2009年 · 第122卷第15期

Abstract：Background Acute massive pulmonary embolism(PE)is a clinical emergency requiring rapid and supportive measures.Percutanous mechanical thrombectomy is considered as a treatment option.The purpose of this study was to evaluate the clinical efficacy and safety of peructaneous mechanical catheter fragmentation in the management of acute massive PE.Methods From January 2003 to June 2007,28 patients(20 men,8 women;mean age 64 years)with acute massive PE initially diagnosed by computed tomography and confirmed by pulmonary angiography were treated with inferior vena caval filter placement and percutaneous catheter fragmentation.Twenty-six patients received thrombolytic agents after embolus fragmentation.Results Technical success was achieved in all patients.The improvement of clinical status and restoration of blood flow in the main branches of the pulmonary artery were seen in 27 patients.Only one case did not benefit from the percutaneous therapy and died from the failure of the surgery.Oxygen saturation increased from(86.2±4.5)%to(96.1+3.2)%(P＜0.001)after the interventional procedure.The post-procedure mean pulmonary artery pressure decreased from(34.2±4.8)mmHg to(25.2±5.1)mmHg(P＜0.001).During clinical follow-up(range,1-5 years),no patients had recurrence of PE.Conclusion Percutaneous catheter fragmentation combined with thrombolysis is an effective and safe therapy in the clinical management of acute massive PE。

Abstract：Background As an alternative to open aneurysm repair,endovascular aortic repair(EVAR)has been applied to ruptured abdominal aortic aneurysm(rAAA).The aim of this study was to evaluate the immediate and long-term outcomes of EVAR for rAAA.Methods From July 1997 to September 2007,20 men and six women with rAAA(median age,68 years)were treated with EVAR.Most patients with suspected rAAA underwent emergency computed tomographic angiography(CTA).The procedure was performed under general or local anesthesia.Endovascular clamping was attempted in hemodynamically unstable patients.Bifurcated endografts and aorto-uni-iliac(AUI)endografts with crossover bypass were used.Patients had CT scan prior to discharge,3,6,12 months after discharge,and annually thereafter.Results Time between diagnosis and EVAR ranged from 1 hour to 5 days.EVAR was performed under general anesthesia in 21 patients,and under local anesthesia in five patients.Endovascular aortic clamping was performed in four patients.There was no conversion to open surgery during EVAR.Stent-graft insertion was successful in all patients.One patient died during EVAR from acute myocardial infarction.Ten patients had systolic blood pressure＜80 mm Hg.Eleven patients received a blood transfusion.Mean aneurysm size was(47c12)mm.Mean ICU stay was(8±3)days,mean hospital stay(18±6)days,and mean procedure time(120±32)minutes.The 30-day mortality was 23%(6/26patients),and major morbidity 35%(9/26 patients).Early endoleak occurred in 8/26 patients(31%).The mean follow-up was(18±7)months.No patient demonstrated migration of the stent-graft.Conclusions EVAR is a safe and effective option for treatment of acute rAAA,independent of the patient's general condition.Immediate and mid-term outcomes are favorable,but long-term outcome is unknown.Multi-center studies are necessary to establish the role of EVAR for rAAA。

