Volume 130 · Issue 20 · 2017

The cesarean section rate (CSR) has been a main concern worldwide. The present study aimed to investigate the CSR in Beijing, China, and to analyze the related factors of CS delivery.

An observational study was conducted in 15 medical centers in Beijing using a systemic cluster sampling method. In total, 15,194 pregnancies were enrolled in the study between June 20, 2013 and November 30, 2013. Independent t-tests and Pearson’s Chi-square test were used to examine differences between two groups, and related factors of the CSR were examined by multivariable logistic regression.

The CSR was 41.9% (4471/10,671) in singleton primiparae. Women who were more than 35 years old had a 7.4-fold increased risk of CS delivery compared with women <25 years old (odd ratio [OR] = 7.388, 95% confidence interval [CI] = 5.561–9.816, P < 0.001). Prepregnancy obese women had a 2-fold increased risk of CS delivery compared with prepregnancy normal weight women (OR = 2.058, 95% CI= 1.640–2.584, P < 0.001). The excessive weight gain group had a 1.4-fold increased risk of CS delivery compared with the adequate weight gain group (OR = 1.422, 95% CI= 1.289–1.568, P < 0.001). Gestational diabetes mellitus (GDM) women and DM women had an increased risk of CS delivery (1.2- and 1.7-fold, respectively) compared with normal blood glucose women. Women who were born in rural areas had a lower risk of CS delivery than did those who were born in urban areas (OR = 0.696, 95% CI = 0.625–0.775, P < 0.001). The risk of CS delivery gradually increased with a decreasing education level. Neonates weighing 3000–3499 g had the lowest CSR (36.2%). Neonates weighing <2500 g had a 2-fold increased risk of CS delivery compared with neonates weighing 3000–3499 g (OR = 2.020, 95% CI = 1.537–2.656, P < 0.001). Neonates weighing ≥4500 g had an 8.3-fold increased risk of CS delivery compared with neonates weighing 3000–3499 g (OR = 8.313, 95% CI= 4.436–15.579, P < 0.001).

Maternal age, prepregnancy body mass index, gestational weight gain, blood glucose levels, residence, education level, and singleton fetal birth weight are all factors that might significantly affect the CSR.

Chronic kidney disease (CKD) with moderate-to-severe renal dysfunction usually exhibits an irreversible course, and available treatments for delaying the progression to end-stage renal disease are limited. This study aimed to assess the efficacy and safety of the traditional Chinese medicine, Niaoduqing particles, for delaying renal dysfunction in patients with stage 3b-4 CKD.

The present study was a prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial. From May 2013 to December 2013, 300 CKD patients with an estimated glomerular filtration rate (eGFR) between 20 and 45 ml·min^-1·1.73 m⁻², aged 18–70 years were recruited from 22 hospitals in 11 Chinese provinces. Patients were randomized in a 1:1 ratio to either a test group, which was administered Niaoduqing particles 5 g thrice daily and 10 g before bedtime for 24 weeks, or a control group, which was administered a placebo using the same methods. The primary endpoints were changes in baseline serum creatinine (Scr) and eGFR after completion of treatment. The primary endpoints were analyzed using Student’s t-test or Wilcoxon’s rank-sum test. The present study reported results based on an intention-to-treat (ITT) analysis.

A total of 292 participants underwent the ITT analysis. At 24 weeks, the median (interquartile range) change in Scr was 1.1 (−13.0–24.1) and 11.7 (−2.6–42.9) μmol/L for the test and control groups, respectively (Z = 2.642, P = 0.008), and the median change in eGFR was −0.2 (−4.3–2.7) and −2.2 (−5.7–0.8) ml·min⁻¹·1.73 m⁻², respectively (Z = −2.408, P = 0.016). There were no significant differences in adverse events between the groups.

Niaoduqing particles safely and effectively delayed CKD progression in patients with stage 3b-4 CKD. This traditional Chinese medicine may be a promising alternative medication for patients with moderate-to-severe renal dysfunction.

Chinese Clinical Trial Register, ChiCTR-TRC-12002448; http://www.chictr.org.cn/showproj.aspx?proj=7102.

