2013年 · 第126卷第18期

Stroke,a global health problem,is the second most common cause of death and a leading cause of adult disability worldwide.1 In developing countries,the premature loss of life and stroke-related disability present a heavy burden and result in increasing economic and social tolls.2 In China,the annual stroke mortality is approximately 1.6 million,which has become the leading cause of death and adult disability.3 Ischemic stroke is the most common type of stroke accounting for 43％-79％ of all strokes。

Abstract：Background DI-3-n-butylphthalide (NBP),first isolated from the seeds of celery,showed efficacy in animal models of stroke.This study was a clinical trial to assess the efficacy and safety of NBP with a continuous dose regimen among patients with acute ischemic stroke.Methods A randomized,double-blind,double-dummy trial enrolled 573 patients within 48 hours of onset of ischemic stroke in China.Patients were randomly assigned to receive a 14-day infusion of NBP followed by an NBP capsule,a 14-day infusion of NBP followed by aspidn,or a 14-day infusion of ozagrel followed by aspidn.The efficacy measures were Barthel index score and the modified Rankin scale (mRS) at day 90.Differences among the three groups on mRS were compared using X2 test of proportions (with two-sided α=0.05) and Logistic regression analysis was conducted to take the baseline National Institutes of Health Stroke Scale (NIHSS) score into consideration.Results Among the 535 subjects included in the efficacy analysis,90-day treatment with NBP was associated with a significantly favorable outcome than 14-day treatment with ozagrel as measured by mRS (P ＜0.001).No significant difference was found among the three groups on Barthel index at day 90.The rate of adverse events was similar among the three groups.Conclusions The 90-day treatment with NBP could improve outcomes at the third month after stroke.The NBP treatment (both intravenous and oral) is safe (ChiCTR-TRC-09000483)。

Abstract：Background The risk of clinical deterioration still exists in the acute phase despite the fact that patients with minor stroke may display less severe symptoms.The impact of this clinical deterioration on long-term outcomes is unknown.We characterized the clinical features of neurological deterioration (ND) in the acute phase of minor ischemic stroke (MIS) and investigated its impact on mid-and long-term outcomes.Methods This was a multi-centered,prospective clinical study involving patients with MIS (the National Institutes of Health Stroke Scale,NIHSS ＜3) recruited from the China National Stroke Registry.Patients were included who had been hospitalized within 24 hours of stroke onset.Baseline characteristics,complication rates during hospitalization,etiology of stroke,as well as 3-,6-,and 12-month post-stroke outcomes were compared between patients with and without ND during the acute phase.Results A number of 368 (15.2％) out of 2424 patients included in the study exhibited ND in the acute phase.Compared to patients without ND,patients with ND had longer hospital stay,increased rate of baseline diabetes,and multiple complications.Multivariate Logistic regression indicated that ND in acute phase was an independent factor predictive of increased dependence (adjusted odds ratio =5.20,95％ Cl,3.51-7.70,P ＜0.001) at 12-month post-stroke.Conclusions The risk of ND in the acute phase is high in patients with MIS.ND in the acute phase is an independent predictor for poor outcomes at 12 months post-stroke onset。

Abstract：Background Dementia is a chronic progressive disease seriously affecting the patient's daily life and working skills and may cause the patient disability and dependence.Thus,caring for dementia patients inevitably falls on families in the mainland of China.Unfortunately,there are rarely enough reports available about mental health and social support in family caregivers for domestic dementia patients.This study aimed to investigate the changes in psychological status and social support in domestic dementia family caregivers and hope the government and relevant departments pay more attention to the family caregiver's psychological change,which may be better for dementia patients.Methods Fifty-eight immediate family caregivers (family group) for dementia patients,including 21 Alzheimer's disease (AD) and 37 vascular dementia inpatients,were recruited for interview.Fifty-eight age-and sex-matched normal volunteers (control group) were also interviewed in the same period.The psychiatric distress was assessed by the Symptom Checklist 90 (SCL-90),family functioning was assessed by the Family Assessment Device (FAD),and the social support was assessed by the Multidimensional Scale of Perceived Social Support (MSPSS).Group differences were analyzed using unpaired t test for comparison of SCL-90,FAD,and MSPSS mean scores.Pearson's correlation coefficient was used to find the association between the various dimensions of FAD and the social support from dementia family caregivers.Results Except phobic anxiety dimension,the other dimensions of SCL-90 mean scores were significantly higher in the family group than those in the control group (P ＜0.05).In the family group,except affective involvement dimension,the other dimensions of FAD mean scores were within the scope of unhealthy family functioning.Significant differences in problem solving,communication,roles,affective responsiveness,behavioral control,general functioning,and the total MSPSS mean scores were seen between the family group and the control group (P ＜0.01).Except affective involvement dimension,the other dimensions of the family functioning correlated with the perceived social support in the family group (P ＜0.05 or 0.01).Conclusions Dementia patients have a negative effect on families' mental health in the mainland of China.Dementia family caregivers experience defected family functioning and low levels of social support。

