2010年 · 第123卷第24期

Abstract：Background Numerous studies have developed a "severity score" or "risk index" for short-term mortality associated with coronary artery bypass grafting (CABG). Due to the different distribution of disease types, the number of valve surgeries in the US and Europe is relatively small. Thus, a risk-scoring system for valve surgeries was developed later and used less than that for the CABG surgery. We retrospectively reviewed 5128 cases of heart valve replacement, to quantitatively assess the risk factors for hospital mortality, and establish risk models for the hospital mortality of cardiac valve replacement patients.Methods A total of 1549 cases of aortic valve replacement, 2460 cases of mitral valve replacement, and 1119 cases of combined aortic valve and mitral valve replacement that were recorded from January 2005 to December 2009 in the cardiac surgery database at Beijing Anzhen Hospital were selected for this study. The cases were randomly assigned to a indicators were selected as possible influencing factors for hospital mortality. Single-factor analysis was performed to screen these factors, and then multi-factor analysis was used to determine the risk factors for hospital mortality in the three surgeries and to establish risk models.Results In the multi-factor analysis, age, body surface area, etiology, cardiopulmonary bypass time, preoperative cardiothoracic ratio, cardiac functional classification, and preoperative creatinine were risk factors for aortic valve replacement. Etiology, preoperative history of heart failure, cardiopulmonary bypass time, preoperative cardiothoracic ratio, and preoperative left ventricular end systolic diameter were risk factors for mitral valve replacement. Age, body mass index, cardiopulmonary bypass time, and cardiac function classification were risk factors for combined aortic valve and mitral valve replacement. The risk models showed good predictive ability (Hosmer-Lemeshow test: P=0.981 in the model for aortic valve replacement, P=0.503 in the model for mitral valve replacement, and P=0.154 in the model for combined aortic valve and mitral valve replacement). The area under the ROC curve of the validation group was 0.958 (95% CI: 0.936-0.975) for the aortic valve replacement model, 0.876 (95% CI: 0.805-0.948) for the mitral valve replacement model, and 0.845 (95% CI: 0.753-0.939) for the combined aortic valve and mitral valve replacement,indicating that the risk models were good in predicting hospital mortality for surgeries.Conclusion The three risk models can quantitatively assess the hospital mortality risk in the patients treated with cardiac valve replacement。

Abstract：Background Liver transplantation in Budd-Chiari syndrome remains controversial; however, some improved techniques lead to better results. We report medium-term follow-up results of liver transplantation with atrioatrial anastomosis for Budd-Chiari syndrome and explore the indications of liver transplantation with atrioatrial anastomosis for patients with end stage liver disease.Methods Nine patients (six Budd-Chiari syndromes, one end stage hepatolithiasis, one hepatocellular carcinoma and one incurable alveolar echinococcosis) underwent liver transplantation with atrioatrial anastomosis in West China Hospital of Sichuan University from 1999 to 2006. Eight liver transplants used cadaveric orthotopic livers and one a living donor liver. The operative technique was transdiaphragmatic exposure for direct atrioatrial anastomosis and replacement of inferior vena cava by cryopreserved vena cava graft with the help of venovenous bypass.Results All liver transplantations were successful. Two patients contracted pulmonary infection and acute rejection took place in another case. With proper treatment, all patients recovered well and had good quality of life. To date, they have been followed up for more than 24 months. The only death followed recurrence of hepatic carcinoma three years after liver transplantation.Conclusions Transdiaphragmatic exposure for direct atrioatrial anastomosis and the cryopreserved vena cava graftreplacement of inferior vena cava are possible for patients with end stage liver disease thus extending the indications of liver transplantation。

Abstract：Background Surgery of pituitary adenomas invading cavernous sinus has always been thought as a challenge due to the complex anatomical structures and high risk of complications. The purpose of this study was to evaluate endoscopic trarssphenoidal approach to pituitary adenomas invading cavernous sinus.Methods The clinical data of 22 patients who admitted to Xuanwu Hospital with pituitary adenomas invading cavernous sinus were analyzed retrospectively. All patients underwent endoscopic transsphenoidal surgery. To expose the surgical field sufficiently, the opening of sellar floor was exceeded the bone overlying the invaded cavernous sinus, and synthetic dura was used to repair and strengthen the sella floor for preventing the leak of cerebrospinal fluid.Results Among 22 patients, total resection was achieved in 14, subtotal resection in 5, and partial resection in 3; no patient underwent insufficient resection. Visual symptoms improved in 7 of 9 patients. In one patient diplopia disappeared.Headache was relieved to various extents in all patients. No serious complications were found. Patient's hospital stay ranged from 7 to 20 days.Conclusion These data suggest that the endoscopic transsphenoid approach is a safe, minimally invasive, and efficient surgical technique, which might be an important therapeutic strategy for the pituitary adenoms invading cavernous sinus。

