2014年 · 第127卷第18期

Abstract：Background Endothelial dysfunction is not only an early stage of atherosclerosis,but also involved in the pathogenesis of cerebral small-vessel diseases.Patients with cerebral microbleeds (CMBs) may have arteriolosclerosis as well as systemic atherosclerosis.However,little is known about the associations among CMBs,atherosclerosis of cerebral large arteries,and endothelial function.Our study aimed to investigate the relationships among them.Methods This was a cross-sectional study.Ninety patients hospitalized in Peking University First Hospital with acute ischemic stroke were enrolled consecutively between November 1,2007 and January 31,2008.All subjects underwent transcranial Doppler and carotid color duplex ultrasonography to record the intima-media thickness (IMT) of common carotid artery,carotid plaque,and cerebral artery stenosis.Brain magnetic resonance imaging (MRI) routine sequences and gradient recall-echo T2*-weighted imaging were performed to count CMBs with clinical data blindness.Endothelial function was evaluated using flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD) of the brachial artery.FMD and NMD were examined by an experienced vascular sonographer using a high-resolution ultrasound.Results Thirty cases (33.3％) had CMBs with counts ranging from 1 to 30.Both FMD ((9.9±4.8)％ vs.(15.2±7.4)％,P=0.001) and NMD ((13.7±6.1)％ vs.(19.0±7.4)％,P=0.001) were significantly decreased in CMB-positive patients than in CMB-negative patients.No significant relationships were demonstrated between CMBs and intracranial and/or extracranial artery stenosis.The frequencies of CMBs in patients with IMT≥1.0 mm,carotid plaque,and extracranial artery stenosis were 37.5％,39.4％,and 47.6％ respectively,with no significant difference,but much higher than in patients with IMT ＜1.0 mm (5％,P ＜0.05).In Logistic regression analysis,impaired FMD (OR=5.783,95％ CI 1.652-6.718,P=0.007) and high pulse pressure (OR=6.228,95％ CI 1.594-3.891,P=0.009) were independently associated with the presence of CMBs,as well as previous ischemic stroke.In contrast,NMD was not correlated with CMBs.Conclusions CMBs may coexist with cerebral atherosclerosis in ischemic stroke.Endothelial dysfunction may play a role in the pathogenesis of CMBs,but may not simply reflect functional alterations of large arteries。

Abstract：Background Although there were criteria for diagnosis of neuromyelitis optica (NMO) and multiple sclerosis (MS),it is still difficult to differentiate NMO from MS,due to the overlapping clinical manifestations.Therefore it is necessary to characterize clinical features of NMO and MS patients in the mainland of China,to simplify the process of disease diagnosis,and to identify criteria for the differential diagnosis of NMO and MS.Methods A total of 138 Chinese Han patients from the mainland of China including 73 NMO,60 MS and 5 MS-like patients with positive NMO-IgG were included in the study.Clinical records were reviewed retrospectively and the results of clinical examination,laboratory experiments,magnetic resonance imaging (MRI) and evoked potentials (EPs) were compared between NMO and MS patients.In addition,the relationship between the NMO-IgG serologic status and clinical characteristics were analyzed.Results Compared with MS patients (1.3∶ 1.0),more female prevalence was observed in NMO patients (4.2∶ 1.0; P=0.003).There were also statistically significant differences in visual EPs,oligoclonal bands,brainstem lesions in MRI and longitudinally extensive spinal cord lesions (LESCLs) between NMO and MS patients.Brainstem lesions observed in brain MRI were found in 17.9％ of MS patients,over 3.7 times higher than in NMO patients (4.8％,P=0.024).When stratified NMO patients by NMO-IgG,LESCLs were found in 42.1％ of NMO-IgG-negative NMO patients,over 3.5 times higher than in NMO-IgG-positive patients (11.9％,P=0.008).Statistical difference was also observed in CD4+/CD8+ ratios between NMO-IgG-positive and-negative NMO patients.Conclusions Comprehensive analysis of MRI,laboratory and EPs data can facilitate differential diagnosis of MS and NMO.In addition,the combination of LESCLs and brain MRI findings failing to satisfy MRI criteria for MS is highly sensitive and specific for NMO。

