2015年 · 第128卷第17期

Background: The prevalence of childhood asthma has been increasing in China. This study aimed to compare the prevalence, diagnosis, and treatment of asthmatic children from urban and rural areas in Beijing, China. Methods: Schools, communities, and kindergartens were randomly selected by cluster random sampling from urban and rural areas in Beijing. Parents were surveyed by the same screening questionnaires. On-the-spot inquiries, physical examinations, medical records, and previous test results were used to diagnose asthmatic children. Information on previous diagnoses, treatments, and control of symptoms was obtained. Results: From 7209 children in rural areas and 13,513 children in urban areas who completed screening questionnaires, 587 children were diagnosed as asthma. The prevalence of asthma in rural areas was lower than in urban areas (1.25% vs. 3.68%, χ2 = 100.80, P < 0.001). The diagnosis of asthma in rural areas was lower than in urban areas (48.9% vs. 73.9%, χ2 = 34.6, P < 0.001). Compared with urban asthmatic children (56.5%), only 35.6% of rural asthmatic children received inhaled corticosteroids (P < 0.05). The use of bronchodilators was also lower in rural areas than in urban areas (56.5% vs. 66.4%, χ2 = 14.2, P < 0.01). Conclusion: The prevalence of asthma in children was lower in rural areas compared with children in the urban area of Beijing. A considerable number of children were not diagnosed and inadequately treated in rural areas.

Background: Obstructive sleep apnea (OSA) syndrome has a negative impact on the health of millions of adolescents and youth. The aim of this study was to evaluate the associations of OSA syndrome with obesity and cardiometabolic risk factors among adolescents and youth at risk for metabolic syndrome (MS). Methods: A total of 558 subjects aged 14–28 years were recruited from the Beijing Child and Adolescent Metabolic Syndrome Study. Each underwent a 2-h oral glucose tolerance test (OGTT), echocardiography, and liver ultrasonography. Anthropometric measures, blood levels of glucose, lipids, and liver enzymes were assessed. Subjects with high or low risk for OSA were identified by Berlin Questionnaire (BQ). Results: Among the subjects in obesity, 33.7% of whom were likely to have OSA by BQ. Subjects with high risk for OSA had higher neck and waist circumference and fat mass percentage compared to those with low risk for OSA (P < 0.001). Moreover, significant differences in levels of lipids, glucose after OGTT, and liver enzymes, as well as echocardiographic parameters were found between the two groups with high or low risk for OSA (P < 0.05). The rates of nonalcoholic fatty liver disease (71.0% vs. 24.2%), MS (38.9% vs. 7.0%), and its components in high-risk group were significantly higher than in low-risk group. Conclusions: The prevalence of OSA by BQ was high in obese adolescents and youth. A high risk for OSA indicates a high cardiometabolic risk. Mechanisms mediating the observed associations require further investigation.

Background: Patent ductus arteriosus (PDA) is one of the most common congenital heart diseases and began to get treated by transcatheter occlusion since 1997 in China. Since then, several devices have been invented for occluding PDA. This study aimed to evaluate the technical feasibility, safety, and efficacy of transcatheter occlusion of PDA with different devices. Methods: One thousand five hundred and twenty-six patients (537 boys, 989 girls) with PDA from January 1997 to September 2014 underwent descending aortogram and transcatheter occlusion procedure. We retrospectively analyzed data of these patients, including gender, age, weight, size and morphology of PDA, and devices used in transcatheter occlusion, outcomes, and postoperational complications. Results: Median age and median weight were 4.0 years (range: 0.3–52.0 years old) and 15.3 kg (range: 4.5–91.0 kg), respectively. Mean ductal diameter, aortic ductal diameter, ductal length, and pulmonary artery pressure were 3.50 ± 2.15 mm, 10.08 ± 2.46 mm, 7.49 ± 3.02 mm, and 30.21 ± 17.28 mmHg, respectively. Morphology of PDA assessed by descending aortogram was of type A in 1428 patients, type B in 6 patients, type C in 79 patients, type D in 4 patients, and type E in 9 patients according to the classification of Krichenko. Of all the 1526 patients, 1497 patients underwent transcatheter PDA closure, among which 1492 were successful. Devices used were Amplatzer duct occluder I (ADO I, 1280, 85.8%), Cook detachable coils (116, 7.8%), ADO II (ADO II, 68, 4.6%), muscular VSD occluder (12, 0.8%), and Amplatzer vascular plug (16, 1.0%). Conclusions: Excellent occlusion rates with low complication rates were achieved with all devices regardless of PDA types. With transcatheter occlusion technique and devices developing, more patients with PDA can be treated with transcatheter closure both safely and efficiently.