Abstract：Background Little quantitative evidence was available regarding the development of NICUs in China.The purpose of this survey was to evaluate the current situation of neurointensive care units (NICUs) across China.Methods The directors of NICUs from 100 tertiary care hospitals across China were contacted and asked to complete a closed response questionnaire regarding their NICUs.Basic information,equipment,and technology information available in the units,as well as staffing information were investigated.Results Seventy-six questionnaires were returned (a 68％ response rate).Of 76 NICUs,43 units constituted the majority.The number of each NICU bed varied from 4 to 45,occupying 2％-30％ of the total department beds.Over 70％ of NICUs were equipped with many emergency treatment equipments as well as physiological and biochemical monitoring equipments,while 34％-70％ of NICUs still lacked some kinds of equipments such as defibrillators.Some specialist equipments were still partially lacking in 62％-95％ of NICUs.A vast majority of the NICUs were equipped with neurocritical care directors,full-time attending physicians,and head nurses,but full-time NICU residents and neurocritical care nurses were still lacking in nearly half (53％) and one-third (33％-37％) of NICUs,respectively.In 76 NICUs,full-time neurointensivists and nurses added up to 359 and 852,respectively.In addition,78％-97％ of all the surveyed NICUs were severely short of non-neurological professional staffs.Conclusion In China,neurocritical care has developed rapidly,but there is still a shortage of well-equipped and wellstaffed NICUs across the nation currently。

Abstract：Background Familial cerebral cavernous malformations (CCMs),characterized by hemorrhagic stroke,recurrent headache and epilepsy,are congenital vascular anomalies of the central nervous system.Familial CCMs is an autosomal dominant inherited disorder and three CCM genes have been identified.We report a Chinese family with CCMs and intend to explore clinical,pathological,magnetic resonance imaging (MRI) features and pathogenic gene mutation of this family.Methods Totally 25 family members underwent brain MRI examination and clinical check.Two patients with surgical indications had surgical treatment and the specimens were subjected to histopathological and microstructural examination.In addition,polymerase chain reaction (PCR) and direct sequencing were performed with genomic DNA extracted from 25 family members' blood samples for mutation detection.Results Brain MRI identified abnormal results in seven family members.All of them had multiple intracranial lesions and four cases had skin cavernous hemangioma.T2-weighted sequence showed that the lesions were typically characterized by an area of mixed signal intensity.Gradient-echo (GRE) sequence was more sensitive to find microcavernous hemangiomas.There was a wide range in the clinical manifestations as well as the age of onset in the family.The youngest patient was an 8-year-old boy with least intracranial lesions.Histopathological and microstructural examination showed that CCMs were typically discrete multi-sublobes of berry-like lesions,with hemorrhage in various stages of illness evolution.They were formed by abnormally enlarged sinusoids and the thin basement membranes.A novel T deletion mutation in exon 14 of CCM1 gene was identified by mutation detection in the seven patients.But unaffected members and healthy controls did not carry this mutation.Conclusions The clinical manifestations were heterogenic within this family.We identified a novel mutation (c.1396delT) was the disease-causing mutation for this family and extended the mutational spectrum of CCMs。