Abstract：Background The long-time exercise test (ET) is used to diagnose the primary periodic paralyses (PPs).However the reference values of ET are many and various.This study aimed to investigate the reference value of long-time ET in the diagnosis of PPs.Methods We recruited 108 healthy subjects,68 patients with PPs,and 72 patients with other diseases for the study.The procedure of ET was made on the basis of the McManis' method.Electrical responses were recorded from right abductor digiti minimi (ADM) muscle when stimulation of the ulnar nerve at the wrist.After the compound muscle action potential (CMAP) was monitored,subjects were then asked to contract the muscle as strongly as possible for 5 minutes.CMAPs were recorded for 2 seconds immediately after cessation of exercise,then every 5 minutes for 10 minutes,and finally every 10 minutes for 50 minutes.In general,the CMAP amplitudes will fall below the pre-exercise levels in an hour.The largest decrease was calculated and used as results of ET.Results The CMAP amplitude decreases had no significant differences between groups when the healthy adults were grouped according to age,gender,height,weight and test time.Decreases in PPs patients (57.76％) were significantly more than in healthy subjects (15.21％) and other disease patients (18.10％,P ＜0.001).Receiver operating characteristic (ROC) curve analysis showed that the best threshold is 35.50％.Conclusions In the long-time exercise test,threshold of 35.50％ for the CMAP amplitude decrease was identified for abnormal.The result is not influenced by age,gender,height,weight,and test time.About 7.4％ of healthy subjects were abnormal in ET。

Abstract：Backgorund Sleep deprivation (SD) has been used in treatment of depression disorder,and could effectively improve the patients' depressive symptoms.The aim of the study was to explore the effects of SD on electroencephalographic (EEG)and executive function changes in patients with depression.Methods Eighteen depression patients (DPs) and 21 healthy controls (HCs) were enrolled in the present study.The whole night polysomnography (PSG) was recorded by Neurofax-1518K (Nihon Kohden,Japan) system before and after 36 hours of SD.The level of subjects' depression state was assessed by Visual Analogue Scale (VAS),and the executive function was assessed by Wisconsin Card Sorting Test (WCST).Results Significantly decreased sleep latency (SL; before SD:(31.8±11.1) minutes,after SD:(8.8±5.2) minutes,P ＜0.01)and REM sleep latency (RL; before SD:(79.8±13.5) minutes,after SD:(62.9±10.2) minutes,P ＜0.01) were found after SD PSG in depression patients.Decreased Stage 1 (S1; before SD:(11.7±2.9)％,after SD:(7.3±1.1)％,P ＜0.01) and Stage 2(S2,before SD:(53.8±15.5)％,after SD:(42.3±14.7)％,P ＜0.05) of non-rapid eye movement (NREM) sleep,and increased Stage 3 (S3,before SD:(11.8±5.5)％,after SD:(23.6±5.8)％,P＜0.01) and Stage 4 (S4,before SD:(8.8±3.3)％,after SD:(27.4±4.8)％,P ＜0.01) NREM sleep were also found.After SD,the depression level in patients decreased from 6.7±2.1to 2.9±0.7 (P ＜0.01).In WCST,the patients showed significantly decreased Response errors (Re,before SD:22.3±2.4,after SD:18.3±2.7,P ＜0.01) and Response preservative errors (Rpe,before SD:11.6±3.6,after SD:9.3±2.9,P＜0.05).Depression patients' RE (t=2.17,P ＜0.05) and Rpe (t=2.96,P ＜0.01) also decreased significantly compared to healthy controls.Conclusion SD can improve depression symptom and executive function in depression patients。

