Volume 96  ·  Issue 29  ·  2016

Shock is a clinical manifestation of circulatory failure caused by cellular oxygen utilization disorder, and it is one of the most common clinical syndromes in critically ill patients^[1]。 Approximately 1 in 3 patients in the Critical Care Medicine Unit (ICU) develop shock^[2]。 The most critical in shock treatment is early detection of shock, definition of the type of shock, and dynamic monitoring of circulating hemodynamic information feedback therapy. In the treatment of shock, if further hemodynamic assessment is required, echocardiographic methods are preferred^[3,4]。 How to detect shock early by severe ultrasound, distinguish the type of shock and make dynamic evaluation has become the focus of clinical attention. China Critical Ultrasound Research Group (CCUSG) put forward a six-step shock assessment process guided by critical ultrasound on the basis of previous clinical research observations and clinical practice experience of critical ultrasound. Its core connotation is to follow the laws of hemodynamics, along the inferior vena cava, right ventricular function, left ventricular systolic function, left ventricular diastolic function and arterial tension. The value of the severe ultrasound-guided six-step evaluation process applied to the management of shock patients is that it can simply and quickly evaluate the patient's flow status, preload and volume responsiveness, cardiac function, peripheral vascular resistance, tissue perfusion and other all-round hemodynamic information, accurately guide clinical treatment^[5]。 Now, the precision shock treatment and how to carry out the six-step shock assessment process guided by ultrasound for severe cases are analyzed.

Spondyloarthritis (SpA) is a group of interrelated chronic inflammatory diseases characterized by inflammation of the spine, peripheral joints, and tendon attachment points, of which ankylosing spondylitis (AS) is the representative. SpA can be divided into central axial type and peripheral type according to its main affected site. Fibromyalgia (FM), often called fibromyalgia syndrome in China, is a disease characterized by chronic extensive pain and obvious physical discomfort in the whole body, often accompanied by fatigue, sleep disorders, morning stiffness, depression, anxiety and other mental symptoms. The concept and diagnostic criteria of FM are constantly evolving and changing^[1,2]It is currently believed to be a pain amplification syndrome caused by central nervous system sensitization^[3]。 FM is more common, with a prevalence of 2% to 6.4% in the general population, and only lower in rheumatic diseases than osteoarthritis^[4,5,6]。 There are many similarities in the clinical manifestations of SpA and FM. Both may have symptoms such as pain and stiffness of spinal limbs, fatigue, depression and sleep disorders, which makes the two diseases difficult to distinguish in some cases and thus misdiagnosis. In recent years, there is an increasing number of misdiagnoses of somatized symptoms of low back pain such as FM or depression or anxiety as SpA in China^[7]And it is not uncommon abroad^[8]。 However, the treatment methods of the two diseases are very different, and the prognosis is completely different, so it is important to correctly identify the two diseases clinically. In addition, long-term physical pain and functional limitation, psychological burden on prognosis and financial burden of treatment often lead to depression and anxiety in patients with SpA, especially AS^[9]Low back pain at night severely affects sleep quality^[10,11]All of these lead to SpA prone to FM, with an incidence of 12.6% ~15%^[12,13,14]While it is higher for women, up to 31.3%^[14]。 For such patients, the efficacy of SpA treatment alone is not ideal, and the efficacy of simultaneous treatment of two diseases is better. Therefore, it is clinically important to accurately identify comorbidities between SpA and FM.

To evaluate the prognostic value of combination of plasma brain natriuretic peptide(BNP) with the ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity(E/E′) in the patients with septic shock.

From June 2012 to December 2013 , 127 patients with septic shock were consecutively recruited and underwent trans-thoracic echocardiography examination within 6 h after admission to Intensive Care Unit(ICU), Zhejiang Provincial People′s Hospital. Plasma BNP concentration was measured using ELISA method. All Clinical, laboratory, and survival data were prospectively collected.

