2002年 · 第115卷第08期

Objective To analyse the characteristics and therapies of patients with acute ischemic syndrome in China. Methods This study is part of the international multicentre registry for acute ischemic syndrome. Since April 1999, the data of patients admitted to designated hospitals with acute ischemic cardiac chest pain were collected by filling in Case Report Forms offered by the Canadian Cardiovascular Collaboration. The main clinical characteristics and in-hospital events of the patients were recorded. Results Fifteen hundred and nine cases of acute ischemic syndrome from 34 hospitals nationwide were enrolled in the registry (including unstable angina and non Q-wave myocardial infarction).The mean age of the patients was 62.3. Male dominance (62.2%) was noted. The percentages of patients with chest pain at presentation and abnormal ECG were 47.8%and 89.5%, respectively. The most common clinical diagnosis on admission was unstable angina, accounting for 91 .3%of the patients and non Q-wave myocardial infarction (Ml), accounting for the other 8.7%. During hospitalization, the following interventions were given: thrombolytic therapy in 50 cases (3.3%), coronary angiography in 528 cases(35.0%), percutaneous transluminal coronary angioplasty (PTCA) in 253 cases (16.8%) and coronary artery bypass graft surgery (CABG) in 62 cases (4.1%). Nitrate (oral or patch) and anti-platelet therapy were used in 1460 cases (96.8%) and 1441 cases (95.5%), respectively. The incidence of in-hospital major events was 18.8%, including 18 deaths (1.2%), with the most common causes being severe arrhythmias and sudden death. Conclusions Patients with acute ischemic syndrome in China have mostly been diagnosed as cases of unstable angina. A relatively high PTCA rate but low CABG rate was noted in China. The most common cause of in-hospital death is severe arrhythmias or sudden death. Chin Med J 2002; 115(8): 1123-1126

Objective To determine whether autoantibodies against β1-adrenergic and M2-muscarinic receptors are related to patients with congestive heart failure (CHF). Methods Both synthetic peptides corresponding to amino acids sequence 197-222 and 169-173 of the second extracellular loops of the β1 and M2 receptors were used as antigens to screen sera from 265 patients. 188 were congestive heart failure (CHF) patients with different heart diseases, among them 42 were ischemic cardiomyopathy (ICD) and 52 were idiopathic dilated cardiomyopathy (IDCM), 44 were hypertensive heart disease (HHD), 50 were rheumatic valvular heart disease (RVHD); 77 were controls,among them 36 were simple hypertension and 41 were healthy donors (NC). Results Positive sera for β1-adrenergic receptor was found in 45.73%(86/188) of CHF patients, while in the controls it was 10.4%(8/77) (P <0.01); positive sera for M2-muscarinic receptor in CHF patients was found in 49.5%(99/188), while in the control it was 11.7%(9/77) (P<0.01). The positive ratio of autoantibodies against β1-adrenergic and M2-muscarinic receptors in CHF patients with cardiac function class Ⅱ -Ⅲ (NYHA) were significantly higher than cardiac function class Ⅳ . The average titer of autoantibodies against β1-adrenergic and M2-muscarinic receptors of the former was significantly higher than the latter; 56.1 %of patients with autoantibodies against β1-adrenergic receptor had autoantibodies against M2-muscarinic receptor. Conclusions Autoantibodies against β1-adrenergic receptor and M2-muscarinic receptor were found in sera from heart failure patients with different cardiac diseases. We propose that autoantibodies against β1 and M2 receptors are not only related to the IDCM, but also to cardiac structural and functional changes. Chin Med J 2002; 115(8): 1127-1131

