2014年 · 第127卷第10期

Acute respiratory distress syndrome (ARDS) is a life threatening respiratory failure due to lung injury from a variety of precipitants.Mechanical ventilation (MV) is the foundation in the supportive management of patients with ARDS.1 However,it is associated with several complications,such as increased risk of pneumonia and development of lung injury.The improved understanding of ARDS and complications from MV has been considered important in designing lung-protective ventilatory strategies aimed at attenuating or preventing organ dysfunction and improving outcomes。

Abstract：Background Colonization with methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for subsequent invasive MRSA infection,particularly in patients admitted for critical care.The purpose of this study was to investigate the risk factors affecting nasal colonization of MRSA in patients admitted to intensive care units (ICU).Methods Between August 1,2011 and June 30,2012,we screened for MRSA nasal colonization in 350 patients by Real-time PCR within 24 hours of admission by means of swab samples taken from the anterior nares.According to the results of PCR,the patients were divided into 2 groups:the positive group with nasal MRSA colonization and the negative group without nasal MRSA colonization.The 31 (8.86％) patients were MRSA positive.The risk factors evaluated included thirteen variables,which were analyzed by t test for continuous variables and X2 test for discrete variables.The variables with significance (P ＜0.05) were analyzed with stepwise Logistic regression.Results There were differences (P ＜0.05) in four variables between two groups.The duration of stay in hospital prior to ICU admission in the positive group was (35.7±16.1) days,vs.(4.5±3.1) days in the negative group.The average blood albumin level was (28.4±2.9) g/L in the positive group,vs.(30.5±4.3) g/L in the negative group.Of 31 patients in the positive group,seven had been treated with antibiotics longer than seven days vs.34 of 319 patients in the negative group.In the positive group,four of 31 patients received treatment with more than two classes of antibiotics prior to admission in ICU,contrasted to 13 of 319 patients in the negative group.Furthermore,stepwise Logistic regression analysis for these four variables indicates that the duration of stay in hospital prior to ICU admission may be an independent risk factor.Conclusions MRSA colonization in ICU admission may be related to many factors.The duration of stay in hospital prior to ICU admission is an independent risk factor。

Abstract：Background The presence of intracellular organisms (ICOs) in polymorphonuclear leukocytes obtained from bronchoalveolar lavage fluid (BALF) is a possible method for rapid diagnosis of ventilator-associated pneumonia (VAP).However,the validity of this diagnostic method remains controversial and the diagnostic thresholds reported by investigators were different.Our objective was to evaluate the accuracy of quantification of ICOs in BALF for the diagnosis of VAP,and to detect the best cutoff percentage of PMNs containing ICOs (PIC) in the microscopic examination of BALF for the diagnosis of VAP.Methods This was a prospective multi-center study conducted in 4 ICUs in Wuhan,China,which involved 181 patients suspected of first episode of VAP.BALF was obtained from all enrolled patients.The BALF samples underwent quantitative culture,cytological and bacteriological analysis to detect the culture results,PIC values and the morphological features of microorganisms.Definite diagnosis of VAP was based on pre-set criteria.The receiver-operating characteristic curve was used to detect the best cutoff point for PIG to diagnose VAP,and the diagnostic accuracy was calculated.Moreover,quantitative culture and Gram's stain of BALF were adopted to diagnose VAP,and their diagnostic accuracy was evaluated as well.Results There were 102 patients definitely diagnosed with VAP (VAP group),and 60 patients definitely diagnosed without VAP (no VAP group).We found that ICOs were present in 96.08％ (98 out of 102) of VAP patients and 20.00％ (12 out of 60) of no VAP patients.The PICs were significantly higher ((9.53±6.65)％ vs.(0.52±1.33)％,P＜0.01) in VAP group.In our study,the best cutoff point for PIC to diagnose VAP was 1.5％,which had a sensitivity of 94.12％,a specificity of 88.33％,a positive predictive value (PPV) of 93.20％ and a negative predictive value (NPV) of 89.83％.The area under the receiveroperating characteristic curve was 0.956 (95％ confidence interval,0.925-0.986; P＜0.01).When the positive quantitative culture results of BALF were used to diagnose VAP,the sensitivity,specificity,PPV and NPV were 65.69％,95.00％,95.71％ and 61.96％,respectively.Whereas they were 70.59％,76.67％,83.72％ and 60.53％,respectively,when the positive Gram's stain results of BALF were used to diagnose VAP.The concordance between the results of Gram's stain and quantitative cultures was poor,only 32.10％ (52 out of 162) was totally right,and 17.28％ (28 out of 162) was partially right.Conclusions PIC＞1.5％ has good diagnostic performance in the microscopic examination of BALF for the diagnosis of VAP.However,Gram's stain is not reliable for the early application of antibiotic therapy,due to the poor bacteriological predictive value。

