2007年·第120卷第21期

In China, the prevalence of type 2 diabetes mellitus is increasing rapidly due to aging of the population,increased frequency of obesity, and suboptimal nutritional habits.1-3

Abstract：Background Drug-eluting stent (DES) has been used widely for the treatment of patients with acute coronary syndrome with or without diabetes mellitus during percutaneous coronary intervention (PCI), but its long-term safety and efficacy in diabetic patients with acute ST elevation myocardial infarction (STEMI) remain uncertain. This study aimed to investigate the clinical outcomes after primary coronary intervention with DES implantation for diabetic patients with acute STEMI, compared with non-diabetic counterparts.Methods From December 2004 to March 2006, 56 consecutive diabetic patients (diabetic group) and 170 non-diabetic patients (non-diabetic group) with acute STEMI who underwent primary PCI with DES implantation in 3 hospitals were enrolled. Baseline clinical, angiographic, and procedural characteristics, as well as occurrence of major adverse cardiac event (MACE) including cardiac death, non-fatal recurrent myocardial infarction (re-MI) and target vessel revascularization (TVR) during hospitalization and one-year clinical follow-up were compared between the two groups.Results Patients in diabetic group were more hyperlipidemic (69.6% and 51.8%, P=0.03) and had longer time delay from symptom onset to admission ((364±219) minutes and (309±223) minutes,P=0.02) than those in non-diabetic group.The culprit vessel distribution, reference vessel diameter, and baseline TIMI flow grade were similar between the two groups, but multi-vessel disease was more common in diabetic than in non-diabetic group (82.1% and 51.2%, P＜0.001).Despite similar TIMI flow grades between the two groups after stenting, the occurrence of TIMI myocardial perfusion grade (TMPG)≥2 was lower in diabetic group (75.0% vs 88.8% in non-diabetic groups, P=0.02). The MACE rate was similar during hospitalization between the two groups (5.4% vs 3.5%, P=0.72), but it was significantly higher in diabetic group (16.1%) during one-year follow-up, as compared with non-diabetic group (6.5%, P=0.03). The cumulative one-year MACE-free survival rate was significantly lower in diabetic than in non-diabetic group (78.6% vs 90.0%, P=0.02).Angiographic stent thrombosis occurred in 5.4% and 1.2% of the patients in diabetic and non-diabetic group, respectively (P=0.19). All of these patients experienced non-fatal myocardial infarction.Conclusions Although the early clinical outcomes were similar in diabetic and non-diabetic patients with acute STEMI treated with DES implantation, the cumulative MACE-free survival at one-year follow-up was worse in diabetic than in non-diabetic patients. More effective diabetes-related managements may further improve the clinical outcomes of diabetic cohort suffering STEMI。

Abstract：Background The sirolimus and paclitaxel distribution patterns and tissue residence time may be modified in atherosclerotic lesions for patients with diabetes, and the biological mechanisms of action for these agents differ significantly. Previous clinical trials have yielded discrepant results of major adverse cardiac events and restenosis between a sirolimus-eluting stent and a paclitaxel-eluting stent in coronary artery disease. Therefore, this study was conduced to compare in-hospital and long-term clinical outcomes between patients receiving sirolimus-eluting stent(Cypher or Cypher Select stent) and paclitaxel-eluting stent (Taxus Express stent) after percutaneous intervention (PCI)in Chinese patients with diabetes.Methods One hundred and sixty-four consecutive diabetic patients underwent PCI in Fuwai Hospital from April 2004 to December 2004. Of them, 101 patients received Cypher or Cypher Select stents (Cypher group, 145 stents) and 63patients received Taxus Express stents (Taxus group, 129 stents). Repeat coronary angiography was performed at6-month and clinical outcomes were evaluated at 1- and 3-year follow-up. Stent thrombosis was classified according to Academic Research Consortium (ARC).Results The two groups did not differ significantly with respect to cardiac death, recurrent myocardial infarction (re-MI),target vessel revascularization (TVR) and occurrence of major adverse cardiac events (MACE). And the MACE-free cumulative survival at 1- and 3-year follow-up and early, late and very late thrombosis rates were also similar in the two groups (all P＞0.05). There was a trend favoring PES over SES with regard to reducing cardiac death (0 vs 2.0%,P=0.524), re-MI (0 vs 2.0%, P=0.524), the composite of the cardiac death and re-MI (0 vs 4.0%, P=0.299) and very late thrombosis (0 vs 3.0%, P=0.295) between 1-year and 3-year follow-up.Conclusion The study indicates that PCI with either Cypher or Taxus stents is associated with similar efficacy and safety in the small population of Chinese diabetic patients during long-term follow-up。

