Volume 99 ·  Issue 45 ·  2019

Electroencephalogram (EEG) monitoring has become an inseparable monitoring technology in neurointensive care units (NCU). It can transmit more clinical signs or information that cannot be obtained by routine monitoring, so that NCU physicians can more accurately understand the brain function status, make medical decisions more firmly, guide treatment more accurately, and carry out brain science research more deeply. These are based on improvements in bedside EEG monitoring technologies, innovations in analytical technologies and specifications of operational technologies. In the next 10 years, the popularization of EEG monitoring technology in NCU in China will benefit more patients with severe brain injury.

osteoporosis (OP) is an age-related bone disease that seriously affects the quality of life of patients^[1]。 According to the first OP epidemiological survey in China released by the National Health Commission in 2018, the prevalence rate of OP among people over 65 years old in my country reached 32.0%, including 10.7% men, 51.6% women, 25.6% urban areas, and 35.3% rural areas. The most serious consequence of OP is OP fracture, which is one of the leading causes of disability and death in elderly patients. It is estimated that medical expenditure for common OP fractures (vertebral body, hip and wrist) in China will reach 174.5 billion yuan by 2050^[2]。 Traditional Chinese and Western medicine have their own advantages in the diagnosis and treatment of OP. In order to clarify the role of integrated Chinese and Western medicine in the diagnosis and treatment of OP and improve the diagnosis and treatment level of integrated Chinese and Western medicine, the Professional Committee of Orthopaedics and Traumatology of Chinese Society of Integrated Chinese and Western Medicine organized experts to formulate this guide after many discussions according to the latest progress in the diagnosis and treatment of OP in recent years, with reference to domestic and foreign guidelines and the latest evidence-based medical evidence, combined with clinical experience. This guideline is an academic opinion only, and should be implemented in conjunction with patient and medical specific circumstances.

Portal hypertension can cause a series of serious clinical symptoms, such as esophageal and gastric varicose bleeding, refractory pleural and ascites effusion, etc. Liver cirrhosis is the most common and main cause of portal hypertension. transjugular intrahepatic portosystemic shunt (TIPS) is one of the key measures to reduce portal pressure in patients with liver cirrhosis by establishing a shunt in the hepatic parenchyma between the hepatic vein and the portal vein to significantly reduce portal vein resistance in a minimally invasive manner. At present, TIPS has been widely used in the treatment of esophageal and gastric variceal bleeding caused by portal hypertension in liver cirrhosis, refractory pleural and ascites effusion, Budd-Chiari syndrome (BCS) and hepatic sinus obstruction syndrome. After nearly 30 years of continuous exploration and development, especially with the clinical application of special covered stents, we have a new understanding of the indications, contraindications, technical operating standards, shunt stent selection and postoperative complications of TIPS^[1,2,3]。 However, at present, there are problems in China, such as understandardized TIPS operation process and perioperative management, poor technical quality control management, and lack of standardized collection and input management of relevant clinical data, which restricts the further improvement and development of domestic TIPS technology.

Radiofrequency therapy technology is to accurately output ultra-high frequency radio waves through special equipment and puncture needles to act on local tissues, and play the role of thermal coagulation, cutting or neuromodulation, thus treating pain diseases. This minimally invasive treatment method is classified into a standard radiofrequency (thermocoagulation) mode and a pulsed radiofrequency mode. Since the 19th century, animal experiments with electrical currents to damage the nervous system have been carried out, and by the middle of the 20th century, the first commercial radio frequency generator was created^[1]So that radiofrequency therapy technology can be put into clinical application. In 1997, Dutch physician Sluijter and engineer Rittman first proposed pulsed radio frequency (PRF) technology^[2]Because it does not damage nerves, does not appear hypoesthesia, soreness, burning pain and dyskinesia caused by nerve thermal disconnection, and has remarkable curative effect, it has great potential and application value in the treatment of pain diseases, and is a further development and supplement to traditional radiofrequency therapy technology. After years of continuous improvement and development, the clinical application range of radiofrequency therapy technology has been continuously expanded, and now it has become an effective means to treat many kinds of intractable pain.