Abstract：Background High-frequency oscillatory ventilation (HFOV) allows for small tidal volumes at mean airway pressures (mPaw) above that of conventional mechanical ventilation (CMV),but the effect of HFOV on hemodynamics,oxygen metabolism,and tissue perfusion in acute respiratory distress syndrome (ARDS) remains unclear.We investigated the effects of HFOV and CMV in sheep models with ARDS.Methods After inducing ARDS by repeated lavage,twelve adult sheep were randomly divided into a HFOV or CMV group.After stabilization,standard lung recruitments (40 cmH2O × 40 seconds) were performed.The optimal mPaw or positive end-expiratory pressure was obtained by lung recruitment and decremental positive end-expiratory pressure titration.The animals were then ventilated for 4 hours.The hemodynamics,tissue perfusion (superior mesenteric artery blood flow,pHi,and Pg-aCO2),oxygen metabolism and respiratory mechanics were examined at baseline before saline lavage,in the ARDS model,after model stabilization,and during hourly mechanical ventilation for up to 4 hours.A two-way repeated measures analysis of variance was applied to evaluate differences between the groups.Results The titrated mPaw was higher and the tidal volumes lower in the HFOV group than the positive end-expiratory pressure in the CMV group.There was no significant difference in hemodynamic parameters between the HFOV and CMV groups.There was no difference in the mean alveolar pressure between the two groups.After lung recruitment,both groups showed an improvement in the oxygenation,oxygen delivery,and DO2.Lactate levels increased in both groups after inducing the ARDS model.Compared with the CMV group,the superior mesenteric artery blood flow and pHi were significantly higher in the HFOV group,but the Pg-aCO2 decreased in the HFOV group.Conclusion Compared with CMV,HFOV with optimal mPaw has no significant side effect on hemodynamics or oxygen metabolism,and increases gastric tissue blood perfusion。

Abstract：Background A new procedure of colonic anastomosis with a degradable stent has already been proven to be simple,feasible,and safe in our porcine model.In this study,we evaluated its impact on the colonic physiologic functions.Methods A total of 20 pigs were assigned randomly to either a stent anastomosis group (SA,n=10) or a conventional anastomosis group (CA,n=10).Colonic anastomosis with a degradable stent was performed in the SA group,and conventional hand-sewn anastomosis was performed in the CA group.Body weight,fecal weight,total colonic transit time,immunohistochemistry staining of interstitial cells of Cajal (ICC),plasma diamine oxidases (DAO) levels,and Western blotting analysis of occludin were evaluated before and after anastomosis.Results No obvious diarrhea or constipation was observed in all pigs.No significant difference in body weight between the groups was detected at any time.Yet,the fecal weight was less in the CA group compared with the SA group on postoperative day (POD) 7.No observable colonic paralysis or retention occurred.For total colonic transit time,there was no significant difference between the two groups at any time or among different time points in the same group.The integrated optical density of ICC showed no significant difference on either POD 14 or 30.The plasma DAO levels were remarkably elevated after surgery,and began to decrease since POD 3.However,there was no significant difference between both two groups in plasma DAO levels at any time either.For both groups,the expression of occludin was not significantly different from their pre-surgery level on either POD 14 or 30.Conclusions According to these results,this procedure with a degradable stent was supposed to be the same as the conventional hand-sewn procedure in their impact on the colonic physiologic functions。

Abstract：Background Apical abscess is an inflammatory process in the peri-radicular tissues caused by biofllms in the necrotic root canal systems.Therefore,a comprehensive analysis of the bacterial colonization is required for a better understanding of the pathogenesis.This study aimed to investigate the patterns of bacterial infection of root canals of teeth with apical abscesses and to determine whether histological and microbiological findings correlated with clinical conditions.Methods Eighteen samples from 18 teeth with apical pathological lesions were analyzed.Nine patients with acute apical abscesses experienced severe pain,and nine patients were asymptomatic with a sinus tract.After extraction,each affected root was divided into two halves.One half was processed for histobacteriologic analysis and examined using light microscopy,and the other half was analyzed using scanning electron microscopy (SEM) to determine the patterns of microbial colonization of the root canals.Results The appearance of each sample subjected to SEM was consistent with the histobacteriologic findings despite the presence or absence of clinical symptoms.Intraradicular biofilms comprising cocci,rods,and/or filaments of amorphous materials were observed in the apical third of the main root canals in all samples.The bacterial biofilms covering the main root canal walls also penetrated the dentinal tubules to varying depths.The morphologies of biofilms varied,and a unique pattern of intraradicular infection was not identified.Conclusion Intraradicular infections formed complex and variable multispecies biofilms and their presence did not correlate with clinical symptoms。

