Volume 97  ·  Issue 14  ·  2017

Dizziness is the most common clinical symptom, involving the most diagnosis and treatment departments, and is also one of the main symptoms of emergency visits. 2009 Gopinath et al.^[1]A prospective interdisciplinary study showed that the prevalence of dizziness or vertigo in elderly patients was 36.2%, with vestibular disorders accounting for 10% and non-vestibular disorders accounting for 14.2%. For many doctors, dizziness is a seemingly "simple and familiar" symptom, but the diagnosis is relatively rough and "unfamiliar". "Simple and familiar" means that doctors often face patients with dizziness symptoms, and simply and very carelessly often diagnose so-called "vestibular peripheral/central vertigo", "vertebrobasilar insufficiency", "cervical dizziness/vertigo" or "cerebral infarction", etc., but this is not the case. Speaking of "strange" means that most doctors do not understand the etiology and composition of common dizziness diseases, nor do they know many concepts such as vestibular migraine (VM) (i.e. migraine vertigo), psychogenic dizziness (now also known as subjective dizziness or persistent postural-perceptual dizziness), and phobic postural vertigo; Secondly, "strange" means that doctors' inquiry about the medical history of dizziness patients is simple and unclear. They don't know that dizziness needs to be asked from childhood, family history, and headache history.

Stanford type A aortic dissection involves the whole course of the aorta, and continuing to tear the iliac vessels downward often causes arterial ischemia of the lower extremities, Lee et al.^[1]And Geirsson et al.^[2]It is reported that the incidence of this condition is 10% ~12.7%. Once the disease is dangerous, it is an independent risk factor for death after aortic dissection. The terminal event is often multiple organ dysfunction syndrome (MODS) caused by massive release of necrotic products and inflammatory factors, which often causes a huge surgical blow to patients, with huge treatment cost and extremely poor prognosis. Patients with lower limb ischemia may not only show the typical signs of thoracic and dorsal tear-like severe pain aortic dissection, but also lead to ischemia of the corresponding organs when important branches of blood vessels are involved. If the iliac and femoral arteries are involved, lower limb pain, paresthesia, weakness, decreased skin temperature and disappearance or weakening of pulse may occur. Because the symptoms of lower limb ischemia are easily masked by the symptoms of aortic dissection itself, early diagnosis and timely surgical intervention for such patients are particularly important.

In recent years, with precision medicine^[1]With the proposed concept, the change of medical model, and the appearance of population aging, food safety, environment and other problems, China's medical and health undertakings are in a critical period of development^[2]It also puts forward higher requirements for the performance management of public hospitals. Hospital F is a provincial large-scale comprehensive public hospital with highly intensive professional and technical talents integrating medical treatment, teaching and scientific research. The hospital currently has more than 3,000 employees, including more than 1,000 doctors, and doctors with senior professional titles account for 40.08% of the total number of doctors. Because the hospital is a technology-intensive organization, the complexity of the post composition, the groups of the performance and the difficulty of quantifying the behavior indicators determine the difficulty of the hospital performance appraisal^[3]。 It is especially necessary to build a scientific, reasonable and operable assessment system to stimulate the enthusiasm and creativity of physicians with senior professional titles in F Hospital and promote the refined management of hospitals.

To investigate the clinical features of vestibular migraine with MRI changes.

The clinical data of 150 patients with vestibular migraine completing MRI examination in navy general hospital from August 2008 to August 2016 were retrospectively analyzed.Clinical features of 94 (62.7%) vestibular migraine patients with MRI changes were collected and analyzed according to the medical history, clinical symptoms and signs, as well as the result of auxiliary examinations.