To assess the feasibility and value of real-time image fusion technique guiding the procedure of transjugular intrahepatic portosystemic shunt(TIPS).

From July 2017 to May 2018,a total of 48 consecutive patients complicated by portal venous hypertension due to cirrhosis who underwent TIPS were prospectively allocated into two groups that 27 cases underwent normal TIPS and 21 cases underwent image fusion guided TIPS. There were 25 males and 23 females with a mean age of 29-74(51±10) years. The differences of portal vein(PV) between image fusion angiographyand digital subtraction angiography(DSA), and the times of puncture PV, X-ray exposure dose and exposure time and contrast agent amount of all cases were collected and analyzed.

The longitudinal and traverse difference of PV between image fusion angiography and DSA were 1.7-2.5(2.1±0.2) mm and 0.9-1.8(1.4±0.3) mm, respectively.The times of puncture PV, X-ray exposure time and dose, and contrast agent amount between normal TIPS group and image fusion guided TIPS group were 1-7(3.8±0.6) times vs 1-3(2.0±0.6) times, 41-63(53±8)min vs 27-42(35±5) min, 513-787(644±96) mGy vs 357-524(423±59) mGy,102-196(151±23) ml vs 87-145(105±14) ml(all P<0.05), respectively.

There are minor differences between image fusion angiography of PV and DSA. Real-time image fusion guided TIPS is feasible and valuable to reduce intraprocedural X-ray exposure time and dose and contrast agent amount of TIPS.

To explore the magnetic resonance imaging (MRI) imaging technique and the clinical application in ligament and tendons of elbow.

The study was reviewed and approved by an institutional review board of Beijing Jishuitan Hospital. A total of 20 normal volunteers with 40 elbows including 12 males and 8 females, aged from 20 to 55 years, with an average age of 35 years and 38 patients with 38 elbows who complained elbow pain with elbow injuries including 23 males and 15 females, ranged in age from 9 to 77 years, with an average age of 41 years old were chosen to undergo magnetic resonance examination between May 2013 and October 2018.All subjects underwent examination on coronal T₁WI scan and PD-FS on three planes respectively in a prone position. Then the MRI characteristics of tendons in elbow of healthy volunteers and patients with elbow injuries were studied and the MRI features of tendon injury were compared with the surgical results and confirmed by double-blind method.

Twenty normal volunteers without tendons or ligament injures showed homogeneous low-signal-intensity on T₁-weighted and proton fat saturation sequence (PD-FS) images.In the 38 patients with elbow injuries, there were 44 tendon injuries, including 14 cases of common extensor tendon injuries, 10 cases of common flexor tendon injuries, 3 cases of biceps tendon injuries, 7 cases of brachialis tendon injuries and 10 cases of triceps tendon injuries. The injuried tendons became thicker and discontinuity in T₁WI and demonstrated heterogeneously increased signal intensity with effusion of tendon sheath in PD-FS. Partial tear showed discontinuity and thickening of tendons and the complete tear showed that the tendons were interrupted, retracted, the fiber structure disappeared and was filled with liquid, and the surrounding soft tissue edema was found.

MRI can demonstrate the anatomy and injuries features of tendons in elbow joint accurately. It is significance for the early diagnosis and treatment protocols of the tendons injuries.

To evaluate the perioperative tranexamic acid (TXA) on blood conservation in pediatric patients undergoing complete repair for tetralogy of fallot (TOF) and its impact on short-term or long-term adverse event and mortality.

