Volume 92  ·   Issue 18  ·  2012

Continuous positive airway pressure (CPAP) has always been considered as the most effective method for the treatment of moderate to severe obstructive sleep apnea (OSA), but it was found that central sleep apnea (CSA) or Chen-Shi breathing (CSR) occurred while OSA was corrected during CPAP titration; Due to the existence of CSA or CSR, the disruption of sleep structure still persists [1-2]. Gilmartin et al. [1] first called this phenomenon complex sleep respiratory disorder in 2005. Morgent haler et al. [2] defined this sleep respiratory disorder as complex sleep apnea (CompSA).

Central sleep apnea (CSA) is a breathing pause caused by the disappearance of the respiratory central drive, which appears as oral and nasal airflow stop and no thoracic and abdominal movement on the conventional sleep multi-map, and lasts>10 s. When the respiratory airflow amplitude decreases by ≥30% compared with the basal level for more than 10 s, and is accompanied by a decrease of blood oxygen saturation by ≥4% or micro-arousal, this event is defined as hypopnea [1]. Hypopnea is central caused by the decrease of the respiratory central drive, and obstructive caused by partial obstruction of the upper airway. Apnea and hypopnea often exist at the same time, and the damage to the body and the pathophysiological changes caused by the two events are similar. Clinically, it is commonly called apnea-hypopnea, and the average number of apneas and hypopneas per hour is called apnea-hypopnea index (AHI). In many cases, obstructive sleep apnea (OSA) hypopnea and CSA hypopnea exist at the same time. If more than 50% of the events are central, it is diagnosed as CSA hypopnea syndrome.

Obstructive sleep apnea hypopnea syndrome (OSAHS) refers to a modern common disease in which upper airway obstruction occurs repeatedly during sleep and causes apnea, and its incidence is increasing day by day. The disease is characterized by repeated upper airway collapse and obstruction during sleep, usually accompanied by the decrease of blood oxygen saturation (SaO2), mainly manifested as snoring, holding breath, sleep structure disorder, repeated SaO2 decrease, daytime drowsiness and other symptoms during sleep. Patients with OSAHS often have complete apnea repeatedly during sleep, accompanied by intermittent hypoxia of different degrees, which can cause various cardiovascular and cerebrovascular and metabolic complications [1], seriously affect patients' quality of life and threaten their life safety, and can cause social security problems such as traffic accidents [2-3]. In recent years, with the development of modern science and the improvement of people's requirements for quality of life, people pay more and more attention to the diagnosis and treatment of OSAHS.

obstructive sleep apnea syndrome (OSAS) is a very common sleep breathing disease. It is difficult to be detected because it occurs in the process of sleep that is difficult for people to perceive, especially for patients themselves. Many people even mistakenly regard loud snoring in sleep as a sign of good sleep quality, so that they don't go to medical treatment for a long time after suffering from illness, and even lead to sudden sleep death without knowing that the real cause of death is OSAS. At the same time, OSAS is very easy to cause complications and will cause damage to many systems of the body, so it is a truly systemic disease. Therefore, doctors, patients and the whole society should pay attention to the widespread and serious harm of OSAS to the body. Clinicians should improve the diagnostic awareness and treatment level of OSAS to ensure the health and quality of life of patients.

Objective To summarize the clinical characteristics and outcomes of Pseudo-Bartter's syndrome and explore its pathogenesis.Methods The clinical data of 5 cases of Pseudo-Bartter's syndrome at our ward from May 2008 to December 2010 was analyzed retrospectively.Results All patients were female. Long-term regimen of purgative or diuretics was prescribed. The clinical features included normotension,hypokalemic alkalosis and activation of renin-angiotensin-aldosterone.The pathological results of 3 cases of kidney biopsy showed the hyperplasia of juxtaglomerular apparatus,thickness of arteriole,infiltration of lymphocytes and monocytes and degeneration of renal tubule. Upon a definitive diagnosis,purgative or diuretics was discontinued and supplement therapy of potassium chloride initiated.The results of laboratory tests reverted to normal ranges within 4 weeks.Conclusion Purgative or diuretics should be prescribed appropriately to avoid the occurrence of Pseudo-Bartter's syndrome.

