Chinese General Practice

Interpretation of SOGC Clinical Practice Guideline：No. 363—Investigation and Management of Non-immune Fetal Hydrops　

HOU Lei，WANG Xin

2018, 21(35): 4289-4294. DOI: 10.12114/j.issn.1007-9572.2018.00.365

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Fetal hydrops is a rather challenging clinical problem.In 2018，the Society of Obstetricians and Gynaecologists of Canada（SOGC） published a clinical practice guideline named No. 363—Investigation and Management of Non-immune Fetal Hydrops（hereinafter referred to as 2018 version guideline）.Compared with the Society for Maternal-Fetal Medicine（SMFM） clinical guideline #7：nonimmune hydrops fetalis　issued in 2014，the 2018 version guideline puts forward some new recommendations on the management of non-immune fetal hydrops on the basis of summarizing the major evidences provided by recent studies.The 2018 version guideline emphasizes the great significance of timely referral for fetal hydrops and suggests that all patients with fetal hydrops should be referred promptly to a tertiary care centre for evaluation，because rapid and timely diagnosis and treatment can significantly improve the prognosis of fetal hydrops caused by fetal anemia，arrhythmia and other factors.Moreover，it suggests that the array CGH（microarray） molecular testing and Doppler measurement of the middle cerebral artery peak systolic velocity should be performed in all hydropic fetuses in order to identify the causes of this disease.Autopsy is strongly recommended for all cases of fetal or neonatal death for which no diagnosis is reached prenatally.Furthermore，non-immune fetal hydrops associated with metabolic disorders are detailed.This guideline is the only one concerning non-immune fetal hydrops published in these 4 years，demonstrating great significance of guidance in clinical practice.

Recent Developments in the Mechanism of Phytoestrogen in Preventing and Treating Tumor　

NIU Mimi，TIAN Jing

2018, 21(35): 4295-4298. DOI: 10.12114/j.issn.1007-9572.2018.00.142

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Phytoestrogens，a class of natural non-steroidal compounds，are widely distributed among plant species and can be extracted from plant material.Most of them have the molecular level structure similar to that of estradiol and can bind to estrogen receptors in various cells and exert estrogenic or antigenic effects.Phytoestrogens have been suggested to be anticarcinogenic.The mechanisms by which they can exert inhibitory effects on tumor development may involve inhibition of cancer cell proliferation，induction of cancer cell apoptosis，suppression of cancer cell invasion and metastasis，inhibition of tumor angiogenesis，suppression of tumor-promoting inflammation，regulation of tumor metabolism and stress response，and modulation of tumor microenvironment.In this paper，the mechanisms of action of phytoestrogens on cancers were reviewed，suggesting that they may play a role in the prevention and treatment of cancers as an alternative to estradiol in the future.

Novel Advances in Estrogen Deficiency and Cognitive Impairment in Postmenopausal Women　

YANG Yanyan，ZHAO Lei，YIN Nan，DAI Congwei，LYU Peiyuan

2018, 21(35): 4299-4304. DOI: 10.12114/j.issn.1007-9572.2018.00.239

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Estrogen is the main sex hormone in women.Circulating estrogen can maintain female reproduction functions，normal sexual desire and female secondary sexual characteristics，in particular，estrogen in the brain can help maintain the steady state of the central nervous system.Epidemiological data show that the lack of estrogen in postmenopausal women can cause cognitive decline in different degrees，such as impaired concentration，memory impairment and even dementia.We analyzed the effects of estrogen deficiency on the cognitive function in this population from neurobiological mechanism of estrogen affecting cognition，morphological changes of cognitive function regulation center due to estrogen deficiency，correlation between estrogen and cognitive function and estrogen hormone therapy，in order to raise the awareness of cognitive impairment due to estrogen deficiency in elderly postmenopausal women for improving the quality of life of this population and to provide a research direction for clinical workers.

Effects of Different Gestational Lipid Levels on Postpartum Lipid Metabolism in Patients with Gestational Diabetes Mellitus　

WANG Teng，ZHENG Wei，HUANG Wenyu，ZHANG Li，TIAN Zhihong，ZHANG Ting，YAN Qi，LI Guanghui

2018, 21(35): 4305-4311. DOI: 10.12114/j.issn.1007-9572.2018.00.341

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Background　Patients with gestational diabetes mellitus（GDM） may have glucose and lipid metabolic disorder during pregnancy，and this metabolic abnormality will continue after delivery and even affect the offspring's healthy in the long term.The incidence of metabolic diseases such as postpartum diabetes and hyperlipemia in patients with GDM increases significantly.Objective　To understand the prognosis of postpartum lipid metabolism，and to analyze the risk factors and predictive indicators of abnormal prognosis of postpartum lipid metabolism in patients with GDM.Methods　A total of 512 GDM patients were selected from the Outpatient Department of Endocrinology and Metabolism in Beijing Obstetrics and Gynecology Hospital，Capital Medical University from 2016 to 2017，who received routine examination，delivery and follow-up.According to postpartum blood lipid levels at 6 to 12 weeks after delivery，the subjects were divided into normal lipid group（n=244） and hyperlipidemia group（n=268）.Basic data of patients were collected.We tested total cholesterol（TC），triglyceride（TG），high density lipoprotein（HDL），low density lipoprotein（LDL） in first trimester（<14 weeks），second trimester（14-28 weeks），third trimester（>28 weeks），adiponectin in third trimester，and 6-12 weeks after delivery，fasting blood glucose（FBG） in first trimester，and third trimester，oral glucose tolerance test（OGTT） in second trimester and 6 to 12 weeks after delivery，and 1 h postprandial glucose（PG），2 hPG，fasting insulin（FINS），1 h insulin（INS），and 2 hINS.The insulin resistance index（HOMA-IR） of third trimester and after delivery were calculated.Results　Among 268 patients with postpartum hyperlipidemia，151 patients had hypercholesterolemia，58 patients had hypertriglyceridemia，54 patients had mixed hyperlipidemia，and 30 patients had low high-density lipoproteinemia.Maternal age，the number of birth and the proportion of insulin treatment in hyperlipidemia group were higher than those in normal lipid group，and TG，TC and LDL in first trimester，second trimester，and third trimester and FBG after delivery were higher in hyperlipidemia group compared with those in normal lipid group（P<0.05）.The results of multivariate Logistic regression analysis showed that elevated TC 〔OR=2.018，95%CI（1.161，3.509），P<0.05〕 in first trimester were independent predictors of hyperlipidemia in GDM patients.The results of path analysis showed that “TC in first trimester→postpartum TC”“TG in first trimester→postpartum TG”“LDL in first trimester→postpartum LDL” had significant mediating effects（β=0.38，β=0.20，β=0.31，P<0.05）；“TC in second trimester→postpartum TC”“LDL in second trimester→postpartum LDL”（β=0.21，β=0.23，P<0.05）；“TG in third trimester→postpartum TG”（β=0.13，P<0.05） had significant mediating effects；“TC in first trimester →postpartum hyperlipidemia”“TG in first trimester→hyperlipidemia”“LDL in first trimester→postpartum hyperlipidemia” had significant mediating effects（β=0.28，β=0.14，β=0.17，P<0.05）.Conclusion　Patients with GDM during pregnancy are more likely to have hyperlipidemia at 6-12 weeks after delivery.The risk factors for the postpartum hyperlipidemia in patients with GDM is elevated TC in first trimester of pregnancy.Blood lipid levels in early pregnancy can affect the occurrence of postpartum hyperlipidemia.

