2013年 · 第126卷第24期

Abstract：Background Partial nephrectomy is currently the standard treatment for clinical T1 renal neoplasms,as it can provide oncologic outcomes equivalent to radical nephrectomy.The aim was to evaluate the efficacy of self-retaining suture (SRS)in renorrhaphy technique in retroperitoneal laparoscopic partial nephrectomy (LPN) for a single renal mass of moderate or high complexity by assessing peri-operative outcomes.Methods A retrospective analysis was done of 64 patients between 2010 and 2012 for complex renal mass (RENAL score ＞7) in whom retroperitoneal LPN was performed with two layers using continuous knotless barbed suture (Quill PDO SRS group; n=34) and absorbable vicryl (non-SRS group; n=30),respectively.Cases were matched for RENAL score.All the surgical procedures were performed by the same surgeon with experience of more than 500 cases of LPN.Comparisons were made in patients and preoperative outcomes and peri-operative complications between SRS group and non-SRS group.Results Mean warm ischemia time (WIT) in SRS group was less than non-SRS group (18.0 vs.24.8 minutes,P=0.021).Renorrhaphy suture cost in SRS group was lower than non-SRS group ($269.6 vs.$335.8,P=0.001).There were no significant differences between the two groups for postoperative changes in creatinine and estimated glomerular filtration rate and the rate of peri-operative complications.Conclusion SRS was safe for complex renal tumor with two layers,continuous and unknot suture,during LPN and would reduce the WIT and renorrhaphy suture cost significantly。

Abstract：Background Although platinum-based chemotherapy is a standard first-line treatment in advanced non-small cell lung cancer (NSCLC),further research for the safety and efficacy of combination chemotherapy in elderly patients has been required.The purpose of this study was to evaluate the efficacy and safety of gemcitabine and carboplatin as first-line treatment in elderly patients with advanced NSCLC and to evaluate the prognostic factors.Methods Eligibility included:(1) age of 70 years or more,(2) histologically confirmed NSCLC,(3) chemotherapy-na(i)ve,(4) advanced disease with stage ⅢB or Ⅳ,(5) Eastern Cooperative Oncology Group (ECOG) performance status (PS)0-2,(6) adequate organ function.Patients received intravenous carboplatin (area under curve (AUC)=5) on day 1 and gemcitabine (1000 mg/m2) on days 1 and 8,every 3 weeks.Results The medical records of forty patients were reviewed retrospectively.Median age was 73.9 years (range,70-84.6),and there were 27 men (67.5％).Thirty-seven patients (92.5％) had ECOG PS 0-1.Adenocarcinoma was found in 57.5％.Median cycles were administrated with 4.5 per person (range:1-6).Best responses were partial response in 22 (55.0％) patients and stable disease (SD) in 13 (32.5％).The median progression free survival (PFS) and overall survival (OS) were 5.9 months (95％ CI:4.5-7.3 months) and 9.6 months (95％ CI:8.2-11.0 months),respectively.Grade 4 hematologic toxicities for neutropenia (7.5％),thrombocytopenia (7.5％) and anemia (5.0％) were observed.Histology was significant prognostic factor for PFS (P=-0.024).Conclusion Gemcitabine and carboplatin combination chemotherapy is an effective and manageable treatment option in elderly advanced NSCLC patients with good performance status。

Abstract：Background With the increase in hemodialysis (HD) patients,the blood dialysis patient's quality of life (QoL) and longterm survival are still a challenge for clinicians.Recent studies have found that most of the HD patients have sleep disorders,which have a certain correlation with long-term survival and QoL.But there are few studies of Chinese in this field.This study aimed to investigate whether increasing the dialysis dose can improve sleep quality,so we treated HD patients on long intermittent hemodialysis (LIHD).Methods Forty patients who were treated by conventional HD at the Beijing Friendship Hospital Blood Purification Center were offered the option of LIHD.The patients' laboratony data,medication use,and questionnaire answers were analyzed.Conventional HD was delivered thrice weekly with 4 hours per treatment,and LIHD was delivered thrice weekly with 8 hours per treatment.The study lasted 6 months.Questionnaires included sleep quality survey and QoL SF-36; the former includes the Athens Insomnia Scale,Pittsburgh Sleep Quality Index (PSQI),and Epworth Sleepiness Scale (ESS).Results After conversion to LIHD the dialysis efficiency (Kt/V) significantly increased than before (P ＜0.05) and clearance rate of urea nitrogen also increased from 67 to 78％ (P ＜0.01).After conversion,median values for Hb increased from 108.95 to 126.55 g/L (P ＜0.01); albumin increased from 38.85 to 40.05 g/L (P ＜0.01).Phosphorus decreased from 2.69 to 1.54 mmol/L (P ＜0.01),but there was no alteration in blood calcium; phosphorus and calcium-phosphate product levels were under more control,but parathyroid hormone (iPTH) level did not change after conversion to LIHD.After conversion,blood pressure (BP) was better controlled than before and the mean number of antihypertensive drugs prescribed declined from 2.9 to 0.5 (P ＜0.01).There was a significant reduction in the use of erythropoietin-stimulating agent of 5250 U/w (P＜0.01).Sleep quality significantly improved in the 2 months after conversion to LIHD,and the PSQI score decreased from 10.80 to 5.45 and the ESS score decreased from 12.05 to 5.30 (P ＜0.01).However,sleep quality started to decline after 2 months on LIHD.QoL SF-36 score increased from 410.92 to 592.53 (P ＜0.01).Conclusion LIHD offers an effective improvement in dialysis adequacy for Chinese maintenance HD patients,but it improves sleep quality only briefly which may be related to loss of serum calcium and parathyroid dysfunction。