Abstract：Background Community acquired pneumonia (CAP) is one of the most common infectious disease in emergency department.In 2005 the concept of healthcare associated pneumonia (HCAP) was proposed by the ATS/IDSA guidelines.The clinical features and microbiology of HCAP are different from CAP,however,the initial antimicrobial treatment is still controversial.We aimed to compare the clinical efficacy between HCAP patients treated initially with HCAP guidelineconcordant antimicrobial agents and those with CAP guideline-concordant antimicrobial agents.Methods We conducted a retrospective observational study on HCAP patients who were admitted to emergency department between December 2011 and December 2012.Patients were divided into 2 groups according to their different initial antimicrobial treatment.We compared clinical features,distribution of pathogen,severity,days and spending on intravenous antimicrobial,length and charge of hospitalization and clinical outcomes,and meanwhile analyzed the clinical efficacy as well.Results Of the 125 HCAP patients,55 patients received CAP guideline-concordant antimicrobial agents and 70 received HCAP agents.The major pathogens were Klebsiella pneumoniae,methicillin-resistant staphylococcus aureus (MRSA),Pseudomonas aeruginosa and Escherichia coll The 2 groups were similar at baseline,including old age,comorbidities,Pneumonia Severity Index scores,APACHE scores,and length of intravenous antimicrobial use and hospitalization duration,and in-hospital mortality.Overall efficacy rate occurred in 70.0％ of HCAP agent patients and 50.9％ of CAP agent patients (P=0.029).Antimicrobial charge and total hospital charge for HCAP agent patients were significantly higher than that for CAP agent patients.Conclusions Initial treatment of HCAP patients in emergency department with HCAP guideline-concordant antimicrobial could increase clinical efficacy rate,as well as antimicrobial charge and total hospital charge,but was not associated with shortening the length of stay,or lowering in-hospital mortality。

Abstract：Background Acute kidney injury (AKI) is a common complication of sepsis,which is associated with higher risks of adverse outcomes.Recently,kidney disease:improving global outcomes (KDIGO) recommended a new guideline forAKI,including a little modification on the AKI staging criteria.Methods This retrospective study included 211 septic patients admitted to the intensive care unit (ICU) at Xiangya Hospital,Central South University from January 2008 to January 2011.AKI was diagnosed and classified according to the KDIGO or acute kidney injury network (AKIN) criteria.Differences between the AKI and non-AKI groups for baseline characteristics,laboratory examinations,etiology,outcomes,as well as the risk factors for AKI and 28-day mortality were analyzed.The reliability of the KDIGO criteria was also evaluated by comparing it with the AKIN criteria.Results The overall incidence of AKI in septic patients was 47.9％,and the 28-day mortality was 32.7％.The incidence of AKI was significantly higher in patients with more severe sepsis.Indicators of hepatic and respiratory function were significantly worse in the AKI group.Furthermore,a higher proportion of patients were infected with Enterobacter cloacae in the AKI group.The independent risk factors for AKI were shock,the number of organ failures,blood urea nitrogen (BUN)levels,and the use of vasopressors.The independent risk factors for mortality were BUN and creatine kinase-MB (CK-MB)levels.Both the KDIGO criteria and the AKIN criteria were significantly associated with 28-day mortality.Conclusions The incidence and 28-day mortality of AKI were very high in ICU septic patients.Greater attention should be paid to AKI-induced hepatic and respiratory dysfunction in clinical practice.Patients with an intra-abdominal source of infection were more likely to develop AKI.KDIGO criteria are reliable in AKI staging。

