2014年 · 第127卷第09期

Abstract：Background Over the last decade,Clostridium difficile infection (CDI) has emerged as a significant nosocomial infection,yet little has been reported from China.This study aimed to characterize the clinical and microbiological features of CDI from a hospital in Shanghai.Methods Patients with CDI seen between December 2010 and March 2013 were included in this study,of which clinical data were retrospectively collected.The microbiological features of corresponding isolates were analyzed including genotype by multi-locus sequence typing (MLST),antimicrobial susceptibility,toxin production,sporulation capacity,biofilm formation,and motility.Results Ninety-four cases of CDI were included during this study period,12 of whom were severe cases.By reviewing the clinical data,all patients were treated empirically with proton pump inhibitor or antibiotics or both,and they were distributed widely across various wards,most frequently to the digestive ward (28/94,29.79％).Comparing the severe with mild cases,no significant differences were found in the basic epidemiological data or the microbiological features.Among the 94 isolates,31 were toxin A-negative toxin B-positive all genotyped as ST37.They generated fewer toxins and spores,as well as similar amounts of biofilm and motility percentages,but exhibited highest drug resistance to cephalosporins,quinolones,macrolide-lincosamide and streptogramin (MLSB),and tetracycline.Conclusions No specific clinical genotype or microbiological features were found in severe cases; antimicrobial resistance could be the primary reason for epidemic strains leading to the dissemination and persistence of CDI。

Abstract：Background Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD).Although alveolar hypoxia is considered as a main cause of PH in COPD,structural and functional changes of pulmonary circulation are apparent at the initial stage of COPD.We hypothesized that an inflammatory response and oxidative stress might contribute to the formation of PH in COPD.Methods We measured the levels of interleukin-6 (IL-6) and 8-iso-prostaglandin (8-iso-PSG) in exhaled breath condensate (EBC) and serum in 40 patients with COPD only or in 45 patients with COPD combined with PH.Pulmonary arterial systolic pressure (PASP) was assessed by Doppler echocardiography and defined as PH when the value of systolic pressure was greater than 40 mmHg.Results Compared with the COPD only group,the level of IL-6 in EBC was significantly increased in all 45 patients with COPD combined with PH ((8.27±2.14) ng/L vs.(4.95±1.19) ng/L,P ＜0.01).The level of IL-6 in serum was also elevated in patients with COPD combined with PH compared with the COPD only group ((72.8±21.6) ng/L vs.(43.58±13.38) ng/L,P ＜0.01).Similarly,we also observed a significant increase in the level of 8-iso-PSG in both EBC and serum in the COPD with PH group,compared with the COPD only group (EBC:(9.00±2.49) ng/L vs.(5.96±2.31) ng/L,P ＜0.01 and serum:(41.87±9.75) ng/L vs.(27.79±11.09) ng/L,P ＜0.01).Additionally,the value of PASP in the PH group was confirmed to be positively correlated with the increase in the levels of IL-6 and 8-iso-PSG in both EBC and serum (r=0.477-0.589,P ＜0.05).Conclusion The increase in the levels of IL-6 and 8-iso-PSG in EBC and serum correlates with the pathogenesis of PH in COPD。

