2014年 · 第127卷第06期

Abstract：Background Primary total knee arthroplasty (TKA) in severe valgus knees may prove challenging,and choice of implant depends on the severity of the valgus deformity and the extent of soft-tissue release.The purpose of this study was to review 8 to 11 years (mean,10 years) follow-up results of primary TKA for varient-Ⅲ valgus knee deformity with use of different type implants.Methods Between January 2002 and January 2005,20 women and 12 men,aged 47 to 63 (mean,57.19±6.08) years old,with varient-Ⅲ valgus knees underwent primary TKA.Of the 32 patients,37 knees had varient-Ⅲ deformities.Pie crusting was carefully performed with small,multiple inside-out incisions,bone resection balanced the knee in lieu of soft tissue releases that were not used in the series.Cruciate-retaining knees (Gemini MKⅡ,Link Company,Germany) were used in 13 knees,Genesis Ⅱ (Simth & Nephew Company,USA) in 14 knees,and hinged knee (Endo-Model Company,Germany) in 10 knees.In five patients with bilateral variant-Ⅲll TKAs,three patients underwent 1-stage bilateral procedures,and two underwent 2-stage procedures.All implants were cemented and the patella was not resurfaced.The Hospital for Special Surgery (HSS) knee score was assessed.Patients were followed up from 8 to 11 years.Results The mean HSS knee score were improved from 50.33±11.60 to 90.06±3.07 (P ＜0.001).The mean tibiofemoral alignment were improved from valgus 32.72°±9.68° pre-operation to 4.89°±0.90° post-operation (P ＜0.001).The mean range of motion were improved from 93.72°±23.69° pre-operation to 116.61±16.29° post-operation (P ＜0.001).No patients underwent revision.One patient underwent open reduction and internal fixation using femoral condylar plates for supracondylar femoral fractures secondary to a fall at three years.Three patients developed transient peroneal nerve palsies,which resolved within nine months.Two patients developed symptomatic deep vein thrombosis that was managed with rivaroxaban and thrombo-embolic deterrent stockings.There was no incidence of pulmonary embolism.Postoperative patient satisfaction was 80.7±10.4 points in the groups.Prosthetic survival rate was 100％ at mean 10 years postoperative.Conclusions Not only hinged implants can be successfully used in variant-Ⅲll valgus knees.As our results show,if proper ligament balancing techniques are used and proper ligament balance is attained,the knee may not require the use of a more constrained components.Our results also present alternative implant choices for severe knee deformities。

Abstract：Background Liver fibrosis normally progresses to cirrhosis and destroys the normal architecture of the liver,resulting in liver dysfunction and irreversible cirrhosis.The aim of this study was to investigate the anti-fibrosis effect and the possible underlying mechanisms of decorin.Methods The mice model of liver fibrosis was induced by intraperitoneal injection of 50％ (v/v) of carbon tetrachloride (CCl4) diluted in olive oil (1 ml/kg body weight) once every 2 days for 5 weeks.Three weeks after injecting CCl4 intraperitoneally,mice were randomly divided into normal control with vehicles only (olive oil),mouse model given CCl4 only,and CCl4 plus decorin (DCN,250 μg/kg).Two weeks later,all the mice were sacrificed and their liver tissues were analyzed for the expressions of genes related to liver fibrosis and under hematoxylin-eosin staining,Masson staining,and immunohistochemical staining of all groups.Aspartate transaminase,alanine transaminase,and total bilirubin of the serum were determined for evaluation of the liver function.Results Exogenous protein decorin could reduce liver fibrosis induced by CCl4 in mice.The degree of fibrosis in the experimental group was alleviated,and the contents of collagen fibers were lower in the experimental group than those of the control group.In addition,expressions of transforming growth factor β1 and α-smooth muscle actin decreased in the experimental group.Conclusions Taking liver fibrosis model of mouse as the experimental target and by injecting exogenous protein decorin into the model,we confirmed that decorin could inhibit the expression of proteins related to fibrosis and reduce the formation of liver fibrosis in mice。

Percutaneous coronary intervention (PCI) is currently the most commonly used revascularization technique in the management of symptomatic coronary disease.However,late stent thrombosis (LST) and in-stent restenosis (ISR) are the most serious late complication related to PCI.Traditionally,intimal hyperplasia after bare metal stent (BMS) implantation has been considered stable,with an early peak between 6 months and 1 year and a late quiescent period thereafter.Recent studies have reported that one-third of the patients with ISR after BMS implantation presented with acute coronary syndrome (ACS),which is not regarded as clinically benign.Seung-Jung et al1 reported that in-stent neoatherosclerosis is the final common pathway of late stent failure.Here we report a patient presenting ACS in whom intravascular ultrasound (IVUS) imaging showed very late thrombosis due to atheromatous changes and neointima plaque rupture 12 years after BMS implantation。

Challenges There are more than 2 000 cardiac catheterization laboratories (CCL) in the US.They could be a full service CCL or they only perform emergency primary coronary interventions (PCI).They could also perform elective PCI without onsite surgery,or only diagnostic procedures.They can be inside a hospital,attached to a hospital or be a free standing facility far away from or near a hospital.However,regardless of where they are located,which facility they are affiliated with or which procedures are performed,the common denomination among these facilities is that they are required to meet the best standard of excellence in patient care and outcomes。

Great changes have been made in the field of interventional cardiology from the time Andreas Gruentzig performed the first coronary angioplasty in 1977.For cardiac catheterization laboratory (CCL) directors,one of the challenges is management skill.This is something that is not taught in medical schools,residency or fellowship programs.There is more to being a CCL director than just being the best interventional cardiologist in a hospital.A CCL director is more of a manager in an information technology (IT) firm or a teacher in a technical school.At times,there is a need to lead by example and at times to lead by making changes in a protocol for physicians to follow。

