Volume 128 · Issue 23 · 2015

Inoperable chronic thromboembolic pulmonary hypertension (CTEPH) is a severe clinical syndrome characterized by right cardiac failure and possibly subsequent liver dysfunction. However, whether serum markers of liver dysfunction can predict prognosis in inoperable CTEPH patients has not been determined. Our study aimed to evaluate the potential role of liver function markers (such as serum levels of transaminase, bilirubin, and gamma-glutamyl transpeptidase [GGT]) combined with 6-min walk test in the prediction of prognosis in patients with inoperable CTEPH.

From June 2005 to May 2013, 77 consecutive patients with inoperable CTEPH without confounding co-morbidities were recruited for this prospective cohort study. Baseline clinical characteristics and 6-min walk distance (6MWD) results were collected. Serum biomarkers of liver function, including levels of aspartate aminotransferase, alanine aminotransferase, GGT, uric acid, and serum bilirubin, were also determined at enrollment. All-cause mortality was recorded during the follow-up period.

During the follow-up, 22 patients (29%) died. Cox regression analyses demonstrated that increased serum concentration of total bilirubin (hazard ratio [HR] = 7.755, P< 0.001), elevated N-terminal of the prohormone brain natriuretic peptide (HR= 1.001, P= 0.001), decreased 6MWD (HR= 0.990, P< 0.001), increased central venous pressure (HR= 1.074, P= 0.040), and higher pulmonary vascular resistance (HR= 1.001, P= 0.018) were associated with an increased risk of mortality. Serum concentrations of total bilirubin (HR= 4.755, P= 0.007) and 6MWD (HR= 0.994, P= 0.017) were independent prognostic predictors for CTEPH patients. Patients with hyperbilirubinemia (≥23.7 µmol/L) had markedly worse survival than those with normobilirubinemia.

Elevated serum bilirubin and decreased 6MWD are potential predictors for poor prognosis in inoperable CTEPH.

Peri-strut low-intensity area (PLIA) is a typical image pattern of neointima detected by optical coherence tomography (OCT) after stent implantation. However, few studies evaluated the predictors and prognosis of the PLIA; therefore, we aimed to explore the genesis and prognosis of PLIA detected by OCT in this study.

Patients presenting neointimal hyperplasia documented by OCT reexamination after percutaneous coronary intervention were prospectively included from 2009 to 2011. Peri-strut intensity was analyzed and classified into two patterns: Low-intensity and high-intensity. Clinical characteristics were analyzed to assess their contribution to peri-strut intensity patterns. Follow-up were performed in patients who did not receive revascularization during OCT reexamination, and the prognosis of the patients was evaluated.

There were 128 patients underwent OCT reexamination after stent implantation included in the study. PLIA was detected in 22 (17.2%) patients. The incidence of PLIA was positively correlated with serum triglyceride (odds ratio [OR]: 2.11, 95% confidence interval [CI]: 1.14–3.90, P= 0.017), low-density lipoprotein (OR: 2.61, 95% CI: 1.22–5.66, P= 0.015), history of cerebrovascular disease (OR: 101.11, 95% CI: 6.54–1562.13, P< 0.001), and initial clinical presentation of acute coronary syndrome (ACS, OR: 18.77, 95% CI: 2.73–128.83, P= 0.003) while negatively correlated with stent implantation time (OR: 0.57, 95% CI: 0.33–0.98, P= 0.043). The median follow-up was longer than 3.8 years. Major adverse cardiovascular events (MACEs) occurred in 7 (7.3%) patients while showed no correlation with PLIA. A total of 17 (17.7%) patients experienced unstable angina (UA) and showed significant correlation with PLIA (hazard ratio: 6.16, 95% CI: 1.25–30.33, P= 0.025).

PLIA detected by OCT was positively correlated with higher serum lipid level, history of cerebrovascular disease and initial presentation of ACS, and negatively correlated with stent implantation time. Patients with PLIA were more likely to have UA than those with high-intensity while no significant difference was found in MACEs.

It was believed that inflammatory response induced by cardiopulmonary bypass (CPB) was blamed for complications after cardiac surgery. To improve the outcome, many pharmacological interventions have been applied to attenuate inflammatory response during CPB. The objective of this study was to investigate the effect of ulinastatin (urinary trypsin inhibitor [UTI]) on outcome after CPB surgery.