Serum Level of Kisspeptin and Its Influence in Patients with Gestational Diabetes Mellitus　

WANG Zhuoqun，WANG Peng，HU Honglin，NIU Min，ZHANG Qiu

2018, 21(35): 4312-4315. DOI: 10.12114/j.issn.1007-9572.2018.00.138

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Objective　To evaluate the fasting serum level of Kisspeptin and its influence in patients with gestational diabetes mellitus（GDM）.Methods　A total of 120 pregnant women who underwent the 75 g oral glucose tolerance test（OGTT） at the Endocrinology Laboratory of the First Affiliated Hospital of Anhui Medical University from April to July 2016 were selected and divided into the GDM group（61 cases） and the normal glucose tolerance（NGT） group（59 cases） according to the 75 g　OGTT results.The GDM group and NGT group were further subgrouped according to body mass index（BMI）.Subjects with a BMI ≤ 24 kg/m2 were divided into the GDM-A subgroup（31 cases） and NGT-A subgroup（30 cases），and subjects with a BMI >24 kg/m2 were divided into the GDM-B subgroup（30 cases） and the NGT-B subgroup（29 cases）.Clinical data including age，weight during pregnancy，difference in weight，fasting blood glucose（FBG），1 h plasma glucose（PG），2 hPG，fasting insulin（FINS），1 h insulin（1 hINS），2 hINS，fasting C peptide，1 h C peptide，2 h C peptide and serum Kisspeptin level were collected.The insulin resistance index（HOMA-IR） and islet β-cell function index（HOMA-β） were calculated.Results　FBG，1 hPG，2 hPG，FINS，2 hINS，fasting C peptide，2 h C peptide，and HOMA-IR in the GDM group were all higher than those in the NGT group ，HOMA-β in the GDM group was lower than those in the NGT group（P<0.05）.The NGT-A subgroup had lower FINS，1 hINS，2 hINS，fasting C peptide，HOMA-IR and HOMA-β than the NGT-B subgroup（P<0.05）.HOMA-IR in the GDM-A subgroup was lower than that in the GDM-B subgroup（P<0.05）.Serum Kisspeptin level in the GDM group was higher than that in the NGT group（P<0.01），and serum Kisspeptin level in the GDM-A subgroup was higher than that in the NGT-A subgroup（P<0.05）.The GDM-B subgroup also had a higher serum Kisspeptin level than the NGT-B subgroup（P<0.05）.The serum Kisspeptin level was positively correlated with FBG，1 hPG，2 hPG，2 hINS，fasting C peptide，2 h C peptide and HOMA-IR，and negatively correlated with HOMA-β（P<0.05）.The serum Kisspeptin level was positively correlated with FBG and 2 hPG in the NGT group（P<0.05）.Conclusion　Serum Kisspeptin level in the GDM group increased significantly compared with the NGT group.Kisspeptin is positively correlated with FBG，1 hPG，2 hPG，2 hINS，fasting C peptide，2 h C peptide and HOMA-IR，and negatively correlated with HOMA-β.

Effect of Timing of Gestational Weight Gain on Birth Weight　

ZHENG Wei，ZHANG Li，TIAN Zhihong，LI Guanghui，ZHANG Weiyuan

2018, 21(35): 4316-4321. DOI: 10.12114/j.issn.1007-9572.2018.00.348

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Background　Excessive or insufficient gestational weight gain（GWG） during pregnancy can increase the risk of adverse pregnancy outcomes，but whether the effects of GWG in different periods of pregnancy on perinatal outcomes are different are still inconclusive.Objective　This study aimed to analyze the effects of GWG in different pregnancy periods on risk of large for gestational age（LGA） and small for gestational age（SGA）.Methods　We conducted a cohort study using the baseline characteristics，GWG in different pregnancy periods and pregnancy outcomes collected from pregnant women.We enrolled a total of 15 334 participants who established a medical record for receiving healthcare at the first trimester of pregnancy and underwent regular antenatal care and delivered a singleton infant between June 1，2014 and May 31，2015 from Beijing Obstetrics and Gynecology Hospital，Capital Medical University.The effects of GWG on neonatal birth weight and corresponding population attributable risk（PAR%） were analyzed.Participants were classified to be underweight（<18.5 kg/m2，n=2 438），normal weight（18.5-24.9 kg/m2，n=11 052），overweight（25.0-29.9 kg/m2，n=1 600）and obese（≥30.0 kg/m2，n=244） according to WHO classification of prepregnancy BMI.GWG during 0-16 weeks of pregnancy was defined as the GWG in early pregnancy，because the formal medical record during pregnancy should be established within 16 weeks' gestation in our hospital.And the GWG during 17-28 weeks of pregnancy and 29 weeks of pregnancy to delivery was determined as the GWG in mid pregnancy，late pregnancy，respectively.Insufficient，normal and excess GWG during early and mid-pregnancy were defined by Institute of Medicine（IOM） average weight gain per week criteria.Results　Prevalences of LGA and SGA were 15.66%（2 401/15 334） and 2.93%（449/15 334），respectively.The total GWG for underweight，normal weight，overweight and obese groups was（16.2±4.7）kg，（15.8±4.9）kg，（13.6±5.5）kg and（10.8±5.8）kg，respectively.Approximately 27.62%（1 456/5 272），73.41%（3 870/5 272） and 49.89%（2 630/5 272） of women gained more weight in early，mid and late pregnancy，respectively，than that was recommended by IOM，while 50.89%（2 683/5 272），13.54%（714/5 272） and 31.83%（1 678/5 272） of women gained less weight than the lower limit of IOM recommendation.Multivariate Logistic regression analysis showed that excessive GWG was associated with an increased risk of LGA（P<0.001），while insufficient GWG in early pregnancy and mid-pregnancy was associated with an increased risk of SGA（P<0.001）.GWG in late pregnancy was not associated with risk of LGA or SGA（P>0.05）.GWG in mid-pregnancy contributed most to LGA in PAR%.Results from trend analyses showed that with the increase of GWG in early and mid pregnancy in all the participants，the risk of LGA increased（P<0.05）；with the increase of GWG in early and late pregnancy in underweight and normal weight participants，the risk of SGA decreased（P<0.05）.Conclusion　This study found that GWG during 0-16 weeks and 17-28 weeks of pregnancy had a significant effect on the risks of LGA and SGA.PAR% for LGA is highest in mid-pregnancy.Early and mid-pregnancy are critical periods of clinical intervention.This finding provides a big data foundation for the development of weight management programs during pregnancy.

