Volume 95  ·  Issue 07  ·  2015

Due to the continuous emergence of dopaminergic drugs, most of the motor symptoms of Parkinson's disease (PD) can be well controlled, but there are still many problems that plague us and directly affect the quality of life and working ability of patients. Recently Deane et al.^[1]Surveys of PD patients, doctors, and nursing staff show that among the top ten studies to be carried out while waiting for a radical cure or effective treatment, the first is to solve balance problems, followed by reducing anxiety and depression in patients, and reducing exercise complications only ranks third. Even though this is a survey based on Western populations, these questions are equally what we should be focusing on. Among the 26 issues of concern screened, only 30% are related to motor symptoms, and more are non-motor symptoms, including cognition, sleep disorders, autonomic dysfunction, gastrointestinal symptoms, pain, etc. These non-motor symptoms not only have a high incidence rate, but also can appear in the early stage of the disease, accompanied by the whole process of PD progression, and even before the appearance of PD motor symptoms, and sometimes can become the main reason affecting the quality of life of patients. Among them, combined pain is not paid attention to in clinic, and it is often an important reason for diagnosis delay in the early stage.

To explore the changes of local brain activity in motor subtypes of Parkinson′s disease (PD) with functional magnetic resonance imaging (fMRI).

A total of 60 idiopathic PD and 30 age– and gender–matched normal controls were examined with resting–state fMRI from January 2013 to March 2014. All subjects gave their written informed consent for the study. The amplitude of low–frequency fluctuation (ALFF) was calculated to measure local brain activity. The PD patients were divided into two groups of tremor dominant (TD) and postural instability/gait difficulty (PIGD) (n=30 each). All subjects gave their written in formed consent for the study. One–way ANOVA and post–hoc t–test were performed to detect the differences of local brain activity between PD and normal subjects. And the correlations were examined between ALFF, scores and levodopa dose.

Compared with normal subjects, the TD group showed increased activity in bilateral cerebellums (–37, –47, –38), thalamus (–18, –17, 0), pons (–3, –23, –37) and left precentral gyrus (–41, –30, 46) versus decreased activity in bilateral frontal lobes (–13, 69, 6), temporal lobes (–42, 18, –21), left insula (–32, 22, 2) and left anterior cingulated (–7, 32, –5). The PIGD group showed increased activity in right postcentral gyrus (63, –18, 39) and decreased activity in bilateral putamens (–24, 12, 3), pre–supplementary motor area (10, 10, 58), frontal lobes (15, –15, 57) , temporal lobes (–39, 18, –3) and left insula (–29, 20, 11). Compared with PIGD, the TD group showed increased activity in temporal lobes, but decreased activity in frontal lobes. Additionally, ALFF in bilateral cerebellums and frontal lobes was positively correlated with TD scores while ALFF in left precentral gyrus, bilateral putamens and temporal lobes negatively correlated with TD scores. ALFF in bilateral frontal lobes and left temporal lobe was positively correlated with PIGD scores. However, in right postcentral gyrus and bilateral putamens, ALFF was negatively correlated with PIGD scores. The levodopa dose was positively correlated with frontal lobes and temporal lobe in TD and cerebellums and inferior parietal lobule in PIGD.

A specific pattern of intrinsic activity in TD and PIGD may provide insights into neurophysiological mechanisms of PD motor subtypes. The changes of brain activity in TD are caused by the interaction between cerebello–thalamo–cortical circuit and basal ganglia loop while the changes in PIGD result largely from damaged basal ganglia loop.

To explore the general characteristics of olfactory and cognitive functions in early Parkinson′s disease (PD) and examine their correlations.

The olfactory functions were assessed for 63 PD patients and 55 age and gender–matched normal subjects using T&T olfactory assessment. The scales of mini–mental state examination (MMSE) and Montreal cognitive assessment (MoCA) were employed. The olfactory and cognitive parameters and their relationship were analyzed. There were five different odors in T&T testing liquid and each odor had 5 concentration gradients. The level had an assigned value of 1 to 5 and number 3 represented the standard threshold of olfactory recognition. The mean value of five odors was overall olfactory detection or cognition threshold.

