Volume 96  ·  Issue 08  ·  2016

Prompt diagnosis and treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) can improve patients' symptoms and reduce related complications. Polysomnography (PSG) is the gold standard for diagnosing OSAHS, but because of its time-consuming, labor-intensive and long waiting time outside the hospital, many patients can't get timely diagnosis and treatment, and it is unrealistic to use its repeated monitoring to judge the progression and efficacy of the disease. Therefore, it is imperative to explore the biomarkers of OSAHS and find convenient indicators.

Obstructive sleep apnea (OSA) is a condition characterized by periodic or complete upper airway occlusion resulting in intermittent hypoxia, hypercapnia, and elevated intrathoracic pressure under ineffective breathing efforts. Repeated hypoxemia and hypercapnia occur at night, and then chemoreceptors are activated, resulting in excessive sympathetic nerve excitation and increased blood pressure. If it is not effectively treated for a long time, it will lead to the occurrence of atrial fibrillation (referred to as atrial fibrillation for short) or increased susceptibility to atrial fibrillation. The development of atrial fibrillation induced by OSA and the underlying mechanism of continuous positive airway pressure (CPAP) against atrial fibrillation are described below.

Major medical malpractice (which leads to the death of the patient or may be a medical malpractice above Grade II or leads to personal injury of more than 3 people is a major medical negligence act) causes serious damage to the patient, has profound lessons and great social impact, and the medical staff involved in the case will face the possibility of medical malpractice crime, which should be paid attention to by medical institutions and medical staff^[1]。 This article summarizes and analyzes the cases of major medical accidents and full liability identified by the National Medical Association in 2014, understands the occurrence law of major medical accidents, grasps their characteristics, finds out the key prevention links of medical risks, finds corresponding countermeasures, further improves medical treatment and prevents the occurrence of major medical accidents.

To compare the characteristics of polysomnography in preschool and school aged children with obstructive sleep apnea hypopnea syndrome (OSAHS).

The clinical data were collected from October 2009 to October 2013 among children monitored in Sleep Medical Center of West China Hospital. Among them, 189 preschool aged (aged 3-5 years) and 211 school aged (aged 6-13 years) children with sleep breathing disorder, and 33 children complained with sleep talking as controls were enrolled and underwent polysomnography. According to apnea hyponea index (AHI), they were classified as primary snoring (AHI<1/h), mild OSAHS (1/h≤AHI<5/h), and moderate/severe OSAHS (AHI≥5/h) and then their sleep architecture was compared among groups.

No significant difference was found in sleep latency, total sleep time, sleep efficiency, the percentage of rapid eye movement stage and N2 stage among groups (P>0.05). In preschool aged children, the percentage of N1 stage in the moderate/severe group was more than other three groups (moderate/severe group vs control group, primary snoring group, mild group: 24.7%±13.7% vs 17.0%±8.7%, 21.7%±12.4%, 20.9%±11.6%, allP<0.05). In school aged children, the percentage of N1 stage in the moderate/severe group was more than the control group (moderate/severe group vs control group: 18.0%±10.4% vs 12.0%±4.8%,P<0.05), the percentage of N3 stage in the moderate/severe group and the mild group were less than the control group (moderate/severe group, mild group vs control group: 28.3%±9.6%, 28.8%±8.8% vs 33.9%±13.0%, bothP<0.05). In addition, in preschool and school aged children group, the arouse index in the moderate/severe group was higher than other three groups, the mean oxygen saturation and the lowest oxygen saturation in the moderate/severe group were lower than those of the other three groups, the differences were statistically significant (allP<0.05). Correlation analysis suggested that no significant correlation was found between AHI and body mass index (BMI) in preschool children (r=-0.02, P>0.05). However, there was significance in school aged children (r=0.26, P<0.01). In addition, the correlations were significant between AHI and arousal index in preschool and school aged (r=0.42, 0.55, both P<0.01).

The sleep architecture is milder affected by OSAHS in preschool children than in school aged children. The severity is mainly related to enlarged tonsils and adenoids. School aged children with OSAHS may be more susceptible to sleep structure disorder and the severity is mainly related to BMI.