The number of percutaneous coronary interventions (PCI) in China continues to grow,most recently by 14％from 2011 (341 069 cases) to2012 (388 836 cases).1 Achievement of maximum benefit-to-risk potential at individual and population levels of this persistently expanding PCI use requires increased focus on quality at pre-,intra-and post-procedural stages.To this end,the National Health and Family Planning Commission of China (NHFPC) formulated institutional and personal criteria for PCI performance and regulations for accreditation and supervision in its Management and techniques specifications in cardiovascular interventions (2011 edition).2 Beyond accreditation,regular monitoring and supervision,internal quality assurance combined with external supervision most effectively strengthens technique management and maximizes quality and patient safety and outcomes.To foster the sharing and discussion of best practices in this area,the upcoming China Interventional Therapeutics (CIT) 2014 congress features a joint symposium with the Society for Cardiovascular Angiography and Intervention (SCAI) on "quality in the cardiovascular catheterization laboratory (CCL)." In this symposium,SCAI faculty will cover United States (US) perspectives and approaches to quality assurance and will discuss with Chinese colleagues.This issue of the Chinese Medical Journal includes two articles by Latif et al3,4 with a US perspective on improvement of quality and safety of care in the CCL,which I trust interventionalists in China will find instructive and useful。

Abstract：Background As a novel device-based approach targeting the renal sympathetic nerves,percutaneous renal denervation (RDN) has been shown to be effective and safe for reducing blood pressure.However,while considerable data on RDN have been obtained from Western populations,there is limited findings from East Asian populations.The purpose of this study was to evaluate one-year outcomes of RDN for the treatment of resistant hypertension in Chinese patients.Methods Between February and August 2012,14 patients (mean age 39±8 years,10 males) with resistant hypertension underwent successful RDN at the Fuwai Hospital.All 14 patients were followed up at 1,3,6 and 12 months postprocedure.Blood pressure,use of antihypertensive agents,renal function,and complications were investigated.Results Baseline values included mean office blood pressure of 164/103±14/10 mmHg,mean 3.9±0.6 anti-hypertensive agents,and an estimated glomerular filtration rate of (79±19) mlmin-1.1.73 m-2.Office blood pressure after the procedure was reduced by-14/-10,-17/-11,-21/-12,and-24/-14 mmHg at 1,3,6,and 12 months respectively,and the reduction of the number of antihypertensive agents at the above corresponding time points was-1.3,-1.5,-1.7 and-1.8 respectively (all P ＜0.001).The mean reduction of 24-hour ambulatory blood pressure was similar to the reduction of office blood pressure at the four corresponding time points.Renal function did not significantly change at any time point (all P ＞0.05).No clinical complications were observed at 12-month follow-up.Conclusion This study showed that RDN seems to be effective in reducing blood pressure of Chinese patients with resistant hypertension,with minimal adverse events at 12-month follow-up。

Abstract：Background Balloon release pressure may increase the incidence of no reflow after direct percutaneous coronary intervention (PCI).This randomized controlled study was designed to analyze the correlation between balloon release pressure and no-reflow in patients with acute myocardial infarction (AMI) undergoing direct PCI.Methods There were 156 AMI patients who underwent PCI from January 1,2010 to December 31,2012,and were divided into two groups according to the stent inflation pressure:a conventional pressure group and a high pressure group.After PCI,angiography was conducted to assess the thrombolysis in myocardial infarction (TIMI) grade with related artery.Examinations were undertaken on all patients before and after the operation including cardiac enzymes,total cholesterol,low-density lipoprotein,blood glucose,homocysteine,β-thromboglobulin (β-TG),Hamilton depression scale (HAMD) and self-rating anxiety scale (SAS).After interventional therapy,the afore-mentioned parameters in both the conventional pressure group and high pressure group were again analyzed.Results The results showed that CK-MB,HAMD,SAS were significantly different (P ＜0.05) in all patients after PCI,especially the CK-MB in the high pressure group ((25.7±7.6) U/L vs.(76.7±11.8) U/L).CK-MB,HAMD,SAS,and β-TG were comparative before PCI but they were significantly changed (P ＜0.05) after intervention.No-reflow phenomenon occurred in 13 patients in the high pressure group,which was significantly higher than in the conventional pressure group (17.11％ vs.6.25％,P＜0.05).Conclusion In stent implantation,using a pressure less than 1823.4 kPa balloon to release pressure may be the better choice to reduce the occurrence of no-reflow following direct PCI。

