Volume 94  ·   Issue 23  ·  2014

Refractory hypertension usually refers to lifestyle adjustments based on the use of optimal doses of three different classes of antihypertensive drugs including diuretics, but blood pressure still fails to reach the standard^[1]。 Estimates of the prevalence of patients with truly refractory hypertension based on the above criteria vary greatly among different populations. Overall, 5% to 10% of hypertensive patients receiving standardized treatment meet the defining criteria of refractory hypertension. So far, the treatment of refractory hypertension has focused on antihypertensive drugs blocking various mechanisms that may lead to increased blood pressure, including the use of low-dose spironolactone as a fourth-line treatment. However, these measures are still difficult to solve some refractory hypertension. In recent years, percutaneous catheter-based renal denervation (RDN) has brought new promise to patients with refractory hypertension. The basic principle is to release energy through the radiofrequency catheter inserted into the renal artery, and selectively destroy the renal sympathetic nerve fibers of the adventitia through the intima and media of the renal artery, thus reducing the activity of renal sympathetic nerves and blocking the excessive excitation of sympathetic nerves in maintaining hypertension, especially refractory hypertension. A proof-of-principle study (Symplicity HTN-1)^[2]and a subsequent randomized efficacy study (Symplicity HTN-2)^[3]and meta-analyses^[4]It indicated that percutaneous catheter-based renal denervation had a significant effect of reducing blood pressure in the clinic. Since the publication of the results of the Symplicity HTN-2 trial, the news media, the medical community, medical device manufacturers and the majority of hypertensive patients are full of expectations for the future of this technology.

To evaluate the effects of continuous paravertebral nerve block after nephrectomy.

60 cases receiving simple nephrectomy, American Society of Anesthesiologists(ASA) grading status Ⅰ or Ⅱ, aged from 30 to 65 years, weighing from 45 to 80 kg, male or female, were randomly divided into 2 groups: control group (CEA group) and continuous paravertebral nerve block group (PVB group), 30 patients in each one. Both groups were performed with 0.2% ropivacaine 250 ml in continuous infusion, assisted with intravenous morphine patient-controlled analgesia. The blood gas was examined in 6, 12, 24 and 48 h postoperatively, and the VAS scores of quiet state and motion state were assessed. In 48 h postoperation, the total amount of morphine was calculated and the complications cases were recorded.

Compared with the CEA group, PaO₂ in PVB group increased and PaCO₂ declined significantly. There was no difference of VAS score under quiet state, but under the motion state the VAS scores declined significantly, the total amount of morphine reduced[(5.2±1.2) vs (13.9±1.6)mg)], the cases of nausea, vomiting, pruritus, orthostatic hypotension decreased and the postoperative first anal exhaust time interval shortened (P<0.05).

Compared with CEA, postoperative administration of PVB for open nephrectomy results in lowering morphine dose as well as side effect related with the use of morphine.

To explore the clinicopathological and imaging features of Ewing's sarcoma/peripheral primitive neuroectodermal tumors in vertebral column and to improve knowledge of the disease.

The imaging information of 15 cases with pathologically proved. Ewing's/PNET were reviewed retrospectively.

There was an earlier onset with a short disease course. The locations of tumor included cervical segment (n=1), thoracic segment (n=5), lumbar segment (n=2) and sacrococcyyeal region (n=7). The imaging showed different extents of bone destruction. Among them, on radiology and computed tomography (CT), osteolytic (n=9) and mixed (n=4) destruction were detected along with large soft tissue masses (cystic and necrotic, n=13; calcification, n=2). Isodensity or low density was shown on CT, heterogeneous contrast enhancement of hypointensity or isointensity or slight hyperintensity on T1WI and slight hyperintensity or hyperintensity on T2WI of magnetic resonance imaging (MRI). Most cases showed obvious strengthening. Ten cases showed a collapse of centrum vertebrae while intervertebral space and disc had no change. All cases grew outside across intervertebral foramina. Hematoxylin-eosin staining demonstrated Homer-Wright (H-W) rosettes in 13 cases. Immunohistochemistry, the highest positive rate of neural markers was CD99 (n=13); secondly, CD56 and Ki67 and Syn (n=9); Vim (n=7), NSE (n=5) and S-100 (n=4), etc.

