2020年 · 第133卷第05期

China has recently experienced extraordinary development in medical care and has achieved both Millennium Development Goals 4 and 5. According to the 2012 China Medical and Health Service White Paper, the pregnancy-related mortality rate (pregnancy-related deaths per 100,000 live births; PRMR) in China dropped from 51.3 in 2002 to 26.1 in 2011. A subnational analysis of 2852 Chinese counties between 1996 and 2015 has demonstrated that PRMR has declined from 108.7 in 1996 to 21.8 in 2015, with an annualized rate of decline of 8.5 % per year.^[1]According to the 2018 National Medical Service and Quality Safety Report, the PRMR in 2018 was 18.3 per 100,000 live births. In contrast, the PRMR in United States was 17.2 per 100,000 live births between 2011 and 2015.^[2]

In recent years, norepinephrine has attracted increasing attention for the management of maternal hypotension during elective cesarean section with spinal anesthesia. Intermittent bolus is a widely used administration paradigm for vasopressors in obstetric anesthesia in China. Thus, in this randomized, double-blinded study, we compared the efficacy and safety of equivalent bolus norepinephrine and phenylephrine for rescuing maternal post-spinal hypotension.

In a tertiary women’s hospital in Nanjing, China, 102 women were allocated with computer derived randomized number to receive prophylactic 8 μg norepinephrine (group N; n = 52) or 100 μg phenylephrine (group P; n = 50) immediately post-spinal anesthesia, followed by an extra bolus of the same dosage until delivery whenever maternal systolic blood pressure became lower than 80% of the baseline. Our primary outcome was standardized maternal cardiac output (CO) reading from spinal anesthesia until delivery analyzed by a two-step method. Other hemodynamic parameters related to vasopressor efficacy and safety were considered as secondary outcomes. Maternal side effects and neonatal outcomes were collected as well.

Compared to group P, women in group N had a higher CO (standardized CO 5.8 ± 0.9 vs. 5.3 ± 1.0 L/min, t = 2.37, P = 0.02) and stroke volume (SV, standardized SV 73.6 ± 17.2 vs. 60.0 ± 13.3 mL, t = 4.52, P < 0.001), and a lower total peripheral resistance (875 ± 174 vs. 996 ± 182 dyne·s/cm⁵, t = 3.44, P < 0.001). Furthermore, the incidence of bradycardia was lower in group N than in group P (2% vs. 14%, P= 0.023), along with an overall higher standardized heart rate (78.8 ± 11.6 vs. 75.0 ± 7.3 beats/min, P = 0.049). Other hemodynamics, as well as maternal side effects and neonatal outcomes, were similar in two groups (P > 0.05).

Compared to equivalent phenylephrine, intermittent bolus norepinephrine provides a greater CO for management of maternal hypotension during elective cesarean section with spinal anesthesia; however, no obvious maternal or neonatal clinical advantages were observed for norepinephrine.

The programmed intermittent epidural bolus (PIEB) technique is widely used in labor analgesia, but the parameter settings of PIEB have not yet been standardized. We designed a study to identify the optimal interval duration for PIEB using 10 mL of ropivacaine 0.08% and sufentanyl 0.3 μg/mL, a regimen commonly used to control labor pain in China, to provide effective analgesia in 90% of women during the first stage of labor without breakthrough pain.

We conducted a double-blind sequential allocation trial to obtain the effective interval 90% (EI90%) during the first stage of labor between April 2019 and May 2019. This study included the American Society of Anesthesiologists physical status II–III nulliparous parturients at term, who requested epidural analgesia. The bolus volume was fixed at 10 mL of ropivacaine 0.08% with sufentanyl 0.3 μg/mL. Participants were divided into four groups (groups 60, 50, 40, and 30) according to the PIEB intervals (60, 50, 40, and 30 min, respectively). The interval duration of the first parturient was set at 60 min and that of subsequent parturients varied according to a biased-coin design. The truncated Dixon and Mood method and the isotonic regression analysis method were used to estimate the EI90% and its 95% confidence intervals (CIs).

