2009年 · 第122卷第16期

Abstract：Background Preoperative tumor grading becomes one of the most important predictors for lymphadenectomy at primary surgery for clinical stage I endometriod adenocarcinoma.However,there is an inconsistency of tumor grade between preoperative curettage and final hysterectomy specimens,and its associated factors are poorly understood.This study aimed to evaluate the accuracy of tumor grade by preoperative curettage so as to achieve a better stratified management for clinical stage I endometriod adenocarcinoma.Methods Clinical data of totally 687 patients with clinical stage I endometdod adenocarcinoma who underwent preoperative curettage and primary surgery were retrospectively collected.Compared with final hysterectomy specimens,the sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of tumor grade by preoperative curettage were calculated and their associations with clinicopathologic parameters,including age,status of menopause,position of uterus,location and size of lesion,histological grade,depth of myometrial invasion,cervical invasion,extrauterine spread,peritoneal cytology,metastasis to retroperitoneal lymph node,serum CA125 level,and hormone receptor status,were analyzed.Results In final hysterectomy specimens,139 of 259 grade 1 patients by curettage were upgraded to grade 1 or 2;31 of 296 grade 2 were upgraded to grade 3,with a significantly discrepant rate of 40.9% (281/687) and an upgraded rate of 24.7% (170/687).The specificity and negative predictive value for grade 3 were 90.7% and 89.9%,while the sensitivity and positive predictive value for grade 1 were 67.1% and 40.9%,respectively.Conclusions Preoperative tumor grade by curettage does not accurately predict final histological results,especially in those classified as grade 1.Complete surgical staging seems to be necessary for clinical stage I endometriod adenocarcinoma。

Abstract：Background Bacterial infection can pose a substantial diagnostic dilemma.99mTc-labeled ciprofloxacin (CPF) was developed as a biologically active radiopharmaceutical to diagnose infection.In the present research,we studied the biodistribution and imaging properties of infection tracer 99mTc-CPF in a mouse model of infection.Methods CPF was labeled with 99mTc and the radiochemical purity and labeling rate were measured.A mouse model of infection was established.We then determined the biodistribution of 99mTC-CPF and conducted the whole body scintigraphy of the animal model.Results 99mTc-Ciprotech was stable for at least 6 hours at room temperature.The labeling rate of CPF by 99mTc was over 90%.Clearance of radioactivity mainly occurred in the liver and kidney,and the clearance from blood was rapid.Both biodistribution and imaging results showed higher uptake of 99mTc-CPF at sites of infection.The infectious tissue/normal tissue ratio peak was 4.30 at 4 hours after injection.Conclusions 99mTc-CPF is a sensitive radiopharmaceutical for scintigraphy of infectious lesions and it is easy to prepare。