The manifestations of MRI in vestibular migraine patients were mainly multiple punctate equal T₁ and long T₂ signals or high signals on FLAIR (fluid attenuated inversion recovery) in subcortical white matter. The average age of the patients at the visit was (52±15) years old, with the male to female ratio of 1∶3.1. The occurrence of vertigo and migraine were in no particular order, with 54.3% patients presenting migraine several years before vertigo. The duration of vertigo was mostly 24 hours to 72 hours (31.9%). The visual aura (55.3%), photophobia and phonophobia (67.0%) were the most frequently associated symptoms.

The vestibular migraine patients with MRI changes have its own specific clinical characteristics and are mainly seen in female with visual aura. The associated symptoms of vestibular migraine appear mostly during the process of vertigo. The pathogenesis of cerebral white matter hyperintensities (WMHs) is not clear.

We aimed to explore the spectrum of causes for patients in department of vertigo and dizziness oriented outpatient, in order to provide a reference for diagnosis and treatment of patients with vertigo or dizziness.

Retrospective analysis were carried out with clinical data of patients in our department of vertigo and dizziness oriented outpatient. The target group under study was diagnosed based on the uniform diagnostic criteria, and re-visiting patients were excluded.

This clinical study was conducted on 5 348 cases, who visited our vertigo and dizziness oriented outpatient from December 2012 to July 2015. The ratio of male to female was 1∶1.48, the age range was between 16 and 93. The frequencies of different etiology were: benign paroxysmal positional vertigo 1 902(35.56%), Chronic subjective dizziness 1 329(24.85%), vestibular migraine 624(11.67%), Meniere′s disease 378(7.07%), multi-sensory neuropathy 231(4.32%), vestibular paroxysmia 177(3.31%), benign recurrent vestibulopathy 171(3.20%), presyncope 66(1.23%), posterior circulation ischemia 57(1.07%), vestibular neuritis 54(1.01%), sudden deafness complicated vertigo 36(0.67%), other reasons 68(1.27%), unknown 255(4.77%).

Our study indicates that the precedent three causes for vertigo or dizziness are benign paroxysmal positional vertigo, chronic subjective dizziness and vestibular migraine, followed by Meniere′s disease、multi-sensory neuropathy, vestibular paroxysmia and benign recurrent vestibulopathy. Presyncope, posterior circulation ischemia, vestibular neuritis and sudden deafness complicated vertigo are relatively infrequent. There are still a certain proportion of patients undetermined.

The aims of this study were to investigate the misdiagnosis of benign paroxysmal positional vertigo (BPPV) and to estimate the associated costs.

During October 2015 to December 2015, eighty patients were diagnosed with BPPV in the outpatient dizziness clinic of Shanghai Changzheng Hospital and the clinical data of all the 80 patients were collected including the demographic and clinical characteristics, the history of diagnosis, inappropriate diagnostic tests, costs of the medical tests, transportation and accommodation. All the data were investigated to estimate the misdiagnosis of benign paroxysmal positional vertigo and the associated costs in Shanghai, China.

This study showed that the misdiagnosis rate of BPPV was 60.0% (48/80) and the common inappropriate diagnostic tests for BPPV included Cranial CT and MRI test, cervical MRI, cervical and cerebrovascular investigations et al. There was no significant difference between the misdiagnosis patients (48) and patients without misdiagnosis (32) in gender, age, duration of symptom, involved canal and type of BPPV.Complications were significantly more frequent in the misdiagnosis group than for those without[81.3%(39 /48) vs 34.4%(11 /32)]. The estimated costs for each misdiagnosed individual were 8 502.98 China Yuan (CNY) and one-year economic burden associated with the misdiagnosis of BPPV in Shanghai was 13.184 7-78.862 1 million CNY.

Our study suggests that the misdiagnosis rate of BPPV is high and the financial impact on patients and society with this disease is huge. The cost-effective Dix-Hallpike or supine roll test maneuver should be used before applying other expensive medical tests in order to minimize misdiagnosis and the waste of health care resources.

To formulate and evaluate a rapid assessment questionnaire for benign paroxysmal positional vertigo(BPPV).

