2000年 · 第113卷第12期

Objective To study gastric rupture, a progressive, rapid and high mortality condition, caused by acute gastric distention(GRAGD)and its appropriate diagnosis and treatment. Methods The etiology, pathology, clinical manitestations and experiences in 3 children with GRAGD were reviewed. Results Case 1: After diagnosising GRAGD and stabilizing her shock with massive fluid replacement, gastrostomy was performed . Her postoperative course was uneventful because of fasting, suction, fluid infusion, correction of acidosis and supporting nutrition. Case 2: After diagnosising gastric distention which subsided with conservative therapy for 9 days, she suddenly had gastric rupture when she had not eaten for 6 days. She died of shock and had no chance for surgery. Case 3: The patient had sudden abdominal pain, distention and vomitting with severe shock for 4 days. Emergency surgery found gastric rupture and the method was the same as Case 1. The patient survived but has brain impairment. Case 1 and 3 showed multifocal transmural necrosis. Conclusions Symptoms like overeating, bulimia, changes in kind of food, X-ray showing large distended stomach and massive pneumoperitoneum were seen after gastric rupture and can help to diagnose this condition. Clinical course of gastric distention with toxic shock progresses rapidly, however subsequent gastric rupture exacerbates the shock and makes the treatment difficult treatment. It is extremely important that a laparotomy be performed at once after stabilizing shock with massive fluid replacement. Postoperative nutritional support and fluid replacement will increase survival. It is very important that when gastric distention disappears after conservative therapy, the doctor should assess carefully whether the gastric wall recovery is under way by using effective methods of examination. Chin Med J 2000; 113(12): 1092-1094

Objective To investigate the clinical characteristics of invasive burn wound infection with sepsis in patients with major burns and to summarize the successful experiences in the treatment of such patients. Methods Eight patients with major burns, complicated by invasive burn wound infection and sepsis were consecutivety admitted to our hospital from September 1997 to October 1998. Among them, 6 patients developed multiple organ dysfunction syndrome(MODS)and 2 developed septic shock. The plasma concentrations of IL-6, IL-8, TNFα and lypopotysaecharide(LPS)were assayed before and after surgical intervention, as well as when the patient's vital signs became stable Results The patients' conditions usually deteriorated abruptly when extensive invasive burn wound infection emerged. While multi-microbial infection was usually found. Pseudomonas aeruginosa was the predominant bacteria isolated from the subeschar tissue. The plasma concentrations of 1L-6, 1L-8, TNFα and LPS before surgical intervention were significantly higher than those after surgical intervention(P <0.05). The lowest levels of the inflammatory mediators were observed when the patients' conditions became stable. and the values were significantly lower than those before surgical intervention(P < 0.001). Conclusion Since the main cause of burn wound sepsis is the presence of a large area of infected burn wound, they shouuld be excised and covered as early as possible. LPS and pro-inflammatory mediators play an important role in the pathogenesis of burn sepsis. Although favorable results should be attributed to comprehensive treatment, we believe that early, aggressive and thorough surgical excision of infected burn wounds, followed by sound and complete coverage of the area, play a crucial role. Chin Med J 2000; 113(12): 1142-1146

Objective To investigate the role of hepatitis C virus(HCV)in the malignant transformation of bile duct cells. Tissues from 6 Chinese patients and 6 American patients with cholangiocarcinoma were studied. Methods RNA was extracted from the selected tumor areas of formalin-fixad, parattin embedded sections, followed by reverse transcription double polymerase chain reaction(RT-PCR)and Southem blotting. Results Positive and negative strand HCV RNA sequences were detected in seven out of twelve patients with chotangiocarcinoma. A high positive rate was found in Chinese patients(83%)as compared to US patients(33%). Conclusion Our finding suggests HCV may play a rote in the malignant transformation of bile duct cells. Chin Med J 2000: 113(12): 1138-1141

Objective To detect the location of inducible nitric oxide synthetase(iNOS)protein and mRNA in lung during endotoxemia in rabbits. Methods Northern blotting was performed before, 1 hour and 5 hours after the intravenous administration of lipopolysaccharide(LPS)in rabbits. Immuno-histochemical analysis(IA), in situ hybridization and in situ reverse transcription-polymerase chain reaction(in situ RT-PCR)were also performed in lung sections. Results iNOS mRNA expression was found using Northern blotting in lung 5 hours after LPS injection, while it was not found in control. The positive stain was found only in macrophages in lung 5 hours after LPS injection by standard hybridization and IA; white by in situ RT-PCR, the amplification products were found in macrophages, airway epithelial cells, vascular endothelial cells, smooth muscle cells and leukocytes, in addition to macrophages distributed abundantly throughout the lung. The signal was absent in control or samples. Conclusions Using an in situ RT-PCR technique, iNOS expression was not only observed in macrophages but also in many other kinds of cells in lung during endotoxemia in rabbits. This suggests that in situ RT-PCR is much more sensitive than in situ hybridization, and can be used to examine genes with low expression. Chin Med J 2000; 113(12): 1133- 1137