(1) The olfactory detection and recognition thresholds were 4.0±1.3/4.8±0.9 in PD group versus 2.5±0.9/2.9±0.9 in normal controls. The scores of MoCA and MMSE were lower in PD group than those in controls (23.7±3.0 vs 25.9±2.0, t=4.727, P=0.000; 27.8±1.9 vs 28.9±0.9, t=4.036, P=0.000). (2) Linear correlation analysis showed that olfactory recognition threshold was correlated negatively with MoCA scores. The olfactory detection and recognition thresholds were correlated negatively with the score of visual–spatial perception and executive capability (r=–0.365, –0.403, P<0.05). The olfactory recognition threshold was correlated negatively with the score of delayed memory (r=–0.299, P<0.05). And this phenomenon was absent in controls.

Early PD patients have olfactory dysfunction and cognitive impairment. And these two non–motor symptoms are negatively correlated.

To explore the effects of levodopa on heart rate variability (HRV) in Parkinson′s disease (PD).

A total of 48 PD patients (M∶F=35∶13, mean age: 59±6 years, duration of illness: 4.7±1.8 years, Hoehn & Yahr stage: 2.2±0.3) on a stable dose of levodopa were recruited from January 2012 to May 2014. For confirming autonomic dysfunction, the baseline patient data (12 hours off-medication) were compared with a control group consisting of 48 age and gender-matched healthy subjects (M∶F=35∶13, mean age 58±6 years). Resting lead Ⅱ electrocardiogram (ECG) was recorded at baseline and continuously after two tablets of 100/10 mg levodopa/carbidopa. However, 5-min segments were selected from every quarter, i. e., Q1 (0–15 min), Q2 (15–30 min), Q3 (30–45 min) and Q4 (45–60 min). Artifact-free 5-min segments of ECG were analyzed offline to acquire the parameters of heart rate variability in time and frequency domains.

At baseline, PD patients had a significantly reduced standard deviation of normal-to-normal intervals (SDRR)[(24±4) vs (26±4) ms, P<0.01)] and total power (TP)[(569±180) vs (652±205) ms^2,P<0.05] when compared to controls. Comparing of HRV in PD patients at baseline and during first hour after drug administration, we observed significant increase in SDRR [(29±12) vs (24±8) ms,P<0.05)], TP [(708±253) vs (569±180) ms^2,P<0.01], low frequency power (LF) [(203±98) vs (168±60) ms^2,P<0.05)] and high frequency power (HF) [158±86) vs (114±90) ms^2,P<0.05] in Q3.

The results suggest an improvement in the overall variability of heart rate resulting from an enhanced vagal tone.

To estimate the efficacies of fluid resuscitations as guided by lactate clearance rate (LC) and central venous oxygen saturation (ScvO₂) in patients with septic shock.

100 patients diagnosed with septic shock from June 2012 to June 2014 in department of critical care medicine of sixteen hospitals were enrolled. They were randomly divided into two groups of study and control (each n=50). After a diagnosis of sepsis shock, they were treated symptomatically timely and fluid resuscitation was started as early as possible according to the 2008 Guideline for Managing Sepsis & Septic Shock. Central venous pressure (CVP) ≥8 mmHg (1 mmHg=0.133 kPa), mean arterial pressure (MAP) ≥65 mmHg, urine output ≥ 0.5 ml·kg ^–1·h^–1, ScvO₂ ≥70% and LC≥10% (or lactate≤ 2.0 mmol) served as target values for fluid resuscitation therapy in study group versus CVP ≥8 mmHg, MAP ≥65 mmHg, urine output ≥ 0.5 ml·kg^–1·h^–1 and ScvO₂ ≥70% in control group. The general conditions and clinical characteristics, changes in CVP, MAP, urine output, ScvO_2, lactate level and/or LC before (0 hour) and every hour (1–6 h) after the start of fluid resuscitation and other related outcome indicators were recorded.

No significant difference existed in general data. The 28–day mortality was 40% for study group versus 56% for control group. There was no significant inter–group difference (P>0.05). The time of mechanical ventilation and length of intensive care unit (ICU) stay were lower in study group than those in control group [mechanical ventilation time (11.200 ±17.069) vs (15.760±14.215),P=0.150; length of ICU stay (13.240±17.127) vs (23.980±18.298), P=0.003]. The 28–day mortality was independently associated with LC and ScvO₂ reaching target values for fluid resuscitation in study group (χ²=10.930, P=0.001) while the 28–day mortality was independently associated with ScvO₂ reaching target value for fluid resuscitation in control group (χ²=6.395, P=0.011). Among all patients, the 28–day mortality was independently associated with ScvO₂ reaching target value for fluid resuscitation (χ²=14.530, P=0.000), but not LC (χ²=1.175, P=0.278).

