Table of Content

20 October 2019, Volume 34 Issue 10

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Diagnosis and management of small for gestational age infants

Sun Yan, Liu Fan, Zhou Yun, Zhou Xinhui, Li Guimei

2019, 34(10):  869-874.  doi:10.3969/j.issn.1004-583X.2019.10.001

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The perinatal mortality and morbidity of small for gestational age infant (SGA) were significantly higher than those of appropriate for gestational age (AGA). The etiology of SGA is diverse,  which is a mixture of physiological (short stature of parents) and pathological (maternal,  fetal and placental) factors. The structural or chromosomal abnormality of fetus is an important cause of SGA，5%20% of SGA is caused by genetic abnormality. Once a SGA infant is born,  clinicians should pay attention to the subsequent acute and chronic complications. The main acute complications show as perinatal asphyxia,  erythrocytosis,  hypoglycemia,  intrauterine infection,  hypothermia,  jaundice and feeding difficulties. Multiple system diseases,  such as growth restriction,  metabolic diseases,  even puberty abnormal development could be traced in the longterm followup. Longterm complications can lead to poor outcomes. Growth hormone treatment is safe and effective to improve height,  and reduce metabolic complications. Furthermore,  the management of SGA needs to summarize the opitical growth model in different types,  especiallly from Chinese real world study, which will be an important direction of SGA management.

Recent advances in idiopathic short stature

Liu Fang, Shen Linghua, Wei Haiyan, Chen Yongxing

2019, 34(10):  875-879.  doi:10.3969/j.issn.1004-583X.2019.10.002

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Idiopathic short stature (ISS) is a kind of short stature disease with unknown etiology and pathogenesis, which is exclusive. Due to the lack of effective and reliable etiology diagnosis methods, the effective treatment for etiology of ISS is uncertain. This review summarizes the advances in etiology, diagnosis and treatment of ISS.

Growth hormone deficiency in children

Li Yuqian, Pi Yalei, Zhang Yanan, Chong Hemeng, Zhang Huifeng

2019, 34(10):  880-884.  doi:10.3969/j.issn.1004-583X.2019.10.003

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Growth hormone deficiency in children is one of the causes of short stature. Growth hormone stimulation test is an important basis for the diagnosis of growth hormone deficiency in children,  but there are also false positives.And the test, together with target indexes,is comprehensively evaluated. Growth hormone deficiency can be divided into isolated growth hormone deficiency and multiple pituitary hormone deficiency. The growth hormone therapy is effective for isolated growth hormone deficiency,  but dynamic monitoring is needed.  Multiple pituitary hormone deficiency needs hormone replacement therapy. The  growth hormone deficiency of both types may last into adulthood,  and isolated growth hormone deficiency may develop into multiple pituitary hormone deficiency,   and dynamic monitoring and followup for life is needed.

Short stature related syndromes

Pi Yalei, Zhang Yanan, Li Yuqian, Chong Hemeng, Zhang Huifeng

2019, 34(10):  885-888.  doi:10.3969/j.issn.1004-583X.2019.10.004

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The etiology of short stature is complex.  There is a variety of genetic and environmental factors can lead to short stature. So far, there are more and more known genetic factors leading to short stature related syndromes. For children with bone deformity, multiple organs and systems involvement and special facial appearance, appropriate molecular genetic detection techniques should be selected according to clinical basic information to make a definite diagnosis, so as to provide basis for treatment and genetic counseling.

Diagnosis and treatment of Noonan syndrome

Chong Hemeng, Zhang Huifeng

2019, 34(10):  889-893.  doi:10.3969/j.issn.1004-583X.2019.10.005

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Noonan syndrome is a relatively common autosomal dominant genetic disease. Genetic heterogeneity of Noonan syndrome has a large rang and involves multiple disciplines. Its main clinical features includes   short stature, craniomaxillofacial deformity,  congenital heart defects,  and cognitive impairment. It can also be accompanied by a series of diseases of the blood system,  and patients with Noonan syndrome have a higher risk of cancer compared to the general population. Recombinant human growth hormone therapy can help improve the height of patients with Noonan syndrome and requires multidisciplinary treatment of congenital abnormalities in other systems.The clinical characteristics and related gene mutations of Noonan syndrome were summarized so as to provide a reference for clinic research.