Objective To determine lactose metabolism and lactase activity in Chinese children of different ages, prevalence of lactase deficiency(LD), and lactose intolerance(U). Methods All 1168 healthy subjects between 3 and 13 years were recruited from schools in four large cities in China. They were screened by a 25 g lactose tolerance test. Some subjects were challenged with 50 g milk powder on different days. Both indicators, the expiratory H2 concentration and intolerance symptoms, were analyzed. Results LD occurred in 38.5% of children in the 3-5 year age group, and 87% of the 7-8 year and 11-13 year old groups. The age of occurrence for LD may be at 7-8 years among Chinese children. The prevalence of LI among Chinese children was 12.2%at age 3-5 years, 33.1% at age 7-8 years, and 30.5% at age 11-13 years, respectively. Conclusion The results demonstrate that LD is very common in Chinese children from these four cities. LD and U have a dose dependent response: lactose absorption and symptoms are based on lactase activity. The relationship between breast feeding history(or the history of cow milk intake)and lactase activity among Chinese children has not been established. Chin Med J 2000; 113(13): 1129-1I32

Objective To characterize the mRNA expression of CXC chemokine IL-8, CC chemokine monocyte chemothractant protein-1(MCP-1)and regulated on activation, normal T cell expressed and secreted(RANTES), and a newly defined DC chemokine DC-CK1 as well as the expression of IL-8 receptor, MCP-1 receptor and RANTES receptor in human monocyte-derived dendritic cells(MoDCs). The migratory responsiveness of MoDC to IL-8. MCP-1 and RANTES was also studied. Methods In vitro generated MoDCs were obtained by differentiating monocytes in the presence of GM-CSF and IL-4 for 5 days. The time course of RNA expression was anafyzed by RT-PCR and migratory ability was assessed by a micromultiwell chernotaxis chamber assay. Results 1L-8, MCP-1, RANTES and their corresponding receptors were consistently expressed in MoDCs. DC-CK-1 expression was detectable after 48 hours of differentiation. MoDC selectively migrated in response to MCP-1 and RANTES but not to IL-8 though transcripts of IL-8 receptor were present. Conclusion Because the capacity of dendritic cells to initiate immune responses depends on their specialized migratory and tissue homing properties, the expression of chemokines and their receptors along with the migratory responsiveness to chemokines of MoDC in our study suggests a potential role of chemokines in the interaction between dendritic cells and T cells and the induction of immune responses. Chin Med J 2000: 113(12):1124-1128

Objective To further investigate the expression of MAGE-1 gene in hepatocellular carcinoma(HCC). Methods The tumors and adjacent liver tissue from 45 HCC patients and liver tissue from 28 non-HCC patients(16 with liver cirrhosis and 12 with normal liver)were characterized by RT-PCR. A 421 bp PCR product from a cDNA fragment spanning exons 1, 2 and 3 was sequenced. The HLA type was assayed by standard ELISA in 43 HCC patients. Results Thirty-two of 45 tumor tissues from HCC patients expressed MAGE-1 mRNA(71.1%). In contrast, MAGE-1 mRNA was not detected in adjacent tissues. Three were found to have point mutations at 3 identical sites resulting in the substitution of two amino acid residues. The most frequent HLA types in 43 HCC patients were: HLA-A2. 53.5%; A11, 25.6%; A24, 20.9%; A33, 20.9%; HLA-B13, 28.3% and B35, 23.2%. Expression of HLA-A33(20.9%)was higher in HCC patients than that predicted in the normal Chinese population(8.8%). There was no discemable correlation between MAGE-1 expression and α-FP level, tumor size and hepatitis B or C virus infection. The identification of peptides which are restricted by haploptypes other than A1 should increase the opportunity for peptide based immunotherapy. Conclusions This study shows that MAGE-1 mRNA is highly expressed in HCC tumor tissue in Chinese patients. Previously unreported point mutations in the MAGE-1 gene are described and may also provide additional opportunities for immunotherapy. Chin Med J 2000; 113(12): 1112-1118

