Cell Proliferation in Hepatocellular Carcinoma MHCC97-H Cells.

This study aimed to explore the effects of RACK1 gene silencing on the apoptosis and proliferation of hepatocellular carcinoma (HCC) MHCC97-H cells. After transfecting MHCC97-H cells with siRNA, RACK1 gene silencing model was established. The cells were divided into blank group, siRNA group and empty plasmid group, respectively. The mRNA and protein expressions of RACK1, cyclin D1 and BAX were determined by qRT-PCR and Western blotting. CCK-8 assay, flow cytometry and FITC-Annexin V/PI staining were used to determine cell viability, cell cycle and cell apoptosis, respectively. The results of qRT-PCR and Western blotting suggested that when compared with the blank group and the empty plasmid group, the mRNA and protein expressions of RACK1 and Cyclin D1 decreased significantly while the mRNA and protein BAX expressions increased substantially in the siRNA group (all P < 0.05). The results of CCK-8 assay revealed that the siRNA group exhibited significantly lower cell viability when compared with the blank group and the empty plasmid group (both P < 0.05); and the cell viability in the siRNA group decreased gradually with the increase of time. The results of flow cytometry and FITC-Annexin V/PI staining indicated that when compared with the blank group and the empty plasmid group, the proportion of cells in S phase was markedly lower and the apoptosis rate was significantly higher in the siRNA group (both P < 0.05). Our study suggests that inhibition of RACK1 could suppress cell proliferation and induce apoptosis in HCC MHCC97-H cells.

All-trans-retinoic acid activates SDF-1/CXCR4/ROCK2 signaling pathway to inhibit chondrogenesis.

Recent studies have indicated that ATRA inhibits chondrogenesis and can lead to congenital clubfoot (CCF). The molecular mechanism of ATRA-induced chondrogenesis is not clear. As RhoA/ROCK and SDF-1/CXCR4 signaling play important molecular roles for a variety of cellular processes, we hypothesized that RhoA/ROCK2 and SDF-1/CXCR4 signaling are involved in ATRA-induced chondrogenesis in rat embryo hind limb bud mesenchymal cells (rEHBMCs). We found that ATRA dose-dependently inhibits proliferation and expression of chondrogenic transcription factors (SOX9 and COL2A1) in rEHBMCs. In contrast, ATRA increases the expression of ROCK2, SDF-1 and CXCR4. Pharmacological inhibition of ROCK signaling and SDF-1/CXCR4 signaling by Y27632 and AMD3100, respectively, resulted in elevated expression of SOX9 and COL2A1. In addition, we found that disturbing SDF-1/CXCR4 signaling by AMD3100 decreases ATRA-induced ROCK2 expression. In vivo studies we also confirm that SOX9 expression of early-stage cartilage progenitors in the proliferative zone and COL2A1 expression in prehypertrophic chondrocytes are decreased in ATRA-treated rat embryo hind limb. Together, these results show that ATRA activates SDF-1/CXCR4/ROCK2 signaling to inhibit chondrogenesis to lead to CCF by suppressing differentiation through down-regulation of SOX9 and COL2A1 expression in rat embryo hind limb bud mesenchymal cells.

[Factors influencing the postoperative resolution of varicocele-associated scrotal pain].

OBJECTIVE: To investigate the factors influencing the postoperative resolution of varicocele-associated scrotal pain. METHODS: Using the keywords "varicocele", "testicular pain", "scrotal pain", "painful varicocele", "ligation", and "varicocelectomy", we searched the PubMed, Embase, Cochrane Collaboration's Database, CNKI, Wanfang, and VIP Database up to October 2016 for the studies relating to surgical treatment of varicocele-associated scrotal pain. We assessed the quality of the cohort studies included using the Newcastle-Ottawa Scale and that of the randomized controlled trials included with the Cochrane Collaboration's tool. We conducted a meta-analysis using the RevMan software. RESULTS: Finally 14 studies were included in this meta-analysis, of which, 2 involved the history of disease, 8 involved the nature of pain, 2 involved the intensity of pain, 9 involved the grade of varicocele, 3 involved the side of varicocele, 9 involved surgical approaches, 3 involved surgical techniques, and 4 involved postoperative recurrence. The pain resolution rate was significantly higher after subinguinal ligation than after high or inguinal ligation (RR = 0.82, 95% CI: 0.76－0.89, P <0.01; RR = 0.92, 95% CI: 0.86－0.99, P = 0.02), and so was it after microsurgery than after laparoscopic varicocelectomy (RR = 0.77, 95% CI: 0.60－0.99, P = 0.04). CONCLUSIONS: Subinguinal varicocelectomy and microsurgery are more effective options than laparoscopic and high or trans-inguinal ligation of the spermatic vein for resolution of varicocele-associated scrotal pain, while the history of disease, the nature and intensity of pain, the grade and side of varicocele, or postoperative recurrence cannot be regarded as the influencing factors.