To study the risk factors contributing to the development of hypertension in patients with obstructive sleep apnoea hypopnea syndrome (OSAHS), and the clinical characteristics of OSAHS with hypertension.

A total of 2 397 OSAHS patients aged above 30 years old and diagnosed by the sleep-disordered breathing center of Guangxi between July 2012 and August 2015 were recruited. OSAHS patients with new-onset hypertension (OSAHS with hypertension group) and those without hypertension (simple OSAHS group) were identified and their clinical data, including general status, family history of hypertension or snoring, Epworth Sleepiness Scale (ESS) score for daytime sleepiness, physical examination findings, and polysomnography monitoring data were collected. OSAHS patients with new-onset hypertension (n=101) and OSAHS patients without hypertension (n=202) matched by age and body mass index (BMI) (age difference, 2 years; BMI difference, 1.5 kg/m²) were recruited in the OSAHS with hypertension group and the simple OSAHS group. A case-control study was used to compare the clinical characteristics of these two groups, and univariate and multivariate Logistic regression were used to analyze all the factors contributing to hypertension development besides age and BMI.

The average age and BMI of the OSAHS with hypertension group and the simple OSAHS group were respectively (46.2±9.3), (46.2±9.2) years old and (28.2±2.8), (28.2±2.8) kg/m². Patients in the two groups were well-matched with respect to age and BMI (P>0.05). The systolic blood pressure (SBP) and diastolic blood pressure (DBP) in the OSAHS with hypertension group were significantly higher than those in the simple OSAHS group at the first admission to the clinic and before and after the PSG examination. ESS values in the OSAHS with hypertension group and the simple OSAHS group were respectively 10.0±6.4 and 9.2±6.3 (P>0.05). There was no significant intergroup difference in neck circumference, waist circumference, duration of snoring, family history of snoring, and family history of hypertension (P>0.05) either. The apnea-hypopnea index (AHI) and apnea index (AI) in the OSAHS with hypertension group were higher than those in the simple OSAHS group (P<0.05); the longest apnea duration (LAD), mean apnea duration (MAD), and the total time spent with oxygen saturation below 90% (T90%) in the OSAHS with hypertension group were significantly longer than those in the simple OSAHS group (P<0.05). The minimal pulse oxygen saturation (MinSpO₂) in the OSAHS with hypertension group was significantly lower than that in the simple OSAHS group (P<0.05). Six factors were identified to be associated with OSAHS with hypertension through univariate analysis: AHI (OR=0.985, P=0.001), AI (OR=0.983, P<0.001), LAD (OR=0.955, P=0.013), MAD (OR=0.874, P=0.015), MinSpO₂ (OR=0.874, P=0.015), T90% (OR=0.997, P=0.036). Only MinSpO₂ (P<0.001,OR=0.894) was closely related to OSAHS hypertension development in the multivariate Logistic regression model.

OSAHS patients with hypertension may show lower MinSpO₂, higher AHI and AI, and longer LAD, MAD, and T90% than OSAHS patients without hypertension. MinSpO₂ is probably closely related to OSAHS hypertension development.

To investigate the effects of chronic intermittent hypoxia (CIH) on neuronal excitatory synaptic transmission in mice and explore their role in CIH-induced neurocognitive impairments.

Three-week old ICR male mice were randomly divided into three experimental groups, the unhandled control + vehicle group (UC+ VEH group), CIH exposure + vehicle group (CIH+ VEH group) and CIH exposure + memantine pretreatment group (CIH+ MEM group) (n=10 each), wherein 5 for electrophysiological recordings, 5 for Western blot. The CIH+ VEH and CIH+ MEM groups were exposed to intermittent hypoxia while UC+ VEH mice to room air for 8 hours per day for 2 weeks. Mice in the CIH+ MEM group were pretreated with intraperitoneal injection of memantine solution 5 ml/kg (concentration of 1 mg/ml) approximately 15 minutes prior to starting daily CIH exposure, and the other two groups were treated with equal saline as vehicle. Using the whole cell patch clamp technique to evaluate the amplitude and frequency of hippocampal neuronal spontaneous excitatory postsynaptic currents (sEPSC) and the electrophysiological characteristics, the western blotting method to measure the expression of N-methyl-D-aspartic acid receptor (NMDAR) subunit 2B (NR2B) and brain derived neurotrophic factor (BDNF) in hippocampus.