Abstract：Background Hyperglycemia has been shown to be a powerful predictor of poor outcome after ST-segment elevation myocardial infarotion (STEMI). This study aimed to evaluate the effect of admission glucose on microvascular flow after successful primary percutaneous coronary intervention (PCI) in patients with STEMI.Methods Successful primary PCI was performed in 267 patients with STEMI. The maximum ST elevation of single electrocardiogram (ECG) lead before and 60 minutes after PCI was measured, and patients were then divided into 3 groups according to the degree of ST-segment resolution (STR): absent (＜30%), partial (30% to 70%) or complete(≥7o%).Results Of the 267 patients, 48 (18.0%) had absent STR, 137 (51.3%) experienced partial STR, and 82 (30.7%) had complete STR. The degree of STR decreased with increasing admission glucose levels (P=0.032), and patients with hyperglycemia (serum glucose level ≥11 mmol/L) were more likely to have absent STR (P=0.001). Moreover,hyperglycemia was an independent predictor of incomplete STR (odds ratio, 1.870; 95% confidence interval, 1.038 to 3.371, P=0.037).Conclusions Hyperglycemia on admission is associated with abnormal coronary microvascular reperfusion in patients with STEMI after successful primary PCI, which may contribute, at least in part, to the poor outcomes in these patients。

Abstract：Background Some single nucleotide polymorphisms (SNPs) in the peroxisome proliferator-activated receptor-Y coactivator (PGC)-1α gene have been reported to be associated with type 2 diabetes in different populations, and studies on Chinese patients yielded controversial results. The objective of this case-control study was to explore the relationship between SNPs of PGC-1a and type 2 diabetes in the southern Chinese population and to determine whether the common variants: Gly482Ser and Thr394Thr, in the PGC-1α gene have any impacts on interaction with myocyte enhancer factor (MEF) 2C.Methods The SNPs in all exons of the PGC-1α gene was investigated in 50 type 2 diabetic patients using polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP) and direct sequencing. Thereafter, 263 type 2diabetic patients and 282 healthy controls were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). A bacterial two-hybrid system and site-directed mutagenesis were used to investigate whether Gly482Ser and Thr394Thr variants in the PGC-1α gene alter the interaction with MEF2C.Results Three frequent SNPs (Thr394Thr, Gly482Ser and Thr528Thr) were found in exons of the PGC-1α gene. Only the Gly482Ser variant had a different distribution between diabetic patients and healthy subjects, with the 482Ser allele more frequent in patients than in controls (40.1% vs 29.3%, P＜0.01). Even in controls, the 482Ser(A) carriers were more likely to have higher levels of total cholesterol and low-density lipoprotein cholesterol than the 482Gly(G) carriers. The 394A-482G-528A haplotype was associated with protection from diabetes, while the 394A-482A-528A was associated with the susceptibility to diabetes. The bacterial two-hybrid system and site-directed mutagenesis revealed that the 482Ser variant was less efficient than the 482Gly variant to interact with MEF2C, whereas the 394Thr (A) had a synergic effect on the interaction between 482Ser variant and MEF2C.Conclusions The results suggested that the 482Ser variant of PGC-1α conferred the susceptibility to type 2 diabetes in the southern Chinese population. The underlying mechanism may be attributable, at least in part, to the altered interaction between the different variants (Gly482Ser, Thr394Thr) in the PGC-1α gene and MEF2C。

