2011年 · 第124卷第10期

Abstract：Background Previous studies have demonstrated that serum uric acid (UA) is an independent predictor of incident type 2 diabetes mellitus (T2DM) in general populations. This study aimed to investigate specific characteristics of UA and its relationship between UA and blood glucose and other risk factors in the Chinese population.Methods A total of 946 subjects were included in this study. UA, glucose, insulin, fractional excretion of UA (FEua),creatinine clearance rate (Ccr), hemoglobin A1c (HbA1c), fructosamine (FA), blood pressure and lipids were studied and also reexamined after the patients underwent two weeks of combined therapeutics.Results UA levels were the highest in subjects with impaired glucose regulation (IGR), followed by subjects with normoglycemia (NGT) and finally by subjects with T2DM. The level of the 2-hour postprandial insulin and the area under the curve for insulin (AUCins) showed a similar tendency. The UA levels initially increased with increasing fasting blood glucose (FBG) and postprandial blood glucose (PPBG) levels, up to 7 mmol/L and 10 mmol/L, respectively, and thereafter decreased at higher FBG and PPBG levels. Compared with subjects in the lower serum UA quartile, subjects in the upper quartile of serum UA levels had higher weights, triglyceride levels, and creatinine levels as well as lower Ccr and FEua levels. Compared with women's group, UA levels were higher, and FEua levels were lower in men's group. Sex,body mass index (BMI), mean arterial blood pressure (MAP), serum triglycerides (TG), FA and Ccr were independent correlation factors of UA. UA decreased and FEua increased after the patients underwent a combined treatment.Conclusions UA increased initially and then decreased as glucose levels increased from NGT to IGR and T2DM.Compared with NGT and T2DM, IGR subjects had higher SUA levels, which related to its high levels of insulin. Under T2DM, male gender, BMI, MAP, Ccr, TG and FA are independent correlation factors of UA. Glucose-lowering,antihypertensive, lipemia-regulating combined treatments were of advantage to decline of SUA of T2DM。

Abstract：Background Recently, there has been a surge of interest in minimally invasive techniques with endoscope in thyroid surgery. The aim of this study was to investigate the possibility of a scarless neck surgery under endoscopy for the treatment of thyroid tumor and to observe the results of this procedure.Methods A total of 68 patients (64 women and 4 men) underwent the surgery. Their ages ranged from 18 to 65 years,with a mean age of (34±3) years. There were 64 cases of thyroid adenoma, and 4 cases of nodular goiter. An incision was made on the surface of the chest bone. The operation cavity was made by dragging the skin. Sixty-four patients underwent partial thyroid lobectomy, four patients underwent thyroid lobectomy.Results All 68 cases showed healing in one stage. None of the cases showed paralysis of the recurrent laryngeal nerve or tumor recurrence within the next 2 to 60 months of follow-up. The patients experienced slight pain after the operation.The patients were satisfied with the cosmetic results of the surgery.Conclusion The gasless endoscopic surgery through the upper chest, which was performed to treat thyroid tumor, did not leave any scar, and was easy to handle, and gave good cosmetic results。

Abstract：Background Acute kidney injury (AKI) is associated with poor prognosis after cardiopulmonary bypass. The aim of this retrospective study was to investigate whether stent implantation before cardiopulmonary bypass has beneficial effect on development of AKI in renal artery stenosis (RAS) patients.Methods In this retrospective study, patients with abnormal baseline serum creatinine (SCr, ＞106 μmol/L) were not included. Included patients (n=69) were divided into two groups. Group 1 included 31 RAS patients receiving no stent implantation before cardiopulmonary bypass. Group 2 included 38 RAS patients having received stent implantation just before cardiopulmonary bypass. To assess AKI after cardiopulmonary bypass, serum urea nitrogen, SCr and creatinine clearance were recorded at baseline, at the end of operation, during the first and second postoperative 24 hours.Results Baseline characteristics were similar between groups. Serum urea nitrogen, SCr, creatinine clearance before and after cardiopulmonary bypass were also similar class groups. Incidence of AKI in group 1 was not significantly different from group 2. In group 1, AKI defined by RIFLE between occurred in 7 (22.6%) patients: 5 (16.1%) with RIFLE-R,2 (6.5%) with RIFLE-I, and no patients with RIFLE-F. In group 2, 10 patients (26.3%) had an episode of AKI during hospitalization: 6 (15.8%) had RIFLE-R, 4 (10.5%) had RIFLE-I, and no patients had RIFLE-F.Conclusions There are no data suggesting that it is necessary to stent RAS patients with normal SCr before cardiopulmonary bypass. However, it cannot be concluded that RAS is not associated with AKI after cardiopulmonary bypass。

