[Diagnostic performance of pathology, culture and ROSE of lung biopsy for suspected pulmonary infectious diseases].

Objective: To explore the diagnostic performance of CT guided percutaneous lung biopsy (PTLB) with pathology, culture and rapid on-site evaluation (ROSE) in patients with pulmonary infectious diseases. Methods: From January 2016 to June 2018, a retrospective study was implemented in the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University. Patients who received PTLB, suspected with lung infection were included. The basic information, clinical symptoms, imaging findings, diagnostic methods, complications, and changes in treatment of cases were collected. The diagnostic sensitivity of histopathology, microbial culture, and ROSE were evaluated at the same time. Results: A total of 529 cases were enrolled, including 354 males and 175 females, (59±14) years old in average. Tuberculosis was identified in 197 cases, non-tuberculosis mycobacteria (NTM) pulmonary disease in 8, cryptococcosis in 95, pulmonary aspergillosis in 27, filamentous fungal pneumonia in 3, talaromyces marneffei pulmonary infection in 3 and pulmonary candidiasis in 1, bacterial pneumonia in 39, and pathogen were unknown in 156 cases. A total of 417 cases were submitted for histopathology and microbial culture at the same time, the diagnostic value of pathology and microbial culture were 35.0% (146/417) and 45.6% (190/417), respectively. Combined pathology with microbial culture, the diagnostic value increased to 62.8% (262/417). The diagnostic accuracy of ROSE was 51.8% (71/137). The most common complication of PTLB was pneumothorax 26.1% (138/529). 56.1% (297/529) of the patients received targeted treatment after the diagnosis was confirmed, and 43.9% (232/529) maintained the original treatment. Conclusion: The pathology, microbial culture, and ROSE of PTLB have relative high diagnostic value for pulmonary infectious diseases.

[Dynamic research of serum cryptococcal capsular polysaccharide antigen titer and chest CT of pulmonary cryptococcosis after antifungal therapy].

Objective: To observe the dynamic changes of serum cryptococcal capsular polysaccharide antigen (CrAg) titer and chest CT of pulmonary cryptococcosis (PC) after antifungal therapy. Methods: A retrospective study was performed for patients with PC admitted to the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University from January 2015 to April 2018. Serum CrAg titers and Chest CT examination were performed for all the cases before and after treatment. The difference between immunocompetent hosts group and immunocompromised hosts group were compared and analyzed. Results: Eighty-two patients with PC including 46 male (56.1%) and 36 (43.9%) female were enrolled. Fifty-two (63.4%) patients were proven PC and thirty (36.6%) patients were probable PC. Forty-five (54.9%) patients had underlying diseases. Fifty-four (65.9%) patients were immunocompetent hosts and twenty-eight (34.1%) patients were immunocompromised hosts. The mean duration of treatment was (7.9±2.4) months and the mean follow-up was (24.0±10.0) months. Improvement (≥75%) in chest CT were found in 64.8% of the cases in immunocompetent group and 67.9% in immunocompromised group after 6 months' treatment. Improvement (≥75%) was found in 88.9% of the cases with patchy infiltrates or consolidation and only 63.0% in nodular or mass-like type and mixed patterns of PC. The serum CrAg titer of 55 cases ranged from 1∶4 to 1∶160 before treatment (median 1∶40) and decreased for all cases after treatment. The serum CrAg titer became negative in 20 cases at last. Mean time of serum CrAg titer turning negative was (11.8±8.1) months. The serum CrAg titer became negative or decreased to 1∶1 in 24 cases after treatment cessation, of whom the serum CrAg titer ranged from 1∶5 to 1∶160 before treatment (median 1∶20). The serum CrAg titer of 31 cases ranged from 1∶4 to 1∶640 before treatment (median 1∶64), of whom the serum CrAg detections were still positive after treatment cessation, and CrAg titer was 1∶10 (ranged from 1∶2 to 1∶160). Conclusions: In PC, chest CT improves after antifungal treatment, and the infiltrates or consolidation type of PC resolves faster than nodular or mass-like shadows and mixed patterns in CT. The serum CrAg titer decreases after antifungal treatment.

[Plasma relative abundance of epidermal growth factor receptor mutations predicts clinical response to epidermal growth factor receptor-tyrosine kinase inhibitors in patients with advanced lung adenocarcinoma].