Effect of Community-based Standardized Mental Disorders Management on Patients with Severe Mental Disorders 　

LI Zhe，YANG Yali，WU Shengli，YE Qing，HUANG Yun，YUSUFUJIANG·Yiming，FANG Jing，GAO Yang，LI Zhixiong

2018, 21(35): 4322-4327. DOI: 10.12114/j.issn.1007-9572.2018.00.202

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Objective　To explore the effect of community-based standardized mental disorders management on patients with severe mental disorders in Xinjiang's Karamay.Methods　We conducted this study from July 2012 to December 2015.We selected 296 patients with 6 types of severe mental disorders from the permanent residents（living at their current residence for 6 months or longer） of 5 communities〔Kunlun and Jinlong（pilot communities），Shengli，Yinhe and Tianshan（non-pilot communities）〕 sampled from Karamay by using cluster random sampling，including 85 from Kunlun and Jinshan communities（experimental group），and 211 from Shengli，Yinhe and Tianshan communities（control group）.The experimental group received community-based standardized mental disorders management（including basic，case and emergency management by the institutions in an internet-based three-level mental disorders control and prevention system），while the control group received the conventional hospitalized treatment and outpatient follow-ups.The management effects were evaluated by hospitalization rate，management rate，rate of mental disorders remaining stable over the intervention period，rate of participating in social activities，treatment rate，drop-out rate，rate of receiving emergency management，rate of causing minor affrays，and rate of causing accidents.Results　The hospitalization rates in the experimental group in 2013，2014，2015 were all much lower than those of the control group（P<0.05）.The experimental group demonstrated obviously higher hospitalization rate in 2012 compared with 2013，2014，2015（χ2=12.66，P<0.01；χ2=4.67，P=0.03；χ2=13.07，P<0.01）.The rate of participating in social activities was similar in both groups（P>0.05）.The experimental group showed much higher management rate，rate of mental disorders remaining stable over the intervention period，treatment rate，and notably lower drop-out rate compared with the control group（P<0.05）.The rate of receiving emergency management in the experimental group in 2013 was similar to that of 2014（χ2=0.03，P=0.84），but was significantly higher than that of 2015（χ2=5.49，P=0.02）.The experimental group exhibited a much decreased rate of causing minor affrays（χ2=7.37，P=0.02），as well as a severely declined rate of causing accidents（χ2=8.27，P=0.02）.Conclusion　The community-based standardized mental disorders management demonstrated good effect on patients with severe mental disorders and achieved good socio-economical benefits，which contributes to the stable development of Karamay，so it can be used more extensively.

Standardization Building of Occupational Rehabilitation Based on ‘Hospital-community Integration’ Service Model for Patients with Mental Disability due to Severe Mental Disorder　

ZHENG Hong，JU Kang

2018, 21(35): 4328-4333. DOI: 10.12114/j.issn.1007-9572.2018.00.293

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Background　As an important pilot project of National Mental Health Comprehensive Management，this study formed a muti-disciplinary team to provide occupational rehabilitation based on “hospital-community integration” service model for people with mental deformity in the Changning District of Shanghai.Objective　To analyze the standardized building of occupational rehabilitation based on “hospital-community integration” service model.Methods　We described the situation from four aspects：team organization，service path，training module and daily operation，and evaluated rehabilitation rate，accident rate and satisfaction rate.Results　The model gained social support from government departments and towns，received technical support from institutions，colleges and universities，acquired professional guidance from mental health multifunctional team，and promoted participation from social organizations，mental health social services and family members of patients.This model established rehabilitation paths and training modules，provided occupational rehabilitation training and comprehensive intervention.As of 2017，the comprehensive service modelhas received 62 patients with severe mental disorder and serviced2 124 visits annually.The statistic results of two consecutive years（from 2016 to 2017） showed the satisfaction rate of patients increased from a baseline of 96.7%（60/62） to 99.3%（142/143），meanwhile the satisfaction rate of their families increased from a baseline of 95.1%（78/82） to 98.6%（140/142），the annual standard rehabilitation rate reached 99.5%（4 227/4 248），the average rate of palindromia and rehospitalization per year reached 4.8%（3/62） and the accident rate remained unchanged at 0.Conclusion　“Hospital-community integration” model in Changning complements the existing system，meets various rehabilitative needs for patients with mental disability due to severe mental disorder and their family members，creates auxiliary jobs and provides policy basis for the standardization building of occupational rehabilitation.

Diagnostic Reliability of the Central Government Support for the Local Management and Treatment of Severe Mental Illnesses Project for Severe Mental Disorders in Hunan Province　

WANG Dongxin，FU Wenbin，LIU Chang，GUO Jing，LI Xiaosong

2018, 21(35): 4334-4339. DOI: 10.12114/j.issn.1007-9572.2018.00.240

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Objective　To investigate the diagnostic reliability of the Central Government Support for the Local Management and Treatment of Severe Mental Illnesses Project（686 Project） for severe mental disorders patients aged 15 or over in Hunan Province. Methods　This epidemiological survey of severe mental disorders was carried out between February and June 2015. By use of multistage stratified cluster sampling，72 999 permanent community-dwelling residents aged 15 or over were recruited from 123 counties/districts of Hunan Province and 720 of them were found with severe mental disorders. The diagnostic results of such populations by the 686 Project were collected from the Internet-based information system of the project. The epidemiological results were used as the gold standard for evaluating the diagnostic reliability of the 686 Project. Results　Of the 720 patients with severe mental disorders found by the survey，349（48.5%） were under the management of the 686 Project，345 of them were registered as severe mental disorders in the 686 Project，so the diagnostic rate by the project was 47.9%（345/720）. The overall diagnostic consistency rate between the 686 Project and the survey was 39.4%（284/720）. The diagnostic consistency rates of schizophrenia，paranoid psychosis，bipolar disorder，schizophrenic psychosis，mental disorder caused by epilepsy and mental retardation with mental disorder were 50.6%（273/539），0，2.7%（2/75），12.5%（1/8），16.7%（4/24） and 6.2%（4/64），respectively. The diagnostic consistency rates of severe mental disorders between the survey and the 686 Project showed no significant differences across different counties/districts（χ2=16.83，P=0.21）. Conclusion　The diagnostic consistency rates of severe mental disorders between the survey and the 686 Project demonstrated no obvious differences between different counties/districts in Hunan Province. The rate of such patients under the management by the 686 Project and the diagnostic reliability of this project carried out in Hunan need to be improved further.