Abstract：Background For patients with moderate to high-risk acute coronary syndromes(ACS)who undergo early,invasive treatment strategies,current guidelines recommend the usage of glycoprotein(GP)lib/Illa inhibitors as an upstream treatment for a coronary care unit or as an downstream provisional treatment for selected patients who are undergoing percutaneous coronary intervention(PCI).The relative advantage of either strategy is unknown.The purpose of this study was to evaluate the effects of upstream tirofiban versus the effects of downstream tirofiban on myocardial damage and 180-day major adverse cardiovascular events(MACE)after PCI in high-risk non-ST-segment elevation ACS (NSTE-ACS)undergoing PCI.Methods From July 2006 to July 2007,160 high-risk NSTE-ACS undergoing PCI were randomized to receive upstream (within 4-6 hours before coronary angiography)tirofiban or downstream(the guidewire crossing the lesion)tirofiban,to evaluate the extent of myocardial damage after PCI by quantitatively and qualitatively analyzing the value of cardiac troponin I(cTnl)as well as MB isoenzyme of creatine kinase(CK-MB)before and after PCI.The incidences of 24-hour,3-day,7-day,30-day and 180-day MACE after PCI were followed up and the rates of bleeding complications and thrombocytopenia during tirofiban administration were recorded.Results The peak release and cumulative release of cTnl levels within 48 hours after PCI were significantly lower with upstream tirefiban than downstream tirofiban(0.45 vs 0.63 and 0.32 vs 0.43,respectively;P＜0.05).Post-procedural cTnl elevation within 48 hours was significantly less frequent among patients who received the upstream tirofiban than those who received the downstream tirefiban(66.3%vs 87.5%,P＜0.05).The peak and cumulative release of CK-MB levels as well as post-procedural CK-MB elevation within 48 hours after PCI were not significantly different between the two groups (16 vs 14,5 vs 3 and 26.3%vs 36.3%,respectively;P＞0.05).The incidences of 24-hour,3-day,and 7-day MACE after PCI were the same between the two groups(0 vs 0,0 vs 0 and 1.25%vs 1.25%,respectively).Although the incidences of 30-day and 180-day MACE after PCI were not statisticially different between the two groups,the incidences were consistently lower with upstream tirofiban(3.75%vs 6.25%and 12.99%vs 16.67%;P＞0.05).Aging(OR=1.164,P＜0.001),hypertension(OR=4.165,P=0.037)and type 2 diabetes(OR=13.628,P＜0.001)were independent risk factors of MACE.The timing of administrating the tirofiban(OR=2.416,P=0.153)plays an extensive role in the incidence of MACE.The incidences of major and minor bleeding complications as well as mild thrombocytopenia during the administration of tirofiban were similar between the two groups(2.50%vs 1.25%,1.25%vs 1.25%and 1.25%vs 1.25%,respectively;P＞0.05).Conclusions Based on the pretreatment with aspirin and clopidogrel,upstream tirofiban was associated with attenuated minor myocardial damage and the tendency of reducing incidences of 180-day MACE after PCI among high-risk NSTE-ACS patients undergoing PCI.Aging,hypertension and type 2 diabetes were independent risk factors of MACE in high-risk NSTE-ACS patients undergoing PCI associated with tirofiban。

Abstract：Background Inflammatory mechanisms had played an important role in the occurrence and prognosis of acute myocardial infarction,inflammatory mediators was associated with adverse outcomes of acute myocardial infarction.This study tested the hypothesis that in the acute phase of myocardial infarction with ST-segment elevation,neutrophil count and high-sensitivity C-reactive protein are predictive of angiographic morphologic features that indicate thrombus formation in the infarct-related artery.Methods This retrospective study included 182 consecutive patients with acute myocardial infarction and ST-segment elevation.Patients were assigned to a thrombus-formation group(n=77)and a non-thrombus-formation group(n=106).All patients had a Killip's classification≤3 and onset＜12 hours prior to presentation.All the cases were going to undergo coronary angiography,including primary percutaneous coronary intervention,simple coronary angiography,or thrombolysis in a coronary artery(or arteries)or coronary artery bypass graft(s).Blood samples for measurement of high-sensitivity C-reactive protein and for routine blood laboratory studies were collected prior to coronary angiography.Results The levels of high-sensitivity C-reactive protein,total leukocyte counts,neutrophil counts,and neutrophil/lymphocyte ratios were substantially higher in the thrombus-formation group than in the non-thrombus-formation group patients(for each,P＜0.05).Stepwise Logistic regression analyses identified high-sensitivity C-reactive protein,neutrophil count,and neutrophil/lymphocyte ratio as independent predictors of thrombus formation in the infarct-related artery(for each,P＜0.05).Conclusions In patients with acute myocardial infarction,higher neutrophil counts,neutrophil/lymphocyte ratio,and levels of high-sensitivity C-reactive protein are predictors to indicate thrombus formation。