Cochlear implants (CIs) can improve speech recognition for children with severe congenital hearing loss, and open-set word recognition is an important efficacy measure. This study examined Mandarin open-set word recognition development among Chinese children with CIs and normal hearing (NH).

This study included 457 children with CIs and 131 children with NH, who completed the Mandarin lexical neighborhood test. The results for children at 1–8 years after receiving their CIs were compared to those from the children with NH using linear regression analysis and analysis of variance.

Recognition of disyllabic easy words, disyllabic hard words, monosyllabic easy words, and monosyllabic hard words increased with time after CI implantation. Scores for cases with implantation before 3 years old were significantly better than those for implantation after 3 years old. There were significant differences in open-set word recognition between the CI and NH groups. For implantation before 2 years, there was no significant difference in recognition at the ages of 6–7 years, compared to 3-year-old children with NH, or at the age of 10 years, compared to 6-year-old children with NH. For implantation before 3 years, there was no significant difference in recognition at the ages of 8–9 years, compared to 3-year-old children with NH, or at the age of 10 years, compared to 6-year-old children with NH. For implantation after 3 years, there was a significant difference in recognition at the age of 13 years, compared to 3-year-old children with NH.

Mandarin open-set word recognition increased with time after CI implantation, and the age at implantation had a significant effect on long-term speech recognition. Chinese children with CIs had delayed but similar development of recognition, compared to normal children. Early CI implantation can shorten the gap between children with CIs and normal children.

Preterm premature rupture of membrane (PPROM) can lead to serious consequences such as intrauterine infection, prolapse of the umbilical cord, and neonatal respiratory distress syndrome. Genital infection is a very important risk which closely related with PPROM. The preliminary study only made qualitative research on genital infection, but there was no deep and clear judgment about the effects of pathogenic bacteria. This study was to analyze the association of infections with PPROM in pregnant women in Shaanxi, China, and to establish Bayesian stepwise discriminant analysis to predict the incidence of PPROM.

In training group, the 112 pregnant women with PPROM were enrolled in the case subgroup, and 108 normal pregnant women in the control subgroup using an unmatched case-control method. The sociodemographic characteristics of these participants were collected by face-to-face interviews. Vaginal excretions from each participant were sampled at 28–36⁺⁶ weeks of pregnancy using a sterile swab. DNA corresponding to Chlamydia trachomatis (CT), Ureaplasma urealyticum (UU), Candida albicans, group B streptococci (GBS), herpes simplex virus-1 (HSV-1), and HSV-2 were detected in each participant by real-time polymerase chain reaction. A model of Bayesian discriminant analysis was established and then verified by a multicenter validation group that included 500 participants in the case subgroup and 500 participants in the control subgroup from five different hospitals in the Shaanxi province, respectively.

The sociological characteristics were not significantly different between the case and control subgroups in both training and validation groups (all P > 0.05). In training group, the infection rates of UU (11.6% vs. 3.7%), CT (17.0% vs. 5.6%), and GBS (22.3% vs. 6.5%) showed statistically different between the case and control subgroups (all P < 0.05), log-transformed quantification of UU, CT, GBS, and HSV-2 showed statistically different between the case and control subgroups (P < 0.05). All etiological agents were introduced into the Bayesian stepwise discriminant model showed that UU, CT, and GBS infections were the main contributors to PPROM, with coefficients of 0.441, 3.347, and 4.126, respectively. The accuracy rates of the Bayesian stepwise discriminant analysis between the case and control subgroup were 84.1% and 86.8% in the training and validation groups, respectively.

This study established a Bayesian stepwise discriminant model to predict the incidence of PPROM. The UU, CT, and GBS infections were discriminant factors for PPROM according to a Bayesian stepwise discriminant analysis. This model could provide a new method for the early predicting of PPROM in pregnant women.

Mucocutaneous lesions are common features of primary Sjögren’s syndrome (pSS), but only a few studies have focused on them. To demonstrate the profile of mucocutaneous lesions of pSS and further explore their potential clinical significance, we performed a cross-sectional study on 874 patients.

Demographic data, clinical manifestations, and laboratory results of 874 pSS patients were collected. Patients were divided into two groups according to the presence of mucocutaneous lesions. Differences in primary symptoms and systemic impairments between the two groups were analyzed. Results of laboratory tests were also compared after excluding those who had taken corticosteroid from both groups. One-year follow-up was done, and occurrences of various new complications were compared.

