Volume 94  ·   Issue 37  ·  2014

At present, with the development of social economy in China, the incidence of craniocerebral trauma caused by road traffic, high altitude fall and infrastructure construction accidents is increasing day by day. China's county, county-level city and township hospitals, that is, the population in the area where primary hospitals are located, accounts for 70% ~80% of the total population of the country, and a considerable number of patients after craniocerebral trauma visit these primary hospitals. Since 2011, the coverage of new cooperative medical care has been wider, patients have paid less medical expenses, and the number of trauma patients treated in primary hospitals has greatly increased.

Systemic lupus erythematosus (SLE) is the prototype of autoimmune diseases, and its treatment concept affects the whole treatment idea of autoimmune diseases. At the European Annual Meeting of Rheumatology in June 2014, a hot topic was "treat to target in systemic lupus erythematosus, T2T/SLE", which was roughly the same as the view that the author put forward in the Chinese Medical Journal more than 3 years ago that "lupus erythematosus needs to introduce the concept of targeted treatment"^[1]。 This year, Europe proposed T2T/SLE in a high profile, suggesting that the treatment concepts and strategies of SLE are being updated, and the concept of treat to target (T2T) has gradually become the consensus of SLE treatment. Clinical disciplines involving SLE, including internal medicine, dermatology, rheumatology and immunology, and nephrology, all need to pay attention to this new concept.

To evaluate the inadequate diagnostic rate of ultrasound guided fine needle aspiration cytology(USFNAC)in thyroid calcified nodules.

208 thyroid calcified nodules in 202 patients were retrospective analyzed, and all of the nodules were acquired cytological diagnosis.

There was no significant complication in the all 208 thyroid calcified nodules. The inadequate diagnostic rate was 25.5% in thyroid calcified nodules. The inadequate diagnostic rates in micro calcifications , macro calcifications and circumjacent arc calcifications were 16.0%, 26.4% and 76.5%.The inadequate diagnostic rate in circumjacent arc calcifications were higher than those in micro calcifications and macro calcifications(P<0.01), and the rates were no significance in micro calcifications and macro calcifications. There was no statistical significance in different size of thyroid calcified nodules.

The inadequate diagnostic rate in circumjacent arc calcifications was higher, and should to avoid USFNAC in these nodules.

To explore the clinical characteristics and maternal and infant prognosis of severe precocious preeclampsia complicated with fetal growth retardation.

A study was conducted for 126 patients with early onset severe preeclampsia. According to the gestational week (GW) of morbility, they were divided into group A (GW<28,n=36), group B (28≤GW<32,n=40) and group C (32≤GW<34,n=50). And then compare the respective clinical characteristics and the result of mother and infant.

At admission, no statistical difference existed among 3 groups in blood pressure, blood platelets, 24 h urine protein quantity, urea nitrogen, D-2 polymer or serum creatinine (P>0.05). the rate of complication declined with advancing gestational weeks of morbility in all three groups. And the composition of complication indicated no statistical difference (P>0.05); there existed statistical difference in asphyxia neonatorum and perinatal mortality rates between any two of three groups (P<0.05 for all). Comparing expectant treatment time and delivery method of three groups, the expectant time of Group B was obviously longer than those of the other two, both indicated statistical difference (P<0.05). However, the difference had no statistical significance between groups A and C (P>0.05). And uterine-incision delivery was the major delivery mode among all three groups.

The rates of asphyxia neonatorum and perinatal mortality decline with advancing gestational weeks of morbility in cases of severe precocious preeclampsia complicated with fetal growth retardation. Therefore, for reducing the perinatal mortality rate, proper measures include early diagnosis, active treatment, close supervision of mother and fetal conditions and termination of gestation when necessary.

To explore the effects of different laparoscopic procedures before embryo transfer (ET) for hydrosalpinx on pregnancy outcomes.

Group A (n=269) underwent laparoscopic bilateral salpingectomy before ET while group B (n=178) had laparoscopic bilateral tubal salpingostomy for hydrosalpinx. And the pregnancy outcomes of ET were evaluated.

The implantation, pregnancy, abortion, ectopic pregnancy and live birth rates were similar in 2 groups (P>0.05). The interstitial pregnancy rate was 10.27% after bilateral salpingectomy. The clinical pregnancy rate increased while the interstitial pregnancy rate decreased when the intervals between salpingectomy and ET were prolonged. But there was no statistical significance (P>0.05).

