China recently instituted a two-child policy in response to its aging population,declining workforce and demographic dividend,and the need to develop asocial economy.Additionally,women generally delay having a second child because of the overwhelming pressure in their lives.With the improvements in assisted fertility technologies in recent years,the number of elderly women attempting to bear children has increased.The quality of woman's eggs and a man's sperm declined dramatically with increasing age,leading to an increased risk of pregnancy-related complications among older women.Therefore,the types of fertility problems experienced by elderly females must be provided with considerable attention by obstetricians.This commentary article focuses on the medical problems faced by older second-child pregnant women.This work discusses their increased rates of infertility,spontaneous abortion,fetal malformation,gestational diabetes,cesarean section,placenta previa,postpartum hemorrhage,postpartum depression,and hypertensive disorders,which complicate pregnancy.

BACKGROUND:Obsolete lateral ankle ligament injury is frequently treated by Chrisman-Snook operation.However,this operation destructs some peroneus brevis tendon,and affects the function of peroneus brevis tendon for foot valgus.OBJECTIVE:Based on previous research,to investigate the effect of allogeneic tendon for reconstruction of ankle lateral ligaments.METHODS:A total of 17 cases of ankle lateral ligament injured were selected,with a course of disease from 3 to 6 months.All lateral ligaments were reconstructed by allogeneic tendon & anchors.During the operation,a drill,4.5 rnm diameter,was used to drill a hole on the lateral ankle;one anchor was drilled into the talus at the end of anterior talofibular ligament,another one was threaded on the calcaneus;the allogeneic tendon was permeated through the hole on the lateral ankle,maintaining ankle neutral and moderate valgus position.The allogeneic tendon was sutured with the thread of the anchors.Following operation,the ankle was fixed in neutral position and slightly valgus position;wound healing,AOFAS score and stress radiograph were observed.RESULTS AND CONCLUSION:All 17 patients showed no rejection,and the wound healing well at the primary stage.At 6,12,24 after operation,all patients were followed-up.According to AOFAS criteria,function of ankle in all patients was significantly improved.No patients complained of instability of the ankle,end stress radiograph confirmed this improvement.Reconstruction of lateral ligaments of the ankle with allogeneic tendon and anchors is a practical treatment,which restores stability and function of ankle without long incision or damaging normal tendons.

Objective To observe the hemostatic efficacy and safety of argon plasma coagulation (APC) through bron?choscope after biopsy. Methods The APC was given to patients suffered from coronary heart disease combined hyperten?sion or paroxysmal auricular fibrillation and accepted bronchoscopy biopsy with much bleeding. The hemostatic effect and changes of heart rate, blood pressure and SPO2 were observed before and after treatment. Results Sixty-two patients were treated with endoscopic hemostasis by APC. The hemostasis was successful in 60 cases. The hemostasis was performed with APC successfully in 2 patients after intubation and mechanical ventilation because of the biopsy hemorrhage. Sixty-two cas?es included 42 cases of airway tumor (26 cases in lobe bronchus and 16 in segmental bronchus), 16 cases of broadening of the trachea ridge and mucosal rough, and 4 cases of granulation tissue of lobe bronchus. There were no significant differenc?es in mean arterial pressure and heart rate before and after treatment in 60 patients (P>0.05). The oxygen saturation was sig?nificantly lower after treatment than that before treatment (0.939±0.027 vs. 0.956±0.017, P<0.05). Conclusion Hemosta?sis treatment by APC through bronchoscope has the characteristics of rapid, thorough and safe, especially for patients com?bined with cardiovascular disease. It can avoid the occurrence of cardiovascular system complications caused by convention?al hemostatic treatment.

Objective To analyze the influence of mode of delivery on post-neonatal gut microbiota using polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) technology.Methods From April to August in 2013,thirty healthy urban full-term neonates in Nanjing City were enrolled in the study,including fifteen exclusive breastfed ones (seven born of caesarean section and eight born vaginally) and fifteen mixed feeding ones (eight born of cesarean section and seven born vaginally).Stool specimens were collected on the 28th day after birth and bacterial genomic DNA was extracted and examined by PCR on 16S rDNA V3 variable region.Bacterial community profiles were obtained by DGGE.Diversity and similarity differences of the gut microbial community structures were analyzed.Two independent sample t test or Chi-square tests were used for stastistical analysis.Results (1)Diversity analysis showed that among exclusive breastfeeding infants,the Strip number and Shannon-Weaver Diversity Index of gut microbiota in infants born abdominally were significantly lower than those born vaginally [9.71 ±4.27 vs 15.12±4.19,2.13±0.39 vs 2.61±0.32,both P＜0.05],but the Simpson index of gut microbiota was significantly higher [0.13 ± 0.04 vs 0.08± 0.03,P＜0.05],and no significant difference was shown in Pielou Index (P＞0.05).In the mixed feeding group,the Strip number and Shannon-Weaver Diversity Index of gut microbiota in infants born abdominally were significantly lower than those born vaginally [10.88±3.23 vs 16.29±5.38,2.26±0.37 vs 2.66±0.31,both P＜0.05],the Simpson index was higher,but together with the Pielou Index,neither showed significant difference (both P＞0.05).(2) Similarity analysis found that gut microbiota from neonates born of same mode of delivery mostly gathered together and had much more similar structures.Conclusions In the post-neonatal period,the species and numbers of gut microbiota in infants born abdominally are all behind of those born vaginally.The predominant microbiota in babies born of cesarean section are more prominent,and gut microbiota in vaginal delivered babies are more uniformly distributed.

