Objective To discuss the surgical treatment of primary pigmented nodular adrenocortical disease(PPNAD).Methods twenty-four cases of PPNAD were treated in our hospital from January 2005 to December 2017.Clinical data of these patients were reviewed.It included 8 males and 16 females with a mean age of 23 years old (range 14 to 58).23 cases presented with typical symptoms of Cushing syndrome, 1 case presented with hypertension.Eight cases could be diagnosed with Carney complex.All cases were confirmed as ACTH-independent Cushing syndrome.Adrenal imaging showed bilateral multiple nodules in 11 cases, unilateral multiple nodules in 4 cases, unilateral single mass or nodule in 3 cases, normal adrenals in 6 cases.Results All of the 24 cases received laparoscope unilateral adrenalectomy or laparoscope unilateral mass resection.After the operation, 8 cases underwent secondary operation because of symptom recurrence and the elevated 24-hour urinary free cortisol.Among them, 5 cases received contralateral subtotal adrenalectomy, 3 cases received contralateral total adrenalectomy.Seven cases with a slightly elevated 24-hour urinary free cortisol but a good recovery of Cushing symptoms were followed-up.Nine cases recovered well after the first operation and they didn't undergo secondary surgical treatment, but 1 of the 9 cases needed glucocorticoid replacement.Conclusions Bilateral adrenalectomy followed with long-term glucocorticoid replacement is the standard treatment of PPNAD.Unilateral adrenalectomy or subtotal adrenalectomy may be suitable for elected patients, but appropriate criteria need to be explored.

Objective:To explore whether perioperative intravenous flurbiprofen axetil can reduce the incidence and intensity of chronic pain for breast cancer atfer surgical treatment. Methods:This randomized, double-blind, controlled trial enrolled 60 patients undergoing mastectomy and axillary lymph node dissection under general anesthesia. All patients accepted Hospital Anxiety and Depression Scale (HAD) tests the day before the surgery to evaluate depression and anxiety. hTe patients were randomly assigned to receive either 50 mg lfurbiprofen axetil intravenously 15 minutes before the surgical incision and 6 hours later (group F) or intravenous 5 mL intralipid as a control (group C). All patients received patient-controlled intravenous analgesia (PCIA) with fentanyl postoperatively. Peripheral venous blood samples were drawn before the surgery, at 4 and 24 h atfer the surgery to detect the plasma level of PGE2 and tumor necrosis factor-α(TNF-α). Postoperative fentanyl consumption, Numerical Rating Scale (NRS) scores and adverse effects were recorded at 2, 6, 12, 24 and 48 h after the surgery. hTe duration and intensity of pain were followed up by telephone at the 2nd-12th month atfer the surgery. Results:The incidence of pain at 2, 4, 6, and 12 months after the breast surgery was 33%, 20%, 15%, and 10%, respectively, and the average pain score was 0.77, 0.57, 0.28, and 0.18, respectively. Compared with group C, the scores of pain in group F were significantly lower at 2, 4, 6 and 12 months postoperatively (F=7.758, P=0.007). The incidence of pain in group F was significantly lower at 2, 4 and 6 months postoperatively (P<0.05). There was no significant difference in the incidence of pain between the groups at 12 months postoperatively (P>0.05). Preoperatively and at 4 and 24 h atfer the surgery, there was no signiifcant difference in the level of TNF-αbetween the two groups (F=0.530, P=0.470);but plasma concentration of PGE2 in group F was significantly lower than that in group C (F=5.646, P=0.021). No patients developed abnormal bleeding, peptic ulcer, impaired liver or renal function and respiratory depression. Conclusion:Perioperative intravenous infusion of 100 mg flurbiprofen axetil can decrease the intensity and incidence of chronic pain for breast cancer atfer surgical treatment.

