Volume 99 ·  Issue 32 ·  2019

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is an important cause of death in patients with COPD. Its heterogeneity makes the definition change constantly and causes many controversies, which hinders the objective judgment in clinical and research. This article reviews the heterogeneity of acute exacerbation, the change of definition, the controversy of definition, and whether the definition needs to be modified, so as to provide reference for the study of acute exacerbation of COPD.

At present, breast cancer is the most common malignant tumor that endangers women's health. About 5% to 10% of breast cancer patients are metastatic breast cancer at the first diagnosis. Advanced metastatic breast cancer is an incurable disease. The purpose of treatment is to relieve and control symptoms and improve the quality of life. Comprehensive treatment is the cornerstone, and local surgical treatment is controversial. This article reviewed the literature to explore whether or not the primary tumor of metastatic breast cancer was operated, what conditions to perform the operation and other hot issues.

Endovascular thoracic aortic therapy (TEVAR) is an important treatment for a variety of thoracic aortic diseases. It is commonly used for thoracic aortic aneurysm, thoracic aortic dissection, intramural thoracic aortic hematoma, penetrating ulcer, pseudoaneurysm and traumatic aortic rupture. Compared with traditional surgery, endovascular aortic treatment significantly reduces trauma, but there is still a risk of perioperative death and serious complications, and perioperative management remains an important part of holistic treatment. With the progress of technology, the indications for endovascular aortic therapy gradually expand, the types of diseases and the complexity of lesions being treated are increasing, and there are often more comorbidities in the patient population, which puts forward higher requirements for perioperative management. This consensus summarizes the common perioperative problems on the basis of the existing relevant guidelines at home and abroad and combined with the clinical practice experience in China.

To investigate the feasibility of surgical treatment of port-site metastasis after laparoscopic radical resection of gastric cancer.

The clinical and follow-up data of five patients with port-site metastases after laparoscopic radical resection of gastric cancer at Zhejiang Provincial People′s Hospital between January 2014 and January 2018 were retrospectively analyzed.

Port-site metastases occurred within 6 months after gastrointestinal tumor resection in three patients, 10 months after the operation in one patient, and 30 months after the operation in one patient, respectively. Metastasis to the abdominal cavity or distant metastasis was excluded before the surgical treatment of the port-site metastases, and all patients recovered well after the operation. No incisional infection or hernia occurred. By December 2018, two patients died (they survived for 13 and 24 months, respectively) and three patients survived. The follow-up duration ranged from 7 to 19 months.

Surgical resection of port-site metastases is not difficult due to their superficial location. Surgical treatment can improve the prognosis of patients without abdominal or distant metastasis/recurrence.

To investigate the characteristics of different phenotypes of refractory non-erosive gastroesophageal reflux disease (NERD), the types of esophageal motility and the related factors of symptoms.

A retrospective analysis was made of the patients with refractory NERD of Beijing Tongren Hospital affiliated to Capital Medical University from September 2015 to August 2017. All patients underwent electronic gastroscopy, esophageal manometry and 24-hour dynamic esophageal pH impedance monitoring. They were divided into four phenotype groups according to the results.

A total of 231 patients were enrolled in the study. There were 111(48.1%)cases in phenotype 1 group, 9 (3.9%)cases in phenotype 2 group, 100 (43.3%)cases in phenotype 3 group and 11 (4.8%) cases in phenotype 4 group. Compared with the other three groups, the number of weak acid reflux [(86±55) vs (37±8), (70±52), (31±9) times] and the number of gas reflux [(86±76) vs (38±13), (58±57), (26±10)] in phenotype 1 group increased significantly (allP<0.005). Dynamics disorders were common in refractory NERD patients (139/231, 60.2%). Mild esophageal dynamics disorder was the main type of dynamics disorder (118/139, 84.9%). There was no significant difference among the phenotype groups. Multivariate unconditional Logistic regression analysis showed that the risk factors for reflux-related symptoms were female ratio, Chicago power classification, gas reflux and weak acid reflux (OR=3.731, 2.452, 1.036 and 1.037, P<0.05).