Abstract：Background The value of artificial colloids in treating patients with liver disease is controversial. The effects of intravascular volume replacement regimens on liver function secondary to alteration of the postoperative inflammatory response are not known. In this study, we evaluated the effects of different volume replacement regimens in hepatocellular carcinoma patients undergoing hepatectomy to clarify whether albumin administration can be replaced by other volume replacement products.Methods Ninety consecutive hepatocellular carcinoma patients scheduled for hepatectomy were prospectively randomized to receive 20% human albumin (HA), 6% hydroxyethyl starch (HES) or lactated Ringer's solution (LR) for postoperative volume replacement. Hemodynamic, liver function and inflammatory response parameters were recorded on postoperative days one, three, and five throughout the investigation period.Results Significantly less volume was required in the HA and the HES groups. Although patients in all groups had similar baseline values, the plasma osmolality was significantly higher in the HA and HES groups. Total bilirubin (TB), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) increased from baseline in all groups, and did not differ significantly between groups. C-reactive protein (CRP) was significantly lower in the HES group compared with the other groups.Conclusions In hepatocellular carcinoma patients undergoing hepatectomy, HA can be replaced by HES or LR in well selected patients. Hemodynamic stability, liver function, and postoperative clinical outcomes could be equivalently achieved in the HES group; also, HES may exert more favorable effects on the acute phase response. (Registered in the Chinese Clinical Trial Registry, ChiCTR-TRC-10000790)

Abstract：Background Wall shear stress is an important factor in the destabilization of atherosclerotic plaques. The purpose of this study was to assess the distribution of wall shear stress in advanced carotid plaques using high resolution magnetic resonance imaging and computational fluid dynamics.Methods Eight diseased internal carotid arteries in seven patients were evaluated. High resolution magnetic resonance imaging was used to visualize the plaque structures, and the mechanic stress in the plaque was obtained by combining vascular imaging post-processing with computational fluid dynamics.Results Wall shear stresses in the plaques in all cases were higher than those in control group. Maximal shear stresses in the plaques were observed at the top of plaque hills, as well as the shoulders of the plaques. Among them,the maximal shear stress in the ruptured plaque was observed in the rupture location in three cases and at the shoulder of fibrous cap in two cases. The maximal shear stress was also seen at the region of calcification, in thrombus region and in the thickest region of plaque in the other three cases, respectively.Conclusion Determination of maximal shear stress at the plaque may be useful for predicting the rupture location of the plaque and may play an important role in assessing plaque vulnerability。

