2013年 · 第126卷第14期

Atrial fibrillation (AF) is the commonest type of arrhythmia which is seen as a growing public health burden affecting patients' morbidity and mortality.1 Since the end of last century,catheter ablation has been evolving as the treatment of choice in a particular subset of patients with AF,2,3 and currently being the most common catheter ablation procedure performed worldwide.Most centers have progressively moved from performing paroxysmal AF to more complex long-standing persistent AF.Although 60％-85％ of paroxysmal AF can be sufficiently managed by ablating the triggers through pulmonary vein isolation (PVI),1-3 numerous studies have reported that the success rates of PVI alone in persistent and long-standing persistent atrial fibrillation (PerAF) is significantly low.This created the need for additional strategies to achieve better success rates in PerAF.4 In 2005,Haǐssaguerre et al 5,6 reported high success rates of catheter ablation in patients with PerAF.In their report,apart from PVI,most of the patients underwent additional substrate modification including linear ablation which presented new information on the role of different atrial structures in PerAF maintainance.5 Different centers have reported different strategies and success rates in patients with PerAF。

Abstract：Background Circumferential pulmonary vein isolation (CPVI),as the basal ablation strategy for treating atrial fibrillation (AF),not only isolates the connection between the left atrium (LA) and the pulmonary veins (PVs),but also induces extensive atrial endocardia damage.This could have an effect on the sinus pulse conduction in the LA and subsequently result in changes of P-wave characteristics of surface electrocardiogram (ECG).Methods Fifty consecutive patients underwent CPVI for symptomatic drug-refractory paroxysmal AF.The 12-lead ECGs were recorded one day before CPVI and seven days after CPVI at sinus rhythm by a standard resting ECG device.Measured characteristics of the P-wave consisted of P-wave duration (PWD),P-wave amplitude (PWA),P-wave polarity (PWP),P-wave notch,P-wave dispersion and P-wave index.Results After CPVI,a prevalent decrease of PWD,PWA,and P-wave dispersion was observed; a transition of P-wave polarity was observed in the leads of Ⅲ,aVL and aVF.The rate of P-wave notch decreased significantly in all leads,especially in the leads of Ⅱ,Ⅲ,aVF and V3.Patients with sinus rhythm had a shorter P-wave dispersion and P-wave index and had a lower rate of P-wave notch compared with the patients with recurrent atrial tachyarrhythmia.Conclusion Observations from using the surface ECG showed that CPVI has instant effects on the electrical conduction in the LA,and several changes of P-wave characteristics associated with development of AF are improved by CPVI。

Abstract：Background Pulmonary vein antrum isolation (PVAI) of pre-excited atrial fibrillation (AF) is controversial.This study aimed to observe the therapeutic effects of PVAI on pre-excited AF.Methods Twenty-nine patients with pre-excited AF were prospectively divided into a PVAI group (group Ⅰ,19 cases) and a control group (group Ⅱ,10 cases).To each case in group Ⅰ,PVAI was performed,and then electroanatomical mapping of accessory pathways (AP) and ablation were constructed on a three-dimensional (3D) map of the valve annulus.Only AP ablation was performed in each case of group Ⅱ.Results Of the 29 cases,three were found to have dual APs,two had intermittent APs,and the remaining 24 had single APs.All APs were successfully ablated after the procedure.There were no significant statistical differences in the AP procedure duration ((77.4±21.3) minutes vs.(85.3±13.1) minutes),the AP ablation time ((204±34) seconds vs.(223±62)seconds) and the AP X-ray exposure time ((18.6±4.4) minutes vs.(19.1±4.5) minutes) respectively between groups Ⅰ and Ⅱ.As compared with the control group (5 of 10 cases,50％),the PVAI group had a significantly lower AF recurrence rate (2 of 19 cases,11％; P ＜0.05) during follow-up of (20.5±10.0) months.All seven patients who recurred were successfully abolished by a second ablation.Conclusions In patients with pre-excited AF,PVAI is an effective therapeutic approach with a low AF recurrence rate.3D electroanatomical maps of AP contributed to the high success rate of ablation without significantly prolonging of operational duration and X-ray exposure time。

