2009年 · 第122卷第17期

Abstract：Background A large transmural myocardial infarction often results in a dyskinetic or akinetic left ventricular aneurysm (LVA). This study aimed to explore the early and long-term clinical outcomes and to identify predictors for survivals and hospital re-admission after the repair of left ventricular aneurysm. Methods We followed up 497 patients who had undergone LVA repair from a single center in China between 1995 and 2005. The perioperative parameters were recorded. Risk factors for early mortality and long-term results were analyzed by multivariate Logistic regression. Cox's proportional hazard model was used to calculate risk factors for major adverse cardiac and cerebrovascular events, cause of death and re-admission. Kaplan-Meier curve was employed to analyze long-term survival. Results The operative mortality was 2.0%. The long-term mortality was 11.1% and cardiac causes contributed to 61.8% of the overall long-term mortality. Four hundred and thirty-two patients survived during the follow-up period and 37.5% of them had been re-admitted at least one time. One hundred and five patients experienced major adverse cardiac and cerebrovascular events. Survival analysis exhibited that the probability of survival at 1 and 5 years after operation was 96% and 86% respectively. Previous atrial fibrillation was the independent risk factor for early mortality. Independent risk factors for long-term mortality were poor left ventricular ejection fraction and stroke, and risk factors for cardiac mortality were intraventricular block, stroke and poor left ventricular ejection fraction. Stroke, intraventricular block and advanced age were independent risk factors for major adverse cardiac and cerebrovascular events, and New York Heart Association (NYHA) class Ⅲ-Ⅳ was the only risk factor for hospital re-admission. Conclusions Postinfarction LVA can be repaired and satisfying early and long-term clinical outcome can be obtained. Endoventricular circular plasty technique is the better choice than linear repair in patients with large LVA. Survival is affected in patients with poor heart function, intraventricular block and stroke.

Abstract：Background Frozen-thawed embryo transfer (FET) is the most common way to prevent serious late ovarian hyperstimulation syndrome and increase the cumulative pregnancy rate. We evaluated the effectiveness of an FET program for improving the embryo implantation and clinical pregnancy rates, and ultimate embryo utilization rate in infertility treatment. Methods Patients undergoing in vitro fertilisation (IVF) cycles from January 2006 to June 2008 were enrolled, including 179 patients who had undergone the first FET cycle after controlled ovarian hyperstimulation (COH) in which all embryos were frozen (group C1) and 1306 patients who had COH with fresh embryo transfer (ET) (group T1). Logistic regression was used to model the embryo implantation and clinical pregnancy rates based on the mother's age, numbers of oocytes retrieved, embryos transferred and high-quality embryos transferred. The embryo implantation and clinical pregnancy rates were also compared between two groups after adjusting for age, the numbers of oocytes retrieved and the numbers of embryos transferred. Results Logistic regression analysis confirmed that embryo implantation and clinical pregnancy rates in group C1 wereboth significantly higher than those in group T1 after adjusting for confounding factors (43.6% vs 29.0%, 63.1% vs 47.0%, respectively; P <0.01). The embryo implantation and clinical pregnancy rates were consistently higher in group C1 by comparing the age groups ≥35 or <35 years. The clinical pregnancy rates for the numbers of oocytes retrieved per cycle being ≥15 or <15 were higher in group C1, as was the embryo implantation rate. These differences were statistically significant for oocyte numbers ≥15 (P <0.05). The embryo implantation and clinical pregnancy rates in group C1 were both significantly higher than in group T1 when two or three embryos were transferred (P <0.05). Conclusion A program of freezing all embryos and performing FET improved the rates of embryo implantation and clinical pregnancy, and ultimately enhanced the embryo utilization rate.