Abstract：Background Hepatoid adenocarcinoma of the stomach (HAS) is a rare type of gastric carcinoma, which has its unique clinicopathological features and poorer prognosis than that of the ordinary gastric adenocarcinoma. At present, there is still a lack of understanding about this disease. The current study aimed to summarize and discuss the clinical,pathological, immunohistochemical, and prognostic features of this disease.Methods A total of 20 patients of HAS were retrospectively studied. All the patients were treated in Cancer Hospital of Chinese Academy of Medical Sciences between March 1998 and October 2009. Statistical analysis, including the Kaplan-Meier method, log-rank test and Cox model, were performed by the SPSS 15.0 software.Results Seventeen patients (85%) had at least 1 lymph node metastases; 17 patients (85%) received postoperative immunohistochemical examinations, with an alpha-fetoprotein (AFP) positive rate of 94.1% (16/17); 14 patients had distant metastases (including 12 liver metastases, 1 lung metastasis, and 1 celiac widespread metastases), and one simultaneously had anastomotic recurrence and liver metastases. The overall survival time was 2-99 months (median:12.0 months). The 3-year survival rate of the 20 patients was 17.2%. The 3-year survival rate of patients with complete hepatocyte-like regions and those with both hepatocellular carcinoma and adenocarcinoma regions was 20.0% and 17.5%, respectively (P=0.361). The survival difference among the radical surgery group, palliative surgery group and no surgery group was statistically significant (P=0.022). The Kaplan-Meier method and log-rank test showed that surgery,pTNM stages, and adjuvant chemotherapy were associated with prognosis (P ＜0.05). The Cox model only confirmed that the pTNM stages and adjuvant chemotherapy had statistical significance for the prognosis of HAS (P＜0.05) due to the limited cases.Conclusions HAS is a special type of gastric carcinoma and has a poor prognosis. The pTNM stage is an independent risk factor for HAS. Multidisciplinary therapy, including surgery and chemotherapy, may improve the prognosis of HAS。

Abstract：Background In the 21st century, minimally invasive treatment is one of the main developmental directions of medical sciences. It is well known that the echocardiography plays an important role during interventional treatments of some structural heart diseases. Because the ruptured right sinus of the Valsalva aneurysm (RRSVA) is a rare disease, there were few reports about percutaneous catheter closure of RRSVA. This study aimed to sum up our experience with transthoracic echocardiography (TTE) during percutaneous catheter closure of RRSVA.Methods Five RRSVA cases were treated with percutaneous catheter closure. The whole procedure was guided and monitored by TTE and fluoroscopy. The maximum diameter of the RRSVA was measured by TTE before and after the catheter passed through the rupture site. A duct occluder 2 mm larger than the maximum diameter was chosen. The closure effects were evaluated with TTE and fluoroscopy immediately after the occluding device was deployed. All patients were followed up by TTE for 8 to 30 months.Results Before the catheter passed through the rupture site the maximum diameter of the RRSVA measured with TTE and aortography were (7.9 ±2.1) mm and (7.8 ± 1.8) mm. After the catheter passed through the rupture site the maximum diameter measured with TTE was (11.2 ± 3.2) mm, which was significantly larger than before the procedure (P ＜0.05). The percutaneous catheter closure was successful in four cases and failed in one. Compared to the aortography the TTE was better at distinguishing residual shunts from aortic valve regurgitation immediately after the occluding device was deployed. There were no complications during 8 to 30 months of follow-up.Conclusion Transthoracic echocardiography can play an important role during percutaneous catheter closure of RRSVA,especially for estimating the size of the RRSVA after the catheter passes through the rupture site, and differentiating residual shunt from aortic valve regurgitation immediately after the occluding device is deployed。

Abstract：Background Twist is a highly conserved epithelial-mesenchymal transcription factor that has been reported to be a key factor in tumor malignancy, including lymph node metastasis. It represents the major step of dissemination and serves as a chief prognostic indicator of disease progression. However, the mechanism by which Twist regulates lymph node metastasis remains incompletely understood. Studies on the mechanism of metastasis are thus required for determining appropriate therapeutic strategies.Methods Immunohistochemistry for lymphatic vessel endothelial receptor 1 (LYVE-1), Ki-67, Twist, vascular endothelial growth factor C (VEGF-C), and vascular endothelial growth factor receptor 3 (VEGFR-3) was performed to detect lymphatic vessel density (LVD), cell proliferation levels and the expressions of Twist, VEGF-C, and VEGFR-3 were determined from 66 primary supraglottic carcinoma tissue samples from 36 patients with lymph node metastasis (pathological N+, pN+) and 30 patients without metastasis (pathological NO, pNO). Western blotting analysis of the proteins in pN+ and pNO primary tumors was used to characterize the expressions of Twist, VEGF-C, and VEGFR-3further.Results The LVD was 22.4±10.3 in pN+ patients and 6.8±4.1 in pNO ones. For Ki-67, the number of proliferous cells in pN+ patients was greater than that in pNO ones. Both, however, were associated with their clinical nodal stages. In pN+patients, Twist, VEGF-C, and VEGFR-3 expressions were 86.11% (31/36), 80.56% (29/36), and 58.33% (21/36),respectively. These values were higher than those found for pNO patients (i.e., 13/30, 11/30, and 7/30, respectively) (P ＜0.05). Among the samples with Twist expression, 88.64% were VEGF-C-positive and 59.09% were VEGFR-3-positive.The pNO counterparts were 4.55% and 9.09%, respectively (P＜0.05). The expressions of Twist, VEGF-C, and VEGFR-3in pN+ patients obtained through Western blotting analysis were significantly higher than those in pNO patients, and the levels of VEGF-C and VEGFR-3 were positively correlated with that of Twist.Conclusions Twist expression correlates with lymph node metastasis. The mechanism involved in such a correlation may be related to lymphangiogenesis。

