2012年 · 第125卷第14期

Abstract：Background The use of transanastomotic stents for Roux-en-Y hepatojejunostomy (RYHJ) in liver transplantation (LT)remains controversial.The aim of this retrospective study was to assess the role of transanastomotic stent for RYHJ in LT.Methods RYHJ for biliary reconstruction in LT was performed in 52 patients.Twenty-five patients had bile duct reconstruction by RYHJ with transanastomotic stents (S group),while 27 patients underwent the same procedure without transanastomotic stents (non-S group).The two groups were compared in terms of post-LT biliary complications and survival.Results The incidences of bile leakage,anastomotic stricture,non-anastomotic stricture,biliary sludge/lithiasis and biliary infection were 12％ (3/25),9.5％ (2/21),23.5％ (4/17),11.8％ (2/17),and 24％ (6/25),respectively in the S group,and 0,0,20.0％ (5/25),10.0％ (2/20),and 16.7％ (4/24),respectively in the non-S group.One and three year survival rates were 48.0％ (12/25) and 34.0％ (8/23),respectively,in the S group and 57.7％ (15/26) and 38.9％ (7/18),respectively,in the non-S group.There was no significant difference between the two groups in terms of the incidence of various biliary complications and survival (P ＞0.05).Conclusion The routine use of transanastomotic stents is not necessary for RYHJ for biliary reconstruction in LT。

Abstract：Background Liver transplantation is the most effective treatment for patients with end-stage liver failure,however infection after transplantation is a serious clinical complication.The purpose of this research was to investigate the molecular epidemiology and the influence of multidrug-resistant Gram-positive infection in patients,following liver transplantation,to provide reference for clinical treatment and prevention of Gram-positive bacterial infection.Methods We isolated and detected bacteria from phlegm,throat swabs,urine,wound or wound secretions,blood,and fecal samples from 221 liver transplant patients in our hospital from January 2007 to April 2010.All isolated bacterial strains were identified and tested by minimal inhibitory concentration (MIC) drug-sensitive detection using the BioMerieux ATB bacterial identification instrument and repetitive extragenic palindromic-polymerase chain reaction (REP-PCR)detection of bacterial homology.Risk factors were calculated by multivariate Logistic regression analysis.Results We collected 250 specimens from 221 patients hospitalized following liver transplantation surgery,of which 29patients developed multiple infections.Sixty-five Gram-positive bacterial strains were isolated from different specimens from 53 infectious patients.We detected 29 multidrug-resistant Gram-positive strains from 29 patients (44.62％),including 20 Staphylococcus aureus (S.aureus) strains (68.97％) and nine Enterococcus strains (31.03％).All 20 S.aureus strains were highly resistant to aminoglycosides (gentamicin),cephalosporins (cefoxitin),quinolones (ciprofloxacin and levofloxacin),lincomycins (clindamycin),penicillin,and erythromycin.The resistance rate reached 100％ in some cases.The S.aureus strains were highly sensitive to vancomycin and oxazolidinone (linezolid),with MIC50 ＜2 μg/ml for both.The nine Enterococci strains were also highly resistant to aminoglycosides,quinolones,and penicillins,and highly sensitive to vancomycin (MIC50 ＜2 μg/ml) and oxazolidinone (MIC50 ＜1μg/ml).Using REP-PCR detection,S.aureus was divided into five genotypes with 14 B-type strains.Enterococcus was divided into 11 genotypes,with two D-type strains,two G-type strains,and two K-type strains.The risk factors for Gram-positive bacterial infection in patients following liver transplantation were preoperative use of antibiotics (OR=3.949,P=0.004),high intra-operative blood input (OR=1.071,P=0.005),and postoperative renal failure (OR=5.427,P=0.043).Conclusions S.aureus and Enterococcus were the main pathogens causing infection following liver transplantation in patients with drug-resistant Gram-positive bacterial infection.The isolated strains were resistant to multiple antibiotics.B-type S.aureus strains were predominant.Reasonable use of antibiotics,decreasing intra-operative blood input,and preventing post-operative renal failure may reduce Gram-positive bacterial infections and the appearance of drug-resistant strains following liver transplantation。

Abstract：Background With the increase of survival in liver transplantation recipients,more patients are at a high risk of developing osteonecrosis,especially in the femoral head,due to immunosuppressive treatment.The purpose of this study was to report the incidence,possible risk factors,and outcome of symptomatic osteonecrosis of the femoral head (ONFH) in adult patients with current immunosuppressive agents and individual protocol after liver transplantation in China.Methods A ratrospective analysis was performed on 226 adult patients who underwent orthotopic liver transplantation (OLT) at a single liver transplantation institution between January 2004 and December 2008.The posttransplant survival time (or pre-retransplantation survival time) of all the patients were more than 24 months.The possible pre- and post-transplantation risk factors of symptomatic ONFH were investigated and the curative effects of the treatment were also reported.Results The incidence of ONFH was 1.33％ in patients after OLT.ONFH occurred at a mean of (14±6) months (range,10-21 months) after transplantation.Male patients more often presented with osteonecrosis as a complication than female patients.The patients with lower pre-transplantation total bilirubin and direct bilirubin levels (P ＜0.05).There was no difference in the cumulative dose of corticosteroids or tacrolimus between the patients with or without symptomatic ONFH.Patients were treated either pharmacologically or surgically.All patients showed a nice curative effect without major complications during the 18-63 months post-treatment follow up.Conclusions The symptomatic ONFH does not occur commonly after adult OLT in the current individual immunosuppressive protocol in China。