Naringin promotes osteogenic differentiation of bone marrow stromal cells by up-regulating Foxc2 expression via the IHH signaling pathway.

Naringin is an active compound extracted from Rhizoma Drynariae, and studies have revealed that naringin can promote proliferation and osteogenic differentiation of bone marrow stromal cells (BMSCs). In this study, we explored whether naringin could promote osteogenic differentiation of BMSCs by upregulating Foxc2 expression via the Indian hedgehog (IHH) signaling pathway. BMSCs were cultured in basal medium, basal medium with naringin, osteogenic induction medium, osteogenic induction medium with naringin and osteogenic induction medium with naringin in the presence of the IHH inhibitor cyclopamine (CPE). We examined cell proliferation by using a WST-8 assay, and differentiation by Alizarin Red S staining (for mineralization) and alkaline phosphatase (ALP) activity. In addition, we detected core-binding factor α1 (Cbfα1), osteocalcin (OCN), bone sialoprotein (BSP), peroxisome proliferation-activated receptor gamma 2 (PPARγ2) and Foxc2 expression by using RT-PCR. We also determined Foxc2 and IHH protein levels by western blotting. Naringin increased the mineralization of BMSCs, as shown by Alizarin red S assays, and induced ALP activity. In addition, naringin significantly increased the mRNA levels of Foxc2, Cbfα1, OCN, and BSP, while decreasing PPARγ2 mRNA levels. Furthermore, the IHH inhibitor CPE inhibited the osteogenesis-potentiating effects of naringin. Naringin increased Foxc2 and stimulated the activation of IHH, as evidenced by increased expression of proteins that were inhibited by CPE. Our findings indicate that naringin promotes osteogenic differentiation of BMSCs by up-regulating Foxc2 expression via the IHH signaling pathway.

Naringin Stimulates Osteogenic Differentiation of Rat Bone Marrow Stromal Cells via Activation of the Notch Signaling Pathway.

Naringin is a major flavonoid found in grapefruit and is an active compound extracted from the Chinese herbal medicine Rhizoma Drynariae. Naringin is a potent stimulator of osteogenic differentiation and has potential application in preventing bone loss. However, the signaling pathway underlying its osteogenic effect remains unclear. We hypothesized that the osteogenic activity of naringin involves the Notch signaling pathway. Rat bone marrow stromal cells (BMSCs) were cultured in osteogenic medium containing-naringin, with or without DAPT (an inhibitor of Notch signaling), the effects on ALP activity, calcium deposits, osteogenic genes (ALP, BSP, and cbfa1), adipogenic maker gene PPARγ2 levels, and Notch expression were examined. We found that naringin dose-dependently increased ALP activity and Alizarin red S staining, and treatment at the optimal concentration (50 µg/mL) increased mRNA levels of osteogenic genes and Notch1 expression, while decreasing PPARγ2 mRNA levels. Furthermore, treatment with DAPT partly reversed effects of naringin on BMSCs, as judged by decreases in naringin-induced ALP activity, calcium deposits, and osteogenic genes expression, as well as upregulation of PPARγ2 mRNA levels. These results suggest that the osteogenic effect of naringin partly involves the Notch signaling pathway.

All-trans-retinoic acid inhibits chondrogenesis of rat embryo hindlimb bud mesenchymal cells by downregulating p53 expression.