Abstract：Background Post-operation pain is a very subjective phenomenon.The aim of this study was to find out the effects of acupuncture or electro-acupuncture on post-cesarean pain.Methods Sixty women,who had had spinal anesthesia during cesarean section at the Department of Obstetrics of China Medical University Hospital,were randomly assigned to the control group,the acupuncture group,and the electro-acupuncture group.After the operation,we applied subjects with acupuncture or electro-acupuncture on the bilateral acupuncture point,San Yin Jiao(Sp6),and the patient controlled analgesia(PCA).The first time of requesting morphine,the frequency of PCA demands in 24 hours,and the doses of PCA used were recorded double blindly.In addition,monitoring the subjects' vital signs,the opioid-related side effects,and the pain scores was done.Results The results showed that the acupuncture group and the electro-acupuncture group could delay the time of requesting morphine up to 10-11 minutes when compared with the control group.The total dose of PCA used within the first 24 hours was 30%-35%less in the acupuncture group and the electro-acupuncture group when compared with the control group,which was indicated in statistical significance.However,there was no significant difference between the acupuncture group and the electro-acupuncture group.The electro-acupuncture group's and the acupuncture group's pain scores were lower than the control group's within the first 2 hours.Both were statistically significant.However,two hours later,there were no significant differences of the visual analogue scale(VAS)scores between either of the treatment groups and the control group.Finally,the incidence of opioid-related side effects,such as dizziness,was less in the acupuncture group and electro-acupuncture group than in the control group.Conclusions This study shows that the application of acupuncture and electro-acupuncture could definitely delay the time of requesting pain relief medication after cesarean section and decrease the PCA doses used within the first 24 hours。

Abstract：Background This retrospective study evaluated the diagnostic accuracy of 2-(F18)-fluoro-2-deoxy-D-glucose-positron emission tomography(18F-FDG-PET)/COmputed tomography(PET/CT)in the preoperative diagnosis of metastatic mediastinal and hilar lymph node in patients with non-small-cell lung cancer(NSCLC).Methods A total of 39 patients received preoperative 18F-FDG PET/CT and the postoperative biopsy.We compared preoperative PET/CT scan results with corresponding intraoperative histopathalogic findings in 39 NSCLC patients.The sensitivity,specificity,accuracy,positive and negative predictive value of 18F-FDG PET/CT were assessed.Results Histopathologic examination confirmed metastasis in 57 out of the 208 excised lymph nodes;23 of the 57 nodes were mediastinal and hilar lymph nodes.The sensitivity,specificity,accuracy,positive predictive value and negative predictive value of PET/CT in the preoperative diagnosis of mediastinal lymph node metastasis in NSCLC patients were 65%,96.8%,92%,78.5%and 90%,respectively.Conclusions PET/CT scan showed good accuracy in the preoperative diagnosis of mediastinal and hilar lymph node metastasis in the patients with NSCLC.We recommend that PET/CT scanning be used as a first-line evaluation tool for tumor diagnosis,therapy evaluation and follow-up。

Abstract：Background The biofragmentable anastomosis ring(BAR)is a simple alternative device to create intestinal anastomosis.Our study was designed to evaluate the clinical value of BAR in intestinal anastomosis.Methods A total of 167 patients performed intestinal anastomosis from January 2002 to February 2006 were randomized to BAR group(n=82)and manual suture group(n=85)as control.They were equally allocated to the two groups regarding sex,age,site of anastomosis,emergent or elective surgery and contaminant diseases.The results of postoperative complications and recovery were recorded in each group.Results Eighty-seven intraperitoneal BAR anastomoses were completed in 82 patients.Two and one postoperative deaths were recorded in BAR and suture group,respectively,no deaths were directly related to anastomotic technique.In suture group,anastomotic leakage and early bleeding both occurred in two patients respectively,no anastomotic bleeding occurred in BAR group,one patient in BAR group developed enterocutaneous fistulae.Perioperative bleeding,operation time and length of hospitalization were similar in two groups(P＞0.05).Time for return of bowel function was significantly shortened in BAR group than that in suture group(P＜0.05).Conclusion The BAR appears to be a standard,easy,safe and effective altemative either in elective or emergent intraperitoneal intestinal anastomotic surgery。

