Volume 96  ·  Issue 43  ·  2016

Anesthesiology is in the process of transition to perioperative medicine^[1]While anesthesia in elderly patients is an important part of this transition process. The rapid aging of Chinese society has caused a sharp increase in the proportion of elderly patients undergoing surgical treatment, and the number and proportion of chronic diseases associated with elderly patients far exceed those of other age stages, which has a serious impact on the incidence of complications, mortality and postoperative outcome of perioperative elderly patients, and significantly increases the medical investment of the state and society for this population and the burden on society and families. Perioperative anesthesia management is playing an increasingly important role in reducing the incidence of complications and mortality of elderly patients. It is mainly reflected in the following aspects.

According to the Third National Retrospective Sampling Survey Report of Causes of Death, from 2004 to 2005, stroke has become the first cause of death for Chinese citizens, and its death number has exceeded that of tumors and cardiovascular diseases. According to the "China Stroke Prevention and Treatment Report 2015", about 15% of people over 40 years old in China are at high risk of stroke, and the comprehensive standardized prevalence of stroke is about 2%. Ischemic stroke is the most common type of stroke, accounting for 60% to 80% of all strokes. At present, both domestic and foreign guidelines recommend antiplatelet drug therapy for primary prevention treatment of people at high risk of stroke and secondary prevention treatment of patients with ischemic stroke^[1,2,3,4]。 According to this calculation, at least 83.2 million people in China need or are using antiplatelet drug treatment. The use of antiplatelet drugs during perioperative period in this part of the population has become an urgent clinical problem to be standardized.

To assess the incidence, risk factors, and outcomes of perioperative stroke in aged patients undergoing nonneurologic and noncardiovascular surgery.

A total of 21 419 in-patients who were older than 65 years undergoing nonneurologic and noncardiovascular surgery in Peking University People′s Hospital from January 2010 to May 2016 were retrospectively recruited in this study.The patients were divided into two groups: patients with perioperative stroke were allocated in stroke group, and the other patients were in the non-stroke group.The following variables were compared between the 2 groups: demographics, comorbidities, preoperative laboratory tests, characteristics of operation and anesthesia and prognosis.A multivariate Logistic regression was used to evaluate the risk factors for perioperative stroke in aged patients undergoing nonneurologic and noncardiovascular surgery.

Stroke occurred in twenty-two patients (0.1%), and the risk factors were: American Society of Anesthesiologists (ASA) classification (P=0.031; OR=2.395; 95%CI: 1.082-5.301), previous stroke or transient ischemic attack (P<0.001;OR=61.305; 95%CI: 19.311-194.617), diabetes on insulin (P=0.015; OR=3.488; 95%CI: 1.275-9.540), carotid stenosis (P=0.001; OR=15.157; 95%CI: 3.068-74.885) and preoperative anemia (P=0.032; OR=3.272; 95%CI: 1.108-9.662). Perioperative stroke led to prolong the hospital stay from 10(6, 17) days to 30(23, 55) days (Z=3.302, P<0.001). The mortality was 18.2% in the stroke group and 0.1% in those without perioperative stroke (P<0.001).

The independent predictors of stroke in this population are ASA classification, previous stroke or transient ischemic attack, diabetes on insulin, carotid stenosis and preoperative anemia.Patients with these characteristics deserve more carefully perioperative management.

To verify whether preprocedural ultrasound of the lumbar spine could improve first-attempt success rate (defined as a successful neuraxial anesthesia with only one skin puncture) of neuraxial block in elderly patients.

From septemble 2015 to February 2016, 200 elderly patients undergoing lower-limb surgery with neuraxial block at the Peking Universty Third Hospital were enrolled in this study.RandA 1.0 software was used to randomize patients into two groups: conventional surface landmark-guided group (group LM) and ultrasound-assisted group (group US). Ultrasound scanning of the lumbar spine was performed to determine the suitable insertion point of US group, using a low-frequency (2-5 MHz) curved-array probe in both paramedian sagittal oblique plane and transverse median plane.Spinal anesthesia was done via the paramedian approach.The primary outcome was the rate of successful access to subarchnoid space on the first needle insertion attempt.Secondary outcomes included the following: number of needle insertion attempts, number of needle redirection times, actual epidural needle insertion depth, time taken to eastablish landmarks, time taken to perform the spinal anesthesia (the duration between local infiltration and bupivacaine injection), procedure time (the duration from sterilizing the back to converting into supine position), total time (the sum of the time to establish landmarks and the procedure time), adverse events during the procedure and anesthesia related complications.

