2013年 · 第126卷第22期

End stage renal disease (ESRD),with a prevalence in China of about 200-250 cases per million,is one of the major diseases that seriously threaten human health and cause poverty.Recently,with the advancement of healthcare system reform in China,basic medical insurance now covers over 95％ of urban and rural residents,and a high-reimbursement system for the catastrophic diseases including ESRD has been established.The improvement of healthcare policy calls on the medical community to strengthen healthcare service capability for severe illness,establish standardized pathways for prevention,diagnosis,treatment and rehabilitation according to disease spectrum and characteristics of Chinese population,organize multicenter clinical trials,promote the research and development of medical equipments,devices and drugs,and achieve the overall progress of China's healthcare industry finally.So to say,we are now facing the unprecedented opportunities and challenges as well。

Abstract：Background Hypertension,diabetes mellitus,hypercholesterolaemia and current smoking are the strongest modifiable cardiovascular risk factors for acute myocardial infarction (AMI).We examined their changing trends over the last 20years.Methods The clinical data of 3498 patients hospitalized in Peking University People's Hospital with AMI from 1991 to 2010 were used.Information was collected regarding to patients' demographic data,cardiovascular risk factors (hypertension,diabetes mellitus,hypercholesterolemia and current smoking).To assess trends over time in the prevalence of risk factors,we categorized patients into four groups (1991 to 1995,1996 to 2000,2001 to 2005 and 2006 to 2010).Results Highly significant increases were observed in the prevalence of hypertension from 40.8％ to 55.6％ for males and from 58.0％ to 69.0％ for females; and diabetes mellitus from 12.9％ to 30.8％ for males and from 23.0％ to 42.3％ for females.Similarly,the prevalence of hypercholesterolaemia decreased from 53.1％ to 30.7％ for males and from 57.0％to 44.0％ for females.The prevalence of current smoking decreased in females from 29.0％ to 11.1％,but remained unchanged in males.In addition,the proportion of patients with more than three modifiable risk factors increased from 19.0％ to 27.1％ and the age at onset of AMI extended to younger as well as older individuals.Conclusions The prevalence of hypertension and diabetes mellitus are still increasing in patients with AMI in Beijing and although the prevalence of hypercholesterolaemia and current smoking decreased,high clustering of risk factors were commonly present.These adverse trends show a compelling need for more effective management of cardiovascular risk factors。

Abstract：Background Cardiac resynchronization therapy (CRT) with biventricular pacing has demonstrated cardiac function improvement for treating congestive heart failure (HF).It has been documented that the placement of the left ventricular lead at the longest contraction delay segment has the optimal CRT benefit.This study described follow-up to surgical techniques for CRT as a viable alternative for patients with heart failure.Methods Between April 2007 and June 2012,a total of 14 consecutive heart failure patients with New York Heart Association (NYHA) Class Ⅲ-Ⅳ underwent left ventricular epicardial lead placements via surgical approach.There were eight males and six females,aged 36 to 79 years ((59.6±9.2) years).The mean left ventricular ejection fraction (LVEF)was (33.6±7.4)％.All patients were treated with left ventricular systolic dyssynchrony and underwent left ventricular epicardial lead placements via a surgical approach.Tissue Doppler imaging (TDI) and intraoperative transesophageal echocardiography were used to assess changes in left heart function and dyssynchronic parameters.Also,echo was used to select the best site for left ventricular epicardial lead placement.Results Left ventricular epicardial leads were successfully implanted in the posterior or lateral epicardial wall without serious complications in all patients.All patients had reduction in NYHA score from Ⅲ-Ⅳ preoperatively to Ⅱ-Ⅲ postoperatively.The left ventricular end-diastolic diameter (LVEDD) decreased from (67.9±12.7) mm to (61.2±7.1) mm (P＜0.05),and LVEF increased from (33.6±7.4)％ to (42.2±8.8)％ (P＜0.05).Left ventricular intraventricular dyssynchrony index decreased from (148.4±31.6) ms to (57.3±23.8) ms (P＜0.05).Conclusions Minimally invasive surgical placement of the left ventricular epicardial lead is feasible,safe,and efficient.TDI can guide the epicardial lead placement to the ideal target location。