Forty-four women were enrolled in this study. The estimated optimal interval was 44.1 min (95% CI 41.7–46.5 min) and 39.5 min (95% CI 32.5–50.0 min), using the truncated Dixon and Mood method and isotonic regression analysis, respectively. The maximum sensory block level above T6 was in nearly 20% of parturients in group 30; however, 5.3%, 0%, and 0% of the parturients presented with sensory block level above T6 in groups 40, 50, and 60, respectively. There were no cases of hypotension and only one parturient complained of motor block.

With a fixed 10 mL dose of ropivacaine 0.08% with sufentanyl 0.3 μg/mL, the optimal PIEB interval is about 42 min. Further studies are warranted to define the efficacy of this regimen throughout all stages of labor.

Chinese Clinical Trial Registry, ChiCTR1900022199; http://www.chictr.org.cn/com/25/historyversionpuben. aspx?regno=ChiCTR1900022199.

Nalbuphine has been suggested to be used for post-cesarean section (CS) intravenous analgesia. However, ideal concentration of nalbuphine for such analgesia remains unclear. The present study was conducted to explore an ideal concentration of nalbuphine for post-CS intravenous analgesia by evaluating the analgesic effects and side-effects of three different concentrations of nalbuphine combined with hydromorphone for post-CS intravenous analgesia in healthy parturients.

One-hundred-and-fourteen parturients undergoing elective CS were randomly allocated to one of three groups (38 subjects per group) according to an Excel-generated random number sheet to receive hydromorphone 0.05 mg/mL + nalbuphine 0.5 mg/mL (group LN), hydromorphone 0.05 mg/mL + nalbuphine 0.7 mg/mL (group MN), and hydromorphone 0.05 mg/mL + nalbuphine 0.9 mg/mL (group HN) using patient-controlled analgesia (PCA) pump. Visual analog scale (VAS) for pain, PCA bolus demands, cumulative PCA dose, satisfaction score, Ramsay score, and side-effects such as urinary retention were recorded.

The number of PCA bolus demands and cumulative PCA dose during the first 48 h after CS were significantly higher in group LN (21 ± 16 bolus, 129 ± 25 mL) than those in group MN (15 ± 10 bolus, 120 ± 16 mL) (both P < 0.05) and group HN (13 ± 9 bolus, 117 ± 13 mL) (both P < 0.01), but no difference was found between group HN and group MN (both P > 0.05). VAS scores were significantly lower in group HN than those in group MN and group LN for uterine cramping pain at rest and after breast-feeding within 12 h after CS (all P < 0.01) and VAS scores were significantly higher in group LN than those in group MN and group HN when oxytocin was intravenously infused within 3 days after CS (all P < 0.05), whereas VAS scores were not statistically different among groups for incisional pain (all P > 0.05). Ramsay sedation scale score in group HN was significantly higher than that in group MN at 8 and 12 h after CS (all P < 0.01) and group LN at 4, 8, 12, 24 h after CS (all P < 0.05).

Hydromorphone 0.05 mg/mL + nalbuphine 0.7 mg/mL for intravenous PCA could effectively improve the incisional pain and uterine cramping pain management and improve comfort in patients after CS.

ChiCTR1800015014, http://www.chictr.org.cn/Chinese Clinical Trial Registry.

Texture features were the intrinsic properties of the human tissues and could efficiently detect the subtle functional changes of involved tissue. The pathologic changes of the lateral pterygoid muscle (LPM) were significantly correlated with the temporomandibular disc displacement. However, the occult functional changes of LPM could not be detected by the naked eye on the medical images. The current study was aimed to evaluate the functional changes of the LPM in the patients with temporomandibular disorders (TMDs) using texture analysis.

Twenty-nine patients with TMD were performed with magnetic resonance (MR) imaging on a 3.0T MR scanner, who were consecutively recruited from the TMD clinic of Hainan Hospital of Chinese People’s Liberation Army General Hospital from February 2019 to September 2019. The patients were classified into three groups according to the disc displacement: disc without displacement (DWoD), disc displacement with reduction (DDWR) and disc displacement without reduction (DDWoR). The gray-level co-occurrence matrix method was applied with the texture analysis of LPM on the axial T2-weighted imaging. The texture features included angular second moment, contrast, correlation, inverse different moment, and entropy. One-way analysis of variance was used for grouped comparisons and receiver operating characteristics (ROC) curve analysis was applied to evaluate the diagnostic efficacy of the texture parameters.