Of 127 patients enrolled, mean values for age were(59.9±17.3) years and APACHE Ⅱ score(16.8±5.8), respectively. 95 patients(74.8%) took mechanical ventilation. 28- , 60-day mortality rate was 36.3% and 42.3%, respectively. Univariate Cox regression analysis showed that age, coronary artery disease, serum creatinine and lactate, plasma BNP, left ventricular ejection fraction(LVEF), E/E′ and APACHE Ⅱ score were significantly(P≤0.05) associated with 60-day mortality. Multivariate analysis revealed that serum lactate, plasma BNP(χ²=9.4, P=0.002) , E/E′(χ²=4.89, P=0.02) and APACHE Ⅱ score(χ²=10.6, P=0.001) remained independent predictors for 60-day mortality. ROC curve analysis showed that the optimal plasma BNP and E/E′ cutoff values identified were 338.8 pg/ml and 10.8, and the areas under ROC curve were 0.89(sensitivity: 83.7%; specificity: 81.4%)and 0.83(sensitivity: 76.7%; specificity: 72.9%)for 60-day mortality, respectively. In addition to plasma BNP and clinical predictors, the E/E′ could provide in independent and incremental prognostic value of 60-day mortality(χ²=59.3 vs 47.8, P<0.001).

Plasma BNP and E/E′ are independent predictors for 60-day mortality, and combination of plasma BNP and E/E′ could improve risk stratification in patients with septic shock.

To compare the efficacy and safety of micafungin with caspofungin for the empirical treatment of severe intra-abdominal infections in surgical intensive care patients.

This was a retrospective cohort study.From May 1 st 2012 to April 30 2015, 47 patients with severe intra-abdominal infection complicated with specific risk of Intra-abdominal invasive candidiasis (IAC) receiving empirical treatment of echinocandins were enrolled in Department of Critical Care Medicine, Peking University First Hospital. Micafungin and caspofungin substituted each other every six months. The baseline information, risk factors of IAC, characteristics of intra-abdominal infections, antifungal treatment and other intra-abdominal infections(IAI) related treatment information, clinical outcome were collected and compared between the micafungin and caspofungin groups.

Forty-seven patients met inclusion/exclusion criteria. The average score of APACHE Ⅱ was (19.0±7.7), the incidence of IAC was 23.4%. The patients were divided into the micafungin group (n=26) and the caspofungin group (n=21). The average therapeutic course was 10 (5, 13) days.There were no significant differences in the baseline information, risk factors of IAC, characteristics of intra-abdominal infections and other IAI related treatment informations between the two groups. SOFA score, body temperature, persistence of extra-gastrointestinal fungal colonization significantly improved from the baseline in both groups. The leukocyte count decrease was different between the micafungin group and the caspofungin group respectively[(12.5±5.4)10⁹/L vs (9.8±4.3) 10⁹/L, P=0.013; (12.9±5.4) 10⁹/L vs (10.4±4.7) 10⁹/L, P=0.134]. There were no significantly differences in the recovery of GI function, the incidence of breakthrough IC, the incidence of newly developed organ failure, the 30-day mortality, the length of ICU stay and hospitalization period or the incidence of alternative antifungal therapy between the micafungin group and the caspofungin group. No drug-related adverse event requiring echinocandins discontinuation occurred.

The empirical treatment of echinocandins for patients with severe intra-abdominal infection and specific risk factors of IAC may be effective. The empirical treatment of micafungin and caspofungin were equally effective and safe.

To evaluate the feasibility of method of bedside ultrasound to confirm correct nasointestinal tube placement of critical patients.

From June 2015 to February 2016 , a total of 70 patients admitted to Emergency Intensive Care Unit, Zhejiang Provincial People′s Hospital, 37 males and 33 females, using bedside ultrasound(vessels signe) to confirm the location of nasointestinal tube at different site of digestive tract, and then comparing with the traditional methods, the point-of-care systems.

Auscultatory method and aspirates from tube method have lower sensitivity(78.6%, 72.7%) and specificity (25.0%, 75.0%) ; bedside ultrasound(vessels signe) method sensitivity (100%), accuracy (100%) , positive predictive value(100%), negative predictive value(100%) and precision ratio are all higher than auscultatory method and aspirates from tube method, the difference was statistically significant(P<0.05).

The bedside ultrasound vessels signe method has more advantages in confirming the location of the tubes at sensitivity , accuracy , specificity and positive predictive value than the traditional methods.

To investigate the effects of rosiglitazone on the structure of the kidney of rats in sepsis with acute kidney injury.

Sepsis models were established using male Sprague-Dawley rats by cecal ligation puncture (CLP). 96 healthy rats were randomly divided into 4 groups: cecal ligation puncture and rosiglitazone group (group CLP+ ROSI), cecal ligation puncture group (group CLP), Sham and rosiglitazone group (group Sham+ ROSI), sham group (group Sham). Six rats were sacrificed at 0, 6, 12, 24 h after CLP respectively in each group. The general status of rats was observed and H&E staining was applied to detect renal pathological histology changes. Myeloperoxidase(MPO) was measured in kidney tissues. Expression of the ligand of peroxisome proliferators-activated receptor γ (PPARγ), and B-cell lymphoma-2(Bcl-2) were also determined by Western blot analysis.

