Volume 129 · Issue 17 · 2016

慢性阻塞性肺疾病（COPD）是一种发病率和死亡率都很高的异质性疾病。^[1]随着计算机断层扫描在COPD患者评估中的应用越来越多，以前未识别的放射学支气管扩张的存在正在被识别。^[2]越来越多的证据表明，支气管扩张对COPD的自然史有重要影响。中重度COPD合并支气管扩张症状更严重，恶化频率更高，死亡率增加。^[3]鉴于支气管扩张在COPD中的预后意义，其检测可以作为更好的管理和最终提高生存率的指南。^[1]因此，2014年更新的全球慢性阻塞性肺疾病倡议（GOLD）提出支气管扩张为COPD的合并症。COPD中支气管扩张的患病率差异很大，主要是由于患者纳入标准如不同的GOLD分期和支气管扩张的不同定义。纵向评估COPD以确定预测性替代终点显示，在所有GOLD分期的COPD患者中，支气管扩张的患病率为4%，^[4]但据报道，COPD患者支气管扩张的患病率要高得多，在初级和二级护理中范围为20%至58%。^[2,5,6]在西班牙的一项研究中，在57.6%的中重度COPD患者中发现支气管扩张，^[7]而在土耳其的一项研究中，患病率为33%。^[8]最近一项来自英国的研究显示，69%的COPD急性加重期患者有一些支气管扩张的证据，严重程度多为轻微或轻度；轻微40%，轻度29%，中度22%，重度8%。^[9]德国2005-2011年全国诊断相关团体医院统计数据表明，在以支气管扩张为主要诊断的住院患者中，高达39.2%发现了COPD。^[10]最近对中国患者的研究表明，34.7%（311/896）^[11]和45.8%（87/190）^[12]肺高分辨率计算机断层扫描（HRCT）显示稳定期COPD患者的支气管扩张并存。

Although radiological features of pneumocystis pneumonia (PCP) in non-Acquired Immune Deficiency Syndrome (AIDS) immunocompromised patients have been reported by other authors, there were no studies on the radiological stages of PCP previously. This study aimed to elucidate the radiological stages and prognoses of PCP in non-AIDS immunocompromised patients.

Retrospective analysis of radiological manifestations and prognoses of 105 non-AIDS PCP immunocompromised patients from August 2009 to April 2016 was conducted. Chest radiograph was divided into three stages: early stage (normal or nearly normal chest radiograph), mid stage (bilateral pulmonary infiltrates), and late stage (bilateral pulmonary consolidations); chest high-resolution computed tomography (HRCT) was also divided into three stages: early stage (bilateral diffuse ground-glass opacity [GGO]), mid stage (bilateral diffuse GGO and patchy consolidations), and late stage (bilateral diffuse consolidations).

The case fatality rate (CFR) of all patients was 34.3% (36/105), all of them took routine chest X-ray (CXR), and 84 underwent chest CT examinations. According to the CXR most near the beginning of anti-PCP therapy, 18 cases were at early stage and CFR was 0 (0/18, P < 0.01), 50 cases were at mid stage and CFR was 28.0% (14/50, P> 0.05), and 37 cases were at late stage and CFR was 59.5% (22/37, P < 0.01). According to the chest HRCT most near the beginning of anti-PCP therapy, 40 cases were at early stage and CFR was 20.0% (8/40, P > 0.05), 34 cases were at mid stage and CFR was 47.1% (16/34, P > 0.05), and 10 cases were at late stage and CFR was 80.0% (8/10, P < 0.05); barotrauma, including pneumothorax, pneumomediastinum, and pneumohypoderma, was found in 18 cases and the CFR was 77.8% (14/18, P < 0.01).

Based on the radiological manifestations, the course of PCP in non-AIDS immunocompromised patients can be divided into three stages: early stage, mid stage, and late stage. The prognoses of patients treated at early stage are good, and those at late stage are poor. Furthermore, the CFR of patients with barotrauma is high.

Increased level of serum macrophage inhibitory cytokine-1 (MIC-1), a member of transforming growth factor-β superfamily, was found in patients with epithelial tumors. This study aimed to evaluate whether serum level of MIC-1 can be a candidate diagnostic and prognostic indicator for early-stage nonsmall cell lung cancer (NSCLC).