Abstract：Background The initiation and expansion of China's national free antiretroviral therapy program has led to significant improvement of survival among its participants. Success of further scaling up treatment coverage rests upon intensifying HIV screening and efficient linkage of care. Timely CD4 cell count testing after HIV diagnosis is necessary to determine whether a patient meets criteria for antiretroviral treatment, and represents a crucial link to engage HIV-infected patients in appropriate care, which has not been evaluated in China.Methods We evaluated all patients ≥16 years who tested HIV positive from 2005 to 2009 in Yunnan and Guangxi.Multivariate Logistic regression models were applied to identify factors associated with lack of CD4 cell count testing within 6 months after HIV diagnosis.Results A total of 83 556 patients were included. Over the study period, 30 635 (37%) of subjects received a CD4 cell count within 6 months of receiving the HIV diagnosis. The rate of CD4 cell count testing within 6 months of HIV diagnosis increased significantly from 7% in 2005 to 62% in 2009. Besides the earlier years of HIV diagnosis, negative predictors for CD4 cell count testing in multivariate analyses included older age, not married or unclear marriage status,incarceration, diagnosis at sexual transmitted disease clinics, mode of HIV transmission classified as men who have sex with men, intravenous drug users or transmission route unclear, while minority ethnicity, receipt of high school or higher education, diagnosis at voluntary counseling and testing clinics, and having HIV positive parents were protective.Conclusions Significant progress has been made in increasing CD4 testing among newly diagnosed HIV positive patients in Yunnan and Guangxi from 2005-2009. However, a sizable proportion of HIV positive patients still lack CD4testing within 6 months of diagnosis. Improving CD4 testing, particularly among patients with identified risk factors, is essential to link patients with ART services and optimize treatment coverage。

Abstract：Background Esophageal variceal bleeding is a frequent and severe complication in patients with cirrhosis. The aim of this study was to identify prognostic factors of esophageal variceal rebleeding in cirrhotic inpatients.Methods Consecutive cirrhotic patients who were admitted to Changhai Hospital because of esophageal variceal bleeding were retrospectively analyzed. To assess the independent factors for recurrent hemorrhage after esophageal variceal bleeding, medical assessment was completed at the time of their initial hospital admission, including documentation of clinical, biochemical, and treatment methods that might contribute to variceal rebleeding. Univariate and multivariate analyses were retrospectively performed.Results Totally 186 patients (35.8%) were assigned to a rebleeding group and the other 334 patients (64.2%) to a non-rebleeding group. Multivariate stepwise regression analysis showed that four variables were positively correlated with rebleeding: Child-pugh grade B (OR=2.664, 95% CI 1.680-4.223) (compared with Child-pugh grade A), total bilirubin (Tbil) (OR=1.0006, 95% CI 1.002-1.0107), creatinine (OR=1.008, 95% CI 1.002-1.015) and the cumulative volume of blood transfusion (OR=1.519, 95% CI 1.345-1.716). The presence of ascites (OR=0.270, 95% CI 0.136-0.536) and prophylactic antibiotics (OR=0.504, 95% CI 0.325-0.780) were negatively correlated with rebleeding of the cirrhotic inpatients. According to standardized coefficient, the importance of rebleeding predictors ranked from the most to the least was as follows: the cumulative volume of blood transfusion, Child-pugh grade B, Tbil and creatinine.Conclusion Rebleeding in cirrhotic inpatients was associated with more blood transfusions, Child-pugh grade B, higher Tbil and creatinine。