Objective To assess the long-term outcome of unilateral adrenaletomy in patients with adrenocorticotropic hormone independent macronodular adrenal hyperplasia (AIMAH).Methods The data from 82 cases of AIMAH were reviewed and summarized including clinical manifestations, endocrinological data, imaging findings and postoperative follow-up.Fouty-nine males and thirty-three females with a mean age of fifty years composed our series.Among the 82 cases, 41 demonstrated Cushing syndrome (CS), 74 presented with hypertension, 38 manifested diabetes mellitus, 35 complicated of osteoporosis and 11 of them with bone fracture, 39 complained of edema.Laboratory tests showed low ACTH plasma levels (＜ 2.2 pmol/L) in 62 of 79 cases.High level of 24-hour urinay free cortisol excretion(＞ 284.2nmol/L) was found in 67 of 79 cases.Elevated serum cortisol with loss of the circadian rhythm was presented in 55 of 60 cases.Failed to suppress cortisol secretion was observed in 61 of 63 conducted with low-dose dexamethasone suppression tests and in 47 of 53 implemented with high-dose dexamethasone suppression tests.Bilateral massively enlarged multinodular adrenal glands were found in all cases with CT or MR imaging.Unilateral adrenalectomy was performed in the larger side of adrenal gland in all 82 cases.All adrenalectomies were carried out including 47 in right sides and 35 in left sides, with 77 by retroperitoneoscopic approach and 5 by open retroperitoneal approach.Results Histopathological examination confirmed nodular hyperplasia of the adrenal cortex for all specimens.After a mean duration of 48.5 months, 80 of 82 patients were available for follow-up.Most clinical symptoms resolved within 6 months after operation.Cushingoid features disappeared in 58.5％ (24/41)of patients who initially presented with typical signs of Cushing Syndrome.Weight loss was seen in 56.3％ (45/80).Improvement of hypertension and diabetes was observed in 63.5％ (47/74) and 76.3％ (29/38) respectively.All the eyelids swelling and edema of the limbs subsided within 3 months.In long-term follow-up (more than 6 months), 82.9％ (63/76) had clinical and biochemical recurrence within a mean time of 14.6 months and 46.0％ (29/63) received contralateral adrenal surgery.Two patients died, one died from heart attack and another one died from pulmonary infection, 2 years and 7 years after unilateral adrenalectomy, respectively.Conclusions Unilateral adrenalectomy just has transient efficiency for AIMAH.Most patients will experience clinical and biochemical recurrence for a long period,and have to receive another operation for the contralateral hyperplastic adrenal gland.