Objective To explore the feasibility and efficiency of new clamping technique of renal arterial branches during laparoscopic partial nephrectomy.Methods Between March and June 2011,10patients (6 males,4 females) with small renal tumor underwent laparoscopic partial nephrectomy with highly selective clamping of renal arterial branches.The mean age was (47 ± 13 ) years and the mean tumor size (2.8 ± 0.9 ) cm.Operative duration,estimated blood loss,time for highly selective clamping of renal arterial branches,postoperative hospital stay,indwelling duration of drainage tube and complications were recorded.Results The operations were successfully performed in all patients.The mean operative duration was (101 ±23) min,the mean estimated blood loss 112 ml and the mean time for the clamping of renal arterial branches (28 ± 6) min.There was neither blood transfusion nor conversion into open surgery.The mean indwelling duration of drainage tube was (5.0 ± 1.3 )days and the mean postoperative hospital stay (8.0 ±0.8)days.The recovery of all patients was uneventful.Conclusion Highly selective clamping of renal arterial branches is a new method of protecting renal function during laparoscopic partial nephrectomy.Further studies and a longer follow-up are warranted.

Objective To explore the feasibility of interventional treatment of Klippel-Trenaunay syndrome(KTS).Methods The clinical data of 20 KTS patients admitted into our hospital from March 2005 to October 2010 were retrospectively analyzed.Results All 20 patients underwent angiography after the relevant examinations.Among them,18 patients underwent interventional treatment (embolization with PVA particles and spring coils).Two patients received no interventional treatment due to non-cooperation,high risk or extremely thin vessels.And 18 patients achieved excellent results after interventional treatment.Neither complications nor peri-operative mortality occurred.The patients were followed-up for an average period of 12 months.Mild symptoms recurred in 2 patients.Conclusion Interventional treatment is an effective,safe and mini-invasive procedure for KTS with satisfactory long-term outcomes.

Objective To explore the association between 25-hydroxyvitamin D level and hypertension so as to provide rationales for developing preventive strategies and understanding the etiology of hypertension.Methods The articles on the association of 25-hydroxyvitamin D level and hypertension were retrieved by searching international and national databases from 2000 to 2011.The relationship between 25-hydroxyvitamin D level and hypertension was assessed by Meta-analysis with Stata11.0 software.Results The results of Meta analysis showed that the pooled OR values of hypertension with 25-hydroxyvitamin D level deficiency and sufficiency was 1.37 ( 95％ CI 1.23 - 1.53 ).Subgroup analysis revealed in 25-hydroxyvitamin D level,can be drawn between 25-hydroxyvitamin D level and the incidence of hypertension was statistically significant.The pooled OR values of hypertension with 25-hydroxyvitamin D level in 35 nmol/L and 35 - 68 nmol/L were 2.02 (95 ％ CI 1.49 - 2.74) and 1.23 (95％ CI 1.02 - 1.49 ) ( P ＜0.05).Conclusions The 25-hydroxyvitamin D level is associated with hypertension.With regards to the question of whether or not the 25-hydroxyvitamin D level deficiency serves as one of the potential risk factor for hypertension,prospective studies of larger sample sizes are warranted.

Objective To evaluate the efficacy and safety of sorafenib in the prevention and treatment of hepatocellular carcinoma (HCC) relapse after liver transplantation.Methods A retrospective cohort study was performed to assess the efficacy and safety of sorafenib for HCC. Forty-four patients who underwent liver transplant for HCC beyond Milan criteria form July 2007 to May 2010 were included study group ( sorafenib,n =22 ) and control group ( without sorafenib,n =22 ).The primary endpoints of the study were disease-free survival (DFS),overall survival (OS).Secondary outcomes included the rates of acute rejection and graft survival Results The clinical data of44 patients were completely collected.There were significantly differences between sorafeinb group and control group in 1-year DFS (81.8％ (n =18) vs 63.6％(n=14),P＜0.05) and OS (90.9％(n=20) vs72.7％(n=16),P＜0.05) respectively.The acute rejection rates in Sorafenib were 13.6％ (3/22),compared with 18.2％ (4/22) in control group (P =0.524) and 1-year graft survival in Sorafenib group were 86.4％ (19/22),compared with 72.7％ (16/22)in control group ( P =0.086).The overall incidence of treatment-related adverse events was 68.1％ ( n =15 ) in sorafenib group and 31.8％ ( n =7 ) in the control group ( P ＜ 0.01 ).Adverse events that were reported for patients receiving sorafenib were predominantly grade 1 or 2 in severity including diarrhea (45.5％,n =10),liver dysfunction (40.9％,n =9),hand-foot skin reaction (31.8％,n =7) and pains of head and four limbs ( 22.7％,n =5 ).Two patients with grade 3 adverse events in study group werestopped continuing to use the sorafenib.Three patients with the dose of 400 mg twice daily and 17 patients with the dose reduction of sorafenib continued to the study endpoint.Conclusion Patients with HCC undergoing liver transplantation could get the benefits of Sorafenib in reducing the incidence of tumor recurrence and extending disease-free and overall survival time.

