Volume 92  ·   Issue 41  ·  2012

chronic cerebral ischemia is a common pathological condition in clinic, and the related concepts include chronic cerebral hypoperfusion, chronic cerebral circulation insufficiency, cerebral artery atherosclerosis, chronic cerebrovascular insufficiency, etc. Because of its latent onset, no specific clinical manifestations, the pathological mechanism has not been fully elucidated so far, its conceptual meaning is not exact, it is easy to be confused with other diseases, it is difficult to give a clear name and definition in disease classification, and the diagnostic criteria have not been reached a consensus.

Objective To summarize the surgical therapy and profiles of lower limb blood flow during surgery for chronic infrarenal aortic occlusion.Methods A total of 36 patients of chronic infrarenal aortic occlusion underwent surgical procedures at our department from 2004 to 2011.Their clinical data were analyzed.Several methods were applied at different time points during surgery to observe the lower limb blood flow.Results SaO2,waveforms of dorsalis pedis artery and posterior tibial artery changed dramatically at different time points during surgery.Before and after blood occlusion,the SaO2 was 82％ ±6％ and 23％ ±4％ respectively,1min after unclamped and after abdomen-closing,the SaO2 increased to 66％ ± 5％ and 88％ ± 8％ respectively.Conclusion Doppler blood flow and blood oxygen saturation monitors are simple,non-invasive and objective detection methods for lower limb blood flow.A combination of both methods can improve the safety of surgery.Keeping the limbs warm and uses of spasmolytic drugs can facilitate the recovery of postoperative blood flow of lower limbs.

Objective To explore the clinical features and surgical management of esophageal gastrointestinal stromal tumors (GIST).Methods The clinical data of patients with esophageal GISTs undergoing surgery at our hospital between January 1999 and April 2012 were retrospectively reviewed.Results Of 14 patients,the male:female ratio was 8∶6; the median age of the patients was 42 years (range 33-63 years).Dysphagia was the most common symptom,and all cases were diagnosed postoperatively.The tumors were resected by enucleation or esophagectomy or endoscopic submucosal resection.The median follow-up was 43.5 months,ranging from 2 to 142 months,with all patients have no recurrence and metastasis.Conclusion Esophageal GIST is rather rare.At present,surgical resection and postoperative diagnosis remain the mainstay for treatment of patients with esophageal GISTs in China.

Objective To explore the microsurgical treatment and clinical efficacies of jugular foramen meningiomas.Methods A total of 28 patients with jugular foramen meningiomas undergoing microsurgical operations at Beijing Tiantan Hospital during the period from April 1996 to April 2011 were analyzed retrospectively.The retrosigmoid suboccipital (n =13),far lateral (n =9),postauricular transsupracondylar (n =4) and trans-paracondylar approaches (n =2) were used.Results Complete tumor resection was achieved in 18 patients and subtotal tumor resection in 10 patients.Twenty-two patients were followed up for a mean follow-up period of 3 years.The postoperative Karnofsky performance scale was above 80 in 19 patients.Twelve patients experienced hoarseness or bucking,11 lived independently and 2 died of tumor recurrence.Conclusion Jugular foramen meningiomas have a higher recurrence rate and severe cranial nerve damages may occur postoperatively.It is important to classify them into different clinical entities and choose appropriate surgical approaches and techniques so as to achieve satisfactory outcomes.

