2003年 · 第116卷第11期

Objective To investigate whether three biallelic polymorphisms at positions -592, -819 and -1082in the promoter region of the IL-10 gene are associated with increased incidence of severe sepsis. Methods The IL-10 -592, -819 and -1082 polymorphisms were typed using polymerase chain reaction followed by digestion with the restriction enzymes Rsa I, Mae III and MnI I, respectively. Results Patients with severe sepsis were more likely to have IL-10 -1082 allele 1, compared with controls (P <0. 05) . Genotype distribution of the IL-10 - 1082 polymorphism significantly differed between patients and controls (P <0. 05). However, the allele frequencies and genotype distribution of the IL-10 -1082 polymorphism did not differ between surviving and dead patients (P>0. 05). No significant differences in the genotype distribution and allele frequencies of the IL-10 -592 and IL-10-819 polymorphisms were observed between patients with severe sepsis and heathy controls, nor between surviving and dead patients (P> 0. 05). Conclusions The polymorphism at position -1082 in the promoter region of the IL-10 gene may be associated with susceptibility to severe sepsis. In constrast, the other two highly linked IL-10polymorphisms are not associated with incidence or the outcome of severe sepsis. Chin Med J 2003; 116(11): 1756-1759

Objective To evaluate the safety and analgesic efficacy of patient controlled intravenous analgesia(PCIA) with tramadol, and to compare its benefits and risks with combined spinal-epidural analgesia(CSEA)+ patient controlled epidural analgesia (PCEA). Methods Eighty American Society of Anesthesiologist (ASA) I - II at term parturients in active labor were randomly divided into 3 groups: the control group (n=30) received no analgesia; group A(n=30) received spinal administration with ropivacaine 2. 5 mg and fentanyl 5 μg, then with PCEA;group B (n=20) received 1 mg/kg tramadol loading dose i. v.. PCIA with 0.75%tramadol and it included: PCA dose 2 ml, lockout time 10 minutes, background infusion 2 ml/h, total dose no more than 400 mg. The intensity of pain was evaluated using Visual Analogue Scale (VAS). Results Both group A and B showed good pain relief. VAS pain scores were significantly decreased in group A and B compared with those in the control group (P<0. 01). In comparison with group B, the VAS pain scores decreased in group A (P <0. 05). The onset times of analgesia in group A were shorter than those in group B (P<0.05). Apgar scores in group B were lower than those in group A(P <0.05) . The periods of second stage of labor in group A were longer than those in the control group and group B (P<0. 05). The cesarean delivery rate was significantly higher in the control group(16. 7%) than in group A (3.3%) and group B (5. 0%), but it did not differ between group A and B. There were no significant differences in vital signs, fetal heart rate, degree of motor block, and uterine contractions among the 3 groups. Conclusions PCIA with tramadol is now a useful alternative when patients are not candidates for CSEA for labor, or do not want to have a neuraxial block anesthesia. However, sometimes it may not provide satisfactory analgesic effect. Chin Med J 2003; 116(11): 1752-1755

Objective To study the stomach role in exogenous oxalate absorption. Methods The kinetic variation of urinary oxalate excretion (mg/min) in 10 healthy adults and 8patients who underwent total gastrectomy was investigated before and after an oral spinach oxalate load. The bioavailability of the oxalate load in the healthy adults was calculated and compared with that in the patients. Results The oxalate content in the oral spinach load was 2567 - 2670 mg. The urinary oxalate excretion (mg/min) in the 10 healthy adults increased significantly 20 minutes after loading (this increase was compared against their basic oxalate excretion level of 0. 0331 ± 0. 0203). Further observations after loading include: a first peak of oxalate excretion 40 minutes after loading; an oxalate excretion level double that of the basic level after 60 minutes (0. 0732 ±0. 0294) and a second peak appearing at 3 hours (P <0. 01). A ''first peak" (0. 063%±0. 062%) was not in any of the patients who underwent a total gastrectomy. Furthermore, a bioavailability of oxalate, which was 50%lower than that in the healthy subjects, appeared 60 minutes after loading (0. 098%±0. 071%, P<0. 01). Conclusions The stomach is a powerful oxalate absorption organ under normal physiological conditions. Further investigation on the relationship between stomach dysfunction and urinary calcium oxalate formation is needed. Chin Med J 2003; 116(11): 1749-1751