Abstract：Background Angiographic evaluation of left main coronary artery (LMCA) bifurcation lesions is often limited.two dimensional (2D) quantitative coronary angiography (QCA) with segmental analysis provides accuracy for quantification of the degree of stenosis in the main vessel and side branch ostium but can be affected by foreshortening and variable magnification.The accuracy of three dimensional (3D) QCA has recently developed to overcome 2D QCA limitations,however,accuracy and precision of 3D bifurcation QCA measurements in LMCA bifurcation lesions has not been established.Methods We investigated whether such 3D and 2D bifurcation QCA measurements differ in their accuracy in assessing significant LMCA bifurcation lesions defined by intravascular ultrasound (IVUS) as a minimum luminal area (MLA) ＜6 mm2 of LMCA and MLA ＜4 mm2 of proximal left anterior descending (LAD) and/or proximal left circumflex (LCX) Results LMCA bifurcation lesions were assessed in 44 patients undergoing elective percutaneous coronary intervention.From 2D QCA measurements,MLA correlated moderately with threshold intravascular ultrasound MLA for LMCA (r=0.81,P ＜0.000 1),LAD (r=0.54,P=-0.000 1) and LCX (r=0.58,P ＜0.000 1).Severity of lesion as MLA by derived 3D QCA,correlated moderately with threshold intravascular ultrasound MLA for LMCA (r=0.84,P ＜0.000 1),LAD (r=0.53,P=-0.000 2); LCX (r=0.66,P ＜0.000 1).Overall,the C statistics tended to be slightly higher for 3D QCA and 2D QCA measurements in LMCA segment compared with proximal LAD and LCX segments,and there were no significant predictive power of percent diameter stenosis and percent area stenosis on 3D QCA for LCX IVUS MLA ＜4 mm2 (percent diameter stenosis:area under curve 0.55,cutoff 23％,sensitivity 88％,specificity 37％,P=-0.618 6; percent arer stenosis:area under curve 0.56,cutoff 41％,sensitivity 83％,specificity 38％,P=-0.518 4,respectively).Conclusions The accuracy of 3D bifurcation QCA in detecting significant LMCA bifurcation lesions is limited,especially the proximal LCX ostium.When IVUS is not available or contraindicated,3D QCA may assist in the evaluation of intermediate LMCA lesions with MLA。

Abstract：Background Blood pressure variability (BPV) is a reliable prognostic factor for cardiovascular events.Currently there is a worldwide lack of large sample size studies in visit-to-visit BPV.Based on the Kailuan Study,we analyzed the visit-to-visit BPV of patients to investigate the range and influencing factors of BPV.Methods In 11 hospitals in the Kailuan Company,4 441 patients received routine health checkups.Physical examination measured blood pressure (BP),body height,body weight,and waist circumference,and body mass index was calculated.Blood samples were analyzed for plasma total cholesterol (TC),triglyceride (TG),high-density lipoprotein cholesterol (HDL-C),low-density lipoprotein cholesterol (LDL-C),fasting blood glucose (FBG),and high-sensitivity c-reactive protein (hs-CRP).Results The effect of gender on systolic BPV was investigated.The average systolic BPV was 10.35 mmHg (1 mmHg=0.133 kPa) overall,10.54 mmHg in males and 10.06 mmHg in females.Multivariate Logistic regression analysis revealed that the age (RR=1.022),systolic BP (SBP,RR=1.007),LDL-C (RR=1.098),and history of hypertension (RR=-1.273) were significant risk factors for higher systolic BPV.We found that aging (RR=1.022),increased SBP (RR=1.007),and a history of hypertension (RR=1.394) were determinants of systolic BPV in males.The risk factors for systolic BPV of females were aging (RR=1.017),increased SBP (RR=1.009),increased LDL (RR=1.136),and increased TG (RR=1.157).Conclusion Our findings indicated that the systolic BPV is closely associated with age,SBP and history of hypertension。

Abstract：Background In the TARGET I randomized controlled trial,the novel abluminal groove-filled biodegradable polymer sirolimus-eluting stent FIREHAWK proved non-inferior to the everolimus-eluting stent in nine-month in-stent late loss in single de novo coronary lesions.This study was aimed at evaluating clinical safety and effectiveness of FIREHAWK in a moderately complex population (including patients with small vessels,long lesions and multi-vessels),and at validating the ability of the SYNTAX score (SS) to predict clinical outcomes in patients treated with this latest generation drug-eluting stent.Methods TARGET Ⅱ was a prospective,multicenter,single-arm study with primary outcome of 12-month target lesion failure (TLF),including cardiac death,target vessel myocardial infarction (TV-MI) and ischemia-driven target lesion revascularization (TLR).Stent thrombosis was defined according to the Academic Research Consortium (ARC) definition.Patients were grouped by tertiles of SS (≤6,＞6 to ≤12,and ＞12).All patients were exclusively treated with the FIREHAWK stent and were followed up at 1,6,and 12 months,and annually thereafter up to five years.Results A total of 730 patients were included in this registry study.The 12-month incidence of TLF was 4.4％ and the incidence of TLF components were,cardiac death 0.5％,TV-MI 3.2％,and TLR 2.2％.One definite/probable stent thrombosis was observed at 12-month follow-up.Mean SS was 10.87±6.87.Patients in the SS ＞12 tertile had significantly higher TLF (P=0.02) and TLR (P ＜0.01) rates than those in lower SS groups.In COX proportional-hazards regression analyses,TLF incidence was strongly related to lesion length (long lesion vs.non-long lesion patients; HR 3.416,95％ CI,1.622-7.195),but unrelated to diabetic,small vessel,and multivessel subgroups.Conclusions The low TLF incidence in this study indicates that FIREHAWK is safe and effective in the treatment of moderately complex coronary disease.SS is also able to predict adverse clinical outcomes in FIREHAWK treated patients.(Clinical Trial.gov identifier:NCT0141264)