Abstract：Background The number of non-responders to cardiac resynchronization therapy (CRT) exposes the need for better patient selection criteria for CRT.This study aimed to identify echocardiographic parameters that would predict the response to CRT.Methods Forty-five consecutive patients receiving CRT-D implantation for heart failure (HF) were included in this prospective study.New York Heart Association (NYHA) class,6-minute walk distance,electrograph character,and multi echocardiographic parameters,especially in strain patterns,were measured and compared before and six months after CRT in the responder and non-responder groups.Response to CRT was defined as a decrease in left ventricular endsystolic volume (LVESV) of 15％ or more at 6-month follow up.Results Twenty-two (48.9％) patients demonstrated a response to CRT at 6-month follow-up.Significant improvement in NYHA class (P ＜0.01),left ventricular end-diastolic volume (LVEDV) (P ＜0.01),and 6-minute walk distance (P ＜0.01) was shown in this group.Although there was an interventricular mechanical delay determined by the difference between left and right ventricular pre-ejection intervals ((42.87±19.64) ms vs.(29.43±18.19) ms,P=0.02),the standard deviation of time to peak myocardial strain among 12 basal,mid and apical segments (Tε-SD) ((119.97±43.32) ms vs.(86.62±36.86) ms,P=0.01) and the non-ischemic etiology (P=0.03) were significantly higher in responders than non-responders,only the Tε-SD (OR=1.02,95％ Cl=1.01-1.04,P=0.02) proved to be a favorable predictor of CRT response after multivariate Logistic regression analysis.Conclusion The left ventricular 12 segmental strain imaging is a promising echocardiographic parameter for predicting CRT response。

Abstract：Background Chronic heart failure (CHF) is a severe clinical syndrome associated with high morbidity and mortality,and with high health care expenditures.No nationwide data are currently available regarding the quality of clinical management of CHF patients in China.The aim of this study was to assess the quality of care of CHF inpatients in China.Methods The American College of Cardiology/American Heart Association Clinical Performance Measures for Adults with Chronic Heart Failure (Inpatient Measurement Set) with slight modifications was used to measure the performance status in 612 CHF patients with acute coronary syndrome (ACS) from 65 hospitals across all regions of China.Results The implementation rates of guideline recommended strategies for CHF management were low.Only 57.5％ of the CHF patients received complete discharge instructions,53.6％ of the patients received evaluation of left ventricular systolic function,62.8％ received an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker at discharge,and 52.7％ received a β-blocker at discharge,56.3％ of the smokers received smoking cessation counseling.The rate of warfarin utilization was only 9.7％ in CHF patients with atrial fibrillation.Most patients (81.4％) did not receive all the first four treatments.There were marked differences in the quality of CHF management among patients with different characteristics.Conclusions Performance measures provide a standardized method of assessing quality of care,and can thus highlight problems in disease management in clinical practice.The quality of care for CHF patients with ACS in China needs to be improved。

Abstract：Background Intra-aortic balloon counterpulsation (IABP) is a mechanical cardiac-assist device that is used for cardiac support.There are no published reports about the use of IABP in eldedy Chinese patients,especially for those over 80 years old.The aim of this study was to describe the clinical outcomes,influencing factors,and complications in patients ≥80 years old and requiring IABP.Methods We performed a retrospective study of 134 consecutive patients who received IABP therapy.Based on age,we defined two groups; those ≥80 years old and those ＜80 years old.Results The overall mortality was 41.8％.Patients ≥80 years old had higher mortality rates than those ＜80 years old (47.9％ vs.30.2％).Patients ≥80 years old had fewer successful revascularizations (45.8％) and more pulmonary infections(47.9％) than patients ＜80 years old (60.3％ and 30.2％,respectively); these differences were statistically significant.The most common non-cardiac complication was pulmonary infection.Cardiogenic shock and pulmonary infection were risk factors for all-cause,in-hospital mortality,whereas revascularization success was a negative risk factor for the ≥80 years old patients.Conclusions IABP may be successfully and safely employed in patients ≥80 years old,having severe heart disease,with few complications.Patients ≥80 years old who need IABP therapy are less likely to have a successful revascularization and are more likely to develop pulmonary infections than patients ＜80 years old。

