Volume 94  ·   Issue 47  ·  2014

The incidence of stroke in China increases by 8.7% every year, which is higher than the world average on a global scale, showing the characteristics of high incidence, high disability, high mortality and high recurrence rate. Stroke changes the lives of patients and brings a heavy burden to their families and society. Given that more than 76% of strokes are the first episode, effective preventive measures are the best way to reduce the burden of stroke^[1]。 Cerebral atherosclerosis, which can be divided into intracranial atherosclerosis and extracranial atherosclerosis, is an important cause of stroke worldwide^[2]Especially in Chinese and Asian populations. In China, 33% to 50% of strokes and transient ischemic attacks have symptomatic cerebral atherosclerotic intracranial artery stenosis^[3,4]。 The screening of cerebral atherosclerosis is helpful for its early diagnosis, thus improving the early warning and prevention and treatment level of cerebral atherosclerotic stroke^[5]To provide effective preventive measures for the first stroke attack, thereby reducing the incidence and disability rate of stroke in China.

This specification includes the definition, screening (strategies and methods), diagnostic basis and diagnostic principles of cerebral atherosclerosis.

This specification includes the definition, screening (strategies and methods), evaluation basis and evaluation principles of cerebral atherosclerosis.

To explore the relationship between basal artery hypoplasia (BAH) and posterior circulation ischemic stroke and its clinical characteristics to improve the understanding of BAH.

A total of 328 hospitalized patients from April 2012 to April 2014 were enrolled retrospectively. With normal course and regular shape of basilar artery on brain magnetic resonance angiography (MRA), other causes of posterior circulation ischemic stroke were excluded. They were divided into BAH (n=48) and non-BAH (n=280) groups according to the morphology and diameter of basilar artery on head MRA. We compared the general information and intracranial vascular variations between two groups, especially the incidence rate of posterior circulation infarction and mean blood flow velocity (Vm) of basal artery by analyzing clinical information and MRI findings. Meantime, their clinical outcomes were observed through follow-ups. And detailed clinical features were discussed for the patients with posterior circulation infarction in the BAH group.

(1) The concurrent lesions included vertebral artery intracranial segment hypoplasia (n=24, VAH), fetal type posterior artery (n=18, FTPA), persistent trigeminal artery (n=1) and giant fenestration variation on vertebral artery (n=1) in the BAH group. In comparison, it was more liable to cranial vascular variations in the BAH group (P<0.05). (2) The incidence rates of posterior circulation infarction for two groups were 35.4% (17/48) and 8.6% (24/280) respectively. In comparison, these cases in the BAH group were more likely to suffer from posterior circulation ischemic stroke (P<0.05) and the Vm of basal artery in the BAH group was obviously lower than that in the non-BAH group (P<0.05). (3) these cases with stroke in two groups had no mortality during a follow-up period of 4-28 months. There were 3 cases with recurrent posterior circulation stroke in the non-BAH group. The number of cases with mRS scoring 2 points or less in the BAH group was more than that in the non-BAH group at discharge, 30 or 90 days after discharge (P<0.05). (4) these cases with posterior circulation stroke in the BAH group often presented as lacunar syndrome (9/17), paramedian infarction in pons (9/17) and bilateral VAH plus unilateral FTPA (8/17).

As a relatively rare disease, BAH often has other intracranial vascular variants. Posterior circulation stroke occurs due to reduced blood supply of vertebrobasilar system, especially pons infarction. Though with relatively good clinical outcomes, we still need to make an early diagnosis and strengthen stroke prevention.

To investigate the prevalence of Fabry disease and GLA gene mutations in young patients with ischemic stroke.

A total of 269 consecutive hospitalized patients of ischemic stroke, aged between 18-55 years, were recruited.DNA was extracted from peripheral blood.And 7 exons and flanking introns of α-galactosidase gene (GLA) were sequenced.