A combination of LC and ScvO₂ may serve an index in confirming the endpoint of fluid resuscitation for patients with septic shock. Fluid resuscitation therapy under the guidance of LC and ScvO₂ is more accurate and reliable than the guidance of ScvO₂ alone.

To explore the correlation between aquaporin-4 (AQP4) gene single nucleotide polymorphism (SNP) and clinical phenotypes of neuromyelitis optica (NMO) and its underlying mechanism.

Eight SNPs in AQP4 gene regulatory region were selected and genotyped for 208 anti-AQP4 autoantibodies (NMO-IgG) seropositive cases during January 2010 to January 2014 and 204 healthy subjects. Then the correlation was further analysed between genotypes and NMO phenotypes. And the effect of microRNA (miRNA) on the expression of AQP4 gene was examined by dual-luciferase reporter technique.

The A/T genotype of rs1058424 (50.61% vs 70.45%, OR=0.430, 95%CI 0.210–0.880) and C/T (50.00% vs 68.18%, OR=0.467, 95%CI 0.231–0.994) genotype of rs3763043 in 3′-UTR were correlated with longitudinal extensive transverse myelitis; the A/T genotype of rs1058424 (46.72% vs 66.28%, OR=0.525, 95%CI 0.276–0.999) and A/C genotype of rs335929 (45.08% vs 58.14%, OR=0.527, 95%CI 0.281–0.987) in 3′-UTR as well as C/T genotype of rs151244 (50.82% vs 69.77%, OR=0.450, 95%CI 0.230–0.881) in promoter 0 region were correlated with optic neuritis. The polymorphism of rs6508459 in 3′-UTR and rs3763040 in intron region were correlated with concurrent systemic autoimmune diseases (P=0.012 and 0.023 respectively). miRNA 323-3p could regulate AQP4 gene expression. However, variation in SNP rs1058424 failed to affect this regulation.

SNP in 3′-UTR of AQP4 gene may be associated with NMO phenotypes.miRNA 323-3p may participate in the pathogenesis of NMO by binding to certain SNP sites in 3′-UTR of AQP4 gene and regulating its expression.

To explore the functions of amygdala functional connectivity in the pathogenesis of refractory epilepsy with resting–state functional magnetic resonance imaging (RS–fMRI).

A total of 19 patients with refractory epilepsy were recruited from August 2013 to June 2014. And 19 healthy persons were selected as the controls. No obvious epileptogenic lesions of intracranial structures were found on multi–modal neuroimaging. Ictal and interictal epileptic activities on long–term video electroencephalogram (EEG) showed spine spread spike and wave in bilateral cerebral hemispheres. All fMRI data were preprocessed after RS–fMRI scanning. Then left and right amygdalas were selected as regions of interest (ROIs) for calculating the linear correlation between amygdala and whole brain. As relative to the control group, the changes of brain areas in functional connectivity were examined for the intractable epilepsy group.

Compared with the controls, left amygdala in refractory epilepsy group showed increased functional connectivity with bilateral fusiform gyrus, bilateral calcarine gyrus and right lingual, on the con trary decreased functional connectivity with bilateral cuneus, bilateral precuneus, bilateral caudatas and left thalamus. However, right amygdala demonstrated increased functional connectivity with bilateral calcarine gyrus and bilateral linguals, but decreased functional connectivity with bilateral caudatas and left putamen (P<0.05).

Altered functional connectivity of amygdala reflects its dysfunction in refractory epilepsy patients. It suggested that amygdala is an important component of "epileptic network" participating in the occurrence and development of refractory epilepsy.

To explore the therapeutic efficacies and the timing of taking bromocriptine during pregnancy in patients with pituitary prolactinoma.

The clinical data were analyzed retrospectively for 230 women with pituitary prolactinoma at our hospital from January 2001 to May 2014. During January 2001 to December 2007, 120 cases were selected as control group. During January 2008 to May 2014, 110 cases were recruited into treatment group. When found pregnant, the control group immediately withdrew while the treatment group continued the original dose of bromocriptine.

The rate of embryo stopping was 16.7%(20/120) in control group. As compared with the rate of natural population, the difference was statistically significant (P<0.05); the rate was 0.91% (1/110) in treatment group. As compared with natural population, the difference had no significance (P>0.05). No significant inter–group difference existed in embryonic malformation rate (P>0.05).