Abstract：Background Left atrial (LA) maximum volume is becoming a prognostic biomarker for left ventricular (LV) diastolic dysfunction.However,we assessed LV diastolic function by measuring LA phasic volumes using real-time threedimensional echocardiography (RT3DE) in patients with stable coronary artery disease (CAD).Methods Sixty-five stable CAD patients with normal LV ejection fraction (LVEF) were divided into three groups according to degree of coronary stenosis:control (n=15) with ＜50％ stenosis as control group,mildS (n=25) with mild stenosis (50％-70％) and severeS (n=25) with ＞70％ stenosis.LA phasic volumes and function were evaluated and compared using RT3DE and two dimensional echocardiography (2DE).N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were examined.The correlations of RT3DE-derived parameters with other conventional indices were analyzed.Results Significant correlations between RT3DE and 2DE for LA volume measurements were:control,r=0.93; mildS,r=0.94; severeS,r=0.90 (all P ＜0.05).Patients with severe coronary stenosis presented higher NT-proBNP level,indices of LA minimum volume and volume before atrial contraction,but lower LA total emptying fraction (LAEF) and LAEFpassive~.Significant correlations of RT3DE dedved LA volume indices with E/E' (r=0.695) and NF-proBNP (r=0.630) level were found.Conclusions RT3DE derived,LA indices correlate well with NT-proBNP level and may be superior to 2DE measurements for the evaluation of LV diastolic dysfunction.Enlargement of LA minimum volume in stable CAD patients without systolic dysfunction appears eadier and may be better correlated with LV diastolic function than that of LA maximum volume。

Abstract：Background Microscope-integrated near-infrared indocyanine green video angiography (ICG-VA) has been used in neurosurgery for a decade.This study aimed to assess the value of intraoperative indocyanine green (ICG) video angiography with Flow 800 software in cerebrovascular surgery and to discover its hemodynamic features and changes of cerebrovascular diseases during surgery.Methods A total of 87 patients who received ICG-VA during various surgical procedures were enrolled in this study.Among them,45 cases were cerebral aneurysms,25 were cerebral arteriovenous malformations (AVMs),and 17 were moyamoya disease (MMD).A surgical microscope integrating an infrared fluorescence module was used to confirm the residual aneurysms and blocking of perforating arteries in aneurysms.Feeder arteries,draining veins,and normal cortical vessels were identified by the time delay color mode of Flow 800 software.Hemodynamic parameters were recorded.All data were analyzed by SPSS version 18.0 (SPSS Inc.,USA).T-test was used to analyze the hemodynamic features of AVMs and MMDs,the influence on peripheral cortex after resection in AVMs,and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in MMDs.Results The visual delay map obtained by Flow 800 software had more advantages than the traditional playback mode in identifying the feeder arteries,draining veins,and their relations to normal cortex vessels.The maximum fluorescence intensity (MFI) and the slope of ICG fluorescence curve of feeder arteries and draining veins were higher than normal peripheral vessels (MFI:584.24±85.86 vs.382.94±91.50,slope:144.95±38.08 vs.69.20±13.08,P ＜0.05).The artefiovenous transit time in AVM was significantly shorter than in normal cortical vessels ((0.60±0.27) vs.(2.08±1.42) seconds,P ＜0.05).After resection of AVM,the slope of artery in the cortex increased,which reflected the increased cerebral flow.In patients with MMD,after STA-MCA bypass,cortex perfusion of corresponding branches region increased and local cycle time became shorter.Conclusion Intraoperative ICG video angiography combined with hemodynamic parameter analysis obtained by Flow 800 software appears to be useful for intraoperative monitoring of regional cerebral blood flow in cerebrovascular disease。

Abstract：Background Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable cardiac disease predominantly caused by mutations in desmosomal protein genes.Previous genetic analyses of the Chinese ARVC population are limited to small size and restriction to a single gene.This study was aimed to investigate the genotype in a large series of Chinese patients with ARVC through comprehensively screening nine ARVC-causing genes.Methods A total of 100 unrelated ARVC patients and 300 age,gender and ethnicity matched healthy controls were genetically tested with multiplexing targeted resequencing for nine previously reported ARVC-causing genes,including plakophilin-2,desmoplakin,desmoglein-2,desmocollin-2,plakoglobin,transforming growth factor beta-3,transmembrane protein 43,desmin and Lamin A/C.Results Fifty-nine mutations were identified in 64％ of the patients,among which,93％ were located in desmosomal protein genes.Plakophilin-2 mutations accounted for 54％ of the total and 58％ of the desmosomal mutations,with a truncating mutation type making up about 2/3 of the plakophilin-2 mutations.Only four mutations were found in nondesmosomal genes; two in transmembrane protein 43 and two in transforming growth factor beta-3.Two of them (one of each gene) appeared as single missense mutations.No mutation was identified in desmin or Lamin A/C.Multiple mutations were found in 23％ of the patients,with plakophilin-2 being found in 57％ of the multi-mutation carriers.Conclusions Plakophilin-2 was the most common gene mutation that was identified in Chinese ARVC patients.Nondesmosomal genes should be added to desmosomal protein genes when performing molecular genetic screening in patients with suspected ARVC。