The characteristics of gastroesophageal reflux and the types of motility disorders are different in different phenotype groups of refractory NERD patients. The risk factors of reflux-related symptoms are female ratio, Chicago motility classification, gas reflux and the frequency of weak acid reflux.

To explore the application of indocyanine green fluorescence navigation in open cholecystectomy.

Forty-eight patients with extrahepatic cholangiography who underwent open cholecystectomy in our hospital from March 2016 to February 2018 were enrolled. They were divided into the control group (24 cases) and the experimental group (24 cases) by using the random number table method. The control group was treated with conventional X-ray cholangiopancreatography, and the experimental group was treated with indocyanine green near-infrared fluorescence imaging for extrahepatic cholangiography. The cholangiography success rate, cholangiography time, cholangiography economic costs, imaging accuracy and security were compared between two groups. The operation time, intraoperative blood loss, blood transfusion amount, length of hospital stays, and hospital expenses were also compared between two groups.

The success rate of cholangiography (98.62% vs 97.22%) and the incidence of adverse reactions (25.00 vs 29.17) were not significantly different between the two groups (P>0.05). The cholangiography time (25.69±3.47 min vs 31.42±4.66 min), operation time (90.18±10.27 min vs 81.44±9.35 min), intraoperative blood loss (82.35±8.24 ml vs 78.14±7.82 ml), blood transfusion volume (35.19±4.77 ml vs 29.58±4.03 ml), hospitalization time (7.59±1.52 d vs 6.24±1.25 d), and hospitalization cost (12.7±3.1 thousands vs 10.4±2.5 thousands) of the experimental group were significant lower than those of the control group. The accuracy rate (92.22% vs 87.50%), sensitivity (85.71% vs 50.00%) and specificity (88.24% vs 68.75%) of cholangiography in the experimental group were significantly higher than those in the control group, with statistically significant differences (P<0.05).

Indocyanine green fluorescent navigation is more timely and accurate than traditional X-ray cholangiography during temporary angiography in open cholecystectomy, which can effectively shorten the operation time, intraoperative blood loss, blood transfusion, hospitalization time and hospitalization expenses. It does not increase the incidence of adverse reactions, has high safety, and is worthy of clinical promotion.

To analyze the clinical characteristics and treatment of female stress urinary incontinence (SUI) combined with bladder neck obstruction (BNO).

The clinical data of 17 cases of female SUI patients with BNO, who was admitted to the Urology department, Beijing Chaoyang hospital from November 2011 to April 2018, were retrospectively analyzed. The mean age was (60.3±2.6) years old and the mean body mass index was (23.8±0.5) kg/m². All patients had the first stage bladder neck incision with the second stage suprapubic urethral support sling. The clinical characteristics, curative effects and outcomes were analyzed.

The maximum flow rate was increased significantly after the bladder neck incision compared with preoperative [(9.3±0.5) vs (25.6±0.8) ml/s, P<0.001]. The postvoid residual urine volume and PdetQmax were decreased significantly than that preoperative [(167.5±4.4) vs (4.1±0.5) ml,P<0.001; (49.4±1.3) vs (24.9±0.7) cmH₂O, P<0.001]. The incontinence questionnaire-short form score was significantly lower after the second stage suprapubic urethral support sling [(2.4±0.4) vs (14.9±0.3),P<0.001]. The number of subjective and objective case of suprapubic urethral support sling was 13, and the treatment effect of other patients was improved. The hospitalization and operation time of the bladder neck incision and the suprapubic urethral support sling were short. All patients had no intraoperative complications, two cases had dysuria and one case had groin pain after the suprapubic urethral support sling operation.

The patients of female SUI combined with BNO are most elderly and obese population. The effectiveness and safety of the first stage bladder neck incision and the second stage suprapubic urethral support sling are high, and the surgeries can effectively relieve the obstruction and improve the quality of patients′ life.

To evaluate the clinical effects of functional neck dissection (FND) and supraomohyoid neck dissection (SOND) in patients with cN0/N1 oral squamous cell carcinoma (OSCC).