Objectives To analyze the technical aspects of uterine artery embolization with dextran microspheres and to evaluate the effectiveness of this technique as the primary treatment of uterine fibroids in a series of 38 patients. Methods Thirty-eight volunteers (age range, 24 - 48 years; mean, 37.2 years) with symptoms caused by uterine fibroids (menorrhagia, mass-related symptoms, and pelvic pain) were randomly included in this study. The fibroids were single in 32 patients and multiple in 6 patients. According to the tumor location,subserous fibroids were found in 4 patients and interstitial or submucosal fibroids in 34. Tumor size was from 2 to 10.9 cm in diameter. We performed embolization with a single Headhunter catheter using the right-femoral artery approach, injection of dextran microspheres (225-450 μm), and an absorbable gelatin sponge. Follow-up included clinical and sonographic examinations at one-month intervals for 6 months. Results Embolization was successfully performed in all patients. Post-procedural pain control was good in 35 (92%) patients. In most patients, symptoms were improved at 3 months (36/38, 95%). Clinical failure of the treatment occurred in only 2 patients (2/38, 5%). Progressive reduction in leiomyoma size was revealed during sonographic follow-up, and the reduction rate at the sixth month after embolization was 68%. The tumor had vanished in five submucosal fibroid patients. Histopathological tests showed that the tumor was degenerative as fibrosis and hyalinosis. Conclusions Uterine artery embolization with dextran microspheres is a micro-invasive method for the treatment of uterine fibroids. It is clinically effective in most patients and induces a progressive reduction in the size of fibroids. Based on this study, we believe that this new technique is much more suitable for submucosal fibroids with massive menorrhagia. Chin Med J 2002; 115(8): 1132-1136

Objectives To determine the clinical value of sentinel lymph node (SLN) detection by lymphoscintigraphy and gamma ray detecting probe (GDP) and to assess the value of hematoxylin and eosin (H&E) staining combined with immunohistochemistry (IHC) analysis for detecting micrometastasis in lymph nodes (LNs). Methods Forty-two patients with breast cancer were included in this study. 99Tcm-dextran was injected peritumourally. Lymphoscintigraphy images were obtained in anterior and lateral views. SLNs were removed with the aid of GDP during surgery. A standard axillary lymph nodes (ALNs) dissection was performed. All lymph nodes were first analyzed by HE staining. When all of the SLNs in a patient were negative, the ALNs were subjected to additional HE staining combined with IHC analysis. Results SLNs were successfully detected and removed in 39 (92.9%) of the 42 patients. The sensitivity,specificity and accuracy of SLN biopsy were 92.9%(13 in 14), 100%(25 in 25) and 97.4%(38 in 39)respectively. Additional HE staining combined with IHC analysis of the ALNs detected micrometastasis in 3 SLNs (2 cases), but there were no positives in the non-sentinal lymph nodes (NSLNs). Conclusions This study suggests that lymphoscintigraphy and GDP may be used to detect SLN. Additional HE staining combined with IHC analysis of the ALNs may help predict micrometastasis. Biopsy of SLN may be an accurate method for staging breast cancer. Chin Med J 2002; 115(8): 1137-1140

Objective To use δ-aminolevulinic acid induced photodynamic therapy (ALA-PDT) increasingly in treating skin cancers and other diseases in many countries and to explore the efficacy of ALA-PDT for skin cancers in China. Methods Eighty-eight patients, including 34 cases of basal cell carcinoma (BCC), 32 cases of squamous cell carcinoma (SCC), two cases of basal-squamous cell carcinoma (BSCC), one case of verrucuous carcinoma nine cases of Bowen disease, two cases Paget disease of the nipple and eight cases of extramammary Paget disease, were treated by the δ-aminolevulinic acid induced photodynamic therapy first in China from 1997 to 2000. Results All BCC, including 11 cases of superficial lesions and 29 solid lesions, achieved complete reaction (CR) by 1 - 4 times of the ALA-PDT. Except one patient with adenoid SCC (grade Ⅲ), all SCC(grade I and grade Ⅱ) patients achieved complete remission by 3 - 6 times of ALA-PDT. All Bowen diseases achieved complete reaction by 1 - 4 times. Although for Paget diseases it could not cure the disease simply by ALA-PDT, it could control the symptoms. The recurrence rates were 11 %(4/34) for BCC, and 22%(7/32) for SCC by following up 1 - 3 years after the therapy. The continuous therapy is still effective . Conclusions ALA-PDT is an effective, non-traumatic treatment for patients with BCC, SCC, Bowen and Paget diseases. It is especially suitable for older and weaker patients or those who are not tolerable to other therapies. It also has a unique advantage for tumors in specific anatomical areas. It is a new alternative modality for skin cancer therapies. Chin Med J 2002; 115(8): 1141-1145