Abstract：Background Primary liver cancer (PLC) is a common malignant tumor.Over the past decade,although farnesyltransferase (FTase) has emerged as a significant target for anticancer therapies and has become a hotspot of cancer research,its exact mechanism of action remains unknown.The aim of this study was to investigate the expression of FTase in PLC and its role in the development of PLC.Methods Expression of FTase was detected by real-time fluorescent quantitative-polymerase chain reaction (FQ-PCR)in cancer and surrounding normal tissues from 32 patients with PLC.Results Expression of FTase mRNA in PLC was significantly higher than that in normal hepatic tissues (P ＜0.001).Overexpression of FTase was as high as 87.5％.The positive rate for FTase mRNA in the high tendency to metastatic recurrence group was obviously higher than that in the low tendency to metastatic recurrence group (P=0.02).The positive rate for FTase mRNA in patients with metastatic recurrence during postoperative follow-up was also significantly higher than that in those without metastatic recurrence (P=0.01).Conclusions The level of FTase mRNA expression in cancer tissues is much higher than in normal tissues.FTase may play an important role in the genesis and development of PLC and may be one of the reliable markers for the metastatic activity gained by liver tumor cells.FTase could be used clinically in predicting metastatic recurrence of PLC。

Abstract：Background Studies on postoperative cognitive dysfunction (POCD) have attracted extensive attention and achieved significant progress.However,the diagnosis of POCD is not very satisfactory as no specific biomarkers have been classified.The aim of the present study was to evaluate differences in serum protein composition between POCD and Non-POCD patients,identify potential biomarkers associated with early POCD,and study the mechanism underlying POCD.Methods Sixty-eight elderly patients (age ≥65 years) received isoflurane inhalation anesthesia for arthroplasty surgeries.One day before and seven days after the surgery,these patients were subjected to a neuropsychological test and venous blood sample collection.Postoperative cognitive dysfunction was determined using Z test scores.Based on the results,the patients were divided into POCD and non-POCD groups.Twenty-five randomly chosen blood samples obtained seven days after the surgery from each group were analyzed on a Bruker ultraFlexTM time of flight (TOF)/TOF mass spectrophotometer.The resulting peptide fingerprints were compared with those from the pre-surgery samples to identify differences in serum protein composition.The model designed to distinguish between a non-POCD group and a POCD group were established and validated.Three proteins with the most significant changes were selected for further characterization.Results Thirty-three cases were diagnosed as POCD.Using the Clinprotools software,58 polypeptides were found to display differential expression (P＜0.05).Using a support vector algorithm method,seven differential peaks were isolated to establish a diagnostic model to distinguish POCD patients from normal individuals.The prediction rate and recognition rate were 96.89％ and 100％,respectively.Validation of this model showed that the accuracy rates were 100％ and 85％using samples from the POCD and non-POCD groups,respectively.Protein analysis also led to the identification of fibrinopeptide A (FPA) as a potential biomarker for POCD.Conclusions Arthroplastic surgery under isoflurane inhalation anesthesia causes differential serum protein expression in elderly patients.These differentially expressed proteins may contribute to the diagnosis of early POCD,which may provide a basis for identifying the underlying mechanism of POCD development。

Abstract：Background Invasive cancer of the cervix is considered a preventable disease because it has a long pre-invasive state,cervical cytology screening programs are currently available,and treatment of pre-invasive lesions is effective.We tested the accuracy of frozen section examination (FSE) of cone specimens to identify the endocervical margin and rule out invasion in patients with high-grade cervical intraepithelial neoplasia (CIN).Methods For 320 consecutive patients with a preoperative biopsy result of CIN stage 2/3,cold-knife conization (CKC)was performed followed by FSE.The results from analyses of permanent paraffin sections (PS) were compared with the FSE findings.Results The accuracy of FSE was 87％ (278/320).For all of the seven patients with an invasive squamous cell carcinoma of the cervix identified by FSE,the diagnosis was confirmed by PS analysis.For one patient,the FSE result was cervicitis,whereas PS ananlysis showed microinvasive carcinoma.Appropriate surgery was performed for all patients based on the FSE and biopsy results.The FSE and PS results were not significantly different (P=0.000).Definitive examination of margin status using PS was concordant with FSE findings in all cases.Conclusions FSE is a rapid and reliable method for evaluating CKC specimens.It can identify frank invasion,permit adequate treatment in a one-stage procedure,and reliably detect clear resection margins.Since discrepancies do exist and may result in inappropriate treatment,further research is required to decrease these discrepancies and avoid missing even one case。