Objective To report our experiences in retroperitonescopic renal pedicle lymphatic stripping for chyluria. Methods Six cases of filarial chyluria were admitted to our hospital from November 2001 to June 2002. Of these cases, 4 were men and 2 women, with age ranging from 34 to 52 years (mean, 42years) . Diagnosis was made by using urine test for the presence of chyle and fat globule,cystoscopy, excretory urogram and retrograde pyelography. Chyluria was found on the left renal unit in 2 cases and on the right side in 4 cases. The technique of retroperitoneoscopic management of chyluria consisted of nephrolympholysis, hilar vessel stripping and ureterolympholysis. Results Operative time ranged from 69 to 120 minutes (mean, 95 minutes). Intraoperative blood loss was 50 -180 ml (mean, 85 ml). Chyluria disappeared in all patients immediately after operation. Mild hematuria occurred in 4 cases within 12 hours and disappeared at 24 hours. Subcutaneous emphysema around the lesions was found in 2 cases and was spontaneously absorbed 3 days after the treatment. There was no lymphatic leak at the lesions. The patients were discharged from the hospital 5-9 days after the treatment. All patients gained weight and their haemoglobin and serum protein increased by 13. 5 g/L and 3. 66 g/L respectively. No chyluria recurrence was reported during 1-1.6 years follow-up. Conclusions Retroperitoneoscopic renal pedicle lymphatic disconnection for chyluria is a safe,effective and efficient surgical procedure with minimal invasion, less pain, lower morbidity, short hospital stay and rapid recovery. Chin Med J 2003; 116(11): 1746-1748

Objective To assess the impact of the number, and time of acute rejection (AR) and outcome of anti-rejection therapy on the long-term survival of renal allografts and the relative risk factors. Methods The Kaplan-Meier analysis and log-rank test were used to calculate the survival rates of patients and grafts in no acute rejection group (NAR, 895 patients), 1 rejection episode group (1 AR, 183), 2 and more than 2 rejection episodes group (2AR, 17), acute rejection group [AR (1AR+2AR), 200], early acute rejection group (within 90 days after transplantation, EAR, 125), late acute rejection group (91 days later, LAR, 58), completely AR reversed group (CAR, 105), and incompletely AR reversed group (IAR, 68). The relative risk factors were analyzed by the Cox proportional hazards regression. Results The 5- and 10-year survival rates of renal allografts were 75. 4%and 17. 1% in AR and 93. 2%and 86. 5%in the NAR group (P<0. 0001). The long-term graft survival was much lower in the 2AR group than in the NAR or 1 AR groups (P<0. 0001 and P=0. 002, respectively). It was similar in either the NAR or CAR groups (P=0. 31), but it was significantly lower (P<0. 0001) in the IAR group. Multivariate Cox regression analysis revealed that the outcome of anti-rejection therapy is an important risk factor affecting the long-term survival of allografts. Conclusions AR is significantly associated with poor long-term survival of renal allografts. But the long-term graft survival of patients with one acute rejection but completely reversed is not significantly different from that of patients without acute rejection. Chin Med J 2003; 116(11): 1741-1745

