2014年 · 第127卷第16期

Abstract：Background Anticoagulation treatments are an important aspect of hemodialysis; however,few reports have addressed these treatments.This investigation intends to increase the understanding of the current status and improvements of hemodialysis-related anticoagulation treatments in China.Methods In this study,an epidemiological investigation was conducted that examined 842 patients in 2007 and 1 175patients in 2012 who underwent hemodialysis anticoagulation treatments in seven blood purification centers in northern Chinese cities.Results Heparin was the most commonly used anticoagulant,although the percentage of use of low-molecular-weight heparin (LMWH) increased from 26.5％ in 2007 to 42.1％ in 2012.In 2007,there were no significant differences in anticoagulant selection among either patients with various primary diseases or patients with hemorrhage,thrombosis,thrombocytopenia,or a low hemoglobin level.However,compared with patients with other diseases,significantly lower doses of LMWH were administered to patients with hypertension (55.5 U/kg vs.67.3 U/kg,P ＜0.05) or diabetes (58.5 U/kg vs.67.3 U/kg,P ＜0.05),and patients with hemorrhage received lower doses of heparin than the other patients (61.6 U/kg vs.71.8 U/kg,P ＜0.01).In 2012,patients with diabetic nephropathy (51.5％ vs.36.5％,P ＜0.01),hemorrhage (43.4％ vs.31.7％,P ＜0.01),or a hemoglobin level below 90 g/L (57.2％ vs.37.1％,P ＜0.01) experienced significantly higher doses of LMWH administration; patients with hemorrhage received significantly reduced LMWH dosages (50.4 U/kg vs.57.8 U/kg,P ＜0.05),and patients with thrombosis received significantly higher doses of heparin (73.8 U/kg vs.62.1 U/kg,P ＜0.01) or LMWH (57.8 U/kg vs.52.6 U/kg,P ＜0.05).Antiplatelet drugs were administered to 20.4％ of the examined patients in 2007 and 20.7％ in 2012.In 2012,patients with hypertension (25.9％ vs.18.5％,P ＜0.01) and thrombosis (36.6％ vs.16.1％,P ＜0.01) had a higher rate of using antiplatelet drugs than patients with other primary diseases and complications.Patients receiving antiplatelet drugs also received higher doses of heparin than patients without using antiplatelet drugs (74.4 U/kg vs.65.9 U/kg,P ＜0.01).However,the use of the drugs was not correlated with thrombocytopenia.The rate at which coagulation indices were determined increased from 45.7％ in 2007 to 64％ in 2012.Conclusion These findings suggested that hemodialysisrelated anticoagulation treatments in China have gradually become more standardized and individualized。

Abstract：Background The plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is frequently elevated in dyspnoeic patients and increasingly used in emergency departments to assess the cause of acute dyspnea.In this study we prospectively tested NT-proBNP levels in patients with congestive heart failure (CHF) and/or acute pulmonary embolism (APE) and determined the utility of NT-proBNP for discriminating APE from CHF.Methods A cohort of 177 dyspnoeic patients with a diagnosis of APE and/or CHF was prospectively studied between June 2010 and March 2013.NT-proBNP was measured by the electrochemiluminescence immunoassay (ECLIA).All patients were evaluated with transthoracic echocardiography (TTE).APE was diagnosed in the presence of thrombi signs in the pulmonary arteries with computed tomographic pulmonary angiography (CTPA) or a high-probability lung ventilation/ perfusion scan.Risk stratification was based on the evaluation on admission according to the ESC guidelines from 2008.The diagnosis of CHF was based on the guidelines of the American College of Cardiology/American Heart Association and the European Society of Cardiology.Two physicians independently reviewed the records to determine the final diagnosis.Results Fifty-nine patients met the criteria for dyspnea caused by APE,and 113 patients were diagnosed with CHF.Most of the APE patients (41,69.5％) were intermediate-risk.The symptoms and signs,such as orthopnea,paroxysmal nocturnal dyspnea and rales in the lungs,were more common in patients with CHF than in patients with APE (P ＜0.01).Median NT-proBNP was significantly lower in patients with APE compared to those in patients with CHF (2 855.9 pg/ml vs.6 911.4 pg/ml,P ＜0.01).We constructed the receiver operating characteristics (ROC) curve in predicting the diagnosis of APE.At a cut point=1 582.750 pg/ml,NT-proBNP provided a specificity of 93％ and a true positive rate (sensitivity) of 17％ for the diagnosis.At a cut point=3 390.000 pg/ml,NT-proBNP had a specificity of 83％ and a sensitivity of 84％ for the diagnosis of APE.At a cut point=6 486.500 pg/ml,they were 54％ and 93％ respectively.Conclusions NT-proBNP can assist in excluding CHF patients from those admitted to the emergency department with acute dyspnea and identifying patients with a high probability of APE,which would reduce the missed diagnosis of APE.Larger studies are necessary to validate these findings。

