Volume 101 ·  Issue 15 ·  2021

Asthma in the elderly is a special type of asthma, with special pathophysiology, clinical characteristics, complications and drug reaction, resulting in its diagnosis and treatment complicated, with higher morbidity and mortality. Combined with the newly published Chinese Expert Consensus on the Diagnosis and Management of Asthma in the Elderly, this paper calls for strengthening the management of asthma in the elderly, promoting relevant research, and perfecting the clinical diagnosis and treatment program suitable for the elderly asthma patients, so as to improve the level of asthma control and improve the prognosis.

To analyze the diagnostic performance of serum and bronchoalveolar lavage fluid (BALF) galactomannan (GM) test in invasive pulmonary aspergillosis(IPA) with severe and critically ill influenza.

A retrospective study was performed for 157 patients with severe and critically ill influenza admitted to the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University from December 2017 to April 2019.Clinical characteristics and serum and BALF GM values were collected. The patients were divided into an IPA group (n=18) and a non-IPA group (n=139). The definition of IPA modified from AspICU algorithm taken as the gold standard (The corresponding clinical manifestations, imaging manifestations and microbiological diagnostic criteria should be met simultaneously), the performance of serum and BALF GM test and their combination to IPA with influenza were analyzed respectively and receiver operating characteristic curve (ROC) was drawn.

A total of 157 cases were enrolled, 95 were critically ill, and the mortality of IPA with influenza was 55.6%(10/18). The APACHE Ⅱ score, PSI score, urea nitrogen, influenza severity (Percentage of critically ill influenza) and invasive ventilator in IPA group were (16±6), (110±31), 10.7 (8.4, 17.8) mmol/L, 88.9% and 66.7%, respectively, which were significantly higher than those in non-IPA group [(10±5), (83±30), 5.2 (3.6, 7.6) mmol/L, 56.8% and 24.5%, P<0.05]. All patients received serum GM test and 32 patients performed BALF GM test at the same time. When the cut-off valve of serum GM test was 0.5 μg/L, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 66.7% (12/18), 95.0% (132/139), 63.2% (12/19) and 95.7% (132/138) respectively. When the cut-off value of BALF GM test was 1.0 μg/L, the sensitivity, specificity, PPV and NPV were 80%(8/10),86.4%(19/22),72.7%(8/11)and 90.5%(19/21)respectively. The BALF GM cut-off value of 0.88 μg/L showed the highest diagnostic efficacy for IPA, for which the sensitivity and specificity were 90%(9/10) and 86.4%(19/22). The areas under the ROC curve of serum GM, BALF GM, and the combination of them were 0.81, 0.85, and 0.94 respectively. The difference was statistically significant (P<0.05) and the combined diagnosis efficiency was higher.

Critically ill influenza patients should be alert for IPA. The sensitivity of serum GM test in the diagnosis of IPA with influenza was low, while the NPV was high. The optimum BALF GM cut-off value was 0.88 μg/L. The combination with BALF and serum GM test can improve the diagnostic performance.

To explore the characteristics of cortical morphology in cerebral small vessel disease (CSVD) patients with subcortical ischemic depression (SID) and its relationship with clinical symptoms.

A total of 88 patients with CSVD in the First Affiliated Hospital of Anhui Medical University were enrolled from July 2017 to July 2020. The subjects were divided into CSVD-non depression group (CSVD-ND, n=58) and SID group (n=30) according to the geriatric depression scale (GDS). The 3D-T₁ MRI images were obtained from all subjects. The computed anatomy toolbox 12 (CAT 12) was used for image processing and cortical segmentation to obtain the cortical thickness (CTh) and surface metrics, including gyrification index (GI), sulcus depth (SD) and fractal dimension (FD). A comparison at the vertex‐ and region‐of‐interest (ROI)‐wise levels were performed by the general linear model, and correlation analysis were conducted between cortical morphometric measurements and GDS scores. Finally, mean CTh (mCTh) was extracted for binary logistic regression analysis.

