2012年 · 第125卷第07期

To say that medicine is not knowledge or skill is apparently a contradiction.But to say that medicine is merely knowledge and skill is also off the mark.The famous remark by the American physician Edward Trudeau,“to cure sometimes,to relieve often,to comfort always,” is the essence of medicine and the embodiment of medical humanities。

One of the most frequent medical complications of pregnancy is diabetes,and its incidence is increasing every year.A portion of pregnant women with diabetes have overt diabetes whereas the major portion have gestational diabetes mellitus (GDM),which accounts for approximately 80％-90％ of diabetes in pregnancy。

Abstract：Pelvic organ prolapse (POP) is non-fatal conditions which can markedly affect a patient's quality of life.Multiple recently developed pelvic reconstructive surgeries have led to a recent expansion in China.In this study,we would like to discuss various aspects of the evaluation and management of POP and raise the question of what is sufficient evidence for the adoption of innovative treatments for POP。

Abstract：Background Vaginal intraepithelial neoplasia (VAIN),as aprecursor of vaginal cancer,is a rare disease.Its prevalence has not been well analyzed.This research is to ascertain the risk factors for VAIN in a Chinese population.@@Methods A case-control study was conducted,including 63 VAIN cases and 64healthy controls.In all subjects Pap smear and HPV tests were performed.A questionnaire survey was distributed,covering information on socio-demographic characteristics,smoking,past history,reproductive and sexual histories.The clinical pathological data were collected from medical records including symptoms,Pap smear results,grade of lesions,and human papillomavirus (HPV) status.@@Results Postmenopausal women had a 2.09 times higher risk for VAIN than pre-menopausal women (95％ C/:1.10-3.85; P=0.024).The patients with previous hysterectomy had an increased risk of VAIN (OR＝4.69; P=0.003).Patients with a history of cervical cancer or CIN were predisposed to VAIN (OR=78.75; P <0.0001).The rate of HPV infection in VAIN was significantly higher than in controls,and an increased risk of VAIN was observed in patients with higher viral load (OR=126.00; P=0.000).Multivariate analysis showed that HPV infection and a history of CIN or cervical cancer were still found to be significant in patients.@@Conclusion HPV infection and a history of CIN or cervical cancer are the main risk factors for the development of VAIN。

Abstract：Background Dehydroepiandrosterone (DHEA) is widely known for its beneficial effect on postmenopausal osteoporosis,although the underlying mechanisms remain mainly unclear.In this study,we tried to determine the activation of mitogen-activated protein kinase signal pathways during DHEA treatment and the indirect role of osteoblasts (OBs) on osteoclasts under the DHEA treatment of postmenopausal osteoporosis.@@Methods Primary human OBs and osteoclast-like cells were cultured and,we pretreated OBs with or without U0126 (a highly selective inhibitor of both MEK1 and MEK2).The OBs were treated with DHEA.We then tested the effects of DHEA on human osteoblastic viability,osteoprotegerin production and the expression of phosphor-ERK1/2 (extracellular signal-regulated kinase).In the presence or absence of OBs,the function of osteoclastic resorption upon DHEA treatment was calculated.@@Results DHEA promoted the human osteoblastic proliferation and inhibited the osteoblastic apoptosis within the concentration range of 108-10-6 mol/L (P <0.05,P <0.01,respectively).Within the effective concentration range,the expression of phosphor-ERK1/2 and osteoprotegerin was increased by DHEA and blocked by U0126.In the presence of OBs,DHEA could significantly decrease the number and the area of bone resorption lacuna (P <0.05 and P <0.01,respectively).Without OBs,however,the effects of DHEA on the bone resorption lacuna were almost completely abolished.@@Conclusions DHEA could indirectly inhibit the human osteoclastic resorption through promoting the osteoblastic viability and osteoprotegerin production,which is mediated by mitogen-activated protein kinases signal pathway involving the phosphor-ERK1/2。

