[Changes of hemodynamic parameters in normal pregnant women and their relationship with maternal basic characteristics].

Objective: To investigate the variation of reference ranges of hemodynamic parameters in normal pregnancy and their relation to maternal basic characteristics. Methods: A total of 598 healthy pregnant women who underwent regular prenatal examination at the Third Affiliated Hospital of Guangzhou Medical University from January to December 2023 were prospectively enrolled, and noninvasive hemodynamic monitors were used to detect changes in hemodynamic parameters of the pregnant women with the week of gestation, including cardiac output (CO), stroke volume (SV), thoracic fluid content (TFC), systemic vascular resistance (SVR), mean arterial pressure (MAP), and heart rate (HR). Relationships between hemodynamic parameters and maternal basic characteristics, including age, height, and weight, were analyzed using restricted cubic spline. Results: (1) CO (r=0.155, P<0.001), TFC (r=0.338, P<0.001), MAP (r=0.204, P<0.001), and HR (r=0.352, P<0.001) were positively correlated with the week of gestation, and SV was negatively correlated with the week of gestation (r=-0.158, P<0.001). There was no significant correlation between SVR and gestational age (r=-0.051, P=0.258). (2) CO exhibited a positive correlation with maternal height and weight (all P<0.001). The taller and heavier of pregnant women, the higher their CO. A linear relationship was observed between maternal weight and SV, MAP and HR (all P<0.01). As maternal weight increased, SV, MAP and HR showed an upward trend. Furthermore, there was an inverse association between maternal age and SVR (P<0.001). (3) There was a significant nonlinear association observed between TFC and body mass index during pregnancy (P<0.05). Additionally, a nonlinear relationship was found between SVR and MAP in relation to maternal age (all P<0.05). Notably, when the age exceeded 31 years old, there was an evident upward trend observed in both SVR and MAP. Conclusions: The hemodynamic parameters of normal pregnant women are influenced by their height, body weight, and age. It is advisable to maintain a reasonable weight during pregnancy and give birth at an appropriate age.

[Effect of reducing-opioids consumption on postoperative delirium incidence in elderly patients after gastric cancer surgery].

Objective: To evaluate the effect of reducing-opioids on postoperative delirium (POD) incidence in elderly patients with gastric cancer surgery. Methods: From July 2016 to September 2021, 130 elderly patients undergoing scheduled gastric cancer surgery in Zhejiang Cancer Hospital were selected and divided into conventional opioid general anesthesia group (group A) and reducing-opioids general anesthesia group (group B) according to random number table. Postoperative analgesic pump formula: group A: 0.2% ropivacaine and 1 µg/ml sufentanil solution; Group B: 0.2% ropivacaine solution. POD assessment was performed once daily between 8 am and 8 pm for 3 days after surgery. The primary outcome measures were POD incidence 3 days after surgery, and the secondary outcome measures included anaesthesia related adverse events 3 days after surgery, such as nausea and vomiting, postoperative fever and fatigue. Results: Among the 130 patients, 7 patients were excluded because they did not comply with the POD test after operation. Finally, 123 elderly patients completed the study. There were 59 cases in group A, aged (73±5) years, including 45 males, and 64 cases in group B, aged (71±6) years, including 56 males. The incidence of total POD 3 days after surgery in group A and B was 30.5% (18/59) and 18.8% (12/64), respectively, with no statistical significance (P>0.05). However, POD incidence at 48 and 72 h after operation in group A [27.1% (16/59) and 16.9% (10/59)] was higher than that in group B [10.9% (8/64) and 4.7% (3/64), both P<0.05]. The incidence of nausea and vomiting in group A was higher than that in group B [15.3% (9/59) vs 1.6% (1/64), P<0.05]. Conclusion: Reducing-opioids consumption have no effect on the incidence of total POD 3 d after gastric cancer surgery in elderly patients, but can reduce the risk of POD 48-72 h after surgery.

[Renal functional compensation after unilateral radical nephrectomy of renal cell carcinoma].