Abstract：Background The amiloride-sensitive epithelial sodium channel a-subunit (a-ENaC) is an important factor for alveolar fluid clearance during acute lung injury. The relationship between adenosine receptor A2a (A2aAR) expressed in alveolar epithelial cells and aα-ENaC is poorly understood. We targeted the A2aAR in this study to investigate its role in the expression of αa-ENaC and in acute lung injury.Methods A549 cells were incubated with different concentrations of A2aAR agonist CGS-21680 and with 100 μmol/L CGS-21680 for various times. Rats were treated with lipopolysaccharide (LPS) after CGS-21680 was injected. Animals were sacrificed and tissue was harvested for evaluation of lung injury by analysis of the lung wet-to-dry weight ratio, lung permeability and myeloperoxidase activity. RT-PCR and Western blotting were used to determine the mRNA and protein expression levels of α-ENaC in A549 cells and alveolar type II epithelial cells.Results Both mRNA and protein levels of α-ENaC were markedly higher from 4 hours to 24 hours after exposure to 100μmol/L CGS-21680. There were significant changes from 0.1 umol/L to 100 μmol/L CGS-21680, with a positive correlation between increased concentrations of CGS-21680 and expression of α-ENaC. Treatment with CGS-21680during LPS induced lung injury protected the lung and promoted α-ENaC expression in the alveolar epithelial cells.Conclusion Activation of A2aAR has a protective effect during the lung injury, which may be beneficial to the prognosis of acute lung injury。

Abstract：Background Lung cancer is one of the most common malignancies in the world and one of the leading cancers that result in death. The aim of this study was to evaluate and compare the diagnostic value of the serum tumor marker pro-gastrin-releasing peptide 31-98 (ProGRP31-98) to pathological diagnosis as reference standard in patients with suspected small cell lung cancer (SCLC).Methods Literature searches covering 1978 through to 2009 were performed in Pubmed, OVID, MEDLINE, EMbase,Cancerlit, China National Knowledge Infrastructure (CNKI), and CBM using the key search words; 'small cell lung cancer','tumor marker', 'ProGRP31-98' and 'diagnostic tests', 'ELISA', 'EIA' and 'diagnostic accuracy'. Studies were collected and data analyzed to evaluate the diagnostic value of serum ProGRP31-98 levels for the diagnosis of SCLC compared with pathology. Eligibility criteria for inclusion in the analysis were based on criteria for diagnostic research published by the Cochrane Screening and Diagnostic Tests Methods Group (SDTMG). The characteristics of the included articles were appraised and the data were extracted from the original articles for further statistical analysis of study heterogeneity using Review Manager 4.2 software. Based on study heterogeneity analysis, a suitable 'effect' model was selected to calculate pooled sensitivity and specificity by meta-analysis. A Summary Receiver Operating Characteristic (SROC) curve and the area under the curve (AUC) were generated and sensitivity analysis conducted.Results A total of 22 articles were entered into this meta-review, including 11 English articles with a quality at level C. In total, the studies involved 6759 subjects, of which 1470 were diagnosed with SCLC by pathology, and 5289 subjects diagnosed with non-SCLC (NSCLC). The meta-analysis showed that heterogeneity among studies was high (P=0.00001,(I2)=86.8%). With ELISA, the pooled sensitivity was 0.72 (0.70 to 0.75 at 95% Cl) and the pooled specificity was 0.93 (0.92to 0.94 at 95% Cl); the SROC and the AUC were 0.8817. These data suggest that ProGRP31-98 has a relatively high rate of missed diagnosis (28%), but a relatively low rate of misdiagnosis (7%).Conclusion From meta-analysis, we concluded that serum ProGRP31-98 is a valuable marker with a high specificity for diagnosis of SCLC with a similar diagnostic accuracy to pathology。