Abstract：Background Neutrophil/lymphocyte ratio (NLR) has been proposed as a novel marker of systemic inflammation and oxidative stress.The objective of this study was to ascertain the relationship between levels of NLR and recurrence of lone atrial fibrillation (AF) after catheter ablation.Methods A total of 379 lone AF patients who underwent catheter ablation were enrolled in the study.The NLR before and after catheter ablation was determined.Cox regression analyses were used to estimate the relationship between NLR and the recurrence of lone AF.Results After a mean follow-up of (30.5±5.3) months,124 (32.7％) patients had AF recurrences.The patients who developed AF recurrence had a higher postablation NLR (post-NLR) than patients with no recurrence (5.74±1.55 vs.4.66±1.27,P ＜0.001).Multivariate Cox regression analysis revealed that post-NLR (hazard ratio (HR) 1.514,95％ confidence interval (CI) 1.364-1.680,P ＜0.001),left atrium diameter (HR 1.035,95％ Cl 1.001-1.071,P=-0.04) and body mass index (HR 1.028,95％ CI 1.002-1.054,P=-0.03)were independent predictors of AF recurrence.Using a cut-off level of 5.15,post-NLR predicted AF recurrence with a sensitivity of 73％ and specificity of 67％.Conclusions Our results indicate that an elevated post-NLR is associated with a high rate of lone AF recurrence.A simple measurement of NLR may help us to identify high-risk patients who need pharmacologic intervention to prevent recurrence。

Abstract：Background Many studies have shown that the serum uric acid (SUA) level is one of the cardiovascular risk factors.The aim of the study is to evaluate the relationship between SUA levels and the severity of coronary artery disease (CAD) assessed by angiography and the Syntax score in patients with obstructive CAD.Methods Participants who visited our hospital for a coronary angiography,from December 2007 to September 2012,were eligible for this analysis.SUA and other blood parameters after at least 12-hour fast were determined.First,the patients were divided into tertiles according to their Syntax scores (low Syntax score group:Syntax score ≤10.0; moderate Syntax score group:10.0 ＜Syntax score ≤18.0; high Syntax score group:Syntax score ＞18.0).Second,to clarify the association between SUA levels and major adverse cardiovascular events (MACEs),all patients were divided into two subgroups on the basis of SUA levels.The cutoff value of SUA was defined by diagnostic criteria of hyperuricemia.Patients were separated into normal SUA group (n=251,with SUA ＜416 μmol/L for men and SUA ＜357 μmol/L for women) and high SUA group (n=96,with SUA ≥416 μmol/L for men and SUA ≥357 tμmol/L for women).All participants were followed for a mean of 22.0 months (1-75 months,interquartile range:28 months) for major adverse cardiovascular events (MACEs),including all-cause death,recurrent nonfatal myocardial infarction (re-MI) and recurrent percutaneous coronary intervention (re-PCI).Results A total of 347 patients were registered for the study.The SUA levels in the high Syntax score group were significantly higher than that of the moderate Syntax score group and the low Syntax score group ((392.3±81.6) μmol/L vs.(329.9±71.0) μmol/L,P ＜0.001; (392.3±81.6) μmol/L vs.(311.4±64.7) μmol/L,P ＜0.001).The SUA level was positively correlated not only with the Syntax score (r=0.421,P ＜0.001; 95％ CI:0.333-0.512),but also with the number of diseased vessels (t=0.298,P ＜0.001; 95％ CI:0.194-0.396).After multiple linear regression analysis,SUA levels were identified to be independently correlated with a high Syntax score (B=0.033,95％ CI 0.023-0.042,P ＜0.001).Compared with the normal SUA subgroup,the high SUA subgroup tended to have a higher Syntax score (19.9±8.7 vs.13.6±7.5,P ＜0.001) and more multi-vessel disease (70.8％ vs.46.6％,P ＜0.001).Follow-up data showed a higher incidence of MACE in the high SUA subgroup (20.8％ vs.6.0％,P ＜0.001).Binary Logistic regression analysis indicated that the elevated SUA can predict the long-term prognosis of patients with obstructive CAD (OR=2.968,95％ CI 1.256-7.011,P=0.013).KaplanMeier analysis showed a significantly lower event-free survival rate in patients with high SUA levels than in the normal SUA subgroup (79.2％ vs.94.0％,Log rank=17.645,P ＜0.001).Conclusions SUA levels were independently associated with the severity of CAD in patients with obstructive CAD.An elevated SUA is associated with cardiovascular events and may be useful as a biomarker of the severity of CAD。

Abstract：Background The survival ratio of implanted mesenchymal stem cells (MSCs) in the infarcted myocardium is low.Autophagy is a complex "self-eating" process and can be utilized for cell survival.We have found that atorvastatin (ATV) can effectively activate autophagy to enhance MSCs survival during hypoxia and serum deprivation (H/SD).The mitogenactivated protein kinase/extracellular signal-regulated kinase (MEK/ERK) pathway is a non-canonical autophagy pathway.We hypothesized that the MEK/ERK pathway mediated ATV-induced autophagy of MSCs under H/SD.Methods MSCs were pretreated with ATV (0.01-10 μmol/L) under H/SD for three hours.For inhibitor studies,the cells were pre-incubated with the MEK1/2 inhibitor U0126.Cell autophagy was assessed by acidic vesicular organelles (AVO)-positive cells using flow cytometry,autophagy related protein using Western blotting and autophagosome using transmission electron microscopy.Results Autophagy was elevated in the H/SD group compared with the normal group.ATV further enhanced the autophagic activity as well as the phosphorylation of ERK1/2 evidenced by more AVO-positive cells ((8.63±0.63)％ vs.(5.77±0.44)％,P ＜0.05),higher LC3-Ⅱ/LC3-Ⅰ ratio (4.36±0.31 vs.2.52±0.18,P ＜0.05) and more autophagosomes.And treatment with U0126 downregulated the phosphorylation of ERK1/2 and attenuated ATV-induced autophagy.Conclusion The MEK/ERK pathway participates in ATV-induced autophagy in MSCs under H/SD,and modulation of the pathway could be a novel strategy to improve MSCs survival。