Totally, 208 patients undergoing elective valves replacement between November 2013 and September 2014 were divided into Group U (n = 70) and Group C (n = 138) based on they received UTI or not. Categorical variables were compared between groups using Fisher’s exact test, and continuous variables using unpaired Student’s t-test or Mann–Whitney U-test. One-way analysis of variance and Dunnett’s or Tukey’s tests were used to compare values at different time points within the same group. The risk of outcomes was estimated and adjusted by multivariable logistic regression, propensity scoring, and mixed-effect models for all measured variables.

Both the serious complications in total, including death, acute lung injury, acute respiratory distress syndrome and acute kidney injury, and the other complications, including hemodialysis, infection, re-incubation, and tracheotomy were similar between the two groups (P > 0.05). After adjusted by multivariable logistic regression and the propensity score, UTI still cannot be found any benefit to improve any outcomes after cardiac surgery. Also, no statistical differences with regard to duration of postoperative mechanical ventilation, the length of Intensive Care Unit and hospital stays (P > 0.05).

UTI did not improve postoperative outcomes in our patients after cardiopulmonary bypass surgery.

Awake fiberoptic intubation (AFOI) is usually performed in the management of the predicted difficult airway. The aim of this study was to evaluate the feasibility of dexmedetomidine with midazolam (DM) and sufentanil with midazolam (SM) for sedation for awake fiberoptic nasotracheal intubation.

Fifty patients with limited mouth opening scheduled for AFOI were randomly assigned to two groups (n = 25 per group) by a computer-generated randomization schedule. All subjects received midazolam 0.02 mg/kg as premedication and airway topical anesthesia with a modified "spray-as-you-go" technique. Group DM received dexmedetomidine at a loading dose of 0.5 μg/kg over 10 min followed by a continuous infusion of 0.25 μg·kg⁻¹·h⁻¹, whereas Group SM received sufentanil at a loading dose of 0.2 μg/kg over 10 min followed by a continuous infusion of 0.1 μg·kg⁻¹·h⁻¹. As necessary, since the end of the administration of the loading dose of the study drug, an additional dose of midazolam 0.5 mg at 2-min intervals was given to achieve a modified Observers’Assessment of Alertness/Sedation of 2–3. The quality of intubation conditions and adverse events were observed.

The scores of ease of the AFOI procedure, patient’s reaction during AFOI, coughing severity, tolerance after intubation, recall of the procedure and discomfort during the procedure were comparable in both groups (z = 0.572, 0.664, 1.297, 0.467, 0.895, and 0.188, respectively, P> 0.05). Hypoxic episodes similarly occurred in the two groups, but the first partial pressure of end-tidal CO₂ after intubation was higher in Group SM than that in Group DM (45.2 ± 4.2 mmHg vs. 42.2 ± 4.3 mmHg, t = 2.495, P< 0.05).

Both dexmedetomidine and sufentanil are effective as an adjuvant for AFOI under airway topical anesthesia combined with midazolam sedation, but respiratory depression is still a potential risk in the sufentanil regimen.

Colorectal adenocarcinoma rarely occurred in adolescent. Clinical feature and prognosis of this population are not clear until now. In addition, DNA mismatch repair (MMR) status may relate to the early disease occurrence. The present study aimed to perform a retrospective analysis of adolescent patients with colorectal cancer, including clinicopathological characteristics and prognosis.

The medical records of 11,503 patients diagnosed as colorectal cancer in Cancer Hospital, Chinese Academy of Medical Sciences from January 1999 to December 2009 were retrospectively reviewed. Finally, 19 patients who were between 10 and 20 years old were selected as the study group. We summarized the clinicopathological characteristics, analyzed the association with prognosis and assessed the expression of MMR protein by immunohistochemical method.

The most common primary site was the right colon in 7 patients. Ten patients had Stage III colorectal cancer, 5 patients had Stage IV disease. Signet ring cell carcinoma was the most frequent pathological type (7/19). Deficient MMR was identified in 2 patients. The 5-year survival rate and median survival time were 23.2% and 26 months. Distant metastasis was identified as an independent prognostic factor (P = 0.02).

