2015 Vol. 6, No. 5

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Original Contributions
Abstract:
  Objective  To describe the disease distribution in endocrine emergency consultation.  Methods  The pattern and characteristics of emergency cases encountered by endocrinology chief resident of Peking Union Medical College Hospital from March 1, 2010 to February 28, 2011 were retrospectively analyzed.  Results  A total of 196 patients received consultation in the Emergency Department and Intensive Care Unit. The most common diagnosis was electrolyte disturbance (69 cases, 35.2%), followed by thyroid disease (56 cases, 28.6%) and carbohydrate metabolic disorder(49 cases, 25.0%). Hyponatremia was the most common electrolyte disturbance (65.2%). The number of emergency consultation cases in winter and spring (110 cases) exceeded that in autumn and summer (86 cases), so did the proportion of electrolyte disturbance cases (39.1% vs. 30.2%). The euthyroid sick syndrome was common in the Intensive Care Unit in the analyzed consultation cases (28.6%).  Conclusion  Disease pattern in endocrine emergency consultation cases has changed. Electrolyte disturbance becomes a common and important disease in endocrine emergency consultation and we should therefore pay serious attention to this condition in clinical practice.
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  Objective  To investigate the phenotypes of a kindred with progressive diaphyseal dysplasia (PDD) and to detect the mutation of transforming growth factor beta-1 (TGFB1) gene.  Methods  A PDD patient of a non-consanguineous family presented with early onset in childhood, who suffered from lower limb pain, fatigability and muscle weakness. Her clinical manifestations, features of skeletal X-ray examination, and bone turnover markers were evaluated. Mutation of TGFB1 was identified by direct Sanger sequencing of polymerase chain reaction amplification product.  Results  The proband presented with elevated bone turnover biomarkers, and nonuniform thickening and sclerosis of bone cortex of limbs in X-ray films. A heterozygous missense mutation c.652C > T(p.Arg218Cys) in exon 4 of TGFB1 was identified in the proband, but not in either of her parents. Glucocorticoid was given and after 4 months of treatment, the bone pain and activity were obviously improved.  Conclusions  The typical clinical manifestations of PDD are limb pain and diaphyseal hyperostosis. The missense mutations at position 218 of TGFB1 are hotspot pathogenic mutations of PDD. Glucocorticoids can mitigate the symptoms in PDD patients.
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  Objective  To investigate the clinical characteristics of Langerhans' cell histocytosis (LCH) involving the thyroid gland.  Methods  We reviewed 6 cases of histologically confirmed LCH with thyroid gland involvement in Peking Union Medical College Hospital in the period of January 2004 to December 2014 and analyzed their clinical menifestations, diagnosis, treatment, and prognosis.  Results  There were 4 males and 2 females in the 6 patients, whose ages of onset were 9-24 years with a mean age of (16.1±5.7) years. All the 6 cases had posterior pituitary involvement, 4 cases had lung involvement, and 3 cases had liver involvement. There were 4 cases with negative thyroid autoantibodies and 2 cases with positive thyroid autoantibodies. Four cases were pathologically confirmed by core-needle aspiration biopsy. Five cases were treated with chemotherapy. In the 4 cases followed up, 3 were in progress-free stable status.  Conclusions  LCH with thyroid involvement should be considered in thyromegaly patients with multiple organs involvement. Thyroid aspiration, especially core-needle aspiration biopsy, is required to confirm pathological diagnosis if necessary. Special attention should be paid to detect liver involvement in patients with thyroid LCH.
