2003年 · 第116卷第10期

Objective To identify predictors of left atrial appendage stunning after the use of electrical cardioversion to restore sinus rhythm in patients with non-valvular atrial fibrillation. Methods A total of 68 consecutive patients(45 men, 23 women, 60. 5 ±8. 7 years of age)with non-valvular atrial fibrillation undergoing electrical cardioversion were enlisted in this study. Clinical and echocardiographic variables were analyzed by univariate regression and multivariate logistic regression to investigate the relationship between occurrences of left atrial appendage stunning and these factors. Results Univariate analysis revealed that, in comparing patients without and with left atrial appendage stunning, there were significant differences in the duration of atrial fibrillation > 8 weeks(32.3% vs 75. 5%, P<0. 001), left atrial diameter > 50 mm(29. 0% vs 54. 1%, P<0. 05), left atrial emptying fraction(31. 5% ±7. 8% vs 27. 1 % ±8. 5%, P<0. 05), left ventricular ejection fraction < 50%(38. 7% vs 67. 6%, P < 0. 05), maximum electrical energy(96. 8 J ±65. 8 J vs 156. 8 J ± 100. 8 J, P<0. 01), cumulative electrical energy 146. 8 J ±142. 6 J vs 290. 5 J ±242. 1 J, P<0. 01)and number of electrical cardioversion shocks(1. 7 ± 0. 9 vs 2. 43 ± 1. 20, P < 0. 05). However, backward stepwise multivariate logistic regression analysis identified as significant and independent predictors of left atrial appendage stunning only duration of atrial fibrillation > 8 weeks(OR =7. 249, 95%CI =1. 998-26. 304, P<0. 01), left atrial diameter > 50 mm(OR =3. 896, 95%CI =1. 105-13. 734, P<0. 05), left ventricular ejection fraction < 50%(OR =4. 465, 95%CI = 1. 51713. 140, P<0. 01)and cumulative energy of electrical cardioversion(OR =1. 004, 95% CI =1. 000-1. 008, P<0. 05). Conclusions Duration of atrial fibrillation >8 weeks, left atrial diameter >50 mm, left ventricular ejection fraction <50%, and cumulative energy of electrical cardioversion are independent predictors of left atrial appendage stunning. Anticoagulation treatment should be individualized for patients undergoing electrical cardioversion to reduce the risk of both cardioversion-related thromboembolic events and hemorrhagic complications caused by warfarin treatment. Chin Med J 2003; 116(10): 1445-1450

Objective To study the effects of percutaneous renal artery intervention on renal function and blood pressure in patients with renal artery stenosis. Methods Eighty-seven patients with severe uni-or bi-lateral renal artery stenosis(luminal diameter narrowing ≥70%)and clinical hypertension received renal artery stenting between January 2002 and December 2002. The changes in blood pressure and serum creatinine level and creatinine clearance(CCr)48 hours after intervention and during 6 months of follow-up were assessed. Results Renal stenting was performed in 98 stenotic arteries of 87 patients, and the procedural success rate was 100%. Serum creatinine level was slightly elevated from(176 ±21)μmol/L to(179 ±11)μmol/L (P = 0. 15)48 hours after the procedure, but significantly decreased to(149 ±15)μmol/L at 6 months(P <0. 001). CCr was also greatly improved [(37 ±11)ml/min before versus(51 ±8)ml/min at 6 months, P < 0. 001 ]. During follow-up, 61 % of the patients experienced a normal renal function. Despite conventional medical treatment, systolic and diastolic blood pressures were also significantly decreased after stenting [(163 ±23)/(96 ±13)mm Hg before versus(148 ± 12)/(79 ±15)mm Hg at 6 months, all P <0. 001 ], and hypertension was well controlled in 67% of the patients at 6 months' follow-up. Conclusion Renal artery stenting has a high success rate and is effective in improving renal function and blood pressure for patients with severe renal artery stenosis. Chin Med J 2003; 116(10): 1451-1454