Abstract：Background Left ventricular (LV) dyssynchrony has been described to occur in patients with myocardial infarction.Dyssynchrony of left ventricular mechanical contraction produces adverse hemodynamic consequences.This study aimed to test the capacity of geometric rebuilding by aneurysm plication to restore a more synchronous contractile pattern after a mechanical,rather than electrical,intervention.@@Methods A total of sixty patients with anterior myocardial infarction,QRS duration <120 ms,electively undergoing operation between January 2008 and January 2010 were included for analysis.Real-time 3-dimensional echocardiography was performed to assess LV function,LV systolic and diastolic dyssynchrony by measuring ejection fraction (EF),peak ejection rate (PER),peak filling rate (PFR) and LV dyssynchrony.LV dyssynchrony was defined as the systolic dyssynchrony of the time to reach the minimum systolic volume for 16 LV segments,expressed in percent cardiac cycle,systolic dyssynchrony index (SDI).We compared changes of LV dyssynchrony at different interval times.@@Results LV contraction was significantly asynchronous because preoperative SDI was higher,EF,PER and PFR were lowered.Compared with function after operation,LV mechanical intraventricular resynchronization was improved with decreased SDI ((8.7±0.5) ％ vs.(14.3±1.6) ％,P=0.01); LV function was improved with EF increasing ((43±9)％ vs.(37±7)％,P=0.001),and LV systolic and diastolic dyssynchreny was improved with more rapid PFR (199.4±15.6 vs.148.4±21.2,P=0.002) and PER (212.4±14.5 vs.156.3±26.2,P=0.001).@@Conclusions Systolic and diastolic dyssynchrony was highly prevalent in patients with aneurysm,irrespective of QRS duration.Aneurysm plication produces a mechanical intraventricular resynchronization。

Abstract：Background Hypertension (HTN) is a major determinant of various cardiovascular events.Plasma levels of plasminogen activator inhibitor 1 (PAl-1) modulate this risk.A deletion/insertion polymorphism within the PAl-1 loci (4G/4G,4G/5G,5G/5G) affects the expression of this gene.The present study investigated the association between PAl-1 loci polymorphisms and HTN in Korean women.@@Methods Korean women (n=1312) were enrolled in this study to evaluate the association between PAl-1 4G/5G gene polymorphisms and HTN as well as other metabolic risk factors.PAl-1 loci polymorphisms were investigated using polymerase chain reaction amplification and single-strand conformation polymorphism analysis.@@Results The three genotype groups differed with respect to systolic blood pressure (P=0.043),and diastolic blood pressure (P=0.009) but not with respect to age,body mass index,total cholesterol,low or high density lipoprotein cholesterol,triglycerides,or fasting blood glucose.Carriers of the PAl-1 4G allele had more hypertension significantly (PAl-1 4G/5G vs.PAl-1 5G/5G,P=0.032; PAl-1 4G/4G vs.PAl-1 5G/5G,P=0.034).When stratified according to PAl-1 4G/5G polymorphism,there was no significant difference in all metabolic parameters among PAl-1 genotype groups in patients with HTN as well as subjects with normal blood pressure.The estimated odds ratio of the 4G/4G genotype and 4G/5G for HTN was 1.7 (P=0.005),and 1.6 (P=0.015),respectively.@@Conclusion These findings might indicate that PAl-1 loci polymorphisms independently contribute to HTN and that gene-environmental interaction may be not associated in Korean women。

Abstract：Background Superficial urothelial carcinoma (SUC) of the bladder is a common urinary tract tumor in China.There is a high recurrence rate of this tumor even after surgery and intravesical instillation.Previous reports have described a suppression of the immune system in cancer patients.Dendritic cells (DCs) play a pivotal role in the induction of an effective antitumor immune response.The aim of this study was to investigate the effects of surgery and epirubicin intravesical chemotherapy (IC) on peripheral blood DCs in subsets of patients with bladder SUC.@@Methods A total of 66 SUC patients and 38 healthy controls were enrolled in this study.All the patients had undergone transurethral resection (TUR) of their cancer and adjunctive IC after tumor removal.The patients were divided into a non-recurrence group (n=40) and a recurrence group (n=26) based on the presence or absence of tumor recurrence.Blood samples were taken preoperatively (PreOP),on postoperative days (POD) 1 and 7,and at postoperative month (POM) 3.Flow cytometric analysis was used for the determination and quantitation of the surface markers CD80 and CD86 in circulating DC subsets.@@Results The preoperative percentages of myeloid dendritic cells (mDCs) and expression of CD80 and CD86 were impaired in SUC patients compared to healthy controls (P <0.05).The percentages of mDCs and these surface markers decreased significantly on POD 1 and increased on POD 7,remaining higher than the preoperative values in POM 3 (P <0.05).The percentages of mDCs,and CD80 and CD86 in the non-recurrence group on PreOP,POD 7,and POM 3 were higher than those in recurrence group.@@Conclusions Surgical removal of SUC and adjunctive IC were associated with improved circulating mDC counts and function.Persistent depression of mDC counts and function after treatment in recurrence patients indicated lower antitumor immunity that may lead to tumor recurrence。

