Objective To evaluate the safety and efficacy of adrenal autotransplantation for the treatment of persistent Cushing's disease after transsphenoidal pituitary tumor resection. Methods Four patients were treated by adrenal autotransplantation with attached blood vessels after bilateral adrenalectomy for persistent Cushing's disease from April 1991 to March 2008 in our institute. The four patients were 3 females and 1 male. Their ages ranged from 14 to 36 years, with an average of 30 years. Right adrenalectomy was performed 1 to 3 months before the left adrenalectomy. 30 % ?50 % of the left hyperplastic adrenal was placed in the left inguinal region with the anastomosis of the inferior epigastric artery and the central adrenal vein, and between the left saphenous vein and the incised adrenal envelope with the adrenal middle artery inside. The hormone replacement dosage decreased gradually after operation. They were followed up for 1.0, 1. 5, 8. 0 and 10. 0 years. The patient's symptoms, adrenal hormone (serum cortisol, urinary free cortisol and adrenocorticotroph) levels and the steroid replacement dosages were recorded and analyzed. Results The symptom of the Cushing's disease disappeared completely after operation and there was no Nelson's syndrome except one patient with slight darken skin. Through 4 ways of imaging examination, operation, clinical presentation and endocrine examination, the 4 transplanted adrenals functioned well with less steroid replacement dosage needed after operation. The 4 transplanted adrenal glands functioned steadily 1 year after the auto-transplantation, and no hyperplasia was detected in the transplanted adrenals with the stimulus of high dosage adrenocorticotroph. Conclusions The long-term effects of adrenal autotransplantation with attached blood vessels after bilateral adrenalectomy is effective and safe. Adrenal autotransplantation can be a feasible option for the treatment of persistent Cushing's disease.

Objective To quantitatively evaluate relative contribution of medical history,physical examination and laboratory investigation to diagnoses for medical outpatients.Methods In total,145 medical visitors to the outpatient department of Peking Union Medical College Hospital (PUMCH) during October 10 to 16,2008 were recruited and followed-up for 12 months.Results Nineteen of 145 visitors (13.1%) were lost during the period of follow-up and diagnoses were established for 86 of them (68.3%)finally with medical history and for 20 (15.9%) with physical examination or laboratory investigation,respectively.Confidence index of internists in their correct diagnosis increased to 7.3 with medical history and to 7.9 and 8.7 with physical examination and laboratory investigation in average,respectively.Conclusions Most visitors to internal medicine department could be diagnosed correctly with medical history only.On the basis of physical diagnosis,selection of adequate laboratory investigation for them is critical to improvement of clinical diagnosis.

Objective To study a modified method of laparoscopic partial nephrectomy with hypothermic renal artery perfusion in situ.Methods Laparoscopic partial nephrectomy with hypothermic renal artery perfusion in situ was performed in 5 patients from March 2009 to May 2009.There were 3 males and 2 females,with an average age of 49 years (39 to 63 years).There were 3 tumors in the left kidney and 2 in the right kidney,with an average diameter of 5.6 cm (range,3.8 to 7.0 cm).There were 2 cases of chronic renal insufficiency,1 case of solitary kidney,1 case of contralateral renal atrophy and 1 case of larger benign tumor.The procedure of laparoscopic partial nephrectomy with hypothermic renal artery perfusion in situ was as follows:A catheter with balloon was placed in the renal artery with percutaneous approach through the femoral artery preoperatively.During the operation the balloon of the catheter was inflated with water in order to block the renal artery,and renal artery perfusion of about 200ml saline of 4 ℃ was conducted through the catheter under high pressure in order to achieve low temperature in situ kidney.The water of the balloon was extracted after the accomplishment of the laparoscopic partial nephrectomy.Results Laparoscopic partial nephrectomies with hypothermic renal artery perfusion in situ were carried out successfully in 5 cases.The average operative time was 102 min (80 to 120 min),the average renal artery occlusion time was 35 min (range,29 to 39 min),and the average amount of bleeding was 190 ml(50 to 300 ml).The temperature of skin,kidneys,and tumor after hypothermic perfusion dropped by an average of 0.6℃,10.0 ℃,and 9.8℃,respectively.The endogenous creatinine clearance rate was(84.7±16.9),(48.9±14.5),(52.1±12.4),(54.5±13.8),and(54.6±11.7)ml/min before and 1 day,3 days,5 days and 10 days after operation.There was significant difference among the 5 groups in endogenous creatinine clearance rate(P=0.001).There was significant difference between each 2 groups except that between the group at 5 days and 10 days after operaton,The endogenous creatinine clearance rate kept steady in 5 days after operation.Conclusions Laparoscopic partial nephrectomy with hypothermic renal artery perfusion in situ is feasible and safe in favor of the extension of renal ischemic time and the protection of renal function.And it has resolved 2 problems in laparoscopic partial nephrectomy,that is,the laparoscopic artery occlusion and the hypothermic perfusion.

Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.

Objective To evaluate the value of continuous glucose monitoring system (CGMS) in the gestational patients with impaired glucose regulation. Methods The glucose level in the subcutaneous tissue was monitored by CGMS for 3 days in 6 patients with gestational diabetes mellitus (GDM) and 6 patients with gestational impaired glucose tolerance (GIGT). The fluctuation coefficient of blood glucose, percentage of hyperglycemic time, and percentage of hypoglycemic time were calculated. Results As shown by CGMS, the fluctuation coefficient of blood glucose, mean glucose level, percentage of hyperglycemic time, percentage of hypoglycemic time, mean fasting blood glucose, and mean postprandial blood glucose (PBG) levels were not significantly different between GDM group and GIGT group (P ＞ 0. 05). The time for reaching the peak PBG level ranged 90-120minutes in both two groups (P ＞ 0. 05). No sensor-related adverse events were noted. Conclusions It is safe to apply CGMS sensor in pregnant women. The blood glucose profiles are comparable between GDM and GIGT patients by CGMS; therefore, control of blood glucose should be equally strict in patients with GIGT as those with GDM.

Objective To study the classification and treatment of juxtaglomerular cell tumor of the kidney. Methods Five cases of juxtaglomerular cell tumors of the kidney were diagnosed and treated surgically in our hospital during the last 4 years. Seven large series of cases report of juxtaglomerular cell tumors have been published in the Pubmed. These series of cases report plus 1 case report of static juxtaglomerular cell tumor were incorporated into a review of 71 cases previously published in English literature. The clinical presentation, laboratory examination and imaging study were summarized. The clinical presentation including blood pressure, the laboratory examinations including kalium, plasma renin activity and aldosterone, and renal venous sampling for renin assay, and the imaging study including ultrasonography, CT, excretory urography, and selective renal angiography were studied retrospectively. Results The 71 cases juxtaglomerular cell tumors could be classified into 3 types, that is, typical type, atypical type and static type. The 57 typical cases had the typical characteristics of hypertension, hyperaldosteronism, and hypokalemia secondary to tumor renin secretion.The 12 atypical cases had hypertension with normal kalium, and the 2 static cases had normal blood pressure and kalium. Typical juxtaglomerular cell tumor of the kidney should be considered in hypertensive patients with secondary aldosteronism. Atypical juxtaglomerular cell tumor of the kidney should be considered in patients with hypertension and renal tumor. Static juxtaglomerular cell tumor of the kidney should be considered in patients with benign renal tumor. Conclusions The classification of typical, atypical and static juxtaglomerular cell tumors depends on blood pressure and serum kalium. As a surgically corrected disease, juxtaglomerular cell tumor of the kidney should be considered in patients with benign renal tumor, and nephron-sparing surgery is the first choice.

