Volume 94  ·   Issue 27  ·  2014

[Editor's note]This article is a special report delivered by Academician Chen Zhu, vice chairman of the Standing Committee of the 12th National People's Congress and president of Chinese Medical Association, at the Global Health Forum on May 13th, 2014 (with deletions). This article is detailed in content and profound in thought, comprehensively showing the world-renowned achievements of China's health cause since the founding of New China, and also pointing out the main health problems and challenges that China is facing at present; The paper comprehensively introduced the basic concepts, key areas, action plans and policy measures of the formulation and implementation of the "Healthy China 2020 Strategy", namely the "Healthy Connotation of the Chinese Dream-Healthy Country". This will make great achievements for safeguarding the health rights and interests of the broad masses of the people, protecting, maintaining and promoting national health. 2015 marks the 100th anniversary of the founding of the Chinese Medical Association and the 100th anniversary of the founding of the Chinese Medical Journal. With the consent of President Chen Zhu, this article is published in a special issue to commemorate it.

The first two authors contributed equally to this paper and are the first authors

Mechanical ventilation is one of the most important treatments to save the lives of adult patients with respiratory distress syndrome (ARDS), but lung injury associated with mechanical ventilation has been a serious clinical problem affecting the prognosis of ARDS patients. Data accumulated over the past half century suggest that mechanical ventilation, the most important treatment for ARDS, can cause or aggravate lung damage. There are two susceptibility factors to ventilator-associated lung injury (VILI) in ARDS: one is the decrease in the number of expandable alveoli upon inspiration, leading to the risk of these alveoli excessively expanding. The other is the injury caused by the periodic opening and collapse of the alveoli. The study showed that mechanical ventilation with a tidal volume of 6 ml/kg compared with a tidal volume of 12 ml/kg resulted in a 22% reduction in mortality^[1]。 According to this study, the strategy of pulmonary protective mechanical ventilation in patients with ARDS is proposed. The use of small tidal volume to prevent lung hyperventilation, and the use of positive end expiratory pressure (PEEP) to prevent periodic alveolar collapse and achieve more consistent lung expansion. This has led clinicians to have a broad understanding of VILI in patients with ARDS, recognizing that safe mechanical ventilation for ARDS should reduce VILI while providing life-sustaining gas exchange. So far, the mechanical ventilation treatment of ARDS has taken a step forward.

stroke is one of the main causes of human disability and death, and acute ischemic stroke (AIS) accounts for about 80% of all strokes. The key of AIS treatment is to open occluded blood vessels and restore blood flow as soon as possible to save ischemic penumbra tissue. At present, the main treatment of early vascular opening in AIS is drug therapy (intravenous thrombolysis), but due to the strict time window limit (3~4.5 h)^[1,2]And the recanalization rate of combined aortic occlusion is low (13% ~18%), less than 3% of patients can benefit from this treatment, and the 90-day mortality and disability rates are as high as 21% and 68%^[3]The therapeutic effect is not satisfactory. In recent years, some new endovascular therapeutic devices (stent thrombectomy and thrombus aspiration devices, etc.) have been used in clinical practice successively, which significantly improved the opening rate of occluded blood vessels. Endovascular therapy (arterial thrombolysis, endovascular thrombectomy, angioplasty stent) has shown a good application prospect^[4,5]However, there is still a lack of positive clinical randomized controlled study support in terms of target population and time window selection, best treatment process, long-term benefits, etc. For a long time, AIS endovascular treatment may still be used as a contraindication for intravenous thrombolysis or intravenous thrombolysis A complementary or salvage treatment for patients with aortic occlusion who are ineffective. The interventional group of the Stroke Prevention and Control Committee of Chinese Association of Preventive Medicine summarized the results and preliminary evidence of existing international clinical trials for endovascular treatment of acute ischemic stroke, and formed this consensus based on the opinions of domestic experts in this field, aiming to provide clinical reference standards and management strategies for endovascular treatment of AIS. We expect further clinical trial results to provide theoretical basis for the problems that cannot be recommended at present.

