2010年 · 第123卷第11期

Acute ST elevation myocardial infarction, caused by the acute occlusion of a coronary artery, is a life-threating emergency. Reperfusion therapy, namely, using the mechanical or chemical method to open the infarction related artery (IRA), has become the key treatment for such patients. As the duration of a coronary occlusion is the main determinant of final infarct size, and the latter determines the outcome of acute myocardial infarction (AMI) patients, the time issue has long been the most important topic in reperfusion therapy. Besides the time issue, several other factors must be considered: the efficiency of the reperfusion therapy, and the availability of the reperfusion therapy。

Abstract：Background Although thrombolytic therapy with rescue percutaneous coronary intervention (PCI) is a common treatment strategy for ST-segment elevation acute myocardial infarction (STEMI), scant data are available on its efficacy relative to primary PCI, and comparison was therefore the aim of this study.Methods This multicenter, open-label, randomized, parallel trial was conducted in 12 hospitals on patients (age ≤70 years) with STEMI who presented within 12 hours of symptom onset (mean interval >3 hours). Patients were randomized to three groups: primary PCI group (n=101); recombinant staphylokinase (r-Sak) group (n=104); and recombinant tissue-type plasminogen activator (rt-PA) group (n=106). For all patients allocated to the thrombolytic therapy arm, coronary angiography was performed at 90 minutes after drug therapy to confirm infarct-related artery (IRA) patency; rescue PCI was performed in cases with TIMI flow grade ≤2. Bare-metal stent implantation was planned for all patients. Results After randomization it required an average of 113.4 minutes to start thrombolytic therapy (door-to-needle time)and 141.2 minutes to perform first balloon inflation in the IRA (door to balloon time).Rates of IRA patency (TIMI flow grade 2 or 3) and TIMI flow grade 3 were significantly lower in the thrombolysis group at 90 minutes after drug therapy than in the primary PCI group at the end of the procedure (70.5% vs. 98.0%, P <0.0001, and 53.0% vs. 85.9%, P <0.0001, respectively). Rescue PCI with stenting was performed in 117 patients (55.7%) in the thrombolytic therapy arm. Rates of patency and TIMI flow grade 3 were still significantly lower in the rescue PCI than in the primary PCI group (88.9% vs. 97.9%, P=0.0222, and 68.4% vs. 85.0%, P=0.0190, respectively). At 30 days post-therapy, mortality rate was significantly higher in the thrombolysis combined with rescue PCI group than in primary PCI group (7.1% vs. 0, P=0.0034). Rates of death/Ml and bleeding complications were significantly higher in the thrombolysis with rescue PCI group than in the primary PCI group (10.0% vs. 1.0%, P=0.0380, and 28.10% vs. 8.91%, P=0.0001, respectively).Conclusions Thrombolytic therapy with rescue PCI was associated with significantly lower rates of coronary patency and TIMI flow grade 3, but with significantly higher rates of mortality, death/Ml and hemorrhagic complications at 30 days, as compared with primary PCI in this group of Chinese STEMI patients with late presentation and delayed treatments。

Abstract：Background The transradial approach is regarded as a useful vascular site for coronary procedures. The aim of this study was to test whether 4Fr catheters assisted by ACIST variable rate injector system can produce comparable angiographic quality and reduce the risk of radial artery injury compared to hand manifold 6 Fr catheters.Methods A total of 1816 patients were studied consecutively, among whom 856 patients received coronary angiography by 4 Fr catheters (4Fr group) and 960 patients by 6 Fr catheters (6Fr group). Angiographic and procedural characteristics were observed and recorded. The luminal inner radial arterial diameter before and after the procedure were collected.Results The baseline clinical characteristics were similar in both groups. There were no significant differences in procedure time, radiation dose and quality scores in both groups (P>0.05), but more contrast media was delivered in the 6Fr group (P <0.001). The mean radial arterial diameter six months after the procedure in the 6Fr group reduced significantly compared to that measured one day prior to the procedure (P <0.001).Conclusions Coronary angiography using the 4Fr catheters with Acist power injection system can achieve an acceptable diagnostic quality while at the same time minimizing radial artery injury and contrast media consumption。

