2014年 · 第127卷第07期

Abstract：Background Community-acquired pneumonia (CAP) is a common infectious disease throughout the world and the incidence continues to grow as the population ages.Aspiration is an important pathogenic mechanism for pneumonia in the elderly and the management of patients with community-acquired pneumonia with aspiration factors is a major medical problem.Our study aimed to assess whether moxifloxacin in comparison to levofloxacin plus metronidazole are effective and safe in the treatment of community-acquired pneumonia with aspiration factors.Methods In this prospective,multicenter,open-label,randomized controlled trial,77 patients with mild-to-moderate community-acquired pneumonia with aspiration factors were enrolled and randomly assigned to receive moxifloxacin or levofloxacin plus metronidazole.The primary efficacy variables were clinical outcomes in evaluable patients at a follow-up visit 7 to 14 days after the end of therapy.Results Seven days after the end of therapy a clinical cure was achieved for 76.7％ (23 of 37) of efficacy-evaluable patients in the moxifloxacin group and 51.7％ (15 of 40) of patients in the levofloxacin plus metronidazole group.There was a significant difference between the two groups (x2=4.002,P ＜0.05).Bacteriological success rates were similar in the moxifloxacin group (93.3％) and levofloxacin plus metronidazole group (96.4％),there was no significant difference between the two groups (P ＞0.05).The overall adverse event rate was 10.8％ (4/37) in the moxifloxacin group versus 17.5％ (7/40) in the levofloxacin plus metronidazole group,there was no significant difference between the two groups (P＞0.05).No serious adverse events were observed.Conclusions Moxifloxacin is effective and safe for treatment of community-acquired pneumonia with aspiration factors.And the regimen of moxifloxacin monotherapy is more convenient compared with levofloxacin plus metronidazole。

Abstract：Background The MAPK phosphatases (MKPs) are a family of dual-specificity phosphatases (DUSPs) that can dephosphorylate both phosphothreonine and phosphotyrosine residues,thus inactivating MAPK signaling.DUSP6 is a cytoplasmic MKP that can inactivate ERK.DUSP6 has been implicated in the development of some tumors.The aim of this research was to investigate the expression of DUSP6 in hepatocellular carcinoma (HCC) and the correlation of DUSP6 with mitogen-activated protein kinases (MAPKs),clinicopathological characteristics,and prognosis.Methods Tissues from 305 patients who had undergone hepatectomy for HCC was used in this study.The expression of DUSP6,p-ERK,p-JNK,and p-p38a was determined using tissue microarrays for immunohistochemical analysis.The prognostic value of DUSP6 and other clinicopathological factors were evaluated.Results The expression of DUSP6 was significantly higher in the tumor tissue when compared to the peritumor or normal liver tissue (P ＜0.001).Tumor DUSP6 expression was significantly associated with disease-free survival (DFS) (P=0.013).Tumor DUSP6 expression was an independent prognostic factor for DFS (Hazard ratio =1.635,P=0.006).Conclusions DUSP6 is over expressed in tumor tissue compared to peritumor or normal liver tissue.Higher expression of DUSP6 in tumor tissue,than in peritumor tissue,is associated with the recurrence after curative resection of HCC,and the relative tumor DUSP6 expression has good power to predict the recurrence of HCC。

Abstract：Background Totally laparoscopic aortoiliac surgery has been newly developed in China.It is known as the most complex laparoscopic technique to learn because of its high-risk procedures.Analysis of the operation-related complications of this surgery is supposed to be helpful for the early success of this technique.Methods Twelve male patients (56-70 years old) with aortoiliac occlusive disease underwent totally laparoscopic aortoiliac bypass surgery (TLABS) in our institute.Clinical data and operation-related complications were retrospectively analyzed.Results Of the 12 patients,TLABS succeeded in nine and conversion to open surgery occurred in three.One of the converted patients finally died of pulmonary infection.Operation-related complications included bleeding from arterial injury,perforation from colonic injury,graft embolism,residual aortic stenosis,and hydronephrosis.Bleeding in two patients and colonic perforation in one patient resulted in three conversions to open surgery.Intraoperative graft embolectomy and postoperative aortic stenting were performed to resolve the thrombus/embolus-referring complications.Left hydronephrosis,which was thought to result from intraoperative injury and treated with ureteric intubation drainage,recovered 6 months after TLABS.Conclusions Good understanding and avoidance of operation-related complications are important to guarantee the technical success of TLABS.Immediate conversion to open surgery is necessary for saving the patient's life in case of lifethreatening complications。