The neuronal spike threshold in CIH+ VEH group was depolarized compared to the UC+ VEH and CIH+ MEM groups ((-40.4±3.5) vs (-43.3±3.7), (-44.7±5.4) mV, both P<0.05). Furthermore, the frequency and amplitude of sEPSC in hippocampal CA1 neurons in CIH+ VEH group were significantly greater than the UC+ VEH and CIH+ MEM groups ((6.7±4.6) vs (3.6±1.7), (3.2±1.4) Hz, and (18.4±11.6) vs (13.0±2.5), (12.4±2.7) pA, bothP<0.05). The expressions of NR2B increased significantly in CIH+ VEH group compared to UC+ VEH and CIH+ MEM groups (1.46±0.14 vs 0.93±0.07, 0.95±0.10, bothP<0.01), whereas the expressions of BDNF decreased significantly in CIH+ VEH group versus UC+ VEH and CIH+ MEM groups (0.44±0.16 vs 0.86±0.08, 0.73±0.06, bothP<0.05). There was no statistical difference between UC+ VEH group and CIH+ MEM group for these electrophysiological and biochemical assessments.

Chronic intermittent hypoxia induces excitatory synaptic transmission abnormal, decreases neuronal excitability, and dysregulates NMDAR mediated signaling pathway, these changes may play an important role in CIH-induced neurocognitive impairments.

To study the clinical features of multiple myeloma (MM) patients with 1q21 amplification and the detection and biological characteristics of 1q21 copy number variation among different stages of plasma cell dyscrasias.

We analyzed the amplification and copy number variation of 1q21 in a cohort of 397 MM patients (290 newly diagnosed patients and 107 relapsed/refractory patients) in Institute of Hematology and Blood Diseases Hospital in the period between January 2009 and December 2012, using fluorescence in situ hybridization (FISH). We compared the incidence and biological characteristics of 1q21 gains among different stages of MM.

Among the newly diagnosed MM patients, the cases without 1q21 gains (148 cases) had difference prevalence of q13 deletion (38.3% (56/146) vs 57.7% (82/142), P=0.001), t(4; 14) translocation (17.4% (25/144) vs 30.7% (42/137), P=0.009), and high-risk cytogenetic abnormalities (28.3% (39/138) vs 41.9% (57/136), P=0.018), and International Staging System (ISS) stage (P=0.010) compared to those with 1q21 gains (142 cases); however, there were no significant differences in age(P=0.448), Durie-Salmon clinical stage (P=0.352) and β2-microglobulin level ( P=0.414). In the newly diagnosed patients, the incidence of this 1q21 aberration with the percentages of plasma cells involved being ≥10%, ≥20%, and ≥30% was 52.4% (152/290), 49.0% (142/290), and 46.2% (134/290), respectively, lower than that in the relapsed/refractory patients (71.0% (76/107), P=0.001; 68.2% (73/107), P=0.001; 63.6% (68/107), P=0.002). Differences were found between the newly diagnosed MM patients and the relapsed/refractory ones in terms of the incidence of 1q21 copy number gains being 2 (52.2% (145/278) vs 33.3% (34/102), P=0.001), but not in the incidence of 1q21 copy number gains being 3, 4, and >5 (all P>0.05).

Amplification of chromosome 1q21 is a common genetic abnormality in MM patients. The copy number varies in patients carrying 1q21 gains, mainly with two or more copies of 1q21. It may therefore be recommended to include testing for 1q21 gains in routine genetic testing of MM patients.

To detect the expression level of growth differentiation factor 11 (GDF11) in patients with myelodysplastic syndrome (MDS), and to evaluate the relationship between GDF11 level and erythropoiesis functions.