The cases were cerebral infarction (n=239, 88.8%) transient ischemic attack and posterior circulation ischemia (n=30, 11.2%). There were 216 males and 53 females with a mean age of 44±8years.Large artery atherosclerosis was predominant at 55.4% according to the TOAST classifications.Among them, there were c. -12G> A point mutation (n=12) and c. -10C> T mutation (n=20). These two sites were located in the 5 'end of non-untranslated region in exon 1.Both loci were polymorphic loci.No disease-causing mutations were detected.

The prevalence of Fabry disease in young stroke patients is not high as in Western countries; there has some difference in TOAST types between patients with c. -10C> T mutation and without, further studies are needed to testing the significance.

To explore the independent predictors of internal borderzone (IBZ) infarcts in patients with atherosclerotic middle cerebral artery stenosis/occlusion (MCAS).

A total of 167 hospitalized patients with atherosclerotic MCAS during January 2008 and March 2014 were retrospectively analyzed. They were divided into "with IBZ group" ( n=55) and "without IBZ group" ( n=112) according to the findings of magnetic resonance images (MRI). Their clinical data were collected including demographics, traditional vascular risk factors, stenotic degree of MCA and other cerebral supply arteries, TICI grading for antegrade blood flow, ASITN/SIR grading for collateral circulation and other variables. The intra-group data were compared by univariate analysis. Variables with P<0.1 were included into multivariate Logistic regression model for obtaining the independent predictors of IBZ. Two models were established including either TICI-grading or stenotic degree of MCAS due to close correlations between two variables.

There were 45 females and 122 males with a mean age of 54±12 years. Variables with a P value <0.1 in univariate analysis included relatively low blood pressure ( P=0.006), stenotic degree of MCAS (P=0.012), TICI-grading (P=0.003), history of hypertension (P=0.055) and ASITN-grading (P=0.067). In multivariate model Ⅰ, independent predictors of IBZ included TICI-grading (OR 4.310, 95%CI 1.698-10.869, P=0.002), history of hypertension (OR 0.458, 95%CI 0.224-0.936, P=0.032), relatively low blood pressure (OR 3.848; 95%CI 1.345-7.983, P=0.039). In multivariate model Ⅱ, independent predictors of IBZ included stenotic degree of MCAS (P=0.006; severe vs moderate: OR 4.796, 95%CI 1.676-13.729, P=0.003; occlusion vs moderate: OR 5.537, 95%CI 1.846-16.603, P=0.002). The two models had a similar area under the curve (AUC) of receiver operating curve (ROC) of 0.702 (95%CI 0.618~0.787, P<0.001) and 0.709 (95%CI 0.626-0.792, P<0.001).

Severe stenosis or total occlusion of MCA, impairment of antegrade blood flow and relatively low blood pressure are the independent risk factors of IBZ. And history of hypertension is a protective fact or of IBZ in patients with MCAS.

To summarize the clinical experiences of microsurgical and endovascular treatments of complicated arteriovenous malformation (AVM) in the conditions of hybrid operating room.

The clinical data were collected and analyzed for 8 patients of complex AVM between June 2012 to June 2013. There were Spetzler grade Ⅲ (n=2) and grade Ⅳ(n=6). And the lesions were complicated with intracranial aneurysms (n=3) and located in motor area (n=2) and basal ganglia (n=2). Five cases of AVM with cerebral hemorrhage underwent emergency surgery, including digital subtraction angiography (DSA) plus intraoperative embolization plus surgical resection of AVM plus intraoperative DSA (iDSA). Two cases underwent embolization plus aneurysm surgery while another had AVM embolization plus AVM resection and γ knife treatment.

All surgical procedures, including iDSA, were completed in the same hybrid operating room. There was no change of surgical position or intraoperative mortality. Five patients of AVM hemorrhage undergoing emergency hematoma evacuation had no residue of AVM on iDSA. Their postoperative consciousness improved without neurological dysfunction. Two patients of limb paralysis recovered to paresis at 3 months postoperation. One case with blurry vision improved somewhat. Two cases undergoing elective surgery had a complete resection of AVM after embolization.

