Ovarian-adnexal reporting and data system ultrasound evaluation and pathological characteristics of ovarian collision tumor

BACKGROUND Collision tumor are neoplasms,including two histologically distinct tumors that coexist in the same mass without histological admixture.The incidence of collision tumor is low and is rare clinically.AIM To investigate ultrasound images and application of ovarian-adnexal reporting and data system(O-RADS)to evaluate the risk and pathological characteristics of ovarian collision tumor.METHODS This study retrospectively analyzed 17 cases of ovarian collision tumor diagnosed pathologically from January 2020 to December 2023.All clinical features,ultrasound images and histopathological features were collected and analyzed.The O-RADS score was used for classification.The O-RADS score was determined by two senior doctors in the gynecological ultrasound group.Lesions with O-RADS score of 1-3 were classified as benign tumors,and lesions with O-RADS score of 4 or 5 were classified as malignant tumors.RESULTS There were 17 collision tumors detected in 16 of 6274 patients who underwent gynecological surgery.The average age of 17 women with ovarian collision tumor was 36.7 years(range 20-68 years),in whom,one occurred bilaterally and the rest occurred unilaterally.The average tumor diameter was 10 cm,of which three were 2-5 cm,11 were 5-10 cm,and three were>10 cm.Five(29.4%)tumors with O-RADS score 3 were endometriotic cysts with fibroma/serous cystadenoma,and unilocular or multilocular cysts contained a small number of parenchymal components.Eleven(64.7%)tumors had an O-RADS score of 4,including two in category 4A,six in category 4B,and three in category 4C;all of which were multilocular cystic tumors with solid components or multiple papillary components.One(5.9%)tumor had an O-RADS score of 5.This case was a solid mass,and a small amount of pelvic effusion was detected under ultrasound.The pathology was high-grade serous cystic cancer combined with cystic mature teratoma.There were nine(52.9%)tumors with elevated serum carbohydrate antigen(CA)125 and two(11.8%)with elevated serum CA19-9.Histological and pathological results showed that epithelial-cell-derived tumors combined with other tumors were the most common,which was different from previous results.CONCLUSION The ultrasound images of ovarian collision tumor have certain specificity,but diagnosis by preoperative ultrasound is difficult.The combination of epithelial and mesenchymal cell tumors is one of the most common types of ovarian collision tumor.The O-RADS score of ovarian collision tumor is mostly≥4,which can sensitively detect malignant tumors.

基于Morning Report的中医内科教学质量评价量表的构建

目的基于Morning Report教学,构建中医内科临床教学质量评价量表,为评价中医内科学临床教学质量提供参考。方法采用目的抽样法,于2022年1—12月从首都医科大学附属北京中医医院医学教育管理人员、中医内科临床教学人员及中医内科临床医师3类人员中遴选咨询专家25名。运用文献研究法和德尔菲法确定基于Morning Report的中医内科学临床教学质量评价指标并计算各指标权重以及各参与主体所占比重。结果从学生表现和教师表现2方面构建了基于Morning Report的中医内科临床教学质量评价量表。评价学生指标包括:学习态度、探索过程、学习效果、实践能力4个一级指标,权重分别为0.1、0.1、0.1、0.2。评价教师指标包括:教学内容、教学方法、教学效果3个一级指标,权重分别为0.1、0.2、0.2。评价主体为参与Morning report教学的学生、教师及教学督导。最终构建的基于Morning Report的中医内科临床教学质量评价量表包括7个一级指标、25个二级指标。评价学生指标,各参与方权重分别为:学生20%,教师40%,教学督导40%;评价教师指标,各参与方权重分别为:学生40%,教师20%,教学督导40%。结论基于Morning Report教学的中医内科临床教学质量评价量表的构建,可以为今后开展中医内科临床教学常态化质量评价提供参考,有助于从量效评价角度促进中医内科临床教学质量的提高。

Metastatic clear cell sarcoma of the pancreas:A rare case report

BACKGROUND Clear cell sarcoma(CCS)is a rare soft-tissue sarcoma.The most common metastatic sites for CCS are the lungs,bones and brain.CCS is highly invasive and mainly metastasizes to the lung,followed by the bone and brain;however,pancreatic metastasis is relatively rare.CASE SUMMARY We report on a rare case of CCS with pancreatic metastasis in a 47-year-old man.The patient had a relevant medical history 3 years ago,with abdominal pain as the main clinical manifestation.No abnormalities were observed on physical examination and the tumor was found on abdominal computed tomography.Based on the medical history and postoperative pathology,the patient was diagnosed with CCS with pancreatic metastasis.The patient was successfully treated with surgical interventions,including distal pancreatectomy and sple-nectomy.CONCLUSION This report summarizes the available treatment modalities for CCS and the importance of regular postoperative follow-up for patients with CCS.

Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction:A case report and review of literature

BACKGROUND Mycobacterium tuberculosis(TB)is the causative agent of TB,a chronic granulo-matous illness.This disease is prevalent in low-income countries,posing a significant global health challenge.Gastrointestinal TB is one of the three forms.The disease can mimic other intra-abdominal conditions,leading to delayed diagnosis owing to the absence of specific symptoms.While gastric outlet obs-truction(GOO)remains a frequent complication,its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy.Gastroduodenal TB can cause upper gastrointestinal hemorrhage,obstruction,and malignancy-like tumors.CASE SUMMARY A 23-year-old male presented with recurrent epigastric pain,distension,nausea,vomiting,and weight loss,prompting a referral to a gastroenterologist clinic.Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation.However,treatment was interrupted,possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes.Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall.Resection revealed gastric wall effacement with TB.CONCLUSION Primary gastric TB is rare,frequently leading to GOO.Given its rarity,suspicions should be promptly raised when encountering relevant symptoms,often requiring surgical intervention for diagnosis and treatment.

Clinical value of the Toronto inflammatory bowel disease global endoscopic reporting score in ulcerative colitis

BACKGROUND Endoscopic evaluation in diagnosing and managing ulcerative colitis(UC)is becoming increasingly important.Several endoscopic scoring systems have been established,including the Ulcerative Colitis Endoscopic Index of Severity(UCEIS)score and Mayo Endoscopic Subscore(MES).Furthermore,the Toronto Inflammatory Bowel Disease Global Endoscopic Reporting(TIGER)score for UC has recently been proposed;however,its clinical value remains unclear.AIM To investigate the clinical value of the TIGER score in UC by comparing it with the UCEIS score and MES.METHODS This retrospective study included 166 patients with UC who underwent total colonoscopy between January 2017 and March 2023 at the Affiliated Hospital of Qingdao University(Qingdao,China).We retrospectively analysed endoscopic scores,laboratory and clinical data,treatment,and readmissions within 1 year.Spearman’s rank correlation coefficient,receiver operating characteristic curve,and univariate and multivariable logistic regression analyses were performed using IBM SPSS Statistics for Windows,version 26.0(IBM Corp.,Armonk,NY,United States)and GraphPad Prism version 9.0.0 for Windows(GraphPad Software,Boston,Massachusetts,United States).RESULTS The TIGER score significantly correlated with the UCEIS score and MES(r=0.721,0.626,both P<0.001),showed good differentiating values for clinical severity among mild,moderate,and severe UC[8(4-112.75)vs 210(109–219)vs 328(219–426),all P<0.001],and exhibited predictive value in diagnosing patients with severe UC[area under the curve(AUC)=0.897,P<0.001].Additionally,the TIGER(r=0.639,0,551,0.488,0.376,all P<0.001)and UCEIS scores(r=0.622,0,540,0.494,and 0.375,all P<0.001)showed stronger correlations with laboratory and clinical parameters,including C-reactive protein,erythrocyte sedimentation rate,length of hospitalisation,and hospitalisation costs,than MES(r=0.509,0,351,0.339,and 0.270,all P<0.001).The TIGER score showed the best predictability for patients'recent advanced treatment,including systemic corticosteroids,biologics,or immunomodulators(AUC=0.848,P<0.001)and 1-year readmission(AUC=0.700,P<0.001)compared with the UCEIS score(AUC=0.762,P<0.001;0.627,P<0.05)and MES(AUC=0.684,P<0.001;0.578,P=0.132).Furthermore,a TIGER score of≥317 was identified as an independent risk factor for advanced UC treatment(P=0.011).CONCLUSION The TIGER score may be superior to the UCIES score and MES in improving the accuracy of clinical disease severity assessment,guiding therapeutic decision-making,and predicting short-term prognosis.