Abstract：Background Hand,foot and mouth disease (HFMD) is an emerging public health problem in China,not only threatening the health of children,but also causing tremendous loss and burden to both families and society.The aim of this study was to characterize the epidemiology and clinical features of HFMD,and to understand the key factors affecting HFMD in the Harbin region to provide scientific evidence for effective prevention and control strategies.@@Methods Epidemiological and clinical information from 2379 randomly chosen cases of HFMD treated at the Harbin Center for Disease Control and Prevention from May 2008 to November 2011 were analyzed.All cases were separated into common and severe HFMD,with key factors for severe HFMD analyzed using multivariable Logistic regression.@@Results Among the 2379 patients,1798 were common cases and 581 severe cases,14 of which resulted in death.Most cases were in children younger than 5 years.Morbidity peaked in July and was higher in the surrounding country and cities than in Harbin proper.Medical expenses were significantly higher for severe than for common cases (P <0.001).The primary clinical symptoms were fever and erythema; laboratory examination showed leucocytosis together with pneumonia,carditis,and abnormal electrocardiogram and electroencephalogram in severe cases.Multivariable Logistic regression analysis showed that the key factors for severe HFMD were age,morbidity location,morbidity area,fever duration,mouth mucosal symptoms,and abnormal serum levels of neutrophils (NEUT),hemoglobin and glucose (P <0.05).@@Conclusions To improve prognosis,reduce medical expense and prevent the development of severe cases,we should improve the epidemiological detection of HFMD to treat patients quickly.We should also closely monitor children with the EV71 virus,who present with continuous fever as well as abnormal laboratory results,from areas highly susceptible to HFMD attacks。

Abstract：Background Previous studies indicate that CD43 plays a role in regulating the adhesion of lymphocytes,cell mutation and activation,however,little is known about its effect on systemic lupus erythematousus (SLE).This study was designed to explore the clinical significance of CD43 in SLE patients.@@Methods We used microarray and real-time PCR to detect the mRNA and protein expression of magnetic bead sorted T cells and B cells from peripheral blood mononuclear cells (PBMCs) of SLE patients,and analyzed the relationship between CD43 and the clinical indexes.@@Results Both microarray and real-time PCR results showed that CD43 mRNA was significantly decreased in PBMCs of SLE patients compared with healthy controls (P <0.001).There were no significant differences between lupus nephritis and non-lupus nephritis patients,and neuropsychiatric and non-neuropsychiatric patients.CD43 mRNA expression was significantly reduced in T cells but not in B-cells in SLE patients compared to healthy controls (P <0.01).Compared with healthy controls,the percentage of CD43+ cells in the PBMCs of SLE was significantly decreased (P=0.004),and the CD43 fluorescence intensity in CD3+/CD43+ cells and CD19+/CD43+ cells was also significantly weaker than in healthy controls (P=0.039 and 0.003).There was no significant difference in the percentage of CD3+/CD43+ cells,CD19+/CD43+ cells between the two groups.The CD43 fluorescence intensity in CD3+/CD43+ cells was inversely correlated with the levels of IgG and IgM (r=-0.8 and -0.6).@@Conclusions Compared to healthy controls,both CD43 mRNA and protein expressions were reduced in T cells from patients with SLE,and were inversely correlated with IgG。