Abstract：Background Stent thrombosis is one of severe complications after sirolimus-eluting stent implantation.Rapamycin (sirolimus) promotes arterial thrombosis in in vivo studies.However,the underlying molecular and transcriptional mechanisms of this adverse effect have not been thoroughly investigated.This study was designed to examine the effects of rapamycin on the expression of the gene,Kruppel-like factor 2 (KLF2),and its transcriptional targets in mice.Methods Mice were randomly divided into four groups:the control group (intraperitoneal injection with 2.5％ of dimethyl sulfoxide (DMSO) only),rapamycin group (intraperitoneal injection with 2 mg/kg of rapamycin only),Ad-LacZ + rapamycin group (carotid arterial incubation with Ad-LacZ plus intraperitoneal injection with 2 mg/kg of rapamycin 10 days later),and Ad-KLF2 + rapamycin group (carotid arterial incubation with Ad-KLF2 plus intraperitoneal injection with 2 mg/kg rapamycin 10 days later).The carotid arterial thrombosis formation was induced by FeCl3 and the time of arterial thrombosis was determined.Finally,the RNA and protein of carotid arteries were extracted for KLF2,tissue factor (TF),plasminogen activator inhibitor-1 (PAl-1),endothelial nitric oxide synthase (eNOS),thrombomodulin (TM) mRNA and protein analysis.Results Compared with controls,treatment with rapamycin inhibited KLF2,eNOS and TM mRNA and protein expression,and enhanced TF and PAl-1 mRNA and protein expression,and shortened time to thrombotic occlusion from (1282±347)seconds to (715±120) seconds (P ＜0.01) in vivo.Overexpression of KLF2 strongly reversed rapamycin-induced effects on KLF2,eNOS,TM,TF and PAl-1 expression.KLF2 overexpression increased the time to thrombotic occlusion to control levels in vivo.Conclusions Rapamycin induced an inhibition of KLF2 expression and an imbalance of anti-and pro-thrombotic gene expression,which promoted arterial thrombosis in vivo.Overexpression of KLF2 increased KLF2 expression and reversed time to thrombosis in vivo。

Abstract：Background Bronchial anthracofibrosis (BAF) has been defined as a luminal narrowing associated with anthracotic pigmentation on bronchoscopy without a relevant history of pneumoconiosis or smoking.The aim of the study is to study the clinical features and imaging manifestations of BAF,and to promote the awareness of this disease.Method Between October 2006 and January 2012,15 patients were diagnosed at our department as BAF that showed a narrowing or obliteration of lobar or segmental bronchi with anthracotic pigmentation in the overlying mucosa on bronchoscopy.The medical records including clinical features,imaging manifestations,electronic bronchoscopic findings,and pathological features were analysed,and the literature was reviewed.Results A total of 15 patients were analyzed; 13 were female (86.7％) and two were male (13.3％) and the age range was from 62 to 86 years with a mean age of 74.5 years.Three cases (20.0％) had a history of tuberculosis.The most common clinical symptoms of BAF were cough (100％),expectoration (73.3％),dyspnea (60.0％),and fever (46.7％).Twelve cases displayed mild to moderate obstructive ventilatory dysfunction.In the electronic bronchoscopic evaluation,the most common findings were black bronchial mucosal pigmentation,bronchial stenosis,bronchial occlusion,and bronchial mucosal folds.Pathological evaluation revealed chronic inflammation of the bronchial mucosa,submucosal carbon particle deposition,and mucosal or submucosal fibrosis.Chest CT scans showed that 15 patients had bronchial stenosis or obstruction (direct signs) with the right middle lobe being the most common site (11 cases,73.3％).The indirect sign was mainly the presence of bronchial obstructive diseases (including secondary infection),represented by 11 cases of pulmonary consolidation (73.3％),seven cases of atelectasis (46.7％),and five cases of nodules (33.3％).The CT mediastinal window showed bronchial lymph node lesions,mediastinal lymph node calcification (12 cases,80.0％),and enlargement of multiple mediastinal lymph nodes.Conclusions The diagnosis of BAF was mainly based on bronchoscopic evaluation.Its pathogenesis is currently unclear,although it may be related to tuberculosis or bio-fuel inhalation.The diagnosis of BAF has important clinical significance,and improved awareness of this disease will contribute to prevention of unnecessary thoracotomies。

Abstract：Background The catheter related infection caused by Staphylococcus epiderrnidis biofilm is increasing and difficult to treat by antimicrobial chemotherapy.The properties of biofilms that give rise to antibiotic resistance are only partially understood.This study aimed to elucidate the penetration of erythromycin through Staphylococcus epidermidis biofilm.Methods The penetration ratio of erythromycin through Staphylococcus epidermidis biofilms of 1457,1457-msrA,and wild isolate S68 was detected by biofilm penetration model at different time points according to the standard regression curve.The RNNDNA ratio and the cell density within the biofilms were observed by confocal laser microscope and transmission electromicroscope,respectively.Results The penetration ratios of erythromycin through the biofilms of 1457,1457-msrA,and S68 after cultivation for 36 hours were 0.93,0.55 and 0.4,respectively.The erythromycin penetration ratio through 1457 biofilm (0.58 after 8 hours)was higher than that through the other two (0.499 and 0.31 after 24 hours).Lower growth rate of the cells in biofilm was shown,with reduction of RNA/DNA proportion observed by confocal laser microscope through acridine orange stain.Compared with the control group observed by transmission electrmicroscope,the cell density of biofilm air face was lower than that of agar face,with more cell debris.Conclusions Erythromycin could penetrate to the Staphylococcus epidermidis biofilm,but could not kill the cells thoroughly.The lower growth rate of the cells within biofilm could help decreasing the erythromycin susceptibility。