Abstract：Background The lack of medical facilities causes delayed diagnosis and treatment of coronary heart disease in remote mountainous area and/or at disaster site.The miniature mobile cardiac catheterization laboratory was developed to be an intervention platform for coronary heart disease diagnosis and treatment by our team.Pre-clinical research indicated that the miniature mobile cardiac catheterization laboratory performed well in the rescue of critical cardiovascular diseases,even ST-segment elevation myocardial infarction.The present study aimed to evaluate the clinical safety and timeliness of the miniature mobile cardiac catheterization laboratory for emergent coronary interventional diagnosis and treatment.Methods X-ray radiation safety and disinfection efficacy in the miniature mobile cardiac catheterization laboratory were tested during working status.Coronary angiography and/or percutaneous coronary intervention were performed in remote mountainous areas on patients who were first diagnosed as having coronary heart disease by senior interventional cardiologists.The percutaneous coronary intervention procedures and results from patients in the miniature mobile cardiac catheterization laboratory were compared with patients who were treated in the hospital catheter lab.Results The X-ray radiation dosages in the miniature mobile cardiac catheterization laboratory were 39.55 μGy/s,247.4 μGy/h,90.3 μGy/h and 39.4 μGy/h which were corresponded to 0 m,1 m,2 m and 3 m away from the tube central of the medium C-arm.And the radiation dosages used in the miniature mobile cardiac catheterization laboratory were less than the corresponding positions in the hospital catheter lab.The numbers of bacteria colonies in the miniature mobile cardiac catheterization laboratory in different environments range from (60±8) cfu/m3 to (120±10) cfu/m3 and met the demands of percutaneous coronary intervention.A total of 17 patients who received angiography in the miniature mobile cardiac catheterization laboratory,eight received percutaneous coronary intervention.The operations were all successfully accomplished without intraoperative and postoperative complications.The average angiography and percutaneous coronary intervention times were 35±9 minutes and 55±11 minutes,respectively.There was no significant difference in immediate percutaneous coronary intervention results between the miniature mobile cardiac catheterization laboratory and the catheter lab.Conclusions It is safe and feasible to carry out clinical interventional diagnosis and treatment in the miniature mobile cardiac catheterization laboratory as determined by this research.The miniature mobile cardiac catheterization laboratory may be considered a newly developed diagnosis and treatment platform for rescuing coronary heart disease patients in remote mountainous areas and/or at disaster sites。

Abstract：Background Amplatz dilation and balloon dilation are different methods in creating the accesses during percutaneous nephrolithotomy (PCNL).The aim of this study was to review the surgical experiences of managing staghorn calculi by Amplatz dilation and balloon dilation for 3 years.Methods We retrospectively analyzed clinical data from 125 patients (129 kidneys)with staghorn kidney stones who underwent PCNL from January 2010 to December 2012,of whom 60 patients underwent Amplatz dilation (AD group) and 65 underwent balloon dilation (BD group) during PCNL.Results The AD and BD groups were similar in age,male-female ratio,stone burden,stone type,hydronephrosis,and proportion of patients who had undergone extracorporeal lithotripsy.However,these two groups showed significant differences in terms of duration of percutaneous access (15.1±3.6) minutes vs.(10.0±3.3) minutes,one-attempt success rate of dilation via a single access 88.9％ (72/81) vs.97.8％ (91/93),hemoglobin drop after surgery (3.5±0.9) g/dl vs.(1.7±0.9) g/dl,number of cases requiring intraoperative and postoperative blood transfusion 27.9％ (n=17) vs.13.2％ (n=9),changes of central venous pressure before and after surgery (2.3±1.2) cmH2O vs.(1.2±0.7) cmH2O,number of patients who experienced postoperative fever ＞37.5℃ 21 (34.4％) vs.13 (19.1％) (all P ＜0.05).No injury of adjacent organs,including pleura,liver,spleen,or bowel,was noted in patients.Conclusions During ultrasound-guided PCNL for staghorn stones,balloon dilation and Amplatz dilation are all effective and safe.Compared with Amplatz dilation,balloon dilation is a better choice,as it has a higher access creation success rate,shorter access creation time less blood loss,and lower proportions of circulatory overload and postoperative fever。

Abstract：Background Transradial approach (TRA) percutaneous coronary intervention (PCI) has been wildly applied among unselected patients.However,only very few small studies have compared the outcomes between TRA and transfemoral approach (TFA) in elderly patients.We aimed to evaluate the efficacy and safety between TRA and TFA in elderly patients by a pooled analysis.Methods Studies that met the inclusion and exclusion criteria were included.Statistical analysis was performed using the Review Manager 5.0.0 developed and maintained by the Cochrane Collaboration and a random-effects model was used to better account for the differences among the sub-studies.The primary endpoint was defined as short-term mortality,and other endpoints included major adverse cardiovascular events,major bleeding events,procedure success,vascular complications and hospital stay.Results Two thousand one hundred and eighty-eight patients from 11 studies were finally included.A non-significant trend toward a lower rate of short-term death was found in favor of TRA (odds ratio (OR):0.56,95％ confidence interval (C/):0.27-1.16).The incidence rates of vascular complications (OR 0.25,95％ CI:0.14-0.46) and major bleeding events (OR:0.31,95％ CI:0.18-0.55) were greatly reduced by TRA compared with TFA.No significant difference was detected in the occurrence rate of major adverse cardiovascular events (OR:0.77,95％ CI:0.45-1.30),but the rate of procedure success was significantly improved by TRA (OR:1.86,95％ CI:1.18-2.94).In addition,the total hospital stay was also significantly reduced by TRA.Conclusions TRA showed greater efficacy and safety compared with TFA in elderly patients.It should be recommend as routine practice for elderly patients undergoing PCI in TRA capable hospitals。

