2009年 · 第122卷第23期

Atrial fibrillation (AF) is the most common heart rhythm disturbance encountered in clinical practice.It affects at least ten million Chinese, constituting a major public health epidemic. For the shortness of resource in the initial stage of new China and the chaos during the culture revolution, there was a scarcity of AF data on the Chinese population. However, Chinese physicians had never stopped exploring in this field, which has provided a solid foundation for today's flourishing development in the research of AF. This paper aims to review the major achievements in dealing with AF in the past 60 years in China, especially in the latest 15 years。

Abstract：Background Reportedly, patients with persistent refractory angina due to end-stage coronary artery disease (CAD) not amenable to traditional revascularization techniques have experienced symptomatic relief following laser revascularization, either surgical transmyocardial revascularization (TMR) or percutaneous myocardial revascularization (PMR). In spite of several hypotheses (i.e., channel patency, placebo effect, denervation, neoangiogenesis), the mechanism of action and the benefit remains controversial.Methods A prospective trial utilizing positron emission tomography (PET) was conducted as an attempt to correlate quantified myocardial blood flow (MBF) to clinical improvement following PMR. Thirteen consecutive patients with angina class ＞Ⅱ in spite of maximal medical treatment underwent PMR with a holmium:yttrium-aluminum-garnet (Ho:YAG) laser.MBF at rest and under hyperemia was assessed by [~(13)N]ammonia PET at baseline, 3 and 6 months following PMR.Results Mean angina class and exercise tolerance time improved at 6 months compared with baseline (P＜0.001). The clinical results were accompanied with an improvement in hyperemic MBF (P=0.05) and a reduction in minimal coronary resistance (MCR; P＜0.05) in PMR-treated segments. Opposite effects, reduced hyperemic MBF and increased MCR,were observed in nontreated segments. The increase in MCR in nontreated segments revealed the favorable therapeutic impact achieved in PMR-treated segments.Conclusion The results of this trial utilizing a quantitative technique to quantify myocardial perfusion link clinical improvement post-PMR to neoangiogenesis and consistently improved microcirculation。

Abstract：Background Rosuvastatin has been claimed to be more potent than other statins in its ability to lower the low-density lipoprotein (LDL) cholesterol levels. This study aimed to investigate the clinical efficacy of rosuvastatin in LDL cholesterol lowering therapy for new or switched hyperlipidaemic Chinese patients.Methods This study was a retrospective one in patients who took rosuvastatin in the outpatient clinics of Prince of Wales Hospital during the period of July 1,2004 to June 30, 2005. The prescribing pattern, the utilization pattern and the side effect profile were recorded. Attainment of lipid goals for each patient was assessed according to the National Cholesterol Education Program Adult Treatment Panel (NCEPATP) III guidelines.Results A total of 261 Chinese patients (mean age (64.8±12) years; 55.6% male) were recruited into the study. The mean LDL-cholesterol level was (3.50±1.29) mmol/L prior to Rosuvastatin and (2.30±1.73) mmol/L after Rosuvastatin treatment (P＜0.0001). Rosuvastatin raised the LDL-cholesterol goal achievement rate from 28.0% to 74.3% in all patients combined (P＜0.0001) and from 11.0% to 79.0% for statin naive patients (P＜0.0001). Approximately 4% of patients developed side effects including myalgia, elevated liver enzymes, and dizziness.Conclusion Rosuvastatin was effective in improving LDL-cholesterol goal attainment and lowering LDL-cholesterol and triglyceride (TG) levels in either newly started or switched patients。

Abstract：Background Cathepsin S and its endogenous inhibitor cystatin C are implicated in the pathogenesis of atherosclerosis, especially in the plaque destabilization and rupture leading to acute coronary syndrome. However, whether circulating cathepsin S and cystatin C also change in association with coronary plaque morphology is unknown yet.Methods We recruited 98 patients with unstable angina (UA, n=56) or stable angina (SA, n=42) who had a segmental stenosis resulting in ＞20% and ＜70% diameter reduction in one major coronary artery on coronary angiography. Thirty-one healthy subjects served as controls. Intravascular ultrasound (IVUS) was used to evaluate plaque morphology. Plasma cathepsin S and cystatin C were measured as well.Results At the culprit lesion site, plaque area ((7.85±2.83) mm~2 vs (6.53±2.92) mm~2, P=0.027), plaque burden ((60.92±11.04)% vs (53.87±17.52)%, P=0.025), remodeling index (0.93±0.16 vs 0.86±0.10, P=0.004) and eccentricity index (0.74±0.17 vs 0.66±0.21, P=0.038) were bigger in UA group than in SA group. Plasma cathepsin S and cystatin C were significantly higher in patients than in controls (P＜0.01). Plasma cathepsin S was higher in UA group ((0.411 ±0.121) nmol/L) than in SA group ((0.355±0.099) nmol/L, P=0.007), so did the plasma cystatin C ((0.95±0.23) mg/L in UA group, (0.84±0.22) mg/L in SA group; P=0.009). Plasma cathepsin S positively correlated with remodeling index (p=0.402, P=0.002) and eccentricity index (r=0.441, P=0.001), and plasma cystatin C positively correlated with plaque area (r=0.467, P＜0.001) and plaque burden (r=0.395, P=0.003) in UA group but not in SA group.s Plasma cathepsin S and cystatin C increased significantly in UA patients. In angina patients, higher plasma cathepsin S may suggest the presence of vulnerable plaque, and higher plasma cystatin C may be a clue for larger atherosclerotic coronary plaque。