The increased MPO activity of group CLP+ ROSI was significantly lower than that of group CLP at 12 h and 24 h[(4.07±0.16)vs(4.62±0.08); P₁₂=0.01, P₂₄=0.006]. The MPO activity of group CLP was significantly higher than that of group Sham at 6, 12 and 24 h[(4.62±0.08)vs(1.30±0.06); P₆=0.00, P₁₂=0.00, P₂₄=0.00]. The MPO activity of group CLP+ ROSI was significantly higher than that of group Sham+ ROSI at 6, 12 and 24 h[(4.07±0.16)vs(1.27±0.06); P₆=0.00, P₁₂=0.00, P₂₄=0.00]. Compared with group Sham and group Sham+ ROSI, in rats of group CLP and group CLP+ ROSI the symptoms of sepsis and organ dysfunction were observed. The symptoms of sepsis and organ dysfunction of group CLP+ ROSI were significantly reduced than that of group CLP. Expression of PPARγ and Bcl-2 were determined by Western blot analysis, the expression of PPARγ and Bcl-2 of group CLP+ ROSI was significantly lower than that of group CLP.

Rosiglitazone, as the ligand of PPARγ, reduced the inflammatory response in sepsis, decreased the apoptosis of kidney cell, reduced kidney injury, and protected acute kidney injury in rats of sepsis.

To summarize surgical experience during the conduction of robotic mitral valve repair and evaluate the long-term follow-up results.

From January 2007 to September 2014, 110 consecutive patients underwent robotic mitral valve repair under da Vinci Surgical System (Intuitive Surgical, USA) in Chinese PLA General Hospital were enrolled. The age of the patients was 14 to 65(45±12) years old. The male to female ratio was 2.3∶1. Among them, 95.5%(105/110) of the cases was diagnosed as mitral regurgitation and 4.5%(5/110) of them was diagnosed as mitral stenosis, and most of them (63.3%) needed triangular or quadrangular resection. Nitinol U-clips (58.1%), running suture (31.2%) and Cor-Knot™ suture device (10.8%) were used to secure the annuloplasty ring. The operative data were collected and patients were regularly followed up echocardiographically as long as 7 years.

All the surgeries were finished by the same surgeon. One case required conversion to sternotomy. The mean cardiopulmonary bypass (CPB) and cross-clamp time was 70 to 152 (121.0±34.3) and 47 to 122 (82.6±25.3) minutes respectively. After surgery, one death (0.91%) and two cases of stroke (1.82%) occurred. Three cases of early prosthetic failure (2.73%) were noticed. All patients were successfully followed up for a median of 50 (range, 1 month to 7 years) months and 94.5%(104/110) of them had no re-operation.

Robotic mitral valve repair is a safe and effective surgical method with excellent long-term outcomes.

To explore the growth pattern of appropriate for gestational age (AGA) infants of mother with gestational diabetes mellitus (GDM).

The objects of this study were offspring of women who delivered in our hospital from January to December 2011. The GDM group included 70 AGA infants (36 male cases and 34 female cases) of mother with GDM. The control group included 154 AGA infants (66 male cases and 88 female cases) of women with normal glucose tolerance. The data of demographic characteristics of mothers of two groups were collected. Body weight and length of infants in two groups were measured at 3, 6 and 12 months age respectively. Body mass index (BMI), weight and height gain during infancy (0-3 months, 3-6 months and 6-12 months) of infants in two groups were also calculated.

Body weight, length and BMI of male AGA infants in GDM group were less than that of control group at 3 months and 6 months age, but more than that of control group at 12 months age, however, there were no significant differences between two group(P>0.05). The weight and height gain during infancy (0-3 months, 3-6 months) of male AGA infants in GDM group were lower than that of control group, but the difference was statistically significant only at 3-6 months[(1.1±0.4) vs (1.4±0.4) kg,P=0.040; (4.9±2.3) vs (6.3±1.2) cm, P=0.026]. The weight and height gain during infancy (6-12 months) of male AGA infants of gestational diabetic mothers were higher than that of control group, but the difference was not statistically significant[(2.1±0.5) vs (1.8±0.5) kg, P=0.361; (8.4±1.3) vs (7.8±1.4) cm, P=0.464].