Despite the well-established role of all-trans-retinoic acid (ATRA) in congenital clubfoot (CCF)-like deformities in in vivo models, the essential cellular and molecular targets and the signaling mechanisms for ATRA-induced CCF-like deformities remain to be elucidated. Recent studies have demonstrated that p53 and p21, expressed in the hindlimb bud mesenchyme, regulate cellular proliferation and differentiation, contributing to a significant proportion of embryonic CCF-like abnormalities. The objective of the present study was to investigate the mechanisms for ATRA-induced CCF, by assessing ATRA-regulated chondrogenesis in rat embryo hindlimb bud mesenchymal cells (rEHBMCs) in vitro. The experimental study was based on varying concentrations of ATRA exposure on embryonic day 12.5 rEHBMCs in vitro. The present study demonstrated that ATRA inhibited the proliferation of cells by stimulating apoptotic cell death of rEHBMCs. It was also observed that ATRA induced a dose-dependent reduction of cartilage nodules compared with the control group. Reverse transcription-polymerase chain reaction and western blotting assays revealed that the mRNA and protein expression of cartilage-specific molecules, including aggrecan, Sox9 and collagen, type II, α 1 (Col2a1), were downregulated by ATRA in a dose-dependent manner; the mRNA levels of p53 and p21 were dose-dependently upregulated from 16 to 20 h of incubation with ATRA, but dose-dependently downregulated from 24 to 48 h. Of note, p53 and p21 were regulated at the translational level in parallel with the transcription with rEHBMCs treated with ATRA. Furthermore, the immunofluorescent microscopy assays indicated that proteins of p53 and p21 were predominantly expressed in the cartilage nodules. The present study demonstrated that ATRA decreases the chondrogenesis of rEHBMCs by inhibiting cartilage-specific molecules, including aggrecan, Sox9 and Col2al, via regulating the expression of p53 and p21.

[Evaluation of the efficacy of bronchial arterial infusion chemotherapy for the treatment of central non-small cell lung cancer].

OBJECTIVE: To evaluate the long-term efficacy of bronchial arterial infusion (BAI) chemotherapy in the treatment of centeral non-small cell lung cancer. METHODS: Fifty-eight patients with central non-small-cell lung cancer, who were assessed as difficult operable or non-operable by imaging examination, received BAI of cisplatin, epirubicin and mitomycin alone or in combination. It includes 51 cases of squamous cell carcinoma, 6 cases of adenocarcinoma and 1 case of adenosquamous carcinoma. The cinical stage before BAI wasIIb in 3 cases, IIIa in 26 cases and IIIb in 29 cases. Long term follow-up was conducted and the results were statistically analyzed. RESULTS: The total effective rate of BAI was 43.1%. The mediam survival (MS) of all 58 patients was 29.1 months. 31 patients after BAI became operable and were resected, had a median survival of 65.2 months. 27 patients after BAI were not resected and had a MS of 15.9 months. There was a significant difference between the patients who had been resected and not. The MS of IIIa stage patients was 39.0 months, and IIIb stage 20.4 months. CONCLUSION: Bronchial arterial infusion chemotherapy is a better choice with a definite efficacy for treatment of center-based NSCLC patients, estimated as difficult operable but without distant metastasis.

Core decompression and implantation of calcium phosphate cement/Danshen drug delivery system for treating ischemic necrosis of femoral head at Stages I, II and III of antigen reactive cell opsonization.

OBJECTIVE: To introduce a new method using calcium phosphate cement/Danshen drug delivery system for treating ischemic necrosis of the femoral head and evaluate its curative effect. METHODS: From May 2000 to June 2005, 48 adult patients (54 hips) with ischemic necrosis of the femoral head at Stages I, II and III of antigen reactive cell opsonization (ARCO) were treated with implantation of calcium phosphate cement/Danshen drug delivery system in the involved femoral head. The operation consisted of removal of the necrotic bone under weight-loading cartilage and the implantation of phosphate cement/Danshen drug delivery system, and all manipulations were made percutaneously through a bone tunnel in the trochanter. The functions of the hip joint were evaluated and X-ray films were taken preoperatively and postoperatively. RESULTS: Postoperative follow-up was 45.5 months on average, ranging from 27 to 78 months. According to the evaluation criterion of "Dandong 1995" for therapeutic effect of adult ischemic necrosis of the femoral head, the therapeutic effects were excellent in 33 hips, good in 17, fair in 3 and poor in 1, with the excellent and good rate of 92.6%. CONCLUSIONS: This method is relatively simple with little invasion. It not only improves the microcirculation of the femoral head by local application of traditional Chinese medicine, but also provides mechanic buttress in the weight-loading area to prevent collapse during repairing, which is beneficial to repair and reconstruction of femoral head. It may be a choice of minimal invasion surgery for ischemic necrosis of the femoral head at Stages I, II and III of ARCO.

