OBJECTIVE To analyze the characteristics of severe cutaneous adverse reactions （SCARs） induced by oral anticoagulants （OACs）， and provide a reference for clinical safety of drug use. METHODS Case reports of SCARs caused by OACs （warfarin， apixaban， rivaroxaban， edoxaban， dabigatran etexilate） were retrieved from PubMed， Embase， CNKI， Wanfang Data， VIP and other databases with search terms as “oral anticoagulants”“factor Ⅹa inhibitor”“direct thrombin inhibitor” and their Chinese equivalents. A descriptive statistical analysis was performed. RESULTS A total of 11 articles were included， involving 11 patients in total， among whom there were 5 males （45.5%） and 6 females （54.5%）， with an average age of （59.6±21.5） years. The primary underlying diseases were mainly atrial fibrillation， pulmonary embolism， joint replacement and valve replacement. The OACs involved included warfarin in 3 cases， rivaroxaban in 4 cases， apixaban in 2 cases， and dabigatran etexilate in 2 cases. SCARs occurred from 10 hours to 42 days after treatment， and 7 cases （63.6%） within 10 to 28 days. Among 11 patients， 5 cases were diagnosed as drug reaction with eosinophilia and systemic symptoms， 4 cases were diagnosed as Stevens-Johnson syndrome or toxic epidermal necrolysis， and 2 cases were diagnosed as acute generalized exanthematous pustulosis. The clinical manifestations mainly included rash， fever and mucosal damage， etc. Except for 1 patient who died of sepsis and diffuse intravascular coagulation， the rest of the patients improved or recovered after withdrawal and treatment with glucocorticoids. CONCLUSIONS SCARs are rare but serious adverse reactions caused by OACs， typically occurring 10 to 28 days after medication. Once SCARs are suspected to be caused by OACs， the medication should be discontinued immediately， and a treatment plan should be formulated based on the type of SCARs to ensure the safety of patients’ drug use.

ObjectiveTo investigate the recurrence of ischemic stroke (IS) and to analyze the association between four indices of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) and the risk of IS recurrence by analyzing the follow-up data related to IS in the community-based natural population of Songjiang District, Shanghai, so as to provide a scientific basis for improving the prognosis of stroke patients in the community and controlling IS recurrence. MethodsA prospective follow-up study was conducted among the IS patients in the community-based cohort population, collecting data about patient’s age, gender, disease history, biochemical indicators, and etc. Cox regression model and restricted cubic spline model were used to analyze the relationship between different levels of plasma lipids and the recurrence of IS in these patients. ResultsA total of 1 368 patients with IS were included. The total follow-up duration was 7 171.46 person-years, with a median follow-up time of 6.24 years. There were 420 cases of IS recurrence, resulting in a cumulative recurrence rate of 30.70%. The results of multivariate Cox regression analysis showed that the recurrence risk of IS was reduced when the baseline TC and LDL-C levels of IS patients were in the ranges of 4.65‒5.67 mmol·L^-1 and 2.52‒3.46 mmol·L^-1, respectively. The results of restricted cubic spline analysis showed a U-shaped relationship between baseline TC and LDL-C levels and the recurrence risk in IS patients. ConclusionThe cumulative recurrence rate of patients with IS in the community of Songjiang District in Shanghai is high, and the levels of TC and LDL-C at baseline survey are correlated with the recurrence of IS in these patients. It is suggested to pay more attention to the levels of LDL-C and TC in patients with IS, so as to improve the prognosis.

Objective To compare the value of transvaginal ultrasound, 3.0T magnetic resonance imaging (MRI) scanning alone and in combination for diagnosis of ectopic pregnancy, so as to provide insights into early screening of ectopic pregnancy. Methods This study enrolled a total of 130 patients with suspected ectopic pregnancy admitted to Dachuan People’s Hospital in Dazhou City, Sichuan Province, China between February 2019 and December 2022. All patients underwent transvaginal ultrasound examination and 3.0T MRI scanning. The consistency of transvaginal ultrasound and 3.0T MRI with clinical diagnostic results was evaluated with surgical pathology or clinical follow-up results as the golden standards. The sensitivity, specificity, and accuracy of transvaginal ultrasound and 3.0T MRI, alone and in combination, were compared for diagnosis of ectopic pregnancy. Results Of the 130 patients with suspected ectopic pregnancy, 108 cases were confirmed with ectopic pregnancy by surgical pathology, and 22 cases were confirmed without ectopic pregnancy by clinical follow-up. The sensitivity, specificity, and accuracy of transvaginal ultrasound were 85.19% (92/108), 54.55% (12/22), and 80.00% (104/130), respectively, with 0.358 consistency with clinical diagnostic results. The sensitivity, specificity, and accuracy of 3.0T MRI were 92.59% (100/108), 81.81% (18/22), and 90.77% (118/130), respectively, with 0.694 consistency with clinical diagnostic results. The sensitivity, specificity, and accuracy of transvaginal ultrasound combined with 3.0T MRI were 98.15% (106/108), 72.73% (16/22), and 93.85% (122/130), respectively, with 0.764 consistency with clinical diagnostic results. In addition, the sensitivity and accuracy of transvaginal ultrasound combined with 3.0T MRI were significantly higher than transvaginal ultrasound alone for diagnosis of ectopic pregnancy (χ² = 11.88 and 10.96, both P < 0.01). Conclusion Transvaginal ultrasound combined with 3.0T MRI may provide more diagnostic information for ectopic pregnancy, and is highly consistent with the clinical diagnostic results. In addition, transvaginal ultrasound combined with 3.0T MRI improves the diagnostic sensitivity and accuracy for ectopic pregnancy than transvaginal ultrasound alone.