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  Objective  To explore the role of preoperative localization of lymph nodes with ultrasound in thyroid carcinoma neck lymphadenectomy.  Methods  Altogether 38 patients (89 located lymph nodes) who underwent thyroid carcinoma neck lymphadenectomy and preoperative localization of lymph nodes with ultrasound in the period from January 2012 to May 2015 in Peking Union Medical College Hospital were enrolled in this study. The location and the ultrasonic features of metastatic lymph nodes were retrospectively analyzed, the value of the ultrasonic features in diagnosis of metastatic lymph nodes was also evaluated.  Results  The short-axis diameter of the 89 lymph nodes located with ultrasound was (0.59±0.25)cm. Twenty-three lymph nodes (25.9%) were located in level Ⅱ, 25 (28.1%) in level Ⅲ, 17 (19.1%) in level Ⅳ, 5 (5.6%) in level Ⅴ, and 19 (21.3%) in level Ⅵ. Surgery pathological findings confirmed that 80 of the 89 located lymph nodes were lymph nodes, of which 60 were metastatic and 20 were non-metastatic (8 inflammatory and 12 normal). No lymph node was found in the corresponding levels of 6 located lymph nodes. Two of the located lymph nodes were diagnosed as fibrous and nervous tissues and one as thymus tissue. There was significant difference in disordered blood flow between metastatic lymph nodes and non-metastatic lymph nodes (46.67% vs. 5.00%, P=0.001). The sensitivity and specificity of disordered blood flow in diagnosing metastatic lymph nodes were 46.67% and 95.00%, respectively. There was no significant difference in short-axis diameter (≥ 1 cm), short-to-long axis (S/L) ratio(≥ 0.5), unclear corticomedullary differentiation, thickened cortex, anechoic, strong echoic, and hyperechoic areas in cortex, peripheral blood flow or abundant blood flow between metastatic and non-metastatic lymph nodes.  Conclusions  The lymph nodes located with preoperative ultrasound are usually too small to be palpated by surgeons. Preoperative localization with ultrasound of lymph nodes could guide the scope of operation and targeted dissection of metastatic lymph nodes. The disordered blood flow is specific in diagnosing metastatic lymph nodes, which could play an important role in preoperative localization of lymph nodes when combined with other ultrasonic features.
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  Objective  To investigate the effects of Huai Qi Huang granules administered alone or combined with predisone on humoral immunity, cellular immunity, and proteinuria of adriamycin nephrosis rats.  Methods  A total of 50 SD rats were randomly divided into 5 groups (all n=10), in which 4 groups were injected with a single dose of 6.5 mg/kg adriamycin into the caudal vein to establish nephrosis model, while the other group was injected with normal saline (NS) as normal control. Two weeks later, the nephrosis rat model was established successfully. The rats were treated by daily intragastric administration for 6 weeks:the normal control group (group A) and the nephrosis+NS group (group B) were treated with 2 ml NS; group C (nephrosis+predisone group), D (nephrosis+Huai Qi Huang group), and E (nephrosis+predisone+Huai Qi Huang group) were treated with 2 mg/kg prednisone, 2 g/kg Huai Qi Huang granule solution, and 2 mg/kg prednisone plus 2 g/kg Huai Qi Huang granule solution, respectively. The 5 groups were compared in terms of death rate, weight changes trend, 24-hour urinary protein increment, serum IgA, IgG and IgM, and percentages of lymphocyte subsets of CD3+T cells, CD3+CD4+T cells, CD3+CD8+T cells, CD45RA+B cells, CD161a+NK cells.  Results  All nephrosis rats model were successfully made, with 24-hour urinary protein being (0.389±0.273)g/24 h. The death rates of group C and group E were significantly higher than those of group A and group B (P < 0.05), while no significant difference was found among group C, group D, and group E. The body weight of group A was sustainably growing; in contrast, the body weight of the other 4 groups grew in the 2 weeks before administration of treatment, but dropped thereafter, with no significant difference among the 4 groups. Six weeks after administration, 24-hour urinary protein of the 4 nephrosis groups were all increased, by (0.313±0.266), (0.404±0.235), (0.120±0.628), and (0.480±0.229)g/24 h, respectively, with no signficant difference in increment. There was no significant difference in the percentages of lymphocyte subsets (CD3+T cells, CD3+CD4+T cells, CD3+CD8+T cells, CD45RA+B cells, CD161a+NK cells) among the 5 groups. IgA, IgG, and IgM were higher in group B than in group A; IgA, IgG, and IgM in group C were lower than in group B; in group D, IgA was lower than in group B, IgG lower than in group A and group B, IgM higher than in group A and group C; and in group E, IgA and IgG were higher than in group A, group C and group D, IgM higher than in group A and group C; the differences were all of statistical significance (all P < 0.05). In addition, there was no significant difference of IgA, IgG, or IgM in the comparison between every other two groups.  Conclusions  Humoral immunity in severe nephrosis rats is hyperfunctional. Huai Qi Huang is a bidirectional immune modulator. It could down-regulate hyperactive humoral immunity when used alone, similar to the effect of prednisone. When combined with prednisone, it could antagonize the immunosuppression effect of prednisone on the body. No regulation effect of different treatments on cellular immunity or proteinuria was found in this study.