Laparoscopic tubal salpingostomy is as effective as salpingectomy for hydrosalpinx before ET. The interstitial pregnancy rate increases after laparoscopic salpingectomy. The interval between salpingectomy and ET should be appropriately scheduled.

To analyze the typical and non-typical magnetic resonance imaging (MRI) findings of neonatal hypoglycemia encephalopathy (NHE).

The clinical data and MRI findings of 20 cases with NHE were retrospectively evaluated.

Among them, blood glucose values were ≤1.4 mmol/L (n = 18) and 2.1 mmol /L (n= 2). And 13 cases had recurrent hypoglycemia. The major clinical symptoms included convulsion, poor response, cyanosis and apnea. The typical MRI findings of abnormal signal in occipital or parietal cortex were found in 9 cases. And the involvement sites were corpus callosum (n = 4) and posterior limb of internal capsule (n = 1) . Another 11 cases revealed non-typical MRI findings of damaged brain regions, involving splenium of corpus callosum (n = 8) , white matte along lateral ventricle (n = 6) , extensive cortical or subcortical white matter (n = 5), internal capsule (n = 3) , centrum semiovale (n = 2), globus pallidus (n = 1) , local cortex (frontal lobe) (n = 1), pons (n = 1), unilateral hippocampus (n = 1) and bilateral thalamus and midbrain, brain stem and medulla oblongata (n = 1).

The typical MRI findings of NHE show abnormal signal in occipital or parietal cortex. And non-typical manifestations involving multiple brain areas may be observed in cases of severe NHE.

To validate whether PET/MR could provide a semi-quantitative measurement (SUV_max) comparable to that produced by PET/CT in normal organs.

277 subjects underwent an ordinary ¹⁸F-FDG PET/CT followed by a PET/MR scan with a 25-45 min interval. Region of interest (ROIs) were drawn in 4 reference normal organs/tissues in both MRAC-PET and CTAC-PET images and the liver and erector spinae in the dual-time point PET/CT images.

259 malignant and 21 benign lesions, pathologically confirmed, were detected in the 220 subjects. SUV_max derived from PET/CT (SUV_max-CT) and PET/MR (SUV_max-MRI) was highly correlated over the reference organ ROIs (r=0.62-0.73), except lung (r=0.44). The SUV_max-MRI was significantly lower than the respective SUV_max-CT in all 4 organs and after delay-correction in liver and muscle.

The results indicate that PET/MR can provide reliable measurement in physiological organs.

To evaluate the treatment outcomes of mini-invasive transforaminal lumbar interbody fusion by Quadrant system for upper lumbar disc herniation.

Between February 2008 and June 2011, 21 patients with upper lumbar disc herniation underwent mini-invasive transforaminal lumbar interbody fusion under Quadrant system at our institution. The relevant patient data included visual analogue scale (VAS) and Oswestry disability index (ODI) scores before and after operation 1 week, 3 months and last follow-up. And all data were collected retrospectively.

No operation-related complications occurred. The mean operative duration was 2.8 (2.5-3) hours. The average blood loss volume was 430 (350-500) ml. Preoperative VAS was 7.3±0.8 and 2.1±0.9, 1.3±0.6, 0.6±0.5 after operation 1 week, 3 months and last follow-up respectively. Statistically significant differences were demonstrated between each group. Preoperative ODI was 43.7±12.9 and 22.5±10.4, 16.2±8.5, 11.3±7.2 after operation 1 week, 3 months and last follow up. Significant differences existed in preoperative and postoperative ODI scores respectively.

Mini-invasive transforaminal lumbar interbody fusion using Quadrant system and special osteotome is safe and efficacious for upper lumbar disc herniation.

To explore the incidence of self-reported neck/shoulder pain (NSP) and lower back pain (LBP) among Chinese adolescents in Shanghai and identify the influencing factors for the incidences of these musculoskeletal disorders.

A total of 3 600 students were selected from 30 high schools randomly chosen from 237 regular full-time high schools registered in Shanghai. From each school, 40 students were selected from each of the tenth, eleventh and twelfth grades for a total of 120 students per school. The questionnaire involved questions pertaining to demographic information, learning environment and exercise habits of each student. The questionnaire also contained questions regarding the amount of weight carried by each student while commuting to and from school. And it was also used to collect specific information related with the occurrence of NSP and LBP. Logistic regression was performed to analyze the potential risk factors for NSP and LBP.