Objective To investigate retrospectively the incidence, distribution of primary disease and clinicopathologic characteristics of diffuse crescentic glomerulonephritis (DCGN) in Chinese patients. Methods One hundred and seventy-two consecutive patients diagnosed as having DCGN out of 9828cases of non-transplanting renal biopsies over sixteen years, were studied. DCGN is categorized into three types according to immunopathologic characteristics. The incidence of this disease, its primary diseases, clinical characteristics and serum antineutrophil cytoplasmic antibodies (ANCAs) were analyzed. Results The distribution of patients among the three classifications was 8. 7%type I, 68. 6%type II and 22. 7%type III. Clinically, the majority of patients (69. 8%) presented rapidly progressive glomerulonephritis (RPGN), but 30. 2%manifested a chronic nephritic syndrome or chronic renal failure. In terms of related conditions, 93%were anemic, 61. 6%had hypertension, 50. 6%oliguria,45. 3%nephrotic syndrome, 43%uremic syndrome and 39. 5%displayed gross hematuria. Those patients who were positive in serum for ANCAs had predominantly type III DCGN. Two cases with anti-GBM-antibody crescentic glomerulonephritis and three with lupus nephritis were also positive for ANCAs in serum. Conclusion DCGN is not rare in Chinese patients. A majority of patients in our study presented with RPGN, but 30. 2%manifested a chronic renal failure. Lupus patients with DCGN that were positive for ANCAs had more severe vasculitic lesions. Chin Med J 2003; 116(11): 1737-1740

Objective To study the human dystrophin gene molecular deletion mechanism, we analyzed breakpoint regions within junction fragments of deletion-type patients and investigated whether the dystrophin gene's intron structure might be related to intron instability. Methods Junction fragments corresponding to exon 46 and 51 deletions were cloned. The breakpoint regions were sequenced, and the features of introns with available Genebank sequences were analyzed. Results An analysis of junction fragment sequences corresponding to exon 46 and 51 deletions showed that all 5' and 3' breakpoints are located within repeat sequences. No small insertions, small deletions, or point mutations are located near the breakpoint junctions. By analyzing the secondary structure of the junction fragments, we demonstrated that all junction fragment breakpoints are located in non-matching regions of single-stranded hairpin loops. A high concentration of repetitive elements is found to be a key feature of many dystrophin introns. In total, 34. 8%of the overall dystrophin intron sequences is composed of repeat sequences. Conclusion Repeat elements in many dystrophin gene introns are the key to their structural bases and reflect intron instability. As a result of the primary DNA sequences, single-stranded hairpin loops form, increasing the instability of the gene, and forming the base for breaks in the DNA. The formation of the single-stranded hairpins can result in reattachment of two different breakpoints, producing a deletion. Chin Med J 2003; 116(11): 1733-1736

Objective To compare the clinical characteristics between type 2 diabetes mellitus (T2DM) and latent autoimmune diabetes in adults (LADA) with different titers of glutamic acid decarboxylase autoantibody (GADA) and to define the two distinct subtypes of LADA. Methods Sera of 750 patients with an initial diagnosis of T2DM from central south of China were screened for GADA using a radioligand assay. The distribution and frequency of GADA levels were described. Two hundred and ninety-five patients were divided into the T2DM group (n=233) and the LADA group (n=62) to compare the age of onset, body mass index, HbA1c, C-peptide, hypertension, dyslipidemia and chronic diabetic complications. Furthermore, LADA patients with different GADA titers were subdivided to analyze the same indexes as the above. Results The prevalence of LADA (defined as GADA≥0.05, namely GADA positive) was 9. 7%in the 750 initially diagnosed type 2 diabetic patients. Compared with T2DM, LADA patients were younger at their ages of onset, had lower C-peptide and body mass index, and also had less cases with hypertension and with dyslipidemia. However, only patients with high titer of GADA had poorer beta cell functions and less diabetic complications compared to T2DM and low GADA titer of LADA patients. Patients with low GADA titer were similar to T2DM patients, except that they were prone to develop ketosis more frequently. Conclusions Two clinically distinct subtypes of LADA can be identified by GADA levels in patients initially-diagnosed as type 2 diabetes. Patients with high titer of GADA (GADA ≥ 0. 5) subsequently develope more insulin dependency, which are classified as LADA-type 1; while those with lower GADA titer (0. 05 ≤ GADA <0. 5) and having clinical and metabolic phenotypes of type 2 diabetes are classified as LADA-type 2. Chin Med J 2003; 116(11): 1728-1732