At the vertex-wise level, compared with the CSVD-ND group, the SID patients showed increased CTh in clusters mainly located in the posterior default mode network (pDMN), such as the precuneus(Pcu), the superior parietal gyrus (SPG) and the right postcentral gyrus (PoCG). As for the surface measurements, the GI value and the FD value were increased in clusters of Pcu and inferior temporal gyrus (ITG), respectively, in the SID group. ROIs analyses showed that apart from the Pcu, the SPG and the right PoCG, CTh alterations in the SID group were involved in a wider range of regions, extending to the right precentral gyrus ((2.27±0.20) cm³ vs (2.12±0.26) cm³, P=0.007), the left paracentral gyrus ((2.18±0.20) cm³ vs (2.05±0.23) cm³, P=0.008) and so on, than that in the CSVD-ND group.Compared with the CSVD-ND patients, the SID patients showed increased GI in the right PoCG ((25.31±1.11) vs (24.23±1.27), P<0.05). Correlation analysis showed that CTh in the right Pcu was positively correlated with the GDS scores (r=0.4, P<0.05). Further binary logistic regression analysis showed that in comparison with the subjects in the reference group (<2.367 cm³), the odds ratio(95%CI) for SID patients in the highest tertile of mCTh (>2.473 cm³) were 6.373 (1.254-32.389) after multivariable adjustment (sex, age, years of education, total intracranial volume, traditional imaging findings of CSVD, cognitive function (CAMCOG-C) and mCTh).

Both CTh and cortical complexity were increased in CSVD patients with SID, especially in the clusters of pDMN, and CTh may be an important risk factor for SID.

To investigate the application status of optimal medical therapy (OMT) in patients with coronary heart disease after percutaneous coronary intervention (PCI) and its influence on the 1-year prognosis of patients after surgery.

Data of 3 812 patients diagnosed with coronary heart disease by coronary angiography and successfully completed PCI in the Department of Cardiology, TEDA International Cardiovascular Hospital from October 2016 to September 2017 were prospectively collected. The OMT status and the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) during the hospitalization and 1, 6, and 12 months after discharge were recorded. Patients were divided into OMT group (n=1 299) and non-OMT group (n=2 289) according to their adherence to OMT after PCI. Chi-square test was used to compare the differences of MACCE between groups, and to screen for significant differences and clinically significant variables between groups. Cox regression model was used to analyze the influencing factors of MACCE after PCI.

Among 3 588 patients (224 cases lost to follow-up), 58.8% (2 110/3 588) used OMT during hospitalization after PCI, and 36.0% (1 293/3 588) still adhered to OMT after 12 months of follow-up. The utilization rates of OMT showed a decreasing trend, among which till the 12^th month, β-blockers and ACEI/ARB showed the greatest decreasing degree, from 75.3%(2 701/3 588) and 75.1%(2 692/3 588) to 59.1%(2 122/3 588) and 53.0%(1 903/3 588). Pearson χ² analysis showed that elderly patients, the number of amalgamative diseases, history of PCI, history of chronic myocardial infarction, history of chronic renal insufficiency, the lesion counts, lesion type, the Gensini score, adhere to the OMT and smoking during the follow-up were related to postoperative MACCE, the difference was statistically significant (P<0.05). Cox regression model showed that OMT adherence after PCI was an independent protective factor for postoperative MACCE events (HR=0.471,95%CI: 0.300-0.734, P=0.001).

The application of OMT after PCI was suboptimal, and the application rate decreased with the lengthening of the discharge time, among which the use of ACEI/ARB and β-blockers deserved more attention. Adherence to OMT after PCI was an independent protective factor, which could reduce the incidence of postoperative MACCE and improve the prognosis of patients.

To investigate the clinical efficacy and safety analysis of bronchial thermoplasty (BT) in the treatment of severe asthma and asthma-chronic obstructive pulmonary disease overlap.

The clinical data of 49 patients with asthma-COPD overlap who received BT in the University of Chinese Academy of Sciences Shenzhen Hospital from January 2016 to December 2018 and 50 patients with severe asthma who received BT in the same period were retrospectively analyzed. Patients were divided into overlap group and asthma group, and the baseline data of two groups were recorded. The pulmonary function before and after treatment (including forced vital capacity (FVC), forced expiratory volume in the first second (FEV₁), FEV₁ as a percentage of predicted value (FEV₁% pred)), hormone consumption, asthma control test (ACT) score, asthma quality of life questionnaire (AQLQ) score, asthma control questionnaire (ACQ) score, the overlap group before and after treatment COPD assessment test (CAT) score, modified British Medical Research Council (mMRC) score and postoperative respiratory adverse events in the next 3 weeks were comparatively analyzed.