Abstract：Background Many studies have shown that continuous renal replacement therapy (CRRT) could clean lactate and treat the hyper-lactatemia.On the contrary,some other studies found that filter lactate clearance only accounted for a very small part of total lactate clearance and the hemofilter's contribution to the overall lactate clearance was negligible.The objective of this study was to evaluate the effects of various doses of continuous veno-venous hemofiltration (CWH) on plasma lactate elimination in critically ill patients.Methods Patients were divided into three groups according to their incipient plasma lactate concentration.Group A:lactate≤2 mmol/L,group B:lactate 2-5 mmol/L,group C:lactate ≥5 mmol/L.Three different doses (20 ml.kg-1.h-1,35ml·kg-1·h-1 and 45 ml.kg1.h-1) of CWH were applied to critically ill patients who experiencing CWH.The concentrations of plasma lactate in pre-(A),post-dialyzer (V) sites and ultrafiltrate were measured after each dosage of CWH was carried out for 30 minutes.Rate of lactate clearance by the filter (RLC) and filter lactate clearance (FLC) and Lactate-Sieving Coefficient (LSC) were calculated under different circumstances,including different doses of CWH and different incipient lactate levels.Results Fifteen patients were enrolled and 104 blood samples were drawn and lactate concentrations were measured in this study.RLC was found increased ((9.36±9.73) mmol/h,(13.92±12.56) mmol/h and (16.52±12.71) mmol/h,P ＜0.05respectively) with the dose of CWH increased.RLC was also increased ((3.46±1.46),(10.38±5.50) and (24.53±14.69) mmol/h,P ＜0.05 respectively) with the incipient lactate increased.FLC was increased ((1.95±0.63),(2.95±0.74) and (3.45±0.54) L/h,P ＜0.05 respectively) with the dose of CVVH increased.There was no significant difference of LSC in different doses of CWH and different incipient lactate levels.Conclusions Plasma lactate can be eliminated by CWH and different doses of CWH affect the rate of lactate clearance in critically ill patients。

Abstract：Background In 2012,the working group on abdominal problems of the European Society of Intensive Care Medicine (ESICM) proposed a definition and also guidelines for the grading system and treatment of acute gastrointestinal injury (AGI).Until now,clinical reports on this topic have not been available,and the practicality of using the AGI grading system requires further validation in the clinic.Therefore,we conducted this study to evaluate the feasibility of utilizing the current AGI grading system in a clinical environment,and to provide evidence for its usefulness in assessing the severity and prognosis of critically ill patients with gastrointestinal dysfunction.Methods A total of 133 patients were examined for the presence or absence of AGI,their scores on the Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ and Lausanne Intestinal Failure Estimation (LIFE) test,and 28 days mortality.The presence and severity of AGI was based on guidelines provided by the ESICM.The patients were assigned to a NOAGI group (n=50) or an AGI group (n=83).The AGI group was then further divided into three subgroups,consisting ofAGI Ⅰ (risk group,n=38),AGI Ⅱ (gastrointestinal dysfunction group,n=33) and AGI Ⅲ+AGI Ⅳ (gastrointestinal failure group,n=12).These subgroups were then compared for differences in AGI indicators.Results There were no statistically significant differences between the AGI group and the NO-AGI group in terms of age,gender,APACHE Ⅱ score or LIFE score (P ＞ 0.05); however,the two groups showed a significant difference in their respective rates of 28 days mortality (32.5％ in the AGI group vs.8.0％ in the NO-AGI group (P ＜ 0.05)).Patients in the three AGI subgroups showed significant differences in their 28 d mortality rates,APACHE Ⅱ,and LIFE scores.AGI grading system showed strong positive correlations with APACHE Ⅱ and LIFE scores (P ＜ 0.05).Conclusions The currentAGI grading system can be used to identify and evaluate gastrointestinal dysfunction in critically ill patients,and also to provide a preliminary assessment regarding the prognosis for patients with different grades of AGI。

