Radical hepatectomy is the well-established and highly effective therapeutic tool for early- and middle-stage hepatocellular carcinoma (HCC) to improve the survival. However, the majority of HCC patients in China are not amenable to surgical excision due to the advanced tumor stage at the initial diagnosis. Therefore, it is the bottom line to convert and downstage unresectable tumor into resectable tumor in clinical practice, which is an important means for improving patient survival rate and is currently a clinical research focus as well. In recent years, the rate of conversion surgery for unresectable advanced HCC has achieved dramatic improvement thanking to the accumulating effective therapeutic arsenals, and an increasing number of patients benefit from conversion therapy. Herein, several clinically relevant issues on conversion therapy for HCC were discussed in this review, including the definition of conversion therapy, the optimal selection of patients as well as conversion strategy, and the timing of sequential surgery together with strategy and safety of surgery.

Sarcopenia is considered to be a disease closely related to the existence and treatment of malignant tumors. It is characterized by a syndrome of progressive and generalized loss of skeletal muscle mass and strength, which can lead to adverse prognostic events such as physical disability, decreased quality of life and even death. Sarcopenia may be a condition in which age,malnutrition, inflammation, tumors, wasting diseases and many other factors are involved. Sarcopenia caused by malignant tumor and related chemotherapy is mostly related to inflammatory reaction, oxidative stress, mitochondrial damage and so on. In this paper, the research progress on tumor-associated sarcopenia in recent years is reviewed from its test methods, pathogenesis, clinical features, and intervention strategies.

Objective To explore the differences of adrenal imaging indicators of patients with subclinical Cushing syndrome (SCS) and different cortisol levels, and analyze the related influencing factors. Methods Retrospectively analyze the clinical data of 65 patients with SCS admitted in the Department of Endocrinology of the First Medical Center of Chinese PLA General Hospital from January 2010 to January 2020. Subjects were undergone 1 mg dexamethasone suppression test (DST) at midnight, then with the blood cortisol level of 138 nmol/L at 8:00 am as a cut-off (1 mg DST-F_8:00), divided into low-level group(n=36) and high-level group (n=29). The clinical characteristics, biochemical indicators, adrenocorticotropic hormone-cortisol(ACTH-F), tumor size, CT value and contralateral adrenal gland image of the two groups were compared. The relationship of contralateral adrenal width to the related factors between the both groups were analyzed by logistic regression, and then multivariate linear regression analysis was performed to analyze the relationship of the contralateral adrenal length, width and height to the different metabolic indicators. Results No statistically significant difference in the course of disease, body mass index (BMI),blood pressure, blood glucose, blood lipid, bone density, and related metabolic abnormalities existed between the two groups. While the patients were significantly younger (P<0.001), the SCS onset time was much earlier (P<0.001), and the proportion of female patients was higher (P=0.014) in high-level group than those in low-level group. In addition, the cortisol level at midnight (F_00.00)and 1 mg DST-F_8:00 were obviously higher in high-level group than those in low-level group (P<0.001). No significant difference existed between the two groups in tumor size, CT value, contralateral adrenal gland length, height and volume, but the width was thinner in high-level group than those in low-level group (P=0.07). The level of 1 mg DST-F_8:00 in SCS patients was negatively correlated with the width of contralateral adrenal gland (β=–1.79, 95%CI –3.05-–0.52, P=0.007). Using sex, age, age of onset, course of disease, BMI, ACTH level, and tumor diameter as adjustment variables, logistic regression was singularly performed to analyze the relationship between 1 mg DST-F_8:00 and the width of contralateral adrenal gland in SCS patients, then the results were still consistent. Multivariate linear regression showed that the width of contralateral adrenal gland was negatively correlated with diastolic blood pressure (β=–2.484, 95%CI –3.883-–1.085, P=0.002), while the contralateral adrenal length and height showed no obvious correlations with the metabolic index. Conclusion SCS patients with higher level of 1 mg DST-F_8:00 had thinner contralateral adrenal gland width and with higher diastolic blood pressure.