BACKGROUND: In valerian-ligusticum extract (VLE), valeriana offici nalis extract (VOE) is γ aminobutyric acid (GABA) receptor kinetin, which can relax cerebral vascular spasm; ligusticum wallichii Fr. Extraxt (LWE)can pass through blood-brain barrier, enhance microcirculation of tissue and inhibit blood platelet aggregation and 5-Hydroxytryptamine (5-HT) release.OBJECTIVE: To probe into the effects of VLE prepared with effective components on prevention and treatment of cerebral ischemic injury.DESIGN:Complete randomized, negative and positive control experiment.SETTING: Institute of Senile Medicine and Pharmacology of Tongji Medical College of Huazhong University of Science and Technology.MATERIALS: The experiment was performed in Institute of Senile Medicine Pharmacology of Tongji Medical College of Huazhong University of ent blood perfusion in brain tissue: Fifty Kunming mice were employed,which was randomized into normal group, solvent control (model) group,ligustrazine 50 mg/kg group, VLE 170 mg/kg group and VLE 85 mg/kg Fifty Wistar rats were employed, which was randomized into solvent control (model) group, compound danshen (Radix Salviae Miltiorrhizae) 5 g/kg group,VLE 156 mg/kg group, VLE 94 mg/kg group and VLE 31.3 mg/kg group,Sixty Wistar rats were employed, which was randomized into sham-operation group, solvent control (model) group, ligustrazine 10 mg/kg group, VLE 156 mg/kg group, VLE 95 mg/kg group and VLE 31.3 mg/kg, 10 mice in each were employed, which was randomized into normal group, solvent control (model) group, ligustrazine 10 mg/kg group, VLE 200 mg/kg group and VLE 40 mg/kg, 10 mice in each one.sue, in advance, VLE (85, 170 mg/kg), ligustrazine (50 mg/kg) or solvent enhancer of equal volume (0.2 mL) were injected abdominally in each group. Twenty minutes later, pituitrin (2.5 u/kg) was injected intravenously; and 10 minutes later, isotope 99Tcm+ L, L-EthylCysteinate Dimer and Stannous Chloride (ECD) 3.7×1010Bq/ L(0.1 mL/per mouse) was injected in coccygeal nerve. Fifteen minutes later, radio-immunity counter was used periment of arteral-ovenous bypass method for thrombosis, before the opercal saline successively, continuously for 7 days, once per day. After 24 hours of medication pause, with abdominal anesthesia with pentobarbitol sodium, a catheter (with surgical thread inside) was used in vitro to connect common cervical vein and carotid artery. Thrombus mass was scaled 15 dominal anesthesia of chloral hydrate, intraluminal thread approach (ITA)was used to block unilateral MCA. Except that ITA was not used, the other management in sham-operation group was same as experimental groups.Gastric perfusion was done with VLE(156, 94, 31.3 mg/kg), ligustrazine operation and 3 hours and 12 hours after operation. 24 hours after modeling, the assessment was done for behavioral neurological damage and brain sive cerebral ischemia experiment, the model was prepared by coccygeal injection of collagen + adrenalin (AD). Respectively, 30 minutes before modeling injection and 1 hour after injection, gastric perfusion was done with VLE (200, 40 mg/kg), ligustrazine (10 mg/kg) or solvent enhancer of equal volume successively to observe the numbers of dead mice in 5 minutes after modeling and the numbers of hemiplegia mice in 15 minutes;and to determine brain mass index 8 hours later after sacrificed and lactic acid level of brain tissue homogenate with ultraviolet spectrophotometry.group.RESULTS: In the experiment of acute extensive brain ischemia in mice, in solvent control, during modeling, 3 mice were died and the rest 207 mice brain tissue in mice, the ratios of brain with and blood γ ray pulsating intensity in VLE 85 mg/kg group and VLE 170 mg/kg were higher than model group (0.53±0.09, 0.55±0.08, 0.45±0.08, t=2.234 6, 2.793 3, P method in rats, the thrombus masses in VLE 156 mg/kg group, 94 mg/kg group and 31.3 g/kg group were lower remarkably than the model group [(12.66±4.79), (13.31 ±3.97), (13.49±4.09), (19.21±5.76) g, (t=2.667 0,31.3 mg/kg group, 94 mg/kg group and 156 mg/kg group was lower remarkably than model group successively [(5.9±1.9), (6.0±2.0), (5.8±2.2),(8.7±0.9) score], and cerebral infarction index was lower than model group [(16.52±5.78)%,(16.54±3.00)%, (14.18±6.13)%, (24.03±4.85)%, (t=3.118 9-chemia in mice, brain mass indexes of VLE 40 mg/kg and 200 mg/kg groups were lower remarkably than model group [(0.91 ±0.20) and (0.82±0.24)%, (1.40±0.32)%], and lactic acid in brain tissue was lower than model group [(17.44±6.71),(14.43±2.81), (29.07±7.33) μmol/g (t=3.388 5-5.800 5, P＜ 0.01)].CONCLUSION: Valerian-liqusticum extract improves significantly cerebral ischemia in mice induced by pituitrin and the damage by medium cerebral artery embolism in rats, and it inhibits significantly blood platelet aggregation and thrombosis induced by AD+ collagen mixture or foreign objects. It is suggested that valerian-ligustrazine extract prevents and treats significantly the perfusion disturbance of cerebral microcirculation.

Objective:In order to accurately evaluate the postoperative rehabilitation of gynecological robotic surgery, a prediction model for evaluating postanesthesia care unit (PACU) extubation time and hospital stay in gynecological robotic surgery was established.Methods:The clinical data of gynecological patients who underwent robotic surgery in Xiangya Third Hospital of Central South University from October 2015 to May 2017 were retrospectively analyzed, and the data were screened to evaluate the postoperative recovery of patients from two aspects: PACU extubation time and postoperative hospital stay. Binary logistic regression was used to screen out the factors affecting PACU extubation time and postoperative hospital stay, and the prediction model was preliminarily established and verified.Results:Finally, there were 456 patients and 30 variables analyzed in the binary logistics regression. According to these variables, the prediction model of the postoperative recovery evaluation after gynecological robotic surgical procedures was established. Among them, age, intraoperative amount of atracurium and midazolam were independent risk factors affecting PACU extubation time (all P<0.05). American Society of Anesthesiologists (ASA) grade, intraoperative amount of midazolam, intraoperative bleeding and operation time were independent risk factors affecting postoperative hospital stay (all P<0.05). All models passed Hosmer lemeshow test (all P>0.05); The areas under the receiver operating characteristic curve (ROC) were 0.647 and 0.806, respectively. Conclusions:The prediction model of PACU extubation time and the postoperative hospitalization time has been established.