Abstract：Background Mitochondrial dysfunction has been reported to be one of the contributing factors of sepsis-associated encephalopathy (SAE).Mitochondrial biogenesis controls mitochondrial homeostasis and responds to changes in cellular energy demand.In addition,it is enhanced or decreased due to mitochondrial dysfunction during SAE.The aim of this study was to explore the changes of mitochondrial biogenesis of astrocytes under septic conditions.Methods Lipopolysaccharide (LPS; 50 ng/ml) and interferon-γ (IFN-γ; 200 U/ml) were incubated with astrocytes to model the effects of a septic insult on astrocytes in vitro.The mitochondrial ultrastructure and volume density were evaluated by transmission electron microscopy.Intracellular adenosine triphosphate (ATP) levels were detected by the firefly luciferase system.The expression of protein markers of mitochondrial biogenesis and the binding ability of mitochondrial transcription factor A (TFAM) were determined by western blot and electrophoretic mobility shift assays,respectively.The mitochondrial DNA (mtDNA) content was detected by real-time polymerase chain reaction.Results The number of mildly damaged mitochondria was found to be significantly greater after treatment for 6 hours,as compared with at 0 hour (P＜0.05).The mitochondrial volume density was significantly elevated at 24 hours,as compared with at 0 hour (P＜0.05).The ATP levels at 6 hours,12 hours,and 24 hours were significantly greater than those at 0 hour (P＜0.05).The protein markers of mitochondrial biogenesis were significantly increased at 6 hours and 12 hours,as compared with at 0 hour (P＜0.05).The TFAM binding activity was not significantly changed among the four time points analyzed.The mtDNA contents were significantly increased at 12 hours and 24 hours,as compared with at 0 hour (P＜0.05).Conclusions Under septic conditions,mitochonddal biogenesis of astrocytes increased to meet the high-energy demand and to promote mitochondrial recovery.Furthermore,the TFAM-DNA binding ability was not sensitive to sepsis-induced injury。

Abstract：Background Obstructive sleep apnea hypopnea syndrome (OSAHS) is the most common sleep-disordered breathing and is still underdiagnosed.This study was designed to evaluate the value of the STOP-Bang questionnaire (SBQ) in screening OSAHS in sleep-disordered breathing clinics in order to extend it into the general Chinese population.Methods Two hundred and twelve patients undergoing overnight polysomnography (PSG) in the sleep-disordered breathing clinic of Pecking Union Medical College Hospital between May 2011 and January 2012 were prospectively included and were asked to fill in the SBQ.A score of 3 or more of the SBQ indicated a high risk of OSAHS.We analyzed the sensitivities and specificities of SBQ in screening OSAHS.Logistic regression analysis was used to evaluate the probabilities of the severity of OSAHS based upon the apnea hypopnea index (AHI).Results The patients at high risk of OSAHS had higher AHI,higher oxygen desaturation index (ODI),lower pulse oxygen saturation (LSpO2) during sleep time and less sleep time in stage N3.SBQ scores were positively correlated with AHI,ODI and the ratio of SpO2 lower than 90％,and negatively correlated with LSpO2 during sleep.The sensitivities of the SBQ with AHI ≥5/h,AHI ≥15/h,AHI ≥30/h as cut-offs were 94.9％,96.5％,and 97.7％,respectively,and the specificities were 50.0％,28.6％,and 17.9％,respectively.The Logistic regression analysis showed the probability of severe OSAHS increased and the probability of normal subjects decreased with increasing SBQ score.Conclusions The STOP-Bang questionnaire has excellent sensitivity in screening OSAHS patients and can predict the severity of OSAHS.More studies will be required to determine the value of SBQ in the general Chinese population。

Abstract：Background The high blood homocysteine (Hcy) levels found in patients with hyperhomocysteinemia (HHcy) have been implicated in an increased risk of cardiovascular disease morbidity and mortality in end-stage renal disease (ESRD).This study investigated the association of HHcy with progression of IgA nephropathy.Methods We analyzed 108 participants newly diagnosed with IgA nephropathy between August 2005 and August 2007 in the Department of Nephrology,Chinese People's Liberation Army General Hospital.The association between clinicopathological factors and the Hcy levels were analyzed by Logistic regression and those with ESRD risk were analyzed by Cox regression.Results Patients were aged (35.71±10.73) years and included 45.71％ women and 12.04％ patients with HHcy.In multivariate Logistic regression analysis,HHcy was associated with arterial lesions (OR 2.60; 95％ CI 1.55-4.34; P＜0.001) even when age,body mass index,estimated glomerular filtration rate,mean arterial pressure,and initial proteinuria were taken into account.Mean follow-up was (67.37±16.21) months.HHcy was also associated with worse ESRD-free survival (HR 4.71; 95％ CI 1.45 to 15.31; P=0.010).Conclusion HHcy is associated with the risk of intrarenal arterial lesions and may be useful for estimating the prognosis of IgA nephropathy。