Abstract：Background The decreased degradation of extra-cellular matrix proteins plays an important role in the onset of diabetic nephropathy. Matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1), which are members of the matrix metalloproteinase family, are associated with this process. Angiotensin il (AII) plays an important role in the development of diabetic nephropathy also. This research aimed to investigate the effect of angiotensin Ⅱ receptor blocker on glucose-induced mRNA expressions of MMP-9 and TIMP-1 in rat mesangial cells.Methods Rat mesangial cells were cultured and divided into 5 groups: normal glucose (group NG), high glucose (group HG), group NG+AII, NG+AIl+saralasin (group NG+AII+S, saralasin is the All receptor blocker) and HG+saralasin (group HG+S). After the cells were incubated for 24 hours, All concentrations in the supernatant were measured by radioimmunoassay and the expression of MMP-9 and TIMP-1 mRNA was assayed by reverse transcription-polymerase chain reaction (RT-PCR).Results All concentrations were higher in group HG ((56.90±13.54) pg/ml) and group HG+S ((51.30±5.96) pg/ml) than in group NG ((37.89±8.62) pg/ml, P＜0.05), whereas there was no significant difference between group HG and group HG+S. The expression of MMP-9 mRNA and MMP-9/TIMP-1 mRNA ratio in group NG+AII (MMP-9, 0.33±0.04;MMP-9/TIMP-1, 0.40±0.06) and group HG (MMP-9, 0.36±0.02; MMP-9/TIMP-1, 0.45±0.03) were decreased more significantly than those in group NG (MMP-9, 0.72±0.02; MMP-9/TIMP-1, 1.21±0.07). These values in group NG+AII+S(MMP-9, 0.71±0.02; MMP-9/TIMP-1, 1.18±0.05) were higher than those in group NG+AII, and the values in group HG+S(MMP-9, 0.71±0.02; MMP-9/TIMP-1, 1.16±0.05) were higher than those in group HG (all were P＜0.05). TIMP-1 mRNA expression was increased more significantly in group NG+AII (0.81±0.03) and group HG (0.80±0.03) than in group NG(0.59±0.02), but it was lower in group NG+AII+S (0.60±0.01) than in group NG+AII and also lower in group HG+S(0.61±0.01) than in group HG (all were P＜0.05).Conclusions High glucose stimulates All production. Both high glucose and All induce a decrease in MMP-9 mRNA expression and MMP-9/TIMP-1 mRNA ratio as well as an increase in TIMP-1 mRNA expression, which can be reversed by saralasin, suggesting that high glucose can aggravate impaired matrix degradation by altering gene expression of MMP-9 and TIMP-1 and that the effect of high glucose may be mediated by All。

Abstract：Background Previous studies showed that preservation of microvascular integrity after myocardial ischemia was associated with myocardial viability. Real-time myocardial contrast echocardiography (RT-MCE) is a promising modality for non-invasive evaluation of microcirculation perfusion. Thus, it provides a unique tool to detect myocardial viability. We sought in this study to investigate the role of RT-MCE in predicting left ventricular (LV) functional recovery and remodeling after revascularization in patients with ischemic heart disease.Methods Thirty-one patients with ischemic heart disease and resting regional LV dysfunction were included. LV volume,global and regional function were evaluated by echocardiography before and 6-9 months after revascularization.RT-MCE was performed before revascularization using low mechanical index power modulation imaging. Myocardial contrast opacification of dysfunctional segments was scored on a 3-point scale and mean contrast score in dysfunctional segments was calculated. Patients were divided into 2 groups according to mean contrast score in dysfunctional segments: group A, patients with mean contrast score ≥0.5 (n=19); group B, patients with mean contrast score ＜ 0.5(n=12).Results Wall motion improvement was found to be 94.5%, 45.5% and 16.1% respectively (P＜0.01) in homogenous,patchy and absent contrast opacification segments. At baseline, there was no significant difference in LV volume and global function between the two groups. After revascularization, group B had significantly larger LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV), lower LV ejection fraction (LVEF) and higher wall motion score index(WMSI) than those of group A (all P＜0.05). Revascularization was followed by significant improvement of LV volume and recovery of global LV function in group A (all P＜0.01); however, in group B, after revascularization, deterioration of LVEDV (P＜0.05) was observed, moreover LVESV, WMSI and LVEF did not change significantly.Conclusions The maintenance of myocardial microcirculation detected by RT-MCE can predict functional recovery and LV remodeling after revascularization in patients with ischemic heart disease, which might be helpful in clinical decision-making and risk stratification。

