Clinical Focus

Application principles of vasodilators in the treatment of acute heart failure

Duan Fang, Cui Wei

2023, 38(9): 773-778. doi:10.3969/j.issn.1004-583X.2023.09.001

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Acute heart failure (AHF) is one of the common diseases in cardiovascular medicine. Its treatment principles include reducing cardiac preload and afterload, and improving cardiac systolic and diastolic function. Currently, evidences supporting the feasibility of vasodilators in the treatment of AHF are scant. The clinical application of vasodilators remains controversial. This review thoroughly described the pathophysiological basis, populations, and blood pressure control goals of intravenous vasodilators in the treatment of AHF, thus providing references for the clinical application.

Correlation between the TNF-α-308 gene polymorphism and gastric cancer susceptibility: A meta-analysis

Lyu Chang, Zhou Liming

2023, 38(9): 779-787. doi:10.3969/j.issn.1004-583X.2023.09.002

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Objective To investigate the correlation between tumor necrosis factor-α (TNF-α) promoter 308 locus (TNF-α-308) gene polymorphism and gastric cancer susceptibility. Methods Case-control studies on TNF-α-308 gene polymorphism and the susceptibility to gastric cancer published before June 2022 were searched in Pubmed, Embase, Web of Science, Cochrane library, Wanfang and China National Knowledge Infrastructure (CNKI). Literature screening, data extraction and evaluation of risk of bias were performed independently by 2 investigators. Meta-analysis was performed via Stata 16.0 software. Results A total of 41 case-control studies were included, involving 7528 gastric cancer patients and 10924 controls. Meta-analysis showed that in allelic, heterozygous and dominant models, TNF-α-308 gene polymorphisms were significantly correlated with with an increased risk of gastric cancer (A vs G: $O R$ =1.21, 95% $C I$ : 1.01-1.44, $P$ =0.039; AG vs GG: $O R$ =1.26, 95% $C I$ : 1.07-1.49, $P$ =0.392; AA+AG vs GG: $O R$ =1.22, 95% $C I$ : 1.00-1.47, $P$ =0.046). Five studies of gastric cancer caused by Helicobacter pylori infection showed that TNF-α-308 gene polymorphisms were not correlated with susceptibility to gastric cancer. Subgroup analyses showed that all genetic models in Asian areas (A vs G: $O R$ =1.29, 95% $C I$ : 1.04,1.61, $P$ =0.022; AG vs GG: $O R$ =1.35, 95% $C I$ : 1.06,1.71, $P$ =0.014; AA+AG vs GG: $O R$ =1.36, 95% $C I$ : 1.07,1.73, $P$ =0.013) and in African areas showed a significant correlation between TNF-α-308 gene polymorphisms and risk of gastric cancer ( $P$ <0.05), which was not correlated in American and European areas. All genetic models in Taqman typing study showed a significant correlation between TNF-α-308 locus gene polymorphisms and risk of gastric cancer ( $P$ <0.05). Conclusion A significant correlation between TNF-α-308 gene polymorphisms and risk of gastric cancer is found in Asian areas. It is not correlated with the susceptibility to gastric cancer caused by Helicobacter pylori infection.