Abstract：Background Sufentanil is a suitable choice for target-controlled infusion (TCI) because of its shorter context-sensitive half-time. The current study was to estimate the pharmacokinetics of sufentanil TCI in Chinese patients using the two-stage analysis. Methods Twelve adult patients with American Society of Anesthesiologists (ASA) physical status Ⅰ or Ⅱ undergoing elective surgery under general anesthesia were included. Anesthesia was induced with propofol, rocuronium and sufentanil administered by TCI lasting for 30 minutes, with target effect-site concentration of sufentanil 4 or 6 ng/ml. Frequent arterial blood samples (1.5 ml) were taken during and up to 24 hours after sufentanil TCI. Before the end of surgery, another arterial blood sample (1.0 ml) was drawn for the blood-gas analysis. Plasma sufentanil concentrations were determined by liquid chromatography-tandem mass spectrometry (limit of quantitation was 5 pg/ml). The data were analyzed with the two-stage approach, linear regression and correlation analysis. Results The pharmacokinetics of sufentanil TCI were adequately described by a three-compartment model. The variables were derived as follows: the volume of central compartment (V1) was 5.4 L, volume of distribution at steady-state (Vdss) was 222.6 L, metabolic clearance (Cl1) was 0.84 L/min and elimination half-life (t1/2Y) was 389 minutes. Patients' age, gender and PaCO2 correlated significantly with the pharmacokinetic parameters. The Vdss, volume of slowly equilibrating compartment (V3) and t1/2Y increased, and rapid distribution clearance (Cl2) decreased with increasing patient age. Male patients had larger values of Vdss, volume of rapidly equilibrating compartment (V2) and V3 than female patients. The Vdss and V3 increased with higher PaCO2 values. There were no significant correlations between the pharmacokinetic variables and body weight, height, lean body mass, plasma albumin, sufentanil dose, duration of surgery, pH or base excess of blood (BE-B). Conclusions The pharmacokinetics of sufentanil TCI in Chinese patients can be optimally described by a three-compartment model. The pharmacokinetic analysis technique may affect the pharmacokinetic parameters and correlations.

Abstract：Background Reports of applying cervical pedicle screw (CPS) system in the posterior cervical spine surgeries are limited because of its inherent risk of neurovascular injury. The clinical results of cervical spine instability treated with CPS system were retrospectively analyzed, and the clinical efficacy and safety of this management were evaluated. Methods Twenty-five patients with cervical spine instability undergoing posterior C3-C7 single/double door laminoplasty and free-hand CPS fixation as well as graft fusion were investigated; of whom, 3 were due to trauma, and 22 degenerative cervical pathogenesis. One hundred and fifty in total, CPSs were implanted in 5 cervical segments for 1 patient, 4 for 2, 3 for 18, and 2 for 4. Japanese Orthopaedic Association (JOA) score and its improvement rate, neck disability index (NDI), segmental stability, pedicle cortex perforation rate and other complication-associated parameters were assessed. Results The average follow-up was 16.6 (6-30) months. Compared with pre-operative values, JOA score improved by 4.10±0.84 points on average (P <0.05) at 6 months post operation, with a mean improvement rate of 61%. While the pre-operative and 6-month post-operative NDI were 32.96±6.13 and 16.84±4.40 (P <0.05), respectively. At 6-month post-operation and the final follow-up, fused segments were stable. Pedicle cortex perforation rate was 8.0%, with no neurovascular complications observed. Conclusions Anatomizing the pre-operative radiographic data facilitates the precise operative design prior to surgery; and CPS system is capable of offering safe and satisfying outcomes in the management of cervical spine instability.

Abstract：Background Transarterial chemoembolization (TACE) is the most widely used primary treatment for unresectable hepatocellular carcinoma (HCC) due to its survival benefit, though its clinical effect is still far from satisfactory. Jiedufang (JDF) granule preparation is a commonly used Chinese herbal medicine formula for HCC. The aim of this study was to evaluate the effect of combined therapy with TACE and JDF granule preparation in treatment of unresectable HCC on survival. Methods A retrospective study of TACE was performed in 165 patients with unresectable HCC who were admitted between January 2002 and December 2007 in Changhai Hospital, Shanghai, China. Of the 165 patients, 80 patients (study group) received combined therapy consisting of TACE and a long-term maintenance treatment with oral JDF granule preparation, and the remaining 85 patients (control group) received TACE alone. The survival rates of both groups were calculated by the Kaplan-Meier method. Factors possibly affecting survival were assessed by multivariate analysis in the Cox proportional hazard model, such as maximum tumor size, number of lesions, portal vein invasion, and etc. Results The median overall survival was 9.2 months (95% Cl: 6.94-11.46) in the study group versus 5.87 months (95% Cl: 4.21-7.52) in the control group. In the study group,survival rates of the 1-, 2- and 3-year follow-up were 41.2%, 18.4%, and 9.6%, respectively. Significant independent prognostic factors identified by the Cox regression analysis were as follows: serum hepatitis B surface antigen (HBsAg) (P=0.014), maximum tumor size (P=0.027), number of lesions (P <0.001), portal vein invasion (P <0.001), and the therapy model (P=0.006). Conclusion Combination therapy of TACE and JDF granule preparation may significantly prolong survival of patients with unresectable HCC.