A total of 210 patients with stage cN0/N1 OSCC underwent FND and SOND between January 2012 and May 2015 were retrospectively reviewed, among which, 147 patients were male and 63 were female, with an age range of 23-82 years and mean age of (62.2±10.2) years. There were 112 and 98 patients in FND and SOND groups, respectively. The follow-up data included cervical lymph node metastasis, movement of shoulder joint, great auricular nerve function, recurrence rate of cervical lymph nodes.

There was no significant difference in gender, age, tumor location, T stage, N stage, histological grades between the two groups (all P>0.05). Compared to patients in FND group, the activities of shoulder joint and earlobe numbness improved significantly in SOND group. Of the 210 patients, 17 patients (8.1%) had cervical recurrence, with 9 patients (8.0%) in FND group and 8 patients (8.2%) in SOND group. No significant difference was observed for neck recurrence between the two groups (P=0.973).

SOND can be safely performed in cN0 or cN1 OSCC patients, which avoids major complications of FND, and improves postoperative quality of life in those patients.

To retrospectively analyze the characteristics of the electromyography (EMG) study in generalized myasthenia gravis (gMG) patients.

A total of 111 gMG patients were enrolled. Patients were divided into two groups: 36 severe patients discontinuing pyridostigmine bromide (PB) for 8 hours were included in 8 h group, and 75 g MG patients discontinuing PB for at least 18 hours were included in>18 h group. The clinical information and EMG study data were collected and analyzed.

There were statistically significant differences in the initial location of the myasthenia muscle (P=0.027), the affected muscle detected by the EMG (P=0.015) and quantitative myasthenia gravis (QMG) score (P<0.01) between the two groups. Comparisons in each group revealed that the highest positive rate of low-frequency repetitive nerve stimulation (RNS) of facial in 8 h group and>18 h group was 94.4% and 60.0%, respectively. Comparisons between the two groups showed that the positive rate of low-frequency RNS in 8 h group was significantly higher than that in>18 h group (94.4% vs 70.7%, χ ²=8.115, P=0.004). In particular, the positive rate of RNS in facial nerves and the extent of the amplitude decrease under different electrical stimulations (1 Hz, 3 Hz, and 5 Hz) were dramatically higher in the 8 h group (P<0.01).

For gMG patients, the facial and accessory nerve detection can improve the positive rate of RNS. Different muscles had various sensitivity to PB, and orbicularis oculi muscle seemed the least sensitive muscle to PB. For suspect MG patients in severe condition, only discontinuing PB medication for 8 h before low-frequency RNS testing can avoid the deterioration and also obtain similar positive rate.

To investigate the clinicopathological features and prognosis of patients with neuroendocrine tumors (NETs).

The clinicopathologic data of enrolled patients with NETs between October 2012 and October 2017 at the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed.

Among the 488 NETs patients, the average age was (51.0±15.8) years, and the sex ratio (male/female) was 1∶1.1. Of the NETs, 370 were located in the digestive system (75.8%), 63 were pulmonary (12.9%), 14 were mediastinal (2.9%), 7 were of unknown primary origin (1.4%), and 34 were located in other sites (7.0%). Among the NETs, the pancreas, rectum and stomach were the most common sites. In the digestive system NETs, the most common tumor grade was G1 (190 cases, 51.4%), followed by G2 (143 cases, 38.6%) and NET-G3 (37 cases, 10.0%). In pulmonary NETs, typical and atypical carcinoid tumors was 47.6% and 52.4%, respectively. There were 310 patients at stage Ⅰ/Ⅱ, 53 at stage Ⅲ, 69 at stage Ⅳ and 56 at stage undiagnosed, respectively. The relationships among age, stage, grade, metastasis, treatment and prognosis were analyzed. All these factors could influence the survival rate of NET patients. Multivariate Cox analysis showed that age (>50 years old) (HR=2.831, 95%CI:1.414-7.029, P=0.025) and distant metastasis (HR=10.208, 95%CI:4.110-25.355, P<0.001) were independent risk factors.