Abstract：Background Transradial approach catheterization is now widely used in coronary angiography and angioplasty.The ulnar artery,which is one of the two terminal branches of the brachial artery,may be a potential approach for cardiac catheterization.The aim of this study was to evaluate the safety and feasibility of a transulnar approach for coronary catheterization in non-selective patients.Methods A total of 535 consecutive patients were randomly assigned to transulnar approach (TUA) group (n=271) or transradial approach (TRA) group (n=264) upon arrival at the catheterization laboratory.Allen's test and inverse Allen's test were not routinely performed.Ultrasound-Doppler assessment of the forearm artery was performed before the procedure,two days after the procedure,and 30 days after the procedure.The primary endpoints of study were the rate of successful artery cannulation and the access-site related complications.The secondary endpoints included the number of needle punctures,total time for the procedure,and major adverse cardiac events (MACE).Results Successful puncture of the objective artery was obtained in 91.5％ of the patients in the TUA group,and 95.1％ of the patients in the TRA group (P ＞0.05).There was no significant difference in hematoma complications between the two groups (7.7％ vs.4.2％,P=0.100).A motor abnormality of the hand was observed in one patient in the TUA group.There were no arteriovenous fistula or pseudoaneurysm observed in our study.Three (1.1％) patients in the TUA group and 8 (3.0％) patients in the TRA group had occlusion of the access artery (P=0.137),but none of the patients had symptoms or signs of hand ischemia.There were no significant differences in MACE between the two groups during follow-up.Conclusion The transulnar approach is an effective and safe technique for coronary catheterization in non-selective patients。

Abstract：Background Low back pain (LBP) is a common clinical problem.Many researchers have demonstrated that LBP disorders have difference in sensory strategies for postural control.Optokinetic stimulation (OKS) of optic flow has been widely applied to study its effect on vision,but has not been applied to LBP.Here we used OKS on different surfaces to investigate the characteristics of chronic nonspecific LBP (CNLBP) posture control,so as to provide new theoretical and experimental data for further recognizing CNLBP and enriching its treatment.Methods Fifteen individuals with CNLBP (age range 25-40 years) and 15 age and gender-matched control subjects were recruited.Each subject,while standing on a stable or soft surface,was exposed to random-dot patterns projected on a large screen,with the dots displaying expansion (+) and contraction (-) and velocities including 80°,40°,and 20° per second.The visual stimulus used a "stimuli-interval" pattern.The peak velocity,different phases' standard deviation (SD) of the anterior-posterior centre of pressure (COP) displacements and the total length of the medial-lateral COP sway (LML) for stable surface and soft surface were recorded by force platform.Results The main effect of surface on all parameters was significant,while the main effect of group and OKS showed no significance with the exception of peak velocity (F(3,95)=3.6,P=0.01) and A2 (F(5,140)=9.34,P ＜0.01) for which the effect of OKS was significant.The interactions of group by OKS of A2 (F(5,140)=3.65,P ＜0.01) and group by surface by OKS (F(5,140)=2.83,P=-0.02),and surface by OKS of A1 and A3 (P ＜0.05) were significant.It was reported that significantly more SD in amplitude in the T2 phase was seen in persons with CNLBP when confronting the + 40 stimuli on the soft surface (P ＜0.05) compared to healthy individuals.Conclusions There was no significance between persons with CNLBP and healthy people when using the stable surface.Subjects with LBP showed decreased efficiency of postural adjustment when exposed to more complicated tasks and environments,especially OKS in the expansion direction,and displayed a visual-dependent phenomenon.This result suggested that the treatment of abnormal motor patterns in people with LBP should take the properties of task and environment into account。