Effect of male obstructive sleep apnea hypopnea syndrome on bone metabolism and bone mineral density in  patients with type 2 diabetes mellitus

Wang Mayan1, Han Xingfa3, Yang Wenhui1, Jiang Panpan1, Liu Yang1, Liu Hua2

2019, 34(10):  894-897.  doi:10.3969/j.issn.1004-583X.2019.10.006

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Objective  To explore the effect of male obstructive sleep apnea hypopnea syndrome (OSAHS) on blood glucose,  bone metabolism and bone mineral density(BMD) in patients with type 2 diabetes mellitus (T2DM). Methods  Male patients with T2DM  admitted to Gansu Provincial People's Hospital from May 2016 to April 2019 were collected.  The patients were divided into simple diabetes group (control group),  T2DM with  mild OSAHS group (mild group)  and T2DM with moderate severe OSAHS (severe group) according to Apnea Hypoventilation Index（AHI）  by polysomnography（PSG） monitor. Calcium (Ca),  phosphorus (P),  vitamin D (VitD),  osteocalcin (OSTE) and beta crosslaps (βCTX)  were detected, average blood glucose level (MBG),  and glycosylated protein (HbA1c) were tested. The  bone mineral density (BMD) of lumbar spine (L14) and left  femur (LF) were measured by US dual energy Xray absorptiometry. The MBG and indexes of bone metabolism and BMD were compared,  and the correlation between AHI and the above indexes were analyzed. Results   There were no significant differences in P,  OSTE,  βCTX,  and L14 BMD among three groups (P>0.05). Compared with control group,  MBG and HbA1c of  mild and severe groups  increased.  While VitD,  Ca and LF BMD decreased (P<0.05). The difference in VitD, Ca, MBG and HbA1c between severe group and mild group were statistically significant (P<0.05).  AHI was positively correlated with BMI,  MBG,  and βCTX in patients with OSAHS and T2DM (r=0.607,  0.208, 0.169; P=0.000,  0.014,  0.046); it was negatively correlated with VitD (r=-0.276,  P=0.001). Conclusion  OSAHS may further aggravate  glucose metabolism and bone metabolism disorder inT2DM patients,  and it will gradually increase with the progress of OSAHS.

Clinical study of dexmedetomidine combined with propofol and sufentanil in painless flexible bronchoscopy

Han Feng1, Tian Xinxin2, Song Junjie1, Chen Huina1, Wang Ying3

2019, 34(10):  898-903.  doi:10.3969/j.issn.1004-583X.2019.10.007

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Objective  To study the safety and effectiveness of dexmedetomidine combined with propofol and sufentanil anesthesia in bronchoscopy and their clinical value. Methods  Sixty patients who accepted  bronchoscopic examination were randomly divided into two groups: DPS group（Dexmedetomidine combined with propofol and sufentanil group,  n=30, 1 μg/kg dexmedetomidine intravenous infusion for 10 minutes  and intravenous infusion of 0.1 μg/kg  sufentanil  for 5 minutes.)  and PS group (Propofol combined with sufentanil,  n=30, 0.25 ml/kg saline was infused intravenously for 10 minutes and intravenous infusion of  0.1  μg/kg  sufentanil  for 5 minutes before operation),  then propofol was used to induce and maintain anesthesia. Results  The MOAA/S score of DPS group was higher than that of PS group at T2 and T3 time points (P<0.05),  and it was lower than that of PS group at T4,  T5 and T6 time points (P<0.05); Ramsay score of DPS group was higher than that of PS group at T1 time point (P<0.05); HR of PS group was higher than that of DPS group at T5 and T6 time points (P<0.05). At T3,  T4 and T5 time points,  SpO2 was lower than DPS group (P<0.05); DBP and SBP of DPS group were lower than those of PS group at T5 and T6 time points (P<0.05); propofol consumption of DPS group was lower than that of PS group (P<0.05),  and anesthesia recovery time of DPS group was longer than PS group (P<0.05). The incidence of cough in DPS group was less than that in PS group (P<0.05),  but the incidence of hypotension was higher than that in PS group (P<0.05).  The satisfaction score of physicians of DPS group was higher than that in PS group. Conclusion  The anesthesia method of dexmedetomidine combined with propofol and sufentanil is safe and effective in painless flexible bronchoscopy,  which can provide stable hemodynamics and deep sedation for patients.