Abstract：Background Endothelin-1 (ET-1) has deleterious effects on water homeostasis,cerebral edema,and blood-brain barrier (BBB) integrity.Highly expressed ET-1 was observed after intracerebral hemorrhage (ICH); however,ET-1 changes and their relationship with BBB disruption within 24 hours of iCH have not been thoroughly investigated.The aim of the present study was to observe the changes in perihematomal ET-1 levels in various phases of ICH and their correlation with the BBB integrity in a rabbit model of ICH.Methods Twenty-five rabbits (3.2-4.3 kg body weight) were randomly divided into a normal control group (five rabbits)and a model group (20 rabbits).Animals in the model group were equally divided into four subgroups (five rabbits each to be sacrificed at 6,12,18,and 24 hours following ICH establishment).An ICH model was prepared in the model group by infusing autologous arterial blood into the rabbit brain.ET-1 expression in perihematomal brain tissues was determined using immunohistochemistry and color image analysis,and the permeability of the BBB was assayed using the Evan's Blue (EB) method.A repeated measures analysis of variance was used to make comparisons of the ET-1 and EB content across the entire time series.Results The number of perihematomal endothelial cells with ET-1 positive expressions following 6,12,18,and 24 hours ICH model establishment was 9.32,13.05,15.90,and 20.44,respectively,but as low as 6.67 in the control group.The average transmittance of ET-1-positive cell bodies at 6,12,18,and 24 hours after ICH was 99.10,97.40,85.70,and 80.80,respectively,but 100.12 in the control group.These data reveal that the expression of ET-1 was significantly increased at 6,12,18,and 24 hours after ICH compared with the control group,and a marked decrease in the average transmittance of ET-1-positive cell bodies was noted (P ＜0.05).Similarly,the perihematomal EB content at 6,12,18,and 24 hours after ICH was 29.39±1.16,32.20±0.73,33.63±1.08,and 35.26±1.12,respectively,in the model group and 28.06±0.80 in the control group.The results indicate that a significant increase in the EB content in the model group was observed compared with that of the control group (P ＜0.05).Moreover,a positive correlation between the number of ET-1-positive endothelial cells and BBB permeability was observed (r=0.883,P ＜0.05).Conclusions High levels of ET-1 are closely associated with BBB disruption.ET-1 may play an important role in the pathogenesis of secondary brain injury after ICH。

Abstract：Background Our previous study had demonstrated that ulinastatin (UTI) had a neureprotective effect in experimental autoimmune encephalomyelitis (EAE).Methylprednisolone has been recommended to be a standard drug in multiple sclerosis (MS) therapies.The present study was to investigate the protective effects of UTI combined methylprednisolone in EAE.Methods Mice were divided into a UTI treatment group,a methylprednisolone treatment group,a combined treatment group with UTI and methylprednisolone,a normal saline treatment group,and a normal control group.EAE mice were induced in groups receiving different combined treatments,or respective monotherapies.Demyelination was evaluated by Solochrome cyanin staining.2′,3′-cyclic nucleotide 3′-phosphodiesterase (CNP)/myelin basic protein (MBP)/the precursor form of nerve growth factor (proNGF)/p75/inducible nitric oxide synthase (iNOS) proteins in cerebral cortex of EAE were detected by Western blotting.Results The combined treatment group had a lower clinical score (0.61±0.06) and demyelinating score (1.33±0.33)than the groups with normal saline (clinical score:1.39±0.08,P ＜0.001; demyelinating score:2.75±0.49,P ＜0.05) or monotheraphies.Compared with the saline treated EAE group,UTI combined methylprednisolone significantly increased expressions of CNP (1.14±0.06 vs.0.65±0.04,P ＜0.001),MBP (1.28±0.14 vs.0.44±0.17,P ＜0.001),and decreased expressions of proNGF (1.08±0.10 vs.2.32±0.12,P ＜0.001),p75 (1.13±0.13 vs.2.33±0.17,P ＜0.001),and iNOS (1.05±0.31 vs.2.17±0.13,P ＜0.001) proteins in EAE.Furthermore,UTI combined methyiprednisolone could significantly upregulate MBP (1.28±0.14 vs.1.01±0.15,P ＜0.05) expression and downregulate iNOS (1.05±0.31 vs.1.35±0.14,P ＜0.05) expression compared to methylprednisolone treatment EAE group.And proNGF expression was significantly lower in combined treatment (1.08±0.10) than that in UTI (1.51±0.24,P ＜0.05) or methylprednisolone (1.31±0.04,P ＜0.05)treatment group.Conclusion Combination treatment of UTI with methylprednisolone was shown to protect EAE,suggesting that combination therapy is a potential novel treatment in MS。