Male infants of gestational diabetic mothers grew slowly during their infancy of 0-6 months, and then their growth became increasingly fast, which suggested that the influence of intrauterine hyperglycemia environment of GDM mothers on fetal growth might continue after birth.

To explore the effects of five different therapy in women at early stage of menopause on menopausal symptoms, quality of Life and cardiovascular risk factors.

A total of 140 women at early stage of menopause were randomly divided into five groups. Thirty women took Conjugated estrogen and medroxyprogesterone acetate(CEE+ MPA) sequential therapy, 27 women took estradiol valerate and medroxyprogesterone acetate(E₂V+ MPA) sequential therapy, 26 women took estradiol valerate and Progesterone Soft Capsules(E₂V+ P) sequential therapy, 30 women took Kuntai capsule, and 27 took Cohosh extract.Patients in the Menopausal Hormone Therapy(MHT) groups took twelve cycles of treatment course, in the botanical drug and Chinese patent drug groups took twelve months. The KMI scalewas used to measure the level of menopausal symptoms. MENQOL scale was used to measure the health-related quality of life before and at the 3^rd month, 6^th month, 9^rd month and 12^th month after the treatment. Some serological indicators which related to cardiovascular risk factors were collected before and at the 12^th month after the treatment.

(1) KMI: It showed that the KMI in five groups after the treatment were significantly different(P<0.01), the group of CEE+ MPA decreased most(13±1). The KMI after the treatment were all significantly lower than that before. (2)MENQOL: It showed that the MENQOL in five groups were significantly different(P<0.01), the group of CEE+ MPA decreased most (84±3), then the group of Kuntai(85±3). The MENQOL after the treatment were all significantly lower than that before. (3)The change of cardiovascular risk factors: it showed that the serological indicators FBGin group of CEE+ MPA after the treatment were significantly lower than that before(P<0.05); the TC, LDL, FI in group of E₂V+ MPA after the treatment were significantly lower than that before(P<0.05); the FBG, FI in group of E₂V+ P after the treatment were significantly lower than that before(P<0.05).

The MHT, botanical drug and Chinese patent drug have great clinical curative effects in treating perimenopause syndrome, improving the health-related quality of life and decreasing risk factors of cardiovascular disease.With rare adverse events and good clinical medication safety, they could be widely applied to clinic to women at early stage of menopause who was suffering menopausal symptoms.

To explore the clinical effect of different surgical methods in the treatment of cesarean scar pregnancy, the decline trend of human chorionic gonadotropin (hCG) and the indications of different treatment methods.

This study was a prospective cohort study. The clinical data of 120 patients with cesarean scar pregnancy who were treated with four different surgical methods in the Beijing Obstetrics and Gynecology Hospital from June 2013 to December 2014 were collected. Seven cases ultrasonic curettage, 63 cases uterine arterial embolization (UAE) with hysteroscopic pregnancy embryo removal surgery, 41 cases UAE + B-ultrasound or laparoscopic monitoring hysteroscopic pregnancy embryo clearance surgery and 9 cases UAE + hysteroscopic and laparoscopic removal of pregnancy scar and uterine repair. The clinical efficacy of different surgical methods and the decrease trend of serum HCG in postoperative period were analyzed.

(1)The levels of serum beta hCG in patients with cesarean scar pregnancy after different surgical treatments decreased (84.5±9.7)%, (97.7±3.2)% and (99.6±1.2)% after the 2 days, 7 days and 14 days respectively. The average time of blood beta hCG level dropped to normal was (22.4±6.7) d. (2)There was a significant difference in the amount of bleeding and the time of hospitalization among the patients treated with different surgical methods. (3)There was a significant difference in the analysis of the decline percentage rate of serum beta hCG under the interactive effect between different surgical methods and postoperative recovery time (P<0.01).

The level of serum beta hCG in patients with cesarean scar pregnancy were reduced to normal range after 3 weeks of operation. The choice of surgical approach should be based on the degree of implantation of embryo sac scar, the thinnest muscle thickness, local blood flow, serum beta hCG levels, gestational sac size, process to the bladder and fertility desire to determine.

To apply amide proton transfer magnetic resonance imaging (APT-MRI) technique to acute ischemic stroke, and to discuss clinical values of the APT-MRI main parameter - MTRasym(3.5 ppm).