Feasibility Analysis of the Use of Limb Linkage Equipment to Assess Cardiorespiratory Fitness in Healthy Youths　

QIAN Zhen，CHEN Wei，LI Jin，GAO Min，ZHANG Qiuyang

2018, 21(35): 4340-4345. DOI: 10.12114/j.issn.1007-9572.2018.00.067

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Objective　To analysis the feasibility of a symptom limited maximal incremental cardiopulmonary exercise test using limb linkage equipment in healthy youths and explore the appropriate equipment for the assessment of the potential energy of the heart and lung.Methods　Between September 2016 and September 2017，108 healthy youths who were tested in Xuzhou Rehabilitation Hospital were recruited and successively underwent two symptom-limited maximal incremental cardiopulmonary exercise tests using two devices：a cycle ergometer and limb linkage equipment，and the cardiopulmonary function indexes were recorded.The Borg Scale was used to evaluate the perceived exertion levels of dyspnea and leg fatigue at maximal exercise load，and the reasons for test termination were recorded.Results　All testees successfully completed the tests and stopped at the attainment of termination standards without any adverse events；72（66.7%） achieved symptom limited maximal exercise levels in the cycle ergometer test，and 102 testees（94.4%） did so in the limb linkage test.The absolute peak oxygen uptake（VO2peak），relative VO2peak，relative VO2peak/predicted oxygen uptake（VO2pred），peak metabolic equivalent，peak heart rate（HRpeak），HRpeak/age predicted maximum heart rate，peak systolic blood pressure，peak respiratory exchange ratio，time to VO2peak，absolute oxygen uptake at anaerobic threshold，relative oxygen uptake at anaerobic threshold（relative VO2AT），and relative VO2AT/relative VO2peak were all significantly higher in the limb linkage test than the cycle ergometer test，whereas the peak load，dyspnea score，and leg fatigue score were invariably lower in the limb linkage test than the cycle ergometer test（P<0.05）.There was a positive correlation between the relative VO2peak（r=0.881，P<0.001） and the HRpeak（r=0.845，P<0.001） between both tests.Conclusion　Limb linkage equipment is safer and more effective and can be feasibly used to assess cardiorespiratory fitness in young people；it provides test results closer to the real scenario.

Value of Blood Alcohol Level for Forecasting Prognosis of Mild Traumatic Brain Injury after Drinking　

ZHUANG Xin，WANG Haizhou

2018, 21(35): 4346-4350. DOI: 10.12114/j.issn.1007-9572.2018.00.156

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Objective　To assess the effect of blood alcohol level（BAL） on the forecasting prognosis of patients with mild traumatic brain injury（mTBI） after drinking.Methods　A retrospective analysis of 58 patients with mTBI after drinking admitted to the Department of Emergency，Wujin Hospital of Traditional Chinese Medicine，Nanjing University of Chinese Medicine from July 2016 to September 2017 was conducted.Subjects were divided into the drinking group（BAL<80 mg/dl，33 cases） and the intoxicated group（BAL≥80 mg/dl，25 cases）.The general data of patients admitted to the hospital were collected.Wechsler Adult Intelligence Scale（WAIS） was used to evaluate patients' non-verbal processing speed，and Glasgow Prognostic Expansion Scale（GOS-E） used to evaluate prognosis after 3 months of discharge.Results　There were significant differences in palinesthesia time，Glasgow Coma Scale（GCS） score and time of consciousness loss between the two groups on admission（P<0.05）.The non-verbal processing speed score of WAIS in the intoxicated group was（102.4±12.3），higher than that of the drinking group（93.6±12.7）（t=2.518，P=0.014） after 3 months.Fifty-five cases completed the GOS-E assessment and 11 of them（20.0%） had a poor prognosis.Multivariate Logistic regression analysis showed that GCS scores being 13-14 on admission 〔OR=3.93，95%CI（2.23，7.19）〕 and BAL≥80 mg/dl 〔OR=4.67，95%CI（1.08，5.46）〕 were influencing factors of poor prognosis of patients with mTBI（P<0.05）.Conclusion　Patients whose BAL are ≥80 mg/dl has decreased GCS score and increased risk of loss of consciousness，and a high risk of reducing non-verbal processing speed and inadequate recovery of cognitive function after 3 months' injury.

Effect of Endoscopic Hemostasis Combined with Intravenous Administration of Different Doses of Esomeprazole Sodium on Acute Peptic Ulcer Bleeding　

LI Yang，QU Yawei，GAO Jianling，GAO Zhi，LIU Haifeng

2018, 21(35): 4350-4353. DOI: 10.12114/j.issn.1007-9572.2018.00.165

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Objective　To explore the clinical effect of endoscopic hemostasis combined with intravenous administration of different doses of esomeprazole sodium on acute peptic ulcer bleeding（APUB）.Methods　We enrolled 160 inpatients with APUB from Department of Gastroenterology，General Hospital of Chinese People's Armed Police Force from January 2016 to January 2018 and equally divided them into standard-dose group（study group） and large-dose group（control group） by the random number table.Based on endoscopic hemostasis，the study group received 3-day management including intravenous injection of esomeprazole sodium 80 mg combined with intravenous drip of esomeprazole sodium 40 mg，once every 12 hours，and the control group received 3-day management consisting of intravenous injection of esomeprazole sodium 80 mg combined with continuous infusion of esomeprazole sodium 8 mg/h by the infusion pump.We compared the indicators for evaluating the treatment effectiveness such as mean time needed for bleeding to stop，mean amount of blood transfusion，rate of re-bleeding，mean length of stay，rate of having adverse events，and rate of receiving surgical intervention between the groups.Results　Both groups showed no significant differences in the aforementioned indicators for evaluating the treatment effectiveness（P>0.05）.Conclusion　Although both regimens achieved similar hemostatic effects，we recommend intravenous administration of standard dose of esomeprazole sodium in combination with endoscopic hemostasis，for it uses less medical resources.

Establishment of a Predictive Model for Disseminated Talaromycosis Marneffei Complicated by Gastrointestinal Hemorrhage　

