Volume 97  ·  Issue 47  ·  2017

To investigate the value of combined use of half-dose spectral CT based on the automatic spectral imaging mode selection (GSI Assist) and adaptive statistical iterative reconstruction (ASIR) in the CT examination of upper abdomen in obese patients as compared with conventional CT.

Eight-two obese patients (body mass index≥29 kg/m²) were prospectively selected from October to December 2016, and contrast-enhanced CT during arterial phase (AP) and portal venous phase (PVP) were carried out in those patients.The patients were randomly assigned to the study group and control group with random number table (41 cases in each group). In the study group, half-dose spectral CT based on GSI Assist was applied and monochromatic images (40 to 70 keV, 10 keV as increment) were reconstructed using 50% ASIR (group A). In the control group, the fixed tube potential of 120 kVp was done with images reconstruction using 30% ASIR (group B). Quantitative parameters of radiation dose, CT value, contrast to noise ratio (CNR) and image noise were compared between the two groups by using two sample t test, while qualitative visual parameters (overall image quality as graded on a 5-point scale) were compared with Mann-Whitney U test.

There was significant difference in effective radiation dose between the two groups[(5.2±0.8) vs (10.4±1.7) mSv, t=-17.822, P<0.001], and it was decreased for 50% in group A. During the arterial phase (AP) and portal venous phase (PVP), at the energy level of 40 keV and 50 keV, higher CT values, higher or similar CNRs, higher image noise and lower overall image quality scores were found in group A when compared with group B. At the energy level of 60 keV, group A had higher CT values, higher or similar CNRs, similar overall image quality scores with higher or similar image noise as compared with group B. At the energy level of 70 keV, the two groups had similar CT values, CNRs and image noise, and higher overall image quality scores were found in group A.

In obese patients, combined use of half-dose spectral CT based on GSI Assist and ASIR can reduce effective radiation dose up to 50% when compared with conventional upper abdominal CT.Monochromatic images at 70 keV can maintain CNR and improve overall image quality.

To evaluate the feasibility of cervical laminoplasty with preservation of the posterior ligament complex for enlarging the spinal canal.

Six up-to-standard human corpse specimens were divided into two groups by simple randomization (start from C4 group, S4; start from C5 group, S5; 3 corpses in each group). Decompression operation of C3-C6 level was performed in a predetermined sequence by using the new procedure with preservation of the posterior ligament complex.The basic depth of spinal canal was measured with a depth gauge at fixed point after the right bone groove of single level was completed.The operation of the contralateral bone groove was continued, and then the spinal canal was measured again when the spinous process was pulled backward by using a tissue forceps until the ligament complex was just tight.Retreat value (RV) of vertebral lamina was obtained by calculating the difference between the two measurements.The earlier measured levels needed to be remeasured when the operation area increased by one level. Two independent sample and one-sample t test were used to analyze the measurement results.

RV of vertebral lamina was small after finishing the first level of the decompression operation [S4: (0.87±0.72) mm; S5: (1.83±0.29) mm], and the value reached its maximum after the completion of C3-C6 level.The overall average RVmaxs from C3 to C6 level were (2.37±0.52) mm, (4.27±0.78) mm, (3.73±0.93) mm and (2.16±0.77) mm, respectively.The overall average retreat rates (RR) were 17%±7%, 32%±9%, 29%±10% and 16%±6%, respectively. The overall average RVmax of C4 and C5 level reached or exceeded the decompression threshold value of 4 mm (t=0.839, -0.703, both P>0.05). The average RVmax of C4/C5 level was similar in the two groups (t=-1.204, 1.189, both P>0.05); however, the difference of average RVmax between C3 and C6 level was significant (t=-4.429, 4.196, both P<0.05).

Cervical laminoplasty with preservation of the posterior ligament complex can enlarge the sagittal diameter of spinal canal and relieve the compression of spinal cord.In addition, RV of each level increases as the number of the operation level increases, and the ability of vertebral lamina to retreat is quite different from C3 to C6 level.The decompression effect in the middle of the operation area is better than that on the cranial and tail side.

To investigate the preliminary applicability of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) score in the condition of 3.0T multi-parametric magnetic resonance imaging (Mp-MRI) combined with clinical classic indicators for the diagnosis of prostate cancer (PCa).