Abstract：Background Chemokines and their receptors have been a research focus in transplantation immunology.Chemokines and their receptors play a role in lymphocyte recruitment and differentiation process.This study aimed to observe whether IL-4 and IL-10 may regulate the expression of chemokine receptors CCR3,CCR5 and CXCR3 on CD4+ T cells in CBA/JxDBA/2 mouse model and to explore the role of CCR3,CCR5,CXCR3 in immune tolerance in pregnancy.Methods The mouse model of spontaneous abortion (CBA/JxDBA/2) and the normal pregnant mouse model (CBA/JxBALB/c) were used.CBA/JxDBA/2 mice were injected with IL-4 (CBA/JxDBA/2-1L-4),IL-4 and IL-10 (CBA/JxDBA/2-1L-4+IL-10),or normal saline (CBA/JxDBA/2-NS) as a control.The expression of CCR3,CCR5 and CXCR3 on CD4+ T cells from mouse peripheral blood was measured by the double-labelled FCM method,and the embryo resorption rate was also examined.Results The embryo resorption rate in the CBA/JxDBA/2 group without any treatment was significantly higher than that in the CBA/JxBALB/c group (17.9% vs 3.7%,P＜0.01).The embryo resorption rate in the CBA/JxDBA/2 group immunized with IL-4 or IL-4 together with IL-10 was significantly decreased,compared with that in the control and NS groups respectively.CCR3 expression on CD4+ T cells in the CBA/JxDBA/2 group without any treatment was significantly lower than that in the CBA/JxBALB/c group (0.3738±0.3575 vs 1.2190±0.2772,P＜0.01 );both CCR5 (3.0900±1.5603 vs 1.2390±0.6361,P ＜0.01)and CXCR3 (2.4715±0.9074 vs 0.9200±0.5585,P ＜0.01 ) expressions on CD4+ T cells of the CBA/JxDBA/2 group without any treatment were significantly higher than those of the CBA/JxBALB/c group.Significant up-regulation of CCR3 and down-regulation of CXCR3 were found in the CBA/JxDBA/2 group treated with IL-4 (CCR3:2.0360±0.6944,CXCR3:1.3510±0.5263,P ＜0.01) or IL-4 and IL-10 (CCR3:1.8160±1.0947,CXCR3:1.0940±0.7168,P＜0.01).Because of the CCR5,IL-4 and IL-10 (1.9400±0.8504 vs 3.0900±1.5603,P ＜0.05),but IL-4 alone (2.5310±1.3595 vs 3.0900±1.5603,P ＞0.05)treatment significantly decreased the expression of CCR5 in CBA/JxDBA/2.Conclusions The abnormal expression of CCR3,CCR5 and CXCR3 on CD4+ T cells may play an important role in the pathogenesis of spontaneous abortion.The pregnancy immune tolerance may be induced through selective induction of CCR3,CCR5 and CXCR3 expressions by IL-4 together with IL-10。

Abstract：Background Cyberknife can greatly raise the fractional dose of stereotactic radiosurgery,thus improving its clinical efficacy.We retrospectively analyzed clinical outcomes of brain metastasis treated with Cyberknife.Methods We analyzed 40 cases of brain metastases treated with Cyberknife in the Tianjin Cancer Hospital from August 1,2006 to August 1,2007,for a total of 68 lesions with maximal diameter of 0.4-7.5 cm (average 1.88 cm).Total hypofractional radiated dosage was 18-36 Gy (5-25 Gy/F,1-5 F) by Cyberknife.We evaluated the remission rate of clinical symptoms,correlation factors to new loci,3-month local control rates,and 3-month and 1-year survival rates.All patients were followed up for more than 14 months.Results After 1 week,clinical remission was 90.0% (36/40).After 3 months,the local control rate and therapeutic effective rate were 77.9% (53/68) and 94.1% (64/68),respectively,as observed by cranium augmentation CT or MRI.The three-month,six-month and 1-year survival rates were 97.5% (39/40),82.5% (33/40) and 67.5% (27/40),respectively.Fourteen patients had neopathy outside the original lesion after 3 months.Neopathy was not correlated with age,whole-brain radiotherapy,number of original lesions,maximum diameter of the original lesion,therapeutic dose per fraction,therapeutic frequency or total therapeutic dose.Conclusions Cyberknife got perfect clinical outcomes by higher dosage per fraction.It is an appropriate and valid treatment shortcut for brain metastasis。

Abstract：Background Endovascular therapy plays an important role in the treatment of brain arteriovenous malformations (BAVMs).Ethylene vinyl alcohol copolymer (Onyx) is a novel liquid embolic material.This study aimed to summarize our experience of using Onyx for embolization of BAVMs with the focus on embolization technique.Methods From September 2003 to November 2007,115 patients (43 women and 72 men,with a mean age of 29 years)with BAVMs were endovascularly treated with Onyx in our department.The following features of all AVMs were evaluated prior to treatment:type of nidus and shunt,draining veins,and feeding arteries.A total of 196 endovascular procedures were performed.Results The course of endovascular treatment was completed in 88 patients.Additional sessions were planned in 27 patients.Of the 88 patients,total occlusion was obtained in 23 patients (26.1%),near-total (＞80% of the original volume) occlusion was obtained in 35 patients (39.8%) and partial occlusion (＜80% of the original volume) was obtained in 30 patients (34.1%) using embolization as the sole therapeutic technique.Mean volume reduction was 72% (range 30%-100%) in 115 patients.Thirty four patients (38.6%,34/88) underwent radiosurgical treatment.Additional embolization sessions were planned in 27 patients.Complications occurred in 19 patients (16.5%,19/115),leading to death in one patient (mortality 0.9%) and permanent disabling in 3 patients (morbidity 2.6%).Conclusions Onyx was shown to be feasible and safe for embolization of BAVMs.Proper use of the Onyx injection technique largely improved the endovascular treatment of BAVMs.Large AVMs can be adequately reduced in size through the use of additional treatment。