Abstract：Background Ertapenem has been demonstrated to be highly effective for the treatment of complicated infections.The aim of this study was to compare the efficacy and safety of ertapenem with ceftriaxone.Methods We searched the PubMed,EMBASE,and the Cochrane Library for published randomized controlled trials (RCTs) that compared the efficacy and safety of ertapenem with ceftriaxone for the treatment of complicated infections including community-acquired pneumonia (CAP),complicated urinary tract infections (cUTIs),and complicated intraabdominal infections (clAIs).Meta-analysis was performed by RevMan 5.0.Results Eight RCTs,involving 2 883 patients,were included in our meta-analysis.Ertapenem was associated with similar clinical treatment success with ceftriaxone for complicated infections (1 326 patients,fixed-effect model,OR:1.13,95％ CI:0.75-1.71).There was no difference between the compared treatment groups with regard to the microbiological treatment success,and no difference was found with regard to the incidence of clinical and laboratory drug-related adverse events between ertapenem and ceftriaxone groups.As to local tolerability,overall,there was no difference between the compared groups; however,in the subgroup analysis,local reaction was significantly less in the ertapenem subgroup than the ceftriaxone plus ceftriaxone subgroup.Conclusions Ertapenem can be used as effectively and safely as ceftriaxone for the treatment of complicated infections.It is an appealing option for the treatment of these complicated infections。

Abstract：Background Tirofiban has been widely used as an adjunctive pharmacologic agent for revascularization in patients undergoing percutaneous coronary intervention,and the outcomes appear attractive.However,the potential benefits from early administration of tirofiban in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) remain unclear.Methods We conducted a search in MEDLINE,EMBASE,and the Cochrane Central Register of Controlled Trials up to September 2012 without language restriction.A total of eight randomized trials (n=1 577 patients) comparing early (emergency department or ambulance) versus late (catheterization laboratory) administration of tiroflban in STEMI patients undergoing PPCI were included in this meta-analysis.Risk ratio (RR) was computed from individual studies and pooled with random-or fixed-effect models.Results There were no differences in post-procedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 and Corrected TIMI Frame Count (RR=1.02,95％ confidence interval (C/):0.99-1.05,P=0.18; weighted mean difference (WMD)=-0.93,95％ CI:-5.37-3.52,P=0.68,respectively) between the two groups.Similarly,there were no significant differences in the incidence of 30-day mortality (RR=1.69,95％ CI:0.69-4.13,P=0.25) and re-myocardial infarction (RR=0.71,95％ CI:0.21-2.35,P=0.57) between early and late administration of tirofiban.As to the safety end points,no significant difference was observed in hospital minor bleeding (RR=1.08,95％ CI:0.54-2.14,P=0.83) and hospital and 30-day major bleeding between the two groups (RR=0.98,95％ CI:0.46-2.10,P=0.96; RR=1.32,95％ CI:0.59-2.97,P=0.49,respectively).Conclusions Early administration of tiroflban in patients undergoing PPCI for STEMI was safe,but no beneficial effects on post-procedural angiographic or clinical outcomes could be identified as compared with late administration.Besides the negative finding,more high-quality randomized clinical trials are still needed to explore the efficacy of adequate,earlier administration of tirofiban in patients undergoing PPCI。

Abstract：Objective To review the presentation,diagnosis and recent developments in the pharmacological and invasive treatment of ST elevation myocardial infarction (STEMI) with a special focus on health-care organization in order to increase accessibility of primary pemutaneous coronary intervention (PCI).Data sources Data were obtained from English publications on STEMI treatment.No formal systematic review was conducted,but an effort was made to be comprehensive.Study selection Studies were selected if they contained data relevant to the topic.Preferably,data from clinical randomized trials,meta-analyses,guidelines and a few recent reviews are referenced.Results The described clinical approach to acute myocardial infarction (AMI) has been a continuum of scientific results and translation into clinical practice over the last four decades since the advent of thrombolytic reperfusion.This has resulted in a dramatic in-hospital mortality decrease from 30％ in the 1960s to the present 5％.The biggest survival benefits have undoubtedly been achieved after the advent of reperfusion strategies.In contemporary treatment of STEMI,additional treatment effects on survival have to be sought in the very early admission phase,as the current mortality hazard drops significantly after the first critical days to continuously very low levels after discharge.Conclusions Optimal treatment of STEMI patients is best performed with a widely accessible reperfusion strategy,preferably primary PCI,with contemporary peri-procedural anti-thrombotic treatment and device implantation.Accessibility of reperfusion strategies is increased by efficient STEMI networks applying prehospital triage with digital tele-transmission of electrocardiograms (ECGs) and seamless patient transitions between health-care unities.Efficient treatments of complicated STEMI with out-of hospital cardiac arrest and/or cardiogenic shock underline the necessity of structured referral systems,preferably immediately after the initial STEMI diagnosis。

Abstract：Objective To update the current status of bioresorbable scaffold,highlights the potential future prospective of innovative bioresorbable scaffold technology.Data sources Data were obtained from papers published in PubMed,presentations from the following conferences:EuroPCR,Transcatheter Cardiovascular Therapeutics,and Chinese Interventional Therapeutics.Results Bioresorbable scaffold has been introduced as a potential workhorse device for the treatment of coronary artery disease,with providing temporary vessel scaffold,then gradually being resorbed free of any caging,eventually restoring the vessel wall physiology and vasomotion.The clinical outcomes regarding the safety and efficacy following bioresorbable scaffolds implantation appear promising in the treatment of patients with either de novo lesions or acute myocardial infarction (AMI).In addition,two bioresorbable scaffolds currently investigated in Chinese population as well as several other bioresorbable scaffolds from Chinese manufactories are under development and preclinical evaluations.Conclusions Bioresorbable scaffolds with potential unique advantages have been rapidly developed and the initial clinical results are promising.Further preclinical and clinical evaluations are necessary to investigate their safety and efficacy in the treatment of Chinese patients with coronary artery disease。