The non-specific imaging findings of Ewing's/PNET show different extents of bone destruction in vertebral column and soft tissue masses outside across intervertebral foramina. Other clinical features and histopathology must be considered for making a definite diagnosis.

To investigate the diagnostic efficiency of decline rate of signal intensity and apparent diffusion coefficient with different b values for differentiating benign and malignant breast lesions on diffusion-weighted 3.0T magnetic resonance imaging.

A total of 152 patients with 162 confirmed histopathologically breast lesions (85 malignant and 77 benign) underwent 3.0T diffusion-weighted magnetic resonance imaging. Four b values (0, 400, 800 and 1 000 s/mm²) were used. The signal intensity and ADC values of breast lesions were measured respectively. The signal intensity decline rate (SIDR) and apparent diffusion coefficient decline rate (ADCDR) were calculated respectively. SIDR=(signal intensity of lesions with low b value-signal intensity of lesions with high b value)/signal intensity of lesions with low b value, ADCDR = (ADC value of lesions with low b value-ADC value of lesions with high b value)/ADC value of lesions with low b value. The independent sample t-test was employed for statistical analyses and the receiver operating characteristic (ROC) curve for evaluating the diagnosis efficiency of SIDR and ADCDR values.

Significant differences were observed in SIDR between benign and malignant breast lesions with b values of 0-400, 400-800 and 800-1 000 s/mm². The sensitivities of SIDR for differentiating benign and malignant breast lesions were 61.2%, 68.2% and 67.1%, the specificities 74.0%, 85.7% and 67.5%, the diagnosis accordance rates 67.3%, 76.5% and 67.3%, the positive predictive values 72.2%, 84.1% and 69.5% and the negative predictive values 63.3%, 71.0% and 65.0% respectively. Significant differences were observed in ADCDR between benign and malignant breast lesions with b values of 400-800 s/mm² and 800-1 000 s/mm². The sensitivities of SDR for differentiating benign and malignant breast lesions were 80.0% and 65.9%, the specificities 72.7% and 65.0%, the diagnostic accordance rates 76.5% and 65.4%, the positive predictive values 76.4% and 67.5% and the negative predictive values 76.7% and 63.3% respectively.

The decline rate of signal intensity and apparent diffusion coefficient with different b values may be used for differentiating benign and malignant breast lesions. And the diagnostic efficiency with b values of 400-800 s/mm² is optimal.

To explore the relationship between primary tumor size and mediastinal nodal metastases among different cell types in non-small cell lung cancer (NSCLC) and clarify the cutoff size for a higher likelihood of metastases.

Retrospective evaluations were conducted for 1 346 NSCLC patients from January 2005 to January 2006. Primary focus was placed upon cases with primary tumor size < 8.0 cm.

It was shown that 2.0 cm was the critical cutoff size for increased mediastinal nodal metastases in adenocarcinoma (P<0.01), but not in squamous cell carcinoma (P>0.05).

Tumor size matters differently in pulmonary adenocarcinoma and squamous cell carcinoma.

To discuss arterial infusion chemotherapy as second-line treatment for advanced pancreatic carcinoma salvage after failed vein chemotherapy.

35 cases with Ⅳ stage pancreatic carcinoma, all cases are failed first-line chemotherapy of Gemcitabine. Via femoral artery puncture, gastroduodenal artery, the dorsal pancreatic artery, pancreatic artery, pancreatic tail artery, the rib waist artery, superior mesenteric artery and tumor related to blood supply artery intubation and chemical drug perfusion. Plan: Cisplatin 30 mg/m², Gemcitabine 1 000 mg/m². Treatment for every 3-4 weeks, there is no limit on the total number.