The rapid assessment questionnaire for benign paroxysmal positional vertigo was developed based on the core clinical manifestations of BPPV.A total of 235 dizzy patients, with an average age of 56±16, were recruited from the Navy General Hospital during October 2015 to March 2016.The assessments were made by two specialists for BPPV, and the diagnoses were confirmed through follow-up.The reliability and validity of the scale questionnaire were analyzed with the SPSS 19.0 and the cutoff point was confirmed with the Receiver operating characteristic(ROC) curve analysis.

Reliability test: Cronbach α value for the questionnaire was 0.644; Validity: KMO (Kasier-Meyer-Olkin) value for the questionnaire was 0.711.Two factors were used with a characteristic root of higher than 0.9.The total cumulative contribution rate was 53.816%.The load of each item was over 0.5.The range of the scale is 0 to 6 points, with the largest ROC curve area (0.894) at 3 points for the diagnosis of BPPV.The relative sensitivity and specialty were 92.45% and 71.60% , respectively.

This rapid assessment questionnaire for benign paroxysmal positional vertigo posses good reliability and validity, and can be used as a tool for a quick diagnosis of BPPV for patients with dizziness. BPPV can be diagnosed with a score of 3 by using this questionnaire.

To investigate whether there are changes in adherens junctions(AJ), including E-cadherin (E-cad) and β-catenin (β-cat), in the colonic mucosa of irritable bowel syndrome (IBS).

Colorectal dilatation combined with restraint stress was used to establish IBS SD rat model. There were 8 rats in the model group and 8 rats in normal control group. From each rat, the colon tissue 5 centimeters away from ileocecum (I) and the junction of the rectum and sigmoid colon (R) were taken, in which E-cad and β-cat mRNA, protein level and structural changes were detected using real-time quantitative-PCR, Western blot, and immunofluorescence. According to the Rome Ⅲ criteria, IBS with diarrhea (IBS-D) patients receiving colonoscopy ( n=17) and healthy volunteers (n=17) were enrolled in Center of Endoscopy of the First Affiliated Hospital of Zhejiang Chinese Medicine University. The colon tissues of I and R locations were collected from them. Colonic epithelial cell AJ protein expression and AJ structural changes in the tissues were detected using Western blot, immunofluorescence and transmission electron microscope (TEM).

(1)Both in I and R sites, the mRNA and protein expression of E-cad in IBS rats were both significantly lower than in normal SD rats (all P<0.05). The mRNA expression of β-cat showed no significant change in IBS SD rats compared with the normal SD rats; the protein expression of β-cat was decreased in I(P<0.05), no significantly different in R. (2)In I and R of IBS-D patients, the expression of E-cad protein were significantly decreased(I: 0.85±0.30 vs 1.24±0.34,P=0.00; R: 0.86±0.17 vs 1.14±0.48, P=0.05); the protein expression of β-cat also showed significant reduction both in I(0.85±0.39 vs 1.22±0.51, P=0.04)and R (0.92±0.22 vs 1.16±0.31, P=0.02) of IBS-D patients, compared with the healthy controls. Immunofluorescence results showed that E-cad and β-cat in colonic epithelial cells of I and R in the healthy controls were distributed along the cell membrane, demonstrating honeycomb linear fluorescence; however, in IBS-D patients, the structure of E-cad and β-cat were fuzzy, with disrupted distribution in the cytoplasm. Under TEM, the gaps of AJ in I and R of IBS-D patients appeared wider than in the healthy volunteers.

In IBS-D patients, there are wider gaps of AJ, and decreased expression with structural disorder of E-cad and β-cat in the colon. The change of AJ plays an important role in the damage of colonic mucosal barrier and the increase of intestinal epithelial permeability in IBS-D patients, but the mechanism is yet to be further explored.

To investigate the change of NIX level of bone marrow nucleated red blood cells in anemia patients with myelodysplastic syndromes (MDS), to explore the significance of NIX-mediated mitochondrial autophagy in the pathogenesis of MDS anemia.

