2009年 · 第122卷第07期

Despite much progress has been made in treatment and research in recent decades,variceal hemorrhage is still one of the most severe complications of liver cirrhosis.1 Studies of the natural history of gastroesophageal varices indicate that gastroesophageal varices are present in about half of cirrhotic patients when endoscopy is performed at the time of the diagnosis of cirrhosis.The presence of gastroesophageal varices correlates with the severity of liver disease。

Portal hypertension is a clinical syndrome which is a consequence of a pathological increase in portal vein pressure due to various causes,liver cirrhosis being the most common.The basic pathophysioiogical characteristic of portal hypertension is resistance to portal vein flow or an increase in portal vein flow,which results in elevation of ressure in the portal vein and its tributaries and the formation of collateral circulation.Portal hypertension is manifested as a clinical syndrome including ascites,hepatoencephalopathy,esophagogastric variceal bleeding (EVB),etc.Among these manifestations,EVB has the highest mortality which is also one of the most common emergencies of the digestive system。

Abstract：Background In the recent years,the incidence of esophageal cancer in China has increased.The key point for raising the survival rate is the diagnosis and treatment at an early stage.Narrow-band imaging (NBI) can enhance the contrast of the mucous membrane of the esophagus without staining.This study aimed to explore the value of NBI in the diagnosis of early esophageal cancer and precancerous lesions.Methods The esophagus was examined with ordinary endoscopy and NBI endoscopy.Pit patterns and blood capillary forms were examined with routine magnifying endoscopy and NBI endoscopy.Finally,a 1.2% Lugoul's iodine solution was used to stain the esophageal mucosal surface and a biopsy was taken at all the sites where NBI or iodine staining was positive.NBI and iodine staining scales were compared with pathologic diagnosis,which was considered as the gold standard.Results A total of 90 cases (138 lesions in total) were diagnosed as early esophageal cancer or precancerous lesions:104 lesions (75.4%) were detected with ordinary endoscopy,120 lesions (87.0%) were detected with NBI endoscopy,and 138 lesions (100%) were detected with iodine staining.The lesion detection rate of NBI was significantly lower than that of iodine staining (X2=17.176,P ＜0.01).However,there was no significant difference between NBI and iodine staining for the diagnosis of high grade intraepithelial neoplasia (X2=1.362,P ＞0.05),while the detection rate of NBI was significantly lower than that of iodine staining for the diagnosis of low grade intraepithelial neoplasia (X2=13.388,P ＜0.01).The pit pattern and blood capillary form of eady esophageal cancer and precancerous lesions could be demonstrated clearer with NBI than with ordinary endoscopy.Conclusions NBI can enhance the contrast of the mucous membrane of the esophagus without staining.The combination of NBI and iodine staining can raise the diagnostic rate of early esophageal cancer and precancerous lesions。

Abstract：Background Recurrent ischemic events occurred even during routine use of 75 mg clopidogrel in addition to aspirin,that indicated a potentially insufficient maintenance dosage of clopidogrel.The aim of the present study was to evaluate the short-term efficacy and safety of a 150 mg maintenance dose of clopidogrel following a 600 mg loading dose in patients with an acute coronary syndrome (ACS) undergoing drug eluting stent (DES) implantation.Methods Between November 2005 and November 2006,a total of 813 consecutive ACS patients undergoing DES implantation were enrolled.A 600 mg loading dose was administered before percutaneous coronary intervention (PCI) nd patients were randomized to receive clopidogrel 75 mg or 150 mg for 30 days in addition to 300 mg aspidn daily.Primary end points were the composite of cardiac death,non-fatal myocardial infarction (MI) and urgent target vessel revascularization (UTVR).Secondary end points included stent thrombosis (ST),major and minor bleeding events at 30days.Results At a follow-up period of 30 days,4 (1.0%) patients in the 150 mg group and 9 (2.2%) patients in the 75 mg group (P ＞0.05) reached the primary end points.There was no significant difference in the incidences of MI (0.5% vs1.2%,P ＞0.05),UTVR (0.7% vs 2.0%,P ＞0.05),and cardiac death (0.2% vs 0.2%,P ＞0.05) between the two groups.The incidence of ST (0 vs 1.5%,P ＜0.05) was significantly lower in the 150 mg group than that in the 75 mg group.There were no significant differences between both groups regarding the risk of major (0.2% vs 0,P ＞0.05) or minor (0.5% vs 0.2%,P ＞0.05) bleedings.Conclusion A high clopidogrel maintenance dose of 150 mg daily following a 600 mg loading dose for the first month after PCI procedure reduces the risk of ST and appears to be safe in patients with ACS undergoing DES implantation。