The clinical and MRI materials of 247 patients of suspicious prostate disease treated in Second Affiliated Hospital of Soochow University from June 2015 to November 2016 were analyzed retrospectively, including 110 cases with PCa and 137 cases without cancer.All cases underwent the high-resolution axial T₂-weighted imaging (T₂WI), diffusion weighted imaging (DWI) and dynamic contrast enhancement-magnetic resonance imaging (DCE-MRI) and were confirmed pathologically by puncture biopsies.The Mp-MRI materials of all cases were scored according to PI-RADS v2.The prostate volume and prostate specific antigen (PSA) density (PSAD) value were calculated according to the formulas.The univariate and multivariate analysis were performed for the observed indicators (age, prostate volume, PSA, PSAD and PI-RADS v2 score) to determine the independent predictors for PCa.Then, a Logistic regression model (combined prediction model) was established by the independent predictors for combined diagnosis of PCa.The receiver operating characteristic curve (ROC) curve analysis was performed to get the sensitivity and specificity of each independent predictor and the model to diagnose PCa.The differences of AUC values of each independent predictor and the model were compared with each other to evaluate the diagnostic performance for PCa.

The differences in the age, prostate volume, PSA, PSAD and the PI-RADS v2 score between patients with PCa and non-cancer group were all statistically significant (t=2.870, Z=-4.230, -7.787, -9.477, -10.826, all P<0.05). The PSAD and PI-RADS v2 score were independent predictors for PCa (OR=3.331, 10.546, both P<0.05). The Logistic regression combined prediction model by PI-RADS v2 score and PSAD to forecast PCa was Logit(P)=-5.097+ 2.309×PSAD+ 1.214×PI-RADS v2 score.The area under the curve (AUC) of ROC in the combined model (0.911) was higher than that in the PI-RADS v2 score (0.886) and PSAD (0.851) and the differences were all statistically significant (Z=2.416, 2.716, both P<0.05); but the difference in the AUC value between PI-RADS v2 score and PSAD was not statistically significant (Z=1.191, P=0.234). The diagnostic sensitivity of PSAD, PI-RADS v2 score and the model were: 0.891, 0.782 and 0.855, respectively; the specificity were 0.449, 0.912 and 0.847, respectively on their positive thresholds (0.15 μg·L ^-1·ml^-1, 4 and -0.82).

PI-RADS v2 score combined with PSAD in diagnosing PCa is superior to the single application of them and it can lead to high diagnostic sensitivity and specificity for PCa.

To study tumors and fertility outcomes after fertility-sparing surgical treatment with borderline ovarian tumors (BOT).

One hundred and nineteen patients with BOT enrolled from 3 hospitals between January 2004 and January 2017 were analysed retrospectively.The clinical data and follow-up results were obtained and analyzed.

Among the 119 BOT patients, 55 patients underwent fertility-sparing surgery.The median age was 43 years (interquartile range: 15-80 years). There were 103 patients (86.55%) in stage Ⅰ, and 16 patients (13.45%) in stage Ⅱ and above.The median follow up time was 68 months (range: 4-155). (1)Tumor outcomes: 13 patients recurred and 3 patients died.Progression free survival (PFS) and the overall survival rate had no significant difference between the two groups (85.45% vs 92.19% P=0.309, 96.4% vs 98.4% P=0.492). PFS was related to FIGO stage, invasive implantation and chemotherapy by univariate analysis (P<0.05). The multivariate Cox regression model analysis showed that FIGO stage and invasive implantation were independent prognostic factors for PFS (P<0.05). (2) Pregnancy outcomes: 28 patients had a planned for pregnancy in fertility-sparing group, with 13 (46.43%) of them were pregnancy.

FIGO stage and invasive implantation were the important factors of prognosis.Fertility-sparing surgery is safe and feasible to preserve the fertility of young patients.

To investigate whether platelet to lymphocyte ratio (PLR) in peripheral blood and body mass index (BMI) can be independent prognostic factors in patients with melanoma.

Clinical date of 140 patients with melanoma in the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital from January 1, 2010 to December 31, 2015 were analyzed retrospectively.Receiver operating characteristic (ROC) curve was performed the optimal cut-off value for PLR.The 140 patients were divided into high PLR group and low PLR group.According to "Guidelines for prevention and control of overweight and obesity in Chinese adults" , the patients were divided into high BMI group and low BMI group.The relationship between PLR, BMI with overall survival (OS), progression free survival (PFS) and disease free survival (DFS) were analyzed.The Kaplan-Meier method and Log rank test was used for univariate survival analysis and Cox proportional hazards regression model for multivariate analysis.