CHEN Tao，JIANG Zhongsheng，LAN Huihui，LI Minji，HU Jiaguang，QIN Chuan，MO Shenglin

2018, 21(35): 4354-4357. DOI: 10.12114/j.issn.1007-9572.2018.00.066

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Objective　To analyze the independent risk factors for disseminated talaromycosis marneffei（DTSM） complicated by gastrointestinal hemorrhage and to establish a predictive model.Methods　Between January 2009 and November 2017，63 patients with DTSM initial treatment who were treated at Liuzhou General Hospital were selected and divided into two groups：a group with gastrointestinal hemorrhage（29 cases） and a group without gastrointestinal hemorrhage（34 cases）.A retrospective analysis of the clinical data of the DTSM patients included basic data，clinical data，comorbidities，laboratory tests，and imaging data.Univariate and multivariate Logistic regression analyses were used to screen independent risk factors for DTSM complicated by gastrointestinal hemorrhage.A prediction model was established，and its predictive value was analyzed via the receiver operating characteristic（ROC） curve method.Results　Multivariate Logistic regression analysis showed that platelet count（PLT）〔β=-0.037，OR=0.946，95%CI（0.937，0.979）〕 and prothrombin time（PT）〔β=0.376，OR=1.457，95%CI（1.082，1.961）〕 were independent risk factors for DTSM with gastrointestinal hemorrhage（P<0.05）.The prediction model was P=1/（1+e-y），and Y=-3.612+0.376×PT-0.037×PLT，where P denotes the probability of hemorrhage，Y denotes the predictive index.The Hosmer–Lemeshow test results showed an ideal goodness of fit of the model（χ2=4.757，df=8，P=0.783）.The area under the ROC curve（AUC） was 0.918〔95%CI（0.815，0.985），P<0.001〕.The P value cut-off was 0.539 3，thus indicating that P≥0.539 3 predicted complication of gastrointestinal hemorrhage，and P<0.539 3 predicted its absence.The sensitivity，specificity，positive predictive value，negative predictive value，and total accuracy of model prediction were 86.21%，94.12%，92.59%，88.89%，and 90.48%，respectively.Conclusion　PLT and PT can be used to build a model for accurate prediction of the incidence of DTSM with gastrointestinal hemorrhage.

Detection of SHOX2 Gene Methylation for Differential Diagnosis of Lung Cancer and Benign Pulmonary Diseases　

XIA Dongping，SHI Xiaowu，ZHOU Ying，ZHU Shan

2018, 21(35): 4358-4363. DOI: 10.12114/j.issn.1007-9572.2018.00.213

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Objective　To evaluate the value of SHOX2 gene methylation level for differential diagnosis in patients with lung cancer and benign lung diseases.Methods　Patients with lung cancer and benign lung diseases hospitalized in the Department of Thoracic Surgery and Department of Eespiration of the Central Hospital of Wuhan from March 2014 to June 2016 were enrolled.Among them，173 patients with lung cancer were defined as lung cancer group，and 194 patients with benign lung diseases as benign lung disease group.Routine serological examination and tumor markers were detected in all patients.The SHOX2 gene methylation was detected by Sanger sequencing，and the SHOX2 gene methylation level was calculated by △△CT method.The value of each index in differential diagnosis of lung cancer was analyzed by receiver operating characteristic（ROC） curve.The relationship between each index and lung cancer pathological type and TNM staging was analyzed.Results　The white blood cell count（WBC） and △△CT value of lung cancer group were lower than those of benign lung disease group，while the serum gastrin releasing peptide precursor（ProGRP），squamous cell carcinoma antigen（SCC-Ag），cytokeratin 21 fragment antigen（Cyfra21-1） and carcinoembryonic antigen（CEA） were higher than those in benign lung disease group（P<0.05）. The result of multivariate Logistic regression analysis showed that serum ProGRP，serum Cyfra21-1，and △△CT values were factors influencing lung cancer（P<0.05）. The area under ROC curve（AUC） of △△CT value for the diagnosis of lung cancer was 0.843.The sensitivity was 58.2%，and the specificity was 93.1% when the optimal threshold was 2.69.The AUC of serum ProGRP was 0.711，with optimal threshold of 32 ng/L，sensitivity of 63.5% and specificity of 77.4%.The AUC of serum Cyfra21-1 was 0.677，the best cut-off value 2.92 μg/L，sensitivity 56.1%，and specificity 72.3%.The AUC of serum ProGRP for the diagnosis of lung cancer was greater than that of serum Cyfra21-1（Z=3.569，P=0.038）. The AUC of the △△CT value combined with serum ProGRP was 0.860.The AUC of △△CT value combined with serum ProGRP in the diagnosis of lung cancer were greater than that of △△CT value，serum ProGRP，and serum Cyfra21-1（Z=4.046，Z=5.607，Z=8.215，P<0.05）. The △△CT value of patients with squamous cell carcinoma，small cell carcinoma was lower than that of patients with adenocarcinoma，large cell carcinoma and other unknown pathological types（P<0.05）. The △△CT value of patients in stage Ⅲ lung cancer was lower than that of those in stage Ⅰ and stage Ⅱ（P<0.05），and the △△CT value of patients in stage Ⅳ lung cancer was lower than that of those in stage Ⅰ，stage Ⅱ and stage Ⅲ（P<0.05）. Conclusion　SHOX2 gene methylation has its value in the differentiation of lung cancer and benign lung disease.It is correlated with lung cancer pathological type and TNM staging，which can be used as an auxiliary index for diagnosis of lung cancer.

The Pathogenetic Effect of Nanobacteria on Damage of HK-2 in Kidney Stone Formation　

WANG Yihe1，WANG Qinzhang，WU Shuang，SHEN Maolei，CHU Hao，QIAN Cheng，QIAN Biao

2018, 21(35): 4364-4370. DOI: 10.12114/j.issn.1007-9572.2018.00.137

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Objective　To explore the pathological mechanism of nanobacteria（NB） on damage of human tubular epithelial HK-2 cells and the subsequent stone formation.Methods　NB was isolated from the urine of patients with kidney stones but without medication or surgery admitted to the Department of Urology Surgery in the First Affiliated Hospital of Medical College，Shihezi University from October 2016 to October 2017.The subjects were divided into control group（fetal bovine serum，1640 medium + HK-2 cells），NB group（NB culture，fetal bovine serum，1640 medium + HK-2 cells），calcium oxalate monohydrate（COM） group（5 mmol/L COM suspension，fetal bovine serum，1640 medium + HK-2 cells），nanograde hydroxuapatite（nHAP） group（300 mg/L nHAP，fetal bovine serum，1640 medium + HK-2 cells） and tetracycline（TET+NB） group（5 mg/L tetracycline，NB culture，fetal bovine serum，1640 medium + HK-2 cells）.The cell morphology was observed via hematoxylin-eosin（HE） staining and transmission election microscope（TEM） 6，12，and 24 hours after co-culture.The activities of Na+/K+ ATPase and Ca2+/Mg2+ ATPase were detected after ultrasonically smashing cells.Lactate dehydrogenase（LDH），hydrogen peroxide（H2O2） and malondialdehyde（MDA） in culture were detected.Laser scanning confocal microscope（LSCM） was used to observe the crystal adhesion to cells.Results　As shown by the observations of HE staining and TEM，the degree of cell damage in nHAP and TET+NB groups were significantly lower than that of NB group.The activities of Na+/K+ ATPase and Ca2+/Mg2+ ATPase in NB group and COM group were lower than those in the control group and the content of H2O2 in NB group and COM group was higher than that in the control group 12，and 24 hours after co-culture（P<0.05）.The activities of Na+/K+ ATPase and Ca2+/Mg2+ ATPase in TET+NB group were higher than those in the NB group 12，and 24 hours after co-culture（P<0.05）.The content of MDA in NB group and COM group was significantly higher than that in control group（P<0.05），while the content of MDA in TET+NB group was significantly lower than that in NB group 6，12，and 24 hours after incubation（P<0.05）.The content of LDH in COM group was higher than that in control group（P<0.05），while the content of LDH in NB group and TET+NB group was significantly lower than that in COM group（P<0.05）.Conclusion　NB may damage HK-2 cells by inducing lipid peroxidation.The degree of cell damage and the amount of crystal adhesion are positively related to the incubation time of NB.Tetracycline showed potential to inhibit this process and reduce crystal adhesion.