Pituitary prolactinoma patients should continue the original dose of bromocriptine for at least 4 months instead of immediate withdrawal during pregnancy. For those with large adenoma, bromocriptine should be taken throughout pregnancy. Blood levels of prolactin, progesterone, human chorionic gonadotropin (HCG) and visual dysfunction should be monitored every 2 weeks. If the levels of progesterone and HCG are low, they should be timely supplemented. If prolactin rises too rapidly and visual dysfunction worsens, the dose of bromocriptine should be appropriately increased. Taking bromocriptine during pregnancy can significantly reduce the rate of embryo stopping without improving the rate of embryo deformity. Thus use of bromocriptine is both safe and necessary.

To explore the feasibility, safety and effectiveness of treatment by Novasure system in abnormal uterine bleeding caused by endometrial polyps (AUB–P) or uterine leiomyomas up to 3 cm (AUB–LSM).

From June 2011 to June 2012, 30 women with abnormal uterine bleeding caused by AUB–P and AUB–LSM were treated by NoveSure system. The clinical efficacies and complications were followed up at months 1, 3, 6, 12.

All operations were completed successfully. The mean operative duration was (84±6)(60–120) s. The volume of blood loss was <10 ml. And the follow–up period was 1, 3, 6 and 12 months. The effective rate was 100% (30/30), 96.67%(29/30), 93.33%(28/30) and 96.67%(29/30) respectively. The rate of amenorrhea was 76.67%(23/30), 70%(21/30), 70%(21/30) and 76.67%(23/30) respectively. The degrees of satisfaction were 100%(30/30), 96.67%(29/30), 96.67%(29/30) and 96.67%(29/30). No severe perioperative or postoperative complications occurred.

Navosure system is both safe and efficacious for abnormal uterine bleeding caused by AUB–P and AUB–LSM. And it is worth wider popularization.

To explore the clinicopathologic features, managements and outcomes of villoglandular adenocarcinoma (VA) of uterine cervix.

From June 2009 to January 2014, a total of 16 cases of VA were reviewed retrospectively.

Their mean age was 41.4 (30–56) years. The major symptoms were post–coital hemorrhage or abnormal vaginal hemorrhage (10/16). And the International Federation of Gynecology and Obstetrics (FIGO) stages were Ⅰa1 (n=1), Ⅰb1 (n=12), Ⅰb2 (n=2) andⅡa1 (n=1). One patient ofⅠa1 stage underwent laparoscopic total hysterectomy and bilateral salpingo–oophorectomy (BSO) after conization; one patient of Ⅰb1 stage total abdominal hysterectomy and BSO after radiotherapy and concurrent chemotherapy while another one ofⅠb1 stage radical vaginal trachelectomy; one pregnancy–associated patient of Ⅰb1 stage was diagnosed at 12 weeks′ gestation and underwent cesarean radical hysterectomy plus pelvic lymphadenectomy after four courses of chemotherapy. Aand the remainder underwent radical hysterectomy plus pelvic lymphadenectomy. None of 14 cases with a known status of lymph node status had positive nodes. And 1/13 cases undergoing ovariectomy had pathologically confirmed cervical cancer metastasis of ovarian surface and the remainder and another patient of ovarian biopsy had negative results for lymph nodes. The median follow–up period was 23.3 (5–60) months. All patients survived and there was one recurrent case of vaginal stump mass at 8 months after initial surgery. The overall and disease–free 5–year survival was 100% and 94% (15/16) respectively.

VA mainly affects younger women and prognosis is generally fair with a lower rate of ovarian metastasis compared to common forms of cervical cancer. Due to a limited sample size and clinical data are studied retrospectively, multi–center prospective studies are warranted for a better understand of this disease.

To explore the association between glucose variability and poor prognosis in critically ill patients.

This prospective study was undertaken in a 24–bed intensive care unit (ICU). A total of 145 patients staying for over 24 hours in ICU were enrolled. Their arterial levels of blood glucose were measured four times daily routinely. And the mean glucose level (MGL), standard deviation (SD) and coefficient of variation (CV) were calculated. The incidence of moderate hypoglycemia (MH), severe hypoglycemia (SH), total dosage of hormone, average daily dosage of insulin, duration of renal replacement– therapy (RRT), mechanical ventilation and ICU free days were also recorded. They were divided into survival (n=85) and nonsurvival (n=60) groups according to survival or not at 28 days. And CV was compared between two groups and the relationship of CV and mortality examined.