Objective To summarize the clinical characters of refractory primary biliary cirrhosis (PBC) versus typical ones and explore the risk factors of prognosis.Methods From 2009 to 2011,60 PBC patients on the therapy of ursodeoxycholic acid (UDCA) over 1 year at our clinic were recruited.According to the response to UDCA by the Paris criteria,they were divided into refractory group (n =23) and typical group (n =37) to analyze the basic clinical conditions,biochemical markers,antibodies and liver biopsies.Results (1) Compared with the typical patients,the refractory ones had more fatigue (73.9％ vs 45.9％),pruritus (60.9％ vs 40.5％) and jaundice (43.4％ vs 18.9％); (2)the serum level of biomarkers (alanine aminotransferase (ALT),aspartate aminotransferase (AST),alkaline phosphatase (ALP),γ-glutamyl transpeptidase (GGT),total bilirubin (TBIL),direct bilirubin (DBIL) and immunoglobulin M (IgM)) were higher in the refractory group (P ＜ 0.05) ; (3) no differences existed between two groups in age,gender,antibodies (antinuclear antibody (ANA),antimitochondrial antibody (AMA),AMA-M2,anti-GP210,anti-SP100 and anti-centromere antibody (ACA)) or liver biopsies.Conclusion Some clinical severe manifestation (fatigue,pruritus and jaundice) and higher biochemical markers levels (ALT,AST,ALP,GGT,TBIL,DBIL and IgM) seem to predict a worse response to UDCA and a rapid progression of disease in PBC patients.

Objective To introduce an innovative procedure for portal hypertension with preliminary results and assess the technical feasibility and efficacy of portosystemic shunt creation through percutaneous transhepatic approach with its potential clinical significance.Methods Between November 2009 and January 2011,8 patients with complicated portal hypertension underwent percutaneous transhepatic intrahepatic portosystemic shunt (PTIPS).The severity of liver disease was Child's A (n =2),Child's B (n =3) and Child's C (n =3).Under fluoroscopic guidance,portal vein (PV) was punctured with a 22-gauge Chiba needle.A 0.018-inch guidewire was advanced through the needle into PV lumen.The needle was exchanged and a 7-French sheath inserted over the wire.Then retrohepatic inferior vena cava (RIVC) or hepatic vein (HV) was punctured with a 20-gauge,20-cm Chiba needle through sheath.Another 0.018-inch guidewire was advanced through the needle into right internal jugular vein and then snared out of body.A 0.035-inch,260-cm-long stiff shaft wire was then introduced through the transjugular sheath and manipulated into main portal vein (MPV) and then into superior mesenteric vein (SMV).Afterward the PTIPS procedure was completed in the standard transjugular fashion.Results The procedure was technically successful in all patients.And effective portal decompression and free antegrade shunt flow were achieved.The mean portal pressure gradient decreased from 31.0 ± 4.3 to 18.9 ± 2.7 mm Hg before and after PTIPS creation respectively and the difference was significant statistically (P ＜ 0.01).Among 8patients,1 developed hepatic coma and died after 5 days while the other 7 patients survived.The median follow-up period was 9 months (range:2-20).Among 5 patients with PTIPS created for bleeding varices,no recurrent bleeding occurred during the follow-up period.For the patient with diffuse portal vein thrombosis,the clinical symptoms disappeared after PTIPS and computed tomography (CT) showed the shunt was occluded after 4 months.One patient with refractory ascites had a recurrence of abdominal distention after 2 months.There was a stenotic shunt on CT.Cure was achieved by replanting a stent in MPV.Conclusion PTIPS is both safe and effective for the treatment of portal hypertension with exceptionally challenging anatomy.It is an available supplement for transjugular intrahepatic portosystemic shunt.

Objective To explore the clinical outcomes of surgical treatment for traumatic cervical disc herniation with MC + PEEK cage.Methods A total of 51 patients with traumatic cervical disc herniation in mono-segment were surgically treated.The patients in group A (n =20) were treated by MC +PEEK cage while those in group B (n =31) by anterior cervical plate with PEEK cage or titanium mesh.Various parameters of operative duration,blood loss volume,operative complications,bone union,height of intervertebral space and Japanese Orthopedic Association (JOA) score were recorded and compared.Results Fifty-one patients were followed up for an average time of 26 months (range:6-40).Operative duration,blood loss volume and operative complications of group A were better than group B with statistical significance (P ＜ 0.05).Bone union,height of intervertebral space and recovery of spinal cord function were satisfactory with no statistical difference (P ＞ 0.05).Conclusion With this new cage,traumatic cervical disc herniation may be safely and micro-invasively treated without the need of anterior cervical plate.

