2012年 · 第125卷第05期

In recent years,great progress has been made in the treatment of cancer;one of the significant reasons is the wide adaptation and implementation of standardized treatment based on high-level clinical evidence.Undoubtedly,the advent of guidelines that represent the achievement of the latest and highest quality clinical studies made a significant contribution to the improvement of cancer treatment and management.Aside from cancer patient care,guidelines have also been widely used as standards or primary references in the diagnosis and treatment of other diseases.Numerous guidelines are being enacted each year by a variety of guideline-makers, including national, regional and intemational academic organizations, medical associations,as well as research institutions and hospitals。

Abstract：Background In epidemiological studies,tuberculosis (TB) appears intimately with vitamin D insufficiency whereas its relationship with vitamin D receptor (VDR) polymorphism caused by radical difference remains unspecified.This study aimed to investigate the relationship between vitamin D genetic polymorphism and tuberculosis in Han ethnic group.Methods Meta-analysis was adopted in the synthetic quantitative analysis of documents home and abroad on the relationship between vitamin D genetic polymorphisms and tuberculosis,which were openly published during June 2000 to January 2010.Random effect model and fixed effect model analyses were used to calculate the incorporated odds ratio (OR) based on the heterogeneity test data.Results A total of 6 eligible studies were included in this analysis.The Fokl-ff genotype showed a significant marginal association (Fixed effect model:OR 1.91,95％ CI 1.44-2.52; Random effect model:OR 1.91,95％ CI 0.94-3.88),yet Taql polymorphisms was not significantly related to TB.Conclusion The interaction between FoKI genotype polymorphism and TB observed demonstrates that vitamin D deficiency might exist as a risk factor during the development of TB in Han ethnic group and more evidences needed to validate the conclusion。

Abstract：Background Magnifying narrow-band imaging has enabled observation of the mucosal and vascular patterns of gastrointestinal lesions.This study investigated the potential value of magnifying endoscopy with narrow-band imaging for the classification of gastric intraepithelial neoplasia.Methods Seventy-six patients with gastric intraepithelial neoplasia (82 lesions) at People's Liberation Army General Hospital from December 2009 to November 2010 were analyzed.All patients underwent magnifying endoscopy with narrow-band imaging,and their lesions were differentiated into probable low-grade intraepithelial neoplasia or possible high-grade intraepithelial neoplasia on the basis of the imaging features.Pathologic proof was subsequently obtained by endoscopic submucosal dissection in every case.The validity of magnifying endoscopy with narrow-band imaging was calculated,considering histopathology to be the gold standard.Results Magnifying endoscopy with narrow-band imaging showed 22 low-grade intraepithelial neoplastic lesions and 60 high-grade intraepithelial neoplastic lesions.Of the 22 low-grade intraepithelial neoplastic lesions,16 showed the same results on both imaging and pathology.Of the 60 high-grade intraepithelial neoplastic lesions,53 showed the same results on both imaging and pathology.Thus,the sensitivity of magnifying endoscopy with narrow-band imaging for high-grade intraepithelial neoplasia was 89.83％,which was higher than that for low-grade intraepithelial neoplasia (69.57％).However,the specificity for high-grade intraepithelial neoplasia (69.57％) was lower than that for low-grade intraepithelial neoplasia (89.83％).The overall accuracy of magnifying endoscopy with narrow-band imaging was 84.15％.Conclusions Magnifying endoscopy with narrow-band imaging can distinguish between gastric low- and high-grade intraepithelial neoplasia.It may be a convenient and effective method for the classification of gastric intraepithelial neoplasia。