The optimal cut-off value of PLR determined by ROC curve was PLR=120.15, and BMI threshold was 24.Univariate survival analysis showed that PLR, BMI and clinical stage were the factors affecting the OS in patients (P<0.05). The median survival time (MST) was 21 months in the whole group and 17 months in the high PLR group, 34 months in the low PLR group, respectively; the MST in the high and low BMI group were 29 months and 13 months, respectively.The difference was statistically significant (P<0.05). The effects of PLR and BMI on PFS and DFS were not statistically significant.Cox multivariate analysis showed that PLR, BMI and clinical stage were independent prognostic factors of OS (P<0.05). And BMI was the only independent protective factor for OS, the risk of death decreased by 0.611 times, with each unit increased for BMI.Clinical subgroup analysis showed that PLR also was risk factor to the prognosis of patients with stage Ⅱ, Ⅲ, and Ⅳ (P<0.05).

PLR is an independent prognostic risk factor for patients with melanoma, and BMI is an independent protective factor.PLR and BMI are important factors in prognostic evaluation of melanoma.

To identify whether pregnancy outcomes vary by the severity of pulmonary hypertension.

A retrospective study was conducted on 78 cases of pregnancies complained with pulmonary hypertension who delivered in the First Affiliated Hospital, Sun Yat-sen University from 2006 to 2016.The selected cases were divided into three groups according to severity of pulmonary hypertension: mild pulmonary hypertension group (mild PAH group) was defined as a mean pulmonary artery pressure 30-49 mmHg, moderate pulmonary hypertension (moderate PAH group) as mean pulmonary artery pressure 50-69 mmHg and severe pulmonary hypertension (severe PAH group) as mean pulmonary artery pressure 70 mmHg or greater.The clinical features, risk pregnant complication, maternal and neonatal outcomes were described between these three groups.Analysis of variance, Chi-square test was used for statistical analysis.

The average age of mild, moderate and severe PAH group were (31±5) years old, (31±5) years old and (27±3) years old, respectively (P=0.050). The rate of natural fertilization (P=0.414), parity (P=0.527) and gestational age (P=0.165) were similar in these three groups. In 78 pregnancies with pulmonary hypertension, 64.9% of pregnancies in mild PAH group was NYHA Ⅰ, 50.0% of moderate PAH group was NYHA Ⅱ and 54.5% of severe PAH group was NYHA Ⅲ(P<0.001). There was no significant difference in the incidence of gestational diabetes mellitus (GDM,P=0.589), preeclampsia (P=0.942), premature rupture of membrane (PROM, P=0.276), scarred uterus (P=0.493) and postpartum hemorrhage (P=0.424). The cesarean section rate was 84.2%, 90.0% and 63.6% in three groups (P=0.208). However, neuraxial anesthesia was performed in 82.5% of cases in mild PAH and 90.0% of cases in moderate PAH, while 27.3% of cases of severe PAH underwent neuraxial anesthesia (P<0.001). The fetal outcome was similar in there groups.But the rate of admission of NICU was significantly different in three groups (P=0.011).

Maternal and neonatal outcomes was similar in different severity of pulmonary hypertension.But the severity of pulmonary hypertension affect the type of anesthesia.Close monitoring during pregnancy and timely termination of pregnancy can improve the outcome of pregnancy.

To explore the expression of microRNA-155 in colonic mucosa and peripheral blood in patients with inflammatory bowel disease(IBD), and to examine the clinical value and significance of microRNA-155 in the diagnosis of IBD.

Quatitative reverse-transcription PCR was performed to detect the expression of microRNA-155 in 20 patients with Crohn disease(CD), 21 patients with ulcerative colitis (UC), 18 patients with IBD type unclassified(IBDU), 25 healthy people(control group), 12 patients with infection colitis and 19 patients with ischemia colitis.Receiver operating characteristic (ROC) curve was performed to analyze the clincal value of microRNA-155 in diagnosis of IBD.