Abstract：Background Tamsulosin,an alpha-1 receptor antagonist,has been demonstrated effective in promoting distal ureteral stone passage and in reducing pain associated with stone expulsion.This study aimed to evaluate the effect of tamsulosin in comparison with nifedipine and extracerporeal shock wave lithotripsy (ESWL) on the expulsion rate of distal ureteral stones at different sizes.Methods We assigned 314 patients to three categories:Ⅰ,the stone with maximal diameter of 4.0-5.9 mm;Ⅱ,6.0-7.9mm,and Ⅲ,8.0-9.9 mm.Patients in each category were randomly subdivided into three treatment subgroups:group A (nifedipine group),group B (tamsulosin group),and group C (ESWL group).Stone-free rate and the dose of analgesics were recorded weekly during the 4-week follow-up period.Results Three hundred and three patients completed the study.The results showed that nifedipine and tamsulosin treatments promoted a small (4-8 mm,categories Ⅰ and Ⅱ) stone expulsive rate that was comparable with ESWL treatment.Nonetheless,when the stone diameter was 8.0-9.9 mm,ESWL showed a greater stone free rate than nifedipine and tamsulosin treatments;no significant difference existed between the latter two therapies.Although the ESWL treatment group required the least analgesics,tamsulosin treatments required less pain medication than nifedipine (P ＜0.05).Conclusions Tamsulosin treatment is recommended for patients with the stone diameter smaller than 8 mm because of its feasibility,effectiveness and safety.ESWL is more appropriate than tamsulosin therapy for the patients whose stones are larger than 8 mm。

Abstract：Background Post myocardial infarction (post-MI) patients with low left ventricular ejection fraction (LVEF) have been candidates for an implantable cardioverter-deflbrillator (ICD) since the Multicenter Automatic Defibrillator Implantation Trail II (MADIT II).However,due to the high costs of ICDs,widespread usage has not been accepted.Therefore,further risk stratification for post-MI patients with low LVEF may aid in the selection of patients that will benefit most from ICD treatment.Methods Four hundred and seventeen post-MI patients with low LVEF (≤35%) were enrolled in the study.All the patients received standard examination and proper treatment and were followed up to observe the all-cause death rate and sudden cardiac death (SCD) rate.Then COX proportional-hazards regression model was used to investigate the clinical factors which affect the all-cause death rate and SCD rate.Results Of 55 patients who died during (32±24) months of follow-up,37 (67%) died suddenly.After adjusting for baseline clinical characteristics,multivariate COX proportional-hazards regression model identified the following variables associated with death from all causes:New York Heart Association (NYHA) heart failure class ≥111 (Hazard ratio:2.361),LVEF ≤20% (Hazard ratio:2.514),sustained ventricular tachycardia (Hazard ratio:6.453),and age ≥70 years (Hazard ratio:3.116).The presence of sustained ventricular tachycardia (Hazard ratio:6.491) and age ≥70 years (Hazard ratio:2.694) were specifically associated with SCD.Conclusions In the post-MI patients with low LVEF,factors as LVEF ≤20%,age ≥70 years,presence of ventricular tachycardia,and NYHA heart failure class≥111 predict an adverse outcome.The presence of sustained ventricular tachycardia and age ≥70 years was associated with occurrence of SCD in these patients。