Surgery plus endovascular treatment in hybrid operating room is efficacious for complex cerebral AVM. It avoids multiple surgeries and inspections. And any lesion residue may be assessed immediately with postoperative DSA.

To report the safety, efficacy of anterior pulmonary vein vestibule intensive ablation and upstream therapy for atrial fibrillation (AF).

AF patients (n=59) undergone radiofrequency ablation were enrolled.The paroxysmal AF patients underwent circumferential pulmonary vein isolation (CPVI). The persistent AF patients underwent CPVI plus linear ablation.During CPVI, the anterior pulmonary vein vestibule was performed intensively by prolonging the ablation time and increasing the ablation energy.Rosuvastatin and telmisartan were used for upstream therapy.The patients underwent follow-up at 1 month after ablation, and then at 3, 6, 12 and 18 months to evaluating whether the procedure is valid and safety.

During the 12±6.5 months follow-up, the success rate of combination therapy was 86.4%.Preoperative and postoperative left atrial diameter was (45 ± 7) mm, and (41 ± 5)mm (P<0.05), left atrial emptying fraction before operation was 46% ± 4%, and 54% ± 5% after operation (P<0.05).

Combination therapy is valid and safety to treat AF.The results of 12 months follow-up showed left atrial diameter was decreased and left atrial emptying fraction was increased.

To explore the clinical efficacies of different internal fixation materials in the treatment of senile proximal humerus fractures.

A total of 284 hospitalized patients of proximal humerus fractures over 60 years of age cases from October 2009 to February 2012 were randomly divided into two groups of locking proximal humeral plate (LPHP) and PHILOS (n=142 each). And the clinical efficacies of two groups were compared.

For PHILOS and LPHP groups, the fracture healing periods were(11.64±3.81)and(14.95±3.95)weeks.And there was statistical significance (P<0.05). At 3 months post-surgery, the incidence of pain was 72.41% and 64.81%.And there was statistical significance (P<0.05). At 2 years, Neer shoulder function score had inter-group statistically insignificant difference (P>0.05).

Both PHILOS and LPHP are effective in the treatment of senile proximal humeral fractures.However, the former is conducive to fracture healing and has shorter healing time and lowered postoperative pain.

To explore the clinical value of high frequency ultrasound in monitoring muscle layer thickness of cesarean section scar in late pregnancy.

A total of 131 patients re-conceived after cesarean section were selected randomly from our hospital.High frequency ultrasound was used for monitoring muscle layer thickness of cesarean section scar.And ultrasonic results and operative findings were compared.

Based upon the ultrasonic results, they were divided into 2 groups: group 1 (≤2 mm, n=61), there were confirmed (n=19) and misdiagnosed (n=11) uterine rupture; group 2 (>2 mm,n=70), confirmed (n=5) and misdiagnosed (n=5) uterine rupture.

Monitoring muscle layer thickness of cesarean section scar is of great significance for preventing uterine rupture in late pregnancy.

To explore the factors associated with recurrence of cervical intraepithelial neoplasia (CIN) after loop electrosurgical excision procedure (LEEP).

A total of 236 patients with CIN owing to high-risk human papillomavirus (HPV) infection underwent LEEP and followed up with thinprep cytologic test (TCT), HPV genotype test and biopsy histology.

Among them, 22 patients (9.3%) developed recurrent disease at 12 months post-LEEP. And the persistent infection rate of high-risk HPV was 10.6% (25/236). The odds ratio for recurrent CIN in patients with persistent infection of high-risk HPV was 38.9 (P<0.01). Recurrent rate was associated with HPV DNA load pre-LEEP (P<0.05), HPV16 infection (P<0.01) and positive margin (P<0.05).

HPV DNA load >1 000 RLU/CO, HPV 16 infection and positive margin are risk factors for recurrence. And persistent infection of high-risk HPV is a significant predictor of recurrent CIN.

To explore the impact and reasons of conversion during video-assisted thoracic surgery (VATS) lobectomy.

