Volume 128 · Issue 19 · 2015

Premature ventricular contractions (PVCs) are common in the general population, and frequent PVCs may result in the poor quality of life or even the damage of cardiac function. We examined the efficacy and safety of a traditional Chinese medicine Wenxin Keli for the treatment of frequent PVCs among a relatively large Chinese cohort.

We performed a randomized, double-blind, placebo-controlled, parallel-group, multicenter trial. A total of 1200 eligible participants were randomly assigned in a ratio of 1:1 to receive Wenxin Keli or the placebo for 4 weeks. The primary and secondary endpoint was the change of PVC numbers and PVC-related symptoms after a 4-week treatment compared with baseline, respectively. In addition, vital signs, laboratory values, and electrocardiographic parameters were assessed in a safety analysis.

At the initial evaluation, no significant differences in the baseline characteristics were observed between the Wenxin Keli group and the placebo group. A smaller number of PVCs was observed after the 4-week treatment than at baseline, in both the Wenxin Keli group (5686 ± 5940 vs. 15,138 ± 7597 beats/d, P < 0.001) and the placebo group (10,592 ± 8009 vs. 14,529 ± 5929 beats/d, P < 0.001); moreover, the Wenxin Keli group demonstrated a significantly greater reduction in the frequency of PVCs than the placebo group (P < 0.001). In a full analysis set, patients in the Wenxin Keli group exhibited significantly higher total effective responses in the reduction of PVCs compared to those in the placebo group (83.8% vs. 43.5%, P< 0.001). The per-protocol analysis yielded similar results (83.0% vs. 39.3%, P< 0.001). Treatment with Wenxin Keli also demonstrated superior performance compared to the placebo with respect to PVC-related symptoms. No severe adverse effects attributable to Wenxin Keli were reported.

Wenxin Keli treatment effectively reduced the overall number of PVCs and alleviated PVC-related symptoms in patients without structural heart diseases and had no severe side effects.

Intravoxel incoherent motion (IVIM) has the potential to provide both diffusion and perfusion information without an exogenous contrast agent, its application for the brain is promising, however, feasibility studies on this are relatively scarce. The aim of this study is to assess the feasibility of IVIM perfusion in patients with acute ischemic stroke (AIS).

Patients with suspected AIS were examined by magnetic resonance imaging within 24 h of symptom onset. Fifteen patients (mean age was 68.7 ± 8.0 years) who underwent arterial spin labeling (ASL) and diffusion-weighted imaging (DWI) were identified as having AIS with ischemic penumbra were enrolled, where ischemic penumbra referred to the mismatch areas of ASL and DWI. Eleven different b-values were applied in the biexponential model. Regions of interest were selected in ischemic penumbras and contralateral normal brain regions. Fast apparent diffusion coefficients (ADCs) and ASL cerebral blood flow (CBF) were measured. The paired t-test was applied to compare ASL CBF, fast ADC, and slow ADC measurements between ischemic penumbras and contralateral normal brain regions. Linear regression and Pearson’s correlation were used to evaluate the correlations among quantitative results.

The fast ADCs and ASL CBFs of ischemic penumbras were significantly lower than those of the contralateral normal brain regions (1.93 ± 0.78 μm²/ms vs. 3.97 ± 2.49 μm²/ms, P = 0.007; 13.5 ± 4.5 ml·100 g^-1·min^-1 vs. 29.1 ± 12.7 ml·100 g^-1·min^-1, P < 0.001, respectively). No significant difference was observed in slow ADCs between ischemic penumbras and contralateral normal brain regions (0.203 ± 0.090 μm²/ms vs. 0.198 ± 0.100 μm²/ms, P = 0.451). Compared with contralateral normal brain regions, both CBFs and fast ADCs decreased in ischemic penumbras while slow ADCs remained the same. A significant correlation was detected between fast ADCs and ASL CBFs (r = 0.416, P < 0.05). No statistically significant correlation was observed between ASL CBFs and slow ADCs, or between fast ADCs and slow ADCs (r = 0.111, P = 0.558; r = 0.200, P = 0.289, respectively).