Experiences of Patients Near the End of Life：a Meta-synthesis　

LIANG Minyu，PAN Yichao，LI Qiaohui，LI Jinqiu

2018, 21(35): 4371-4376. DOI: 10.12114/j.issn.1007-9572.2018.00.131

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Objective　To analyze experiences of patients near the end of life，so as to provide the basis for realizing “good death” for patients.Methods　Through Meta synthesis，qualitative researches which reported the experience of patients near the end of life were enrolled and summarized from Chinese databases such as CNKI，Wanfang，CBM，VIP and English databases such as Cochrane Library，PubMed，Medline，EBSCO，CINAHL，Web of Knowledge and EMBase.Results　A total of 6 research literatures were collected.Five themes were identified spiritual distress；desire of alleviating burdens；desire of talking about the death；differences in attitudes towards death；and returning to the essence of life.Conclusion　Near-death experience reflected the experience of human body，mind and spirit.The key to meet the needs of human body，mind and spirit of dying patients and to realize “good death” is to face death with positive attitude，gaining the internal force of peace and returning to the essence of life.

Bibliometric Analysis of Health-related Quality of Life Assessment Instruments for Chronic Hepatitis Patients　

RAN Xuerong，ZHANG Tangqin，CAI Yifan，LUO Kui，WU Hongyan，YANG Xing，ZHANG Man

2018, 21(35): 4377-4382. DOI: 10.12114/j.issn.1007-9572.2018.00.105

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Objective　To analyze the application of health-related quality of life（HRQOL） instruments in chronic hepatitis patients，providing a reference for quality of life assessment including the choice of an appropriate instrument in such a population in China.Methods　From March to September 2017，we searched the databases of CNKI，Wanfang Data Knowledge Service Platform，VIP and CBM，to identify the articles about HRQOL assessment.We analyzed the included articles by general information and contents of article，type of used HRQOL instrument and so on.Results　A total of 233 articles were included，including 221 journal articles and 12 conference articles.Except those using instruments developed by the undetermined developer，among the remaining articles，the using times of general HRQOL instruments，chronic hepatitis-specific HRQOL instruments，and mental health assessment instruments developed in foreign countries were 150（75.76%），42（65.63%），92（95.83%），respectively，while those of the aforementioned 3 types of instruments developed in China were 37（18.67%），10（15.63%），0，respectively.158 articles（67.81%） used 1 type of HRQOL instrument〔including 124（78.48%），17（10.76%），17（10.76%） using the general HRQOL instrument and chronic hepatitis-specific HRQOL instrument，mental health assessment instrument，respectively〕，most of which used SF-36，CLDQ or SAS+SDS.Seventy-one（30.47%）used 2 types of HRQOL instruments，and most of which used SF-36/WHOQOL-BREF+CLDQ，SF-36/WHOQOL-BREF/GQOLI-74+SAS/SDS，or CLDQ+SAS/SDS.Four（1.72%） used 3 types of HRQOL instruments of WHOQOL-BREF+CLDQ/SDSS/medication adherence scale+SAS/SDS.Conclusion　For assessing HRQOL of chronic hepatitis patients，most articles published in China use foreign instruments，and domestic instruments need to be further developed and used extensively by which more choice can be offered for such studies.

Clinical Analysis of Androgen-secreting Tumors in Women　

2018, 21(35): 4383-4387. DOI: 10.12114/j.issn.1007-9572.2018.00.332

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Objective　To analyze the etiology，clinical manifestations and pathological features of androgen-secreting tumors（AST） in women，offering a reference for the diagnosis，treatment and prognosis improvement of the disease.Methods　Twenty patients with postsurgical pathology confirmed AST 〔AST arising from ovaries in 11 cases（ovary tumor group） and from adrenals in 9 cases（adrenal tumor group）〕 were recruited from Chinese PLA General Hospital between January 2012 and January 2018.A retrospective analysis was conducted on their personal characteristics，clinical manifestations，laboratory findings，imaging features，pathological features and prognosis.Results　The average age for ovary tumor group and adrenal tumor group was（37.4±20.2）（32.2±14.8） years old，respectively.The average duration of AST was（2.8±2.7） years（range：7 months to 10 years） for ovary tumor group，and（0.7±0.6） years（range：7 days to 2 years） for adrenal tumor group.All the cases in ovary tumor group showed virilism，and 10 showed de-feminization.In the adrenal tumor group，5 demonstrated virilism，and 4 demonstrated de-feminization.The serum levels of testosterone（T），17-hydroxyprogesterone（17-OHP），and dehydroepiandrosterone sulfate（DHEAS） were 14.1（9.0，25.4） nmol/L，（2.5±0.8） μg/L，（188±101） μg/dl，respectively for ovary tumor group，and 7.1（4.9，16.1） nmol/L，（6.2±3.3） μg/L，（676±312） μg/dl，respectively for adrenal tumor group.In the ovarian tumor group，10 were found with tumor by transvaginal ultrasonography，and other 1 was found by surgical exploration.The average diameter of the tumor was（5.2±3.2） cm，which had no linear correlation with serum T level（r=-0.50，P>0.05）.In the adrenal tumor group，the tumor was found by enhanced adrenal gland CT in all cases.The average diameter of tumor was（10.7±4.1） cm，which showed no linear correlation with serum T level（r=-0.23，P>0.05）.Postsurgical pathological test found that in the ovarian tumor group，3 were found with Sertoli-Leydig cell tumors，7 with ovarian steroid cell tumors，and 1 with teratoma；in the adrenal tumor group，3 were found with adrenocortical adenoma，and other 6 with adrenocortical adenocarcinoma.During the follow-up period，9 cases of ovarian tumors survived，but other 2 were lost to follow-up；4 cases of adrenal tumors survived，2 died，and other 3 were lost to follow-up.Conclusion　Both androgen-secreting ovarian tumors and androgen-secreting adrenal tumors could cause virilism and defeminization.Moreover，both of them could significantly increase the serum T level，but showed no significant difference in the growth level.Compared with patients with androgen-secreting ovarian tumors，those with androgen-secreting adrenal tumors had higher serum levels of 17-OHP and DHEAS，larger tumor diameter，and poorer prognosis.

