2013年 · 第126卷第13期

Abstract：Background Effects of prophylactic somatostatin on post-endoscopic retrograde cholangiopancreatography (ERCP)pancreatitis (PEP) and hyperamylasemia remain inconclusive.This study aimed to examine whether high-dose,long-term continuous infusion of somatostatin can reduce the incidence of PEP and post-ERCP hyperamylasemia.Methods This was a randomized,placebo-controlled pilot trial.One hundred and twenty-four patients scheduled for ERCP from December 2008 to May 2010 randomly received one of the following three interventions:pre-ERCP somatostatin (0.5 mg/h for 24 hours,starting 1 hour prior to ERCP; n=36),post-ERCP somatostatin (0.5 mg/h for 24 hours,starting 1 hour after ERCP; n=47),or placebo (saline for 24 hours,starting 1 hour prior to ERCP; n=41).Serum amylase and lipase concentrations were measured 1 to 3 hours prior to ERCP and 6,24,and 48 hours after ERCP.Results The three groups did not differ in age,gender,medical history,or ERCP procedure (catheterization using contrast or guidewire,pancreatic duct visualization,procedure time,or procedure type).The rate of PEP was 13.7％ (17/124)in the overall study sample and 16.7％ (6/36),10.6％ (5/47),and 14.6％ (6/41) in the pre-ERCP somatostatin,postERCP somatostatin,and placebo groups,respectively (P=0.715).The rate of post-ERCP hyperamylasemia was 19.4％ (7/36),21.3％ (10/47),and 46.3％ (19/41) in the pre-ERCP somatostatin,post-ERCP somatostatin,and placebo groups,respectively (P=0.011).Conclusions High-dose,long-term continuous infusion (0.5 mg/h for 24 hours) of somatostatin,performed as either a pre-or post-ERCP,can reduce the incidence of hyperamylasemia,but not PEP。

Abstract：Background Currently available evidence suggests that outcomes are less favorable when left main (LM) bifurcation lesions are treated with 2-stent techniques compared with a single-stent technique.We aimed to evaluate the long-term outcomes of the 2-stent techniques for treating unprotected LM bifurcation lesions in Chinese patients.Methods We enrolled 301 consecutive patients treated with drug-eluting stents (DES) implantation using 2-stent techniques for unprotected LM bifurcation lesions (MEDINA 1,1,1,70.5％).The 2-stent techniques included crush technique,V stenting,T stenting,and Culottes stenting.After stenting,both vessels were redilated at a high pressure before final kissing balloon (FKB).Clinical and angiographic data were analyzed.The primary endpoints were major adverse cardiac events (MACE),whichincluded death,myocardial infarction,and target lesion revascularization.Results Immediate procedural success was obtained in all cases with a FKB success rate of 95.3％.Follow-up data were available for all patients.The overall incidence of angiographic in-stent restenosis (ISR) rate was 20.3％ and most ISRs were of the focal type.During long-term follow-up (mean duration,(54±22) months),the cumulative incidence of MACE was 11.0％,with 8 (2.7％) deaths,7 (2.3％) myocardial infarctions,and 18 (6.0％) repeated lesion revascularization.MACEs in high SYNTAX score terciles were significantly higher compared with those in low and intermediate SYNTAX score terciles (p=0.001).Conclusions Although percutaneous coronary intervention (PCI) with 2-stent technique for unprotected LM bifurcation lesions was accompanied with a slightly high incidence of ISR,the long-term clinical follow-up is acceptable.Technical modifications and stent innovations may further improve both the angiographic and clinical outcomes for patients with LM bifurcation disease treated by PCI。