Abstract：Background Bloodstream infections (BSls) remain a major cause of morbidity and mortality in patients undergoing surgery.This study aimed at elucidating the clinical characteristics of community-acquired BSls (CABs) and nosocomial BSls (nBSls) in patients admitted to the surgical wards of a teaching hospital in Beijing,China.Methods This cross-sectional study compared 191 episodes of BSls in 4074 patients admitted to the surgical wards between January 2008 and December 2011.Cases of BSls were classified as CABs or nBSls,and the characteristics,relevant treatments,and outcomes of CABs and nBSls were compared.Results Of the 191 BSls,52 (27.2％) and 139 (72.8％) were CABs and nBSls,respectively.Eschedchia coli,coagulasenegative staphylococci,and Klebsiella spp,were the most frequently isolated microorganisms.There were significant differences between CABs and nBSls with respect to the use of hormonal drugs,ventilation,acute physiology and chronic health evaluation (APACHE) Ⅱ and American Society of Anesthesiologists scores,and prevalence of cancer (P ＜0.05).Empirical antibacterial therapy did not decrease the crude mortality,but multivariate analysis showed that high APACHE Ⅱ was independently associated with a risk of mortality (odds ratio =0.97,95％ confidence interval:0.93-1.02 for APACHE Ⅱ).Conclusions We found significant differences in the clinical characteristics of surgical patients with CABs and nBSls.The outcome of patients seems to be related to high APACHE Ⅱ scores。

Abstract：Background Tumors with different gene expression develop and progress in different ways.To deepen our understanding of the progression in endometrial cancer,and provide a useful tool for accurate diagnosis and prognosis assessment,we identified the new molecular prognostic markers in endometrial carcinoma and analyzed the relationship of them with clinical and pathological features of endometrial carcinoma.Methods Ninety-four cases of endometrial endometrioid adenocarcinoma with complete data from the Peking University People's Hospital from 2000 to 2008 and 40 cases of normal endometrium were enrolled.Among these,30 endometrial endometrioid adenocarcinoma samples of different International Federation of Gynecology and Obstetrics (FIGO) stage were selected for further Agilent genome-wide microarray analysis.Significance analysis of microarrays (SAM) was used to identify genes that are significantly associated with tumor progress.Immunohistochemistry was utilized to identify the genes of interest in endometrial carcinoma and normal endometrium.The relationship between the genes and the age,clinical stage,histological grade,myometrium invaded depth,lymph node metastasis status,and the expression of ER,PR,P53,and PTEN were analyzed by x2 test.Results Analysis between FIGO 1988 stage Ⅰ and stage Ⅲ identified a 362-gene "progress signature"; 171 downregulated and 191 up-regulated genes.Among the alterative genes,TARP (T cell receptor gamma alternate reading frame protein) and KRT5 (keratin 5) decreased 3.57 fold and 5.8 fold in FIGO stage Ⅲ patients.The expression of TARP in endometrial carcinoma increased compared to normal endometrium,while that of KRT5 decreased (P＜0.05).The expression of TARP and KRT5 decreased when stage,histological grading,myometrium invaded depth increased (P＜0.05).In the cases with lymph node metastasis,the expression of TARP decreased,while the expression of KRT5 did not differ (both P＜0.05) both.The expression of P53 had a negative relationship with the expression of KRT5 (P＜0.05),but not with the expression of TARP (P＞0.05).There was no correlation between the expression of TARP and KRT5 and the expression of ER,PR,PTEN (all P＞0.05).There was no significant difference in TARP and KRT5 expression in patients aged 50 or younger and patients older than 50 (P＞0.05).Conclusion The expression of TARP and KRT5 was correlated with the progress of endometrial cancer and their role needs further study。