Abstract：Background Glucosylceramide synthase (GCS) can reduce ceramide levels and help cells escape ceramide-induced apoptosis,thus leading to multidrug resistance (MDR).However,its expression and clinical significance in thyroid neoplasms still remain unclear.We aimed to elucidate the expression of GCS and explore its correlation with the clinicopathological characteristics in papillary thyroid carcinomas (PTCs).Methods We retrospectively investigated GCS protein expression level in tissue specimens obtained from 108 consecutive PTC patients by immunohistochemistry and Western blotting.Results GCS was weakly positive or negative in normal follicular cells,but it was frequently overexpressed in PTC cells.GCS overexpression was associated with primary tumor size,local infiltration,lymph node metastasis,and local recurrence,but not associated with gender,age,pathological variants,tumor multifocality,tumor stage or distant metastasis.Western blotting also showed that GCS protein levels were much higher in PTCs' tissues than in normal thyroid tissues.Conclusion GCS was upregulated in PTCs and might be an independent factor affecting prognosis。

Abstract：Background Dental implant technology has developed rapidly in recent years.However,the use of implant-supported fixed bridges with cantilevers has been controversial.The purpose of this study was to evaluate the clinical results of the mandibular anterior implant-supported fixed bridges with a cantilever.Method Thirty-three patients (15 males,18 females; mean age,42.6 years; range 20-54 years) with two missing anterior mandibular teeth had single implant-supported fixed bridges with a cantilever.Clinical examination was recorded and radiographs were taken.The mean duration of follow-up was 30 months (15-44 months).Results All implants survived.Loosening or fracture of the prosthesis was not observed.All patients were satisfied with the treatment.The mean bone resorption values after 12,24,and 36 months of implant loading were 0.94,1.18 and 1.35 mm respectively.The changes of gingival papilla height ranged from 0 to 0.5 mm.There was significant difference between 1-year and 2 or 3 years restoration groups regarding the average gingival height changes (P ＜0.05).Conclusion After careful and precise selection of patients,restoration with a single implant-supported fixed bridge with a cantilever can be recommended if two anterior mandibular teeth are missing。

Abstract：Background The most common obstruction sites for obstructive sleep apnea hypopnea syndrome (OSAHS) are the oropharynx and the glossopharyx.The diagnosis of glossopharyngeal airway obstruction is difficult.The study aimed to assess the effect of upper airway reconstructive surgery for OSAHS based on polysomnography (PSG) after nasopharyngeal tube insertion (NPT-PSG),and to evaluate the clinical value of NPT-PSG in localizing the obstructive sites.Methods Seventy-nine OSAHS patients diagnosed with PSG were included in the study.PSG was repeated with a nasopharyngeal tube in place (NPT-PSG).Results of the two PSGs were compared.A NPT-PSG apnea hypopnea index (AHI) greater than 15 times per hour was used as a threshold for glossopharyngeal surgery.The cause of glossopharyngeal airway obstruction was taken into consideration in planning glossopharyngeal surgery.Assessment of efficacy was followed-up.Results After NPT-PSG,patients' AHI significantly decreased and lowest oxygen saturation (LaSO2) significantly increased.Of the 79 patients,47 were treated with uvulopalatopharyngoplasty (UPPP) alone and 32 with UPPP + glossopharyngeal surgery.Thirty-two patients were considered cured,33 markedly improved,and 14 failed.The overall surgery success rate was 82.3％.Conclusions NPT-PSG can be used as a diagnosis tool for localizing airway obstruction in OSAHS patients.Surgical treatment based on NPT-PSG results in good treatment efficacy。

Abstract：Background Sequence variants in the β-adrenergic receptor (ADRB) genes have a close relationship with the development of coronary artery disease (CAD) and the patient's prognosis.However,there is a lack of data on the role of the variants in ADRBs genes in Han Chinese patients with CAD.We aimed to investigate the association of genetic variants in the ADRB1 and ADRB2 genes with the incidence of major adverse cardiac event (MACE) in Han Chinese patients with CAD.Methods A total of 545 Han Chinese patients with CAD undergoing percutaneous coronary intervention (PCI) were recruited to the study and followed for one year.Three variant sites in ADRB1 (rs1801253) and ADRB2 (rs1042713 and rs1042714) were genotyped.The effect of the ADRB1 and ADRB2 genotypes on MACE within one year was assessed.Results There were 47 cases of MACE during follow-up.There was no significant difference in the incidence of MACE among patients carrying different genotypes of the three variants in ADRB1 and ADRB2 (Log-rank,all P ＞0.05).Cox regression analysis showed no association between three variants in ADRB1 and ADRB2 genes and the incidence of MACE during one-year follow-up,the adjusted hazard ratios (95％ confidence interval) for rs1801253,rs1042713 and rs1042714 were 1.05 (0.54-2.02),1.24 (0.58-2.64) and 1.66 (0.81-3.42),respectively.Conclusion Our data did not support a relationship between the three polymorphisms of ADRB1 (rs1801253) and ADRB2 (rs1042713 and rs1042714) genes and risk of subsequent cardiovascular events after PCI in Han Chinese patients with CAD。