Abstract：Background This study was designed in an attempt to determine the influence of neoadjuvant chemotherapy on estrogen receptor (ER),progesterone receptor (PR),human epidermal growth factor receptor 2 (Her-2),and Ki-67 expressions in patients with breast cancer.Methods Pre-and post-neoadjuvant chemotherapy,paired-tumor specimens from 103 patients with breast cancer administrated with anthracycline or anthracycline combined taxane regimen were collected.Immunohistochemical staining for ER,PR,Her-2,and Ki-67 was performed by the DAKO EnVision method.Results Among the 103 cases,five patients (4.9％) had a complete response (CR),82 (79.6％) partial response (PR),15 (14.6％) stable disease (SD),and one (0.9％) progressive disease (PD),yielding an overall response rate (CR + PR)of 84.5％.Nine patients achieved pathological CR.There was a significant decrease in the average index of Ki-67 postneoadjuvant chemotherapy,compared with that before chemotherapy (24.1％ vs.39.7％,P ＜0.001).After neoadjuvant chemotherapy,the changes of Ki-67 in different subtypes of breast cancer were different (P ＜0.001),and these changes correlated with response to neoadjuvant chemotherapy (P ＜0.001).No significant changes in immunohistochemical expression were observed for ER,PR and Her-2.Conclusions Neoadjuvant chemotherapy apparently reduced Ki-67 index in primary breast carcinomas,but profiles for ER,PR and Her-2 were not significantly different before and after neoadjuvant chemotherapy.The change of Ki67 correlated with molecular subtypes and response to neoadjuvant chemotherapy,suggesting that Ki-67 index was a surrogate marker to predict the treatment response of neoadjuvant chemotherapy。

Abstract：Background Accurate and precise preoperative planning can provide information instrumental for performing less invasive articular fracture surgery.The purpose of this study was to determine that computer-assisted preoperative planning (CAPP) has the potential to improve efficiency and time in the operating room.Methods Sixty-four patients with proximal humeral fractures were treated using locking plates by minimally invasive plate osteosynthesis (MIPO) with CAPP.The time needed for virtual segmentation,reduction,and fixation of the fracture fragments were recorded.Intra and interobserver reliabilities were analyzed using the intraclass correlation coefficient.The clinical function was analyzed using Constant Score and radiology.Results The mean total time required for CAPP of two-part,three-part,and four-part proximal humeral fractures were (13.63±1.38) minutes,(23.14±2.18) minutes,and (39.61±3.01) minutes,respectively.The intra and interobserver reliabilities for all variables were high,ranging from 0.785 to 0.992.The mean operation time was (50.1±6.7) minutes.Fiftytwo patients were followed up with an average time of 34.2 months.The mean Constant Score of the injury side was (82.5± 9.9).Three of the fifty-two patients had four complications.Conclusion The application of CAPP was efficient and reliable,and provided excellent clinical and radiographic outcomes for the treatment of proximal humerus fractures by MIPO。