Abstract：Background Atherosclerosis is a chronic inflammatory disease. Accumulated evidences suggest a deep involvement of oxidative damage in the development of atherosclerosis, but little is discussed over the relationship between plasma glutathione redox status as the most important intrinsic antioxidant defensive mechanism and the atherosclerosis. Methods A total of 132 patients suspected with atherosclerosis were assigned to three groups by high frequency ultrasonic examination of the carotid artery. With the thickness of intima of the carotid artery as an index of degree of atherosclerosis progression, 56 were included in plaque-forming group (A), 42 in carotid artery intima-thickening group (B), and 34 in normal carotid artery intima-thickness group (C). All patients were subjected to the measurement of plasma glutathione (GSH) (reduced form GSH and oxidized form GSSG), nicotinamide adenine dinucleotide phosphate (NADP) (reduced form NADPH and oxidized form NADP~+), oxidized low density lipoprotein (oxLDL), and malondialdehyde (MDA). The GSH/GSSG and NADPH/NADP~+ redox potentials were calculated according to the Nernst equation, and their correlation with intima thickness and oxLDL was analyzed.Results With the thickening of artery intima (from group C to A), GSH concentration and the ratio of GSH/GSSG gradually reduced, and GSSG and GSH/GSSG redox potential gradually increased (more positive) (P＜0.05). The NADPH and NADPH/NADP~+ redox status also showed similar but milder changes. The products of oxidative stress oxLDL and MDA increased significantly along with the thickening of artery intima (P＜0.05). The analysis of the relationship between GSH/GSSG redox potential, intima thickness, and oxLDL showed positive correlations (P＜0.05). The plasma GSH/GSSG redox status was positively correlated with the intima thickness of the carotid artery and the oxidized injury of LDL. The redox status shifted to oxidizing direction along with the intima thickening and plaque-forming. Conclusion Elevated peroxidative glutathione redox status was deeply implicated in atherosclerosis progressing, and it may be a sensitive and reliable index for monitoring oxidative status in atherosclerosis。

Abstract：Background Cell therapy for cardiac regeneration is still under investigation. To date there have been a limited number of studies describing the optimal time for cell injection. The present study aimed to examine the optimal time for human umbilical cord blood cells (HUCBCs) transplantation after myocardial infarction (MI).Methods The animals underwent MI by ligation of the left anterior descending coronary artery and received an intravenous injection of equal volumes of HUCBCs or phosphate buffered saline at days 1,5,10 and 30 after MI. HUCBCs were detected by immunostaining against human human leucocyte antigen (HLA). Cardiac function, histological analysis and measurement of vascular endothelial growth factor (VEGF) were performed 4 weeks after cell transplantation. Results HUCBCs transplantation could improve cardiac function in rats that received transplantation at 5 and 10 days after MI. The best benefit was achieved in rats that received cells at 10-day after MI. Survival of engrafted HUCBCs, angiogenesis and VEGF expression were more obvious in the 10-day transplantation group than in the other transplantation groups. No evidence of cardiomyocyte regeneration was detected in any transplanted rats. Conclusions HUCBCs transplantation could improve cardiac function in rats that received HUCBCs at days 5 and 10 after MI with the optimal time for transplantation being 10 days post MI. Angiogenesis, but not cardiomyocyte regeneration, played a key role in the cardiac function improvement。

Abstract：Background Mutations of the LMNA gene encoding lamin A and C are associated with dilated cardiomyopathy (DCM), conduction system defects and skeletal muscle dystrophy. Here we report a family with a mutation of the LMNA gene to identify the relationship between genotype and phenotype.Methods All 30 members of the family underwent clinical and genetic evaluation. A mutation analysis of the LMNA gene was performed. All of the 12 exons of LMNA gene were extended with polymerase chain reaction (PCR) and the PCR products were screened for gene mutation by direct sequencing.Results Ten members of the family had limb-girdle muscular dystrophy (LGMD) and 6 are still alive. Two patients suffered from DCM. Cardiac arrhythmias included atrioventricular block and atrial fibrillation; sudden death occurred in 2 patients. The pattern of inheritance was autosomal dominant. Mutation c.73C＞G (R25G) in exon 1 encoding the globular domains was confirmed in all of the affected members, resulting in the conversion of arginine (Arg) to glycine (Gly). Conclusions The mutation R25G in exon 1 of LMNA gene we reported here in a Chinese family had a phenotype of malignant arrhythmia and mild LGMD, suggesting that patients with familial DCM, conduction system defects and skeletal muscle dystrophy should be screened by genetic testing for the LMNA gene。