Abstract：Background The prevalence of Helicobacter pylori(H.pylon)infection varies by geographic locations.Studies indicate that the infection rate of H.pylori was previously high in China but that rates had been declining worldwide over recent decades.The aims of our study were:(1)to determine the current prevalence of H.pylori infection among children and adults residing in areas with high(Muping County,Shandong)and low(Yanqing County,Beijing)incidences of gastric cancer in China,and(2)to compare the prevalence for 2006 with the prevalence for the early 1990s.Methods Using Warthin-Starry silver staining of gastdc mucosal biopsy specimens and H.pylori stool antigen tests (HpSA),we tested a total of 2065 asymptomatic children aged 8-15 years and adults aged 40-79 years in the above two regions from May to July 2006.We evaluated 520 children and 526 adults from Muping,and 516 children and 503 adults from Yanqing.Subjects were selected randomly and H.pylon status was determined by HpSA in children and either HpSA or histology of gastric biopsies in adults.Data obtained in the early 1990s in the same two areas of China were also collected and studied.Results For children,the prevalence of H.pylori infection was significantly higher in Muping(37.69%)than it was in Yanqing(25.58%,P＜0.001).In both regions,the prevalence of H.pylori increased with age but was not related to gender.A significant difference was observed between 8-9-years old and 10-11-years old(P＜0.05),but not between other adjoining age groups(P＞0.05).From 1991 to 2006 H.py/ori prevalence among 8-10-year-old children decreased in Muping(60.00%vs 32.07%,P＜0.001),but not Yanqing(24.06%vs 19.10%,P＞0.05).In the adult group,H.pylori prevalence was 50.95%in Muping,which was significantly higher than the 41.35%positive rate in Yanqing(P＜0.01).But there were no statistically significant differences between different age groups of 40-49,50-59,and 60-79 years,or between males and females.A significant decrease in H.pylori prevalence in both regions was observed when the results of 2006 were compared with the data obtained in 1990 in Muping(50.95%vs 73.78%,P＜0.001)and in 1992 in Yanqing(41.35%vs 55.35%,P＜0.01).Conclusions After fifteen years,the prevalence of H.pylori infection among both children and adults remained significantly higher in areas with a high incidence of gastric cancer in China compared with that in areas with a low incidence of gastric cancer.H.pylori infection rates have decreased in the general Chinese population during recent years。

Abstract：Background Estrogen receptor alpha(ER a)is the most important endocrine therapy responsiveness predictor for women with breast cancer.The accuracy of the prediction of the response to endocrine therapy was thought to be affected by involving the estrogen receptor coregulatory proteins and cross-talk between ER and other growth factor-signaling networks.Nuclear corepressor 1(NCOR1)is one of the ERa transcription repressor.The objective of the study is to investigate the expression of NCOR1 at the protein level and pursue its predictive value for breast cancer endocrine therapy.Methods In the present study,the level of expression of NCOR1 protein has been assessed by immunohistochemistry in 104 cases of invasive carcinoma of the breast.Associations between NCOR1 protein expression and different clinicopathological factors and survival were sought.Results It was found that NCOR1 was expressed at significantly higher levels in responsive patients treated with endocrine therapy as first-line treatment on relapse.Responsive patients also had a significantly longer post-relapse survival and overall survival.No NCOR1 expression difference was found between patient by age,tumor size,lymph node status,different histological grade groups and human epidermal growth factor receptor 2(HER2)status.Multivariate analysis showed that NCOR1 is an independent prognostic factor for over-all survival.Conclusions In breast cancer,NCOR1 protein expression level predicts response to endocrine therapy as first-line treatment for breast cancer patients on relapse and NCOR1 protein level assay may increase the accuracy in the endocrine treatment determination and,therefore,improving the patients survival。

