Objective:To investigate the safety and efficacy of laparoscopic simultaneous bilateral adrenalectomy in treating ectopic ACTH syndrome (ACTH)caused by medullary thyroid carcinoma(MTC).Methods:A 56-year-old male patient was admitted after MTC surgery and 7 months of general fatigue. The patient had a history of two open thyroid surgeries for medullary thyroid carcinoma, with previous pathological reports indicating lymph node metastasis in the upper mediastinum and mediastinum, accompanied by weak cytoplasmic expression of ACTH and negative CRH staining. After the operation, the patient developed diabetes, hypertension, and hypokalemia. Upon admission, the patient presented with a blood pressure reading of 200/95 mmHg (1 mmHg = 0.133 kPa), a weight of 61.5 kg, a height of 160 cm, a body mass index (BMI)of 24.02 kg/cm 2, and a waist circumference of 83 cm. Laboratory tests revealed the following: blood potassium level of 2.71 mmol/L, blood calcium level of 1.47 mmol/L, parathyroid hormone level of 6.0 pg/ml, fasting blood glucose level of 10.51 mmol/L, glycated hemoglobin level of 8.2%, blood calcitonin level exceeding 2 000 pg/ml, and blood CEA level of 70.8 μg/L. The plasma ACTH levels at 8∶00, 16∶00, and 24∶00 were 189.0, 125.0, and 65.0 pg/ml, respectively. Serum cortisol levels at 08∶00, 16∶00, and 24∶00 were 429.30, 408.14, and 446.61 μg/L, respectively. The 24-hour urine free cortisol measurement was 1 200 μg, and after the midnight 1mg dexamethasone suppression test at 8∶00, the plasma ACTH level was 183.0 pg/ml, and the serum cortisol level was 538.27 μg/L. The aldosterone level in standing position after 2 hours was 8.2 pg/ml. There were no significant abnormality in catecholamine hormone detection or thyroid function in blood and urine samples. An 18F-FDG-PET/CT examination showed multiple lymph node metastases in the neck, while an abdominal CT scan revealed bilateral adrenal hyperplasia. Enhanced MRI revealed pituitary gland thinning, and lung CT and sputum culture examinations showed scattered multiple lung infections. After a multidisciplinary discussion, the patient was diagnosed with EAS, postoperative MTC metastasis, diabetes, hypertension, hypokalemia, pulmonary infection, mild anemia, liver dysfunction, hypoparathyroidism, and hypocalcemia. The patient were accepted laparoscopic bilateral adrenalectomy via an abdominal approach under general anesthesia. The left adrenal gland was removed first, followed by the right adrenal gland after repositioning. Results:The surgery was successful with a surgical duration of approximately 60 minutes and an intraoperative bleeding volume of about 20 ml. No surgical complications occurred during the perioperative period. Pathological examination confirmed nodular hyperplasia of the adrenal cortex and bilateral adrenal medullary hyperplasia with negative ACTH staining. After a 3-month postoperative follow-up, blood calcitonin levels remained above 2000 pg/ml. The blood ACTH levels at 1 week, 1 month, and 3 months after surgery were 183.0, 220.0, and 731.0 pg/ml, respectively. However, hypertension, diabetes, and hypokalemia rapidly improved. One month after surgery, blood pressure was 100/80 mmHg, fasting blood glucose was 4.4 mmol/L, and blood potassium was 3.87 mmol/L. Pulmonary infection showed improvement, and no adrenal crisis occurred. Glucocorticoid replacement therapy consisted of 20 mg of hydrocortisone tablets in the morning and 10 mg in the afternoon, and thyroid hormone replacement therapy involved daily administration of 100 μg of levothyroxine. Genetic testing revealed heterozygous mutations in the Ret gene. The patient is currently undergoing clinical trial treatment with Ret inhibitors.Conclusions:Based on the data from this case and existing literature reports, laparoscopic simultaneous bilateral adrenalectomy might be safe and effective treatment option for EAS caused by unresectable MTC metastasis. It can correct hypertension, diabetes, and hypokalemia and increase the opportunity for MTC treatment.