Meta-analysis of the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury

Li Hai, Liu Wenhu, Peng Shaopeng, Wang Fei

2023, 38(9): 788-795. doi:10.3969/j.issn.1004-583X.2023.09.003

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Objective To compare the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury. Methods Relevant articles reporting the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury published from the establishment of the database to November 2022 were searched in the PubMed, Embase, The Cochrane Library, Web of Science, Wanfang Medical Network, China National Knowledge Infrastructure (CNKI), Chinese Biomedicine Database (CBM) and VIP databases. Data were extracted from the eligible literatures for performing a meta-analysis using RevMan 5.4 software. Results A total of 23 eligible articles were included, involving 17 retrospective clinical controlled studies and 6 randomized controlled trials. Finally, 2141 patients with severe craniocerebral injury were included, involving 1080 patients managed by controlled stepwise decompression and 1061 managed by rapid standard large bone-flap decompression. Meta-analysis results showed that compared to those treated with rapid standard large bone flap decompression, controlled stepwise decompression provided an earlier time of decompression ( $M D$ =-25.39, 95% $C I$ : -30.96, -19.81; $P$ <0.01), less operation time ( $M D$ =-21.49, 95% $C I$ : -34.22, -8.76; $P$ <0.01), shorter length of stay ( $M D$ =-3.02, 95% $C I$ : -3.70, -2.34; $P$ <0.01), less intraoperative bleeding ( $M D$ =-23.82, 95% $C I$ : -32.42, -15.22; $P$ <0.01), lower intracranial pressure (ICP) on the first day after decompression ( $M D$ =-4.58, 95% $C I$ : -6.03, -3.13; $P$ <0.01), lower total incidence of intraoperative and postoperative complications ( $O R$ =0.18, 95% $C I$ : 0.15, 0.23; $P$ <0.01), lower Glasgow Coma Scale (GCS) score at 2 weeks postoperatively ( $M D$ =1.94, 95% $C I$ : 1.31, 2.56; $P$ <0.01) and higher rate of good prognosis with the Glasgow Outcome Scale (GOS) score ≥4 ( $O R$ =3.08, 95% $C I$ : 2.15, 4.43; $P$ <0.01). Conclusion Compared to those of rapid standard large bone-flap decompression, controlled stepwise decompression has certain advantages in the time of decompression, operation time, intraoperative bleeding, postoperative length of stay, total incidence of intraoperative and postoperative complications, and postoperative recovery. The controlled stepwise decompression is preferred to lower ICP in most cases of craniocerebral injury, which can be promoted and applied in clinical practice.

Correlation analysis of monocyte-to-high density lipoprotein cholesterol ratio, red cell distribution width, and uric acid with the severity of coronary artery disease in patients with coronary heart disease

Wei Yuhan, Zhao Yanan, Zhang Guibin, Wu Yuqing, Dong Bohua, Hu Jiayuan, Yang Wenqi

2023, 38(9): 796-801. doi:10.3969/j.issn.1004-583X.2023.09.004

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Objective To explore the correlation of monocyte-to-high density lipoprotein cholesterol ratio (MHR) and red cell distribution width (RDW), and serum uric acid (SUA) with the severity of coronary artery disease in patients with coronary heart disease (CHD). Methods A total of 358 patients admitted to our hospital from February 2022 to February 2023 were included. They were divided into normal control group ( $n$ =70) and CHD group ( $n$ =288). According to the Gensini score, patients in CHD group were subgrouped into mild stenosis group, moderate stenosis group and severe stenosis group. General data, MHR, RDW and SUA among all groups were compared. Logistic regression was performed to evaluate the correlation of MHR, RDW and SUA with the severity of coronary artery stenosis, and receiver operating characteristic (ROC) curve was drawn to analyze the clinical diagnostic value of MHR, RDW and SUA in predicting the degree of coronary artery stenosis. Results There were significant differences in the high-density lipoprotein cholesterol (HDL-C), MHR, RDW and SUA among the three subgroups of CHD ( $P$ <0.05). Spearman correlation analysis showed that MHR, RDW and SUA were positively correlated with the degree of coronary artery stenosis ( $P$ <0.05), and HDL-C was negatively correlated with it ( $P$ <0.05). Logistic regression analysis showed that MHR, RDW and SUA were independent risk factors for the severity of coronary artery disease in CHD patients ( $P$ <0.05). ROC curve analysis showed that the area under the curve (AUC) of MHR, RDW and SUA in predicting the severity of coronary artery disease was 0.611, 0.778 and 0.769, respectively. Conclusion MHR, RDW and SUA are independent risk factors for the severity of coronary artery disease in CHD patients.

Correlation between serum cystatin C level and nonobstructive coronary artery disease