[Clinical study on the early reconstruction of complex acetabular fractures].

OBJECTIVE: To explore the best opportunity of structure reconstruction for complex acetabular fracture in order to provide the accurate time for clinical operative treatment. METHODS: Complex acetabular fracture patients were divided into experimental group (93 cases, 96 hips) and control group (98 cases, 101 hips) randomly according to the operative time. The operation of patients were done respectively at the 7th, 10th day after injury in experimental group and control group. The operative time, the excellent and good rate of reduction,the postoperative complications,the joint function (ache to walk,joint activity),the SF-36 were evaluated. RESULTS: (1) The operative time of experimental group was obviously shorter than control group according to different fracture classification. (2) According to the standard of Matta' joint function and X-ray, the experimental group was better than control group. (3) The excellent and good rate of reduction in experimental group was obviously higher than control group, according to CT scan before operation and after operation. CONCLUSION: The early structure reconstruction of complex acetabular fracture can obviously decrease operative time and complications, increase the rate of operative reduction.

[Evaluation of efficacy and influence factors of transarterial interventional therapy in patients with liver metastasis from malignancy of alimentary tract].

OBJECTIVE: To evaluate the efficacy and prognostic factors of transarterial interventional therapy (TAIT) in patient with liver metastasis from malignancy of the alimentary tract. METHODS: 266 patients with unresectable liver metastases from malignancy of the alimentary tract received totally 754 sessions of transarterial interventional therapy. Cox regression was used in the proportional hazard analysis. RESULTS: The overall response rate of TAIT was 45.4%, The median survival time (MS) was 14.3 months in this series. The 0.5-, 1-, 2-, 3-, 5-year cumulative survival rate (CSR) was 83.1%, 56.8%, 17.7%, 9.3% and 1.5% , respectively. No severe adverse reaction was observed except nausea, vomiting and mild fever as well as pain in the hepatic area. It was found that portal vein tumor thrombosis (PVTT), the blood supply of tumor, metastasis from esophageal carcinoma, the number of metastasis, multi-lobe involvement, resection nature of primary tumor were independent factors affecting survival. CONCLUSION: Transarterial interventional therapy is effective for treatment of liver metastasis from malignancy of the alimentary tract. Portal vein tumor thrombosis, metastasis from esophageal carcinoma, multiple metastatic lesions, multi-lobe involvement are poor prognostic factors, while complete resection of the primary tumor and rich blood supply of metastatic lesion are good independent prognostic factors.

[Correlation of serum calcium level with tumor size and stage of renal cell carcinoma].

OBJECTIVE: To analyze the correlation between serum calcium level and tumor size/ stage in patients with renal cell carcinoma (RCC). METHODS: Totally 173 RCC cases were divided into 3 groups according to their serum calcium level, namely low, normal and high level groups. SPSS10.0 software was used for statistical analysis of the tumor sizes/stages and their association with serum calcium level in the 3 groups. RESULTS AND CONCLUSION: Kruskal-Wallis H test revealed no significant difference in the tumor size between the 3 groups (X(2)=4.768, df=2, P=0.092), but Spearman correlation analysis suggested inverse correlation between serum calcium and tumor size (r=-0.166, P=0.029). Kruskal-Wallis H test also failed to suggest significant difference in the tumor stage between the 3 groups (X(2)=4.277, df=2, P=0.118), but serum calcium was found to be inversely correlated with the tumor stage (r=-0.157, P=0.039 by Spearman correlation analysis).