A total of 191 patients successfully received combined spinal-epidural anesthesia by resident anesthesiologists, 9 patients (7 patients in group LM vs 2 patients in group US) failed.The first-attempt success rate in group LM was 37.6%, while the first-attempt success rate in group US was 68.4%, the difference between the two groups was significant (χ²=18.112, P<0.01). In group LM, the number of needle insertion attempts and needle redirection attempts were 2(1, 3) and 5(3, 10), respectively. In group US, the number of needle insertion attempts and needle redirection attempts were 1(1, 2) and 3(0, 5), respectively.The differences in the number of needle insertion attempts and needle redirection attempts between the two groups were significant (Z=-4.132, -4.077, all P<0.01). In group US, the time spent on determining the insertion point, on puncture, on finishing the procedure and the total time were as the following: 2.8(2.6, 3.1), 2.5(1.8, 4.1), 7.8(6.5, 8.9), 10.6(9.5, 11.9) min.In contrast, in group LM, those indices were as the following: 0.4(0.3, 0.4), 4.1(2.2, 6.3), 8.8(7.5, 11.4), 9.2(7.8, 11.9) min.There were significant differences in the above factors between the two groups (Z=-11.931, -4.025, -3.550, -3.290, all P<0.01). The paramedian sagittal oblique scanning image was superior to that of the transverse median plane.

For elderly patients, ultrasound imaging before neuraxial block increases first-attempt success rate, decreases puncture time.The strengths of prepuncture ultrasound scanning outweighs its longer total time.

To investigate the effect of goal-directed haemodynamic management based on stroke volume variation (SVV), cardiac index (CI) and mean arterial blood pressure (MAP) on the postoperative outcome in elderly patients with fragile cardiac function undergoing gastrointestinal surgery.

Ninety patients with fragile cardiac function, aged 65-90 years old, ASAⅡ or Ⅲ, NYHA Ⅱor Ⅲ, scheduled for abdominal surgery were enrolled in this study.The patients were randomly assigned to two groups: Experience anesthesia group (group E, n=45) and goal-directed hemodynamic management group (G group, n=45). After anesthesia induction, in group G, the SVV and CI were monitored by Vigileo and according SVV (≤12%), CI (≥2.5 L·min^-1·m^-2) and MAP (maintain the base value of ±20%) to adjust the preloaded infusion fluid and give positive inotropic drugs and positive pressure drugs; in group E, fluid and vasoactive agent were used according to the experience of anesthesiologist.Multi-mode monitoring anesthesia management using BIS, TCI of propofol, low-tidal-volume lung protective ventilation management strategy, body temperature protection, and postoperative multimodal analgesia techniques was performed in the two groups.Values of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) were recorded before operation, at the end of operation, and postoperative 24 h. The incidence of myocardial infarction/angina, heart failure, arrhythmia and cerebral infarction, renal failure, length of hospitalization, and complications in 30-days after surgery were recorded by telephone follow-up.

Crystal, colloid, total liquid of group E were (1 110.20±332.00), (536.65±72.25), (1 677.20±424.44) ml and these of group G were (708.72±240.85), (414.41±74.31), (878.51±199.13) ml, respectively.Compared with group E, the fluid infusion were reduced in group G (t=6.057, 2.701, 9.742, all P<0.05). The lactic acid value of 24 hours after surgery in group G was significantly lower than that in group E [(0.89±0.31) mmol/L vs (1.11±0.43) mmol/L,t=-2.848, P<0.05]. Arterial partial pressure of oxygen at 24 hours after surgery in group G was higher than that in group E [(78.77±6.86) mmHg vs (76.46±10.96) mmHg,t=-1.108, P<0.05]. The length of hospitalization of group G was shorter than that of group E [(12.21±2.20) d vs (13.16±3.84) d,t=-1.341, P<0.05]. The incidence of total complication in hospital and in 30-days after surgery of group G were 10.26% and 5.13%, while these of group E were 29.73% and 24.32%, (χ²=4.545, 4.520, all P<0.05). ΔNT-proBNP₁ (the base value of NT-proBNP′s minus the value of NT-proBNP′s at the end of the operation) and ΔNT-proBNP ₂ (the base value of NT-proBNP′s minus the value of NT-proBNP′s 24 hours postoperatively) of group G were 12.0(-291.0, 1 517.0) and 0(-6 770.0, 291.0), both higher than these of group E [0(-440.0, 200.0) and -12.0(-7 200, 22.0), (Z=-2.412, -2.163, all P<0.05)].