Abstract：Background Thrombolysis with recombinant tissue plasminogen activator (rt-PA) has gained international recognition,clinical outcomes following this thrombolytic therapy varied from patient to patient.Factors affecting clinical outcomes have not been well understood yet,so this retrospective case-control study aimed to investigate factors that may influence clinical outcomes of acute ischemic stroke treated with intravenous rt-PA.Methods One hundred and one patients with acute ischemic stroke who received intravenous rt-PA thrombolysis within 4.5 hours from disease onset were included.Patients were divided into good or poor outcome group according to modified Rankin Scale (mRS) score,good outcome group:mRS score of 0-1; poor outcome group:mRS of 2-6.Stroke characteristics were compared between the two groups.Factors for stroke outcomes were analyzed via univariate analysis and Logistic regression.Results Of the 101 patients studied,patients in good outcome group (n=55) were significantly younger than patients in poor outcome group (n=46,(62.82±14.25) vs.(68.81±9.85) years,P=0.029).Good outcome group had fewer patients with diabetic history (9.09％ vs.28.26％,P=0.012),fewer patients with leukoaraiosis (7.27％ vs.28.26％,P=0.005) and presented with lower blood glucose level ((5.72±1.76) vs.(6.72±1.32) mmol/L,P=0.012),lower systolic blood pressure level ((135.45±19.36) vs.(148.78±19.39) mmHg,P=0.003),lower baseline NIHSS score (12.02±5.26 vs.15.78±4.98,P=0.002) and shorter onset-to-treatment time (OTT) ((2.38±1.21) vs.(2.57±1.03) hours,P=0.044) than poor outcome group.Logistic regression analysis showed that absence of diabetic history (odds ratio (OR) 0.968 (95％ CI 0.941-0.996)),absence of leukoaraiosis (OR 0.835 (95％ CI 0.712-0.980)),lower baseline NIHSS score (OR 0.885 (95％ CI 0.793-0.989)),lower pre-thrombolysis systolic blood pressure (OR 0.962 (95％ CI 0.929-0.997)),and lower blood glucose level (OR 0.699 (95％ CI 0.491-0.994)) before thrombolysis were significantly associated with better outcome.Conclusion Patients with no history of diabetes,no leukoaraiosis,low blood glucose level,low systolic blood pressure level and low baseline NIHSS score before thrombolysis have a better outcome。

Abstract：Background Immune-related hematocytopenia (IRH) is considered to be related with the production of autoantibody,as well as the activation of humoral immunity which is stimulated by B lymphocyte.This study aimed to observe the levels of various cytokines in the blood serum and the in situ active state of macrophage (Mφ) in the medullary hematopoietic microenvironment of IRH patients,and to probe into the immune mechanism and clinical significance of Mφ in hematopoietic cell injury.Methods ELISA is used to detect the IL-4,IL-6,IL-12,IL-17,and IFN-Y levels in the peripheral blood serum of 376 patients in pre-and post-therapy.Cytochemistry and cell immunochemistry methods are used to observe the peroxidase (POX),nonspecific esterase (NSE),hemosiderin granules,and HLA-DR activity of Mφ in the bone marrow of patients.Immunofluorescence is used to observe the expression of hemocyte antihuman globulin IgG antibody,lymphocytes CD4 molecule,Mφ membrane Fcyllreceptor (FcYllR),mannitose receptor (MR),IFN-y,ICAM-1,IL-12,and IL-17A and the formation mechanism of antibody-dependent cell-mediated cytotoxicity (ADCC) hematopoietic cell islands (HI) in the medullary hematopoietic microenvironment of patients.Glucocorticoid is used for treatment on the basis of anti-infection therapy,and gamma globulin stoss therapy is used for the appearance of ADCC-type HI or serious Mφ bloodthirsty phenomenon; if necessary,association of Cyclosporine A (CsA) should be used and chalybeate should be supplemented.Results In the patient group,the levels of IL-4,IL-6,IL-12,IL-17,and IFN-y were increased.After treatment,the cytokine levels gradually became normal.The activated Mφ in the marrow highly expressed NSE and POX,and Mφ swallowed more hemosiderin particles,but the iron in the cytoplasm of immature erythrocytes decreased.The activated Mφ expressed HLA-DR,MR,ICAM-1,IFN-Y,and IL-12.For patients with humoral immunity activation and bacterial infection,Mφ weakly expressed IL-17A but highly expressed FcYllR,and the phenomenon that ADCC-type HI broke pathological blood corpuscles often occurred; for the cellular immune activation along with virus infection,the white blood count (WBC)significantly reduced,Mφ weakly expressed FcYllR,secretory highly expressed IL-17A,and the phenomena that Mφ adhered to,captured and swallowed blood cell often occurred.After four weeks of anti-infective and immunosuppressive therapy,nuclear apoptosis of Mφ occurred in the bone marrow of patients,HI and bloodthirsty phenomenon disappeared,and the peripheral blood picture started to improve.Conclusions Mφ is an important antigen presenting cell in the IRH marrow for hematopoiesis destruction and an immune effector cell of hematopoietic injury; infection can promote the activation of Mφ,upregulate the impression of immune molecule and receptors,form ADCC HI,aggravate hematopoietic injury,and accelerate the destruction on hematopoietic cell。

Abstract：Background The need for transvenous lead extraction procedures of coronary sinus (CS) leads is increasing due to rising numbers of implanted cardiac resynchronization therapy devices during the past decade.Methods From January 2009 to June 2013,27 CS leads were scheduled for extraction in 27 patients (mean age (63.1±14.6) years).Indications for lead extraction were infection in 13 and lead dysfunction in 14 cases.Isolated extraction of CS leads was performed in eight,extraction of multiple leads in 19 cases.Among leads with an implant time of ＞12months (n=19) mean implant duration (MID) was (46.4±15.2) (12-76) months.Groups were formed depending on infectious or non-infectious indications (INF vs.Non-INF),and the use or non-use of extraction tools (ET1 vs.ET0).Results Among patients with an implant duration of ＞12 months,complete procedural success was 94.7％ and clinical success 100％.Operative mortality was zero.In the INF versus NON-INF groups complete procedural success (100％vs.91.7％,P=0.43),mean number of required extraction tools (0.7 (0-2) vs.0.9 (0-3),P=0.65) and MID (49.1±15.0 vs.44.7±15.8,P=0.83) did not differ significantly.Comparing the groups ET1 and ET0 showed no significant differences in complications (n=1 vs.n=1,P=0.81) and MID (47.0±17.5 vs.45.5±12.6,P=0.71).Conclusions In specialized centers transvenous lead extraction of coronary sinus leads with a mean implant duration of almost four years can be performed safely and effectively.Neither non-infectious indications nor the use of extraction tools negatively affected the outcome of the procedure。