Abstract：Background There has been an increase in the incidence of breast cancer in China,but no definite risk and protective factors for breast cancer have been identified in Chinese females.This study was designed to identify the risk factors for female breast cancer in North and East China.Methods A 1:3 matched,case-control study was conducted.All of the subjects in the case and control groups were selected from a previous epidemiological survey of 122 058 females aged 25 to 70 years.Single and multiple Logistic regression analyses were used to study potential factors in the development of breast cancer.Results Significant differences at the level of α=0.20 between case and control groups were observed for the following factors:economic status,social status,family annual income,bean product consumption,body mass index (BMI),family history of breast cancer in the first or second degree,number of miscarriages,menstrual pattern,benign breast disease history,nipple leakage,inverted nipple,history of diabetes mellitus,history of hypertension,history of ovarian cyst,physical exercise,current and global quality of life satisfaction,healthy behavior and prevention,and scores of breast cancer-related knowledge.After Cox-regression model analysis (α=0.10),six factors were found to be significantly related to breast cancer,of which the ORs and 95％C/s were:BMI,1.696 (1.169-2.460,P=0.005); benign breast disease history,2.672 (0.848-8.416,P=0.093); family history of breast cancer,7.080 (1.758-28.551,P=0.006); number of miscarriages,1.738 (1.014-2.978,P=0.044); global quality of life satisfaction,3.044 (1.804-5.136,P=0.000); healthy behavior and prevention,3.294 (1.692-6.412,P=0.000).Conclusions A comprehensive range of factors related to breast cancer was identified.Women should be educated about a healthy lifestyle,especially those with a family history of breast cancer or a personal history of benign breast disease。

Abstract：Background Dihydropyrimidine dehydrogenase (DPD),a key enzyme involved in the catabolism of 5-fluorouracil (5-FU),is the attractive candidate for pharmacogenetic research on efficacies and toxicities of 5-FU.The aim of this study is to explore the association between polymorphisms of dihydropyrimidine dehydrogenase gene (DPYD) and clinical outcomes of gastric cancer patients treated with fluorouracil-based adjuvant chemotherapy in the Chinese population.Methods Three hundred and sixty-two patients with gastric cancer in the Chinese population were treated with fluorouracil-based adjuvant chemotherapy.The single nucleotide polymorphic genotypes of DPYD were determined by matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF-MS) using DNA samples isolated from peripheral blood collected before treatment.Results The average response rate for chemotherapy was 46.7％.A significantly different distribution of the rs1801159 (x2=8.76,P=0.012) genotypes was observed.Homozygous genotype rs1801159A/A was over-represented in responsive patients.Conversely,carriers of the rs1801159A/G genotype were prevalent in non-responsive patients.In the haplotype association analysis,there was significant difference in global haplotype distribution between the groups (x2=3.96,P=0.0465).Conclusions These results suggest that polymorphisms of rs1801159 in DPYD may be used as valuable predictors of the response to fluorouracil-based chemotherapy for gastric cancer patients in the Chinese population.Well-designed,comprehensive,and prospective studies on determining these polymorphisms of DPYD as predictive markers for gastric cancer in response to fluorouracil-based therapies are warranted。

Abstract：Background Many studies have reported the benefit of hepatic resection for solitary and metachronous metastases from gastric cancer.However,indications and surgical results for synchronous hepatic metastases from gastric carcinoma have not been clearly defined.This study was performed to assess the benefits and limits of simultaneous combined resection of both primary gastric cancer and synchronous hepatic metastases,as well as to identify prognostic factors affecting the survival.Methods Between January 2005 and June 2008,13 patients with synchronous hepatic metastases underwent simultaneous combined resection.The clinicopathologic features and the surgical results of the 13 patients were retrospectively analyzed.Patient,tumor (primary and metastatic carcinoma),and operative parameters were analyzed for their influence on survival.Results No patient died and two patients (15.4％) developed complications during peri-operative course.The actuarial 6-month,1-year,and 2-year survival rates after hepatic resection were 76.9％,38.5％,and 30.8％,respectively,and two patients survived for more than 2 years after surgery without any signs of recurrences until latest follow-up.In univariate analysis,hepatic tumor distribution (P=0.01) and number of hepatic metastases (P=0.003) were significant prognostic factors that influenced survival.Factors associated with the primary lesion were not significant prognostic factors.Conclusions Satisfactory survival may be achieved by simultaneous combined resection of both primary gastric cancer and synchronous hepatic metastases in strictly selected patients.The number of hepatic metastases and hepatic tumor distribution are significant prognostic determinants of survival。