Colorectal cancer in Chinese adolescents was very rare. The chinese adolecents with colorectal cancer were frequently diagnosed in the right colon, as Stage III/IV disease with signet ring cell carcinoma. The prognosis was relatively poor.

Laparoscopic cholecystectomy (LC) has been a standard operation and replaced the open cholecystectomy (OC) rapidly because the technique resulted in less pain, smaller incision, and faster recovery. This study was to evaluate the value of blunt dissection in preventing bile duct injury (BDI) in laparoscopic cholecystectomy (LC).

From 2003 to 2015, LC was performed on 21,497 patients, 7470 males and 14,027 females, age 50.3 years (14–84 years). The Calot’s triangle was bluntly dissected and each duct in Calot’s triangle was identified before transecting the cystic duct.

Two hundred and thirty-nine patients (1.1%) were converted to open procedures. The postoperative hospital stay was 2.1 (0–158) days, and cases (46%) had hospitalization days of 1 day or less, and 92.8% had hospitalization days of 3 days or less; BDI was occurred in 20 cases (0.09%) including 6 cases of common BDI, 2 cases of common hepatic duct injury, 1 case of right hepatic duct injury, 1 case of accessory right hepatic duct, 1 case of aberrant BDI 1 case of biliary stricture, 1 case of biliary duct perforation, 3 cases of hemobilia, and 4 cases of bile leakage.

Exposing Calot’s triangle by blunt dissection in laparoscopic cholecystectomy could prevent intraoperative BDI.

The cross-section of thoracolumbar vertebral body is kidney-shaped with depressed posterior boundary. The anterior wall of the vertebral canal is separated from the posterior wall of the vertebral body on the lateral X-ray image. This study was designed to determine the sagittal distance between the anterior border of the vertebral canal and the posterior border of the vertebral body (DBCV) and to analyze the potential role of DBCV in the estimation of cement leakage during percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP).

We retrospectively recruited 233 patients who had osteoporotic vertebral compression fractures and were treated with PVP or PKP. Computed tomography images of T11–L2 normal vertebrae were measured to obtain DBCV. The distance from cement to the posterior wall of the vertebral body (DCPW) of thoracolumbar vertebrae was measured from C-arm images. The selected vertebrae were divided into two groups according to DCPW, with the fracture levels, fracture grades and leakage rates of the two groups compared. A relative operating characteristic (ROC) curve was applied to determine whether the DCPW difference can be used to estimate the degree of cement leakage. The data were processed by statistical software SPSS version 21.0 using independent sample t-test and Chi-square tests.

The maximum DBCV was 6.40 mm and the average DBCV was 3.74 ± 0.95 mm. DBCV appeared to be longer in males than in females, but the difference was not statistically significant. The average DCPW of type-B leakage vertebrae (2.59 ± 1.20 mm) was shorter than that of other vertebrae (7.83 ± 2.38 mm, P < 0.001). The leakage rate of group DCPW ≤6.40 mm was lower than that of group DCPW >6.40 mm for type-C and type-S, but much higher for type-B. ROC curve revealed that DCPW only has a predictive value for type-B leakage (area under the curve: 0.98, 95% confidence interval: 0.95–0.99, P< 0.001), and when the cut-off value was 4.05 mm, the diagnostic sensitivity and the specificity were 94.87% and 93.02%, respectively.

Depression of the thoracolumbar posterior vertebral body may be informative for the estimation of cement location on C-arm images. To reduce type-B leakage, DCPW should be made longer than DBCV on C-arm images for safety during PVP or PKP.

Hamstring (HS) autograft and bone-patellar tendon-bone allograft are the most common choice for reconstruction of anterior cruciate ligament (ACL). There was a little report about the clinical outcome and difference of arthroscopic ACL reconstruction using allograft and autograft. This study aimed to compare the clinical outcome of autograft and allograft reconstruction for ACL tears.

A total of 106 patients who underwent surgery because of ACL tear were included in this study. The patients were randomly divided into two groups, including 53 patients in each group. The patients in group I underwent standard ACL reconstruction with HS tendon autografts, while others in group II underwent reconstruction with bone-patellar tendon-bone allograft. All the patients were followed up and analyzed; the mean follow-up was 81 months (range: 28–86 months). Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC), Lysholm scores, physical instability tests, and patient satisfaction questionnaires. The complication rates of both groups were compared. Tibial and femoral tunnel widening were assessed using lateral and anteroposterior radiographs.