Abstract：Objective To introduce the recent developments in cancer immunoinformatics with an emphasis on the latest trends and future direction.Data sources All related articles in this review were searched from PubMed published in English from 1992 to 2013.The search terms were cancer,immunoinformatics,immunological databases,and computational vaccinology.Study selection Original articles and reviews those were related to application of cancer immunoinformatics about tumor basic and clinical research were selected.Results Cancer immunoinformatics has been widely researched and applied in a series of fields of cancer research,including computational tools for cancer,cancer immunological databases,computational vaccinology,and cancer diagnostic workflows.Furthermore,the improvement of its theory and technology brings an enlightening insight into understanding and researching cancer and helps expound more deep and complete mechanisms of tumorigenesis and progression.Conclusion Cancer immunoinformatics provides promising methods and novel strategies for the discovery and development of tumor basic and clinical research。

Acute cardiac tamponade is a life threatening complication of interventional procedures usually requiring immediate management.Open-chest surgery is needed occasionally when emergency percutaneous pericardial drainage was failed,which is accompanied with higher mortality and cost.This report describes a twopigtail technique for failed pericardial drainage to avoid surgical intervention。

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder in which the nerve tissue grows tumors that may be benign and may cause serious damage by compressing nerves and other tissues.The NF1 gene mutation has high penetrance but a variable phenotypic expression in patients with NF1.Bony lesions such as tibial pseudarthrosis,scoliosis,and bony dysplasia of the skull are well recognized in the NF1 population.In 3％-11％ of patients with NF1,it could be accompanied by sphenoid wing dysplasia but calvarial defects are rare.1,2 Dandy-Walker malformation (DWM) is also a rare developmental abnormality of the central nervous system that is characterized by an enlarged fourth ventricle,vermian hypoplasia,cerebellar dysgenesis,and cystic dilation of the posterior fossa.Hydrocephalus which is due to maldevelopment of the rostral embryonic roof of the hindbrain is also usually present.DWM in association with NF 1 has never been reported before.We present clinical and radiological characteristics,discuss the pathogenesis of calvarial defects and DWM in association with NF 1,and describe individualized surgical treatment。

Immunodeficiency due to anti-interferon-gamma (anti-IFN-γ) autoantibody is an emerging adult-onset immunodeficiency syndrome associated with severe or disseminated infections caused by non-tuberculous mycobacteria,non-typhoidal salmonella,Burkholderia sp.,Penicillium marneffei,Cryptococcus neoformans,Histoplasma capsulatum,and varicella zoster virus (VZV) in non-HIV-infected patients caused by the presence of high-titer serum neutralizing anti-IFN-γ autoantibodies which inhibit IFN-γ-induced STAT1 phosphorylation and interleukin-12 production.1-3 It was first reported in an otherwise immunocompetent Filipino man with disseminated Mycobacterium chelonae infection in 2004.1 Since then,the condition has been increasingly reported in Asians including Filipino,Thai,Vietnamese,Japanese,and Chinese residents from Hong Kong and Taiwan,and less commonly in other ethnic groups.1,2

In the first decade of the 21 st century,the activities in the American cardiac catheterization laboratories underwent significant changes.From mostly cardiac diagnostic catheterization and basic angioplasty and stenting the procedures became more complex,diverse,involving the peripheral vascular,carotid,renal,aortic,or venous systems.As interventional cardiology is still a young and hyperdynamic playfield,new devices have been constantly developed and new procedures were invented.While these new equipment improved the success,safety of procedures and outcome of patients,they also carried a heavy price tag。

Pan-drug resistant Acinetobacter baumannii (A.baumannii) (PDRAB) is resistant to all currentlyavailable antimicrobials (including carbapenems),with the exception of colistin (polymyxin).Recently,PDRAB infection has become a serious medical problem.The mechanisms of A.baumannii drug resistance include low permeability of the outer membrane to antibiotics,an antibiotic effiux pump,and an extended-spectrum β-lactamase,etc.In addition,drug resistance can be easily acquired by incorporating genetic elements such as plasmids,transposons,and integrons.Multidrug-resistant A.baumannii (MDRAB;ie,strains with resistance to ≥3 classes of drugs) strains are being increasingly reported worldwide.Infections due to such resistant microbes are associated with increased morbidity and mortality.Carbapenems,which used to be the antimicrobials of choice,have become increasingly ineffective against such multi-resistant strains and no longer constitute salvage therapy for A.baumannii infections.In the last few years,PDRAB infections have been encountered several times during the treatment of patients with extensive burns.A.baumannii is susceptible to polymyxin B,which is not available in China.Therefore,the nine PDRAB infected patients were successfully treated with high doses of meropenem,cefoperazone-sulbactam and minocycline。