The criteria provide the screening and diagnosis for gestational diabetes mellitus and it should be applied to all medical institutions and health care practitioners for gestational diabetes mellitus (DM) diagnosis in China。

Abstract：Background Respiratory failure caused by metastatic pulmonary chodocarcinoma usually develops rapidly and is associated with a high mortality.The clinical management strategy is important in choriocarcinoma patients with acute respiratory failure.The objective of this study was to evaluate the clinical characteristics,treatment outcome and potential risk factors in patients with acute respiratory failure from metastatic pulmonary choriocarcinoma.@@Methods Sixteen patients with acute respiratory failure from pulmonary metastases choriocarcinoma were enrolled and treated at Peking Union Medical College Hospital from 1995 to 2010.Clinical characteristics,causes of pulmonary failure,treatment profiles and outcomes were analyzed retrospectively.@@Results The presence of respiratory infection or hemorrhage was associated with acute respiratory failure in patients with metastatic choriocarcinoma.Fifteen (93.8％) patients presented with pulmonary infection,8 (50.0％) patients with pulmonary hemorrhage.All patients were treated with face mask or mechanical ventilation.Fourteen (87.5％) patients received initial chemotherapy at a low dosage or with modified regimens,with a median of 2 cycles (range 1 to 4).Seven patients achieved a complete remission (CR),two had a partial remission.Six CR patients remained alive with a median follow-up of 59 months (range 16 to 120).Seven patients developed progressive diseases and subsequently died.@@Conclusions Respiratory infection and hemorrhage were associated with acute respiratory failure in metastatic pulmonary choriocarcinoma.The initial administration of gentle chemotherapy regimens,accompanied with mechanical ventilation,is feasible andeffective in attenuating respiratory failure in patients with metastatic pulmonary chodocarcinoma。

Abstract：Background Prenatal hyperglycaemia may increase metabolic syndrome susceptibility of the offspring.An underlying component of the development of these morbidities is hepatic gluconeogenic molecular dysfunction.We hypothesized that maternal hyperglycaemia will influence her offsprings hepatic peroxisome proliferator-activated receptor coactivator-1α (PGC-1α) expression,a key regulator of glucose production in hepatocytes.@@Method We established maternal hyperglycaemia by streptozotocin injection to induce the maternal hyperglycaemic Wistar rat model.Offspring from the severe hyperglycemia group (SDO) and control group (CO) were monitored until 180 days after birth.Blood pressure,lipid metabolism indicators and insulin resistance (IR) were measured.Hepatic PGC-1α expression was analyzed by reverse transcription polymerase chain reaction and Western blotting.mRNA expression of two key enzymes in gluconeogenesis,glucose-6-phospha-tase (G-6-Pase) and phosphoenolpyruvate carboxykinase (PEPCK),were analyzed and compared.@@Results In the SDO group,PGC-1α expression at protein and mRNA levels were increased,so were expression of G-6-Pase and PEPCK (P<0.05).The above effects were seen prior to the onset of IR.@@Conclusion The hepatic gluconeogenic molecular dysfunction may contribute to the metabolic morbidities experienced by this population。