The expression of microRNA-155 in colonic mucosa in CD, UC and IBDU group was significantly higher than that in control group(P<0.05). MicroRNA-155 expression was also significantly higher in UC group in comparison to CD group (35.4±3.0 vs 18.6±5.9,P<0.01), IBDU group in comparison to CD group (23.0±3.7 vs 18.6±5.9,P<0.05) and UC group in comparison to IBDU group (35.4±3.0 vs 23.0±3.7,P<0.01). The plasma level of microRNA-155 in UC group (55.6±2.5) and IBDU group (48.1±6.2) was significantly higher than that in control group(P<0.05), while no significant difference in CD group was observed when compared with control group(P>0.05). ROC curve shows an AUC of 0.83 and 95%CI of 0.679-0.986 of microRNA-155 expression in colonic mucosa.The sensitivity and specificity of microRNA-155 expression in colonic mucosa in diagnosis of IBD was 68.4% and 78.6%, respectively.

MicroRNA-155 showed high expression in colonic mucosa and peripheral blood in patients with IBD.MicroRNA-155 shows promise as a biomarker in diagnosis of IBD.Furthermore, the aberrant expression indicates that microRNA-155 may be involved in pathogenesis and progression of IBD.

To investigate the presence of colistin resistance gene mcr in gut bacteria from patients with acute diarrhea.

Fresh stool samples were collected from 150 outpatients with acute diarrhea in the intestinal clinic of Henan Provincial People′s Hospital, and were directly detected for the presence of mcr by PCR after enrichment in the broth.The mcr-producing bacteria were further isolated and identified by MALDI-TOF MS (Bruker Biotyper). Antimicrobial susceptibility of these isolates was conducted by micro-broth dilution method.The presence of other antimicrobial genes were investigated by PCR and sequencing.

Among the 150 cases of acute diarrhea, 4 patients(2.7%) were positive for mcr-1 gene, and only 1(0.7%) contained both mcr-1 and mcr-3.Four isolates of Escherichia coli and one isolate of Aeromonas veronii were obtained from the mcr positive cases.The presence of mcr-1 gene was found in all of the E. coli isolates, and the mcr-3 gene was identified in A. veronii.

Our study demonstrated the relatively low prevalence of colistin resistant gene in the faeces of acute diarrhea outpatients, and mcr-1 is the dominant colistin resistant gene.The presence of mcr-3 gene was also found in the clinical sample, and it indicats the coexistence of mcr-1 and mcr-3 in the intestinal tract of diarrhea patient.We should pay attention to the potential transmission of these resistance genes and further investigations are urgently needed.

To explore the neuromechanism of nicotine smoking, we use independent component analysis (ICA) of resting-state functional magnetic resonance imaging (fMRI) to investigate the differences of functional connectivity of resting-state networks (RSN) in chronic smokers.

Forty-five chronic smokers and thirty-four age and gender matched normal nonsmoking controls experienced resting-state fMRI scanning in 3.0T MRI scanner.Differences of the function connection in each RSN between chronic smokers group and nonsmoking controls group were analyzed by SPM software which was based on Matlab platform.

Compared with normal nonsmoking controls, changes of functional connectivity within each RSN in chronic smokers: (1) medial visual network: functional connectivity decreased in right cuneus (t=4.17, P<0.05) and left calcarine (t=3.08, P<0.05); (2) lateral visual network: decreased in left gyrus occipital superior (t=3.42, P<0.05); (3) occipital pole visual network: decreased in right gyrus occipital medius and left gyrus occipital medius (t=3.58, P<0.05); (4) dorsal attention network (DAN): increased in right gyrus occipital superior (t=3.42, P<0.05); (5) left frontoparietal network: decreased in left inferior parietal lobe (t=3.77, P<0.05); (6) right frontoparietal network: increased in right gyrus frontalis medius (t=3.42, P<0.05).

There are some RSNs changes of chronic smokers compared with normal nonsmoking controls, with multiple brain regions functional connectivity abnormalities.

To investigate the value of split hand in the differential diagnosis of amyotrophic lateral sclerosis(ALS) and cervical spondylotic amyotrophy (CSA).

A total of 62 ALS patients, 57 CSA patients and 65 normal controls who visited the Neurology and Spine Department of Beijing Jishuitan Hospital from May 2013 to June 2017 were enrolled into this study.The amplitudes of compound muscle action potentials (CMAP) were recorded from abductor digiti minimi (ADM) and abductor pollicis brevis (APB). Moreover, the ratio of CMAP amplitude between ADM and APB (ADM/APB) was calculated.