Objective: To determine whether relative abundance of epidermal growth factor receptor (EGFR) mutations in plasma predicts clinical response to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in patients with advanced lung adenocarcinoma. Methods: In this prospective study, adult patients with advanced lung adenocarcinoma were enrolled in our hospital from 1 April 2016 to 1 January 2017. EGFR mutations in tumor tissues were detected by ADx-amplification refractory mutation system (ADx-ARMS). EGFR mutations of plasma free tumor DNA were detected by ADx-ARMS and ADx-super amplification refractory mutation system (ADx-SuperARMS) at the same time. Patients with EGFR-mutant in tumor tissues and receiving EGFR-TKIs were finally enrolled. Plasma mutation-positive patients with both methods were high abundance group.Patients with positive mutations by ADx-SuperARMS but negative by ADx-ARMS were medium abundance group. Mutation-negative patients with both methods were recognized as low abundance group. The correlation between EGFR mutation abundance and clinical response to EGFR-TKIs were analyzed. Results: Among 71 patients enrolled, 42 harbored EGFR mutations in plasma were detected by ADx-ARMS, while 53 were found by ADx-SuperARMS.There were 42 patients in high abundance group, 11 in medium group while the other 18 in low group. The objective response rates (ORRs) were 69.0%, 7/11 and 10/18 in high, medium and low groups, respectively. The difference was significant between high and low abundances groups (P=0.006). Median progression-free survival (PFS) in high, medium and low groups were 11.0, 8.5 and 9.0 monthes, respectively (P<0.001). In patients with tumor 19-Del, the ORRs were 70.4%, 5/7 and 6/11 in high, medium and low abundance groups, respectively. The median PFS of high abundance group was significantly longer than the other two groups (12.0 monthes vs 9.0, 9.0 monthes). As to subjects with L858R mutation, the ORRs were 10/15, 2/4 and 3/6, respectively, with median PFS 9.6, 5.5 and 9.5 monthes. Conclusions: The relative abundance of EGFR mutations in plasma predicts clinical response to EGFR-TKIs in patients with advanced lung adenocarcinoma. The higher the mutation abundance is, the better the efficacy of EGFR-TKIs is.

[Diagnostic performance of T-SPOT.TB on peripheral blood in combination with adenosine deaminase on pleural fluid for the diagnosis of tuberculous pleurisy within different age group].

Objective: To evaluate the performance of T cell enzyme-linked immuno-spot assay (T-SPOT) on peripheral blood in combination with adenosine deaminase (ADA) on pleural fluid for diagnosis of tuberculous (TB) pleurisy within different age groups. Methods: The data of patients with pleural effusion from the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University from April 2012 to November 2016 were retrospectively analyzed, and the diagnoses of these patients were histopathologically confirmed through medical thoracoscopy. The cases who had confirmed diagnosis, in the same time, received peripheral blood T-SPOT.TB were enrolled. The performance of peripheral blood T-SPOT.TB in combination with pleural fluid ADA on diagnosing TB pleurisy in the younger patients (16-59 years old) and elderly patients (≥60 years old) were analyzed respectively. The sensitivity, specificity and the receiver operating characteristic (ROC) curve were adopted for statistical analysis. Results: A total of 448 cases were finally enrolled, 341(76.1%) confirmed with TB pleurisy, 224 males, 117 females, (47±19) years old; and 107 (23.9%) classified as non-TB pleurisy, 65 males, 42 females, (61±14) years old. There were 285 cases who were classified as younger group, and the other 163 cases were classified as elderly group. The sensitivity and specificity of peripheral blood T-SPOT.TB were 85.4% (204/239) and 71.7% (33/46) in the younger patients, 76.5% (78/102) and 59.0% (36/61) respectively in the elderly patients. The sensitivity of peripheral blood T-SPOT.TB in the younger patients was significantly higher than that in the elderly patients (P=0.047). The sensitivity and specificity were 99.2% and 95.7% in combination with peripheral blood T-SPOT.TB and pleural fluid ADA respectively in the younger patients. The area under ROC curve (AUC) of T-SPOT.TB in the younger patients was 0.833, AUC of T-SPOT.TB combined with ADA was 0.911. The combination test of 2 tests had the sensitivity of 96.1% and the specificity of 90.2% respectively in the elderly patients. The AUC of T-SPOT.TB in the elderly patients was 0.747, AUC of T-SPOT.TB combined with ADA was 0.911. Conclusion: Peripheral blood T-SPOT.TB combined with pleural fluid ADA can improve the diagnostic performance for TB pleurisy with different ages, especially for elderly patients who can't tolerate pleural biopsy.