Abstract：Objective Tobacco smoking results in increased platelet aggregability, which suggests that low-dose aspirin used in common clinical practice may not effectively inhibit platelet activity in smokers with coronary heart disease (CHD). This review was performed to assess the effect of aspirin on platelet aggregation in patients with CHD.Data sources We performed an electronic literature search of MEDLINE (starting from the beginning to March 15, 2009)using the term "smoking" or "tobacco" paired with the following: "platelet", "aspirin" or "coronary heart disease".Study selection We looked for review articles regarding the effect of tobacco smoking on platelet activity and on the anti-platelet efficacy of aspirin in healthy people and patients with CHD. The search was limited in "core clinical journal".In total, 1321 relevant articles were retrieved, and 36 articles were ultimately cited.Results Tobacco smoking results in increased platelet aggregability, which can be inhibited by low-dose aspirin in the healthy population. However, in patients with CHD, the increased platelet aggregability can not be effectively inhibited by the same low-dose of aspirin. A recent study indicated that clopidogrel or an increased dose of aspirin can effectively inhibit the increased platelet aggregability induced by tobacco smoking in patients with CHD.Conclusions It is important for patients with CHD to quit smoking. For the current smoker, it may be necessary to take larger doses of aspirin than normal or take an adenosine diphosphate receptor inhibitor along with aspirin to effectively inhibit the increased platelet activity。

Abstract：Background Ovarian cancers are often at an advanced stage at diagnosis because early detection is difficult. The poor prognosis of ovarian cancers highlights the crucial need to develop better therapeutic agents and strategies. The objective of this study was to investigate the inhibitory effects of a new modified antisense oligonucleotides targeting vascular endothelial growth factor A (VEGF-A) in SKOV3 ovarian cancer cells.Methods Antisense oligonucleotides targeting VEGF-A was designed, synthesized and transfected into SKOV3ovarian cancer cells. Western blotting and real-time RT-PCR were used to analyze the inhibitory effects of antisense oligonucleotides on VEGF-A protein and mRNA expression. Transwell matrix assay was used to detect cell migration inhibition.Results The antisense oligonucleotides targeting VEGF-A significantly decreased VEGF-A protein and mRNA expression and inhibited cell migration in SKOV3 ovarian cancer cells.Conclusions This new modified antisense oligonucleotides targeting VEGF-A can decrease VEGF-A expression and inhibit cell migration in SKOV3 ovarian cancer cells. This new oligonucleotides may be a promising therapeutic agent for ovarian cancers。

Abstract：Background The duration of viral shedding and the transmission of 2009 H1N1 influenza among individuals, especially among the younger population with mild illness, are not well understood now. The aim of this study was to determine the viral shedding of the young adult patients with mild 2009 H1N1 influenza in China.Methods From September 2009 to January 2010, the clinical data and serial nasopharyngeal swabs of 67 patients with 2009 H1N1 influenza and 37 patients with seasonal influenza aged from 18 years to 35 years were collected. The nasopharyngeal swab samples were detected by real time RT-PCR to determine the viral shedding. All the patients did not receive the antiviral therapy but Chinese medicine for detoxicating.Results Among the patients with H1N1 virus infection, 82.1% (55/67) patients presented with fever symptom, while more patients with high fever (≥39℃) were found in seasonal influenza patients (P＜0.05). For the H1N1 patients, the median interval between the symptom onset and the undetectable RNA was six days (4-10 days). But viral shedding was still found in 31.3% patients after 7 days following illness onset. The median interval between disappearance of fever and an undetectable viral RNA level was three days (2-8 days), and 17.9% patients were found to be viral shedding 6 days later after normalization of body temperature. For the seasonal influenza patients, 94.6% patients were detected out viral RNA within 7 days. The median interval of seasonal influenza between the symptom onset and the undetectable RNA was four days (3-8 days). The median interval between disappearance of fever and an undetectable viral RNA level was three days (2-6 days).Conclusion It suggests that 7 days isolation period from the illness onset or 24 hours after the resolution of fever and respiratory symptoms are not long enough to cut off the transmission among Chinese young adults with mild illness。