Abstract：Background The human leukocyte antigen-G (HLA-G) has been considered to be an important tolerogeneic molecule playing an essential role in maternal-fetal tolerance,upregulated in the context of transplantation,malignancy,and inflammation,and has been correlated with various clinical outcomes.The aim of this study was to investigate the clinical relevance of the expression of membrane HLA-G (mHLA-G),intracellular HLA-G (iHLA-G),and soluble HLA-G (sHLA-G) in the peripheral blood of live kidney transplant recipients.Methods We compared the expression of the three HLA-G isoforms in three groups,healthy donors (n=20),recipients with acute rejection (n=19),and functioning transplants (n=30).Flow cytometry was used to detect the expression of mHLA-G and iHLA-G in the T lymphocytes of peripheral blood from subjects in the three groups.Enzyme-linked immunosorbent assays were used to detect sHLA-G in the plasma from the three groups.Results There were no significant differences in mHLA-G and intracellular HLA-G among the three groups,but the sHLA-G plasma level was higher in the functioning group than in the acute rejection or healthy group.We found a subset of CD4+HLA-G+ and CD8+HLA-G+T lymphocytes with low rates of mHLA-G expression in the peripheral blood of kidney transplantation recipients.Intracellular expression of HLA-G was detected in T lymphocytes.However,there was no correlation between acute rejection and the mHLA-G or intracellular HLA-G expression.Conclusion sHLA-G was the major isoform in the peripheral blood of live kidney transplant recipients and high sHLA-G levels were associated with allograft acceptance。

Abstract：Background Patients with maxillary tumor often suffer from trismus after maxillectomy,which could turn out to be a permanent sequela without proper intervention.In this study,the efficacy of mouth opening exercises in preventing and treating trismus was observed in patients with maxillary tumor early after their operations.At the same time,radiotherapy as an influencing factor for the mouth opening exercises was evaluated.Methods In this study,22 patients with maxillary oncology began their mouth opening exercises at an early stage (1-2 weeks) after maxillectomy.They were divided into two groups based on the principle of voluntariness:11 patients in group 1 chose TheraBites as their instruments of mouth opening exercises,and the other 11 in group 2 chose stacked tongue depressors to help their exercises.All participants were trained to exercise 3-5 times a day,30-40 oscillations at one time,with a 2-second pause at their maximum possible mouth open position.The maximal interincisor distances (MID) of patients were measured and recorded by a single investigator every week after the beginning of the mouth opening exercises.Medical information and the responses of patients were also recorded.Initial and final MIDs were calculated by SPSS 13.0.Results The changes of the mouth aperture every week during exercises in both groups were described in figures,and there were statistical increases in the final MIDs compared with the initial ones.However,no significant differences were achieved between groups 1 and 2 (P ＞0.05).Radiotherapy seemed to have no negative impact on the mouth opening results during the exercises.Conclusion Physical mouth opening exercises should be executed early after maxillectomy for the prevention and treatment of trismus,especially for those who had radiotherapy as part of antitumor treatments。