The nonsurvival group had higher CV value accompanied by higher RRT proportion, higher incidences of MH and SH, shorter free mechanical ventilation time and free ICU stay. The higher CV value was found in surviving nondiabetics. However, no significant difference existed in diabetes group.

Critically ill patients have higher CV of glucose variability especially in non–diabetic patients. Blood glucose fluctuations denote a worse prognosis. And hypoglycemia should raise a high alert. Frequent blood glucose monitoring is beneficial to detecting the changes of condition and adjusting treatment regimens accordingly.

To explore the application of B–ultrasound monitoring plus gastric insufflation for nasointestinal tube indwelling in critical neurosurgical patients.

A total of 96 critical comatose neurosurgical patients indicated for nasointestinal tube indwelling were randomized into three groups of routine (A, n=32), gastric insufflation (B, n=31) and B–ultrasound monitoring plus gastric insufflation (C, n=33). And the position of nasointestinal tube was observed within 24 h and at 72 h in three groups.

The general profiles of three groups showed no significant differences (P>0.05). The proportions of nasointestinal tube passing pylorus within 24 h in three groups were 43.8%, 74.2% and 93.9% respectively. Comparing group C with groups A and B, the differences presented statistical significance. The proportions of nasointestinal tube passing pylorus at 72 h in three groups were 68.8%, 83.9% and 100% respectively. Comparing group C with groups A and B, the differences had statistical significance.

Refined method of nasointestinal tube indwelling and B–ultrasound monitoring may boost the rate of successful indwelling. It is worth wider promotion and application.

To explore the levels of autoantibodies against AT1–receptor (AT1–AA) in hypertensive patients with acute coronary syndrome (ACS) and observe the in vitro effects of AT1–AA on resting tension of isolated anterior descending artery of vascular ring in male Wistar rats.

All patients were recruited from June 2007 to August 2008. There were hypertensive patients with ACS (n=120), those with simple hypertension (n=253) and those with simple ACS (n=115). And the outpatients for health examination during the same period were selected as healthy control group (n=188). The second extracellular loop amino acid sequences of peptides of ATI receptor was synthesized and used as antigen (AT1–Ag) and sialic acid–enzyme–linked immunosorbent assay (SA–ELISA) for detect the serum levels of AT1–AA. Microvascular ring tension technology was used to test the vascular loop resting tension of anterior descending coronary artery from rats induced by a high–fat diet.

The positive rates of AT1–AA in patients with simple hypertension (35.2%) and those with simple ACS (30.4%) were significantly higher than those in healthy control group (7.2%, P<0.01). And the positive rate of AT1–AA in hypertensive patients with ACS (43.3%) was significantly higher than that in those with simple hypertension (35.2%,P<0.05) and that in healthy control group (7.2%,P<0.05). Furthermore, AT1–AA increased the vascular loop resting tension of anterior descending coronary artery rings in rats induced by a high–fat diet in a dose–dependant manner. And the vasoconstrictive action of AT1–AA was equal to 46.4% of AngⅡ′s action. And such an action was blocked by losartan and antigens.

The level of AT1–AA increases markedly in hypertensive patients with ACS. And AT1–AA induces vasoconstrictive effects on anterior descending artery rings in rats induced by a high–fat diet.

To explore the computed tomographic (CT) and pathological findings of small intrahepatic cholangiocarcinoma and improve its understanding.

A total of 20 patients with bile duct non-dilatation peripheral small intrahepatic cholangiocarcinoma were retrospectively analyzed. All of them were examined by plain and enhanced CT and pathological studies.

CT plain scan: there were 15 cases of low-density lesions with fibers and necrotic tissue and surviving tumor tissue in peripheral or central portions. There were 4 cases of lesions with mixed high and low densities. Abundant necrotic tissues were found with a rare vascular distribution. Or abundant fibers and connective tissues around tumor were manifested as hardened cholangiocarcinoma. One lesion showed equal density with abundant necrotic tissue and fibrous connective tissue with peripheral tumor tissue; dynamic contrast-enhanced CT: (1) there were 6 cases of lesion with peripheral thin ring-enhanced and tumor margin of viable tumor tissue. And internal tumor was fibrous tissue; (2) there were 7 cases of lesions with peripheral thick ring-enhanced and enhanced portion was surviving tumor tissue, no enhanced central portion was mainly necrotic tissue mixed with little fibrous tissue; (3) there were 2 cases of whole tumors without enhancement. There were significant hemorrhage and necrosis with few surviving tumor cells in tumor and normal liver tissue; (4) there were 5 cases of lesions with heterogeneous enhancement and the heterogeneous enhancement portion was surviving tumor tissue and little fibrous connective tissue. And some necrotic tissue remained; (5) only one case had overall enhancement of same-sized tumor cells without necrosis.