Background: Although heart transplantation (HTx) has become a standard therapy for end-stage heart diseases, experience with pediatric HTx is limited in China. In this article, we will try to provide the experience with indications, complications, perioperative management, immunosuppressive therapy, and survival for pediatric HTx based on our clinical work. Methods: This is a retrospective chart review of the pediatric patients undergoing HTx at Department of Cardiovascular Surgery of Union Hospital from September 2008 to December 2014. We summarized the indications, surgical variables, postoperative complications, and survival for these patients. Results: Nineteen pediatric patients presented for HTx at Union Hospital of Tongji Medical College, of whom 10 were male. The age at the time of transplantation ranged from 3 months to 18 years (median 15 years). Patient weight ranged from 5.2 kg to 57.0 kg (median 38.0 kg). Pretransplant diagnosis included cardiomyopathy (14 cases), complex congenital heart disease (3 cases), and tumor (2 cases). All recipients received ABO-compatible donor hearts. Postoperative complications occurred in 12 patients, including cardiac dysfunction, arrhythmia, pulmonary infection, renal dysfunction, and rejection. Two of them experienced cardiac failure and required extracorporeal membrane oxygenation. The immunosuppression regimen was comprised of prednisone, a calcineurin inhibitor, and mycophenolate. All patients recovered with New York Heart Association (NYHA) Class I–II cardiac function and were discharged. Only one patient suffered sudden death 19 months after transplantation. Conclusion: Orthotopic HTx is a promising therapeutic option with satisfying survival for the pediatric population in China with end-stage heart disease.

Background: The spectrum of abnormal behaviors in amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) has been described, but its practical meaning, namely its impact on caregiver burden, has not been clearly documented in Chinese population. This study aimed to assess the distribution of abnormal behaviors in Chinese population, and to analyze the relationship between behavior changes and caregiver burden. Methods: Sixty-five patients with ALS/MND have been consecutively enrolled into registry platform of Peking Union Medical College Hospital. An investigation was performed to these patients and their caregivers using the revised ALS function rating scale, Frontal Behavioral Inventory-ALS version, the Frontal Assessment Battery, and the Caregiver Burden Inventory. Results: Twenty-eight (43.1%) patients displayed abnormal behaviors of varying degrees, with one fulfilling the diagnostic criteria of frontotemporal lobe degeneration. Irritability, logopenia, and inflexibility ranked top 3 of abnormal behavior list. Correlation analysis revealed that the degree of behavioral change and frontal cognitive status were significantly associated with caregiver burden, with more extensive impact from disinhibitive behaviors. Analysis of covariance analysis showed that after associated factors were corrected, caregivers of patients with moderate to severe behavior change reported significantly heavier developmental burden, physical burden, and total burden than those with no behavioral change. Conclusions: Neurobehavioral symptoms could present in around 40% of Chinese patients with ALS/MND, and the distribution of these behaviors was also unique. Besides, abnormal behaviors were highly related to caregivers’ burden.

Background: For patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) and type 2 diabetes mellitus (T2DM), the night sleep interruption and intermittent hypoxia due to apnea or hypopnea may induce glycemic excursions and reduce insulin sensitivity. This study aimed to investigate the effect of continuous positive airway pressure (CPAP) therapy in patients with OSAHS and T2DM. Methods: Continuous glucose monitoring system (CGMS) was used in 40 patients with T2DM and newly diagnosed OSAHS. The measurements were repeated after 30 days of CPAP treatment. Subsequently, insulin sensitivity and glycohemoglobin (HbA1c) were measured and compared to the pretreatment data. Results: After CPAP therapy, the CGMS indicators showed that the 24-h mean blood glucose (MBG) and the night time MBG were significantly reduced (P < 0.05 and P = 0.03, respectively). The mean ambulatory glucose excursions (MAGEs) and the mean of daily differences were also significantly reduced (P < 0.05 and P = 0.002, respectively) compared to pretreatment levels. During the night, MAGE also significantly decreased (P = 0.049). The differences between the highest and lowest levels of blood glucose over 24 h and during the night were significantly lower than prior to CPAP treatment (P < 0.05 and P = 0.024, respectively). The 24 h and night time durations of high blood glucose (>7.8 mmol/L and > 11.1 mmol/L) decreased (P < 0.05 and P < 0.05, respectively) after the treatment. In addition, HbA1c levels were also lower than those before treatment (P < 0.05), and the homeostasis model assessment index of insulin resistance was also significantly lower than before CPAP treatment (P = 0.034). Conclusions: CPAP therapy may have a beneficial effect on improving not only blood glucose but also upon insulin sensitivity in T2DM patients with OSAHS. This suggests that CPAP may be an effective treatment for T2DM in addition to intensive diabetes management.