Abstract：Background The abnormal blood volume regulation is one of the most important pathogenesis in postural tachycardia syndrome in children.This study was designed to investigate the plasma atrial natriuretic peptide and antidiuretic hormone levels in postural tachycardia syndrome children,and their associations with the changes in heart rate and blood pressure in head-up test.Methods Twenty-one postural tachycardia syndrome patients ((12±2) years) and 26 healthy children ((12±1) years) were included.According to blood pressure changes in head-up test,the postural tachycardia syndrome patients were divided into two subgroups:postural tachycardia syndrome with orthostatic hypertension and postural tachycardia syndrome without orthostatic hypertension.The plasma atrial natriuretic peptide and antidiuretic hormone levels were measured using enzyme-linked immunosorbent assay.Results The plasma atrial natriuretic peptide level in postural tachycardia syndrome patients was higher than the control (P=0.004),whereas the difference in plasma antidiuretic hormone level between postural tachycardia syndrome and controls was not significant (P=0.222).The plasma antidiuretic hormone level of patients suffering from postural tachycardia syndrome with orthostatic hypertension was much higher than that of children having postural tachycardia syndrome without orthostatic hypertension (P ＜0.05).In postural tachycardia syndrome patients,the updght max heart rate was positively correlated with the plasma atrial natriuretic peptide level (r=0.490,P＜0.05) and the upright systolic blood pressure was positively correlated with the plasma antidiuretic hormone levels (r=0.472,P ＜0.05).Conclusions There was a disturbance of plasma atrial natriuretic peptide and antidiuretic hormone in postural tachycardia syndrome children。

Abstract：Objective To highlight current knowledge about M-type phospholipase A2 receptor (PLA2R) which is the first human autoantigen discovered in adult idiopathic membranous nephropathy.Data sources Relevant articles published in English from 2000 to present were selected from PubMed.Searches were made using the terms "idiopathic membranous nephropathy,M-type PLA2R and podocyte." Study selection Articles studying the role of M-type PLA2R in idiopathic membranous nephropathy were reviewed.Articles focusing on the discovery,detection and clinical observation of anti-PLA2R antibodies were selected.Results M-type PLA2R is a member of the mannose receptor family of proteins,locating on normal human glomeruli as a transmembrane receptor.The anti-PLA2R in serum samples from MN were primarily IgG4 subclass.Technologies applied to detect anti-PLA2R autoantibody are mainly WB,lIFT,ELISA and so on.Studies from domestic and overseas have identified a strongly relationship between circulating anti-PLA2R levels and disease activity.Conclusion Recent discoveries corresponding to PLA2R facilitate a better understanding on IMN pathogenesis and may provide a new tool to its diagnosis,differential diagnosis,risk evaluation,response monitoring and patient-specific treatment。

Abstract：Objective Following traumatic brain injury (TBI),brain tissue that surrounding the regional primary lesion is known as traumatic penumbra; this region may undergo secondary injury and is considered to have the potential to recover.This review aimed to reveal the existence and significance of traumatic penumbra by analyzing all relevant studies concerning basic pathologic changes and brain imaging after TBI.Data sources We collected all relevant studies about TBI and traumatic penumbra in Medline (1995 to June 2013) and ISI (1997 to March 2013),evaluated their quality and relevance,then extracted and synthesized the information.Study selection We included all relevant studies concerning TBI and traumatic penumbra (there was no limitation of research design and article language) and excluded the duplicated articles.Results The crucial pathological changes after TBI include cerebral blood flow change,cerebral edema,blood-brain barrier damage,cell apoptosis and necrosis.Besides,traditional imaging method cannot characterize the consequences of CBF reduction at an early stage and provides limited insights into the underlying pathophysiology.While advanced imaging technique,such as diffusion tensor imaging (DTI) and positron emission tomography (PET),may provide better characterization of such pathophysiology.Conclusions The future of traumatic brain lesions depends to a large extent on the evolution of the penumbra.Therefore,understanding the formation and pathophysiologic process of the traumatic penumbra and its imaging research progress is of great significant for early clinical determination and timely brain rescue。