Objective To evaluate the diagnostic accuracy of three-dimensional CT angiography in the surgical treatment of intracranial aneurysms. Methods Twenty-four patients suspected of intracranial aneurysms underwent routine catheter four-vessel angiography, three dimensional CT angiography (3D-CTA), magnetic resonance angiography (MRA) or conventional digital subtraction angiography (DSA). Results A total of 28 aneurysms were detected by CT angiography in this study. Twenty-one patients each had a single aneurysm, two patients each had two aneurysms, and one had three aneurysms. The shapes of aneurysms revealed by 3D-CTA were round in 20 lesions, elliptical in 5, and 1 obulated in 3. Of the 24 lesions which were completely disclosed during surgery, the shapes correlated well with the 3D-CT angiograms. The mean diameter of the aneurysmal neck was 5.9 mm in 3D-CTA images, with the smallest being 1 .6 mm and the largest 13.7 mm. The size was very close to the actual size measured at surgery(P <0.001), revealing that 3D-CT angiograms correlated well with surgical findings. Compared with images obtained by routine catheter four-vessel angiography, MRA and DSA, 3D-CTA images depicted the relationship of aneurysms to parent vessels and other branches more clearly. Conclusion 3D-CTA enables surgeons to understand the 3D structure of intracranial aneurysms and is very useful in planning the surgical treatment of cerebral aneurysms. Chin Med J 2002; 115(8): 1146-1149

Objective To detect the feasibility and theoretic basis for treatment with hyperbaric oxygenation (HBO) in chronic hepatitis and to compare the changes in hepatic function, immunity, pathologic morphology,ultrastructure and HBV in hepatic tissues before and after treatment. Methods Sixty cases of chronic hepatitis were randomly selected and divided into two groups: the experiment (n=30) and control groups (n=30) . Patients in the experimental group were treated with HBO for 6 courses. Patients in the control group were treated for 60 days with the usual drugs used in the clinic. The function and bloodstream graph of liver were examined and liver biopsies were made before and after treatments. Routine paraffin sections were stained with HE and observed under the light microscope. Ultra thin slides from paraformaldehyde and glutaraldehyde fixed liver tissue were stained with lead citrate and observed with the transmission electric microscope. HBsAg and HBcAg in liver of the experimental group were detected with ABC immunohistochemistry method before and after treatment. Results For the experimental group, ALT, SB, γ-GT, AKP, IgG, and IgM in blood and the degeneration and necrosis of hepatocytes were remarkably decreased (P <0.05), the mean contractive wave of bloodstream in liver and the bloodstream in right ramus of janitrix were remarkably increased (P <0.05),and the swelling of mitochondria, increase of lysosomes, generation of Kupffer cells, infiltration of lymphocytes in portal area and capillary generation were all remarkably alleviated (P <0.05) after treatment with HBO. There were significant differences between the experimental and control groups after treatment with different methods (P <0.05). For patients in the experimental group, the fibrosis and fat-storing cells in the liver were not reduced (P> 0.05), and the expression of HBsAg and HBcAg in liver was not weakened (P <0.05) after treatment. Conclusions Treatment with HBO for chronic hepatitis was effective and recommendable, but it could not reverse liver fibrosis. However, it might be able to delay or prevent the liver from fibrosis, so it might be more effective at the early and middle stages of chronic hepatitis. HBO could not inhibit the HB virus. So we consider that treatment with HBO should be simultaneous with anti HBV therapy. Chin Med J 2002; 115(8): 1153-1157

Objective To investigate the possibility of urethral reconstruction with a free colonic mucosal graft. Methods Ten female dogs underwent a procedure in which the urethral mucosa was totally removed and replaced with a free graft of colic mucosa. A urodynamic study was performed before the operation and sacrifice. The dogs were sacrificed 8 to 16 weeks after the operation for histological examination of the urethra. Results Urethral stricture developed in 1 dog. The results of urody namic studies showed that the difference in maximum urethral pressure between pre-operation and pre-sacrifice in the remaining 9 dogs was not of significance (P> 0.05). Histological examination revealed that the colonic free mucosa survived inside the urethral lumen of the 9 dogs. Plicae surface and unilaminar cylindric epithelium of the colonic mucosa was observed in dogs sacrificed 8 weeks after the operation. Plicae surface and unilaminar cylindric epithelium of the colonic mucosa was not observed and metaplastic transitional epithelium covered a large proportion of the urethral mucosa in dogs sacrificed 12 weeks after the operation. Conclusions Urethral mucosa can be replaced by colonic mucosa without damaging the continence mechanism in female dogs. This technique is useful when local or preputial skin and buccal or bladder mucosa are not available. Chin Med J 2002; 115(8): 1163-1165