Abstract：Background CT perfusion imaging (CTP) has been proved to be a powerful functional imaging technique.This study aimed to evaluate the value of CTP in guiding biopsy of pulmonary lumps.Methods A total of 147 patients with pulmonary lumps who had CT guided biopsies were enrolled in this study from February 2005 to June 2007.The patients were assigned to 3 groups:33 cases guided by CTP as group Ⅰ,45 cases guided by contrast-enhanced scan of CT as group Ⅱ,and 69 cases guided by plain scan of CT as group Ⅲ.Each group was subdivided into central and peripheral types according to the location of the lumps.The achievement ratio of biopsy,the accuracy in grouping,and grading of lung cancer,and the incidence of complication were compared.Results The total achievement ratios of biopsy from group Ⅰ to Ⅲ were 100% (33/33),91% (41/45),and 80% (55/69)respectively,and the difference was statistically significant between group Ⅰ and Ⅲ (P ＜0.05).For the central type,they were 100% (18/18),88% (15/17),and 79% (11/14) respectively,and the difference was also statistically significant between group Ⅰ and Ⅲ (P ＜0.05).For the peripheral type,they were 100% (15/15),93% (26/28),and 80% (44/55) espectivelies,and the difference was not statistically significant among the three groups.The total accuracies in grouping and grading of lung cancer from group Ⅰ to Ⅲ were 100% (27/27),91% (31/34),and 72% (33/46) respectively,and the difference was statistically significant between group Ⅰ and Ⅲ and between group Ⅱ and III (P ＜0.05).For the central type,they were 100% (16/16),94% (16/17),and 70% (8/12) respectively,and the difference was statistically significant between group Ⅰ and Ⅲ (P ＜0.05).For the peripheral type,they were 100% (11/11),88% (15/17),and 72%(26/36) respectively,and the difference was statistically significant between group Ⅰ and Ⅲ (P ＜0.05).The total incidence of complication from group Ⅰ to Ⅲ were 15% (5/33),27% (12/45),and 43% (30/69) respectively,and the difference was statistically significant between group Ⅰ and Ⅲ (P ＜0.01 ).For the central type,they were 11% (2/18),24% (4/17),and 57%(8/14) respectively,and the difference was statistically significant between group Ⅰ and Ⅲ (P ＜0.01).For the peripheral type,they were 20% (3/15),29% (8/28),and 40% (22/55) respectively,and no statistically significant difference was found among the three groups.Conclusions CTP guided biopsy of pulmonary lumps using multi-detector row CT has the potential to improve the accuracy of histopathological diagnosis with a lower risk and higher achievement ratio.More research and technical improvements are needed before it is widely used。

Abstract：Background Children with anisometropic amblyopia are often noncompliant with traditional treatment including spectacules and contact lenses.This study was to evaluate the long-term efficacy of excimer laser in situ keratomileusis (LASIK) for children with high anisometropic amblyopia.Methods A retrospective analysis of 24 children with high unilateral anisometropic amblyopia,who underwent LASIK during the period between August 2000 and September 2005 in our hospital,was conducted.The mean age of these children was (7.4±1.9) years (range 5-14 years) and the mean follow-up period was (33.3±14.2) months (range 18.5-74.2 months).After LASIK,visual acuity,refraction and far or near stereoacuity were analyzed.Near stereoacuity was measured by the random-dot butterfly stereogram and the pre-school random-dot stereogram,while far stereoacuity was measured by the synoptophore with Yan's random-dot stereogram.Results Mean preoperative uncorrected visual acuity was 0.06±0.05,while mean postoperative uncorrected visual acuity was elevated to 0.43±0.33.Mean preoperative best-corrected visual acuity was 0.26±0.22,while mean postoperative best-corrected visual acuity was elevated to 0.67±0.40.For patients with myopic anisometropia,preoperative mean spherical equivalent refraction was (-8.01±2.70) D while postoperative value significantly reduced to (-1.32±2.47) D.For patients with hyperopic anisometropia,preoperative mean spherical equivalent refraction was (+7.35±1.55) D while postoperative value significantly reduced to (+3.30±0.86) D.These results demonstrated that there was statistical difference in these parameters between preoperative and postoperative tests.At the last follow-up,20 patients had near stereoacuity,and the mean near stereoacuities measured by the random-dot butterfly stereogram and the preschool random-dot stereogram were (149.00±152.93)" and (201.05±235.94)",respectively.In contrast,11 patients had far stereoacuity,and the mean far stereoacuity measured by the synoptophore was (210.91±17.51)".Three cases of patients developed mild corneal complications.Conclusion LASIK for the correction of high anisometropia in children with monocular amblyopia may be safe and effective,and this can help effectively conduct postoperative amblyopia training and improve the cure rate。