Abstract：Background Blood glucose control improves the outcome of diabetic patients with stroke, but the target range of blood glucose control remains controversial. The functional recruitment of ischemia penumbra is extremely important to the recovery after stroke. The present study aimed to explore the expression of brain-type glucose transporters (GLUT1 and GLUT3) in cerebral ischemic penumbra at different blood glucose levels and different ischemic-reperfusion time in diabetic hypoxia-ischemia rats. The results might provide an experimental basis for clinical treatment of diabetic patients with stroke. Methods The Wistar rats included in this study were randomly assigned to 4 groups (50 rats each): normal control group (NC), uncontrolled diabetic group (DM1), poorly-controlled diabetic group (DM2), and well-controlled diabetic group (DM3). Diabetic rats were induced by single intraperitoneal injection of streptozotocin, and the focal ischemic rat model of middle artery occlusion (MCAO) was made by insertion of fishing thread in 6 weeks after the establishment of the diabetic model. Each group was divided into 5 subgroups (10 rats each): four focal ischemic subgroups at different ischemic-reperfusion time (at 3,12, 24 and 72 hours after reperfusion, respectively) and one sham-operated subgroup. The mRNA and protein expression of GLUT1 and GLUT3 was assessed by RT-PCR and Western blotting, respectively. Results There was significant difference in the mRNA expression of GLUT1 and GLUT3 between the four focal ischemic subgroups and the sham-operated subgroup at different reperfusion time in each group. The mRNA expression of GLUT1 and GLUT3 in the 4 ischemic groups began to increase at 3 hours, peaked at 24 hours after reperfusion and maintained at a higher level even at 72 hours compared with that of the sham-operated subgroup. The mRNA expression of GLUT1 increased more significantly than that of GLUT3. The mRNA expression of GLUT1 and GLUT3 was significantly different between the diabetic groups and normal control group. The mRNA expression of GLUT1 and GLUT3 was increased more significantly in the diabetic groups than that in the normal control group. There was a significant difference in the mRNA expression in the groups with different blood glucose levels. The mRNA expression tended to decrease with increased blood glucose levels. The expression trend of GLUT1 and GLUT3 protein was similar to that of GLUT1 and GLUT3 mRNA. Conclusions GLUT1 and GLUT3 expression was notably up-regulated in the penumbra region after cerebral ischemia in this study. But the up-regulated amplitude of GLUT1 and GLUT3 in the diabetic rats with cerebral ischemic injury became smaller than that of the normal controls. In the treatment of diabetic patients with cerebral embolism, blood glucose control should not be too strict, otherwise the up-regulation of GLUT1 and GLUT3 induced by cerebral ischemic injury might not be able to meet the needs of energy metabolism in cells.

Abstract：Background Real-time perfusion imaging (RTPI) using ultrasound contrast agents has shown good "accuracy" in detecting myocardial infarction, however its accuracy in the assessment of peri-infarct ischemia and stress echocardiography are not known. The aim of this study was to determine the accuracy of RTPI in assessment of ped-infarct ischemia during dobutamine and adenosine stress. Methods We employed the RTPI modality (Agilent and ATL Philips) in a canine model (18 dogs) of distal coronary occlusion and proximal coronary stenosis. Using coronary flow probe recordings, the physiologic significance of proximal coronary stenosis was established by confirming abolition of the coronary reserve. The contrast agent Optison was given as a slow bolus injection at baseline, during prolonged distal coronary occlusion, dudng adenosine bolus stress and dudng dobutamine stress. Tdphenyltetrazolium chloride (TTC) staining was used to verify a distal infarction. RTPI recordings at baseline, the distal coronary occlusion and stress protocols were randomly mixed and reviewed blindly. Results In all but one dog, RTPI detected a distal infarct as small as 9% of the left ventricle. The sensitivity, specificity and overall diagnostic accuracy of RTPI in the detection of distal infarcts were: 94%, 89% and 92%, respectively. The sensitivity, specificity, and overall diagnostic accuracy of RTPI in the assessment of peri-infarction ischemia were 83%, 92% and 88% for adenosine stress and 95%, 86% and 91% for dobutamine stress, respectively. Conclusions Even small distal infarcts can be detected by RTPI; peri-infarct ischemia can be accurately recognized by RTPI during stress; adenosine and dobutamine stress appear equally reliable in the RTPI evaluation of peri-infarct ischemia.