The ADM/APB of the ALS group (1.93±1.97)was significantly higher than that of the normal control group (0.92±0.22)(P<0.05); the ADM/APB of the CSA group (0.74±0.32)was significantly lower than that of the normal control group (0.92±0.22)(P<0.05); the ADM/APB of the ALS group (1.93±1.97)was significantly higher than that of the CSA group(0.74±0.32)(P<0.05); the areas under receiver operator characteristic curve in patients with ALS was 0.843, the diagnostic sensitivity and specificity for ALS were 75.8% and 83.1% with the cutoff value of ADM/APB=1.077; the areas under receiver operator characteristic curve in patients with CSA was 0.737, the diagnostic sensitivity and specificity for CSA were 64.9% and 87.1% with the cutoff value of ADM/APB=0.739.

The ADM/APB has certain clinical value for the differentiation of ALS and CSA.

To investigate the feasibility of blood oxygen level-dependent MR (MR-BOLD) in assessing renal fibrosis of ureteral obstruction of rabbits.

Forty healthy New Zealand rabbits were randomly divided into control group (n=8) and unilateral ureteral obstruction (UUO) group (n=32). The rabbits in the UUO group were subjected to unilateral ureteral obstruction of the left kidney.Coronal T₂ weighted imaging (T₂WI) and axial BOLD examinations were performed before operation, 2, 4, 6 and 8 W after operation (each subgroup n=8). After the examinations, nephrectomy was performed for histologic evaluation.The T₂^* relaxation rate of the renal cortex (CR₂^*) , medulla (MR₂^*) and the same level of muscle(R₂^*_muscle) were measured separately.The normalization of the cortex and medulla (sR₂^*), and the difference of sR₂^* between renal cortex and medulla before and post UUO (ΔsR₂^*) were calculated.The differences of sR₂^* (sCR₂^*, sMR₂^*, sCR₂^*_control, sMR₂^*_control) at each time point between control and UUO group were compared by using independent sample t test.The LSD test was used to compare the sR₂^* in the control with that in the UUO group.The ΔsCR ₂^* and ΔsMR ₂^* values of the subgroups at UUO 2, 4, 6 and 8 W were compared by independent sample t test.

The sR₂^* values of UUO group were all lower than those of control group (all P<0.05), while sR₂^*_control and sR₂^* in UUO group before operation were not significant different (P>0.05). The sCR₂^* values of UUO 2, 4, 6 and 8 W were 0.32±0.01, 0.37±0.01, 0.47±0.02 and 0.50±0.03.The sMR₂^* values were 0.39±0.02, 0.48±0.02, 0.58±0.04 and 0.65±0.05.There were significant differences of sCR₂^*_between UUO 2 W and 6 W, UUO 2 W and 8 W, UUO 4 W and 6 W, UUO 4 W and 8 W (all P<0.01). There were significant differences of sMR₂^*_between UUO 2 W and 6 W, UUO 2 W and 8 W, UUO 4 W and 8 W (all P<0.01). No significant difference was founded between sCR₂^* and sMR₂^* at each time point in control group (P>0.05). The ΔsCR₂^* values of UUO 2, 4, 6 and 8 W were 0.31±0.02, 0.20±0.02, 0.14±0.20, 0.09±0.04; the ΔsMR ₂^* values were 0.51±0.05, 0.36±0.04, 0.28±0.05, 0.19±0.05. The ΔsCR ₂^* values of UUO 2, 4 and 6 W were less than ΔsMR ₂^* (P<0.05). There was no significant difference between ΔsCR₂^* and ΔsMR ₂^* in UUO 8 W (P>0.05).

The R₂^* change in medulla resulted from renal fibrosis is more significant than cortex.MR-BOLD can reflect the process of renal fibrosis.It′s feasible and of great value to use renal MR-BOLD for the assessment of renal fibrosis induced by unilateral ureteral obstruction.

To perform a meta analysis of studies that investigated the effects of repetitive transcranial magnetic stimulation (rTMS) on upper limb motor function in patients with stroke.

We searched for related articles published before October 2015 in MEDLINE(Pubmed) (January 1966 to October 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (October 2015), EMBASE(SCOPUS) (January 1974 to October 2015), Chinese Biomedical Database (CBMDisc) (January 1978 to October 2015), China National Knowledge Infrastructure (CNKI) (January 1979 to October 2015) and Wanfang database(January 1989 to October 2015).