Abstract：Background The prognosis of unresectable large hepatocellular carcinomas is poor.This study evaluated the efficacy and safety of sorafenib combined with transcatheter arterial chemoembolization and radiofrequency ablation in the treatment of hepatocellular carcinomas larger than 5 cm.Methods The treatment of 22 patients with large,unresectable hepatocellular carcinomas (5.0-16.5 cm) treated with sorafenib after transcatheter arterial chemoembolization combined with radiofrequency ablation between 2007 and 2011was reviewed.The local effects,survival rates,toxicity,and prognostic factors were analyzed.Results During a follow-up of 9-49 months,19 patients died and three survived.The median overall survival was 32 months.The overall cumulative 12,24,and 36-month survival rates were 85.9％,66.8％,and 23.5％ respectively.Technical effectiveness was achieved in 12 out of 28 lesions (42.85％) at the first CT check.The median time to tumor progression was 21 months.The progression-free survival rates at 6,12,and 24 months were 90.9％,72.0％,and 38.4％,respectively.Combined therapy was generally well tolerated.There was only one major procedure-related complication,biloma (4.5％).Sorafenib-related adverse events exceeding grade 3 were hand-foot skin reaction (2/22,9.1％),gastrointestinal hemorrhage (1/22,4.5％),and diarrhea (2/22,9.1％).The absence of vascular invasion before treatment was found to be the best prognostic factor in the univariate analysis.Conclusions Sorafenib combined with transcatheter arterial chemoembolization and radiofrequency ablation is a promising approach to the treatment of large,unresectable hepatocellular carcinomas.However,large-scale randomized clinical trials are needed to determine the future role of this treatment。

Abstract：Background Pediatric patients are susceptible to lung injury that does not respond to traditional therapies.Total liquid ventilation has been developed as an alternative ventilatory strategy for severe lung injury.The aim of this study is to investigate the effect of total liquid ventilation on oleic acid (OA)-induced lung injury in piglets.Methods Twelve Chinese immature piglets were induced acute lung injury by OA.Twelve piglets were randomly treated with conventional gas ventilation (control group) or total liquid ventilation (study group) for 240 minutes.Samples for blood gas analysis were collected before,and at 60-minute intervals after OA-induced lung injury.The degree of lung injury was quantified by histologic examination.The inflammatory cells and the levels of IL-1β,IL-6,IL-10 and TNF-α in plasma,tissue and bronchoalveolar lavage were analyzed.Results Neutrophil and macrophage counts in bronchoalveolar lavage were significantly decreased in the study group (P＜0.05).The total lung injury score was also reduced in the study group (P＜0.05).The cconcentrations of IL-1β,IL-6,IL-10and TNF-α in plasma,tissue and bronchoalveolar lavage were significantly reduced in the study group (P＜0.05).Conclusions Total liquid ventilation reduces biochemical and histologic OA-induced lung injury in piglets。

Abstract：Background A multi-center large scale study is needed to confirm the efficacy and safety of domestic peritoneal dialysis (PD) solutions.Some researchers believe that 6 L/d is enough for adequate dialysis,but there is no multi-center prospective study on Chinese population to confirm this.In this study,we evaluated the efficacy and safety of domestic PD solution (Changfu) and its difference between 6 L and 8 L dosage.Methods Adult PD patients who had taken PD therapy for at least one month were selected and divided into four groups according to two dialysis solution brands and two dialysis dosages,i.e.,6 L dose with Changfu dialysis solution,6 L dose with Baxter dialysis solution,8 L dose with Changfu dialysis solution,and 8 L dose with Baxter dialysis solution.After 48 weeks,the changes of primary and secondary efficacy indices were compared between different types and different dosages.We also analyzed the changes of safety indices.Results Changes of KW from baseline to 48 weeks between Changfu and Baxter showed no statistical differences; so did those of creatinine clearance rate (Ccr).Normalized protein catabolic rate (nPCR) from baseline to 48 weeks between Changfu and Baxter showed no statistical differences; so did those of net ultrafiltration volume (nUF) and estimated glomerular filtration rate (eGFR).Changes of nPCR from baseline to 48 weeks between 6 L and 8 L showed no statistical differences; so did those of nUF and eGFR.The decline of KW from baseline to 48 weeks in 6 L group was more than that in 8 L group.Change of Ccr was similar.During the 48-week period,the mean Kt/V was above 1.7/w,and mean Ccr was above 50 L·1.73 m-2·w-1.More adverse events were found in Changfu group before Changfu Corporation commenced technology optimization,and the statistical differences disappeared after that.Conclusions The domestic PD solution (Changfu) was proven to be as effective as Baxter dialysis solution.During 48-week period,a dosage of 6 L/d was enough for these patients to reach adequate PD.Clinical study promotes technological optimization,further helps to improve the safety indices of the medical products。