Carry out risk stratification to optimize the allocation of medical resources, and urgently initiate clinical evaluation and secondary prevention of TIA and mild stroke, which is beneficial to reducing the high risk of early stroke recurrence. Commonly used TIA early stroke risk stratification tool is ABCD scoring system^[6,10,18](Table 1，Table 2), wherein ABCD2^[10]The score can predict the risk of short-term stroke in TIA well and is the most widely used. Recent studies suggest that increasing the frequency of TIA episodes in addition to the ABCD2 score is associated with imaging (ABCD3 and ABCD3 – I)^[18]It can more effectively assess the early stroke risk of TIA patients. It is recommended that patients with suspected TIA should undergo early ABCD2 assessment and undergo comprehensive examination and assessment as soon as possible. The primary objective of the evaluation is to judge the etiology and possible pathogenesis of TIA^[19]。

To evaluate the effects of high-frequency oscillatory ventilation (HFOV) on mortality in patients with acute respiratory distress syndrome (ARDS).

Randomized controlled trials (RCTs) of HFOV as compared with conventional mechanical ventilation (CMV) in adult patients with ARDS from January 1970 to May 2013 were recruited. The data were analyzed with the methods recommended by the Cochrane Collaboration's software RevMan 5.0.

Six RCTs using HFOV in adult patients with ARDS were collected for analysis. Among 1 634 eligible ARDS patients, 827 of them were enrolled into HFOV group and the reminder into CMV group. Meta-analysis revealed HFOV did not significantly decrease the hospitalization or 30-day mortality of adult ARDS patients (OR=0.95, 95%CI 0.62-1.46, P=0.83).

Compared with CMV, HFOV dose not improve prognosis in adult patients with ARDS. Thus more high-quality RCTs with larger samples are warranted.

To explore the diagnostic and prognostic values of serum procalcitonin (PCT) and C-reactive protein (CRP) in patients of bacterial sepsis.

From July 2012 to May 2013, a total of 120 critically ill patients at our intensive care unit (ICU) were recruited. They included septic (sepsis group, n=63) local infection (local infection group, n=57) and healthy people (control group, n=30). The serum levels of PCT and CRP were measured. Septic patients were divided into survival and death groups according to the prognosis. They were also divided into gram-positive and gram-negative bacteria groups according to the results of bacterial cultivation.

The serum levels of PCT and CRP, as well as acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) scores and sepsis related organ failure assessment (SOFA) scores in the sepsis group were significantly higher than those in the local infection and control groups (P<0.05). And those in the local infection group were higher than those in the control group (P<0.05). The sensitivity, specificity, positive predictive value and negative predictive value for serum PCT in diagnosing bacterial sepsis were significantly larger than those for serum CRP (P<0.05). The serum levels of PCT and CRP in survival group were less than those in death group at Day 1, 5, 10 and 15 (P<0.05). Moreover, there were significant time effects on the serum levels of PCT and CRP in the survival group (P<0.05), but not in the death group (P>0.05). When PCT was ≥10.0 μg/L, the patients of gram-negative bacteria were more than those of gram-positive bacteria (P<0.05).

The serum levels of PCT and CRP are reliable in the diagnostic and prognostic evaluations of bacterial sepsis. Both also have certain reference value for local infection. Moreover the sensitivity and specificity of serum PCT were better those of serum CRP.

To assess the variations of renal vascularization scale and resistive index in septic shock patients during the first 6 h in intensive care unit (ICU).

A total of 39 septic shock patients were prospectively enrolled to receive echocardiographic and renal ultrasound examinations. And the data of mean arterial pressure (MAP), central venous pressure (CVP), cardiac output (CO), renal vascularization scale (VS) and resistive index (RI) were recorded.

Among 19 patients without an increase of CVP, 8 of them showed significant increase in MAP and CO. Six of 8 patients with increases both in MAP and CO displayed an increase of VS while only 1 out of the remaining 11 patients had an increase of VS (P=0.027). Among 20 patients with an increase of CVP, 9 of them showed no significant increase in MAP or CO.Eight out of 9 patients without significant increase in MAP or CO displayed a decrease of VS while only 2 out of the remaining 11 patients displayed a decrease of VS (P=0.086). They were divided into two groups according to the variations of MAP, CVP and CO respectively. No significant change of RI was found between oh and 6 h in each group.