A total of 18 emergency admitted patients, with acute ischemic stroke from Beijing Hospital, were recruited from March to November 2015. Eventually, 18 patients (male 14, female 4, average age 72 years old, age ranged from 52 to 92 years, symptom onset ≤24 hours, 2 patients≤ 6 hours) were included in this study. All patients underwent MR scanning on the brain at 3.0 Tesla. Besides the conventional scans for stroke, the APT sequence (saturation time 0.8 s, saturation power 2 μT) was performed. APT weighted (APTW) images were calculated using magnetization transfer ratio asymmetry at 3.5 ppm with respect to water. MRI signals in APTW, diffusion weighted images (DWI) and fluid attenuated iversion recovery (FLAIR) were visually evaluated. Shapiro-Wilk tests were performed to find out the distribution of MTRasym(3.5 ppm) in the whole sample, infarction regions, and normal appearing white matter (NAWMs), respectively. Detrended normal P-P plots were also used to evaluate its normality. Paired-t test and two-sample t test were applied to compare the mean MTRasym(3.5 ppm) of infarction regions with that of contra lateral NAWMs.

(1) High signal intensity was observed in DWI and FLAIR in all 18 patients. However, signal intensity was somewhat different in APTW. 13 patients were found decreased APT effect, and 5 patients were with equal APT effect in infarction regions. In NAWMs, 14 patients were found equal APT effect, and 4 patients were with decreased APT effect. (2) MTRasym(3.5 ppm)s were proven, with Shapiro-Wilk test, to distribute normally within the whole sample (W=0.964, P=0.288), infarction regions (W=0.962, P=0.645), and NAWMs(W=0.929, P=0.187). However, its normality was not so satisfactory due to greater deviations (absolute value>0.06) of some cases in detrended normal P-P plots. (3) Paired-t test analysis showed that MTRasym(3.5 ppm) in infarction regions (-0.035%±1.020%) was significantly lower than that in NAWMs (0.386%±0.790%) (t=-2.273, P=0.036). However, there was no statistically significant difference between infarction regions and NAWMs when two sample t-test was performed (t=-1.386, P=0.175).

MTRasym(3.5 ppm) can be used to evaluate acute ischemic stroke with a broad future scope in clinical.

To observe the effects of functional electrical stimulation(FES) based on normal gait pattern on walking function in subjects with recovery of stroke.

From December 2010 to January 2013, 58 patients with recovery of stroke were recruited from the Rehabilitation Medicine Departments of Sun Yat-sen Memorial Hospital and the Guangdong Provincial Traditional Chinese Medicine Hospital. And the Minimize software was used to divide them randomly into 1 of the 3 groups: four-channel FES group (n=29), single-channel FES group (n=15) and placebo electrical group (n=14) at the rate of 2∶1∶1. All received standardized rehabilitation program. The four-channel FES group received four-channel FES treatment based on normal gait pattern, the single-channel FES group received single-channel FES treatment, the placebo electrical group received the same electrical stimulation as the four-channel FES group, but without current output when stimulating. Stimulation lasted for 30 min/d, 1 session / d, 5 d/w for 3 weeks. All subjects in the three groups received Fugl-Meyer Assessment scale (FMA), Berg Balance scale (BBS), gait speed during a 10-meter walking test, muscle co-activation index (CI) of the lower extremity during walking and the Modified Barthel index (MBI) assessments before and after 3 weeks treatment.

Before treatment, the FMA, BBS and gait speed during a 10-meter walking test of the four-channel FES group were (23.0±2.2), (31±71) and (0.23±0.10), respectively. After 3 weeks treatment, the scores were improved to (28.4±1.5), (42±6)and(0.43±0.09), respectively. And the FMA, BBS and gait speed during a 10-meter walking test of the ingle-channel FES group increased from (21.9±3.4), (31±6) and (0.24±0.09) to (26.6±1.8), (38±5) and (0.34±0.08), respectively. The placebo electrical group increased from (23.6±3.0), (33±5) and (0.25±0.09) respectively to (26.0±2.4), (36±4) and (0.29±0.08). And the FMA, BBS and gait speed during a 10-meter walking test of the three groups were significantly higher than those in pre-treatment (P<0.05), and the scores in four-channel FES group were significantly higher than the single-channel group and the placebo electrical group′s (P<0.05). The MBI score of the three groups were all improved, but it didn′t show difference among the three groups (P>0.05). The results of surface electromyography showed significant decrease in CI of quadriceps / hamstring of the 3 groups, and the four-channel FES group had more significant decrease than the other two groups (P<0.05).