A total of 374 patients undergoing VATS lobectomy during May 2007 and May 2012 were divided into 2 groups according to whether conversion was necessary.And their clinical data were retrospectively analyzed.

Among them, 36 cases (9.6%) converted into thoractomy during VATS lobectomy.Their clinical profiles of age, gender and surgical type were similar.The conversion group had longer operative duration, more blood loss and more benign proportion than VATS group.No inter-group difference existed in postoperative complication, mortality; tube removal time or hospitalization length.The reasons of conversion included hemorrhage (n=12), vascular adhesion (n= 6), instrumentation complication (n=5), incomplete fissure (n=5), uncertain anatomy (n=3), abnormal blood vessels (n=3) and insufficient margin (n=2).

Conversion during VATS lobectomy may prolong operative duration and increase blood loss.However there is no effect upon patient recovery.

To explore the necessity of interrupting nerve fibers of bypass thoracic sympathetic chain during edoscopic sympathicotomy (ETS) for palmar hyperhidrosis.

Randomized controlled trial was performed for 200 patients of severe palmar hyperhidrosis from January 2009 to June 2011.They were randomly divided into 2 groups of R3 thoracic sympathctomy (R3) and R3 thoracic sympathicotomy plus bypass fiber resection at the same level (R3+ ) (n=100 each). Clinical observations were recorded during a follow-up period of 3 years.

The curative rates of palmar and axillary hyperhidrosis were 100% for two groups.No statistically significant inter-group difference existed in left hand temperature increase after transecting thoracic sympathetic nerve(3.6±1.4 ℃ vs 3.5±1.3 ℃), right hand increase (3.8±1.3 ℃ vs 3.9±1.1 ℃), incidence of compensatory hyperhidrosis (40% vs 44%), recurrence rate (1% vs 2%) and postoperative satisfaction rate (92% vs 90%). But pain scores of R3 group was significantly lower than those of R3+ group (3.0±1.9 vs 3.6±1.9, P<0.05).

Simple transaction of thoracic sympathetic chain during ETS is sufficient in the treatment of palmar hyperhidrosis.And it is unnecessary to transect bypass fibers.

To explore the techniques and efficacies of surgical resection of giant sellar region tumors via anterior interhemispheric approach.

A series of 110 consecutive cases of giant sellar region tumors undergoing microsurgery through an anterior interhemispheric approach at our hospital were retrospectively analyzed. Their mean age was 35.6 (3-72) years. There were craniopharyngioma (n=57), pituitary adenoma (n=33), hypothalamic glioma (n=5), meningioma (n=4) and other lesions (n=11). The maximal tumor diameter varied from 4.0 to 8.2 cm with a mean diameter of 4.8 cm. Active measurements were taken for managing blood sodium disorder and diabetes insipidus. During the follow-ups, the patients were monitored for residual or recurrent tumor by hormonal assessment (in cases of functioning adenomas) and postoperative contrast magnetic resonance imaging (MRI) performed 1-3 months after surgery.

Total lesion removal was achieved in 76 cases (69.1%). Twenty patients (18.2%) underwent subtotal resection and 14 (12.7%) had partial removal. No surgery-related mortality occurred. Visual acuity was preserved or improved in 97 patients (88.2%) within 1 week after surgery. The major postoperative complications included diabetes insipidus (n=76, 69.1%), permanent diabetes insipidus (n=23, 20.9%), electrolyte disorder (n=62, 56.4%), seizures (n=7, 6.4%), brain damage (3 cerebral contusions and 5 hematomas) (n=8, 7.3%) and infarction(n=2, 1.8%). During a median post-surgical follow-up period of 26 (3-96) months, 11 patients had recurrence. And 35 cases (31.8%) of endocrinological deficit received hormonal replacement after surgery.

The interhemispheric approach is feasible for removing giant sellar region tumors without significant sequels. Active postoperative managements of diabetes insipidus and electrolyte disorder may accelerate early patient recovery.