A total of nine studies with 289 patients were included in this analysis.The results showed that rTMS had a significant effect for ischemic stroke patients with upper limb motor disorder with SMD 0.43, 95%CI 0.19-0.67, P=0.000 4. Further subgroup analyses about high or low frequency rTMS demonstrated low frequency rTMS showed prominent effects for the stroke patients with SMD 0.50, 95%CI 0.14-0.85, P=0.007.Only 3 patients from the 9 studies included in this analysis reported adverse effects from rTMS.

The meta analysis suggests that rTMS has a positive effect on motor recovery in patients with stroke, especially the low frequency rTMS may be more beneficial.The clinical application of rTMS in patients with stroke is relatively safe.Intermittent theta-burst stimulation might be a useful intervention.

Cases of lymphoma metastasis to the pituitary gland, both in cases already reported and in patients with advanced clinical tumors, are very rare^[1]。 Malignant tumors that involve the pituitary gland usually show diabetes insipidus or imaging with thickening of the hypothalamus or pituitary infundibulum^[2]。 How to quickly and accurately judge the disease through clinical symptoms and other auxiliary examinations, and give patients correct treatment in time and relieve patients' pain is the focus of research on this kind of disease. The neurosurgery department of Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine diagnosed and treated two patients with lymphoma invading the pituitary gland. The diagnosis and treatment experience of these two cases is reported below.

A 50-year-old male was admitted to the Department of Gastroenterology of Peking Union Medical College Hospital for "repeated diarrhea and abdominal pain for 11 months". The patient developed diarrhea in early December 2015, which was thin watery stool, about 50 ml each time, 4 to 5 times/d, fever, body temperature up to 37.9℃, accompanied by dull pain in the right middle and lower abdomen, no mucus, bloody stool, and night sweats. The blood routine in the local hospital was normal, the erythrocyte sedimentation rate was 48 mm/1 h, and the C-reactive protein was 113 mg/L; Tuberculin test negative. Gastroscopy showed groove-shaped ulcer with peripheral nodular hyperplasia, and multiple shallow ulcers in the stomach body, sinus and angle 34~39 cm away from the incisor; The pathology showed chronic inflammation of the lower esophageal mucosa. Colonoscopy showed multiple ulcers with segmental distribution in the terminal ileum, some ulcers showed longitudinal manifestations, the mucosa between ulcers was normal, and the whole colon was scattered with aphthous ulcers; The pathology showed moderate to severe chronic inflammation of the mucosa, focal erosion, granuloma formation, negative acid-fast staining and negative cytomegalovirus immunohistochemistry. Considering the possibility of infectious enteritis, infusion of levofloxacin, clindamycin and nutritional support were given. The condition improved transiently and worsened again after one month. In March 2016, I went to another hospital. Considering the possibility of "Crohn's disease", I was added with prednisone 20 mg/d for 1 month, then reduced by 5 mg every 3 weeks to 5 mg/d for maintenance, and added mesalazine 0.8 g/d. The patient's diarrhea and fever symptoms improved compared with before, but the diarrhea worsened again after prednisone was reduced to 10 mg/d, accompanied by fatigue. The onset to deny repeated oral vulvar ulcers, arthralgia, pyoderma gangrenosum, erythema nodosum, no anal fistula, perianal abscess. The body mass decreased by about 17.5 kg in half a year. Past history: Hepatitis B virus surface antigen, e antibody, c antibody positive for many years, hepatitis B virus DNA negative, no antiviral treatment was added. He suffered from tuberculosis when he was young, and recovered after regular anti-tuberculosis. Personal history: Hospital pharmacist, denying history of intimate contact with tuberculosis patients. Admission physical examination: wasting, anemic appearance, superficial lymph nodes not reached, clear breathing sounds in both lungs, and no murmur in the heart. The abdomen was soft, without tenderness and rebound pain, and the liver and spleen were not reached under the costs, and the abdominal mass was not palpable.