Effects of Internet-Based Acceptance and Commitment Therapy (IACT) on Adolescents: A Systematic Review and Meta-Analysis

Objectives:This study reviewed published randomized controlled trials(RCTs)and evaluated the efficacy of internet-based acceptance and commitment therapy(IACT)on adolescent mental health.Methods:Searches were conducted in PubMed,ProQuest,APA(PsycNET/PsycINFO),and Web of Science from inception to Jan-uary 2022 to identify RCTs evaluating the effects of IACT on adolescents.The included studies were assessed for quality and risk of bias.This study was performed using the standard mean difference and associated 95%confidence interval of effective measures.Review Manager 5.4 software was adopted to calculate the effect size.Results:Compared to adolescents in control groups,those in the IACT groups showed some improvement in the efficacy of depression symptoms(SMD=−0.24,95%CI=[−0.44,−0.05],p=0.01)and had a small but sig-nificant effect on reducing experiential avoidance(SMD=−0.24,95%CI=[−0.46,−0.01],p=0.04).However,the effect size on anxiety did not reach the threshold(SMD=−0.18,95%CI=[−0.27,−0.09],p<0.0001).In addition,there were no significant differences in stress and well-being compared to those of the control group.Compared with universal adolescents,IACT was found to have a more significant therapeutic effect on targeted adolescents.Conclusions:IACT is effective in adolescent mental health interventions,but its clinical reliability and significant efficacy are limited,and more rigorous RCTs are needed in future studies.

Tricuspid mass-curious case of Li-Fraumeni syndrome: A case report

BACKGROUND Li-Fraumeni syndrome(LFS)is a rare autosomal dominant cancer-predisposing syndrome,which can manifest as a polymorphic spectrum of malignancies.LFS is associated with an early onset in life,with the majority of cases occurring prior to the age of 46.Notwithstanding the infrequency of primary cardiac tumors,it behooves clinicians to remain vigilant in considering the differential diagnosis of such tumors in LFS patients who present with a cardiac mass.This is due to the markedly elevated risk for malignancy in this particular population,far surpassing that of the general populace.CASE SUMMARY Herein,we present a case of a 30-year-old female with LFS who was found to have a tricuspid valve leaflet mass.CONCLUSION This case exemplifies valuable learning points in the diagnostic approach for this exceptionally rare patient population.

Appendiceal intussusception complicated by adenocarcinoma of the cecum:A case report

BACKGROUND Appendiceal intussusception is a pathological condition in which the appendix is inverted into the cecum,which may cause symptoms that resemble those of other gastrointestinal disorders and may induce intestinal obstruction.The rarity of this case presentation is the co-occurrence of appendiceal intussusception and cecal adenocarcinoma,a combination that to our knowledge has not previously been reported in the medical literature.This case provides new insights into the complexities of diagnosing and managing overlapping pathologies.CASE SUMMARY A 25-year-old woman presented with persistent periumbilical pain and bloody stools.An initial biopsy showed cecal cancer;however,subsequent colonoscopy and computed tomography findings raised the suspicion of appendiceal intussus-ception,which was later confirmed postoperatively.This unique case was charac-terized by a combination of intussusception and adenocarcinoma of the cecum.The intervention included a laparoscopic right hemicolectomy,which led to the histopathological diagnosis of mucinous adenocarcinoma with appendiceal intussusception.The patient recovered well postoperatively and was advised to initiate adjuvant chemotherapy.This case highlights not only the importance of considering appendiceal intussusception in the differential diagnosis,but also the possibility of appendicitis and the atypical presentation of neoplastic lesions.CONCLUSIONS Physicians should consider the possibility of appendiceal intussusception in cases of atypical appendicitis,particularly when associated with neoplastic presentation.

Multilocular thymic cysts can be easily misdiagnosed as malignant tumor on computer tomography:A case report

BACKGROUND Multilocular thymic cyst(MTC)is a rare mediastinal lesion which is considered to occur in the process of acquired inflammation.It is usually characterized by well-defined cystic density and is filled with transparent liquid.CASE SUMMARY We report on a 39-year-old male with a cystic-solid mass in the anterior mediastinum.Computer tomography(CT)imaging showed that the mass was irregular with unclear boundaries.After injection of contrast agent,there was a slight enhancement of stripes and nodules.According to CT findings,it was diagnosed as thymic cancer.CONCLUSION After surgery,MTC accompanied by bleeding and infection was confirmed by pathological examination.The main lesson of this case was that malignant thymic tumor and MTC of the anterior mediastinum sometimes exhibit similar CT findings.Caution is necessary in clinical work to avoid misdiagnosis.

