2009年 · 第122卷第19期

The millions of medical and health care professionals in China celebrate with great pleasure and confidence the 60th birthday of the people's republic. In this issue of the journal, our readers will see a part of what fruitful achievements have been obtained by the government, health and medical professionals and researchers in various fields of health and medical care and research as well as what challenges the Chinese medical professionals face。

On the occasion of the 60th anniversary of the founding of the People's Republic of China, I am honored to review the interventional treatment of cardiovascular diseases in China. It is really interesting to evaluate the progress in such a field that did not exist 25 years ago in this country in the present context with the term "interventional cardiology"。

INVENTION OF GASTROINTESTINAL ENDOSCOPY

Urological surgery did not take shape as a discipline until the establishment of the new China. From small and weak to large and strong, and with the painstaking efforts of several generations since the inception of reform and opening-up policy, China's urological surgery has developed into a significant subject subordinated to clinical medicine。

Laparoscopic surgery in the mainland of China began in 1991, when Dr. XUN Zu-wu from the Second Hospital of Qujing City in Yunnan Province successfully performed the first laparoscopic cholecystectomy (LC). From then on, the implementation of laparoscopic techniques has been increased rapidly all over China。

China's liver transplantation, after 3 decades of rises and falls since its first clinical trial in 1978, has now been accepted as an effective treatment for all kinds of end-stage liver diseases。

Radiation therapy is one of the main treatment modalities used in cancer management. It is the primary curative modality for about 30% of patients with cancer, and more than half of all cancer patients received radiation therapy sometime during the course of their disease. It is estimated that 70% of the patients with cancer required radiation therapy in China。

Hepatitis virus infection, especially chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV), is a serious issue to global public health. Although the prevalence of HBsAg in the general population has been declined dramatically in China due to universal HBV vaccination in newborns, chronic hepatitis B and hepatitis C are still the main causes of cirrhosis and hepatocellular carcinoma (HCC) that are responsible for a high rate of morbidity and mortality.1,2 HBV- and HCV-related end-stage liver disease are also the leading indications of liver transplantation in China。

This year marks the 60th anniversary of the founding of the People's Republic of China. On this occasion, it is worthy to recall the past and look towards the future in order to do a better job in research and control of children's respiratory diseases。

Much has been achieved in child health care over the past 60 years since the founding of People's Republic of China in 1949。

Although infectious diseases are still common in Chinese children, great changes have taken place in the spectrum of the diseases。

Abstract：Background In response to the increasing concem with the safety of the drug-eluting stent (DES), the present study aimed to evaluate the long-term safety and efficacy of DES used for a Chinese patient population. Methods All patients, who underwent an index elective percutaneous coronary intervention with an implantation of either DES or bare-metal stent (BMS) in a single institution from April 2004 to December 2006, were included in the analysis. A propensity-score matching technique was applied to adjust and to minimize the impact of confounding factors. Results Overall, there were 1465 patients (20.2%) who had undergone an implantation of only BMS, and 5769 patients (79.8%) of only DES. The propensity-score matching technique set up 1321 pairs of patients for analysis. There were no significant differences between the rates of stent thrombosis (definite and probable) of the two groups (1.06% vs 1.21%, P=-0.8580). Although rates of mortality and myocardial infarction (MI) during the 2-year follow-up period had not differed significantly, rates of death/MI (3.0% vs 4.5%, P=0.0263), target-lesion revascularization (TLR, 3.2% vs 8.5, P=0.0001), target-vessel revascularization (TVR, 5.8% vs 9.5%, P <0.0001) and any revascularization (10.0% vs 13.3%, P=0.0066) were significantly lower for the DES group than for the BMS group. Among the patients in whom devices were implanted for off-label indications, the propensity-score matched rates of stent thrombosis, mortality, MI, and death/MI were not significantly different, while rates of TLR, TVR and any revascularization were significantly lower for the DES group than for the BMS group.Conclusions During the 2 years of follow-up post stenting, DES use is associated with lower rates of death/MI, TLR, TVR and any revascularization, compared with BMS, in propensity-score matched Chinese patient populations. In the setting of off-label usage, DES use is also associated with similar advantages。