To establish the multiple risk factors models for patients with acute coronary syndromes (ACS) of different genders and quantitatively assess the pathopoiesis of all factors.

A total of 2 308 consecutive ACS inpatients and a control group of 256 cases with normal coronary artery from January 2010 to December 2012 were enrolled and divided into 4 groups of female ACS (n=970), male ACS (n=1 338), female control (n=136) and male control (n=120). All demographic and clinical data were collected by the physicians and master degree candidates in the division of cardiology.

The Logistic regression models of multiple risk factors were established for ACS by different genders. More than 45 years of age, dyslipidemia, type 2 diabetes mellitus, obesity and hypertension were all independent risk factors of ACS for different genders (P<0.05). However, the same risk factors had different pathogenic effects on ACS between genders. The odds ratio (OR) was markedly different for females and males: per 5-year increase aged over 45 years (1.45 vs 1.13), dyslipidemia (3.45 vs 1.68), type 2 diabetes mellitus (4.06 vs 2.33), obesity (2.93 vs 1.91) and hypertension (1.78 vs 3.80) respectively (all P<0.05). In addition, current smoking increased the risk of ACS attack in males by 5.49 (P<0.05) while not statistically significant in females. Particularly cerebral ischemic stroke increased the risk of ACS attack by 5.49 folds in males other than females (P<0.05).

Type 2 diabetes mellitus, dyslipidemia and obesity may present higher risks of ACS attack for females than males. And smoking and hypertension are much more dangerous for males. Males with cerebral infarction are more susceptible for ACS than females.

To observe the in vivo vertebral motion of adjacent segments in patients with degenerative spondylolisthesis (DS) during functional weight-bearing activities.

A total of 15 symptomatic L4 DS patients (mean age 54.4 years) and 15 asymptomatic volunteers (mean age 53.4 years) were recruited. The vertebral segment motion of each subject was reconstructed with three-dimensional computed tomography and solid modeling software. In vivo lumbar vertebral motion during functional postures (flexion-extension, left-right twisting and left-right bending) was observed with dual fluoroscopic imaging. Coordinate systems were established at the vertebral center of L3-S1 to obtain the intervertebral range of motion (ROM) at L3/4, L4/5 and L5/S1 in DS and normal groups.

The motion pattern at L3/4 with DS was altered. During left-right bending, the rotation along sagittal axis was significantly larger than normal group (4.4°±2.8° vs 2.1°±1.7°, P<0.05). During left-right twisting, the rotation along vertical axis was significantly larger than normal group (4.3°±2.8° vs 2.1°±1.3°,P<0.05). During flexion to extension, the rotation along frontal axis was larger than DS group (3.9°±3.3° vs 3.2°±2.5°). However the difference was insignificant. The motion pattern at L4/5 and L5/S1 with DS had no significant difference with normal group.

The slipped segments of degenerative spondylolisthesis are stable. However, the ROM of cranial segment increases.

To evaluate the surgical feasibility of uterine autologous transplantation in female cynomolgus monkeys and explore the effect of microsurgical technique.

From May 2011 to March 2014, 6 female cynomolgus monkeys, aged 7 to 12 years, were randomly divided into 2 surgical groups. In group A, gross surgeries were performed with naked eyes. In group B, uterine re-transplantation was performed under 10-time-magnifying microscopy. Anatomical data and operative durations were recorded and analyzed. Viable uterine tissue and vascular patency were observed on trans-abdominal ultrasonography and second-look laparotomy after 3 months.