Functional electrical stimulation based on normal gait pattern could improve walking function in subjects with recovery of stroke.

Insular and opercular cortex is involved in complicated physiological function.Insular seizures involve extensive epileptic network, which results in the complex and diverse semiology.Electrical cortical stimulation(ECS) can explore the functional mapping and symptomatogenic zone.

The clinical presurgical evaluation and ECS data of 20 patients whose electrode contacts were located in the insular and opercular were analyzed retrospectively.CT scan/3D MRI data fusion was performed in order to accurately identify and locate each contact and check the electrode trajectory by the MRI images performed after the electrodes were removed.ECS was applied between two contiguous contacts.Stimulation usually lasted for 5 s at 50 Hz(pulse width=0.3 ms). Depending on the area of stimulated cortex, the stimulation intensities ranged from 0.2 to 3.0 mA.The classification of the insular were anterior short gyrus, middle short gyrus, precentral gyrus, postcentral gyrus, posterior long gyrus and insular pole.The classification of the opercular were orbital, frontal, precentral, central, parietal and temporal opercular.

One hundred and six contacts were located in the insular and 51 responses were evoked (48.11%). Four hundred eighteen contacts were located in the insular and 132 responses were evoked (31.58%). We classified the principal responses as somatosensory, pain, auditory, oropharyngeal, speech disturbances and neurovegetative response.Somatosensory responses were mainly evoked in parietal opercular and postcentral gyrus, while pain response distributed sporadically.Auditory were only evoked in temporal opercular(transverse temporal gyri) and posterior long gyrus.Oropharyngeal symptoms were only evoked in central opercular.Speech disturbances were located in precentral and central opercular and neurovegetative responses were mainly evoked in insular pole and middle short gyrus.

These findings may indicate a functional specificity for the insular gyrus and opercular, which contribute to the understanding of anatomo-functional organization and the role in insular and opercular epileptic network.Moreover, it could optimize the implantation strategy for exploring these structures.

To report the clinical and myopathological features of 16 patients with Jo-1 syndrome.

Sixteen patients were recruited in this study, who were diagnosed as Jo-1 syndrome in Department of Neurology of Peking University First Hospital from January, 2011 to July, 2015. The clinical data and myopathological data were analyzed.

The mean onset age was 41±14 (21-68) years old. 87.5% was female. The median duration was 9.5 months (1-192 months). The main clinical manifestations were weakness in 13 cases (81.2%), arthritis in 10 cases (62.5%), interstitial lung diseases in 8 cases (50%), dermatomyositis-like skin lesions in 5 cases (31.2%), fever in 3 cases (18.8%), Raynaud′s phenomenon in 2 cases (12.5%) and mechanic′s hands in 2 cases (12.5%). There were 3 cases with other connective tissue diseases and 1 case with non-Hodgkin′s lymphoma. Mean serum CK was 3 054±2 058(470-5 222) U/L. All patients had anti-Jo-1antibody, combined with anti- Mi-2 antibody in 1 case, anti-Ro-52 antibody in 5 cases, and anti-nuclear antibody in 5 cases. 4/5 cases showed myopathic changes for electromyography (EMG) tests. Myopathological changes included edema, fragmentation and inflammatory infiltration in perimysium in 14 cases (87.5%), muscle atrophy in 13 cases including 7 cases(43.8%) predominantly in perifascicular field. Muscle fiber necrosis appeared in 8 cases with predominantly in perifascicular area in 4 cases (25%). Muscle fiber regeneration occurred in 11 cases with predominantly in perifascicular field in 5 cases (31.2%). CD8 positive T-lymphocytes, CD20 positive B-lymphocytes and CD68 positive macrophages infiltrated in various degrees, most of which were located in perimysium. MHC-Ⅰ were expressed on muscle fiber membranes in different degrees, including 7 cases (43.8%) predominantly in the cytoplasm of perifascicular muscle fibers. C5b-9 deposited in perifascicular muscle fiber membranes in 7 cases (43.8%) and perifascicular capillaries in 2 cases (12.5%).

The main manifestations of this group of Jo-1 syndrome are weakness, arthritis and interstitial lung diseases, and dermatomyositis-like skin lesions, fever, Raynaud′s phenomenon, and mechanic′s hands can also be seen. Edema, fragmentation and inflammatory infiltration in perimysium are common. Pathological changes in perifascicular fields appear in some cases.