Among 3 600 distributed questionnaires, a total of 2 842 valid questionnaires were returned. The results revealed that the incidences of NSP and LBP in the Chinese adolescent population were 41.1% and 32.8%, respectively. Both NSP and LBP were more common in girls than in boys. And 6.3% students reported at least one NSP- or LBP-induced absence from school. Chinese adolescents generally experienced a heavy academic burden (32.7% failing to achieve daily academic goals) and mental stress (16.3% suffering from insomnia); the problem of insufficient sleep was even more pronounced (52.0% falling asleep after midnight and 64.3% suffering insufficient sleep while only 31.9% feeling physically relaxed after awaking). The multivariate Logistic regression analysis suggested that gender, grade, academic burden, stress and sleep situation had a significant correlation with NSP and LBP in adolescents.

The incidences of NSP and LBP are relatively high among adolescents in Shanghai. And several factors, including sedentary behaviors, personal exercise habits and backpack weight, influences the occurrences of NSP and LBP in youth.

To create and validate a L1-L5 lumbar three-dimensional finite element model.

The L1-L5 lumbar spines of a male healthy volunteer were scanned with computed tomography (CT). And a L1-L5 lumbar three-dimensional finite element model was created with the aid of software packages of Mimics, Geomagic and Ansys. Then border conditions were set, unit type was determined, finite element mesh was divided and a model was established for loading and calculating. Average model stiffness under the conditions of flexion, extension, lateral bending and axial rotation was calculated and compared with the outcomes of former articles for validation.

A normal human L1-L5 lumbar three-dimensional finite element model was established to include 459 340 elements and 661 938 nodes. After constraining the inferior endplate of L5 vertebral body, 500 kg·m·s^-2compressive loading was imposed averagely on the superior endplate of L1 vertebral body. Then 10 kg·m²·s^-2moment simulating flexion, extension, lateral bending and axial rotation were imposed on the superior endplate of L1 vertebral body. Eventually the average stiffness of all directions was calculated and it was similar to the outcomes of former articles.

The L1-L5 lumbar three-dimensional finite element model is validated so that it may used with biomechanical simulation and analysis of normal or surgical models.

To evaluate the cardiac protective effects of ischemic postconditioning (IPC) in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI).

Both foreign and Chinese databases including PubMed, EMbase, Cochrane library, and CNKI were searched to identify randomized controlled trials (RCTs) that reported the effects of IPC on the myocardial infarction size, myocardial blush grade (MBG), left ventricular ejection fraction (LVEF) and major adverse cardiac events (MACE). Two reviews assessed the quality of each trial and extracted data independently.The Cochrane Collaboration′s RevMan 4.2.8 software was used for statistical analysis.

Twelve studies were identified and the Meta-analysis included a total of 937 patients with AMI undergoing primary PCI with or without IPC. Pooled analysis of all studies demonstrated no significant reductions of peak CK and CK-MB with IPC relative to standard care. A secondary analysis of the studies didn′t show improvements of left ventricular ejection fraction during hospitalization with IPC. However, the incidence of MACE within 3 month after primary PCI in IPC group was less than that in the control group (P=0.04).

No significant benefit of IPC for reduction of myocardial infarct size as determined by peak creatine kinase and CK-MB release, as well as LVEF. The incidence of MACE was improved in patients who received IPC.

To evaluate the efficacy and tolerability of benazepril in Chinese patients with chronic systolic heart failure.

We searched the databases of Cochrane, PubMed, EMbase, CBM and CNKI from January 1989 to November 2010 for the relevant studies. Two investigators identified randomized controlled trials (RCTs) independently according to the predefined inclusion and exclusion criteria. Statistical data analysis was performed with the Stata 11 software.