The general baseline characteristics of the two groups are compared. The patients in the overlap group were older than those in the asthma group, and the course of disease and smoking history were longer than those in the asthma group. The inhaled hormone dosage in asthma group was greater than those in the overlap group ((64±11) years vs (48±11) years; 10.00 (10.00, 25.00) years vs 9.00 (1.75, 20.00) years; 20.00(2.00, 40.00) years vs 0 (0, 10.00) years; 320 (320, 640) μg/d vs 960 (320, 960) μg/d) (all P<0.05). The predicted values of lung function indexes FVC, FEV₁, FEV₁% pred in the overlap group before treatment were all lower than those in the asthma group (1.98 (1.43, 2.43) L vs 2.54 (2.02, 3.15) L; 0.92 (0.61, 1.26) L vs 1.69(1.17, 2.16) L; (50±16) L vs (65±14) L) (all P<0.05). There were no significant differences in ACT, ACQ, and AQLQ scores between the two groups before treatment (allP>0.05). Within 3 months after treatment, except for no significant improvement in FEV₁% predicted value and inhaled hormone dosage in the overlap group (all P>0.05), other indexes in both groups were improved compared with those before treatment (allP<0.05). After 1 year of treatment, all indexes of the two groups were significantly improved than those before treatment, and all indexes of the asthma group were better than those of the overlap group (allP<0.05). In terms of respiratory adverse events occurring within 3 weeks after the operation, the incidence of cough and bloody sputum in the overlap group was higher than that in the asthma group, while the incidence of sputum and short-term wheezing was lower than that in the asthma group (allP<0.05). There were no statistically significant differences in the incidence of chest tightness, chest pain, segmental atelectasis and pneumonia between the two groups (allP>0.05), and the postoperative adverse reactions could be effectively controlled in a short period of time.

BT treatment could not only improve the lung function, clinical symptoms and quality of life of asthmatic patients, but was also effective for asthma-COPD overlap patients. However, BT treatment had more benefits for asthmatic patients without serious adverse events occurred.

To compare the clinical efficacy and the level of muscle and soft tissue damage between modified posteromedial approach via lateral side of flexor hallucis longus and modified posteromedial approach in the treatment of posterior Pilon fracture.

Total of 43 patients (27 males and 16 females, aged from 19 to 71 years) diagnosed with posterior Pilon fracture from June 2016 to June 2018 in Foshan Hospital of Traditional Chinese Medicine were randomly divided into observation group (modified posteromedial approach via lateral side of flexor hallucis longus, 21 cases) and control group (modified posteromedial approach, 22 cases) according to the operation approach. The preoperative waiting time, intraoperative time, intraoperative blood loss, hospitalization time and the complications were recorded and compared between the two groups. The differences of blood creatine kinase (CK), myoglobin (Myo) and C-reactive protein (CRP) at different time points before and after operation were compared between the two groups to elevate the level of muscle and soft tissue damage. The fracture reduction qualities of the two groups were compared by Burwell-Charnley criteria. The differences of fracture healing time, range of motion of metatarsophalangeal joint of the great toe (MTP-ROM), ankle range of motion (Ankle-ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score and visual analogue scale (VAS) score of pain were compared between the two groups at the last follow-up.

The observation group and the control group were followed-up for (19±6) months and (16±8) months, respectively; there was no significant difference between the two groups (P>0.05). There were no significant differences in preoperative waiting time, intraoperative blood loss, hospitalization time and fracture healing time between the two groups (allP>0.05). At the last follow-up, there was no significant difference in the MTP-ROM and Ankle-ROM between the two groups (bothP>0.05); the AOFAS score of the observation group was 88.2±7.8 and it was 84.5±7.6 in the control group (P>0.05); the VAS score of the observation group was (0.9±1.0) and it was (1.3±0.8) in the control group(P>0.05). Anatomical reduction rate in observation group was higher than that in control group (90.5% vs 81.8%,P>0.05). The operation time in the observation group was (87±16) min and it was (98±11) min in the control group (P<0.05). CK, Myo and CRP were increased in both groups after surgery, but there was no statistical significance between groups at the same time point (allP>0.05). There was no nerve injury in the observation group, while 2 cases (9.0%) of nerve paralysis occurred in the control group. No incision infection and checkrein deformity of the Hallux was found in the two groups.

The modified posteromedial approach via lateral side of flexor hallucis longus can obtain good operative field exposure, and does not increase muscle and soft tissue injury, with shorter operative time and fewer complications, without nerve injury and checkrein deformity, it is a safe approach for the treatment of posterior Pilon fracture.

To compare the postoperative outcomes and urinary continence recovery time between standard robotic-assisted laparoscopic radical prostatectomy (RARP) and Retzius-sparing robotic-assisted laparoscopic radical prostatectomy (RsRARP).

A total of 92 patients with low to intermediate-risk prostate cancer who underwent RARP (n=52) and RsRARP (n=40) in Sir Run Run Shaw Hospital from October, 2016 to January, 2018 were retrospectively reviewed. Perioperative data (operative time, estimated blood loss, complications, postoperative staging, postoperative Gleason score) and surgical outcomes (rate of margin positive, urinary continence recovery time) of RARP and RsRARP group were comparatively analyzed.