Texture contrast of LPM presented significantly lower in DDWoR (46.30 [35.03, 94.48]) than that in DWoD (123.85 [105.06, 143.23]; test statistic= 23.05; P < 0.001). Texture entropy of LPM showed significant differences among DWoD (7.62 ± 0.33), DDWR (6.76 ± 0.35), and DDWoR (6.46 ± 0.39) (P_DWoD-DDWR < 0.001, P_DWoD-DDWoR < 0.001, and P_DDWR-DDWoR = 0.014). Area under the ROC curve (AUC) demonstrated that texture entropy had an excellent diagnostic accuracy for DWoD-DDWR (AUC = 0.96) and DWoD-DDWoR (AUC = 0.98).

The texture contrast and entropy could identify the altered functional status of LPM in patients with TMD and could be considered as the effective imaging biomarker to evaluate the functional changes of LPM in TMD.

Whether occupation has an impact on contact heat evoked potential (CHEP) results has not been investigated. In this study, we investigated the difference of CHEP parameters between knowledge workers and unskilled labors.

A total of 137 healthy participants were recruited between November 20, 2014 and December 31, 2016. All participants underwent neurologic examination, laboratory examination, and nerve conduction studies. CHEP was performed on four body sites: the upper border of the distal third of the volar forearm, the upper border of the distal third of the lateral leg, the spinous process of seventh cervical vertebrae (C7), and the spinous process of 12th thoracic vertebrae (T12). Independent t test and nonparametric test were performed using SPSS software to compare the difference of the CHEP parameters between knowledge workers and unskilled labors.

The "N₂ latency/height" (Z = -2.290, P = 0.022) and "P₂ latency/height" (Z = -2.020, P = 0.043) on the volar forearm of unskilled labors significantly increased than those of knowledge workers. The "N₂ latency/height" (F = 6.348, P = 0.016) and "P₂ latency/height" (F = 5.920, P = 0.018) in the distal leg of unskilled labors significantly prolonged than those of knowledge workers. The N₂-P₂ amplitude (F = 5.797, P = 0.020) in the distal leg of unskilled labors significantly decreased than those of knowledge workers.

Our study found that significantly prolonged N₂ latency and P₂ latency and significantly decreased N₂-P₂ amplitude in the distal leg and the volar forearm in unskilled labors as to knowledge workers.

The eosinophilic chronic obstructive pulmonary disease (COPD) is known to be more sensitive to corticosteroid. The sputum microbiome has been shown to affect COPD prognosis, but its role in acute exacerbations of eosinophilic COPD is unclear. This study aimed to investigate the dynamic changes of the airway microbiome in patients with acute exacerbations of eosinophilic COPD.

Fifty-seven patients with acute exacerbations of COPD from the First Affiliated Hospital of Guangxi Medical University between June 2017 and June 2018 were divided into two groups. Patients with eosinophils ≥300 cells/μL in the peripheral venous blood were assigned to the eosinophilic group (Eos) and the rest to the non-eosinophilic group (Noneos). All patients received similar treatment including inhaled budesonide according to the guidelines. The induced sputum microbiome was analyzed on the 1st and 7th day of treatment using the 16S ribosomal RNA (rRNA) method. The levels of interleukin (IL)-6 and IL-8 were measured in the plasma and the sensitivity to corticosteroids was determined in isolated peripheral blood mononuclear cells. Quantitative data were compared between the two groups using the independent samples t test or Mann-Whitney U test. Categorical data were evaluated using Chi-squared test or Fisher’s exact test.

Twenty-six patients were classified into Eos group and 31 patients were classified into Noneos group. Prior to treatment, the alpha diversity (Shannon index) (2.65 ± 0.63 vs. 2.56 ± 0.54, t = 0.328, P = 0.747) and the structure of the sputum microbiome were similar in the Eos group and the Noneos group. After 7 days of treatment, alpha diversity increased in both groups, while the microbiome richness (Ace index) was significantly lower in the Eos group (561.87 ± 109.13 vs. 767.88 ± 148.48, t = -3.535, P = 0.002). At the same time, IL-6 (12.09 ± 2.85 pg/mL vs. 15.54 ± 2.45 pg/mL, t = -4.913, P < 0.001) and IL-8 (63.64 ± 21.69 pg/mL vs. 78.97 ± 17.13 pg/mL, t = -2.981, P = 0.004) decreased more significantly in the Eos group, and the percentages of inhibition of IL-8 at dexamethasone concentrations 10^-8 to 10^-6 mol/L were significantly higher in the Eos group than those in the Noneos group (all P < 0.05).