Abstract：Background Gallbladder carcinoma (GBC) is a commonly-seen malignancy of the biliary tract characterized by difficult early diagnosis,rapid growth,early metastasis,and poor prognosis.Nearly half of GBC patients also have jaundice,which is a mark of the advanced stage of GBC.The role of radical resection in patients of gallbladder carcinoma with jaundice is still a matter of uncertainty,which we attempted to clarify in this study.Methods Totally,251 GBC patients who received treatment at the Eastern Hepatobiliary Surgery Hospital (EHBH) from December 2002 to January 2010 were recruited into this study.We divided them into group A (jaundice group,n=117) and group B (non-jaundice group,n=134).Clinical records and follow-up data were collected and retrospectively analyzed in both groups.Results Compared with group A,patients in group B had a longer median survival time ((6.0±0.5) months vs.(15.0±2.6) months,P＜0.01).Even in patients with stage Ⅲ or stage Ⅳ GBC,the median survival time in patients without jaundice (n=111),was still longer than that in patients with jaundice (n=116) (P ＜0.01).The radical resection rate was lower in group A patients than in group B patients with stage Ⅲ or stage Ⅳ GBC; 31.9％ vs.63.1％.However,the median survival time of patients undergoing radical resection did not show a statistical difference between jaundice patients and non-jaundice patients; (12.0±4.3) months vs.(18.0±3.0) months (P ＞0.05).Conclusions GBC with jaundice usually implies advanced stage disease and a poor prognosis for the patients.However,our findings indicate that as long as the patient's condition allows,radical resection is still feasible for GBC patients with jaundice,and may achieve a prognosis close to those GBC patients without jaundice。

Abstract：Background Gastric cancer (GC) is one of the most common types of cancer in the world.A change in the metabolism of lipids in tumor cells could lead to the pathogenesis of cancer.In this study,we investigated fatty acid and fatty acid amide metabolic perturbations associated with GC morbidity.Methods Gas chromatography/mass spectrometry (GC/MS) was utilized to analyze fatty acids (FAs) and fatty acid amides (FAAs) of GC tissues and matched normal mucosae from 30 GC patients.Acquired lipid data was analyzed using non parametric Wilcoxon rank sum test to find the differential biomarkers for GC and diagnostic models for GC were established by using orthogonal partial least squares discriminant analysis (OPLS-DA).Results A total of 13 FAs and 4 FAAs were detected using GC/MS and 5 differential FAs as well as oleamide were identified with significant difference (P ＜0.05).The OPLS-DA model generated from lipid profile showed adequate discrimination of GC tissues from normal mucosae while the OPLS-DA model failed to separate GC specimens of different TNM stages.A total of 8 variables were obtained for their most contribution in the discriminating model (Variable importance in the projection (VIP) value ＞1.0),five of which were detected with significant difference (P＜0.05).Conclusions FA and FAA metabolic profiles have great potential in detecting GC and helping understand perturbations of lipid metabolism associated with GC morbidity。