OBJECTIVE: To investigate factors influencing renal functional compensation(RFC) of the preserved kidney after radical nephrectomy (RN). METHODS: A total of 286 patients treated with RN in Peking University People's Hospital were retrospectively analyzed. Preoperative body mass index (BMI), systolic blood pressure (SBP), history of smoking, history of chronic diseases and other basic information, as well as preoperative blood biochemistry, urine routine, imaging examination results were recorded. All the patients underwent 99mtechnetium-diethylenetriamine pentaacetic acid (99mTc-DTPA) renal scans before operation. The surgical method, pathology and blood creatinine values from 1 month to 60 months after RN were recorded. Preoperative and postoperative estimated glomerular filtration rate (eGFR) was calculated by the chronic kidney disease epidemiology collaboration (CKD-EPI) formula. Renal functional compensation was defined as percent change in eGFR of the preserved kidney after RN compared with the preoperative eGFR. Univariate and multivariate regression analyses were used to identify predictive factors of RFC. RESULTS: Median age was 61 years and 65.4% of the patients were male. Early stage (T1 or T2) tumors were found in 83.6% of the cases. 18.5% of the patients had preoperative diabetes mellitus, 39.5% had hypertension, 19.2% had a history of smoking, and 27.6% were found to have renal cyst on the contralateral side. In the study, 226 cases underwent laparoscopic radical nephrectomy and 60 cases underwent open radical nephrectomy. Renal clear cell carcinoma was the most common pathological type, accounting for 88.5%. The median tumor maximum diameter was 4.5 cm (0.7-13.5 cm). Median renal function compensation was 27% one month after radical nephrectomy. Functional stability was then observed to 5 years. The results of univariate analysis showed that age, gender, preoperative blood uric acid, preoperative urine protein, contralateral renal cyst, and percentage of split renal function of contralateral kidney were correlated with RFC (P < 0.05). Among them, UA level and split renal function of contralateral kidney were strongly negatively correlated with RFC. The results of multivariate linear regression analysis showed age (P < 0.001), blood uric acid (P < 0.001), urine protein (P=0.002), preoperative eGFR (P < 0.001) and the split renal function of contralateral kidney (P < 0.001) were independent predictors of RFC. CONCLUSION: The basic examinations, such as blood biochemistry, urine routine and renal scan before RN are of great significance in predicting the compen-satory ability of the preserved kidney after RN, which is supposed to be taken into consideration when making clinical decision.

[Severe alcoholic hepatitis-associated infection].

Patients with severe alcoholic hepatitis is sensitive to concurrent infection and impact glucocorticoid response and disease prognosis. Glucocorticoids can increase the incidence and of serious infections and fungal infections. Among them, Gram-negative bacterial infections are the major one, and invasive fungal infections are not uncommon. Early diagnosis and empiric anti-infective therapy are important means for severe alcoholic hepatitis with concurrent infection. Anti-infective strategies covering multiple drug-resistant bacteria should be timely formulated after determining the high risk of multiple drug-resistant bacterial infections.

Clinical significance of perioperative EMT-CTC in rectal cancer patients receiving open/laparoscopic surgery.

The objective of this study was to explore the clinical significance of perioperative CTCs (circulating tumor cells) counts and EMT-CTCs (epithelial-mesenchymal transition-CTCs) in rectal cancer patients. A total of 30 patients with rectal cancer who underwent radical resection of rectal cancer at the Guangxi Zhuang Autonomous Region People's hospital were enrolled. Five ml peripheral blood was withdrawn from 30 patients with rectal cancer before the operation and seven days after the operation and at the corresponding time also from 20 healthy volunteers. CanPatrol™ CTC detection technique was used to enrich and identify CTCs and IER3 expression simultaneously. We found out that the preoperative total CTCs were correlated with lymph node metastasis (p=0.008) and tumor size, and mixed CTCs were closely correlated with lymph node metastasis (p=0.009). The number of IER3-positive total CTCs and mesenchymal CTCs were statistically associated with tumor size, p=0.034 and 0.043, respectively. The number of CTCs varied significantly before and after the operation in all patients (p=0.049). There were significant differences in CTCs variations between the open operation group and the laparoscopic operation group. In the laparoscopic operation group, the average number of single-cell CTCs was 6.9 before operation and 3.5 after the operation (p=0.013). In the open operation group, the average number of single-cell CTCs was 5.9 before operation and 4.2 after the operation. To conclude, surgery is associated with a decrease of CTCs in rectal cancer patients, especially in patients receiving laparoscopic surgery. The number of CTCs before the operation in rectal cancer patients is related to the size of tumors and regional lymph node metastasis. CTCs detection and characterization may be useful for clinical staging and lymph node dissection during operation.

[The 474th case: anemia, ostealgia, proteinuria].

A 49-year-old woman was admitted to hospital with intermittent dizziness and fatigue for 7 years. The symptoms were aggravated and accompanied by bone pain for more than 4 months. She was referred to our hospital. Laboratory tests and imaging findings suggested that acquired Fanconi Syndrome (FS) was associated with smoldering multiple myeloma (MM). Renal biopsy and electron microscopy confirmed the diagnosis of proximal light chain tubular disease (LCPT). LCPT causes proximal tubular dysfunction, which is characterized by the cytoplasmic crystal deposition usually kappa monoclonal light chain in the proximal tubule. MM with FS and LCPT is less common in clinical practice because it is difficult to diagnose. This is a typical case focusing on the differential diagnosis of monoclonal gammopathy of renal significance(MGRS) such as LCPT and plasma cells diseases.

[Clinical and pathological analysis of small renal cell carcinoma].