Abstract：Background Obstructive lung disease (OLD,chronic obstructive pulmonary disease or asthma) is an important cause of death in older people.There has been no exhaustive population-based mortality study of this subject in Shanghai.The objective of this study was to use a multiple cause of death methodology in the analysis of OLD mortality trends in the Yangpu district of Shanghai,from 2003 through 2011.Methods We analyzed death data from the Shanghai Yangpu District Center for Disease Control and Prevention for Medical Cause of Death database,selecting all death certificates for individuals 40 years or older on which OLD was listed as a cause of death.Results From 2003 to 2011,there were 8 775 deaths with OLD listed,of which 6 005 (68％) were identified as the underlying cause of death.For the entire period,a significantly decreasing trend of age standardized rates of death from OLD was observed in men (-6.2％ per year) and in women (-5.7％ per year),similar trends were observed in deaths with OLD.The mean annual rates of deaths from OLD per 100 000 were 161.2 for men and 80.8 for women from 2003 to 2011.While,as the underlying cause of death,the main associated causes of death were as follows:cardiovascular diseases (70.7％),cerebrovascular diseases (13.3％),diabetes (8.6％),and cancer (4.3％).The associated causes and the principal overall underlying causes of death were cardiovascular diseases (37.0％),cancer (30.3％),and cerebrovascular disease (15.3％).A significant seasonal variation,with the highest frequency in winter,occurred in deaths identified with underlying causes of chronic bronchitis,other obstructive pulmonary diseases,and asthma.Conclusions Multiple cause mortality analysis provides a more accurate picture than underlying cause of total mortality attributed on death certificates to OLD.The major comorbidities associated with OLD were cardiovascular disease,cancer,and cerebrovascular disease.From 2003 to 2011,the mortality rate from OLD decreased substantially in the Yangpu district of Shanghai。

Abstract：Background Since 2009,health reform had launched in China and essential public health services were provided for all residents to ensure service equity and accessibility,and to achieve sustained population-wide health improvement.This study aimed to investigate the differences and determinants among populations with different characteristics access to essential public health services in China,especially hypertension people and children aged 0-6 years.Methods A cross-sectional study with socio-demographic data analysis was undertaken to estimate distribution characteristics of receiving essential public health services of hypertension patients and children.Regular follow-ups and effective blood pressure control reflected the effective management for hypertension patients,and for children,public services provided were vaccination on schedule and regular physical check-up.Logistic regression was used to determine the predictors for effective management.Results A total of 1 505 hypertension patients and 749 children were involved; 39.14％ of hypertension participants could control their blood pressure in the normal range,and the rate in urban areas (43.61％) was higher than that in rural (31.88％).And 34.68％ of them could receive more than 4 times follow-ups by the medical technician.Of 754 children,79.84％ could receive the periodic physical examination and 98.40％ had vaccinated regularly.Children living in rural areas were more likely to have regular check-ups (83.96％) and regular vaccination (nearly 99％).Overall,geographic location and education level were the determinants of people access to essential public health services.Conclusions Implementation of the health reform since 2009 has headed China's public health system in the right direction and promoted the improvement of public health system development.Our study highlights the growing needs for more public health services in China,and China's public health system needs to be greatly improved in terms of its quality and accessibility。

Abstract：Background The "National" Health Insurance (NHI) in Taiwan,China is a single-payer system that was introduced in 1995 to provide universal health care.It is worth noting that three stakeholders are involved in Taiwan's NHI,which can be seen as a triangular governance regime between the Bureau of "National" Health Insurance (BNHI),the insured and providers.Accordingly,this study intended to assess the efficiency of various different production processes that occur among these stakeholders in Taiwan's NHI system.Methods A two-stage relational Data Envelopment Analysis (DEA) model is adopted to investigate the sub-process efficiencies of the health care resources held by 23 cities and counties through stages Ⅰ or Ⅱ,where the outputs of the first stage serve the inputs of the second.The dataset was collected from the annual reports published by the Department of Health,Taiwan,China.Results Under the proposed framework,the efficiency of the whole process can be obtained from the product of productivity and allocative efficiency.Ten DMUs are efficient either in stages Ⅰ or Ⅱ,with only two DMUs being efficient with regard to both sub-processes.Conclusion The relational DEA model not only demonstrates the physical relationship between the whole process and the sub-process components,but also produces reliable outcomes in efficiency measurement among different stakeholders in Taiwan's NHI system。