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  Objective  To explore the plastic surgery to treat facial hemiatrophy combined with facial paralysis.  Methods  From March 2006 to March 2012, 12 patients of facial hemiatrophy with facial paralysis were treated in Department of Plastic Surgery of Peking Union Medical College Hospital, including 3 males and 9 females. Their ages ranged from 16 to 49 years. The average duration of facial hemiatrophy was 6.9 years (5-30 years), and the average duration of facial paralysis was 4.5 years (2-18 years). Several reconstructive procedures were applied for reconstruction of appearance and function, taking into consideration of the individual conditions of each case. For correction of facial hemiatrophy with facial paralysis, dermis-fat grafts were used in 4 patients, groin dermis-fat free flaps in 2, and extensor pollicis brevis and extensor digitorum brevis free flaps combined with suspension in 6. To achieve the satisfied symmetrical results, nasolabial fold suspension and additional fat injection at the depression edge of the graft were performed.  Results  The adipofascial flaps survived in all the 12 patients. The incisions all healed without fat liquefaction or other complications. In the follow-up of 0.5-6 years, all the patients were satisfied with the results. The facial contour of all the patients were well corrected.  Conclusion  Dermis-fat free grafts combined with free small muscle free grafts could achievesatisfied symmetrical effect for patients of facial hemiatrophy with facial paralysis.
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  Objective  To discuss the clinical features, diagnosis, and treatment of deep venous thrombosis at specific positions in first trimester of pregnancy.  Methods  Three cases in first trimester of pregnancy with deep venous thrombosis at specific positions treated in Peking Union Medical College Hospital in the period from September 2013 to June 2014 were retrospectively analyzed. The clinical manifestations, diagnosis, treatment, and prognosis of these cases were summarized.  Results  Among the 3 cases, 1 was pregnancy with pulmonary embolism and 2 were with mesenteric-portal venous thrombosis. All deep venous thrombosis occurred at first trimester of pregnancy and might have great effect on the prognosis of the maters and fetuses. Doppler ultrasound was the diagnosis method of option for thrombosis, and anticoagulation was the main therapeutic method, similar to the deep venous thrombosis in non-pregnancy. All the 3 patients chose surgical or medical abortion. The medical abortion was performed successfully in 2 patients after the thrombus got stable, and forceps curettage was performed in 1 patient after enterectomy.  Conclusions  Deep venous thrombosis at specific positions in first trimester is a rare condition. The diagnosis relies on clinical manifestations and examinations. Anticoagulation is the key in treatment, and deep venous thrombosis at different positions may need corresponding thrombolytic or surgicaltreatments. Abortion, if necessary, after stabilization of thrombus will lead to better outcomes.
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  Objective  To analyze the current status and characteristics of perioperative transfusion in patients undergoing gynecologic surgery and to explore the rational management of blood product use.  Methods  Clinical data of patients who underwent gynecologic surgery in Peking Union Medical College Hospital from January to October in 2014 were retrospectively reviewed. Those who received perioperative transfusion were analyzed to summarize the status and characteristics of transfusion for different diseases and surgical procedures. The data of patients in 2014 were compared with those of patients in the corresponding period of 2013.  Results  Altogether 6203 patients underwent gynecologic surgery in Peking Union Medical College Hospital from January to October in 2014, including 286 patients who had allogeneic transfusion during perioperative period, and 80 who had autologous transfusion. The total number of surgery in 2014 increased by 10.5% compared with the same period in 2013, while the allogeneic transfusion rate in 2014 (4.6%) decreased by 27% compared with the same period in 2013 (P=0.001). Operations for malignancies had higher transfusion rates than those for mild diseases. Cytoreductive surgery and re-cytoreductive surgery for ovarian cancer had the highest rate of transfusion (45.3%), and the average transfusion volume was 6.7 U. Laparoscopy had lower transfusion rate compared with laparotomy. In radical resection of cervical cancer, approach by laparoscopy had a lower rate of transfusion than by laparotomy (6.2% vs. 10.9%). Autologous transfusion was applied mainly in operations for ectopic pregnancy or internal bleeding due to rupture of corpus luteum, myomectomy and total hysterectomy, with autologous transfusion rates being 17.0%, 5.2%, and 2.8%, and average transfusion volume being 749, 429, and 397 ml, respectively.  Conclusions  Perioperative transfusion rate in 2014 was lower than in 2013 despite more gynecologic operations in 2014. Rational blood use in gynecologic patients can be managed by strategies including selection of appropriate surgery procedures, application of minimally invasive surgery, and proper use of autologous trasfusion.
2015, 6(5): 321-323. doi: 10.3969/j.issn.1674-9081.2015.05.001
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2015, 6(5): 342-342.