Abstract：Background Three randomised trials have demonstrated that combining bevacizumab with first-line chemotherapy significantly improves progression-free survival versus chemotherapy alone in HER2-negative locally recurrent/metastatic breast cancer (LR/mBC).However,data from Chinese populations are limited and possible differences between ethnic and geographic populations are unknown.This study was conducted to determine whether there are differences in safety and efficacy in patients with HER2-negative LR/mRC between Chinese and Western populations after they receive first-line bevacizumab combined with taxane-based therapy.Methods In the single-arm,open-label,Avastin Therapy for Advanced Breast Cancer (ATHENA) study (NCT00448591),patients with H ER2-negative LR/mBC received first-line bevacizumab (investigator's choice of 10 mg/kg every 2 weeks or 15 mg/kg every 3 weeks) combined with taxane-based therapy.The primary endpoint was safety profile and the secondary is time to progression (TTP).A subpopulation analysis was conducted to assess safety and efficacy in Chinese patients.Results Of 2264 patients treated in ATHENA,202 were enrolled in China.Bevacizumab was combined with docetaxel in 90％ of Chinese patients and paclitaxel in 10％.The most common grade 3/4 adverse events were diarrhoea (in 5.0％ of patients) and hypertension (in 2.5％ of patients).Grade 3/4 proteinuria occurred in 0.5％.After median follow-up of 17.6 months and events in 56％ of patients,median TTP was 9.0 months (95％C/,8.4-11.1).Overall survival data were immature.Conclusions We found no evidence of increased bevacizumab-related toxicity or reduced efficacy in Chinese LR/mBC patients receiving first-line bevacizumab-taxane therapy compared with predominantly Western populations.The safety profile was generally similar to previously reported LR/mBC trials.Subtle differences may be attributable to different lifestyle and cardiovascular risk factors in Chinese patients compared with the overall population.It appears reasonable to extrapolate findings from bevacizumab-based randomised trials to Chinese populations。

Abstract：Background Assessment of lymph node metastasis (LNM) is important in early gastric cancer (EGC) and affects treatment decisions.However,the relationship between clinicopathological characteristics and LNM in EGC remains unclear.This study therefore explored favorable predictors of LNM in EGC.Methods A total of 716 specimens from gastric cancer patients who underwent curative gastrectomy between 1996 and 2003 at Zhejiang Provincial People's Hospital were reviewed.Forty-five cases were EGC,and clinicopathological characteristics such as gender,age,tumor size,location,gross type,differentiation,invasion depth,and vessel involvement were assessed to identify predictive factors for LNM and survival time.Results The overall cumulative 5-year survival rate of EGC patients was 88.92％.Among these,22.4％ developed LNM,which was associated with a poor 5-year survival rate of only 72.7％.Patients with tumors larger than 2 cm in diameters,with depth of tumor invasion to the submucosa,and with positive lymphatic or nerve involvement were also inclined to have poorer survival performances.EGC limited to the mucosa but poorly differentiated also had a high risk for LNM.Multivariate analysis identified lymphatic invasion and tumor size as independent prognosis factors related to survival in EGC patients.Conclusions Careful planning is required in EGC patients at high risk of lymph node metastases.Endoscopic mucosal resection or endoscopic submucosal dissection and laparoscopic partial gastrectomy should be cautiously used in EGC,and curative gastrectomy including lymphatic dissection and postoperative adjuvant therapy might be considered to improve the prognosis。

Abstract：Background Treatment option for metastatic breast cancer (MBC) patients pre-treated with chemotherapy is limited.Oral etoposide has shown some promises in these patients.However,patients who received heavy prior chemotherapy may have poor tolerance to prolonged oral etoposide exposure.This study is a single-arm clinical trial that evaluates the efficacy and safety of short-term oral etoposide in Chinese patients with MBC who had received heavy prior therapy.Methods MBC patients receiving at least two chemotherapy regimens prior to the enrollment were treated with repeated cycles of oral etoposide (60 mg.m-2.d-1 on days 1-10,followed by 11 days of rest).The primary end point was the progression free survival (PFS).The secondary end points were objective response rate (ORR),clinical benefit rate (CBR),overall survival (OS),and toxicity profiles.Results Thirty-two patients received 230 cycles of oral etoposide with a median of 6 cycles (range,2-20 cycles) per patient.Eight patients (25％) had partial response (PR) and 14 patients achieved stable disease (SD).The ORR was 25％.Nine patients achieved SD for more than 24 weeks and CBR was 53％.The median PFS and OS were 5 (range,1.5-17.0 months) and 16 months (range,3.0-51.0 months),respectively.The patients who achieved clinical benefit had longer survival time than those who did not (25.0 versus 11.0 months,P ＜0.01).Among the 16 patients who received more than four regimens prior to this study,four patients achieved PR and four achieved SD for more than 24 weeks,with a CBR of 50％.The most common hematologic adverse events were anemia (43.8％) and neutropenia (38.5％).Nausea/vomiting (75.0％) and alopecia (62.5％) were the most frequent non-hematologic toxicities.Conclusion Oral etoposide is effective and well tolerated in Chinese women with heavily pretreated MBC。