The decrease in cerebral blood perfusion primarily results in the decrease in fast ADC in ischemic penumbras; therefore, fast ADC can reflect the perfusion situation in cerebral tissues.

High intracuff pressure can cause severe pharyngeal complications including sore throat or hoarseness after laryngeal mask airway (LMA) removal postoperatively. Though the application of minimum effective cuff inflating volume is suggested to maintain airway sealing and adequacy of ventilation for patients receiving general anesthesia with LMA at lower level of the intracuff pressure, it is currently not a standard care in most of the anesthetic departments. In this study, the minimum effective cuff inflating volume was determined for classic LMA Well Lead^TM (Well Lead Medical Co., Ltd., China) and its impact on postoperative pharyngeal complications was also explored.

Patients with American Society of Anesthesiologists physical status (I–III) undergoing the short-duration urological surgery were recruited in this trial. First, the minimum effective cuff inflating volume was determined for size 4 or 5 LMA Well Lead^TM in the study 1. Immediately following placement and confirmation of ideal LMA position, the cuff was inflated with 5, 7, 10 ml of air and up to 30 ml at 5 ml increment. The intracuff pressure, oropharyngeal leak pressure (OLP), and inspiratory peak airway pressure under positive pressure ventilation at the corresponding cuff volume as indicated above were recorded. Second, the enrolled patients were randomly allocated into minimum effective cuff inflating volume group (MC) and routine care (RC) group in the study 2. The minimum effective cuff inflating volume was applied and maintained in MC group, whereas the cuff volume was inflated with half of the maximum cuff inflating volume recommended by manufacturer in RC group throughout the surgical procedure and stay in postanesthesia care unit prior to LMA removal. The incidence of pharyngeal complications at 0, 2, 24, and 48 h after removal of LMA and other intra-operative adverse events were also documented.

The intracuff pressure varied with the cuff inflating volume in a positive linear correlation manner (Y = 11.68X − 42.1, r²=0.9191) under the range of 5–30 ml for size 4 LMA. In similar with size 4 LMA, the data were also showed the linear relationship between the intracuff pressure and the cuff inflating volume (Y = 7.39X − 10.9, r²=0.8855) for size 5 LMA. The minimal effective cuff inflating volume for size 4 or 5 LMA was 7–9 ml in combination of considering OLP needed to maintain airway sealing during intermittently positive pressure ventilation. The intracuff pressure in MC group was lower compared with RC group (63.0 ± 3.7 vs. 126.4 ± 24.0 cmH₂O for size 4 LMA; 55.6 ± 2.4 vs. 138.5± 26.8 cmH₂O for size 5 LMA; P < 0.0001). The incidence of pharyngeal adverse events was lower in MC group versus the RC group at 2, 24 h after LMA removal.

The relationship between the cuff inflating volume and the intracuff pressure for size 4 or 5 LMA Well Lead^TM is in a linear correlation manner at the range of 5–30 ml. The minimal cuff inflating volume is adequate for satisfactory airway sealing and consequently associated with lower incidence of postoperative pharyngeal complications for LMA Well Lead.^TM

Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery. This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia.

Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Patients received 6, 8, 10, 12, or 14 mg intrathecal hyperbaric ropivacaine with 5 µg sufentanil. Successful spinal anesthesia was defined as a T₄ sensory level achieved with no need for epidural supplementation. The 50% effective dose (ED₅₀) and 95% effective dose (ED₉₅) were calculated with a logistic regression model.

ED₅₀ and ED₉₅ of intrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA) were 8.28 mg (95% confidence interval [CI]: 2.28–9.83 mg) and 12.24 mg (95% CI: 10.53–21.88 mg), respectively.

When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery, the ED₅₀ and ED₉₅ of intrathecal hyperbaric ropivacaine along with 5 µg sufentanil were 8.28 mg and 12.24 mg, respectively. In addition, this local anesthetic is unsuitable for emergent cesarean delivery, but it has advantages for ambulatory patients.