Multi-systemic melioidosis in a patient with type 2 diabetes in nonendemic areas:A case report and review of literature

BACKGROUND Melioidosis,an infectious disease caused by Burkholderia pseudomallei(B.pseudomallei),occurs endemically in Southeast Asia and Northern Australia and is a serious opportunistic infection associated with a high mortality rate.CASE SUMMARY A 58-year-old woman presented with scattered erythema on the skin of her limbs,followed by fever and seizures.B.pseudomallei was isolated successively from the patient’s urine,blood,and pus.Magnetic resonance imaging showed abscess formation involving the right forehead and the right frontal region.Subsequently,abscess resection and drainage were performed.The patient showed no signs of relapse after 4 months of follow-up visits post-treatment.CONCLUSION We present here a unique case of multi-systemic melioidosis that occurs in nonendemic regions in a patient who had no recent travel history.Hence,it is critical to enhance awareness of melioidosis in non-endemic regions.

Perforated gastric ulcer causing mediastinal emphysema: A case report

BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,esophageal perforation,medi-cally induced factors,etc.Its common symptoms are chest pain,tightness in the chest,and respiratory distress.Most mediastinal emphysema patients have mild symptoms,but severe mediastinal emphysema can cause respiratory and circulatory failure,resulting in serious consequences.CASE SUMMARY A 75-year-old man,living alone,presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol.Due to the remoteness of his residence and lack of neighbors,the patient was found by his nephew and brought to the hospital the next morning after the disease onset.Computed tomography(CT)showed free gas in the abdominal cavity,mediastinal emph-ysema,and subcutaneous pneumothorax.Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated.Therefore,we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia.An operative incision of the muscle layer of the patient's abdominal wall was made,and a large amount of subperitoneal gas was revealed.And a continued incision of the peritoneum revealed the presence of a perforation of approx-imately 0.5 cm in the gastric antrum,which we repaired after pathological examination.Postoperatively,the patient received high-flow oxygen and cough exercises.Chest CT was performed on the first and sixth postoperative days,and the mediastinal and subcutaneous gas was gradually reduced.CONCLUSION After gastric perforation,a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm,and upper gastrointestinal angiography can clarify the site of perforation.In patients with mediastinal emphysema,open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure.In addition,thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.

Mechanical upper bowel obstruction caused by a large trichobezoar in a young woman: A very unusual case report

BACKGROUND Bezoars usually compile human fibers and debris.A special form of bezoar in case of psychologically altered individuals is the trichobezoar.It consists of voluntarily swallowed hair bulks and is normally removed via gastroscopy.Trichobezoars leading to ileus have rarely been reported.CASE SUMMARY A 24-year-old female patient presented to the emergency room with abdominal pain,nausea,and vomiting for 3 d.Her previous medical and psychiatric history was unremarkable.Laboratory analysis showed iron deficiency anemia,leukocytosis,and elevated liver enzymes.An abdominal CT scan revealed a dense structure in the patients’stomach which turned out to be a huge trichobezoar completely obstructing the pylorus.The trichobezoar had to be removed surgi-cally.During her postoperative course,a subcutaneous seroma formed.After a single puncture,the rest of the recovery process was unremarkable,and the patient recovered fully.CONCLUSION A mechanical bowel obstruction is a potentially life-threatening event for every patient.In our case a young female was suffering from severe symptoms of an obstruction which might have resulted in serious harm without successful surgical management.

Diagnosis of poorly differentiated adenocarcinoma of the stomach by confocal laser endomicroscopy:A case report

BACKGROUND In recent years,confocal laser endomicroscopy(CLE)has become a new endoscopic imaging technology at the microscopic level,which is extensively performed for real-time in vivo histological examination.CLE can be performed to distinguish benign from malignant lesions.In this study,we diagnosed using CLE an asymptomatic patient with poorly differentiated gastric adenocarcinoma.CASE SUMMARY A 63-year-old woman was diagnosed with gastric mucosal lesions,which may be gastric cancer,in the small curvature of the stomach by gastroscopy.She consented to undergo CLE for morphological observation of the gastric mucosa.Through the combination of CLE diagnosis and postoperative pathology,the intraoperative CLE diagnosis was considered to be reliable.According to our experience,CLE can be performed as the first choice for the diagnosis of gastric cancer.CONCLUSION CLE has several advantages over pathological diagnosis.We believe that CLE has great potential in the diagnosis of benign and malignant gastric lesions.