Abstract：Background Many clinical studies suggest the inverse relationship between testosterone levels and insulin sensitivity in men, however the causative relationship of these two events is still not determined. The purpose of this study was to investigate the effects of testosterone replacement therapy (TRT) on insulin sensitivity, body composition, serum lipid profiles and high sensitivity C-reactive protein (hsCRP) in hypogonadotropic hypogonadal (HH) puberty undeveloped male patients.Methods In this prospectively designed study, we compared homeostasis model assessment of insulin resistance (HOMA-IR), insulin areas under the curves (AUC) of 3-hour oral glucose tolerance test (OGTT) and other metabolic parameters between 26 HH patients and 26 healthy men. The patients' HOMA-IR, insulin AUC, body composition, lipid profiles, hsCRP and other parameters were compared before and after nine-month TRT.Results The average levels of total testosterone (TT) in HH and healthy group were (0.9±0.6) nmol/L and (18.8±3.4) nmol/L, respectively. HOMA-IR in HH group was significantly higher than the healthy group (5.14±5.16 vs 2.00±1.38, P＜0.005). Insulin AUC in 3-hour OGTT in HH group was significantly higher than the healthy group (698.6±414.7 vs 414.2±267.5, P＜0.01). Fasting glucose level in HH group was significantly higher than control group ((5.1±0.6) mmol/L vs (4.7±0.3) mmol/l, P＜0.005). Height, weight and grasp strength of the patients were significantly increased after 9-month TRT. Significant reductions in HOMA-IR (from 5.14±5.16 to 2.97±2.16, P＜0.01), insulin AUC (from 698.6±414.7 to 511.7±253.9, P＜0.01) and hsCRP (from (1.49±1.18) mg/L to (0.70±0.56) mg/L, P＜0.05) were found after TRT. Serum total cholesterol, LDL-C, HDL-C and triglyceride were all decreased, albeit with no significant difference compared to the level prior to TRT.Conclusions HOMA-IR, insulin AUC and fasting glucose level in HH young male patients were significantly higher than those of the control group, which suggests that low level of testosterone in male adolescents might be a risk factor for insulin resistance. TRT can significantly improve patients' insulin sensitivity and suppress serum hsCRP, which in return suggests that TRT may prevent the HH patients from developing diabetes mellitus and cardiovascular diseases (CVD) in future。

Abstract：Background Correct drug selection, the key to successful chemotherapy, is one of the most difficult clinical decisions for the treatment of platinum-resistant recurrent ovarian cancer worldwide. The exact procedures for choosing drugs are undefined, currently relying on clinical trials and personal experience, which often results in disappointing outcomes. Here, we propose a new drug selection method, the "predictive molecule targeted routine chemotherapy", to choose relatively sensitive routine drugs and avoid relatively resistant routine drugs based on the specific predictive molecule expression of the individual tumor tissue.Methods From January 2004 to June 2008,26 cases of platinum-resistant recurrent ovarian cancer were prospectively recruited. Their routine chemotherapy drug choice was based on the expression of 6 predictive molecules (including p53) as determined by immunohistochemistry (the predictive molecule targeted routine chemotherapy group). A further 18 cases of platinum-resistant recurrent ovarian cancer were treated by experience and formed the control group. The response rate and the overall survival were compared between the two groups.Results The response rate to second-line chemotherapy was 28% in the control group and 77% in the predictive molecule targeted routine chemotherapy group (P=0.002). The response rate to third-line chemotherapy was 14% in the control group and 33% in the predictive molecule targeted routine chemotherapy group (P=0.268). The median overall survival of the predictive molecule targeted routine chemotherapy group (88 weeks) was significantly longer than the median overall survival of the control group (56 weeks) (P=0.0315).Conclusion The predictive molecule targeted routine chemotherapy is a new effective protocol for choosing drugs when treating platinum-resistant recurrent ovarian cancer。

Abstract：Background The perforator flap has become a very useful reconstructive means of soft tissue defect of extremities.The perforator flap from the inguinal region has advantages that include the ability to cover a large area with little donor site morbidity and provision of suitable thickness for reconstruction.Methods From July 1, 2005 to June 30, 2007, 10 patients with various types of soft tissue defect underwent reconstruction with 10 perforator flaps from the inguinal region. Six flaps were applied to the upper extremities and four flaps to the lower extremities. The dimensions of the transferred flaps ranged from 7-30 cm in length and 4-10 cm in width.Results The postoperative course of all 10 flaps was uneventful and all flaps survived. Distal small partial necrosis was observed in one case due to arterial insufficiency of the distal part of the flap. All patients were satisfied with the functional and esthetic resurfacing outcome.Conclusion Use of perforator flap from the inguinal region could overcome the disadvantages of the traditional free groin flap, and represents a safe and useful tool for coverage of soft tissue defects。