Objective:To determine the impact of body mass index (BMI) on perioperative and oncological outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion.Methods:Clinical data of bladder cancer patients undergoing robot-assisted radical cystectomy with intracorporeal urinary diversion in Zhejiang Provincial People's Hospital from January 2017 to January 2020 were retrospectively analyzed. Patients were divided into three groups according to BMI, including 61 cases in normal group (<25.0 kg/m2), 52 cases in overweight group (25.0-29.9 kg/m2) and 33 cases in obese group (≥30.0 kg/m2). In the normal group, the median age was 73.6(59, 79), including 45 male(73.8%), with 51 cases(83.6%) of ASA score 0-2, 10 cases (16.4%)of 3 or higher, and 10 cases (16.4%) undergoing neoadjuvant chemotherapy. Past medical history included smoking in 34 cases (55.7%), hypertension in 19 cases (31.1%), diabetes in 10 cases (16.4%), heart disease in 12 cases (19.7%), and abdominal surgery in 6 cases (9.8%). In the overweight group, the median age was 69.7(60, 78), including 38 male (73.1%), with 25 cases (48.1%)of ASA score 0-2, 27 cases (51.9%) of 3 or higher, and 9 cases (17.3%) undergoing received neoadjuvant chemotherapy. Past medical history included smoking in 30 cases (57.7%), hypertension in 20 cases (38.5%), diabetes in 10 cases (19.2%), heart disease in 9 cases (17.3%), and abdominal surgery in 5 cases (9.6%). In the obses group, the median age was 69.9(61, 78), including 21 male(63.7%), with 20 cases (60.6%)of ASA score 0-2, 13 cases(39.4%) of 3 or higher, 9 cases (27.3%) undergoing neoadjuvant chemotherapy. Past medical history included smoking in 18 cases (54.5%), hypertension in 17 cases (51.5%), diabetes in 19 cases (57.6%), heart disease in 7 cases (21.2%), and abdominal surgery in 4 cases (12.1%). After statistical comparison among the three groups, it was found that the proportion of patients with hypertension and diabetes in the obesity group and overweight group was higher than that in the normal group (all P<0.05), but there was no significant difference in other factors (all P>0.05). During the surgical process, robot-assisted radical cystectomy and bilateral pelvic lymph node dissection were performed firstly. The scope of lymph node dissection was divided into standard range and expanded range, and the diversion was divided into orthotopic neobladder and ileal bladder. During the orthotopic neobladder process, 40-50 cm ileum at the distance of 15 cm away from ileocecum was obtained by stapler, and then the U-shaped neobladder was made, and the new bladder was anastomosed with urethra and bilateral ureter. For ileal bladder, the ileum was cut off 15cm away from the ileocecum with stapler to obtain the 15 cm ileum to prepare the ileal conduit and restore the continuity of the ileum. The bilateral ureteral spacing 3cm was implanted on the ileal conduit. In the normal group, standard range lymphatic dissection was performed in 20 cases (32.8%), enlarged dissection in 41 cases (67.2%), orthotopic neobladder in 22 cases(36.1%), and ileal conduit in 39 cases (63.9%). In the overweight group, standard range lymphatic dissection was performed in 12 cases (23.1%), enlarged dissection in 40 cases (76.9%), orthotopic neobladder in 26 cases (49.1%), and ileal conduit in 26 cases (50.9%). In the obesity group, the standard range of lymphatic dissection was performed in 7 cases (21.2%), enlarged dissection in 26 cases (78.7%), orthotopic neobladder in 7 cases (21.2%), and ileal conduit in 26 cases (78.8%). There was no significant difference among the three groups (all P>0.05). Compared the operation time, intraoperative blood loss, postoperative exhaust time, postoperative time of taking solid food, postoperative hospital stay, postoperative complications (according to the Clavien-Dindo grading system, postoperative complications are reported inⅠ-Ⅱ grade as mild complications and above Ⅲ grade as serious complications) and pathology results in three groups. Results:All cases successfully underwent robotically without conversion or major intraoperative complications. The operation time in overweight and obsess group were longer than that of normal group with RARC or orthotopic neobladder [310(250, 350) min, 370(310, 420) min, 250(230, 310) min, ( P<0.05)], but there was no significant difference in RARC and ileal conduit[270(220, 300) min, 280(230, 300) min, 240(220, 290)min, P>0.05]. The estimated blood loss in overweight and obsess group was more than that in normal group [230(150, 450)ml, 310(250, 600)ml, 190(100, 350)ml, P<0.05], but there was no difference in blood transfusion rate [4(7.7%), 2(6.1%), 5(8.2%), P>0.05]. The exhaust time [2(1, 3) days, 2(1, 4)days, 2(1, 4)days], postoperative solid food intake time [4(3, 5)days, 4(3, 6)days, 4(3, 6)days] and the hospital stay[10(5, 16)days, 10(6, 17)days, 12(6, 20)days] were not different in three groups(all P>0.05). The mild complication rates in 90 days were significant higher in overweight and obsess groups[28 (53.8%), 16(48.5%), 20(32.8%), P<0.05], but the total and severe complication rates were not significantly different. The incidences of urinary system complications and incision complications in obese and overweight patients were significantly higher than those in normal group ( P<0.05). There was no significant difference in the incidence of gastrointestinal complications and ureteral anastomosis-related complications (stricture or urinary leakage)( P>0.05). There was no significant difference in the number of dissected lymph node, positive lymph node, positive rate of incisional margin and postoperative pathological stage among three different BMI groups(all P>0.05). Conclusion:Robot-assisted radical cystectomy combined with intracorporeal urinary diversion is a safe and effective method for the treatment of overweight, obese and even morbidly obese patients with bladder cancer. The recovery of intestinal function and the oncological results are not affected by body mass index. However, laparoscopic radical cystectomy for overweight and obese patients, especially for orthotopic neobladder, has the risk of long operation time, large amount of intraoperative bleeding and increased risk of minor postoperative complications.