Abstract：Background Bone damage around the joints is one of the major pathophysiological mechanisms that leads to rheumatoid arthritis (RA) chronic disability.Serum tartrate-resistant acid phosphatase 5b (TRACP-5b) is secreted by osteoclasts,its activity can be used as a clinically relevant bone resorption marker.The aim of this study was to test whether the measurement of serum levels of TRACP-5b in patients with RA would correlate with measures of disease activity and with responses to therapy.Methods Fifty-six patients were randomly assigned to receive recombinant human cytotoxic tlymphocyte-associated antigen-4 immunoglobulin (RhCTLA4-lg),infliximab or methotrexate (MTX).The clinical and serologic indicators of RA activity were evaluated at baseline and at 24 weeks.Serum TRACP-5b was measured by Enzyme-linked Immunosorbent Assay (ELISA) at 0,12 and 24 weeks.Hand X-rays were obtained at baseline.Results At baseline,the levels of TRACP-5b correlated with the severity of X-ray damage,disease duration (r=0.332,P=0.012),and tender joint count (r=0.408,P=0.002).The 24 weeks values of TRACP-5b for RhCTLA4-lg group and infliximab group differed significantly from the baseline values in each group (P ＜0.05; P ＜0.05),whereas only the value for RhCTLA4-lg group differed significantly from the 24 weeks value for the MTX group (P ＜0.01).Considering the two biologics-treated groups together,the TRACP-5b levels at 24 weeks differed significantly from the baseline values only in those patients who reached an ACR70 level (P ＜0.05).Conclusions Measurement of serum TRACP-5b in RA patients reflects clinical and radiological measures of disease activity,treatment with certain biologics,and degree of response to therapy.TRACP-5b should be investigated further as a potential biomarker to predict response to therapy,including slowing of radiographic progression。

Abstract：Background Augmentation plating has been used successfully to treat hypertrophic non-union after nail fixation.This study compared the efficacy of augmentation plating and exchange plating for treating hypertrophic non-union of femoral shaft fracture after intramedullary nail fixation.Methods A total of 12 patients received augmentation plating and 15 patients received exchange plating as treatment for femoral shaft hypertrophic non-union.The procedures were conducted at our medical centre between January 2005and January 2012.Clinical follow-up was conducted at 2 weeks,1 month and then monthly until union was achieved to compare union time,operation time,bleeding and complications between the two groups.Results All patients underwent follow-up examinations until fracture union was achieved.The average length of followup time after the second treatment was (18.37±3.28) months.The time needed for union was (4.17±0.94) months in the augmentation plating group and (5.33±1.72) months in the exchange plating group.The operation time was (90.00±17.58) minutes in the augmentation plating group and (160.00±25.35) minutes in the exchange plating group.The amount of blood loss during the operation was (270.00±43.32) ml in the augmentation plating group and (530.00±103.65) ml in the exchange plating group.Both groups showed significant difference (P ＜0.05) in their results.No complications were reported after the second operation.Conclusions Augmentation plating after nail fixation could remove local rotation instability,facilitate simple operation,create minimal damage and enable exercise for early functional recovery.Therefore,augmentation plating is excellent for treating hypertrophic non-union after nail fixation in femoral shaft fracture。