At the end of follow-up, no significant differences were found between the groups in terms of IKDC, Lysholm scores, physical instability tests, patient satisfaction questionnaires, and incidences of arthrofibrosis. Tibial and femoral tunnel widening was less in the HS tendon autografts. This difference was more significant on the tibial side.

In the repair of ACL tears, allograft reconstruction is as effective as the autograft reconstruction, but the allograft can lead to more tunnel widening evidently in the tibial tunnel, particularly.

The effect of ovarian hyperstimulation syndrome (OHSS) on pregnancy outcomes of in vitro fertilization (IVF) patients is still ambiguous. This study aimed to analyze pregnancy outcomes of IVF with or without OHSS in Chinese patients.

A retrospective cohort study was undertaken to compare pregnancy outcomes between 190 women with OHSS and 197 women without OHSS. We examined the rates of clinical pregnancy, multiple pregnancies, miscarriage, live birth, preterm delivery, preterm birth before 34 weeks’ gestation, cesarean delivery, low birth weight (LBW), and small-for-gestational age (SGA) between the two groups. Odds ratios (ORs) and 95% confidence intervals (CIs) of measure of clinical pregnancy were also analyzed.

The clinical pregnancy rate of OHSS patients was significantly higher than that of non-OHSS patients (91.8% vs. 43.5%, P< 0.001). After controlling for drug protocol and causes of infertility, the adjusted ORs of moderate OHSS and severe/critical OHSS for clinical pregnancy were 4.65 (95% CI, 1.86–11.61) and 5.83 (95% CI, 3.45–9.86), respectively. There were no significant differences in rates of multiple pregnancy (4.0% vs. 3.7%) and miscarriage (16.1% vs. 17.5%) between the two groups. With regard to ongoing clinical pregnancy, we also found no significant differences in the rates of live birth (82.1% vs. 78.8%), preterm delivery (20.9% vs. 17.5%), preterm birth before 34 weeks’ gestation (8.6% vs. 7.9%), cesarean delivery (84.9% vs. 66.3%), LBW (30.2% vs. 23.5%), and SGA (21.9% vs. 17.6%) between the two groups.

OHSS, which occurs in the luteal phase or early pregnancy in IVF patients and represents abnormal transient hemodynamics, does not exert any obviously adverse effect on the subsequent pregnancy.

Thin endometrium is associated with poor reproductive outcomes; estrogen treatment can increase endometrial thickness (EMT). The aim of this retrospective cohort study was to investigate the factors influencing the effectiveness of estrogen treatment and reproductive outcomes after the treatment in patients with thin endometrium.

Relevant clinical data of 101 patients with thin endometrium who had undergone estrogen treatment were collected. Possible factors influencing the effectiveness of treatment were analyzed retrospectively by logistic regression analysis. Eighty-seven infertile women without thin endometrium who had undergone assisted reproduction served as controls. The cases and controls were matched for age, assisted reproduction method, and number of embryos transferred. Reproductive outcomes of study and control groups were compared using Student’s t-test and the Chi-square test.

At the end of estrogen treatment, EMT was ≥8 mm in 93/101 patients (92.1%). Effectiveness of treatment was significantly associated with maximal pretreatment EMT (P = 0.017) and treatment duration (P = 0.004). The outcomes of assisted reproduction were similar in patients whose treatment was successful in increasing EMT to ≥8 mm and the control group. The rate of clinical pregnancy in patients was associated with the number of good-quality embryos transferred in both fresh (P = 0.005) and frozen-thawed (P = 0.000) embryo transfer cycles.

Thinner EMT before estrogen treatment requires longer treatment duration and predicts poorer treatment outcomes. The effectiveness of treatment depends on the duration of estrogen administration. Assisted reproductive outcomes of patients whose treatment is successful (i.e., achieves an EMT ≥8 mm) are similar to those of controls. The quality of embryos transferred is an important predictor of assisted reproductive outcomes in patients treated successfully with exogenous estrogen.