Abstract：Background There are few reports of micresurgical treatment of dorsum sellae meningiomas-which,because of location,size,and differences in growth direction,clinical presentations,degree of surgical difficulty,have varied posttreatment sequelae.In pursuit of an optimal micresurgical treatment option for dorsum sellae meningioma patients,we performed a retrospective analysis of eight microsurgery-treated patients in our set up.Methods Clinical data of eight microsurgery-treated dorsum sellae meningioma patients were analyzed.Dorsum sellae meningiomas were classified into 2 types based on tumor location,size,and direction of growth.Type Ⅰ tumors (dorsum sellae-inferior third ventricle type,four cases) were resected by craniotomy via the frontotemporal or orbitozygomatic approach.Type Ⅱ tumors (dorsum sellae-third ventricle type,4 cases) were resected by frontal craniotomy via the transcallosal-interfomiceal approach.Results Complete tumor resection was achieved in all the eight patients.In Type Ⅰ tumor patients,the only postoperative complication was oculomotor nerve palsy.In Type Ⅱ tumor patients,the postoperative complications included hyperthermia,electrolyte imbalances,endocrinologic disturbances,and hydrocephalus.The mean follow-up was 2.1 years.Four patients returned to normal life and found a job,two were able to live independently,one required assistance,while one died.Conclusions Dorsum sellae meningioma surgery is challenging,and resection of Type Ⅱ tumors is more difficult than Type Ⅰ tumors.The selection of a suitable microsurgical approach based on tumor type,and the active treatment of postoperative complications are important means of increasing therapeutic efficacy。

Abstract：Background The surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge.As the laparoscopy has been an important tool for the treatment of uterovaginal anomalies,we evaluated the feasibility of laparoscopic vaginoplasty using an ileal segment retrospectively.Methods Totally 86 patients who underwent laparoscopic vaginoplasty using an ileal segment in Beijing Anzhen Hospital during February 2004 to July 2007 were enrolled in this study.Of the 86 patients,70 (81.4%) underwent primary operations and 16 (18.6%) secondary operations.Nineteen (22.1%) patients underwent total laparoscopic vaginoplasty and 67 (77.9%) patients underwent laparoscope-assisted vaginoplasty.The operation time,cost of hospitalization,and hospital duration were compared between the two laparoscopic groups.The Student's t test and the Mann-Whitney test were used to examine the differences.Results All the surgeries were successfully completed with no any intraoperative complication.There were three major surgical complications in the postoperative period:one case of intra-abdominal hemorrhage,one case of meatal stenosis,and one case of intestinal obstruction.The mean follow-up period of this series was 18 months.Seventy-eight patients were satisfied with their sexual lives after the surgeries except 5 women complaining of vaginal stenosis and 3 with no sexual partner during the follow-up.Significant differences were obtained between total laparoscopic and laparoscope-assisted vaginoplasty groups,such as the operation time,cost of hospitalization,and hospital duration (P＜0.01).There were no significant differences in sexual function between the two groups.Conclusions The laparoscopic vaginoplasty using an ileal segment is satisfactory for cosmetic,functional,and anatomic results.Vaginoplasty with an ileal segment,performed by either total laparoscopic or laparoscope-assisted techniques,has a high success rate for a functional vagina。