Abstract：Background Schwannomatosis is a recently recognized peripheral nerve polyneoplasm with clinical characteristics and a genetic background that differ from those of neurofibromatosis 2 (NF2).The diagnostic and treatment criteria of this rare disorder are herein discussed.Methods The data of 180 patients who underwent operations for benign schwannomas from 2003 to 2012 in our center were reviewed.Eight of them were classified as schwannomatosis according to the diagnostic criteria suggested by MacCollin.The demographic characteristics were documented and compared between the two groups of patients.The patients' clinical presentations,imaging characteristics,histological features,and treatment results were retrospectively investigated and summarized.Results Of the 180 cases of benign schwannomas we reviewed this time,eight patients presented with schwannomatosis (4.44％).The mean age of the two groups was not significantly different (40.0 vs.44.7 years,t=0.88,P=0.378).However,schwannnomatosis seems to more generally occur in females (75％ vs.48％ were females,P=0.162),although the difference was not statistically significant.The initial main symptom was pain.The neurological examination was otherwise normal.Magnetic resonance imaging (MRI) revealed multiple discrete,well-defined round,or oval lesions distributed along the course of the peripheral nerves in the extremities with low-to-intermediate signal intensity on T1-weighted images and high-signal intensity on T2-weighted images.Vestibular schwannomas were excluded in four patients by cranial MRI.The lesions in all patients were resected and were pathologically proven to be schwannomas.The average follow-up period was 26 months.Six individuals obtained a good result without symptoms or function loss.Conclusions Schwannomatosis is characterized by the development of multiple schwannomas without evidence of the vestibular tumors that are diagnostic for NF2.It commonly occurs in middle-aged females.It has similar demographic features to solitary benign schwannoma.Surgical resection always results in a good outcome。

Abstract：Background Epidemiological study showed that the use of angiotensin-converting enzyme inhibitors was associated with higher bone mineral density (BMD) in older people,especially male subjects,which suggested that angiotensin Ⅱ may have a detrimental effect on bone.Therefore,blocking its effect may have a beneficial effect on bone health.Methods Six-month-old male spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY) were used.Animals of each model were randomly assigned to the following four groups:Group 1,SHAM operated+vehicle;Group 2,orchidectomy (ORX)+vehicle; Group 3,ORX+low-dose losartan (10 mg.kg-1·d-1); and Group 4,ORX+high-dose losartan (25 mg.kg-1.d-1).Blood pressure was recorded weekly.SHAM and ORX operations were performed,followed by daily losartan and vehicle treatment from day 4 after operation for 16 weeks.Serum and 24-hour urine samples were collected for measurement of bone turnover markers before euthanasia and then the left femur was collected for measurements of BMD and microarchitecture before mechanical test.Results Urine deoxypyridinoline/urine creatinine (DPD/Cr) ratio was significantly higher in SHR than in WKY.BMD and microarchitecture parameters also showed bone deterioration in SHR.After ORX,serum osteocalcin concentration decreased and urine DPD/Cr ratio increased significantly accompanied by a significant decrease in cortical and trabecular BMD and cortical bone thickness in both WKY and SHR.High-dose losartan significantly increased DPD in urine in both SHR and WKY.Apart from marginal favorable changes in bone architecture in WKY treated with high-dose losartan,losartan did not show significant effect on BMD,bone area,bone microarchitecture,and mechanical properties in both SHR and WKY.Conclusion Angiotensin Ⅱ type Ⅰ receptor blocker losartan was not able to demonstrate significant effect on ORX-induced bone deterioration in both hypertensive and normotensive rats。

Abstract：Background Although video-assisted radical operation for lung cancer has been widely accepted for treatment of nonsmall cell lung cancer (NSCLC),the debate over video-assisted thoracic surgery (VATS) segmentectomy still remains.This study analyzed the clinical outcomes using VATS segmentectomy for stage Ⅰ NSCLC patients to explore the safety and efficacy of VATS segmentectomy for la NSCLC.Methods Retrospective review was conducted of patients who underwent VATS segmentectomy for clinical stage Ⅰ NSCLC at Shanghai Chest Hospital between November 2009 and May 2012.VATS segmentectomy was performed on 36 patients.Analyses of the patient group were performed on patient demographics and clinical characteristics,intraoperative parameters,complications,and postoperative survival.Results Thirty-five of thirty-six patients underwent VATS segmentectomy with only one conversion to open thoracic surgery.There was one peri-operative mortality from the segmentectomy group and all other patients are alive with a median follow up of 327 days.The mean volume of chest tube drainage after operation for segmentectomy was 1021.4 ml.Among other parameters,the mean blood loss was 162.5 ml (50.0-1600.0 ml),the mean operation time 124.8 minutes (75.0-271.0 minutes),chest tube duration 4.1 days (2-8 days),and the mean length of hospital stay 6.2 days (4-11 days).There was one (2.8％) locoregional recurrence after segmentectomy.Two patients successfully underwent bilateral segmentectomies and are still disease free.Conclusion For patients with stage Ⅰ NSCLC,VATS segmentectomy offers a safe and equally effective option and can be applied to complicated operations such as bilateral segmentectomy。