The induced sputum microbiome richness decreased more significantly following treatment in the Eos patients compared to the Noneos patients. The lower plasma inflammatory factor levels and the higher percentage of inhibition of IL-8 might be due to higher corticosteroid sensitivity in Eos patients.

After neoadjuvant chemotherapy (NAC), non-pathological complete response of breast cancer patients can benefit from tailored adjuvant chemotherapy. However, it is difficult to select patients with poorer prognosis for additional adjuvant chemotherapy to maximize the benefits. Our study aimed to explore whether the subtypes of tumor-infiltrating lymphocytes (TILs) in residual tumors (RT) is related to the prognosis of triple-negative breast cancer (TNBC) after NAC.

Data from patients with primary TNBC consecutively diagnosed at the Breast Disease Center of Peking University First Hospital from 2008 to 2014 were retrieved, and the cases with RT in the breast after NAC were enrolled. TILs subtypes in RT were observed by double-staining immunohistochemistry, and counted with the median TILs value per square millimeter as the cut-off to define high versus low TILs density in each subtype. The relationships between the TIL density of each subgroup and the clinicopathological characteristics of the RT after NAC patients were analyzed by Fisher exact test. Disease-free survival (DFS) and overall survival (OS) were analyzed by the Kaplan-Meier method and log-rank statistics.

A total of 37 eligible patients were included in this study, and the median follow-up period was 50 months (range 17–106 months). There was no significant correlation between the infiltrate density of CD4⁺, CD8⁺, CD20⁺, and CD68⁺ lymphocytes and clinic-pathological characteristics. Significantly better prognosis was observed in patients with high CD4⁺-TILs (DFS: P = 0.005, OS: P = 0.021) and high CD8⁺-TILs (DFS: P = 0.018) and low CD20⁺-TILs (OS: P = 0.042). Further analysis showed that patients with CD4⁺/CD20⁺ ratio greater than 1 (DFS: P = 0.001, OS: P = 0.002) or CD8⁺/CD20⁺ ratio greater than 1 (DFS: P = 0.009, OS: P = 0.022) had a better prognosis.

Subtypes of TILs in RT is a potential predictive biomarker of survival in TNBC patients after NAC.

Although the use of expanded-criteria donors (ECDs) alleviates the problem of organ shortage, it significantly increases the incidence of delayed graft function (DGF). DGF is a common complication after kidney transplantation; however, the effect of DGF on graft loss is uncertain based on the published literature. Hence, the aim of this study was to determine the relationship between DGF and allograft survival.

We conducted a retrospective, multicenter, observation cohort study. A total of 284 deceased donors and 541 recipients between February 2012 and March 2017 were included. We used logistic regression analysis to verify the association between clinical parameters and DGF, and Cox proportional hazards models were applied to quantify the hazard ratios of DGF for kidney graft loss.

Among the 284 deceased donors, 65 (22.8%) donors were ECD. Of the 541 recipients, 107 (19.8%) recipients developed DGF, and this rate was higher with ECD kidneys than with standard-criteria donor (SCD) kidneys (29.2% vs. 17.1%; P = 0.003). The 5-year graft survival rate was not significantly different between SCD kidney recipients with and without DGF (95.8% vs. 95.4%; P= 0.580). However, there was a significant difference between ECD kidney recipients with and without DGF (71.4% vs. 97.6%; P = 0.001), and the adjusted hazard ratio (HR) for graft loss for recipients with DGF was 1.885 (95% confidence interval [CI] = 1.305–7.630; P = 0.024). Results showed that induction therapy with anti-thymocyte globulin was protective against DGF (odds ratio= 0.359; 95% CI= 0.197–0.652; P= 0.001) with all donor kidneys and a protective factor for graft survival (HR = 0.308; 95% CI = 0.130–0.728; P = 0.007) with ECD kidneys.