Objective To analyze the unipolar electrogram from successful and unsuccessful ablation sites of focal atrial tachycardia(AT), and to evaluate its value in the identification of successful targets. Methods Fifteen consecutive patients with focal AT were referred for radiofrequency catheter ablation(RFCA). Both unipolar(from the tip electrode of ablating catheter)and bipolar(from the distal pair of electrode of ablating catheter)electrograms were used to identify the ablation targets of focal AT. Results Successful ablation was echieved in 14 patients. Radiofrequency energy was delivered at a total of 27 sites. The bipolar electrograms associated with successful ablation sites showed earlier atrial deflection relative to P wave onset(36 ms ± 15 ms vs 30 ms ± 11 ms, P < 0.05)than the electrograms associated with failed ablation sites. At the 14 successful ablation sites, the unipolar electrograms displayed a completely negative atrial wave("QS"morphology)beginning with intrinsic deflection. However, at the 13 unsuccessful ablation sites, a"rS" morphology of atrial wave was shown on the unipolar electrogram. Conclusion The"QS"morphology of the atrial wave on unipolar electrograms appears to represent a reliable marker for identifying the successful ablation targets of focal AT, with a high sensitivity and specificity. Chin Med J 2003; 116(10): 1455-1458

Objective To investigate the association between catecholamine-β-adrenoceptor(β-AR)-adenosine 3', 5'-monophosphate(cAMP)system and long-term prognosis in patients with chronic heart failure(CHF). Methods The study population comprised 73 patients with CHF(EF: 23% ±10％)with a mean follow-up of 3. 8 ±1. 9 years. Plasma levels of norepinephrine(NE)were measured using high performance lipid chromatography, β-adrenergic receptor density(Bmax)and the content of cAMP in peripheral lymphocytes were calculated using 3H-dihydroalpneolo as ligand and competitive immunoassay, respectively. Deaths due to cardiovascular events within the follow-up period were registered. Results The total mortality was 64. 7%, 57. 4% of which was for cardiogenic(worsening heart failure: 32. 4%; sudden death: 25. 0%). In the cardiogenic death group, plasma levels of NE and epinephrine(E)(3. 74 nmol/L ±0. 09 nmol/L and 3. 17 nmol/L ±1. 0nmol/L)and the contents of peripheral lymphocyte cAMP(3. 64 pmol/mg protein ±1.4 pmol/mg protein)were significantly increased as compared with the survival group(2. 68 nmol/L ±0. 07 nmol/L, 2. 41 nmol/L ±0. 24 nmol/L and 2. 73 pmol/mg protein ±0. 9 pmol/mg protein, respectively, all P <0. 01). In the sudden death group, plasma levels of NE and E(5. 01 nmol/L ± 0. 06 nmol/L and 4. 13 nmol/L ± 0. 08 nmol/L)were significantly increased as compared with the worsening heart failure group(2. 49 nmol/L ±0. 07 nmol/L and 2. 33 nmol/L ± 0. 8 nmol/L, all P < 0. 001)and to the survival group(2. 68 nmol/L ±0. 07 nmol/L and 2. 41 nmol/L ±0. 14 nmol/L, all P<0. 01). The incidences of sudden death were 0%, 75%, and 100%(χ2 =16. 018, P<0. 01)in patients with plasma NE <2. 5 nmol/L, NE 2. 5 nmol/L-4. 5 nmol/L, and NE > 4. 5 nmol/L, respectively. In the worsening heart failure group, the content of peripheral lymphocyte cAMP(4. 46 pmol/mg protein ±0. 18 pmol/mg protein)was significantly increased compared with the sudden death group(2. 39 pmol/mg protein ±0. 9 pmol/mg protein, P<0. 001)and to the survival group(2. 73 pmol/mg protein ±1. 1 pmol/mg protein, P< 0. 001). The worsening heart failure death occurences were 5. 0%, 72. 2%, and 100%(χ2 =14. 26, P <0. 01)in patients with a content of peripheral lymphocyte cAMP <2. 5 nmol/L, cAMP 2. 5 nmol/L-4. 5 nmol/L, and cAMP > 4. 5nmol/L, respectively. Bmax in peripheral lymphocyte was not significantly different(P>0. 05)among the sudden death, worsening heart failure, and survival groups in CHF patients. Conclusions Plasma levels of catecholamine increase significantly, and Bmax and the contents of cAMP in peripheral lymphocytes decrease significantly in patients with CHF. High plasma catecholamine levels may be associated with sudden death, and high intralymphocyte cAMP content may be associated with worsening heart failure in CHF patients. Chin Med J 2003; 116(10): 1459-1463