Abstract：Background Surgical resection is the most effective treatment for renal cell carcinoma (RCC).Currently several prognostic factors and models are used for outcome prediction.However,whether intratumoral changes are independent prognostic factors for RCC or not remains unclear.The aim of the study was to investigate the prognostic roles of intratumoral changes in surgical treated localized clear cell renal cell carcinoma (ccRCC).Methods Patients who received partial or radical nephrectomy between 2004 and 2009 in our center were retrospectively reviewed.Univariate and multivariate analyses were used to assess gender,age,body mass index (BMI),intratumoral hemorrhage,tumor necrosis,cystic degeneration,sarcomatoid change,Ki-67 expression,Fuhrman grade,and T stage on recurrence-free survival (RFS) and cancer-specific survival (CSS).Results A total of 378 patients were included in our study.In univariate analysis,age,BMI,intratumoral hemorrhage,tumor necrosis,sarcomatoid change,Ki-67 expression level,Fuhrman grade,and T stage were prognostic factors for RFS.Age,BMI,tumor necrosis,sarcomatoid change,Ki-67 expression level,Fuhrman grade,and T stage were prognostic factors effecting CSS.In multivariate analysis,age,BMI,tumor necrosis,sarcomatoid change,Ki-67,Fuhrman grade,and T stage were independent prognostic factors for both RFS and CSS.Conclusion Intratumoral changes such as tumor necrosis and sarcomatoid change are independent prognostic factors for ccRCC。

Abstract：Background Both in vitro and in vivo data have demonstrated the TGFBI gene functions as a putative tumor suppressor and is frequently downregulated in human tumors of different histological types.The hypermethylation of the TGFBI promoter,as one of the main regulatory mechanisms,is associated with TGFBI silencing.In this study,we used a methylation-specific PCR (MSP) method to evaluate the methylation status of the TGFBI promoter in human leukemias.Methods Real-time RT-PCR and methylation-specific PCR approaches were performed to define the TGFBI expression and promoter methylation in human leukemia call lines and clinical samples.Genomic DNA was isolated from peripheral blood mononuclear cells from leukemia patients,bisulfite-converted,and analyzed by the MSP method.Results Hypermethylation of the TGFBI promoter occurred in leukemia cell lines and demethylation treatment reexpressed TGFBI at a substantially increased level in most of leukemia cell lines tested.Furthermore,a much higher level of CpG island methylation and a significantly lower TGFBI expression were also identified in clinical leukemia samples.Conclusion The results suggest an important role of promoter methylation in regulating TGFBI expression in leukemia,which provides a useful diagnostic marker for clinical management of human leukemias。

Abstract：Backgorund Nicotine may improve schizophrenia patient's cognitive deficit symptoms.This study was to explore the chronic effects of smoking on prepulse inhibition of the startle reflex (PPI) and P50 in the patients with first-episode schizophrenia (FES).Methods The event-related potentials (ERP) recording and analysis instrument made by Brain Products,Germany,was used to detect PPI and P50 in 49 male FES patients (FES group,n=21 for smokers and n=28 for non-smokers) and 43 normal male controls (control group,n=19 for smokers and n=24 for non-smokers).Results Compared with normal controls,the FES group had prolonged PPI latency when elicited by single stronger stimulus (P ＜0.05); the FES group had prolonged PPI latency and increased PPI amplitude (P ＜0.05,0.01) when elicited by weak and strong stimuli.The FES group had lower PPI inhibition rate than normal controls (P ＜0.05).Compared with normal controls,the FES group had increased P50-S2 amplitude and increased amplitude ratio S2/S1 (both P ＜0.05).In the control group,the smokers had a tendency of increase in P50-S2 amplitude (P ＞0.05) and shorter P50-S2 latency (P ＜0.05) than the non-smokers.The smokers had higher PPI amplitude than the non-smokers (P ＜0.05).In the FES group,the smokers had higher P50-S1 amplitude,shorter P50-S2 latency,and higher amplitude ratio S2/S1 than the non-smokers (P ＜0.05,0.01).The smokers had higher PPI amplitude than the non-smokers (P ＜0.05).Conclusions There is obvious PPI and P50 deficits in schizophrenic patients.However,these deficits are relatively preserved in the smokers compared with the non-smokers,which suggests that long-term smoking might partially improve the sensory gating in schizophrenic patients.Whether this conclusion can be deduced to female patients requires further follow-ups。