The renal vascularization scale increases in patients with increases both in CO and MAP while CVP remains almost unchanged. No significant relationship exists between resistive index and such hemodynamic parameters as CO, MAP and CVP.

A 5-year-old male was found to have a cardiac murmur for 5 years. Physical examination: blood pressure of right upper limb 95/50 mmHg (1 mmHg =0.133 kPa), left upper limb undetectable, both lower limbs 85/45 mmHg, developmental deviation, no cyanosis in the whole body, symmetrical development of both upper limbs, 2~4 intercostal systolic murmur on the left margin of sternum. After admission, cardiac ultrasound showed double right ventricular outlet, ventricular septal defect, right ventricular outflow tract stenosis, right aortic arch, and patent ductus arteriosus. Thoracic CTA showed that the left subclavian artery was not connected to the aortic arch but connected to the left pulmonary artery through an abnormal blood vessel, the left common carotid artery originated from the ascending aorta, and the left superior vena cava persisted (Figure 1)。 Right femoral vein puncture showed that the catheter could enter the pulmonary artery, aorta and left ventricle through the right ventricle. Right ventriculography showed stenosis of right ventricular outflow tract, and pulmonary artery and aorta were developed. Entering the ascending aorta angiography, the ascending aorta emits the left common carotid artery, and the right aortic arch emits the right common carotid artery and the right subclavian artery in turn. Delayed development of left subclavian artery, blood flow direction from left vertebral artery to left subclavian artery to pulmonary artery, left subclavian artery not connected to aorta (Figure 2)。 Comprehensive analysis showed that the isolated left subclavian artery connected to the pulmonary artery naturally formed a Blalock-Taussig shunt mechanism, so the child did not develop cyanosis. The operation was performed under general anesthesia and cardiopulmonary bypass. The intraoperative exploration was in line with the preoperative judgment, and the intracardiac defect was radically cured, and the postoperative recovery was smooth.

To investigate the MRI characteristics and differential diagnosis of testicular epidermoid cyst.

The MRI imaging features of 7 testicular epidermoid cyst cases were retrospectively analyzed and compared with that of testicular seminoma.All cases were examined by contrast-enhanced MRI scans.

The group of 7 cases of testicular epidermoid cyst MRI showed characteristic: On T₁-weighted MR images, some lesions showed low signal-based, center with spotty high signal ( "target sign" ). On T ₂-weighted MRI, some lesions had a laminated appearance, with alternating low and high signal intensity areas( "onion skin" sign). On contrast-enhanced images, all lesions were sharply demarcated low signal intensity masses, and contrast enhancement were not seen in any of the cases.

MRI characteristics of testicular epidermoid cyst are distinctive in certain extent.It may express "target sign" , "onion skin" sign, T ₂ low signal intensity complete rings, and without enhancement.

To investigate the changes of Broca's area functional connectivity in ischemia stroke patients with motor aphasia during resting state using functional magnetic resonance imaging(fMRI).

The functional connectivity of Broca's area was analyzed by observing the correlation between low frequency signal fluctuations in Broca's area and those in all brain regions.

In the normal controls group, there was multiple brain area positively correlated with Broca's area during resting state.The patients group compared with controls group, the functional connectivity between Broca's area and adjacent brain regions around its is most significant, and its controlateral brain area correlated with Broca's area reduced, but some cerebellum, occipital lobe, middle temporal gyrus and corpus callosum spenium correlated with Broca's area strengthened.

There is a wide range of motor function of language network during resting state.The right anterior cingulate gyrus, knee of corpus callosum and hemisphere play an important part in motor language function network.The enhancement functional connectivity between the adjacent brain regions surrounding Broca's area, the right cerebellum, occipital lobe, middle temporal gyrus and spenium of corpus callosum and Broca's area may be one compensatory mechanism remodeling for the language recover of ischemia stroke patients with motor aphasia.