Abstract：Background Keloids have a predilection for the aural region because of the special shape of the pinna. It is difficult to resect keloids entirely and maintain a satisfactory pinnal shape. Surgical excision in combination with radiotherapy is considered to be the most efficacious treatment available for severe keloids. This study was conducted to evaluate the treatment of aural keloids with intralesional excision and immediate postoperative adjuvant radiotherapy. Methods Forty-six patients with a combined total of 74 aureloids were treated by intralesional excision and immediate postoperative adjuvant radiotherapy. All patients received a total dose of 20 Gy in 10 consecutive days. The time interval between keloid excision and delivery of the first radiotherapy fraction was ＜24 hours in all cases. The median follow-up was 2.2 years.Results Twenty-nine patients with 48 keloids (64.9%) were highly satisfied with their outcome, and were rated as good by the surgeon. Six patients with 12 keloids (16.2%) showed general satisfaction but wanted aesthetic refinement, and these patients were rated as fair by the surgeon. Three patients with four keloids (5.4%) showed no evidence of recurrence after surgery, but disliked the result because of the discoloration and irregularity of the scar surface. These patients were rated as poor by the surgeon. Partial recurrence occurred in 8 patients with 10 keloids (13.5%). No major complications were observed.Conclusion Intralesional excision and immediate postoperative adjuvant radiotherapy is well tolerated and very effective in preventing recurrence of aural region keloids。

Abstract：Background Recent studies have reported germline mutations in the perforin gene (PRF1) in some types of hemophagocytic lymphohistiocytosis (HLH). However, the prevalence of PRF1 mutations in HLH in Chinese pediatric patients has not been extensively studied. The aim of this study was to investigate the prevalence of mutations and sequence variations in the PRF1 gene in Chinese pediatric patients with HLH.Methods Polymerase chain reaction (PCR) was performed with five pairs of primers for the coding exons and the flanking intron sequences of PRF1. Sequencing of PCR products was subsequently applied in 30 pediatric patients with HLH and in 50 controls.Results Three heterozygous mutations in a coding region were found, which resulted in amino acid changes (C102F, S108N and T450M) in three patients. These mutations were not detected in control subjects. One patient had compound heterozygous mutations (S108N and T450M) in PRF1 as the background defect, and documented familial HLH type 2 (FHL2). One synonymous sequence variant (Q540Q) was observed in one patient but not in the controls. Two SNPs (A274A, H300H) in the coding region were detected in HLH patients and controls, but without differences in the heterozygosity rate between the two groups (P＞0.05 for all comparisons).Conclusions We have identified three patients with three heterozygous missense mutations in PRF1; two of those three mutations (C102F and S108N) have so far been found only from Chinese patients. These findings are useful in evaluating the prevalence of PRF1 mutations in Chinese pediatric patients with HLH, and to correlate their genotype with phenotype. Some patients without familial history probably have primary HLH, which should be suspected even beyond the usual age range。

Hepatic fibrosis is the liver's wound healing response to virtually all forms of chronic liver injury: toxic insult, viral infection, immunological conditions and metabolic diseases. Uncontrolled liver fibrosis eventually results in cirrhosis and associated complications, such as cancer and liver failure。

The pulmonary veins have been demonstrated to be the major source of atrial fibrillation (AF).~1 Isolation of the pulmonary veins is effective in curing patients with paroxysmal AF. However, this strategy is associated with limited success in some patients with paroxysmal AF and in most patients with persistent and permanent AF.~(2,3)

Hypereosinophilic syndrome (HES) is a rare disorder that can be seen in various organ systems, but its major tissue target is the heart.~1 The most characteristic cardiovascular abnormality in HES is endomyocardial fibrosis, initially described in 1936 by Loffler, who called it "fibroplastic parietal endocarditis with blood eosinophilia."

Mucinous cystadenoma is a rare benign tumor. Because it has no specific clinical manifestations or imaging features, preoperative clinical and radiologic diagnoses are difficult to make.~(1-3) We report here a case of primary mucinous cystadenoma of the terminal ileum wall. In this report, the characteristics of the disease will be discussed and the previous reports in literature on mucinous cystadenoma in other organs will be reviewed。

To the Editor: We read with a great interest the recent article by Zhang et al,~1 in which they reported a rare case of isolated right ventricular noncompaction with normal left ventricular systolic function in a 23-year-old female。