Objective To explore the clinical features and etiology of cholestasis in neonates,and elucidate the difference between preterm and term infants.Methods A retrospective study was conducted for 176 cases of cholestasis during neonatal periods from January 2004 to December 2010 of Children's Hospital of Fudan University. Their etiologies included parenteral nutrition-associated cholestasis (PNAC),infection,biliary tract disorders,congenital abnormalities and chromosomal disorders,metabolic diseases,others (prenatal hypoxia,post unconjugated hyperbilirubinemia,neonatal lupus and congenital chylothorax)and unknown reasons.They were also divided into term and preterm groups according to gestational age,the relative factors,such as feeding patterns,use of parenteral nutrition (PN),infection and hypoxic history,and the clinical features,such as cholestasis onset age,bilirubin level,liver function and outcome were compared between two groups.Results The time of fasting,age of starting feeding,age of reaching to full feeding and the time of overall PN time were all longer in the preterm group than those in the term group ( all P＜0.01).The preterm group had more PN and infection cases (all P ＜0.05).The term group presented earlier with cholestasis and liver function damage versus the preterm group ( both P ＜ 0.05 ).The rate of recovery in term group is lower than in preterm group which is (62.9％ (22/35) vs 82.3％ ( 116/141 ),P=0.014).The etiologies of 35 term infants were infection (n =11,31.4％),biliary tract disorders (n =4,11.4％ ),congenital abnormalities and chromosomal disorders (n =7,20.0％ ),metabolic diseases (n=3,8.6％),others (n=7,20.0％) and unknown reasons (n=3,8.6％).There were 97cases (68.8 ％ ) of PNAC in preterm infants and the average gestational age was 30+4 (25+3 - 36 +2 ) weeks.And the etiologies of the remaining 44(31.2％ ) preterm cases without PNAC were infection (n =21),biliary tract disorders ( n =3 ),metabolic diseases ( n =2),others ( n =5 ) and unknown reasons ( n =13 ).Conclusions The etiologies of neonatal cholestasis are diverse.It may be more complicated in term and non-PNAC preterm infants.It is important to screen cholestasis in neonatal inpatients. Basic etiological elucidation and long-term follow-up are necessary for the positive cases.

Objective To assess the predictive ability of CD8+ T-cell counts and the expressions of CD28,CD38,HLA-DR on CD8+ T cells in immunocompromised critically ill (ICCI) patients with pulmonary invasive fungal infections (PIFI).Methods The evolution of CD8 + T-lymphocyte subgroups ( CD8+,CD8 + CD28 +,CD8 +CD38 +,CD8 + HLA-DR+ ) were measured in the peripheral blood of 80 ICCI patients with pulmonary infection on day 1 ( D1 ),3 ( D3 ) and 7 ( D7 ) of intensive care unit ( ICU )admission by quantitative flow cytometry. Forty immunocompetent,uninfected critically ill patients were analyzed as control subjects at the time of admission.Immunocompromised risk factors and PIFI was diagnosed according to European Organization for Research and Treatment of Cancer-Mycoses Study Group (EORTC-MSG) 2008 definitions.Results PIFI were diagnosed in 71.3％ of the ICCI patients (57/80)and included 22 molds infections,22 Candida infections and 13 mixed infections.Among the 80 ICCI patients,CD8 +,CD8 + CD28 +,and CD8 + CD38 + T-cell counts were significandy lower ( P ＜ 0.01 ) and CD8 + HLA-DR+ T-cell counts were significantly higher (P ＜0.01 ) than in the control subjects during the monitoring period,while CD8 +,CD8+ CD28 +,and CD8 + CD38 + T cells demonstrated an additional significant decrease in PIFI patients compared with non-PIFI patients ( P ＜ 0.01 ).Receiver operating characteristic (ROC) analysis for discrimination of the 28-day mortality revealed area under the curve(AUC) values of 0.83,0.84 and 0.87 for the CD8+ CD28+ T-cell counts ( D1,D3 and D7,respectively).Cutoff values of D1 ＜64 cells/mm3,D3 ＜75 cells/mm3,and D7 ＜88 cells/mm3 had sensitivities of 0.73(95％ CI:0.61 -0.85),0.74 (95％ CI:0.62-0.85),and 0.71 (95％ CI:0.58-0.84),specificities of 0.90 (95％ CI:0.77 -1.00),0.91(95％ CI:0.78 -1.00),and0.95 (95％ CI:0.85 -1.00),and efficiencies of77.8％,79.5％ and 78.5％ respectively.The time interval between ICU admission and CD8 +CD28+ positive 1.7 days (range:1.0-7.0) was significantly shorter than the time to diagnosis of IFI by radiological 4.1 days ( range:1.0 - 21.0) and microbiological 7.5 days ( range:3.0 - 17.0) criteria ( P ＜0.01 ).Conclusions An extreme distribution of CD8 + T-lymphocyte subgroups in ICCI patients was closely related to PIFI.The measurement of CD8 + CD28+ T-cell counts may be an early predictor of PIFI in ICCI patients.