The average uterus retrieval time, average vascular anastomotic time, average perfusion time and average total operative time of group B were 88.7, 147.3 and 320.0 min versus 123.7, 180.7 and 393.7 min in group A. The average perfusion durations were 35.0 and 27.3 min. And there was no inter-group difference. A total of 12 successful vascular procedures (including 6 internal iliac arteries and 6 uterine-ovary veins) of vascular anastomosis were recorded in group B versus 4 cases (including 1 artery and 3 veins) in group A (vein, P>0.05; artery,P<0.05). In group A, there was only 1 successful operation but uterus turned necrotic after 4 weeks. In group B, the surgical success rate was 100%. However one animal died due to intestinal obstruction. And in another 2 animals, viable uterine tissue and vascular patency were observed on trans-abdominal ultrasonography and second-look laparotomy. Two survivors resumed cyclicity at days 17 and 50 respectively as a sign of re-established uterine function.

This study has demonstrated the feasibility of uterus transplantation by vascular anastomosis in cynomolgus monkeys. And assistance of microsurgical technique can significantly improve the success rate of arterial anastomosis during uterus transplantation.

To establish the murine model of moderate endometrial injury.

Electrocoagulation was applied to induce endometrial injury of ICR mice with 0.5 watts power while contralateral uterine cavity acted as control without electrocoagulation. The endometrial histomorphology was observed in 7 days later by microscopy and fetal number of each lateral uterus assessed at 17.5 days after pregnancy.

At 7 days post-electrocoagulation, the average endometrial thickness of operating side was significantly thinner than that of control side (1.14±0.08 vs 1.88±0.15 mm, P<0.05). The density of endometrial glands of operating side was significantly lower than that of control side (20±2 vs 32±3 per 100x field,P<0.05). After pregnancy, the average number of embryos at operating side decreased by 63.1% compared with control (3±2 vs 8±2,P<0.01).

The established model of endometrial electrocoagulation injury shows morphologic changes and decreased fertile ability. It has potential uses for animal studies of endometrial injury treatment.

To synthesize the RGD-modified magnetic resonance imaging (MRI)-visible gene transfer nanocarrier and assess its gene delivery ability and MRI visibility for hepatocellular carcinoma.

The multifunctional nanocarrier RGD-PEG-PEI-SPION was constructed.And the degree of binding between nanocarrier and siRNA was determined by agarose gel electrophoresis.The zeta potential and particle size of cationic polymer vectors were measured with a Zeta-Plus instrument.Immunocytochemical assay was performed for detecting the expression of α _vβ₃ in Bel-7402 cells.The active targeting ability of nanocarrier to Bel-7402 cells was evaluated by flow cytometry and laser confocal microcopy.The MRI visibility of nanocarrier to Bel-7402 cells was assessed.

RGD-PEG-PEI-SPION could condense siRNA entirely at a N/P ratio of 2.8; the membranes of Bel-7402 cells possessed an enrichment of α _vβ₃ receptors.At a nitrogen/phosphate ratio of 10, the particle size of RGD-PEG-PEI-SPION/siRNA attained a constant size of 85.2±5.6 nm, the zeta potential reached + 12.4±1.2 mV, the gene transfection efficiency of nanocarrier to Bel-7402 cells attained 71.2%±2.1% and the cells showed significantly stronger RGD-PEG-PEI-SPION (red) and siRNA (green) fluorescence under laser confocal microcopy.The cells incubated with RGD-PEG-PEI-SPION exhibited significantly lower normalized MR T₂^*WI signal intensity.

A RGD-modified MRI-visible gene delivery nanocarrier RGD-PEG-PEI-SPION has been successfully synthesized.It has a higher transfection efficiency of transferring siRNA into Bel-7402 cells and could sensitively detect hepatocellular carcinoma with MRI.

To explore the risk factors of giant cell tumor on extremities for patients with postoperative recurrence.

The literature reports published before June 2014 were searched in the electronic databases of CBM, CNKI, PUBNED, MEDLINE and EMBASE.Meta-analysis was performed by software Review Manager (Version 5.3). The odds ratios (OR) of gender, age, tumor site, Campanacci Classification, pathological fracture, selection of treatment and soft tissue invasion were analyzed with heterogeneity test.Publication bias were tested by funnel plot and fail-safe number.Sensitivity analysis was performed to assess the stability.