Abstract：Background Many recipients of implantable cardiac electronic devices have atrial fibrillation (AF) occurrences after device implantation,even if there is no previous history of AF,and some of the episodes are asymptomatic.The purpose of this study was to evaluate trends in AF burden following early AF detection in patients treated with pacemakers equipped with automatic,daily Home Monitoring function.Methods Between February 2009 and December 2010,the registry recruited 701 pacemaker patients (628 dual-chamber,73 biventricular devices) at 97 clinical centers in China.Daily Home Monitoring data transmissions were analyzed to screen for the AF burden.In-office follow-ups were scheduled for 3 and 6 months after implantation.Upon first AF (i.e.,mode-switch) detection in a patient,screening of AF burden by Home Monitoring was extended for the next 180 days.Results At least one episode of AF was observed in 22.9％ of patients with dual-chamber pacemakers and in 28.8％ of patients with biventricular pacemakers.The first AF detection in a patient occurred,on average,about 2 months before scheduled follow-up visits.In both pacemaker groups,mean AF burden decreased significantly (P＜0.05) over 180 days following first AF detection:from 12.0％ to 2.5％ in dual-chamber and from 12.2％ to 0.5％ in biventricular pacemaker recipients.The number of patients with an AF burden ＞10％ per month was significantly reduced over 6 months of implantation in both dual chamber (38 patients in the first month vs.21 patients in month 6,P＜0.05) and biventricular (7 patients in the first month vs.0 patient in months 4-6,P＜0.05) pacemaker recipients.Conclusions Automatic,daily Home Monitoring of patients treated with cardiac pacemakers allows early detection of AF,and there is a gradual and significant decrease in AF burden。

Abstract：Background There may be concems over disbenefits to patients who have chosen to undergo laparoscopic gastrectomy by experts in open gastrectomy,considering the disparity between the level of proficiency in open gastrectomy,at which they are already experts,and that in laparoscopic gastrectomy,at which they are beginners.The aim of this study was to compare surgical radicality and outcomes between laparoscopic gastrectomy and open gastrectomy during the learning period of laparoscopic gastrectomy for a senior surgeon who was already an expert in open gastrectomy.Methods Data of short-term surgical outcomes were obtained from patients following laparoscopy assisted distal gastrectomy (LADG) by a surgeon.The initial and following 30 experiences were grouped into LADG-Ⅰ and LADG-Ⅱ,respectively.Patients who underwent open distal subtotal gastrectomy (ODSG) and yet could have been candidates for LADG were grouped into ODSG.Known indicators of proficiency levels and the postoperative hospital course were compared.The consequences of extended lymphadenectomy,and the radicality of surgery by completing D2 lymphadenectomy were analyzed.Results The LADG group revealed longer operation time and less bleeding compared to the ODSG group (P ＜0.001).The number of retrieved lymph nodes and the rate of complications were not significantly different.In the LADG-Ⅰ group,the D1+:D2 ratio was 4:1,showing significant differences from those in the LADG-Ⅱ (0.36:1) and ODSG (0.16:1) groups (P ＜0.001).The surgeon was able to complete D2 lymphadenectomy during LADG without significant change in the amount of bleeding and the rate of complications,but with a longer operation time (P=-0.009).The number of lymph nodes from the 12a station was not significantly different between the LADG and ODSG groups with D2 lymphadenectomy.Conclusions The surgical outcomes were comparable between LADG and ODSG even during the learning period of LADG,and the equivalence of radicality in lymphadenectomy was soon achieved.As long as the surgeon can accept a long operation time,an expert in open gastrectomy should not refrain from performing laparoscopic gastrectomy in well selected patients because of concerns about disbenefits to patients from choosing laparoscopic gastrectomy over open gastrectomy。

Abstract：Background In bone marrow transplant patients,the microenvironment in bone marrow is damaged after chemotherapy or radiotherapy.Subsequent to allogenic hematopoietic stem cell transplantation in patients with clinically successful engraftments,the source of mesenchymal stem cells (MSCs) remains controversial.To further verify the stimulatory effect of the simultaneous transplantation of cells from second donors on engraftment success for hematopoietic stem cell transplantation in support of donor MSCs engraftments,the aim of this study is to monitor the dynamics of the engraftment of bone marrow-derived MSCs in patients after transplantation with mismatched-sex hematopoietic stem and third-party cells.Methods In this study,the hematopoietic stem cells from 32 clinical donors of different sexes that resulted in successful engraftments were selected for transplantation and were classified into three groups for research purposes:group A consisted of 14 cases of transplantation with bone marrow and recruited peripheral hematopoietic stem cell transplantation,group B contained 8 cases of simultaneous re-transfusion of MSCs from the second donor,and group C contained 10 cases of simultaneous re-transfusion of umbilical blood from the second donor.The bone marrow from 32 patients with successful engraftments of hematopoietic transplantation were selected and sub-cultured with MSCs.Flow cytometry (FCM) was used to measure the expression of surface antigens on MSCs.Denaturing high-performance liquid chromatography (DHPLC) in combination with polymerase chain reaction amplification of short tandem repeats (STR-PCR) was used to measure the engraftment status of fifth-generation MSCs in patients.Fluorescence in situ hybridization (FISH) revealed the sex origin of the fifth-generation MSCs in 32 patients.Dynamic examinations were performed on patients receiving donor transplantations.Results The progenies of fifth-generation MSCs were successfully cultured in 32 cases.The results of FCM demonstrated that the expression levels of CD14+ and CD45+ cells were lower than 0.04％ in the fifth-generation MSCs.The analysis using DHPLC and FISH showed similar results.One patient from group B also received a temporary transplantation of MSCs from the donor.The MSCs in the remaining 31 patients all originated from the patients themselves.Conclusions After transplantation,the MSCs present in patients originated from the host.In patients transplanted with MSCs from a second donor,the phenomenon of temporary chimerization of MSCs was observed。