Objective To investigate the characteristics of clopidogrel-associated thrombocytopenia to provide references for clinically safe drug use.Methods The case reports of thrombocytopenia induced by clopidogrel published in PubMed,Embase,CNKI,Wanfang and VIP were searched from the establishment of each database to November 2022,and their occurrence was collated and analysed.Results A total of 44 cases from 43 articles were identified and included in the analysis.There were 30 males(68.2％)and 14 females(31.8％).Ages ranged from 37 to 88(65.0±11.4)years,of which 30(68.2％)were ≥60 years old.Thrombocytopenia was found from 8 h to 9 months after medication,of which 29 cases(65.9％)appeared within two weeks.There were 31 cases(70.5％)with severe thrombocytopenia and 38 cases(86.4％)with complications,of which 24 cases(63.2％)with bleeding and 19 cases(50.0％)with thrombotic thrombocytopenic purpura(TTP).The platelet countof41 cases(93.2％)returned to normal after drug withdrawal and symptomatic treatment,and 3 cases(6.8％)died finally.Conclusion Clopidogrel related thrombocytopenia is mainly severe thrombocytopenia,and often accompanied by bleeding or thrombotic thrombocytopenic purpura(TTP),but the overall outcome is good.Platelet count should be regularly monitored within the first two weeks after medication.Clopidogrel should be stopped and symptomatic treatment should be given in case of any abnormality.

Ankylosing spondylitis (AS) combined with lower cervical fracture is often categorized into unstable fracture, with a high incidence of neurological injury and a high rate of disability and morbidity. As factors such as shoulder occlusion may affect the accuracy of X-ray imaging diagnosis, it is often easily misdiagnosed at the primary diagnosis. Non-operative treatment has complications such as bone nonunion and the possibility of secondary neurological damage, while the timing, access and choice of surgical treatment are still controversial. Currently, there are no clinical practice guidelines for the treatment of AS combined with lower cervical fracture with or without dislocation. To this end, the Spinal Trauma Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate Clinical guidelines for the treatment of ankylosing spondylitis combined with lower cervical fracture in adults ( version 2024) in accordance with the principles of evidence-based medicine, scientificity and practicality, in which 11 recommendations were put forward in terms of the diagnosis, imaging evaluation, typing and treatment, etc, to provide guidance for the diagnosis and treatment of AS combined with lower cervical fracture.

Objective:To explore the incidence of chronic obstructive pulmonary disease (COPD) in a cohort aged 40 years and above in Songjiang District, Shanghai, and to analyze the association of Mediterranean diet pattern and dietary approaches in stopping hypertension pattern (DASH) with the risk of developing COPD.Methods:Based on a natural population cohort in Songjiang District, Shanghai, 27 474 adults aged 40 years and above who did not have COPD at baseline were enrolled in the study. The Cox proportional risk regression model was used to analyze the association of baseline Mediterranean diet pattern score and DASH score with the risk of COPD, and the hazard ratio ( HR) of the risk and its 95% CI were calculated. Restricted cubic spline was used to analyze the nonlinear association between the two diet scores and the risk of COPD. Stratified analyses were performed according to gender, age, smoking status, etcetera. Sensitivity analyses were conducted by censoring cases diagnosed within one year after the baseline survey or people with a history of malignant tumor disease. Results:As of June 30, 2023, after a median follow-up time of 6.21 years, there were 1 089 (4.0%) new COPD cases with an incidence density of 64.00 per 10 000 person-years. After adjusting for relevant confounders, in the Mediterranean tertile subgroups under diet pattern score, the risk of developing COPD could be reduced by approximately 14% in the intermediate scoring group ( HR=0.86, 95% CI: 0.75-0.99) and 15% in the highest scoring group ( HR=0.85, 95% CI: 0.72-0.99) compared to the lowest scoring group. The association remained after censoring cases diagnosed within one year of the baseline survey ( HR=0.82, 95% CI: 0.70-0.95; HR=0.82, 95% CI: 0.68-0.97) or censoring people with a history of malignant tumor disease ( HR=0.84, 95% CI: 0.73-0.97; HR=0.84, 95% CI: 0.71-0.99). No statistical association was found between the DASH score and the risk of COPD. Conclusions:The Mediterranean diet pattern was associated with a lower risk of COPD. Increasing the intake of vegetables, fruits, legumes, and whole grains and decreasing the intake of red meat and others can reduce the risk of COPD. No association was found between the DASH dietary pattern and the risk of COPD in this community population.