To decipher the cognitive and linguistic feature of logopenic variant primary progressive aphasia (lv-PPA) and nonfluent variant primary progressive aphasia (nfv-PPA) and to explore the extent to which cognitive and language impairment contribute to the dysfunction of activity of daily living(ADL).

Seven lv-PPA and five nfv-PPA were enrolled in memory clinic of Xuanwu Hospital, Capital Medical University from January 2015 to January 2016 accordig to the international consensus criteria for PPA and its three subtypes. 20 age-matched normal controls (NC) were included. Both the patients and the NC completed a battery of neuropsychological test, lingusitic test and brain magnetic resonance imaging. All the patients conducted ¹¹C Pittsburgh compound B (PiB) PET imaging.

Lv-PPA patients were characterized by deficits in lexical retrieval and long sentenses repetition, while nfv-PPA were with motor speech apraxia and phonetic distortion. Compared with nfv-PPA, lv-PPA patient displayed more severe cognitive deficit with younger onset of age (56±5 vs 61±5, P<0.05) , rapid decline of MMSE score within 1.5 years and pariental cortex dysfunctions such as ideomotor praxis, Gerstmann syndrome and contructional apraxia. Correlation analysis indicated that there was more significant association between pariental cortex dysfunction and ADL/mini-mental state examination(MMSE) than that of language deficit(r=-0.868, r=-0.922; r=0.312, r=-0.257). All seven lv-PPA were PiB-PET positive and five nfv-PPA were negative.

This study enriched the chinical and linguistic characterization of lv-PPA and nfv-PPA, which has implication for diagnosis, disease management and treatment for clinicians.

To establish and evaluate a rat model of diabetes comorbid depression, and observe alterations in expression of glial fibrillary acidic protein (GFAP) in several cerebral regions.

Eighteen Wistar rats were randomly divided into three groups, the control group (group CON, n=6), the diabetes mellitus group (group DM, n=6), and the diabetes comorbid depression group (group DD, n=6). Rats of group DM and group DD were injected intraperitoneally with STZ (64 mg/kg), the control rats received sham injections of citrate buffer alone. Group DD was then exposed to chronic unpredictable mild stress for 28 days. All rats were submitted to the open-field test and Morris water maze test immediately after the CUMS procedure. After brain tissue collection, the expression of GFAP in bilateral frontal cortex, hippocampus and hypothalamus were measured by immunohistochemistry.

Rats of group DD and group DM exhibited classic diabetic signs of weight loss, hyperphagia, polydipia, gloomy hair and increasing urine and stool, group DD showed mental fatigue and slow response.The STZ-treated groups showed high blood glucose level (>33.3 mol/L) compared to the control group throughout the study. Group DD ((176± 11), (157±8), (154± 12)g)and group DM ((176±10), (161±8), (160±13)g)showed decline on body weight, whereas group CON ((245±14), (276±21), (314±25)g)showed continuously elevated body weight 0, 14, 28 days after CUMS.In behavioral tests, group DD ((4.1±3.1), (115±73), (26±13))showed reduced total traveling distance, activity time and times of locomotion compared to group CON ((9.3±3.2), (200±53), (40±11),P<0.05). Throughout the probe trial of Morris water maze test, group DD and group DM ((0.5±0.5), (0.5±0.6))performed less times of crossing the former platform area compared to group CON ((2.6±2.2),P<0.05). The mean optical density (MOD) of GFAP positive cells in frontal cortex, hippocampus and hypothalamus of group DD ((0.18±0.03), (0.19±0.02), (0.21±0.02)) were decreased compared with group DM ((0.26±0.03), (0.27±0.03), (0.30±0.04),P<0.01), but increased compared with group CON ((0.13±0.04), (0.15±0.02), (0.16±0.03),P<0.05 orP<0.01).

Combination of intraperitoneally STZ injection and proper CUMS procedure can successfully build a rat model of diabetes comorbid depression. The expression of GFAP in bilateral frontal cortex, hippocampus and hypothalamus of group DD is significant different form group DM and group CON, which is helpful for understanding the pathogenesis of diabetes comorbid depression.