Abstract：Background Single-fiber electromyography is the most sensitive neurophysiological test for the diagnosis of myasthenia gravis (MG),but its use is limited by the potential risk of transmission of infections.Jitter analysis with disposable concentric needle electrodes (CNEs) is therefore being investigated.This pilot study aimed to evaluate jitter analysis with CNEs for the diagnosis of MG.Methods Forty-two healthy Chinese volunteers and 44 MG patients were prospectively enrolled.MG patients were classified according to the Osserman classification,and acetylcholine receptor antibody titer was measured.Jitter analysis with CNEs in the extensor digitorum communis and repetitive nerve stimulation (RNS) testing were performed.Jitter was expressed as the mean consecutive difference (MCD),and 20 action potential pairs were analyzed in each subject.The mean MCD in each subject and the mean individual MCD of all action potential pairs were compared between groups.Results The mean MCD and mean individual MCD were higher in MG patients ((42.3±20.0) μs and (42.2±26.0) μs) than in healthy volunteers ((23.0±3.1) μs and (22.8±7.5) μs).The area under the receiver operating characteristic curve for the mean MCD of MG patients and healthy volunteers combined was 0.85.The mean MCD and mean individual MCDwere higher in generalized MG patients ((64.1±18.5) μs and (63.6±30.0) μs) than in ocular MG patients ((33.1±12.0) μs and (33.2±17.6) μs),and were higher in MG patients with abnormal RNS results ((57.2±18.3) μs and (57.3±29.2) μs) than in MG patients with normal RNS results ((32.9±14.8) μs and (32.7±18.3) μs).Abnormal RNS results were observed in 38.60％ (17/44) of MG patients and abnormal jitter were observed in 72.70％ (32/44) of MG patients.Conclusion Jitter analysis with CNEs is feasible for the diagnosis of MG。

Abstract：Background Episodic memory includes information about item memory and source memory.Many researches support the hypothesis that these two memory systems are implemented by different brain structures.The aim of this study was to investigate the characteristics of item memory and source memory processing in patients with Parkinson's disease (PD),and to further verify the hypothesis of dual-process model of source and item memory.Methods We established a neuropsychological battery to measure the performance of item memory and source memory.Totally 35 PD individuals and 35 matched healthy controls (HC) were administrated with the battery.Item memory task consists of the learning and recognition of high-frequency national Chinese characters; source memory task consists of the learning and recognition of three modes (character,picture,and image) of objects.Results Compared with the controls,the idiopathic PD patients have been impaired source memory (PD vs.HC:0.65±0.06 vs.0.72±0.09,P=0.001),but not impaired in item memory (PD vs.HC:0.65±0.07 vs.0.67±0.08,P=0.240).Conclusions The present experiment provides evidence for dissociation between item and source memory in PD patients,thereby strengthening the claim that the item or source memory rely on different brain structures.PD patients show poor source memory,in which dopamine plays a critical role。

Abstract：Background The mutation frequencies of three common deafness genes (MT-RNR1 m.1555A＞G,GJB2,and SLC26A4) among patients with nonsyndromic sensorineural hearing loss (NSHL) were different in previous studies.Inconsistent selection criteria for recruiting patients could have led to differences in estimating the frequencies of genetic mutations thus resulting in different mutation frequencies among these studies.The aim of this study was to reveal the differences in the mutation spectrums of the three common genes between familial and sporadic Chinese Han patients.Methods Totally,301 familial probands and 703 sporadic patients with NSHL were enrolled in this study.Three genes,MT-RNR1 m.1555A＞G,GJB2,and SLC26A4,were screened for mutation in our study cohort.A X2 test was performed to compare the mutation frequencies between the two groups.Results The study showed that the disease-causing mutation frequencies of MT-RNR1 m.1555A＞G,GJB2,and SLC26A4 were 12.29％,14.62％,and 18.27％ in familial probands and 3.56％,18.63％,and 18.92％ in sporadic patients,respectively.The mutation frequency of MT-RNR1 m.1555A＞G in familial probands was significantly higher than in sporadic patients (X2 test,P=0.000),while there were no significant differences in the mutation frequencies of GJB2 and SLC26A4 between the familial and sporadic groups (X2 test,P ＞0.05).Conclusions It is necessary to reveal the differences in gene mutation frequencies between patients of different sources or characteristics by comparative studies in order to avoid selection bias.The mutations of GJB2,SLC26A4,and MTRNR1 m.1555A＞G are the most important etiological factors in Chinese Han patients,among which SLC26A4 might be the most frequent。