Diagnostic value of procalcitonin in exhaled breath condensate for ventilatorassociated pneumonia

Qiu Zhengfeng, Zhang Guopei, Li Quanye, Xiang Bin

2019, 34(10):  904-906.  doi:10.3969/j.issn.1004-583X.2019.10.008

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Objective  To investigatethe clinical value of procalcitonin(PCT) in exhaled  ventilator condensate (EVC) in the early diagnosis of patients with ventilator  associated pneumonia (VAP). Methods  Totally fortyfive patients requiring assisted breathing with ventilator were divided into VAP group and nonVAP group depending on whether the patients developed VAP or not in 5 days after assisted breathing with ventilator.  PCT in  EVC was  measured on day  1, 3, 5 of intubation by enzyme linked immunosorbent assay(ELISA). At the same time, the peripheral blood Creactive protein (CRP) concentration,  and Clinical Pulmonary Infection Score(CPIS) were measured. The  accuracy of these indicators in the diagnosis of ventilator  associated pneumonia  were evaluated by receiver operating characteristic (ROC)  curve.Results  PCT and CPIS in EVC  of VAP group on day 3 and 5 were significantly higher than those of nonVAP group (P<0.05). ROC analysis indicated the area under the ROC curve (AUC) of PCT in EVC concentration was 0.777. Using 0.87 ng/ml as the best cutoff, the sensitivity was 81% and the specificity was 64.3%. The combined diagnosis of VAP with PCT(≥0.87) ng/ml and CPIS(≥6) showed no significant improvement in sensitivity (76.7%), but  significant improvement in specificity (88.0%).Conclusion  PCT in EVC had a great diagnostic value in early diagnosis of VAP. Using 0.87 ng/ml as the boundary value,  it had the best sensitivity. The combined diagnosis of VAP with PCT and CPIS can significantly improve the diagnostic specificity to reduce falsepositive of VAP.

Value of central venousarterial carbon dioxide difference  in initial fluid resuscitation towards patients with septic shock

Qing Nan, Li Jingwen, Xie Yongle, Su Wentao, Xin Hongwei, Tian Jing, Li Yun, Zhu Junnian

2019, 34(10):  907-910.  doi:10.3969/j.issn.1004-583X.2019.10.009

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Objective  To evaluate the guidance value of venousarterial carbon dioxide difference  (PcvaCO2)  in fluid resuscitation towards patients with septic shock. Methods  A total of 105 patients with septic shock admitted to ICU of  the hospital  from January 2016 to December 2018 were collected. All  patients underwent initial resuscitation on the basis of the early goal directed therapy principle. The blood gases analysis of radial artery and superior vena cava were carried out  simultaneously 6 hours before resuscitation and 6 hours after resuscitation,  PcvaCO2 was also calculated.  The patients were divided into four groups on the basis of lactic acid(lac)  level and PcvaCO2 6 hours  after  fluid  resuscitation:group A,  lac＞2 mmol/L, PcvaCO2＜6 mmHg; group B,  lac＞2 mmol/L,  PcvaCO2≥6 mmHg;  group C,  lac＜2  mmol/L, PcvaCO2＜6 mmHg;  group D,  lac＜2  mmol/L,  PcvaCO2≥6 mmHg. Sequential Organ Failure Assessment（SOFA）  scores at day1 and day3,  length of ICU stay and 28day motality of all four groups were recorded. Results  After resuscitation, the heart rate(HR) of the patients of all four groups was lower than that before resuscitation, while mean arterial pressure,  central venous pressure and central venous oxygen saturation were higher than those before resuscitation(P<0.05). The lac level of group C and D were lower than that of group A and B after resuscitation；PcvaCO2 of group A and C were lower than that of group B and D(P<0.05). Moreover,  SOFA score at day3, 28day motality of group C were lower than that of the rest three groups(P<0.05). Conclusion  During the initial resuscitation towards spetic shock patients,  those whose PcvaCO2 and lac level reach the criterion will have a better prognosis. Also,  PcvaCO2 combined with lac level can guide the initial resuscitation towards patients with septic shock.