Li Hua, Chen Jianjun, Wei Jitao, Zhang Qi

2023, 38(9): 802-805. doi:10.3969/j.issn.1004-583X.2023.09.005

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Objective To investigate the correlation between serum cystatin C level and nonobstructive coronary artery disease. Methods A total of 331 elderly patients who underwent coronary angiography with suspected coronary artery disease in the Department of Cardiology, Baoding No.1 Central Hospital were enrolled between June 2021 and December 2021. They were divided into coronary normal group and nonobstructive coronary artery group according to the results of coronary angiography. Single-vessel, 2-vessel and 3-vessel lesions were classified according to the number of diseased coronary arteries and the Gensini score was calculated according to the results of coronary angiography. The general clinical data and biochemical indicators were compared between the two groups and multivariate Logistic regression analysis was used to identify the risk factors for nonobstructive coronary artery disease. Results There were no significant differences between the two groups in the body mass index (BMI), platelet count, fasting plasma glucose, low-density lipoprotein cholesterol (LDL-C), smoking and the family history of coronary artery disease ( $P$ >0.05). Age, sex constitution, proportion of hypertension, diabetes, and hyperlipidemia, and cystatin C levels were significantly higher in nonobstructive coronary artery group than those of coronary normal group ( $P$ <0.05 or <0.01). In nonobstructive coronary artery group, the proportion of single-vessel lesion was lower in patients with high cystatin C levels than those with low cystatin C levels (28.1% vs 46.7%, $P$ <0.05), but the proportion of 3-vessel lesion was significantly higher (37.5% vs 20.0%, $P$ <0.05). With the increase in cystatin C level, the Gensini score increased significantly, showing a positive correlation ( $r$ =0.525, $P$ <0.01). The multivariate Logistic regression analysis result showed that age, sex, hyperlipidemia, cystatin C were risk factors for nonobstructive coronary artery disease. Conclusion Cystatin C might serve as a significant prognostic marker for nonobstructive coronary artery disease.

The causes of death in 54 patients with type 2 diabetes mellitus complicated with COVID-19

Wei Zeng, Cao Ling, She Dunmin, Liu Yan, Wang Yan, Zhang Zhenwen

2023, 38(9): 806-812. doi:10.3969/j.issn.1004-583X.2023.09.006

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Objective To analyze the clinical characteristics and possible influencing factors for death of patients with type 2 diabetes mellitus (T2DM) complicated with coronavirus disease 2019 (COVID-19). Methods It was a retrospective analysis involving T2DM patients with COVID-19 who died during hospitalization in the Clinical Medical College of Yangzhou University from December 2022 to February 2023. General information and laboratory examination data of patients were recorded in detail, and the detection indicators in the early stage and end-stage of admission were compared. Results The mean age of 54 T2DM patients with COVID-19 who died during hospitalization was (74.31±10.64) years. There were 50 (92.6%) cases who had other underlying diseases. Among them, 74% had more than two underlying diseases. Compared with the laboratory data in the early stage of admission, the blood glucose, pH, red blood cell count, albumin, and globulin in the last laboratory testing before death significantly decreased, while the partial pressure of carbon dioxide, lactate, lactate dehydrogenase, sodium ions, myoglobin, prothrombin time, procalcitonin, C-reactive protein, and D-dimer increased significantly (P<0.05). Among the 54 patients who died, 96.3% showed large patchy shadows and ground glass shadows in both lungs on chest CT scans, and 81.5% showed pleural effusion in both lungs. Logistic regression analysis results showed that PCO₂ and LDH were independent risk factors for the mortality of T2DM patients combined with COVID-19. Conclusion T2DM patients with COVID-19 have a poor prognosis, and partial pressure of carbon dioxide and lactate dehydrogenase are independent risk factors for their death.

Analysis of the follow-up results of 163 patients with acute promyelocytic leukemia

Dong Zhengrong, Tao Qianshan, Shen Yuanyuan, Dong Yi

2023, 38(9): 813-818. doi:10.3969/j.issn.1004-583X.2023.09.007

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Objective To explore the prognosis factors for patients with acute promyelocytic leukemia (APL). Methods Clinical data of 163 newly diagnosed APL patients in the Second Hospital of Anhui Medical University from January 2010 to December 2022 were retrospectively analyzed, including demographic data, hematological characteristics, treatment course, toxicity, complications, and prognosis. Results The median age of recruited patients was 35 (2-84) years. There were 13 (8.0%) cases of early death (ED), and 90.8% achieved a complete remission. There were 23 (14.1%) cases of additional chromosomal abnormalities (ACA) and 19 (11.7%) cases of FLT3-ITD mutation. Among them, 38 (23.3%), 74 (45.4%) and 51 (31.3%) were classified as low risk, intermediate risk, and high risk, respectively. A total of 78 (47.9%) cases were managed by a combination chemotherapy, including 29 cases in the high-risk group and 49 cases in the low-to-intermediate-risk group. The age of ED patients was significantly higher than that of non-ED group ( $P$ <0.01), and the proportion of ED in the high-risk group was significantly higher than that of other groups ( $P$ =0.001). The median follow-up time was 42.5 (0.1-156) months, with the 5-year progression-free survival (PFS) and 5-year overall survival (OS) of 73.3% and 79.5%, respectively, both of which did not reach the median PFS and OS. The univariate logistic regression analysis showed that age and treatment regimen significantly influenced PFS ( $P$ <0.01, and $P$ =0.053, respectively) and OS ( $P$ <0.01, and $P$ =0.021, respectively). Multivariate logistic regression analysis showed that age was the only risk factor for the PFS ( $P$ <0.01) and OS of APL ( $P$ <0.01). Treatment regimen was identified without a significant influence on the PFS ( $P$ =0.213) and OS ( $P$ =0.097). Conclusion Age and the classification of high risk are influencing factors for ED in APL patients. Age is an independent prognostic factor for the PFS and OS of APL. Reducing the chemotherapy cycles is proven feasible in high-risk APL patients.