Abstract：Background The medial plica may be caused by direct trauma or joint degeneration,which also could be iatrogenic.There have been few reports in the literature discussing incidence of the medial plica caused by an operation on the knee joint,specifically after the reconstruction of anterior cruciate ligament (ACL).In this study,we aimed to evaluate and analyze the relationship between the incidence of the medial plica and reconstruction of the ACL.Methods A retrospective case series study was conducted to review the findings of 1085 patients between 2003 and 2007,who underwent second-look arthroscopy after reconstruction of the ACL (between 2002 and 2006).The correlation of the incidence of medial plica with the stability of the knee joint,the time from onset of injury to reconstruction surgery,the associated injuries,and the rate of progress during postoperative rehabilitation were analyzed.Results We found that 722 patients had the structure of a medial plica.The incidence after reconstruction of the anterior cruciate ligament (66.5%) was significantly higher than usually reported.All these medial plica had avascular fibrotic and thickened edges.An excision of pathologic medial plica and fat pad synovial fringes were done.The incidences were significantly different between the two groups with their reconstruction operation time,from onset of injury to surgery (less than one month or over 2 years),and the progress rate of postoperative rehabilitation (knee flexion could not be over 90° in four weeks).The incidence was not different between the groups with knee stable conditions.Conclusions Medial plica is more common in patients after reconstruction of ACL.More associated injuries and more rehabilitation difficulties can increase the medial plica incidence。

Abstract：Background The onsets of needling sensation introduced by acupuncture stimulus can vary widely from subject to subject.This should be explicitly accounted for by the model blood oxygenation-level dependent (BOLD) time course used in general linear model (GLM) analysis to obtain more consistent across-subject group results.However,in standard GLM analysis,the model BOLD time course obtained by convolving a canonical hemodynamic response function with an experimental paradigm time course is assumed identical across subjects.Although some added-on properties to the model BOLD time course,such as temporal and dispersion derivatives,may be used to account for different BOLD response onsets,they can only account for the BOLD onset deviations to the extent of less than one repetition time (TR).Methods In this study,we explicitly manipulated the onsets of model BOLD time course by shifting it with-2,-1,or 1 TR and used these temporally shifted BOLD model to analyze the functional magnetic resonance imaging (fMRI) data obtained from three acupuncture fMRI experiments with GLM analysis.One involved acupuncture stimulus on left ST42acupoint and the other two on left GB40 and left BL64 acupoints.Results The model BOLD time course with temporal shifts,in addition to temporal and dispersion derivatives,could result in better statistical power of the data analysis in terms of the average correlation coefficients between the used BOLD models and extracted BOLD responses from individual subject data and the T-values of the activation clusters in the grouped random effects.Conclusions The GLM analysis with ordinary BOLD model failed to catch the large variability of the onsets of the BOLD responses associated with the acupuncture needling sensation.Shifts in time with more than a TR on model BOLD time course might be required to better extract the acupuncture stimulus-induced BOLD activities from individual fMRI data。

Abstract：Background X-linked hearing impairment is clinically and genetically a heterogeneous disease.Although many disorders manifest with hearing loss,a limited number of sex-linked loci and only one gene (POU3F4) have been shown to be implicated in X-linked non-syndromic hearing impairment.In the present study,we have performed a clinical and genetic analysis of a Chinese family with X-linked non-syndromic hearing loss,with emphasis on audiological findings and genomic mapping.Methods The clinical features of Family JX01 were evaluated by physical and audiometric examination in eighteen family members.Mutation screening of POU3F4 was identified by polymerase chain reaction (PCR) amplification and sequencing.Molecular evaluation consisted of X-chromosome wide genotyping by microsatellite makers (STR),followed by analyzing using MLINK computer program.Results Five affected males demonstrated bilateral,symmetrical sensorineural and profound hearing loss.The hearing impairment started prelingual.The female carriers did not have any complain of hearing loss,however,two of them were tested with milder loss with high frequency.No causative mutations in POU3F4 gene were detected by DNA sequencing.Linkage analysis indicated that the responsible gene was linked to locus DXS1227 (maximum lod score=2.04 at θ=0).Conclusions The affected males in Family JX01 have profound prelingual sensorineural hearing impairment,In addition,two female carriers showed mild to moderate hearing losses.However,none of females complained of any hearing loss.Analysis of hereditary deafness in this family mapped most compatibly to the Xq27.2。