Abstract：Background Anxiety appears to be more common in patients with coronary artery disease (CHD) than in the general population,and anxiety symptoms may precede onset of CHD and play an important role in development of CHD.Little is known about the prevalence of anxiety symptoms in Chinese patients with premature ventricular contractions (PVCs).Our objective was to study anxiety symptoms and potential risk factors in a Chinese population with PVCs but without structural heart disease.Methods The Zung self-rating anxiety scale (ZSAS) was used to assess anxiety symptoms.Correlation between anxiety symptoms and socio-demographics and medical factors were analyzed by Logistic regression.Results Of 1144 patients with PVCs (487 males and 657 females),age (53±23) years old,disease duration 1 month to 24 years,a total of 381 (33.3％) patients were categorized as having anxiety symptoms.Anxiety symptoms increased with age,low income,low education level,nationality,PVC count/24 hours,bad social support,village settlement type (P＜0.05).Multivariate Logistic regression indicated that six variables—education level,ethnic minorities,dwelling place,age,PVC count/24 hours,and social support—significantly and independently related with anxiety symptoms (P＜0.05).Conclusions In the Chinese population,anxiety symptoms in subjects with PVCs were frequent.Education level,ethnic minorities,dwelling place,age,PVC count/24 hours,and social support were independent risk factors for anxiety symptoms.Further research on the relationship between PVCs and anxiety symptoms in China is necessary。

Abstract：Background The plasma cystatin C concentration (PcyC) has been demonstrated to have prognostic value in acute coronary syndrome,but the study of PcyC in patients with borderline coronary lesions is limited.Moreover,the effects of atorvastatin and probucol on PcyC and the severity of coronary lesions are unknown.This study was to evaluate the effects of the combination of atorvastatin and probucol on PcyC and severity of coronary lesion in patients with borderline coronary lesions.Methods One hundred and thirty consecutive patients with borderline coronary lesions (40％ to 60％ isolated single stenosis assessed by quantitative coronary angiography) were enrolled into the borderline coronary lesion (BCL) group,and one hundred and thirty-six subjects without coronary lesions comprised the controls (CTR).The subjects in the BCL group were randomized into routine treatment (RTT,n=60),and combined treatment with atorvastatin 20 mg plus probucol 1.0 g daily added to routine medication (CBT,n=70),both groups were treated for 6 months continuously.The levels of PcyC,high-sensitive C-reactive protein (hs-CRP),total cholesterol (TC),low-density lipoprotein cholesterol (LDL-C),high-density lipoprotein cholesterol(HDL-C),and triglycerides (TG) were determined.One hundred and four subjects in the BCL group were rechecked by coronary angiography.Results PcyC levels were significantly higher in the BCL group than in the CTR group;(2003.26±825.73) ng/ml vs.(1897.83±664.46) ng/ml (P＜0.01).Compared with patients in the RTT group,the levels of PcyC,TC,LDL-C,TG and hs-CRP were significantly lower in the CBT group (P＜0.05).Moreover,there was a trend towards a slight decrease in the RTT patients,(54.38±10.67)％ vs.(50.29±9.89)％ (P ＞0.05),and a significant decrease in the CBT patients,(53.65±9.48％) vs.(40.38±12.93)％ (P＜0.05),in the mean percent stenosis of borderline coronary lesions before and after six months of treatment.Conclusions Cystatin C played an important role in the development of coronary artery disease,and was associated with the severity of coronary lesions.The combination of atorvastatin and probucol decreased PcyC levels,and could be the treatment of choice。

Abstract：Background Systemic lupus erythematosus (SLE) mostly occurred in young women.This study was undertaken to investigate the different clinical characteristics of SLE between male and female patients,and to identify the sex hormone levels and clinical outcomes of different gender in SLE patients.Methods Of the 516 SLE patients admitted to the Peking University People's Hospital from January 2008 to December 2010,58 were male and 458 were female.Clinical manifestations,laboratory profiles and disease activity scores were evaluated in male and female patients.Sex hormones levels were also compared among male patients.Results The median age at SLE onset in male and female patients was 27.2 and 28.6 years,respectively.Compared with female patients,at onset of SLE,male patients showed higher rates of serious renal disease (58.6％ vs.47.2％,P=0.064),neuropsychiatric SLE (20.7％ vs.12.0％,P=0.055),and a higher incidence of anti-ds-DNA (25.9％ vs.16.8％,P=0.069),anti-Sm (17.2％ vs.8.7％,P=0.002),anti-Ro (46.6％ vs.28.4％,,P=0.004),anti-U1RNP (29.3％ vs.15.3％,P=0.010),anticardiolipin antibody (25.9％ vs.11.4％,P=0.004),and decreased C3 levels (67.2％ vs.49.8％,P=0.009).Systemic lupus erythematosus disease activity index (SLEDAI) scores were higher in men than in women (16.8 vs.12.8,P=0.038).Of the 58 male patients,24 had not received aggressive treatment during the three months prior to the study.Levels of testosterone and dihydroepiandrosterone (DHEA) were lower in male SLE patients than in male healthy controls (P=0.004 and P=0.006,respectively).Low serum testosterone was an independent risk factor for the development of lupus nephritis (P=0.043).Male patients with elevated serum prolactin were at increased risk of developing neuropsychiatric manifestations of SLE (P=0.081).Conclusion Early recognition of risk factors and appropriate intervention are essential,which might lead to high disease activity and serious systemic damage in male SLE patients。

