2012 Vol. 3, No. 3

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Original Contributions
Abstract:
  Objective  To observe the metabolic and structural changes in different cerebral areas in patients with Alzheimer's disease (AD) and to explore the value of the changes in parietal lobe in the diagnosis of AD.  Methods  Totally 123 patients with suspected AD who were assessed in our hospital from January 2007 to December 2010 were entrolled in this study. The brain functions were evaluaed using fluorodeoxy glucose-positron emission tomography (FDG-PET). Changes in different cerebral areas were evaluated by direct observation, SUV measurement, and NeuroQ analysis. The brain structure was obseved under three-dimensional megnatic resonance imaging (MRI), which were further anlysed via voxel-based morphometric (VBM) and diffusion tensor imaging (DTI).  Results  Totally 41 patients were diagnosed as probable AD and 43 as possible AD. FDG-PET revealed that, among these 84 patients, hypomatebolism was detected in the parietal lobe of all patients (100%), and also in posterior cingutate (79.8%), posterior temporoparietal lobe (71.4%), and medial temple lobe (61.9%). MRI showed atrophy on parietal lobe in 67.9% (57 cases of both sides) to 84.5% (71 cases of single side) of the patients. Among 24 patients who can be assessed using VBM, MRI showed the atrophy of parietal lobe was much more obvious. No hypomatebolism or atrophy of the parietal lobe was found in 12 clinically probable frontotemporal dementia patients.  Conclusion  Hypometabolism (as shown by functional imaging) and atrophy (as shown by structural imaging) of the parietal lobe can be suggestive for the diagnosis of AD.
Abstract:
  Objective  To explore the clinical and polysomnographic characteristics of narcoleptic patients with status cataplecticus.  Methods  We collected the clinical data of 5 patients with status cataplecticus out of 115 narcoleptic patients admitted to Department of Neurology in Peking Union Medical College Hospital from January 2002 to December 2011. The 5 patients had a mean age of 49.1 years (range, 46-59 years) at diagnosis. Their disease course ranged from 3 to 9 months. All of them underwent physical and neurological examinations, neuroimaging, and multiple sleep latency test (MSLT). Three of them underwent polysomnography (PSG).  Results  The first symptom was excessive daytime sleepiness in 4 patients, cataplexy in 1 patient. All patients had frequent cataplectic attacks, diagnosed as status cataplecticus. Other symptoms included hypnagogic hallucinations (2/5) and sleep paralysis (3/5). The MSLT showed a mean sleep latency from 0.5 to 2.5 minutes, and 4 patients had more than 2 sleep-onset rapid eye movement period (SOREMP), and 1 patient had 1 SOREMP. PSG showed that a waking electroencephalography (EEG) existed during cataplectic attacks. Electromygraphy showed suppressions of activity. All patients were treated with clomipramine, which completely resolved the attacks.  Conclusions  Cataplexy in narcoleptic patients showing the recurrent episodes can be diagnosed as status cataplecticus. PSG supports that cataplectic attacks represent dissociated rapid eye movement phenomena in which there is only the somatic component (atonia) without the cerebral one (sleep).
Abstract:
  Objective  To study the diagnostic value of cerebrospinal fluid (CSF) cytology in the diagnosis of primary central nervous system lymphoma (PCNSL).  Methods  We retrospectively analyzed the clinical data of 21 PCNSL patients with positive CSF cytological findings. Conventional CSF cytology, immunocytochemistry, flow cytometric immunophenotypic analysis (FCA), and PCR of the rearranged IgH and TCR genes of CSF were performed.  Results  The clinical and neuroimaging types of 21 patients included meningeal type (n=13), parenchymal type (n=4), ependymal type (n=3), and optic type (n=1). The CSF of all the 21 patients had a number of blast cells or atypical lymphocytes, suspected of lymphoma on conventional cytology Of the 20 patients undergoing the immunocytochemical studies of the CSF, 17 showed B-lymphocyte predominance, which was consistent with the diagnosis of B cell lymphoma. FCA of 7 cases showed a significant increase in the percentage of B cells in 5 patients, indicating B cell lymphoma, and NK/T-lymphocyte predominance in 1 case, indicating an NK/T lymphoma. On analysis of the IgH and TCR genes in the CSF of 4 patients, IgH monoclonal was found in 3 cases and TCR monoclonal in 1 case.  Conclusion  CSF cytology, immunocytochemistry, FCA, and PCR of the rearranged IgH and TCR genes of CSF are useful in the diagnosis of PCNSL.