Goal-directed haemodynamic management based on SVV, CI and MAP could improve the outcome of the elderly patients with fragile heart function undergoing abdominal surgery.

To evaluate the clinical efficacy of lumbar plexus-the first posterior sacral foramina block as an anesthesia technique for hip arthroplasty in elderly patients.

Forty-four patients, aged 60-91 years, weighing 37-100 kg, American Society of Anesthesiologists (ASA) Ⅰ-Ⅲ, underwent elective hip arthroplasty in Tongji Hospital from February 2015 to January 2016.All patients received lumbar plexus and the first posterior sacral foramina block.The first posterior sacral foramina puncture point of 23 cases were located by traditional positioning method, the others were orientated via ultrasonic method.Measurements included effect of sensory blockade after 30 min of completed injection, hemodynamic parameters, quality of surgery blockade, and postoperative adverse reactions related to nerve block.

The success rates of the sensory blockade of pinprick for the dermatomes L1-S3 were from 73% to 100%, with 93% success rates of surgical analgesia.Compared with baseline (T₀) , the systolic blood pressure (SBP) decreased at 10 min after incision (T₅) and 20 min after incision (T₆) [T₀ vs T₅: (137±23) mmHg vs (119±20) mmHg, t=3.825, P<0.05; T₀ vs T₆: (137±23) mmHg vs (118±18) mmHg, t=4.403, P<0.05]. Heart rate (HR) and diastolic blood pressure (DBP) had no significant changes at different time points (F=0.877, 1.439, P>0.05). One patient suffered urinary incontinence.

Lumbar plexus-the first posterior sacral foramina block is one of safe and effective anesthetic techniques for hip arthroplasty in aged patients.

To explore the effectiveness and feasibility of conscious sedation with a low dose of dexmedetomidine and sufentanil during multiple intestinal polyps resection in elderly patients.

Sixty elderly patients who underwent multiple intestinal polyps resection in Peking University Third Hospital from Janurary to May 2016 were randomly divided into dexmedetomidine group (D group, n=30) and propofol group (P group, n=30). There were 28 males and 32 females with a mean age of (70.4±4.5) years old (range: 65-80 years old). The patients in the dexmedetomidine group received a loading dose of 0.3 μg/kg followed by a continuous infusion of 0.2-0.4 μg·kg ^-1·min^-1 of dexmedetomidine and sufentanil (0.1 μg/kg) respectively.The patients in the propofol group received sufentanil 0.1 μg/kg and propofol 1.5 mg/kg and followed by a continuous infusion of 3-6 mg·kg ^-1·h^-1 of propofol.Blood pressure, heart rate, pulse oxygen saturation (SpO₂), respiratory rate and bispectral index (BIS) were recorded at the basic status and at the beginning of operation, 10 min, 20 min, 30 min after operation, the end of operation and departure.The observer′s assessment of alertness/sedation (OAA/S) scores and the clinical responses were also recorded.A statistical analysis was performed.

All patients in the two groups were sedated compared with baseline.The BIS values of patients in group D at beginning of the operation, 10 min, 20 min, 30 min after operation and the end of operation were 89.6(87.8-91.0), 79.4(78.0-80.0), 76.9(75.0-80.0), 76.0(73.0-79.0) and 75.6(70.0-79.0) respectively, and those values were all significantly lower than baseline value[96.4(95.0-98.0)], (Z=-4.645, -4.788, -4.787, -4.789, -4.789, P<0.05). The OAA/S score at beginning of the operation, 10 min, 20 min, 30 min after operation and the end of operation were 4.5(4.0-5.0), 3.4(3.0-4.0), 3.0(3.0-3.0), 3.5(3.0-4.0) and 3.3(3.0-4.0) respectively, and were significantly lower than baseline score [4.8(5.0-5.0)] (Z=-2.828, -4.862, -5.031, -4.420, -4.710, P<0.05). The BIS value of patients in group P at beginning of the operation, 10 min, 20 min, 30 min after operation and the end of operation were 54.7(50.0-59.3), 54.8(50.0-59.3), 50.7(47.8-56.8), 54.4(51.5-58.0) and 53.7(50.0-57.3) respectively, and were significantly lower than baseline value[95.8(95.0-96.3)] (Z=-4.786, -4.787, -4.788, -4.786, -4.786, P<0.05). The OAA/S score at beginning of the operation , 10 min, 20 min, 30 min after operation and the end of operation were 0.4(0.0-1.0), 0.4(0.0-1.0), 0.4(0.0-1.0), 0.4(0.0-1.0) and 0.4(0.0-1.0) respectively, and were significantly lower than baseline score[4.9(5.0-5.0)] (Z=-4.927, -4.901, -4.912, -4.912, -4.901, P<0.05). The sedation state of group D were lighter than group P. The BIS value and OAA/S score at beginning of the operation, 10 min, 20 min, 30 min after operation and the end of operation in group D were higher than group P (P<0.05). The breath and circulation were more stable in group D. The mean arterial pressure, breath rate and SpO₂ at beginning of the operation, 10 min, 20 min, 30 min after operation and the end of operation in group D were higher than group P (P<0.05). There was no oxygen desaturation , hypotension and drowsiness in group D and the incidence in group P were 30.0%, 33.3% and 13.3% respectively.The emergency time and duration of stay in the PACU (post anesthesia care unit) were (2.0±1.2) and (22.0±7.4) min in group D, and they were (4.9±2.4) and (35.8±11.6) min in group P (t=-5.839, t=-5.472, P<0.05). There was no difference in surgery time, patient satisfaction and acceptance rate of reexamination (t=-3.031, t=-7.322, t=2.069, P>0.05).