Abstract：Background Dynesys dynamic stabilization system was first implanted in patients in 1994,and introduced to China in 2007.Therefore,it was a new technique for Chinese orthopedics and hence necessary to collect clinical data about Dynesys in China.The objective of this study was to report the preliminary results of Dynesys for the lumbar degenerative disease in China.Methods Twenty-seven patients were treated with the Dynesys between July 2007 and January 2009.The diagnosis included degenerative spondylolisthesis (12 cases),degenerative spinal stenosis (nine cases),and lumbar intervertebral disc herniation (six cases).Back pain and leg pain were evaluated using 100-mm visual analog scales (VAS).The Oswestry Disability Index (ODI) was used to evaluate the patients' function.The intervertebral disc height and range of motion at the operative level were taken on radiographs.Results All the patients were followed-up,with an average of (22.40±4.23) months (range 15-32 months).VAS of back pain and leg pain were improved significantly (P ＜0.05) at follow-up.The ODI scores were reduced from (62.58±12.01)％preoperatively to (15.01±5.71)％ at follow-up (P ＜0.05).The preoperative mean height of the intervertebral disc was (11.21±1.58) mm (range 8.5-13.8 mm) and mean was (10.10±1.78) mm (range 7.0-13.4 mm) at follow-up (P ＜0.05).The mean range of motion of the implanted segment was (6.00±1.79)° (range 2.5-9.3°) preoperatively and (5.47±1.27)°(range 2.9-7.8°) at follow-up (P=0.11).Conclusions The preliminary results of Dynesys for the lumbar degenerative disease in China are similar to the published results of other countries.It can significantly improve the clinic symptoms and preserved motion at the level of implantation.However,the long-term follow-up data need to be collected。

Abstract：Background Famitinib is a novel and potent multitargeting receptor tyrosine kinase inhibitor.The phase I clinical study showed that famitinib was well tolerated and had a broad anti-tumor spectrum.The purpose of this study was to examine the efficacy and safety of famitinib for the treatment of metastatic renal cell carcinoma (mRCC).Methods The data of famitinib in treating patients with mRCC from the single-center phases Ⅰ and Ⅱ clinical trials were analyzed.Famitinib was administered orally at the dose of 13-30 mg once daily until tumor progression,occurrence of intolerable adverse reactions or withdrawal of the informed consent.Results A total of 24 patients with mRCC were treated including 17 patients at a dose of 25 mg once daily,4 patients at a dose of 27 mg and 1 patient each at a dose of 13 mg,20 mg and 30 mg,respectively.Twelve (50.0％) patients achieved partial response (PR) and 9 patients achieved stable disease (SD).Progressive disease was found in 3 (12.5％) patients.The disease control rate was 87.5％.The median follow-up time was 17.6 months; the median progression free survival (PFS) was 10.7 (95％ Cl7.0-14.4) months; and the estimated median overall survival (OS) time was 33.0 (95％ Cl8.7-57.3) months.The adverse drug reactions mainly included hypertension (54.1％),hand-foot skin reactions (45.8％),diarrhea (33.3％),mucositis (29.2％),neutropenia (45.8％),thrombocytopenia (29.2％),hyperlipidemia (41.7％) and proteinuria (41.7％).The incidence rate of grades 3 and 4 adverse events was low,mainly including hypertension 12.5％,hand-foot skin reactions 4.2％,neutropenia 4.2％,thrombocytopenia 4.2％,hyperlipidemia 4.2％ and proteinuria 12.5％.Conclusions Famitinib has significant anti-tumor activity in mRCC.The common adverse reactions are generally manageable。