The 22-year-old male was admitted to the Department of Gastroenterology of Peking Union Medical College Hospital in April 2016 because of "anemia found for 13 years, repeated melena and abdominal pain for 7 years". In 2003, the patient was diagnosed with "iron deficiency anemia" due to "upper respiratory tract infection" in a routine blood test in another hospital showing hemoglobin 60 g/L, no dizziness and palpitations. After oral iron supplementation treatment for about 2 weeks, the drug was discontinued spontaneously, and the blood routine was not re-examined. In June 2009, dull periumbilical pain with melena occurred without trigger, 1 to 2 times a day, lasting for 2 to 3 days, and then relieved spontaneously. In July 2009, the hemoglobin was checked at 40-50 g/L, and the hemoglobin was rechecked at 120 g/L after 2-3 months of oral iron supplementation. In 2014, I began to have recurrent abdominal pain and melena, which lasted for about 2 days and could relieve by itself, with an attack once every 4 weeks. Since 2015, the frequency of attacks has increased to once every 2 weeks, each lasting for 3 to 4 days. During the period, many blood tests showed that microcytic hypochromic anemia could be improved after iron supplementation treatment. Gastroscopy in an external hospital showed: postoperative changes of hiatal hernia; Chronic gastritis; Biliary reflux. Capsule endoscope (Figure 1) shows that the small intestine is scattered with less smooth mucosa, scattered with redness, swelling, erosion and ulcers, accompanied by intestinal lumen stenosis, and the lesion may be located in the jejunum. PET/CT showed multiple enlarged lymph nodes in the mesangial area of peritoneal cavity, but no significant increase in metabolic activity was observed; Esophageal retention. Weight loss of 5 kg 1 year before admission, denied oral vulvar ulcers, perianal lesions, joint swelling and pain, rash, etc. Past history and personal history: The parents were not close relatives, and the mother gave birth naturally at 38 weeks of pregnancy. The patient was diagnosed as "hiatal hernia" at the age of 7 months due to repeated vomiting after eating. He underwent "esophageal hiatal tightening + esophageal fundoplication + diaphragm overlap repair" in the external hospital. He did not vomit again after the operation, but repeated reflux after eating, accompanied by acid reflux, heartburn, and retrosternal pain. He was lying on his back, and occasionally choked and coughed after falling asleep. Since childhood, it is prone to upper respiratory tract infection, and its physical strength and weight are worse than those of peers, and its intelligence level is the same as that of peers.

A 62-year-old female was admitted to the Department of Gastroenterology, the First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine because of "repeated abdominal distension for more than 8 years". The patient had obvious abdominal distension after eating, and no symptoms such as abdominal pain, nausea and vomiting. The local hospital has repeated gastroscopy, colonoscopy, abdominal CT and other examinations. Weight loss of about 15 kg in 8 years. After admission, there were no differences in biochemistry, tumor, coagulation, thyroid function and blood routine. The imaging examination showed abdominal B-ultrasound and abdominal CT. Gastroscopy showed an irregular shallow depression of about 0.8 cm ×1.5 cm in the body of the stomach, with uneven bottom and unclear boundary (Figure 1)； Magnification endoscopy combined with narrowband imaging (ME-NBI) technique showed that the local microstructure disappeared, some crypts were widened, and the microvessels were thickened and uniform in thickness. The thickened microvessels were in the glandular duct (FIG. 2A), dendritic vessels are visible locally, (Figure 2B)。 Endoscopic ultrasound showed that the lesions were located in the mucosal layer and submucosal layer. Pigment staining endoscopy showed that the extent of the lesions was unclear. Multiple gastroscopic pathologies showed chronic inflammation of the mucosa, and lymphoma could not be excluded. Considering that the previous biopsy site was superficial, in order to further clarify the condition and communicate with the patient's family members, the patient and his family members gave up another deep biopsy, and after excluding the contraindications of surgery, diagnostic endoscopic submucosal dissection (ESD) was performed. The size of the ESD macro-examination specimen was 4 cm ×3.8 cm ×0.3 cm, with a superficial depression in the center, about 1.5 cm ×0.8 cm, and a white scar was seen on the surface of the specimen (Figure 3)。 Microscopic examination showed diffuse infiltration of small to medium-sized lymphocytes in the lamina propria with lymphoid follicular formation, and lymphoepithelial lesions (Figure 4), negative margin, consistent with gastric mucosa-associated lymphoid tissue (MALT) lymphoma, HP (+). Immunohistochemical results: P53 (<5% +), Ki-67 (10%), CD20 (+), CD79a (diffuse +), Bcl-2 (+), MUM1 (+), CD21 (+), CK broad spectrum [glandular epithelium (+)], CD3-, CD4-, CD5 [small amount (+)], CyclinD1 (-), Bcl-6 (-) (Figure 5)。 The final diagnosis was gastric MALT lymphoma stage I, which was treated with conventional anti-Helicobacter pylori for 2 weeks. After HP turned negative, no abnormalities were found in gastroscopy for 3 years.