Purpose To study the clinicopathological features of lymphangiomyomatosis (LAM) of pelvis lymph node.Methods A patient with endometrial endometrioid adenocarcinoma and LAM was analyzed including clinical data and pathological features.HE and immunohistoehemistry of EnVision stainings were used,and the literatures were reviewed.Results Well-moderately differentiated endometrioid adenocarcinoma could be observed in the endometrium.Proloferation of LAM cells were seen in the capsule and medulla of the pelvic lymph node.The LAM cell was spindle,epitheliod and polygonal cells with oxyphilic or clear cytoplasm which arranged surrounding lacunes.The LAM cells showed no atypia and mitosis could not seen.The tumor cells showed diffusely positive for SMA,Caldesmon,desmin,vimentin,ER and PR,the cells lining the lacunes were positive for CD34 and D2-40.The epitheliod cells were positive for HMB-45 and negative for Melan-A.The Ki-67 immunostaining showed a proliferation index of ＜ 1％.Conclusion LAM is an uncommon neoplastic multisystem disease that affects the lungs mostly.Endometrial endometrioid adenocarcinoma with LAM of pelvic lymph node is extremely rare.The diagnosis can be made according to the histological characteristics and immunohistochemical features.Moreover this conclusion will provide the clinicopathological materials for the future study about LAM.

Objective To investigate the expressions of DKK1,SFRP4 and Wnt1 in cervical squamous cell carcino-ma(SCC), and the clinical significance thereof. Methods There were 76 samples of cervical squamous cell carcinoma were included in SCC group and 36 benign uterine resection specimens were control group (NC). The immunohistochemical meth-od was applied to detect the expressions of DKK1,SFRP4 and Wnt1 in two groups. Results The expression of DKK1 was significantly lower in SCC group than that in NC group (P＜0.05). The expression levels of SFRP4 and Wnt1 were significant-ly higher in SCC group than those of NC group (P＜0.05). There were significant differences in the expressions of DKK1, SFRP4 and Wnt1 between samples of different clinical staging, differentiation, sizes of tumor and lymph node metastasis (P＜0.05). The expression of DKK1 was negatively correlated with SFRP4 and Wnt1 in SCC group (P＜0.05). The expression of SFRP4 was positively correlated with Wnt1 in SCC group (P＜0.05). Conclusion The roles of SFRP4 and Wnt1 are syn-ergistic interactions in the development of SCC. DKK1 is an inhibiting factor of SCC.

Objective:To investigate the main clinical features of critically ill patients with influenza A (H1N1) influenza virus pneumonia, and the relationship between airway secretions and cardiopulmonary pathology change with continuous hypoxemia. Methods: The retrospective analysis was made in critically ill patients with H1N1 influenza virus pneumonia admitted to a respiratory intensive care unit(RICU). Twenty-four patients were all administrated antiviral drugs (oseltamivir 75/150 mg Bid). Twenty of them were subjected to application of hormonal therapy, and 6 of them with mechanical ventilation. Results: The average age of 24 patients was (48.25±19.73) years old. Fifteen of them were pregnant women, obesity and who suffered from chronic underlying diseases. The main symptoms of them were progressive shortness of breath, cough and myalgia. It was found by X-ray that 22 patients(91.67%) had multiple lung consolidation shadow. After admission, airway secretions were collected, and the protein concentration of which was 34.1-37.7 g/L in 5 cases. The concentration of l-lactate dehydrogenase(LDH) was 792-1 890 U/L. White blood cell count was (0.722-1.470)×10~9/L, included 0.21-0.44 neutrophils, 0.111-0.560 mononuclear cells, 0.027-0.110 eosinophils, 0.018-0.054 basophils. Pathological changes of these patients were hyaline membrane formation, alveolar cavity collapse, myocardial cell degeneration and focal myocardial necrosis. Intubation and mechanical ventilation were performed in 6 cases, 5 of them dead and the mortality rate was 20.83%. Conclusion: The lung pathological damages were increased LDH and protein in airway secretions, and increased count of inflammatory cells. Effect of mechanical ventilation was not satisfied in part of patients who had diffuse lung consolidation in X-ray, and the related complications leaded to exacerbation or death in part of them.