Objective To investigate the effect of chronic treatment of enbrel (EB), a TNF-a antagonist, in a well defined congestive heart failure (CHF) rat model and test the hypothesis that chronic treatment of EB in CHF rats may limit the progression of Left ventricular (LV) dysfunction and structure remodeling and decrease cardiac IL-1β levels. Methods We measured cardiac conformation, contractile performance and cytokines level in 8 age-matched normal adult rats (control group) and 8 rats with isoproterenol (ISO)-induced Heart failure (ISO group) and 8 rats with ISO-induced lesion but received EB treatment (EB group). Results LV end diastolic diameter and LV end systolic diameter in EB group were significantly less and LV fractional shortening was significantly larger than ISO group (9.2 ± 0.3 mm vs 9.5 ± 0.2 mm, 5.8 ± 0.5 mm vs 6.5 ± 0.3 mm, 0.37 ± 0.03 vs 0.31 ± 0.02, P <0.05, P <0.01, P <0.01 respectively), but there was no significant difference of LV posterior wall thickness at end diastole between the two groups; LV end systolic pressure (PES), dp/dtmax in EB group were significantly greater than ISO group (104.8 ±4.6 mm Hg vs 98.4 ±4.9 mm Hg, 8395 ±940 mm Hg/s vs 6898 ±612 mm Hg, P <0.05, P <0.01 respectively), and LV end diastolic pressure (PED), dp/dtmin, time constant of LV relaxation were significantly lower than ISO group (3.8 ± 0.6 mm Hg vs 7.1 ± 0.8 mm Hg, - 5963 ±475 mm Hg/s vs -5030±316 mm Hg/s, 15.4± 0.8 ms vs 21.3 ± 1.4 ms, P <0.01, respectively). Although cardiac contractile performance in the EB group was greatly improved, there still was a big gap when compared with the control group. The ratio of LV weight to body weight in the EB group was significantly higher than control group (2.82 ± 0.07 mg/g vs 2.28 ± 0.08 mg/g, P <0.01), but there was no significant difference when compared with the ISO group. There was no significant difference between the serum level of TNF-a in EB group and ISO group, the it could not be detected in control group. TNF-α levels in LV of EB group was significantly higher than control group, (757.6 ±46.8 pg/g vs 367.5 ±22.7 pg/g, P <0.01), but there was no significant difference when compared with ISO group. The IL-1β level in LV of EB group was significantly lower than ISO group (356.2 ±28.5 pg/g vs 518.4 ±32.5 pg/g, P <0.05), and it could not be detected in control group. The serum level of IL-1β could not be detected in any rats. Conclusion EB administered as soon as possible when ISO induced myocardial necrosis occurs can greatly improve cardiac contraction, and the improvement may be partly due to a decrease in the IL-1β level in LV, besides the direct blocking effect of EB on TNF-α. EB can alleviate cardiac remodeling by its effect on LVEDD. Chin Med J 2002; 115(8): 1166-1169

Objective To study whether recombinant adeno-associated virus (rAAV)-mediated foreign gene, LacZ,could pass the blood-brain barrier by intra-carotid artery delivery and express in vivo in ischemic brain of the focal embolic stroke rats to investigate a possibility of delivering foreign gene through carotid artery to treat acute ischemic stroke . Methods The carotid artery territory in 41 rats was embolized with or without arterial-like fibrin rich clots to make a model of focal embolic stroke rat. rAAV containing LacZ gene (rAAV-LacZ) was constructed in 293 cells by calcium phosphate cotransfection. The rats were assigned to one of the following treatments:①control (without embolism) groups, including PBS treated (n=6), pLacZ treated (n=6) and rAAV-LacZ treated (n=6); ② embolic groups, including embolism + PBS (n=7), embolism + pLacZ (n=8) and embolism + rAAV-LacZ (n=8). Brains were cryosectioned and X-Gal stain was performed at 2, 4, and 8 weeks, respectively, after transfection, and then infarct volume was measured and the percentage of LacZ staining-positive cells was calculated. Results In all the control groups and embolism + PBS treated animal, no X-Gal staining-positive cells were found, but in embolism + pLacZ (n=8) and embolism + rAAV-LacZ groups a lot of X-Gal staining-positive cells were found. The expression cells were in the tissues around the infarction. The gene expression persisted only nearly four weeks in embolic group with pLacZ. In the embolic group with rAAV-LacZ the expression was very stable during the experiment course (eight weeks) and the percentage of the expressed cells was significantly higher than that of its contralateral areas at the same time points,respectively . Conclusions The plasmid vector and rAAV could enter the brain through the ischemia-damaged blood barrier and foreign gene can be expressed in brain. The positive gene expression is mainly in the peripheral areas of the infarction. rAAV as a permanent expression vector may ultimately be used for gene therapy of human ischemia cerebravascular diseases. Chin Med J 2002; 115(8): 1170-1174