Abstract:
  Objective  To investigate the relationship between amplitude of compound muscle action potential (CMAP) and muscle strength in critically ill patients with paralysis.  Methods  Motor nerve conduction study was performed in 30 critically ill patients with paralysis. Muscle strength was evaluated at the same time. The relationship between the amplitude of CMAP and muscle strength was analyzed.  Results  Amplitude of CMAP and motor conduction velocity was normal in 5 patients with paralysis, including 3 with significant muscle weakness. The detection results supported the diagnosis that the lesions were located in central nervous system. Six patients with significant muscle weakness had motor never conduction block, slow conduction velocity, and decreased amplitude, which supported the diagnosis of demyelinating neuropathy. Nineteen patients had decreased amplitude of CMAP, including obviously decreased amplitude in 8 patients (no response in 3 patients). Physical examinations identified 8 patients with significant muscle weakness, 10 with mild weakness, and 1 with normal muscle strength, which confirmed the diagnosis of neuromuscular disease.  Conclusion  The combined assessment of muscle strength and amplitude of CMAP is helpful for the diagnosis of critically ill patients with paralysis, especially for those with significant muscle weakness.
Abstract:
  Objective  To investigate the changes of serum uric acid (UA) level and its relationship with relapse rate, Expanded Disability Status Scale (EDSS) score, and the number of contrast-enhancing lesions (CELs) in Chinese patients with classic multiple sclerosis (CMS) before and after interferon (IFN) -beta 1b treatment.  Methods  Twelve patients (10 women and 2 men, aged 24 to 54 years) with definite CMS were enrolled into a 6-month open-label observational treatment study. IFN-beta 1b (250 μg, qod) was injected subcutaneously during remission stage. EDSS, relapse rate, number of CELs, and serum UA levels were examined both at baseline and at the end of the study.  Results  After treatment, the median relapse rate (0.0 vs. 0.9, P=0.011) and median number of CELs (0.0 vs. 1.5, P=0.007) decreased significantly compared with those before treatment. The median EDSS score also decreased from 2.8 to 2.0, but the difference was not statistically significant (P=0.064). Serum UA level increased from 222.2 μmol/L to 239.4 μmol/L after treatment, although the difference was not statistically significant (P=0.213). However, there was significant correlation between the increase in UA level and the decrease in number of CELs (r=-0.716, P=0.009).  Conclusions  UA may serve as an easily detectable and economic marker for the blood-brain barrier function in CMS patients and for the responses to IFN-beta 1b treatment.
Abstract:
  Objective  To investigate the expression of titin epitope in normal thymus, thymoma, and thymus carcinoma and explore the correlation of titin expression in thymus with the clinical manifestation of myasthenia gravis (MG).  Methods  Thymoma tissues from four thymoma patients with MG, thymus carcinoma tissue from one patient, hyperplastic thymus tissue from one thymoma patient with MG, and normal thymus tissue from one patient were obtained. Each specimen underwent HE staining and immunohistochemistry staining using anti-cytokeratin (CK) and anti-titin antibodies. Surum anti-titin antibody level of thymoma patients with MG was also examined.  Results  In MG-associated thymoma, the expression of anti-titin antibody was strongly positive, and its distribution was consistent with that of epithelial cells. However, the lymphocytes and other structures were not stained. In the tissue of thymus carcinoma, the expression of anti-titin antibody was negative. In normal thymus tissue, only the expression of Hassall body was weakly positive, while other structures were not stained. Serum anti-titin antibody was detected in three of the four thymoma patients with MG.  Conclusions  Titin epitope is expressed only on the epithelial cells in thymoma patients with MG. In normal thymus, titin epitope is expressed only in the area of Hassall bodies. These findings indicate pathogenic change of immune microenvironment in the thymoma patients with MG.