Abstract：Background ADULT syndrome (acro-dermato-ungual-lacrimal-tooth syndrome) is a rare ectodermal dysplasia disorder known as autosomal dominant inheritance.Recent studies have linked p63 gene mutation to the development of this disease.However,the genetic characteristics of ADULT syndrome were still not well understood.Methods Mutation analysis of p63 gene in the first Chinese ADULT syndrome family was performed using direct DNA sequencing.Results The sequence analysis of exon 8 of p63 gene disclosed a heterozygous G＞A substitution at nucleotide 893 (R298Q) in the proband.In addition,a single nucleotide polymorphism (SNP) rs16864880 in the downstream flanking region (DFR) of p63 exon 8 was also identified in this family.The proband and the paternal side including her father exhibited the C/G genotype at this position.The C/G variant frequency in the paternal was significantly higher as compared with the maternal (6/10 vs 0/6,P=0.034).Conclusions ADULT syndrome may be caused by the p63 gene mutation,and it might have closer genetic association with the paternal side in this family。

Abstract：Background On May 12,2008,a major earthquake hit Wenchuan County in Sichuan Province of China.The number of cases of crush injury following this event was high.Ultrasonic appearance of rhabdomyolysis (RM) caused by crush injury in the Wenchuan earthquake was observed to evaluate the diagnostic value of ultrasound for detection of rhabdomyolysis.Methods We analyzed clinical and ultrasonic manifestations of 50 cases of RM and 18 cases of RM with osteofascial compartment syndrome (OCS).All cases were caused by crush injury in the Wenchuan earthquake.For these RM patients,we also evaluated the correlations between creatine kinase (CK) and the scope of the muscle lesions as observed by ultrasound.Results There were differences in clinical symptoms,physical signs and ultrasonic appearance between the two groups of patients.The ultrasonic characteristics of the RM were as follows:the striated muscle in the lesions thickened with good overall continuity,and the muscle texture was vague;the strength of the echo was uneven and the echo was cloudy or ground glass-like.Liquid dark zones appeared between muscles and were spindle-like or irregular in shape.There were no blood flow signals in the liquid dark areas.The volume of the striated muscle increased in patients with OCS;the fascia wrapping the muscle showed arched protrusions and significant displacement.The flow velocity of the distal arteries decreased and the spectrum was abnormal.The muscle lesion scope of RM group and RM and OCS group was (7.8±9.0) cm and (13.6±3.1) cm,respectively.The correlation coefficient (r) between the muscle lesion scope and the CK was 0.681 for the RM group (P＜0.05) and 0.516 for the RM and OCS group (P ＜0.05).Conclusions The ultrasonogram of RM has characteristic manifestations and can provide important information for clinical diagnosis and treatment of rhabdomyolysis。

Abstract：hypogammaglobulinemia of infancy;follow-upBackground Hypogammaglobulinemia is common in infant humoral immunodeficiencies and has complicated causes and outcomes.We aimed to determine the clinical manifestations,immunological changes and outcomes of Shanghai infants with hypogammaglobulinemia.Methods Patients under 2 years old,having one or more warning signs of primary immunodeficiency disorders,serum immunoglobulin levels below the lower limit of reference range per age,and with normal numbers for lymphocyte subsets,were analyzed and followed up for 2 to 3 years.Results A total of 91 children (male-to-female ratio:2.25:1) participated in the study.Initial clinical presentation was recurrent upper respiratory tract infection (46%),invasive infection (3%),atopic disease (32%).IgA reduction (77%) was prevalent;34% patients had more than one isotype reduced.During follow-up,51 of 62 patients (82.25%) had immunoglobulins normalized at the age between 12-48 months; these were diagnosed as transient hypogammaglobulinemia of infancy (THI).Long-term follow-up may reveal a diagnosis for the remaining 11 infants with persistent lower immunoglobulin levels,who did not have antibody titers measured.Earlier onset was correlated with higher rates of normalization.More patients were diagnosed with isolated hypogammaglobulinemia in 2006 compared with the previous 4 years (2002-2005).Conclusions The awareness of immunodeficiency among pediatricians has been greatly improved.Recurrent otitis media was not a major infection in our patients.THI is a relatively common condition associated with infant hypogammaglobulinemia.In the absence of specific antibody titers,the diagnosis of THI can be confirmed retrospectively with lg levels normalized in follow-up visits.Therefore,long-term follow-up and frequent re-evaluation of these patients are necessary to distinguish them from true primary immunodeficiency。