The most common primary sites of NETs are the pancreas, rectum, and stomach. Age and distant metastasis are independent risk factors for the prognosis of NETs.

Percutaneous renal biopsycurrently is the most important and widely used method of renal biopsy. However, there still are some patients in whom a percutaneous approach may be considered a major risk. In these patients, renal biopsy under direct vision is a reliable alternative. We described our personal technique and experience in a series of Chinese patients who underwent retroperitoneal laparoscopic renal biopsy.

We retrospectively reviewed the patients who had performed retroperitoneal laparoscopic renal biopsy over a 4-year period (Jan 2013 to Jan 2017).Forty-three patients with renal dysfunction were involved inour center.Especially some patients showed atrophic kidney and poor visualization on ultrasonography. The patients′ abnormal conditions includeddialysis (10 cases), morbid obesity (5 cases), deaf-mutes (2 cases) and uncontrolled severe hypertension. The kidney was approached via alaparoscopic retroperitoneal route using athree-ports technique. Then biopsies were performed bya 16-gaugebiopsy needle, and hemostasis was achieved by compression.In less cases, a topical spray hemostatic gel was required.

Biopsy was performed successfully in all cases and adequate renal tissue was acquired.Mean operative time was 59.4 minutes, mean blood loss was 36.5 ml.Under general anesthesia, no anesthetic accidents and related complications were recorded. Forty-onepatients were discharged within 24 h after operation. Onepatient occurred disseminated intravascular coagulationduring operation. Red blood cell transfusion and fresh-frozen plasma infusion were performed. Injury at hilum of kidney was detected in another patient. And extrapyelogenic repair surgery was performed.

The retroperitoneallaparoscopic renal biopsy is a safe, reliable, minimallyinvasive alternative renal biopsy method with better haemostasis, fewer complications and a rapid recovery. As the helpful supplement of percutaneous renal biopsy, this technique may have to be used more often in the future.

To observe the effects of artesunate on airway responsiveness and airway inflammation in asthmatic mice.

Thirty female BALB/c mice aged 6-8 weeks were randomly divided into control group, asthma group and artesunate group. In the asthma group and the artesunate group, the mice were sensitized by intraperitoneal injection of 20 μg of ovalbumin (OVA) and 0.2 ml of aluminum hydroxide suspension (2 mg) on day 0 and 14, respectively, and 1% OVA 10 ml dissolved in sterile phosphate (PBS) buffer was aerosolized for 30 min from the 21st to 28th day. The control group was sensitized with 0.2 ml of 2 mg suspension of aluminum hydroxide on day 0 and 14, and aerosolized by 10 ml of sterile PBS from the 21st to 28th day. Before the challenge, the artesunate group was intraperitoneally injected with 0.2 ml of artesunate. Artesunate was replaced with the same amount of normal saline in the control group and the asthma group. The mice were treated after 24 hours of last stimulation. The airway responsiveness of mice was measured by airway intubation and the changes of airway resistance and compliance were observed. Bronchoalveolar lavage fluid (BALF) was classified by cytology, and pathological changes of left lung tissue were observed and scored.

The airway resistance of the three groups increased and the lung compliance decreased with the increase of methacholine (Ach) concentration. The airway resistance and lung compliance of the three groups were different under the same concentration (P<0.05). The airway resistance of the artesunate group at Ach 6.25, 12.5, 25, 50, 100 mg/ml was lower than that of the asthma group at the same concentration [(1.01±0.48) vs (1.30±0.22), (1.06±0.44) vs (1.70±0.31), (1.30±0.64) vs (2.66±0.79), (1.82±0.55) vs (3.38±1.35), (2.49±0.85) vs (4.07±1.34) cmH₂O·s^-1·ml^-1(1 cmH₂O=0.098 kPa); t=3.862, 7.376, 9.113, 7.051, 6.685, all P<0.05]; the degree of lung compliance decrease at the concentration of Ach 3.125, 6.25, 12.5, 25, 50, 100 mg/ml was lower than that of the asthma group at the same concentration [(3.89±0.55)×10^-2 vs (3.07±0.63)×10^-2, (3.61±0.52)×10^-2 vs (3.04±0.58)×10^-2, (3.48±0.38)×10^-2 vs (2.78±0.57)×10^-2, (3.09±0.52)×10^-2 vs (1.73±0.62)×10^-2, (2.32±0.60)×10^-2 vs (1.29±0.54)×10^-2, (1.87±0.59)×10^-2 vs (1.15±0.44)×10^-2 ml/cmH₂O; t=-6.295, -4.921, -6.533, -11.135, -8.48, -6.319, all P<0.05]. The proportion of eosinophils in artesunate group in BALF was significantly lower than that in asthma group [(16.63±8.58)% vs (40.44±12.94)%; t=4.336, P<0.05]. In the asthma group, the inflammatory cells infiltration of the bronchi and the perivascular area, the bronchial epithelial edema and degeneration can be observed, and the artesunate could reduce the infiltration of inflammatory cells around the bronchus and blood vessels, and the mucus secretion was also reduced in the artesunate group.