Malnutrition and tuberculosis (TB) tend to interact with each other. TB may lead to nutrition deficiencies that will conversely delay recovery by depressing immune functions. Nutrition support can promote recovery in the subject being treated for TB. The aim of this study was to evaluate the effectiveness of nutrition support on promoting the recovery of adult pulmonary TB patients with anti-TB drug therapy.

English database of the Cochrane Controlled Trials Register, PubMed, EMBASE, and Chinese database of CBM, CNKI, VIP, and WANFANG were searched. Randomized controlled trials comparing nutrition support (given for more than 2 weeks) with no nutrition intervention, nutrition advice only, or placebo-control for TB patients being anti-TB treated were included. Two reviewers conducted data extraction, assessed the quality of the studies independently, and any discrepancies were solved by the third reviewer. Data were entered and analyzed by RevMan 5.2 software, and meta-analysis was done using risk ratios (RRs) for dichotomous variables and mean differences (MDs) for continuous variables with 95% confidence intervals (CIs).

A total of 19 studies (3681 participants) were included. In nutritional support for TB patients, pooled RR and its 95% CI of sputum smears- or culture-negative conversion rate and chest X-ray (CXR) absorption rate were 1.10 (1.04, 1.17) and 1.22 (1.08, 1.39), respectively, the pooled MD and its 95% CI of body mass index (BMI) and time of sputum smears or culture negativity were 0.59 (0.16, 1.2) and − 5.42 (−7.93, −2.92), respectively, compared with the control group. The differences in outcomes of CXR zone affected, TB score, serum albumin, and hemoglobin were not statistically significant (P = 0.76, 0.24, 0.28, and 0.20, respectively) between the intervention group and the control group. No systemic adverse events were recorded.

During anti-TB course, nutrition support may be helpful in treatment of TB patients by improving both sputum smears- or culture-negative conversion rate and BMI, shortening the time of sputum conversion negative. Whether it can improve the final clinical effect, there still needs high-level quality studies to confirm in the future.

To introduce the imaging characteristics of moyamoya disease (MMD) using high-resolution magnetic resonance imaging (HR-MRI) and to discuss the role of HR-MRI in differentiating MMD from other intracranial artery diseases, especially intracranial atherosclerotic disease (ICAD).

This review was based on the data in articles published between 2005 and 2015, which were obtained from PubMed. The keywords included HR-MRI, MMD, ICAD, and intracranial artery diseases.

Articles related to HR-MRI for MMD or other intracranial artery diseases were selected for review.

There are differences between the characteristic patterns of HR-MRI in MMD and ICAD. MMD is associated with inward remodeling, smaller outer diameters, concentric occlusive lesions and homogeneous signal intensity, while ICAD is more likely to be associated with outward remodeling, normal outer diameters, eccentric occlusive lesions, and heterogeneous signal intensity. Other intracranial artery diseases, such as dissection and vasculitis, also have distinctive characteristics in HR-MRI. HR-MRI may become a useful tool for the differential diagnosis of MMD in the future.

HR-MRI of MMD provides a more in-depth understanding of MMD, and it is helpful in evaluating pathological changes in the vessel wall and in differentiating MMD from other intracranial artery steno-occlusive diseases, particularly ICAD.

“终末期心脏病”通常是指由不能使用常规药物或传统外科治疗治疗的多种病理引起的心脏失代偿的不可逆阶段。终末期心脏病患者的预期寿命从<6个月至1年。终末期心脏病患者的治疗策略主要基于三种方法：内科治疗、外科治疗（心脏移植）和通过机械循环辅助核心方法的多器官保护治疗。在这些方法中，心脏移植已成为公认的最有效的治疗方法。

自身免疫被定义为以针对身体自身组织成分(自身抗原)的特异性体液或细胞介导的免疫应答为特征的病症。在许多自身免疫性疾病中，这种免疫应答是公认的，其导致免疫系统产物对身体组织的自身成分的损害。格雷夫斯甲状腺机能亢进发生在对促甲状腺激素受体（TSHR）的耐受性丧失和模拟促甲状腺激素（TSH）作用的促甲状腺抗体产生之后。^[1]