Objective To investigate the association of cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) gene A/G polymorphism with susceptibility to diabetes mellitus in Han Chinese. Methods An A/G transition at position 49 of exon 1 was analyzed in 31 patients with type 1 diabetes, 31 patients with type 2 diabetes, and 36 controls were analyzed by polymerase chain reaction-restriction fragment length polymorphism analysis. Results A highly significant increase in the frequency of the G allele was seen in patients with type 1 diabetes compared with controls (66.1 %vs. 34.7%, respectively; P <0.0005; OR=3.670). This reflected an increase in the GG genotype in patients (48.4%vs. 22.2%, respectively; P=0.025; OR= 3.281) and a significant decrease in the AA genotype (16.1 %vs. 52.8%, respectively; P=0.002). The allele frequencies of A and G in patients with type 2 diabetes were not significantly different from controls(A/G, 50.0/50.0%vs. 65.3/34.7%; P=not significant). The distribution of genotype, however,differed significantly. This difference reflected an increase in the AG genotype in patients (54.8%vs. 25.0%, respectively; P=0.012; OR=3.643) and a decrease in the AA genotype (22.6%vs. 52.8%,respectively; P=0.011). Conclusions CTLA-4 49 AA is protective from diabetes mellitus, whereas, CTLA-4 49 G allele (both as homozygotes and as heterozygotes) confers an increased risk of diabetes mellitus. Chin Med J 2002; 115(8): 1248-1250

Objective To provide insight into the psychosocial factors underlying the utilisation of health services by women with reproductive tract infection (RTI) symptoms. Methods A cross-sectional study, adopting Aday and Andersen's Social Behaviour Model, was conducted between 1998 and 1999 in Chinese Hebei province and Beijing. A total of 864 eligible married women (age 21 to 60 years) were face to face interviewed. Results The percentage of self-reported symptoms of RTIs in urban and rural women was 35.6 and 46.8, respectively; the proportion of women with RTIs who utilised health services was 27.5%and 26.7%, respectively. Compared to urban women, rural women had less knowledge on RTIs and more traditional beliefs, and were more satisfied with local health services. The results of logistic regression analysis showed that the common factor influencing health service utilisation in women with RTIs was current experience of RTIs. Knowledge about self-medication, perceived social stigma attached to RTIs, prior experience of RTIs, family income and perceived severity of RTIs were also predictors of utilisation of health services in rural women with RTIs. Satisfaction with health providers, information received from health providers, prior experience of RTIs, occupation and medical care coverage were predictors of utilisation of health services in urban women with RTIs. Conclusion The prevalence of RTIs is high, but the rate of seeking health services is low. There is a great need for emphasizing culturally acceptable reproductive health education in different places to improve women's ability for self-care. Regular medical check-ups for women are also important. It is necessary to improve the quality of health service, complete the reform of health insurance and alleviate women's social stigma related to RTIs, giving women social and moral support. Chin Med J 2002; 115(8): 1253-1256

Objective To review the current regional distribution of echinococcosis in China for the purpose of providing the scientific data for the control of echinococcosis in the future. Data sources All data in this paper were originated from related references in Chinese or English language Chinese journals except one from Lancet. Study selection Thirty-one original articles published from 1983 - 2001 were selected according to the stated purpose and 7 of them were written by the author. Data extraction The present paper addresses cystic echinococcosis (CE) and alveolar echinococcosis(AE), as well as their respective regional distribution. Results CE was distributed chiefly in Western China where Gansu, Xinjiang, Qinghai, Ningxia, Inner Mongolia, Tibet, west Sichuan and Qingzang plateau were hyper-endemic areas. Regional distribution of AE was not so extensive as that of CE, but it was found mainly in northwest China as well. Moreover, AE was extremely harmful to human body and "AE cancer" is popularly called. Conclusion Steps should be taken in the future heath policy to control its spread. Regional distribution of echinococcosis is so extensive in China that CE and AE should be increasingly controlled today. Chin Med J 2002; 115(8): 1244-1247