Fetal congenital heart anomalies are the most common congenital anomalies in live births. Fetal echocardiography (FECG) is the only prenatal diagnostic approach used to detect fetal congenital heart disease (CHD). FECG is not widely used, and the antenatal diagnosis rate of CHD varies considerably. Thus, mastering the anatomical characteristics of different kinds of CHD is critical for ultrasound physicians to improve FECG technology. The aim of this study is to investigate the applications of a fetal CHD anatomic database in FECG teaching and training program.

We evaluated 60 transverse section databases including 27 types of fetal CHD built in the Prenatal Diagnosis Center in Peking University People’s Hospital. Each original database contained 400–700 cross-sectional digital images with a resolution of 3744 pixels × 5616 pixels. We imported the database into Amira 5.3.1 (Australia Visage Imaging Company, Australia) three-dimensional (3D) software. The database functions use a series of 3D software visual operations. The features of the fetal CHD anatomical database were analyzed to determine its applications in FECG continuing education and training.

The database was rebuilt using the 3D software. The original and rebuilt databases can be displayed dynamically, continuously, and synchronically and can be rotated at arbitrary angles. The sections from the dynamic displays and rotating angles are consistent with the sections in FECG. The database successfully reproduced the anatomic structures and spatial relationship features of different fetal CHDs. We established a fetal CHD anatomy training database and a standardized training database for FECG. Ultrasound physicians and students can learn the anatomical features of fetal CHD and FECG through either centralized training or distance education.

The database of fetal CHD successfully reproduced the anatomic structures and spatial relationship of different kinds of fetal CHD. This database can be widely used in anatomy and FECG teaching and training.

Myocarditis is an uncommon but serious manifestation of systemic lupus erythematosus (SLE). This study aimed to investigate clinical characteristics and outcomes of lupus myocarditis (LM) and to determine risk factors of LM in hospitalized Chinese patients with SLE.

We conducted a retrospective case–control study. A total of 25 patients with LM from 2001 to 2012 were enrolled as the study group, and 100 patients with SLE but without LM were randomly pooled as the control group. Univariable analysis was performed using Chi-square tests for categorical variables, and the Student’s t-test or Mann–Whitney U-test was performed for continuous variables according to the normality.

LM presented as the initial manifestation of SLE in 7 patients (28%) and occurred mostly at earlier stages compared to the controls (20.88 ± 35.73 vs. 44.08 ± 61.56 months, P= 0.008). Twenty-one patients (84%) experienced episodes of symptomatic heart failure. Echocardiography showed that 23 patients (92%) had decreased left ventricular ejection fraction (<50%) and all patients had wall motion abnormalities. A high SLE Disease Activity Index was the independent risk factor in the development of LM (odds ratio = 1.322, P< 0.001). With aggressive immunosuppressive therapies, most patients achieved satisfactory outcome. The in-hospital mortality was not significantly higher in the LM group than in the controls (4% vs. 2%, P= 0.491).

LM could result in cardiac dysfunction and even sudden death. High SLE disease activity might potentially predict the occurrence of LM at the early stage of SLE. Characteristic echocardiographic findings could confirm the diagnosis of LM. Early aggressive immunosuppressive therapy could improve the cardiac outcome of LM.

Ossification of the ligamentum flavum (OLF) is being increasingly recognized as a cause of thoracic myelopathy. This study was to describe a rare clinical entity of spinal cord kinking (SK) in thoracic myelopathy secondary to OLF.

The data of 95 patients with thoracic myelopathy secondary to OLF were analyzed retrospectively. The incidence and location of SK were determined using preoperative magnetic resonance imaging (MRI). The clinical presentation and radiological characteristics in patients with SK were analyzed. Posterior en bloc laminectomy with OLF was performed, and the surgical results were evaluated.