A total of 15 studies with 1 355 Chinese patients of chronic systolic heart failure fulfilled the inclusion criteria. Among them, 546 received benazepril monotherapy. The dose range of benazepril was 5 to 40 mg daily. And it was similar to angiotensin Ⅱ receptor blockers (ARBs) in improving left ventricular ejection fraction (LVEF)(P=0.674), reducing LVEDD (P=0.511) and improving cardiac output (P=0.363). The combination therapy of benazepril and ARB was superior to ARB monotherapy in reducing left ventricular end-diastolic diameter (LVEDD)(P=0.001). However, LVEF was comparable between patients with ACEI/ARB combination therapy and those with ARB monotherapy (P=0.105). Compared with blank control, benazepril treatment was associated with a significant improvement in LVEF from baseline to follow-up (WMD=6.5%; 95% CI: 0.9%, 12.0%; P=0.022). Compared with baseline, benazepril treatment significantly increased LVEF (WMD=10.4%; 95% confidence interval [CI]: 7.1%, 13.8%; P<0.001) and cardiac output (WMD=1.5 L;CI: 0.3, 2.6 L, P=0.016). A significant reduction in LVEDD (WMD=5.3 mm; CI: 2.7, 7.8 mm, P<0.001) was also observed in benazepril group. As the most common side effect after benazepril treatment, cough had a prevalence of 11.6%. Other side effects were rare.

Benazepril is both efficacious and safe in the management of Chinese patients with chronic heart failure.

The patient was a 48-year-old male. He was admitted to the Department of Rheumatology and Immunology of Peking Union Medical College Hospital in February 2012 due to skin erythema ulcer with muscle weakness for 8 months, sore throat and dysphagia for 4 months. Eight months ago, the patient developed periorbital, facial, anterior chest, and extensional erythema of both elbows, partial ulceration, accompanied by proximal muscle weakness of the limbs, difficulty in lifting the upper limbs and squating the lower limbs, accompanied by joint pain of both shoulders and wrists, without swelling and morning stiffness; The local hospital found that creatine kinase (CK) was elevated (unknown), and the electromyogram showed myogenic damage. It was diagnosed as "dermatomyositis", and the symptoms improved after treatment with prednisone 40 mg/d. Four months ago, the dose of prednisone was reduced to 10 mg/d, and the rash worsened, with sore throat and hoarseness, which gradually worsened to dysphagia. One month ago, it progressed to inability to eat or drink, accompanied by fever, body temperature 38 ℃, cough and cough a small amount of white phlegm. He went to the emergency department of Peking Union Medical College Hospital and underwent laryngoscopy: nasopharynx, posterior wall of oropharynx, purulent coating of vocal cords, albuginea (FIG. 1A)。 The indwelling gastric tube was unsuccessful and esophageal obstruction was suspected. Admitted for further diagnosis and treatment. Weight loss of 20 kg after onset. Past, personal, marriage and childbirth, and family history are not special. Physical examination at admission: body temperature 36.5℃, heart rate 90 beats/min, breathing 18 beats/min, blood pressure 95/60 mmHg (1 mmHg =0.133 kPa); Poor nutrition, thin body shape, dark red maculopapular rash in V area of face, neck and chest, and scalp desquamation. Multiple finger tips ulcers and necrosis, fresh ulcers can be seen on the back of the left hand and left elbow joint, with deep wounds and yellow purulent coating, and multiple maculopapular rash, ulcers and crusts on the right shoulder, right elbow joint, multiple proximal interphalangeal joints of the right hand, metacarpophalangeal joint, left hip, both heels and the extension of the first metatarsophalangeal joint. Deep ulcer on the posterior pharyngeal wall with yellow-white purulent coating. Snow feeling under the skin of the neck and right chest. A small amount of wet rales was smelled in both lower lungs. Heart, abdomen (–). There was no edema in both lower limbs. Proximal muscle strength of both upper limbs grade IV, proximal muscle strength of both lower limbs grade V^–Grade. Laboratory test: blood routine: white blood cells 5.45×10⁹/L, hemoglobin 111 g/L, platelets 143×10⁹/L. Blood biochemistry: alanine transferase 59 U/L, aspartate transferase 34 U/L, albumin 22 g/L, creatinine 62 μ mol/L, urea 12.25 mmol/L; CK 13 U/L, lactate dehydrogenase 293 U/L. High sensitivity C-reactive protein (hsCRP) 21.49 mg/L; Erythrocyte sedimentation rate (ESR) 77 mm/1 h; Immunoglobulin, complement and rheumatoid factor were normal; Anti-nuclear antibody, anti-extractable nuclear antigen antibody, anti-phospholipid antibody, myositis antibody spectrum was negative. Tumor screening: CA125 was slightly higher, but the rest was normal. Whole body bone scan and abdominal CT were normal. Chest CT (FIG. 2A): interstitial lesions of both lungs, bullae at the left apex, thickened pleura, subcutaneous and mediastinal emphysema of the right chest. Cardiac ultrasound: reduced left ventricular compliance, minor pericardial effusion. Pathology of pharyngeal ulcer biopsy: acute and chronic inflammation, with inflammatory exudation necrosis and fungal hyphae. Hexamine silver staining (+). Upper gastrointestinal angiography: laryngopharyngeal fistula, subcutaneous, mediastinal development (Figure 3), suspected stenosis of the lower esophagus. Swab culture at cutaneous ulcers: methicillin-sensitive Staphylococcus aureus.