Objective Diffuse panbronchiolitis, a distinct clinical entity of unknown etiology, has been reported originally and primarily in Japanese and rarely in non-Japanese populations. Macrolide therapy is effective for this once dismal disease. Diffuse panbronchiolitis complicated with thymoma is uncommon; only 2 cases have been reported to date. The aims of this study were to describe the clinical profiles, assess the response to macrolide therapy, and to discuss the possible pathogenesis of diffuse panbronchiolitis in this setting. Methods The clinical profiles, macrolide therapy response of diffuse panbronchiolitis complicated with encapsulated thymoma in 2 histologically confirmed cases were described and discussed with the 2 cases reported in the literature: one complicated with encapsulated thymoma, another with invasive thymoma. Results Of the 2 cases, both had negative PPD skin testing and abnormal serum levels of various immunoglobulins, 1 had positive anti-nuclear antibody, but none had elevated cold hemagglutinin titers, and both had an excellent response to macrolide therapy. Of the 2 cases reported in the literature, both had negative PPD or tuberculin skin testing, 1 had severe hypogammaglobulinemia, 1had elevated IgA, 1 had positive anti-DNA, 1 had elevated cold hemagglutinin titers, but both died of respiratory failure in spite of macrolide therapy in 1 case. Conclusions Prognosis for diffuse panbronchiolitis complicated with thymoma may depend on the nature of the thymoma and on the disease course. Macrolide therapy is also effective if administered early in the disease course and if the thymoma is cured. Immunological factors may play an important role in the pathogenesis of diffuse panbronchiolitis in this setting. Chin Med J 2003; 116(11): 1723-1727

Objective To characterize the differences between clinical manifestations in immunocompromised patients (ICPs) and non-immunocompromised patients (non-ICPs) with tuberculosis. Methods Underlying diseases, clinical presentations, misdiagnosis, treatment and prognosis, etc,were analyzed retrospectively in 115 tuberculosis patients, including 39 ICPs and 76 non-ICPs. Results Compared with non-ICPs, the individuals who were ICP had more expectoration (64. 1 %vs 35. 5%), pulmonary moist rale (41. 0%vs 9.2%), miliary pulmonary tuberculosis (30. 8%vs 2. 6%), pleural effusion (48. 7% vs 25. 0%) and lymphadenopathy (18. 0% vs 4. 0 %). ICPs had less lung cavity (15. 4%vs 22. 4%) and pleural thickening (15. 4%vs 23. 7%) compared to non-ICPs. Pulmonary tuberculosis in ICPs was prone to be misdiagnosed as pneumonia (23. 1 %vs 6. 6%). Pulmonary tuberculosis was found in the apicoposterior segment (SI + SII) in more cases in non-ICPs (21. 7%, 10/46) than ICPs (10. 3%, 3/29). The diagnostic value of tuberculin skin test and adenosine deaminase in pleural effusions was limited in ICPs. ICPs had significantly poorer prognoses than non-ICPs. Conclusion The clinical manifestations of ICPs with tuberculosis are atypical, misdiagnosis often occurs, resulting in a worse prognosis. Chin Med J 2003; 116(11): 1717-1722

Objective A retrospective study was undertaken to examine therapeutic strategies used in 6 patients with left renal venal nutcracker phenomenon. Methods Three patients underwent surgical transposition of the superior mesenteric artery. Three patients underwent endograft stent implantations with intervention. Results All 6 cases were completely relieved of left renal vein compression after the operations, leading to improved clinical symptoms and normal urine tests. Conclusions Transposition of the superior mesenteric artery is a feasible method, but leads to complications and great trauma. Treating left renal venal nutcracker phenomenon with endografting techniques is minimally invasive in certain cases, and seems to have a prospective future. Chin Med J 2003; 116(11): 1782-1784