Abstract：Background Diagnostic hysteroscopy and directed biopsy has been widely used to evaluate abnormal uterine bleeding. We aimed to explore the value of hysteroscopy and directed biopsy in the diagnosis of endometrial carcinoma.Methods Two hundred and eighty-seven patients with endometrial carcinoma who were treated in Beijing University People's Hospital, Beijing, China were distributed into 2 groups: Group A (90 patients) was examined using hysteroscopy and directed biopsy, and Group B (197 patients) was examined using fractional dilatation and curettage (D&C). The diagnostic veracity of the two methods, the rate of positive peritoneal cytology and the prognosis of the 2 groups were compared.Results In Group A, 97.8% (88/90) of patients were diagnosed pathologically before surgery; the rate was 88.8% (175/197) for Group B. The difference between the 2 groups was statistically significant (P ＜0.05). The sensitivity,specificity, positive predictive value and negative predictive value for the two methods for detecting cervical involvement were 77.8%, 100%, 100% and 97.6% for Group Aand 65.3%, 92.6%, 74.4% and 90.0% for Group B, respectively. The positive peritoneal cytology rate was 5.6% (5/90) in Group A and 6.09% (12/197) in Group B. The difference was not statistically significant (P ＞0.05). The 3-year and 5-year overall survival rates were 91.4% (33/36) and 82.4% (14/17) for Group A and 95.6% (87/91) and 86.7% (39/45) for Group B. There were no statistically significant differences between the two groups' survival rates (P ＞0.05).Conclusion Compared with fractional D&C, hysteroscopy and directed biopsy offered improved pathological diagnostic accuracy before surgery and discovered cervical involvement more precisely in endometrial carcinoma patients, but it did not increase the positive peritoneal cytology rate or affect the prognosis of these patients。

Abstract：Background Accurate identification of bacterial isolates is an essential task in clinical microbiology. This study compared culturing to analyzing 16S rRNA gene sequences as methods to identify bacteria in clinical samples. We developed a key technique to directly identify bacteria in clinical samples via nucleic acid sequences, thus improving the ability to confirm pathogens.Methods We obtained 225 samples from Beijing Tongran Hospital and examined them by conventional culture and 16S rDNA sequencing to identify pathogens. This study made use of a modified sample pre-treatment technique which came from our laboratory to extract DNA. 16S rDNA was amplified by PCR. The amplified product was sequenced on a CEQ8000 capillary sequencer. Sequences were uploaded to the GenBank BLAST database for comparison.Results Among the positively cultivated bacterial strains, seven strains were identified differently by Vitek32 and by 16S rDNA sequencing. Twelve samples that were negative by standard culturing were determined to have pathogens by sequence analysis.Conclusion The use of 16S rRNA gene sequencing can improve clinical microbiology by providing better identification of unidentified bacteria or providing reference identification of unusual strains。

Abstract：Background Cockroaches are an important indoor allergen source causing allergic rhinitis and asthma. The aim of this study was to investigate the cockroach prevalence in mainland of China and the cross-reactivity of IgE between cockroach and house dust mite allergen in Chinese patients.Methods The cockroach sensitization pattern was based on a skin prick test (SPT) obtained from a national multicenter prevalence study, in which 6304 patients from 25 allergy centers across China participated. Factors, including different regions of China, age, gender and the correlations between the American and German cockroaches and house dust mite Der p were investigated. Eighteen out of 1236 clinical sera from south China were selected to perform the cross-inhibition assay between house dust mites and cockroaches.Results Totally 25.7% of patients were SPT positive to the American cockroach (Periplaneta Americana, Per a) and 18.7% SPT positive to the German cockroach (Blattella germanica, Bla g). The prevalence of positive cockroach SPT was higher in southern than in northern China, higher in adults than in children, and higher in males than in females.Patients had relatively low levels of cockroach SPT reactions, mainly class 1 or 2. Of the SPT positive cockroach patients,88% were also SPT positive to house dust mite (Dermatophagoides pteronyssinus, Der p). An IgE cross-inhibition study confirmed that Der P sensitization could cause false positive SPT reactions against cockroach.Conclusions A relatively high prevalence of cockroach sensitivity was found in mainland of China. However, a cross-inhibition study showed that only a small number of patients appear to have Bla g and/or Per a as primary sensitizing source. The importance of cockroaches as a risk factor for sensitization and triggers of allergic symptoms in mainland of China needs to be further investigated。