Abstract：Background Hepatectomy is a standard hepatic surgical technique. The safety of hepatectomy has been improved in line with improvements in surgical techniques. This study analyzed the operative and pedoperative factors associated with hepatectomy.Methods A total of 2008 patients who underwent consecutive hepatectomies between January 1986 and December 2005 were investigated retrospectively. Diagnoses were made based on pathological findings. Results Malignant and benign liver diseases accounted for 58.5% and 41.2%, respectively, of the conditions requiring resections. Primary liver cancers accounted for 76.1% of the malignant tumors, while hilar cholangiocarcinomas accounted for 6.7%. Hemangiomas (41.7%) and hepatolithiasis (29.6%) were the most common of the benign conditions. Microwave in-line coagulation was used in 236 of our liver resection cases. The overall postoperative complication rate was 14.44%, of which 12.54% of resections were performed for primary liver cancer, 16.40% for secondary liver cancer, and 16.32% for hepatolithiasis. The overall hospital mortality was 0.55%, and that for malignant liver disease was 0.51%. A high mortality (2.53%) was associated with extensive liver resections for hilar cholangiocarcinomas (two deaths in 79 cases). Microwave in-line pre-coagulation resection, Child-Pugh grading, operating time, postoperative length of stay, and preoperative serum albumin level were independent predictors of morbidity. Blood loss, Child-Pugh grading, operating time and preoperative serum albumin level were independent predictors of mortality. Conclusions Hepatectomy can be performed safely with low morbidity and mortality, provided that it is carried out with optimal perioperative management and innovative surgical techniques。

Abstract：Background The safety of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions in remote hospitals without surgical facilities remains unknown. This study aimed to evaluate three-year outcomes after CTO for PCI in ten centers around China where no on-site coronary artery bypass grafting (CABG) support was available. Methods A total of 152 patients from 10 Chinese hospitals without on-site surgical facilities were prospectively studied. Intra-procedural and in-hospital events were assessed. Angiographic follow-up was indexed eight months after the initial procedure. Clinical follow-up was extended to three years. The primary outcome was the rate of major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction and target-vessel revascularization (TVR). Results The incidence of CTO was 7.9% in patients who underwent PCI. Successful recanalization was achieved in 132 patients (86.8%). Compared with patients in the PCI success group, patients with PCI procedural failure had longer lesion lengths ((42.32±92.08) mm vs (27.61±92.85) mm, P=0.023), a higher rate of perforation (25.0% vs 0, P=0.014), and a greater need for pericardial puncture. There were significant differences in MACE in-hospital and at one year and three years between the failure (10.0%, 30.0% and 35.0%) and the success (3.0%, 12.1% and 14.4%) groups (P=0.037, 0.034 and 0.040, respectively). These led to a significant decrease in the MACE-free survival rate at one and three years in the failure group, compared with the success group (P=0.031 and 0.023, respectively). Stump was the only predictor of recanalization success (HR 0.158, 95% CI 0.041-0.612, P=0.008), whereas procedural failure (OR 13.023, 95% CI 6.67-13.69, P=0.002), incomplete revascularization (OR 9.71, 95% CI 2.93-5.59, P=0.005), and total stent length (OR 6.02, 95% CI 1.55-11.93, P=0.027) were three independent predictors of MACE.Conclusions PCI for CTO was unsafe in remote hospitals without CABG facilities. Paying attention to coronary perforation is important for successful procedures。

Abstract：Background The management of intrahepatic cholangiocaminoma (ICC) remains a challenge due to poor prognosis. The aim of this study was to summarize the surgical management experience in recent 10 years and to identify the influencing factors related to outcome of patients with ICC in a single hepatobiliary center. Methods From January 1995 to June 2005, 136 patients with ICC undergoing surgery were reviewed retrospectively. Survival rates of patients were calculated using the Kaplan-Meier method and compared by using the log-rank test. The prognostic factors were identified by the Cox regression model.Results Seventy-nine of 136 patients underwent resection, and 65 of 79 patients were curative (R0). The surgical mortality was 2.2%. The 1-, 3- and 5-year survival rates of patients undergoing R0 resection were 72.1%, 35.6% and 20.1% respectively, which were significantly longer than those who underwent palliative resection and exploration, respectively (P <0.01). At stage IV of the disease, 10 patients who underwent aggressive curative resection achieved a better median survival than those (n=12) without resection (14 months vs 3 months, P <0.001). The independent prognostic factors of the whole group were TNM stage (OR, 2.013, P=0.008) and curative resection (OR, 2.957, P=0.003). Higher TNM stage (OR, 1.894, P=0.004) and lymph node metastasis (OR, 4.248, P=0.005) linked to poor prognosis after R0 resection. For patients without lymph node metastasis, the median survival of those who underwent regional lymphadenectomy was comparable with those who did not (18 months vs 22 months, P=0.817).Conclusions R0 resection is mandatory for ICC patient to achieve long-term survival. Aggressive resection benefits for selected patients with local advanced disease. Higher TNM stage and lymph node metastasis were poor prognosticfactors for ICC patients after R0 resection。