The study was a retrospective cohort study. From January 2009 to December 2010, 386 consecutive patients aged from 31 days to 8 years old, ASA physical status Ⅱ or Ⅲ, receiving primary complete repair for TOF in Fuwai Hospital were enrolled in the study. They were divided into two groups: the control group (n=161) and the TXA group (n=225), according to whether TXA was used during the operation. Patients and their families were followed up by telephone in the 8th-year after surgery. The amount of perioperative blood loss, allogeneic transfusion, short-term or long-term adverse event and mortality were recorded and analyzed.

The patients in the TXA group were associated with significant decreased 12 h and total postoperative blood loss compared with the control group [(7.8±0.3) ml/kg vs (8.8±0.3) ml/kg, t=2.412, P<0.05; and (14.0±0.6) ml/kg vs (17.0±0.7) ml/kg, t=3.141, P<0.05]. There were no significant differences in both the volume and incidence of red blood cell, plasma, and platelet transfusion, postoperatively (P>0.05). There were no significant differences in the incidence of reoperation for bleeding and prolonged mechanical ventilation, ICU stay, postoperative hospital length of stay, the short-term and long-term incidence of seizure, stroke, renal failure, deep venous thrombosis, pulmonary embolism and death between the two groups(P>0.05).

TXA can decrease postoperative blood loss, but has little impact on the allogeneic blood transfusion, as well as the short-term or long-term adverse event and mortality in pediatric patients undergoing complete repair for TOF.

To investigate the feasibility, efficacy and safety of endovascular reconstruction of the carotid artery with severe stenosis and extracranial distortion under proximal protection.

A retrospective analysis of 21 patients with severe carotid stenosis and extracranial distortion who were admitted to the Second Affiliated Hospital of Soochow University between January 2011 and August 2017, of which 16 patients were symptomatic stenosis with acute ischemic stroke. All the patients were treated with carotid artery stenting under (CAS) proximal protection technique, and assessed with the National Institutes of Health Stroke Scale (NIHSS) before the treatment and hospital discharge. The clinical outcome and vascular morphology were followed-up regularly after the treatment.

Twenty-one patients were successfully completed the CAS procedure under the proximal protection technique, the average blocking time was 241.0 (232.5-261.0) seconds. Nine patients received 1block attempt, 6 patients received 2 block attempts, and the other 6 patients received 3 block attempts. Three patients experienced transient ischemic attack (TIA) during the procedure, the maximum duration of TIA was 10 minutes. In 16 patients with symptomatic stenosis, there were no significant differences in NIHSS score before CAS procedure and hospital discharge (P>0.05). The residual stenosis rate of the carotid artery after stenting was(13±6)%, compared with preoperative (87±16)%, which appeared a significant difference (t=19.948, P<0.05). All the patients had no adverse events such as myocardial infarction, recurrent ischemic stroke and death in the follow-up period. Restenosis was assessed in 6 patients by DSA or CTA and no restenosis was found.

Endovascular reconstruction of the carotid artery with severe stenosis and extracranial distortion under proximal protection technique has been proven as a safe and effective therapy.

To investigate the effect of HLA-DP gene expression on the susceptibility and disease status of neuromyelitis optica spectrum disorders (NMOSD).

A total of 86 NMOSD patients (52 in acute phase and 34 in remission phase), 52 multiple sclerosis (MS) patients (20 in acute phase and 32 in remission phase) diagnosed in Department of Neurology, the Third Affiliated Hospital of Sun Yat-sen University and 29 healthy controls were enrolled prospectively. Genotyping of HLA-DP was performed. The expression levels of HLA-DP molecules in peripheral blood B cells and monocytes were measured by flow cytometry. The transcription levels of HLA-DPB1 mRNA in peripheral blood mononuclear cells (PBMC) were measured by real time-PCR. The results were compared among different groups