Abstract：Background FOXP3 was thought to express in the T-cell lineage exclusively until recently when FOXP3 was shown to be expressed by cancer cells. It was indicated that FOXP3 may play a wider role in biology by endowing tumor cells with immune suppressive activity. However, researches between FOXP3 and lymph node metastasis of gastric cancer were relatively infrequent, so the present work was aimed to investigate the relationship between FOXP3 expression and lymph node metastasis in human gastric cancer.Methods A total of 122 gastric cancer patients were enrolled in this study, and gastric tumor specimens and lymph nodes were acquired. Thirty patients who had chronic superficial gastritis diagnosed by gastroscopy contemporaneously in the Peking University People's Hospital were chosen randomly as the control group. Immunohistochemistry was performed to evaluate FOXP3 expression. A survival analysis on the 122 patients was then performed. Then, NCI-N87cell lines were used to confirm FOXP3 expression in gastric carcinoma cells. Finally, evaluation of FOXP3 expression in gastric tumor and peritumor tissues in 12 patients were conducted using immunohistochemistry and Western blotting. A X2 test or Fisher's exact test (bilateral) was conducted to compare the percentage of positive percentage staining between groups. Kaplan-Meier analysis was performed for survival analysis.Results FOXP3 was expressed by gastric cancer cells and peritumor epithelial cells. FOXP3 expression was increased in primary tumors (58.2%) than that in control group (26.7%). In the lymph-node metastasis group, the incidence of lymph node metastasis which was less than 60% had a significant upregulation of FOXP3 in primary tumors and lymph nodes.However, the frequency of FOXP3 expression had no relationship with survival.Conclusion FOXP3 probably has a relationship with lymph node metastasis of gastric cancer。

Abstract：Background Blood coagulation factor Ⅶ (FⅦ) is physiologically synthesized in the liver and released into the blood. Binding of FⅦ to tissue factor (TF) is related to the metastatic potential of tumor cells, also a significant risk factor in the development of hepatic metastasis in patients with colorectal cancer (CRC). It has been found that some cancer cells can produce FⅦ extrahepatically. However, litte is known about FⅦ and CRC. We therefore hypothesized that CRC cells may synthese FⅦ, leading to tumor invasion and metastasis.Methods We detected the expression of FⅦ protein in 55 CRC specimens by immunohistochemical staining. The FⅦ mRNA in 45 of 55 CRC cases, 6 colon cancer cell lines and one hepatoma cell line was measured by real-time reverse transcription-PCR (RT-PCR). Transwell invasion assays were performed to evaluate the changes of cell migration and invasion of LoVo cancer cells in vitro. We further observed the likely effectors regulated by the TF/FⅦa complex Western blotting assay.Results Extrahepatic synthesis of FⅦ was detected in the cytoplasm of 32 (58.2%) CRC specimens byimmunohistochemistry, but not in normal mucosa. Liver metastasis (P=0.003) and TNM staging (P=0.005) were significantly correlated with FⅦ antigen expression. The positive ratios in stages Ⅰ, Ⅱ, Ⅲ and Ⅳ were 33.3%, 40.0%,52.4% and 87.5%, respectively. The expression of FⅦ mRNA in CRC with hepatic metastasis was significantly higher than CRC without hepatic metastasis (5.33±2.88 vs. 1.47±0.51, P=0.03). Ectopic FⅦa induced a slight increase (1.34-fold) in the number of migrating cells, which was inhibited by the specific TF antibody. The formation of TF/FⅦacomplex resulted in a marked increase in the expression of matrix metalloproteinases (MMP)-2 (3.5-fold) and MMP-9(4.7-fold) in a time-dependent and dose-dependent manner.Conclusions Extrahepatic synthesis of FⅦ by CRC cells may promote tumor invasion and metastasis. MMPs, as downstream effectors of TF/FⅦa signaling, facilitate the development of metastasis in colon cancer。