Artesunate can improve airway hyperresponsiveness and airway inflammation in asthmatic mice and has a certain therapeutic effect on asthma.

To observe the expression of the Receptor of Advanced glycation end products (RAGE) in asthmatic rats, and explore the intervention of Roxithromycin.

A total of 18 Specific Pathogen Free-class Brown Norway male rats were randomly divided into control group, asthma model group and Roxithromycin group, with 6 rats in each group. The asthmatic model was sensitized by intraperitoneal injection of Ovalbumin (OVA)+Al(OH)₃, and challenged with OVA. Rats in Roxithromycin group were given Roxithromycin 30 mg/kg 30 minutes before each challenge. Rats in control group and asthma model group were treated with equal volume of saline. The concentrations of RAGE and interleukin (IL)-4 in serum and bronchoalveolar lavage fluid (BALF) were measured by enzyme-linked immunosorbent (ELISA); the pathological changes of lung tissues were observed by HE-staining; the thickness of airway wall and airway smooth muscle were measured by Image-Pro Plus; the relative expression of RAGE in lung tissues were detected by Western blot.

In asthma model group, the concentrations of RAGE and IL-4 in the serum and BALF were obviously higher than those in control group [(494±32) vs (327±45) ng/L; (32.4±5.8) vs (13.1±2.9) ng/L; (553±38) vs (399±56) ng/L; (37.8±3.4) vs (19.4±2.5) ng/L] (all P<0.01); in Roxithromycin group, the concentrations of RAGE and IL-4 in the serum and BALF were obviously lower than those in asthma model group [(438±18) vs (494±32) ng/L; (22.8±6.0) vs (32.4±5.8) ng/L; (444±42) vs (553±38) ng/L; (25.6±4.5) vs (37.8±3.4) ng/L] (all P<0.05). In asthma model group, the bronchial wall was thickened, the lumen was narrow, the mucosal wrinkles were significantly increased, edema appeared under the mucosa, and a large number of inflammatory cells infiltrated and aggregated in the bronchi, perivascular and alveolar spaces; the thickness of airway wall and airway smooth muscle were significantly increased than those in control group (P<0.01); in Roxithromycin group, airway inflammation and remodeling were alleviated compared with those in asthma model group (P<0.05). In asthma model group, the expression of RAGE in lung tissues were significantly increased than those in control group (P<0.01); in Roxithromycin group, the expression of RAGE were significantly decreased than those in asthma model group (P<0.01). There were positive correlations between the expression of RAGE and IL-4 in BALF and serum (r=0.782, 0.804, all P<0.01); there were positive correlations between RAGE and total white cell counts, eosinophil counts, smooth muscle thickness (r=0.897, 0.927, 0.860, all P<0.01).

The increasing of RAGE in asthmatic rats are positively correlated with airway inflammation and airway remodeling. Roxithromycin may inhibit the development of asthma by reducing the expression of RAGE.