Abstract：Background Autoimmune hemolytic anemia (AIHA) is an uncommon complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) which has only been reported in a few cases.We here aimed to explore its mechanism.Methods We retrospectively analyzed 296 patients who underwent allo-HSCT in our center from July 2010 to July 2012.Clinical manifestations were carefully reviewed and the response to currently available treatment approaches were evaluated.The survival and risk factors of AIHA patients after allo-HSCT were further analyzed.Results Twelve patients were diagnosed with AIHA at a median time of 100 days (15-720 days) after allo-HSCT.The incidence of AIHA after allo-HSCT was 4.1％.IgG antibody were detected in ten patients and IgM antibody in two patients.The two cold antibody AIHA patients had a better response to steroid corticoid only treatment and the ten warm antibody AIHA patients responded to corticosteroid treatment and adjustment of immunosuppressant therapy.Rituximab was shown to be effective for AIHA patients who failed conventional therapy.Survival analysis showed that the combination of AIHA in allo-HSCT patients hinted at poor survival.Cytomegalovirus (CMV) infection,graft-versus-host disease (GVHD) and histocompatibility leukocyte antigen (HLA) mismatch seemed to increase the risk of developing AIHA.Conclusions Patients who develop AIHA after allo-HSCT have poor survival compared to non-AIHA patients.Possible risk factors of AIHA are CMV infection,GVHD,and HLA mismatch.Rituximab is likely to be the effective treatment choice for the refractory patients。

Abstract：Background Sporadic fundic gland polyps (FGPs) are common gastric polyps.Some studies reported that FGPs dramatically increased due to proton pump inhibitors (PPIs) use and a decreased prevalence of Helicobacter pylori (H.pylon) infection in Western countries.However,data are still controversial.This study aimed to identify the relationships between these two factors and FGPs in China.Methods Consecutive patients with FGPs detected were retrospectively analyzed.Data including patients' age,sex,symptoms,H.pylori infection,history of PPIs use,and the polyps were documented.Each patient was compared with two randomly selected age-and sex-matched controls with similar symptoms in the same period.Results During the period from March 2011 to March 2012,a total of 328 patients were diagnosed as FGPs in 23 047 patients who underwent routine esophagogastroduodenoscopy and 656 patients without FGPs as controls.The mean age was (55.12±12.61) years,and 75.91％ were women.The prevalence of H.pylori in patients with FGPs was significantly lower than in those without FGPs (22.30％ (64/287) vs.42.26％ (224/530),P ＜0.001,OR 0.392,95％ Cl 0.283-0.544).Overall,a total of 54 patients with FGPs (54/328,16.46％) and 136 patients without FGPs (136/656,20.73％) received PPIs therapy (P=0.110).According to the different duration of PPIs use,no significant differences of PPIs use were found between the cases and controls among all subgroups.Moreover,the PPIs use was also similar,regardless of age,sex,H.pylori infection,and the number of polyps.Conclusion Sporadic FGPs may not be induced by PPIs therapy but negatively correlate with H.pylori infection in China,which is not the same with the data in Western countries。

Abstract：Background Mycoplasma pneumonia (M.pneumoniae) is one of the key pathogens of community-acquired pneumonia.A global pandemic of M.pneumoniae has occurred since 2010.The aim of this study was to survey the prevalence of M.pneumoniae in children in Beijing from 2007-2012.Methods A total of 3 073 clinical specimens were obtained from pediatric patients with respiratory tract infections from January 2007 to December 2012,and examined by nested polymerase chain reaction.PCR products were visualized by 2％ agarose gel electrophoresis,positive products sequenced,and compared with reference sequences in GenBank.Macrolide resistance-associated mutations were also detected for some positive samples.Results Of the 3 073 specimens,588 (19.13％) were positive for M.pneumoniae,12.4％ of which were accompanied by viral infections.Positive rates for M.pneumoniae were highest in 2007 and 2012,showing a significant difference when compared with other years.Infections tended to occur in autumn and winter and positive rates were significantly higher for children aged 3-16.The rate of macrolide resistance-associated mutations was 90.7％,and the predominant mutation was an A→G transition (89.92％) at position 2063 in domain V of the 23S rRNA gene.Conclusions M.pneumoniae outbreaks occurred in 2007 and 2012 in pediatric patients in Beijing,which is consistent with the global prevalence of M.pneumoniae.M.pneumoniae can cause multi-system infections in children,and may be accompanied with viral infections.We determined that school-age children are more susceptible to this disease,particularly in autumn and winter.Gene mutations associated with macrolide resistance were very common in M.pneumoniae-positive specimens during this period in Beijing。