Abstract：Background Our previous study confirmed that oligodendrogliomas had higher frequency of chromosome 1p/19q deletion. In order to improve the diagnostic criteria and to predict the prognosis of oligodendroglioma patients, the status of chromosome 1 p/19q deletion, the methylation of O6-methylguanine-DNA methyltransferase (MGMT), and the expression of p53 protein were evaluated and investigated in relation to patients' outcomes.Methods Methylation of MGMT in 73 cases was analyzed by nested methylation-specific PCR (MSP). The levels of MGMT and p53 protein were tested with immunohistochemistry. Pearson's chi-square test and Fisher's exact test were used. Multivariate and Kaplan-Meier analysis were performed to determine patients' outcomes.Results Both oligodendrogliomas and astrocytic gliomas exhibited frequent methylation of MGMT. However, the results of MSP did not completely correspond to that of the immunohistochemical staining for MGMT. The expression of p53 protein was more frequently observed in patients without a 1 p or 19q deletion in anaplastic oligodendrogliomas (=0.032,0.025). In low-grade oligodendrogliomas, methylation of MGMT was more frequent in patients with 1 p/19q deletion than in patients with 1p/19q intact (P=0.038). Patients with oligodendrogliomas with 1p/19q loss of heterozygosity and p53-negative showed a longer progression-free survival.Conclusion Detection of chromosome 1p/19q status combined with p53 protein immunohistochemistry might be beneficial to improve the pathological diagnosis and to determine the prognosis of patients with oligodendrogliomas。

Abstract：Background The prevalence of hepatitis C virus (HCV) infection among maintenance hemodialysis (MHD) patients varies among countries and among dialysis units within a single country. The present study aimed to investigate the prevalence and characteristics of HCV infection in MHD patients in a Chinese hemodialysis unit.Methods One hundred and ninety-two patients on MHD for an average of (86.1±30.0) months (range 6-181 months) were enrolled in this cross-sectional study. HCV antibody and HCV-RNA were measured in these MHD patients before hemodialysis by enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) methods.According to the result, all the patients were then divided into two groups: GroupⅠwas positive for HCV antibody and/or HCV-RNA (n=32), and Group Ⅱ was negative for HCV antibody and HCV-RNA (n=160). The following information was obtained for all the patients: socio-demographic data, history of blood transfusions and kidney transplantation, and some laboratory values. The MHD patients who were positive for HCV antibody and/or HCV-RNA were followed for more than three years. The disease activities were graded into "asymptomatic" if alanine aminotransferase (ALT) was less than 40 U/L,"low activities" if ALT was 40-79 U/L, and "high activities" if ALT was equal to or above 80 U/L.Results The prevalence of HCV infection in MHD patients in our dialysis unit in May 2009 was 16.7, which was significantly higher than in general population (3.2%). Among the 32 MHD patients with HCV positive, 20 patients were positive for HCV antibody but negative for HCV-RNA, eight patients were positive both for HCV antibody and HCV-RNA,four patients were negative for HCV antibody but positive for HCV-RNA. Eleven patients had a history of kidney transplantation and 12 had a history of blood transfusion, which were significantly more than among the MHD patients without HCV. Thirty of the 32 MHD patients were asymptomatic. There were no significant differences in age, aspartate aminotransferase (AST), ALT, or between HCV-RNA positive group and HCV-RNA negative group. But the dialysis duration in the HCV-RNA positive group was significantly longer than that in the HCV-RNA negative group. All the 20HCV-RNA negative patients were asymptomatic. Two of the 12 HCV-RNA positive patients had low activity. None of the 32 cases with HCV positive markers had cirrhosis.Conclusions A high prevalence of HCV infection in MHD patients is related to blood transfusion and kidney transplantation. Occult HCV infection is present in MHD patients. Chronic hepatitis C among MHD patients is mild in disease activity, and is not progressive, perhaps due to immunological abnormalities in these patients。

Abstract：Background Coronary slow flow phenomenon (CSFP) is an important, angiographic clinical entity but is lacking non-invasive detecting techniques. This study aimed to elucidate the value of transthoracic Doppler echocardiography (TTDE) in the diagnosis and monitoring of coronary slow flow in left anterior descending (LAD) coronary artery.Methods We consecutively enrolled 27 patients with CSFP in LAD detected by coronary arteriography from August 2009 to April 2010. Thirty-eight patients with angiographically normal coronary flow served as control. Corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) was used to document coronary flow velocities. All subjects underwent TTDE within 24 hours after coronary angiography. LAD flow was detected and the coronary diastolic peak velocities (DPV) and diastolic mean velocities (DMV) were calculated.Results Sixty of 65 (92.3%) subjects successfully underwent TTDE. Baseline clinical characteristics were similar between the two groups. Coronary DPV and DMV of LAD were significantly lower in the CSFP group than in the control group ((0.228±0.029) m/s vs. (0.302±0.065) m/s, P=0.000; (0.176±0.028) m/s vs. (0.226±0.052) m/s, P=0.000,respectively). There was a high inverse correlation between CTFC and coronary DPV and DMV (r=-0.727, P=0.000;r=-0.671, P=0.000, respectively). Receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) was less than one half for coronary DPV (AUC=0.104) and DMV (AUC=0.204), respectively.Conclusions In patients with CSFP, there is a high inverse correlation between CTFC and coronary diastolic flow velocities in the LAD coronary artery, as measured by TTDE. The value of TTDE in the monitoring and evaluation of coronary flow in patients with CSFP deserves further investigation。