Abstract：Background Brachial plexus injury is one of the difficult medical problems in the world.The aim of this study was to observe the clinical therapeutic effect of comprehensive rehabilitation in treating dysfunction after brachial plexus injury.Methods Forty-three cases of dysfunction after brachial plexus injury were divided into two groups randomly.The treatment group,which totaled 21 patients (including 14 cases of total brachial plexus injury and seven cases of branch brachial plexus injury),was treated with comprehensive rehabilitation including transcutaneous electrical nerve stimulation,mid-frequency electrotherapy,Tuina therapy,and occupational therapy.The control group,which totaled 22patients (including 16 cases of total brachial plexus injury and six cases of branch brachial plexus injury),was treated with home-based electrical nerve stimulation and occupational therapy.Each course was of 30 days duration and the patients received four courses totally.After four courses,the rehabilitation effect was evaluated according to the brachial plexus function evaluation standard and electromyogram (EMG) assessment.Results In the treatment group,there was significant difference in the scores of brachial plexus function pre- and post-treatment (P ＜0.01 ) in both "total" and "branch" injury.The scores of two "total injury" groups had statistical differences (P ＜0.01),while the scores of two "branch injury" groups had statistical differences (P＜0.05) after four courses.EMG suggested that the.appearance of regeneration potentials of the recipient nerves in the treatment group was earlier than the control group and had significant differences (P ＜0.05).Conclusion Comprehensive rehabilitation was more effective in treating dysfunction after brachial plexus injury thannonintegrated rehabilitation。

Abstract：Background There is little information of non-perianal fistulating Crohn's disease in the consensus published by the European Crohn's and Colitis Organization in 2006 and 2010.This study was designed to demonstrate the clinical characteristics of non-perianal fistulating Crohn's disease among homogenous Chinese population.Methods One-hundred-and-eighty-four patients were retrospectively collected.All of these patients were diagnosed of Crohn's disease between February 2001 and April 2011.Results The male-to-female ratio was 2.7:1.The most common symptoms at onset were abdominal pain (88.0％),diarrhea (34.7％),and fever (28.3％).The most common disease location and behavior at diagnosis were small bowel (56.0％) and penetrating (51.6％).Among 324 non-perianal fistulae,the most common types were ileocolonic anastomotic (30.9％),terminal ileocutaneous (19.7％),and enteroenteric anastomotic (11.4％).One-hundred-and-thirty-eight (75.0％) patients received antibiotics,and β-lactam (85.5％) and metronidazole (67.4％) are most frequently used.One-hundred-and-seventy-eight (96.7％) patients suffered 514 surgical operations,and the cumulative surgical rates after 1,3,and 5 years were 38.0％,52.2％,and 58.7％ respectively.Nine patients died during the follow-up period,and the cumulative survival rates after 1,3,and 5 years were 97.8％,96.7％,and 96.2％ respectively.Conclusions This study displayed the clinical characteristics of non-perianal fistulating Crohn's disease in our center.Large population-based studies are required for further investigation in China。

Abstract：Background A prior study showed significant antibioti resistance to quinotone in our poputation.In this study we aimed to evaluate and compare the efficacy of a single versus a combined prophylactic antibiotic regimen before transrectal ultrasound-guided prostate biopsy(TRUGPB).Methods A prospective randomized study was conducted at a university hospital.Patients undergoing TRUGPB were randomized into an amoicillin-clavulanate alone(1mg;one dose before and two doses after biopsy)or an amoxicllin-clavulanate+ciprofloxacin group(250mg;one dose before and two doses after biopsy).Patients were surveyed for infection symptoms by phine on days 3 and 30 after TRUGPB.We defined an infective complication as the iccurrence of symptoms including fever,chills or rigor within 30 days after prostate biopsy,requiring medical treatment or hospitalization,aided by a tertiory-wide etectronic medical record system.Results Between November 2007 and July 2009,367 patients were randomized to either amoxicillin-clavulanate alone or amoxicillin-caavulanate+ciprofloxacin group.The infection rates after TRUGPB were 3.9％in the former group(7 out of 179 patoents)versus 0.53％(1 out of 188 patients)in the latter.Sixty-three percent(5/8)of patients with infective complications needed hospitalization.There was no intensive care unit admission or mortality during the study period.Conclusions Combining prophylactic antibiotics with amoxicllin-clavulanate+soprofloxacin significantly reduced the in cidence of infective complications after TRUGPB.We recommended a combination regimen,especially in centre with high incidence of post-TRUGPB infection。