A total of 44 MDS patients (18 low-risk group patients and 26 high-risk group patients) in Department of Hematology in Tianjin Medical University General Hospital and 10 normal controls were selected from September 2014 to June 2015. The concentration of GDF11 in peripheral blood was detected using enzyme-linked immunosorbent assay (ELISA). GDF11 mRNA expression in bone marrow mononuclear cells (BMMNC) was detected using RT-PCR method. The percentage of erythroid cells (CD235a) in bone marrow was detected by flow cytometry. The correlation between these indexes and erythropoiesis functions (including red blood cell count (RBC), hemoglobin level (Hb), hematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), reticulocyte percentage (Ret%), and proportion of nucleated eryhrocyte in bone marrow) were evaluated.

(1) The GDF11 level in peripheral blood was significantly higher in high-risk group ((128.67±47.62) μg/L) than in low-risk group ((65.96±36.55) μg/L, P<0.01) and in normal controls ((29.76±10.10) μg/L,P<0.01), also significantly higher in low-risk group than in normal controls (P<0.05). The concentration of GDF11 in severe/moderate anemic MDS patients ((80.97±9.94) μg/L) was higher than that in normal controls/ mild anemic MDS patients((66.82±19.52) μg/L), but with no statistically significant (P>0.05). (2) The percentages of CD235a⁺ cells in high-risk and low-risk groups were 38.49%±5.42% and 42.64%±7.36%, respectively, showing no statistically significant difference (P>0.05). (3) In high-risk group, the GDF11 level in peripheral blood was negatively correlated with Hb, RBC and Hct in peripheral blood (r=-0.437, -0.430, -0.306, all P<0.05), and positively correlated with nucleated eryhrocyte, Ret%, MCV and CD235a⁺ cells in bone marrow (r=0.465, 0.392, 0.505, 0.387, all P<0.05), but not correlated with MCH and MCHC (bothP>0.05). In low-risk group, the GDF11 level in peripheral blood was positively correlated with CD235a⁺ cells in bone marrow (r=0.429, P<0.05), and not correlated with Hb, RBC, Ret%, MCHC, MCV, MCH, Hct and nucleated eryhrocyte (allP>0.05). (4) The mRNA expression of GDF11 in MDS patients (39.82±14.55) was higher than that in the controls (1.84±0.64,P<0.01).

GDF11 level in peripheral blood is higher in patients with MDS and increases with the disease risk. The more severe the anemia, the higher the GDF11 level. It may be closely correlated with erythropoiesis indicators in MDS.

To establish the classification of colorectal cancer recurrence patterns based on their relations to prognosis and recurrence.

A total of 463 patients with recurrent rectal cancer (Stage Ⅰ-Ⅲ) following curative resection in our hospital from June 2002 to June 2012 were included consecutively. Recurrence status, time, location, survival time after relapse, curability, symptoms and CEA level were recorded. The correlation between each recurrent pattern and recurrent survival (RS) rate were analyzed retrospectively. The survival curve was drawn by Kaplan-Meier method. The Log-rank test was used to test the significance. Univariate analysis was performed by using Cox proportional hazard model.

Patients with recurrence within one year, multiple metastases, symptomatic disease, elevated CEA level and unresectable recurrence had significantly lower RS rate than patients with recurrence after one year, solitary metastasis, asymptomatic manifestation, normal CEA level and resectable recurrence respectively. The hazard ratio were 1.34 (95%CI 1.02-1.76, P= 0.033), 1.41 (95%CI 1.04-1.91, P= 0.026), 1.74 (95%CI 1.05-2.88, P= 0.032), 4.06 (95%CI 2.11-7.85, P<0.001) and 1.99 (95%CI 1.34-2.97, P= 0.001) respectively.

Early recurrence (<12 months), multiple metastases, symptomatic, unresectable recurrence and elevated CEA indicate poor prognosis after relapse. This study provides a systematic basis for the classification of recurrence in colorectal cancer after radical resection.