Objective To analyze the clinical characteristics of pheochromocytoma/paraganglioma (PPGL) patients with normal level of plasma free metanephrines (MNs), and offer a proposal for the diagnosis and treatment of such patients. Methods A retrospective study was conducted of 99 patients hospitalized from January 2019 to April 2021 and diagnosed as PPGL, of which 98 patients were pathologically confirmed as PPGL and 1 patient was clinically diagnosed as Von Hippel-Lindau (VHL) syndrome.Plasma free MNs were detected, and according to the MNs level, all the patients were divided into PPGL with normal MNs group(n=10) and PPGL with elevated MNs group (n=89). The differences were contrasted and analyzed between the two groups in clinical manifestation, imaging characteristics, preoperative preparation and intraoperative blood pressure fluctuation. Results No significant difference was detected in the incidence of typical triad between the two groups, but the incidence of nausea and vomiting in PPGL with normal MNs group was higher (40.0% vs. 13.5%, P=0.031). The proportion of retroperitoneal paraganglioma was obviously higher in PPGL with normal MNs group than in PPGL with elevated MNs group (60.0% vs. 20.2%, P=0.027), and the proportion of patients possessing typical PPGL imaging manifestations (70.0% vs. 92.1%, P=0.028) and tumor necrosis (40.0% vs.71.9%, P=0.039) was lower in PPGL with normal MNs group than in PPGL with elevated MNs group. Among 10 patients in PPGL with normal MNs group, 2 cases had slightly increased urinary metanephrine (MN) or 3-MT, and the maximum diameter of tumor in 8 cases was ≥3 cm. CT or MRI showed that tumors with typical PPGL imaging features in 7 cases, and functional imaging was positive in 6 cases. Conclusions Normal plasma MNs can not be used as sufficient exclusion of PPGL diagnosis. For patients suspected with PPGL, when normal MNs are obtained, it is recommended to measure extra indexes such as 24 h urine MNs and 3-MT.In addition, functional imaging is of great value in this condition.

Objective To study the effects of semaphorin 3A (Sema3A) on myoblast function and its transcriptional regulation mechanism. Methods Myoblasts were treated with 1.0 µg/ml, 0.1 µg/ml, 0.01 µg/ml recombinant Sema3A protein, and the control group was set up. The proliferation and migration of myoblasts were observed by the IncuCyte system and scratch test. The expression levels of myogenic differentiation factors were detected by RT-qPCR. Transcriptome sequencing was performed for the myoblasts intervened by 1.0 µg/ml recombinant Sema3A protein and those in control group. The differential expressed genes were screened out for GO enrichment analysis. Part of differential expressed genes were verified of transcription level by RT-qPCR. Results IncuCyte cell imaging count showed that Sema3A promoted proliferation of myoblasts, the cell count increased about 17.36% in 1.0 µg/ml Sema3A group than in control group (P<0.001). Scratch test showed the enhanced migration ability of myoblasts by Sema3A, the cell scratch healing rate increased by 69.66% in 1.0 µg/ml Sema3A group than in control group (P<0.001).RT-qRCR showed that during myoblast differentiation, 1.0 µg/ml Sema3A up-regulated the expression of Myf5 by 37.47%±11.67%(P<0.01), and up-regulated the expression of MyoG by 26.57%±11.31% (P<0.05). Bioinformatics analysis showed that Sema3A up-regulated the functional pathway associated with the development and maturation of muscle cells and muscle fibers, bone and chondrocyte proliferation, osteogenic differentiation, and bone mineralization; down-regulated the functional pathway associated with the lipoprotein metabolism and chylomicrons. RT-qPCR verified the partial differentially expressed genes in enrichment pathway, among which the expressions of Prox1 and Myh11 increased by 22.48%±14.42% (P<0.05) and 21.42%±5.81% (P<0.01),respectively; and of LipC and ApoC2 decreased by 23.08%±15.38% (P<0.05) and 55.97%±26.51% (P<0.05), respectively. Conclusion Exogenous Sema3A protein can up-regulate the expression of myoblast differentiation related genes Myf5 and MyoG, and may promote the proliferation and migration of myoblasts by transcriptional regulation of skeletal muscle development,maturation and lipoprotein metabolism.