DGF is an independent risk factor for graft survival in recipients with ECD kidneys, but not SCD kidneys.

A surgical site infection (SSI) is a major post-operative complication from elective colorectal surgery; however, few studies have focused on evaluating the risk factors for SSI. This study aimed to analyze the relative correlation of medical and environmental factors as well as patient-related factors that contribute to the incidence of all types of SSI.

A retrospective search for eligible patients was conducted using the patient database of the Gastrointestinal Surgery Center of the Third Affiliated Hospital of Sun Yat-sen University from January 2011 to August 2017. Pre-operative demographic and surgical data were extracted and recoded according to the study protocol. Univariate and multivariate analyses were performed to clarify factors affecting the incidence of SSI. Propensity analysis was conducted to minimize bias in the demographic characteristics to explore the prophylactic effect of pre-operative administration of oral antibiotics.

Univariate analysis of the baseline characteristics revealed that younger age (odds ratio [OR]: 0.378; 95% confidence interval [CI]: 0.218–0.657) and pre-operative oral antibiotic use (OR: 0.465; 95% CI: 0.255–0.850) were protective factors, while pre-operative anemia (OR: 4.591; 95% CI: 2.567–8.211), neoadjuvant chemotherapy history (OR: 2.398; 95% CI: 1.094–5.256), and longer surgical duration (OR: 2.393; 95% CI: 1.349–4.246; P = 0.002) were identified as risk factors for SSI. Multivariate analysis indicated that age (P = 0.003), surgical duration (P = 0.001), and pre-operative oral antibiotic use (P < 0.001) were independent factors that affect the incidence of SSI. Furthermore, a propensity-matched analysis confirmed the protective effect of oral antibiotic use, with a 1-day course of oral antibiotic producing a similar effect to a 3-day course.

Age, surgical duration, and pre-operative oral antibiotic use were associated with the incidence of SSI. However, pre-operative oral antibiotic use was the only controllable factor. From the results of our study, pre-operative oral antibiotic use is recommended before elective colorectal surgery and a 1-day course is enough to provide the protective effect.

Although the impact of tumor complexity on peri-operative outcomes has been well established using several nephrometry scoring systems, the impact of adherent perirenal fat remains poorly defined. This study aimed to develop a novel nephrometry scoring system for predicting the peri-operative outcomes of laparoscopic partial nephrectomy (LPN) by integrating and optimizing the RENAL score (RNS) and Mayo adhesive probability (MAP) score.

We retrospectively evaluated 159 patients treated with retroperitoneal LPN. The patients’ demographic parameters, RNSs, and MAP scores were evaluated as potential predictors of perioperative outcomes, including operation time, estimated blood loss (EBL), and margin, ischemia, and complication (MIC) achievement rate. The independent predictors were used to develop a novel nephrometry scoring system. The predictive value and inter-observer agreement for the novel nephrometry scoring system were evaluated.

Tumor radius (R score), nearness to the renal sinus or collecting system (N score), and posterior perinephric fat thickness were independent predictors of peri-operative outcomes and were used to develop the RNP score. The univariate analysis revealed that the RNP score was significantly associated with operation time, EBL, and MIC achievement rate (P < 0.050). The RNP score was an independent predictor of operation time (P < 0.001), EBL (P = 0.018), and MIC achievement rate (P = 0.023) in the multivariate analysis. The RNP score was not inferior to RNS in the area under the curve for predicting peri-operative outcomes and performed better in inter-observer agreement (76.7% vs. 57.8%) and kappa value (0.804 vs. 0.726).

The RNP score, combining the advantages of the RNS and MAP score, demonstrated a good predictive value for the peri-operative outcomes of retroperitoneal LPN and better inter-observer agreement.

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

Labor is a complex process and labor pain presents challenges for analgesia. Epidural analgesia (EA) has a well-known analgesic effect and is commonly used during labor. This review summarized frequently encountered and controversial problems surrounding EA during labor, including the labor process and maternal intrapartum fever, to build knowledge in this area.

We searched for relevant articles published up to 2019 in PubMed using a range of search terms (eg, "labor pain," "epidural," "analgesia," "labor process," "maternal pyrexia," "intrapartum fever" ).