Abstract：Background Optic nerve injury, caused by retinal and optic nerve diseases, can eventually result in vision loss. To date, few effective treatments have been discovered to restore visual function. Previous studies showed that recombinant human erythropoietin (rhEPO) has a neuroprotective effect on the central nervous system, particularly in nerve injury. In this study, we investigated the effects of rhEPO on axonal regeneration and functional restoration following optic nerve injury. This was done by measuring the expression of growth associated protein 43 (GAP-43), a marker for neuronal regeneration, on the retina and flash-visual evoked potential (F-VEP). Methods Adult Wistar rats were randomly assigned to rhEPO and control (saline) groups. Optic nerve crush injury models were established and rhEPO or saline were immediately injected into the vitreous cavity. The expression of GAP-43 was detected by immunohistochemistry and the F-VEP was measured pre-injury, immediately after injury, 1 week and 2 weeks post-injury. Results No detectable staining for GAP-43 was observed in normal retina. In the control group, the level of GAP-43 expression was higher at 1 week post-injury, but decreased at 2 weeks. In the rhEPO group, the level of GAP-43 expression was notably higher at both 1 week and 2 weeks. At each time point post-injury, the expression of GAP-43 in rhEPO group was significantly higher than the control group (P <0.05). Obvious changes in F-VEP examination were detected immediately after optic nerve injury, including significantly prolonged latency and decreased amplitude of the P1 wave. In the control group, the changes were still obvious at 1 week. The latency was decreased and the amplitude had slightly recovered to 28.23% of the normal value at 2 weeks. In rhEPO group, there was significantly more recovery than the control group at 1 week and 2 weeks post-injury (P <0.05). The latency most close to the normal level and the amplitude had recovered to 65.51% of the normal value at 2 weeks. Conclusions rhEPO can prolong the expression of GAP-43 and increase its intensity after optic nerve injury, thereby promoting neural repair and axonal regeneration. Under the protection of rhEPO, the conduction velocity of the optic nerve recovered significantly. Therefore, rhEPO has neuroprotective effects on the optic nerve and promotes functional restoration of the optic nerve.

Abstract：Background Epidermal growth factor (EGF), a mitogenic polypeptide that binds to cell surface receptors, is an important regulator of cell differentiation and fetal lung surfactant synthesis. We investigated the preventive and therapeutic effects of EGF in respiratory distress syndrome, by administering EGF and dexamethasone (Dex) to mother rat before delivery. Methods Six female Sprague-Dawley (SD) rats were assigned to three groups (2 rats each); EGF or Dex was given to pregnant rats (EGF group and Dex group, respectively) from gestational day 16 to day 18 by intraperitoneal injection, while the group with normal saline injection was used as negative controls. Fetal rats were taken out of womb by hysterotomy on day 19 of pregnancy, then 24 fetal rats were randomly chosen from each group. Their body weights were measured, and pulmonary surfactant protein-A and -B (SP-A and SP-B) antigens were determined by immunohistochemical staining in each group. The histologic structure was examined under a light microscope, a light microscopic image system or an electron microscope. Results The expressions of SP-A and SP-B could be detected in each group. A significant difference was observed for SP-A and SP-B in the EGF and Dex groups compared with the control group (P<0.01). Image analysis showed that the relative values of air space area and interalveolar septa area in the EGF and Dex groups were significantly greater than those in the control group (P <0.01), while no significant difference was found between the two groups (P >0.05). The ultrastructural features of fetal lungs showed that the number of alveolar type 11 cells containing lamellar bodies in the EGF and Dex groups was apparently increased compared with that in the control group. The mean body weight of fetus from the Dex group was smaller than that from the control group ((1.3192±0.0533) g, (1.3863±0.0373) g), but there was no significant difference between the EGF group and the control group ((1.3986±0.0730) g, (1.3863±0.0373) g). Conclusions Maternal treatment with EGF and Dex on days 16-18 of gestation could promote morphogenesis and increase the surfactant levels in premature fetal lung. However, maternal treatment with Dex, not EGF, decreased the body weight.