Abstract：Background Bacteremia remains a significant cause of morbidity and mortality after kidney transplantation.This study was conducted to investigate whether the polymorphisms of tumor necrosis factor (TNF)-β,interleukin (IL)-1β,and IL-1 receptor antagonist (IL-1ra) gene predicted the susceptibility to bacteremia within the first 6 months after kidney transplantation.Methods Subjects comprised 82 infected kidney transplant recipients and 60 non-infected kidney transplant recipients.Bacteremia was diagnosed in 16 of the 82 infected recipients.Genomic DNA from these 142 kidney transplant recipients was extracted from peripheral blood leukocytes.Regions containing the Ncol polymorphic site at position +252 of TNF-βgene and the Aval polymorphic site at position-511 of IL-1β gene were amplified by polymerase chain reaction (PCR) and subsequently digested with Ncol and Aval restriction enzymes,respectively.The polymorphic regions within intron 2 of IL-1ra gene containing variable numbers of a tandem repeat (VNTR) of 86 base pairs were amplified by PCR.Results Genotypic and allelic frequencies were similar between infected recipients and non-infected ones.Individual locus analysis showed that recipient TNF-β and IL-1ra gene polymorphisms were not associated with the presence of bacteremia (P=0.684 and P=0.567,respectively).However,genotype analysis revealed that recipient IL-1β-511CC genotype was strongly associated with susceptibility to develop bacteremia (P=0.003).Recipient IL-1β-511CC genotype (odds ratio 5.242,95％ confidence intervals 1.645-16.706,P=0.005) independently predicted the risk for bacteremia within the first 6 months after kidney transplantation.Conclusions These findings indicate a critical role of IL-1β gene polymorphisms in susceptibility to bacteremia after kidney transplantation,which may be useful to screen for patients at higher risk for post-transplant bacteremias.Thus,the identified individuals can benefit from preventive treatment and a less potent immunosuppressive regimen。

Abstract：Background Growing epidemiologic evidence has indicated that genetics can predispose individuals to the occurrence of lone atrial fibrillation (AF).The angiotensin-converting enzyme 2 (ACE2) gene has been established to be associated with hypertension and left ventricular hypertrophy.The objective of our study was to investigate the association of ACE2 gene polymorphisms with lone AF.Methods A total of 265 consecutive lone AF patients and 289 healthy controls were successfully investigated.The polymorphisms rs2106809 and rs2285666 were genotyped by polymerase chain reaction (PCR) and direct sequencing.A Logistic regression model was used to determine the odds ratio (OR) and 95％ confidence intervals (CI) of variations of ACE2 for lone AF.Results The T allele of rs2106809 conferred an increased risk for lone AF (OR 1.24,95％ CI 1.01-1.52,P=0.03) in males after adjustment for conventional risk factors.SNP at rs2285666 in males was not significantly different between AF patients and controls.No association was found between the two polymorphisms in the female population with lone AF.After (36.3±4.5) months of follow-up,the end point data were obtained:death (cardiac and noncardiac),ischemic stroke,and heart failure.In the male subgroup,the associations between rs2106809 T male carriers and combined end points including ischemic stroke,heart failure,and death in our study were of significance (OR 3.6,95％ CI 1.0-13.1,P=0.04).Conclusions The results indicate that polymorphism at ACE2 gene is associated with male lone AF in a Chinese Han population.Lone AF males who carry the rs2106809 T allele are associated with adverse cardiac events。

Abstract：Background An accelerated muscle wasting was the pivotal factor for protein-energy wasting in end stage renal disease.However,very few researches have examined the skeletal muscle quantity and quality in clinical patients.This study investigated the muscle morphologic changes by magnetic resonance imaging (MRI) and analyzed the related factors in hemodialysis patients.Methods Fifty-eight patients receiving maintenance hemodialysis (HD) were investigated and 28 healthy adults with gender and age matched were used as controls (Control).Anthropometry,cytokine factors,and laboratory data were measured.The muscle and intermuscular adipose tissues (IMAT) were analyzed via a Thigh MRI.The bicep samples were observed after HE staining.Homeostatic model assessment of insulin resistance (HOMA-IR) was measured and their association with muscle wasting was analyzed.Results HD patients tended to have a lower protein diet,anthropometry data,and serum albumin,but the C reactive protein and interleukin-6 increased significantly.The MRI showed that HD patients had less muscle mass and a lower muscle/total ratio,but the fat/muscle and IMAT was higher when compared to the Control group.The muscle fiber showed atrophy and fat accumulation in the biceps samples come from the HD patients.Moreover,we found that the HD patients presented with a high level of plasma fasting insulin and increased HOMA-IR which negatively correlated with the muscle/total ratio,but positively with the fat/muscle ratio.Conclusions Muscle wasting presented early before an obvious malnutrition condition emerged in HD patients.The main morphological change was muscle atrophy along with intermuscular lipid accumulation.Insulin resistance was associated with muscle wasting in dialysis patients。

Abstract：Background Little is known about the influence of metabolic syndrome (MetS) on coronary artery calcification (CAC) in China.In this article,we aimed to explore the distribution of CAC in populations with and without MetS,and estimate the influence of MetS and its components on CAC in a community-based population of Beijing.Methods A total of 1647 local residents of Beijing,age 40-77 years,were recruited for a cardiovascular risk factors survey and were determined fasting plasma glucose (FPG),blood lipids,and 64 multi-detector computed tomography (64-MDCT)coronary artery calcium score (CACS) measurement (Agatston scoring).The distribution of CAC was described,and the influence of MetS components on CAC was evaluated.Results In this population,the prevalence and extent of CAC increased with increasing age and both were higher in MetS subjects compared to nonMetS subjects (all P ＜0.05),with the exception of those older than 65 years old.The risk of CAC increased with increasing numbers of MetS components,and the odds ratios for predicting positive CAC in subjects with 1,2,3,and-＞4 MetS components were 1.60,1.84,2.12,and 3.12,respectively (all P ＜0.05).Elevated blood pressure,elevated FPG,elevated triglycerides,and overweight increased the risk of CAC,yielding odds ratios of 2.64,1.67,1.32,and 1.37,respectively (all P ＜0.05).Conclusions In the Beijing community-based population,MetS increases the risk of CAC.The risk of CAC increases with increasing numbers of MetS components.Not only the number,but also the variety of risk factors for MetS is correlated with the risk of CAC.Elevated blood pressure,hyperglycemia,hypertriglyceridemia and overweight increase the risk of CAC。