Abstract：Background Postsystolic shortening (PSS) has been proposed as a marker of myocardial dysfunction. Strain rate imaging (SRI)is a novel ultrasonic technique, allowing reliable and noninvasive measurement of myocardial deformation.The purpose of this study was to investigate the characteristics of myocardial longitudinal PSS by SRI in ischemic and infarct myocardium in patients with coronary artery disease, and to explore its clinical applicability.Methods Eleven patients with angina pectoris, 21 patients with myocardial infarction and 20 healthy subjects were included in the study. Apical four-, three- and two-chamber views were displayed; and septal, lateral, anteroseptal,posterior, anterior and inferior walls of the left ventricle were scanned, respectively. PSS strain (εpss), the ratio of εpss and systolic strain (εpss/εsys), the ratio of εpss and maximum strain (εpss/εmax) and the duration of PSS (Tpss) in ischemic, infarct and normal myocardium were analyzed.Results PSS was found more frequent in the ischemic and infarct segments compared with the normal segments (39%vs 22% and 56% vs 22%, respectively; both P＜0.01). It was even more frequent in the infarct segments than in the ischemic segments (56% vs 39%, P＜0.01). The absolute magnitude of εpss, εpss/εsys, εpss/εmax were significantly larger and Tpss significantly longer in the ischemic and infarct segments compared with that in the normal myocardium (P＜0.01).εpss/εsys, εpss/εmax were even larger and Tpss even longer in the infarct than in the ischemic segments (P＜0.01).Conclusions PSS is a common and important feature of the ischemic and infarct myocardium. εpss, εpss/εsys, εpss/εmax and Tpss as measured by SRI may be promising markers for the quantitative assessment of regional myocardial dysfunction in patients with coronary artery disease. εpss/εsys, εpss/εmax and Tpss may be helpful in differentiating infarct from ischemic myocardium。

Abstract：Background There remains controversy about whether Brugada syndrome (BS) has structural heart changes. We occasionally noted that a patient with BS had a quite unusual regional wall motion abnormality at the basal segment of the interventricular septum (IVS) during echocardiographic examination. The unexpected finding promoted us to reexamine our patients with BS by echocardiographic interrogation in the present study.Methods Patients with BS (n=11), patients with complete right bundle branch block (RBBB) (n=11), and control subjects(n=11) were enrolled in this study. Two-dimensional echocardiography (2DE) was performed to obtain parasternal left ventricular long axis view on which M-mode scanning line was adjusted to be perpendicular to the basal segment of IVS for delineation of the segmental motion curve, with a simultaneously electrocardiographic tracing.Results 2DE revealed a rapid swing motion shifting toward the right ventricle of the IVS basal segment at early systole in 73% (8/11) patients with BS, which was further confirmed on the M-mode curve evidenced by an early systolic notch toward the right ventricle. The position of the notch corresponded to C-point on the mitral motion curve, lasting for (53±5)ms. There were no similar changes both in patients with RBBB and in the control subjects.Conclusion IVS basal motion abnormalities at early-systolic phase may be the novel finding of BS。