Abstract：Background Pathological myopia (PM) is the leading cause for choroidal neovascularization (CNV) in people below 50 years of age,the anti-vascular endothlial growth factor (VEGF) medicine is now available to treat CNV secondary to PM.This study aimed to observe the efficacy of intravitreal ranibizumab for PM associated with subfoveal or juxtafoveal CNV in Chinese patients.Methods Fifty-four eyes of 52 consecutive patients were included,they treated with intravitreal ranibizumab 0.5 mg for PM associated with CNV.The best corrected visual acuity (BCVA) of Snellen chart,letters of ETDRS chart,retinal thickness,leakage of CNV lesion,and complications with surgery were analyzed pre-and post-treatment.Eligibility criteria included diopter ≥-8.0 D or eye axis ≥28 mm with fundus changes of PM (lacquer crack,optic disc atrophy,chorioretinal atrophy,posterior scleral staphyloma); CNV secondary to PM; subfoveal or juxtafoveal CNV.Results For 54 affected eyes of 52 consecutive patients,the average BCVA of Snellen chart and letters of ETDRS chart were 0.29 and 30.4,respectively; fundus fluorescein angiography (FFA)/indocyanine green angiography (ICGA) showed CNV leakage,and average retinal thickness on optical coherence tomography (OCT) was 267.2 μm before treatment.Injections of ranibizumab ranged from 1 to 4 (mean 2.2).Follow-up time varied from 12 to 36 months (mean 31.9 months).At the last visit,the BCVA of Snellen chart was increased by three lines (mean 0.65) (P ＜0.01); the letters of ETDRS chart were increased to 17.0 letters (mean 47.4,P ＜0.01); the visual acuity increased more than 15 letters in 30 eyes (55.5％),decreased in 1 eye (1.9％); the retinal thickness on OCT images was decreased by 17.0 μm (mean 250.2 μm) (P=0.082); no active leakage from the CNV lesion occurred in 18 eyes (33.3％),reduced leakage in 30 eyes (55.6％),and no change in 6 eyes (11.1％) as shown by FFA/ICGA.Increased retinoschisis was observed in one eye after the second injection.Conclusions Intravitreal ranibizumab for neovascular PM was well tolerated in Chinese patients,with functional and anatomic improvements in a short-term study,while a long-term study is still needed。

Abstract：Background There is no large population-based study of the distribution and changing trend of strabismus surgeries in China.This study aimed to investigate the distribution and the changing trend of strabismus surgery in a tertiary hospital of China.Methods A retrospective study of all the strabismus surgeries performed in Beijing Tongren Eye Center from 2003 to 2012 was carried out.Characteristics analyzed included the type of strabismus,age,and gender.Results Totally 26 524 strabismus surgeries were performed in Tongren Eye Center during the 10-year period.The number of surgeries increased steadily from 1 507 in 2003 to 3 482 in 2008 and slightly decreased to 3 124 in 2009,but there was a sharp drop to 2 569 in 2010 and then kept relatively steady at 2 760 in 2011 and 2 463 in 2012.Intermittent exotropia (30.3％) was the most common among all kinds of strabismus.The number of strabismus surgeries performed on children under 12 years of age (43.60％) was significantly higher than those of the other age groups (P ＜0.05).Unilateral superior oblique paralysis was the most common subtype of paralytic strabismus (8.64％).Conclusions The type distribution of strabismus surgery has changed during the recent decade.The age and type distribution of different strabismus remained basically constant,among which intermittent exotropia was the most common。

Abstract：Background The causes and mechanisms of chronic diarrhea are complex.This study aimed to explore the relationship between chronic diarrhea with normal colonoscopy findings and terminal ileum lesions.Methods All cases were collected from January 2009 to June 2010.The 40 patients in the patient group had chronic diarrhea with normal colonoscopy findings.Those who had hyperthyroidism,diabetes,chronic pancreatitis,cirrhosis,atrophic gastritis,short bowel syndrome and connective tissue diseases had been excluded.The control group contained 40 healthy individuals without diarrhea.Endoscopy of the terminal ileum was applied in both groups,with the endoscope inserted into terminal ileum for more than 20 cm.The patients diagnosed of chronic diarrhea with terminal ileum lesions were treated with metronidazole and probiotics for 10-14 days.Results Before treatment there were significant differences in endoscopy findings of the terminal ileum between the two groups (P ＜0.05).In the patient group,endoscopy showed congestion,edema,erosion and ulcers in 29 cases,hyperplasia and enlargement of lymphoid follicles in 10 cases with a maximal diameter of 7-8 mm,and 1 case showed normal endoscopy results.After treatment,35 patients recovered from diarrhea,and terminal ileum lesions disappeared in 30 cases as determined by endoscopy.In the control group,endoscopy showed scattered hyperplasia of lymphoid follicles in 5 cases,and the follicles were small with the maximal diameter being 3 mm.There was no hyperemia,edema,erosion or ulcers.Conclusions Chronic diarrhea patients with normal colonoscopy findings may have lesions in the terminal ileum that can be detected by endoscopy; including hyperemia,erosion,ulcers and lymphoid follicle hyperplasia.Therapeutic effect is good with metronidazole and probiotics。