Abstract：Background Some research groups have hypothesized that human rhinoviruses (HRVs) delayed the circulation of the 2009 pandemic influenza A(H1N1) virus (A(H1N1)pdm09) at the beginning of Autumn 2009 in France.This study aimed to evaluate the relationship between HRV and A(H1N1)pdm09 in pediatric patients with influenza-like illness in Beijing,China.Methods A systematic analysis to detect A(H1N1)pdm09 and seasonal influenza A virus (FLU A) was performed on 4 349 clinical samples from pediatric patients with influenza-like illness during the period June 1,2009 to February 28,2010,while a one-step real-time RT-PCR (rRT-PCR) assay was used to detect HRV in 1 146 clinical specimens selected from those 4 349 specimens.Results During the survey period,only one wave of A(H1N1)pdm09 was observed.The percentage of positive cases for A(H1N1)pdm09 increased sharply in September with a peak in November 2009 and then declined in February 2010.Data on the monthly distribution of HRVs indicated that more HRV-positive samples were detected in September (2.2％) and October (3.3％),revealing that the peak of HRV infection in 2009 was similar to that of other years.Among the 1 146 specimens examined for HRVs,21 (1.8％) were HRV-positive,which was significantly lower than that reported previously in Beijing (15.4％ to 19.2％) (P ＜0.01).Overall,6 samples were positive for both A(H1N1)pdm09 and HRV,which represented a positive relative frequency of 1.60％ and 2.08％ HRV,considering the A(H1N1)pdm09-positive and-negative specimens,respectively.The odds ratio was 0.87 (95％ CI 0.32; 2.44,P=0.80).Conclusions HRVs and A (H1N1)pdm09 co-circulated in this Chinese population during September and October 2009,and the HRV epidemic in 2009 did not affect A(H1N1)pdm09 infection rates in Beijing,China as suggested by other studies.However,the presence of A(H1N1)pdm09 might explain the unexpected reduction in the percentage of HRV positive cases during the period studied。

Abstract：Background The purpose of this study was to conduct thyroid ultrasound examinations on a large sample of subjects and explore the occurrence,distribution,and characteristics of thyroid nodules and thyroid cancer to provide some information on the epidemic trend of thyroid nodules and cancer.Methods The thyroid ultrasonic examination results of 19 895 healthy physical examinees who visited the Department of Health Management,Peking Union Medical College Hospital from January 2009 to December 2011 were analyzed retrospectively to determine the detection rate and characteristics of thyroid nodules.Fine needle aspiration or surgical resection was suggested to subjects suspected of having thyroid cancer.Results The detection rate of thyroid nodules was 42.6％ (8 480/19 895),40.0％ (4 661/11 678) in men and 46.5％ (3 819/8 217) in women.The detection rate noticeably increased with increasing age.The detection rate of thyroid nodules by palpation was obviously lower than by ultrasonic examination in various age groups.Among those with thyroid nodules,61.3％ were multiple and 38.7％ were solitary; multiple nodule was the major type both in men and women.Twenty-nine cases of malignant nodules were solitary,and 30 cases of malignant nodules were multiple.There was no significant difference.The detection rate of thyroid cancer was 0.30％ for the entire group of examinees,and 0.15％ in men and 0.50％ in women.Among all sex and age groups,30-to 40-year-old women had the highest detection rate (0.76％).The detection rate of thyroid nodules correlated with age,systolic blood pressure,height,and weight.Increasing age and/or higher systolic blood pressure correlated with a higher detection rate,while smaller height and weight also correlated with a higher detection rate with significant differences.However,there were no significant correlations between the detection rate and diastolic blood pressure or body mass index.Conclusions The detection of thyroid cancer increased significantly,especially in women.Thus,precautions needed to be taken.Regular physical examination and timely intervention after detection of malignant nodules are critical to improve the prognosis in thyroid cancer patients。