A total of 54 patients with MDS diagnosed in the Department of Hematology of General Hospital, Tianjin Medical University from July 2015 to July 2016 were enrolled into the MDS group, 33 cases of immune thrombocytopenia or idiopathic leukopenia as controls.The level of NIX, the number of mitochondria, mitochondrial membrane potential, the level of reactive oxygen species (ROS) in GlycoA⁺ nucleated red blood cells were measured by flow cytometry; the level of NIX mRNA was measured by PCR.

(1) The expression of NIX in GlycoA⁺ nucleated red blood cells in high-risk MDS patients (0.61±0.24) was significantly lower than that in controls (0.79±0.16, P=0.027), and lower than that in low-risk MDS patients (0.81±0.15, P=0.011), while there was no significant difference between the controls and low-risk MDS patients. The expression of NIX mRNA in GlycoA⁺ nucleated red blood cells in high-risk MDS group (0.36±0.09) was lower than that in the controls (1.44±0.41, P=0.027) and that in the low-risk group (1.02±0.22, P=0.012); there was no significant difference between the controls and the low-risk group. (2) The number of mitochondria in GlycoA⁺ nucleated red blood cells in high-risk MDS patients (937.17±707.85) was significantly higher than that in the controls (513.49±372.33, P=0.019) and that in low-risk MDS patients (461.74±438.02, P=0.008); while there was no significant difference between low-risk MDS patients and the controls. (3) The level of mitochondrial membrane potential in GlycoA⁺ nucleated red blood cells in high-risk MDS patients (0.33±0.18) was significantly lower than that in the controls (0.61±0.32, P=0.001) and that in low-risk MDS patients (0.61±0.34, P=0.001); with no significant difference between low-risk MDS patients and the controls. (4)The level of ROS in GlycoA⁺ nucleated red blood cells in high-risk MDS patients (438.65±322.83) was significantly higher than that in the controls (242.77±136.87, P=0.006), and higher than that in low-risk MDS patients (197.40±95.07, P=0.001); no significantly different between low-risk MDS patients and the controls. (5) The number of mitochondria in GlycoA⁺ nucleated red blood cell was positively correlated with the percentage of ring sideroblast (r=0.457, P=0.028) in the MDS patients.(6) The number of mitochondria in GlycoA⁺ nucleated red blood cells was negatively correlated with the concentration of hemoglobin (r=-0.521, P=0.009) in high-risk MDS patients, but not correlated with the concentration of hemoglobin in low-risk MDS patients.

NIX level is reduced in nucleated red blood cells of high-risk MDS patients, which leads to impaired mitochondrial autophagy, increased damaged mitochondria and apoptosis of nucleated red blood cells, thus related with anemia.

To investigate the clinicopathological features of acantholytic mammary Paget′s disease (AMPD).

From January, 2010 to October, 2016, a total of 28 patients were diagnosed as AMPD in the Department of Dermatology, Peking Union Medical College Hospital. The clinical and histopathological data of these patients were analyzed retrospectively.

The patients were all female. The mean age of onset was (51±15)years (range, 24 to 78 years). The median course of disease was 10.5 months (range, 3 months to 2 years). All the cases were unilaterally involved. The ratio of left breast involvement to the right breast involvement was 1.55∶1. In histopathological examination, all the cases showed acantholytic pattern. In addition to that, the prototypical pattern accounted for 50.0% (14/28) of all the AMPD cases. The frequencies of other different accompanied histopathological patterns were: 3 (10.7%) upper nest, 2 (7.1%) budding, 1 (3.6%) tall nest, and 1 (3.6%) sheet-like. Hailey-Hailey-disease-like acantholysis was observed in 18 patients (64.3%), whereas pemphigus-vulgaris-like acantholysis was noted in 7 patients (25.0%) and Darier′s-disease-like acantholysis in 3 patients (10.7%). About 75.0% (21/28) of the AMPD cases were found to be accompanied with underlying breast cancers. There was no recurrence in 18 of 20 patients who completed treatment and were followed up for over 1 year.