Critical care has become a central part of modern medicine and an integral essential to improve the outcomes in acute care.The increasing complexity of surgical procedures,severity of co-morbid diseases,life expectancy and societal expectation is likely to escalate the burden and the global need for critical care resources.While millions of patients are ventilated worldwide every year,projections suggest that the number of ventilated patients is expected to rise by 31％ over the following decade.1

Avian influenza A(H7N9) virus is one subgroup among the larger group of H7 viruses,which normally circulate among birds.The H7N9 subtype of avian influenza viruses has not been known to infect humans until only recently.On March 31,2013,China confirmed the first three human cases of novel avian influenza A(H7N9)infection in Shanghai and Anhui,two of these patients died.1 As of February 27,2014,367 laboratory-confirmed human cases have been reported from 15 provinces/municipalities in mainland China,the most (136) from China's Zhejiang province.2 H7N9 virus transmission and infection continue endash 127 confirmed human H7N9 cases were reported in January 2014.3

In this day and age,few issues have aroused more bitter controversy than the one of how to keep the balance between fairness and cost-effectiveness in healthcare system.On one hand,a well-designed healthcare system must be armed with the elements of equality,accessibility,and high quality,which could provide people health to the largest extent.On the other hand,the sustainability of economic development makes every government to consider more investment to healthcare budget。

Necrotizing fasciitis (NF) caused by vibrio vulnificus (VV) is a rare but fatal clinical emergency characterized by hemorrhagic bullous skin lesions,septic shock and multiple organ dysfunction syndrome (MODS),commonly occurring in patients with chronic liver disease.1,2 In general,mortality of these patients is higher than 60％,which could approach 100％ when complicated with septic shock.Therefore,early diagnosis and effectively surgical intervention in emergency room are the mainstays for better outcomes of these patients.However,many emergency physicians lack experiences in diagnosing and managing vibrio NF.Furthermore,due to the preexisting severe medical complications including hypotension,lactic acidosis,coagulation disorders and thrombocytopenia,the optimal therapeutic strategies for these critical patients should obviously be evaluated on a patient-to-patient basis,which remains largely undefined。

Hereditary spastic paraplegia (HSP) is one of the most.heterogeneous genetic neurodegenerative diseases,caused by mutations in more than 50 different genes.The eighth HSP locus,SPG8,is on chromosome 8p24.13.SPG8 is a rare autosomal dominant-HSP (AD-HSP) caused by mutations in the KIAA0196 gene,with only seven SPG8families described to date.1 Here,we described the clinical characteristics of AD-HSP caused by a novel mutation in the KIAA0196 gene in a Chinese family。

Several studies reported the impact of cardiac surgical operation on morbidity and mortality in renal transplant recipients as well as on renal graft function and safety and effect of immunosuppressant medication.1-3 However,few data are available about the risk and immunosuppressant medication in patients who undergo cardiac surgical operation after successful renal transplantation,especially in patients who underwent offpump coronary artery bypass grafting (CABG) with previous renal transplantation.This research provides important insights into the immunosuppressive management of a patient requiring valve replacement or CABG after renal transplantation during the perioperative period。

To the editor:A two-and-half-year-old girl was admitted to our hospital due to recurrent seizures.At 6 months old,she was found to have developmental retardation accompanied with polydipsia and polyuria.At 2 years and 2 months old,it developed to epileptic seizures with a frequency of 2 or 3 times a day.At the time of hospitalization,the neurological examination was normal.Routine urine test revealed a high pH value (8.0) with normal specific gravity.Blood biochemical examination displayed hypokalemia,hypouricemia,and hyperchloremia.Blood gas analysis indicated a low pH value,actual bicarbonate radical and base excess.Both blood amino acids and urinary organic acids were normal.Enzymatic activity detection of the mitochondrial respiratory chain in peripheral blood lymphocytes showed enzyme defects of complex Ⅰ and complex Ⅰ plus Ⅲ.Electroencephalography showed adventitious high-voltage sharp waves in the parietooccipital area.And no abnormal change was detected by brain magnetic resonance imaging。