Abstract：Background In the years around 1990,in Beijing Tiantan Hospital Affiliated to Capital Medical University many children with infantile hemiplegia and intractable epilepsy were treated with further modified anatomical hemispherectomy.We report the follow up of the first six cases.To make good use of these precious clinical data and make clear their neuropsychological state,we performed neuropsychological and neurophysiological measurements in these patients,who were at a median of 17.8 years after hemispherectomy.Methods Oddball task was given to the patients and to a normal control group to collect the peak latency(PL)and peak amplitude(PA)of event-related potentials(ERPs)-P300.The P300 data of the two groups were analyzed and the P300 patterns of the six patients are presented.The baseline characteristics and long-term follow-up of the six hemispherectomized patients,especially the long-term seizure control and cognitive function after surgery,are described.Results Five patients had no seizures and one was almost seizure-free during the years after surgery.Clear P300 was obtained from every electrode in the patients.Differences of P300 between patients and normal control group had no statistical significance.And the maximum PA was at the site of electrode Pz or Cz which was consistent with that of the control group and with previous findings.Conclusions Further modified anatomical hemispherectomy has preferable long-term antiepileptic effects.The P300results of the patients mean that the basic cognitive function of the patients has no difference from the control group.This reflects the plasticity of the hemisphere to some extent and increases the affirmation of the long-term curative effects of further modified anatomical hemispherectomy from both neuropsychological and neurophysiological aspects。

Protein kinase C(PKC)consists of a family of serine/threonine kinases that are identified by the presence of two copies of the C1 domain,which form the diacylglycerol(DAG)-binding module。

Magnetic particles have unique features and are being used in biological and medical science such as drug targeting,diagnosis and therapy.' We have developed technologies that enable magnetic particle to be changed from microscale to nanoscale,and the latter are termed magnetic nanoparticles(MNPs)。

Chromophobe renal cell carcinoma(CRCC)is a distinctive,but not rare,malignant renal neoolasm.Series studies have revealed that the incidence of CRCC is between 3.6%and 10.4%of all kidney neoplasms.1-3 In China,the first CRCC case was described by our hospital in 1998;4,5 there have since been only a few case reports of CRCC in China and very few instances of long-term follow-up。

Meningiomas without attachment to the dura are rare.These meningiomas are more common in children than in adults,1 and are found more often in the supratentorial region than in the infratentorial region.2 Thus,adult meningiomas contained entirely within the brain parenchyma and located in the posterior fossa are extremely rare。

Nephrotic syndrome(NS)is a common disease in children with a group of symptoms including heavy proteinuria(≥50 mg/kg per 24 hours),hypoalbuminaemia,hypercholesterolaemia and edema.Bartter syndrome(BS)is a clinically and genetically heterogenous kidney disease characterized by hypokalemia,hypochloremic metabolic alkalosis,obvious increase of rennin,angiotesin II,and normal blood pressure。

Malignant priapism is an uncommon clinical disease characterized by prolonged erection secondary to the invasion of malignant neoplasm into corpora cavemosa.1 Penile metastasis of malignant tumors is relatively rare,and only approximately 370 cases were reported by 2006 from a wide range of primary sites with a descending order of the prostate 125(34%),bladder 112 (30%)and recto-sigmoid + rectum 48(13%);only 11 cases of malignant priapisms(3%)were attributed to penile metastasis of testicular tumors.2 Here,we present an interesting case of malignant priapism caused by penile metastasis of a mixed germ cell tumor of the testes in a 25-year-old man。