Abstract：Background Bladder leiomyoma is an uncommon type of bladder neoplasms.Most publications are reports of isolated cases.The influence of tumor size on patients' early symptoms was seldom analyzed.We aim to investigate the clinical characteristics of bladder leiomyoma and the influence of tumor size on patients' symptoms in Chinese population.Methods We reviewed the medical records of eight patients diagnosed with bladder leiomyoma at our department,collected 53 cases from Chinese National Knowledge Infrastructure (CNKI),Wangfang data base,and Chinese Biological Medicine Disk,and performed a pooled analysis.The clinical characteristics of the patients were analyzed and then classified into symptomatic and asymptomatic groups.The association between tumor size and the occurrence of symptoms was evaluated.Furthermore,Logistic regression model was constructed to discriminate variables.Results Women comprised the majority of the patients (49/61,80.3％ ).The mean age and tumor size were (42.3±14.0)years and (45.0±25.7) mm,respectively.Among all the symptoms,irritative symptoms occurred most frequently (37.7％,23/61 ),followed by obstructive urinary symptoms (31.1％,19/61),hematuria (24.6％,15/61),and abdominal bulge or pain (14.8％,9/61).In our study,patients who were 45 years old or younger tended to be asymptomatic compared with elder ones (14/36 vs.3/25,P=0.021).The histological,as well as anatomical,location of tumor,did not show significant differences between symptomatic and asymptomatic patients (P=0.306 and 0.700).Tumors larger than 30 mm in the greatest diameter would cause clinical symptoms such as obstructive urinary symptoms (P=0.048) and irritative symptoms (P=0.037).Logistic regression confirmed the association between tumor size and the occurrence of symptoms,which was related with age.Conclusions Bladder leiomyoma occurs mainly in women and most frequently with irritative symptoms.The occurrence of symptoms is related to tumor size rather than the location.In this setting,patients with endovesical tumors smaller than 30 mm in the greatest diameter tended to be asymptomatic,which were usually treated with transurethral resection of bladder tumor。

Abstract：Background Hirayama disease is a juvenile muscular atrophy of the distal upper extremities and affects mainly young males.The present study aimed to investigate the neuroelectrophysiological characteristics of Hirayama disease.Methods We retrospectively analyzed the neural conduction velocity (NCV) parameters and needle-electrode electromyograms (EMG) of 14 patients with Hirayama disease.According to the clinical features of the patients,NCV was performed on affected upper-limb including median nerves and ulnar nerves,while EMG was selectively performed on upper and lower extremities,sternocleidomast and thoracic paraspinal muscles.Results The median nerves of all affected upper limbs of patients with Hirayama disease had normal conduction velocities and compound motor action potentials (CMAPs).The ulnar nerves of all affected upper limbs also had normal conduction velocities.Of the 16 measured ulnar nerves of the affected upper limbs,eight had normal CMAPS,while the other eight showed CMAPs below the normal value by ＞20％.All patients had neurogenic injury on the affected side in muscles innervated by anterior horn cells at the lower cervical region (C7-8,T1).Four patients had unilateral upper-limb muscle neurogenic injury on the affected side.Seven patients had bilateral upper-limb muscle neurogenic injury,while only two patients experienced bilateral upper-limb muscle atrophy / weakness.The other three patients showed extensive neurogenic injury (unilateral upper-limb muscle atrophy/weakness in one patient,bilateral symptoms in the other two patients).Conclusions Electromyographic examination showed that the majority of Hirayama disease patients exhibited characteristic segmental injury in the anterior horn of the lower cervical region,while a few patients exhibited extensive neurogenic injury.These data suggest that the actual influence of Hirayama disease may be more extensive than indicated by the clinical presentations。

Abstract：Background The presence of residual tumor after surgery for pituitary adenoma may necessitate further treatment.The suprasellar and parasellar extension of the tumor have been widely considered as the predictors for residual tumor.However there is scarcity of studies regarding the preoperative tumor volume and residual tumor.This study was conducted to evaluate if tumor volume could predict the outcome of transsphenoidal pituitary surgery.Methods A prospective study was designed and 48 patients who underwent transsphenoidal pituitary surgery within 1 year in the First Affiliated Hospital of Xi'an Jiaotong University were included in this study.The preoperative tumor volume and immediate postoperative tumor volume (within 4-7 days) were calculated in the contrast magnetic resonance imaging by using the formula of ellipsoid.All these volumes were divided into three subgroups,i.e.group 1,group 2 and group 3 with preoperative volume of less than 4 cm3,4-8 cm3,and more than 8 cm3 respectively.The parasellar and suprasellar extension of the tumor were also classified by Knosp and modified Hardy's classifications.Results Baseline characteristics were comparable.The preoperative tumor volume of more than 8 cm3 (group 3,(12.1±1.1) cm3) had increased risk on postoperative tumor residue (P＜0.01 ) than the other two groups ((2.1±0.3) cm3and (6.1±0.3) cm3 in groups 1 and 2).The mean postoperative volume in group 3 patients ((2.2±0.1) cm3) was significantly higher than the other two groups (P＜0.01).Conclusion Preoperative volume of more than 8 cm3 can be considered as a predictor for postoperative residual volume。