Abstract：Background Bladder cancer is the ninth most common cancer in the world; fewer than 15％ of transitional-cell carcinoma patients survive 2 years if left untreated.Although radical cystectomy is the standard treatment of choice,much of them relapse and the necessity of adjuvant chemotherapy is still under debate.The aim of the study was to evaluate the efficacy of adjuvant intraarterial chemotherapy (IAC) with gemcitabine and cisplatin (GC) on locally advanced bladder cancer.Methods This is a retrospective study on 60 patients with locally advanced bladder carcinoma who underwent radical cystectomy between May 2000 and June 2011.Patients were studied in two groups based on IAC and followed up for up to 5 years.Results Among 60 patients,there were 25 patients who underwent IAC (GC) after radical cystectomy (the IAC group) and 35 patients who underwent radical cystectomy alone (the control group).Although not significant,the relapse rates were slightly reduced in the IAC group than in the control group.Patients with IAC had a reduction in mortality compared with patients without IAC over 5 years.Specifically,IAC significantly reduced about 82％ of mortality within the first year (hazard ratio=0.18,95％ Cl 0.03-0.97,P=-0.04).Additionally,IAC was well tolerated and safe.The most common adverse effect was transient myelosuppression (10/25,40％),which was resolved by various medical treatments.Conclusions Compared with radical cystectomy alone,radical cystectomy in combination with adjuvant IAC moderately but significantly reduces 1-year mortality.Our preliminary data showed only marginal benefit for the early survival.However,a randomized clinical study is needed to determine the long-term survival benefit。

Abstract：Background Gestational diabetes mellitus (GDM) is a common complication during pregnancy,and gestational weight gain is one of the major and modifiable risk factors.This study aims to estimate the relationship between the rate of gestational weight gain before diagnosis of GDM and the subsequent risk of GDM.Methods A case-control study was conducted with 90 GDM cases and 165 women in the control group from May 2012 to August 2012 at Peking University First Affiliated Hospital.GDM was diagnosed according to the standards issued by the Ministry of Health of China in 2011.The plasma glucose levels,weights,and covariate data of the women were obtained based on medical records.Univariate analysis and unconditional Logistic regression model were used to estimate the associations.Results After adjusting for age at delivery,parity,and pre-pregnancy body mass index,the risk of GDM increased with increasing rates of gestational weight gain.Compared with the lower rate of gestational weight gain (less than 0.28 kg per week),a rate of weight gain of 0.28 kg per week or more was associated with increased risk of GDM (odds ratio:2.03; 95％ confidence interval:1.15 to 3.59).The association between the rate of gestational weight gain and GDM was primarily attributed to the increased weight gain in the first trimester.Conclusion High rates of gestational weight gain,particular during early pregnancy,may increase a woman's risk of GDM。

Abstract：Background Chronic hepatitis C virus (HCV) infection can affect multiple organ systems and cause a variety of extrahepatic manifestations (EMs).We sought to assess the constituent ratio of EMs in Chinese patients with chronic HCV infection and identify the clinical and biological factors associated with EM.Methods The medical records of 297 patients with chronic HCV infection were analyzed and demographic and epidemiological information was collected.The diagnosis of chronic HCV infection was based on positive anti-HCV combined with a positive HCV-RNA or at least two times of elevated aminotransferases attributable to HCV infection.Patients with HBV and/or HIV coinfection,autoimmune hepatitis,and history of alcohol abuse were excluded.Results Sixty-two percent (184/297) of the patients had at least one EM,including fatigue (29.4％),type 2 diabetes mellitus (28.2％),renal involvement (12.5％),lymphadenopathy (9.6％),fever (9.4％),thyroid dysfunction (8.1％),and arthralgia (7.4％).Neuropathy,sicca syndrome,B-cell lymphoma,Raynaud's phenomenon,and lichen planus were rare.The mean age of patients with EM was older compared with those without EM.Conclusions EMs were common in Chinese patients with chronic HCV infection,particularly fatigue,type 2 diabetes,renal impairment,lymphadenophy,fever,and thyroid dysfunction.Older age was associated with EMs。