To evaluate the effects of two kinds of individual extralevator abdominalperineal excision(ELAPE) on female pelvic floor biomechanics.

Four kinds of finite element model were developed: intact models, ELAPE models and two kinds of individual ELAPE models. The maximal stress and stress distributions of each model under the same pressure were analyzed and compared.

In the individual ELAPE models of dissection plane close to rectum on one side, non-levator ani tissue's maximal stress on levator ani partly reserved side and totally removed side were (3.114±0.129) and (4.856 ±0.128) MPa. The former were lower than the latter (P<0.01). They were both lower than those in ELAPE models which were (5.127±0.070) MPa (P<0.01), and were higher than those in intact model which were (1.963±0.061) MPa (P<0.01). In the individual ELAPE models of dissection plane close to pelvic on one side, non-levator ani tissue's maximal stress on both sides, which were (5.131±0.067) MPa, were similar to those in ELAPE models (P>0.05).

ELAPE of dissection plane close to rectum on one side is able to reduce the stress of non-levator ani tissue on both sides, especially on levator ani partly reserved side; conversely, ELAPE of dissection plane close to pelvic on one side may not reduce the stress of non-levator ani tissue on either side.

To explore the clinical application of automated digital image analysis in leukocyte morphology examination when review criteria of hematology analyzer are triggered.

The reference range of leukocyte differentiation by automated digital image analysis was established by analyzing 304 healthy blood samples from Peking University First Hospital. Six hundred and ninty-seven blood samples from Peking University First Hospital were randomly collected from November 2013 to April 2014, complete blood cells were counted on hematology analyzer, blood smears were made and stained at the same time. Blood smears were detected by automated digital image analyzer and the results were checked (reclassification) by a staff with abundant morphology experience. The same smear was examined manually by microscope. The results by manual microscopic differentiation were used as"golden standard", and diagnostic efficiency of abnormal specimens by automated digital image analysis was calculated, including sensitivity, specificity and accuracy. The difference of abnormal leukocytes detected by two different methods was analyzed in 30 samples of hematological and infectious diseases.

Specificity of identifying abnormalities of white blood cells by automated digital image analysis was more than 90% except monocyte. Sensitivity of neutrophil toxic abnormities (including Döhle body, toxic granulate and vacuolization) was 100%; sensitivity of blast cells, immature granulates and atypical lymphocytes were 91.7%, 60% to 81.5% and 61.5%, respectively. Sensitivity of leukocyte differential count was 91.8% for neutrophils, 88.5% for lymphocytes, 69.1% for monocytes, 78.9% for eosinophils and 36.3 for basophils. The positive rate of recognizing abnormal cells (blast, immature granulocyte and atypical lymphocyte) by manual microscopic method was 46.7%, 53.3% and 10%, respectively. The positive rate of automated digital image analysis was 43.3%, 60% and 10%, respectively. There was no statistic significance between two methods (χ² = 0.067, 0.271, 0.000, all P>0.05). Automated digital image analysis could be used to morphology examination with abnormal leukocytes and optimize review criteria of hematology analyzer.

Sensitivity and specificity of recognizing abnormal blood leukocytes by automated digital image analysis are satisfactory, which can be used as a tool of leukocyte morphology review when review criteria of hematology analyzer are triggered.

To evaluate the short-term efficacy and toxicity of Nimotuzumab combined with simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) in the treatment of locally advanced esophageal carcinoma.

Twenty-nine patients with esophageal carcinoma were treated with SIB-IMRT. Planning gross target volume (PGTV) was given at a dose of 60 Gy/2.4 Gy/25 F and planning target volume (PTV) was given at a dose of 50 Gy/2 Gy/25 F. Nimotuzumab was given by intravenous drip at the dose of 200 mg, once a week before radiotherapy. Short-term efficacy and toxicity were evaluated in all patients.