Conscious sedation with dexmedetomidine and sufentanil is effective and feasible in elderly patients undergoing multiple intestinal polyps resection.

To explore the whole brain activity features of childhood and adolescence-onset schizophrenia using resting state fMRI.

A total of 63 childhood and adolescence-onset schizophrenia patients (patients group), admitted to the second affiliated hospital of Xinxiang Medical University from October 2013 to October 2015 and fulfilled our inclusion criteria, and 39 healthy controls with age, sex and education matched (control group) were enrolled, then a resting-state fMRI scan was conducted for each participant. Fractional amplitude of low-frequency fluctuations (fALFF) approach was used to explore the differences of resting-state brain function between patients and controls.

Compared with the healthy control group, patients group showed significantly decreased fALFF in left superior temporal gyrus and parietal lobe (MNI coordinate: x=-42, -57; y=-3, -21; z=-12, 9; voxels: 22, 32; t=-4.792 3, -5.269 7; Alphasim corrected, corrected P<0.05); patients group showed significantly increased fALFF in left frontal lobe and medial frontal gyrus, right superior frontal gyrus, Postcentral Gyrus, caudate, (MNI coordinate:x=-42, -21, 12, 27, 15; y=54, 39, 48, -18, 15; z=0, 21, 33, 30, 9; voxels: 12, 21, 17, 28, 18; t=4.784 8, 4.90 7, 4.861 5, 5.444 1, 4.270 4; Alphasim corrected, corrected P<0.05). When included age as a covariant, the analysis found that the brain region with significant fALFF change was the left thalamus with decreased fALFF (MNI coordinate:x=-6, y=-12, z=24; voxels: 9; t=-4.268 4; Alphasim corrected, corrected P<0.05) in patients group, while for other brain regions, there was no obvious change in the fALFF, compared with healthy group.

Compared with control group, the results indicate that there are intrinsic brain activity abnormalities of some brain regions in childhood and adolescence-onset schizophrenia.

To summarize the therapeutic approaches of patients with Hirayama disease and investigate the patient′s compliance to cervical collar therapy and its influencing factors.

This was a retrospectively study.The clinical data of 73 patients was collected from Peking university 3^rd hospital between 2010 and 2014.

(1)Of the 73 patients, 10 patients received surgery, 36 patients received collar therapy , and 27 patients received other conservative therapy at first visit.(2)The mean collar wearing time was from 0.3 to 36 months (means was 7±11 months). 28 patients (77.8%) wore less than 6 months, only 8 patients (22.2%) wore for more than 1 year. (3)The influencing factors were affecting appearance (33.3%), inconvenience to work (22.2%), surgical treatment performed after the exacerbation of symptoms(14.3%), illness stabilization (9.5%), choosing other conservative therapy (9.5%), personally feeling not seriously (8%) and discomfort while wearing (3.2%). (4)The patients with younger age of onset and treatment were more likely to choose neck care, while patients with older age of onset and treatment tended to choose more conservative treatment(P<0.05).

As Hirayama disease can cause disability, application of a cervical collar to minimize neck flexion can prevent progressive muscular weakness in the early stages of the disease. But from our study, the compliance to cervical collar therapy is unsatisfactory.Multiple factors influence the compliance.Education for patients must be enhanced, and other methods to promote the therapeutic compliance should also be developed.