Abstract：Background There is no validated blood biomarker available for glioma management.Invasive growth is the key feature of glioma.We assessed the clinical usefulness of plasma tissue inhibitor of metalloproteinase 1 (TIMP-1),which has less molecular weight than metalloproteinases,as a potential blood biomarker for glioma.Methods A total of 285 patients and 59 normal subjects were studied.Plasma concentration of TIMP-1 was measured with enzyme-linked immunosorbent assay.Plasma TIMP-1 was compared between normal and glioma patients,between patients with different pathological grades,and between patients with different prognoses.Longitudinal changes in plasma TIMP-1 during treatment were also evaluated.Plasma matrix metalloproteinase (MMP)-9 level was also assayed and its clinical usefulness was compared with that of TIMP-1.Results Plasma TIMP-1 and MMP-9 were both increased in glioma patients compared with normal controls (TIMP-1:P ＜0.001; MMP-9:P=-0.007).Plasma TIMP-1 increases with increased tumor grade.In Grade Ⅳ gliomas,plasma TIMP-1 significantly increased after "successful removal" of the tumor (paired samples t-test,before operation vs.during chemotherapy without recurrence,t =-2.131,P=0.038),but did not change significantly at the time of tumor recurrence (during chemotherapy without recurrence vs.after tumor recurrence,t =-0.652,P=0.632).High plasma TIMP-1 level correlated with better survival in Grade Ⅳ glioma patients (hazard ratio:0.550,95％ CI:0.101-1.000,P=0.036).In Grade Ⅳ gliomas,patients with higher plasma TIMP-1 had significantly longer survival time than those with lower plasma TIMP-1level (25.23 vs.18.95 months,log-rank P=0.045).Plasma MMP-9 did not show significant association with either the pathological grade or the prognosis of glioma patients.Conclusions Plasma TIMP-1 is associated with the diagnosis and prognosis of glioma patients.It appears to have better usefulness for guiding clinical decision making than plasma MMP-9.Further studies in an expanded patient population are needed to better define its clinical usefulness。

Abstract：Background A wealth of evidence has indicated that labor epidural analgesia is associated with an increased risk of hyperthermia and overt clinical fever.Recently,evidence is emerging that the epidural analgesia-induced fever is associated with the types of the epidural analgesia and the variations in the epidural analgesia will affect the incidence of fever.The aim of the present study was to investigate the effects of epidural analgesia with 0.075％ or 0.1％ropivacaine on the maternal temperature during labor.Methods Two hundred healthy term nulliparas were randomly assigned to receive epidural analgesia with either 0.1％ ropivacaine or 0.075％ ropivacaine.Epidural analgesia was initiated with 10 ml increment of the randomized solution and 0.5 μg/ml sufentanyl after a negative test dose of 5 ml of 1.5％ lidocaine,and maintained with 7 ml bolus doses of the abovementioned mixed analgesics every 30 minutes by the patient-controlled epidural analgesia.The measurements included the maternal oral temperature,visual analog scale pain scores,labor events and neonatal outcomes.Results Epidural analgesia with 0.075％ ropivacaine could significantly lower the mean maternal temperature at 4 hours after the initiation of analgesia and the oxytocin administration during labor compared with the one with 0.1％ropivacaine.Moreover,0.075％ ropivacaine treatment could provide satisfactory pain relief during labor and had no significant adverse effects on the labor events and neonatal outcomes.Conclusion Epidural analgesia with 0.075％ ropivacaine may be a good choice for the epidural analgesia during labor。

Abstract：Background Developmental dyslexia (DD) is a disorder in which children with normal intelligence and sensory abilities show learning deficits in reading.Abnormal eye movements have been found in DD.However,eye-movement abnormalities during visual search among Chinese children with DD remain unknown.We aimed to identify the eyemovement characteristics and search efficiency of Chinese children with DD during visual search for targets of different conceptual categories,under same-category conditions.Methods We compared 32 Chinese dyslexic children and 39 non-dyslexic children in visual search tasks,which were assessed using EyeLink Ⅱ High-Speed Eye Tracker (SR Research Ltd.,Canada).Letters,single Chinese characters,digits,Chinese phrases,figures and facial expressions were used as stimuli.Targets were similar to distractors in meaning,phonology and/or shape.Results A main effect of task on visual search scores and all eye-movement parameters were found.Search scores,average saccade amplitude and saccade distance were significantly smaller in the DD group than in the controls.An interaction between group and task was found for pupil diameter.Conclusions Unlike normal readers,children with DD had a reduction in the visual attention span and search accuracy.Besides,children with DD could not increase their mental workload with increase in task difficulty.The conceptual category of the stimulus materials significantly impacts search speed,accuracy and eye-movement parameters。