[The diagnostic performance of galactomannan detection for invasive pulmonary aspergillosis in non-neutropenic hosts].

Objective: To evaluate the diagnostic performance of galactomannan(GM)detection in serum and BALF for invasive pulmonary aspergillosis (IPA) in non-neutropenic hosts. Methods: A pospective study was performed for 1 356 non-neutropenic hosts admitted to the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University from September 2014 to October 2015. Serum GM test was performed for all, and BALF GM test for a proportion of the patients. The patients were divided into an IPA group and a non-IPA group. SPSS 20.0 was adopted for statistical analysis. Results: A total of 1 361 cases were enrolled, aging 18-96 years, with an average age of (64±15) years. There were 879 male and 477 female patients. Thirty-nine cases were diagnosed as IPA, accounting for 2.9%. For serum GM test, the sensitivity, specificity, PPV and NPV were 43.6%(17/39), 94.1%(1 239/1 317), 17.9%(17/95)and 98.3%(1 239/1 261)respectively. Ninety-six cases received serum and BALF GM tests at the same time. If the cut-off value of BALF GM test was 0.8, the sensitivity, specificity, PPV and NPV were 86.7%(13/15), 60.5%(49/81), 28.9%(13/45), 96.1%(49/51)respectively, but if the value was 1.0, the sensitivity, specificity, PPV and NPV were 86.7%(13/15), 74.1%(60/81), 38.2%(13/34), 96.8%(60/62)respectively. The ROC curve area of BALF GM, serum GM and the combined serum and BALF GM was 0.87, 0.75 and 0.90, respectively. Conclusions: The sensitivity of serum GM test in non-neutropenic hosts was low, but it had a high negative predictive value.The best BALF GM cut-off value was 1.0. The combined serum and BALF GM tests improved the diagnostic performance.

First Report of a Leaf Spot of Radermachera sinica in China Caused by Bacillus megaterium.

Radermachera sinica is widely planted as an ornamental plant in homes, offices, and malls in China. A leaf spot of R. sinica occurred in Luoyang, China, from 2013 to 2014. Lesions mostly occurred in wounds and were irregular with light brown centers and purple borders. One or more lesions on a leaf sometimes covered the entire blade. Eighty plants were surveyed in Luoyang, with disease incidence of 17%. Five millimeter pieces from the borders of lesions were surface-disinfected with 75% ethanol for 30 s, 1% sodium hypochlorite for 5 min, washed three times in sterilized distilled water, placed on nutrient agar (NA) medium at 25°C in darkness, and incubated for 24 to 48 h. Four white, round, smooth, and shiny colonies were selected for further identification. All strains were gram-positive, aerobic rods with many peritrichous flagella, and could grow in medium containing 5% NaCl. The strains were positive for catalase, starch hydrolysis, liquefaction of gelatin, reduction of nitrate, acid production from glucose, mannitol, maltose, lactose, xylose, and pectinose. The strains were positive for phenylalanine deaminase, decomposition of tyrosine, and utilization of citrate. The strains were identified by biochemical tests as Bacillus megaterium (1). To confirm pathogenicity, the strains were grown on NA for 48 h and suspended in sterile distilled water to produce a suspension with a final concentration of 108 CFU/ml. Healthy leaves of biennial R. sinica plants were sterilized with 75% ethanol and washed three times with sterilized distilled water. Fresh wounds were made with a sterile needle on the healthy leaves. Each of four strains was tested by spray inoculation with a bacterial suspension on three leaves. Sterile distilled water was used as negative control. Plants were enclosed in plastic bags and placed in a growth chamber at 28°C with 80% relative humidity. After 5 days, water-soaked lesions were observed. Two weeks later, lesions 4 mm in diameter turned light brown with purple borders, and most of lesions occurred in puncture wounds. Symptoms similar to those observed on field plants developed on all inoculated leaves, while no symptoms appeared on the control leaves. B. megaterium was re-isolated from the lesions of inoculated leaves, but not from the control leaves. To confirm the bacterial identification, PCR was performed on the 16S rDNA gene with P1/P2 (P1: CAGAGTTTGATCCTGGCT, P2: AGGAGGTGATCCAGCCGCA) (2) and 1,463 bp of the 16S rDNA gene (GenBank Accession No. KJ789369) showed 100% sequence identity to B. megaterium DSM 319 (NC_014103.1). To our knowledge, this is the first report of a leaf spot of R. sinica caused by B. megaterium in China as well as anywhere in the world. References: (1) P. Vos et al. Bergey's Manual of Systematic Bacteriology. Vol 3: The Firmicutes. Springer, 2009. (2) W. G. Weisbury et al. J. Bacteriol. 173:697, 1991.