Objective·To detect the effects of propofol sedation on cognitive function in rats and its mechanism. Methods?·?Forty-eight SD rats were randomly divided into three groups, i.e. control group, 100?mg/kg group and 300?mg/kg group. Rats were administrated intraperitoneally with propofol (10?mg/mL, 100?mg/kg or 300?mg/kg). The mRNA levels of brain derived neurotropic factor (BDNF)-TrkB/p75 signal molecules in rat hippocampus were evaluated by realtime PCR 45 min after propofol treatment. Learning and memory ability was examined by inhibitory avoidance (IA) test after propofol treatment. Results?·?The mRNA levels of BDNF in the hippocampal tissue were (1.20±0.13) fold (P=0.002) and (88±12) % (P=0.044) of that in control group, respectively, in 100?mg/kg group and 300?mg/kg group after injection of propofol. The mRNA levels of TrkB were (1.01±0.11) fold ( P=0.982) and (86±11) % (P=0.018) of that in control group, respectively, in 100?mg/kg group and 300?mg/kg group. The mRNA levels of p75 were (1.02±0.10) fold (P=0.778) and (1.59±0.18) fold (P=0.000) of that in control group, respectively, in 100?mg/kg group and 300?mg/kg group. There was no significant difference of the 24 h IA memory retention latency between 100?mg/kg group and control group. The 24 h IA memory retention latency in 300?mg/kg group was significantly decreased compared with control group (P=0.028) and 100?mg/kg group (P=0.020). Conclusion?·?Propofol dose-dependently regulates the expression of BDNF-TrkB/p75 signal molecules, and high dose propofol may reduce cognitive function via BDNF-TrkB/p75 signal.