Abstract：Background Robotic assisted minimally invasive cardiac sugery is a new technique that uses small port sites and peripheral vessel cannulation for cardiopulmonary bypass (CPB) has been used.The right internal jugular vein (IJV)is commonly used for intraoperative venous access to the central circulation and identified with an external landmark.Previous studies have demonstrated the superiority of ultrasound guidance over external landmark technique in anaesthetic and intensive care settings.The aim of the present study was to delineate the utility of ultrasound-guided cannulation of the IJV during establishment of peripheral CPB in robotic cardiac surgery.Methods We prospectively studied 296 adult patients undergoing ultrasound-guided right IJV cannulation during establishment of peripheral CPB in robotic cardiac surgery at our institute from January 2007 to October 2012 (ultrasound group).The success rate,the first attempt success rate,access time and the complication rate of ultrasound-guided method were compared with the landmark-guided method used for 302 historical control patients (landmark group).Results In the ultrasound group,296 consecutive adult patients underwent ultrasound-guided right IJV cannulation during establishment of peripheral CPB in robotic cardiac surgery.In the landmark group,302 patients underwent right IJV cannulation using the landmark-guided technique.The success rate and the first attempt success rate in the ultrasound group were significantly higher than that in the landmark group (100％ vs.88.1％,P ＜0.000 and 98.6％ vs.38.4％,P ＜0.000).Average access time in the ultrasound group was shorter than that in the landmark group ((6.3±13.6) seconds;interquartile range (4-62) seconds vs.(44.5±129.5) seconds; interquartile range (5-986) seconds).The complication rate in the ultrasound group was significantly lower than that in the landmark group (0.3％ vs.8.3％,P ＜0.000).Conclusion Compared with the landmark-guided approach,ultrasound-guided cannulation of the right IJV significantly improves success rate,decreases access time and reduces complication rate during establishment of peripheral CPB in robotic cardiac surgery。

Abstract：Background Tumor surgery in brain motor functional areas remains challenging.Novel techniques are being developed to gain maximal and safe resection for brain tumor surgery.Herein,we assessed the magnetic resonance diffusion tensor imaging (MR-DTI) and fluorescein sodium dyeing (FLS) guiding technique for surgery of glioma located in brain motor functional areas.Methods Totally 83 patients were enrolled according to our inclusion and exclusion criteria (56 patients in experimental group,27 patients in control group).In the experimental group,the surgical approach was designed by DTI imaging,which showed the relationship between the tumor and motor tract.The range of resection in the operation was determined using the FLS-stained area,which recognized the tumor and its infiltrated tissue.The traditional routine method was used in the control group.Postoperatively,all patients underwent enhanced brain MRI within 72 hours to ascertain the extent of resection.Patients were followed in our outpatient clinic over 6-24 months.Neurological deficits and Karnofsky scoring (KPS) were evaluated.Results There were no significant differences in balance test indexes of preoperative data (sex,age,lesion location and volume,and neurological deficits before operation) and diagnosis of histopathology between the two groups.There was a trend in the experimental group for greater rates of gross total resection (80.4％ vs.40.7％),and the paralysis rate caused by surgery was lower in experimental (25.0％) vs.control (66.7％) groups (P ＜0.05).The 6-month KPS in the low-grade and high-grade gliomas was 91±11 and 73±26,respectively,in the experimental group vs.82±9 and 43±27,respectively,in the control group (P ＜0.05 for both).Conclusions MR-DTI and FLS dye guiding for surgery of glioma located in brain motor functional areas can increase the gross total resection rate,decrease the paralysis rate caused by surgery,and improve patient quality of life compared with traditional glioma surgery。