Objective To explore the anesthetic management experiences of patients with Stanford A aortic dissection undergoing surgical treatment through moderate or deep hypothermia circulatory arrest (DHCA).Methods From June 2008 to December 2011,a total of 77 patients undergoing surgical treatment of Stanford A aortic dissection was recruited.Results Cardiopulmonary bypass (CPB) was established under general anesthesia in all patients.The procedures included moderate hypothermia (n =51)and DHCA (n =26).The total surgical duration was 152-600(292 ±91)min,CPB time 38-310(128 ±43) min and aortic cross-clamp time 31-169 (87 ± 26)min.The time of circulatory arrest under deep hypothermia was 20-113 (41 ± 19) min in 26 patients.Among 77 patients,there were 5 intraoperative and 7 postoperative fatalities.The remained 65 patients were discharged postoperatively and received a regular outpatient follow-up.None of them died or required reoperation.Conclusion Surgical treatmcnt is appropriate and efficient for the patients with Stanford A aortic dissection.During surgery,the keys of preventing neurological complications are blood volume monitoring and blood protection.

Objective To evaluate the diagnostic value of 18F-FDG positron emission tomography/computed tomography (PET/CT) plus serum tumor marker assay in lung cancer and explore the correlation between standard uptake value (SUVmax) with clinicopathologic factors in lung cancer.Methods A total of 177 cases of lung cancer diagnosed by radiography or computed tomography (CT) were recruited.18F-FDG PET/CT imaging and detection of three lung cancer related serum markers (carcinoembryonic antigen,CYFRA21-1 and neuron specific enolase) were performed within one week in all cases.The sensitivity,specificity and accuracy of those approaches were calculated through comparing the results with pathologic examinations.Also the associations between SUVtnax and clinicopathologic features were analyzed.Results Among them,145 patients were detected to have lung cancer by pathologic diagnosis while the other 32 patients had benign lung diseases.The sensitivity,specificity,accuracy of 18F-FDG PET/CT imaging,serum tumor markers and their combination in assessing lung cancers were 89.7％,78.1％,87.6％ ; 89.7％,78.1％,87.6％ and 96.6％,56.3％,89.3％ respectively.The combination of 18F-FDG PET/CT and serum tumor markers in lung lesions showed significantly higher sensitivity than serum tumor markers and 18F-FDG PET/CT alone(P =0.000,P =0.002).Its accuracy was also significantly higher than those of tumor markers (P ＜ 0.05).Compared with 18 F-FDG PET/CT alone,the accuracy was higher in combination group.But the difference showed no statistical significance (P ＞ 0.05).SUVmax was significantly associated with tumor staging,tumor size and pathologic type.Conclusion The combination of 18 F-FDG PET/CT and tumor markers may improve the positive diagnostic rate of lung cancer.And SUVmax can help to evaluate tumor staging and determine pathological types.

Objective To explore the response to nociceptive stimuli in spinal cord of neonatal rat and observe the electrical stimulation of sciatic nerve on synaptic plasticity of spinal dorsal horn,hippocampal CA1 region and spinal c-fos,hippocampal CA1 region expression in neonatal rats.Methods The rats were divided into neonatal and adult groups.The evoked potentials of left spinal dorsal horn from T13-L1 and right hippocampal CA1 region were recorded.After conditional electric stimulations,the potential amplitudes were recorded.When the incubation period reached 120 min,D-AP5 was added to spinal cord of rats and resulting changes in field potential and c-fos expression were recorded.Results Long-term potentiation (LTP) in neonatal rats was mainly evoked by A-type nerve fibers whereas LTP in adult rats was mainly evoked by C-type nerve fibers.C-fos expression was significantly increased in superficial,deep layers of spinal dorsal horn,ventral horn and hippocampal CA1 region in neonatal rats.Conclusion Pain signals change with age.