CT scanning of peripheral small cholangiocarcinoma lacks distinguishing characteristics. However the findings of contrast-enhanced CT have certain characteristics. Due to different pathological types, each attribute has corresponding characteristic with different pathological features.

To explore the correlation between liver T₂^* value and bone mineral density (BMD) in ovariectomized (OVX) rats.

A total of 60 rats, including sham (n=25) and OVX (n=35) groups, underwent dual–energy X–ray absorptiometry (DEXA) and liver magnetic resonance (MR)–T₂^* mapping for lumbar vertebra BMD and T₂^*values before and after operation monthly for 4 timepoints. Also micro–computed tomography (micro–CT) and biochemical measurements were performed. The sensitivity of liver T₂^* relaxation time detecting early osteoporosis were estimated and the correlation between liver T₂^* values and BMD analyzed.

BMD of lumber vertebra in OVX group decreased compared to control group at Month 2 postoperation ((554±27) mg/cm³ vs (722±19) mg/cm^3,P<0.05) in synchrony with an elevation of serum ferritin concentration ((521±41) ng/ml vs (441±29) ng/ml,P<0.01) and liver iron concentration ((291±18) μg/g vs (237±27) μg/g,P<0.01). A significant inter–group difference of liver T₂^* was detected at Month 1 postoperation ((13.2±0.7) ms vs (13.9±0.4) ms, P<0.01). Liver T₂^* was significant positively correlated with BMD in sham group (r=0.410, P<0.01) and OVX group (r=0.434, P<0.01).

Liver T₂^* relaxation time may a valuable detection tool of assessing pathophysiological changes of osteoporosis in early stage.

To evaluate the diagnostic values of computed tomographic angiography (CTA) for liver VX2 tumor in rabbits.

A total of 40 New Zealand white rabbits were employed by implanting tumor fragment into left liver by computed tomography (CT)–guided percutaneous puncture. And successful modeling was established in 38 rabbits. Plain and three–phase enhanced CT scan and its CTA reconstruction were performed in different stages (14, 21 and 28 days) after tumor implantation, followed by digital subtraction angiography (DSA) via femoral artery and hepatic artery. Dynamic observations of tumor growth characteristics were recorded by plain and enhanced CT and comparing CTA and DSA images. And comparisons of CTA and DSA were made for identifying the origin, course and blood supply of transplanted tumors.

(1) Multi–slice computed tomography (MSCT) could dynamically monitor the growth transfer characteristics. And all tumors became strengthened obviously in arterial phase and washed out in venous and delayed phases. (2) CTA showed that the feeding artery of transplanted tumor was hepatic artery. (3) No obvious differences existed in the display of feeding artery of transplanted tumor between CTA and DSA. However CTA was superior to DSA in displaying three–dimensional structure.

Liver VX2 tumors are hypervascular in rabbits. CT enhanced scanning may dynamically monitor the growth patterns of tumors and CTA is a better method than DSA in visualizing the feeding arteries of tumors. Before and after interventions, CTA may replace DSA in evaluating liver VX2 tumors in rabbits.

Skin and soft tissue injuries in the posterior calcaneal area are more common in children. Because of children's poor self-protection awareness, such injuries are increasing day by day. The peroneal artery perforator pedicled sural neurovascular flap is a common method for clinical repair of soft tissue defects in the heel of foot because of its reliable blood supply and stable survival. However, when the cutting area of the flap is large, the donor area cannot be directly sutured, and skin grafting is often used to repair the postoperative depression and scar hyperplasia, which seriously affects the appearance of the calf. Based on the shortcomings of the above surgical methods, this study proposed a method of repairing the skin and soft tissues of the posterior calcaneal region by peroneal artery perforator pedicled sural neurovascular flap on the basis of anatomy, and repairing the wound of the donor site of the sural nerve island flap by proximal tibial artery perforator pedicled V-Y advancing flap. The goal of direct suture of the donor site wound was achieved by proximal perforator pedicled V-Y advancing flap.