Abstract：Background The efficacy of pemetrexed in the second-line treatment of Chinese patients with advanced non-small cell lung cancer (NSCLC) has been shown to be similar to that of docetaxel in a recent study; additionally,pemetrexed was associated with much better safety and toxicity profiles.Here,the survival without common toxicity criteria grade 3/4toxicity (SWT) data from a post hoc analysis of this recent prospective NSCLC study in Chinese patients is reported.This post hoc analysis differs from the main study; it focuses on the nonsquamous population to align with the current approval for pemetrexed in China.Methods A total of 154 patients with nonsquamous NSCLC received either pemetrexed (500 mg/m2 intravenously (Ⅳ)) or docetaxel (75 mg/m2 Ⅳ) on day 1 of 21-day cycles.SWT was analyzed using Kaplan-Meier and univariate Cox methods.Results Patients treated with pemetrexed had a longer median SWT than patients treated with docetaxel (7.4 months versus 1.2 months; unadjusted hazard ratio =0.59,95％ confidence interval (CI):0.41-0.84:P=0.003).At 12 and 18 months,the SWT event-free probability for pemetrexed patients (18 months:24.5％,95％C/ 13.9％-36.6％,vs.12.3％,95％ CI 4.8％-23.6％) was greater than that for docexatel patients (12 months:37.3％,95％ CI 26.5％-48.0％,vs.23.3％,95％ CI 14.4-33.4).The progressionfree survival without common toxicity criteria grade 3/4 toxicity (PFS-WT) was also statistically significantly longer for patients treated with pemetrexed than patients treated with docetaxel (1.9 months vs.1.1 months,P=0.002).Conclusions Chinese patients with nonsquamous NSCLC disease treated with pemetrexed had improved SWT beyond 6 months than those receiving docetaxel.This analysis supports a benefit-to-risk profile that favors pemetrexed over docetaxel in the second-line treatment of Chinese nonsquamous NSCLC patients。

Abstract：Background Reflux cholangitis has been the most common complication after Roux-en-Y choledochojejunostomy.In this study we intended to evaluate the perioperative and long-term efficacy of a new anastomosis method for choledochojejunostomy.Methods Clinical data of 143 eligible patients who underwent choledochojejunostomy in the Eastern Hepatobiliary Surgery Hospital affiliated to the Second Military Medical University,China between January 2007 and December 2010 were retrospectively analyzed.Among the patients,38 consecutive cases underwent this new anastomosis method for choledochojejunostomy (improved group,IG) and 105 underwent standard Roux-en-Y choledochojejunostomy (control group,CG).Changes in the incidence of cholangitis,the time of beginning to eat liquid meals,post-operative delayed gastric emptying and liver function between the two groups were compared.Results There was no statistical difference in the levels of alanine transaminase,alkaline phosphomonoesterase and gamma-glutamy transferase between the two groups.The time of beginning to eat liquid meals was significantly shorter in IG than CG (P ＜0.05).The incidence of delayed gastric emptying was lower in IG than CG,with statistical tendency between the two groups (P=0.052).Among nine patients with different degrees of acute cholangitis in the two groups,one patient (2.6％) in IG and eight (7.6％) in CG suffered from acute cholangitis within six months of follow-up after discharge,but with no statistical difference between the two groups (P ＞0.05).Of the nine patients with acute cholangitis,none in IGand four in CG were hospitalized for further treatment (P ＞0.05).Conclusions Patients in IG had satisfactory perioperative and long-term prognosis with shorter time of beginning to eat liquid meals and lower incidence of delayed gastric emptying.This new procedure of choledochojejunostomy by the way behind antrue pyloricum was easy and safe to perform with no mortality and low complication rates。

Abstract：Background There are not many studies about treatment of shoulder spasticity.Although botulinum toxin injection has been reported to be effective for shoulder spasticity,the effectiveness was judged by pain and limited motion change,but not the spasticity itself.Shoulder spasticity is considered to play an important role in hemiplegic frozen shoulder.However,the subscapularis muscle,unlike the pectoralis major muscle,is located deep beneath scapula,where conventional injection is difficult to perform.As extracorporeal shock wave therapy (ESWT) has been reported to be effective for spasticity relief,and we thought spasticity of subscapularis muscle located deep beneath the scapula would be a good candidate for ESWT treatment.This study was to evaluate the beneficial effects of radial ESWT (rESWT) on spastic subscapularis muscle in stroke patients.Methods This is an uncontrolled,prospective,unicenter,clinical pilot study.Stroke patients (n=57; mean age 55.4years) with spastic shoulders were recruited between June 2011 and February 2012 at the University Rehabilitation Hospital.rESWT was administered to each patient every two or three days for two weeks (five total treatments).Evaluation consisted of 11 measurements for each patient; at the start of each of the five treatments and once per week during the following six weeks.Spasticity was measured at external rotator muscles of the shoulder using the modified Ashworth scale (MAS),and passive range of motion (ROM) of the shoulder in external rotation was recorded.Pain was measured using a visual analogue scale (VAS) during passive ROM of the shoulder in external rotation,and was additionally recorded for patients who preserved cognitive and communicative ability (Pain group).Results Reduction in MAS and VAS and improvement of ROM during and after rESWT treatments were prominent compared to baseline.The reduction in MAS and VAS and improvement of ROM continued four weeks after the last treatment and the effects of the treatment decreased afterward.Conclusion rESWT will be able to provide stroke patients with an effective and safe procedure for the reduction of spasticity and pain as well as for the improvement of ROM of spastic shoulders。