Among the 874 pSS patients, 181 patients had mucocutaneous lesions, accounting for 20.7%. Multiple mucocutaneous manifestations were displayed, and the top four most common types of lesions were purpuric eruptions (39.8%), urticaria (23.8%), Raynaud’s phenomenon (14.9%), and angular stomatitis (9.9%). Incidences of pulmonary interstitial fibrosis, pulmonary bullae, leukopenia, and anemia were significantly higher among patients with mucocutaneous lesions (P < 0.05). Increase in IgG and decrease in C4 among patients with mucocutaneous lesions displayed statistical significance after excluding patients from both groups who had taken corticosteroid (P < 0.05). After one-year follow-up, patients with mucocutaneous lesions presented a slightly higher incidence of new complications compared to those without.

Mucocutaneous manifestations of pSS patients were common and diverse. Patients with mucocutaneous manifestations had more systemic damages, higher level of IgG, and lower level of serum C4, suggesting a higher activity of the primary disease.

How to evaluate the quality of donation after cardiac death (DCD) kidneys has become a critical problem in kidney transplantation in China. Hence, the aim of this study was to develop a simple donor risk score model to evaluate the quality of DCD kidneys before DCD.

A total of 543 qualified kidneys were randomized in a 2:1 manner to create the development and validation cohorts. The donor variables in the development cohort were considered as candidate univariate predictors of delayed graft function (DGF). Multivariate logistic regression was then used to identify independent predictors of DGF with P < 0.05. Date from validation cohort were used to validate the donor scoring model.

Based on the odds ratios, eight identified variables were assigned a weighted integer; the sum of the integer was the total risk score for each kidney. The donor risk score, ranging from 0 to 28, demonstrated good discriminative power with a C-statistic of 0.790. Similar results were obtained from validation cohort with C-statistic of 0.783. Based on the obtained frequencies of DGF in relation to different risk scores, we formed four risk categories of increasing severity (scores 0–4, 5–9, 10–14, and 15–28).

The scoring model might be a good noninvasive tool for assessing the quality of DCD kidneys before donation and potentially useful for physicians to make optimal decisions about donor organ offers.

Mitochondrial DNA (mtDNA) content measured by different techniques cannot be compared between studies, and age- and tissue-related control values are hardly available. In the present study, we aimed to establish the normal reference range of mtDNA copy number in the Chinese population.

Two healthy cohorts of 200 Chinese minors (0.1–18.0 years) and 200 adults (18.0–88.0 years) were recruited. Then, they were further categorized into eight age groups. The absolute mtDNA copy number per cell was measured by a quantitative real-time polymerase chain reaction. We subsequently used this range to evaluate mtDNA content in four patients (0.5–4.0 years) with molecularly proven mitochondrial depletion syndromes (MDSs) and 83 cases of mitochondrial disease patients harboring the m.3243A>G mutation.

The reference range of mtDNA copy number in peripheral blood was 175–602 copies/cell (mean: 325 copies/cell) in minors and 164–500 copies/cell (mean: 287 copies/cell) in adults. There was a decreasing trend in mtDNA copy number in blood with increasing age, especially in 0–2-year-old and >50-year-old donors. The mean mtDNA copy number level among the mitochondrial disease patients with m.3243A>G mutation was significantly higher than that of healthy controls. The mtDNA content of POLG, DGUOK, TK2, and SUCLA2 genes in blood samples from MDS patients was reduced to 25%, 38%, 32%, and 24%, respectively.

We primarily establish the reference intervals of mtDNA copy number, which might contribute to the clinical diagnosis and monitoring of mitochondrial disease.

Although various studies have been conducted on the effects of radiation therapy for prostate cancer, rectal toxicity after radiation therapy for prostate cancer, which is an important late adverse event associated with radiation therapy, has not been sufficiently examined. This study aimed to assess the associations of late rectal disorder (LRD) with dosimetric, anatomic, and clinical factors in patients with prostate cancer who underwent three-dimensional conformal radiation therapy (3D-CRT).