Abstract：Background Stroke occurs upon obstruction of cerebral blood circulation and is clinically characterized by sudden onset symptoms.Advanced age is the main risk factor of stroke,but cases of pediatric stroke have been rarely reported.This study aimed to determine the etiology,clinical presentation,and radiologic features of neurological deficit for pediatric arterial ischemic stroke (PALS).Methods The medical records of 42 PAlS patients (age range:9 months to 13 years) treated at Wuhan Children's Hospital between July 2007 and January 2011 were retrospectively reviewed.Infarction location was first determined by craniocerebral computed tomography and magnetic resonance (MR) imaging.The stenotic or occluded main cerebral arteries and/or branches were determined by MR angiography and digital subtraction angiography.Results The majority of the 42 PAlS cases (66.7％,n=28) were ＜3 years old (vs.＞3 years old:33.3％,n=14; P＜0.05),but the male:female ratio was similar in both groups (P＞0.05).The most frequently reported signs and symptoms for both age groups were limited physical activity followed by convulsions and delirium,but convulsions were more prevalent in children ＜3 years-old.Children＞3 years-old mainly experienced the limited physical activity symptoms,including hemiparalysis,aphasia,and ataxia.For all 42 cases,the most frequent etiologies were infections (38.1％,n=16),iron deficiency anemia (16.7％,n=7),and moyamoya syndrome (11.9％,n=5).The predominant infarcts among all cases were middle cerebral artery (63.6％,n=21)and basal ganglia (64.3％,n=27).Conclusions PAlS occurs more frequently in younger children and this group most frequently presents with convulsion as the initial symptom.The overall etiologies of PAlS may be different from those of adult stroke and the involved regions may be distinguishing features of PAlS or its different forms,but more research is required。

Abstract：Background Long-term use of antiplatelet agents,statins,beta-blockers and angiotensin-converting enzyme inhibitors are proven therapies for secondary prevention in acute coronary syndrome.However,little is known of physicians' opinion about their use in China.Methods In 2010,standard questionnaires were posted to chief cardiologists in 1397 geographically diverse and representative sample of tertiary and secondary hospitals in China,collecting information about their opinions on the recommended treatments for acute coronary syndrome.Results A total of 1009 (72％) cardiologists responded with a valid questionnaire.Of them,77％ reported routine use of all the four main secondary preventive treatments,with little difference between secondary and tertiary hospitals (75％ vs.79％,P=0.16).Of the cardiologists reporting routine or selective use of aspirin,beta-blockers,statins and angiotensin-converting enzyme inhibitors,94％,85％,73％ and 86％ would recommend indefinite use respectively.For all the 4 treatments combined,only 63.5％ reported indefinite use at the same time,with no significant difference between secondary and tertiary hospitals (62％ vs.65％,P=0.17),nor between hospitals with or without fast track for primary percutaneous coronary intervention (66％ vs.61％,P=0.50).Conclusions Although Chinese cardiologists seem well informed about the value of main secondary preventive treatments for acute coronary syndrome,there is still gap in their understanding of the need for combined and prolonged use of these treatments。

Abstract：Background Occluders licensed for clinical use are not fit for some special Krichenko E patent ductus arterioses.The Amplatzer vascular plug I (AVP1) has not been licensed for use for closure of patent ductus arteriose.We report our initial experience to occluding special type patent ductus arterioses with the AVP1-a single lobe device of single layer Nitinol mesh for short vessel landing zones.Methods Patients referred with small and long Krichenko E patent ductus arterioses 1 mm to 3 mm in diameter underwent occlusion using AVP1.All cases underwent pre-,intra-and post-procedural echocardiography and chest X-ray at the completion of the procedure,the next day and at a 30-day,3-month and 6-month follow-up visits.Device sizing for device waist diameter and length was based on aortography.Results From April 2008 to June 2012,26 patients with a mean age of (7.6±8.0) years (range 6 months-32 years)and a mean weight of (23.8±14.8) kg (range 7-67 kg) underwent successful patent ductus arteriose closure.The mean ductus diameter was (2.1±0.7) mm (range 1-3 mm).Transpulmonary (22/26) and transaortic approaches (4/26) were used.No persistent patency was observed after 24 hours and after one month.No device displacement,residual flow and iatrogenic coarctation of the aorta were observed after three months and six months.Conclusions The AVP1 makes it easy to close some Krichenko E patent ductus arterioses.Smaller delivery catheter profile and symmetric cylindrical device shape allow for use for small and long Krichenko E patent ductus arterioses 1 mm to 3 mm in diameter and small patients through transaortic approaches.Broader experience is required to further delineate device and patient selection as well as to document its long-term efficacy and safety。