Objective To investigate the relationship between the presence of the TNF2 allele and plasma concentrations of tumor necrosis factor-α (TNFα) and soluble TNF receptor (sTNF-R) with the development of acute severe pancreatitis (ASP) and severe sepsis. Methods Genomic DNA was prepared from peripheral blood leukocytes. The TNF1 and TNF2 biallelic polymorphisms were identified by analyzing Ncol-digested DNA fragments obtained from PCR products. Plasma levels of TNFa and sTNF-R were measured by EASIA. Results The overall TNF2 allele frequency in ASP patients was comparable to that found in healthy volunteers (29.2%vs. 29. 3%, P>0.05). Severe sepsis occurred in 26 of 72 patients. Patients with severe sepsis showed a significantly higher prevalence of TNF2 than those without (46.2% vs. 19. 6%, P<0.05). Plasma TNFa, sTNF-R I, and sTNF-R II levels were (36±31) pg/ml, (5.4 ±3.5) ng/ml, and (11.2 ±7.8) ng/ml, respectively, in patients with severe sepsis, and (31 ±25)pg/ml, (4.6 ±3. 8) ng/ml, and (8. 8 ±6. 6) ng/ml in non-severe sepsis subjects. Differences in TNF levels were not statistically significant between patients with ASP and control group (P>0. 05). Moreover, there was no correlation between TNF2 allele frequency and TNFa levels [(37 ±31) pg/ml vs. (31 ±25) pg/ml in TNF2 group and TNF1 group, respectively, P>0. 05]. Conclusions Our results suggest that there is no relationship between ASP and the TNF2 allele, but that the TNF2 allele is associated with a susceptibility to severe sepsis as a result of ASP. Chin Med J 2003; 116(11): 1779-1781

Objective To investigate the protective effects of vitamin B12, ginseng saponin, and folic acid on mouse embryos subjected to high heat. Methods Mice were used for the experiment. Results After exposure of pregnant mice to high heat, the rates of teratism, stillbirth, and fetal absorption were markedly lower in mice treated with ginseng saponin and folic acid following heat exposure than in untreated mice. There were no significant differences in these rates when comparing mice treated with vitamin B12 with the untreated mice. Conclusions Ginseng saponin and folic acid can lessen injuries to murine embryos caused by high heat, while vitamin B12 has little protective effect against high temperature except for promoting overall embryonic growth. Chin Med J 2003; 116(11): 1776-1778

Objective To establish a new diagnostic method for Down's syndrome using polymerase chain reaction (PGR). Methods DNA extracted from five healthy individuals and five Down's syndrome patients was amplified in six specific tetranucleotide repeat loci on chromosome 21 using PGR. An accurate diagnosis was made by analyzing allelic distribution at each locus. Results All Down's syndrome patients were identified as having at least two loci with three alleles,while none of the healthy individuals had three alleles. In addition, when two alleles were identified for a particular locus in the Down's syndrome samples, it was more likely that the intensity ratio between the two alleles was close to 2: 1. Conclusion The molecular method can provide a fast, accurate, and economical alternation for the traditional cytogenetic diagnostic method for Down's syndrome. Chin Med J 2003; 116(11): 1773-1775