This paper reports the clinical diagnosis and treatment process of a rare case of Takayasu arteritis complicated by pulmonary vasculitis, myocarditis, acute left heart failure, right ventricular and pulmonary artery thrombosis, pulmonary hypertension, central nervous system involvement, ophthalmoplegia and other rare complications. Combined with the literature, the reasons for long-term misdiagnosis and misdiagnosis, diagnostic ideas, diagnostic difficulties, diagnosis and treatment experience and lessons are analyzed, and the clinical thinking on differential diagnosis of pulmonary migratory shadow and the understanding of pulmonary vasculitis are deepened.

Hepatic sinus obstruction syndrome (HSOS) is a kind of hepatic vascular disease in which endothelial cells of hepatic sinuses, hepatic venules and interlobular veins are edema, necrosis, and shedding caused by various reasons, resulting in micro-thrombosis, causing intrahepatic congestion, liver injury and portal hypertension. The main clinical manifestations are abdominal distension, pain in the liver area, ascites, jaundice, liver enlargement, etc. It can be seen after pretreatment of bone marrow hematopoietic stem cell transplantation, but in China, the most common cause of HSOS is taking plants containing pyrrolidine alkaloids. This paper reports a case of multiple serous effusion with peritoneal effusion, who was misdiagnosed as Budd-Chiari syndrome and suspected POEMS syndrome. However, after questioning, it was found that he had a history of taking Chrysanthemum notoginseng, and the diagnosis was confirmed after imaging and liver puncture pathology. Combined with the analysis of pathogenesis and liver puncture results, the patient's condition was relieved after low molecular weight heparin anticoagulation and short-term hormone therapy.

Legionella is one of the pathogens of community-acquired pneumonia. Immunosuppressed patients are susceptible to Legionella pneumonia, and the mortality rate is high, but the clinical manifestations are often atypical, and it is difficult to confirm early diagnosis in clinical work. This paper reports a case of immunosuppression complicated with Legionella pneumonia without clear environmental exposure history, and analyzes its possible infection route, clinical manifestation, treatment and outcome, in order to help clinicians to diagnose early, effectively treat and reduce the mortality rate.

The patient was a middle-aged man whose left kidney occupied space for more than 3 months due to physical examination. CT angiography of renal artery showed renal cancer. After partial left nephrectomy, the postoperative pathological result was adenoid cystic carcinoma of the kidney. Combined with the previous patient's history of left palatal mass resection 2 years ago (the pathological result at that time was malignant transformation of pleomorphic adenoma), the final diagnosis was: adenoid cystic carcinoma of the kidney, with possible large metastasis. The postoperative patient was not treated, regularly reviewed, and the follow-up has been more than 10 months. Generally, the patient is in good condition and has no recurrence.

A 6-year-old child with mental retardation, learning disabilities, abnormal behavior and personality, feeding difficulties, constipation, special appearance, pestle fingers, refractory epilepsy and other special manifestations was found by whole exome sequencing. The cytosine of the 1373rd base of the protein sequence encoded by the WAC gene was deleted, and it was finally diagnosed as a rare autosomal dominant genetic disease DeSanto-Shinawi syndrome (DESSH).

Two adult-onset patients with sporadic intranuclear inclusion body disease were reported. The main clinical manifestations were cognitive decline, with fluctuating clinical symptoms, transient sharp decline of cognitive function or abnormal mental behavior. MRI of the head showed band-like hyperintensity in the corticomedullary junction area. Finally, skin biopsy confirmed that they were intranuclear inclusion body disease.

Large granular lymphocytic leukemia (LGLL) is a chronic lymphocyte proliferative disease, which originates from two cell lines, cytotoxic T cells and natural killer cells. It is characterized by the coarse aniline blue particles in the cytoplasm of clonal lymphocytes. Where T cell LGLL (T-LGLL) typically exhibits classical CD8⁺CD4^-clonal expansion of large granular lymphocytes (LGL), while CD4⁺It is extremely rare, and CD4 has been reported in previous domestic and foreign literatures⁺About 200 cases of T-LGLL. This article reports CD4⁺CD8^-One case of T-LGLL, and its clinical characteristics, pathogenesis and diagnosis and treatment plan were reviewed in combination with previous literatures.