Abstract：Background Connexin43 (Cx43) is the predominant gap junction protein in heart and is involved in the control of cell-to-cell communication to modulate the contractility and the electrical coupling of cardiac myocytes. Left ventricular(LV) hypertrophy is accompanied by changes of Cx43 expression. Recent studies have demonstrated that statins reduced cardiac hypertrophy. However, it is unknown whether statins can affect Cx43 expression in hypertrophied left ventricular myocardium. This study was designed to assess the effects of atorvastatin on LV hypertrophy and Cx43 expression in spontaneously hypertensive rats (SHR).Methods Nine-week old SHRs were randomly divided into two groups. Some received atorvastatin at 30 mg/kg by oral gavage once daily for 8 weeks (SHR-A); others received vehicle. Age-matched Wistar-Kyoto rats (WKY) received atorvastatin or vehicle for 8 weeks were used as controls. At the end of the experiment, we investigated LV hypertrophy and the expression of Cx43 in LV myocardium in four groups. Cx43 expression was investigated by the methods of Western blotting, immunohistochemistry, and transmission electron microscope. LV hypertrophy was accessed by pathological analysis and plasma brain natriuretic peptide (BNP) level.Results LV hypertrophy was prominent in untreated SHR. In SHR, LV myocardium Cx43 level was upregulated, and the distribution of Cx43 was displaced from their usual locations to other sites at various distances away from the intercalated disks. After atorvastatin treatment, myocardium Cx43 level was reduced in SHR-A, and the distribution of Cx43 gap junction became much regular and confined to intercalated disk. Statins also prevented LV hypertrophy in SHR.Conclusions These results provide novel in vivo evidence for the key role of Cx43 gap junctions in LV hypertrophy and the possible mechanism in anti-hypertrophic effect of statins. Atorvastatin treatment may have beneficial effects on LV hypertrophy in spontaneously hypertensive rats。

Abstract：Background At present, many administrators lack a theoretical guide to build management systemsto cope with public health emergencies. This study developed a detailed function list for public health emergency management to help building the management systems scientifically.Methods The five steps in this study including literature review, semistructured interviews with experts, focus group,Delphi study and focus group were conducted to develop the detailed list of functions.Results An initial list of 25 functions with 188 items was formed through literature review. The list was reduced to 10 functions with 57 items by semistructured interviews with experts and focus group. Next, all these 57 items reached the consensus through one-round Delphi study. Some revisions of the consensus were done by the same focus group.Conclusion The final 10 functions with 57 items could be used as a guide for most countries during their building of a public health emergency management system。

The prevalence of both type 2 diabetes and metabolic syndrome is increasing exponentially all over the world because of global changes in obesity, sedentary lifestyle, and the aging of the population.1

Abstract：Objective To review the mechanisms of epithelial to mesenchymal transition (EMT) and its role in the progression of tubulointerstitial fibrosis.Data sources The data used in this review were obtained mainly from the studies of EMT reported from 2000-2006.Study selection Relevant articles on studies of EMT in tubulointerstitial fibrosis were selected. Data were mainly extracted from the 45 articles listed in the reference section of this review.Results The process of EMT has gained wide recognition as candidate mechanism in progression of chronic fibrotic disorders. New markers were identified and facilitate the observation of EMT. EMT is regulated by many factors through activation of kinase-dependent signaling cascades. Recent findings suggest that EMT is a reversible process, which can be controlled by factors for their epithelial inducing activities.Conclusion Remarkable progresses of EMT research have been made recently. Preventing or reversing EMT is a promising strategy against renal fibrosis。

Amyloid-beta peptides (Aβ) are believed to be responsible for the mental decline in patients with Alzheimer's disease (AD). In 1999, Schenk et al1 reported that immunization with Aβ attenuated AD-like pathology in the PDAPP mouse, and developed a new vaccination approach to AD。

Laser in situ keratomileusis (LASIK) is currently the most popular keratorefractive procedure performed worldwide with generally excellent outcomes.1

Rectal carcinoid tumors are often diagnosed as submucosal tumors on radiological or endoscopic examinations。

Postcardiac injury syndrome (PCIS) is characterized by inflammation of the pericardium, pleura and pulmonary parenchyma following a cardiac injury.1

Pseudoaneurysms of the femoral artery usually progress and can rupture if left untreated. Therefore,intraoperative hemostasis is of the paramount importance in the management of these emergent situations,especially for the patients with poor general health。

To the Editor: I read with great interest the case report of multiple myocardial bridges affecting both coronary arteries in a patient with hypertrophic cardiomyopathy.1