OBJECTIVE: To analyze the clinical and pathological features of small renal cell carcinoma (RCC), especially of those with diameter less than 4 cm and to understand the characteristics and factors related to recurrence and progression. METHODS: A total of 200 patients with RCC were stratifiedly selected for retrospective analysis. Their baseline demographic features, tumor-specific clinical features, pathological features of renal lesions, especially microscopic features were collected. The patients were divided according to the largest diameter of renal tumor lesions. Univariate analysis was used to compare the differences between tumor staging and microscopic pathological features between the groups. Binary multivariate Logistic regression was used to investigate factors related to tumor progression and prognosis in the patients with small RCC. RESULTS: The tumor diameters of 127 RCC patients were less than 4 cm and most of them had clear cell renal cell carcinoma (ccRCC). The increase in tumor diameter resulted in significantly higher T stage (P<0.01), higher WHO/International Society of Urological Pathology (ISUP) grade (P<0.05) and increasing chance of lymph node metastasis (P<0.01). Even when the tumor diameter was less than 4 cm, the patients might still have perirenal fat invasion, renal sinus invasion and greater elevated tumor grade (greater than grade 3) and synchronous lung metastasis. The incidences of intravascular thrombus (9.3% vs. 0) and tumor necrosis (27.8% vs. 5.5%) in the patients with RCC between 4-7 cm were significantly higher than those with RCC less than 4 cm (P<0.01). Sub-group analysis of small RCC (less than 4 cm) indicated that the patients with RCC between 2-4 cm were more likely to have intratumoral hemorrhage (44.7% vs. 23%, P<0.05) and necrosis than those with RCC less than 2 cm (8.2% vs. 0, P=0.095). Logistic regression analysis of small RCC showed that the incidence of tumor invasion to renal capsule was higher in ccRCC (OR=5.15, 95%CI: 1.36-19.52). Necrosis was closely related to the formation of peritumor pseudocapsule in small RCC (OR=14.90, 95%CI: 1.41-157.50). Increase in the tumor diameter was related to higher tumor grade (greater than grade 3) (OR=3.49, 95%CI: 1.11- 10.93). CONCLUSION: The tumor stage and grade of small RCC (less than 4 cm) are low, but extra-renal invasion and synchronous distant metastasis may occur. Internal hemorrhage and necrosis in tumor, ccRCC subtype, along with microscopic features, such as the renal capsule invasion and perirenal pseudocapsule formation are relevant factors of malignant behavior of small RCC and could be considered in prognosis evaluation.

[Clinical and pathological analysis of renal cell carcinoma bone metastasis].

OBJECTIVE: To analyze the clinical and pathological characteristics of renal cell carcinoma bone metastasis (RCC-BM) patients. METHODS: Data of RCC-BM patients from July 2003 to November 2017 were retrospectively reviewed. The patients' baseline characteristics (age, gender), tumor characteristics [specific sites of bone metastasis, time to bone metastasis (TTBM), imaging features of bone disease, coexistence of other metastasis], as well as pathological features (histological classification of primary and bone metastasis, immunohistochemical stain results) were collected. Descriptive analysis and difference analysis were used. RESULTS: A total of 113 RCC-BM patients were enrolled with the gender ratio (male:female) of 4:1, mean age of 59.39 years, and all present of osteolysis bone lesions. The common sites of bone metastasis were vertebra (46.0%) and pelvis (38.9%). Other distant metastasis sites coexisted in 28.3%, while 48.18% RCC-BM patients presented with synchronous metastasis (TTBM=0). The median TTBM for metachronous metastasis was 48 months. The majority in this cohort were determined to have primary tumor of clear cell carcinoma. After immunohistochemical examination to 104 RCC-BM patients and sub-group analysis, tendencies of higher positive rates of vascular endothelial growth factor (VEGF) was also found in synchronous group (P=0.097) while tendencies of higher positive rates of carbonic anhydrase (CA)-IX was found in the same group (P=0.100). The patients with clear cell RCC-BM had a significantly higher positive expression of epithelial growth factor receptor (EGFR, P<0.05) than those with non-clear cell RCC-BM group. CONCLUSION: More male and younger patients with metastatic lesions in axial skeleton were found in this cohort. Tendencies in the expression of CA-IX and VEGF in different TTBM sub-group and EGFR in different histology-derived subgroup indicate that they might be associated with risk and prognostic factors and support further target therapies of RCC-BM.

[Renal mucinous tubular and spindle cell carcinoma combined with multiple bone metastasis: a case report and literature review].