Abstract：Background Spontaneous attack of variant angina (VA) is a unique component of coronary artery disease (CAD), and associated with severe cardiac events. However, no data are available regarding sex differences in Chinese patients with spontaneous attacks of VA. Accordingly, the present retrospective study was initiated to evaluate the Clinical characteristics of Chinese female patients with spontaneous attacks of VA.Methods From January 2003 to January 2008, a total of 209 patients were diagnosed to have had a spontaneous attack of VA at Fu Wai Hospital. Of them, 27 were female, and their clinical findings were collected and compared with male patients for aspects of risk factors, clinical features and angiographical findings.Results Spontaneous attacks of VA was relatively uncommon in female (12.9%) compared with male patients. The female patients were less likely to have a history of smoking (14.8% vs. 79.7%, P <0.001), more likely to have a family history of CAD (33.3% vs. 11.0%, P<0.01), and to have had a greater incidence of ventricular fibrillation during attack (11.1% vs. 2.2%, P<0.05). There were no significant differences in other characteristics between the two groups.Conclusion Chinese female patients who experienced a spontaneous attack of VA had the characteristics of less smoking history, more family history of CAD and higher occurrence of ventricular fibrillation than male patients。

Abstract：Background Genetic factors can influence antihypertensive response to metoprolol, and many studies focused on the relationship between the genotype in β1-adrenergic receptor and blood pressure (BP), little was known about the association of angiotensin-converting enzyme (ACE) genotype with the therapeutic result of metoprolol. The present study aimed to investigate whether the ACE gene insertion (I) / deletion (D) polymorphism Is related to the response to metoprolol in Chinese Han hypertensive patients.Methods Ninety-six patients with essential hypertension received metoprolol (100 mg once daily) as monotherapy for 8 weeks. Twenty-four hours ambulatory blood pressure monitoring and dynamic electrocardiogram were performed before and after treatment. Genotyping analysis was performed using PCR. The association of the ACE gene I/D polymorphism with variations in BP and heart rate (HR) was observed after the 8-week treatment.Results The patients with ACE gene II polymorphism showed greater reduction in 24-hour average HR than those with ID or DD polymorphisms (P=0.045), no effect of this genotype on the reduction in seating HR or in BP was observed. After adjusting for age, gender, body mass index, BP and HR at baseline, the ACE gene I/D polymorphism was still an independent predictor for variations in 24-hour average HR.Conclusions The II polymorphism in ACE gene could be a candidate predictor for greater reduction in 24-hour average HR in Chinese Han hypertensive patients treated by metoprolol. Greater benefits would be obtained by patients with II polymorphism from the treatment with metoprolol. Larger studies are warranted to validate this finding。

Abstract：Background The association between increased serum uric acid (SUA) levels and cardiovascular risk has been debated for decades. Several large studies have provided conflicting results regarding the clinical significance of elevated SUA levels in cardiovascular disease (CVD) or cerebrovascular disease. The aim of this study was to investigate the relationship between SUA and CVD and all-cause mortality and their potential diagnostic value.Methods A total of 3570 in-patients ranging in age from 56 to 95 years (mean (67.36±11.36) years) were selected from 20 hospitals in Beijing and Shanghai. A carefully designed questionnaire was used to gather baseline data of each patient. All patients were divided into two main groups according to their SUA levels: high SUA and normal SUA groups. Serum indices and other important parameters were measured.Results Compared with normal SUA group, high SUA group had significant difference in systolic blood pressure (SBP), total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), body mass index (BMI), and age (P <0.05 or P <0.01). High SUA prevailed in female and patients with history of essential hypertension, while history of smoking and diabetes showed no significant difference between two groups. All-cause and CVD mortality occurred more frequently in high SUA group than in normal SUA group. In the accumulative survival analysis, high SUA group had lower survival rate than normal SUA group both in CVD and all-cause mortality. COX regression analysis indicated that the history of smoking, age and high SUA were independent risk factors for the development of CVD. Conclusions These preliminary observations suggest that patients with high SUA levels would face higher risk of mortality. SUA measurement may be applied as a routine predictor for clinical assessment。