35 cases were local chemotherapy for 217 cycles, at least 1 cycle, a maximum of 9 cycles, 6.2 cycles on average. Among which: CR 1 case, PR 6 cases, SD 15 cases, effective rate (CR+ PR)is 20%, disease control rate(DCR)is 68.75%. The median survival time was 9.6 months. The median TTP was 3.7 months. Total effective rate of CBR, the stability rate of CBR and inefficiency rate of CBR were 51.4%, 25.7% and 22.9% respectively. Pain score improvement 88.57%(31/35), 42.86%(15/35)Pain relief last for 3-20 days(median time11 days).17.14%(6/35)Pain relief last for more than 20 days. Pain relief maintain the most elderly 160 days. Half of the patients have different degree of side reaction, Ⅲ, Ⅳdegree leukopenia accounted for 17.14% (6/35), 8.57% (3/35).

The arterial perfusion chemotherapy as second-line treatment of advanced pancreatic cancer salvage is of clinical value, with better disease control rate and the rate of pain relief.

To evaluate the usefulness and safety of bronchoscopy by the laryngeal mask airway (LMA) compared with by nose and by mouth.

Between April 2009 and Dec 2012, we prospectively studied 150 analgesia brochoscopy in the operating theater of the our hospital. All the patients were randomly assigned by computer to LMA group, non-LMA by nose group(NLBN) and non-LMA by mouth group(NLBM) according the way of bronchoscopy. Each group had 50 cases. We recorded the time of bronchoscopy just through subglottic, total operation time, the times of blood oxygen less than 80% so as to suspend procedure and so on.

Intergroup comparisons showed no difference in gender, age, and the successful rate of biopsy(P>0.05). The time of bronchoscopy just through subglottic in LMA group was lower than that in NLBN group and in NLBM group significantly(P<0.01), and no difference between two latter groups(P>0.05). Also, total operation time of LMA group was higher than that of others (P<0.05), but no difference between the latter two groups. There were 18 cases in NLBN group and 15 cases in NLBM group respectively, which were suspended procedure during operation due to low oxygen, and the difference did not reach statistical sense(P>0.05). There were 19 patients presented with nasal discomfort after operations in NLBN Group. The patients in all the three groups had no bad memory or fear, and the acceptance rate of reoperation was all 100%. In general, as to the cases of the patients who presented with pharyngeal discomfort and abnormal pronunciation, there was significance difference between LMA Group and NLBN Group and also between LMA Group and NLBM Group, while the difference between NLBN Group and NLBM Group was not statistically significan.

The use of the LMA during FFB is safe, provides excellent patient comfort, reduces the time of bronchoscopy just through subglottic so as to decrease the total operation time, and is better to control the situation of patient in operation.

To explore the clinical manifestations, diagnosis, treatment and prognostic features of primary headache associated with sexual activity(PHASA).

Fifteen patients were prospectively analyzed over the past 7 years at our hospital. There were 11 males and 4 females with a mean age of(42±11)(26-56) years.

Their mean ages of onset were 38±7 (26-44) years. For preemptive therapy, 8 patients had received indomethacin (25-50 mg, 30-60 min prior to sexual activity). Among them, 7 patients reported good outcomes and there was one case of limited success. Four patients received sumatriptan (50-100 mg, 30-60 min prior to sexual activity). And 2 patients reported good outcomes and the remaining 2 had no response. They received ibuprofen for preemptive therapy with a complete success. Prophylactic treatment of propranolol 60 mg was indicated for 8 patients. The outcomes were good (n=6) and non-successful (n=0). Among 4 patients with a prophylaxis of nimodipine, there were successful (n=2) and non-successful (n=2).

The first-line option for PHASA should be indomethacin. Other drugs may be used for preemptive therapy if there is no relief or adverse effects are intolerable.

To perform non-invasive prenatal diagnosis (NIPD) of chromosome aneuploidy by detecting free DNA in maternal peripheral plasma by massively parallel genomic sequencing and determine the feasibility of detecting cell-free fetal DNA in chromosomal copy.

The plasma samples from 1 264 gravidas were collected from February 2012 to July 2013 at our center. Those pregnant women with a gestational age of 13 to 33 weeks having high risks in serological screening or aged over 35 years or abnormal fetus on ultrasonography. The peripheral venous blood samples were drawn from pregnant women and plasma DNA was extracted for preparing a sequencing library. By using Illumina HiSeq2000, high-throughput sequencing was performed. Amnocentesis and karyotypic analysis were conducted for positive cases and those with negative results were followed up.