Abstract：Background Novel influenza A viruses of avian-origin may be the precursors of pandemic strains.This descriptive study aims to introduce a novel avian-origin influenza A (H10N8) virus which can infect humans and cause severe diseases.Methods Collecting clinical data of three cases of human infection with a novel reassortment avian influenza A (H10N8)virus in Nanchang,Jiangxi Province,China.Results Three cases of human infection with a new reassortment avian influenza A(H10N8) virus were described,of which two were fatal cases,and one was severe case.These cases presented with severe pneumonia that progressed to acute respiratory distress syndrome (ARDS) and intractable respiratory failure.Conclusion This novel reassortment avian influenza A (H10N8) virus in China resulted in fatal human infections,and should be added to concerns in clinical practice。

Abstract：Background Postoperative hypocalcemia is one of the most common complications following parathyroidectomy for primary hyperparathyroidism (PHPT).The aim of this study was to analyze the predictive value of biochemical parameters as indicators for episodes of hypocalcemia in patients undergoing parathyroidectomy for PHPT.Methods The patients with PHPT who underwent parathyroidectomy between February 2004 and February 2014 were studied retrospectively at a single medical center.The patients were divided into biochemical,clinical,and no postoperative hypocalcemia groups,based on different clinical manifestations.Potential risk factors for postoperative hypocalcemia were identified and investigated by univariate and multivariate Logistic regression analysis.Results Of the 139 cases,25 patients (18.0％) were diagnosed with postoperative hypocalcemia according to the traditional criterion.Univariate analysis revealed only alkaline phosphatase (ALP) and the small area under the curve (AUC) of receiver operating characteristics (ROC) curve for ALP demonstrates low accuracy in predicting the occurrence of postoperative hypocalcemia.Based on new criteria,22 patients were added to the postoperative hypocalcemia group and similar biochemical parameters were compared.The serum ALP was a significant independent risk factor for postoperative hypocalcemia (P=0.000) and its AUC of ROC curve was 0.783.The optimal cutoff point was 269 U/L and the sensitivity and specificity for prediction were 89.2％ and 64.3％,respectively.Conclusions The risk of postoperative hypocalcemia after parathyroidectomy should be emphasized for patients with typical symptoms of hypocalcemia despite their serum calcium level is in normal or a little higher range.Serum ALP is a predictive factor for the occurrence of postoperative hypocalcemia。

Abstract：Background Intense exercise can cause injury and apoptosis,but few studies have reported its effect on the central nervous system (CNS).The initial reason for hippocampus injury is the excitotoxicity of glutamate and calcium overload.Intracellular free Ca2+ ([Ca2+]i) overload may trigger the apoptosis pathway and neuron damage.The aim of this study was to investigate whether intense exercise could cause hippocampus apoptosis and neuron damage and then to determine which pathway was activated by this apoptosis.Methods We used one bout of swimming exhaustion rats as models.Intracellular [Ca2+]i was measured to estimate the calcium overload by Fura-2/AM immediately after exhaustion; glial fibrillary acidic protein (GFAP) and synaptophysin (SYP)immunofluorescence were performed for estimating astrocyte activation and synapse plasticity 24 hours after exhaustion.Apoptosis cells were displayed using dUTP nick end labelling (TUNEL) stain; endoplasmic reticulum (ER) stress-induced apoptosis pathway and mitochondrial apoptosis pathway were synchronously detected by Western blotting.Results An increasing level of intracellular [Ca2+]i (P ＜0.01) was found in the hippocampus immediately after exhaustion.GFAP and SYP immunofluorescence showed that the astrocytes are activated,and the synapse plasticity collapsed significantly 24 hours after exhaustion.TUNEL stain showed that the number of apoptosis cells were notably raised (P ＜0.01); Western blotting of the apoptosis pathway showed increasing levels of caspase-3 cleavage (P ＜0.01),Bax (P ＜0.01),caspase-12 cleavage (P ＜0.01),C/EBP-homologous protein (CHOP) (P ＜0.01),and phospho-Junaminoterminal kinases (p-JNK; P ＜0.01) and decreasing level of Bcl-2 (P ＜0.01).Our results proved that exhaustion can induce hippocampus injury and apoptosis by [Ca2+]i overload,with collapsed synaptic plasticity as the injury pattern and ER stress-induced apoptosis as the activated pathway.Conclusion Intense exercise can cause excessive apoptosis and synapse plasticity damage in the hippocampus with [Ca2+]i overload as the initial reason,and thus provides leads for therapeutic interventions in the brain health of athletes。