Abstract：Background The mortality and disability associated with progressing ischemic stroke are much higher than general ischemic stroke. This study was conducted to determine the risk factors for progressing ischemic stroke in the Han population of northeast China.Methods A total of 2511 patients with ischemic stroke within 24 hours admitted to Department of Neurology, First Affiliated Hospital of Harbin Medical University were studied, from November 2007 to May 2009. All of the patients were classified into the progressing or non-progressing group according to the scores of the Scandinavian Neurological Stroke Scale. Fifteen putative risk factors were evaluated. The influence of risk factors for progressing ischemic stroke was analyzed with the simple Logistic analysis, the multiple Logistic analysis, and the stepwise Logistic regression model. All the statistical analysis was performed by SAS 9.1.Results Totally 359 (14.3%) patients met the criteria for progressing ischemic stroke. The Logistic analysis showed that age, family stroke history, smoking history, hypertension on admission, a drop in blood pressure after admission to the hospital, high serum glucose on admission, and fever were related to progressing ischemic stroke in the Han population of northeast China.Conclusion People of the ischemic stroke with these factors are more likely to develop progressing ischemic stroke。

Abstract：Background Glanzmann thrombasthenia (GT) is an autosomat recessive bleeding disorder characterized by the tendency to hemorrhage and the inability of platelets to aggregate in response to agonists. GT is caused by a defect of the platelet glycoprotein IIb/IIIa complex. The objective of this study was to describe the clinical features and the genetic cause of GT in a 6-year-old girl from south China.Methods A three-generation family was studied. The proband patient aged 6 years and her parents undertook examinations of platelet counts, blood film, bleeding time, platelet aggregation, and flow cytometry. All coding exons of the ITGA2B and ITGB3 genes were amplified by polymerase chain reaction (PCR), and direct sequencing was performed for mutational screening on the patient and normal controls consisted of 52 healthy blood donors. Reverse transcription PCR was conducted to test for exon skipping.Results The proposita patient showed dispersing platelets, prolonged bleeding time, and severely reduced platelet aggregation in response to the physiological agonists adenosine diphosphate (ADP), epinephrine, collagen, and ristocetin. Flow cytometric measurements showed that the contents of allb and β3 were significantly decreased. Sequencing results demonstrated two different types of heterozygous mutations existed in the allb gene (c.2930delG and IVS15-1delG). The compound mutations were also confirmed in the patient's mother and father separately.Conclusions The allbp3 deficiency of the proband was caused by two compound ITGA2B mutations, which were first reported in Chinese GT patients. The IVS15-1delG was first confirmed to cause an exon skipping。

Abstract：Background Although neurologic manifestations often complicate the course of patients with multiple myeloma, direct central nervous system invasion is rare. This study explored the neurologic symptoms, signs, clinical features, therapy and prognosis of Chinese patients with central nervous system myeloma invasion.Methods The diagnosis, therapy and prognosis were analyzed retrospectively in 11 Chinese multiple myeloma patients with central nervous system infiltration from a total of 625 patients who have been treated at Changzheng Hospital (Shanghai, China) between January 1993 and May 2009. Survival curve was constructed with the use of Kaplan-Meier estimates.Results There were 11 patients with central nervous system involvement from 625 multiple myeloma patients. The occurrence rate was 1.8%. Ten of the 11 patients had other extramedullary diseases. Symptoms included cerebral symptoms, cranial nerve palsies, and spinal cord or spinal nerve roots symptoms.Cerebrospinal fluid was abnormal in 7 patients, usually exhibiting pleocytosis and elevated protein content, plus positive cytologic findings. Specific magnetic resonance imaging findings suggestive of central nervous system invasion were found in 9 patients. After a median follow-up of 19 months, 3 patients were alive. The median overall survival for all patients was 23 months, while the median overall survival for patients after central nervous system invasion was merely 6 months.Conclusions It is exceedingly rare for there to be central nervous system infiltration in multiple myeloma patients. When it occurs, the prognosis is extremely poor despite the use of aggressive local and systemic treatment including stem cell transplantation。