Abstract：Background Although exercise testing has been suggested to help predict clinical outcome,limited data are available to guide how exercise Doppler echocardiography (ECG) can be used clinically in asymptomatic patients with aortic stenosis (AS).The aim of this study was to assess the clinical value of exercise echocardiographic testing in asymptomatic patients with severe AS.Methods Symptom-limited treadmill exercise testing using the modified Bruce protocol was performed in 31 asymptomatic patients (mean age (62±11) years) with severe AS (aortic valve area ＜1 cm2,peak aortic velocity (AV Vmax) ＞4 m/sec,or a mean transaortic pressure gradient (AV mean PG) ＞40 mmHg (1 mmHg=0.133 kPa)) with normal left ventricular (LV)systolic function (LV ejection fraction (EF) ＞50％).Clinical symptoms,vital signs,ECG,and Doppler hemodynamics were obtained during and/or immediately after exercise.Results Aortic valve replacement (AVR) was performed in 18 patients during follow-up.The patients who had AVR exhibited higher baseline AV mean PG (51 (35-84) vs.44 (25.2-57.0) mmHg; P=0.031).There were no significant differences between the AVR group and non-AVR group including exercise duration (7.47 (2.32-11.59) vs.7.25 (4.06-10.52) minutes,P=0.917),exercise capacity (10.1 (4.6-12.8) vs.10.1 (7.0-12.8) metabolic equivalents,P=0.675),and an increment in AV mean PG by exercise (18.5 (3.2-48.0) vs.12.6 (4.4-32.1) mmHg,P=0.366).Univariate regression analysis revealed that independent determinant of AVR was the baseline AV mean PG (P=0.031).Conclusions Although additional value of exercise ECG was demonstrated,baseline transaortic mean pressure gradient is the major determinant of AVR.Further large-scale prospective studies are required to determine whether surgery should be recommended in the presence of an abnormal exercise ECG in asymptomatic severe AS。

Abstract：Background 2-Suture longitudinal vasoepididymostomy shows superiority to transverse technique in an animal study; to date,this has not been consistently confirmed in human body.In the present study,we evaluated the effectiveness of 2-suture transverse intussusception vasoepididymostomy and compared the rationality between transverse and longitudinal techniques.Methods From May 2007 to December 2008,we performed 2-suture transverse vasoepididymostomy in 19 consecutive patients,as described by Marmar with modification.Between March 2009 and January 2010,the internal diameter of the vas lumen and the outer diameter of the epididymal tube were measured using microruler (21 patients and 37 sides).Results Three patients lost to follow-up.At the first follow-up period (ranged from 10 to 24 months),the patency rate was 56.3％ (9/16) and the natural pregnancy rate was 25％ (4/16).At the second follow-up period (ranged from 46 to 63months),the patency rate was 68.8％ (11/16),the natural pregnancy rate was 37.5％ (6/16),respectively,and the takehome baby rate was 31.3％ (5/16).The diameter of the vas lumen and the outer diameter of the epididymal tubule were (0.512±0.046) mm and (0.572±0.051) mm (P ＜0.001),respectively.Conclusion Transverse 2-suture intussusception vasoepididymostomy is still an effective technique in treating obstructive azoospermia。

Abstract：Background Drug-eluting stents represent a major advance in interventional cardiology.However,the current drugeluting stents have significant limitations.One of the major problems is very late stent thrombosis,which is likely caused by inflammation and a hypersensitivity reaction related to a polymer on the stent.A polymer-free sirolimus-eluting stent with a unique nano-porous surface has been developed.This study aimed to evaluate this novel polymer-free sirolimuseluting stent for its efficacy and safety in a pig model.Methods Stents were directly coated with sirolimus (a drug concentration of 2.2 μg/mm2 on the stent surface).The polymer-free sirolimus-eluting stents (PFSES) were compared to standard polymer-coated sirolimus-eluting stents (PCSES) and bare-metal stents (BMS) in 18 pigs.Results At one month the degree of neointimal hyperplasia was similar between the two sirolimus-eluting stent groups and was significantly less compared to BMS ((1.93±0.51) mm2,(1.57±0.69) mm2 vs.(4.45±1.05) mm2,P ＜0.05) At three months,PFSES maintained the low level of neointima ((2.41±0.99) mm2 vs.(4.32±1.16) mm2,P ＜0.05),whereas PCSES had developed significant neointimal proliferation similar to BMS.The inflammation level was significantly higher in PCSES when compared with BMS three months post-implantation (2.50±0.55 vs.0.83±0.75,P ＜0.05) whereas PFSES showed a low level of inflammation comparable to PCSES (1.33±0.52 vs.2.50±0.55,P ＜0.05).Conclusion The PFSES is effective and safe,and appears to be superior to standard PCSEs。

Abstract：Background Decorin is a small leucine-rich proteoglycan and it plays an important role in regulation of cell growth and migration in various tumor cell lines.Decorin was found down-regulated in non-small cell lung cancer tissue and may be involved in regulation of lung cancer development.Methods In this study,lentivirus-mediated RNA interference and over expression were employed to change the expression levels of decorin in lung cancer A549 cells.We tested the cell cycle of A549 cells and the expression of transforming growth factor (TGF)-β1,cyclin D1,epidermal growth factor receptor (EGFR),P53,and P21.Results We found that up-regulation of decorin could inhibit proliferation,block cell cycle at G1 and decrease invasive activity of A549 cells.Moreover,we also show that up-regulation of decorin induced significant decreases of TGF-β1,cyclin D1 expression,phosphorylation of EGFR,and increases of P53 and P21 expression.Opposite results were observed in A549 cells with down-regulation of decorin.Conclusion Our results suggest that decorin is a key regulator involved in proliferation and migration ofA549 cells。