Abstract：Background In our clinical practice we have been attracted by a group of patients with airway aspergillosis who have airway obstruction; we termed the condition as pseudomembranous necrotizing tracheobronchial aspergillosis (PNTA).In this study we analyzed the clinical data from patients with PNTA,so as to guide the diagnosis and treatment of the disease.@@Methods A total of 16 PNTA patients were treated in Changhai Hospital from January 2000 to January 2009.Their clinical data,including the demographic information,clinical symptoms,imaging findings,bronchoscopy findings,treatment strategies and efficacy,and prognosis,were retrospectively analyzed.@@Results All 16 patients were found to have primary systemic immunodeficiency diseases and/or damage of the focal airways.Nine patients (9/16,56.3％) had pulmonary and tracheobronchial tumors,5/16 (31.3％) had tracheobronchial involvement secondary to non-pulmonary tumors,and 2/16 (12.5％) had lung transplantation.The most common causes of PNTA included local radiotherapy (10/16,62.5％),repeated chemotherapy (7/16,43.8％) and recurrent intervention therapy by bronchoscope (4/16,25.0％).Aspergillus fumigatus was the most frequent pathogen (62.5％,10/16).The main clinical manifestations included progressive dyspnea (14/16,87.5％) and irritable cough (12/16,75.0％).The trachea was involved in 9/16 patients (56.3％),right main bronchus in 10/16 (62.5％).All 16 patients were treated with systemic anti-aspergillosis agents,local anti-aspergillosis agents with amphotedcin B inhalation and direct perfusion of amphotericin B by bronchoscope,and interventional treatment by bronchoscope to ensure an unobstructed airway.The total efficiency was 31.3％.@@Conclusions PNTA is an infectious disease caused by aspergillus and it mainly involves the trachea,primary bronchus and segmental bronchus.A.fumigatus is the most common pathogen.PNTA can pose a severe clinical threat and often occurs after systemic immunodeficiency and/or local airway damage,with the main symptoms including dyspnea and irritable cough.Bronchoscopic findings supply the main evidence for diagnosis of PNTA.Treatment of PNTA is difficult and requires a long course.Systemic and local anti-aspergillosis agents plus bronchoscopy debridement can improve the prognosis of the disease。

Abstract：Background As intraocular pressure (lOP) and lOP fluctuation are known risk factors for glaucoma,it is important to understand the effects of high myopia on these ocular parameters.The aim of this study was to investigate if primary open-angle glaucoma (POAG) patients with high myopia exhibit higher lOP and greater lOP fluctuations at resting conditions over 24 hours.@@Methods We designed a prospective control clinical study.Eighty-two eyes of 82 high-tension Chinese POAG patients only on prostaglandin analogue locally were divided into 3 groups according to various myopic grades (<-6.0 D,n=27 and between -0.76 and -5.99 D,n=33) or without myopia (-0.75 to 0.75 D,n=22).Single time lOP at 10 am,mean corrected 24-hour lOP,mean corrected night lOP,24-hour lOP fluctuation and lOPs of 10 am,2 pm,6 pm,10 pm,2 am,6 am and 8 am were measured.@@Results The lOP was higher in POAG patients with high myopia over those POAG alone in three ways:the elevated lOP value was 0.65 mmHg measured in single time lOP at 10 am,0.84 mmHg in mean corrected 24-hour lOP,0.97 mmHg in mean corrected night lOP.The 24-hour lOP fluctuation was lower in the two myopia groups than in non-myopia group.Further,using repeated measurement analysis of variance,there was no statistical significance among groups regarding the lOPs at the seven time points (P=0.77) and there was no interaction between groups and time points (P=0.71),but the difference of lOPs at the seven time points in same group was statistically significant (P=0.01).@@Conclusion High-tension POAG patients with high myopia,even on pharmacological glaucoma therapy,still have higher lOp,but 24-hour lOP fluctuation at resting conditions was lower in these patients。

Abstract：Background Intravenous urography (IVU) combined with add-on CT (IVU-CT) can help to provide more diagnostic information for determining the localization and nature of ureteral abnormalities with less irradiation dose.This study aimed to determine the value of IVU-CT for diagnosis of ureteral diseases,where IVU is insufficient to determine the diagnosis.@@Methods Two hundred and eighty patients underwent IVU for suspected ureteral disorders,which identified a definite diagnosis in 184 cases and was insufficient for definite diagnosis in 96 cases designated as indeterminate diagnosis.Subsequently 90 patients (six patients declined CT) with indeterminate diagnosis consented to undergo immediate or delayed helical CT scan.The CT data were transferred to the workstation for post-processing,and the cost and mean effective dose for each imaging method were calculated and compared indirectly.@@Results Of the 90 indeterminate diagnosis cases,diagnosis was determined in 86 cases by IVU-CT with a diagnostic accordance rate of 95.6％,while 184/280 (65.7％) had diagnosis determined by IVU alone.There was a significant difference between IVU and IVU-CT in the determination of the diagnosis of ureteral diseases (x2=36.4,P <0.05).The cost of IVU equals to 1/8-1/9 of that for CT urography (CTU),and the cost of IVU-CT is as much as 1/3 of CTU.CTU results in the highest mean effective dose,approximately nine times that for IVU and three times that for IVU-CT.@@Conclusion IVU-CT provides valuable information for the localization and diagnosis of ureteral abnormalities and may be considered as an efficient,cost-effective and low-dose diagnostic technique in this setting。