Mucinous tubular and spindle cell carcinoma (MTSCC) is a rare sub-type of renal cell carcinoma (RCC). It has been considered to be a kind of "indolent" tumor with low-grade fashion, weak invasive capacity and relatively favorable prognosis. However, in the current case, a 3.7 cm×2.8 cm spherical mass with contrast enhancement was found in the left kidney incidentally by computed tomography (CT) in a 60-year-old male patient. A lesion in the right humerus (2.1 cm×1.6 cm×3.1 cm) was found at the same time without any symptoms or sign of pathological fracture by magnetic resonance (MR) imaging. Further positron emission tomography (PET)/CT scan which was ordered immediately after admission suggested multiple bone destruction including skull, pelvis, sternum, right humerus and femur, left scapula, multiple vertebrae and libs. Pathological examination after radical nephrectomy and palliative resection with internal fixation of the lesion in the right humerus indicated that both renal (3.0 cm×3.0 cm×2.5 cm) and bone lesions were MTSCC with the features of high-grade ovoid epithelioid cells, cord-like spindle cells and mucinous matrix under light microscope. The diagnosis of renal MTSCC concurrent with multiple bone metastasis was made. This case report suggested the necessity of general evaluation, especially bone scan for possible distant metastasis, as MTSCC might present unexpected advanced behaviors without any orthopedic symptoms. The behavior of bone metastasis might be associated with male and elderly age. MTSCC has similar enhancement features to papillary RCC on CT scan. As results, attentions are needed to differentiate MTSCC from papillary RCC as they both tend to show lesser enhancement degrees than cortex. Rather than exhibiting a dedifferentiating appearance, the pathological characteristics of bone metastasis lesion were close to those of primary renal lesion. The reason of distant metastasis to the bone remained unclear, negative expression of cytokeratin (CK) 7 might be attributed to. Though immunotherapy, chemotherapy and target therapy could all be methods for systematic therapies, procedures to remove renal lesions and prevent skeletal related events are still highly recommended.

[Clinical analysis of multiple myeloma-associated amyloidosis].

Objective: To investigate the clinical features and survival of multiple myeloma-associated amyloidosis patients. Methods: Twenty three multiple myeloma-associated amyloidosis patients were retrospectively analyzed from January 2009 to December 2016. Results: The overall response rate(ORR)was 65.2% and the remission rate (sCR+ CR) was 21.7%. The median progression-free survival(PFS) was fourteen months(1-63), and the median overall survival(OS)was fifteen months(3-63). The early death rate (death rate within one year)was 33.3%. The median OS of patients(n=9)with the performance status(PS) score >2 was seven months(1-15), and the median OS of patients(n=14)with the PS score ≤2 was thirty months(10-63). There was a statistically significant difference in OS(P<0.05); the median PFS and OS of the patients (n=15) who responded to inductive treatment were seventeen months(2-63) and twenty four months (4-63)respectively, and the median PFS and OS of the patients (n=8)who did not respond to inductive treatment were three months(1-8) and eleven months (3-15) respectively. There was a statistically significant difference in PFS and OS(P<0.05). There was a statistically significant difference in PFS and OS between patients treated with remission (n=5)and those who did not(n=18) (P<0.05). Conclusions: The multiple myeloma-associated amyloidosis patients had a high early death rate and short survival time. Early identification and effective treatment are the preconditions for improving the poor prognosis.

[Effects and safety of quadratus lumborum block in analgesia after hip arthroplasty].

Objective: To evaluate the efficacy of ultrasound guided quadratus lumborum block combined with non-steroidal anti-inflammatory drugs for postoperative analgesia in patients undergoing total hip arthroplasty. Methods: From January to June 2017, sixty American Society of Anesthesiologists (ASA) physical status Ⅰ to Ⅲ patients, aged 55-75 yr, scheduled for total hip arthroplasty, were randomly divided into control group(group N) and quadratus lumborum block (group R). Ultrasound guided quadratus lumborum block was implemented on the affected side at the end of operation.Then 30 ml 0.33% ropivacaine were administrated in group R, while the control group did not receive the same block. A sufentanil patient-controlled analgesia pump was connected to the patient. The rest visual analogue score (VAS) were recorded at 0 h(T(0)), 3 h(T(1)), 6 h (T(2)), 12 h(T(3)), 24 h (T(4)), 36 h (T(5)) and 48 h(T(6)) after sugery, the VAS scores on movement were evaluated at T(4), T(5) and T(6) time points.The consumption of sufentanil within each period time were recorded.The maximal flexion and abduction degrees of the hip joint were evaluated at 12, 24, 36 and 48 h after operation. The number of patients for rescue pain relief by intravenous analgesia pump during 24 h and 48 h after surgery were counted in both groups. The postoperative adverse effects and overall satisfaction in the two groups were recorded. Results: The VAS at rest in group R were 0.8±0.4, 1.0±0.3, 1.2±0.5, 2.0±0.5, 1.7±0.4 , 1.6±0.5 at T(1), T(2), T(3), T(4), T(5), T(6) respectively, and those in group N were 3.0±0.7, 3.5±0.9, 3.8±0.9, 3.3±1.1, 3.3±0.7, 3.0±0.7 at the same time points. The VAS at rest were lower in group R than those in control group at all time points (F=203.090, 216.354, 203.956, 35.548, 96.332, 80.577, all P<0.01). The VAS on movement in group R were 2.7±0.9, 2.9±0.7 , 2.0±0.6 at T(4), T(5), T(6) respectively , and those in group N were 6.0±1.5, 5.8±1.1, 4.5±1.0. The VAS on movement were also lower in group R than those in control group(F=154.561, 143.224, 141.479, all P<0.01). The maximum flexion degrees in group R were (61±12)degrees, (64±10)degrees, (69±15)degrees and(78±19)degrees at 12, 24, 36, 48 h after operation, and those were (45±11) degrees, (49±10)degrees, (52±12)degrees and(60±14)degrees at the same time points. The maximum flexion degrees in group R were increased more than control group at 12, 24, 36, 48 h after operation(F=34.981, 35.575, 52.106, 41.681, all P<0.01). The abduction degrees in group R were(22±6)degrees, (26±6)degrees, (27±8)degrees and(28±7)degrees at 12, 24, 36, 48 h after surgery, and those in group N were (14±5) degrees, (17±6)degrees, (20±6)degrees and(20±5)degrees. The abduction degrees in group R were increased more than those in group N(F=58.974, 33.402, 19.151, 20.575, all P<0.01). The rates of rescue analgesia for pain relief were 10% and 16.7% at 24 h and 48 h after operation respectively in group R, and those were 100% and 100% in group N. Compared to group N, the rates of rescue analgesia for pain relief in group R were significantly decreased (χ(2)=49.091, 42.857, all P<0.01). The incidences of postoperative nausea and vomiting, pruritus in group R were 3.3% and 3.3% respectively, and those in group N were 23.3% and 20.0%. The incidences of nausea and vomiting, pruritus in group R were lower than those in group N (χ(2)=5.192, 4.875, all P<0.01). The overall satisfaction scores in group R (3.7 ± 1.0 ) were higher than those (1.9±0.7) in the group N(t=7.841, P<0.01). Conclusion: The quadratus lumborum block combined with parecoxib sodium for multimodal analgesia after total hip arthroplasty is effective and provides satisfactory analgesia.