Abstract:
  Objective  To summarize the clinical features and neuropathological characteristics of peripheral nerves in patients with POEMS syndrome.  Methods  We retrospectively analyzed the clinical and neuropathological characteristics of 11 patients with POEMS syndrome who underwent electrophysiology and sural nerve biopsy in our department from January 2003 to December 2008.  Results  Among these 11 patients, there were 8 men and 3 women, aged 40 to 64 years, with a disease course ranging from 8 months to 8 years. All patients suffered from sensorimotor polyneuropathy. Monoclonal immunoglobulins were detected in 10 patients, including IgAλ (n=6), IgGλ (n=2), and monoclonal λ light chain with unknown typing (n=2). Ten patients had organomegaly, 8 had endocrine disease, and 10 had skin changes. Biopsy of sural nerve presented loss of myelinated fibers. Five showed axonal degenation and six showed both axonal degeneration and demyelination. Changes in the endoneurial and epineurial microvessels, including hyperplasia of endothelial cells and widened basement membrane, were observed.  Conclusion  Biopsy of the sural nerve in patients with POEMS syndrome shows both axonal degeneration and demyelination or axonal degeneration, as well as small ves-sel lesions without inflammation.
Abstract:
  Objective  To introduce a novel presurgical extraoral orthopedic appliance and treatment approach for the newborns with unilateral cleft lip and palate.  Methods  A novel presurgical extraoral orthopedic appliance was self-designed. In a 12-day-old male newborn presented with complete unilateral cleft lip and palate, an adhesive taped lip supported the novel preformed nasal stent without any oral appliance was used to decrease the alveolar gap and improve the symetry of the nose. The treatment course was 3 months.  Results  The intraoral cleft gap was decreased by 3 mm after 3 weeks and closed at the 14th week by the gradual activations with a rounding nostril on the cleft side. The shape of the cartilaginous septum, alar cartilage tip, medial and lateral crus, and alveolar segments were molded to resemble the normal shape of these structures.  Conclusion  The novel extraoral orthopedic appliance can effectively decrease the intraoral cleft gap and mold the oronasal tissues into normal form, and therefore can be helpful for the cleft lip and palate repair surgery in the newborns with unilateral cleft lip and palate.
Abstract:
  Objective  To explore the clinical characteristics and physiotherapy for the Chinese hemophilia patients with femoral nerve injury due to illiopsoas bleeding.  Methods  Thirty-four hemophilia patients with femoral nerve injury due to illiopsoas bleeding who had been treated in Peking Union Medical College Hospital between January 2006 and December 2010 were enrolled. The comprehensive treatment included factor replacement, joint protection and weight-bearing exercise, proprioception training, neurotrophic drugs, neuromuscular electronic stimulation, pulsed magnetic field, and low-intensity laser. The clinical characteristics including age distribution, clinical manifestations, complications, ultrasound image, and physiotherapy efficacy were retrospectively analyzed.  Results  All the 34 patients were male and their mean age was (17.6±3.3) years. All patients had loss of range of motion in the affected hip, decreased strength on quadriceps and deficiency of superficial sensory in front of thigh. Twenty patients had secondary knee bleeding. Twenty patients accompanied with quadriceps atrophy. Pseudotumor developed in one patient. The main findings of the ultrasound image were low-echo mass in illiopsoas muscles or inguinal region. Thirty-two patients received 8-to 12-week comprehensive physiotherapy under the support of factor replacement. Thirty-one patients regained same range of motion of hip as baseline with hematoma disappeared completely, 27 patients got ≥ 4 grade of quadriceps force, and 12 patients obtained improved superficial sensory function of femoral nerve.  Conclusions  In this cohort of femoral nerve injury due to illiopsoas bleeding, most of the patients are adolescent. The high prevalence of secondary knee bleeding is found. Comprehensive physiotherapy under the support of factor replacement is safe and effective for hematoma absorption and neurological function recovery.