Abstract：Background The new medical insurance policy (JRSYF(2010) No.255) was released by the Beijing Municipal Government and became effective on January 1,2011.Medical expenses incurred during a stay in an emergency department (ED) observation unit can be reimbursed as a hospital admission.The aim of this study was to evaluate the impact of a new charging scheme during stays in ED observation unit under Beijing's Basic Medical Insurance.Methods Data for those patients who had stayed in ED observation unit in 2010 (before the implementation of a new charging scheme) and 2012 (after the implementation of this policy) were retrospectively analyzed in terms of length of stay,patients who were observed (PO),and median medical costs.Results After the implementation of a new charging scheme,compared with the year of 2010,in year of 2012,there were statistically significant longer lengths of stay at the observation unit (6 (4-9) vs.5 (4-7) days; P＜0.001),more PO (2 257vs.1 783; P＜0.001),and more median medical costs (RMB 6 026 vs.3 650 Yuan; P＜0.01).The proportion of elderly patients (≥60 years of age) in 2012 was larger than that in 2010 (70.22％ vs.63.71％; P＜0.01).It was performed on those patients who were admired after the implementation of a new charging scheme.Compared with patients who were not admired had stayed in ED observation units,the patients who were admired had stayed in ED observation units that had a higher proportion for ＞15 days (36.22％ vs.5.61％; P＜0.01); they had higher median medical costs RMB (9 186 vs.5 668Yuan; P＜0.001) and they were more elderly (≥60 years of age) (86.10％ vs.66.39％; P＜0.01).Conclusions The new charging scheme under Beijing's Basic Medical Insurance allows patients to get access to inpatient admission more easily.It lowers patients' financial burden in ED observation unit.Since more people stay at ED observation unit,it increases ED payments by the insurance system.However,it slows the turnover rate of ED observation unit and causes overcrowding in ED.Hence,the advantages and disadvantages of the new policy are obvious。

Abstract：Background Crossover stenting across the origin of the profunda femoral artery (PFA) and occasionally into the common femoral artery (CFA) is commonly used after suboptimal balloon angioplasty of ostial occlusive lesions of the superficial femoral artery (SFA) involving the bifurcation.Late stent occlusion at the bifurcation is not rare and results in severe lower extremity ischemia.Therefore,we tried to assess its possible causes,prevention and reintervention.Methods Using a prospectively maintained single-center database,12-month femoral bifurcation patency was retrospectively compared and lesion and procedural predictors of stent occlusion were determined among 63 patients (64 lesions) who between July 2011 and February 2013 underwent crossover (36 non-jailed and 15 jailed SFA,and 12 distal and 1 complete CFA) stenting of de novo ostial SFA lesions.Results Twelve-month overall patency rate at the femoral bifurcation was 88％,with no significant difference between jailed-ostial SFA (80％) and distal CFA (67％) stenting (P=0.731),and significant differences between either and non-jailed ostial stenting (100％,P=0.035 and 0.002).When PFA ostium was jailed by the stent,patients with preexisting CFA or PFA lesions had a 12-month bifurcation patency rate of 20％,significantly lower than those with simple ostial SFA lesions (83％,P=0.015).Stent induced intimal hyperplasia caused bifurcation occlusion in 6 surgical reintervention cases.Conclusions In crossover stenting of ostial lesions in SFA,bifurcation patency loss was significantly higher in distal CFA and jailed ostial SFA stenting than non-jailed ostial SFA stenting.Preexisting CFA or PFA lesion is a significant risk factor for bifurcation patency loss when PFA ostium is jailed by crossover stenting。