[Preliminary study of whole-tumor volume analysis of mono-exponential and intravoxel incoherent motion models in the preoperative histologic grading of hepatocellular carcinoma].

Objective: To investigate the diagnostic performance of whole-tumor volume analysis of mono-exponential and intravoxel incoherent motion (IVIM)parameters in the preoperative grading of hepatocellular carcinoma (HCC). Methods: A total of 106 patients who undewent parital hepatectomy were prospectively enrolled and underwent with routine MR and IVIM examination.112 HCCs were confirmed by the surgical pathology.The original images of IVIM were imported into the GE AW 4.6 workstation.Two independent radiologist who were blinded to the histopathological results analyzed the data.Freehand ROI was used to cover the whole tumor volume, ADC, ADC(slow), ADC(fast) and f was calculated.Intra-class correlation coefficient (ICC) was used to evaluate the inter-observer agreement, One-way ANOVA and Kruskal-Wallis sign rank test were used to evaluate the difference of these parameters in grading HCC, Spearman correlation analysis was used to determine the correlation between these parameters and histologic grade, receiver operating characteristics (ROC) curves were performed to evaluate the diagnostic performance. Results: ICC value of ADC, ADC(slow), ADC(fast) and f were 0.948, 0.966, 0.901 and 0.940, respectively.Statistical significances were obtained from the ADC(slow)(R1: χ(2)=74.403, P<0.001; R2: F=44.973, P<0.001) and ADC (R1: χ(2)=52.987, P<0.001; R2: F=30.851, P<0.001) in grading HCC.Between the multiple-comparison in grading HCC, the ADC(slow) and ADC (except for E-S 3 and 4, R1: P=0.134; R2: P=0.069) also demonstrated a statistical significant difference (all P<0.05). Area under curve (AUC) value of two radiologists for ADC(slow) were 0.905 and 0.917, for ADC were 0.831 and 0.829, a negative correlation was obtained from the ADC and ADC(slow) (all P<0.05). Conclusion: Mono-exponential and intravoxel incoherent motion (IVIM) model can be used to evaluate the pathological differentiated grade of HCC, ADC and ADC(slow) value entailed the highest diagnostic performance.

[Efficacy of Yisaipu tapering in the treatment of ankylosing spondylitis].

Objective: To assess the efficacy of Yisaipu tapering in patients with ankylosing spondylitis (AS). Methods: A total of 87 cases of AS patients from Guangdong Second Provincial General Hospital who were treated with Yisaipu and celecoxib were retrospectively analyzed from February 2013 to April 2017.All patients received full dose Yisaipu and celecoxib in the initial 12 weeks.After that, the patients in the full dose group maintained Yisaipu (50 mg/w) treatment from the 13(rd) to 24(th) week, while tapering group received Yisaipu 50 mg subcutaneous injection once every other week.By using AS disease activity score (ASDAS), Bath AS functional index (BASFI) and magnetic resonance (MR) score of sacroiliac joint (SIJ) plus recording adverse events, differences of efficacy and safety between groups were compared. Results: ASDAS and BASFI of tapering group were 1.1±0.7 and 1.3±1.1, while those of full dose group were 1.0±0.7 and 1.1±1.0, respectively.No significant difference of ASDAS or BASFI was found between groups.Besides, the MR scores of tapering and full dose groups were 8±7 and 8±6 respectively before therapy, while they were significantly lower in the 24(th) week (4±4 and 4±3, P<0.05). However, changes of MR score between groups were similar (P>0.05). Conclusion: Dose tapering of Yisaipu subcutaneous injection might be effective for keeping stable of disease activity and function in patients with AS.Its efficacy is similar to those of full dose Yisaipu.