Abstract：Background Palliative chemotherapy has been shown to have a survival benefit for patients with recurrent or metastatic gastric cancer.We conducted a Phase Ⅱ trial to determine the efficacy and safety of S-1 plus oxaliplatin (SOX regimen) as first-line chemotherapy for patients with unresectable locally advanced or metastatic gastric cancer.Methods Eligible patients had measurable lesions and no previous history of chemotherapy (except adjuvant chemotherapy).Oxaliplatin was administered intravenously at a dose of 130 mg/m2 on day 1.S-1 was administered orally in doses of 80,100,or 120 mg/d according to body surface areas of ＜1.25 m2,1.25-1.5 m2,or ＞1.5 m2 respectively;the total dose was divided into two daily doses on days 1-14.Treatments were repeated every 3 weeks until disease progression or intolerable toxicity occurred.Results Forty-three patients were enrolled in the study.All were assessable for efficacy and adverse events.The objective response and disease control rates were 55.8％ and 76.7％ respectively.The median follow-up time was 16.5 months.The median progression-free survival time was 7 months (95％ Cl,5.8-8.2 months) and the median overall survival time was 16.5 months (95％ Cl,9.7-23.3 months).The one-year survival rate was 54.2％.Major adverse reactions were grade 3/4 neutropenia (9.3％) and thrombocytopenia (20.9％).Conclusion The SOX regimen with oxaliplatin at a dose of 130 mg/m2 was found to be effective and safe as a first-line chemotherapy in Chinese patients with advanced gastric cancer。

Hypoxia inducible factor-1 (HIF-1) was first discovered by Semenza et al1 in 1991 as a protein which could specifically bind to the oligonucleotide sequence of the erythropoietin gene enhancer.The dimmers of HIF-1 were isolated in the following year.As its subunits were found to be induced by hypoxic conditions,it was subsequently named as hypoxia inducible factor.2 HIF-1,commonly found in human and mammalian cells,also expressed in normoxic conditions。

Here we reported a 59-year-old woman with diabetes who was found to have massive hemolysis associated with clostridium (C.) perfringens blood stream infection.She died 13 hours after admission in spite of aggressive treatment. The lady referred to our hospital with high fever,chills,body ache and right hypochondriac pain for 1 day。

Complex internal carotid artery (ICA) aneurysms include intracavemous,paraclinoid large/giant,dissecting and blood-blister aneurysms.Proximal parent artery occlusion (PAO) and trapping are long-practiced safe and effective option for these complex aneurysms.1 Trapping refers to both proximal and distal occlusion of parent artery including aneurysms,which is considered more reliable than proximal PAO due to without reverse flow.We hereby describe a rare case of subarachnoid hemorrhage (SAH)after trapping ICA to treat complex ICA aneurysms.The report was approved by the Ethics Committee of our institute and written informed consent was obtained from the patient。

The human WFDC2 protein,also known as human epididymal secretory protein 4 (HE4),is a new marker of tumor progression1 that is used for the differential diagnosis of ovarian cystadenocarcinomas.At present,the pathology of ovarian carcinomas is defined by the "dualistic model"2 and "heterogeneity of ovarian carcinomas"3 theories.Previously,it was considered that ovarian carcinomas originate from the ovaries themselves.The "dualistic model" assumes an external origin for ovarian carcinomas,in which it is considered that serous ovarian carcinomas originate from secondary implantation of oviduct mucosa epithelium.Epithelial ovarian carcinomas are not a single disease,but a set of "heterogeneous diseases"。