Although medical damage risks really exist, an effective medical risk sharing system is still not available in China right now. By analyzing the status quo of Chinese medical damage risks sharing system, the authors put forward the following suggestions to improve the current system: Upgrading the preventive strategy for medical disputes, establishing multi-level and multi-channel comprehensive medical damage risks sharing system, promoting the effective cooperation between insurance relief systems and mediation system for medical disputes, and constructing highly effective pathways to resolve the medical disputes.
China ; Dissent and Disputes ; Humans ; Insurance, Liability ; Malpractice ; Negotiating ; Risk Sharing, Financial

Objective To evaluate the efficacy of facial acupoint injection combined with nerve block in treating hemifacial spasm. Methods Fifty?four patients of both sexes, aged 26-73 yr, with the course of disease 6 months-17 yr from February 2015 to January 2016, were included in this study accord?ing to diagnostic criteria for hemifacial spasm based on expert consensus in 2014. Patients were divided into 2 groups(n=27 each)using a random number table: facial acupoint injection combined with nerve block group(group A)and nerve block group(group B). In group A, the mixed injection 2 ml(2% lidocaine hydrochloride 5 ml, compound betamethasone 1 ml, mecobalamin 1 mg, diluted to 18 ml in normal sa?line)was given at facial Sibai, Jiachengjiang, Xiaguan and Yifeng acupoints once every 5 days, 3 times in total;facial nerve block was performed via the stylomastoid foramen with the mixed injection(5 ml) previously described once every 5 days, 3 times in total;stellate ganglion block was performed on the right and left side alternately once a day, 5 times on each side. In group B, patients received facial nerve block and stellate ganglion block, and no facial acupoint injection was applied. The Cohen rating and Shorr out?come were recorded before treatment and at 10th day, 3rd month and 1 yr after treatment, and the recur?rence was recorded at 3 months and 1 yr after treatment. Results Compared with group B, Cohen classifi?cation was significantly decreased, and the effective rate was increased at 10th day, 3rd month and 1 yr af?ter treatment, and the recurrence rate was decreased at 3 months and 1 yr after treatment in group A(P<0.05). Conclusion The facial acupoint injection combined with nerve block produces better long?term ef?ficacy in treating hemifacial spasm than nerve block alone.

Objective To analyze the clinical characteristics for hypertensive attack during operation and clinical experience of preoperative evaluation and preparation in patients with pheochromocytoma and paraganglioma(PHEO/PGL).Methods A total 219 PHEO/PGL cases from September 2016 to September 2018 were retrospectively reviewed.It included 99 males and 120 females,aged 13 to 76 (average 47) years old.The mean diameter of tumor was 5.3 cm (1.5-18.0 cm).140 cases were unilateral PHEO,6 cases were bilateral PHEO,68 cases were PGL(jugular,mediaphragm,heart,retroperitoneum,pelvic and bladder) and 5 cases were PHEO combined with PGL.Preoperative highest systolic blood pressure (SBP)was 240 mmHg(1 mmHg-0.133 kPa) and highest diastolic blood pressure (DBP) was 160 mmHg.20 cases were occult PHEO without hypertension.217 cases accepted preoperative preparation of alpha-blocker [phenoxy-benzamine,dosage ranging from 5 mg Q12h to 40 mg Q8h,maximum dosage not exceeding 1 mg/(kg· 24 h)].2 cases did not accept preoperative preparation.All cases accepted open or endoscope surgery.The patients were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery.Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack.Results Histopathological results showed that all cases were PHEO or PGL,while 205 cases were benign,14 cases were malignant.Hypertensive attack were recorded in 112 cases(51％).The diameter of tumors in the hypertensive attack group were larger than that in the non-hypertensive attack group[(6.70 ± 2.95)cm vs.(3.95 ± 1.70) cm,P =0.005].There was no significant difference between the two groups among age [(51.0 ± 10.8) years vs.(38.5 ± 17.6) years,P =0.105],preoperative catecholamine level [norepinephrine (111.20 ± 41.49) μg/24 h vs.(419.15 ± 154.81) μg/24 h,P =0.075],time of use of alpha blockers [(53.0 ± 7.5) d vs.(38.0 ± 6.4) d,P =0.139],daily dosage of alpha blocker [(40.0 ±7.2)mg vs.(27.1 ± 1.8) mg,P =0.111] and blood pressure at diagnosis[(173.75 ± 26.69) mmHg vs.(155.0 ± 20.75) mmHg,P =0.139].Among 219 cases,2 case had emergency hemostasis after operation,1 case had catecholamine cardiomyopathy after operation for occult pheochromocytoma,and no perioperative death occurred.Conclusions Patients with large tumor tend to have hypertensive attack during operation so that should be better prepared.