Osteoporosis is a systemic disease characterized by low bone mass and destruction of bone tissue microstructure, which leads to increased bone fragility and easy fracture. It is characterized by high incidence (84 million osteoporosis patients in China alone). With the increase of social aging population, the incidence of fractures caused by osteoporosis not only increases significantly, but also leads to an increase in medical expenses and socio-economic problems (at least 15 billion yuan is consumed in China every year).^[1]。 The medical expenses of treating osteoporosis and fractures caused by osteoporosis have exceeded those of other chronic diseases, such as cerebral infarction, myocardial infarction, breast cancer and chronic obstructive pulmonary disease. Therefore, the research on osteoporosis has attracted increasing attention.

autophagy, or self-phagocytosis, is the self-degradation of cells under stress, removing damaged or excess proteins and organelles and realizing the recycling of intracellular components. This process is strictly controlled and highly conserved in cells, and is closely related to cell growth, proliferation and tumorigenesis^[1], and play different roles in different tumors or different stages of the same tumor and in the course of radiotherapy and chemotherapy of tumors^[2]。

The patient was a 28-year-old female. Due to the right breast mass for 4 years with enlargement for 1 month, she was admitted to the Affiliated Obstetrics and Gynecology Hospital of Zhejiang University on April 29, 2013. She had a history of cesarean section 2 months ago. Physical examination: A 2.0 cm ×2.5 cm mass can be seen in the outer upper quadrant of the right breast, which is hard in texture, unclear in boundary, average in mobility, negative in dimple sign and orange peel sign, and no obvious swollen lymph nodes under both axillaries. Imaging: Breast ultrasound revealed hypoechoic foci at the junction of right breast and axilla (BI-RADS-US: category 5). Mammograms showed an isodensity mass of 1.7 cm ×1.4 cm ×1.5 cm in the upper outer quadrant of the right breast near the axilla (Figure 1), shallowly lobulated, with blurred boundaries, short burr shadows and no obvious calcification. MRI showed a mass of 2.4 cm ×2.0 cm ×1.9 cm in size near the axilla in the upper outer quadrant of the right breast, 0.9 cm from the skin, T₁WI and other signals, showing star-like changes (Figure 2), T₂WI lipid suppression sequence showed slightly high signal, and low signal shadow was seen in the center (Figure 3), diffusion-weighted imaging (DWI) showed diffusion limitation, and the apparent diffusion coefficient (ADC) value of normal breast was 1.80×10^–3mm²/s, the ADC value around the mass was 1.26×10^–3mm²/s (Figure 4,Figure 5), the dynamic enhancement scan mass enhancement was roughly uniform, and short burr shadows were seen around it, showing a plateau enhancement curve (Figure 6)。 MR imaging evaluation: mass in the upper external quadrant of the right breast (BI-RADS-MRI: category 5). Surgical and pathological results, fine needle puncture of right breast mass: patches of ductal epithelium were seen in the smear, the cytoplasm was rich in red staining, the shape was single, and the abnormality was not obvious. The possibility of low-grade special type cancer was not excluded. Freezing during operation was recommended; Hollow core needle puncture of right breast mass: granular cell tumor (GCT) of right breast is possible. During the operation, the mass was located near the edge of the gland in the outer upper quadrant of the right breast, with a clear boundary with the pectoral muscle and no obvious infiltration. It was 2.5 cm ×2.0 cm ×2.0 cm in size, hard in texture, gray-yellow in section, uneven in texture, and the surrounding gland tissue was fine granular (changes during lactation). Final diagnosis: granulosa cell tumor of the right breast (Figure 7，Figure 8)。