Objective To study the pharmacokinetics and pharmacodynamics of the 40/60 premixed recombinant human insulin injection preparation,and to compare with 30/70 preparation,regular insulin,and neutral protamine Hagedorn (NPH).Methods In this positive control,single dose,open label,Latin square crossover study,20 male healthy volunteers were recruited from May 2006 to March 2007,and divided into four groups.On 4 test days,40/60 preparation,30/70 preparation,regular insulin,and NPH were administered to each of the 4 groups,the interval was 7-70 days before 2 test days.The pharmacokinetics and pharmacodynamics were evaluated by euglycemic glucose clamp technique.Results According to the analysis of variance,there were statistically significant differences in pharmacokinetics and pharmacodynamics of the 4 insulin formulations between the 4 groups (all P ＜ 0.05).For the 40/60 premixed recombinant human insulin,the pharmacokinetic parameter time to peak (Tmax) and mean retention time (MRT) were (105.00 ±24.33) minutes and (321.77 ± 56.29) minutes,respectively;the glucose-lowering effects reflected by the pharmacodynamic parameter Tmax and MRT were (167.75 ± 26.48) minutes and (248.33 ± 14.96) minutes,respectively.Compared with 30/70 premixed recombinant human insulin,40/60 preparation showed no significant differences in the pharmacokinetics parameters of blood insulin concentration,including peak concentration [(91.67 ± 13.03) mU/L vs.(84.96 ± 14.75) mU/L,P =0.119],Tmax [(105.00 ± 24.33) minutes vs.(122.25 ± 39.35) minutes,P =0.128],MRT [(321.77 ± 56.29) minutes vs.(332.12 ± 49.20) minutes,P =0.645] and area under the curve in 0-16 hours [AUCIns 0-16,(24 918 ± 6 610)h · mU/L vs.(26 768 ± 8 032)h· mU/L,P=0.084];however,statistically significant differences were observed in AUCIns0-4 [(16 991 ± 3 673) h · mU/L vs.(12 407 ± 3 441) h · mU/L,P =0.042] and AUCIns 0-8 [(23 283 ± 4 939) h · mU/L vs.(19 397 ±5 314)h · mU/L,P =0.046].Pharmacodynamic parameters showed no statistically significant differences (all P ＞ 0.05).Compared with 30/70 premixed insulin,the relative bioavailability of 40/60 premixed insulin was (118.9 ± 35.9) ％,and the relative biological effectiveness was (106.6 ± 35.2) ％.There was no clinically significant abnormalities in the safety indexes before and after the tests.No hypoglycemic events,allergic reactions,or local injection adverse reaction occurred in this trial.Conclusions The 40/60 premixed recombinant human insulin preparation demonstrated different properties in insulin absorption in 8 hours after injection compared with the 30/70 preparation,mainly because of the difference in proportions of short-and intermediate-acting insulin in the mixture.This new premixed insulin may provide a new option for personalized diabetes management.

Objective To study the pharmacokinetics and pharmacodynamics of recombinant human insulin preparations SciLin TM R and Humulin (R) R,and to evaluate their bioequivalence in Chinese healthy volunteers.Methods In this positive control,single dose,open label,randomized cross-over study,20 male healthy volunteers were recruited from March to October 2007,and tested on two experimental days with an interval of 7-14 days.The volunteers were divided into two groups with a random number table,one group was injected with SciLin TMR for the first time and Humulin (R) R for the second time,the other group was injected with the opposite.The pharmacokinetics and pharmacodynamic properties were evaluated by euglycemic glucose clamp study.Results Time to peak concentration [Tmax,(105.8 ± 19.1) minutes vs.(103.5 ± 18.1) minutes,P =0.389) and time to maximum glucose infusion rate [TGIRmax,(132.8 ± 16.8) minutes vs.(132.8 ± 18.6) minutes,P =0.697] for SciLin TMR and Humulin(R) R were similar.The relative bioavailability of SciLin TMR was (102.2 ± 7.6) ％,and the relative biological effectiveness was (107.4 ± 18.8) ％.The 90％ confidence interval(CI) of peak concentration(Cmax) and area under the curve of blood glucose concentration at 0-10 hours (AUCIns 0-10) of SciLin TM R were 99.32 ％-102.62 ％ (equivalent range 70％-143 ％) and 98.98 ％-104.99 ％ (equivalent range 80％-125％),respectively;90％ CI of the maximum glucose infusion rate (GIRmax) and AUCGIR0-10 were 97.36％ ～ 103.49％ (equivalent range 70％-143％) and 98.72％-113.54％ (equivalent range 80％-125％),respectively,indicating that SciLin TMR and Humulin (R) R was bioequivalent.There was no clinically significant abnormalities in the safety indexes before and after the tests.During the trial,no hypoglycemic events,allergic reactions,or local injection adverse reaction occurred.Conclusion The studied recombinant human insulin preparation SciLin TMR may be bioequivalent as Humulin (R) R.