Correlation analysis on serum level of 25hydroxy vitamin D3 and lipoproteinassociated phospholipase A2 with early diabetic nephropathy

Mao Weiwei, Dong Ping

2019, 34(10):  911-914.  doi:10.3969/j.issn.1004-583X.2019.10.010

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Objective  To investigate the level of 25hydroxy vitamin D3 (25［OH］D3)  and lipoprotein associated phospholipase A2 (LpPLA2) in diabetic nephropathy(DN) patients and explore the correlation between serum level of 25(OH)D3 and LpPLA2 and the early DN. Methods  A total of 160 patients with type 2 diabetes mellitus(T2DM) were randomly divided into microalbuminuria group (n=80) and normal albuminuria group (n=80) according to the urinary albumin excretion rate (UAER). Another 80 health volunteers served as the control group. Serum LpPLA2 level was measured by enzyme linked immunoadsorption determination (ELISA). Serum 25(OH)D3 level was measured by chemiluminescence method,  and the biochemical indicators were measured by automatic biochemical analyzer. The differences of LpPLA2 and 25(OH)D3 among three groups were compared,  and the correlation between serum level of 25(OH)D3 and LpPLA2 and the early  DN  was analyzed. Results  ①Seurm LpPLA2 was significantly higher in normal albuminuria and microalbuminuria group than that in control group,  but serum 25(OH)D3 was significantly lower in normal albuminuria and microalbuminuria group than that in control group (P<0.05). Seurm LpPLA2  was significantly higher in microalbuminuria group than that in normal albuminuria group,  but seurm 25(OH)D3  was significantly lower in microalbuminuria group than that in normal albuminuria group (P<0.05). ②The level of UAER was positively correlated with the low density lipoprotein cholesterin(LDLC),  systolic blood pressure (SBP),  diastolic blood pressure (DBP),  disease  course, fasting plasma glucose (FPG),  glycosylated hemoglobin (HbA1c),  uric acid(UA),  homocysteine(Hcy),  Cys C and LpPLA2(P<0.05 or P<0.01),  but was negatively correlated with 25(OH)D3 (P<0.01). ③SBP,  DBP,  course of sisease, FPG,  HbA1c,  CysC and LPPLA2 were independent risk factors for early DN,  but 25(OH)D3 was protective factor for it. Conclusion  The levels of 25( OH) D3 and LPPLA2 are closely related to the occurrence and development of  early DN.  25(OH)D3 is the protective factor, while LPPLA2 is a risk factor for it．

Correlation between red cell distribution width and  prognosis in patients with multiple myeloma

Li Feng, Wang Fei, Yue Yanhua, Guo Yanting, Dong Weimin, Lin Yan

2019, 34(10):  915-920.  doi:10.3969/j.issn.1004-583X.2019.10.011

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Objective  To investigate the prognostic value of baseline red cell distribution width (RDW) level  in patients with multiple myeloma (MM) at the first visit.  Methods  A total of 279 MM patients were included and divided into high RDW group (>15.5%,  n=146) and normal RDW group (≤15.5%,  n=133). RDW levels were detected on the latest day within 1 week before the frontline treatment,  within 1 week after patients had good treatment response confirmed,  and within 1 week after disease progression confirmed. Clinical data such as treatment response and survival data were collected,  and the prognostic value of RDW was evaluated with Cox proportional hazards models.Results  There were significant changes of RDW levels between the time points of diagnosis and good treatment response (P=0.0491),  and the time points of obtaining good treatment response and disease progression  (P=0.0314),  when estimated the series of samples of the same individual patient. It was indicated that RDW might act as a biomarker for disease progression surveillance. The median overall survival (OS) times of high RDW and normal RDW groups were 22 months and 46 months,  respectively (P<0.01). And the median progression free survival (PFS) times of high RDW and normal RDW groups were 12 months and 30 months,  respectively (P<0.01). Multivariate analysis showed that RDW level was an independent risk factor for OS (P=0.0010,  HR=2.248,  95%CI: 1.3683.694) and PFS (P=0.0000,  HR=2.797,  95%CI: 1.8424.248). Conclusion  The elevated RDW level at the first visit predicted adverse clinical outcomes in MM patients.