Abstract：Laparoscopic radical prostatectomy is considered the first treatment of choice for local prostate cancer due to its minimal invasion advantage. To further achieve the goal of minimal invasion, single port laparoscopic radical prostatectomy has been developed to minimize the complications associated with puncture tracks. The aim of this study was to illustrate the technique for single port laparoscopic radical prostatectomy and evaluate its efficacy and safety. We reported 8 cases of radical prostatectomy with excellent early outcome carried out in Shanghai Changzheng Hospital from June 2009 to August 2009 using a home-made multiple instrument access port and adding an additional small incision at McBumey point。

Abstract：Tricho-rhino-phalangeal syndrome (TRPS) was first reported in 1966. Although mutation of TRPS1 gene is considered to be responsible for the syndromes in 2000, investigation of bone metabolism and changes of serum insulin-like growth factor (IGF)-1 level in this kind of patients is rare. Here, we report a patient with TRPS I (MIM 190350) presenting a novel mutation (1096insA) and abnormal changes of severe osteoporosis as well as low serum IGF-I level。

Abstract：Ablation of persistent atrial fibrillation is still a challenge for the ablationist. Extensive ablation is required under some conditions and could lead to some unintended complications. Here we report a case of atrium-atrioventricular node block complicating multiple catheter ablation procedures for persistent atrial fibrillation. After extensive ablation, including circumferential pulmonary vein ablation, linear ablation at the left atrial roof, mitral isthmus, atrial septum, cavotricuspid isthmus, and complex fractionated atrial electrogram ablation, conduction obstacle was found, and sinus impulse could not travel from the right atrium, atrial septum and left atrium to atrioventricular node. The case indicated that intensive ablation at some key sites, especially the interatrial septum, should be careful during ablation of atrial fibrillation。

Abstract：A 62-year-old woman with frequent occurrence of symptomatic atrial tachycardia with a foci located at the root of the upper crista terminalis was found to have right diaphragm paresis after receiving a total of 8 radiofrequency energy deliveries (40-60 W, 50-60℃) and a total duration of 540 seconds of ablation therapy (7Fr 8 mm deflectable ablation catheter). The right diaphragm paresis remained resolved up to 14 months after the procedure as confirmed by repeated chest X-rays。

Migration of a bullet to a distant part of the body after a gunshot is rarely observed in the clinical setting, and migration to the heart is even rarer.There are usually no clear symptoms or signs from migration of a bullet.The bullet can be easily missed and sometimes identified in a review examination.A case of bullet migration to the heart 2 months after a gunshot to the left knee was reported。

Abstract：Cases of psoriasis complicated with venous thromboembolism are rarely reported. Here, we report two cases and review the current literature on the subject. Two patients with long-standing severe psoriasis presented with chest pain,shortness of breath and breathing difficulties. The patients were diagnosed using lung ventilation-perfusion scans or computed tomographic pulmonary angiography. Anticoagulation or thrombolytic therapy was initiated, and long-term continuous anticoagulation with warfarin prevented any recurrences。

Abstract：Malignant meningiomas are uncommon intracranial tumors. The metastasis of malignant meningiomas to distant extracranial sites are well known. However, dissemination of the tumours in the cerebrospinal fluid (CSF) is rare and few cases have been reported. We present a case of histologically proven malignant meningioma with CSF dissemination at the remote intracranial area and into the spinal canal detected with magnetic resonance imaging。

To the editor: Hepatitis C virus (HCV) is a hepatotropic virus and a common cause of chronic hepatitis.Several extrahepatic complications have been associated with HCV including autoimmune and kidney diseases.It can cause a variety of extrahepatic immunological manifestations.1 Chronic HCV infection and cirrhosis are risk factors of a variety of extrahepatic diseases such as mixed cryoglobulinemia and membranoproliferative glomerulonephritis (MPGN).2 We presented a cirrhosis patient with mixed cryoglobulinemia (MC) associated with HCV; the diagnosis was made by renal biopsy and improved completely after interferon (IFN) and ribavirin treatment。