Objective To explore the different gene expressions of normal versus tumor tissues of gastric cancer at molecular levels.Methods Gene chip technology was used to determine the differentially expressed genes between gastric cancer( n =12) and normal tissues( n =12) from December 2009 to June 2010 of Xinhua Hospital of Shanghai Jiaotong University School of Medicine.And reverse transcriptase (RT)-PCR was performed to validate the results of gene chip analysis.Results Sixty-nine up-regulated genes and 80 down-regulated genes were identified by significance analysis of microarrays (SAM).And these genes were correlated with cell adhesion,angiogenesis,cell proliferation and apoptosis,et al.They were also closely correlated with the signaling pathways of Wnt ( 1/151,0.66％ ) and vascular endothelial growth factor (VEGF) (2/76,2.63％ ).The differential expressions of ATP4A,CLDN10,OLFM4,SAA1 and PROK2 were confirmed by RT-PCR ( 0.94 ± 0.19 vs 4.33 ± 0.39,1.00 ± 0.14 vs 3.04 ± 0.26,5.37±0.30 vs 1.02±0.14,4.37 ±0.30 vs 0.95 ±0.29,2.62±0.54 vs 1.35 ±0.35,all P ＜0.05).Conclusion The classifier genes identified in this study may be closely correlated with the carcinogenesis of gastric cancer.

Objective To explore the correlations of genetic polymorphisms in tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) gene and the plasma levels of soluble Trail (sTRAIL) with ulcerative colitis (UC).Methods From May 2004 to April 2011,a total of 393 UC patients were recruited from Second and First Affiliated Hospitals of Wenzhou Medical College and Second Renmin Hospital of Wenzhou City.During the same period,a total of 1292 healthy controls were recruited from Physical Examination Center at Second Affiliated Hospital of Wenzhou Medical College.After PCR amplification,the genetic polymorphisms in TRAIL (G1525A,G1588A,C1595T) genes were examined by direct sequencing,and the haplotype analysis were also performed in all study subjects.Furthermore,the plasma levels of sTRAIL were determined by enzyme-linked immunosorbent assay ( ELISA ).Results The frequencies of variant genotypes in TRAIL ( G1525A,G1588A,C1595T) genes were significantly lower in the UC patients than those in the controls ( all P ＜0.01 ).Both of variant allele frequencies in TRAIL G1525A and G1588A were significantly decreased in UC patients ( 40.08％ ( 315/786 ) vs 54.95％ ( 1420/2584),49.49％(389/786)vs 55.53％ ( 1435/2584),both P ＜ 0.01 ).However,the variant allele frequency in TRAIL C1595T gene was not significantly lower in the UC patients (P =0.133).According to disease severity,the UC patients were divided into mild,intermediate and severe groups.The frequencies of variant allele (T)and genotype ( CT + TT) in TRAIL C1595T gene were also significantly higher in the patients with severe UC than those in others ( 63.50％ (127/200) vs 49.15％ (288/586),77.00％ (77/100) vs 61.43％(180/293),both P ＜ 0.01 ).In haplotype analysis,the frequency of GAT haplotype was significantly higher in the UC patients than that in the controls.However,the frequency of AAT haplotype was significantly lower in the UC patients ( both P ＜ 0.01 ). Furthermore,the plasma levels of sTRAIL were significantly higher in the UC patients than those in the controls( ( 1.05 ±0.48) vs (0.96 ±0.90) ng/L,P ＜0.01).Conclusion The genetic polymorphisms of TRAIL (G1525A,G1588A,C1595T) and the plasma levels of sTRAIL are correlated with UC in Chinese patients.