Objective:To investigate the clinicopathological features, molecular genetic features, and differential diagnosis of intraductal carcinomas (IDC) of the salivary glands.Methods:Twenty-five cases of salivary gland IDC diagnosed at the Department of Oral Pathology, Shanghai Ninth People′s Hospital and two cases from Department of Pathology, Henan Provincial People′s Hospital, Zhengzhou, China from January 2008 to July 2023 were collected. Their clinical and pathological features were analyzed retrospectively. Fluorescence in situ hybridization and Sanger sequencing were performed. The patients were followed up and related literatures were reviewed.Results:There were 27 patients with IDC, including 15 males and 12 females, ranging in age from 20.0 to 80.0 years (mean 55.9 years). Clinically, the tumor often presented as a painless mass with a tumor diameter of 1.0-3.0 cm (mean 2.0 cm). All patients received surgical treatment. Twenty patients were followed up. One of them (1/20) died of lung cancer, while the rest survived without tumor recurrence. Histologically, IDC were classified as: intercalated (63.0%, 17/27), apocrine (25.9%, 7/27), oncocytic (7.4%, 2/27) and mixed (3.7%, 1/27) types. Intercalated tumors showed positive S-100 and negative androgen receptor (AR) immunoreactivity. Ki-67 proliferation index was low (about 1%-5%). Nine cases had the RET gene disruption, and 2 cases showed the BRAF V600E mutation. Apocrine tumors showed strong AR immunoreactivity but no S-100 immunoreactivity. Ki-67 proliferation index was high (about 10%-60%), and the RET gene rupture was detected in 1 case. Oncocytic tumors were similar to that of intercalated type in 2 cases, and RET gene disruption was detected in the both cases. Mixed tumors showed histologic features of oncocytic and apocrine patterns and harbored the RET gene disruption.Conclusions:IDC is a rare low-grade malignant tumor of the salivary gland and easily confused with other salivary gland tumors with similar morphology. Molecular testing is helpful for its differential diagnosis.

Objective:To investigate the efficacy of radiofrequency ablation combined with ozone therapy under CT guidance in the treatment of lumbar disc herniation.Methods:A total of 93 patients with lumbar disc herniation who were admitted to The First Hospital of Jiaxing from January 2019 to May 2022 were included in this study. They were randomly divided into an observation group ( n = 47) and a control group ( n = 46). The control group was treated with radiofrequency ablation and the observation group was treated with radiofrequency ablation combined with ozone therapy. Efficacy was compared between the two groups at 3 months after surgery. The pain was compared between the two groups before and 7 days and 3 months after surgery. Inflammatory factors were compared between the two groups before and 7 days after surgery. The lumbar spine function was compared between the two groups before and 3 months after surgery. Results:At 3 months after surgery, the excellent and good rate in the observation group was significantly higher than that in the control group [89.36% (42/47) vs. 71.74% (33/47), χ2 = 4.63, P < 0.05). At 7 days and 3 months after surgery, Visual Analogue Scale scores in the observation group were (2.91 ± 0.54) points and (1.32 ± 0.31) points, respectively, which were significantly lower than (3.76 ± 0.62) points and (2.08 ± 0.47) points in the control group ( t = 7.06, 9.22, both P < 0.001). At 7 days after surgery, serum interleukin-1β, interleukin-6, and tumor necrosis factor-α in the observation group were (0.24 ± 0.05) μg/L, (18.49 ± 3.47) ng/L, and (97.94 ± 17.43) ng/L, respectively, which were significantly lower than (0.37 ± 0.09) μg/L, (24.31 ± 4.12) ng/L, and (148.87 ± 20.13) ng/L, respectively in the control group ( t = 8.63, 7.37, 13.05, all P < 0.05). At 3 months after surgery, the Japanese Orthopedic Association score in the observation group was significantly higher than that in the control group [(25.68 ± 2.28) points vs. (21.17 ± 3.24) points, t = -7.78, P < 0.001], and the Oswestry Disability Index in the observation group was significantly lower than that in the control group [(9.84 ± 1.43) points vs. (13.46 ± 2.18) points, t = 9.49, P < 0.001]. Conclusion:Radiofrequency ablation combined with ozone therapy under CT guidance is highly effective on lumbar disc herniation. The combined therapy can reduce pain and inflammatory reactions in patients and improve lumbar function.

Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.

The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.