Intravenous glucocorticoids therapy in the treatment of Graves’ ophthalmopathy: a systematic review and Meta-analysis

AIM: To evaluate the benefit and harms of high-dose intravenous glucocorticoids(IVGC) as first-line treatment for Graves’ ophthalmopathy(GO).METHODS: A systematic review and Meta-analysis of randomized clinical trials(RCTs) comparing IVGC for the treatment of GO, with placebo or other treatments, were conducted. Electronic databases were searched, and standard methodological guidance of Cochrane Handbook for Systematic Reviews of Interventions was used. The primary outcome was overall response, and secondary outcomes included the improvement and change in clinical activity score(CAS), and adverse events.RESULTS: Ten RCTs were included in the Meta-analysis. Low quality evidence(one trial) showed that participants receiving IVGC achieved significantly higher response compared to participants receiving placebo [risk ratio(RR) 7.50, 95% confidence interval(CI) 1.14 to 49.26]. Moderate quality evidence(four trials) support appreciable benefit of IVGC in response compared with oral glucocorticoids(OGC), with of RR being 1.51(95%CI 1.25 to 1.83). There was low quality evidence(one trial) compatible with appreciable benefit for IVGC plus orbital radiotherapy in response(RR 1.38, 95%CI 1.07 to 1.79), compared with OGC plus orbital radiotherapy. One IVGC versus rituximab trial provided moderate quality evidence suggesting that participants using IVGC achieved significantly lowerresponse compared to participants using rituximab(RR 0.70, 95%CI 0.50 to 0.98). One IVGC versus mycophenolate mofetil(MMF) trial provided moderate quality evidence suggesting that participants using IVGC achieved significantly lower response compared to participants using MMF(RR 0.74, 95%CI 0.63 to 0.88). Very low quality evidence(one trial) showed that participants with dysthyroid optic neuropathy(DON) receiving IVGC were more likely to achieve response compared to participants receiving orbital decompression(RR 3.33, 95%CI 0.51 to 21.89).CONCLUSION: The current evidence is moderate quality, which is sufficient to support IVGC to be as the first-line treatment for moderate-to-severe GO, and the use of rituximab or MMF to be the second-line treatment instead of IVGC. However, the evidence is very low quality, which is insufficient to support the use of IVGC or orbital decompression as the first-line treatment of DON.

Rare common bile duct metastasis of breast cancer:A case report and literature review

BACKGROUND Breast cancer is the most common tumor in women,and about one-third of cases develop metastatic disease.However,metastatic breast cancer rarely invades the common bile duct(CBD)directly without involving the liver,and involvement of the gastrointestinal tract is rare.Cases of such metastases pose a particular diagnostic challenge.CASE SUMMARY A 55-year-old female presented to the Department of Gastroenterology with complaint of a 2 mo history of right upper abdominal pain accompanied by pain in the right back,aggravated after eating greasy diet.The patient had received a diagnosis of breast cancer 3 years prior.Physical examination showed obvious superficial protuberant erythema on the left neck and chest skin,with slight tenderness and burning sensation.Endoscopic retrograde cholangiopancreatography showed an obstruction at the end of the CBD.Histopathology of the CBD and symptomatic skin biopsies showed positivity for cytokeratin 7 and trans-acting T-cell-specific transcription factor breast cancer biomarkers.A cancer embolus was also found in the skin vasculature.Accordingly,the diagnosis of breast cancer metastases to the skin and biliary ducts was made.A plastic biliary sent was placed,which relieved the right upper abdominal pain and protected against unnecessary hepatectomy surgery.CONCLUSION Although rare,biliary metastasis should be considered in patients with bile duct stenosis and a history of breast cancer.

Correlation between iron deposition and Alzheimer's disease In vivo preliminary quantitative study with susceptibility-weighted imaging