Statin is being used widely in patients who have hyperlipidemia,coronary arterial disease (CAD)or other atherosclerosis diseases.Analysis shows that lowering plasma low density lipoprotein cholesterol C (LDL-C) level depends on the dose and various statins treated.LDL-C will achieve the maximal effects after 7-10 days administration.1,2 Rosuvastatin is a hydrophilic statin,does not metabolize depending on cytochrome P 450 3A4,meaning less drug-drug interactions in cases of multipharmacy。

Optic neuritis is defined as inflammation of the optic nerve.Pain and vision loss are common symptoms of optic neuritis.The most frequent cause of optic neuritis is multiple sclerosis;other reasons include viral and bacterial infections,such as hepatitis B and syphilis。

An 11-years-old boy presented with 7 days history of abdominal pain,precordial pain and intermittent hematemesis.The physical examination revealed appearance of anemia,precordial tenderness without other positive findings。

Primary Hodgkin disease (HD) of bone is rare.The recognition on it is relatively confined.Both cases arising in male adults were suspected to be Potts disease (spinal tuberculosis) on imaging,and pathologic misdiagnosed initially.The clinical situations rapidly aggravated.The pathomorphology was remarkable malignant changed.They shared similar process in clinical,radiological and diagnostic process and could be representative.We retrospectively analyzed correlative results of them and review points of distinction from other disease entities that might be confused with it。

Hemophagocytic syndrome (HPS) is recognized as a disorder characterized by a variety of symptoms including fever,jaundice,skin rash,lymphadenopathy,and hepatosplenomegaly related to uncontrolled systemic T-cell activation.1 Two forms of HPS have been characterized:primary/familial hemophagocytic lymphohistiocytosis and secondary/reactive HPS.Reactive HPS was first described in 1979 by Risdall et al。

To the editor:Subcutaneous panniculitis-like T-cell lymphoma (SPTL) is an uncommon type of cutaneous lymphoma,especially SPTL accompanied with autoimmune disease has been rarely reported.Here we report a case of SPTL accompanied with discoid lupus erythematosus (DLE) and clinical features of dermatomyositis.A 34-year-old woman presented with facial plaque for 6 years and eyelid erythema,papules of the metacarpophalangeal joints and two masses in her breast and back for 4 months.Physical examination revealed symmetrical,violaceous erythema on her cheeks,forehead,eyelids and jaw,and papules over the metacarpophalangeal joints。

To the editor:A 28-year-old Chinese woman was referred for the evaluation of whitish macules.The macules firstly appeared in left upper back three years ago and then spread to left limb slowly but steadily in size.After the first gravidity at age of 26 years,the patient observed a marked acceleration of this process.She was previously diagnosed with pityriasis versicolor and was treated with ciclopirox cream and zinc pyfithione shampoo without improvement.There was no history of itching or dysaesthesia.The patient denied recreational sun exposure in past five years.When exposed to sunlight,the whitish macules did not change in the color whereas the non-affected skin became more tanned,thus the contrast against the whitish macules skin was remarkably intensified.There is no similar individual in her family.Skin findings of this patient consisted of scattered,partial confluent,non-scaly,well-defined,round or oval hypopigrnented macules which asymmetrically distributed on left upper back and left limb (Figure 1A and 1C),and no similar lesions on the other side of the body (Figure 1B).No signs of inflammation were present in these macules。

To the editor:a 34 year-old (gravida one,para one) female with a 1-year history of menorrhagia diagnosed 5 days earlier with cervical cancer was admitted to our hospital on April 16th,2009.Previous medical history and family history were not remarkable,and physical examination was normal.Gynecologic examination showed normal vagina with an 8 cm diameter hard cervical mass that bled easily.The uterus was normal and movable.No mass was found in the adnexal area.Lateral ligaments were not thickened.Ultrasound indicated cervical diameter was 5.9 cm with 5.7 cm × 5.8 cm low echo mass be identified.A cervical biopsy done after admission,the pathologic finding showed diffuse,medium-sized oval or round cells with high nuclear/cytoplasm ratio.Nuclei had an oval shape with weak basophilic staining and reticular-like chromatin with scantly distributed eosinophils.Nucleoli was small and immature。