Background: Tuberculum sellae meningiomas (TSMs) present a special symptom because of the adherence and compression to the optic nerve, optic artery, and the chiasm. A significant number of patients with TSMs appear visual deficits. This study aimed to investigate the surgical indications of exploring the optic canal and visual prognostic factors in the neurosurgical treatment of TSMs. Methods: Totally 21 patients with TSM, who were operated from September 2007 to August 2011 in the Department of Neurosurgery, Tongren Hospital were enrolled in this study. Results of orbital computed tomography (CT) and magnetic resonance imaging (MRI), visual acuity, Goldmann visual field test, orbital color Doppler flow imaging (CDI) test in these patients were retrospectively analyzed. Results: Visual deficit and optic canal involvement (OCI) were detected in all the 21 patients. Fourteen patients had bone proliferation within the area of the optic canal. After the operation, visual outcomes were improved in 13 patients, unchanged in 7 patients, and deteriorated in 1 patient. All the 21 patients performed orbital CDI test preoperatively, the results showed that if the peak systolic velocity (PSV) of central retinal artery (CRA) value was ≤8 cm/s, the visual outcome would be better. Conclusions: The surgical indications of exploring optic canal in TSM cases included: (1) The neuroimaging evidences of OCI (CT and/or MRI); (2) PSV of CRA in orbital CDI test was ≤8 cm/s; (3) visual acuity was below 0.1; (4) visual field deficit. The PSV of CRA in CDI test could be a prognostic factor for visual outcomes of TSMs.

Background: Unstable pelvic fractures are complex and serious injuries. Selection of a fixation method for these fractures remains a challenging problem for orthopedic surgeons. This study aimed to compare the stability of Tile C pelvic fractures fixed with two iliosacral (IS) screws and minimally invasive adjustable plate (MIAP) combined with one IS screw. Methods: This study was a biomechanical experiment. Six embalmed specimens of the adult pelvis were used. The soft tissue was removed from the specimens, and the spines from the fourth lumbar vertebra to the proximal one-third of both femurs were retained. The pubic symphysis, bilateral sacroiliac joints and ligaments, bilateral hip joints, bilateral sacrotuberous ligaments, and bilateral sacrospinous ligaments were intact. Tile C pelvic fractures were made on the specimens. The symphysis pubis was fixed with a plate, and the fracture on the posterior pelvic ring was fixed with two kinds of internal fixation in turn. The specimens were placed in a biomechanical machine at a standing neutral posture. A cyclic vertical load of up to 500 N was applied, and displacement was recorded. Shifts in the fracture gap were measured by a grating displacement sensor. Statistical analysis used: Paired-samples t-test. Results: Under the vertical load of 100, 200, 300, 400, and 500 N, the average displacement of the specimens fixed with MIAP combined with one IS screw was 0.46, 0.735, 1.377, 1.823, and 2.215 mm, respectively, which was significantly lower than that of specimens fixed with two IS screws under corresponding load (P < 0.05). Under the vertical load of 500 N, the shift in the fracture gap of specimens fixed with MIAP combined with one IS screw was 0.261 ± 0.095 mm, and that of specimens fixed with two IS screws was 0.809 ± 0.170 mm. The difference was significant (P < 0.05). Conclusion: The stability of Tile C pelvic fractures fixed with MIAP combined with one IS screw was better than that fixed with two IS screws.

Background: A quantitative and accurate measurement of the range of hip joint flexion (RHF) is necessarily required in the evaluation of disordered or artificial hip joint function. This study aimed to assess a novel method to measure RHF more accurately and objectively. Methods: Lateral radiographs were taken of 31 supine men with hip joints extended or flexed. Relevant angles were measured directly from the radiographs. The change in the sacrofemoral angle (SFA) (the angle formed between the axis of the femur and the line tangent to the upper endplate of S1) from hip joint extension to hip joint flexion, was proposed as the RHF. The validity of this method was assessed via concomitant measurements of changes in the femur-horizontal angle (between the axis of the femur and the horizontal line) and the sacrum-horizontal angle (SHA) (between the line tangent to the upper endplate of S1 and the horizontal line), the difference of which should equal the change in the SFA. Results: The mean change in the SFA was 112.5 ± 7.4°, and was independent of participant age, height, weight, or body mass index. The mean changes in the femur-horizontal and SHAs were 123.0 ± 6.4° and 11.4 ± 3.0°, respectively. This confirmed that the change of SFA between hip joint extension and hip joint flexion was equal to the difference between the changes in the femur-horizontal and SHAs. Conclusions: Using the SFA, to evaluate RHF could prevent compromised measurements due to the movements of pelvis and lumbar spine during hip flexion, and is, therefore, a more accurate and objective method with reasonable reliability and validity.