We retrospectively analyzed 104 patients undergoing 3D-CRT between January 2009 and October 2011. Thirty patients were administered anticoagulation/antiplatelet (AC/AP) agents. The standard dose was 74 Gy. Uni- and multi-variate analyses were performed to identify factors predictive of LRD after 3D-CRT.

The median follow-up period was 66 (range: 14–87) months. LRD occurred in 10.6% (11/104) of patients. The median time from RT to LRD was 15 months (range: 7–41 months). Sixty-four percent of those with LRD (7/11 patients) had been given AC/AP agents. Fifty-five (6/11) patients had severe internal iliac artery calcification. By univariate analysis, significant predictors of LRD were internal iliac artery calcification, administration of AC/AP agents, and age. Being very elderly was the significant predictor identified by multivariate analysis (P = 0.0276). For patients receiving AC/AP agents and those with severe internal iliac artery calcification, the LRD incidences were 23.3% (7/30 patients) and 23.1% (6/26 patients), respectively, and being 75 years of age or older was a significant predictor in these subsets.

Our results suggest advanced age, administration of AC/AP agents, and severe internal iliac artery calcification to be risk factors for LRD in patients undergoing standard RT. Therefore, it is necessary to administer radiation with particular caution in the very elderly, especially those receiving AC/AP agents and/or with severe internal iliac artery calcification.

Renal cell carcinoma (RCC) is the most common type of malignant renal tumors with a growing incidence in the recent years. This study aimed to investigate the influencing factors and variation trend of hospitalization expenditures among RCC patients in a single-centered hospital in Beijing during 5 consecutive years and to find the major cost items and fluctuation tendency of inpatient medical expenditures.

The information of medical expenditures among RCC patients in a Grade-A tertiary hospital during the years 2012–2016 was investigated to find the main cost items and changes affecting the medical cost structure. Gray correlation method was adopted in quantitative analysis to analyze the composition of medical expenditures, and the variation of hospitalization expense structure during the five years was studied by analyzing the degree of structural variation.

The cost item constitution of the hospitalization expenditures among RCC patients was relatively stable in the sample hospital during the past five years. To be specific, drug costs accounted for the largest proportion of medical expenditures each year, with the highest of 37.81% in 2012, and showed a slowly declining tendency in the coming years. The cost item with the highest correlation degree was drug costs, with the value of 1.0000; followed by the costs of surgeries, 0.8423. Furthermore, drug costs shared the largest proportion (40.95%) of structural variation, followed by the costs of surgeries (18.35%).

Drug costs are the major influencing factors of the hospitalization expenditures among RCC patients. Thus, reasonable control on excessive drugs as well as the standardization of the diagnosis and treatment behaviors is conducive in reducing medical expenditures as well as easing patients’ economic burdens. Besides, the positive growth on surgery costs suggests that the labor value of medical staffs has been gradually recognized.

Tracheobronchial mucoepidermoid carcinoma (MEC) is a rare airway tumor in adults for which surgery is considered a first-line treatment. However, some patients already lost the best opportunity of a surgical intervention when diagnoses are confirmed, and surgery causes considerable trauma resulting in partial loss of pulmonary function. Moreover, the tumor is resistant to radiotherapy and chemotherapy. These factors make the treatment of tracheobronchial MEC challenging. This study aimed to evaluate the safety and efficacy of interventional bronchoscopic therapy in adult patients with tracheobronchial MEC.

We retrospectively analyzed the clinical manifestations, bronchoscopic interventions, complications, and outcomes of 11 adult patients with tracheobronchial MEC. Paired t-test was used to analyze the parameters of the American Thoracic Society Dyspnea Index and the Karnofsky Score before and after the first interventional bronchoscopic therapy.

All tumors occurred in the main bronchus and were easily visualized by bronchoscopy. After interventional bronchoscopic therapy, the symptoms of all patients showed significant improvement. The American Thoracic Society Dyspnea Index decreased from 1.91 ± 1.22 to 0.27 ± 0.47 (t = 6.708, P < 0.001) and the Karnofsky Score increased from 78.18 ± 16.62 to 95.46 ± 8.20 (t = −5.190, P < 0.001). Bronchoscopic intervention did not result in serious complications or mortality. During the follow-up period between 3 and 96 months after the first therapy, the following results were noted: (1) among the eight patients with low-grade tracheobronchial MEC, only one patient had a relapse and agreed to surgical treatment; (2) among the three patients with high-grade tracheobronchial MEC, one patient required repeated bronchoscopic interventions, one patient died of pulmonary infection, and one patient died of systemic failure owing to tumor metastasis.