Arteriovenous malformations (AVMs) are vascular abnormalities that consist of multiple fistulous connections between arteries and veins without the normal intervening capillary bed.Microsurgical resection is regarded as the gold standard treatment,as it can achieve complete elimination of AVM.However,it may be prone to postoperative complications,including fatality and neurological deficits,especially in cases involving mild or no neurological deficits.1 Therefore,an appropriate balance is necessary between the extent of removal of AVM and functional preservation in the resection of AVM within eloquent brain areas.Intraoperative MRI (iMRI),which provides real-time images for neuronavigation to compensate for errors caused by brain tissue deformation and brain shift,has been rapidly developing and widely applied in neurosurgery.However,the role of iMRI in the surgical treatment of AVMs remains controversial.In this study,we report on our preliminary clinical experiences with 3.0 T iMRI-guided surgeries in seven cases of AVM to determine whether the use of iMRI has a favorable impact on the surgical treatment of such vascular malformations。

To the editor:We read with great interest an article by Zhang et al.1 The soluble ST2 level was shown to be increased in the early period and an independent predictor of prognosis.They additionally proposed that it might contribute to the predictive value of GRACE score and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) level。

To the editor:We read with great interest the article by Lin and co-authors.1 The authors assessed the clinical usefulness of plasma tissue inhibitor ofmetalloproteinase 1 (TIMP-1) as a potential blood biomarker for glioma.They concluded that plasma TIMP-1 is associated with the diagnosis and prognosis of glioma patients and have better usefulness for guiding clinical decision making than plasma matrix metalloproteinase-9 (MMP-9).Although we commend the authors for the excellent data that they have provided,some comments may be of beneficial。

To the editor:A 53-year-old woman presenting with eyelid edema,and foamy urine for a period of 3 years was admitted to the Qingdao Medical College Hospital.She had been a hepatitis B virus (HBV) carrier for 30 years.Upon admission,the 24-hour urinary protein quantity was 3.6 g.Plasma albumin level was 29 g/L.Serum amyloid A (SAA) level was 45 μg/ml.The renal biopsy results are given in Figure 1.Consequently,this case was diagnosed as secondary AA amyloidosis associated with HBV-associated glomerulonephritis (HBV-GN).We believed that HBV infection had a key role in amyloid deposition and heavy proteinuria.Lamivudine was administered orally at 100 mg/d.Six months later,the patient 24-hour urinary protein excretion was 1.0 g,and peripheral edema disappeared completely。

To the editor:Spontaneous spinal epidural hematoma (SSEH) is rare.Typical symptoms can develop from chest and back pain,numbness,radicular paresthesis,and sensory deprivation to progressive paralysis within several hours.1 Once SSEH is diagnosed,surgical treatment is the first choice as long as it is within the generally recommended 12-hour time window.2 However,conservative therapy should be taken if surgery chance is lost.Here,we report a case of SSEH who recovered well after delayed surgery。

Challenges Change in the healthcare landscape:life on the fast lane The working environment in American cardiac catheterization laboratories (CCL) has changed significantly over the last two decades (http://www.scai.org/QIT/Default.aspx).It has moved from performing mostly cardiac diagnostic catheterization to more complex and diverse interventional procedures.About 60％ of the percutaneous coronary interventions (PCI) are done ad hoc.With more robust operator training in combination with excellent refinement and miniaturization of equipment,the risk of procedure-related complications including emergent coronary artery bypass grafting (CABG) has decreased significantly.As a consequence,almost one third of the CCL in the United States (US) are performing PCIs without on-site cardiac surgery.A significant number of procedures are non-coronary including peripheral,carotid,renal,aortic,venous angioplasty,and stenting.Therefore,the responsibilities of the interventional cardiology community and expectations from American society and patients have increased tremendously,thus demanding near perfect performance and adherence to the highest quality and standards。

Challenges Since its inception,the field of invasive and interventional cardiology has witnessed tremendous procedural and technological advancements,thereby offering quantum expansion in clinical applications.As the complexity of the subspecialty continues to grow,so does the need for systematic guidelines and appropriate utilization criteria for these procedures.To this end,the American College of Cardiology (ACC),in association with the Society for Cardiovascular Angiography and Interventions (SCAI) and several other professional societies,has developed recommended indications for diagnostic cardiac catheterizations and percutaneous coronary interventions (PCI) based upon evidence-based literature or expert concensus.By and large,these guidelines have emphasized the importance of optimal medical therapy (OMT),regardless of whether an invasive or conservative approach is followed.The Appropriate Use Criteria (AUC) aim "to improve patient care and health outcomes in a costeffective manner while recognizing that some ambiguity and nuance are intrinsic to clinical decision making".1

The sympathetic nervous system regulates cardiac output,blood pressure (BP) and volume,electrolyte balance,and the composition of body fluids.The afferent nervous signals to the brain are regulated by mechano-sensitive baroreceptors,volume sensors and chemoreceptors located in the vessels and in plenty other organs,particularly in the heart,the kidneys,the lung,the brain and the muscles.Sympathetic nervous system outflow is coordinated by the nucleus tractus solitarius,located in the midbrain.Efferent sympathetic signals regulate BP and cardiac output through β-adrenergic receptors,and regulate vasoconstriction through α-adrenergic receptors.In the kidneys,sodium and water retention is stimulated by activation of α-adrenergic receptors in the proximal tubules.1Catheter-based renal denervation (RDN) offers a new approach to selectively interrupt these fibers,thereby reducing central sympathetic activity and office blood pressure。

Diabetes has emerged as a worldwide epidemic chronic disease with rapidly increasing prevalence.In 2011,the global prevalence of diabetes among adults was 6.4％,affecting 366 million adults and will rise to 552 million adults by 2030.1 According to the latest epidemiological data in a nationally representative sample of 98 658 Chinese adults in 2010,the prevalence of total diabetes has already reached 11.6％,affecting 113.9 million Chinese adults.2