Abstract：Background The prognosis of R1-resection at the bronchial stump in patients with non-small cell lung cancer (NSCLC) remains unclear.This study intends to identify the prognostic factors and to optimize treatments for these patients under update conditions.Methods The data of 124 NSCLC patients who underwent R1-resection at the bronchial stump was reviewed.There were 41 patients in the surgery group (S),21 in the postoperative radiotherapy (PORT) group (S+R),30 in the postoperative chemotherapy (POCT) group (S+C),and 32 in the PORT plus POCT group (S+R+C).The constitute proportion in different groups was tested using the X2 method,univariate analysis was performed using the Kaplan-Meier and log-rank method,and multivariate analysis was done using the Cox hazard regression with entry factors including age,sex,pathological type and stage,classification of the residual disease,and treatment procedure.The process was performed stepwise backward with a maximum iteration of 20 and an entry possibility of 0.05 as well as an excluded possibility of 0.10 at each step.Results In univariate analysis,survival was more favorable for patients with squamous cell carcinoma,early pathological T or N stage,and chemotherapy or radiotherapy.There was no significant difference in the survival for patients with different types of the residual disease,except for the difference between patients with carcinoma in situ and lymphangiosis carcinomatosa (P=0.030).The survival for patients receiving chemoradiotherapy was superior to that for those undergoing surgery alone (P=0.016).In multivariate analysis,the pathological type (HR 2.51,95％ CI 1.59 to 3.96,P=0.000),pathological T (HR 1.29,95％ CI 1.04 to 1.60,P=-0.021) or N stage (HR 2.04,95％ CI 1.40 to 2.98,P=0.000),and chemotherapy (HR 0.24,95％ CI 0.13 to 0.43,P=0.000) were independent prognostic factors.Conclusion Patients with squamous cell carcinoma,early pathological T or N stage,or receiving chemotherapy had a more favorable prognosis。

Abstract：Background Pancreatic neuroendocrine tumors (pNETs) are a type of tumors with the characteristics of easy metastasis and recurrence.Till date,the risk factors affecting the prognosis are still in the debate.In this study,several risk factors will be discussed combined with our cases and experience.Methods Thirty-three patients diagnosed as pNETs were enrolled and the clinical features,blood tests,pathological features,surgical treatment,and follow-up data of these patients were collected and analyzed.Results In this study,operation time of G3 cases was longer than G1/G2 cases (P=0.017).The elevated level of tumor markers such as AFP,CEA,Ca125,and Ca19-9 may predict easier metastasis,earlier recurrence,and poor prognosis (P=0.007).The presence of cancer embolus and nerve invasion increases along with the TNM stage (P=0.037 and P=0.040),and the incidence of positive surgical margin increased (P=0.007).When the presence of nerve invasion occurs,the chance of cancer embolus and lymph node metastasis also increases (P=0.016 and P=0.026).Conclusions pNETs were tumors with the features of easy recurrence and metastasis and many risk factors could affect its prognosis such as the elevated levels of tumor markers and the presence of nerve invasion,except some recognized risk factors.If one or more of these factors existed,postoperative treatments may be needed to improve prognosis。