The search returned 835 articles, including randomized control trials, retrospective cohort studies, observational studies, and reviews. The articles were screened by title, abstract, and then full-text, with a sample independently screened by two authors. Thirty-eight articles were included in our final analysis; 20 articles concerned the labor process and 18 reported on maternal pyrexia during EA.

Four classic prospective studies including 14,326 participants compared early and delayed initiation of EA by the incidence of cesarean delivery. Early initiation following an analgesia request was preferred. However, it was controversial whether continuous use of EA in the second stage of labor induced adverse maternal and neonatal outcomes due to changes in analgesic and epidural infusion regimens. There was a high incidence of maternal pyrexia in women receiving EA and women with placental inflammation or histologic chorioamnionitis compared with those receiving systemic opioids.

Early EA (cervical dilation ≥1 cm) does not increase the risk for cesarean section. Continuous epidural application of low doses of analgesics and programmed intermittent epidural bolus do not prolong second-stage labor duration or impact maternal and neonatal outcomes. The association between EA and maternal pyrexia remains controversial, but pyrexia is more common with EA than without. A non-infectious inflammatory process is an accepted mechanism of epidural-related maternal fever.

Being the focus of worldwide attention nowadays, severe pain during labor and delivery is an important topic in pain treatment. As an effective intervention to alleviate labor pain, the administration of labor analgesia did not start late in China, but its development has faced many difficulties, and its dissemination and popularization have faltered. This article provides a perspective on the low labor analgesia rate in China and practical solutions for its improvement.

Anaphylaxis is a rare, but severe, potentially life-threatening allergic reaction, which most commonly presents with multi-system involvements, such as cutaneous, cardiovascular, respiratory, gastrointestinal and central nervous system signs and symptoms. It can hardly be recognized when occurring in the perioperative period due to the many influencing factors, for example, the cutaneous changes concealed by sterile drapes, inability to describe their symptoms when patients are sedated or anesthetized, and the application of anesthetics leading to sympathetic blockade which presents with blood pressure decrease. All of the above reasons make the identification and immediate treatment of perioperative anaphylaxis difficult and are partially attributable to high mortality.

During labor, most women suffer exceptionable pain, especially after the first stage of labor. Numerous studies and research contributions have confirmed that neuraxial labor analgesia (NLA) is an effective, safe, and cost-effective method to relieve pain during labor.^[1]More than a decade ago, a British survey on epidural analgesia reported that 90% of centers offered 24 h epidural analgesia.^[2]In comparison, according to surveys conducted in 2006 by the First Hospital of Peking University of China, among the 76 hospitals in China that performed NLA, only ten hospitals (13.1%) offered 24 h service.^[3]Although some improvements have been made in recent years, the overall rate of analgesia use during labor in China is still low compared to western counterparts.

In China, patients with advanced laryngeal cancer are treated either with radical surgery followed by adjuvant radiotherapy or with non-surgical comprehensive treatment for organ preservation. Although important clinical trials have confirmed the possibility of laryngeal organ preservation in the treatment of advanced laryngeal cancer,^[1,2]the best larynx-preservation strategy continues to be debated.^[3,4]Here, we evaluated the efficacy of non-surgical comprehensive treatment that sought to preserve laryngeal function for patients with advanced laryngeal carcinoma.

To the Editor:Most researchers in China are concerned that the whole labor process of traditional continuous epidural analgesia (CEA) will hinder the maternal force in the second stage of labor. In contrast, a local anesthetic drug can be used for a relatively long time. Excessive intraspinal administration may inhibit the contraction of the uterine smooth muscle,^[1]which may lead to a longer labor stage, increased oxytocin use, and increased rates of forceps delivery, cesarean section, and neonatal asphyxia. Therefore, some obstetricians and midwives in China choose to stop epidural labor analgesia when the cervix opens to 7 to 8 cm or at complete cervical dilation. Thus, most parturients cannot enjoy ideal full-term labor analgesia.