Abstract：Background Bone morphogenetic protein (BMP) is a member of the superfamily of transforming growth factor-β.Recent studies show that it is an indispensable factor in hematopoiesis.To better characterize the effect of recombinant human BMP (rhBMP)-2 in hematopoiesis,we set out to determine whether rhBMP-2 could promote the proliferation of mesenchymal stem cells (MSCs) and increase the levels of hematopoietic cytokines in MSCs.Methods 2,3-bis (2-methoxy-4-nitro-5-sulfophenyl)-5-((phenylamino) carbonyl)-2H-tetrazolium hydroxide (XTT),real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) were used to deteMP-2 on the proliferation and hematopoietic cytokine levels of MSCs.In addition,MSCs marked with Hoechst33342 were transplanted into BALB/c mice by the intravenous route or intra-bone marrow transplantation,and cluster numbers were counted.Results The XTT test revealed that rhBMP-2 significantly induced proliferation of MSCs in doses ranging from 10 ng/ml to 0.1 mg/ml in a dose-dependent manner.The experiments in vivo showed that there were more clusters of donor cells in bone marrow,spleen,liver and lung of the BMP group than those in the control group after both intra-bone marrow transplantation (P＜0.001,P ＜0.001,P ＜0.001,and P=0.001,respectively) and intravenous transplantation (P ＜0.001,P ＜0.001,and P ＜0.001 respectively).The results of real-time PCR and ELISA revealed that rhBMP-2 significantly increased mRNA expressions and protein levels of IL-6,IL-7,IL-11,G-CSF,M-CSF and SCF.Conclusions The treatment with rhBMP-2 promotes the proliferation of MSCs in vivo and in vitro and increases the levels of hematopoietic cytokines in MSCs,which may contribute to the improvement of hematopoietic function。

Abstract：Background Since January 2002,adult-to-adult living donor liver transplantation (AALDLT) has gained increasing popularity in China in response to the shortage of cadaveric donor livers.This study presents a detailed analysis of the outcomes of AALDLT in a single center.Methods A total of 70 patients underwent AALDLT at our center between January 2002 and January 2007.Among these,67 patients received a right lobe graft without the middle hepatic vein and 3 patients received dual grafts.Three-dimensional volumetric computed tomography,magnetic resonance imaging with angiography and cholangiography were performed preoperatively.Recipient operation time,intraoperative transfusion requirement,length of intensive care unit stay,length of hospital stay,liver function tests,coagulation tests and surgical outcomes were routinely investigated throughout this study.Results All donors survived the procedure with an overall complication rate of 15.3%.Overall recipient 1-year survival and complication rates were 87.1% and 34.2%,respectively.Among the 70 cases,average graft recipient weight ratio was 0.94% (0.72%-1.43%) and average graft volume/standard liver volume ratio was 46.42% (31.74%-71.68%).All residual liver volumes exceeded 35%.Liver function and coagulation recovered rapidly within the first 7 days after transplantation.Conclusions AALDLT is a safe procedure for the donors and an effective therapy for patients with end-stage liver disease.Patient selection and timely decision-making for transplantation are essential in achieving good outcomes.With accumulation of experience in surgery and clinical management,timely feedback and proper modification,we foresee better outcomes in the future。