To compare the fertility rate and embryo outcome between normal fertilization and the use of Calcium ionophore A23187 on the same period of the same cycle of human ovum for artificial activation.

Patients who conducted the intracytoplasmic sperm injection (ICSI) cycle in vitro fertilization assisted reproductive from January 2015 to December in reproductive center of the Third Affiliated Hospital of Zhengzhou University were enrolled.The protocol of this study was approved by the ethics committee of The Third Affiliated Hospital of Zhengzhou University.The subjects must met at least one of the inclusion criteria: (1)the normal fertilization rate was less than 30% ICSI in the previous ICSI cycle; (2)no good quality embryos in a previous period of third days in ICSI; (3)patients with globozoospermia.The ovum were randomly divided into two groups, control group and artificial oocyte activation (AOA) group. In the control group, the eggs were treated with routine ICSI operation, and the AOA group was activated by A23187 after ICSI. Normal fertilization rate, cleavage rate, pregnancy and birth outcome of two groups were compared.

The 2PN fertilization rate in the AOA group 65.93% (60/91) was significantly higher than that in the control group 46.67% (41/89) (P<0.05). In addition, in patients who met the inclusion criteria of 1 categories (2PN≤30%), the 2PN fertilization rate was significantly higher (P<0.05) in the AOA group [79.59% (39/49)] compared with the control group [57.14% (28/49)]. In patients who met the inclusion criteria of 3 categories (globozoospermia), the 2PN fertilization rate was significantly higher (P<0.05) in the AOA group [75% (6/8)] compared with the control group [0% (0/5)].

The use of calcium ionophore A23187 assisted activation could be helpful to improve the normal fertilization rate of ICSI. But the effects of early embryonic development and the safety of generation need to be further studied.

To assess the image quality, radiation dose and diagnostic efficiency of peripheral arterial CT angiography (CTA) performed at tube voltage of 70 and 120 kV.

Between January 2014 and December 2015, a total of 200 consecutive patients with known or suspected lower extremity arteriosclerosis obliterans (LEASO) underwent CTA.Patients were randomly divided into 2 groups by different scanning protocols.Group A (n=100): 70 kV and 0.8 ml/kg contrast agent, group B (n=100): 120 kV and 100 ml contrast agent.The vessel enhancement, image noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of 3 segments were quantified for each protocol.30 patients in group A (420 vessels) and 28 patients in group B (384 vessels) confirmed by DSA.Based on vessel assessments, compared with DSA findings, the diagnostic efficacy of 70 kV and 120 kV protocols for the detection of stenoses over 50% was evaluated.The dose of radiation and contrast agent were recorded.Subjective image quality was evaluated.

The subjective image quality of segment crural of group A was significantly higher than that of group B (2.20±0.36 vs 1.72±0.34, P<0.01). The enhancement of 3 segments in group A (500 HU) were significantly higher than these in group B (310 HU) (P<0.05). For the detection of stenoses over 50%, the sensitivity, positive and negative predictive values and accuracy of segment crural in group A (98.6%, 95.8%, 98.1%, 96.7%) were significantly higher than that in group B (90.9%, 88.5%, 91.0%, 89.7%) (P<0.05). Mean DLP for 70-kV protocol was significantly lower than that for 120-kV protocol ( (396±34) vs (1 041±159) mGy·cm,P=0.001). Mean dose of contrast agent and the total amount of iodine for 70-kV protocol were significantly lower than that for 120-kV protocol (53.5 vs 100 ml; 18.7 vs 35 g; P<0.01).

CT angiography of peripheral arteries with a low tube voltage of 70 kV and low dose of iodine provides reliable information and serves as a rapidly performed and easily available imaging modality in the diagnosis of LEASO.

To evaluate the effect of snow sports to the knee cartilage maturation of children and adolescent with quantitative analysis of 3.0 T MRI.

Twenty children and adolescent who underwent snow sports training more than 6 months (11 males and 9 females) were recruited and named with sports group, and twenty children and adolescent who live regularly without any exercise (10 males and 10 females) were recruited as control group from June 2014 to June 2015.Each group was divided into subgroups according to their gender.Both groups were scanned by 3.0 T MR.According to the loading features of knee articular cartilage in snow sports, medial femoral condyle, lateral femoral condyle, medial tibial condyle and lateral tibial condyle were divided into subareas.T₂ values and cartilage thickness were measured in all areas.