There was no statistically significant difference of the distributions of HLA-DPB1*0501/HLA-DPB1*0501, HLA-DPB1*0501/X and X/X genotypes and the frequencies of allele of HLA-DPB1*0501 among NMOSD, MS patients and healthy controls (P=0.96 and 0.71, respectively). The expression levels of HLA-DP on the surface of B cells in NMOSD patients, especially in remission phase patients, were significantly higher than those in healthy controls(212±328 and 374±394 vs 55±57, P=0.049 and 0.002, respectively). The expression levels of HLA-DP on the surface of monocytes in NMOSD patients in acute phase were significantly higher than those in healthy controls(158±175 vs 65±90, P=0.025). The transcription levels of PMBC HLA-DPB1 mRNA in acute phase and remission phase of NMOSD patients were significantly higher than those in healthy controls (3.0±1.4 and 2.9±1.3 vs 1.5±1.4, P=0.000 and 0.003, respectively). The expression levels of HLA-DP molecules on the surface of peripheral blood B cells and monocytes and the transcription levels of PMBC HLA-DPB1 mRNA in MS patients at the acute and remission stages were not significantly different from those in healthy controls. The expression levels of HLA-DP molecules on the surface of B cells in patients with HLA-DPB1*0501/HLA-DPB1*0501, HLA-DPB1*0501/X and X/X genotypes were statistically different (P=0.017).

HLA-DP gene transcription and molecular expression levels in antigen presenting cells may affect the susceptibility and disease status of NMOSD patients, while HLA-DPB1*0501 allele may affect the transcription and molecular expression levels of HLA-DP gene in antigen presenting cells.

To investigate the abnormal changes of gray matter volume and its relationship with cognitive function in first-episode childhood- and adolescence-onset schizophrenia.

A total of 39 (aged 10-16 years) first-episode childhood- and adolescence-onset schizophrenia (patient group) were recruited from the inpatient departments of Second Affiliated Hospital of Xinxiang Medical University between 2014 and 2016, meanwhile, 30 age-, sex- and education years-matched healthy children and adolescents (control group) were also enrolled. All the subjects underwent 3.0 T magnetic resonance imaging (MRI) scan. The volume of gray matter in two groups was compared by voxel based morphometric method (VBM). MATRICS Consensus Cognitive Battery (MCCB) and the Stroop Color and Word Test (SCWT) were employed to evaluate the cognitive function of the two groups, and the relationship between the abnormal gray matter region and the cognitive function in the two group was analyzed.

Compared with the control group, brain gray matter volume in the right insula, left inferior frontal gyrus, the left limbic edge were significantly decreased (t=-5.303, -5.302, and -6.211; all P<0.05). Trail making test scores in the patient group were higher than those of the control group (t=3.22, P<0.01). However, scores of symbol coding, HVLT-R, BVMT-R, word fluency, digital span, maze test, word, color and color word were lower than those of the control group (t=-6.41, -5.42, -7.77, -5.59, -8.78, -6.99, -6.98, -6.47 and 4.84, all P<0.01). Pearson correlation analysis showed that the right insula was positively correlated with the BVMT-R and maze test scores, and the left inferior frontal gyrus was positively correlated with the maze scores in the patient group (r=0.32, 0.50 and 0.45, all P<0.05). The left inferior frontal gyrus was positively correlated with the digital span in control group (r=0.46, P<0.05).

The first-episode childhood-and adolescence-onset schizophrenia exhibits abnormal changes of gray matter volume and cognitive function, and the pathophysiological mechanisms of a wide range of cognitive impairments may be related to abnormal volume changes of gray matter.

To summarize the clinical characteristics of cardiomyopathy complicated with ventricular thrombosis.

The clinical data of inpatients suffered from cardiomyopathy complicated with ventricular thrombosis in Fuwai Hospital between January 2015 and May 2019 were analyzed retrospectively.