First Report of a Chaetomella sp. Causing a Leaf Spot on Sansevieria trifasciata in China.

Sansevieria trifasciata originates from tropical West Africa. It is widely planted as a potted ornamental in China for improving indoor air quality (1). In February 2011, leaves of S. trifasciata plants in an ornamental market of Anle, Luoyang City, China, were observed with sunken brown lesions up to 20 mm in diameter, and with black pycnidia present in the lesions. One hundred potted plants were examined, with disease incidence at 20%. The symptomatic leaves affected the ornamental value of the plants. A section of leaf tissue from the periphery of two lesions from a plant was cut into 1 cm2 pieces, soaked in 70% ethanol for 30 s, sterilized with 0.1% HgCl2 for 2 min, then washed five times in sterilized distilled water. The pieces were incubated at 28°C on potato dextrose agar (PDA). Colonies of two isolates were brown with submerged hyphae, and aerial mycelium was rare. Abundant and scattered pycnidia were reniform, dark brown, and 200 to 350 × 100 to 250 µm. There were two types of setae on the pycnidia: 1) dark brown setae with inward curved tops, and 2) straight, brown setae. Conidia were hyaline, unicellular, cylindrical, and 3.75 to 6.25 × 1.25 to 2.50 µm. Morphological characteristics suggested the two fungal isolates were a Chaetomella sp. To confirm pathogenicity, six mature leaves of a potted S. trifasciata plant were wounded with a sterile pin after wiping each leaf surface with 70% ethanol and washing each leaf with sterilized distilled water three times. A 0.5 cm mycelial disk cut from the margin of a 5-day-old colony on a PDA plate was placed on each pin-wounded leaf, ensuring that the mycelium was in contact with the wound. Non-colonized PDA discs were placed on pin-wounded leaves as the control treatment. Each of two fungal isolates was inoculated on two leaves, and the control treatment was done similarly on two leaves. The inoculated plant was placed in a growth chamber at 28°C with 80% relative humidity. After 7 days, inoculated leaves produced brown lesions with black pycnidia, but no symptoms developed on the control leaves. A Chaetomella sp. was reisolated from the lesions of inoculated leaves, but not from the control leaves. An additional two potted plants were inoculated using the same methods as replications of the experiment, with identical results. To confirm the fungal identification, the internal transcribed spacer (ITS) region of rDNA of the two isolates was amplified using primers ITS1 and ITS4 (2) and sequenced. The sequences were identical (GenBank Accession No. KC515097) and exhibited 99% nucleotide identity to the ITS sequence of an isolate of Chaetomella sp. in GenBank (AJ301961). To our knowledge, this is the first report of a leaf spot of S. trifasciata caused by Chaetomella sp. in China as well as anywhere in the world. References: (1) X. Z. Guo et al. Subtropical Crops Commun. Zhejiang 27:9, 2005. (2) T. J. White et al. PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, CA, 1990.

Diffusion-weighted MR imaging: diagnosing atypical or malignant meningiomas and detecting tumor dedifferentiation.

BACKGROUND AND PURPOSE: Atypical and malignant meningiomas are uncommon tumors with aggressive behavior and higher mortality, morbidity, and recurrence compared with benign tumors. We investigated the utility of diffusion-weighted (DW) MR imaging to differentiate atypical/malignant from benign meningiomas and to detect histologic dedifferentiation to higher tumor grade. MATERIALS AND METHODS: We retrospectively compared conventional and DW MR images (b-value 1000 s/mm(2)) acquired on a 1.5T clinical scanner between 25 atypical/malignant and 23 benign meningiomas. The optimal cutoff for the absolute apparent diffusion coefficient (ADC) and normalized ADC (NADC) ratio to differentiate between the groups was determined by using receiver operating characteristic (ROC) analysis. RESULTS: Irregular tumor margins, peritumoral edema, and adjacent bone destruction occurred significantly more often in atypical/malignant than in benign meningiomas. The mean ADC of atypical/malignant meningiomas (0.66 +/- 0.13 x 10(-3) mm(2)/s) was significantly lower compared with benign meningiomas (0.88 +/- 0.08 x 10(-3) mm(2)/s; P < .0001). Mean NADC ratio in the atypical/malignant group (0.91 +/- 0.18) was also significantly lower than the benign group (1.28 +/- 0.11; P < .0001), without overlap between groups. ROC analysis showed that ADC and NADC thresholds of 0.80 x 10(-3) mm(2)/s and 0.99, respectively, had the best accuracy: at the NADC threshold of 0.99, the sensitivity and specificity were 96% and 100%, respectively. Two patients had isointense benign tumors on initial DW MR imaging, and these became hyperintense with the decrease in ADC and NADC below these thresholds when they progressed to atypical and malignant meningiomas on recurrence. CONCLUSIONS: ADC and NADC ratios in atypical/malignant meningiomas are significantly lower than in benign tumors. Decrease in ADC and NADC on follow-up imaging may suggest dedifferentiation to higher tumor grade.