To the editor:Carbapenem-resistant Acinetobacter baumannii (CRAB) is one of the most representative multidrug-resistant gram-negative bacteria,and its resistant rate has steadily increased in recent years.1'2 CRAB infections can currently be treated with tigecycline.However,with its rapid promotion and wide application in clinical therapy,it is reported that the tigecycline minimum inhibitory concentration (MIC) presented an increasing trend for CRAB.Some studies also pointed out that susceptibility to tigecycline varied among different testing methods.3-5 Nowadays the interpretation of tigecycline susceptibility testing results is based on the Enterobacteriaceae breakpoints (MIC ≤2 μg/ml) recommended by tigecycline manuals。

To the editor:A 30-year-old male was admitted to our hospital on February 11,1986.He complained of dysphagia for 1 year and was diagnosed with tumor of the esophagus entrance.Then he underwent trans-cervical esophageal tumor resection,and smooth masses of 2 cm × 2 cm × 1 cm,2 cm × 2 cm × 3 cm,3 cm × 3 cm ×4 cm were excised respectively.The postoperative pathology reported fibrolipoma.Eight years after the first surgery,the patient suffered from dysphagia of gradually increasing degree with a smooth tumor regurgitated into his oral cavity repeatedly,and difficulty in taking solid food.His esophageal barium swallow X-ray showed a dilation of the upper esophagus with a maximum diameter of 7 cm。

To the editor:Endogenous bacterial endophthalmitis accounts for a small minority (2％-6％) of cases of endophthalmitis,but the visual outcome is almost always poor) Group B streptococcus (GBS)accounts for only 5.2％ among 267 endogenous endophthalmitis cases,1 and only about 30 cases have been reported in literature.We describe a rare case of bilateral GBS endogenous endophthalmitis and suggest that GBS should be a leading suspect in bilateral endogenous endophthalmitis。

To the editor:A 55-year-old woman was admitted to orthopaedics department in our hospital with a 3-month history of severe low backache and difficulty in walking in June 2010.Physical examination revealed restricted lumbar spine movement with marked tendemess of lumbar region,but no other joint and extra-articular abnormal features.Blood analysis revealed normal white blood cell count and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP),pure protein derivative and rheumatoid factor and antinuclear antibody were all negative,T-spot.Tuberculosis (TB) and human leukocyte antigen-B27 were positive,MRI showed normal sacroiliac joint and discitis at L1/2 (Figure 1A).The patient had no a history of other diseases including TB before the start of symptoms except a positive family history of spondyoarthropathy。

Oracle bone inscriptions,the earliestform of Chinese writings,were used from the Shang dynasty to the Western Zhou dynasty (1 600 BC 1 000 BC).These inscriptions were carved on turtle shells and animal bones,which were primarily used for divination at that time.Among over 150 000 oracle bone pieces excavated,41 956pieces were collected in the book named Jia Gu Wen He Ji in Chinese (Collection and Analyses of Oracle Bone Inscriptions).So far about 4 500 oracle bone inscriptions have been interpreted and about 2 600 have been decoded.Among those,about 1 056 oracle bone inscriptions have been widely accepted by authorities in China and abroad.1 Here we scrutinized the well-interpreted oracle bone inscriptions and selected 95 characters related to medicine and dermatology for discussion。

Multifocal motor neuropathy (MMN) is a rare,.focal,inflammatory,demyelinating disease of the peripheral nerves with pure motor involvementJ MMN is clinically characterized by slowly progressive,asymmetric,distal,upper limb predominant weakness,in the absence of sensory disturbances) Weakness is usually multifocal and connected to a distinct motor nerve,such as the musculocutaneous nerve resulting in biceps weakness,the posterior interosseus nerve resulting in finger drop,the median,ulnar,or radial nerve resulting in dexterity problems or grip weakness,or the peroneal nerve resulting in a foot drop.Onset of clinical manifestations is between 20 and 50 years of age.The prevalence of MMN is reported as 1-2 per 100 000.2 MMN is three times more frequent in men as compared to women。