By massively parallel genomic sequencing, 20 of them showed positive results. By the standard of chromosomal karyotypic analysis, there were 21 positive cases of 13 trisomy and the diagnostic accordance rate was 100%. Among 18 positive cases of 6 trisomy, there were amniocentesis (n=5, except for one dead fetus), trisomy 18 (n=4) and normal karyotype with placenta chimera (n=1). One positive case of 13 trisomy was in accordance with karyotypic analysis.

Massively parallel sequencing for NIPD may be used as further screening for pregnant women with high risks of serological screening. And this technology is highly consistent with karyotypic analysis in terms of sensitivity and specificity.

To explore the relevance of health behaviors and influencing factors for detection rate of carotid plaques to prevent the formation of carotid plaque.

A total of 2 628 healthy subjects aged over 40 years were selected randomly from Department of Cardiology at our hospital from 2009-2010. A questionnaire survey was conducted on age, education level, marriage, occupation, income, diet, living habits and lifestyle factors. Logistic regression analysis was made for the influencing factors of internal carotid artery plaque.

Single factor analysis showed that gender, age, smoking rate, fasting blood glucose, blood pressure, carotid artery intima-media thickness (intima-media thickness, IMT), total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) had significant effects on plaque formation. Multivariate Logistic regression analysis showed that gender, age, TG, LDL-C, HDL-C and number of health behaviors were the major influencing factors for the formation of carotid plaque. Compared with the <2 ideal cardiovascular health factors and actuators, the risk levels of 3, 4, 5, >5 ideal cardiovascular health behaviors/factors and occurrence of carotid plaques were 0.65, 0.45, 0.39 and 0.29 respectively.

The formation of carotid plaque is affected by many factors. The number of ideal cardiovascular health behaviors is negatively correlated with plaque formation and it can prevent the occurrence of carotid plaque.

To analysis the factors related to the complications of vascular surgeries in a general hospital.

A single-center and prospective study was organized from January, 2012 to December, 2012 in Peking Union Medical College Hospital. Patients who underwent selective primary vascular procedures were included in the study.

Totally 826 consecutive cases who met the inclusive criteria were recruited, with 566 males (68.5%) and an average age of (59±14) (13-89) years old. There were 38 patients (4.6%) suffering complications after the procedures, including 2 deaths (0.2%) during hospitalization. The complication rates were significantly higher in the patients with hypertension, cardiac disease, history of cerebral strokes, renal function insufficiency or diabetic mellitus (P<0.05). The complication rates were significantly higher in group with high grade of ASA (ASA class 3 and 4) or in group underwent high grade of vascular surgeries (Class 3 and 4), comparing with group with low grade of ASA (ASA class 1 and 2) (relative risk ratio,RR=2.579; 95%CI: 1.333-4.993; P<0.01), or with group underwent low grade of vascular surgeries (Class 1 and 2) (RR=4.268; 95%CI: 2.197-8.293; P<0.01).

Hypertension, cardiac disease, history of cerebral stroke, renal function insufficiency or diabetic mellitus are risk factors related to complications of vascular surgeries. The patients with high grade of ASA or underwent high grade of vascular surgeries may have significant higher risks of complications after the procedures.

To explore the regulation of the expression of bone morphogenetic protein (BMP) of nerve growth factor (NGF) and examine the mechanism of nerve growth factor in promoting fracture repair.

A total of 108 healthy New Zealand white rabbits, weighting 2.5-3.0 kg, male or female, were randomly divided into 3 groups of NGF (Group A), antagonistic NGF(Group B)and control(Group C)(n=36 each). A standard model of right mid-piece radial fracture was established. Group A received an intravenous injection of NGF 200 ng/kg twice daily 1 week while group B an intraperitoneal injection of NGF antibody 400 ng thrice daily for 3 weeks; group C physiological saline 1 ml twice daily for 3 weeks. And 6 rabbits in each group were sacrificed at 24 h, 48 h, 1 week, 3 weeks, 6 weeks and 8 weeks respectively. And BMP proteins of fracture specimens were analyzed by Western immunoblot.