To the editor:We present a fast growing conjunctival melanoma within 3 weeks after injury from the earthquake,which from a rice-size (about 3.0 mm x 4.0 mm) one proliferated rapidly into a giant mass with a size of 5.7 cm x 3.4 cm. A 76-year-old female who lived in Dujiangyan city,Sichuan,China,near the epicenter of the Wenchuan earthquake,was admitted into hospital for a fast growing big mass in the right orbit within 3 weeks.More than half a year ago,the patient found "a painless,rice-size,brown spot" (about 3.0 mm × 4.0 mm) in the temporal surface of right conjunctiva,and it did not change much.Three weeks ago,the Wenchuan earthquake happened,she fell down,the "rice-size brown spot" abrasion,and subconjunctival hemorrhage in the right eye occurred.Two weeks ago,the original rice-size spot grew into a big mass with discharge on the surface。

To the editor:Radiofrequency ablation is a potentially curative therapy for primary liver cancer,besides hepatic resection.In this letter,we report on a case of primary liver cancer that was initially treated unsuccessfully with radiofrequency ablation.The tumor was then resected surgically。

To the editor:A 15-year-old girl presented to the Hematology Outpatient Department of the Provincial Hospital Affiliated to Shandong University (China) with anemia and thrombocytopenia.Clinical investigation revealed pale lips,a few petechiae in her upper and lower limbs.Specifically,the firm,immobile and painless breast masses were noted to be approximately 8 cm.The preliminary bone marrow morphology in the community hospital indicated that the percentage of blast-like cells was high to 90.5％ and she was diagnosed as acute leukemia.Further leukemia immunophenotyping of single cell suspension showed the abnormal cells in bone marrow expressing CD56,CD81,partly expressing CD57,and rarely expressing CD117,CD34,HLA-DR,CD7,CD28,CD19,CD138,GlyA,cCD3,CD41 a,cMPO,and cCD79a。

To the editor:A 25-year-old male had been well until October 2009,when he developed abdominal pain,diarrhea,and fever.The results of the hematological examination were as follows.White blood cells were 108.76× 109/L.The bone marrow was hypercellular with 32.5％ lymophoblasts and 55.5％ infantile lymphocytes which were cytochemically positive for PAS.Flow cytometric analysis revealed that the blasts were positive for CD7,CD2,CD3,CD8,TCR-α-β-1,CD38,CD19,CD13,pgP,CD56,cyCD79a,and CD117。

To the editor:Dengue is a mosquito transmitted,newly emerging urban epidemic in tropical and subtropical countries.Usual symptoms are fever,headache,arthralgia and myalgia with severe prostration.Hemorrhagic manifestations as rash and thrombocytopenia are common.The two widely known,potentially fatal,complications are Dengue hemorrhagic fever and Dengue Shock Syndrome。

To the editor:We report a tricky subarachnoid haemorrhage (SAH).Our patient was a 59-year-old woman with generalized headache for 1 day,which was constricting in nature and rated grade 6/10.Her symptoms were aggravated by lying flat and improved with vomiting.The Glasgow coma scale was full,blood pressure was 142/83 mmHg and pulse 75 beats/min.There was neither neck stiffness nor focal neurological deficit.Fundoscopic examination was normal.She was noted to have hyponatremia (sodium (Na) 122 mmol/L) with serum osmolarity 263 mmol/kg,urine osmolarity 582 mmol/kg,urine Na 117 mmol/L,normal thyroid stimulating hormone and cortisol level.Plain computed tomography (CT) brain was normal (Figure 1A).Lumbar puncture (LP) was performed on day two,and multiple attempts were required。

To the editor:The number of studies of antibodies against neuronal surface antigens in patients with idiopathic or paraneoplastic limbic encephalitis (LE) has increased significantly.1 But γ-aminobutyric acid-B receptor antibodies (GABABR-ab) in patients with LE are rare.Detailed characteristics and responses to treatment remain unclear so far.Herein,we present a case of a female patient affected with LE and GABABR-ab positive in cerebrospinal fluid (CSF)。

To the editor:Eye movement disorder caused by cerebral stem infarction was common in clinical practice.1 However,isolated medial rectus palsy due to a tiny infarction lesion was rarely seen. An 80-year-old man with a 10-year history of hypertension and diabetes,presented to the hospital for a sudden onset of diplopia.Neurological examination of cranial nerves revealed left medial rectus palsy when gazing to the right side (Figure 1A)。