Liver failure is a common severe liver disease syndrome in clinic, and the mortality rate is extremely high. Artificial liver technique is one of the important methods in the treatment of liver failure in recent years. It can temporarily replace part of the failed liver function, create conditions for hepatocyte regeneration and liver function recovery, and effectively improve the short-term survival rate of patients with liver failure^[1]。 During the clinical application of artificial liver treatment, adverse reactions are more common in allergy, hypotension, digestive tract symptoms, etc. Heparin-induced thrombocytopenia (HIT) is the thrombocytopenia and thrombosis caused by the application of heparin, and has a high disability and mortality rate^[2,3]。 At present, many methods of artificial liver in clinic involve cardiopulmonary bypass and the use of anticoagulants, among which heparin is the most widely used anticoagulant. Thrombocytopenia caused by heparin in the treatment of artificial liver is rare, which will have an extremely serious impact on the patient's recovery, and clinicians need to actively deal with it. A case of heparin-induced thrombocytopenia in a patient with liver failure admitted to our department during artificial liver therapy is reported as follows.

The 25-year-old male was admitted to the First Affiliated Hospital of Zhengzhou University in March 2017. He had urethral neoplasms for half a year. Two months after urethral splitting and intraurethral mass resection, the neoplasms recurred for two weeks. Six months ago, due to the discovery of multiple cauliflower-like vegetations in the urethral opening, the surface was rough and the urine line became thinner, and I went to many local hospitals successively. X-ray contrast showed irregular filling defect of the anterior urethra (Figure 1)； Urethroscopy showed that villous neoplasms covered the urethral mucosa from the outer opening of the urethra to the root of the penis; Pathological examination of intraurethral neoplasms: squamous epithelial papilloma with cavity-like cells in the epithelium (Figure 2)； HPV-DNA type 11, 58 positive; Color Doppler ultrasound showed no obvious abnormalities in both kidneys and ureters, poor bladder filling, smooth inner wall, and no obvious abnormal echoes. Diagnosis: (1) multiple urethral tumors; (2) Viral warts. For further treatment, I went to a hospital in other places 2 months ago. After urethral splitting and intraurethral mass resection, the skin lesions resolved. Two weeks ago, extensive cauliflower-like growth was found in the urethral mucosa from the outer urethral opening to the root of the penis, so I went to the Department of Dermatology, the First Affiliated Hospital of Zhengzhou University. In the past, he was healthy and denied the history of metallurgical tours. After admission, the routine of hematuria and feces was normal; Treponema pallidum antibody and human immunodeficiency virus antibody were both negative; There were no obvious abnormalities in immunoglobulin and complement; Lymphocyte subsets: absolute T lymphocyte count 3 277 (770-2 860) /μ l, absolute helper T lymphocyte count 2 006 (414-1 440) /μ l, suppressor T lymphocyte count 1 010 (238-1 250) /μ l, helper/suppressor lymphocyte count 1.99 (0.68-2.47). Physical examination: No obvious abnormalities in heart and lung. Dermatological examination: After urethral splitting, the anterior urethra is open, and multiple cauliflower-like vegetations can be seen in the urethral mucosa from the outer opening of the urethra to the root of the penis, the size of millet to soybean, partially fused, pale, reddish to gray-red, and the surface is rough (Figure 3)。 According to the medical history, clinical manifestations, imaging examination, pathological examination and HPV-DNA test results, the diagnosis was: extensive condyloma acuminatum in the anterior urethra. 5-aminoketovaleric acid-photodynamic (ALA-PDT) therapy, supplemented with recombinant human interferon a-2b gel for topical use, thymosin tablets 10 mg and lentinan polysaccharide tablets 20 mg, orally administered twice/d; The concentration of 5-aminoketovaleric acid in photodynamic therapy was 5%, the application time was about 4~5 h, and the irradiation time of 100 mW He-Ne laser was 30 min. After one treatment, the wart resolved by about 90% (Figure 4), the skin lesions resolved after 3 treatments, and the mucosa was smooth and pink, but HPA-DNA re-examination was not performed, and the patient was lost to follow-up after the 4th treatment.