All 92 cases were successfully performed with robot. RARP group had a significantly shorter mean operative time when compared with that in RsRARP group ((103±23) min vs (130±26) min, P<0.05). The two groups had comparable estimated blood loss ((100±54) ml vs (103±64) ml,P>0.05), rate of postoperative infection (5.8% (3/52) vs 5.0% (2/40),P>0.05) and rate of postoperative urine leakage (3.8%(2/52) vs 2.5%(1/40),P>0.05). The two groups had a comparable rate of margin positive (7.7%(4/52) vs 12.5%(5/40),P>0.05). Compared with RsRARP group, the RARP group had a lower rate of urinary continence recovery immediately after the catheter removing at 1 week, 1 month and 3 months after the operation (allP>0.05). The two group had a comparable rate of urinary continence recovery at 6 months after the operation (P>0.05).

The RsRARP technique has a good tumor control and obvious advantage of early urinary continence recovery compared with the standard RARP technique. RsRARP technique is safe and effective for the treatment of localized prostate cancer.

To investigate the general situation, detection range, testing reagents, and clinical performance of non-invasive prenatal testing (NIPT) for fetal chromosomal copy number variations (CNVs) in Chinese laboratories.

The National Center for Clinical Laboratories of the National Health Commission designed a questionnaire for the detection of CNVs by NIPT, which included the investigation of whether the laboratory has carried out NIPT to detect CNVs and its testing scope, reagents/platforms, intended uses, screening populations and clinical performance. The questionnaires were distributed to 355 laboratories in 31 provinces, autonomous regions, and municipalities across the country on October, 2020. Further, the feedbacks were statistical analyzed.

Two hundred and twenty-eight laboratories had performed NIPT to detect CNVs, including 116 types of CNVs, and more than 95% of laboratories chose to detect the CNVs of 5p15 deletion, 22q11.2 deletion, 1p36 deletion, and 15q11.2 deletion. All testing reagents used were laboratory-developed tests and were based on massive parallel sequencing, the minimum amount of sequencing data was 3-15 M reads, the detection limit of fetal fraction was 3%-5%, and the minimum size of variants that can be detected was 1-5 Mb. The proportion of laboratories that apply CNVs testing for daily project, voluntary requirements of patients, and scientific research were 58.8% (134/228), 57.5% (131/228), and 20.6% (47/228), respectively. One hundred and thirty-four laboratories were fully or partially aware of the clinical performance of NIPT to detect microdeletion/microduplication syndromes, and the laboratories′ declared sensitivity of NIPT for Cri du Chat syndrome, 22q11.2 deletion syndrome, 1p36 deletion syndrome, and Angelman syndrome were 50.0%-100%, 60.0%-100%, 50.0%-100%, and 33.3%-100%, and the positive predictive values were 9.0%-50.0%, 18.0%-100%, 20.0%-30.0%, and 20.0%.

The detection of CNVs by NIPT in Chinese laboratories need to be standardized. Laboratories should detect CNVs with clear clinical significance in accordance with the guidelines, conduct performance validation of the reagents, then perform NIPT test and provide adequate interpretation after mastering the clinical performance sufficiently.

Three cases with age-related cerebral small vessel disease and normal pressure hydrocephalus in the Department of Neurology of Sun Yat-sen University were retrospectively reviewed. All the patients exhibited gait disturbance, cognitive impairment and urinary incontinence. Meanwhile, the Craniocerebral imaging demonstrated cerebral small vessel disease and communicating hydrocephalus. The cerebralspinal fluid (CSF) Aβ42 levels decreased, and apolipoprotein E (APOE) genotypes were ε3/ε4,ε3/ε3,ε2/ε3, respectively. After treatment in an all-cause individualized manner, the symptoms of 3 patients were stable or improved.

Bedside hypertonic saline-contrast electrical impedance tomography (EIT) method for lung perfusion evaluation has several advantages of bedside, simple, noninvasive and radiation-free. For a long time, EIT perfusion image of hypertonic saline was mostly limited to animal experiments, and related clinical research is in the ascendant. This technical specification for clinical application is reached based on our previous researches, review of literatures in this field. The purpose of this technical specification is to facilitate the unified and standardized use of hypertonic saline-contrast EIT technology for regional lung perfusion, to evaluate the safety and quality control of the technology, and to unify the results.