Abstract：Background The brain death confirmation tests occupy a different position in each country's diagnostic criteria (or guideline); the choices of tests are also different.China brain death criteria include clinical judgment and confirmation tests.This study aimed to confirm the preferred confirmatory test and complementary confirmatory tests.Methods We did a clinical brain death determination on deep coma patients,and then divided them into brain death group and non-brain death group.According to the Chinese standards for determining brain death,both the groups accepted confirmatory tests including electroencephalograph (EEG),somatosensory evoked potentials (SEP),and transcranial Doppler (TCD).The sensitivity,specificity,false positive rate,and false negative rate were calculated to evaluate the accuracy of the confirmatory tests.Results Among the 131 cases of patients,103 patients met the clinical criteria of brain death.Respiratory arrest provocation test was performed on 44 cases and 32 cases (73％) successfully completed and confirmed that they have no spontaneous breathing.Of the three confirmation tests,EEG had the highest completion rate (98％) and good sensitivity (83％) and specificity (97％); TCD had followed completion rate (54％) and not good sensitivity (73％) and specificity (75％); SEP had the lowest completion rate (49％),good sensitivity (100％),and not good specificity (78％).After the combination of SEP or TCD with EEG,the specificity can increase to 100％.Conclusions The completion rate of respiratory arrest provocation test remains a problem in the clinical diagnosis of brain death.If the test cannot be completed,whether to increase a confirmatory test is debatable.SEP had an ideal sensitivity,and the specificity will reach 100％ after combining with TCD or EEG.When a confirmed test was uncertain,we suggest increasing another confirmatory test。

Abstract：Background Currently there is a trend towards reducing radiation dose while maintaining image quality during computer tomography (CT) examination.This results from the concerns about radiation exposure from CT and the potential increase in the incidence of radiation induced carcinogenesis.This study aimed to investigate the lowest radiation dose for maintaining good image quality in adult chest scanning using GE CT equipment.Methods Seventy-two adult patients were examined by Gemstone Spectral CT.They were randomly divided into six groups.We set up a different value of noise index (NI) when evaluating each group every other number from 13.0 to 23.0.The original images were acquired with a slice of 5 mm thickness.For each group,several image series were reconstructed using different levels of adaptive statistical iterative reconstruction (ASIR) (30％,50％,and 70％).We got a total of 18 image sequences of different combinations of NI and ASIR percentage.On one hand,quantitative indicators,such as CT value and standard deviation (SD),were assessed at the region of interest.The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated.The volume CT dose index (CTDI) and dose length product (DLP) were recorded.On the other hand,two radiologists with ＞5 years of experience blindly reviewed the subjective image quality using the standards we had previously set.Results The different combinations of noise index and ASIR were assessed.There was no significant difference in CT values among the 18 image sequences.The SD value was reduced with the noise index's reduction or ASIR's increase.There was a trend towards gradually lower SNR and CNR with an NI increase.The CTDI and DLP were diminishing as the NI increased.The scores from subjective image quality evaluation were reduced in all groups as the ASIR increased.Conclusions Increasing NI can reduce radiation dose.With the premise of maintaining the same image quality,using a suitable percentage of ASIR can increase the value of NI.To assure image quality,we concluded that when the NI was set at 17.0 and ASlR was 50％,the image quality could be optimal for not only satisfying the requirements of clinical diagnosis,but also achieving the purpose of low-dose scanning。