Abstract：Background Surgical treatment of intracranial aneurysms is often compromised by incomplete exclusion of the aneurysm or stenosis of parent vessels.Intraoperative microvascular Doppler (IMD) is an attractive,noninvasive,and inexpensive tool.The present study aimed to evaluate the usefulness and reliability of IMD for guiding clip placement in aneurysm surgery.Methods A total of 92 patients with 101 intracranial aneurysms were included in the study.IMD with a 1.5-mm diameter,20-MHz microprobe was used before and after clip application to confirm aneurysm obliteration and patency of parent vessels and branching arteries.IMD findings were verified postoperatively with digital subtraction angiography (DSA) or dual energy computed tomography angiography (DE-CTA).Ninety consecutive patients,harboring 108 aneurysms,who underwent surgery without IMD was considered as the control group.Results The microprobe detected all vessels of the Circle of Willis and their major branches.Clips were repositioned in 24 (23.8％) aneurysms on the basis of the IMD findings consistent with incomplete exclusion and/or stenosis.IMD identified persistent weak blood flow through the aneurismal sac of 11 of the 101 (10.9％) aneurysms requiring clip adjustment.Stenosis or occlusion of the parent or branching arteries as indicated by IMD necessitated immediate clip adjustment in 19 aneurysms (18.8％).The mean duration of the IMD procedure was 4.8 minutes.The frequency of clip adjustment (mean:1.8 times per case) was associated with the size and location of the aneurysm.There were no complications related to the use of IMD,and postoperative angiograms confirmed complete aneurysm exclusion and parent vessel patency.About 8.3％ (9/108) aneurysms were unexpectedly incompletely occluded,and 10.2％ (11/108) aneurysms and parent vessel stenosis without IMD were detected by postoperative DSA or DE-CTA.IMD could reduce the rate of residual aneurysm and unanticipated vessel stenosis which demonstrated statistically significant advantages compared with aneurysm surgery without IMD.Conclusion IMD is a safe,easily performed,reliable,and valuable tool that is suitable for routine use in intracranial surgery,especially in complicated,large,and giant aneurysms with wide neck or without neck。

Abstract：Background The etiological spectrum of cirrhosis has changed over the years,but our knowledge of it is limited.The present study aimed to investigate the etiological features of cirrhosis inpatients and their variation in the past 18 years in Beijing.Methods A retrospective analysis was performed on all patients with cirrhosis diagnosed for the first time in Peking University People's Hospital from January 1,1993,to October 25,2010.Data were analyzed using SPSS 20.0.Results A total of 2119 cirrhosis inpatients were included in this study:1412 (66.6％) male and 707 (33.4％) female.Chronic hepatitis B accounted for 58.7％; chronic hepatitis C for 7.6％; chronic hepatitis B and hepatitis C virus co-infection for 0.8％ (16 cases); alcoholic liver disease for 9.4％ (200 cases); and autoimmune diseases for 9.4％ (199 cases).In the past 18 years,the percentage of chronic hepatitis B has decreased from 75.2％ to 48.7％; alcoholic liver disease has increased from 5.1％ to 10.6％; and autoimmune disease has increased from 2.2％ to 12.9％.The percentages of chronic hepatitis B and alcoholic liver disease were higher among men,whereas the percentages of chronic hepatitis C,autoimmune diseases and cryptogenic cirrhosis were higher among women.Conclusions Chronic hepatitis B was still the most common etiology of cirrhosis in China,but the percentage has been decreasing.The percentages of alcoholic liver disease and autoimmune diseases have been increasing.The etiological spectrum of cirrhosis inpatients differed significantly according to sex。

Abstract：Background Gastric stromal tumors are the most common type of tumor originating from mesenchymal tissue.The traditional method for the treatment of gastric stromal tumor is surgical operation or therapeutic laparoscopy.More recently,endoscopic micro-traumatic surgery has become possible for gastric stromal tumors,with any perforation caused by endoscopic therapy mended endoscopically.We assessed the effectiveness of endoscopic full-thickness resection (EFR)in the treatment of gastric stromal tumors arising from the muscularis propria.Methods Of the 42 gastric stromal tumors,each ＞2.0 cm in diameter,arising from the muscularis propria,22 were removed by EFR and 20 by laparoscopic surgery.Tumor expression of CD34,CD117,Dog-1,S-100,and smooth muscle actin (SMA) was assessed immunohistochemically.Operating time,complete resection rate,length of hospital stay,incidence of complications,and recurrence rates were compared between the two groups.Continuous data were compared by using independent samples t-tests and categorical data by using X2 tests.Results Comparisons of the 22 gastric stromal tumors treated with EFR and the 20 treated with laparoscopic surgery showed similar operation times (60-155 minutes (mean,(90±17) minutes) vs.50-210 minutes (mean,(95±21) minutes),P ＞0.05),complete resection rates (100％ vs.95％,P ＞0.05),and length of hospital stay (4-10 days (mean,(6.0±1.8)days) vs.4-12 days (mean,(7.3±1.7) days),P ＞0.05).None of the patients treated with EFR experienced complications,whereas one patient treated with laparoscopy required a conversion to laparotomy and one experienced postoperative gastroparesis.No recurrences were observed in either group.Immunohistochemical staining showed that of the 42 gastric stromal tumors diagnosed by gastroscopy and endoscopic ultrasound,six were leiomyomas (SMA-positive) and the remaining 36 were stromal tumors.Conclusions Gastric stromal tumors arising from the muscularis propria can be completely removed by EFR.EFR may replace surgical or laparoscopic procedures for the removal of gastric stromal tumors。