NGF promoted the expression of BMP in fracture while NGF antagonist inhibited its expression. NGF group produced more BMP earlier than control or NGF antagonist group during fracture healing while the production of BMP was more pronounced in control group than that in NGF antagonist group during fracture healing. And the differences were statistically significant (P<0.05).

Capable of promoting the expression of BMP in radial fracture of rabbit, NGF may be beneficial to fracture healing directly or indirectly.

To observe the effects of electrical hippocampal stimulation of α ₅ subunit of extrasynaptic GABA_A receptor in kainic acid-induced epileptic rats, explore the optimal therapeutic parameters and elucidate the possible mechanism of electrical stimulation for hippocampal epilepsy.

A total of 40 healthy male Sprague Dawley (SD) rats were randomly divided into 5 groups of epilepsy, sham operation, low-frequency stimulation (LFS), high-frequency stimulation (HFS) and normal control (n=8 each). The expression of α ₅ subunit of extrasynaptic GABA_A receptor as well as the association with the curative effects of LFS were evaluated by behavioristics, real-time fluorogenic quantitative polymerase chain reaction (PCR) and Western blot.

The kainic acid kindling rats had class Ⅴ attack with a modeling success rate of 67%. After treatment, as compared with sham operation and epilepsy groups, the number of seizures decreased significantly in LFS and HFS treatment groups (P<0.01). But LFS and HFS treatment groups were compared, the number of seizures has no statistical significance (P>0.05). When sham operation and epilepsy groups were compared, the number of seizures was not statistically significant (P>0.05). The paired inter-group comparisons showed that LFS and HFS treatment groups and sham operation and epilepsy groups had significant differences in α₅ subunit mRNA and protein (P<0.01). No statistical significance existed between LFS and HFS treatment groups (P>0.05) or sham operation and HFS treatment groups (P>0.05). As compared with normal control group, LFS treatment and HFS groups had significant difference (P<0.01).

Electrical hippocampal stimulation can effectively inhibit seizures. Both LFS and HFS are equally effective, but the former offers greater benefits. And an inhibition of extrasynaptic α ₅ subunit plays an important role in seizure during hippocampal stimulation.

To explore the possible relationship between angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), Tie-2 and vascular endothelial growth factor (VEGF) and radiation brain injury (RBI) and detect the expressions of VEGF, Ang-1, Ang-2 and Tie-2 in co-cultured endothelial cells and astrocytes after an irradiation of X-ray.

Murine brain microvascular endothelial cells bEnd.3 and astrocytes were co-cultured in a Transwell culture plate and then exposed to X-ray at various doses (5, 10, 20 and 30 Gy) and cultured for 24 hours. The group without radiation acted as a control. Western blot was used to detect the expressions of VEGF, Ang-1, Ang-2 and Tie-2.

As compared with the control group, the expression of VEGF increased in 5, 10, 20 and 30 Gy dose groups [(1.71±0.11), (2.03±0.05), (2.20±0.06), (2.19±0.08) vs (1.26±0.10), P<0.05]; the expression of Ang-1 decreased in 5, 10, 20 and 30 Gy dose groups [(2.27±0.07), (2.28±0.06), (2.01±0.05), (1.54±0.08) vs (2.46±0.04),P<0.05]; the expression of Tie-2 decreased in 5, 10, 20 and 30 Gy dose groups [(2.40±0.10), (2.47±0.06), (1.05±0.09), (1.00±0.08)vs(4.80±0.07),P<0.05]; the expression of Ang-2 increased in 5 Gy and 10 Gy dose groups [(2.10±0.07), (2.43±0.08)vs (1.69±0.05),P<0.05] while decreased in 20 Gy and 30 Gy dose groups [(1.12±0.10), (1.21±0.04)vs(1.69±0.05),P<0.05].

X-ray could differentially affect the expressions of VEGF, Ang-1, Ang-2 and Tie-2 in co-cultured endothelial cells and astrocytes. And the differential expressions of VEGF, Ang-1, Ang-2 and Tie-2 may be related with microvascular injury in RBI.