Background: Intravascular ultrasound (IVUS) examination can provide useful information during endovascular stent graft repair. However, its actual clinical utility in thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (type B-AD) remains unclear, especially in complicated aortic dissection. We evaluated the effect of IVUS as a complementary tool during TEVAR. Methods: From September 2011 to April 2012, we conducted a prospective cohort study of 47 consecutive patients with "complicated" type B-AD diagnosed. We divided the patients into two groups: IVUS-assisted TEVAR group and TEVAR using angiography alone group. The general procedure of TEVAR was performed. We evaluated the perioperative and follow-up events. Patient demographics, comorbidities, preoperative images, dissection morphology, details of operative strategy, intraoperative events, and postoperative course were recorded. Results: A total of 47 patients receiving TEVAR were enrolled. Among them (females, 8.51%; mean age, 57.38 ± 13.02 years), 13 cases (27.66%) were selected in the IVUS-assisted TEVAR group, and 34 were selected in the TEVAR group. All patients were symptomatic. The average diameter values of IVUS measurements in the landing zone were greater than those estimated by computed tomography angiography (31.82 ± 4.21 mm vs. 30.64 ± 4.13 mm, P < 0.001). The technique success rate was 100%. Among the postoperative outcomes, statistical differences were only observed between the IVUS-assisted TEVAR group and TEVAR group for total operative time and the amount of contrast used (P = 0.013 and P < 0.001, respectively). The follow-up ranged from 15 to 36 months for the IVUS-assisted TEVAR group and from 10 to 35 months for the TEVAR group (P = 0.646). The primary endpoints were no statistical difference in the two groups. Conclusions: Intraoperative IVUS-assisted TEVAR is clinically feasible and safe. For the endovascular repair of "complicated" type B-AD, IVUS may be helpful for understanding dissection morphology and decrease the operative time and the amount of contrast used.

Background: Current views on continuous positive airway pressure (CPAP) treatment to improve the cognitive deficits of patients with obstructive sleep apnea syndrome (OSAS) are controversial, so we performed a meta-analysis. Methods: A comprehensive literature search was undertaken in PubMed, CINAHL, Medline, PsycInfo, EMBASE, Cochrane Library, CNKI, WanFang, VIP, and CBMdisc for studies published from June 1971 to July 2014. The outcome measures included neuropsychological tests of the 7 cognitive domains detailed below. Results: After screening the titles and abstracts and thoroughly reading the full text, we obtained 13 studies with little risk of bias that incorporated 1744 middle-aged obese participants with mild to severe OSAS. The studies were published from 1994 to 2012. Treatment durations varied from 1 to 24 weeks. The effect sizes of attention, vigilance, processing speed, working memory, memory, verbal fluency, and visuoconstructive skills domains were -0.10 (P = 0.24), -0.12 (P = 0.04), -0.08 (P = 0.16), 0.00 (P = 0.95), -0.04 (P = 0.30), -0.06 (P = 0.34), and -0.01 (P = 0.92), respectively. Conclusions: Cognition partially improved in patients with OSAS after CPAP treatment. The only domain with significant improvement was vigilance. Rigorous randomized controlled trials need to be performed to obtain clear results.

Background: This meta-analysis was to determine the association of the cumulative dose of 130/0.4 or 0.42 (hydroxyethyl starch [HES] 130/0.4*) or delta daily fluid balance (i.e., daily fluid balance in HES group over or below control group) with the heterogeneity of risk ratio (RR) for mortality in randomized control trials (RCTs). Methods: Three databases (PubMed, EMBASE, Cochrane) were searched to identify prospective RCTs reporting mortality in adult patients with sepsis to compare HES130/0.4* with crystalloids or albumin. Meta-analysis was performed using random effects. Sensitivity and meta-regression analyses were used to examine the heterogeneity sources of RR for mortality. Results: A total number of 4408 patients from 11 RCTs were included. The pooled RR showed no significant difference for overall mortality in patients with administration of HES130/0.4* compared with treatment of control fluids (RR: 1.02, 95% confidence interval: 0.90–1.17; P = 0.73). Heterogeneity was moderate across recruited trials (I2 = 34%, P = 0.13). But, a significant variation was demonstrated in subgroup with crystalloids as control fluids (I2 = 42%, P < 0.1). Sensitivity analysis revealed that trials with high risk of bias did not significantly impact the pooled estimates for mortality. Meta-regression analysis also did not determine a dose-effect relationship of HES130/0.4* with mortality (P = 0.298), but suggested daily delta fluid balance being likely associated with mortality in septic patients receiving HES130/130/0.4* (P = 0.079). Conclusions: Inappropriate daily positive fluid balance was likely an important source of heterogeneity in these trials reporting HES130/0.4* associated with excess mortality in septic patients.