Abstract：Background Visceral pain is a common cause for seeking medical attention.Afferent fibers innervating viscera project to the central nervous system via sympathetic nerves.The lumbar sympathetic nerve trunk lies in front of the lumbar spine.Thus,it is possible for patients to suffer visceral pain originating from sympathetic nerve irritation induced by anterior herniation of the lumbar disc.This study aimed to evaluate lumbar discogenic visceral pain and its treatment.Methods Twelve consecutive patients with a median age of 56.4 years were enrolled for investigation between June 2012 and December 2012.These patients suffered from long-term abdominal pain unresponsive to current treatment options.Apart from obvious anterior herniation of the lumbar discs and high signal intensity anterior to the herniated disc on magnetic resonance imaging,no significant pathology was noted on gastroscopy,vascular ultrasound,or abdominal computed tomography (CT).To prove that their visceral pain originated from the anteriorly protruding disc,we evaluated whether pain was relieved by sympathetic block at the level of the anteriorly protruding disc.If the block was effective,CT-guided continuous lumbar sympathetic nerve block was finally performed.Results All patients were positive for pain relief by sympathetic block.Furthermore,the average Visual Analog Scale of visceral pain significantly improved after treatment in all patients (P ＜0.05).Up to 11/12 patients had satisfactory pain relief at 1 week after discharge,8/12 at 4 weeks,7/12 at 8 weeks,6/12 at 12 weeks,and 5/12 at 24 weeks.Conclusions It is important to consider the possibility of discogenic visceral pain secondary to anterior herniation of the lumbar disc when forming a differential diagnosis for seemingly idiopathic abdominal pain.Continuous lumbar sympathetic nerve block is an effective and safe therapy for patients with discogenic visceral pain。

Abstract：Background C-reactive protein (CRP) gene +1059 G/C polymorphism has been reported to be associated with coronary heart disease (CHD) risk,but the results remain inconclusive.This meta-analysis was therefore conducted to clarify these controversies.Methods A comprehensive search was conducted to identify all case control studies on the association between CRP gene +1059 G/C polymorphism and CHD risk.All the related studies were further strictly selected according to the inclusion criteria.Meta-analysis was performed with STATA 10.1 (StataCorp,USA).The association was assessed by odds ratio (OR) and 95％ confidence interval (CI); both Begg's funnel plot and Egger's regression test were used to assess the publication bias.Results This meta-analysis on a total of 13 studies comprising 6316 CHD cases and 4467 controls showed no significant association between CRP gene +1059 G/C polymorphism and CHD risk in the overall study (for C/C+C/G vs.G/G:OR=1.01,95％ CI=0.81-1.25,P=0.96; for C/C vs.C/G+G/G:OR=1.17,95％ CI=0.77-1.77,P=0.47; for C/C vs.G/G:OR=1.17,95％ CI=0.77-1.77,P=0.47; for C allele vs.G allele:OR=1.01,95％ CI=0.81-1.24,P=0.96).However,in the subgroup analysis by ethnicity,the results showed significant association between CRP gene +1059 G/C polymorphism and CHD risk among Caucasians (for C/C vs.G/G:OR=2.54,95％ CI=1.13-5.72,P=0.02; C/C vs.C/G+G/G:OR=2.45,95％ CI=1.09-5.51,P=0.03),but not among Asians and Africans (P ＞0.05).Conclusion CRP gene +1059 G/C polymorphism may be associated with increased CHD risk among Caucasians and more evidences need to validate the conclusion。

Part Ⅰ.CRITERIA FOR DETERMINATION OF BRAIN DEATH Ⅰ.Prerequisites of the determination A.The cause of coma is known. B.Exclusion of reversible coma. Ⅱ.Clinical diagnosis The clinical diagnosis of brain death should fulfill all thethree conditions listed as follows: A.Deep coma. B.Absence of brainstem reflexes. C.No spontaneous respiration (depending on mechanicalventilation to maintain breath completely and apnea testto confirm no spontaneous respiration)。

Autoimmune pancreatitis (AIP) is a rare and special type of chronic pancreatitis,which was earlier referred to as lymphoplasmacytic sclerosing pancreatitis (LPSP),idiopathic duct destructive pancreatitis,or granulocyte epithelial lesion-positive pancreatitis.The concept of AIP was not coined by Yoshida until 1995.1 Although AIP was initially reported in Japan,USA and Europe,AIP cases have increased rapidly in China in the last few years.According to statistics,AIP accounts for 2.2％-2.4％ of pancreatectomy and 19.5％-28.0％ of benign pancreatic operation.2 Because AIP is induced by autoimmune mechanism,oral steroid therapy is usually effective and most of the time operation is unnecessary.In order to deepen our understanding about the diagnosis and treatment of AIP,to reduce the chances of unwanted operation,we retrospectively analyzed AIP cases admitted to our hospital in the recent years。

Takayasu's arteritis (TA) is a chronic inflammatory disease of the aorta and its thoracic and abdominal parts,most commonly involving the aortic arch and the arteries that arise from it.TA is an autoimmune disease,although certain HLA-linked genetic predispositions have been observed.TA affects females 2 to 8 times more frequently than males.The onset age is between 10 to 40 years old.1 TA is extremely uncommon in Poland.Corticosteroids are the choice of treatment for TA,producing evident improvement of systemic and focal symptoms in approximately 50％ of patients.Surgery is used in the advanced phase of TA,when symptoms resulting from organ ischemia caused by occlusion or stenosis of the arteries predominate.1