Abstract：Background Diabetic cardiovascular complication is a major cause of mortality in type 2 diabetic patients.Hyperglycemia markedly increases the risk of cardiovascular disease.Endothelial dysfunction is common in type 2 diabetes mellitus (DM) and is an early indicator of diabetic vascular disease.Therefore,it is necessary to identify the effect of different hypoglycemic agents on vascular endothelium.The aim of the study was to examine and compare the effects of metformin and gliquidone on atherosclerotic lesions in streptozotocin-induced diabetic rats.Methods Forty male Sprague-Dawley rats (age,8 weeks; weight,180-200 g) were included in this study and fed with a normal chow diet for 1 week.Rats (n=10) served as the normal control group (NC group) were fed with a normal chow for another 2 weeks and received an injection of saline.The rest 30 rats fed with a high-fat diet for 2 weeks and injected streptozotocin were randomly assigned to three groups (n=10 rats per group) as follow:type 2 DM group (DM group),DM + gliquidone group (GLI group) and DM + metformin group (MET group).Five weeks later,all rats were fasted overnight and taken tail blood samples for biochemical determinations.Then rats in the NC and DM groups were administrated with normal saline,while rats in the MET and GLI groups were administrated with metformin (100 mg/kg) or gliquidone (10 mg/kg),respectively.All medicines were given via intragastric administration for 8 weeks.After 16 weeks,plasma triglyceride (TG),total cholesterol (TC),low density lipoprotein cholesterol (LDL-C),high density lipoprotein cholesterol (HDL-C) were measured.The aortic arch was isolated from diabetic rats and was assessed by pathological sectioning using H&E staining.Results Metformin treatment prevented weight gain ((315.80±52.16) g vs.(318.70±68.48) g,P=0.773),improved plasma TG,HDL-C and LDL-C levels (P=0.006,0.003,0.001,respectively,all P ＜0.05).However,gliquidone showed no significant effects on plasma TG and TC levels (P=0.819,0.053,respectively).LDL-C and HDL-C in the GLI group changed ((0.46±0.10) mmol/L vs.(0.36±0.14) mmol/L,P=0.007; (0.99±0.27) mmol/L vs.(1.11±0.18) mmol/L,P=0.049).Both metformin and gliquidone treatment lowered blood glucose levels (P=0.001,0.004,respectively,P ＜0.05).Under light microscopy,no changes were observed in the aortic wall structure of each layer; the intima was smooth and the membrane elastic fibers were normal in the NC group.In the DM group,the aortic wall structure was unclear,the intima was thickened with irregular intima,and membrane elastic fibers collapsed.The aortic intima in the MET and GLI groups was smoother compared with the DM group,but the endothelial structure of the MET group was closer to that of the NC group.Conclusions Both metformin and gliquidone have anti-atherosclerotic effects.But the endothelial structure of the MET group was closer to that of the NC group.Metformin and gliquidone therapy can reduce serum level of LDL-C and increase level of HDL-C,whereas gliquidone therapy did not lose weight and decrease serum level of TG.These data may have important implications for the treatment of patients with type 2 DM。

Abstract：Objective To review the advances of studies on clinical results of aspirin's chemopreventive effect against esophageal squamous cell carcinoma (ESCC) and evidences for mechanisms of the antitumoural effects of aspirin in experimental research.Data sources A comprehensive search of the PubMed literatures without restriction on the publication date was carried out using keywords such as aspirin and esophageal cancer.Study selection Articles associated with aspirin and esophageal cancer are analyzed.Results This review focuses on the current evidence for use of aspirin as a chemopreventive agent in ESCC.Aspirin is the most widely used among all nonsteroidal anti-inflammatory drugs (NSAIDs),which is cheap and acceptable to patients.Several observational results provide the further investigation of prevention and therapy of aspirin or similar drugs in esophageal cancer.Data from case control studies,cohort studies and randomized controlled trials (RCTs) also give some support of a beneficial role of aspirin on ESCC.Experimental data suggest that aspirin may prevent carcinogenesis of ESCC by favorably affecting proliferation,apoptosis,or other as yet unidentified growth-regulating processes.But the mechanism by which aspirin influence on esophageal squamous cell carcinoma needs further investigation.Conclusion A wealth of evidences ranging from clinical data to experimental results are building to suggest that aspirin has significant effects in reducing both the incidence and mortality of ESCC。

To the editor:Histiocytoid Sweet's syndrome (HSS) is an entity which has clinical features similar to typical Sweet's syndrome (SS) but is distinguished by dermal infiltration of immature neutrophilic granulocytes.Herein,we report a case of HSS associated with rheumatoid arthritis (RA) and pleuritis.She initially responded to prednisone。

To the editor:During the spring of 2013,a novel avian-origin influenza A (H7N9) virus emerged and spread among humans in China.1 In this report,we described the dynamic change of clinical characteristics in a case of H7N9 virus infection,who got cured without treatment with invasive mechanical ventilation。