A 58-year-old female was admitted to the hospital on 13 October 2015 due to "58 years of discovery of a buttock mass with superficial skin ulceration for 1 d". Shortly after birth, the patient was found to have a mass the size of a quail egg on the buttock, and the posterior mass increased progressively. 1 day ago, the skin on the surface of the mass was red, swollen and ulcerated, with brown and a small amount of bloody fluid flowing out. There was no fever, no lower abdominal pain, difficulty in defecation and other symptoms. Physical examination: A mass with a diameter of about 12 cm ×8 cm in the middle of the buttock, with uneven texture, cystic and solid, and poor mobility. A 1.5 cm long ulcer was seen on the surface, and there was pigmentation on the local skin. After admission, the secretions were collected and sent to bacteria for culture, which indicated the growth of Staphylococcus epidermidis, and the tumor indexes such as carcinoembryonic antigen (CEA), fetal globulin alpha (AFP) and serum carbohydrate antigen 125 (CA125) were all negative. CT of lower abdomen: A huge spindle-shaped mass was seen under the skin in the middle of the buttock, with polycystic septal changes in the lesion, and fat density, calcification and gas density shadows were seen in it. Sacrococcygeal enhanced MRI: A cystic-solid lesion with a size of 11.0 cm ×14.6 cm ×9.1 cm was seen in the central area of the sacrum and behind the urogenital diaphragm, showing polycystic changes, and the cystic part was composed of multiple ascuses surrounding the main capsule; After enhancement, the solid area in the lesion showed obvious and uniform enhancement, and the boundary with the urogenital diaphragm and pelvic floor muscles was clear. No involvement of the sacrococcygeal vertebra was observed, considering the possibility of teratoma posterior to the urogenital diaphragm (Figure 1,Figure 2，Figure 3，Figure 4，Figure 5)。 Sacrococcygeal tumor resection by parasacral posterior approach was performed on 20 Oct 2015. Routine intestinal preparation was performed. After successful general anesthesia, the patient lay prone and folded the knife position, retracted the buttocks, and incised the skin about 14 cm long along the mass rupture through the parasacrococcygeal approach. The subcutaneous tissue was incised to expose the tumor. The tumor tension was high and the capsule was weak. About 80 ml of yellow viscous capsule fluid was aspirated with a decompression needle. After the tension was reduced, there was a tough pelvic diaphragmatic fascia separating the anterior and upper part of the tumor from the rectum. Anterior and inferior are not closely related to external anal sphincter; The posterior part of the cyst wall surrounds and compresses the coccyx, but the adhesion is not tight. The gluteus maximus muscles on both sides were retracted, and the mass was carefully excised along the cyst wall. The wound surface was repeatedly washed with iodophor and physiological saline, and a drainage tube was placed after complete hemostasis. The surgical incision was closed in layers. The incision wound surface was covered with seaweed salt foam material (Wuhan Wisdi Medical Technology Co., Ltd.), sealed with semipermeable membrane, and the drainage tube was connected to the central negative pressure for negative pressure closed suction (VSD) treatment. Gross postoperative specimens: The mass was oval, with polycystic changes of different sizes, ranging from 1.5 to 5.0 cm in diameter, and gray-red organized necrotic tissue in some cystic cavities, with medium texture. Microscopic examination showed that the cyst wall was covered with pseudo-stratified ciliary columnar epithelium, squamous epithelium and transitional epithelium, and the tissue inflammation in the interstitial tissue, and multinucleated giant cells were found locally. Combined with the tumor site, it is consistent with the diagnosis of caileum cyst (Figure 6，Figure 7)。 The VSD was removed 5 days after surgery, the incision healed in the first stage, and the suture was removed 10 days after surgery. The incision healed well and there was no local recurrence at 2 months after surgery.

Glioblastoma, also known as glioblastoma multiforme (GBM), is the most malignant type of glioblastoma and the most common malignant tumor in the nervous system, accounting for about half of primary intracranial malignant tumors in adults. The prognosis of patients with GBM is still not ideal, with a median survival of only about 15 months and a 5-year survival rate<10%^[1]。 autophagy is a common phenomenon in eukaryotic cells. Through autophagy, its organelles and cytoplasm can be interpreted and recycled, thus maintaining cell self-homeostasis and promoting cell survival^[2]。 It has always been believed that radiotherapy and chemotherapy play a role by inducing apoptosis of tumor cells. In recent years, more and more studies have shown that radiotherapy and chemotherapy can not only promote apoptosis, but also induce protective autophagy in tumor cells, thus making cells resistant to radiotherapy and chemotherapy, thus ensuring cell survival, and by inhibiting this protective autophagy, the effect of radiotherapy and chemotherapy can be enhanced^[3]。 However, some studies have shown that chemoradiotherapy can also cause autophagic death, which is another way of tumor cell death caused by chemoradiotherapy^[4]。 The role of autophagy in the treatment of GBM is summarized below.