Abstract：Background In-hospital medical complications are associated with poorer clinical outcomes for stroke patients after disease onset.However,few studies from China have reported the effect of these complications on the mortality of patients with acute ischemic stroke.In this prospective work,the China National Stroke Registry Study,we investigated the effect of medical complications on the case fatality of patients with acute ischemic stroke.Methods From September 2007 to August 2008,we prospectively obtained the data of patients with acute stroke from 132 clinical centers in China.Medical complications,case fatality and other information recorded at baseline,during hospitalisation,and at 3,6,and 12 months after stroke onset.Multivariable Logistic regression was performed to analyze the effect of medical complications on the case fatality of patients with acute ischemic stroke.Results There were 39741 patients screened,14526 patients with acute ischemic stroke recruited,and 11560 ischemic stroke patients without missing data identified during the 12-month follow-up.Of the 11560 ischemic patients,15.8％ (1826)had in-hospital medical complications.The most common complication was pneumonia (1373;11.9％ of patients),followed by urinary tract infection and gastrointestinal bleeding.In comparison with patients without complications,stroke patients with complications had a significantly higher risk of death during their hospitalization,and at 3,6 and 12 months post-stroke.Having any one in-hospital medical complication was an independent risk factor for death in patients with acute ischemic stroke during hospital period (adjusted OR=6.946;95％ CI 5.181 to 9.314),at 3 months (adjusted OR=3.843;95％ Cl 3.221 to 4.584),6 months (adjusted OR=3.492;95％ CI 2.970 to 4.106),and 12 months (adjusted OR=3.511;95％ Cl 3.021 to 4.080).Having multiple complications strongly increased the death risk of patients.Conclusion Short-term and long-term outcomes of acute stroke patients are affected by in-hospital medical complications。

Abstract：Background Autosomal recessive polycystic kidney disease (ARPKD) is a rare inherited disease,which is a disorder with multiple organ involvement,mainly the kidney and liver.It is caused by mutations in the PKHD1 gene.Here,we reported the clinical characteristics of a case with ARPKD and analyze the genetic features of this patient as well as of his father using targeted exome sequencing and Sanger sequencing.Methods Genomic DNA was extracted from peripheral blood leukocytes obtained from a patient with ARPKD.The mutations were identified using exome sequencing and confirmed by Sanger sequencing.Results The patient was diagnosed as ARPKD based on ultrasonography and abdominal computed tomography which showed polycystic changes,multiple calcinosis of both kidneys,and multiple dilated bile ducts of the liver.Compound heterozygous PKHD1 gene mutations A979G and G5935A,which lead to substitution of an asparagine for an aspartate at amino acid 327 (N327D) and a glycine for an arginine at amino acid 1979 (G1979R) respectively,were identified using targeted exome sequencing and confirmed by Sanger sequencing for the patient.In addition,the father of the patient was identified to be a carrier of heterozygous A979G mutation of this gene.Conclusions We identified that the compound heterozygous PKHD1 gene mutations are the molecular basis of the patient with ARPKD.Targeted exome sequencing is suitable for genetic diagnosis of single-gene inherited diseases like ARPKD in which the pathogenic gene is a large。

Abstract：Background Operative decision-making of Pilon fractures are of great challenges until now.The aim of this study was to investigate the guidance of the four-column theory in decision-making therapeutic strategies for Pilon fractures and its result.Methods One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF,were reviewed.According to the four-column classification scheme,lateral column of 85 cases,posterior column of 66 cases,medial column of 77 cases,and anterior column of 61 cases are involved.Among all the 110 cases,single column of 14 cases,two columns of 46 cases,three columns of 17 cases,and all of four columns of 33 cases are involved.Results One hundred and eight cases have been followed up.The average follow up time is 14.7 months,varying between 7 and 52 months.The average healing time is 3.6 months,ranging from 2.5 to 8.0 months.Reduction of 86.1％reviewed Pilon cases are good or acceptable according to Burwell and Charley's Radiology Evaluation System.Ankle function of 87.1％ cases are excellent or good according to the AOFAS evaluation system.Conclusion As a simple and comprehensive classification,the four-column classification can contribute to reasonable oneration decision-making and nood oroonosis of Pilon fracture。