Abstract：Background Colon cancer is one of the major malignancies worldwide and it still remains resistant to much of the currently available chemotherapy.Downregulation of HGF/c-Met signaling pathway is an emerging therapy for cancer treatment.Methods In this study,the inhibitory effects of c-Met phosphorylation were observed with SU11274 on different colon cancer cell lines in vitro.Results The results revealed the significant inhibitory effects of SU 11274 on cell proliferation and cell survival,in a time and dose-dependent manner.Furthermore,the inhibitory effects of SU11274 on different subgroups of colon cancer cells via the HGF/c-Met signaling pathway were implicated in this study.Conclusion The results suggested the possible selective therapeutic effects of c-Met inhibitor on colon cancer。

Abstract：Objective Life-threatening critical congenital heart disease (cCHD) is often not detected in the neonatal period.Unrecognized cCHD results in high morbidity and mortality rates.As a non-invasive,convenient,quick and accurate measuring method,pulse oximetry is considered to be a promising strategy to screen for cCHD in neonates.This article is a review on the neonatal pulse oximetry screening for cCHD.Data sources Articles on neonatal pulse oximetry screening for cCHD were accessed from PubMed,using keywords including congenital heart defects,neonatal screening and oximetry.Study selection Original articles and critical reviews selected were relevant to the review's theme.Results The factors in the course of implementation,including threshold for positive pulse-oximetry screening results,the pulse oximeters used,timing of the screening,and the measuring position,influence the accuracy of the screening.It is recommended that the screening is completed on the second day of life,before hospital discharge.Motion-tolerant pulse oximeters,which can also be applied to measure the saturation in low-perfusion conditions,should be used.The probe should be put on both the right hand and on one foot.Thresholds of ＜95％ in either limb or a difference of ＞3％ between the limbs as a positive result may be appropriate.It should be emphasized that pulse-oximetry screening cannot be used as the only way to detect cCHD,clinical examination is also important in this situation.Cost-benefit analysis in the United Kingdom revealed it was plausible to use pulse oximetry as an adjunct to clinical examination.However,it is still controversial as to whether pulse oximetry can be used as a routine screening method for cCHD in neonates.Conclusions Neonatal pulse oximetry screening improves detection of cCHD.Further studies should be carried out before it becomes one of the routine newborn screening programs。

Abstract：Objective To review the current status and progress on nuclear medical molecular imaging of angiogenesis.Data sources A literature search was performed in Medline and PubMed published in English up to May 31,2012.The search terms were molecular imaging,nuclear medicine and angiogenesis.Study selection Articles studying molecular imaging of angiogenesis using radionuclide were selected and reviewed.Results Molecular imaging has been used for studying angiogenesis by targeting integrin αVβ3,VEGFNEGFR,and matrix metalloproteinases (MMPs) with radionuclide-labeled tracers.The technology has been shown to be able to assess the angiogenesis status and/or predict the efficacy of anti-angiogenic therapy.Future directions of the research on the molecular imaging of angiogenesis include development of new tracers with better tumor targeting efficacy,desirable pharmacokinetics,and easy translation to clinical applications.Conclusion Advances in molecular imaging of angiogenesis using radioculcide will make the technology a valuable tool for personalized anti-angiogenesis treatment。

Atrial fibrillation (AF) is the most frequent arrhythmia whose incidence increases with age.At present about 1％-2％ of the European population suffer from AF.Presumably about 25％ of the population between 40 and 50 years will develop AF in their life course and the prevalence of AF will increase by at least 2.5-fold in the next 50 years.Apart from the hemodynamic impact and an increased mortality rate,non-valvular AF is associated with an increased 5-7 fold risk for stroke caused by embolism originating from the left atrium (LA) and especially from the left atrial appendage (LAA) as compared to patients without AF.Overall 20％-25％ of all ischemic strokes are caused by cardiac embolism,about 50％ of them occur in patients with non-valvular AF.In addition most AF patients are symptomatic and complain about palpitations,tachycardia,dizziness,dyspnea,and reduced physical capacity.Hospitalization due to AF related symptoms and complications is common.Besides clinical aspects,AF will have an increasing socio-economic impact in the future。

Atrial fibrillation (AF) is the most common cardiac dysrrhythmia encountered in the clinical practice.1 The Framingham Heart Study reported the lifetime risks for AF development are 1 in 4 for men and women 40 years of age and older with a doubling of the overall mortality.2,3 Therefore,it carries a significant risk to the patients and also brings a tremendous economic burden to the social and health care systems。