A prospective study enrolled 152 patients with Stage I–II NSCLC, who were followed up after surgical resection. Forty-eight patients with benign pulmonary disease (BPD) and 105 healthy controls were also included in the study. Serum MIC-1 levels were measured using an enzyme-linked immunosorbent assay, and the association with clinical and prognostic features was analyzed.

In patients with NSCLC, serum protein levels of MIC-1 were significantly increased compared with healthy controls and BPD patients (all P < 0.001). A threshold of 1000 pg/ml of MIC-1 was found in patients with early-stage (Stage I and II) NSCLC, with sensitivity and specificity of 70.4% and 99.0%, respectively. The serum levels of MIC-1 were associated with age (P = 0.001), gender (P = 0.030), and T stage (P = 0.022). Serum MIC-1 threshold of 1465 pg/ml was found in patients with poor early outcome, with sensitivity and specificity of 72.2% and 66.1%, respectively. The overall 3-year survival rate of NSCLC patients with high serum levels of MIC-1 (≥1465 pg/ml) was lower than that of NSCLC patients with low serum MIC-1 levels (77.6% vs. 94.8%). Multivariate Cox regression survival analysis showed that a high serum level of MIC-1 was an independent risk factor for reduced overall survival (hazard ratio = 3.37, 95% confidential interval: 1.09–10.42, P = 0.035).

The present study suggested that serum MIC-1 may be a potential diagnostic and prognostic biomarker for patients with early-stage NSCLC.

Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae bacteria, which cause serious disease outbreaks worldwide, was rarely detected in Xiangya Hospital, prior to an outbreak that occurred from August 4, 2014, to March 17, 2015. The aim of this study was to analyze the epidemiology and molecular characteristics of the K. pneumoniae strains isolated during the outbreak.

Nonduplicate carbapenem-resistant K. pneumoniae isolates were screened for bla_KPC-2 and multiple other resistance determinants using polymerase chain reaction. Subsequent studies included pulsed-field gel electrophoresis (PFGE), multilocus sequence typing, analysis of plasmids, and genetic organization of bla_KPC-2 locus.

Seventeen bla_KPC-2-positive K. pneumoniae were identified. A wide range of resistant determinants was detected. Most isolates (88.2%) coharbored bla_KPC-2 and rmtB in addition to other resistance genes, including bla_SHV-1, bla_TEM-1, and aac(3)-IIa. The bla_KPC-2 and rmtB genes were located on the conjugative IncFIB-type plasmid. Genetic organization of bla_KPC-2 locus in most strains was consistent with that of the plasmid pKP048. Four types (A1, A2, A3, and B) were detected by PFGE, and Type A1, an ST11, was the predominant PFGE type. A novel K. pneumoniae sequence type (ST1883) related to ST11 was discovered.

These isolates in our study appeared to be clonal and ST11 K. pneumoniae was the predominant clone attributed to the outbreak. Coharbing of bla_KPC-2 and rmtB, which were located on a transferable plasmid, in clinical K. pneumoniae isolates may lead to the emergence of a new pattern of drug resistance.

Bronchiolitis obliterans syndrome (BOS) often develops in transplant patients and results in injury to the respiratory and terminal airway epithelium. Owing to its rising incidence, the pathogenesis of BOS is currently an area of intensive research. Studies have shown that injury to the respiratory epithelium results in dysregulation of epithelial repair. Airway epithelial regeneration is supported by stromal cells, including fibroblasts. This study aimed to investigate whether the supportive role of lung fibroblasts is altered in BOS.

Suspensions of lung cells were prepared by enzyme digestion. Lung progenitor cells (LPCs) were separated by fluorescence-activated cell sorting. Lung fibroblasts from patients with BOS or healthy controls were mixed with sorted mouse LPCs to compare the colony-forming efficiency of LPCs by counting the number of colonies with a diameter of ≥50 μm in each culture. Statistical analyses were performed using the SPSS 17.0 software (SPSS Inc., USA). The paired Student’s t-test was used to test for statistical significance.