The differences in valgus were related to age, gender, shoe-wearing habits, genetics and other factors. It can occur at any age, and the incidence rate increases with the increase of age. The incidence of female is much higher than that of male, and the ratio of male to female can reach 1:40^[1]And often associated with lateral, especially metastatic ostealgia of the 2nd and 3rd metatarsal heads. The main clinical manifestations were deformity and pain of the forefoot, pain under the lateral metatarsal head with corpus callosum formation, which was aggravated when walking.Because of its complexity, valgus makes it impossible to have a single surgical approach to treat allThere are many surgical methods for valgus deformity. According to the literature reports, there are more than 130 kinds^[2]。 We summarized the past experience, referred to various surgical methods at home and abroad, combined with actual clinical work, selected modified Scarf osteotomy combined with lateral metatarsal head shortening osteotomyPatients with valgus combined with metastatic bone pain of the 2nd and 3rd metatarsal heads.

angiocentric glioma (AG) is a benign solid brain tumor associated with refractory epilepsy discovered in recent years. It was included in the WHO classification of neurological tumors in 2007 and specifically described^[1]。 This disease is rare, and epilepsy is mostly the first and main symptom in clinic, and most drugs are difficult to control. Through Pubmed database search, there are 65 cases of AG described in detail in foreign literature at present, while less than 10 cases have been reported in China. The clinical, imaging features and pathological manifestations of AG are reviewed systematically in order to improve the awareness and attention of relevant doctors and avoid misdiagnosis or misdiagnosis.

The mortality rate of acute respiratory distress syndrome (ARDS) is still above 41%^[1]。 The damage of pulmonary capillary endothelium plays an important role in the development of ARDS. Therefore, maintaining the structure and function of endothelial cells is the key to the treatment of ARDS. Endothelial cell surface polysaccharide coating layer (EGL) is a highly hydrated membrane structure covering the surface of vascular endothelial cells formed by interconnecting various macromolecular substances. Polysaccharide coating Because it is a "sugar coating" on the surface of vascular endothelial cells, Bennet^[2]It is named "polysaccharide coating". It was found that polysaccharide coating plays an important role in maintaining the structure and function of vascular endothelial cells, regulating capillary permeability, and participating in systemic inflammatory response^[3,4]。 Polysaccharide coating is the first protective layer of vascular endothelial cells, and maintaining the intact performance of polysaccharide coating reduces the occurrence of ARDS and prevents its further progression. This provides another new target and new direction for the treatment of ARDS.

Case 1, a 25-year-old female, was admitted to the hospital due to "confused speech for more than half a month, accompanied by fever for 3 days". The patient had intermittent speech confusion, abnormal behavior and insomnia half a month ago. He had visited a psychiatric hospital and was considered "schizophrenia". He was treated with risperidone for 1 week. After the symptoms did not improve, he stopped taking the drug on his own. Three days before admission, there was disturbance of consciousness and increased body temperature, up to 39.2 ℃, and there was no cough, sputum, nausea and vomiting. Physical examination on admission: confusion, mutism, pupils of equal size, sensitivity to light. Sign of meningeal irritation was positive, muscle tone of limbs increased, tendon hyperreflex, involuntary tremor, and the pathological sign was not drawn out. Auxiliary examination: white blood cells 16.96×10⁹/L, serum potassium 3.6 mmol/L, serum sodium 157.0 mmol/L, blood chloride 119.0 mmol/L, mild abnormal liver and kidney function, urine and stool routine, ten items of immunity, twelve items of antinuclear antibody and tumor, blood Torch series, etc. No abnormalities were found. Cerebrospinal fluid pressure, routine and biochemistry were normal, and cranial MRI showed patchy slightly long T in the corpus callosum pressure area₁, T₂Signal and FLAIR High Signal (Figure 1), EEG mild-moderate abnormalities. Consider viral encephalitis, after active salt restriction, antiviral and symptomatic rehydration treatment. After 1 week, the patient's consciousness gradually became clear, the body temperature was normal, the meningeal irritation sign was negative, and the blood white blood cells were 6.83×10 after re-examination⁹/L, blood sodium 134.5 mmol/L, blood chloride 97.4 mmol/L, EEG normal. After 2 weeks, his condition was stable and he could get out of bed. Because the patient had always had delusions of persecution, he was transferred to a psychiatric hospital for treatment. One month later, the MRI lesions of the head disappeared after re-examination in another hospital.