Diagnostic challenges and individualized treatment of cervical adenocarcinoma metastases to the breast:A case report

BACKGROUND Cervical cancer is a rare primary tumor resulting in metastases to the breast with few cases reported in literature.Breast metastases are associated with poor prognosis.The following case highlights the diagnostic challenges associated with metastatic cervical cancer to the breast along with individualized treatment.CASE SUMMARY A 44-year-old G7P5025 with no significant past medical or surgical history presented with heavy vaginal to an outside emergency department where an exam and a pelvic magnetic resonance imaging showed a 4.5 cm heterogenous lobulated cervical mass involving upper two thirds of vagina,parametria and lymph node metastases.Cervical biopsies confirmed high grade adenocarcinoma with mucinous features.A positron emission tomography/computed tomography(PET/CT)did not show evidence of metastatic disease.She received concurrent cisplatin with external beam radiation therapy.Follow up PET/CT scan three months later showed no suspicious fluorodeoxyglucose uptake in the cervix and no evidence of metastatic disease.Patient was lost to follow up for six months.She was re-imaged on re-presentation and found to have widely metastatic disease including breast disease.Breast biopsy confirmed programmed death-ligand 1 positive metastatic cervical cancer.The patient received six cycles of carboplatin and paclitaxel with pembrolizumab.Restaging imaging demonstrated response.Patient continued on pembrolizumab with disease control.CONCLUSION Metastatic cervical cancer to the breast is uncommon with nonspecific clinical findings that can make diagnosis challenging.Clinical history and immunohistochemical evaluation of breast lesion,and comparison to primary tumor can support diagnosis of metastatic cervical cancer to the breast.Overall,the prognosis is poor,but immunotherapy can be considered in select patients and may result in good disease response.

Early adenocarcinoma mixed with a neuroendocrine carcinoma component arising in the gastroesophageal junction: A case report

BACKGROUND Early adenocarcinoma mixed with a neuroendocrine carcinoma(NEC)component arising in the gastroesophageal junctional(GEJ)region is rare and even rarer in young patients.Here,we report such a case in a 29-year-old Chinese man.CASE SUMMARY This patient presented to our hospital with a 3-mo history of dysphagia and regurgitation.Upper endoscopy revealed an elevated nodule in the distal esophagus 1.6 cm above the GEJ line,without Barrett’s esophagus or involvement of the gastric cardia.The nodule was completely resected by endoscopic submu-cosal dissection(ESD).Pathological examination confirmed diagnosis of intra-mucosal adenocarcinoma mixed with an NEC component,measuring 1.5 cm.Immunohistochemically,both adenocarcinoma and NEC components were positive for P53 with a Ki67 index of 90%;NEC was positive for synaptophysin and chromogranin.Next-generation sequencing of 196 genes demonstrated a novel germline mutation of the ERCC3 gene in the DNA repair pathway and a germline mutation of the RNF43 gene,a common gastric cancer driver gene,in addition to pathogenic somatic mutations in P53 and CHEK2 genes.The patient was alive without evidence of the disease 36 mo after ESD.CONCLUSION Early adenocarcinoma with an NEC component arising in the distal esophageal side of the GEJ region showed evidence of gastric origin.

Upadacitinib for refractory ulcerative colitis with primary nonresponse to infliximab and vedolizumab:A case report

BACKGROUND Many patients with ulcerative colitis(UC)do not respond well to,or tolerate conventional and biological therapies.There is currently no consensus on the treatment of refractory UC.Studies have demonstrated that the selective Janus kinase 1 inhibitor upadacitinib,a small-molecule drug,is effective and safe for treating UC.However,no studies have revealed that upadacitinib is effective in treating refractory UC with primary nonresponse to infliximab and vedolizumab.CASE SUMMARY We report the case of a 44-year-old male patient with a chief complaint of bloody diarrhoea with mucus and pus,in addition to dizziness.The patient had recurrent disease after receiving mesalazine,prednisone,azathioprine,infliximab and vedolizumab over four years.Based on the endoscopic findings and pathological biopsy,the patient was diagnosed with refractory UC.In particular,the patient showed primary nonresponse to infliximab and vedolizumab.Based on the patient’s history and recurrent disease,we decided to administer upadacitinib.During hospitalisation,the patient was received upadacitinib under our guidance.Eight weeks after the initiation of upadacitinib treatment,the patient’s symptoms and endoscopic findings improved significantly.No notable adverse reactions have been reported to date.CONCLUSION Our case report suggests that upadacitinib may represent a valuable strategy for treating refractory UC with primary nonresponse.