LPCs were isolated with the surface phenotype of CD31^-CD34^-CD45^- EpCAM⁺Sca-1⁺. The colony-forming efficiency of LPCs was significantly reduced when co-cultured with fibroblasts isolated from patients with BOS. The addition of SB431542 increased the colony-forming efficiency of LPCs to 1.8%; however, it was still significantly less than that in co-culture with healthy control fibroblasts (P < 0.05).

The epithelial-supportive capacity of fibroblasts is impaired in the development of BOS and suggest that inefficient repair of airway epithelium could contribute to persistent airway inflammation in BOS.

There is an unmet need for a reliable method of airway management for patients in the lateral position. This prospective randomized controlled two-center study was designed to evaluate the feasibility of intubation using a flexible fiberoptic bronchoscope in the lateral position during surgery.

Seventy-two patients scheduled for elective nonobstetric surgery in the lateral decubitus position requiring tracheal intubation under general anesthesia at Lishui Central Hospital of Zhejiang Province and Jiaxing First Hospital of Zhejiang Province from April 1, 2015, to September 30, 2015, were enrolled in this study. Patients were randomly assigned to the supine position group (Group S, n = 38) and the lateral position group (Group L, n = 34). Experienced anesthetists performed tracheal intubation with a fiberoptic bronchoscope after general anesthesia. The time required for intubation, intubation success rates, and hemodynamic changes was recorded. Between-group differences were assessed using the Student’s t-test, Mann–Whitney U-test, or Chi-square test.

The median total time to tracheal intubation was significantly longer in Group S (140.0 [135.8, 150.0] s) compared to Group L (33.0 [24.0, 38.8] s) (P < 0.01). The first-attempt intubation success rate was significantly higher in Group L (97%) compared to Group S (16%). Hemodynamic changes immediately after intubation were more exaggerated in Group S compared to Group L (P = 0.02).

Endotracheal intubation with a flexible fiberoptic bronchoscope may be an effective and timesaving technique for patients in the lateral position.

Chinese Clinical Trial Register, ChiCTR-IIR-16007814; http://www.chictr.org.cn/showproj .aspx?proj=13183.

Urine output (UO) is an essential criterion of the Kidney Disease Improving Global Outcomes (KDIGO) definition and classification system for acute kidney injury (AKI), of which the diagnostic value has not been extensively studied. We aimed to determine whether AKI based on KDIGO UO criteria (KDIGO_UO) could improve the diagnostic and prognostic accuracy, compared with KDIGO serum creatinine criteria (KDIGO_SCr).

We conducted a secondary analysis of the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a 2-month prospective cohort study (July 1, 2009 to August 31, 2009) involving 3063 patients in 22 tertiary Intensive Care Units in Mainland of China. AKI was diagnosed and classified separately based on KDIGO_UO and KDIGO_SCr. Hospital mortality of patients with more severe AKI classification based on KDIGO_UO was compared with other patients by univariate and multivariate regression analyses.

The prevalence of AKI increased from 52.4% based on KDIGO_SCr to 55.4% based on KDIGO_SCr combined with KDIGO_UO. KDIGO_UO also resulted in an upgrade of AKI classification in 7.3% of patients, representing those with more severe AKI classification based on KDIGO_UO. Compared with non-AKI patients or those with maximum AKI classification by KDIGO_SCr, those with maximum AKI classification by KDIGO_UO had a significantly higher hospital mortality of 58.4% (odds ratio [OR]: 7.580, 95% confidence interval [CI]: 4.141–13.873, P < 0.001). In a multivariate logistic regression analysis, AKI based on KDIGO_UO (OR: 2.891, 95% CI: 1.964–4.254, P < 0.001), but not based on KDIGO_SCr (OR: 1.322, 95% CI: 0.902–1.939, P = 0.152), was an independent risk factor for hospital mortality.

UO was a criterion with additional value beyond creatinine criterion for AKI diagnosis and classification, which can help identify a group of patients with high risk of death.

The primary cause of ischemic heart failure (HF) is myocardial infarction (MI) resulting in left ventricle (LV) wall motion abnormality secondary to ventricular remodeling. A prospective, nonrandomized study conducted in China was designed to assess safety and efficacy of the percutaneous ventricular restoration therapy using Parachute device (CardioKinetix, Inc., CA, USA) in ischemic HF patients as a result of LV remodeling after anterior wall MI.