Abstract：Background Since the 1980s, various approaches to interventional therapy have been developed, with the development and achievement of medical imaging technology. This study aimed to evaluate the effectiveness of comprehensive sequential interventional therapy especially personal therapeutic plan in 53 radical cure patients with hepatocellular carcinoma (HCC).Methods From January 2003 to January 2005, a total of 203 patients with HCC received sequential interventional treatment in our hospital. Fifty-three patients achieved radical cure outcomes. Those patients were treated with transcatheter arterial chemoembolization (TACE), radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), or high intensity focused ultrasound (HIFU), sequentially and in combination depending on their clinical and pathological features. PET-CT was used to evaluate, assess, and guide treatment.Results Based on the imaging and serological data, all the patients had a personal therapeutic plan. The longest follow-up time was 24 months, the shortest was 6 months, and mean survival time was 16.5 months.Conclusion Comprehensive sequential interventional therapy especially personal therapeutic plan for HCC play roles in interventional treatment of HCC in middle or advanced stage。

Abstract：Background We used abdominal ultrasound scan (USS), computed tomography (CT) and magnetic resonance imaging (MRI) findings in venous spread of renal cell carcinoma (RCC) to determine the superior extent of inferior vena cava (IVC) thrombus and IVC wall invasion and compared them with surgical and pathological reports. Methods From January 1999 to August 2007, 25 patients were diagnosed with RCC with IVC turnout thrombus. Before their operation, all patients had USS, contrast enhanced CT and MRI to find the superior extent of turnout thrombus and IVC wall invasion. All postprocessing techniques were performed by experienced radiologists. Two pathologists reported on all pathology specimens. The superior extent of tumour thrombus was confirmed by the senior surgeon at each operation, using the levels of thrombus defined according to 2004 Mayo Clinic classification. The radiographic results were compared with surgical and pathological findings.Results All patients had radical nephrectomy and tumour thrombus excision. Eight patients had RCC on the left side and 17 on the right side. According to the clinical and pathological findings, 6 patients had level Ⅰ tumour thrombus, 9 level Ⅱ, 5 level Ⅲ and 5 level Ⅳ. Six patients had IVC wall invasion. No patient had evidence of lymph node or distant metastases. Of the 25 patients, USS correctly diagnosed the superior extent of tumour thrombus in 18/25, CT 23/25 and MR123/25. USS found 1 case of IVC wall invasion preoperatively.Conclusions Multidectector computed tomography and magnetic resonance imaging are comparable and more effective than abdominal ultrasound in diagnosing inferior vena cava tumour thrombus in renal cell carcinoma. None of the three methods can detect inferior vena cava wall invasion。

Abstract：Background Excessive expression of thymic stromal lymphopoietin (TSLP) has been demonstrated in asthmatic airway epithelia and in nasal epithelia from animal models of allergic rhinitis (AR), but the evidence of expression of TSLP in nasal epithelial cells (NECs) of patients with AR is lacking. We aimed to investigate the expression of TSLP in NECs of patients with mugwort sensitive-seasonal AR and determine whether it is associated with severity of symptoms and the number of infiltrated eosinophils in nasal mucosa.Methods NECs specimens were obtained by scraping with plastic curettes from the nasal inferior turbinates of patients with mugwort pollen sensitive-seasonal AR (n=22) and nonallergic controls (n=11) during last peak mugwort pollen season. The severity of nasal symptom was assessed using a Visual Analog Scale (VAS). In addition, serum mugwort pollen IgE levels were tested from each patient. In situ hybridization (ISH) was performed to test the messenger RNA (mRNA) of TSLP in the NECs. Furthermore, immunohistochemical staining (IHC) was scored to evaluate the expression TSLP and all other parameters was analyzed in this study.Results The mRNA level of TSLP was significantly increased in NECs of patients with AR compared with the nonallergic control group (P <0.05). In addition, IHC results showed that expression of TSLP in NECs from patients with AR was up-regulated which was correlated with VAS score (r=0.598; P <0.05) and nasal eosinophils count (r=0.702; P <0.05), but it was unrelated with mugwort pollen specific IgE level.Conclusions These preliminary findings indicate a potential relationship between TSLP expression, severity of symptoms and nasal eosinophils count in pathogenesis of AR, but TSLP expression did not correlate with mugwort pollen specific IgE level. The elevated expression of TSLP might play a critical role in local atopical responses of AR. In the future, the TSLP has the potential to be one of the most important molecular markers for AR diagnoses and assessment。