SK was found in seven patients (7.4%) based on preoperative MRI. The patients included one male and six females with an average age of 55.6 years (range, 48–64 years). Five patients presented with radiculomyelopathy and two presented with typical thoracic myelopathy of spastic paraparesis. In all cases, the kinking was located just above the end of the spinal cord where the conus medullaris (CM) was compressed by the OLF. The degree of SK varied from mild to severe. The tip of the CM was located between the upper third of T11 to the lower third of L1, above the lower edge of L1. With an average follow-up of 30.4 months, the modified Japanese Orthopedic Association score significantly improved from 5.7 ± 1.8 preoperatively to 8.9 ± 1.4 postoperatively (t = 12.05; P < 0.0001) with an improvement rate of 63.1 ± 12.3%.

SK is a rare radiological phenomenon. It is typically located at the thoracolumbar junction, where the CM is compressed by the OLF. Our findings indicate that these patients may benefit from a posterior decompressive procedure.

Over past two decades, vagus nerve stimulation (VNS) has been widely used and reported to alleviate seizure frequency worldwide, however, so far, only hundreds of patients with pharmaco-resistant epilepsy (PRE) have been treated with VNS in mainland China. The study aimed to evaluate the effectiveness of VNS for Chinese patients with PRE and compare its relationship with age cohort and gender.

We retrospectively assessed the clinical outcome of 94 patients with PRE, who were treated with VNS at Beijing Fengtai Hospital and Beijing Tiantan Hospital between November 2008 and April 2014 from our database of 106 consecutive patients. The clinical data analysis was retrospectively examined.

Seizure frequency significantly decreased with VNS therapy after intermittent stimulation of the vagus nerve. At last follow-up, we found McHugh classifications of Class I in 33 patients (35.1%), Class II in 27 patients (28.7%), Class III in 20 patients (21.3%), Class IV in 3 patients (3.2%), and Class V in 11 patients (11.7%). Notably, 8 (8.5%) patients were seizure-free while ≥50% seizure frequency reduction occurred in as many as 60 patients (63.8%). Furthermore, with regard to the modified Engel classification, 12 patients (12.8%) were classified as Class I, 11 patients (11.7%) were classified as Class II, 37 patients (39.4%) were classified as Class III, 34 patients (36.2%) were classified as Class IV. We also found that the factors of gender or age are not associated with clinical outcome.

This comparative study confirmed that VNS is a safe, well-tolerated, and effective treatment for Chinese PRE patients. VNS reduced the seizure frequency regardless of age or gender of studied patients.

Recent studies have suggested that the presence of a pathological fracture does not impact on oncologic outcomes and the feasibility of limb salvage surgery (LSS) in appropriately selected patients when combined with neoadjuvant chemotherapy. These have largely been single institutional studies with limited numbers. The Eastern Asian Musculoskeletal Oncology Group reviewed the data from three large volume Asian orthopedic oncology centers to determine whether the presence of a pathologic fracture affected outcomes in osteosarcoma patients.

A retrospective review of the data was conducted. Ninety-five cases of nonmetastatic extremity osteosarcoma with a pathological fracture and 887 cases without fracture treated during the same period were compared.

In the fracture group, the LSS rate was 62.1%, and the rate of amputation was 37.9%. In the nonfracture group, the LSS rate was 74.7%, and the amputation was 25.3%. In patients with a pathologic fracture, the rate of local recurrence for LSS and amputation groups was 8.5% and 2.8%, respectively. In this group, the 5-year survival in the LSS group was 66% as against. 46.8% in the amputation group.

Our study suggests that surgically treated patients with pathologic fractures in osteosarcoma have adequate local control and do not have a poorer outcome compared to patients without a fracture. Though osteosarcoma with a pathologic fracture is not a contraindication for limb salvage, appropriate case selection is important when deciding local control options to ensure adequate oncologic clearance.

It is not clear whether the benefits of tracheostomy remain the same in the population. This study aimed to better examine the effect of tracheostomy on clinical outcome among prolonged ventilator patients.

Data were from the medical claims data in Taiwan. A total of 3880 patients with ventilator use for more than 14 days between 2005 and 2009 were identified. Among them, 645 patients with tracheostomy conducted within 30 days of ventilator use were compared to 2715 patients without tracheostomy on death during hospitalization and study period, and successful weaning and medical utilization during hospitalization. Cox proportional hazards and linear regression models were used to examine the associations between tracheostomy and the main outcomes.