Abstract：Background Pre-operative chemotherapy has gained widespread interest while treating advanced gastric cancer in eastern countries.However,there is currently no established standard regimen for gastric cancer.The aim of this research was to explore the value of preoperative chemotherapy with a combination of intravenous and intra-arterial intensified chemotherapy in advanced gastric cancer.Methods A total of 56 histologically proven gastric cancer patients,who were considered to be stage Ⅱ or higher with metastatic lymph nodes and with or without distant metastasis (T2-4,N1-3,and M0-1),were treated with a neoadjuvant chemotherapy.Patients received a combination of intravenous 5-Fu (370 mg/m2) and leucovorin (200 mg/m2) on days 1-5,and intra-arterial etoposide (80 mg/m2) and cisplatin (80 mg/m2) on days 6 and 20.After two cycles of preoperative chemotherapy,patients with resectable tumors underwent laparotomy.Results All patients finished two cycles of chemotherapy.The overall response rate was 78.57％ (44 cases),of which 7.14％ (four cases) clinical complete response.Forty-six patients underwent resection,including 21 initially unresectable diseases.R0 resection rate for prechemotherapy resectable and unresectable diseases was 96.15％ (25/26 cases) and 66.67％ (20/30 cases),respectively.Pathological complete response was observed in 8.70％ of patients.Toxicity was moderate and there were no chemotherapy-related deaths.With a median follow-up of 31 months (range 6-76 months),the 5-year survival rate for the whole group and patients with initially resectable tumors were 21.8％ and 42.3％,respectively.The median survival for initially resectable and unresectable patients were 41 months (95％CI,31.006-50.994) and 18 months (95％CI,13.399-22.601; P ＜0.01),respectively.Conclusion Preliminary results proved that the combined intensive chemotherapy was a safe and promising regimen for pre-operative treatment of advanced gastric cancer。

To the Editor:Propofol,a gamma-aminobutyric acid (GABA)-mediated inhibitor of excitatory neurotransmitter,is a popular intraveneous agent for gastrointestinal endoscopy sedation in past few years.Propofol is a rapid and short-acting anesthetic because of its high lipid solubility.In this letter,we report a case of propofol-induced seizures after endoscopic procetures。

Abstract：Background Integrin-linked kinase (ILK) dysregulation is involved in the progression of diabetic nephropathy (DN).The aim of this study was to investigate the effects of angiotensin Ⅱ receptor blocker (ARB),irbesartan,on ILK expression and podocyte injury in DN.Methods DN was induced by the combined feeding of high-sucrose,high-fat diet and intra-peritoneal injection of low dose of streptozotocin (35 mg/kg) in spontaneously hypertensive rats.Diabetic rats were treated with irbesartan (50 mg·kg-1·d-1) by gavage for 8 weeks.The renal morphologic changes and podocyte injury were investigated by light and electron microscopy,and the ILK expression was evaluated by real-time RT-PCR and Western blotting analysis.Results Diabetic rats exhibited with the similar clinical feature of type 2 DN.Morphologically,they were characterized by expansion of mesangial matrix,loss of podocyte and podocyte injury.Impressively,compared to controls,the ILK expression in diabetic rats were upregulated,which were positively correlated with both podocyte injury and albuminuria.Irbesartan significantly prevented ILK overexpression,along with the amelioration of podocyte injury and albuminuria.Conclusions ILK plays an important role in mediating podocyte injury in DN; irbesartan inhibits ILK upregulation and attenuates podocyte injury,which might offer a new insight into the role of ARB in preventing DN progression。