The patient, a 50-year-old man, developed dull pain in the upper abdomen without obvious trigger 1 week ago, which was interstitial, radiated to the lower back, and did not relieve with the change of body position. He had no fear of cold and fever at the time of attack, and no skin and sclera yellowing. He was admitted to the Second Affiliated Hospital of Nanjing Medical University for hospitalization in April 2014. Physical health in the past, no special physical examination. Laboratory tests: high sensitivity C-reactive protein 12 mg/L (elevated), blood glucose 7.36 mmol/L (slightly elevated), globulin 36.5 g/L (slightly elevated), neurospecific enolase 27.09 μ g/L (slightly elevated), CA19-9 30.06 U/ml (normal), and other blood tumor indexes were normal. Using Philips Brilliance 64-slice CT, total abdominal plain scan + enhanced examination showed that the body and tail of the pancreas were obviously enlarged, and 6.8 cm ×4.4 cm low-density soft tissue masses were seen, with uniform density. The CT value was 24-28 HU (normal pancreas CT value 35-40 HU). After enhancement, the lesions in the arterial phase were less enhanced than those in the normal pancreas, and the enhancement was less uniform. The CT value was 34-50 HU (normal pancreas 60-65 HU). The lesions in the portal vein phase and the delayed phase continued to delay the enhancement, and the enhancement tends to be uniform. The CT values were 45-55 HU (normal pancreas 55-60 HU) and 52-58 HU (normal pancreas 45-50 HU), respectively. CT diagnosis: mass in the body and tail of the pancreas, pancreatic cancer possible; Multiple small lymph nodes in splenic hilum and retroperitoneum (Figure 1)。 Surgery considers surgical treatment of pancreatic tumors. During the operation, tumors in the body and tail of the pancreas were seen, invading the kidney fat sac, and multiple enlarged lymph nodes were seen next to the splenic artery. Pancreatectomy and splenectomy were performed. Postoperative pathology showed that the size of the pancreas was 9.0 cm ×7.0 cm ×5.0 cm, and a gray mass was seen on the section, the size was 6.0 cm ×7.0 cm ×4.5 cm. The mass adhered to the spleen, and the boundary with the surrounding tissues was unclear. Pathological diagnosis: Chronic inflammation of the body and tail of the pancreas with lymphoid tissue hyperplasia, considering that IgG4-related immune disease may be large.

A 19-year-old male was admitted to the hospital for "repeated fever for 2 months with thoracic, lumbar and back pain". Physical examination: Body temperature 37.3℃, no anemia, superficial lymph nodes not swollen, both lungs normal, mild tenderness in chest and back, mild limitation of lumbar spine movement, and normal sensory movement of limbs. Imaging examination: CT showed multiple circular low-density changes in lumbar vertebra, sacral vertebra, left ilium and ischium, thoracic vertebra, ribs and sternum, with smooth boundaries, high central density, partial cortical bone destruction and slight swelling of soft tissue (Figure 1、Figure 2)； Chest enhanced CT showed patchy low-density shadows in the upper lobe of the left lung, with uneven enhancement after enhancement (Figure 3)。 The erythrocyte sedimentation rate was significantly increased in laboratory (75 mmHg, 1 mmHg =0.133 kPa). The patient was admitted for diagnosis: multiple bone destruction. Malignant lymphoma? Bone tuberculosis? There were no abnormalities in other relevant laboratory tests and abdominal B-ultrasound. CT showed circular annular bone destruction of thoracic 7 vertebral bodies and adnexes, local cortical bone rupture, and no obvious soft tissue mass (Figure 4)。 MRI showed multiple circular annular signal shadows in lumbar and sacrococcygeal vertebrae, with smooth boundaries, T₁WI and T₂WI showed low signal in the upper interior, slightly high signal in the periphery, partial bone destruction, accompanied by slight swelling of soft tissue, and ring enhancement and surrounding soft tissue enhancement were observed after enhancement (Figure 5)。 Under the guidance of CT, puncture of thoracic 7 vertebral lesions, left ilium and left lung paramediastinal lesions was performed successively, but the diagnosis could not be confirmed. Therefore, incision biopsy of thoracic 7 lesions was performed. During the operation, fish-like soft tissue was seen under the thoracic 7 vertebral lamina, adhering to surrounding tissues, and local dead bone was formed. Epithelioid cells and many Langhan's giant cells were observed under the postoperative pathological microscope, and dead bone (Figure 6)。 After the pathological diagnosis was confirmed as tuberculosis, anti-tuberculosis treatment was given. The pain basically disappeared after 12 months of treatment. MRI reexamination showed that the abnormal signal range of lower thoracic vertebra, lumbar vertebra and sacral vertebra was reduced, T₁WI signals vary from high to low, T₂WI is dominated by high signal (Figure 7), the erythrocyte sedimentation rate dropped to 35 mm/h, and is currently continuing anti-tuberculosis therapy.