The tracheostomy rate was 30%, and 55% of tracheostomies were performed within 30 days of mechanical ventilation. After adjustments, patients with tracheostomy were at a lower risk of death during hospitalization (hazard ratio [HR] =0.51; 95% confidence interval [CI] =0.43–0.61) and 5-year observation (HR = 0.73; 95% CI= 0.66–0.81), and a lower probability of successful weaning (HR = 0.88; 95% CI = 0.79–0.99). Higher medical use was also observed in patients with tracheostomy.

The beneficial effect for tracheostomy observed in our data was the reduction of death. However, patients with tracheostomy were less likely to wean and more likely to consume medical resources.

To evaluate the technical characteristics and application of mass casualty incident (MCI) primary triage (PT) methods applied in China.

Chinese literature was searched by Chinese Academic Journal Network Publishing Database (founded in June 2014). The English literature was searched by PubMed (MEDLINE) (1950 to June 2014). We also searched Official Websites of Chinese Central Government’s (http://www.gov.cn/), National Health and Family Planning Commission of China (http://www.nhfpc.gov.cn/), and China Earthquake Information (http://www.csi.ac.cn/).

We included studies associated with mass casualty events related to China, the PT applied in China, guidelines and standards, and application and development of the carding PT method in China.

From 3976 potentially relevant articles, 22 met the inclusion criteria, 20 Chinese, and 2 English. These articles included 13 case reports, 3 retrospective analyses of MCI, two methods introductions, three national or sectoral criteria, and one simulated field testing and validation. There were a total of 19 kinds of MCI PT methods that have been reported in China from 1950 to 2014. In addition, there were 15 kinds of PT methods reported in the literature from the instance of the application.

The national and sectoral current triage criteria are developed mainly for earthquake relief. Classification is not clear. Vague criteria (especially between moderate and severe injuries) operability are not practical. There are no triage methods and research for children and special populations. There is no data and evidence supported triage method. We should revise our existing classification and criteria so it is clearer and easier to be grasped in order to build a real, practical, and efficient PT method.

肺部疾病是新生儿和儿童中最常见的疾病，也是5岁以下儿童死亡的主要原因。^[1]因此，准确和及时的诊断对于有效治疗和改善肺部疾病患者的预后极其重要。过去，肺部疾病的诊断主要依赖于胸片（CR）和/或计算机断层扫描（CT）。然而，由于运输和不可避免的辐射，这些成像技术的使用受到限制。超声成像是基于发生在不同介质之间的界面处的超声波束的反射和散射。传统上，认为肺不是超声的目标，因为超声波不能穿透充满气体的解剖结构。近年来，随着对超声认识的不断深入，病变肺在超声穿透肺组织时，由于组织/气体/组织界面异常而产生超声伪影。超声伪影是肺部超声（LUS）在临床应用的基础。最近，LUS因其床边方便、准确和无辐射而越来越多地用于检测肺部疾病。^[2,3,4,5]因此，本研究的目的是介绍LUS在儿科呼吸系统疾病领域的应用。

隆鼻是亚洲人群中最常见的隆鼻手术。亚洲鼻的特点是背宽低，鼻尖突出减少，皮肤厚，皮下组织丰富，软骨框架薄弱。^[1]因此，患者通常要求更高的鼻背和更突出的鼻尖。已经报道了用于隆鼻成形术的各种材料。同种异体植入物在亚洲被广泛使用，具有良好的美学效果和无供区发病率。硅胶和Gore-Tex是最常用的同种异体植入物，可以取得良好的效果。然而，有限的生物相容性可能导致过敏反应、挤压、移位和感染。^[2]肋软骨质量丰富，可以雕刻成各种形状。对于需要大量隆鼻和翻修隆鼻的患者来说，这是一种有用的移植物。