Abstract：Background Thin-flap laser in situ keratomileusis (LASIK) is the new trend of refractive error correction surgery,the formation of corneal flap is crucial for a success of LASIK surgery.This study aimed to assess and compare the variations of LASIK flap created by the IntraLase femtosecond laser,Moria One Use-Plus SBK and Moria M2 Single-Use 90 μm-head microkeratome using Anterior segment optical coherence tomography (Visante OCT).Methods One hundred and sixty-one eyes of 81 consecutive patients were enrolled in this prospective study and randomly divided into three groups depending on the flap creation method:flap creation with the the IntraLase femtosecond laser (IntraLase group,59 eyes),flap creation with the Moria One Use-Plus SBK (SBK group,44 eyes),and flap creation with the Moria M2 Single-Use 90 μm-head microkeratome (M2SU90 group,58 eyes).The nominal flap thickness was 110 μm for all patients and for the three devices.One month after surgery,Visante OCT was used to measure the flap thickness at 20 locations on each cornea and the results were assessed for uniformity,regularity,and accuracy.Results At 1 month after surgery,the mean central flap thickness was (111±3) μm in the IntraLase group,(114±8) μm in the SBK group,and (118±13) μm in the M2SU90 group respectively.The flaps in the IntraLase group and the SBK group were more regular,showing an almost planar configuration,than the meniscus-shaped flaps in the M2SU90 group.The maximum deviation from the intended flap thickness (110 μm) was 6 μm in the IntraLase group,10 μm in the SBK group,and 20 μm in the M2SU90 group respectively.A difference greater than 20 μm was observed in 0.42％ of measurements in the I ntraLase group; 2.95％ of the measurements in the SBK group and 21.12％ of measurements in the M2SU90 group.Conclusions The flaps created by the IntraLase femtosecond laser and Moria One Use-Plus SBK are more uniform;more regular,and more accurate than those created by the Moria M2 Single-Use 90 μm-head microkeratome.The first two methods can make precise flaps for Sub-Bowman Keratomileusis。

Abstract：Background Hypotension due to the induction of sedation with dexmedetomidine infusion may be harmful in critically ill patients.Changes in pulse pressure induced by the passive leg raising test (PLR-△PP) as marker of fluid responsiveness,assessed prior to sedation,may predict hemodynamic changes.The present study was to investigate the power of the PLR test in critically ill patients in predicting hypotension induced by the induction of dexmedetomidine sedation.Methods Fluid responsiveness was estimated by a passive leg raising (PLR) test before dexmedetomidine sedation.Patients were assigned to either the "Nonresponders" or "Responders" group according to their hemodynamic responses to the PLR test ("Nonresponders",PLR-△PP ＜10.3％; "Responders",PLR-△PP ＞10.3％).Sedation was performed with a dexmedetomidine infusion (0.5 μg/kg over a 10-minute loading period,then 0.2-0.7 μg-kg-1.h-1)and titrated to maintain the target Richmond agitation sedation scale (RASS) score in the range of-2 to-1 and the bispectral index value in the range of 60 to 75.Radial artery pulse pressure,heart rate (HR),and central venous pressure (CVP) were measured at each phase of the study procedure.Hemodynamic fluctuations during the use of dexmedetomidine sedation were recorded and compared between the two groups.Results Fifty patients had a median (25％-75％ interquartile range) of 71 (61-78) years old were studied.At baseline,39 of the 50 patients were "Nonresponders" and 11 were "Responders".Following dexmedetomidine sedation,patients classified as "Responders" had a significantly greater systolic blood pressure decrease during the induction of dexmedetomidine sedation than the "Nonresponders" ((-26.3 ± 6.8)％ vs.(-11.8 ± 8.5)％,P ＜0.001).In addition,the "Responders" group required significantly more fluid boluses (8 vs.3; P ＜0.001) and vasopressors (2 vs.0; P ＜0.05)than the "Nonresponders" group to restore blood pressure.Finally,PLR-△PP was positively correlated with changes in systolic blood pressure (PLR-△SBP) (r2 =0.576; P ＜0.001) and significantly correlated with dexmedetomidine infusioninduced changes in SBP (r2=0.202; P ＜0.05).AUC for PLR-△PP was 0.84 (95％C/0.71-0.93).PLR-△PP predicted hypotension with a sensitivity of 73％ and a specificity of 92％.Conclusions The fluid responsiveness assessment pre-sedation was found to predict blood pressure fluctuation during the induction of dexmedetomidine sedation.The PLR test conducted prior to sedation may be a useful tool to identify patients with a high risk of hemodynamic events and may be used to indicate the need for prophylactic treatment。