Perioperative stroke after carotid endarterectomy. Etiological risk factors and management.

291 patients were subjected to carotid endarterectomy from January 1985 to June 1992 in two Australian medical institutions. Of the 291 patients, perioperative stroke occurred in 22 (6.3%) after 347 operations (moderate 17 and severe 5). The 22 patients were studied with Doppler scan, angiography, reexploration and CT. Reexploration showed that 12 of 14 patients had thrombosis in the internal carotid artery at operation. The etiological factors for perioperative strokes included thrombosis at the operative sites in 14 patients (64%), cerebral embolism after operation in 4, clamping ischemia in 2, intracerebral hemorrhage in 1 and unknown cause in 1. Six patients (27%) recovered completely in 4 weeks, 10 (45%) had mild residual neurological deficits, 5 (23%) had moderate neurological deficits and 1 died 3 days after operation. Only 6 patients had permanent neurological deficits (6/347, 17%).

[Treatment of middle stage arterial embolism through both Fogarty catheter embolectomy and directly pouring thrombolytic agents into artery].

We treated successfully 9 patients with middle stage arterial embolism through both Fogarty catheter embolectomy and directly pouring thrombolytic agents into artery. In all patients the extremities were salvaged and symptoms disappeared. The patients were operated upon 15, 30, 60 hours and 3, 5, 8, 30, 39, 40 days respectively after onset of the disease. The indications for this treatment are dependent on how many hours last between onset and treatment and whether the extremity is gangrened. The main embolus in the greater artery can be removed by Fogarty catheter, while the thrombosis in smaller artery can be resolved by directly arterial luminal pouring thrombolytic agents, so the result is better if the two methods are combined.

Surgical treatment of atherosclerotic infrarenal abdominal aortic aneurysms. A review of 30 years' experience.

During the 30 years from 1960 to 1989, 100 sequential patients with atherosclerotic infrarenal abdominal aortic aneurysm (AAA) were admitted to Zhongshan Hospital. Twenty-eight were not treated surgically and 72 underwent resection of the AAA with prosthesis replacement. Nineteen non-surgical patient were followed up, and 8 died from ruptures with a five-year survival rate of 41.3 +/- 13%. In 72 surgically treated patients, the operative mortality was 2.8%. The five-year survival rate is 77.5 +/- 6.2%, which is higher in comparison with the non-surgical group (P < 0.01). The data show that the operation for AAA is safe and the postoperative long-term results are satisfactory.

Role of aorto-angioplasty in hypertension caused by Takayasu's arteritis.

Sixteen patients with Takayasu's arteritis and a long-stenotic segment of the descending thoracic aorta and/or proximal and middle portion of the abdominal aorta, with or without renal artery stenosis, were treated by percutaneous transluminal aorto-angioplasty (PTAA). These patients might be subdivided into three groups: A. with normal renal artery, B. with severe renal artery stenosis or occlusion without treatment or with failure of dilatation, and C. with renal artery stenosis but relieved by percutaneous transluminal renal angioplasty (PTRA). It was found that the hypertension may be caused by the suprarenal aortic stenosis itself. PTAA has an excellent effect to normalize the blood pressure in Group A. The elevated blood pressure may also be decreased in various extent in the patient with severe renal artery stenosis after PTAA, but not to normal. An additional PTRA or other renal vesel reconstruction procedure is necessary in this group. No recurrence of the aorta stenosis was found by non-invasive examinations or aortography during the long-term follow-up. PTAA may be considered as the first choice for the aortic stenosis caused by Takayasu's arteritis.