Abstract：Background Invasive pulmonary aspergillosis (IPA) is a severe and frequently fatal disease in patients receiving treatment with immunosuppressive agents such as cyclophosphamide. Aspergillus fumigatus (A. fumigatus) now is a leading cause of IPA. Dectin-1 and Toll-like receptor 2 (TLR2) are important pattern recognition receptors involved in immune responses to A. fumigatus in vitro. However, the expression of the two receptors during the infection of A. fumigatus in vivo is not completely understood. The effects of cyclophosphamide treatment on the expression of the receptors need to be further studied. Methods We established different immune status in mice models with or without A. fumigatus infection. On days 1, 3 and 5 post inoculation, pulmonary tissues from mice of the different groups were harvested. Dectin-1 and TLR2 mRNA expression in the lungs of the mice were investigated by real-time PCR. The pulmonary fungal burden in the mice with A. fumigatus infection was also evaluated. Results In the immunocompetent mice, three days after A. fumigatus inoculation, dectin-1 and TLR2 expression increased markedly compared with the normal control group. Cyclophosphamide inhibited the clearance of pathogens and the expression of dectin-1 with or without A. fumigatus infection in the lungs as well. There was no statistical difference in TLR2 expression between the different immune status groups. Conclusions Our results suggest that in vivo, dectin-1 and TLR2 are activated during the experimental period which would provide a broad range of possibilities for a specific and effective inflammatory response to kill A. fumigatus. Inhibition of dectin-1 expression may be one of the mechanisms of cyclophosphamide in the development of IPA.

Abstract：Background Most patients with acute myelogenous leukemia (AML) suffer from disordered hemostasis. We have previously shown that annexin II (Ann II), a high-affinity co-receptor for plasminogen/tissue plasminogen activator, plays a central role in primary hyperfibrinolysis in patients with acute promyelocytic leukemia (APL). The expression of Ann Ⅱ in cells from patients with major subtypes of AML and the effect of arsenic trioxide (As2O3) on Ann Ⅱ expression in AML cells were investigated to determine whether As2O3-mediated downregulation of Ann Ⅱ could restore hemostatic stability. Methods A total of 103 patients (48 females and 55 males; age, 19-58 years) were included. Plasma samples were collected before and after treatment as well as after complete remission. Ann Ⅱ and plasminogen activation were Results Before As2O3 treatment, Ann II mRNA expression (real-time PCR) was the highest in M3 cells (P <0.05), higherin M5 cells than that in M1, M2, M4, and M6 cells (P<0.001), and positively correlated with Ann II protein expression (flowcytometry) (r=0.752, P <0.01). Exposure for up to 120 hours to As2O3 (1 pmol/L) had no significant effect on Ann Ⅱ protein in M1 and M2 leukemic cells, but decreased Ann Ⅱ protein expression twofold within 48 hours of exposure in M3 cells (P <0.05) and twofold within 96 hours in M5 cells (P<0.05). The rate of plasmin generation was higher in APL, M5, and M4 cells than in M1, M2, and M6 cells. Conclusions As2O3 may reduce hyperfibrinolysis in AML by downregulation of Ann II. Furthermore, As203 affects more than one form of AML (APL, M4 and M5), suggesting its potential role in their management.