Abstract：Background The endovascular treatment of abdominal aortic aneurysm (AAA) has improved greatly in the last 15 years.The present study aimed to evaluate the endografting experience for the treatment of unfavorable abdominal aortic aneurysm (uAAA).Methods During December 2001 and December 2007,41 patients with uAAA were treated with endografting using concomitant techniques.Patients were followed up for 1 to 48 months (mean 20.5 months).Results Technical success rate was 97.6% (40/41) with 1 failure converted to open surgery for an unaccessed lilac stenosis.Nine (22.5%) type Ⅰ endoleaks (5 proximal and 4 distal) were observed on the completion angiograrns and successfully corrected with aortic cuffs and iliac extensions during the procedure.Twenty-two of the planed adjunctive procedures were concomitantly performed just before endograft-implantation.There were 2 (5.0%) type Ⅰ endoleaks at 30 days;one type Ⅰ patient was treated by open conversion,another type Ⅰ patient died from a rupture before treatment in the ward,causing a 2.5% of initial mortality.The two type Ⅱ endoleaks were observed without aneurismal expansion.No buttock or leg claudication or ischemic colitis occured.During late follow-up,one additional death occurred from stroke.One new type Ⅰ endoleak was encountered from thrombocytopenia,which caused a 2.6% secondary endoleak that converted to an open surgery in the third month after a failed transabdominal banding of the aortic neck in the second month.All type Ⅱ endoleaks had disappeared in the third and sixth month.The Endografts did not present signs of material fatigue and no other type of endoleak formed.One patient presented with left limb ischemia,which underwent percutaneous transluminal angioplasty.There was no additional aneurysm rupture or any endograft imgration.Conclusion The endografting with concomitant procedures is a feasible and efficient alternative for managing unfavorable AAAs,achieving low morbidity and mortality rates and has a good clinical outcome。

Abstract：Background Erythropoietin elicits protective effects in lung tissue injury induced by ischaemic reperfusion and hyperoxia.We investigated the protective roles of erythropoietin in pulmonary inflammation and lung injury during acute endotoxaemia.Methods A total of 32 male Sprague-Dawley rats were randomly assigned to four groups:saline group,erythropoietin+saline group,saline+lipopolysaccharide group and erythropoietin+lipopolysaccharide group.Rats were treated with erythropoietin (3000 U/kg,i.p.) or saline,30 minutes prior to lipopolysaccharide administration (6 mg/kg,i.v.).Four hours after lipopolysaccharide injection,samples of pulmonary tissue were collected.Optical microscopy was performed to examine pathological changes in lungs.Wet/dry (W/D) ratios,myeloperoxidase activity,malondialdehyde concentrations and tumour necrosis factor-alpha (TNF-a) as well as interleukin 1 beta (IL-1β) levels in lungs were measured.The pulmonary expression of nuclear factor kappaB (NF-kB) p65 was evaluated by Western blotting.Differences between the different groups were analysed by one-way analysis of variance (ANOVA).Results The lung tissues from the saline+lipopolysaccharide group were significantly damaged,which were less pronounced in the erythropoietin+lipopolysaccharide group.The W/D ratio increased significantly in the saline+lipopolysaccharide group (5.75±0.22) as compared with the saline group (3.85±0.20) (P ＜0.01),which was significantly reduced in the erythropoietin+lipopolysaccharide group (4.50±0.35) (P ＜0.01).Myeloperoxidase activity and malondialdehyde levels increased significantly in the saline+lipopolysaccharide group compared with the saline group,which was reduced in the erythropoietin + lipopolysaccharide group.The TNF-a level of pulmonary tissue increased significantly in the saline+lipopolysaccharide group ((9.80±0.82) pg/mg protein) compared with the saline group ((4.20±0.42) pg/mg protein,P ＜0.01).However,the increase of TNF-a level of pulmonary tissue was significantly reduced in the erythropoietin+lipopolysaccharide group ((6.50±66) pg/mg protein,P ＜0.01).Similady,pulmonary IL-1β levels were elevated markedly in the seline+lipopolysaccharide group in contrast to the saline group,whereas the elevation was much less in the erythropoietin+lipopolysaccharide group.The nuclear localization of p65 increased markedly in the saline+lipopolysaccharide group and this enhancement of nuclear p65 expression was much less in the erythropoietin+lipopolysaccharide group.Conclusion Erythropoietin attenuates pulmonary inflammation and suppresses TNF-a and IL-1β overproduction during acute endotoxaemia,which is partially mediated by inhibition of NF-kB。

Rosai-Dorfman disease (RDD),also known as sinus histiocytosis with massive lymphadenopathy (SHML),is a rare benign entity of unknown etiology.Extranodal SHML (ESHML) may occur as part of a generalized process involving lymph nodes or may involve extranodal sites independent of the lymph node status.Here we report a case with a Rosai-Doffman disease of the lung and review the literature。