Objective To study the predictive value of evaluation in oxygen partial pressure[p(O2)] and carbon dioxide partial pressure[p(CO2)] of pleural cavity to the closure of visceral pleura in primary spontaneous pneumothroax (PSP) pa-tients. Methods Seventy-six hospitalized pneumothroax patients were divided into two groups:closed pneumothroax group (n=40) and open pneumothroax group (n=36), according to the radiographic information.To collect the expiratory gas by the device which we designed and produced, to collect the gas in the pleural cavity by thoracentesis. To detect the p(O2)and p(CO2)respectively, and the blood gas analysis of radial artery was done at same time. Results There was significantly low-er value of p(O2)of the gas in the pleural cavity in patients of closed pneumothroax than that of open pneumothroax (P <0.05). The level of p(CO2)was higher in patients of closed pneumothroax than that of open pneumothroax ( P<0.05). There were no significant differences in values of p(O2)and p(CO2)in expiratory gas and the blood gas analysis between two groups (P>0.05). There was significantly higher value of the expiratory gas/the pleural cavity gas p(O2) and a significantly lower value of p(CO2), in closed pneumothroax group than those of open pneumothroax group (P<0.05). Logistic regression analy-sis showed that values of the expiratory gas/the pleural cavity gas p(O2) and p(CO2) were the effective factors for the closure of visceral pleura. ROC curve showed that the areas under ROC curve (AUC) for the expiratory gas/the pleural cavity gas p(O2) and p(CO2) was 0.985 and 0.867, the sensitivities were 92.5% and 77.8%, the specificities were 100%and 85.0%and the reference values were 1.81 and 0.97. Conclusion To utilize the evaluation of gas partial pressure can predict whether the leakage of the visceral pleura is closed.

Objective To evaluate the positive rate, reliability and safety of thoracoscope pleural brushing for diagnosing malignant pleural effusion. Methods Seventy patients with unexplained pleural effusion were performed with medical thoracoscopy:(1) Observe the visceral and parietal pleura then use disposable cell brush to obtain specimens from suspect areas and take cytological examination. (2) Observe the parietal pleura then use biopsy forceps to forceps specimens from suspect areas and take histological examination. (3) Compare the positive rate of diagnosis, coincidence rate of pathological type and complication between two methods individual and combination in diagnosis. Results In 51 patients diagnosed as malignant pleural effusion, the diagnosis-positive rate of biopsy was 88.24%(45/51) and the diagnosis-positive rate of pleural brushing cytology was 90.20%(46/51). The diagnosis-positive rate of pleural brushing combined with biopsy was 96.08%(49/51), but there was no significant difference in diagnosis-positive rate between two methods individual and combination for malignant pleural effusion (P>0.05). In 51 patients, pathological type determination rate was 76.47%(39/51) evaluated by pleural brushing, 88.24% (45/51) by biopsy, and there was no significant difference in pathological type determination rate between two methods (P>0.05). Biopsy was performed for 168 times, more bleeding was found in 5 cases (2.98%), feeling pain in 134 cases (79.76%). Pleural brushing examination was performed for 198 times, no significant bleeding and pain were found. Conclusion Medical thoracoscopic pleural brushing under direct vision is a safe and reliable method, which can be use as an effective diagnostic method for malignant pleural effusion.

Objective Little research has been done on the risk factor analysis of BK virus(BKV) infection in renal transplant recipients in Chinese population.The article aimed to investigate BKV infection and analyze its risk factors in renal transplant recipients in China.Methods Renal transplant recipients who had received the detection of BKV DNA in urine and blood samples in Nanjing General Hospital from June 2015 to July 2016 were selected, while the patients with uremia hemodialysis and healthy living donors were included as control group.According to the detection results of BKV DNA in urine and blood samples, renal transplant recipients were divided into BKV DNA positive group(n=89, positive urine or blood and urine BKV DNA) and BKV DNA negative group(n=359, negative blood and urine BKV DNA).Analysis was made on BKV infection in renal transplant recipients in order to investigate the effects of factors including clinical condition, postoperative complications and immunosuppressive regimen on BKV infection.Results The positive rate of BKV DNA in urine samples of renal transplant recipients was 19.9%, which was higher than those of patients with dialysis and healthy living donors(6.3% and 4.2% respectively, P<0.001).Multivariate logistic regression analysis showed BKV infection was associated with pulmonary infection(OR[95%CI], 3.468[1.227-9.802];P=0.019) , acute rejection (OR[95%CI], 2.645[1.142-6.127];P=0.023), and FK506 (OR[95%CI], 2.408[1.104-5.254];P=0.027).Conclusion The incidence of BKV infection in renal transplant recipients increases significantly.Pulmonary infection, acute rejection and FK506-based immunosuppressive regimen are risk factors leading to BKV infection.