Volume 133 · Issue 05 · 2020

中国最近在医疗保健方面取得了非凡的发展，并实现了千年发展目标4和5。根据2012年中国医疗卫生服务白皮书，中国妊娠相关死亡率（每10万活产妊娠相关死亡；PRMR）从2002年的51.3下降到2011年的26.1。对1996年至2015年间2852个中国县的地方分析表明，PRMR从1996年的108.7下降到2015年的21.8，年化下降率为8.5%。^[1]根据2018年国家医疗服务和质量安全报告，2018年的PRMR为每10万活产18.3人。相比之下，2011年至2015年间，美国的PRMR为每10万活产17.2人。^[2]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

分娩过程中的剧烈疼痛是当今世界关注的焦点，是疼痛治疗的重要课题。分娩镇痛作为缓解分娩疼痛的有效干预措施，在我国起步并不晚，但其发展面临诸多困难，传播和普及步履蹒跚。本文提供了中国分娩镇痛率低的观点和提高分娩镇痛率的实际解决方案。

过敏反应是一种罕见但严重的、可能危及生命的过敏反应，最常见的是多系统受累，如皮肤、心血管、呼吸、胃肠和中枢神经系统体征和症状。当它发生在围手术期时，由于许多影响因素，例如无菌盖布隐藏的皮肤变化，当患者被镇静或麻醉时无法描述其症状，以及麻醉剂的应用导致交感神经阻滞，表现为血压下降，因此很难识别。所有上述原因使得围手术期过敏反应的识别和立即治疗变得困难，并且部分归因于高死亡率。

在分娩过程中，大多数女性会遭受异常的疼痛，尤其是在第一产程之后。大量研究和研究贡献已经证实，神经轴分娩镇痛（NLA）是一种有效、安全、经济的缓解分娩疼痛的方法。^[1]十多年前，英国一项关于硬膜外镇痛的调查报告称，90%的中心提供24小时硬膜外镇痛。^[2]相比之下，根据北京大学第一医院2006年进行的调查，在中国76家进行NLA的医院中，只有10家医院（13.1%）提供24小时服务。^[3]尽管近年来有所改善，但与西方同行相比，中国分娩镇痛的总体使用率仍然较低。

在中国，晚期喉癌患者要么采用根治性手术，然后进行辅助放疗，要么采用非手术综合治疗以保留器官。尽管重要的临床试验证实了喉器官保存在晚期喉癌治疗中的可能性，^[1,2]最佳的喉保存策略仍在争论中。^[3,4]在这里，我们评估了寻求保留晚期喉癌患者喉功能的非手术综合治疗的疗效。

致编辑：国内多数研究者关注传统持续硬膜外镇痛（CEA）的整个产程会阻碍第二产程的产妇力量。相比之下，局部麻醉剂可以使用相对较长的时间。椎管内过量给药可抑制子宫平滑肌收缩，^[1]这可能导致产程延长，催产素使用增加，产钳分娩、剖宫产和新生儿窒息率增加。因此，我国部分产科医生和助产士选择在宫颈开口至7~8厘米或宫颈完全扩张时停止硬膜外分娩镇痛。由此可见，大多数产妇不能享受到理想的足月分娩镇痛。

致编辑：患者女，29岁，孕31±1周未产妇（体重68 kg，身高159 cm），主诉下肢水肿3个月，呼吸困难1周，近2天加重。在经历闭经40天后，她在当地医院被确认怀孕。所有常规检查都是正常的，直到她在妊娠18周时被发现贫血而没有症状。她的血红蛋白（Hb）为77 g/L，无地中海贫血。口服多糖铁复合物4周后，她的Hb增加到81 g/L，并伴有下肢水肿。尿液检测蛋白（+）和潜血（3+）呈阳性。孕30周感觉胸闷、心悸、乏力，夜间不能保持仰卧位。血常规检查显示Hb水平67 g/L，经胸超声心动图显示二尖瓣轻度狭窄伴中度反流和轻度心包积液。随后，她因端坐呼吸和水肿住进了我们的急诊医院。她的体检显示心率为120次/分钟，血压为110/70毫米汞柱。左肺可听到湿罗音。实验室检查显示，她的Hb为73 g/L，脑利钠肽（NT-BNP）10,300 pg/mL，肌钙蛋白0.098 μ g/L，肌血红蛋白146.4 μ g/L，谷丙转氨酶98 IU/L，谷草转氨酶100 IU/L，白蛋白25.7 g/L，尿素氮（BU）11.64 mmol/L，肌酐（Cr）138 mmol/L，钾5.63 mmol/L。尿检蛋白（3+）呈阳性。超声检查显示左侧胸腔积液。经多科室会诊，终止妊娠，改善患者状况。

致编辑：腰椎管狭窄症（LSCS）是老年人的常见病。肥厚性腰椎黄韧带（LLF）在LSCS的发病机制中起着至关重要的作用。生理性LLF是一种厚度为2~4 mm的致密结缔组织，主要由成纤维细胞和细胞外基质（ECM）组成。ECM包含弹性纤维、胶原纤维和基质。纤维的分布特征表明，大量的弹性纤维与少量的胶原纤维混合在一起；主要是I型和III型胶原纤维。这些纤维沿着柱的轴线方向紧密且规则地排列。LLF位于椎管硬脑膜的背侧，附着于椎板前表面的上边缘和下部。LLF的营养不良是几个因素的结果，如衰老、炎症过程、应激负荷和遗传倾向。一旦LLF肥大，可引起中央椎管、神经根管和椎间孔的狭窄。这种病理会导致腰痛、坐骨神经痛，甚至泌尿和肠道疾病。

致编辑：血管肉瘤（AS）是一种罕见且高度恶性的间叶肿瘤，占成人软组织肉瘤的2%。AS由于转移和复发率高，预后较差。根据拉哈特的一项回顾性研究等人还有费耶特等人,^[1,2]121例患者中有31例（19%）在初次诊断时有转移，90例（74%）有复发和进展。AS的中位生存期为3.4年，转移患者下降至10个月。为了试图改善AS治疗结果，提倡多模式方法，包括手术切除与放疗、化疗、免疫治疗和/或抗血管生成治疗相结合。在此，我们报告了一名男性，他之前接受了直肠系膜衍生的中间性血管内皮瘤（HAE）切除术，并在一年内发生了AS肺转移。病史值得注意，因为（1）原发部位罕见：只有2例与肠系膜相关；（2）临床病程不典型：初诊为中间型血管内皮瘤，后进展为肺转移性AS；和（3）一系列成功的多学科治疗程序，尤其是转移瘤切除前的选择性动脉灌注（SAI）化疗。

致编辑：急性泛发性发疹性脓疱病（AGEP）是一种主要由药物诱发的罕见临床反应，其特征是急性起病的泛发性、非滤泡性无菌性脓疱，伴有发热和中性粒细胞计数升高，通常伴有相对有利的预后。^[1]在此，我们提出一个AGEP并发落叶性天疱疮（PF）的特殊病例。