Objective To examine the expression of lymphokines damaging hematopoietic cells by CD8 + HLA-DR + effector T cells in peripheral blood (PB) of the patients with severe aplastic anemia (SAA)and explore further the heterogeneous immunopathogenesis of SAA.Methods The CD8+ HLA-DR+ cells were sorted by immunomagnetic separation from the PB of 24 untreated SAA patients and 23 normal controls.The mRNA expressions of perforin,granzyme B,FasL and tumor necrosis factor β (TNF-3) of sorted cells were analyzed by reverse transcription-polymerase chain reaction (RT-PCR).Results The mRNA levels of perforin,granzyme B of CD8 + HLA-DR+ T cells in untreated group were higher than those of the controls (0.66 ±0.25,0.56 ±0.26 vs 0.53 ±0.14,0.40 ±0.13,P =0.042,0.012).The mRNA level of FasL in CD8+ HLA-DR+ T cells of untreated SAA patients was higher than that of the controls (0.77 ± 0.24 vs 0.61 ±0.16,P =0.011 ).The mRNA of TNF-β in CD8 + HLA-DR+ T cells of untreated SAA patients was also higher than that of the controls (0.58 ± 0.16 vs 0.46 ± 0.15,P =0.011 ).Conclusions CD8 + HLA-DR+ T cells may damage hematopoiesis through the actions of perforin,granzyme B,TNF-β and FasL.And it thus contributes to the immunopathogenesis of SAA

Objective To explore the effect of C-reactive protein (CRP) on the expression of Fcγ receptors in human renal tubular epithelial cells and determine the role of Fcγ receptors in CRP-induced expression of transforming growth factor β1 ( TGFβ1 ).Methods Human renal tubular epithelial cells ( HK-2) were cultured and stimulated with recombinant human CRP.The mRNA expression of Fcγ receptors,including FcγR Ⅰ ( CD64 ),FcγR Ⅱ a ( CD32a ) and FcγR Ⅲ( CD16 ),was detected by real-time polymerase chain reaction (PCR).On the basis of real-time PCR results,CD32a was selected for further analysis:the CD32a expression in HK-2 cells incubated with 10 mg/L CRP for 24 h was determined by flow cytometry and Western blotting.HK-2 cells were preincubated with or without anti-CD32a IgG,followed by the addition of recombinant human CRP.Subsequently the biological effects of CRP were tested.TGFβ1,type Ⅰ collagen ( Col Ⅰ ) and type Ⅳ collagen ( ColⅣ ) released into media were detected by enzyme-linked immunosorbent assay.And TGFβ1 mRNA expression was measured by real-time PCR.Results On realtime PCR,CRP was found to significantly up-regulate the CD32a mRNA expression in HK-2 cells in a dosedependent manner (P ＜ 0.01 ).The peak up-regulation was observed at a dose of 10 mg/L.In contrast,mRNAs of CD16 and CD64 were not detected in HK-2 cells.Flow cytometry showed that CD32a expressed on HK-2 cells incubated with 10 mg/L recombinant human CRP for 24 h accounted for 23.35％ ± 7.43％,significantly higher than that on non-CRP-treated cells ( 1.66％ ± 0.28％,P ＜ 0.01 ).Western blottingshowed that CRP up-regulated CD32a expression in a dose-dependent manner.And 10 m/L CRP induced the peak effect.Antibodies to CD32a inhibited the stimulatory effect of CRP on the generation of TGFβ1,Col I and Col Ⅳ ( all P ＜ 0.05 ) and down-regulated the expression of TGFβ1 mRNA ( P ＜ 0.01 ).Conclusion The stimulation of CRP can significantly increase CD32a expression in renal tubular epithelial cells and up-regulate the expression of transforming growth factor TGFβ1 through CD32a receptor.

Recently, it has been reported that children with asthma often have symptoms of reflux esophagitis (GER). Previous non-randomized and non-blinded clinical studies have shown that proton pump inhibitor (PPI) treatment can alleviate asthma symptoms in children with asthma and GER. However, it is still inconclusive whether GER is one of the causes of intractable asthma. The results of a recent randomized, double-blind, controlled clinical trial were published in JAMA (JAMA, 2012, 307:373-381).