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive liver disease characterized by intermittent attacks of cholestasis that was first reported by Summerskill and Walshe in 1959.1 A few reports on patients with BRIC in China have been described in recent years,however,it is still a challenge to give the patients a correct diagnosis.Therefore,we collected five cases in the Beijing Friendship Hospital and the China-Japan Friendship Hospital in the past two years to summarize their clinical features,and explore the mutation region of the ATP8B1 gene from Chinese patients with BRIC。

Takayasu arteritis (TA) is a chronic progressive nonspecific vasculitis that involves the aorta and its main branches,resulting in luminal stenosis in the large vessels.Steroid therapy is the foundation for TA treatment and the guarantee of surgery.When a patient presents with uncontrolled symptoms,surgical treatment is the only measure that may be adopted to prevent greater risk to life.However,surgical repair for extensive arteriopathy requires an ingenious design to avoid morbidity in response to the complexity of the pathophysiology of TA.A 41-year-old woman presented with pulselessness,recurrent dizziness,and visual disturbance for the past 23 years.The patient had been diagnosed with TA 13 years ago and had received steroid therapy.However,the symptoms of dizziness and visual disturbance had increased in intensity and duration over the last 2 years。

Hepatic ectopic pregnancies are extremely rare and can be associated with excessive maternal morbidity and mortality.1 Given the rarity of such a form of ectopic pregnancy and the associated potential mortality,early diagnosis and appropriate treatment is essential.We present a unique case of an ectopic pregnancy with a 10-week-old fetus implanted on the liver,which was treated successfully by hepatic resection。

Rheumatic heart disease is still highly prevalent in developing countries where the incidence of coronary artery disease (CAD) is also arising.Consequently the occurrence of coexistent CAD and mitral stenosis (MS)dominantly caused by rheumatic fever is more frequent in these countries.Comorbidities such as pulmonary and renal dysfunction occur frequently in these aging populations.Off-pump surgery is widely applied in patients with concomitant CAD and severe comorbidities due to lower incidence of postoperative morbidity.Closed mitral commissurotomy (CMC) is a well established treatment for patients with mitral stenosis.We report here a case of moderate stenosis combined with seriously diffuse 3-vessel CAD and severe chronic obstructive pulmonary disease (COPD) in an elder male treated with off-pump coronary artery bypass (OPCAB) plus CMC。

Human chorionic gonadotropin (hCG) level in cerebrospinal fluid (CSF hCG) is very useful for the diagnosis of intracranial germinoma.We have previously reported on two patients with germinoma located in the basal ganglia.Their CSF hCG levels were extremely low upon presentation.1 However,significantly increased CSF hCG levels were detected when these two patients had a relapse.The experience acquired in these two cases is helpful to appropriately interpret the CSF hCG levels that are used to detect intracranial germinoma,evaluate the effectiveness of treatment and monitor recurrence。

To the editor:In a retrospective observational clinical study including 482 elderly patients with coronary heart disease undergoing elective major noncardiac surgery,Liu et al1 showed that the incidence of perioperative major adverse cardiac events (MACEs)was 12.7％,and five risk factors were independently associated with perioperative MACEs.This study makes an important contribution to the effort to define risk factors for perioperative MACEs in elderly patients with coronary heart disease undergoing noncardiac surgery.Strengths of this study include a large sample of patients and most of the known risk factors that can affect perioperative MACEs.Furthermore,the authors have used appropriate methods to identify independent risk factors for perioperative MACEs.However,in our view,there are several aspects of this study that should be considered。

To the editor:We reported three cases of cavernous angiomas in different locations that were surgically treated and discussed the surgical strategy of cavernous angiomas.Case 1:A 35-year-old woman experienced right-side numbness,right facial palsy,swallowing difficulty,gait disturbance and refractory hiccups.Magnetic resonance imaging (MRI) showed a round 3 cm cavernous angioma in the medulla oblongata (Figure 1A).She underwent surgery via a midline suboccipital approach (Figure 1B and 1C).The postoperative MRI confirmed total resection.She discharged on foot with residual right sided numbness,trunkal ataxia and nystagmus。

To the editor:In March 2013,three urban residents were admitted to hospitals with acute infections of the lower respiratory tracts.Later,it was found that the infections were caused by a newlyemergent reassortant avian-origin virus:influenza A (H7N9)。

To the editor:Antineutrophil cytoplasmic antibodies (ANCA) are a group of autoantibodies associated with various diseases and can be detected in drug-induced vasculitides.Here,we report two patients of drug-induced vasculitides combind with kidney damage (one is followed-up 10 years,the other is followed-up 3 years) and review the literature for the occurrence of this complication,share the common phenomenon with our peers。

To the editor:Cardiogenic shock is one of the devastating complications of acute myocardial infarction.The mortality rate is still unacceptably high though having some treatment options such as complete revascularization,vasoactive drugs and mechanical support devices.Intra-aortic balloon pump (IABP) is the oldest and most frequently used supporting method.In one of the past issues of the joumal,Wu et al1 retrospectively analyzed the factors affecting the outcomes of the elderly Chinese patients with cardiogenic shock treated with IABP.This study stimulated us to bring up some controversial issues of IABP support.Some current data in terms of IABP usage should be reviewed more comprehensively beyond knowing the factors affecting the outcomes。

To the editor:Hospital management in China has been in a transition for a long period oftime.1 There have been four major stages of development which have coincided with the major stages of hospital management development:(1) The stage of establishing civilized hospitals (1978-1984);(2) The stage of standardizing hospital management (1985-1988);(3) The stage of hospital stratified management (1989-2004);(4) The stage of comprehensive implementation of the hospital management evaluation guide (2005-).2 Each stage had its challenges and changes in hospital management,but the most changes have come since the opening and reform policy and afterward。

To the editor:Malignant ventricular tachyarrhythmias after cardiac resynchronization therapy (CRT) have been reported recently.Such arrhythmia is always lethal to the patients.The specific mechanisms for this phenomon are still unknown.1,2