Abstract：Background Routine anteroposterior radiographs of the acromioclavicular (AC) joint with or without weight bearing have limitations in demonstrating the AC joint.Transarticular fixation with Kirschner wire is a treatment choice for AC dislocations.However,percutaneous fixation of the AC joint is technically demanding.The C-arm fluoroscopy can be used as routine intraoperative guidance to facilitate this procedure.The current study aims to introduce new projections,the axial and tangential views of AC joint,to help evaluate the severity of the injury and facilitate the percutaneous procedure.Methods Three shoulder specimens were used to find the projection directions of the axial and tangential views of the AC joint by using the digital radiography (DR) unit.The axial and tangential views were taken of 20 adult volunteers by referencing the projection directions determined in the shoulder specimens.The angles showed on the DR system and the angles between the coronal plane of the body and the vertical plane of the flat panel detector (FPD) during taking these radiographs were recorded.The C-arm fluoroscopy unit was used to take the axial and tangential views referencing the angles measured on the DR system.Routine anteroposterior radiographs of the AC joint were taken on the volunteers.The minimal distances from the distal clavicle to the acromion were measured on both tangential and anteroposterior radiographs.The data was statistically analyzed.Results The clear axial and tangential radiographs of AC joints of the volunteers were obtained using both DR and C-arm fluoroscopy units.The angles demonstrated on the DR window are (20.8±2.4)° for male and (18.3±2.3)° for female.During taking the axial views,the angles between the coronal plane of the body and vertical plane of FPD are (23.3±3.2)° for male and (20.1±2.4)° for female.During taking tangential views,the corresponding angles are (117.5±3.7)° for male and (113.1±3.3)° for female.On the tangential radiographs,the minimal distance from the distal clavicle to the acromion is (6.1±1.2) mm,wider than the same measurement on the anteroposterior radiographs (P＜0.05).Statistical analyses showed no significant differences in the above-mentioned angles and the minimal distancesbetween the left and right AC joints (P ＞0.05).There were no significant differences in the above-mentioned angles between DR and C-arm fluoroscopy units (P＞0.05).Conclusions The axial and tangential radiographs of the AC joint can demonstrate the joint clearly and they can be easily obtained with both DR system and C-arm fluoroscopy unit in similar projection directions。

Abstract：Background Pain is a common post-operative complication.Incidence of pain directly affects patients' quality of life in terms of patient physiology,psychology,and social characteristics.This study was to understand clinical attitudes with regards to Beijing surgeons,and patients' attitude towards pain treatment after orthopedic surgery.Methods A hospital-based cross-sectional and cluster sample survey of 40 hospitals in Beijing was conducted,including 20 level Ⅲ (tier three) and 20 level Ⅱ (tier two) general hospitals.Enrolled subjects completed a specifically designed interview-questionnaire.Results The prevalence of pain 2 weeks post-orthopedic surgery was high in Beijing (96.1％).Meanwhile,collected data indicated most subjects in Beijing suffered moderate to severe pain,45.1％ and 41.4％,respectively,post-surgery.And for the concern of patients before surgery,most subjects chose full recovery from surgery (78.6％),as well as,the pain after operation was 39.2％ ranked the third.According to the data from the study,Tramadol use was more common in Level Ⅲ hospitals,where Somiton was preferred in Level Ⅱ hospitals.When it came to the education of pain before and after operation,more patients get educated before operation than after it,In our study,case physicians or attending physicians enacted education before and after surgery.Related to the sense of patients,among the surgeons preferring post-operative analgesia,67.6％ considered administration when receiving complaints of moderate level pain,50.0％indicated they will terminate analgesic treatment once pain degree scale wise decreases to benign pain.Conclusions The majority of orthopedic patients experience post-operative pain.Identification of post-operative pain will facilitate future awareness on pain treatment and nursing care in Beijing hospitals,with pain relief through regulated improvements in strategic pain management。

Abstract：Background Several studies have evaluated the association between polymorphisms of thymidylate synthase (TS)and cancer risk in diverse populations but with conflicting results.By pooling the relatively small samples in each study,it is possible to evaluate the association using a meta-analysis.Methods A comprehensive search was conducted to identify all case-control studies on TS on a 28-bp tandem repeats in 5′untranslated region (5′UTR) and a 6-bp insertion (ins) and deletion (del) mutation in 3′UTR of the gene and cancer risk.Meta-analysis was conducted using a fixed and random effect model.Results Our meta-analysis on a total of 13307 cancer cases and 18226 control subjects from 37 published case-control studies showed no significant association between the risk of cancer and the 5′UTR 28-bp tandem repeats polymorphism (3R/3R vs.2R/2R:OR=1.06,95％ CI,0.93-1.20) or the 3′UTR 6-bp ins/del polymorphism (del6/del6 vs.ins6/ins6:0R=0.93,95％ CI,0.81-1.08) with significant between-study heterogeneity.In the cancer type- and ethnic subgroup-stratification analyses,we did not find any association between TS polymorphisms and cancer risk either.Conclusion TS 5′UTR 28-bp tandem repeats and 3′UTR 6-bp ins/del polymorphisms may not be associated with cancer risk。