Objective: Blood transfusion saves lives but may also increase the risk of injury. The objective of this review was to evaluate the possible adverse effects related to transfusion of red blood cell (RBC) concentrates stored for prolonged periods. Data Sources: The data used in this review were mainly from PubMed articles published in English up to February 2015. Study Selection: Clinical and basic research articles were selected according to their relevance to this topic. Results: The ex vivo changes to RBC that occur during storage are collectively called storage lesion. It is still inconclusive if transfusion of RBC with storage lesion has clinical relevance. Multiple ongoing prospective randomized controlled trials are aimed to clarify this clinical issue. It was observed that the adverse events related to stored RBC transfusion were prominent in certain patient populations, including trauma, critical care, pediatric, and cardiac surgery patients, which leads to the investigation of underlying mechanisms. It is demonstrated that free hemoglobin toxicity, decreasing of nitric oxide bioavailability, and free iron-induced increasing of inflammation may play an important role in this process. Conclusion: It is still unclear whether transfusion of older RBC has adverse effects, and if so, which factors determine such clinical effects. However, considering the magnitude of transfusion and the widespread medical significance, potential preventive strategies should be considered, especially for the susceptible recipients.

Objective: To evaluate the utility of zinc transporter-8 (ZnT8) in the improvement of type 1 diabetes mellitus (T1DM) diagnosis and prediction, and to explore whether ZnT8 is a potential therapeutic target in T1DM. Data Sources: A search was conducted within the medical database PubMed for relevant articles published from 2001 to 2015. The search terms are as follows: "ZnT8," "type 1 diabetes," "latent autoimmune diabetes in adults," "type 2 diabetes," "islet autoantibodies," "zinc supplement," "T cells," "β cell," "immune therapy." We also searched the reference lists of selected articles. Study Selection: English-language original articles and critical reviews concerning ZnT8 and the clinical applications of islet autoantibodies in diabetes were reviewed. Results: The basic function of ZnT8 is maintaining intracellular zinc homeostasis, which modulates the process of insulin biosynthesis, storage, and secretion. Autoantibodies against ZnT8 (ZnT8A) and ZnT8-specific T cells are the reliable biomarkers for the identification, stratification, and characterization of T1DM. Additionally, the results from the animal models and clinical trials have shown that ZnT8 is a diabetogenic antigen, suggesting the possibility of ZnT8-specific immunotherapy as an alternative for T1DM therapy. Conclusions: ZnT8 is a novel islet autoantigen with a widely potential for clinical applications in T1DM. However, before the large-scale clinical applications, there are still many problems to be solved.

Objective: Intermediate-risk acute myeloid leukemia (IR-AML), which accounts for a substantial number of AML cases, is highly heterogeneous. We systematically summarize the latest research progress on the significance of gene mutations for prognostic stratification of IR-AML. Data Sources: We conducted a systemic search from the PubMed database up to October, 2014 using various search terms and their combinations including IR-AML, gene mutations, mutational analysis, prognosis, risk stratification, next generation sequencing (NGS). Study Selection: Clinical or basic research articles on NGS and the prognosis of gene mutations in IR-AML were included. Results: The advent of the era of whole-genome sequencing has led to the discovery of an increasing number of molecular genetics aberrations that involved in leukemogenesis, and some of them have been used for prognostic risk stratification. Several studies have consistently identified that some gene mutations have prognostic relevance, however, there are still many controversies for some genes because of lacking sufficient evidence. In addition, tumor cells harbor hundreds of mutated genes and multiple mutations often coexist, therefore, single mutational analysis is not sufficient to make accurate prognostic predictions. The comprehensive analysis of multiple mutations based on sophisticated genomic technologies has raised increasing interest in recent years. Conclusions: NGS represents a pioneering and helpful approach to prognostic risk stratification of IR-AML patients. Further large-scale studies for comprehensive molecular analysis are needed to provide guidance and a theoretical basis for IR-AML prognostic stratification and clinical management.