Thirty-one patients with New York Heart Association (NYHA) Class II, III ischemic HF, ejection fraction between 15% and 40%, and dilated akinetic or dyskinetic anterior-apical wall without the need to be revascularized were enrolled from seven sites in China from October to December 2014. The Parachute device was implanted through femoral artery. All patients received low-dose aspirin and anticoagulation with warfarin for at least 12 months postdevice implantation. The primary end-point was the assessment of efficacy as measured by the reduction in LV end-systolic volume index (LVESVI) against baseline LVESVI at 3 months postdevice implantation, determined by the echocardiography and measured by echocardiography core laboratory. Quality of life was assessed using EQ-5D and visual analog scale (VAS). For quantitative data comparison, paired t-test (normality data) and signed-rank test (abnormality data) were used; application of signed-rank test was for the ranked data comparison.

A change in LVESVI as measured by echocardiography from the preimplant baseline to 3-month postdevice implantation revealed a statistically significant reduction from 77.5 ± 20.0 ml/m² to 53.1 ± 17.0 ml/m² (P < 0.0001). The trial met its primary end-point. Of the 31 patients, the procedural success was 96.8%. Overall, NYHA HF class assessment results showed an improvement of more than half a class at 3 months (P < 0.001). Quality of life assessed by the VAS value increased 11.5 points (P < 0.01), demonstrating improvement at 3 months.

The favorable outcomes observed in the high-risk patients provide reassuring safety and efficacy data to support adoption of this technology as a therapeutic option for ischemic HF patients.

ClinicalTrials.gov, NCT02240940; https://clinicaltrials.gov/ct2/show/NCT02240940.

Spontaneous potentials in electromyography (EMG) of paraspinal muscles are associated with diaphragm denervation and, therefore, poor respiratory function in amyotrophic lateral sclerosis (ALS) is understandable. EMG changes in the rectus abdominis (RA) display an effect similar to those in paraspinal muscles with respect to the function of lower motor neurons in the thoracic spinal cord. The RA denervation was examined to determine its association with ventilation dysfunction in ALS.

We collected the clinical data of 128 patients with sporadic ALS in Department of Neurology of Peking University Third Hospital from 2009 to 2013. EMG, Revised ALS Functional Rating Scale (ALSFRS-R) and forced vital capacity (FVC) were performed in all patients and the differences in the EMG changes in RA between those with and without FVC ≥ 80% were analysed.

The mean FVC value was 83.4% ± 17.1% (range: 45%–131%) of the predicted value. A total of 79 patients displayed FVC ≥80%, and 49 patients displayed FVC <80%. Compared with the patients displaying a normal FVC (60/79, 75.9%), spontaneous activity in RA was significantly different among those patients displaying an FVC <80% (47/49, 95.9%). In addition, spontaneous potentials in RA were more frequently detected in patients exhibiting dyspnea (32/33, 97.0%) than in patients without dyspnea (75/95, 78.9%).

Spontaneous potentials in RA are associated with ventilation dysfunction and dyspnea in ALS patients.

Percutaneous nephrolithotomy (PCNL) is the most widely recommended treatment for calyceal diverticular calculi, providing excellent stone-free results. However, its invasiveness is not negligible considering its major complication rates. Flexible ureteroscopy (FURS) is currently used to treat calyceal diverticula. However, the greatest drawback of FURS is locating the diverticulum since its neck is narrow and concealed. In such a case, the FURS procedure must be converted to PCNL. The aim of this study was to evaluate ultrasound-guided flexible ureteroscopy (UFURS) identifying diverticulum and the management of calyceal diverticular calculi.

A retrospective analysis was conducted on 24 patients who had calyceal diverticular calculi. In all 12 patients in the UFURS group, direct FURS failed to find evidence of calyceal diverticula but were confirmed with imaging. The other 12 patients in the PCNL group received PCNL plus fulguration of the diverticular walls.