BACKGROUND: Under indirect co-culture conditions, chondrocytes can induce bone marrow mesenchymal stem cells to differentiate into chondrocytes. Osteocytes are the seed cells of chondrocytes, but co-culture of osteocytes with chondrocytes is rarely reported. OBJECTIVE: To induce the chondrogenic differentiation of periosteum-derived cells (PDCs) by indirect co-culture with chondrocytes. METHODS: Chondrocytes were isolated from the rabbits by trypsin and collagenase Ⅱ digestion. Rabbit PDCs were obtained by the explants culture method. Passage 2 chondrocytes and PDCs underwent indirect co-culture at 1:1 in Transwell system as experimental group. PDCs cultured alone were as control group. After 2 weeks of culture, the cellular morphological changes were observed by inverted contrast phase microscope. The expression levels of collagen type Ⅱ and proteoglycan were detected by collagen type Ⅱ immunohistochemistry and toluidine blue staining. The mRNA expression levels of proteoglycan, collagen type Ⅱ and SRY-related protein-9 were detected by RT-PCR. RESULTS AND CONCLUSION: After 2 weeks of culture, PDCs in the experimental group were gradually transformed to chondrocyte-like cells, while PDCs in the control group still remained long spindle-shaped. Collagen type Ⅱ immunohistochemistry staining and toluidine blue staining were positive in the experimental group, while the results were negative in the control group. Additionally, RT-PCR results indicated that the relative mRNA expression levels of proteoglycan, collagen type Ⅱ and SRY-related protein-9 in the experimental group were significantly higher than those in the control group. Therefore, chondrocytes can induce PDCs to differentiate into chondrocytes under indirect co-culture conditions.

Objective: To study the expression and significance of Notch1-Jagged1 in nasal mucosa of allergic rhinitis (AR) mouse model in various stages and in the serum of AR patients. Methods: Thirty-six mice were divided into 3 groups: control group, basal sensitization group (OVA) and OVA/AR group, with 12 mice in each group. Allergic symptom in each group were scored after AR model establishment. HE staining method was used to observe the nasal mucosa eosinophils infiltration. ELISA was used to detect the serum level of total IgE. Flow cytometry was used to detect the change of Treg cells in each group. Western blot was used to detect the expression of Notch1 and Jagged1 in nasal mucosa. Flow cytometric bead array (CBA) was used to detect the level of Th1/Th2/Th17 cytokines in splenic lymphocytes. The serum was obtained from 50 patients with AR and 30 control volunteers in Department of Otorhinolaryngology Head and Neck Surgery, Renmin Hospital of Wuhan University from June to October 2017. ELISA was used to detect the expression of Notch1 and Jagged1. Results: Compared with the control group, the allergy symptom, the number of nasal mucosal eosinophils and the level of total IgE were not significantly different in basal sensitization group, but increased significantly in OVA/AR group (6.11±0.78 vs 0.67±0.50, 77.67±5.61 vs 10.33±0.82, (106.80±11.91) pg/ml vs (82.45±19.80) pg/ml, t value was 19.471, 34.848, 2.542, respectively, all P<0.05). Compared with the control group, the ratio of Treg cell increased in basal sensitization group but decreased in OVA/AR group ((10.29±0.47)% vs (9.28±0.16)%, (8.49±0.15)% vs (9.28±0.16)%, t value was 5.838, 4.540, respectively, all P<0.01). Compared with control group, the expression of Notch1 increased significantly both in basal sensitization group and OVA/AR group (1.04±0.05 vs 0.71±0.05, 1.83±0.10 vs 0.71±0.05, t value was 9.293, 31.363, respectively, all P<0.01); and the expression of Jagged1 only increased significantly in OVA/AR group (0.41±0.04 vs 0.21±0.01, t=13.472, P<0.01). It was found that Notch1 was positively correlated with the level of IL-6, IL-10 by Pearson test (r value was 0.98, 0.87, respectively, all P<0.01). Compared with control volunteers, the expression of Notch1 and Jagged1 increased significantly in AR group patients ((1 135.0±254.9) pg/ml vs (436.0±139.3) pg/ml, (1 200.2±401.0) pg/ml vs (559.9±124.2) pg/ml, t value was 13.99, 11.94, respectively, all P<0.01). Conclusions The expression of Notch1 receptor and ligand increased significantly in the pathogenesis of AR. Notch1-Jagged1 may promote the occurrence and development of AR by up-regulating the expression of IL-6 and IL-10.