Objective To explore the correlation of lumbar stenosis and knee osteoarthritis by establishing a rabbit lumbar spinal stenosis model and observing the hind limb movement function and pathological change of articular cartilage of knee joint.Methods A total of 36 healthy adult rabbits were randomly divided into model group and control group.In the model group,spinal canal was filled with bone pieces to make lumbar spinal stenosis ; in the control group,sham operation was performed and materials were inserted into spinal canal.Movement function was evaluated by Tarlov method and pathological features were observed by Mankin's scores under light microscope at 4,8 and 12 weeks.Results Early degenerative changes of knee cartilage were observed in the model group at 4 and 8 weeks post-operation.There were synovial hyperemia and hyperplasia,increased synovial fluid effusion and lightly-stained cartilage.The Mankin score was 3.3-4.5 and Tarlov score 3-4.Intermediate stage changes of osteoarthritis were found in the model group at 12 weeks post-operation,showing synovial hyperplasia,decreased synovial fluid,fissure in cartilage surface,tangled cartilage cells and unevenly stained matrix.The Mankins score was 7-9 and Tarlov score 2-3.Most of articular cartilage was normal in the control group with Mankin score of 0-1 and Tarlov score of 4.Conclusion Lumbar stenosis may be correlated with knee joint degeneration.

Objective To explore the feasibility and safety of mdr1 gene transferred into placenta derived mesenchymal stem cells (P-MSCs) by reconstructed retroviral vector.Methods Human P-MSCs were isolated and expanded by Percoll density gradient and then transduced repeatedly by reconstructed retroviral vector containing mdr1 gene.The transfection and expression of mdr1 gene was detected by reverse transcription-polymerase chain reaction (RT-PCR) and fluorescence-activated cell sorting (FAGS).Meanwhile,the biological features of mdr1-MSCs were identified and analyzed.Results The expression of mdr1 mRNA was found in transfected cells.The expression of P-glycoprotein (P-gp) encoded by mdr1 gene was(27.6 ±5.1)％ in the transfected P-MSCs cells versus (0.4 ± 0.1)％ in the non-transfected P-MSCs cells (t =14.291,P ＜ 0.01).The percent of P-MSCs at quiescent phase (G0/G1 phase) was around 95.40％ and it was in accord with the characterization of stem cells.The mdr1-MSCs exhibited typical ultrastructures of low-differentiated stem cells.Moreover,they still retained the potency of adipogenic and osteogenic differentiation in the presence of appropriate conditioned media.Conclusion A stable expression of P-gp may be obtained by reconstructed retroviral-mediated transfection in vitro.And transfected MSCs retain the characteristics of stem cells.

The fracture of the humeral head is rare in clinic, often occurs in adolescents, and belongs to intra-articular fracture; In pediatric orthopedics, it is often called epiphyseal coronal fracture of the lateral condyle of the humerus. Because it is rare, it is easy to miss the diagnosis in clinic, resulting in delay in treatment and limited elbow function. Because of the low attention of this disease, there are few reports, and there is a lack of effective, systematic and standardized surgical treatment in clinic. We used open reduction and cannulated tension nail internal fixation to treat type I fracture of the humeral head and obtained complete follow-up, and the curative effect was satisfactory. The treatment experience is summarized as follows.

The patient was a 57-year-old female who came to the doctor in 2006 (51 years old) with the main complaint of "difficulty in defecation for 44 years, limb weakness for 20 months and right blepharoptosis for 5 months". At the age of 7, the patient had difficulty in defecation, slight abdominal distension, no abdominal pain, and needed "castor oil" to defecate every time, which persisted. At the age of 30, the difficulty in defecation began and gradually worsened. After taking honey orally and eating a lot of bananas every day and using "Kaiselu", the defecation was still not smooth, and the defecation was about once a week, and the defecation time was long and laborious every time.