To the Editor:A 29-year-old nulliparous woman (weight 68 kg, height 159 cm) at 31 ± 1 gestational weeks was admitted to the West China Second Hospital, complaining of lower limb edema for 3 months and dyspnea for 1 week, which had become more severe over the last 2 days. She was confirmed pregnant at a local hospital after experiencing amenorrhea for 40 days. All routine tests were normal until she was found to be anemic without symptoms at 18 gestational weeks. Her hemoglobin (Hb) was 77 g/L without thalassemia. After oral intake of a polysaccharide iron complex for 4 weeks, her Hb increased to 81 g/L with edema in her lower limbs. Urine testing was positive for protein (+) and occult blood (3+). At 30 gestational weeks, she felt chest distress, palpitations, and fatigue and could not maintain a supine position at night. A routine blood examination showed an Hb level of 67 g/L, and the transthoracic echocardiography showed mild mitral stenosis with moderate regurgitation and mild pericardial effusion. She was then admitted to our emergency hospital with orthopnea and edema. Her physical examination showed a heart rate of 120 beats/min and blood pressure of 110/70 mmHg. A wet rale could be heard at the left lung. Laboratory tests showed that her Hb was 73 g/L, brain natriuretic peptide (NT-BNP) 10,300 pg/mL, troponin 0.098 μg/L, myohemoglobin 146.4 μg/L, glutamic-pyruvic transaminase 98 IU/L, glu- tamic oxalacetic transaminase 100 IU/L, albumin 25.7 g/L, urea nitrogen (BU) 11.64 mmol/L, creatinine (Cr) 138 mmol/L, and potassium 5.63 mmol/L. The urine test was positive for protein (3+). An ultrasound test showed left pleural effusion. After multiple department consultations, the pregnancy was terminated to improve the patient’s situation.

To the Editor:Lumbar spinal canal stenosis (LSCS) is a common disease among older individuals. Hypertrophic lumbar ligamentum flavum (LLF) plays a vital role in the pathogenesis of LSCS. The physiological LLF is a kind of dense connective tissue with thickness of 2 to 4 mm, which is mainly composed of fibroblasts and extracellular matrix (ECM). ECM contains elastic, collagen fibers and ground substances. The distribution characteristics of fibers show that a large number of elastic fibers are mixed with a small amount of the collagen fibers; mainly type I and type III collagen fibers. These fibers are arranged tightly and regularly along the direction of column’s axis. The LLF is located in the dorsal part of the dura mater of the spinal canal, and it attaches to the upper border and lower parts of anterior surfaces of the laminas. The hypotrophy of LLF is the consequence of several factors such as aging, inflammatory process, stress loading and genetic predisposition. Once the hypertrophy of LLF occurs, it can cause the stenosis for the central spinal canal, nerve root canal and intervertebral foramen. This pathology can lead to low back pain, sciatica, and even urinary and bowel disorders.

To the Editor: Angiosarcoma (AS) is a rare and highly malignant mesenchymal tumor that accounts for 2% of adult soft tissue sarcomas. The prognosis of AS is poor due to the high rate of metastasis and reoccurrence. According to a retrospective study by Lahatet aland Fayetteet al,^[1,2]31 of 121 (19%) patients had metastases upon initial diagnosis, and 90 (74%) had relapse and progression. The median survival of AS was 3.4 years, declining to 10 months in patients with metastasis. To attempt to improve AS treatment outcomes, a multimodality approach is advocated, including surgical resection combined with radiation, chemotherapy, immunotherapy, and/or anti-angiogenetic therapy. Herein, we present a man who previously underwent resection of a mesorectal-derived intermediate hemangioendothelioma (HAE) and developed pulmonary metastasis of AS within a year. The history is remarkable because of (1) the rare primary location: only 2 cases were mesenteric-related; (2) the uncharacteristic clinical course: the primary diagnosis of intermediate hemangioendothelioma later progressed to pulmonary metastatic AS; and (3) a successful series of multidisciplinary therapeutic procedures, especially selective arterial infusion (SAI) chemotherapy before metastases resection.

To the Editor:Acute generalized exanthematous pustulosis (AGEP) is a rare clinical reaction mainly induced by drugs, characterized by an acute onset of generalized, non-follicular sterile pustules on erythematous skin with fever and increased neutrophil count, which is usually accompanied by a relatively favorable prognosis.^[1]Hereby, we present a special case of AGEP complicated with pemphigus foliaceus (PF).