Abstract：Background Fungal keratitis is a rare but serious corneal disease that may result in loss of vision.The poor prognosis might be due to limited treatment option.This study aimed to evaluate the clinical efficacy of 0.25% terbinafine eye drops comparing with 5% natamycin suspension on fungal keratitis.Methods A retrospective clinical trial was performed on 90 patients presenting with direct smear and/or culture positive fungal keratitis at Beijing Tongren Hospital,Beijing,China from January 2006 to May 2008.Corneal ulcers were categorized as mild or severe.Forty-five patients were treated with topical terbinafine and the next 45 cases received topical natamycin hourly.Results Filamentous fungi were found in corneal scrapings among all 90 cases.Fungal cultures were positive in 64 patients (71%).Species of Fusarium and Aspergillus were the principal isolates.Forty (89%) patients showed favorable response to terbinafine,while forty-two (93%) patients exhibited favorable response to natamycin (P ＞0.05).The mean course of treatment was significantly showed in the terbinafine treatment group than natamycin group ((26.5±11.2) days versus (19.3±6.4) days;P ＜0.05).In terbinafine group,twenty patients with ulcers smaller than 4 mm had favorable outcome,while 20 of 25 patients with ulcers more than 4 mm in diameter had favorable response (P ＜0.05).Twenty-seven patients with depth of infiltration less than half of stroma thickness had favorable response to terbinafine,while 13 of 18 patients with depth of infiltration more than half of stroma responded to terbinafine.This difference was statistically significant (P＜0.05).Conclusions Our findings suggest that topical terbinafine is an effective antifungal drug for the management of filamentous mycotic keratitis,particularly in cases with smaller and shallower ulcers.Its mean duration of treatment was longer than natamycin。

Abstract：Background The Chinese medical archive,Shang-Han Lun,is said to be written by ZHANG Zhong-jing (150-219 A.D.).This great influential work introduced the specific symptoms of six-channel disorders (Tai-Yang,Yang-Ming,Shao-Yang,Tai-Yin,Shao-Yin,and Jue-Yin) and their corresponding treatments,the combined syndromes,deterioration due to malpractice,and the concept of six-channel transitions.The concept of Shang-Han Lun is widely accepted by Chinese herbal doctors.However,no clinical data about Shang-Han symptoms are described in oriental or western medical reports.Methods The clinical prescription data of traditional Chinese medicine visits were extracted under the National Health Insurance in Taiwan.The application rate of 42 Shang-Han formulae in clinical practice was analyzed in detail with the software SPSS.Results Between 1999 and 2002,the prescription rate of Shang-Han formula was only 5.22% among a total of 528 889 576 Chinese herbal formula prescriptions.The most frequently used formula was Tai-Yang formulae (71.31%),followed by Shao-Yang formulae (17.49%) and the most commonly prescribed individual Shang-Han formulae were Ge-Gen Tang (16.11%),Shao-Yao-Gan-Cao Tang (12.97%),Xiao-Qing-Long Tang (11.79%),Ban-Xia Xie-Xin Tang (10.24%),and Xiao-Chai-Hu Tang (9.11%),which comprised 60.22% of the utilization rate of total Shang-Han formulae.Conclusions From the prescription patterns of Shang-Han formulae,there was no evidence of transitions among the six channels.Despite the fundamental role of Shang-Han Lun in traditional Chinese medicine,prescription of Shang-Han formulae was limited in clinical practice。