Abstract：Background As female sex workers (FSWs) were becoming the driving force behind the HIV epidemic in Central China,a project to promote condom use by FSWs was implemented from 2004 to 2009.In this study,we discussed the evaluation of the project,the factors associated with condom use among FSWs within the Chinese context,and proposed suggestions for future interventions for FSWs in China.Methods Two surveys using structured questionnaires were conducted in 2004 and 2009.Data collected from the surveys were analyzed and guided by a behavior change framework.We reviewed relevant articles to supplement the information that was not able to be obtained from the surveys.Results In general,the HIV prevalence among FSWs remained low (less than 1％) in the 5 years.With a high coverage of interventions for all FSWs in Central China,the project yielded better outcomes than the national average over the same time period.The awareness about HIV and condom use grew dramatically during the project period.The four factors/determinants that influence the behavior of FSWs using condoms are population characteristics,opportunity,ability,and motivation.Statistical model shows that the significant variables for using a condom are age,availability of services,HIV-related knowledge,and intention.Conclusions With a high coverage of interventions for FSWs,the project achieved its goals.The differences among workplaces of FSWs may serve as a symbol of their socioeconomic status,patterns of condom use,and therefore risks of acquiring HIV。

Abstract：Background Apurinic apyrimidinic endonuclease/redox effector factor 1 (APE1/Ref-1) is an important enzyme in the repair of reactive oxygen species-induced DNA damage,and its expression/activation can be induced by reactive oxygen species.The aim of this research was to investigate the relationship between multiple-organ injuries and expression of Ref-1 in the early period after liver transplantation.Methods One hundred and fifty adult male Wistar rats were divided randomly into three groups:liver transplantation,sham surgery,and untreated control.After liver transplantation,animals were sacrificed at different time points.Hepatic and renal functions were analyzed by serology.Histology,apoptotic levels,and Ref-1 expression were examined by immunohistochemistry in the liver,kidneys,intestines,and lungs.Results Serum levels of alanine aminotransferase and aspartate aminotransferase peaked 6 hours after liver transplantation and decreased appreciably after 12 hours in the transplantation group,suggesting that the degree of liver injury in the early period after transplantation peaked at 6 hours and then decreased.Pathological analyses showed that hepatic tissues were more severely injured in the transplantation group than in the sham and untreated groups.A considerable number of infiltrating inflammatory cells was observed around the portal vein in the transplantation group.Injuries to the kidneys,intestines,and lungs were milder after liver transplantation.Apoptotic levels increased after liver transplantation in all four organs examined.Ref-1 expression was higher in the transplantation group in the early period after liver transplantation than in the sham surgery and untreated control groups.Conclusion Ref-1 expression induced by ischemia-reperfusion injury may have a critical role in repairing multiple-organ injuries after liver transplantation。

The prevalence of type 2 diabetes (T2DM),which is characterized by insulin resistance,is increasing dramatically worldwide,and it has become a major public health issue.T2DM and cancer are common diseases that are frequently diagnosed in the same individual and the relationship of them appears to be complex.Epidemiologic data have shown T2DM is significantly associated with cancer,but potential biologic links between the two diseases are not fully understood。