Ipsilateral retroperitoneal papillary renal cell carcinoma 27 years after simple nephrectomy for a renal abscess:A case report

BACKGROUND Cases of severe inflammatory renal disease and renal cell carcinoma(RCC)that occur simultaneously in the same kidney have been occasionally reported.However,extrarenal RCC that does not originate from the native kidney has rarely been reported.To our knowledge,this is the first reported case of RCC developing in the ipsilateral retroperitoneal space after a simple nephrectomy(SN)for inflammatory renal disease.CASE SUMMARY A 63-year-old woman was referred to our hospital following the incidental discovery of a left retroperitoneal mass without specific symptoms.Her medical history revealed a left SN 27 years ago due to a renal abscess.Magnetic resonance imaging of the abdomen revealed three oval masses in the left retroperitoneum.The masses were successfully excised,and subsequent pathology confirmed papillary RCC.After surgery,the patient remained disease-free for 11 years without adjuvant therapy.CONCLUSION Clinicians should be vigilant of RCC in patients with retroperitoneal masses,especially after SN for inflammatory renal disease.

Abnormal uterine bleeding successfully treated via ultrasoundguided microwave ablation of uterine myoma lesions: Three case reports

BACKGROUND Microwave endometrial ablation(MEA)is a minimally invasive treatment method for heavy menstrual bleeding.However,additional treatment is often required after recurrence of uterine myomas treated with MEA.Additionally,because this treatment ablates the endometrium,it is not indicated for patients planning to become pregnant.To overcome these issues,we devised a method for ultrasound-guided microwave ablation of uterine myoma feeder vessels.We report three patients successfully treated for heavy menstrual bleeding,secondary to uterine myoma,using our novel method.CASE SUMMARY All patients had a favorable postoperative course,were discharged within 4 h,and experienced no complications.Further,no postoperative recurrence of heavy menstrual bleeding was noted.Our method also reduced the myoma’s maximum diameter.CONCLUSION This method does not ablate the endometrium,suggesting its potential appli-cation in patients planning to become pregnant.

Paradoxical herniation associated with hyperbaric oxygen therapy after decompressive craniectomy: A case report

BACKGROUND Whether hyperbaric oxygen therapy(HBOT)can cause paradoxical herniation is still unclear.CASE SUMMARY A 65-year-old patient who was comatose due to brain trauma underwent decompressive craniotomy and gradually regained consciousness after surgery.HBOT was administered 22 d after surgery due to speech impairment.Paradoxical herniation appeared on the second day after treatment,and the patient’s condition worsened after receiving mannitol treatment at the rehabilitation hospital.After timely skull repair,the paradoxical herniation was resolved,and the patient regained consciousness and had a good recovery as observed at the follow-up visit.CONCLUSION Paradoxical herniation is rare and may be caused by HBOT.However,the underlying mechanism is unknown,and the understanding of this phenomenon is insufficient.The use of mannitol may worsen this condition.Timely skull repair can treat paradoxical herniation and prevent serious complications.

Conversion therapy of a giant hepatocellular carcinoma with portal vein thrombus and inferior vena cava thrombus:A case report and review of literature

BACKGROUND The prognosis of hepatocellular carcinoma(HCC)combined with portal and hepatic vein cancerous thrombosis is poor,for unresectable patients the combination of targeted therapy and immune therapy was the first-line recommended treatment for advanced HCC,with a median survival time of only about 2.7-6 months.In this case report,we present the case of a patient with portal and hepatic vein cancerous thrombosis who achieved pathologic complete response after conversion therapy.CASE SUMMARY In our center,a patient with giant HCC combined with portal vein tumor thrombus and hepatic vein tumor thrombus was treated with transcatheter arterial chemoembolization(TACE),radiotherapy,targeted therapy and immunotherapy,and was continuously given icaritin soft capsules for oral regulation.After 7 months of conversion therapy,the patient's tumor shrank and the tumor thrombus subsided significantly.The pathology of surgical resection was in complete remission,and there was no progression in the postoperative follow-up for 7 months,which provided a basis for the future strategy of combined conversion therapy.CONCLUSION In this case,atezolizumab,bevacizumab,icaritin soft capsules combined with radiotherapy and TACE had a good effect.For patients with hepatocellular carcinoma combined with hepatic vein/inferior vena cava tumor thrombus,adopting a high-intensity,multimodal proactive strategy under the guidance of multidisciplinary team(MDT)is an important attempt to break through the current treatment dilemma.