Abstract：Background A number of studies have examined the association between estrogen receptor alpha (ESR-α) gene polymorphisms and bone mineral density (BMD),but previous studies of ESR-α gene Xbal (rs9340799) and Pvull (rs2234693) polymorphisms have been hampered by small sample size,regional restrictions and inconclusive results.Thus a meta-analysis is needed to assess their pooled effects.üMethods This study reviewed all published articles indexed in Pubmed using the keywords in the title or abstract.All data were extracted independently by two reviewers using a standard form,the studies were mete-analyzed and minor discrepancies were resolved by authors' discussion.Results Twenty seven eligible studies involving 8467 women and 2032 men were identified.The Xbal and Pvull polymorphisms were significantly associated with BMD of the lumbar spine.XX and PP homozygotes had a protective effect in comparison with carriers of the x and p alleles,the effects were more significant in premenopausal women or Western women.At the femoral neck,the results were different.XX served as a protective factor in postmenopausal women,Western women,Western postmenopausal women,and men,while PP was likely to serve as a risk factor in Eastern women,Eastern postmenopausal women,and men.Conclusions The Xbal polymorphism is correlated to BMD at diverse skeletal sites.PP had a protective role for the lumbar spine but might be a risk factor for the femoral neck。

Abstract：Background Rhabdomyosarcoma (RMS) is an uncommon malignancy of the breast.The aim of this study was to summarize its clinicopathologic features and biological behavior.Methods Five primary or secondary breast RMSs were collected.Their clinicopathological characteristics and all published literature about breast RMS were reviewed.Immunohistochemical study of desmin,myogenic differentiation 1 (MyoD1),myogenin,leukocyte common antigen (LCA),vimentin,cytokeratin (AE1/AE3),E-cadherin,neuron specific enolase (NSE),CD99,chorioallantoic membrane 5.2 (CAM5.2) and epithelial membrane antigen (EMA) expression were performed.Results The five patients were all female with ages ranging from 16 to 46 years old (mean,30 years).Three were metastatic breast RMSs,two embryonal and one solid variant alveolar,with the primary tumor sites the right labium majus,left nasal meatus and nasopharynx,respectively.The other two,one embryonal and one alveolar,were primaries.Grossly,the surgical specimens revealed round or oval,well-demarcated but nonencapsulated masses.Their cut surfaces consisted of homogeneous grayish yellow or white tissue.Microscopically,most tumor cells were poorly differentiated small round,oval or small polygons with eosinophilic cytoplasm.All cases were positive for vimentin,desmin,MyoD1 and myogenin.One embryonal RMS also had a few cells with perinuclear staining of AEI/AE3.The other markers were negative.Conclusions Although primary or metastatic RMS in breast was almost confined to young adolescent females,our cases suggested that it can also happen to the middle-aged women.Embryonal RMS has a certain metastatic potential.MyoD1 and myogenin are two useful markers when making differential diagnosis.Axillary lymph node status and age may play a role in the prognosis of primary breast RMS patients。

Abstract：Patients who suffer severe bums are at increased risk for local and systemic infections.The incidence of fungal infections has increased in recent years,and these infections represent a major issue in bum intensive care units.Herein,we report three cases of fungal infection due to Candida species occurring in patients undergoing supportive therapy and antibiotic treatment during their hospitalization.Two of these patients were infected with Candida parapsilosis,and one was infected with Candida albicans.The risk factors for these patients' Candida infections were multiple and prolonged courses of antimicrobial treatment,steroid treatment,tracheal intubation and smoke inhalation.Susceptibility testing of nine antifungal compounds was performed,and the minimum inhibitory concentration (MIC) values of all isolated strains were lower than the breakpoint MIC value for resistance of the relevant drug.All three patients were cured by treatment with antifungal agents.Candida infection may occur 1-3 weeks after thermal injury,and the prompt recognition and treatment of such infections with antifungal therapies may result in decreased morbidity and mortality associated with these infections in burn patients。

Abstract：Trichosporon species now ranks as the second most common cause of disseminated yeast infections with a high mortality rate.Breakthrough trichosporonosis in patients receiving echinocandins therapy is being recognized recently.We present a case of breakthrough trichosporonosis with acute viral myocarditis while receiving caspofungin therapy.Trichosporon infection should be considered in patients,who have risk factors for invasive fungal infection and develop unexplained clinical manifestations of infection despite treatment with echinocandins。

Abstract：Intralobar sequestration (ILS) is an uncommon abnormality that accounts for 75％ of all pulmonary sequestrations.Over the years there have been several reports of various presenting signs of which hemoptysis was commonly described,however,massive hemoptysis and hemothorax is extremely rare in literature.We present a case of a 45-year-old man who died of fatal complication from an ILS.This case report shows an uncommon presentation of ILS with massive hemoptysis and hemothorax resulting in a dramatic course of disease and a fatal outcome,and for this reason in the absence of trauma or other causes for massive hemoptysis,hemothorax,or lung hematoma,this possibility should be kept in mind so as to avoid misdiagnosis,and resection of the sequestered tissue should be considered in all patients。