Abstract：Background L-shaped incision of pronator quadratus (PQ) muscle along its radial and distal borders was always taken for distal radius fractures reduction and internal fixation.Repair of the PQ muscle was always recommended at the end of operation for some instructive reasons.But repair of PQ is not satisfied because of poor quality of muscle and fascial tissues which may cause pain or impede forearm pronation and supination for post-operative scarring around PQ.Inserting the locking palmar plate to pass under the pronator quadratus muscle and the locking screws are inserted through miniincisions in pronator quadratus in some patients with distal radius fractures is a reasonable technique which can preserve the pronator quadratus.The purpose of this study was to evaluate and compare the clinical effects after volar plating of the distal radius fractures while preserving the pronator quadratus and pronator quadratus repair.Methods Between September 2010 and April 2012,65 patients (42 males and 23 females; aged 20-68 years and a mean age of 42.5 years) with distal radius fracture underwent open reduction and internal fixation using the volar locking palmar plates (Depuy or Smith companies).The patients were classified as 23A-2 through 23C-3 according to the Orthopaedic Trauma Association (OTA) classifications.All surgeries were completed by the same trained team.The volar locking palmar plates of distal radius performed with preserving pronator quadratus group involved 30 patients including 19 males and 11 females and performed with pronator quadratus repair group involved 35 patients including 23 males and 12 females.We compared the two groups for wrist pain,forearm range of motion,grip strength,pedoperative complications and wrist functional recovery score.Results The minimum follow-up for the whole cohort was one year.The differences between the two groups were significant with regard to wrist pain,forearm range of motion,grip strength and wrist function at 1,2,and 6 weeks postoperatively,but insignificant at 6 and 12 months postoperatively.No significant differences were found in the pedoperative complications and radiographs postoperatively.Conclusions Preservation of the pronator quadratus muscle is a satisfactory method for the treatment of majority of the fractures of the distal radius with volar locking palmar plates,as this technique can yield better early wrist function and shorten the rehabilitation。

Abstract：Background Controversy still exists regarding whether medial parapatellar approach (MP) or midvastus approach (MV) is preferable in total knee arthroplasty (TKA) up to now.The aim of this meta-analysis was to compare the clinical and radiological outcomes following the MV or MP for TKA.Methods A comprehensive search of unrestricted-language literature of all studies comparing MP with MV was conducted through the electronic literature databases of PubMed,EMBASE,Cochrane Library,CNKI,VIP,and WANFANG.Retrieval time was from the time when databases were built to October 2013.Manual search of relevant trials,reviews,and related articles was also performed.Outcomes of interest included postoperative knee extensor and flexor function,postoperative pain,patella tilt,and complications.Relative risk (RR) and weighted mean differences (WMD) from each trial were pooled using random-effects or fixed-effects model depending on the heterogeneity of the included studies.A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary.Results Twenty-one randomized controlled trials (RCTs) comprising 1 188 patients (1 450 knees) were eligible.Our results showed that MV was associated with better early postoperative extension (WMD=-1.26,95％ CI-2.36 to-0.16,P=0.02) and flexion (WMD=10.13,95％ CI 5.36 to 14.90,P ＜0.01),less postoperative pain (WMD=-0.21,95％ CI-0.34 to-0.07,P=0.002),and no greater risk for complications than MP.The patella tilt did not differ significantly between the two groups (WMD=-0.70,95％ CI-1.94 to 0.54,P=0.27).Conclusions MV may be a better approach than MP,as it improves postoperative early joint function and decreases oain.Future multi-center randomized controlled studies with large sample sizes are required to verify the current findings。

Abstract：Background Coronary heart diseases (CHD) have been identified as one of topmost diseases affecting the Chinese population.However,depression in CHD has not been reported and there are limited high quality empirical studies in China focused on the prevalence of the comorbidity.This study aimed to estimate the pooled prevalence of depression with CHD in China.Methods Systematic review and meta-analysis of published epidemiologic studies on the depression in CHD patients in China were conducted.The research findings dated before 30 September 2013 were obtained from Ovid Medline,EMBASE and two Chinese electronic publication libraries WANFANG and CNKI.We used "cardiovascular disease","depression" and "China" as the search themes in Ovid Medline and EMBASE and "cardiovascular disease" and "depression" in WANFANG and CNKI.Random-effects meta-analysis was used to estimate the prevalence of depression in CHD patients.Results Twenty-seven studies were included in the review.Twenty-three studies had 5 236 participants who were hospitalized and four studies had 1 353 participants from community.The overall prevalence of depression in CHD from hospital was 51％ (95％ CI:0.43,0.58; Ⅰ-squared=97％,P=-0.000).The prevalence of depression in CHD from community ranged between 34.6％ to 45.8％,and the severe depression was found ranging between 3.1％ to 11.2％.Conclusions On comparing data with other countries,the prevalence of depression in CHD among admitted patients in China was found to be high.The physicians and healthcare providers should pay more attention to the "physical-mental" health of the CHD patients。

Abstract：Objective To highlight the current understanding of mixed phenotype acute leukemia (MPAL).Data sources We collected the relevant articles in PubMed (from 1985 to present),using the terms "mixed phenotype acute leukemia","hybrid acute leukemia","biphenotypic acute leukemia",and "mixed lineage leukemia".We also collected the relevant studies in WanFang Data base (from 2000 to present),using the terms "mixed phenotype acute leukemia" and "hybrid acute leukemia".Study selection We included all relevant studies concerning mixed phenotype acute leukemia in English and Chinese version,with no limitation of research design.The duplicated articles are excluded.Results MPAL is a rare subgroup of acute leukemia which expresses the myeloid and lymphoid markers simultaneously.The clinical manifestations of MPAL are similar to other acute leukemias.The World Health Organization classification and the European Group for Immunological classification of Leukaemias 1998 cdteria are most widely used.MPAL does not have a standard therapy regimen.Its treatment depends mostly on the patient's unique immunophenotypic and cytogenetic features,and also the experience of individual physician.The lack of effective treatment contributes to an undesirable prognosis.Conclusion Our understanding about MPAL is still limited.The diagnostic criteria have not been unified.The treatment of MPAL remains to be investigated.The prognostic factor is largely unclear yet.A better diagnostic cdteria and targeted therapeutics will improve the therapy effect and a subsequently better prognosis。

Abstract：Objective Diabetic nephropathy (DN) is the major cause of end-stage renal disease worldwide and its prevalence continues to increase.Currently,therapies for DN provide only partial renoprotection; hence new targets for therapeutic intervention need to be identified.In this review,we summarized the new target,sphingosine kinase-1/sphingosine 1-phosphate (SphK1/S1P) pathway,explored its potential therapeutic role in the prevention and treatment of DN.Data sources Most relevant articles were mainly identified by searching PubMed in English.Study selection Mainly original articles and critical review articles by major pioneer investigators in this field were selected to be reviewed.Results SphK1/S1P pathway can be activated by hyperglycemia,advanced glycation end products,and many proinflammatory cytokines,which leads to fibronectin,transforming growth factor-31 up-regulation and AP-1 activation.And then it could promote glomerular mesangial cells proliferation and extracellular matrix accumulation,mediating the initiation and progression of diabetic renal fibrosis.Conclusions SphK1/S1P pathway is closely correlated with the pathogenesis of DN.The results suggest that SphK1/ S1P pathway as a new target for clinically improving DN in future is of great prospect。

Abstract：Objective To review the current knowledge about the pathophysiological mechanisms,preclinical models,novel contributors and potential therapies of cardiorenal syndrome.Data sources The literature concerning cardioranal syndrome in this review was collected from PubMed published in English up to January 2014.Study selection Original articles and critical reviews related to cardiorenal syndrome were selected and carefully analyzed.Results Cardiorenal syndrome is a condition characterized by kidney and heart failure where failure of one organ worsens the function of the other thus further accelerating the progressive failure of both organs.The pathophysiology of cardiorenal syndrome is not fully understood,but may be caused by a complex combination of neurohormonal system activation,endothelial dysfunction,proteinuria,oxidative stress,uremic toxins and other factors.Managing cardiorenal syndrome is still a major therapeutic challenge in clinical practice because many of the drugs used to control heart failure can worsen renal function,and vice versa.Non-dialyzable uremic toxins,such as indoxyl sulfate,causing detrimental effects on the heart and kidney as well as stimulation of inflammatory responses,may be an effective therapeutic target for cardiorenal syndrome.Conclusions Suitable disease models of cardiorenal syndrome are urgently needed to investigate the pathophysiology and effective therapeutic approaches to the condition.Non-dialyzable protein-bound uremic toxins that may have cardiac and renal effects may provide therapeutic benefit to cardiorenal syndrome patients。