Abstract：Background It has been proposed that parkinsonian motor signs result from hyperactivity in the output nucleus of the basal ganglia, which suppress the motor thalamus and cortical areas. This study aimed to explore the neuronal activity in the globus pallidus internus (GPi) and the ventrolateral thalamic nuclear group (ventral oral posterior/ventral intermediate, Vop/Vim) in patients with Parkinson's disease (PD).Methods Twenty patients with PD who underwent neurosurgery were studied. Microelectrode recording was performed in the GPi (n=10) and the Vop/Vim (n=10) intraoperatively. Electromyography (EMG) contralateral to the surgery was simultaneously performed. Single unit analysis was carried out. The interspike intervals (ISI) and coefficient of variation (CV) of ISI were calculated. Histograms of ISI were constructed. A unified Parkinson's disease rating scale (UPDRS) was used to assess the clinical outcome of surgery.Results Three hundred and sixty-three neurons were obtained from 20 trajectories. Of 175 GPi neurons, there were 15.4% with tremor frequency, 69.2% with tonic firing, and 15.4% with irregular discharge. Of 188 thalamic neurons, there were 46.8% with tremor frequency, 22.9% with tonic firing, and 30.3% with irregular discharge. The numbers of three patterns of neuron in GPi and Vop/Vim were significantly different (P <0.001). ISI analysis revealed that mean firing rate of the three patterns of GPi neurons was (80.9±63.9) Hz (n=78), which was higher than similar neurons with 62.9 Hz in a normal primate. For the Vop/Vim group, ISI revealed that mean firing rate of the three patterns of neurons (n=95) was (23.2±17.1) Hz which was lower than similar neurons with 30 Hz in the motor thalamus of normal primates. UPDRS indicated that the clinical outcome of pallidotomy was (64.3±9.5)%, (83.4±19.1)% and (63.4±36.3)%, and clinical outcome of thalamotomy was (92.2±12.9)%, (68.0±25.2)% and (44.3±27.2)% for tremor, rigidity and bradykinesia, respectively. A significant difference of tremor and rigidity was found between GPi and VopNim (P <0.05). Conclusions Different changes in neuronal firing rate and the pattern in GPi and Vop/Vim are likely responsible for parkinsonian motor signs. The results support the view that abnormal neuronal activity in GPi and VopNim are involved in the pathophysiology of parkinsonism。

Abstract：Background There was a hospital outbreak of venous diethylene glycol poisoning in Guangzhou, China. It is the only massive episode of venous diethylene glycol poisoning in history. Here we report its clinical features, laboratory findings, and imaging appearances.Methods The clinical features of 15 venous diethylene glycol poisoning patients with liver disease were analyzed and summarized. Their laboratory findings and imaging appearances were comparatively analyzed before and after poisoning.Results All poisoned patients presented with oliguric acute renal failure with anuria after a mean of 6 days. Carbon dioxide combination power of 13 patients dropped after a mean of 9 days with valley value on the 10th day, when metabolic acidosis developed. Gastroenteric symptoms or aggravation of gastroenteric symptoms were displayed in 11 patients after a mean of 9 days. Neurological system impairment was observed in 10 patients after a mean of 14 days. Seven patients had low fever after a mean of 6 days. Causes of death of 14 patients included multiple organ dysfunction syndrome, severe lung infection and massive haemorrhage of digestive tract. Blood creatinine and urea nitrogen were abnormal after a mean of 5 days with peak value on the 11th and 14th days, respectively. Serum calcium had no obvious change, and phosphorus was distinctively increased. Liver functions did not change significantly. Poisoned patients had higher white blood cell counts, but lower red blood cell counts and hemoglobin value. Of the 7 patients who exhibited mild, moderate or severe patchy consolidation shadowing in the lung, 2 manifested mild or severe gaseous distention and dilation of gastroenteric tract.Conclusions Main features of venous diethylene glycol poisoning in patients with liver disease include oliguric acute renal failure, metabolic acidosis, gastroenteric symptoms or aggravation of gastroenteric symptoms, neurological system impairment and low fever, with a mortality rate of 93.33% in poisoned patients. There is also higher white blood cell counts and anemia, patchy consolidation shadowing in the lung, gaseous distention and dilation of gastroenteric tract, which occurs later than mild patchy consolidation shadowing and earlier than moderate patchy consolidation shadowing in the lung。