Abstract：Background Difficulties persist in differentiating pancreatic ductal adenocarcinomas (PDAC) from pancreatic inflammatory masses (PIM).Auxiliary diagnostic techniques which enhance the endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) diagnostic yield have been attempted,for example,K-ras mutation analysis.We aimed to evaluate the accuracy of K-ras mutation analysis combined with EUS-FNA for the differential diagnosis of PDAC and PIM by pooling data of existing trials.Methods We systematically searched the Medline,PubMed,Web of Science,Embase,and Cochrane Central Trials databases for relevant published studies.Meta-analysis was performed.Pooling was conducted in fixed-effect model or random-effect model.Results In total eight studies,with 696 cases of PDAC and 138 cases of PIM,met our inclusion criteria.The pooled sensitivity,specificity,positive likely ratio and negative likely ratio of K-ras mutation analysis combined with cytopathology for diagnosis of PDAC versus PIM were 90％,95％,13.45,and 0.13,respectively.Especially,among total 123 patients whose EUS-FNA results were inconclusive or negative,fifty-nine had K-ras mutations and were finally diagnosed with PDAC (48％,59/123).Publication bias was not present.Conclusions Combining K-ras mutation analysis with routine cytology moderately improves the ability of EUS-FNA to differentially diagnose between PDAC and PIM,especially for patients with suspected PDAC yet inconclusive EUS-FNA findings,and may prove to be a valuable supplemental method to EUS-FNA。

Abstract：Objective To review the advances in studies on renal denervation.Data sources References concerning renal denervation and resistant hypertension cited in this review were collected from PubMed published in English and those of renal denervation devices from official websites of device manufacturers up to January 2014.Study selection Articles with keywords "renal denervation" and "resistant hypertension" were selected.Results Renal and systemic sympathetic overactivity plays an important role in pathology of hypertension as well as other diseases characterized by sympathetic overactivity.Renal denervation is a new,catheter based procedure to reduce renal and systemic sympathetic overactivity by disruption of renal sympathetic efferent and afferent nerves through radiofrequency or ultrasound energy delivered to the endoluminal surface of both renal arteries.Although several studies have shown the efficacy and safety of renal denervation in the treatment of resistant hypertension and the potential benefit of the procedure in other diseases,Symplicity HTN 3 study,the most rigorous clinical trial of renal denervation to date,failed to meet its primary endpoint.The procedure also has other limitations such as the lack of long term,efficacy and safety data and the lack of the predictors for the blood pressure lowering response and nonresponse to the procedure.An overview of current renal denervation devices holding Conformité Européenne mark is also included in this review.Conclusions Renal denervation is a promising therapeutic approach in the management of resistant hypertension and other diseases characterized by sympathetic overactivity.In its early stage of clinical application,the efficacy of the procedure is still controversial.Large scale,blind,randomized,controlled clinical trials are still necessary to address the limitations of the procedure。

Human outbreaks of highly pathogenic avian influenza (HPAI) such as H5N1 and novel avian strains such as H7N9 have provoked significant public health concern. An outbreak of H5N! in humans was first reported in Hong Kong (HK), China in 1997. This event was curtailed by a variety of public health measures including the culling of over 1.5 million chickens in the city.~ H5N1 has since re-emerged in multiple countries with over 600 reported infections and, since 2003, a case fatality of about 59% (World Health Organization (WHO) report, as of January 24, 2014). A clear picture of the prevalence and transmissibility of avian influenza strains in humans is lacking, in part due to sparse epidemiological data and limitations in current detection methods。

Wang et al1 recently showed that in patients withtransient ischemic attack (TIA) or minor stroke that can be treated within 24 hours after the onset of symptoms, the combination of clopidogrel and aspirin was superior to aspirin alone for reducing the risk of stroke in the first 90 days, without increasing the risk of hemorrhage. We report a patient treated with this combination but suffered recurrent stroke and hemorrhage。