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice.Its prevalence increases with age,ranging from less than 1％ of persons younger than 50 years to nearly 10％ of those older than 80 years.1,2 In view of the rapidly aging US population,as well as the increase in the age-adjusted incidence ofAF,3 this sustained arrhythmia is fast becoming a disease of epidemic proportions.It is projected that more than 5.6 million Americans will have AF by the year 2050,with more than half of affected individuals aged 80 years and older.2 The cost of treating AF in the US,including the 350 000 hospitalizations,5 million office visits,together with the necessary medications and procedures,was 6.65 billion US dollars in 2001;4 one can only expect this figure to rise as the population ages.Nonetheless,lone AF in younger patients has no effect on their mortality rate;although AF may precipitate adverse events,such as hemodynamic impairment and thromboembolism,it is the associated comorbidities (such as congestive cardiac failure,hypertension,diabetes mellitus,systemic atherosclerosis and age) interacting with AF that,to varying degrees,contribute much of the resulting morbidity and death。

Emergency department (ED) overcrowding is a worldwide problem which is common in daily practice and after disasters.1-3 During daily practice,it is more so in large hospitals.ED overcrowding may cause a series of adverse outcomes such as prolonged waiting time for treatment,an increase in ambulance diversion and a reduction in working efficiency.4 Therefore,it is urgently necessary to clearly define ED overcrowding and search for effective ways to solve the problem。

Syphilis (historically called lues) is a sexually transmitted disease (STD) caused by the spirochete bacterium Treponema pallidum subspecies pallidum.Syphilis had many alternate names,such as the "great pox" in order to distinguish it from smallpox,and was given many national attributions,such as the French pox,the English pox,and the Italian pox,due to the disease often being spread by foreign sailors and soldiers during their frequent,unprotected sexual contact with local prostitutes.1 The French pox was widely used before it was named syphilis by the Italian physician and poet Girolamo Fracastoro in 1530.2 Syphilis first reached Canton (Guangzhou) of China through the sea in 1505 and was called "Canton sores" or "Canton rash" (kuang chuang).However,"plum-blossom sores" (yangmei chuang) was more widely used in medical records in China because they had a shape resembling plum-blossoms.Syphilis is almost transmitted through unprotected sexual contact with an infected person although it is possible to contract the infection by coming into contact with the broken skin of an infected person.Syphilis can also be passed from an infected mother to her unborn child。

According to the latest Chinese Healthcare Reform Plan,the medical insurance system is one of the four components of the healthcare sector.The Healthcare financing and payment in China are mainly based on medical insurance.So it is important to learn the experiences of the developed countries.This paper examines the key issues of the German Healthcare system and reforms,with a particular emphasis on basic social medical insurance,which has the broadest coverage in Germany.It reviews the evolution of the background of the German social medical insurance system,describes how the system functions,and analyzes the existing and emerging problems with the system which push the Germany government to adapt a series of reforms.It concludes with a discussion of some enlightenments and suggestions of the German medical insurance system reforms for the development of the Chinese medical insurances system。

Diabetes mellitus (DM) is a considerably common public health problem,which is associated with severe complications.In China,considerably increasing people are diagnosed as DM each year.It has been reported that DM has an increased risk of several neoplasm,notably cancer of the pancreatic,liver,breast,bladder and colon.1 However,there is a growing epidemiologic literature suggesting an inverse association between history of diabetes and risk of prostate cancer (PCa).One meta-analysis for papers published between 1971 and 2002 indicated an inverse association (HR:0.91,95％ CI:0.86,0.96) in 2004。

In the past 50 years,dramatic advances have been achieved in male infertility treatment.Intracytoplasmic sperm injection (ICSI) provides an effective manipulation for bypassing some severe etiologies of male fertility.However,some men may encounter difficulty in semen collection by masturbation on demand at the time of undergoing assisted reproductive technology (ART).If a patient is unable to provide semen by masturbation,he has to undergo testicular sperm extraction (TESE) to collect spermatozoa for ICSI,which is expensive and invasive。

The left pulmonary artery sling (LPAS) is a rare vascular anomaly causing respiratory distress in which the left pulmonary artery arises from the posterior aspect of the right pulmonary artery,courses posteriorly to the right of the bronchus and passes between the trachea and oesophagus to reach the hilum of the left lung.The LPAS is frequently associated with tracheobronchial tree anomalies and congenital cardiac defects.Proper assessment of the tracheobronchial and cardiovascular anomaly is essential in LPAS for planning management of the patient.Currently,the most important prognostic factor is considered to be an associated tracheobronchial tree anomaly.1 The purpose of this study was to demonstrate the role of multi-detector computed tomography (MDCT) for diagnosing LPAS and assessing the anatomical relationship with tracheobronchial tree anomaly。

Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac malformation.Here we report a case of ALCAPA with atrial septal defect (ASD) initially visualized by transthoracic echocardiography,subsequently confirmed by the coronary angiography。

A1-month-old boy was transferred postpartum from sn outside hospital.The boy weighing 3.2 kg and measuring 50 cm long was born after an uneventful,first pregnancy at term by caesarean section.The mother was given oral medication for a week to treat diarrhea in the fifth month of pregnancy.At birth he was found to have a huge scalp defect covered only with a transparent membrane that covered the underlying brain.The wound gradually desiccated and formed an eschar。

To the editor:Depending on the relationship between the tumor and the dura mater,dumbbell tumors can be divided into intradural-epidural (ID-ED) and epidural (ED) tumors.The surgical procedures and postoperative complications of both types are different.Nine cases of cervical dumbbell Schwannomas were treated at our hospital between June 2004 and August 2012.There were five cases of ED tumors and four cases of ID-ED tumors (Figure 1)。

To the editor:Median arcuate ligament syndrome (MALS) or celiac axis compression syndrome is an uncommon cause of mesenteric iSchemia.Median arcuate ligament usually passes superior to the origin of the celiac axis.Celiac trunk is compressed by the median arcuate ligament during expiration.1 The majority of patients are observed with symptoms weight loss and abdominal pain.Celiac artery compression with Doppler ultrasound,Computed tomography (CT) angiography,selective catheter angiography and magnetic resonance angiography can be ascertained.After the disease is diagnosed,surgery is performed to relieve the compression。

To the editor:Amniotic fluid embolism (AFE),first described by Meyer in 1926,is a sporadic and unpredictable obstetric complication.The incidence of AFE ranges between 2.0 per 100000 in the United Kingdom1 to 7.7 per 100 000 deliveries in the United States.2 The maternal mortality ratio associated with AFE ranges between 0.5-1.7 deaths per 100 000 live births or deliveries in developed countries.3 AFE is a leading cause of maternal mortality。

To the editor:We read with great interest a longitudinal study by Zhang et al.1 The authors reported that transradial approach (TRA) reduced bleeding complication,and improved 30-day clinical outcomes.Despite a non-randomized study,it would provide an important contribution regarding TRA in patients with ST-segment elevation myocardial infarction (STEMI) treated with contemporary antitrombotic therapy such as tirofiban,which still remains unclear。

To the editor:We read with great interest the article by Feng and co-authors1 entitled Pacemaker implantation in a patient with noncompaction and aneurysm of right ventricular combination with postclosure of atrial septal defect,which was published in the current issue of Chinese Medical Journal.Authors presented a case of pacemaker implantation in a patient with right ventricular (RV)noncompaction.They mentioned that the echocardiogram is the key method for myocardial noncompaction diagnosis and they offered the optimal pacing site of ventricular electrode should be the intermediate septum of RV due to echocardiographic visualization.This case gives detailed information and highlights the management of pacemaker implantation in a patient with noncompaction.Some comments may be of interest。

To the editor:An 85-year-old woman,presented with a macula in the front region of parietal bone one year ago,which was slightly protruding from the epidermis without pain and pruritus.After scratching,ulceration and the scope was increasing gradually.A month ago,the tumor was about walnut size,and now about egg size,accompanied with bleeding when knocked,without special feeling.Apart from this,the patient has been suffering from hypertension,diabetes for many years.The size of the tumor was 6 cm × 7 cm × 8 cm,dark red,hard shell,endoplasmic soft.The surface was contaminated,oozy,scabing,poor activity,the boundary was not clear,and pressing with no feeling.The pathological examination showed squamous cell carcinoma (SCC),as shown in Figure 1.Immunohistostaining revealed positive staining for PAS and ABPAS in the tumor tissue.We also performed immunohistostaining analysis,such as keratins AE1/AE3,EMA,cytokeratin 7,cytokeratin 18,cytokeratin 20,vimentin,S-100,HMB45,CD68,CKH and CD34.Of which,keratins AE 1/AE3,cytokeratin 18,CKH,CD34 and EMA were positive,others were negative.The tumor was diagnosed as huge clear cell SCC.After expansion excision,skin grafting,abdominal skin surgery,postoperative recovery was uneventful,and flakiness has survived well。