The median ages of the sports group and control group were 14.2 and 13.6 years old, which showed no statistical difference between two groups.The BMI of the sports group and control group were 18.3 and 17.9 kg/m^2, which showed no statistical difference between two groups.Both in sports group and control group, the thickness and T₂ values of all areas showed significant differences between man and women in each group (all P<0.05). The cartilage thickness of sports group was higher than control group (P<0.05). The T₂ values showed no statistical difference in anterior central, posterior central of femoral condyles and anterior, central areas of tibial condyles between sports group and control group(P≥0.05). The T₂ values of anterior part of posterior femur and posterior areas of tibial condyle in sports group was higher than control group (P≥0.05).

Gender difference may be an important effect factor of cartilage thickness. Scientific snow sports training maybe has positive influence for cartilage maturation of children and adolescent.

To report the clinical, genetic and ultrastructural pathological features of neuronal ceroid lipofuscinosis (NCLs) in 5 Chinese patients.

A total of 5 patients with NCLs were collected from 2013 to 2015 diagnosed by the department of pediatrics of Beijing Tian Tan Hospital. Their clinical, electrophysiological and neuroimaging data of the patients were reviewed.A total of 9 underlying genes of NCLs were tested in 4 cases and their parents.Ultrastructural pathology by skin biopsy was performed in 3 cases respectively.

We identified two novel homozygous mutations and one novel heterozygous pathogenic mutation in 3 patients. The confirmed mutations included c. 1153G >C (p.Gly385Arg) MFSD8 homozygous mutation, c 321-1G >A CLN5 intron splice site homozygous mutation and c 407G >A (p.Arg136His)CLN6 heterozygous mutation, which had never been reported before. While no gene mutation was detected in the rest 1 case. Among the 3 cases received electron microscope testing of skin biopsy, 2 presented with fingerprint inclusions mixed with granular osmiophilic deposits, rectilinear profiles mixed with granular osmiophilic deposits were noted in another case.

The patients of NCLs caused by the mutations of MFSD8, CLN5 and CLN6 genes in Chinese population were firstly reported in this study. There are some relevence between genotype, pathomorphology and clinical presentation of NCLs. The pathomorphology is still a gold standard for the diagnosis of NCLs.

To explore the clinical short-term result of proximal fibular osteotomy with arthroscopy in the treatment of knee osteoarthritis.

From August 2015 to March 2016 thirty six patients with medial compartment knee osteoarthritis were treated by proximal fibular osteotomy with arthroscopy in Department of Orthopaedics, Beijing Tongren Hospital, Capital Medical University.The preoperative and postoperative visual analogue scale (VAS) and the hospital for special surgery (HSS) knee score were compared in follow-up.

The follow-up period was 3 and 10 months.The postoperative HSS knee scoreincreased significantly[(56.1±11.1)score vs(83.0±5.9), (83.7±3.9)score](P<0.05) and the VAS scoredecreased significantly [(7.9±0.8)score vs(2.4±0.7), (1.8±0.9)score](P<0.05) compared with pre-operation.There are 3 cases of superficialperonealnerve injury and recovered 3 months after operation.

Proximal fibular osteotomy with arthroscopy in the treatment of medial compartment knee osteoarthritis can provide satisfactory early effects.

To retrospective analysis the clinical characteristics of diagnosis and treatment the disease of tuberculous psoas abscess (TPA).

The medical records of 13 consecutive patients presenting to our hospital with TPA were reviewed from November 2002 to December 2015.Demographic data, presenting features, predisposing factors and the investigations performed were recorded and the outcomes were analysed.

The thirteen patients were included, 11 cases all had lower backache, 6 cases had Lower abdomen or groin area pain, 2 cases had fever, eleven cases were treated with Open drainage, one with Ultrasound guided drainage, and the last case used antibiotics alone, median hospital stay of 35 days, follow-up showed no recurrence or death in patients.

The incidence of TPA is probably underreported.The vague presentation leads to delays in diagnosis and increases morbidity and a high index of suspicion is the key to early diagnosis.Open drainage has Lower recurrence and death rates, and used widely, is the most reliable method for the treatment of primary tuberculous psoas abscess.

To explored the effects of lumbar dorsal muscle damage on local lumbar vertebral bone quality.

Thirty SD female rats, at age of 20 weeks, were randomly divided into three groups: control group, or say pseudo surgery group, an incision in the back were performed as CNT; bilateral erector spinal muscle group in which group bilateral lumbar erector spinal muscle were removed as RESM; castration group in which bilateral ovaries were resected as OVX.After three months, bone mineral density, microscopic CT and vertebral compression test were taken in lumbar vertebral (L4-6) in turn.