Puncture of calyceal diverticulum was successful in all 12 UFURS patients. Two patients in this group had postoperative residual calculi and two patients developed fever. In the PCNL group, percutaneous renal access and lithotomy were successful in all 12 patients. One patient in this group had residual calculi, one had perirenal hematoma, and two patients developed fever. No significant difference was found in the operating time (UFURS vs. PCNL, 91.8 ± 24.2 vs. 86.3 ± 18.7 min), stone-free rate (UFURS vs. PCNL, 9/12 vs. 10/12), and rate of successful lithotripsy (UFURS vs. PCNL, 10/12 vs. 11/12) between the two groups (all P > 0.05). Postoperative pain scores in the FURS group were significantly lower than that in the PCNL group (2.7 ± 1.2 vs. 6.2 ± 1.5, P < 0.05). Hospital stay in the UFURS group was significantly shorter than that in the PCNL group (3.4 ± 0.8 vs. 5.4 ± 1.0 days, P < 0.05). All patients were symptom-free following surgery (UFURS vs. PCNL, 10/10 vs. 12/12).

Ultrasound-guided puncture facilitates identification of calyceal diverticula during FURS and improves the success rate of FURS surgery.

Previous studies revealed that culprit vessels of ST-segment elevation myocardial infarction (STEMI) were often related to mild or moderate stenosis. However, recent studies suggested that severe stenosis was primarily found in culprit lesions. The objective of this study was to analyze the stenosis severity of culprit lesions in STEMI patients and to clarify the paradoxical results.

A total of 489 consecutive STEMI patients who underwent primary percutaneous coronary intervention were retrospectively studied from January 2012 to December 2014. The patients were divided into three groups based on stenosis severity using quantitative coronary analysis: Group A, 314 cases, stenosis ≥70%; Group B, 127 cases, stenosis 50–70%; and Group C, 48 cases, stenosis ≤50%. The clinical, demographic, and angiographic data of all groups were analyzed.

Patients in Group A exhibited a significantly higher prevalence of history of angina pectoris (95.9% vs. 62.5%, P < 0.001), multivessel disease (73.2% vs. 54.2%, P = 0.007), and lower cardiac ejection fraction (53.3 ± 8.6 vs. 56.8 ± 8.4, P = 0.009) than those in Group C. Multivariable analysis revealed that history of angina pectoris (odds ratio [OR]: 13.89, 95% confidence interval [CI]: 6.21–31.11) and multivessel disease (OR: 2.32, 95% CI: 1.25–4.31) were correlated with severe stenosis of the culprit lesion in Group A.

Most culprit lesions in STEMI patients were severe stenosis. These patients exhibited a higher prevalence of angina history and multivessel diseases.

High-quality information provision can allow stroke patients to effectively participate in healthcare decision-making, better manage the stroke, and make a good recovery. In this study, we reviewed information needs of stroke patients, methods for providing information to patients, and considerations needed by the information providers.

The literature concerning or including information provision for patients with stroke in English was collected from PubMed published from 1990 to 2015.

We included all the relevant articles on information provision for stroke patients in English, with no limitation of study design.

Stroke is a major public health concern worldwide. High-quality and effective health information provision plays an essential role in helping patients to actively take part in decision-making and healthcare, and empowering them to effectively self-manage their long-standing chronic conditions. Different methods for providing information to patients have their relative merits and suitability, and as a result, the effective strategies taken by health professionals may include providing high-quality information, meeting patients’ individual needs, using suitable methods in providing information, and maintaining active involvement of patients.

It is suggested that to enable stroke patients to access high-quality health information, greater efforts need to be made to ensure patients to receive accurate and current evidence-based information which meets their individual needs. Health professionals should use suitable information delivery methods, and actively involve stroke patients in information provision.

心肺复苏（CPR）后昏迷患者的预后可能较差（定义为大脑功能类别评分为3至5分）。^[1,2]因此，准确预测其神经系统结局是心脏骤停后评估的重要组成部分，尤其是对于限制或撤销维持生命护理的决定。从20世纪60年代开始，国内外一系列研究开始关注CPR后昏迷患者的评估，并在该领域取得了相当大的进展。