Abstract：Background Patients with septic shock have a high mortality. This study used the Surviving Sepsis Campaign (SSC)database to compare characteristics, treatments and outcomes of septic shock patients diagnosed in the emergency department (ED) to patients developing septic shock on hospital floors (HF).Methods The studied population included patients admitted to the intensive care unit (ICU) of an urban tertiary care medical center over an 18-month period. Acute physiology and chronic health evaluation (APACHE Ⅱ) scores, need for mechanical ventilation (MV), performance on four of the SSC resuscitation bundle indicators, ICU length of stay (LOS),hospital LOS and in-hospital mortality were ascertained.Results Sixty-six ED and 27 HF septic shock patients were included in this study. Urinary tract infections (UTI) and pneumonia were the two most common sites of infection in the ED patients. The sources of infection for HF septic shock patients were fairly well distributed across etiologies. The time to achieve superior vena cava oxygen saturation (ScvO2)＞ 70% in HF patients ((10.8±9.1) hours) was longer when compared to the ED patients ((6.6±-6.1) hours) (P ＜0.05).Hospital mortality for the ED and HF patients were 25.8% and 59.3%, respectively (P ＜0.05). Use of MV during the first 24 hours of shock was 44% in the ED patients and 70% in the HF patients (P ＜0.05) and was linked to mortality.Conclusions When compared to HF patients, ED septic shock patients have lower in-hospital mortality, there was less use of MV during the first 24 hours following onset of septic shock and the HF patients required a longer time to achieve target ScvO2. The need for mechanical ventilation is independently associated with increased mortality。

Abstract：Background Insulin-like growth factor-Ⅱ mRNA-binding protein 3 (IMP3) is a newly identified mRNA-binding protein that is involved in embryogenesis and carcinogenesis of some malignant tumors. The aim of this study was to detect the expression of IMP3 protein in gastric adenocarcinoma (GAC) and the correlation with clinicopathological features.Methods IMP3 protein in 92 samples of GAC was evaluated by immunohistochemical method. The Mann-Whitney U test and Kruskal-Wallis H test were used to compare IMP3 expression and clinicopathological parameters. Kaplan-Meier survival curve, log-rank test and Cox-regression model were used to evaluate the correlation of IMP3 protein expression to the prognosis of patients.Results Out of 92 cases of adjacent normal mucosa (ANM), 10 with dysplasia demonstrated weak expression of IMP3 and 82 without dysplasia showed negative expression. Out of 92 cases of GAC, positive immunohistochemical stain for IMP3 was identified in 75 (82%) cases. A comparison of IMP3 expression in GAC and ANM showed stronger immunohistochemical reactivity in GAC (P ＜0.05). High expression of IMP3 was found to be associated with lymphoid metastasis, high Ki-67 labelling index, and patient poor outcome (P ＜0.05). There was a significant TNM stage difference between GAC with and without IMP3 expression (P＜0.05). Tumors with higher stage showed higher level of IMP3 expression, In multivariate analysis, IMP3 emerged as an independent predictor of survival.Conclusions Increase of IMP3 expression suggests that IMP3 may play an importent role in the carcinogenesis and tumor metastasis in GAC. It could be regarded as a novel proliferation and prognostic indicator for patients with GAC。

Abstract：Background Drug-eluting stents (DES) are the most common device used in percutaneous treatment of coronary artery disease. Recently, there has been an increased concern regarding their safety profile, in particular the late and very late stent thrombosis rate compared to bare metal stents (BMS). The aim of the study was to compare the reported incidence of late and very late stent thrombosis of DES and BMS in patients from published clinical studies with an extended follow-up period to four years.Methods A search strategy was developed to identify publications reporting on late or very late thrombosis of BMS and DES available through MEDLINE and Cochrane Library databases. Two independent reviewers appraised eligible studies and extracted data. Odds ratios (OR) were calculated for each outcome and presented with 95% confidence intervals (CI).Results Fourteen randomized controlled trials, which were at least single blinded, were identified. There was no difference in the incidence of late and very late stent thrombosis in patients treated with DES compared with patients treated with BMS (late OR 0.55, 95%Cl 0.23-1.31 and late/very late OR=1.08, 95%CI 0.61-1.91).Conclusions The safety profile of DES was similar to BMS in terms of stent thrombosis. We found no evidence of increased risk of late and very late thrombosis for DES。