A total of 15 case-control studies were identified.Age, location and type of surgery were associated with tumor recurrence.The combined OR(95%CI) was 1.83(1.04-3.24) P=0.04 for aged <20 years, 0.52(0.31-0.86) P=0.01 for aged >40 years, 1.60(1.06-2.42) P=0.02 for distal radius, 0.35(0.14-0.90) P=0.03 for proximal humerus, 3.64 (1.88-7.04) P=0.0001 for curettage, 0.56(0.35-0.91) P=0.02 for curettage with PMMA, 1.79(1.11-2.88) P=0.02 for curettage with bone graft and adjuvant and 0.29 (0.12-0.66) P=0.003 for resection respectively.There were not significant relationship between tumor recurrence and gender, tumor location (distal femur, proximal femur, distal tibia, proximal tibia), Jaffe staging, Campanacci classification, Enneking classification, pathological fracture, soft tissue invasion, extensive curettage, curettage with bone graft, curettage with polymethylmethacrylate and adjuvant (P>0.05).

Youth (aged <20 years), distal radius, curettage and curettage with bone graft and adjuvant are the risk factors for recurrence of giant cell tumor.However, advanced age (aged >40 years), proximal tibia, curettage with PMMA and resection appear to have lower risks for tumor recurrence.

A 54-year-old male was admitted for "repeated dyspnea for 2 years, limb weakness for 1 1/2 years, aggravated for 1 month." The patient began to experience breathing difficulty during mild activity in April 2011, which could be relieved after rest and was not paid attention to. In October, there was ptosis of both eyelids, accompanied by weakness of the right hand and neck, fatigue and light morning and heavy evening. Mediastinal tumor revealed by PET-CT in December. In March 2012, he was diagnosed with "myasthenia gravis" in the First Affiliated Hospital of Sun Yat-sen University. On April 12th, we underwent "sternal split mediastinal mass resection + pericardial repair + wedge resection of right upper lung". Pathology showed mixed B2/B3 thymoma, invading lung and mediastinum. Postoperative myasthenia crisis, three-line cytopenia (bone marrow cytology examination showed decreased bone marrow hyperplasia, decreased erythroid proportion, biopsy showed low bone marrow hyperplasia, and scattered distribution of granulocyte cells in partial maturity stage was seen), which improved after treatment. In August and September, the patients underwent radiotherapy 27 times in our hospital and Guangzhou Military Region General Hospital, and chemotherapy once in November. At the beginning of March, 2013, he began to have repeated cough and sputum. On April 12th, he developed dysphagia and dyspnea. On April 17th, he underwent tracheal intubation ventilator-assisted breathing. The patient had persistent high fever, chest radiograph showed "double lung infection", sputum culture showed Acinetobacter baumannii infection, and gradually developed septic shock and decreased blood pressure. Norepinephrine was given to maintain at about 70~90/50 mmHg (1 mmHg =0.133 kPa). Blood routine showed that the lowest white blood cell was 2.33×10⁹/L, red blood cells 2.39×10¹²/L, hemoglobin 73 G/L, platelets 44×10⁹/L. Cefoperazone, sulbactam sodium, linezolid, imipenem, cilastatin sodium, piperacillin, tazobactam combined with vancomycin, voriconazole and other anti-infections were given successively, and recombinant human granulocyte colony-stimulating factor and recombinant human thrombopoietin were infused every other day to increase blood cells. The patient was emotionally anxious and could not sleep at all for 21 consecutive days and 24 hours. The use of alprazolam and dexmedetomidine to induce sleep was ineffective. Enteral nutrition suspension (TPF) was given 2 000~2 500 ml nasogastric feeding daily, but the patient was losing weight day by day. On May 13th, he was transferred to this district. After admission, his body temperature fluctuated between 37 and 39 ℃, and his heart rate fluctuated between 100 and 130 beats/min. He continued ventilator-assisted ventilation, and was given norepinephrine 20 mg +5% glucose 50 ml intravenously at a rate of 5 ml/h to maintain the blood pressure fluctuation at 100-130/55-70 mmHg. Loss of weight, coarse breathing sounds in both lungs, a small amount of dry rales and phlegm sounds can be heard in the right lower lung, and no dry and wet rales can be heard in the left lower lung. Heart rate: 108 beats/min, homogeneous rhythm, strong heart sounds, no pathological murmur. Neurological specialist examination: clear consciousness, mental stress, anxiety state, no abnormalities in advanced nerve activity, no drooping of both eyelids, good movement of both eyeballs in all directions, no diplopia, symmetric nasolabial folds on both sides, inability to speak, no choking and dysphagia during drinking water, and extending the tongue in the center. The muscles of the whole body were atrophied uniformly, the muscle tone of the limbs was normal, the muscle strength was grade V, and the fatigue test was positive. No abnormalities were found in the whole body deep and superficial sensory examination; The bilateral limb tendon reflexes were symmetrical and did not elicit pathological reflexes; Negative for meningeal irritation.