Objective To analyze diagnostic approach to severe acute respiratory syndrome(SARS)according to the diagnostic criteria issued by the Ministry of Health of China(MHO). Methods The clinical data and the diagnostic results of 108 cases of SARS were retrospectively reviewed according to the MHC criteria. Results There were 55 men and 53 women, with a median age of 34. 5 years(range, 12-78 years). The interval between their first visit and clinical diagnosis was 3 days(range, 0-14 days). The diagnosis was made at the first visit in 7(6. 5%, 7/108)cases with a history of exposure to SARS patients and infiltrates on chest radiograph. Eighty-nine(82. 4%)and 12(11. 1 %)patients were categorized as probable cases and suspected cases respectively at their first visit and a clinical diagnosis of SARS was made subsequently. The interval between first visit and reaching the final diagnosis was 1-3 days in 72(66. 7%)cases and 4 days in 29(26. 9%)cases. The final diagnosis was made in 0-14 days(median, 2 days)for those(n =59, 54. 6%)with a history of close contact with SARS patients and 2-8 days(median, 3 days)for those(n =49, 45. 4%)living in Beijing but without such a history (P = 0.03). The chest radiograph was interpreted as unremarkable in 26(24. 1 %)cases at their first visit, and the diagnosis was made in 4 days(range 2-8 days), which was significantly longer compared with other cases(P <0. 001). In patients without a history of close contact with SARS patients, all the five criteria were met after combination antibiotic therapy had failed. Conclusions A chest radiograph without infiltrates at the early stage of SARS is an important factor responsible for delayed diagnosis. In patients without a history of close contact with SARS cases, antibiotic effect was a major factor influencing doctors' diagnosis. Chin. Med J 2003; 116(10): 1464-1466

Objective To investigate the expression of human telomerase catalytic subunit, hTERT, in human non-small cell lung cancer(NSCLC)and its correlations to c-myc gene. Methods hTERT and c-myc mRNA expressions were detected by semiquantitative reverse transcription-polymerase chain reaction(RT-PCR). Statistical correlation analysis was made to estimate whether there was interrelation between them. Results Positive rate of hTERT expression in 51 surgically resected lung cancer specimens was 86. 3%, significantly higher than that in adjacent non-neoplastic lung tissues and benign lesions, which were 14. 3% and 27. 3% respectively. No statistical significance was observed between the frequency of hTERT expression and histologic types, degree of differentiation, TNM stages, tumor size or lymph nodes metastases. Correlation analysis revealed that the expression of c-myc gene was significantly related to that of hTERT(correlation coefficient, r= 0. 633, P<0. 001). Conclusions hTERT may be a useful tumor marker in diagnosing lung cancer. Significant correlation between the expression of hTERT and c-myc mRNA indicates that the activation and up-regulation of hTERT might be conferred by over-expression of c-myc gene. Chin Med J 2003; 116(10): 1467-1470

Objective To establish a novel bioartificial liver(BAL)consisting of spheroids of porcine hepatocytes in a hollow-fiber bioreactor, and to perform an in vitro study on its metabolic effects on the serum from severe hepatitis B patients. Methods Hepatocytes were isolated from pup pigs and cultured as aggregate spheroids through rotation and vibration. Phase-contrast microscopy, transmission electron microscopy, and scanning electron microscopy were used for morphological detection of hepatocyte spheroids. The hepatocyte spheroids were then transferred into the shell of a polysulfone hollow-fiber bioreactor, creating a novel BAL. Diluted serum samples of severe hepatitis B patients were circulated for 3 hours each into the bioreactor, by using an extracorporeal circulatory system. Every half hour, including both before and after perfusion, serum samples were collected to assay total bilirubin(TBIL), total protein(TP), albumin(ALB), and globulin(GLB)concentrations in order to judge the metabolic effects of this novel BAL. Results Most hepatocytes had formed spheroids with high viability after 24 hours in culture. After 3 hours of perfusion, when compared with the control group, the serum concentration of TBIL in the treatment group decreased significantly(P < 0. 01), but the serum concentrations of TP and ALB increased significantly(P <0. 05). Conclusions Hepatocytes can be conveniently cultured as aggregate spheroids through a rotation and vibration method. The novel BAL is efficient in removing bilirubin from the serum of severe hepatitis B patients, and in supplying the serum with ALB. Thus, the BAL might provide effective therapy for patients with severe hepatitis B. Chin Med J 2003; 116(10): 1471-1474