Abstract：Background Left atrial enlargement has been suggested as a more robust marker of diastolic dysfunction. We hypothesize that the ratio of left atrial volume to left ventricular volume (LAV/LVV) may be more reasonable to reflect left atrial enlargement in the patients with hypertension, because hypertensive patients have a characteristic of concentric remodeling of the left ventricle which is often accompanied with diastolic dysfunction. The aim of this study was to determine if the LAV/LVV can be used as a new parameter to assess left atrial size in hypertensive patients and the relationship between the LAV/LVV and diastolic dysfunction.Methods Ninety-one patients with hypertension and forty-three normal controls were studied. The hypertensive patients were assigned to the normal wall (NW) and hypertrophic wall (HW) groups. The left atrial diameter (LAD), LAV, left atrial volume index (LAVi), LVV and LAV/LVV were measured and calculated by 2-dimensional echocardiography and real time 3-dimensional echocardiography. All of the above parameters were used to evaluate the size of the left atrium. The ratio of peak E velocity of mitral valve inflow to peak E' velocity of lateral mitral annulus (E/E') was measured by pulse Doppler and tissue Doppler. This parameter was used to evaluate diastolic function. Results The LAD, LAV, LAVi, LAV/LVV and E/E' in hypertensive groups were significantly higher than those in the normal group (P <0.05 or 0.01), and those in the HW group were significantly higher than those in the NW group (P <0.05 or 0.01). The E/E' had a positive correlation with LAV, LAVi and LAV/LVV. The correlation coefficient between E/E' and LAV/LVV was relatively higher than that between E/E' and LAD or LAVi.Conclusion LAV/LVV may be used as a new index to evaluate left atrial size in hypertensive patients with diastolic dysfunction。

Abstract：Background Surgical resection remains the treatment of choice for pulmonary arteriovenous malformation but removes some normal lung parenchyma. This study aimed to evaluate the effect and safety of the lung-saving procedure of fistulectomy as an alternative to lung resection.Methods From July 2003 to July 2008, 6 selected patients with pulmonary arteriovenous malformations underwent fistulectomies. Among them, 1 patient underwent emergency operation and 2 underwent bilateral operations. One patient received postoperative embolotherapy.Results No hospital deaths or postoperative morbidity occurred. PaO2 increased significantly after operation. All patients were free of symptoms and hypoxia during a follow-up for 9 months to 5 years.Conclusions Fistulectomy is a safe and effective procedure for patients with pulmonary arteriovenous malformation and may be an alternative to lung resection。

Bioglass, with the code name 45S5, contains 45% silica, 24.5% CaO, 24.5% Na2O and 6% P2O5 in weight percent. All of these oxides are mixed together and melted at around 1350℃ to form a homogeneous silica network glass.1 Bioglass possesses fast biological response and fast bioactivity, when implanted in living tissue。

With the utilization of coronary-stents, coronary remodeling and restenosis were reduced compared with balloon angioplasty alone.1 However, the risk of restenosis is still in the range of 15% to 20%. Drug-eluting stents (DES), which could release antiproliferative pharmacological agents after deployment. were designed to inhibit the response to injury reaction after bare-metal stent (BMS) implantation。

Stent implantation has been a great advance in percutaneous coronary intervention (PCI), decreasing the frequency of acute closure and restenosis. But stent thrombosis is a severe complication of this therapy regardless of the stent type: bare-metal stent (BMS) and drug-eluting stent (DES)。

Castleman's disease (CD), also known as angiofollicular lymph node hyperplasia, giant lymph node hyperplasia, and angiomatous lymphoid hyperplasia, was first described by Castleman in 1954.1 It is an uncommon disorder characterized by benign proliferation of lymphoid tissue。

Recent analyses have suggested that implantation of drug-eluting stents (DES) is associated with a higher rate of very late stent thrombosis when compared with bare metal stents (BMS)。