AMPD might involve the left breast more frequently. It is mostly associated with the prototypical pattern of mammary Paget′s disease. Hailey-Hailey-disease-like acantholysis may be the most frequent subtype of AMPD. Most AMPD cases are associated with underlying breast cancers, but with a low recurrence rate after treatment.

To investigate the effects of perioperative transfusion of blood components on the long-term prognosis of hepatocellular carcinoma (HCC) patients.

A total of 339 patients with primary HCC who underwent curative hepatectomy between January 2003 and December 2010 at the Cancer Hospital, Chinese Academy of Medical Sciences were enrolled. The clinical data of the patients were retrospectively analyzed. These patients were divided into non-transfusion, fresh frozen plasma (FFP) transfusion only and concentrated red cells (CRC) transfusion groups. Disease-free survival and overall survival were estimated using the Kaplan-Meier method, and Cox regression was performed to identify clinicopathological factors related with survival.

Among the 339 patients, the 1-, 3- and 5-year disease-free survival rates were 63.1%, 35.4% and 22.4%, respectively, and the median disease-free survival was 22 months. While the 1-, 3- and 5-year overall survival rates were 90.5%, 69.5% and 56.4%, respectively, and the median overall survival was 72 months. The median disease-free survivals of the non-transfusion (n=181), FFP transfusion only (n=48) and CRC transfusion (n=110) groups were 28, 22 and 12 months, respectively, while the median overall survivals of the three groups were 99, 63 and 40 months respectively. Significant differences in the disease-free and overall survivals were observed among the three groups (both P<0.01). Multivariate Cox regression analyses showed that FFP transfusion only (HR=1.658, P=0.026), CRC transfusion (HR=1.470, P=0.030), serum alpha-fetoprotein>400 μg/L (HR=1.686, P=0.002), albumin<35 g/L (HR=1.782, P=0.047), tumor capsule (HR=0.597, P=0.012), tumor necrosis (HR=1.820, P=0.001) and the TNM stage Ⅲ or above (HR=2.537, P=0.000) were independent predictors of overall survival after hepatectomy.

Both perioperative FFP only transfusion and CRC transfusion may have detrimental effect on the long-term prognosis of HCC.

To study the efficacy and safety of linezolid for the treatment of patients with bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA).

Totally 52 cases of MRSA bacteremia patients, from January 2010 to April 2014 in the First Affiliated Hospital, School of Medicine, Zhejiang University, were retrospectively analyzed. They were classified into two groups based on linezolid therapeutic regimen: primary treatment with linezolid (19 cases) and alternated to linezolid (33 cases). The following data were collected and compared: clinical characteristics, lasting time of fever, bacterial clearance rate, clinical efficacy, fatality rate, and adverse events.

Forty three of the 52 patients (82.7%) suffered complicated MRSA bacteremia. The most common clinical feature was fever[86.5%(45/52)]. Linezolid was initiatively used mostly because of renal insufficiency[68.4%(13/19)]. In the other 33 patient, glycopeptides were initiatively used, then alternated to linezolid because of persistent fever[69.7%(23/33)]; damage of kidney function during treatment period of glycopeptides[12.1%(4/33)]; occurrence of new infectious site related to MRSA[18.2%(6/33)]. The clinical efficacy were 78.9%(15/19) in the group of primary treatment with linezolid and 81.8% (27/33) in the group of alternated to linezolid, persistent time of fever were 4(3, 15) d and 12(5, 24) d, mortality during 28 d period were 15.8% (3/19) and 9.1% (3/33), adverse rate were 15.8% (3/19) and 12.1% (4/33) in these two groups, respectively (allP>0.05).

Linezolid is an option with high clinical efficacy and good safety for MRSA bacteremia patients.