Status epilepticus is one of the critical illnesses involving multiple clinical disciplines. Although treatment is comprehensive, rapid termination of status epilepticus episodes is critical. The purpose of this article is to provide an actionable approach to rapidly terminating status epilepticus episodes by organizing multidisciplinary experts to improve patient outcomes.In the consensus, the experts put forward the purpose of the consensus, the scope of adaptation, the method and clinical practice of rapid termination of status epilepticus, and discuss several issues that need to be paid attention to in the treatment of status epilepticus, hoping to provide clinicians with an alternative when faced with status epilepticus.

Pulmonary hypertension is a clinical syndrome with progressive abnormal increase of pulmonary artery pressure resulting from multiple factors, which eventually leads to patient death by right heart failure. Patients with pulmonary hypertension are often accompanied by pleural effusion clinically and the pleural effusion produced by patients with different types of pulmonary hypertension has its own characteristics. At present, it is widely acknowledged that the occurrence of pleural effusion is closely related to left heart failure, while the relationship between right heart failure and pleural effusion remains controversial. Pulmonary hypertension is an ideal model to study the effects of isolated right heart failure on the development of pleural effusion. This article summarizes the research results of domestic and foreign scholars on pleural effusion related to various types of pulmonary hypertension in recent years, concludes the clinical characteristics, diagnosis and treatment of pleural effusion caused by pulmonary hypertension, describes the hemodynamics, pathophysiology and other mechanisms of pleural effusion and explores the association between the development of pleural effusion and right heart failure. Hoping to be helpful for the diagnosis and treatment of pulmonary hypertension and the study of the relationship between right heart failure and pleural effusion.

Objective By comparison of the urinary free cortisol (UFC) levels in post- to prior-dexamethasone suppression test (post UFC/pre UFC) with primary pigmented nodular adrenocortical disease (PPNAD), primary bilateral macronodular adrenal hyperplasia (PBMAH) and adrenocortical adenoma (ADA), to explore the optimal differential diagnostic cut-off point of PPNAD from PBMAH and ADA. Methods The clinical data were collected and retrospectively analyzed of in patients admitted from January 2008 to December 2020 with finally diagnosed as PPNAD (n=7), PBMAH (n=31) and ADA (n=130) in the First Medical Center of Chinese PLA General Hospital. Based on the receiver operating characteristic (ROC) curve, the value of post UFC/pre UFC in low-dose dexamethasone suppression test (LDDST) and high-dose dexamethasone suppression test (HDDST)was used as the detection variable, and the diagnosis of PPNAD was used as the status variable to search the best cut-off point for the differential diagnosis of PPNAD. Results The serum cortisol (F) levels of all the 3 groups of patients (PPNAD, PBMAH and ADA) increased significantly in the baseline, LDDST and HDDST, and no statistical difference existed among them (P>0.05). The adrenocorticotropic hormone (ACTH) levels in all the 3 groups of patients were inhibited, and ACTH levels in PBMAH group were the highest at the baseline and after HDDST, and the ACTH levels of ADA group were the lowest among the three groups (P<0.05).The baseline 24 h UFC levels elevated obviously with no statistical difference (P>0.05) among the three groups. For patients in PPNAD group, the LDDST post UFC/pre UFC [1.88(1.39, 2.59)] was obviously higher than that in PBMAH group [1.13(0.82,1.37), P=0.001] and ADA group [1.11(0.70, 1.49), P=0.003]; and the HDDST post UFC/pre UFC in PPNAD group [2.31(1.23,3.08)] was still higher than that in PBMAH group [1.22(0.94, 1.63), P=0.004] and ADA group [1.39(1.08, 1.53), P=0.008].Compared with PBMAH group and ADA group, the diagnostic cut-off point for PPNAD group after LDDST post UFC/pre UFC was 1.385, with 85.7% sensitivity and 71.5% specificity; and after HDDST post UFC/pre UFC was 2.290, with 57.1% sensitivity and 95.0% specificity. Conclusion The cut-off points of post UFC/pre UFC in DST had a clear advantage in distinguishing PPNAD from PBMAH and ADA. The diagnosis of PPNAD may be considered once the value of post UFC/pre UFC after LDDST is greater than 1.385, or after HDDST is above 2.290.