After three months bone mineral density in RESM group was obviously lower than the control group [(0.211±0.028) g/cm² vs(0.253±0.021) g/cm², P<0.01], however, there was no significant difference between OVX and RESM[(0.197±0.015) g/cm² vs(0.211±0.028) g/cm², P>0.05]. In microscopic CT three-dimensional reconstruction and bone histomorphometry analysis, compared with control group CNT , in the experimental groups OVX and RESM, bone trabecula of vertebral bodies were more sparse, the overall number and interconnection of trabecula were less.Especially in the OVX, osteoporotic trend of trabecular network trend is more obvious.In vertebral compression test, the maximum load, energy absorption, the maximum stress and elastic modulus in both OVX and RESM were significantly reduced (P<0.01). In the RESM the above four biomechanical parameters were significantly higher than those of OVX (P<0.05).

Integrity and vigor of paravertebral muscles would be of great significance to maintain adjacent vertebral bone quality.Resection of lumbar dorsal muscles could lead to a significant decrease of local vertebral bone quality.Damage and atrophy of lumbar dorsal muscle could cause osteoporosis of vertebral bodies.

The patient was a 25-year-old male. He was admitted to the Department of Neurology of the Third Hospital of Peking University in December 2015 due to "progressive weakness and numbness of both lower limbs for 1 year". One year before admission, the patient showed weakness and numbness in both lower limbs without obvious triggers, feeling of walking on cotton, and unlimited daily activities. Symptoms progressively aggravated. In the past six months, walking on the flat ground was slow, going up and down stairs was laborious, and I could not walk with my toes and heels. The symptoms are more severe at night, with slippers falling off and shoes going to bed. Slight tremor during fine activities such as holding objects in the upper limbs. No dizziness, diplopia, unclear speech, choking and coughing after drinking water, and no dyspnea. Second, stool, diet and sleep are normal. Physical health in the past, long-distance running endurance is poor, and sports can reach the standard. Deny family history of genetic diseases and similar diseases. Medical physical examination: normal development, good nutrition, no abnormalities in cardiopulmonary and abdominal examination. Physical examination of the nervous system: Shen Qing Yu Li; Cranial nerve normal; Bilateral anterior tibialis muscle and gastrocnemius muscle atrophy, normal muscle tone of limbs, proximal muscle strength of limbs grade V, distal muscle strength of both upper limbs grade V-, bilateral anterior tibialis muscle strength grade III, gastrocnemius muscle strength grade IV; Slight postural and intentional tremor in both hands; When walking, he showed a slightly bilateral cross-domain gait, with a slightly wider step base, Romberg sign (+) and one-word step sign (+), squatting was acceptable, but the toe and heel could not walk; Hypersensitivity to needle pricking below the bilateral ankle joint, normal touch, decreased position sensation and disappearance of vibration sensation of both lower limbs; The tendon reflexes of the extremities were not drawn out, and the pathological sign was (-).

The patient was a 59-year-old female. He was admitted to hospital on July 13, 2015 due to numbness of his left upper limb for more than 3 months, aggravated with pain on the left side of his neck for 2 weeks. The patient developed left upper limb numbness without obvious trigger 3 months ago, no fever, nausea, headache, dizziness and other symptoms, and was not diagnosed and treated. Two weeks ago, the patient's left upper limb numbness symptom was aggravated, accompanied by pain on the left side of the neck, persistent dull pain in the standing position, no radiant pain, and improved in the recumbent position. He went to the local hospital and was treated according to "cervical spondylosis". The specifics were unknown, and the patient's symptoms did not improve. Two days ago, magnetic resonance (MR) examination in the local hospital showed that the cervical spinal cord occupied space behind the cervical 1 and cervical 2 vertebrae. Physical examination: No melanoma-like lesions were found in the skin and mucosa of the whole body, and the muscle strength of the limbs was grade IV, and the pathological signs were negative. MR examination: plain scan showed a massive lesion in the cervical spinal cord at the level of cervical 1 and cervical 2, with a size of 24 mm ×14 mm ×13 mm and a short T₁Hybrid T₂Signal shadow, regular shape, clear boundary, no obvious space occupying effect, no peritumoral edema (Figure 1)。 Diffusion weighted imaging (DWI) (b =1 000 s/mm²) showed a low signal, and the apparent diffusion coefficient (ADC) value showed a slightly higher signal (Figure 1C)。 After intravenous injection of gadopentetic acid meglumine (Gd-DTPA), C₁~ C₂The abnormal signal shadow in the horizontal cervical spinal cord was significantly enhanced (Figure 1D)。 Initial diagnosis: cavernous hemangioma with hemorrhage. Surgery and pathology: During the operation, the spinal cord was cut along the median line and the subdural space was explored. The spinal cord was enlarged at the level of cervical 1 and cervical 2, and the tumor was located in the medulla. The spinal cord was longitudinally incised along the posterior median line and separated deeper, and the tumor tissue was visible. The tumor was black, irregular in shape, adhered tightly to the surrounding tissues, substantial, and had abundant blood supply. It was removed in blocks under the microscope. Visible to the naked eye: gray-brown gray-black fragmented tissue, size 30 mm ×25 mm ×10 mm. Immunohistochemistry: S-100 positive, human melanoma antibody (HMB45), melanocyte differentiation marker (Melan-A), vascular endothelial factor (CD34), smooth muscle actin (SMA) all negative, nuclear proliferation antigen (Ki-67) 80% (Figure 2)。 Pathological diagnosis: (cervical 1-2 intramedullary space occupied) conforms to melanoma.