BACKGROUNDParoxysmal kinesigenic dyskinesia (PKD) is a rare movement disorder characterized by recurrent dystonic or choreoathetoid attacks triggered by sudden voluntary movements. Under the condition of psychological burden, some patients' attacks may get worsened with longer duration and higher frequency. This study aimed to assess nonmotor symptoms and quality of life of patients with PKD in a large population.

METHODSWe performed a cross-sectional survey in 165 primary PKD patients from August 2008 to October 2016 in Rui Jin Hospital, using Symptom Check List-90-Revised (SCL-90-R), World Health Organization Quality of Life-100 (WHOQoL-100), Self-Rating Depression Scale, and Self-Rating Anxiety Scale. We evaluated the differences of SCL-90-R and WHOQOL-100 scores in patients and Chinese normative data (taken from literature) by using the unpaired Student's t-test. We applied multivariate linear regression to analyze the relationships between motor manifestations, mental health, and quality of life among PKD patients.

RESULTSCompared with Chinese normative data taken from literature, patients with PKD exhibited significantly higher (worse) scores across all SCL-90-R subscales (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism; P= 0.000 for all) and significantly lower (worse) scores of five domains in WHOQoL-100 (physical domain, psychological domain, independence domain, social relationship domain, and general quality of life; P= 0.000 for all). Nonremission of dyskinesia episodes (P = 0.011) and higher depression score (P = 0.000) were significantly associated with lower levels of quality of life. The rates of depression and anxiety in patients with PKD were 41.2% (68/165) and 26.7% (44/165), respectively.

CONCLUSIONSDepression, anxiety, and low levels of quality of life were prevalent in patients with PKD. Co-occurrence of depression and anxiety was common among these patients. Regular mental health interventions could set depression and anxiety as intervention targets. Considering that the motor episodes could be elicited by voluntary movements and sometimes also by emotional stress, and that symptoms may get worsened with longer duration and higher frequency when patients are stressed out, intervention or treatment of depression and anxiety might improve the motor symptoms and overall quality of life in PKD patients.

OBJECTIVE The aim of the study was to evaluated the difference and consistency in tumor size measured by sonographic and pathological examination in papillary thyroid carcinoma(PTC).METHODS A total of 114 patients with PTC, including 122 malignant nodules, was collected from Hangzhou First People's Hospital between Jun 2012 and Jun 2014. The tumor sizes were measured by preoperative sonographic and postoperative pathologic evaluation. Pearson correlation analysis, paired t-test, and Bland-Altman plot were used to evaluate the correlation and consistency in tumor size measured by the two methods.RESULTS Pearson correlation analysis showed that the largest tumor size measured by sonography were positively correlated with pathologic size (r=0.957, P=0.000). Paired t-test showed that there were statistically difference between sonographic size and pathological size (8.24±5.06) mmvs (7.79±4.75) mm,P=0.001. The absolute difference value of the largest tumor size measured by the two methods was from zero to 6.5 mm, with the average of (1.03±1.14) mm. Bland-Altman analysis showed that the limits of agreement (LoA) of difference was from -2.41 mm to 3.33 mm, with the 95% confidence interval from -2.87 mm to 3.78 mm.Within the limit of the consistency, the maximum moduli was 2.9 mm.CONCLUSION There is a significant discrepancy between the preoperative sonographic and the pathologic size of the papillary thyroid carcinoma, which should be taken into account in clinical practice.