All patients completed the treatment successfully. Fourteen of them achieved a complete response (CR, 48.3%), 13 had a partial response (PR, 44.8%), 1 showed stable disease (SD, 3.6%), and 1 showed progressive disease (PD, 3.6%). The overall response rate (CR+ PR) was 93.1%. Most adverse reactions were radioactive esophagitis, radioactive dermatitis and bone marrow suppression (grade 1-2). Only 1 patient developed a slight skin rash.

Nimotuzumab combined with SIB-IMRT is a safe and effective modality for locally advanced esophageal cancer. The patient is well tolerated and worthy of further clinical study.

To investigate the causes of missed diagnosis in transrectal ultrasound-guided transperineal prostate biopsy.

The biopsy results of total 278 patients who received transrectal ultrasound-guided transperineal prostate biopsy from January 2012 to December 2014 in Subei People's Hospital were retrospectively analyzed, using 11 systemic divisions.

One hundred and twenty-nine patients were diagnosed with prostate cancer, and 149 patients were hyperplasia of prostate. Fifty-six patients with biopsy-negativeand obvious symptoms of lower urinary tract obstruction were underwent transurethral resection of the prostate. Four of which were found to be prostate cancer.

Early-stage prostate cancer, special prostate tumor location, inadequate biopsy tissue, special patients in limited position, and dissatisfied anesthesia may increase the risk of missed diagnosis. Targeted and individualized puncture may improve the effectiveness.

To investigate clinical value of serum IgG subclass distribution in differential diagnosis of autoimmune pancreatitis.

Inpatients were enrolled as follow, autoimmune pancreatitis (AIP, n=28), acute and chronic pancreatitis (ACP, n=112), pancreatic cancer (PC, n=15), cholangiocarcinoma (CC, n=9), retroperitoneal fibrosis (RPF, n=37), together with healthy controls (n=52). IgG subtypes, amylase, lipase, glucose and CA19-9 were tested.For patients with autoimmune pancreatitis and pancreatic cancer, radiographic CT of abdomen and pathological staining were included for comparison.

IgG4 subtype distributed in a wide range as 7.6(1.7-13.8)g/L in AIP, 0.4(0.2-0.7)g/L in ACP, 0.7(0.2-0.9)g/L in PC, 0.5(0.4-6.5)g/L in CC and 0.4(0.2-0.7)g/L in control group, the difference was significant(H=40.536, P<0.001). There were no significant differences of IgG1, IgG3 level in AIP , RPC and control group(allP>0.05). While IgG4 level was 7.6(1.7-13.8), 1.3(0.5-2.6), 0.4(0.2-0.7)g/L in AIP , RPC and control group, respectively. The difference was significant(H=36.833, P<0.001). IgG4 level in RPC group was lower than that in AIP group(P<0.05). And it was meaningful in the differential diagnosis.

Serum IgG4 subtype plays an important role in differentiation of autoimmune pancreatitis from associated diseases.

To evaluate the bias of three different methods in determination of glycated hemoglobin A₁c (HbA₁c).

According to Clinical and Laboratory Standards Institute(CLSI)EP9-A3 document, 40 serum specimens among linear range were tested by immunoturbidimetry assay (Roche Tina-quant), capillary electrophoresis (Sebia Minicap FP), high performance liquid chromatography system (HPLC, Trinity Biotech Premier Hb 9210™). Results were analyzed by pairwise comparision. The difference plots and scatter plots were analyzed. The results of outliers were examined by extreme studentized deviate (ESD) method. The best regression model was chosen to fit the regression equation and the biases were calculated at the level of medical decision and judged the comparability according to the half of Tea acceptance standard.

Scatter plots and ESD results showed good correlation among test results of 40 samples, no abnormal values were found. Based on proportional difference deviation plots, proportional difference rank order deviation plots, numerical deviation plots and ranked order difference plots, weighted least squares(WLS)(Roche(X)vs sebia(Y₁)), ordinary linear regression (OLR)(Roche(X)vs Trinity (Y₂)) and Deming (Sebia(Y₁)vs Trinity(Y₂))were chosen to fit regression analysis model. The regression equations were Y₁ =-0.420 3+ 1.052 7X, Y₂ =-0.174 0+ 1.027 0X, Y₂=0.423 1+ 0.959 0Y₁, respectively. Assuming the HbA₁c medical decision points of 10%, 16% to regression equation, the proportional biases were 1.06% and 2.61% at Roche(X)and sebia(Y₁) system, 0.96% and 1.60% at Roche(X)and Trinity (Y₂) system, 0.13% and -1.47% at Sebia(Y₁)and Trinity(Y₂)system respectively, which were all lower than the acceptable values.