Abstract：Background The interleukin (IL)-32/tumor necrosis factor (TNF) α pathway is supposed to play a key role in the amplification of the immune response in chronic obstructive pulmonary disease (COPD) inflammation.Inhaled corticosteroids (ICS) in combination with long-acting β2-agonists (LABA) have shown airway anti-inflammatory effects in recent studies,but the mechanism is still uncertain.Methods Patients were treated in a randomized,open-labeled,parallel group clinical trial with either a combination of salmeterol xinafoate/fluticasone propionate (SF; Seretide,GlaxoSmithKline) Diskus (50/500 μg twice daily) or ipratropium bromide/salbutamol (IS; Combivent,Boehringer Ingelheim) MDI (42 μg/240 μg quartic daily) for 12 weeks.At the start and the end of treatment,induced sputum was collected and the concentration of IL-32 and TNF-α,the number of neutrophils and eosinophils were measured.Results Following 12 weeks of treatment,a statistically significant fall from baseline in the concentration of TNF-α in sputum (P=0.004) was seen after treatment with SF but not with IS.However,neither treatment had significant effects on the concentration of IL-32 in sputum.There was a decrease from baseline in the number of sputum neutrophils with SF that approached statistical significance (P=0.028) but not with IS,while the number of sputum eosinophils did not change significantly from baseline in either treatment group.There was a statistically significant decline from baseline in the quality of life as assessed by the St George's respiratory questionnaire in both the SF (P=0.004) and IS (P=0.030) treatment groups,but no evidence of improvement in lung function was observed in either group.Conclusion The sputum TNF-α and neutrophils,but not IL-32 and macrophages,could be reduced by ICS/LABA treatment,suggesting that IL-32 could be involved in the corticosteroid resistance of COPD inflammation。

Abstract：Background Numerous studies have described the association between polymorphisms in the tumor necrosis factor (TNF) gene and risk of endometriosis.However,the results remain controversial.Here we reviewed studies reporting the association between TNF gene polymorphisms and endometriosis risk in Asians.Methods PubMed and Embase were searched.Twelve case-control studies assessing the role of multiple TNF gene polymorphisms in endometriosis were included.If no less than two articles evaluated one variant,meta-analysis was conducted; otherwise,narrative analysis was chosen.A fixed-or random-effects model was employed according to the heterogeneity among studies.The strength of the association between TNF gene polymorphisms and endometriosis risk was assessed by odds ratios and 95％ confidence intervals.Results For TNF-α-238G＞A,-308G＞A,-857C＞T,and-863C＞A,no significant associations were identified from all genetic models.For TNF-α-850T＞C,results from one study showed that patients harboring the heterozygote TC were less susceptible to endometriosis than patients harboring the homozygote TT.For TNF-α-1031T＞C,a mild increase in endometriosis risk was found in the Asian population.Meta-analysis from two studies found that the TNF-β +252＞G polymorphism had a protective effect in Chinese individuals.Due to the limitations of the included studies,it is necessitated to perform more studies to elucidate the possible roles of TNF gene polymorphisms in the pathogenesis of endometriosis.Conclusions TNF-α-1031T＞C and TNF-β +252A＞G were significantly associated with the risk of endometriosis in Asian and Chinese populations,respectively.To further evaluate these associations,more large-scale,rigorously designed studies are needed。