Abstract：Background Inside out transobturator vaginal tape (TVT-O) and tension-free vaginal tape (TVT) are predominant surgical treatments for female stress urinary incontinence.This meta-analysis evaluated the complications and cure rates of TVT-O versus TVT.@@Methods A comprehensive literature search was conducted according to the Cochrane Collaboration methodology to identify randomized controlled clinical trials with no language restriction.Two authors independently assessed papers for eligibility and methodological quality.Estimates were measured by relative risk with 95％ confidence intervals.Outcome measures were objective cure,subjective cure and complications.Quality rating for each outcome of the meta-analysis and recommendations were performed by the Grading of Recommendations Assessment,Development,and Evaluation (GRADE) system.@@Results Twenty randomized controlled trials met the inclusion criteria,and a pooled estimate of effectiveness and complications was made.Relative risks with 95％ confidence intervals for pooled effects under the fixed effects model were:0.20 (0.09-0.45),for bladder injury,0.37 (0.16-0.86) for hematoma,and 2.35 (1.57-3.51) for postoperative pain,suggesting an 80％ risk reduction of bladder injury,63％ risk reduction of hematoma,and a 1.35％ risk elevation for postoperative pain with TVT-O.There was no significant difference between complications of urinary tract infection 1.14 (0.78-1.65),lower urinary tract symptoms 1.60 (0.67-3.79),recatheterization 0.93 (0.59-1.44),and tape erosion 0.90 (0.48-1.67),total objective cure rate 1.06 (0.39-2.84) and for the subjective cure rate 0.98 (0.93-1.04).The quality rating for each outcome and recommendations was high for objective cure,bladder injury,hematoma,lower urinary tract symptoms,and tape erosion and moderate for subjective cure,pain,and urinary tract infection.@@Conclusions TVT-O is associated with a reduced risk of bladder injury and hematoma and an elevated risk of postoperative pain.Other complications,including tape erosion,urinary tract infection,lower urinary tract symptoms,and recathetefization,are similar to those of TVT。

Abstract：Convulsion is the medical condition where body muscles contract and relax rapidly and repeatedly,resulting in an uncontrolled shaking of the body.The impaired inhibition of electrical activity in the brain is one of leading causes of convulsion.y-aminobutyric acid (GABA) is the chief inhibitory neurotransmitter in the mammalian central nervous system (CNS).GABA acts at inhibitory synapses in the brain by binding to specific transmembrane receptors in the plasma membrane of both pre- and post-synaptic neuronal processes.GABAA receptor (GABAAR) is the most important inhibitory receptor,and is the target receptor of anticonvulsant drugs in the clinic.In this review,we describe GABAergic signaling mediated by GABAAR,the mechanisms of GABAAR and their expression,and the progress being made on understanding the role of GABAAR in convulsion with emphasis on the association between GABAAR mutations or GABAAR subunit expression and convulsion.We also describe progress of anticonvulsant drugs based on the GABAAR。

Abstract：Osteogenesis imperfecta is a group of inherited connective-tissue disorders in which synthesis or structure of type Ⅰ collagen is defective and causes osseous fragility.Type Ⅳ osteogenesis imperfecta is dominant inheritance.Here,we report a case of type Ⅳ osteogenesis imperfecta family and their female member's pregnancy.Abnormal sonographic findings (marked bowing and shortening of long bones) and family history made the diagnosis of fetus with osteogenesis imperfecta.The parents decided to give up rescuing the infant and a caesarean section at 27 weeks of gestation was implemented.n conclusion,it is possible to make a prenatal diagnosis of osteogenesis imperfecta by ultrasound.For the pregnant women with osteogenesis imperfecta,management decision should be made on an individual basis。