Abstract：Background Rheumatoid arthritis (RA) is characterized by inflammation of the synovial membrane, leading to invasion of synovial tissue into the adjacent cartilage matrix with degradation of articular cartilage and bone as a consequence. Dickkopf-1 (DKK-1) and osteoprotegerin (OPG) have been demonstrated to be key molecules involved in bone erosion and bone remodeling. The aim of this study was to explore the potential role of DKK-1 and OPG in different stage of RA.Methods The protein levels of DKK-1 and OPG were detected by ELISA. The serum samples were collected from 300 patients with RA and 60 healthy controls. Of which, 150 RA patients were defined as early RA (disease duration ≤1 year), and other 150 RA patients were defined as longlasting RA (disease duration ≥5 years). At the time of serum sampling, various clinical and laboratory parameters were assessed. The correlations of DKK-1 or OPG and clinical/laboratory parameters were analyzed.Results The serum level of DKK-1 was elevated in patients with longstanding RA compared with healthy controls, while no significant difference was observed between the two groups in the level of OPG.In contrast, in early RA patients, the circulating OPG was elevated, while there was no significant difference between the two groups in expression of DKK-1. The serum DKK-1 was correlated with Sharp score and DAS28 in longstanding RA patients. In early RA, age was the only parameter that was significantly related to serum OPG.Conclusions There was a cross-talk between DKK-1 and OPG,which involved in bone destruction in RA. In different stage of RA, DKK-1 and OPG may play different roles in the pathogenesis of RA。

Abstract：Background The Pringle maneuver, which has been the standard for hepatic resection surgery for a long time, has the major flaw of ischemic damage in the liver. The aim of this research was to evaluate hepatic blood inflow occlusion with/without hemihepatic artery control vs. the Pringle maneuver in hepatocellular carcinoma (HCC) resection.Methods Two hundred and eighty-one cases of resection of HCC with hepatic blood inflow occlusion (with/without hemihepatic artery control) and the Pringle maneuver from January 2006 to December 2008 in our hospital were analyzed and compared retrospectively; among them 107 were in group I (Pringle maneuver), 98 in group II (hepatic blood inflow occlusion), and 76 in group III (hepatic blood inflow occlusion without hemihepatic artery control). The operation time, intraoperative blood loss, postoperative liver function and complications were used as the endpoints for evaluation.Results The operative duration and intraoperative blood loss of three groups showed no significant difference; alanine aminotransferase, total bilirubin and incidence of postoperative complications were significantly lower in groups II and III postoperation than those in group I.Conclusion Hepatic blood inflow occlusion without hemihepatic artery control is safe, convenient and feasible for resection of HCC, especially for cases involving underlying diseases such as cirrhosis。

Early repolarization pattern (ERP) is a common electrocardiographic (ECG) variant, characterized by J point elevation manifested either as QRS slurring (at the transition from the QRS segment to the ST segment) or notching (a positive deflection inscribed on terminal S wave), ST-segment elevation with upper concavity and prominent T waves in at least two contiguous leads.1,2 The prevalence of ERP in normal population varies from 1 % to 13%, depending on the age (predominant in young adults), the race (highest amongst black population), and the criterion for J point elevation (0.05 mV vs. 0.1 mV).3-7 In addition, higher incidence of ERP exists in males, athletes and individuals with high vagal tone or selective loss of sympathetic tone (e.g. spinal cord injury).8

According to Joint United Nations Program on HIV/AIDS (UNAIDS) report in 2009, the estimated number of people living with HIV-1 is 33.4 million, and half of the infected adults (aged 15-49 years) are women, who acquired HIV-1 mainly through heterosexual exposure. In China, HTV-1 transmission through sexual contact has also increased rapidly, and has reached over 70% in overall cases; heterosexual transmission accounted for 40% and men who had sex with man (MSM) for 32.0%.2,3

Charcot-Marie-Tooth disease (CMT), also known as hereditary motor and sensory neuropathies, comprises a genetically heterogeneous group of inherited peripheral neuropathies. Clinically it is characterized by progressive distal weakness, muscle atrophy, distal sensory loss and loss of deep tendon reflexes. Following electrophysiological criteria, CMT is divided into two main forms: the primarily demyelinating neuropathy CMT1 with severely decreased nerve conduction velocity (NCV) (<38 m/s), and CMT2, the primarily axonal form with normal or slightly reduced NCV (>38 m/s) but decreased amplitudes.1 CMT2A, an autosomal dominant disease caused by mitofusin 2 gene (MFN2) mutations, is the most common type of CMT2, accounting for up to 33% of familial CMT2 cases.2 We reported a patient with clinical diagnosis of CMT2 caused by a novel MFN2 mutation. To our knowledge, this is a relatively early report of genetically confirmed CMT2A in Chinese。