Clinical characteristics of hemichorea associated with nonketotic hyperglycaemia

Wang Xiaoyu, Zhang Yuting, Yang Fan, Han Jing, Zhang Yang, Jiang Xia

2019, 34(10):  921-926.  doi:10.3969/j.issn.1004-583X.2019.10.012

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Objective  To summarize the clinical features and imaging findings of patients with hemichorea associated with nonketotic hyperglycaemia(HCNH),  and to explore the possible pathogenesis,  diagnosis and treatment of the disease. Methods  Retrospective analysis was performed on the case data of  three patients with HCNH admitted to the hospital recently. The three patients were treated in the department of endocrinology,  neurology and  of neurosurgery in our hospital, respectively. Meanwhile,  relevant literature were consulted for further study. Results  HCNH usually presented as a triad of nonketone hyperglycemia,  lateral chorea,  and typical imaging manifestations of head MRI or CT,  but the manifestations were not the same,  and imaging features were also  different.  And the disease also presented a diversified trend in clinical practice. All three patients were given glucoselowering drugs,  and improved with or without combination of drugs to control symptoms of chorea. Conclusion  Fast judgement and recognition of the disease is a top priority,  timely and correct control of blood glucose is the key to the treatment. When necessary,  dopamine receptor antagonists with combination therapy in the patients can accelerate improvement of the clinical symptoms. The disease prognosis is good.

Meta analysis of the effectiveness of bronchofiberscope lavage in treatment of acute lung abscess

Li Huafenga，Mei Bob，Zhao Chonga，Zhang Linga，Liu Zhongyangb

2019, 34(10):  927-932.  doi:10.3969/j.issn.1004-583X.2019.10.013

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Objective  To prove the effectiveness of bronchofiberscope lavage in the treatment of acute lung abscess and provide basis for its priority in clinical work. Methods  Chinese and English databases such as (CNKI),  (VIP),  Wanfang,  PubMed,  Embase,  Cochrane,  etc. were searched for the clinical effectiveness of bronchofiberscope lavage in the treatment of acute lung abscess from January 1,  2010 to December 1,  2018. Two researchers obtained relevant data according to the original document inclusion and exclusion criteria,  and the quality of the included literature was evaluated by the Cochrane bias risk assessment tool. Statistical analysis was performed with Mevman 5.3 software.Results  Altogether, 20 articles were included in the literature,  and a total of 1332 patients were analyzed. The results showed that bronchofiberscope lavage for acute lung abscess was more effective than conventional treatment group (RR=1.27,  95%CI［1.18,  1.37］,  P<0.01),  FEV1 level (WMD=0.36,  95%CI ［ The improvement of 0.29, 0.42］,  P<0.01)  and its PaO2 level (WMD=9.12,  95%CI［7.94, 10.30］,  P<0.01)   was significantly higher than that of the conventional treatment group,  and its hospitalization time (WMD=-9.96,  95%CI［-12.95,-6.96］,  P<0.01),  body temperature recovery time (WMD=-4.29,  95%CI［-5.29, -3.29］,  P<0.01),  cough and sputum relief time (WMD=-3.91,  95%CI［-4.43,-3.40］, P<0.01),  diminution time of abscess (SMD=-1.74,  95%CI［-2.63,-0.86］, P=0.01)  were also shorter than thoseofthe conventional treatment group. Conclusion  Current clinical research data show thatfiberoptic bronchoscopy has its unique advantages in the treatment of acute lung abscess.

Clinical analysis of Gitelman syndrome and short stature with SLC12A3 mutation in one case

Xu Jinteng1, Ma Kai2, Li Xiaoqing2, Yang Ying3

2019, 34(10):  933-936.  doi:10.3969/j.issn.1004-583X.2019.10.014

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Gitelman syndrome (GS),  also known as familial hypokalemic  hypomagnesemia,  is an autosomal recessive inherited and saltlosing renal tubular disease characterized by hypokalemic and  hypochloremic alkalosis,  hypomagnesemia,  hypocalciuria  and high renin activity. And GS patients  may have  normal or low blood pressure.Most patients have good prognosis after “food supplement+drug” replacement therapy. Early detection and corresponding treatment can significantly improve the life quality of patients. Together with other related literature,  this paper reports  the clinical data,  diagnosis and treatment of a patient with Gitelman syndrome and short stature admitted to Xi 'an Children's Hospital.