The clinical and magnetic resonance imaging(MRI) data of 8 cases of fungal spondylitis were retrospectively enrolled in the study, and the typical MRI findings were mainly discussed. The results released that fungal spondylitis should be suspected when the infection spreads along paraspinal ligament, and vertebral lesions show jumping discontinuous distribution. A blurred and incomplete outline of endplate on T1 weighted imaging sequence, loss of hyperintensity of the vertebral body, and banded like hypointensity under endplate on T₂ weighted imaging sequence, indicate fungal spondylitis. These features contribute to the diagnosis and differential diagnosis of fungal spondylitis.

This article reports a case of a patient with acute paresthesia, weakness of lower limbs, and urinary and stool disorders. He had a history of infection before the onset, which was consistent with acute disseminated encephalomyelitis. However, Sjogren's syndrome was found by secondary factors, and the final diagnosis considered the possibility of neurological involvement in Sjogren's syndrome. The patient was complicated with pulmonary tuberculosis, and anti-tuberculosis treatment was initiated at the same time as hormone shock, and the disease was finally controlled. The neurological involvement of Sjogren's syndrome can be manifested as involvement of the central nervous system and peripheral nervous system, among which demyelinating lesions, cognitive dysfunction and meningoencephalitis are common in the central nervous system. The first-line treatment of hormone combined with cyclophosphamide is the first-line treatment.

Epithelioid hemangioendothelioma (EHE) is a rare mesenchymal tumor. The most commonly affected organs are the liver, lung, mediastinum, etc. EHE occurring in the pleura is extremely rare. This paper reports a case of epithelioid hemangioendothelioma of the pleura.

Programmed death protein 1 (PD-1) and its ligand (PD-L1) (PD-1/PD-L1) signaling pathway is one of the important pathways involved in tumor immune escape. PD-1 inhibitors targeting this mechanism have become a new choice for anti-tumor therapy. However, under this treatment mode, the immune system can be over-activated leading to immune-related adverse events. Among them, renal tubulointerstitial injury is the main factor in kidney, and nephrotic syndrome is rare. This paper reports a case of nephrotic syndrome during treatment of Hodgkin's lymphoma with PD-1 inhibitor, which was relieved after discontinuation and hormone therapy.

Alzheimer's disease (AD) is a neurodegenerative disease whose etiology and pathological mechanism are still unclear, and there is no effective prevention and treatment at present. Recent evidence indicates that intestinal flora is involved in the occurrence and development of AD, and it is expected to become a new drug target. This article mainly reviews the research progress of intestinal flora in the etiology, pathological mechanism and treatment drugs of AD, so as to provide reference for clinicians to understand and engage in related research.

Although asthma patients can be effectively controlled through drug treatment, there are still 5% to 10% of severe asthma patients who are uncontrolled or partially controlled, and are more likely to have recurrent attacks and possibly life-threatening deterioration than mild asthma patients, seriously damaging the quality of life and bringing a heavy economic burden to individuals and society. Bronchial thermoplasty (BT) aims to reduce airway smooth muscle and improve asthma control. To investigate the safety and efficacy of BT in patients with symptomatic severe asthma, the study will use fluticasone (750 mg/d) or an equivalent dose of long-acting beta₂Thirty-two adult asthmatic patients who were treated with receptor agonists and other drugs, including prednisone tablets at 30 mg/d or less, but still had symptoms, were randomly divided into BT and control groups, 15 in BT and 17 in control. Following treatment, the subject entered a 16-week steroid stable phase (Week 6 to Week 22), a 14-week steroid discontinuation phase (Week 22 to Week 36) and a 16-week steroid reduction phase (Week 36 to Week 52). The results showed that BT caused a transient aggravation of asthma symptoms. During the treatment period, 7 of 4 subjects in the BT group were hospitalized for developing respiratory symptoms, 3 subjects had 5 hospitalizations after treatment, 2 for segmental atelectasis, and 1 of them had bronchoscopy and sputum plug aspiration. Seventeen control subjects were not hospitalized during the treatment period, and hospitalization rates were similar in both groups after treatment. At week 22, BT subjects showed significant improvements in rescue medication use, first second forced expiratory volume (FEV1) as a function of predicted value (prior to relaxant use), and asthma control questionnaire (ACQ) scores compared to controls [(-22.6 ± 40.1) actuations/7 d vs. (-1.5 ± 11.7) actuations/7 d,P<0.05）； (14.9±17.4) % to (-0.94±22.3) %,P=0.04； -1.04 ± 1.03 vs. -0.13 ± 1.00,P=0.02], there were still statistically significant differences in rescue medication use and ACQ score compared to the control group at week 52. Although BT is associated with short-term increases in asthma-related symptoms, preliminary confirmation suggests long-term sustained improvement in asthma control.