Objective To investigate the impact of hyponatremia on the prognosis of neurointensive care patients. Methods A retrospective study of 942 neurointensive care patients admitted to the First Medical Center of PLA General Hospital between August 2010 and May 2020 was performed. We classified these patients into two groups according to serum sodium level within 24 hours of admission: hyponatremia group 233 cases (<135 mmol/L), normonatremia group 709 cases (135-145 mmol/L).The 233 hyponatremia patients were subdivided into two groups: mild hyponatremia group (130-135 mmol/L, n=165) and moderate-severe hyponatremia group (<130 mmol/L, n=68). Primary endpoints were evaluated at 1-month and 6-month respectively with modified Rankin Scale (mRS), mRS scores of 4-6 were defined as poor outcomes. The general clinical data and prognosis were compared between the groups. Logistic regression was used to analyze the influencing factors of patient prognosis. Results Compared with the normonatremia group, the body temperature, blood glucose, urea, and creatinine, diagnosed as cerebrovascular disease, the proportion of poor prognosis at 6 months as well as hospitalization costs in the hyponatremia group were significantly different (P<0.05). There was no significant difference in the prognosis of patients with different degrees of hyponatremia (P>0.05). Multivariate logistic regression showed that hyponatremia, older age, high serum creatinine level, diagnosed as cerebrovascular disease, higher hospitalization costs, and low GCS score were independent risk factor for poor prognosis of NICU patients at 1 month after discharge. And multivariate logistic regression showed that hyponatremia, older age and low GCS score were independent risk factor for poor prognosis of NICU patients at 6 months after discharge. Conclusions Hyponatremia,a common electrolyte disorder in neurointensive care patients, is an independent risk factor influencing prognosis. Even mild hyponatremia may have an impact on outcomes.

Objective To investigate the effect of circulatory management strategy with regional cerebral oxygen saturation(rScO₂) and central venous-arterial differential pressure of carbon dioxide (Pcv-aCO₂) as the main targets on the short term prognosis of children with cyanotic congenital heart disease (CCHD). Methods A total of 72 children with CCHD aged 0-1 year,who underwent cardiac surgery under cardiopulmonary bypass (CPB) in the Seventh Medical Center of Chinese PLA General Hospital from October 2020 to June 2021, were selected as research objects, and randomly divided into control group (n=36)and intervention group (n=36). The control group was implemented with traditional circulation management strategy, while the intervention group was implemented the individualized circulation management strategy with rScO₂ and Pcv-aCO₂ as the main targets. The mean arterial pressure (MAP) of endotracheal intubation opening the arteries and veins (T₁), 5 minutes after clipping of ascending aorta (T₂), 5 minutes after opening of ascending aorta (T₃), end of ultrafiltration (T₄), 3 hours after end of CPB (T₅),8 hours after end of CPB (T₆) and 24 hours after end of CPB (T₇) of the two groups of children were recorded, respectively, as well as the pharyngeal temperature (T), hemoglobin (Hb), arterial oxygen saturation (SaO₂), partial pressure of carbon dioxide in artery (PaCO₂), rScO₂, Pcv-aCO₂, arterial blood lactate (Lac) and central venous oxygen saturation (ScvO₂), CPB time, operation time, extubation time, ICU stay time, discharge time, and acute kidney injury (AKI), lung infection, and respiratory failure. Results No significant difference existed in MAP, T, Hb and SaO₂ between the two groups at T₁-T₇ (P>0.05). Compared with control group, PaCO₂ in the intervention group was significantly increased at T₂, T₃, T₆ and T₇, rScO₂ was significantly increased at T₃-T₆(P<0.05), and Pcv-aCO₂ was significantly decreased at T₁-T₇ (P<0.05), Lac levels were significantly decreased at T₃ and T₅ (P<0.05),and ScvO₂ levels were significantly decreased at T₂ and T₃ (P<0.05). No significant difference existed in CPB time, operation time,extubation time, postoperative pulmonary infection and respiratory failure rate between the two groups (P>0.05). The ICU stay time and hospital stay time were significantly shorter in intervention group than in control group [(5.67±1.50) d vs. (7.28±2.11) d,P<0.05; (14.67±3.41) d vs. (19.00±2.63) d, P<0.05], the incidence of postoperative AKI was significantly lower than the control group [25.0% (9/36) vs. 50.0% (18/36), P<0.05]. Conclusion The individualized circulatory management strategy with rScO₂ and Pcv-aCO₂ as the main targets in the perioperative period can significantly improve the short term prognosis of children with CCHD.