PURPOSE: Upward feedback is becoming more widely used in medical training as a means of quality control. Multiple biases exist, thus the accuracy of upward feedback is debatable. This study aims to identify factors that could influence upward feedback, especially in medical training. METHODS: A systematic review using a structured search strategy was performed. Thirty-five databases were searched. Results were reviewed and relevant abstracts were shortlisted. All studies in English, both medical and non-medical literature, were included. A simple pro-forma was used initially to identify the pertinent areas of upward feedback, so that a focused pro-forma could be designed for data extraction. RESULTS: A total of 204 articles were reviewed. Most studies on upward feedback bias were evaluative studies and only covered Kirkpatrick level 1-reaction. Most studies evaluated trainers or training, were used for formative purposes and presented quantitative data. Accountability and confidentiality were the most common overt biases, whereas method of feedback was the most commonly implied bias within articles. CONCLUSION: Although different types of bias do exist, upward feedback does have a role in evaluating medical training. Accountability and confidentiality were the most common biases. Further research is required to evaluate which types of bias are associated with specific survey characteristics and which are potentially modifiable.
Bias (Epidemiology) ; Confidentiality ; Quality Control ; Social Responsibility

Objective To study the relationship between serum neuron-specific enolase(NSE)and clinical features of pheochromocytoma/paraganglioma(PPGL).Methods Totally 501 PPGL patients diagnosed from January 2019 to December 2022 were divided into normal NSE group(NSE≤16.3 ng/mL)and elevated NSE group(NSE＞16.3 ng/mL).The clinical characteristics were compared between the two groups.Results Compared with normal NSE group,patients in the elevated NSE group had larger diameter in primary tumor(5.00 cm vs.4.60 cm),higher 24-hour urinary norepinephrine(NE)and 24-hour urinary dopamine(DA)levels,and a higher rate of metasta-sis(31.6%vs.13.7%)(P＜0.05).NSE level was positively correlated with the primary tumor size(r=0.131,P＜0.05),24-hour urinary NE level(r=0.195,P＜0.05)and 24-hour urinary DA level(r=0.119,P＜0.05).Conclusions The level of NSE is related to tumor size,secretion function and metastasis in PPGL patients.

Pheochromocytomas/Paragangliomas(PPGLs)are rare neuroendocrine tumors with a high hereditary predisposition.The pseudo-hypoxic PPGLs dominated by SDHx mutations show a higher potential of metastasis.Ap-proximately 10%-17%of PPGLs develop metastasis and patients with metastatic diseases have restricted treatment options and a poor prognosis.Tumor immune microenvironment(TIME)plays a crucial role in the development and progression of tumors as well as predicting patients'prognosis and their response to immune checkpoint inhibitors.Several studies have initially characterized the immune landscape of PPGLs.This review focuses on the infiltration of immune cells,the expression of immune checkpoints in the TIME of PPGLs and their relationships with genetics and metastasis of tumors in order to better understand the mechanisms of tumor immune evasion in PPGLs and pro-vide insights to support novel treatment strategy for metastatic PPGLs.

Familial hyperaldosteronism type Ⅲ(FH-Ⅲ) is extremely rare, and there are no reported cases in China. Herein, we reported two cases with FH Ⅲ, both of which presented with severe hypertension and hypokalemia in their early childhood. One patient had significantly enlarged adrenal glands and developed clinical manifestations of Cushing′s syndrome at the age of 20. Complete relief of symptoms was achieved after bilateral adrenalectomy. The other case had normal adrenal imaging, and with spironolactone treatment, blood pressure and potassium levels were well-controlled. Both cases had germline mutation of KCNJ5 gene which were c. 433G>C(p.Glu145Gln) and c. 452G>A(p.Gly151Glu), respectively.

Objective To evaluate 99mTc-HYNIC-TOC somatostatin receptor and 131 I-MIBG imaging in clinical diag-nostic of pheochromocytoma and paraganglioma(PPGL).Methods This was a retrospective study.359 PPGL pa-tients diagnosed by pathology microscopy were included.The diagnostic sensitivity and influencing factors on 99mTc-HYNIC-TOC somatostatin receptor and 131 I-MIBG imaging were analyzed.Results The positive rate of 99mTc-HYN-IC-TOC somatostatin receptor scintigraphy was 57.7%(184/319)and 131I-MIBG imaging was 83.2%(232/279).The positive rates of 99m Tc-HYNIC-TOC somatostatin receptor imaging in the adrenal glands,retroperitoneum,head and neck,heart and mediastinum,pelvis and bladder were 53.3%,62.5%,95.0%,66.7%,50.0%and 11.0%respec-tively and the positive rates of 131I-MIBG imaging were 86.7%,88.5%,45.4%,50.0%,75.0%and 33.3%respec-tively.The positive rate of the two imaging did not showed difference among patients with different genetic back-grounds(SDH,VHL,RET mutations).The median maximum diameter of tumors was 4.4(3.0,6.1)cm.and the diag-nostic sensitivity of somatostatin receptor imaging and 131 I-MIBG imaging for larger tumors(≥4.4 cm)was signifi-cantly higher than those for the smaller tumor group(＜4.4 cm)(64.0%vs.51.3%;92.3%vs.74.1%)(P＜0.01).Tumors in 19 patients(5.3%)failed to uptake neither imaging method.Conclusions This is the largest PPGL cohort in China concerning 99m Tc-HYNIC-TOC somatostatin receptor imaging and 131 I-MIBG imaging.The sensitivity of 131 I-MIBG imaging is higher than that of 99m Tc-HYNIC-TOC somatostatin receptor imaging,but for some tumors,such as head and neck paraganglioma,the latter has obvious advantages.These two imagings technol-ogies are complementary and the choice of them should depend the individual situation of patients.

Objective To explore the clinical characteristics of renal paraganglioma(PGL).Methods The clinical data of a rare case of renal paraganglioma in a pediatric patient were reported and published cases of renal paragan-gliomas both domestically and internationally were reviewed.Results A 12-year-old male patient underwent surgery for a right renal mass,with histopathological confirmation revealing a renal paraganglioma.Immunohistochemical staining results were positive for CgA and S-100,while Ki-67 index showed positivity in hot spots at 20%.The SDHB stain was negative.Germline genetic testing detected a heterozygous mutation in exon 6 of the SDHB gene,c.641A＞C(p.Gln214Pro).Following surgery,local radiotherapy was administered to the operative area.A posto-perative 18 F-FDG-PET/CT scan did not reveal any metastatic lesions.A total of 15 cases of renal paraganglioma have been reported at home and abroad since 2001,of which 8 were male and 7 were female,with an average age at diagnosis being(42±17)years old.Only 5 patients had hypertension preoperatively,and only 2 pres-ented with typical clinical symptoms.Out of 8 patients who underwent catecholamine testing before surgery,only 4 demonstrated elevated levels.The maximum tumor diameter was(9.9±7.3)cm,with 67%(10 out of 15 cases)having tumors larger than or equal to 5 cm in diameter.In this group,30%(3 out of 10 cases)had tumors that were S-100 negative,and 50%(2 out of 4 cases)had tumors with a Ki-67 index of≥3%.Conclusions Renal paraganglioma is extremely rare,and some patients present without clinical symptoms and with normal catecholamine,making misdiagnosis more likely.Due to the frequent occurrence of large tumors and high Ki-67 indexes,such tumors carry a relatively higher risk of recurrence and metastasis.Therefore,close follow-up is essential after the operation.