To compare the application value between reduced field-of-view diffusion weighted imaging(rFOV DWI)and single-shot echo-planar-imaging diffusion weighted imaging(SS-EPI DWI)of the breast.

78 cases(68 normal breast, 10 breast cancer) were canned with SS-EPI DWI(FOV 360 mm×360 mm), rFOV DWI1(FOV 360 mm×180 mm) and rFOV DWI2(FOV 280 mm×140 mm). Image quality and ADC values of breast were compared with three groups.SNR were compared with rFOV DWI1 and rFOV DWI2.

The image quality score of 78 cases was 4.74 by rFOV DWI1, 3.59 by SS-EPI DWI and 3.55 by rFOV DWI2.The mean ADC value of 68 normal breast was 1.832×10^-3mm²/s by SS-EPI DWI, 1.701×10^-3mm²/s by rFOV DWI1 and 1.615×10^-3mm²/s by rFOV DWI2.The mean ADC value of 10 breast cancer was 1.345×10^-3mm²/s by SS-EPI DWI, 1.220×10^-3mm²/s by rFOV DWI1 and 1.149×10^-3mm²/s by rFOV DWI2.SNR of rFOV DWI1 images was much higher than FOV DWI2.

Sizeable rFOV DWI has higher resolution, less distortion than SS-EPI DWI, rFOV DWI will be useful in the diagnosis of the breast diseases.

To explore the influence of caloric restriction combined with psychotherapy and chemotherapy associated by hybaroxia on the prognosis of patients with intracranial glioblastoma multiforme.

This was a perspective, nonrandom, no-double-blinded controlled study. All patients underwent total resection during November 2007 to April 2009 at Beijing Tiantan Hospital and Beijing Tiantan Puhua Hospital. All diagnoses were confirmed by molecule pathology. While 23 patients in control group underwent resections and radiochemotherapy, 11 patients in experimental group were further treated by caloric restriction plus psychotherapy and chemotherapy-associated hybaroxia. The life spans were compared between two groups.

The mean survival time of patients in experimental group was (38±13) months versus (20±12) months in control group. The survival time of patients in experimental group was significantly longer than that in control group (P<0.05).

Caloric restriction plus psychotherapy and chemotherapy-associated hybaroxia can apparently prolong the life span of patients with glioblastoma multiforme.

To observe the co-variation of acetylated histone H3 levels of peripheral blood mononuclear cells (PBMCs) and onset time of acute ischemic stroke and examine the histone H3 acetylation levels in PBMCs of acute cerebral infarction patients with different stroke subtypes and injury degrees.

The peripheral blood samples 2 ml from patients at different timepoints (1, 3, 5, 7, 14 d) from April 2013 to July 2013 and normal controls were collected to observe the dynamic change of Ac-H3 levels of PBMCs in cerebral infarction patients. Also between April 2013 and October 2013, blood samples from 103 patients within 7 d after acute ischemic stroke were collected. Global histone was extracted by assay kit and differential histone H3 acetylation levels were determined by Western blot. All patients were measured by the Oxfordshire Community Stroke Project (OCSP) classification and National Institutes of Health Stroke Scale (NIHSS) score.

The levels of acetylated histone H3 in PBMCs of acute cerebral infarction patients started to decrease as early as 1 d and remained below those normal controls for at least 7 d after stroke. It fulfilled the minimum at 3 d after infarction (P<0.001). Acetylated histone H3 levels of PBMCs differed in OCSP classification (P<0.05) and reached a nadir in TACI group. Histone H3 acetylation levels of PBMCs were major affecting factors of neurological injury severity and negatively correlated with it through multiple regressive analysis (β=-0.297, P=0.001).

Histone H3 acetylation level in PBMCs of acute cerebral infarction patients is lower than healthy persons. And it decreases markedly in TACI group and patients with severe neurological dysfunction.

To evaluate the clinical efficacy and radiological changes in patients with painful osteoporotic vertebral compression fractures (OVCFs) after percutaneous vertebroplasty (PVP).