To the editor:We read with great interest the article by Zhu et al.1The authors presented Chinese twins both with aortic dissection.They have examined the whole members of twins' family and found that their two sons represent dilated ascending aorta,but not their girls.They have recommended their sons to well monitor their blood pressure and repeat ultrasonic cardiogram every year.And they have wondered if there is an inheritance tendency for aortic dissection in Chinese? Although the current cases are well-presented,and we commend the authors for valuable information that they have provided,some comments may be of beneficial。

To the editor:Communication between normal coronary arteries (ICC) is a substantially rare anomaly.The reason of the fact that two-directional coronary connection causes coronary ischemia in the absence of obstructive coronary artery disease is not clear.This coronary anomaly which is thought to be congenital can be readily visualized on coronary angiography. A 58-year-old female patient presented to the cardiology outpatient clinic with angina.The effort test was found to be positive and coronary angiography was performed.It was observed that the circumflex (CX) artery was dominant and the right coronary artery (RCA) was weak by way of the connection.On selective RCA angiography,it was observed that the CX artery was filled more prominently (Figure 1).The patient who was started on diltiazem treatment is being followed up for 6 months and is asymptomatic。

To the editor:Dual antiplatelet therapy (DAPT) is mandatory for the prevention of thrombosis at least for one year after especially drug-eluting stent implantation as recommended by the guidelines.In patients receiving anticoagulants,optimal antiplatelet regimen is still a debatable issue because of its higher bleeding risk.The guidelines strongly recommend us to assess the riskbenefit ratio,to keep the duration of DAPT as short as possible and to adjust the prothrombin time at the level of 2-2.5 with close follow-up.There are no sufficient data regarding how to use new antiplatelet and anticoagulant therapies after stenting.Cilastazol is a relatively new antiplatelet agent which is popular in Asia,and some beneficial effects after coronary stenting were shown in some studies.The results of triple antiplatelet therapy in patients taking warfarin are obviously attractive for invasive cardiologists.Therefore,a meta-analysis published in a past issue by Saheb et al 1 shed light on some dark parts in this regard.In this analysis,majority of the studies were retrospective.Despite reducing the rate of stroke,triple antiplatelet therapy was associated with increased risk of bleeding as expected.Obviously,we need to review the data in the literature for better understanding this issue。

Abstract：Background Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy.No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication.We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction (duct-to-mucosa versus invagination),by meta-analysis and assessment of evidence quality.Methods Databases searched including The Cochrane Library,Medline,PubMed,Embase,etc.Randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination pancreaticojejunostomy were included.Outcomes of interest were pancreatic fistula rate,mortality,morbidity,reoperation and hospital stay.Pooled estimates were expressed as risk ratio (RR) or mean difference.Results From 321 identified abstracts,four RCTs (467 patients; duct-to-mucosa:232; invagination:235) were included.Pancreatic fistula rate (RR,0.74; 95％ confidence interval (Cl):0.24-2.28; P=0.60),mortality (RR,1.18; 95％ CI:0.39-3.54; P=0.77),morbidity (RR,0.91; 95％ CI:0.69-1.21; P=0.53),reoperation (RR,1.09; 95％ CI:0.54-2.22; P=0.81)and hospital stay (mean difference,-1.78; 95％ CI:-4.60-1.04; P=0.22) were similar between techniques.Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters.High-quality,large-volume,multi-center RCTs with standard outcome definitions are required。

Abstract：Objective We aimed to examine the current developments and challenges confronted by old age security in rural China.Data sources This study is based on the data from PubMed,Elsevier,Wiley,EBSCO,EMBASE,SCI Expanded,ProQuest,Google,and CNKI which is the most informative database in Chinese.Study selection Articles were selected with the search terms "rural","China","old","older",or "elder","elderly",or "aged","aging","security","culture","value","medical insurance" or "community based medical insurance" or "cooperative medical scheme".Related websites and yearbooks were searched as well.Results The socio-economic development has made the burden of traditional care for the rural elderly heavier than ever,and new challenges are emerging in rural communities,such as poor economic,deteriorating natural environment and health crisis.Conclusions The governments should improve the scale and caliber of rural old age security and strengthen regulations with great efforts in developing the rural economy and protecting the natural environment of rural communities。

Hematopoietic stem cell transplantation (SCT) is a potentially curative treatment for patients with hematologic malignancies,such as acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS).There has been tremendous progress in the past several decades in allogeneic SCT with better outcomes through improvements in supportive care,expansion of stem cell donor options (HLA-matched unrelated donors (MUD),haploidentical related donors,and cord blood units (CBUs)etc.),and introduction of better tolerated reduced intensity conditioning (RIC) regimens。