慢性阻塞性肺疾病（COPD）是发达国家死亡的主要原因之一，并与高个人和社会经济负担相关。^[1]其特征是持续的气流受限，通常是进行性的，并与气道和肺对有害颗粒或气体的慢性炎症反应增强有关。细支气管周围纤维化在COPD早期状态下发生于小气道，继而发生结构改变，最后成为持续性气流受限。^[2]近年来的研究表明，上皮-间质转化（EMT）是多种疾病中纤维化的主要原因之一。

猝死始终是一个重要的话题，引起了医生和卫生专业人员的关注。医生和临床科学家已经在数千（如果不是数百万）出版物中报告了他们对婴儿、儿童、年轻运动员、士兵、患有慢性病的成年人和老年人意外死亡的发现。^[1,2]然而，没有关于医生和医务人员猝死的现有临床报告。最近，中国医生，尤其是麻醉师的猝死成为媒体和新闻的头条。中国医生正在医院值班时间变成猝死的高危专业人员。据官方调查显示，截至2014年底，中国共有医疗机构984926家，医师9700多万人，而每年的医学毕业生和研究生数量接近60万（http://yyh.dxy.cn/article/105034）。随着中国经济的快速增长和医院规模的急剧扩张，中国医生猝死成为重要的社会问题和当代健康问题，对医学教育和医院管理提出了挑战。在此，我们调查了中国医生猝死的问题和问题，以达到自我警觉、自我保护和自我拯救的目的。

深囊性结肠炎（CCP）是一种良性疾病，其特征是粘膜肌层下充满粘蛋白的囊肿。^[1]CCP可以以息肉样病变的局部形式存在，或作为涉及可变长度的直肠粘膜或结肠的更弥漫性过程存在。^[2]囊肿可能相当大，位于直肠乙状结肠区，通常距离肛门边缘6至7厘米。在30至40岁的患者中观察到CCP。

一名75岁男性因过去10个月左半部腹部逐渐进行性沉重到我院就诊。病史显示发热、体重减轻和盗汗均为阴性。体格检查值得注意的是中度苍白和大量脾肿大[图1a].

致编者：水痘-带状疱疹病毒（VZV）感染可导致带状疱疹或脑神经麻痹，如拉姆齐亨特综合征（RHS），或中枢神经系统（CNS）并发症，如脊髓炎、小脑炎、脑炎和中风综合征。^[1,2]然而，据我们所知，RHS和VZV脑干脑炎的共存是极其罕见的。因此，我们报告了一例出现RHS和多发性脑神经麻痹的患者。

致编辑：一名20岁的女大学生和足球运动员因急性腹痛、恶心和呕吐到急诊科就诊。在就诊当天早上，她醒来时突然出现持续的上腹部疼痛，严重程度为10/10。患者否认有任何便秘、便秘、腹泻、近期腹部外伤或任何潜在刺激事件。值得注意的是，患者确实承认以前有过餐后上腹痛发作，但从未如此严重。她过去的内科和外科病史并不显著。

致编者：女，55岁，突发双下肢对称性无力伴躯干无力、尿潴留7天。然而，她否认有任何疼痛、创伤、意识丧失的病史，或任何上肢无力、呼吸困难或脑神经受累的证据。根据病史，临时诊断为急性横贯性脊髓炎，在来到巴纳拉斯印度教大学医学科学研究所之前，她正在接受治疗。

致编辑：我们报告了一例使用烟囱支架进行胸主动脉腔内修复术（TEVAR）后的罕见并发症。

致编辑：在最近一期中，胡等人进行了一项全国性回顾性队列研究，并调查了血流储备分数（FFR）引导的经皮冠状动脉介入治疗（PCI）在日常实践中的临床结果和费用。^[1]如文献所示，FFR引导下的PCI可改善临床结局，降低成本。我们想稍微扩展一下讨论部分，以便更全面地了解这个问题。

这篇题为“MreBCD相关的细胞骨架是染色体末端在分裂周期中正确分离所必需的”的文章大肠杆菌”，发表于第128卷第9期第1209-1214页中华医学杂志^[1]正在被撤回。人们注意到，作者冯路使用了劳伦斯·罗斯菲尔德和他的实验室研究员崔成博士未发表的数据。他之前在同一个研究小组工作。