Objective: The CT/MRI Liver Imaging Reporting and Data System (LI-RADS) demonstrates high specificity with relatively limited sensitivity for diagnosing hepatocellular carcinoma (HCC) in high-risk patients. This study aimed to explore the possibility of improving sensitivity by combining CT/MRI LI-RADS v2018 with second-line contrast-enhanced ultrasound (CEUS) LI-RADS v2017 using sulfur hexafluoride (SHF) or perfluorobutane (PFB). Materials and Methods: This retrospective analysis of prospectively collected multicenter data included high-risk patients with treatment-naive hepatic observations. The reference standard was pathological confirmation or a composite reference standard (only for benign lesions). Each participant underwent concurrent CT/MRI, SHF-enhanced US, and PFB-enhanced US examinations. The diagnostic performances for HCC of CT/MRI LI-RADS alone and three combination strategies (combining CT/ MRI LI-RADS with either LI-RADS SHF, LI-RADS PFB, or a modified algorithm incorporating the Kupffer-phase findings for PFB [modified PFB]) were evaluated. For the three combination strategies, apart from the CT/MRI LR-5 criteria, HCC was diagnosed if CT/MRI LR-3 or LR-4 observations met the LR-5 criteria using LI-RADS SHF, LI-RADS PFB, or modified PFB. Results: In total, 281 participants (237 males; mean age, 55 ± 11 years) with 306 observations (227 HCCs, 40 non-HCC malignancies, and 39 benign lesions) were included. Using LI-RADS SHF, LI-RADS PFB, and modified PFB, 20, 23, and 31 CT/MRI LR-3/4 observations, respectively, were reclassified as LR-5, and all were pathologically confirmed as HCCs. Compared to CT/MRI LI-RADS alone (74%, 95% confidence interval [CI]: 68%–79%), the three combination strategies combining CT/MRI LI-RADS with either LI-RADS SHF, LI-RADS PFB, or modified PFB increased sensitivity (83% [95% CI: 77%–87%], 84% [95% CI: 79%–89%], 88% [95% CI: 83%–92%], respectively; all P < 0.001), while maintaining the specificity at 92% (95% CI: 84%–97%). Conclusion The combination of CT/MRI LI-RADS with second-line CEUS using SHF or PFB improved the sensitivity of HCC diagnosis without compromising specificity.

Objective: The CT/MRI Liver Imaging Reporting and Data System (LI-RADS) demonstrates high specificity with relatively limited sensitivity for diagnosing hepatocellular carcinoma (HCC) in high-risk patients. This study aimed to explore the possibility of improving sensitivity by combining CT/MRI LI-RADS v2018 with second-line contrast-enhanced ultrasound (CEUS) LI-RADS v2017 using sulfur hexafluoride (SHF) or perfluorobutane (PFB). Materials and Methods: This retrospective analysis of prospectively collected multicenter data included high-risk patients with treatment-naive hepatic observations. The reference standard was pathological confirmation or a composite reference standard (only for benign lesions). Each participant underwent concurrent CT/MRI, SHF-enhanced US, and PFB-enhanced US examinations. The diagnostic performances for HCC of CT/MRI LI-RADS alone and three combination strategies (combining CT/ MRI LI-RADS with either LI-RADS SHF, LI-RADS PFB, or a modified algorithm incorporating the Kupffer-phase findings for PFB [modified PFB]) were evaluated. For the three combination strategies, apart from the CT/MRI LR-5 criteria, HCC was diagnosed if CT/MRI LR-3 or LR-4 observations met the LR-5 criteria using LI-RADS SHF, LI-RADS PFB, or modified PFB. Results: In total, 281 participants (237 males; mean age, 55 ± 11 years) with 306 observations (227 HCCs, 40 non-HCC malignancies, and 39 benign lesions) were included. Using LI-RADS SHF, LI-RADS PFB, and modified PFB, 20, 23, and 31 CT/MRI LR-3/4 observations, respectively, were reclassified as LR-5, and all were pathologically confirmed as HCCs. Compared to CT/MRI LI-RADS alone (74%, 95% confidence interval [CI]: 68%–79%), the three combination strategies combining CT/MRI LI-RADS with either LI-RADS SHF, LI-RADS PFB, or modified PFB increased sensitivity (83% [95% CI: 77%–87%], 84% [95% CI: 79%–89%], 88% [95% CI: 83%–92%], respectively; all P < 0.001), while maintaining the specificity at 92% (95% CI: 84%–97%). Conclusion The combination of CT/MRI LI-RADS with second-line CEUS using SHF or PFB improved the sensitivity of HCC diagnosis without compromising specificity.