Investigation of the Distribution Characteristics of the Facial Nerve in Acoustic Neuroma　

SONG Haimin，ZENG Hailan，XIAO Daoxiong，YANG Ruijin，JIANG Qiuhua

2018, 21(35): 4388-4391. DOI: 10.12114/j.issn.1007-9572.2018.00.034

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Objective　To investigate the distribution of the facial nerve in acoustic neuroma using preoperative diffusion tensor imaging（DTI） combined with intraoperative exploration of the positional relationship between the facial nerve and acoustic neuroma. Methods　A total of 45 patients with acoustic neuroma who were treated in Ganzhou Hospital Affiliated Nanchang University between January 2014 and July 2017 were selected.The positional relationship between the facial nerve and the tumors was detected through DTI. The position of the facial nerve was verified and monitored by electrophysiology during the operation. The House-Brackmann（H-B） facial nerve grading scale was used to assess patient facial nerve function before surgery and within 2 weeks after surgery. Results　Among the patients，there were 42 patients whose facial nerve could be displayed by DTI；in 39 patients（92.9%），the facial nerve position detected by DTI was consistent with intraoperative electrophysiology monitoring and anatomical marks. The facial nerves of these patients were all located on the ventral side of the tumor；among them，17 cases（43.6%） were located in the middle third of the tumor，9 cases（23.1%） were located in the lower third of the tumor，8 cases（20.5%） were located in the upper third of the tumor，3 cases（7.7%） were located in the lower pole of the tumor，and 2 cases（5.1%） were located in the upper pole of the tumor. The facial nerve was anatomically preserved in 41 cases（91.1%）. The facial nerve was not detected in 2 cases（4.4%） during surgery，and facial nerve injury occurred in 2 cases（4.4%），owing to inconsistencies in the facial nerve position and the position detected by preoperative DTI. The H-B facial nerve grading scale within 2 weeks after surgery was as follows：25 cases of grade Ⅰ-Ⅱ（55.6%），15 cases of grade Ⅲ-Ⅳ（33.3%） and 5 cases of grade Ⅴ-Ⅵ（11.1%）. Forty-two cases（93.3%） had total tumor resection；1 case（2.2%） had residual tumor tissue in the auditory canal；2 cases（4.4%） had a small amount of tumor residue adjacent to the brain stem and adhering to the facial nerve；2 cases（4.4%） underwent bone flap removal after surgery，owing to cerebellar swelling；1 case（2.2%） died of postoperative bleeding at the operation site；and 1 case（2.2%） experienced hemiplegia due to a partial infaRCTs of the brainstem and was able to live independently after 3 months of rehabilitation. Conclusion　Preoperative facial nerve DTI can predict the position of the facial nerve. The position of the facial nerve in the cerebral cisternal side in acoustic neuroma is variable. Understanding the distribution of the facial nerve in acoustic neuroma can improve anatomical and functional preservation of the facial nerve.

Clinical Features of Primary Hyperparathyroidism　

WANG Yan，ZHANG Jinsong，MIAO Gang，LI Miao，ZHOU Yan，ZHANG Lina

2018, 21(35): 4392-4396. DOI: 10.12114/j.issn.1007-9572.2018.00.112

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Objective　To investigate the clinical features of primary hyperparathyroidism（PHPT），improving the premium of physicians paid on PHPT.Methods　We conducted a retrospective analysis of 687 cases of PHPT who received treatment from Department of Endocrinology，General Surgical Wards，and Osteoporosis Clinic，Beijing Hospital from 2008 to 2015.We collected their data concerning demographic data，prevalence of commodities，parathyroid lesion resection，pathological results of parathyroid lesions，serum parathyroid hormone（PTH），serum calcium（SCa），serum phosphorus（SP），serum creatinine（Scr），and alkali phosphatase（ALP），fasting plasma glucose（FPG），urinary calcium（UCa），and urinary phosphate（UP）.We divided them into group 1（348 with SCa >2.54 mmol/L），group 2（339 with SCa of 2.03-2.54 mmol/L） by SCa levels，group A（93 aged ≤50 years），group B（191 aged 51-60 years），group C（173 aged 61-70 years），and group D（230 aged ≥74 years） by age，non-lesion group（345 cases），parathyroidoma group（320 cases），parathyroid carcinoma group（8 cases），and　other lesions group（14 cases） by the results of ultrasound examination.Results　There was significant difference in the distribution of thyroid lesions between group 1 and group 2 （P<0.05），and the proportion of renal calculi，fracture and parathyroid lesions in group 1 was higher than that in group 2（P<0.05）. The proportion of fracture in group B was lower than that in group A（P<0.05）; the proportion of osteoporosis in group C was higher than that in group A（P<0.05）; the proportion of parathyroidectomy in group C and D was lower than that in group B，and the proportion of adenoma was lower than that in group A and B（P<0.05）; the proportion of male and fracture in group D was higher than that in group B and C（P<0.05）. The age，the proportion of osteoporosis，the level of SP and Scr in adenoma group were lower than those in undiscovered group，the proportion of fracture and SCa were higher than those in undiscovered group（P<0.05）; the age and SP in adenoma group were lower than those in undiscovered group and adenoma group，and the proportion of renal calculi and operation were higher than those in undiscovered group，and SCa was higher than that in undiscovered group（P<0.05）. The proportion of osteoporosis in other lesion groups was lower than that in non-lesion group，the proportion of renal calculi was higher than that in non-lesion group and adenoma group，the proportion of parathyroid lesion resection was higher than that in non-lesion group，and SCa was lower than that in non-lesion group and adenoma group（P<0.05）.Multivariate Logistic regression analysis showed that older age，surgical treatment，elevated PTH and SCa and decreased SP levels were independent risk factors for parathyroid lesions in PHPT patients（P<0.05）. Conclusion　Parathyroidoma is the most common cause of PHPT，but asymptomatic cases of PHPT are increasing.Clinicians should increase the awareness of PHPT，routinely perform PTH，SCa，and parathyroid ultrasound examinations on the patients in order to identify the causes of the disease as early as possible.

Analysis of the Causes of Airway Mucus Plug Formation in Children with Mycoplasma Pneumoniae Pneumonia　

LU Sukun，LIU Jianhua，SHUAI Jinfeng，WANG Le，YANG Huirong，LYU Wenshan，HUANG Kunling，CAO Lijie

2018, 21(35): 4397-4400. DOI: 10.12114/j.issn.1007-9572.2018.00.144

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Objective　To explore the correlation of mucus plug formation in children with mycoplasma pneumoniae（MP） pneumonia and MP load，mixed bacteria or virus infection.Methods　A total of 87 children with lung consolidation infected by MP admitted to Children' s Hospital of Hebei Province between June 2014 and December 2015 were divided into mucus plugs group（34 cases） and non-mucus plugs group（53 cases） according to the image of flexible bronchoscopy.MP-DNA was quantitatively detected by fluorescent real-time PCR in bronchoalveolar lavage fluid（BALF），bacterial culture was conducted from sputum and BALF，and the GeXP based mRT-PCR assay was performed to test sputum viruses.Results　The proportion of high MP load and mixed virus infection rate in mucus plug group were 64.7%（22/34）and 52.9%（18/34），higher than those of non-mucus plugs group〔24.5%（13/53），20.8%（11/53）〕（P<0.05）.There was no statistic difference in the two groups in terms of the mixed bacteria infection rate（P>0.05）.The Logistic regression analysis indicated that high MP load〔OR=10.682，95%CI（1.447，78.877）〕 was the risk factor for mucus plugs in children with MP pneumonia（P<0.05）.Conclusion　The formation of airway mucus in children with MP pneumonia is related to high MP load and mixed virus infections，but not related to sex and age.