To investigate the efficacy of general anesthesia with epidural anesthesia and postoperative epidural analgesia in terms of pain relief and post-operative functional recovery.

Ninety-six patients were randomly assigned to general anesthesia and intravenous analgesia group (GI) or general anesthesia combined with epidural anesthesia and epidural analgesia group (GE). Demographic and operative data, postoperative VAS pain scores, gastrointestinal function, postoperative hospital stays, general complications were assessed prospectively.

(1) The postoperative VAS scores of patients in the group GE at 2, 24, 48, and 72 hours were significantly lower than those in the group GI. (2) Compared with the group GI, the patients in group GE had earlier postoperative flatus and a shorter postoperative hospital stay (8.4 ± 2.5 vs 10.0 ± 3.2, P=0.012 8).

General anesthesia combined with epidural anesthesia and postoperative epidural analgesia could provide better pain relief, enhance early rehabilitation and reduce the duration of hospital.

To explore the clinical outcome of the surgical treatment for aortic dissection with lower extremity ischemia.

Between March 2009 and April 2013, 14 patients with type A aortic dissection and lower extremity ischemia underwent Sun′s procedure in Beijing Anzhen Hospital. Ascending aorta-iliac artery bypass, ascending aorta-femoral artery bypass, femoral-femoral artery bypass and axillary -femoral artery bypass were performed on some severe patients at the same time.

Two death occurred, and the others were improved or recovered from symptoms. Follow-up was complete with an average time of 24 months and no aortic relevant complications occurred.

As for patients with type A aortic dissection and lower extremity ischemia, simultaneous radical femoral artery bypass procedure is effective in improving their survival rate and quality of life.

To prepare the quality control material for detection of platelet membrane glycoproteins by flowcytometry and evaluate the appearance traits, homogeneity and stability of it.

Fresh platelets from the blood group O donors were fixed by the certain concentration of aldehyde solution and then washed by the imidazole buffer. After that, adding certain concentration of lyophilized protection solution into the preparations. The preparations were dispensed to be lyophilized and then were kept refrigerated in 2-8 ℃.According to the protocol of control of lyophilized biological products, the quality indicator for monitoring the prepared process, containing the appearance traits, the residual water, the platelet recovery and the rehydration quality were evaluated. The homogeneity and stability of these preparations were evaluated according to the CNAS-GL03 Guidance on evaluating the homogeneity and stability of samples used for proficiency testing and the ISO Guide 35 Reference material-general and statistical principles for certification.

The appearance traits and the rehydration quality of the quality control materials meeted the requirements, with the residual water distributed between 3.96% to 4.04% and the platelet recovery rate ranged from 68% to 72%.The homogeneity evaluation showed that there was no significant difference among the groups(P>0.05). The stability test indicated that the positive rate of platelet membrane glycoproteins CD42b, CD41 and CD62P of the quality control material was -0.14%, -0.14% and 0.74%, respectively, at 16 weeks after storage. There was no linear trend between the percentage of positive platelets with membrane glycoproteins and time(P>0.05).

The quality control material for detection of platelet membrane glycoproteins by flow cytometry prepared by us meets the needs of the appearance traits, the residual water, the rehydration quality, the homogeneity and the longtime stability.It is hopeful to be used as internal quality control of the assay in clinic laboratory, the external quality assessment and proficiency evaluation.

Foreign bodies in the laryngopharynx and upper esophagus are common diseases in the outpatient and emergency department of otolaryngology head and neck surgery. At present, otolaryngology head and neck surgeons still use indirect laryngoscope and fiber electronic laryngoscope to take foreign bodies in the laryngopharynx, and rigid esophagoscope to take foreign bodies in the upper esophagus. However, it is often restricted by unclear vision and weak light, or the operation requires the cooperation of two people. We comprehensively used three methods to remove foreign bodies from laryngopharynx and upper esophagus: removing foreign bodies under rigid nasal endoscope video display, removing foreign bodies under rigid nasal endoscope video display under supporting laryngoscope, and removing foreign bodies by neck incision. Among them, the innovative application of rigid nasal endoscope is intuitive and convenient, which improves the detection rate and removal rate, and also reduces iatrogenic foreign body imprisonment. The clinical data of 181 cases are retrospectively analyzed and summarized, and the reports are as follows.