T1 mapping combined with Gd-EOB-DTPA-enhanced magnetic resonance imaging in predicting the pathologic grading of hepatocellular carcinoma.

The aim of this study was to investigate the value of Gd-EOB-DTPA-enhanced MRI on hepatobiliary phase (HBP) imaging and T1 mapping sequence in the differentiation of hepatocellular carcinoma (HCC). A total of 45 patients with HCC who were to undergo a resection were enrolled in this study. Gd-EOB-DTPA-enhanced magnetic resonance examination was performed prior to resection. T1 mapping was performed before and 20 min after injection of Gd-EOB-DTPA. T1 values of the lesions were measured on pre-contrast (T1p) and during HBP (T1-HBP) on T1 maps. The signal intensity, the diameter and the margin of HCC lesions on HBP images were analyzed. The reduction in T1 value (T1d) and the reduction rate (ΔT1%) of T1 mapping between pre-contrast and HBP were calculated. The Edmondson-Steiner classification of each lesion was made after surgery. The SPSS software package was used for statistical analysis and the analysis of receiver operator characteristic (ROC) curve and area under the curve (AUC) were carried out by using MedCalc software package. Mean values of T1p and T1-HBP were 1935.4±730.8 ms and 1257.1±529.1 ms, respectively. T1p accuracy (AUC = 0.685, p = 0.037) in predicting pathological grading was similar to that of T1-HBP (AUC = 0.751, p = 0.005). A T1p of 1648.2 ms or greater had a sensitivity and specificity of 85.19% and 61.11%, respectively. A T1-HBP of 1006 ms or greater had a sensitivity and specificity of 81.84% and 61.11%, respectively. The number of HCCs with a non-smooth tumor margin was 20 (44.4%), and a non-smooth tumor margin correlated moderately with the Edmondson-Steiner grade (Spearman r = 0.491, p = 0.041). There was no significant correlation between T1d, ΔT1%, HCC signal intensity on HBP image and lesion diameter with pathologic grading. T1 mapping in pre-contrast and HBP of Gd-EOB-DTPA-enhanced MRI, a non-smooth tumor margin in the HBP of Gd-EOB-DTPA-enhanced MRI, are useful in predicting the pathologic grading of HCC.

[A prospective multi-center trial of non-interventional and observational study of lenalidomide in Chinese patients with multiple myeloma].

Objective: To evaluate the efficacy and safety of lenalidomide in a real-world clinical practice in Chinese patients with multiple myeloma (MM). Methods: It was a prospective, multi-center, observational study. A total of 165 consecutive patients with MM treated with lenalidomide-based regimens were enrolled in 12 hospitals from June 2013 to November 2015. Relevant information was recorded, such as baseline clinical data, cytogenetic abnormalities, treatment regimens, and duration of treatment, safety, and survival. Results: (1)There were 126 relapsed and refractory MM (RRMM) patients, 25 newly diagnosed patients and 19 maintenance patients. The evaluable RRMM patients accounted for 120 cases, among which 74 cases(61.7%) reached the partial response (PR) or above, and a very good partial response (VGPR) in 16 patients (13.3%), a complete response (CR) in 14 cases (11.7%), a strictly complete response (sCR) in 4 cases (3.3%). Thus, a VGPR or above in 34 patients accounted for 28.3%. (2)The median follow-up was 13 months, the median time to progression 12 months. The median survival after receiving lenalidomide was 19 months, and the median overall survival (OS) was 62 months. (3) The univariate analysis in 120 RRMM patients suggested that prognostic factors for significant improvement in PFS included normal karyotype, international staging system (ISS) Ⅰ-Ⅱ, t(4; 14) negative (detected by fluorescence in situ hybridization), non-bortezomib resistance and response to previous regimens. As to OS, non-bortezomib resistance, response to previous regimens and non-primary refractoriness were positive factors. Multivariate analysis showed that the response to previous regimens (PR or better) was an independent good prognostic factor for progress-free survival(PFS), non-bortezomib resistance and non-primary refractoriness for OS. (4) Grade 3 or 4 adverse events that occurred in more than 10% of all enrolled patients were neutropenia (12.7%), leukocytosis(11.5%) and thrombocytopenia (12.7%). Owing to intolerance of toxic side effects, 7 cases withdrew lenalidomide. Conclusions: No matter what combination, regimens containing lenalidomide are effective to RRMM patients with overall response rate 61.7%, a time to progression 12 months and an overall survival 62 months.The toxicity is quite tolerable and manageable. In addition, the response to previous treatment (reached PR or above) is the independent good prognostic factor for PFS, non-bortezomib resistance and non-primary refractoriness for OS. Clinical trail registration: Clinicaltrials.gov, NCT01947309.