Abstract：Objective Robot-assisted endoscopic surgery has been increasingly accepted because of its unique three-dimensional vision and precise simulation-based technology.However,the utilization of robotic systems in thyroid surgery is limited.We conducted a systematic review to assess the application and development of robot-assisted endoscopic surgical technique in thyroid surgery.Data sources Articles published in PubMed before June,2011 about robot-assisted endoscopic surgery were selected.Study selection Original articles and critical reviews selected were related to robot-assisted (thyroid) surgery or endoscopic thyroid surgery,and a total of 3540 relevant articles were retrieved and 34 were finally cited.Results Robot-assisted operation of benign thyroid diseases were successfully performed,although the operation time is too long to exhibit its advantages.Nevertheless,the superiority of robot-assisted endoscopic surgical technique compared to conventional endoscopic surgery in the treatment of thyroid carcinoma were obvious,since robotic radical thyroidectomy with central and lateral neck lymph node dissection could be achieved while maintaining operative results and cosmetic outcomes equivalent to or better than conventional endoscopic surgery.Furthermore,the learning curve duration of robot-assisted endoscopic thyroid surgery was shorter than that of conventional endoscopy,especially for the novices without any endoscopic surgical basis.Conclusion Robot-assisted endoscopic thyroid surgery,with its safety,feasibility,thoroughness,cosmetic benefits,and ability to overcome the limitations of conventional endoscopic surgery,will be further improved and applied,and is worthy of attention。

Abstract：Background Primary Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET) of urogenital tract is a rare condition with non-specific clinical presentations,which can make it difficult to diagnose.In this study,we summarize the clinical presentation,pathological features,therapeutic strategies,and prognosis of ES/PNET.Methods Clinical information on two cases of ES/PNET in the penis and ureter was analyzed,and relevant literature was reviewed.Results ES/PNET was confirmed pathologically,immunohistochemically and via molecular biology techniques in the penis (n=1) and ureter (n=1).In one case,a tumor was found at the base of penis,which had invaded the corpus cavernosum,and resulted in a massive enlargement of the penis.This tumor was initially diagnosed as an endocrine disorder.However,a confirmed diagnosis was made 11 months later when massive metastases in both lungs were noted.A tumor biopsy was performed to confirm the diagnosis,and chemotherapy with a CAV (cyclophosphamide+doxorubicin+vincristine) + IE (ifosfamide+ etoposide) regimen for 9 months was prescribed.In the second case,a child was admitted due to abdominal pain and a hydroureter in the right kidney,as determined by ultrasonography.A tumor was found in the right ureter at the level of iiiac vessels.Removal of the tumor and ureteral anastomosis were performed,and chemotherapy with CAV+IE for 8 months were prescribed.Both patients are currently being followed-up closely.Conclusions ES/PNET is a highly malignant tumor and has poor prognosis.Pre-operative diagnosis of ES/PNET of urogenital tract is difficult and largely depends on pathology,immunohistochemistry,and,if applicable,molecular biology.Comprehensive therapy may include surgery,chemotherapy and radiotherapy。

Abstract：Klinefelter's syndrome (KS) is the most common sex chromosome disease in men.Classical features of the syndrome include a eunuchoidal body habitus,small testes and hypergonadotrophic hypogonadism.There has been an increased risk of diabetes mellitus and autoimmune disease for KS patients.This paper reports a case of KS in association with type 1 diabetes mellitus.The patient was a 21-year-old man,who has been confirmed by absolute insulin deficiency and positive IA-2 autoantibody.The hyperinsulinemic euglycemic clamp test indicated his insulin sensitivity in normal range,and his blood glucose was controlled well by the insulin therapy。