Abstract:
  Objective  To evaluate the effectiveness of nosocomial infection control in cardiac surgery.  Methods  We collected records of surgical cases between January 2007 and December 2009 in People's Hospital of Peking University and analyzed the status of nosocomial infection in cardiac surgery before and after intervention, which was initiated in May 2008 and fully implemented since 2009. The nosocomial infection rate before and after intervention was compared.  Results  The rate of nosocomial infection in cardiac surgery was high in 2007 and 2008, reaching 6.07% and 7.56%, respectively. Meanwhile, the rate of nosocomial infection throughout the whole surgical system was 1.34% and 1.38%. After the adoption of intervention, the rate of nosocomial infection in cardiac surgery significantly decreased to 3.62% compared to the rate before intervention (χ2=7.584, P=0.006).  Conclusions  Cardiac surgery patients have high risk of nosocomial infection. Taking appropriate intervention measures for nosocomial infection control can effectively reduce the rate of nosocomial infection in cardiac surgery.
Abstract:
  Objective  To compare the diagnostic accuracy of transthoracic echocardiography (TTE) versus transesophageal echocardiography (TEE) in patients with suspected infective endocarditis (IE).  Methods  The clinical and echocardiographic characteristics of 95 patients with IE diagnosed from January 2003 to December 2011 in Peking Union Medical College Hospital were retrospectively analyzed. The detection rate of TTE and TEE for valvular vegetations and periannular complications of IE was compared, and the diagnostic accuracy of TTE was assessed using TEE as the reference standard for diagnosis of IE.  Results  TEE was more sensitive than TTE in identifying valvular vegetations (81.1% vs. 52.6%, P < 0.001). Using positive TEE cardiac findings as the reference standard, the sensitivity and specificity for TTE was 64.9% and 94.4% for the detection of vegetation, respectively. Also, TEE was significantly more sensitive than TTE at defining periannular complications of IE (P < 0.05). Vegetation on TTE and positive blood cultures were correlated with vegetation on TEE.  Conclusion  TTE has a limited capacity in detecting valvular vegetations. TEE is more sensitive than TTE in detecting valvular vegetations and identifying periannular complications in IE patients.
Abstract:
  Objective  To compare the cardiovascular responses and complications to tracheal intubation with Shikani seeing optical stylet or Macintosh laryngoscope in non-difficult airway patients and to assess the clinical values and prospects of Shikani seeing optical stylet.  Methods  Forty female patients scheduled for gynecological laparoscopy or laparotomy under general anesthesia were randomly assigned to Shikani group or Macintosh group. Their mean arterial blood pressure and heart rate before and after intubation, esophageal intubation, time needed for intubating, and incidence of sore throat and hoarseness were recorded.  Results  No significant difference was found on the demographic data between these two groups. In the Shikani group, the mean arterial blood pressure and heart rate were (69.0±6.7) mm Hg and (70.8±8.8) bpm before intubation and (86.0±11.6) mm Hg and (78.3±9.9) bpm after intubation. In the Macintosh group, the mean arterial blood pressure and heart rate were (69.3±9.0) mm Hg and (71.2±12.5) bpm before intubation and (93.6±8.9) mm Hg and (87.6±13.5) bpm after intubation. Both groups had significantly higher blood pressure and heart rate after intubation (P < 0.05), while such change was smaller in Shikani group (P < 0.05). No significant difference was found in terms of intubation time, incidences of sore throat and hoarseness (P > 0.05).  Conclusion  The cardiovascular response to Shikani seeing optical stylet is less severe than Macintosh laryngoscope.
2012, 3(3): 245-246. doi: 10.3969/j.issn.1674-9081.2012.03.001
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