The measurement values of HbA₁c by capillary electrophoresis (Sebia Minicap FP), HPLC (Trinity Biotech Premier Hb 9210™ ) and immunoturbidimetry assay (Roche Tina-quant ), are comparable.

To explore the method of cheek blood sampling in mice in continuous blood test.

Cheek blood sampling was carried out in 10 9-week-old mice once every 2-3 days. The volumes of blood samples were recorded. Reactions of the mice were observed.

Cheek blood sampling collected 0.3-0.6 ml of blood every time, and did not affect the normal activities of the mice. The blood sampling could be repeated every 2-3 days.

Cheek blood sampling has several advantages including being capable to draw adequate blood, simple and easy to operate, well tolerated, and ethical in treating laboratory animals.

Adrenocorticotropic hormone (ACTH) is an important hormone for maintaining the normal morphology and function of the adrenal gland, and its function is regulated by the pituitary adrenal system. At the same time, the function of adrenal cortex is regulated by the adrenal medulla. Under physiological conditions, hypothalamus, pituitary gland and adrenal gland (HPA axis) are in relatively dynamic balance. HPA axis is the most important self-stabilizing system in the body, and HPA axis is active under stress state, which promotes the body to produce stress response^[1,2]。 The clinical detection of ACTH is an important indicator for the diagnosis of Cushing's disease and anterior hypopituitary function^[3,4]Therefore, the accuracy of patient test results directly affects clinicians' diagnosis and treatment of diseases. According to the experimental requirements and relevant data report of ACTH detection^[5]Immediately after blood collection, dipotassium ethylenediaminetetraacetate (EDTA-K₂) The sampling tube was stored in ice water, centrifuged at low temperature, and the plasma samples were separated and tested within 22 ℃ for 2 h. It can be seen that the storage time and temperature of specimens after collection are very important for ACTH detection. In actual work, due to workflow and other factors, the submission of specimens for inspection may be delayed, and the requirements stipulated in the experiment cannot be met. The purpose of this study is to understand the influence of clinical specimen storage time and temperature on ACTH determination.

A 48-year-old female patient went to the Department of Gastroenterology of a hospital in Beijing in February 2013 due to weight loss. Blood test routine: white blood cells 99×10⁹/L, hemoglobin 88 g/L, mean erythrocyte volume 78 fl, mean erythrocyte hemoglobin 24.2 pg, mean erythrocyte hemoglobin concentration 311 g/L, platelet count 249×10⁹/L, considering hematological diseases, visited the Institute of Hematology of Peking University. Morphology of bone marrow cells: bone marrow hyperplasia grade III, active granulocyte hyperplasia, 4% blast cells, high proportion, high proportion of middle and late granulocytes, 21% middle and late granulocytes, 20% late granulocytes, eosinophils and basophils can be seen, and 1% mature plasma cells can be seen. Bone marrow cell immunotyping: Abnormal myeloid phenotype. Myelocytes accounted for 83.38%, and some cells expressed CD56 with abnormal phenotype; Basophils accounted for 6.30% and eosinophils for 2.82%. Bone marrow cell genotyping: BCR-ABL (P210) fusion gene =102.0% (normal value is negative), PRAME gene =0.7% (normal value is<0.3%), WT1 gene =6.7% (normal value is<0.6%), JAK2-617 site mutation was negative, and MPLW515L/K mutation tested negative. Karyotyping G banding: 46, XX, t (9; 22) [20]。 He was diagnosed as chronic myeloid leukemia (CML) in the chronic phase and started oral imatinib mesylate (trade name: Gleevec) 400 mg daily treatment in May 2013.