Alzheimer disease (AD) often attacks, mainly manifested as progressive development of memory loss, aphasia, apraxia, agnosia, visual and spatial skill impairment, executive dysfunction, personality and behavior changes, etc. It has become one of the main diseases that seriously threaten the life health and quality of life of the elderly. According to the annual report of the International Academic Organization of Alzheimer's Disease, in 2010, there were 759 million elderly people aged>60 years old in the world, of which 35.56 million (about 4.7%) suffered from AD of different degrees, and it is expected to reach 65.69 million in 2030. China will also become the country with the largest number of dementia, so it is urgent for us to have a clearer understanding of the pathogenesis of AD. However, the etiology and mechanism of AD are not fully understood at present. Researchers are trying to explore it from the aspects of genetics, neurotransmitter disorders, inflammation theory, cytoskeletal changes, immune dysfunction, etc. In recent years, with the rapid development of imaging technology, the relationship between AD and vascular diseases has attracted much attention. More and more studies have found that microvascular diseases are common in the brain of AD patients, such as cerebral amyloid angiopathy, white matter damage, lacunar infarction, blood-cerebrospinal fluid barrier destruction and cerebral microbleeds (CMBs), etc. It was found that these cerebral microvascular lesions may accelerate the production, aggregation and deposition of A β, reduce the clearance of A β, promote the pathological process of AD, and thus aggravate the cognitive impairment^[1]。 At present, the influence of cerebral microhemorrhage on the cognitive function of AD has become a hot research topic. Therefore, this paper reviews the clinical research status of AD and cerebral microhemorrhage.

In 1895, Roentgen reported the first use of X-ray imaging of hand bones, and won the 1st Nobel Prize in Physics in 1901. Since then, medical imaging has developed for 118 years. The development of imaging equipment such as MRI (the discovery of nuclear magnetic resonance phenomenon in 1930 produced three Nobel Prizes; the application of nuclear magnetic resonance imaging produced two Nobel Prizes in 1973), CT (invented in 1970, Nobel Prize in 1979), PET and ultrasound have further provided more accurate information for clinical medicine and matured into the core content of medical imaging.

Most of the time, malignancy death occurs due to metastasis and complications rather than the primary tumor itself. The most common site of metastasis of the tumor is the liver, followed by the lungs and bones. Spinal metastases account for about 70% of bone metastases, and 5% ~20% of patients with spinal metastases eventually lead to spinal cord compression^[1]。 Anticipatory prognostic studies of spinal metastases are significant in guiding treatment decisions. On the one hand, spinal metastases can cause severe bone pain and pathological fractures, and spinal cord compression can often lead to paraplegia, so the treatment of spinal metastases needs to be carried out in a short time. On the other hand, the adverse factors such as bone marrow suppression, severe neurological impairment, urinary incontinence, obesity, malnutrition and corticosteroid use after radiotherapy and chemotherapy in patients with spinal metastases are difficult to control before operation, and the incidence of complications such as incision non-union and infection after operation is high. In addition, although the survival expectancy of patients with metastatic spinal cord compression (MSCC) is relatively short, the treatment of spinal metastases and their complications consumes healthcare resources and costs^[2]。 Prognostic studies of spinal metastases mainly include three categories: (1) studies that predict risk factors affecting overall survival; (2) To determine the risk factors affecting the survival of MSCC and/or spinal compression fractures after surgery and radiotherapy; (3) Studies to assess clinical or imaging risk factors for the progression of spinal metastases to MSCC and/or spinal compression fractures. The purpose of the predictive prognosis study of spinal metastases is to: (1) avoid excessive medical treatment and avoid the risk of surgery; (2) before the patient's health deteriorates, choose the treatment mode reasonably; (3) Define the risk factors and reduce the postoperative complication rate of aggressive surgery; (4) Provide the basis for the choice of interventional treatment.