Abstract：Background The specificity for early interventions of prostate-specific antigen (PSA) in prostate cancer (PCa) is not satisfactory.It is likely that prostate cancer antigen 3 (PCA3) can be used to predict biopsy outcomes more accurately than PSA for the early detection of PCa.We systematically reviewed literatures and subsequently performed a meta-analysis.Methods A bibliographic search in the database of Embase,Medline,Web of Science,NCBI,PubMed,CNKI,and those of health technology assessment agencies published before April 2013 was conducted.The key words used were "prostatic neoplasms","prostate","‘prostate,' ‘carcinoma' or ‘cancer' or ‘tumor',or ‘PCa,'" and free terms of "upm3","pca3","dd3","aptimapca 3",and "prostate cancer antigen 3".All patients were adults.The intervention was detecting PCA3 in urine samples for PCa diagnosis.We checked the quality based on the QUADAS criteria,collected data,and developed a meta-analysis to synthesize results.Twenty-four studies of diagnostic tests with moderate to high quality were selected.Results The sensitivity was between 46.9％ and 82.3％; specificity was from 55％ to 92％; positive predictive value had a range of 39.0％-86.0％; and the negative predictive value was 61.0％-89.7％.The meta-analysis has heterogeneity between studies.The global sensitivity value was 0.82 (95％ Cl 0.72-0.90); specificity was 0.962 (95％ Cl 0.73-0.99); positive likelihood ratio was 2.39 (95％ Cl 2.10-2.71); negative likelihood ratio was 0.51 (95％ Cl 0.46-0.86); diagnostic odds ratio was 4.89 (95％ Cl 3.94-6.06); and AUC in SROC curve was 0.744 1.Conclusion PCA3 can be used for early diagnosis of PCa and to avoid unnecessary biopsies。

Abstract：Objective This review focuses on the role of the large conductance calcium-activated potassium (BKCa) channels in diabetic vascular complications.Data sources Relevant articles published in English or Chinese from 1981 to present were selected from PubMed.The search terms were "BKCa channels" and "diabetes".Important references from selected articles were also retrieved.Study selection Articles regarding the role of BKCa channels in diabetic vascular complications and relevant mechanisms were selected.Results The BKCa channels are abundantly expressed in vascular smooth cells and play an important role in regulation of vascular tone.Multiple studies indicated that the expression and function of BKCa channels are altered by different mechanisms in diabetic vascular diseases such as coronary arterial disease,cerebral arterial disease,and diabetic retinopathy.Conclusion BKCa channels may play an important role in diabetic vascular complications and may be an effective therapeutic target for relieving and reducing the burden of diabetic vascular complications。

Brachial plexus injury is regarded as one of the most difficult international medical problem.Microsurgery is an advanced technology and has progressed further on the operation,especially on the nerve repair.1,2 In recent years,rehabilitation on the brachial plexus injury has been reported home and abroad,3 but there is no clear report on the rehabilitation treatment of brachial plexus injury after nerve bridging or nerve transfer.Hence,we designed the research to ensure that comprehensive rehabilitation has obvious effect on the nerve recovery after operation.Comprehensive rehabilitation is the using of health care measures to treat the dysfunction left by hurt or diseases that always lead to the loss of life or work ability temporarily or permanently.And then it can restore the functionality to the maximum possible and help the patients to recover physically,psychologically,and vocationally。

Aneurysmal bone cyst (ABC) is a rare and benign disease that demonstrates active biological behavior,can promptly expand,and exhibits an invasive or destructive capability.1 Currently,the major therapy for ABC is complete curettage of the lesion.1,2 However,the therapy for sacral ABC has risks such as severe bleeding and nerve root damage.2 Arterial embolization is used to treat large sacral giant cell tumors and ABCs and can promptly relieve pain,reduce lesion volume,and promote osteogenesis.3

Congenital aural atresia is usually associated with facial nerve (the seventh cranial nerve,CN7) anomalies with an incidence rate of 60％-75％.These anomalies include facial nerve displacement,facial nerve component overlying the oval window,bony canal dehiscence,and bifurcation,which increase the risk of surgical facial nerve injuries.Among all these anomalies,congenital bifurcation of the tympanic segment of facial nerve is the most confusing situation that significantly increases the surgical risk during hearing reconstruction。

Rotating-hinge total knee prostheses are often used for the treatment of global instability or severe bone loss around the knee,which is often accompanied by severe deformity.1 Competent and functional collateral ligaments are a prerequisite for performance of conventional total knee arthroplasty (TKA).In cases of primary surgery for knees with severe deformities or in revision surgery for knees with substantial bone loss,standard condylar implants do not allow for proper stabilization of the joint.Under these circumstances,condylar TKA designs will fail within a short period of time,or other complications such as anterior knee pain will occur soon after surgery.2