BACKGROUND： Studies have demonstrated iron deposition in Alzheimer＇s disease （AD） patients. Therefore, quantitative measurements and tracing of iron deposition are important for early detection and treatment.OBJECTIVE： To quantitatively measure iron deposition in the brain and evaluate the relationship between iron deposition and AD using magnetic susceptibility-weighted imaging. DESIGN, TIME AND SETTING： A case-control study was performed at the Department of Radiology, Huashan Hospital of Fudan University from February to July 2008. PARTICIPANTS： A total of 20 AD patients, comprising 11 males and 9 females, with a mean age of 72.5 years （range, 51-80 years）, and 20 healthy volunteers, comprising 10 males and 10 females, with a mean age of 69.9 years （range, 55-78 years）, were selected. AD was diagnosed according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer Disease and Related Disorders Association criteria.METHODS： Sagittal T2-weighted images were acquired to locate precise positions of the anterior and posterior commissures. The susceptibility-weighted magnetic resonance images were parallel to the anterior-posterior commissural line through the use of a three-dimensional gradient-echo sequence. All participants underwent measurement of corrected phase （CP） value and Mini-Mental State Examination. Pearson correlation coefficients were used to assess the association between CP values and Mini-Mental State Examination results.MAIN OUTCOME MEASURES： CP values of regions of interest in the hippocampal regions were measured on CP images.RESULTS： CP values were significantly reduced in bilateral hippocampal regions of AD patients compared with normal controls （P〈0.01）, but there were no significant differences between left and right CP values （P〉0.05）. The hippocampal mean CP value positively correlated with the Mini-Mental State Examination score in AD patients and normal controls （r= 0.57, P〈0.01）. CONCLUSION： Susceptibility-weighted imaging can be used to measure CP values to determine iron deposition in the brains of AD patients and could serve as a useful diagnostic tool for AD.

Biomechanical comparison of locking plate and crossing metallic and absorbable screws fixations for intra-articular calcaneal fractures

The locking plate and percutaneous crossing metallic screws and crossing absorbable screws have been used clinically to treat intra-articular calcaneal fractures, but little is known about the biomechanical differences between them. This study compared the biomechanical stability of calcaneal fractures fixed using a locking plate and crossing screws. Three-dimensional finite-element models of intact and fractured calcanei were developed based on the CT images of a cadaveric sample. Surgeries were simulated on models of Sanders type III calcaneal fractures to produce accurate postoperative models fixed by the three implants. A vertical force was applied to the superior surface of the subtalar joint to simulate the stance phase of a walking gait. This model was validated by an in vitro experiment using the same calcaneal sample. The intact calcaneus showed greater stiffness than the fixation models. Of the three fixations, the locking plate produced the greatest stiffness and the highest von Mises stress peak. The micromotion of the fracture fixated with the locking plate was similar to that of the fracture fixated with the metallic screws but smaller than that fixated with the absorbable screws. Fixation with both plate and crossing screws can be used to treat intra-articular calcaneal fractures. In general, fixation with crossing metallic screws is preferable because it provides sufficient stability with less stress shielding.

Laparoscopic transcystic common bile duct exploration and laparoscopic transductal common bile duct exploration in elderly patients with cholecystolithiasis combined with choledocholithiasis

To the Editor:With the development of minimally invasive surgical technology,laparoscopic transcystic common bile duct exploration plus laparoscopic cholecystectomy (LTCBDE + LC) has become the first choice of treatment for cholecystolithiasis combined with biliary calculi.In addition,there is little prospective research.We compared 150 patients who underwent LTCBDE + LC with 150 patients who underwent laparoscopic transductal common bile duct exploration (LTDBDE)+ LC.All patients and participants were informed of the study and voluntarily provided informed consent.

Augmented reality(AR)and fracture mapping model on middle-aged femoral neck fracture:A proof-of-concept towards interactive visualization

A thorough understanding of the fracture characteristics can assist the decision-making process for surgery.This study aimed to characterize the femoral neck fractures among middle-aged patients and illustrated a biomedical visualization method using a fracture mapping model and augmented reality.We collected plain radiography and computed tomography(CT)data from 156 adult patients with a femoral neck fracture.The descriptive study showed that Type I and Type II fractures accounted for 8(5%)and 64(41%)cases.In comparison,Type IV fractures accounted for 44(28%)and 40(25%)cases according to the Garden classification.Comminuted fractures and cortical defects were identified in 14.74%and 29.49%of the cases.A fracture mapping model was reconstructed based on the CT data and demonstrated the location and distribution of the major fracture lines surrounding the head-neck junction.We also illustrated the application of augmented reality technology to visualize and interact with the patient-specific fracture model and the fracture mapping model that facilitated education,training,and surgical planning.Future studies may consider mapping other biomechanical data,such as joint loading and stress distribution,and exploring artificial intelligence via deep reinforcement learning for computer-aided fracture reduction and procedure planning.