Kidney disease is a worldwide public health problem. The orevalence of end-stage renal disease (ESRD), a final outcome of kidney disease, has increased progressively in the past decades and has emerged as a great burden to the healthcare system in China. Glomerulonephritis is still the most common cause of ESRD in China. However, the prevalence of diabetes and hypertension are increasing dramatically. There are modifiable risk factors for the development of progressive renal dysfunction。

Respiratory disease is the term for diseases of the respiratory system. These diseases range from mild and self-limiting such as the common cold to life-threatening such as bacterial pneumonia or pulmonary embolism. They are common and important causes of illness and death. In the US, people suffer 1 billion colds per year. One out of 7 people in the UK are affected by some kinds of chronic lung diseases, most commonly chronic obstructive pulmonary disease (COPD) and asthma. Respiratory disease accounts for over 10% of hospitalizations and over 16% of deaths in Canada。

Cutaneous warts are common skin diseases caused by human papillomavirus (HPV) infection. The prevalence of cutaneous warts varied from 2.4%-12.9%, with common warts, planta warts and genital warts being the most common ones.1-4 About 67% of patients with warts might resolve spontaneously within 2 years,4 while in some patients warts persist for years.3 A cellular immune response is essential for the clearance of HPV.6,7 Treatment modalities are usually ablative。

Hereditary spastic paraplegia (HSP), also known as familial spastic paraparesis or Striimpell-Lorrain disease, is a large group of inherited, heterogeneous neurologic disorders caused by the degeneration of corticospinal axons.1,2 The prevalence is estimated at 3-10 cases per 100000 people in Europe,3 and is uncertain in other continents. Most patients have the same core features, which are characterized by spastic gait, lower limb hypertonicity, hyperreflexia, extensor-plantar responses, muscle weakness, and occasionally decreased vibration sense at the ankles, bladder dysfunction, pes cavus, or scoliosis.1,4

Patients with hepatoceUular carcinoma (HCC) frequently develop life-threatening spontaneous rupture (SR) of their tumors. The extent of tumor rupture and rate of patient mortality increases with tumor volume.1 After an acute phase, the majority of patients die within 12 months of rupture due to disease progression and/or extensive peritoneal metastases with a median survival time of 9.7 months if untreated by an additional effective excision.2 For those with effective excision, the 1-, 3-, and 5-year survival rates are only 54%, 35%, and 21%, respectively.3 Herein we report on the case of a giant medial lobe HCC that ruptured spontaneously and was primarily treated with repeated radiofrequency ablation (RFA).

Aplastic anemia (AA), myelodysplastic syndrome (MDS), and paroxysmal nocturnal hemoglobinuria (PNH) are bone marrow failure disorders closely related to each other. PNH often occurs in the course of AA or MDS-refractory anemia (RA). Acquired AA patients, particularly with PNH clones, have benefited from the immunosuppressive therapy (IST). Although the possible immune abnormality was not considered as the core mechanism in MDS pathology,1 MDS-RA cases with PNH clones also reflected a high probability of response to IST. We report here one rare case of advanced MDS with PNH clones diagnosed by flow cytometry (FCM).

Diabetes mellitus (DM) is a most common endocrine disorder and it is characterized by high serum glucose levels and by disturbance of lipid metabohsm. As a result, the patients can develop long-term systemic complications. Numerous skin lesions are associated with either type 1 or type 2 diabetes mellitus, and they are specific chronic complications of the disease.2 Cutaneous xanthomas result from deposition of lipids in the histiocytes in the dermis or subcutaneous tissue. Eruptive xanthomas are a characteristic, but uncommon complication of diabetes mellitus associated with a more sustained hypedipidemia affecting plasma triglycerides and cholesterol, and hyperglycemia with glycosuria.1,3

Multiple epiphyseal dysplasia (MED) is an osteochondrodvsolasia characterized clinically by mild short stature and early-onset degenerative joint disease and radiographically by epiphyseal hypoplasia/ dysplasia. However, the intelligence of the patients is within the normal range. We report a rare case of a MED family with five affected individuals seen in 2009 as follows。

Gastric duplication is a congenital malformation occurring mpstly in infants or childhood. It is rarely found in adults.' Some are completely separate cystic lesions unconnected to the stomach, which makes them more difficult to diagnose in a clinical setting.2 Differential diagnoses of this separate form often include a pancreatic pseudocyst or pancreatic cystic tumor according to the anatomic location. Some associated anomalies have been documented in the literature, but these are rare. Herein, we report a case of gastric duplication at the splenic hilum of a young female adult with a clinical impression of endometriosis due to the coexistence of a right ovarian cyst and image findings。