Objective To investigate the antitumor effects of intrasplenically transplanted interleukin-18(IL-18)gene-modified hepatocytes on murine implanted liver carcinoma. Methods Embryonic murine hepatocyte cell line(BNL-CL2)was transfected with a recombinant adenovirus encoding IL-18 and used as delivery cells for IL-18 gene transfer. Two cell lines, BNL-LacZ and BNL-CL2, were used as controls. One week after intrasplenic injection of C26 cells(colon carcinoma line), tumor-bearing syngeneic mice underwent the intrasplenic transplantation of IL-18 gene-modified hepatocyte cell line and were divided into treatment group(BNL IL-18)and control groups(BNL-LacZ and BNL-CL2). Two weeks later, the serum levels of IL-18, interferon-y(IFN-γ), tumor necrosis factor-a(TNF-α)and nitric oxide(NO)in the implanted liver carcinoma-bearing mice were assayed, the cytotoxicity of murine splenic cytotoxic T-lymphocytes(CTLs)was measured, and the morphology of the hepatic tumors was studied to evaluate the antitumor effects of the approach. Results In the treatment group, the serum levels of IL-18, IFN-γ, TNF-α and NO increased significantly. The splenic CTL activity increased markedly(P<0. 01), accompanied by a substantial decrease in tumor volume and the percentage of tumor area and prolonged survival of liver carcinomo-being mice. Conclusions In vivo IL-18 expression by ex vivo manipulated cells with IL-18 recombinant adenovirus is able to exert potent antitumor effects by inducing a predominantly T-cell-helper type 1(Th1)immune response. Intrasplenic transplantation of adenovirus-mediated IL-18 gene-modified hepatocytes could be used as a targeting treatment for implanted liver carcinoma. Chin Med J 2003; 116(10): 1475-1479

Objective To evaluate retrospectively the effectiveness of image-guided navigation techniques in the management of cerebral CMs. Methods Between July 1997 and January 2001, 44 patients underwent image-guided resection of cerebral CMs. To counteract brain shift, a small silicon catheter was implanted as a guide in the case of deep-seated lesions(except in the case of brain stem CMs)and before excision of multiple lesions. Results A total of 27 men and 17 women with a mean age of 35 years underwent surgical procedures(5 patients had multiple lesions). The lesions were located in the frontal(n =14), lobe temporal lobe(n =12), parietal lobe(n = 6), cerebellum(n = 6), thalamus(n = 5), pons(n = 5), and orbital region(n = 1). Under the guidance of a StealthStation navigator, total removal of the lesions was achieved in all patients. Follow-up revealed marked improvement of preoperative symptoms in 26 patients and no additional deficits in 13 patients. Five patients suffered from additional neurological deficits, but two of them gradually improved during the follow-up period. Conclusions With the assistance of an image-guided surgical system, functional areas can be effectively avoided and surgical injury can be decreased. This system is well suited for accurate localization and safe resection of small, deep-seated CMs. Chin Med J 2003; 116(10): 1480-1483