Abstract：Background Lymphangioleiomyomatosis (LAM) is a rare disease that predominantly affects young females.It is considered as an "orphan" life-threatening disease of unknown etiology,with uncertain clinical prognosis,and no effective treatment.LAM can arise sporadically or in association with tuberous sclerosis complex (TSC),an autosomal inherited syndrome characterized by hamartoma-like tumor growth and pathologic features that are distinct from manifestations of pulmonary LAM.The clinical course of LAM is characterized by progressive dyspnea on exertion,recurrent pneumothorax,and chylous fluid collections.Methods Fourteen cases of tAM from Zhongshan Hospital,Fudan University are reviewed,twelve were confirmed by lung biopsy,one by retroperitoneal lymphangioleiomyoma resection,and one by autopsy.Results All 14 patients were women,aged 18 to 69 years (mean 43.3 years,median 46.5 years).Haemoptysis (57.1%)and chylothorax (35.7%) were more frequent than those described in previous case series.Extrapulmonary findings such as renal angiomyolipoma (AML),enlarged abdominal lymph nodes,liver AML and retroperitoneal lymphangioleiomyoma were seen in 21.4%,14.3%,7.14% and 7.14% in 14 cases respectively,which is remarkably lower than in the previously reported.Abnormal smooth muscle cells (LAM cells) were found to line the airways,bronchioles,lymphatics and blood vessels leading to airflow obstruction and replacement of the lung parenchyma by cysts.There were some surprises in the autopsy case as several LAM cell emboli were found in the veins of mediastinum lymph nodes;LAM cells were found to be disseminated in soft tissues adjacent to the ilium.Conclusions Women with unexplained recurrent pneumothorax,tuberous sclerosis,or a diagnosis of primary spontaneous pneumothorax or emphysema in the setting of limited or absent tobacco use should undergo high-resolution computed tomography (HRCT) scan screening for LAM.Routine abdominal and pelvic imaging examinations should be performed to detect extrapulmonary involvement.The autopsy studies histologically suggested that LAM could be a multisystemic disease and LAM cells might possess metastatic potential。

Abstract：Objective To throw light on the superiority of the anti-angiogenesis activity of endostatin (ES) derivatives by reviewing the recent progress in the field of ES molecular structure modification.Data sources The data used in this article were mainly from PubMed with relevant English articles published from 1971 to May 2008.The search terms were "endostatin" and "angiothesis".Study selection Articles involved in the ES molecular structure modification and the original milestone articles were selected.Results A number of ES derivatives were designed and studied to improve its clinical relevance.The modified ES with polyethylene glycol (PEG),low molecular weight heparin (LMWH) and IgG Fc domain extended the circulation half-life.Meanwhile the recombinant ESs showed more potent anti-tumor activity than native ES in mouse xenografts.Mutated ES also changed its anti-angiogenesis activity.Conclusions The anti-angiogenesis treatment remains a promising tumor therapeutic strategy.New ES derivatives would be a good choice to meet the future challenge on clinical application of ES。

Homocysteine may impair vascular endothelial cell function.Besides,it may also induce cell damage,smooth muscle cell proliferation,thrombogenesis and oxidation of low-density lipoproteins.1

Epistaxis remains one of the most common otolaryngology emergencies.Severe epistaxis may be caused by internal carotid artery (ICA) pseudoaneurysm or cavernous fistula,which is clinically rare but life threatening if it is not diagnosed and treated timely.Most ICA pseudoaneurysms are mainly caused by trauma with few other causes.1-8 From January 1998 to December 2005,a total of 8 cases with non-traumatic carotid artery pseudoaneurysm were correctly diagnosed through digital subtraction angiography (DSA) in Ganzhou People's Hospital.The patients had suffered from serious nose bleeding repeatedly and had been resistant to routine treatments。

Relapsing polychondritis (RP) is a rare disorder of unknown cause.It is characterized by recurrent inflammation of cartilage and connective tissue.Airway complications are the most serious manifestations.1,2 The anesthetic management of patients with RP is challenging.Airway management is of primary importance because of the potential for collapse of supporting airway structures with resulting inability to intubate and ventilate the patient) Although it tends to occur in middle age (＞40 years),it has been reported in younger individuals.Herein we report a case of anesthetic management of a child with RP for tracheotomy combined with insertion of T tube stent and review several other cases。