With the widespread use of imaging technology, the detection rate of adrenal calcification is increasing, and a variety of adrenal diseases such as tumor and hemorrhage can cause secondary adrenal calcification^[1]Primary adrenal calcification is clinically rare. In June 2015, a patient with primary giant adrenal calcification was admitted to the Department of Urology, the First Affiliated Hospital of Guangxi Medical University. The diagnosis and treatment results are reported below.

The patient, a 58-year-old male, went to the local hospital on April 26, 2013 due to "cough, expectoration and fever for 3 months". CT examination showed "multiple nodules in both lungs, considering the possibility of metastasis", but he was not admitted to hospital for treatment. After returning home, he received intravenous "anti-infective treatment" in the local infirmary, and his symptoms improved significantly. In order to confirm the diagnosis, the patient was admitted to Zhejiang Cancer Hospital on May 7th of the same year. Positron emission computed tomography (PET-CT) examination showed that "multiple round nodules were scattered in both lungs, which were considered to be multiple metastases in the lungs". Fine needle puncture was performed in the left lung, and the pathological report was "a small number of columnar epithelial cells; no tumor basis was found". He came to our hospital on July 24th, and underwent "thoracoscopic exploration + thoracotomy wedge resection of right lung nodule" on July 31st. Intraoperative observations: dense thoracic adhesions with pleural calcification and multiple nodules in both lungs. Postoperative pathological examination: A piece of wedge-shaped lung tissue, about 6.0 cm ×3.0 cm ×2.0 cm in size, multiple gray-white nodules with a diameter of 0.1~0.5 cm were seen on the section, with medium quality and clear boundary. Microscopic observation: The tumor cells were round or polygonal, with abundant cytoplasm, translucent or eosinophilic, round or elliptical nucleus, no mitotic image, no obvious abnormality, interstitium rich in thin-walled blood vessels, and no necrosis (Figure 1)。 Immunohistochemical test results: Anti-melanoma specific monoclonal antibody (HMB-45) (FIG. 2A), vascular endothelial cell marker (CD34) (Figure 2B), vimentin were all positive, melanin A (Figure 2C), common acute lymphoblastic leukemia antigen (CD10) is partially positive; Broad-spectrum cytokeratin (CK), thyroid transcription factor 1 (TTF-1), acid calcium binding protein (S-100), chromaffin A, neuronal adhesion factor (CD56), neuron-specific enolase (NSE) and synaptophysin were all negative; Proliferating cell nuclear antigen (Ki-67) is low proliferative activity (Figure 2D)。 Periodate Schiff staining (PAS staining) was partially positive (Figure 3)。 Pathological diagnosis: Multiple clear cell tumors of the lung (CCTL).

Organ transplantation is the preferred treatment option for end-stage liver disease. However, the lack of donor liver has prompted many transplant medical institutions to turn back to cardiac death donor (DCD) donors in an attempt to expand the scope of donor liver access. The first DCD donor liver transplantation was carried out long before Harvard announced the definition of brain death, but the recipient survival rate was low at that time. It was not until the early 1990s that occasional liver transplantation with DCD donor livers began, but the results were poor. In view of the lack of brain dead donors and the high risk of living donor liver transplantation, it is urgent for people to re-discuss and weigh the advantages and disadvantages of DCD donor liver transplantation, so as to make it an important way to obtain donor liver in the future.

Macrophages are important components of human body's natural immune system, usually originating from peripheral blood mononuclear cells, circulating to tissues through blood, and having functions such as phagocytosis, antigen presentation, cytotoxicity and tissue remodeling. Some macrophages are distributed in the interstitial of lymphoma tissues, which are the main components of lymphoma microenvironment, and are called lymphoma-associated macrophages (Lymphoma-Associated macrophage, LAM). LAM promotes tumor growth by promoting lymphoma cell proliferation, invasion, and angiogenesis; It can also secrete cytokines such as interleukin (IL) 10 to induce immune tolerance to tumor cells.