Objective To evaluate the restoration of function after spinal cord injury(SCI)in patients of different ages who have underwent intraspinal transplantation of olfactory ensheathing cells(OECs). Methods One hundred and seventy-one SCI patients were included in this study. Of them, 139 were male and 32 were female, with age ranging from 2 to 64 years(mean, 34. 9 years). In all SCI patients the lesions were injected at the time of operation with OECs. According to their ages, the patients were divided into 5 groups: ≤20 years group(n =9), 21-30 years group(n =54), 31-40 years group(n = 60), 41-50 years group(n = 34)and >51 years group(n =14). The spinal cord function was assessed based on the American Spinal Injury Association(ASIA)Classification System before and 2-8 weeks after OECs transplantation. One-way ANOVA and q test were used for statistical analysis, and the data were expressed as mean ± SD. Results After surgery, the motor scores increased by 5. 2 ±4. 8, 8. 6 ±8. 0, 8. 3 ±8. 8, 5. 7 ±7. 3 and 8. 2 ±7. 6 in 5 age groups respectively (F = 1. 009, P = 0. 404); light touch scores increased by 13. 9 ±8. 1, 15. 5 ±14. 3, 12. 0 ±14. 4, 14. 1 ±18. 5 and 24. 8 ±25. 3 respectively(F = 1. 837, P = 0. 124); and pin prick scores increased by 11. 1 ±7. 9, 17. 2 ±14. 3, 13. 2 ±11. 8, 13. 6 ± 13. 9 and 25. 4 ±24. 3 respectively (F = 2. 651 , P = 0. 035). Restoration of pin prick in > 51 years group was better than other age groups except 21-30 years group. Conclusion OECs transplantation can improve the neurological function of spinal cord of SCI patients regardless of their ages. Further research into the long-term outcomes of the treatment will be required. Chin. Med J 2003; 116(10): 1488-1491

Objective To determine whether the clinical and pathologic characteristics and prognoses of myasthenia gravis(MG)patients below 15 years differ from those patients over 50 years after thymectomy. Methods We reviewed the registry material of 30 pediatric and 32 elderly MG patients after thymectomy, including their age, sex, clinical classification, pathological types, and prognoses. The Chi-square test or Wilcoxon's rank-sum test was used to determine the statistical differences between the children and elderly groups. Results No significant difference was seen in sex distribution between the two groups(Chi-square test, P = 0. 625), but there were differences in clinical classification: more type I was observed in the pediatric group than in the elderly group, but more type Ⅱ or Ⅲ was seen in the elderly group(Wilcoxon's rank-sum test, P < 0. 001). As to pathological types, the pediatric group was also significantly different from the elderly group(Chi-square test, P<0. 01). All of the patients(100%)in the pediatric group had thymus hyperplasia, but in the elderly group more than half(56. 26%)were found to have thymoma(benign or malignant). The prognoses after thymectomy were better in the pediatric group than in the elderly group(Wilcoxon's rank-sum test, P <0. 001). Conclusions Because the prognoses are generally better than those of the elderly patients, we should be careful when operating on pediatric patients of ocular type. The elderly patients tend to receive more aggressive treatment because of more severe generalized types often associated with thymoma and poor prognoses. Both pediatric and elderly patients are seldom associated with other autoimmune disease. Chin Med J 2003; 116(10): 1578-1581

Objective To investigate the therapeutic effect of retroviral endostatin gene transfer on the human colon cancer cell line, LoVo. Methods A retroviral vector pLESSN expressing secretable endostatin was constructed and packaged with a titer of 8. 2 × 105 CFU/ml. A LoVo cell line was subjected to retrovirus-mediated endostatin gene transfer. The proviral integration of endostatin was analyzed with PCR. The function of endostatin was tested by MTT assay in vitro and a mouse xenograft model in vivo. Results After transfection and superinfection, amphotropic retrovirus was collected, and transduction with amphotropic retroviruses resulted in endostatin proviral integration. The endostatin secreted by transduced LoVo cells markedly inhibited endothelial cell growth up to 67%(P < 0. 001), compared with the control cells. The gene expression of endostatin in LoVo colon tumor cells significantly inhibited tumor growth in vivo. There was an 86% reduction in tumor size in the endostatin-transduced group, accompanied by a reduction in vessels, compared with the control group(P <0. 01). Conclusion Retroviruses can allow functional expression of the endostatin gene in human colon tumors, showing promise for an antitumor strategy using antiangiogenesis. Chin Med J 2003; 116(10): 1582-1584

Objective To investigate the K-ras mutation pattern in six pancreatic cancer cell lines from Chinese patients. Methods All six cell lines were analyzed for mutations in exon 1 of the K-ras gene by polymerase chain reaction(PCR)and direct sequencing. Results All 6 pancreatic cancer cell lines had GGT→GTT mutations at K-ras codon 12 but no mutations at codon 13. Conclusion The unique GGT→GTT mutation at codon 12 plays a potential role in the carcinogenesis of pancreatic cancers in Chinese. Chin Med J 2003; 116(10): 1585-1587