Interventional bronchoscopic therapy, as an alternative treatment, shows promise in some adult patients with low-grade tracheobronchial MEC confined to the bronchus. However, for adult patients with high-grade tracheobronchial MEC, early diagnosis and surgical treatment are still strongly recommended.

近年来，随着社会经济的发展以及生活方式和饮食的改变，中国高尿酸血症（HUA）的患病率有所增加，并有发病年龄年轻化的趋势。HUA已成为仅次于糖尿病的第二大常见代谢性疾病。与痛风一样，HUA也与泌尿、内分泌、代谢、心脑血管等系统疾病的发生和进展有关。不同的专家小组在各自的领域制定了关于HUA和痛风的指南和共识。这一共识是由包括风湿科医生、肾病科医生、内分泌科医生、心脏病科医生、神经科医生、泌尿科医生和中医专家在内的工作组按照系统的医学模式制定的。这是中国首个关于HUA及其相关疾病的多学科专家共识，旨在促进多学科合作并为最佳临床实践提供指南。

To provide a comprehensive and latest overview of susceptibility-weighted imaging (SWI) in the application of thrombolysis in acute ischemic stroke, and to update the decision-making effect and clinical value of SWI on identifying stroke patients suitable for thrombolytic therapy and possible benefits and risks followed.

Literatures referred to this review were collected from PubMed, Medline, and EMBASE published till May 2017, using the search terms including susceptibility-weighted imaging, gradient-echo, T2*, thrombolysis, recombinant tissue plasminogen activator (rt-PA), thrombolytic therapy, and stroke.

Papers in English or with available English abstracts were considered, with no limitation of study design. References were also identified from the bibliographies of identified articles and the authors’ files.

SWI is of guiding significance for thrombolytic therapy in stroke patients, it can predict the location and length of thrombus and ischemic penumbra. It is worthy of noting that susceptibility vessel sign (SVS) on SWI can be used to predict recanalization after thrombolytic therapy and whether it is better to implement endovascular thrombolectomy in combination or alone. SWI is sensitive in detecting cerebral microbleed (CMB), and CMB might not be a contraindication for thrombolytic therapy, yet CMBs in multiple foci could possibly be related to intracranial hemorrhage (ICH) after thrombolysis. SVS and CMB on SWI sequence are of instructive value in performing antiplatelet therapy after thrombolytic therapy. Cerebral venous change on SWI is related to lower recanalization rate and poor outcome after thrombolysis.

It seems that SWI can be applied to guide individualized thrombolytic therapies and assist clinicians in making better decisions by weighing benefits and risks. However, there still exist controversies about the relationship between signs on SWI and thrombolytic therapy.

谵妄是危重患者预后不良（包括住院死亡率、住院时间延长、医疗费用增加和长期认知障碍）的重要独立指标。重症医学专家一直在关注并开展谵妄的研究，以便更好地预测、预防、管理、治疗，甚至更好地改善危重患者的预后。根据理论研究的最新发现，结合临床经验，复习有关谵妄的文献，明确对危重病人谵妄的十点基本认识。

白塞氏病（BD）是一种慢性、复发性自身免疫性疾病，其特征是口腔和生殖器溃疡伴葡萄膜炎，以及多器官系统的其他临床表现。据报道，BD中血管受累的发生率在5-30%之间。^[1]血管性BD（VBD）分为三种亚型，以静脉闭塞、动脉闭塞或动脉瘤为特征。VBD的最佳治疗方法，尤其是动脉瘤或假性动脉瘤，仍有争议。尽管动脉瘤和假性动脉瘤可能危及生命，但由于VBD的罕见性，缺乏治疗经验通常使治疗决策变得困难。^[2]在这篇手稿中，我们报告了两例伴有主动脉瘤和假性动脉瘤的BD病例的相反结果，以阐明在这种情况下与治疗决策和症状管理相关的困难。