A 45-year-old male, a farmer, was admitted to the hospital on July 18, 2015 due to "repeated fever and cough for 3 years, and recurrent aggravation for 40 days". Three years ago, the patient had repeated fever, cough and expectoration without obvious inducement, mainly dry cough, with a maximum body temperature of 37.8℃. Every time he took oral anti-inflammatory drugs or went to the local hospital for infusion treatment, the fever and cough could improve, but the specific diagnosis and treatment were unknown. 40 days ago, the patient had fever and cough again, mainly low fever, with no obvious rule of fever, with the highest body temperature of 38.0℃, accompanied by night sweats, fatigue, dry cough, no expectoration, hemoptysis, chest pain, dyspnea, fatigue, anorexia, muscle pain and joint swelling and pain, and painless subcutaneous nodules in both lower limbs. He was hospitalized in a local hospital on 17 June 2015 for further treatment. Chest CT showed multiple small patches and nodular high-density shadows of different sizes in both lungs, irregular thick-walled cavities formed in massive lesions in the right lower lung, and multiple lymph nodes swollen in the mediastinum. The initial diagnosis was: (1) Secondary tuberculosis in both lungs and cavity formation in the right lower lung? (2) Lung cancer Fever and cough did not improve significantly after 15 days of quadruple anti-tuberculosis (isoniazid, rifampicin, ethambutol and pyrazinamide). Bronchial examination and right upper lobe bronchial mucosa biopsy and brushing examination were performed. Under bronchial examination, the right upper bronchus and left lower bronchus were considered to be more likely to be tuberculous. The pathological report of mucosal biopsy was "caseous necrosis under the microscope, but no tuberculous nodules, no abnormal cells and cancer cells, acid-resistant staining (-)". Continued to give quadruple anti-tuberculosis treatment for 15 days and antifungal (fluconazole) and anti-infective (cefoxitin) treatment, but the symptoms of fever and cough were not relieved. Mycobacterium tuberculosis-specific cellular immune response (-) was tested on July 8, and anti-tuberculosis treatment was discontinued. Because the patient had repeated fever and cough, it still did not improve significantly, and the peak body temperature was higher than before, with the highest body temperature of 39.0℃. Occasionally, he coughed yellow phlegm, without hemoptysis and dyspnea. Then he was transferred to our hospital for treatment on July 18th. Since the onset of the disease, the patient's body weight has decreased by 7.5 kg, and his sleep and appetite are acceptable. Previous denial of rhinitis and sinusitis, no history of exposure to tuberculosis and tuberculosis, denial of history of diabetes.