重症肌无力（MG）是一种由抗乙酰胆碱受体抗体（AChR-Ab）或其他病因引起的自身免疫性神经肌肉疾病。40-50%的MG患者首次出现眼部症状。上睑下垂和复视是眼部MG（OMG）最常见的症状。有限的研究表明，47%的OMG患者仅出现上睑下垂的初始症状，14%的患者仅出现复视，39%的患者同时出现上睑下垂和复视。^[1]复视或上睑下垂的变化对OMG的身体或精神状态没有显著影响。对于OMG患者，并发上睑下垂和复视的初始表现与对吡啶斯的明不敏感显著相关。然而，OMG各种表型之间的临床特征差异，包括发病年龄、性别、胸腺瘤以及其他自身免疫性疾病仍未确定。

副肿瘤性神经综合征（PNSs）在癌症患者中发生的频率增加，并且几乎总是早于其诊断。这些综合征包括一组与癌症相关的神经系统疾病，并且它们可以影响神经系统的任何部分。副肿瘤过程同时累及神经系统的不同区域并不罕见。迄今为止，这是首次报道乙型肝炎（HB）疫苗接种后同时发生与晚期卵巢癌和抗Yo抗体相关的副肿瘤性小脑变性（PCD）和副肿瘤性边缘性脑炎（PLE）。大多数PNS的原因被认为是针对肿瘤表达的神经元蛋白的免疫应答。^[1]

冠状动脉疾病（CAD）及其临床表现，包括心肌梗塞（MI），是全世界死亡和虚弱的主要原因。多种环境和遗传风险因素与CAD相关，包括高胆固醇血症、高血压、肥胖、糖尿病和早期CAD家族史。然而，除了鉴定其产物参与脂质代谢以及胆固醇和脂蛋白处理的基因突变之外，在鉴定可能使个体易患CAD和MI的基因方面进展相对较少。直到2003年，肌细胞增强因子-2A（MEF2A）的突变版本被命名为adCAD/MI1对于第一个常染色体显性CAD和MI基因座。^[1]然而，一些研究否定了MEF2A在CAD中的作用，而另一些研究证实了其有影响力的作用。理解CAD病因学的一个重要线索是其实质性的遗传性，这表明DNA序列的变异会影响风险。

致编辑：几个合作组织的指南推荐肾上腺素注射用于过敏反应的及时初始治疗。^[1]给药的剂量和途径通常基于症状的严重程度和期望的反应的速度。尽管肾上腺素被广泛用于治疗过敏反应，但严重并发症如急性冠状动脉综合征、心律失常和颅内出血的报道很少。^[2]

致编者：一名40岁男性体力劳动者，有吸烟史，颈部和右上肢肿胀，呼吸困难5天。颈部肿胀发作急性，疼痛与右上肢全身肿胀相关。呼吸急促，但与胸痛无关。无咳嗽、发热、外伤史及其他凝血病家族史。

致编者：一名49岁男性出现咳嗽和呼吸急促，持续3个月。他去了不同的医院，接受了左下叶肺炎的抗生素治疗。查体口唇发绀，胸部听诊示左侧呼吸音降低。胸部计算机断层扫描（CT）、冠状CT和虚拟支气管镜成像显示左主支气管有一圆形病变，左主支气管几乎完全被肿块阻塞[图1a].支气管镜检查显示一圆形粉红色息肉样肿瘤阻塞左主支气管远端[图1b].我们最初认为病变可能是类癌、平滑肌瘤或孤立性纤维肿瘤（SFT）。且该病灶CT增强不明显。因此，我们通过支气管镜活检获得了一些组织。活检显示纤维性肿瘤。之后，我们与患者及其家人讨论了这种疾病的治疗方法以及益处和风险。患者选择了手术。最终，我们通过手术切除获得了一个2 cm × 2 cm的肿块，组织学检查证实了SFT，CD34、CD100和CD99呈阳性反应，免疫组织化学研究证实了肌动蛋白、CK和间变性淋巴瘤激酶呈阴性反应。

致编者：睫状色素上皮腺瘤（CPE）是一种极其罕见的肿瘤，临床上很难与恶性黑色素瘤鉴别。^[1]在此，我们报告了一例中国女性CPE腺瘤，并讨论了这种不寻常肿瘤的临床特征。