Investigation of the Efficacy of Artificial Dura Mater Combined with Autologous Adipose Tissue Repair in the Treatment of Dural Rupture　

YANG Yi，ZHANG Shuwen，YEERZATI?Hajiaheman，NUERHANATI?Shayilanbieke，YANG Xinming，JIN Gele

2018, 21(35): 4401-4404. DOI: 10.12114/j.issn.1007-9572.2018.00.082

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Objective　To compare the efficacy of artificial dura mater combined with autologous adipose tissue and artificial dura mater alone in repairing dural rupture.Methods　Thirty patients with spine disease with dural rupture who were treated in the First Affiliated Hospital of Xinjiang Medical University between January 2010 and July 2016 were selected and divided into an artificial dura mater alone group（n=20） and an artificial dura mater combined with autologous adipose tissue group（n=10） according to the repair method used.The conventional repair method was used in the artificial dura mater alone group；in the artificial dura mater combined with autologous adipose tissue group，in addition to conventional treatment，the surface of the artificial dura mater was covered with autologous adipose tissue.The general patient data were collected，and the drainage volume after surgery，duration of drainage，duration of antibiotic treatment，number of days of hospitalization and cost were compared between the two groups.Results　The drainage volumes on the 2nd and 3rd day after surgery in the artificial dura mater combined with autologous adipose tissue group were both less than those in the artificial dura mater alone group（P<0.05）.In the artificial dura mater combined with autologous adipose tissue group，the drainage volume on the 1st day after surgery was more than that on the 2nd and 3rd day after surgery（t=15.060，28.460，P<0.001），and the drainage volume on the 2nd day was more than that on the 3rd day after surgery（t=7.041，P<0.001）.In the artificial dura mater alone group，the drainage volume on the 1st day after surgery was less than that on the 2nd and 3rd day after surgery（t=-9.235，-9.521，P<0.001）.The drainage duration，duration of antibiotic use and number of days of hospitalization were all shorter in the artificial dura mater combined with autologous adipose tissue group than those in the artificial dura mater alone group（P<0.05）.The hospitalization cost was not significantly different between the two groups（P=0.191）.Conclusion　Artificial dura mater combined with autologous adipose tissue repair is effective in treating dural rupture and can decreased drainage volume，shorten drainage time and reduce antibiotic use.

Clinical Effect of Using Tranexamic Acid on Intraoperative and Postoperative Blood Loss in Total Knee Arthroplasty　

ZHAO Dong，WANG Wenliang，ZHANG Ling，DONG Hui

2018, 21(35): 4405-4407. DOI: 10.12114/j.issn.1007-9572.2018.00.110

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Objective　To investigate the effect of tranexamic acid（TXA） on intraoperative and postoperative blood loss in patients with knee osteoarthritis undergoing total knee arthroplasty（TKA）.Methods　We enrolled 98 cases of knee osteoarthritis treated by unilateral TKA from Affiliated Hospital of Logistics University of Chinese People's Armed Police Force，including 52 received the surgery between June and December 2015（control group），and 46 received the surgery between March and September 2016（TXA group）.The control group did not use TXA，while the TXA group received TXA intraoperatively and postoperatively via various ways（intravenous drip of TXA 1 g at 10 min before making a skin incision，intra-articular injection of TXA 1 g via a draining tube when the suturing was completed，and intravenous drip of TXA 1 g at 6，12 and 24 h after TKA）.We analyzed both groups' visible and hidden blood loss，rate of receiving blood transfusion and the incidence of lower extremity deep vein thrombosis（DVT） .Results　Compared with the control group，TXA group showed less visible blood loss〔（224±59） ml vs（361±70） ml〕，hidden blood loss〔（486±69）ml vs（633±79）ml〕 as well as lower rate of receiving blood transfusion〔6.5%（3/46） vs 46.2%（24/52）〕（P<0.05）.However，the incidence of lower extremity DVT in the TXA group and the control group was 4.3%（2/46） and 7.7%（4/52），respectively，with no significant difference（P>0.05）.Conclusion　Local application combined with intravenous drip of TXA can reduce intraoperative and postoperative blood loss and rate of receiving blood transfusion without increasing the risk of lower extremity DVT in patients with knee osteoarthritis undergoing TKA.

Diagnostic Procedure and Perspective Analysis of a Case of Multisystem Lesions Associated with Vitamin B12 Deficiency　

SONG Zhipeng，WANG Liuyi，LIU Xiaoyu，DUAN Hongyan，REN Zhuozhuo

2018, 21(35): 4408-4411. DOI: 10.12114/j.issn.1007-9572.2018.00.114

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Vitamin B12 deficiency is a nutritional deficiency in the world whose incidence is far higher than estimated，especially in the elderly.However，due to insufficient awareness of and attention to it，frequently the patient does not obtain a definite diagnosis until he develops multisystem lesions.In order to improve clinicians' awareness of illnesses associated with vitamin B12 deficiency，we reported a case of multisystem lesions associated with vitamin B12 deficiency and reviewed the relative studies，then discussed metabolic pathways of folic acid and vitamin B12，and illnesses caused by the deficiency of folic acid and vitamin B12.Moreover，from the patient-centered systemic perspective，clinical problem-oriented perspective and evidence-based clinical decision-making perspective，we made the final diagnosis after carefully excluding other conditions，which well interprets the essential ideas in general practice as well as the monistic principle，providing guidance for clinicians.

Delayed Diagnosis of Severe Acute Atypical Hepatitis E：Report of One Case　

BI Zhenshui

2018, 21(35): 4412-4414. DOI: 10.12114/j.issn.1007-9572.2018.00.065

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The incidence of acute hepatitis E（AHE） in China is on the rise.In clinical settings，sporadic cases of AHE are very common.However，a patient with AHE may easily receive a missed diagnosis or incorrect diagnosis if his symptoms are atypical，which can lead to delayed treatment.As AHE is mainly characterized by rapid onset and high risk，partial patients without receiving timely treatment may rapidly evolve into severe AHE，even hepatic failure and hepatic encephalopathy，with a high mortality.We analyzed the diagnosis and treatment of a case of severe acute atypical hepatitis E：due to clinicians' insufficient understanding of AHE，he had been diagnosed with acute gastroenteritis，and appendicitis successively and received anti-infection and other treatment，the conditions deteriorated progressively，and eventually developed into hepatic encephalopathy.We suggested that in order to ensure timely diagnosis and treatment，liver function test as well as viral hepatitis test should be performed for patients with digestive tract symptoms.

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