Tricuspid valve regurgitation is a rare complication of blunt chest trauma.Approximately 150 cases have been reported since first being described by Todd et al in 1848.1 During the past few decades traumatic tricuspid regurgitation has been reported with increasing frequency,which may in part be attributed to more patients surviving blunt chest trauma as well as improved diagnostic imaging studies,such as echocardiography.The incidence of traumatic tricuspid regurgitation is likely underestimated since chronic,isolated tricuspid insufficiency may be well tolerated in some patients who experience few or no symptoms after the traumatic event.2 Furthermore,some patients may not recall antecedent chest trauma unless specifically questioned.Most cases of traumatic tricuspid regurgitation are secondary to blunt chest trauma.1

To the editor:On 5th March 2013,a 50-year-old male patient developed an intermittent dull pain of his right lower abdomen without any other symptoms.He performed crunches 2 days ago.Abdominal radiograph was unremarkable.The abdominal dull pain continued but it could be tolerated.On 12th March,2013,the patient developed increasingly server abdominal pain when he moved a heavy table,and it was intensified when pressed.The patient then came to our clinic for further consultation.His medical history included chronic atrial fibrillation and transient cerebral ischemia 2 years before.He was maintained on warfarin therapy since then.Physical examination revealed a moderate tenderness with fullness mass over the right lower abdominal quadrant。

To the editor:Pulmonary sequestration is an uncommon congenital anomaly in which the arterial supply derives most frequently from the thoracic or abdominal aorta and other origins of blood supply are rarely described.Here we report a patient with the blood supply of pulmonary sequestration originating from right coronary artery (RCA)。

To the editor:Infection with the novel H7N9 influenza virus broke out in the mainland and Taiwan area of China in 2013.1 In critically ill patients the survival was low.2 However,with extracorporeal membrane oxygenation (ECMO) we rescued a critically ill patient infected with H7N9 influenza.The case was a 36-year-old man (weight 100 kg) who had previously been exposed to poultry.On April 21,2013,the patient was admitted to Zaozhuang Municipal Hospital with a temperature of 39℃ and severe hypoxemia.Laboratory results showed a white blood cell count of 3.3× 109/L and neutrophils of 73.7％.Respiratory secretions were sent to the Shandong CDC and it was positive for the H7N9 influenza virus.Then he was treated with oseltamivir (150 mg) every 12 hours。

To the editor:a 55-year-old postmenopausal woman was referred to dermatology department with a three months history of five erythematous nodules on the pubis (Figure 1A).These asymptomatic skin lesions had enlarged gradually.She did not present fever or systemic symptoms.Four years ago,she was diagnosed to have FIGO stage Ⅱb adenocarcinoma of endocervix and was treated with radical hysterectomy and radiotherapy.Alongside this lesion,we considered the possibility of skin metastasis.Histological studies confirmed the cutaneous metastasis of endocervical adenocarcinoma (Figure 1B).Laboratory test were normal but the chest and abdominal scanner revealed lung and liver metastasis.Extirpation of the skin lesions and local radiotherapy were performed.Unfortunately,due to a lung infection she was dead after hospitalized 5 months。

To the editor:A 60-year-old man presented to our emergency department in November 2012,due to an episode of chest pain associated with angina-linked syncope attacks.His past medical history was notable for drug-controlled hypertension (nifedipine 30 mg/d).On physical examination following the 30 minutes after chest pain,he was asymptomatic,with vital signs in the normal range,and an unremarkable chest X-ray.ECG was also carried out and showed sinus bradycardia rhythm (Figure 1A).The morning after initial presentation,the patient experienced acute onset of chest pain,lasting for a total of 30 minutes.An emergency ECG was performed and showed 3 mm ST-segment elevation in the inferior leads and specular antero-lateral ST depression (Figure 1B)。