Objective To investigate early changes in systemic and splanchnic hemodynamics after orthotopic liver transplantation(OLT)in normal and cirrhotic rats. Methods Male Sprague-Dawley rats were divided into 4 groups: normal controls (NL, n = 10), intrahepatic portal hypertension(IHPH, n = 10)induced by injection of CC14, nornal rats with OLT(NL-OLT, n = 9)and(HPH rats with OLT(IHPH-OLT, n = 16). IHPH-OLT rats were divided into 2 subgroups: 3 days(Group A, n = 9)and 7 days(Group B, n = 7)after OLT. OLT was performed in rats using cuffs for the anastomosis of the suprahepatic inferior vena cava, infrahepatic vena cava and portal vein. Two weeks after production of IHPH rats, 7 days after NL-OLT rats, 3 days and 7 days after IHPH-OLT rats, radioactive microspheres were used in a hemodynamic study. Results There were no significant differences in hemodynamic changes between NL-OLT and NL rats, except mean arterial blood pressure(MAP). The characteristics of systemic and splanchnic hyperdynarmic circulatory state, including increased cardiac output and splanchnic blood flow, decreased mean arterial blood pressure, total peripheral vascular resistance and splanchnic vascular resistance were observed in IHPH, IHPH-OLT A, and IHPH-OLT B rats. The magnitude of hyperhemodynamics was in the order of IHPH > IHPH-OLT A > IHPH-OLT B rats. Moreover, the derangement of splanchnic hyperhernodynamics was more significant than that of systemic hyperhemodynarnics. Conclusions The present study dermonstrates that the persistence of early systemic and splanchnic hyperkinetic circulation after OLT may be the consequence of factors which maintain hyperhemodynamics in liver cirrhosis, where portal hypertension is not completely eliminated. Hyperherrodynamics is not induced by OLT per se. Chin Med J 2000; 113(12): 1108-1111

Objectives To report the clinical experiences of simultaneous hepatorenal transplantation. Methods We performed simultaneous hepatorenal transplantation in one patient with liver cinrtiosis of hepatitis B and uremia of chronic nephritis on February 1, 1999 and one patient with liver cirrhosis of hepatitis B complicated by hepatorenal syndrome on March 12, 1999. The donors were heart arrest cases. Rapid muttiple organ harvesting techniques and UW solution infusion in situ were used. Liver and kidney transplantation were orthotopic and ordinary methods, respectively. Immunosuppressive drugs consisted of cyclosporine, Cellcept, ALG and cortstco steroids. Lamividine was used on day 50 and day 40 postoperation, respectively. Results Both transplanted organs rapidly achieved normal function postoperation and the patients recovered well but suffered mild kidney rejection day 110 postoperation in No 1 patient. In No 2 patient, acute renal function failure, mental symptoms, muscle spasm, cerebral artery thrombosis, inhalation pneurnonia and chronic liver graft rejection ensured sequentialty but were controlled. The patients have survived for more than nine and eight months, respectively, with normal life quality. Conclusions Combined hepatorenal transplant is a radical treatment method for liver and kidney function failure and requires more comprehensive techniques than isolated single organ transplantation. Preventing the recurrence of hepatitis B by oral iamividine may be a key to long-term survival. Chin Med J 2000; J 13(12): 1104-1107

Background The incidence of breast cancer in Hong Kong is increasing and breast self-examination(BSE)as a screening tool is becoming more popular. especially among first-degree relatives(FDR)of breast cancer victims. BSE may be more applicable to Chinese women as their breast size is smaller. This study explores the BSE practice in this group of women. Methods A cross sectional study was conducted by sending questionnaires to 330 FDR of breast cancer patients treated in the Department of Surgery, University of Hong Kong. BSE behavior was studied with respect to its frequency, awareness, completeness and confidence of practice、 Results 110 subjects returned the questionnaires with a response rate of 33%, The mean age of the respondent was 37 years. Only 57 women(52%)were practicers. The practicers have a stronger BSE awareness(P < 0.01)and a lower mean score on thought barriers(P = 0.002)than the non-practicers. 40% of the practicers gain their BSE knowledge through clinicians and their mean period of practice was 3.2 years. 68% of the practicers performed BSE completely. The overall confidence rate was 35%, but the rate was 43% among those who performed complete BSE. Thirteen factors possibly related to the completeness and rate of confidence of BSE examination were studied. The only factor that significarrtly detemined completeness was the time spent for each examination(P = 0.002). The complete practicers required a longer time than the incomplete practicers(6.60 and 2.96 min, respectively). Women with a stronger BSE intention(P = 0.001)and a lower mean score on thought barriers(P = 0.001)performed the examination confidently. Conclusions Slightly over half of the FDR practice BSE. The majority perform a complete BSE but they are not confident in finding abnormalities. Women spending more time on BSE are associated with a higher rate of completeness. However, only those with a stronger BSE intention and lesser thought barriers are more confident in their practice, Chin Med J 2000; 113(12): 1100-1103