A 33-year-old male was admitted to the hospital on 24 April 2016 due to "intermittent abdominal pain for 6 years, aggravated with abdominal distension for 6 months". In October 2010, the patient developed distension and pain in the left middle abdomen without trigger, no fever, stopped exhausting and defecation, and his body weight decreased by 20 kg. The erythrocyte sedimentation rate (ESR) was 24 mm/1 h, and the C-reactive protein (CRP) was 29.6 mg/L. Barium enema showed: ileocecal deformation, cecal shortening, and terminal ileal stenosis (Figure 1)。 Abdominopelvic enhanced CT reconstruction of small intestine indicated that the formation of local intestinal fistula in ileum and ileocecal region may be accompanied by peripheral fat and mesenteric lesions; There were multiple lymph nodes of varying size around the lesion, mesenteric root and retroperitoneum (Figure 2)。 The ileocecal intestinal lumen was deformed and narrowed with local superficial ulcer after colonoscopy (Figure 3)。 Laparoscopic exploration was performed in January 2011. A tumor with a diameter of 1 cm was seen in the abdominal wall of the left lower abdomen. Pathology showed: fat necrotic nodules with lymphoid tissue hyperplasia; A mass of about 15 cm in diameter can be seen retroperitoneally, which is hard in texture and easy to bleed when touched. Intraoperative freezing and postoperative pathology showed that adipose tissue was necrotic and absorbed. Considering the possibility of diagnosis of mesenteric panniculitis, with Crohn's disease not excluded, prednisone 40 mg was added orally once a day, and the dose was regularly reduced until February 2012. During this period, the abdominal pain improved and the body weight increased by 15 kg. CT reexamination in December 2011 showed that the lesion was less than before (Figure 4)。 There was no regular follow-up and maintenance medication after hormone reduction. In October 2015, the patient developed abdominal distension in the right lower abdomen, with a palpable local mass, accompanied by fatigue, and a weight loss of 20 kg. Admitted to hospital for further treatment. Previous: Appendectomy in 1990, surgical treatment for perianal lesion (specificity unknown) in 1998. Personal or family history is not special. Admission physical examination: Body mass index (BMI) 19.1 kg/m²The abdomen was flat and soft, no intestinal type was seen, no tenderness, rebound pain, no clear abdominal mass was palpable, and the intestinal sound was high-key, 8 times/min.

A 57-year-old male was found to have a sacrococcygeal mass for 1 week due to lumbosacral pain and distension for more than 2 months. Color ultrasound examination in the outer hospital showed that a cystic mass of about 5.4 cm ×4.7 cm could be seen in the sacrococcygeal region, with cord-like segmentation and clear boundary. Come to the First Affiliated Hospital of Zhengzhou University for treatment.

With the increase of the average life expectancy, the aging of the population, the increase of social occupation, education, economic pressure and the progress of medical technology, coupled with the liberalization of the "two-child policy" in China, the age structure of both spouses is undergoing great changes, and the proportion of advanced maternal age and advanced paternal age is gradually increasing^[1]。 At present, all countries in the world have generally classified female pregnancies aged ≥35 as advanced pregnancies, but there is no unified conclusion on advanced childbearing fathers. Some experts regard 40 as the boundary^[2,3,4]。 So far, there have been a lot of research reports on the adverse effects of advanced pregnancy on offspring^[5,6]However, research reports on older childbearing fathers are relatively rare abroad, and even only a handful in China. With the liberalization of the "two-child policy", China's population will usher in a round of rapid growth, but at the same time, with the increase of the proportion of older parents in China, the influence of older age on offspring will also increase. Because there are few studies on the adverse effects of older childbearing fathers on offspring in China, the following research on cognition of older childbearing fathers and offspring is summarized.

Exosomes are extracellular vesicles secreted by a variety of living cells, containing a variety of bioactive components, playing an important role in cellular information transmission, and participating in a variety of pathophysiological processes, such as apoptosis, angiogenesis, immune regulation, tumor migration, etc^[1]。 Recent researches have shown that exosomes are closely related to Mycobacterium tuberculosis infection. The fatty arabinomannan, phosphatidylinositol mannoside and various mycobacterial proteins contained in exosomes are involved in the antigen presentation, immune response, inflammatory response and other processes of Mycobacterium tuberculosis infection, and have broad prospects in the diagnosis and treatment of diseases^[2]。 This article reviews the related studies of exosomes and Mycobacterium tuberculosis infection.

persistent postural-perceptual dizziness (PPPD) is a clinically common chronic dizziness. It is a new independent disease named by the World Health Organization in early 2014. PPPD is hardly recognized by clinicians in China, which brings difficulties to clinical diagnosis and treatment. This article reviews the historical evolution, diagnostic criteria, basic characteristics, pathogenesis and clinical treatment of PPPD.