Objective To determine whether the extent of prolongation of the transisthmus interval after ablation predicts complete bidirectional block. Methods Since 1996 to 2002, 30 consecutive patients underwent ablation procedures for isthmus-dependent atrial flutter. There were 23 males and 7 females [mean age (47. 85 ±9. 35) years]. With the use of fluoroscopic view of anatomy, radiofrequency ablation was performed during coronary sinus pacing at a cycle length of 600 ms. Results Bidirectional block was achieved with ablation in 29 (97%) of 30 patients. The transisthmus intervals before ablation and after complete transisthmus block were (73. 82 ± 13.01) ms and(140. 47 ±20. 48) ms, respectively, in the clockwise direction (P <0. 0001), and (77. 63 ±8. 36) ms and (138. 17 ±15. 55) ms, respectively, in the counterclockwise direction (P <0. 0001). A period of incomplete isthmus block was observed during 17 (58%) of the 29 ablation procedures. The clockwise transisthmus intervals during incomplete block [(107. 65 ± 21.33) ms] were (45. 5 ±8. 7)% longer than the baseline transisthmus intervals. An increase in the transisthmus interval by ≥50%in both directions after ablation predicted complete bidirectional block with 100. 0%sensitivity and 83. 3%specificity. The positive and negative predictive values were 90. 6%and 100.0%, repectively. The diagnostic accuracy of a ≥50%prolongation in the transisthmus interval was 83. 3%. Conclusion The analysis of transisthmus interval is a valuable method for determining complete bidirectional isthmus block. Chin Med J 2003; 116(11): 1770-1772

Objective To investigate the effect of micronized fenofibrate on vascular endothelial function in patients with hypertriglyceridemia. Methods Using high-resolution ultrasound, we measured flow- and nitroglycerin-induced dilatation of the brachial artery in 30 patients with hypertriglyceridemia before and after treatment with micronized fenofibrate at a dose of 200 mg once daily for 4 weeks. Simultaneously, both serum lipid and plasma endothelin (ET) levels were determined. Results After micronized fenofibrate therapy, serum triglyceride (TG) levels decreased significantly(P <0. 05) . Plasma ET levels also decreased markedly [(82. 66 ± 15. 46) μg/L vs. (106. 22 ±19. 16) μg/L, P <0. 001]. Flow-induced vasodilatation was much improved (11. 0%± 9. 0% vs 2. 7%±2. 0%, P<0. 01). However, no significant changes in vasodilatation occurred in response to nitroglycerin (16. 2%±6. 0%vs 15. 0%±5. 0%, P>0. 05) in patients with hypertriglyceridemia. Conclusions Micronized fenofibrate can improve impaired endothelium-dependent vasodilatation in patients with hypertriglyceridemia. Improving endothelial function may also be the mechanism responsible for the beneficial effects of micronized fenofibrate. Chin Med J 2003; 116(11): 1767-1769

Objective To investigate the cardiac effect of QT interval prolongation in the treatment of acute promyelocytic leukemia (APL) with arsenic trioxide (As2O3), and the relationship between QT and serum arsenic concentration. Methods Blood serum arsenic concentrations of thirty APL patients were determined at 2 hours, 4hours, 8 hours, and 24 hours after As2O3 injection using atomic fluorophotometry. Cardiac functions were measured simultaneously using a 12-lead body-surface electrocardiogram (ECG). Q-T intervals were manually measured, and then corrected using Bazett's formula (QTc). QT dispersion (QTd)was also calculated. In order to assess the effects of arsenic on the symptoms of anemia, twenty-four anemia patients were divided into two groups on the basis hemoglobin concentration: Groupl (Hb≥90g/L), and Group 2 (60 g/L≤Hb <90 g/L). QTc and QTd of these patients were also manually measured. Results All QT intervals of APL patients treated with As2O3 injection were prolonged [32. 2 ms (27,41 ms); P <0. 05], but the changes of QTd were not prominent [3 ms (-8, 7 ms), P> 0. 05]. There was a delay of 2 hours in maximum QTc following peaks in serum arsenic concentration. Changes in QTc and QTd of the two anemic groups were not prominent. Conclusions As2O3 can prolong QTc intervals in APL patients, but the effects are delayed compared to peak serum arsenic concentrations. As2O3 has no prolongation effect on QTd. Mild and moderate anemia do not effect QTc and QTd. Chin Med J 2003; 116(11): 1764-1766