Patients with systemic lupus erythematosus (SLE) are susceptible to multiple infections, including tuberculosis infection, which is the second most fatal infectious disease after AIDS [1]. The epidemiology, pathogenesis and clinical characteristics of SLE complicated with tuberculosis infection are reviewed.

A 22-year-old female came to the clinic due to "episodic limb twitching for 2 months". The patient developed episodic limb twitching without obvious trigger 2 months ago. CT examination of the brain in the local hospital showed multiple low-density foci in bilateral cerebral hemispheres. After anti-inflammatory treatment was ineffective, she underwent puncture biopsy of right frontal and parietal foci. After operation, the pathology of the local hospital considered demyelinating lesions, and the effect of methylprednisolone impulse treatment was not good, so she came to the Department of Neurology of Qilu Hospital of Shandong University and was admitted to the hospital on February 18, 2008. The patient had menarche at the age of 14, irregular menstruation at the age of 18, and gradually menopaused.

A 35-year-old male was admitted to hospital due to chills and high fever for more than 20 days, accompanied by low back pain and soy sauce urine for 3 days. The patient worked in Myanmar since 2009. On July 30, 2011, he developed chills without obvious trigger, followed by high fever, which lasted for about 2 hours. After sweating, his body temperature gradually dropped to normal, accompanied by fatigue, nausea and loss of appetite. Blood smear found "Plasmodium falciparum", so artemisinin and pyronalidine phosphate were given to treat; After medication, severe low back pain and oliguria appeared, urine color deepened to soy sauce color, and gradually irritability and unconsciousness appeared. Laboratory examination: blood Cr 642 μ mol/L, BUN 30.5 mmol/L, HGB 72 g/L, PLT 14×109/L, K +2.6 mmol/L; After receiving hemodialysis treatment and antimalarial treatment, the patient's body temperature dropped, low back pain gradually relieved, consciousness recovered, but the urine output was still low and melena was relieved. Blood examination Cr 391 μ mol/L, BUN 14.1 mmol/L, HGB 54 g/L, PLT 85×109/L; Chest CT showed "a small amount of pleural effusion"; On August 18th, he was transferred to our hospital. Physical examination: body temperature 38 ℃, heart rate 100 beats/min, blood pressure 110/70 mm Hg (1 mm Hg =0.133 kPa), general condition is poor, acute disease appearance, severe anemia appearance, clear consciousness, slow response, moderate yellowing of skin and sclera, oral herpes, damp roaring sound can be heard in both lower lungs, full abdomen, untouched liver subcostal, spleen subcostal 5 cm, moderate edema in both lower limbs; Blood TP 52 g/L, ALB 27 g/L, TBil 45 μ mol/L, IBil 30 μ mol/L, ALT 57 U/L, AST 95 U/L, LDH 1526 U/L, Cr 320 μ mol/L, BUN 13.9 mmol/L, HGB 49 g/L, PLT 45×109/L; Urinary examination showed proteinuria (+ +) and urine specific gravity 1.010; Considering "falciparum malaria with acute hemolytic uremic syndrome", artemether, dexamethasone and symptomatic supportive treatment were given; On August 24th, the body temperature dropped to normal, followed by polydipsia and polydipsia, and the urine output increased significantly to 10 000 ml per day. No abnormality was found in the examination of kidney B-ultrasound and head CT. Blood: Cr, BUN, K, PLT and other indexes were normal, HGB 88 g/L, Ca and P were normal; Urine test: protein (-), specific gravity 1.001; considering "diabetes insipidus"; On September 2nd, desmopressin 0.1 mg was given orally, once every 12 hours. After 3 days, the urine volume gradually decreased to about 3000 ml per day, and the oral desmopressin treatment continued after discharge.