A total of 125 cases were reviewed, and 24.8% were female. Dilated cardiomyopathy was the most common disease (62.4%), followed by arrhythmogenic right ventricular cardiomyopathy (ARVC) (13.6%) and hypertrophic cardiomyopathy (11.2%). There were 74.4% thrombosis in left ventricle, 12.8% in right ventricle and 12.8% in biventricle. The proportions of right ventricle thrombosis were higher in ARVC than in other cardiomyopathies (52.9% vs 6.5%, P<0.01). The majority suffered from cardiac function New York Heart Association (NYHA) Class Ⅲ (45.6%) and class Ⅳ (39.2%). The ratio of NYHA Class Ⅳ was higher in female patients than in male ones (25.8% vs 10.6%, P<0.05). In lab detection, positive results of D-Dimer and N terminal-pro B type natriuretic peptide (NT-proBNP) accounted for 72.8% and 97.6%, respectively. There were 2.5% patients died in the hospital or discharged because of the worsening of illness, the chances were higher in female than male patients (9.7% vs 0, P<0.01). Among these patients, one succumbed to massive ischemic stroke caused by ventricular thrombus detachment under standard anticoagulation therapy.

Dilated cardiomyopathy is the most common cardiomyopathy complicated with ventricular thrombosis. The most common location of thrombosis is left ventricle. Right ventricle thrombosis is more common in ARVC. The majority suffer from moderate or severe cardiac dysfunction. Higer proportion of female patients suffer from anemia, severe condition and poor prognosis.

To observe the effect of traditional and modified Ilizarov transverse tibial bone transport on microvascular regeneration of lower limbs in dogs.

After general anesthesia on 10 experimental dogs, traditional and modified transverse tibial bone transport were performed on both tibias respectively. The control group was treated with the traditional method (the periosteum and bone flap were completely isolated), while the experimental group was treated with the modified method (the fibular periosteum of the open window bone flap was retained). All the external fixators were pulled outwards at a speed of 1 mm every day from 5 days after operation;after one week, the external fixators were moved back every 3 days for one week. The situation of wounds and activity of lower limbs were observed. Simultaneously, the angiogenesis was observed by digital subtraction angiography (DSA) through femoral artery at different stages, and the density of vascular endothelial cells measured by local tissue sections. The data before and after the operation were compared with paired t test.

The operation was successfully completed in 10 experimental dogs, and all wounds healed about 1 week after the operation. There was no significant abnormality in lower limb movements in all dogs. Peripheral blood vessel area in middle leg of lower limb in 4 weeks and 8 weeks after operation was (5.9±0.4) mm² and (6.9±0.6) mm² in control group and it was (6.2±0.6) mm² and (8.0±0.6) mm² in experimental group, respectively; all were significantly improved than those before the operation ((5.0±0.4) mm², (4.9±0.4) mm², respectively) (F=446.457, 829.192, both P<0.05). There was no significant differences in vessel area between the two groups at the 4th week after operation (t=1.216, P=0.240), but there was significant difference at the 8th week after operation between the two groups (t=4.423, P=0.000). The percentage of vascular endothelial cells in stained cells under endoscopy was 4.42%±0.28% and 5.63%±0.53% in the control group at the 8th week; and in the experimental group, it was 5.35%±0.26% and 7.18%±0.25%, respectively;all were significantly elevated than those before the operation; and there were significant differences between the two groups (t=7.35, 8.30, both P<0.05).

Transverse tibial bone transport and microvascular network regeneration technology can reconstruct the microvasculature below the calf of dogs; the method of window-opening osteotomy is improved to "door" type window-opening, it can retain the lateral periosteum of tibial crest and regenerate the microvasculature network more abundantly.

Sepsis is an infection-induced dysregulated body response that leads to life-threatening organ dysfunction. Disorders of the immuno-inflammatory response play a crucial role in the development of sepsis. In recent years, there has been a certain consensus on the necessity of immunomodulatory therapy for sepsis, but there are still many controversies in the object, timing and drug selection of immunomodulatory therapy. It is of great clinical significance to systematically review the research progress of immunomodulatory therapy in sepsis and summarize the consensus and controversy in this field.