A 48-year-old male was seen in Shanxi Provincial People's Hospital due to right exophthalmos for 2 months and blurred vision in his right eye for 1 month. Orbital CT examination of the patient a few days before admission showed that the right sphenoid ridge occupied extracranial and intraorbital communication (Figure 1)。 There is no obvious headache, dizziness, fatigue, nausea, loss of appetite and other symptoms recently. He had previously suffered from hepatitis B and did not receive special treatment because of normal liver function tests in the past. Physical examination: visual acuity of right eye 0.8, visual acuity of left eye 1.0, right eyeball protruding outward, no pulsatile sensation when touched, no murmur in auscultation, no abnormalities in lung and pleura visual examination, palpation, percussion and auscultation, abdominal palpation did not touch the liver and spleen, and no obvious positive signs were found in other physical examinations and specialist examinations. No abnormalities were found in liver function and routine chest X-ray after admission, and no special positive results were found in other cases. MRI of the brain showed that the tumor appeared uniform enhancement, showing "meningeal tail sign" (Figure 2)。 After the patient completed the relevant preoperative examination, on the 6th day after admission, the frontal-orbital-zygomatic approach was used to surgically remove the space. During the operation, the tumor was gray-white, with cord-like blood vessels in it, and the blood supply was extremely abundant. The boundary between the tumor and the surrounding brain tissue was clear, and there was occasional adhesion to the temporal muscle. The bone of the middle skull base was eroded and destroyed, and the bone on the lateral side of the supraorbital fissure was absent. The tumor grew into the orbit, and the intraoperative bleeding volume was large, about 4 500 ml. After total tumor tissue resection, pathological examination was performed, and the pathological diagnosis was metastatic hepatocellular carcinoma, seeFigure 3。 The serum alpha-fetoprotein (AFP) was 0.5 μ g/L (0~20). Abdominal CT examination showed low density lesions in the right lobe of the liver.

Urinary tract injury is a rare complication of gynecological surgery, but 50% ~75% of urinary tract injury comes from gynecological surgery^[1,2]Relevant litigation is higher than other comorbidities of gynecological surgery^[3]The risk of litigation is 70~90 times higher^[4]； Intraoperative detection and identification of urinary tract injuries can reduce the risk of litigation^[5]。 It is hoped that early diagnosis and early treatment can be achieved by identifying high risk factors and adequate prevention of urinary tract injury in gynecological surgery. This article reviews the prevention and diagnosis of urinary tract injuries in gynecological surgery as follows.

In China, the incidence and mortality of lung cancer rank first among all kinds of malignant tumors^[1]30% to 40% of lung cancer patients will have bone metastasis, and 22% to 59% of lung cancer patients with bone metastasis will have skeletal related events (SREs), such as cancerous bone pain, pathological fracture, spinal cord compression, hypercalcemia, etc.^[2]Not only increase the medical burden of patients, but also seriously affect the quality of life of patients. As more and more bone-targeting agents have been used for the treatment of bone metastases in recent years, bisphosphonates and denosumab have been approved in the United States and Europe for the clinical treatment of solid tumor bone metastases and the prevention of SREs. In addition, endogenous radioactive agents and targeted drugs are also continuously used for the treatment of bone metastases.

The prevention, treatment and rehabilitation of children's sports injuries are attracting great attention^[1]How to carry out children's sports medicine research in order to benefit the healthy development of children and avoid the negative impact of sports injury and corresponding treatment on growth and development has always been the focus and difficulty of our children's and adolescent's sports medicine research^[2]。