Oral anti-hepatitis B virus nucleoside (acid) analogs mainly include nucleoside analogs and nucleotide analogs, the former includes lamivudine, entecavir, telbivudine, etc., and the latter includes adefovir dipivoxil (ADV), tenofovir (TFV), etc. Nucleotide drugs are actively secreted by the renal tubules and excreted from the body after being filtered by the glomeruli, and are easy to accumulate in the proximal renal tubular epithelial cells, thus producing nephrotoxicity^[1,2]。

Anterior cervical decompression surgery is a common surgical method for treating cervical spine diseases. It can effectively treat anterior compression such as intervertebral disc, osteophyte and posterior longitudinal ligament, but various complications may occur after surgery, including dysphagia, abnormal pronunciation, dural rupture, esophageal injury, hematoma formation, vertebral artery hemorrhage, postoperative airway compression, spinal cord injury and bone graft material displacement, among which dysphagia is the most common complication^[1]。 Dysphagia after cervical spine surgery refers to the absence of swallowing discomfort before surgery, but the corresponding symptoms only appear after surgery. The incidence, possible pathogenesis, evaluation methods, prevention and treatment of dysphagia after anterior cervical decompression are reviewed.

The patient, a 74-year-old male, first visited Qingdao Mental Health Center on August 21, 2013 due to nightmares accompanied by violent behavior in dreams for 8 years. Eight years ago, the patient gradually had nightmares at night without obvious triggers, mostly angry or frightened, accompanied by shouting, punching and kicking, etc., sometimes hitting his spouse, and then the patient would wake up, and after waking up, he could recall the dream scene, which would appear 2 to 3 times a month. Once, in a dream, I fought with someone. The patient fell from the bed to the floor. His hands, face and head were injured, and five stitches were stitched at the corner of his mouth. The patient suffered from this, so he went to major general hospitals. Brain CT only showed old cerebral infarction. He had taken traditional Chinese medicine and various drugs to improve cerebrovascular disease (details unknown), but they were ineffective. In the past 2 years, the attacks were more frequent, increasing to 7 to 8 times per month. In order to avoid hurting his spouse and himself, the patient asked his spouse to tie his hands with a cloth belt before going to bed every night, and then switched to a seat belt because he undid the cloth belt by himself in his dream. Three days ago, I unbuckled my seat belt by myself and was woken up by my spouse on my bicycle at home. In order to avoid causing more harm, we consulted our hospital. He has a history of hypertension and gastroptosis for 30 years and a history of coronary heart disease for 20 years. At present, he is treated with valsartan and domperidone, and his condition is under stable control. Personal history: Smoking history for more than 50 years, with an average of 30 cigarettes per day, which has been reduced to 10 cigarettes per day in the past 10 years. He has a history of drinking for more than 50 years, drinking 0.3~0.5 kg of liquor every day, and now he has quit for 7 years. Positive family history denied. CT of the brain showed: cerebral cavity foci, and EEG was normal. Initial diagnosis: sleep disturbance (sleepwalking).