2013年3月底，上海确诊首例人感染甲型H7N9禽流感病毒病例。2013年4月至5月，上海市公共卫生临床中心收治了18例甲型H7N9禽流感病毒感染患者，最终，其中12例存活。这些患者的短期预后已经在前面描述过，^[1]但长期预后仍不清楚。2013年9月至11月，复旦大学附属中山医院收治了5例从上海市公共卫生临床中心出院的甲型H7N9禽流感病毒感染幸存者。从患者处获得人口统计学特征、诊断和潜在合并症的数据。然后，患者接受了胸部高分辨率计算机断层扫描（HRCT）和肺功能测试（PFT）。HRCT由放射科医生和肺科医生独立评估，然后达成共识。评估了每例患者以下放射学异常的存在和分布，即实变、毛玻璃样阴影（GGO）、空气支气管造影、小叶中心结节、小叶间隔增厚、网状、胸膜下线性阴影、囊性改变和胸腔积液。PFT的以下指标，即用力肺活量(FVC)、1 s用力呼气量(FEV)₁），二月₁评估/FVC、总肺活量（TLC）和肺一氧化碳扩散能力（DLCO），并表示为预测值的百分比。方案中不包括支气管激发和扩张试验。本研究由复旦大学中山医院机构审查委员会批准。

相对于胃肠道的长度和表面积，小肠恶性肿瘤非常罕见，全球发病率为<每10万人口中有1人。^[1]在40种不同的小肠癌组织学亚型中，原发性鳞状细胞癌（SCC）异常罕见，文献中只有偶尔的病例报告。本研究报告了一例原发性小肠鳞状细胞癌，并回顾了英文文献中报道的所有病例，以提供这种罕见疾病的系统概述。

乳房发育症被定义为两个乳房的内侧汇合或乳房被胸骨上的软组织统一，使它们不可分离。它最早是由Spence在整形外科文献中描述的等人.1984年。^[1,2,3]存在两种形式的对称性；后天和先天性。^[1,2,3]获得性乳房发育症是一种非常常见的疾病，其结果是在隆胸或重建过程中过度解剖口袋或使用直径与胸壁成比例过大的植入物的医源性并发症。^[2,3]鉴于，先天性乳房发育症是一种极其罕见的疾病，由乳腺组织发育异常增生引起，导致乳腺间网穿过胸骨中线。^[2,3]这种网状软组织由不同比例的腺体组织、皮下脂肪和纤维隔组成，横穿胸骨向内侧连接双乳。^[1,2,4,5]先天性合乳症以前仅有少数病例报告，对其病理生理学、确切发病率和理想治疗方法的认识仍然不足。^[2,3]在此，我们报告了一例先天性同乳伴巨乳的病例，通过吸脂术和乳房缩小术矫正，具有良好的美学效果。据我们所知，亚洲仅报告了一例病例，^[5]目前的病例报告在韩国很少见。

致编者：一名65岁女性患者，主诉咯血和左上胸疼痛约1周。病史提示冠心病、阵发性房颤，吸烟40年左右，不饮酒，无特殊接触史。既往有慢性咳嗽史，无呼吸困难或咯血约20年。体格检查显示，一名发育良好、营养良好的女性没有明显的痛苦。患者无发热，心率78次/分钟，血压130/70 mmHg，呼吸频率18次/分钟，室内空气氧饱和度100%。无外周淋巴结病。胸部听诊稍减弱，左上肺闻及呼吸音，双肺未闻及干湿罗音。

致编者：肺叶切除术微创技术的疗效在文献中引起了极大的兴趣。最近，已经报道了电视辅助胸外科（VATS）的新手术策略和技术改进。^[1]此外，术后理疗方面是一个令人感兴趣的来源；据观察，步行距离（计算为术前6分钟步行试验（6MWT）的平均评分）代表了肺叶切除术后可能的术后并发症发作的预测指标。^[2]然而，6MWT在术后早期的适用性受到术后通常存在的常见功能限制的限制，包括术后第一天可能需要补充氧气和胸腔引流。

致编辑：裂褶菌属是一种普遍存在的担子菌真菌，通常在腐烂的木材中定居。^[1]肺部受累的报告S.公社是有限的。我们在此报告了一例肺部真菌病，原因是S.公社在浙江大学医学院第一附属医院。

在《中华医学杂志》第128卷第1期第7-14页发表的题为“出生缺陷率对出生登记制度的调查”的文章中，^[1]下列句子中“‰”号写错为“%”号：