Retrospective analysis was conducted on 195 vertebrae in 142 patients with painful OVCFs treated with vertebroplasty in our hospital from May 2007 to June 2012.The scores of visual analogue scale (VAS) were recorded and the heights of vertebral bodies and Cobb angles were measured in the mid-sagittal plane of the reformatted images at 64-detector row CT during the period of follow-up. Polymethylmethacrylate (PMMA) distribution in vertebrae and whether leakage was observed on CT within 3 days after PVP.The changes in VAS, heights of vertebral bodies and Cobb angles were compared between the cases with and without leakages.

The successful rate of technique of PVP was 100%.The mean volume of PMMA injected in each vertebra was (4.5±1.1) ml and (6.0±1.2) ml respectively in thoracic and lumbar.The mean follow-up was (17±6) months.Asymptomatic leakages of PMMA were demonstrated by CT in 38 patients with 43 vertebrae (22.1%). The average decrease in VAS was 5.25 and 1.12 respectively in 24 hours and a month after PVP.The changes in VAS respectively at 1 month, 3 months, 6 months and more than 1 year after procedure were not significantly different.In postoperative 3 days, the average increase in height of vertebral body was 1.55 mm anteriorly and 1.38 mm centrally, the average reduction in Cobb angle were 2.37°.The heights and Cobb angles of vertebral bodies between in 3 days and in more than 1 year after PVP were not significantly different.The scores of VAS and the changes in vertebral body heights and Cobb angles between the patients with or without cement leakages were not significantly different during the period of follow-up.

PVP is an effective treatment for patients with painful OVCFs that provides immediate and sustained pain relief, increases in the heights of vertebral bodies injected in cement and keeps stable radiological progression within at least 1 year after PVP.Asymptomatic cement leakages around vertebrae have no influence on pain relief and vertebral stability in this group of patients.

To explore the ultrastructural features of endometrial-myometrial interface (EMI) of adenomyosis and normal myometrium.

From May 2010 to September 2013, 102 uterine myometrial specimens were obtained from 102 patients undergoing hysterectomy. There were 56 adenomyosis patients as ADS group (including proliferative endometrium, n=26 and secretory endometrium, n=30) and another 46 with cervical intraepithelial neoplasis (CIN) Ⅲ as control group. The myometrium underneath endometrium and the outer third of myometrium were immediately harvested after operation. And the samples were processed and observed under transmission electron microscopy.

(1) In the presence of uterine adenomyosis, the nuclei were significantly larger than controls and significantly enlarged with less prominent collagen fibrils. The cytoplasm was abundant, denoting cellular hypertrophy. The rough endoplasmic reticulum and Golgi apparatus became more prominent. But the dense patches and dense bodies appeared similar to the control; (2) EMI myocytes ultrastructure showed cyclic changes in controls. In proliferative cycle, the average nuclear size was larger than that in secretory cycle [(3.24±0.41), (2.44±0.27) μm, P<0.05]. But there was not any differences from different cyclic phases in adenomyosis [(2.34±0.17), (2.63±0.39) μm,P>0.05]; (3) EMI myocytes appeared significantly different than that of outer myometrium. The nuclei of EMI myocytes were much smaller than outer myometrium. And there was less prominent collagen fibrils. The dense patches, dense bodies and myofilament-cytoplasm ratio of EMI were smaller than outer myometrium. The nuclei-to-myocyte ratio was larger than outer myometrium.

Abnormal ultrastructural features of EMI may be correlated with the development of adenomyosis.

To explore the cyclic changes of S100A10 expression in human endometrium.

The gene and protein expression of S100A10 in human endometrium was examined by real-time polymerase chain reaction (PCR), immunohistochemical staining and Western blot.

S100A10 protein was predominantly expressed in cytoplasm and cytomembrane of luminal and glandular epithelia. The S100A10 protein was continuously expressed from proliferative phase to secretory phase of menstrual cycle. However the expression in the secretory phase was much higher than in the proliferative phase (2.26±0.17, 3.75±0.22, 2.65±0.20 vs 1.17±0.11, 1.32±0.14, both P<0.05). Specifically, the highest level of S100A10 expression occurred during the mid-secretory phase. Then real-time PCR was used to analyze the mRNA expression of S100A10 in human endometrial samples at various points during the menstrual cycle. And the results confirmed the corresponding changes at the genetic level (0.50±0.05, 1.02±0.10, 0.55±0.05 vs 0.25±0.02, 0.30±0.03, bothP<0.05).