Abstract：The present report demonstrates two cases of transient inferior ST-segment elevation accompanied by profound hypotension and bradycardia immediately after transseptal puncture for catheter ablation of atrial fibrillation.This rare complication of transseptal puncture was resolved quickly within several minutes.The most likely mechanism of this phenomenon is coronary vasospasm,although coronary embolism can not be ruled out completely.This complication is characterized as follows:(1) The right coronary artery might be the most likely involved vessel and therefore myocardial ischemia usually occurs in the inferior wall of left ventricular; (2) Reflex hypotension and bradycardia by the Bezold-Jarisch reflex secondary to inferior ischemia often occur at the same time.Though it appears to be a transient and completely reversible phenomenon,there are still potential life-threatening risks because of myocardial ischemia and profound haemodynamic instability.Clinical cardiologists should be aware of this rare complication and properly deal with it。

Abstract：Classical angiomyolipomas are benign tumors composed of various tissues,including fat,abnormal blood vessels and smooth muscle cells.The present study reports a male patient affected by mediastinal angiomyolipomas with massive chvlous pleural effusion.The tumors were characterized with histological and immunohistochemical methods。

Abstract：Both human hereditary spherocytosis (HS) and chronic myelogenous leukemia (CML) are life threatening.Herein we have reported the case of a woman with a combined disorder of HS and CML who underwent the matched sibling allogeneic stem cell transplantation.The complete donor erythroid cells were obtained.The red blood cell counts significantly improved throughout life comparing with pre-hematopoietic stem cell transplantation (HSCT).Reticulocyte counts normalized,and BCR-ABL was cleared away.The total bilirubin level was also corrected in this recipient.Our case is a rare example with a combined disorder of HS and CML following allogeneic stem cell transplantation.HS was not a contraindication for patient in the matched sibling transplant setting。

Abstract：Varicella is a self-limited disease,but sometimes it may be associated with some serious life-threatening complications.Necrotizing fasciitis is a rare complication of varicella.This is a case of a 7-year-old girl with septic shock caused'by necrotizing fasciitis as a complication of varicella.Swelling and pain in the left inguinal region and left axillary region were found five days after varicella.Then a high fever occurred followed by hypotension.Fluid infusion,vasopressor and antibiotics were administered.Group A beta-hemolytic Streptococcus was isolated from exudates from the wounds.The clinical symptoms markedly improved after surgical drainage and removal of the necrotic tissue.Both wounds were covered with skin grafts after healthy granulation tissue formed.Although there have been few reports of life-threatening necrotizing fasciitis following varicella in western countries,it is rare in China.Usually patients with varicella were admitted to pediatric or infectious disease department but not surgical departments; so that the clinicians should be aware that varicella may be complicated by life-threatening surgical infections.Necrotizing fasciitis should be suspected in patients of varicella who showed an increasing pain and swelling in any body areas associated with increasing fever and local erythema.Early identification,surgical drainage and debridement are essential for successful treatment of necrotizing fasciitis。

Abstract：Recently,we treated a patient with pulmonary vein sarcoma.The patient was a 41-year-old woman,had cough,short of breath and apsychia,with obvious jugular venous distention,rales in both lungs and a diastolic murmur at the apex.CT and Echo revealed a tumor in the left atrium.She received an emergency surgery to remove the mass in the heart.The pathological diagnosis demonstrated it as leiomyosarcoma.Though the patient accepted radiotherapy and chemotherapy,she still died of recurrence and metastasis of the sarcoma 10 months after operation。

Abstract：A 90-year-old Chinese man was transferred to the Emergency Department of the Affiliated Shantou Hospital of Sun Yat-sen University for treatment of an acute myocardial infarction.He suffered chest pain with three days of cough,dyspnea and fever.A diagnosis of Takotsubo cardiomyopathy was made in normal coronary arteries from urgent coronary angiography and characteristic apical dyskinesis and basal hyper contractility in left ventriculography.The patient died from severe multi-organ failure on the second day of hospitalization。