Radiofrequency ablation (RFA), especially percutaneous RFA (PRFA), is a novel technique for the treatment of hepatocellular carcinoma (HCC) that is becoming increasingly more popular because of its feasibility, effectiveness, repeatability, and safety.1 The complications of PRFA mainly include pneumothorax, hemopneumothorax, visceral organ perforation, liver abscess, bile duct injury, intraperitoneal hemorrhage and tumor seeding.2,3 The prevalence of major complications was evaluated to be between 2.1%-6.0% and the mortality rate between 0.09%-0.50%.2,4,5 Acute hemorrhagic cardiac temponade (AHCT) is a life threatening and fatal condition, which however rarely complicated RFA procedure for HCC.6 Moumouh and his colleagues7 reported the first case of AHCT during PRFA procedure leading to death. Herein we described another severe case of PRFA induced AHCT, which was treated successfully。

Androgen insensitivity syndrome (AIS) was first described by the American gynecologist Morris in 1953 and was initially described in 82 patients.1 The syndrome was designated "testicular feminization syndrome" , because the testes produce hormones with estrogen-like actions.1 Clinical AIS manifestations include the appearance of normal female external genitalia without internal female genital organs. Other clinical manifestations include undescended testes, normal female breast development, and scant axillary and pubic hair. AIS is the most common condition that cancause male undermasculinisation。

Lung transplantation has been performed internationally as an effective treatment for a variety of end-stage lung diseases. A great disparity between the supply of donor organs and the demand of potential recipients has resulted in longer waiting time and annual increases in deaths on the lung transplant waiting list. Living-donor lobar lung transplantation (LDLLT) has become an established strategy to deal with the shortage of cadaveric donors. Encouraged by Starnes et al1 and Date et al,2 we began to apply the operation to a critically ill patient with bronchopulmonary dysplasia (BPD) firstly at Shanghai Pulmonary Hospital in China。

T° the Editor We are interested in a recent article "Embolization of brain arteriovenous malformations with ethylene vinyl alcohol copolymer: technical aspects" written by GAO et al.1 Ethylene vinyl alcohol copolymer (Onyx) is a novel liquid embolic material used to cure brain arteriovenous malformations. They performed the embolization on 115 patients and they found that the complications of the treatment are scarce。

Loeffler endocarditis is clinically presented as restrictive cardiomyopathy, which is the least common of the three major categories of cardiomyopathic disorders.1 The endomyocardial fibrosis was considered as its main pathophysiologic changes.2-4 Generally speaking, the characteristics include thickening of the apex and inflow tracts of one or both ventricles, and the papillary muscle and chordae tendineae also can be involved in some cases. The onset of apical thrombosis is very common. In the aspect of showing all of these characteristics, ultrasound cardiography (UCG) has low diagnostic accuracy (not more than 80%);5 CT has been reported rarely; cardiac magnetic resonance (CMR) imaging has dramatic advantages. We present the CMR findings in a typical case of Loeffler endocarditis pre- and post-operation。

Primary breast lymphoma (PBL) is rare, accounting for 0.04%-0.50% of breast malignancies and 1.7% of extranodal lymphoma.1,2 The originally described diagnostic criteria for PBL2 remains the standard definition for this disease. These criteria are breast location as the clinical site of presentation, absence of history of previous lymphoma or evidence of widespread disease at diagnosis, close association of lymphoma with breast tissue in pathologic specimens, and involvement of ipsilateral lymph nodes if they develop simultaneously with PBL。

Hemangiopericytomas (HPCs) originating from central nervous system were increasingly reported recently.1 Intravertebral HPCs are predominantly epidural. Primary intradural HPCs of spinal cord are rare.2-5 Little subarachnoid dissemination has been reported. We reported a HPC of the cervical spinal cord with subarachnoid dissemination。