[Comparison of aortic annular diameter defined by different measurement mordalities before transcatheter aortic valve implantation].

Objective: To compare aortic annular diameter measured by transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multislice computed tomography (MSCT) in patients with severe aortic stenosis, and to evaluate the impact on selection of prosthetic valve type in transcatheter aortic valve implantation (TAVI). Methods: Clinical data of 138 patients with severe aortic stenosis referred for TAVI between January 2014 and June 2016 in our hospital were retrospectively analyzed.The difference of aortic annular diameter measured by TTE, TEE, and MSCT were compared.TTE was performed after TAVI to evaluate the accuracy of measurement before TAVI. Results: (1) Aortic annular diameter was (23.37±2.22) mm by TTE and (23.52±1.70) mm by TEE (P=0.12). Pearson correlation analysis showed that aortic annular diameter measured by TTE was correlated to that measured by TEE (r=0.87, P<0.05). (2)The long-axis diameter and the short-axis diameter measured by MSCT multiplanar reconstruction were significantly different ((27.86±2.87) mm vs. (21.91±2.53) mm, P<0.05). There was no significant difference between the mean of the long- and short-axis diameters and the diameter derived from cross-sectional area by MSCT ((24.92±2.38) mm vs. (24.84±2.25) mm, P=0.08). However, the diameter derived from the circumference ((25.35±2.34) mm) was significantly larger than the mean of the long- and short-axis diameters and the diameter derived from cross-sectional area by MSCT, and the difference were (0.43±0.62) mm and (0.51±0.62) mm respectively(both P<0.05). (3) Measurements of the aortic annulus diameter by MSCT including the mean of the long- and short-axis diameters, diameter derived from cross-sectional area, and diameter derived from the circumference were larger than the measurement by TTE and TTE (all P<0.05). (4) Implantation was successful in all patients.Moderate to severe paravalvular leakage was detected in 3 patients at 7 days post TAVI, and 1 patient developed severe prosthetic valve restenosis at 6 months post TAVI and received valve-in-valve implantation. Conclusions: In severe aortic stenosis patients referred for TAVI, the aortic annular diameter derived from TTE and TEE measurements are smaller than that from MSCT.In the absence of a gold standard, selection of prosthetic valve type in TAVI procedure should rely on comprehensive considerations, which is of importance to get good clinical results for severe aortic stenosis patients underwent TAVI.

[A clinical analysis of 69 newly diagnosed multiple myeloma patients with renal insufficiency].

Objective: To investigate the efficacy and outcome in newly diagnosed multiple myeloma (MM) patients with renal insufficiency using bortezomib- or thalidomide-based regimens as front line treatment. Method: Sixty-nine newly diagnosed MM patients with renal insufficiency were retrospectively analyzed from August 2006 to August 2014. Results: ① Among thirty-nine patients with bortezomib based regimens (the bortezomib group), the overall response rate (ORR) was 89.7% and complete response (CR) plus near CR(nCR) rate was 41.0%. By contrast, among thirty patients with thalidomide based regimens (the thalidomide group), the ORR was 83.3% and CR+ nCR rate was 26.7%. There was no significant difference of either ORR or CR+ nCR rate between bortezomib and thalidomide groups. ② The improvement rate of renal function in bortezomib group and thalidomide group were 87.2% and 60.0% respectively (P=0.012). The median duration time of renal injury was 45 days in 52 patients with renal function improved, which was significantly shorter compared with 222 days in 17 patients without improvement (P<0.05). There was no difference of median serum creatinine and creatinine clearance rate between the two groups.③ The median progression-free survival (PFS) and the overall survival (OS) were 18 and 33.5 months, respectively in all patients. The three-year and five-year OS rates were 57% and 17%, respectively. The median PFS was 19 months in bortezomib group, while it was only 12 months in thalidomide group (P=0.023). The median OS were 36.5 months and 25.5 months respectively, which was no difference (P=0.285). Conclusions: The newly diagnosed MM patients with renal insufficiency could get higher ORR and the longer PFS using bortezomib-containing regimens as initial therapy. Meanwhile the improvement rate of renal function and the living quality in patients with bortezomib are better compared with those with thalidomide based treatment.

[Effects of ifosfamide in combination with pegylated liposomal doxorubicin and dexamethasone in the treatment of relapsed/refractory multiple myeloma].