脑室周围结节性异位（PNH）是一种皮层畸形，常见于癫痫患者，由神经元迁移失败引起。^[1]PNH患者表现出各种临床表现和基因突变。尽管PNH患者有显著的结构畸形，但通常没有神经功能缺损或认知障碍。然而，特别是在皮质发育异常的患者中，系统性异常也可能严重延迟。大约70%的PNH患者患有癫痫，通常在生命的第二个十年出现癫痫发作。^[2]在这里，我们描述了中国患者队列中PNH的表型图片，包括临床特征、神经影像学和脑外发现，以表征PNH患者和健康对照组（HCs）之间的差异。此外，我们还报告了他们获得社会支持的情况以及PNH对他们教育和经济状况的影响。

缩窄性心包炎引起的乳糜性腹水和乳糜胸膜少见，以白色乳白色腹水和胸水为特征。通过乳糜微粒的存在来确定诊断。然而，这种情况的处理是非常困难的。我们报告一例乳糜性腹水和乳糜胸，其中积水可归因于缩窄性心包炎。在本病例中，心包切除术联合胸导管结扎和胸膜固定术治愈了由缩窄性心包炎引起的乳糜性腹水和乳糜胸，这在以前从未被描述过。

胸部计算机断层扫描（CT）筛查在中国越来越受欢迎。因此，越来越多的罕见病和肺部疾病的早期阶段被发现。在此，我们报告了一例在胸部CT扫描中偶然发现的多发性毛玻璃结节的病例，该病例曾被怀疑为同步性多原发肺癌（SMPLC）和/或转移性癌症。她最终被诊断为结节性硬化症（TSC），这是一种常染色体显性疾病，其特征是在皮肤、眼睛、肾脏和中枢神经系统中形成错构瘤性病变。^[1,2]结节性硬化症1（TSC1）在她和她的家族成员中发现了基因突变（c.1030-1G>A）。这在国内是非常罕见的报道。

心房颤动(AF)是最常见的心律失常类型，据报道，它会使中风的发病率增加5至7倍，导致不规则的室性心律并对生活质量产生不利影响，并且AF也会增加死亡率本身.^[1]参松养心（SSYX）胶囊是由十几种中草药组成的具有显著抗心律失常作用的新型中药。在目前的研究中，SSYX胶囊的作用已经在动物研究中进行了测试，并且还通过随机双盲、阳性药物对照临床试验进行了指示。^[2]但SSYX胶囊作为抗心律失常药物的作用机制尚不完全清楚。^[3,4]本研究试图探讨SSYX胶囊对急性房颤犬模型心肌电生理的影响。

编者：局部泛萎缩，由Gower于1903年首次描述，也称为Gowers泛萎缩，是一种极其罕见的疾病，其特征是覆盖皮肤的无症状萎缩以及皮下组织的部分或全部丧失，并可能涉及下面的肌肉和骨骼。^[1]在此，我们报告了一例与剧烈疼痛相关的疾病。

致小编：2016年我院收治一名35岁中国男性，多发性血栓形成9年，严重乏力，少尿共3周。该患者9年前在当地医院被诊断为肺栓塞和多发性深静脉血栓形成。患者接受了华法林治疗，国际标准化比值（INR）维持在2.42至3.18之间。虽然实验室检查结果显示，当时活化部分凝血活酶时间（APTT）延长（77.8 s），但未进行进一步研究，患者的抗凝治疗在3个月后终止。

致编者：硬脑膜动静脉瘘（dAVF）是一种罕见疾病，占所有脑血管畸形的不到10%。^[1]合并髓周静脉引流的颅内dAVF非常罕见，由于其临床和放射学表现不明确，容易误诊。在这里，我们提出这样一个病例，最初被误诊为脑干肿瘤。

在题为“真实世界恩替卡韦疗法在治疗初治慢性乙型肝炎患者中的疗效”的文章中，发表在第18期第2190-2197页。130的中华医学杂志^[1]，作者的隶属关系被错误地写成“北京大学肝病研究所，北京市丙型肝炎和肝病免疫治疗重点实验室，北京大学人民医院，北京100044”，而不是“北京大学人民医院，北京大学肝病研究所，北京市丙型肝炎和肝病免疫治疗重点实验室，北京100044”。