The endometrial expression of S100A10 increases during the window of embryo implantation. It suggests that it may increase the endometrial receptivity of uterine epithelial cells for embryos.

To explore the role of miR-200a in chemosensitivity regulation of ovarian cancer.

Firstly miR-200a was up-regulated in ovarian cancer cell lines (SKOV-3 and ES-2) by lentiviral vector. Then the effects of miR-200a on cytotoxicity of paclitaxel and cisplatin were investigated by methyl thiazolyl tetrazolium (MTT). Furthermore miR-200a regulation of chemoresistance associated with ATP-binding cassette (ABC) family genes expression was detected by quantitative real-time polymerase chain reaction (PCR) and Western blot. Finally the interaction between miR-200a and ABCG2 mRNA 3'untranslated region (3'-UTR) was verified by dual-luciferase reporter assay.

An over-expression of miR-200a were successfully achieved in SKOV-3 and ES-2 cells.MiR-200a enhanced the chemosensitivity of SKOV-3 and ES-2 to paclitaxel, but not to cisplatin. Chemoresistance associated ABC family (ABCB3, ABCC1, ABCC2, ABCC3, ABCG2) were down-regulated by miR-200a at several levels. However, the direct interaction between miR-200a and the 3'-UTR of ABCG2 mRNA was not found.

An over-expression of miR-200a may increase chemosensitivity to paclitaxel in ovarian cancer cells through negatively regulated chemoresistance associated ABC family. However, no direct action on 3'-UTR of ABCG2 was not found after its down-regulation by miR-200a .

To generate familial ALS patient specific induced pluripotent stem (iPS) cell lines and motor neurons and provide a cell-based disease model for amyotrophic lateral sclerosis (ALS) in Han Chinese.

iPS cells were derived from familial ALS patient by introducing 4 transcription factors OCT3/4, SOX2, KLF4 and c-MYC into fibroblast cells by retroviruses. Karyotypic analysis, immunofluorescence staining and quantitative reverse transcription-polymerase chain reaction (RT-PCR) were used to identify the pluripotency of these iPS cell lines. In addition, motor neurons were derived from these iPS cells by inhibiting SMAD pathway.

IPS cell lines were established from ALS patient carrying SOD1-V14M mutation. They had pluripotency and were similar to human ES cells. Furthermore, motor neurons were successfully induced from these iPS cells.

SOD1-V14M mutation does not affect the reprogramming of fibroblast cells and pluripotency of iPS cells, nor does it prevent differentiation of motor neurons. Furthermore, the above cell-based disease model can recapitulate key aspects of ALS pathogenesis so that it provides an indispensible resource for further elucidating ALS disease pathogenesis and screening appropriate drug candidates in Han Chinese.

The American Society of Reproductive Medicine (ASRM) defines recurrent miscarriage (RSA) as 2 or more consecutive spontaneous miscarriages with the same sexual partner^[1]。 At present, the incidence of RSA is about 2% ~4%, among which 65% ~70% of patients with recurrent abortion have abnormal immune factors^[2]。 This article summarizes its pathogenesis and treatment progress as follows.

Acute respiratory distress syndrome (ARDS) is the most common type of acute respiratory failure, and mechanical ventilation is its main supportive treatment. Despite the continuous improvement of mechanical ventilation techniques and strategies, the mortality rate of ARDS remains high, and ventilator-associated lung injury (VILI) is closely related to this. Pulmonary stress and strain can directly reflect the mechanical changes of lung tissue. Excessive stress and strain are the essence of VILI in ARDS patients. Therefore, pulmonary stress and strain have attracted more and more attention in mechanical ventilation treatment of ARDS. Based on the concepts of pulmonary stress and strain, the relationship with VILI, and the application in the treatment of ARDS, this paper reviews.