Anti-thymocyte globulin combined with cyclosporine A in the treatment of severe aplastic anemia-induced caplillary leak syndrome in children: A case report

Gu Cuihong, Wang Yang, Lin Li, Wang Lihong, Zhang Zhihua

2023, 38(9): 819-322. doi:10.3969/j.issn.1004-583X.2023.09.008

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Objective To improve clinicians' understanding of capillary infiltration syndrome (CAS), to reduce missed diagnosis and misdiagnosis, and improve the prognosis. Methods Clinical data of a child with severe aplastic anemia (SAA)-induced CAS treated with anti-thymocyte globulin (ATG) combined with cyclosporine A (CSA) were retrospectively analyzed. The clinical characteristics and treatment course were summarized. Relevant literatures were reviewed as well. Results In this study, we reported a SAA child with CLS on the 13 days of the immunosuppressant treatment. The clinical features included progressive dyspnea, hypotension, peripheral edema, hypoproteinemia, and multiple plasma cavity effusions. After hormonal shock, hydroxyethyl starch expansion, furosemide diuretic dehydration and blood transfusion support, the symptoms and signs were gradually improved. Conclusion CLS is a rare complication during the application of ATG combined with immunosuppressive therapy of CSA in SAA patients, which has the risk of death that should be well concerned. Early recognition, diagnosis and treatment can improve the prognosis.

Secondary infection of spontaneous perirenal hemorrhage with fever as the main symptom: A case report and literature review

Liu Yan, Liu Qiong, Liang Xiaomei, Liu Bing

2023, 38(9): 823-826. doi:10.3969/j.issn.1004-583X.2023.09.009

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Objective To summarize the effective differential diagnosis and treatment of spontaneous perirenal hemorrhage (SPH) with fever as the main symptom. Methods The clinical data of a case of SPH with atypical first manifestations were retrospectively analyzed. Relevant literatures were reviewed as well. Results An elderly male patient was admitted for 10-day fever and 1-week elevation of blood creatinine. He denied trauma and surgery history. Fever was the only clinical manifestation, and lumbar pain, abdominal pain and shock were absent. After laboratory testing and imaging examination, the patient was diagnosed as SPH. Body temperature returned normal after ultrasound-guided puncture drainage and anti-infectious therapy. Conclusion It is necessary for clinicians to master atypical manifestations of SPH, so as to provide references and clinical experiences.

A case report of abdominal cocoon syndrome and literature review

Wang Xiaoting, Wang Yan, Feng Zhijie, Yao Dongmei, Yang Xincheng, Qiu Shaofan, Li Meng, Tian Hui

2023, 38(9): 827-831. doi:10.3969/j.issn.1004-583X.2023.09.010

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Objective To investigate the diagnosis and treatment of the rare abdominal cocoon syndrome (AC) by a case report. Methods Clinical data of a case of AC were analyzed retrospectively, and the relevant literatures were reviewed. Results A 72-year-old male patient presented with nausea, vomiting and abdominal pain. Double-contrast radiography of the upper gastrointestinal tract suggested the incomplete intestinal obstruction of the upper segment of the intestine. The abdominal CT suggested the suspected AC. Consequently, the exploratory laparotomy was performed, and we found that the stomach, small intestine, colon and mesentery were all surrounded by fibrous capsules. Ultimately, intestinal adhesiolysis was carried out, and the patient’s condition improved and discharged. Conclusion Clinical manifestations of AC are atypical. Affected patients usually ask for medical help due to clinical symptoms of intestinal obstruction like nausea, vomiting and failure of defecation and gas pass. Its diagnosis depends on the history medical, imaging examinations and even exploratory laparotomy. Surgery is the most effective therapeutic strategy for AC, which effectively alleviates the clinical symptoms and signs.

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