According to the Outline of National Medium and Long-term Science and Technology Development Plan issued by the State Council on February 9, 2006, it has been determined that by 2020, the number of international papers cited in China will be among the top five in the world. Obviously, no matter how many SCI papers there are by then, only the "citation rate" will be used to judge heroes [1]. At present, foreign scientists and scientific and engineering researchers in China have paid great attention to their own h index (that is, h papers of scientific researchers have been cited at least h times respectively), and high-level scientific research management departments at home and abroad more and more tend to use the citation frequency to measure the importance of papers [2]. Comparatively speaking, medical researchers in China have not gotten out of the misunderstanding of paying attention to the number of papers, and they have not paid enough attention to the citation number of published papers.

Long-term facilitation of respiration (LTF) is a form of neuroplasticity, which is characterized by the gradual enhancement of respiratory activity during the intermittent hypoxia-reoxygenation phase and the continuous improvement of respiratory activity after the end of intermittent hypoxia. Studies have shown that respiratory LTF may be a physiological compensation for obstructive sleep apnea-hypopnea syndrome (OSAHS) [1], and its research has become a hot spot at home and abroad. However, due to the different experimental methods adopted by various research institutions and the differences in laboratory conditions at different levels, it is difficult to compare the results of each research. In order to optimize the experimental methods for studying respiratory LTF, the experimental methods adopted in different studies are analyzed and summarized as follows.

telomere (telomere) is a special DNA sequence at the end of eukaryotic chromosomes, which can protect and stabilize chromosomes and prevent the loss of genetic material due to cell division. There are two main regulatory mechanisms of telomere length: (1) telomerase pathway; (2) telomere elongation bypass pathway (ALT), in which telomerase pathway is the main regulatory mode of human bone marrow stem cells. Recent studies have found that telomere abnormalities are related to acquired aplastic anemia (AA).

Objective To explore the feasibility of transferring the skills from the AccuTouch flexible endoscopy simulator colonoscopy training to clinical practices.Methods The novice colonoscopists were divided into 2 groups.Group A ( control group) including 4 trainees for traditional training,Group B (experimental group) including 4 trainees for simulator training.After training,we compared the number of cases for achieving independent competence,assisted competence and incompetence in the first ten patients.Results No significant differences existed between two groups in terms of age and gender ( both P ＞ 0.05 ).Significant differences existed in educational background and the controlled group was better than the experimental group ( Z =- 2.005,P =0.04 ). The cases of independent completion,assisted competence and incompetence of the control and experimental groups were 2,4,9 and 21,29,15respectively.Rank tests show that the simulator training was better than the traditional counterpart( average rank:56.14 vs 24.86,Z =- 6.393,P =0.00).Conclusions The skills acquired from AccuTouch(R) Endoscopy Simulator may be well transferred into the clinical colonoscopy environment.It clearly supports the scheme of integrating simulator training into colonoscopic education curricula.

A 64-year-old male was admitted to the hospital on March 11, 2011, mainly due to "cold" for 3 days and hemoptysis for 1 day. The patient felt "cold" 3 days before admission, cough, sore throat, no fever, oral cephalosporin antibiotics (details unknown), and hemoptysis 1 day before admission, bright red, volume about 20 ml, no fatigue, no epistaxis and gingival bleeding, no skin bleeding spots and ecchymosis. Previous physical health. Physical examination: body temperature 36.5℃, pulse 92 beats/min, breathing 23 beats/min, blood pressure 90/60 mm Hg (1 mm Hg =0.133 kPa), no anemia, occasional bleeding spots on the skin, no ecchymosis, no blood blisters and gingival bleeding in the oral cavity, coarse breathing sounds in both lungs, wet rales can be heard, low and dull heart sounds, no sternum tenderness, liver and spleen failure. Blood routine: white blood cells 11.37×109/L, hemoglobin 130g/L, platelets 5×109/L. The coagulation routine, urine routine, fecal routine and biochemical indexes were all normal. When admitted, the patient complained of dry mouth and chills, and the blood pressure was immediately remeasured at 85/55 mm Hg, which showed a downward trend, and the lowest was 70/50 mm Hg. The vital signs recovered stable after active fluid replacement, hemostasis, volume expansion and platelet suspension transfusion. The following auxiliary examinations were gradually improved: