2004年 · 第117卷第02期

Background It is still controversial whether or not the correlation between lipid abnormality and coronary heart disease (CHD) becomes weaker in the elderly, and whether patients above 80 years old still benefit from lipid management for the secondary prevention of CHD. The purpose of this study is to assess the correlation between hyperlipidemia and the risk of CHD events in the elderly, and to determine if it is appropriate to use lipid-lowering drugs in those aged above 80, as prescribed by the recommended guidelines for lipid management. Methods One thousand two hundred and eleven retirees, mainly males (92%), aged 70 ± 9 years, were enrolled in this study. Lifestyle habits and medical history were recorded via questionnaires. During the period 1986 -2000, all subjects participated in an annual physical examination with a blood chemistry survey. The mean follow-up period was 11.2 years. Subjects with incidental illnesses,especially cardiovascular diseases, were diagnosed or treated promptly. Serum lipid parameters, including total cholesterol (TC), low and high-density lipoprotein cholesterol (LDL-C and HDL-C) and triglyceride (TG) levels were analyzed according to standardization of lipid and lipoprotein measurements. The association between lipid levels and the prevalence of acute myocardial infarction(AMI) or coronary death was analyzed statistically. Results Lipid abnormalities occurred in 2/3 of the 1211 subjects. The most common lipid disorder was high TC and high LDL-C, which was much more prevalent than high TG. Among the subjects, 51. 6%had TC levels above 5. 2 mmol/L Mean TC and LDL-C reached peak levels in the 65 -74age group without significant decrease until ages over 90. The cumulative total number of deaths due to various causes was 397 in the 15-year follow-up period, with the mortality rate in the high lipid group slightly lower than that in the normal lipid group (30. 6%vs 35.3%), although the difference was not significant (P=0.1931). However, there were more cases of coronary death in the high lipid group than in the normal lipid group (7. 9%vs 4. 6%, P=0. 0045). When examining AMI survivors, more AMI cases were found in the high lipid group than in the low lipid group (20.9%vs 11.4%, P <0. 0001). The cumulative number of coronary deaths was 89 (with 88 cases above age 70), and the total number of CHD cases was 214 (17. 7%of the whole group). Logistic regression analysis reveals that age, hypertension, LDL-C, and HDL-C are important risk factors for CHD. Lifestyle changes were common, but only 45%of the hyperlipidemic cases received drug treatment Statins were commonly used only in recent years. Conclusion The above results show that high TC and LDL-C levels are correlated with a high CHD risk even in people over 80. For elderly patients with clinical CHD and an aggregation of CHD risk factors, cholesterol-lowering therapy might be considered if the general health of the patient makes this permissible. Chin Med J 2004; 117(2): 163-167

Background The aim of this study was to clarify the electrocardiographic characteristics of repetitive monomorphic ventricular tachycardia (RMVT) originating from the left ventricular outflow tract, and to describe the results of treatment with radiofrequency catheter ablation (RFCA). Methods Routine 12-lead surface electrocardiography and electrophysiological studies were performed on 11 RMVT patients with no organic heart disease, who were subsequently treated with RFCA directed at targets identified by pace mapping. Results The surface electrocardiogram QRS characteristics of RMVT included an atypical left bundle branch block and right axis deviation, with a low amplitude "rs" or "rS" pattern in lead I, an "rS" or "RS" pattern inV1, and a precordial R wave transition zone in V2 or V3. In 1 patient, a small S wave was observed in V5. Using pace mapping techniques, we selected the left coronary cusp as the ablation target. RMVT was eliminated in all 11 patients immediately after radiofrequency energy delivered. During a follow-up of 13 ±7 months, RMVT recurred in only 1 patient. Conclusion RMVT originating from the left ventricular outflow tract has specific electrocardiographic characteristics, and can be successfully and safely cured using RFCA directed at the left coronary cusp. Chin Med J 2004; 117(2): 168-171

Background Inflammation is a major cause of restenosis after coronary stenting. Intercellular adhesion molecule-1 (ICAM-1) is an important adhesion molecule that plays a key role in the tight adhesion between leukocytes and vascular endothelium. The object of this study was to investigate the association between the K469E polymorphism of the ICAM-1 gene and restenosis after coronary stenting in North Chinese population. Methods The ICAM-1 K469E polymorphism was genotyped using polymerase chain reaction-restriction fragment length polymorphism method in 124 patients who had undergone coronary stenting and coronary angiography at least 3 months earlier. Information on clinical risk factors and procedure-related data were also collected. Results Of 124 enrolled patients in total, there were 72 cases of in-stent restenosis. The restenosis rate in this population was 58.1%. The frequencies of the three possible genotypes of the ICAM-1K469E polymorphism were: KK genotype 50. 8%, EE genotype 41. 9%, and EK genotype 41. 9%. Among restenosis patients, the frequency of the KK genotype was 58.3%and the frequency of E allele carriers was 41.7%, Among non-restenosis patients, the frequency of the KK genotype was 40. 4%, and the frequency of E allele carriers was 59. 6%. The distribution of these two genotype groups between restenosis and non-restenosis patients was significantly different (P=0. 049). Using multivariate logistic regression, the difference between the two groups was more apparent. The odds ratio of KK homozygotes vs E allele carriers was 2.6, with 95%confidence interval 1.2 -5. 8 (P=0.018). After grading of risk factors, we found that the KK genotype was a stronger predictor of in-stent restenosis in obesity or hyperlipemia patients, with an odds ratio of 9. 3 and 3.7, respectively (P<0.05). Conclusion In our study population, KK homozygotes of the ICAM-1 codon 469 mutation had a higher risk of restenosis after coronary stenting, especially in the case of obese or hyperlipemia patients. Chin Med J 2004; 117(2): 172-175

Background Chronic heart failure is a significant cause of cardiovascular morbidity and mortality. This study tested the hypothesis that restrictive filling pattern may provide useful prognostic data for identifying patients with chronic heart failure at high risk of all-cause cardiac death. Methods Ninety patients with chronic heart failure [70 men and 20 women, mean age (58.1 ±11.6) years] were investigated and followed for (18. 8 ±7. 9) months. During this period, 14 patients died of progressive pump failure, 12 patients underwent heart transplantation, 5 patients died suddenly, and 2 patients died of acute myocardial infarction. A new criterion, the restrictive filling index (RFI), was designed to subgroup patients into a restrictive and a non restrictive group. Results Patients with restrictive filling pattern had a more severe left ventricular dysfunction and a higher cardiac mortality. Analysis by the Kaplan-Meier method revealed that patients in the RFI≥1 and RFI <1 groups had a cardiac events-free survival rate of 52%versus 94%at 1 year, and 27.5%versus 92% at 2 years, respectively. The multivariate Cox proportional hazard model selected RFI as the most powerful prognostic factor (χ2=8. 8017, P=0.0030) for all-cause cardiac death. Conclusion These results indicate that RFI is a simple, noninvasive, and specific clinical predictor for adult chronic heart failure patients who are at a high risk for all-cause cardiac death. Chin Med J 2004; 117(2): 176-182

Background An increasing incidence of Crohn's disease has been found in China in recent years. Our study has been focused on evaluating the diversity of the clinical manifestations of Crohn's disease in order to improve early diagnostic accuracy and therapeutic efficacy. Methods Thirty patients with active Crohn's disease were enrolled and their clinical data, including diagnostic and therapeutic results, were analyzed. Endoscopy combined with histological examination of biopsy specimens provided characteristic features of the disease. Transabdominal bowel sonography (TABS) was used for detecting intestinal complications. Nutritional supportive therapy was given to 20 subjects with active cases of the disease. Results Most patients were young adults with a higher proportion of females to males (ratio: 1.14: 1). The disease affects any segment or a combination of segments along with the alimentary tract(from the mouth to the anus). In this study, the colon and small bowel were the major sites involved. Recurrent episodes of abdominal pain in the right lower quadrant and watery diarrhea were the most common symptoms. Granulomas were identifiable in nearly one-third (30.8%) of all biopsy specimens. In moderate cases of the disease, remission was achieved more quickly through the use of oral prednisone therapy than with SASP or 5-ASA. Beneficial effects on the host's nutritional status were observed. Immunosuppressives were used on an individual basis and showed variable therapeutic effects. Sixteen patients had surgery due to intestinal obstruction or failure to respond to drug therapies. Rapid improvement after surgery was reported. Conclusion Endoscopy (with biopsy) and TABS were both crucial procedures for diagnosis. SASP(or 5-ASA) and prednisone were effective as inductive therapies. Azathioprine has demonstrable benefits after induction therapy with prednisone. Surgery, as an alternative treatment, provided another effective choice in selected patients. Chin Med J 2004; 117(2): 183-188

Background To compare the efficacy and safety of hormone replacement therapy (HRT) combined with fluoxetine, with HRT alone, in post-menopausal women suffering from depression. Methods A randomized, open-label, parallel trial was applied. HRT was administered to all patients for 2 cycles, with 14 days of estrogen therapy and 14 days of estrogen plus progesterone. Patients who were randomly assigned to the HRT plus fluoxetine group were given fluoxetine in combination with HRT. Hamilton Depression Rating Scale (HAMD), Kupperman Menopausal Index (KMI), and Clinical Global Impressions scale were used to measure the efficacy. Results One hundred and twenty-three post-menopausal patients with depression were enrolled in the study. Among them, 120 had at least one post-treatment visit and entered into the statistical analysis. The mean total HAMD scores were significantly lower, and the percentages of HAMD score reductions were higher in the HRT plus fluoxetine Group compared with the HRT Group, after at least 3 weeks of treatment, with an average difference of 5 points at the endpoint. The Clinical Global Impression-Severity and Clinical Global Impression-Improvement scores were significantly different in the 2 groups, in favor of the combination therapy. The mean total KMI was significantly lower in the Combination Group compared with the HRT Group, after at least 6 weeks of treatment, with an average 4.5-point difference between the groups. No statistically significant differences were found in most of the adverse events reported in the Combination Group compared with the HRT group, with the exception of 3 symptoms, i. e., dry mouth, loss of appetite, and abdominal distention. They were mild to moderate in severity. Two patients in the HRT group, but none in the combination group, dropped out due to adverse events. Conclusion HRT plus fluoxetine therapy was effective in the treatment of menopausal depression with a satisfactory safety profile. Chin Med J 2004; 117(2): 189-194

Background Portasystemic shunts, especially total shunts, are effective tools for reducing portal pressure and controlling variceal bleeding but lead to high risk of encephalopathy and accelerating liver failure. The purpose of this study is to evaluate the clinical effects of small-diameter expanded polytetrafluoroethylene (ePTFE) H-graft portacaval shunts in the treatment of portal hypertension. Methods Thirty-one patients with portal hypertension were treated with ePTFE small-diameter H-graft portacaval shunts from December 1995 to April 2002. Twenty-one had externally ringed grafts and 10had non-ringed grafts; 20 had 10 mm diameter grafts and 11 had 8 mm grafts. The left gastric artery and coronary vein were ligated in 22 patients. Additionally, 6 patients underwent pericardial devascularization, and splenectomies were performed on 30 patients. Results An average decrease of free portal pressure (FPP) from (32.13 ±4. 86) cmH2O before shunting to (12. 55 ±5. 57) cmH2O after shunting was observed. Portal blood flow was reduced by 1/3 compared with the levels measured before shunting. Twenty-eight patients survived after the operation, and no upper gastrointestinal rebleeding occurred in the follow-up period (40.2 months on average). We lost contact with one patient Color Doppler ultrasonography and/or portography revealed the shunts to be patent in 28 cases and occluded in 2 (6.4%) cases. Encephalopathy developed in 4 patients (12. 9%). Conclusion Small-diameter ePTFE H-graft portacaval shunts can effectively reduce portal pressure. Moreover, the majority of the hepatopetal flow from the portal vein can be adequately maintained. The reinforced shunts may achieve a higher rate of patency. Morbidity from encephalopathy was less frequent than in pateints receiving total shunts. Small-diameter H-graft portacaval shunts are also effective in preventing recurrent variceal bleeding.Chin Med J 2004; 117(2): 195-198

Background The purpose of this study was to evaluate the efficacy of topical melagenine for repigmentation in child patients with vitiligo on the scalp. Methods Twenty-two child patients with vitiligo on the scalp were treated with 1.2 mg/ml aqueous melagenine in combination with 20 minutes of infrared exposure twice daily. Results In 4 patients (18. 2%), melagenine treatment in combination with infrared exposure led to complete recovery; in 6 patients (27. 3%), treatment was shown to be effective; in 8 patients(36. 3%), treatment led to improvements in patient condition; and only 4 patients (18. 2%) showed no response after 1 - 2 treatment sessions. The general effective rate of melagenine-infrared combination treatment was 45. 5%for the children with vitiligo on the scalp, and treatment was accompanied by minimal side effects. Conclusion Melagenine may be efficacious and a safe treatment option for childhood vitiligo affecting the scalp. Chin Med J 2004; 117(2): 199-201

Background It was reported that telomerase expression is closely associated with cellular immortality and cancer. This study was designed to investigate the relationship between telomerase expression and the carcinogenesis of cervical cancer, the possible use of telomerase as a marker of cervical intraepithelial neoplasia (CIN) progression or regression, and the natural history of CIN. Methods Telomeric repeat amplification protocol (TRAP) assay was used to measure telomerase activity in cervical scrapings and biopsy samples obtained from 105 cases affected with various cervical conditions, including chronic cervicitis (n=20), CIN (n=64, 16 cases of CIN I, 20 cases of CIN II, and 28 cases of CIN III), and invasive squamous cell carcinoma (n=21). Results In exfoliated cell samples, telomerase activity was detected in 5 of 20 (25. 0%) cases of cervicitis, 10 of 16 (62. 5%) cases of CIN I, 11 of 20 (55. 0%) cases of CIN II, 23 of 28 (82.1 %)cases of CIN III, and 13 of 21 (61. 9%) cases of carcinoma. In cervical biopsy samples, telomerase activity was detected in 6 of 20 (30.0%) cases of cervicitis, 8 of 16 (50.0%) cases of CIN I, 9 of 20 (45. 0%) cases of CIN II, 27 of 28 (96. 4%) cases of CIN III, and 20 of 21 (95. 2%) cases of carcinoma. Telomerase activation was significantly higher in CIN samples than in cervicitis samples. Telomerase activity was detected at similar frequency in samples from cervical scrapings and cervical biopsies. Conclusion These results seem to suggest that telomerase expression may be associated with carcinogenesis of the cervix. TRAP assay of cervical scraping samples could be used to monitor and predict the development of CIN in clinical practice. Chin Med J 2004; 117(2): 202-206

Background In the case of hypertension, lesions in the microvessels of the target organs precede and deteriorate futher after arteriosclerosis in the small arteries. Thus coronary microvascular lesion(CML) was considered the crucial factor contributing to damage to the target organs. The purpose of this study is to observe the characteristics and differences of CML in autopsies of elderly patients with essential hypertension (EHT), coronary heart disease (CHD), or EHT with CHD, given the same degree of left ventricular wall thickness (LVWT). Methods A retrospective study was performed on 246 cases of patients over 60 years old with EHT, CHD, or EHT with CHD, and on 26 cases without cardiovascular disease as controls, out of a total of 3195 consecutive autopsied cases. The arterioles (with diameter 10-60 μm) and the capillaries in the cardiac muscle layer were examined by haematoxylin and eosin staining, elastic van Gieson staining,and CD31 immunohistochemistry. To quantify CML severity, measurements were taken of arteriole density (AD), the ratio of wall-to-lumen area of arteriole (RWL), and capillary density (CD), using light microscopy and computer image analysis. Based on LVWT, the cases were divided into four degrees, from I to IV. The EHT, CHD, and EHT with CHD groups all rated LVWT I-IV, and the control group rated LVWT I. SAS software was used for statistical analysis. Results With the aggravation of LVWT, both AD and RWL increased while CD decreased significantly in the EHT group (P<0.05 -0. 0001); there were similar but more severe changes in the EHT with CHD group (P<0. 001 -0. 0001); and AD increased (P <0. 001) while RWL and CD did not change significantly in the CHD group. Conclusion Comparing EHT with CHD patients, there are similar patterns of change to AD, but different patterns of change to RWL and CD. CML is much more severe in EHT patients with CHD. We conclude that CML is one of the main causes of decreased coronary flow reserve and myocardial damage in both EHT patients and EHT patients with CHD. Chin Med J 2004; 117(2): 207-212

Purpose The purpose of this study is to review the urine products of bone breakdown as markers of bone resorption and usefulness of urinary hydroxyproline. Data Related researches published in 1985 -2000 were systematically reviewed. Results Bone markers could be used for early diagnosis of bone metabolic diseases. Biochemical markers of bone resorption that reflect osteoclast activity and/or collagen degradation provide a new and potentially important clinical tool for the assessment and monitoring of bone metabolism. Assessment of bone resorption can be achieved with measurement of urinary hydroxylysine glycosides, urinary excretion of the collagen pyridinium cross-links, urinary excretion of type I collagen telopeptide breakdown products (cross-linked telopeptides) and urinary hydroxyproline. Conclusion Urinary hydroxyproline has been in use as a marker of bone resorption, but it lacks sensitivity and specificity. It is a modified aminoacid that is a metabolic product of collagen breakdown. Hydroxyproline may be released either free or with fragments of the collagen molecule attached during bone resorption, and it is also liberated by the breakdown of complement and nonskeletal collagen. Chin Med J 2004; 117(2): 291-295