OBJECTIVE To explore the feasibility of detection for mutated BRAF V600E gene based on amplification refractory mutation system(ARMS),and to evaluate its clinical significance of BRAF V600E gene mutation in thyroid nodules.METHODS The method of ARMS was used to detect BRAF V600E mutation status in 179 patients with PTC and 115 patients with benign lesions.The diagnosis index of BRAF V600E mutation status for identifying the nature of the thyroid nodule was calculated.The potential correlation between BRAF V600E mutation and PTC clinicpathological characteristics was also analyzed.RESULTS Detection of BRAF V600E mutation status in thyroid lesions based on ARMS was feasible and believable.The positive rate of mutated BRAF V600E gene in PTC was 82.68％,whereas the rate in benign lesions was only 1.74％,indicating statistical differences between the two groups(x2=183.568,P＜0.01).The diagnostic sensitivity of BRAF V600E mutation was 82.68％,specificity was 98.26％,accuracy was 88.76％,and Youden index was 0.8094.There was no associations between the BRAF V600E mutation status and PTC clinicpathological characteristics(eg.gender,age,tumor size,numbers of lesions,bilateral lesions,extrathyroidal extension and lymph node metastasis).CONCLUSION Detection of BRAF V600E mutation based on ARMS has higher sensitivity and specificity in distinguishing PTC from benign lesions,indicating BRAF V600E gene is an ideal marker of PTC for clinical early diagnosis.

[ABSTRACT]OBJECTIVETo study the expressions of 34βE12, Galectin-3 and HBME-1 in thyroid nodules, and to explore its diagnostic value for papillary thyroid carcinoma (PTC).METHODSEn VisionTM immunohistochemical technique was used to detect the expression of 34βE12, Galectin-3 and HBME-1 in 352 thyroid lesions. The correlation between the expressions of the 3 protein markers and clinicopathological characteristics was evaluated. The receiver operating characteristic area under the curve (ROC-AUC) and their index for diagnosis evaluation were also calculated.RESULTSThe positive rates of 34βE12, Galectin-3 and HBME-1 in 246 PTC lesions were significantly higher than those in benign nodules (P<0.001). There was no relationship between the expression of the 3 protein markers and clinicopathological characteristics (eg. gender, age, numbers of lesions, tumor size, capsular invasion, lymph node metastasis, TNM staging). The ROC-AUC of 34βE12, Galectin-3 and HBME-1 for diagnosis of PTC was 0.936, 0.915 and 0.898 respectively. The sensitivity of 34βE12, Galectin-3 and HBME-1 for diagnosis of PTC was 94.3%, 95.5% and 91.1% respectively, while the specificity was 81.1%, 71.7% and 83.0% respectively, and the diagnostic accuracy rate was 90.3%, 88.4% and 88.6% respectively.CONCLUSION The expressions of 34βE12, Galectin-3 and HBME-1 are statistically different between PTC and benign lesions, but no associations are found with clinicopathological characteristics, indicating the three protein markers have important diagnostic value for PTC.

Objective To explore the application and efficacy of autogenous septal cartilage in the correction of cleft lip nasal deformity.Methods A total of 31 patients with secondary nasal deformity of cleft lip were involved in this study.After autologous nasal cartilage was released,the dislocation of nasal cartilage was corrected,nasal septum cartilage was used as substitute to raise the alar collapse,to reshape the nasal tip cartilage structure and correct the nasal deformity.Results Postoperative incision was primarily healing.For cartilage donor area there was no serious complications,and incision scar was concealed and unobvious; after 6 months to 2 years follow-up,there was no cartilage absorption deformation,the tip of the nose was flat,crack side nosewing collapses,and nasal columella skew was totally corrected,with stable rhinoplasty effects.Conclusions For secondary nasal deformity of cleft lip,the use of nasal septum cartilage to repair nose deformity can not only solve the cartilage source,but also give septal straightening and at the same time the correction effect of external nasal deformity is good.