Objective: To investigate the efficacy and adverse effects of ifosfamide in combination with pegylated liposomal doxorubicin and dexamethasone (CDD) in treating patients with relapsed/refractory multiple myeloma (MM). Methods: The clinical data of 30 relapsed/refractory MM patients treated with CDD regimen in Department of Hematology and Oncology of Beijing Chaoyang Hospital from November 2012 to November 2015 were retrospectively analyzed. The CDD treatment included ifosfamide 0.5-1.0 g/d on d1-4, pegylated liposomal doxorubicin 40-60 mg/d on d1, and dexamethasone 10-20 mg/d on d1-4. One cycle consisted of 21 or 28 days. Efficacy analysis was performed after every two cycles. Results: (1)The overall response rate (ORR) was 50.0% and the complete remission and near complete remission (CR+ nCR) rate was 10.0%. (2)The ORR of the 23 patients without extramedullary plasmacytoma(EMP)was 43.5% and the CR+ nCR rate was 8.7%. The ORR of the 7 patients with EMP was 5/7 and the CR+ nCR rate was 1/7. There were no statistically significant differences in ORR and CR+ nCR rate between the two groups (both P>0.05). (3)Except for the 5 patients with disease progression, the median progression-free survival (PFS) of the other 25 patients was 8.0 (3.0-25.0) months. The median PFS of the patients without EMP was 8.5 (3.0-25.0) months, that of the patients with EMP was 6.0 (2.0-21.0) months, with no statistically significant difference (P>0.05). The adverse effects included constipation, infection, hyperglycemia, and hemocytopenia, which were controlled by symptomatic treatment and did not affect the chemotherapy. Conclusion: CDD regimen can be used for the treatment of relapsed/refractory MM, especially in patients with EMP, with good efficacy and tolerance.

[Levels of dichlorodiphenyltrichloroethane internal exposure levels in pregnant women of Xiamen and influencing factors].

Objective: To investigate the level of and factors influencing internal exposure to dichlorodiphenyltrichloroethane (DDT) in pregnant women. Methods: In all, 1 064 pregnant women were recruited in a hospital of Xiamen. Participants were asked to complete a questionnaire to obtain data on sociodemographic characteristics and lifestyle. Peripheral venous blood and cord blood samples were collected. Of the 1 064 pregnant women, 600 were enrolled in this study after completing the questionnaire and providing peripheral venous blood and cord blood. Among those women, 150 were selected randomly using a systematic sampling method. A gas chromatography coupled electron capture detector was used to determine the concentration of six DDT homologues: p,p'-dichlorodiphenyltrichloroethane (p,p'-DDT), o,p'-dichlorodiphenyltrichloroethane (o,p'-DDT), p,p'-dichlorodiphenyldichloroethane (p,p'-DDD), o,p'-dichlorodiphenyldichloroethane (o,p'-DDD), p,p'-dichlorodiphenylethylene (p,p'-DDE), and o,p'-dichlorodiphenylethylene (o,p'-DDE) . Pregnant women were divided into two groups according to DDT concentration: a low concentration group (detection value≤P50) and a high concentration group (detection value>P50). multivariate logistic regression was used to analyze the association between the DDT levels and potential influencing factors which investigated in the questionnaire. Results: The detection rates of p,p'-DDT, o,p'-DDT, p,p'-DDD, o,p'-DDD, p,p'-DDE and o,p'-DDE in the peripheral venous blood samples from the 150 pregnant women were 83.3% (125), 29.3% (44), 58.0% (87), 24.0% (36), 82.0% (123), and 34.7% (52), respectively. The median concentrations were 1.56, 0.03, 0.07, 0.03, 0.93 and 0.03 µg/ml, respectively. The detection rates of p,p'-DDT, o,p'-DDT, p,p'-DDD, o,p'-DDD, p,p'-DDE and o,p'-DDE in the cord blood samples were 69.3% (104), 10.7% (16), 29.3% (44), 20.7% (31), 81.3% (122) and 45.3% (68), and the median concentrations were 0.41, 0.03, 0.03, 0.03, 0.42 and 0.03 µg/ml, respectively. The concentration ranges in the low and high DDT concentration groups which contained 75 respondents respectively were 0-3.69 and 3.74-82.09 µg/ml, respectively. In the single-factor analysis, the number (percentage) of those who consumed seafood " rarely" , "less than twice a week" , and " twice a week or more" was 15 (20.3%), 22 (29.7%), and 37 (50.0%), respectively, in the low concentration group, and 4(5.3%), 20(26.7% ), and 51(68.0% ) in the high concentration group (χ2=8.69, P=0.013). The results of the multivariate logistic regression analysis indicate that pregnant women who consume seafood less than twice a week, twice a week or more have higher peripheral blood DDT concentrations compared with those who rarely consume seafood. The OR (95% CI) values were 1.14 (1.08-1.21), 2.11 (1.55-2.85), respectively. Conclusion: The exposure level of pregnant women to DDTs in the Xiamen area is higher than that of women in other regions. High seafood intake is a risk factor for internal exposure to DDTs.