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  Objective  To compare the effects of Eastern Association for Surgery of Trauma/AmericanCollege of Critical Care Medicine/Society of Critical Care Medicine (EAST/ACCM/SCCM) red blood cell transfusion in adult trauma and critical care guidelines (2009) guided red blood cell (RBC) transfusion strategy and tissue perfusion oriented RBC transfusion strategy in critically ill patients.  Methods  In 2013, RBC transfusion in Department of Critical Care Medicine of Peking Union Medical College Hospital followed the EAST/ACCM/SCCM guidelines recommendation in critically ill patients, and in 2014 tissue perfusion oriented RBC transfusion strategy was adopted. The in-hospital mortality, length of Intensive Care Unit (ICU) stay, incidence of new organ injury, mean pre-transfusion hemoglobin (Hb) level, blood lactate acid level upon admission (Lac admitted), pre-transfusion blood lactate acid level (Lac pre-transfusion), mean RBC transfusion volume, and incidence of transfusion-related complications in all ICU patients and patients with Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) ≥ 15 were compared between the year 2013 and the year 2014.  Results  In 2013 and 2014, 2110 and 2638 patients were admitted to ICU, respectively. The mean APACHE Ⅱ score upon admission and the proportion of patients with APACHE Ⅱ ≥ 15 were both higher in 2014 than in 2013(P < 0.05). The proportion of patients treated with RBC transfusion was significantly lower in 2014 than in 2013(P < 0.05). The mean pre-transfusion Hb level, Lac admitted, and the proportion of patients with Lac admitted < 4 mmol/L showed no significant difference between the two years (P>0.05). Lac pre-transfusion in 2014 was significantly higher than that in 2013[(4.16±1.18)mmol/L vs. (2.78±1.03)mmol/L, P=0.031]. In the patients treated with RBC transfusion, the proportion of patients with Lac admitted < 4 mmol/L was significantly lower in 2014 than in 2013 (20.5% vs. 33.4%, P=0.018). The mean RBC transfusion volume was significant lower in 2014 than in 2013[(1.02±0.51)U vs. (1.55±0.70)U, P=0.037]. The in-hospital mortality was not significantly different between the two years in all ICU patients (2.77% vs. 2.39%, P=0.749), but the mean length of ICU stay was significantly shorter in 2014 than in 2013[(5.31±1.98)d vs. (6.84±2.36)d, P=0.025]. The incidences of new onset acute kidney injury, acute liver injury, acute myocardial injury, and acute lung injury showed no significant difference between the two years (P>0.05). In patients with APACHE Ⅱ ≥ 15, the in-hospital mortality was significant lower (7.00% vs. 12.01%, P=0.018) and the length of ICU stay significantly shorter in 2014 than in 2013[(7.16±3.53)d vs. (12.44±5.27)d, P < 0.001]; the incidences of new onset acute kidney injury, acute myocardial injury, and acute lung injury were significantly lower in 2014 (P < 0.05). No transfusion-related infection or hemolysis occurred in the two years. The incidences of non-hemolytic febrile transfusion reaction and transfusion-related lung injury in all the ICU patients and patients with APACHE Ⅱ ≥ 15 were not significantly different between the two years (P>0.05).  Conclusions  Compared with EAST/ACCM/SCCM guideline based RBC transfusion strategy, tissue perfusion oriented RBC transfusion strategy in critically ill patients can reduce RBC transfusion volume and shorten length of ICU stay. Especially for ICU patient with APACHE Ⅱ ≥ 15, it can also reduce in-hospital mortality and incidences of new onset acute kidney injury, acute myocardial injury, and acute lung injury, without increasing the incidence of transfusion-related complications.
2015, 6(5): 369-371. doi: 10.3969/j.issn.1674-9081.2015.05.011
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2015, 6(5): 372-375. doi: 10.3969/j.issn.1674-9081.2015.05.012
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2015, 6(5): 375-375.
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2015, 6(5): 376-380. doi: 10.3969/j.issn.1674-9081.2015.05.013
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2015, 6(5): 381-383. doi: 10.3969/j.issn.1674-9081.2015.05.014
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2015, 6(5): 383-383.
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2015, 6(5): 384-386. doi: 10.3969/j.issn.1674-9081.2015.05.015
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2015, 6(5): 387-389. doi: 10.3969/j.issn.1674-9081.2015.05.016
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Managing the Diabetic Foot(3rd ed)(2014)
2015, 6(5): 389-389.
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2015, 6(5): 390-393. doi: 10.3969/j.issn.1674-9081.2015.05.017
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2015, 6(5): 393-393.
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2015, 6(5): 394-400. doi: 10.3969/j.issn.1674-9081.2015.05.018
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