Volume 121  ·   Issue 11  ·  2008

Abstract：Background The peritoneal dialysis (PD) therapy for end stage renal disease (ESRD) is expensive. The main reason for non-acceptance onto dialysis programs is the great cost. In the present study, we design an auxiliary business insurance program to provide the potential ESRD patients who have no access to governmental medical insurance or can not afford the remaining part besides the limited reimbursement for peritoneal dialysis therapy.Methods The information applied in this study was extracted from the medical records of 641 PD patients, who were treated in two dialysis centers of the first and the third teaching hospitals of the Peking University respectively. A collective risk model was employed to estimate the expenses on PD therapy. Survival analyses were performed to obtain the average survival time of PD patients and the average length of time from the onset of the primary disease to the beginning of PD. An annuity method was used to determine the pure premium.Results For chronic nephritis, diabetes mellitus and hyperpietic as primary diseases, the mean survival time ± standard errors were (55.1±3.7) months, (38.9±3.2) months and (61.4±4.6) months respectively, and they were significantly different from each other (all P=0.000). The expenses of whole PD therapy were 242 159.05 Yuan, 182 525.02 Yuan and 284 579.24 Yuan respectively.Conclusions An auxiliary business insurance for PD patients was designed with the pure premium for any individual who had chronic nephritis, diabetes mellitus or hyperpietic as primary disease was RMB 35.94 Yuan/year, 87.73Yuan/year or 7.71 Yuan/year respectively without considering the additional premium for coping with the business expenditures and accidental risks。

Abstract：Background Because patients with scar contracture of the neck are at a high risk of loss of the airway control after anesthesia induction, awake intubation is usually recommended. This retrospective clinical study was designed to evaluate the possibility, safety and efficacy of airway management and tracheal intubation under general anesthesia in such patients.Methods This retrospective study included 1683 patients from January 1994 to December 2006 with scar contracture of the neck, aged 1.5-67.0 years, who were scheduled for elective plastic surgery under general anesthesia in Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. Based on the results of the preoperative airway assessment, the patients were classified into group 1 (including 1375 patients with the atlanto-occipital extension of ＞20° and the Mallampatti's grade Ⅰ or Ⅱ) and group 2 (containing 308 patients with the atlanto-occipital extension of ＜20° and the Mallampatti's grade Ⅲ or Ⅳ. In group 1, the intravenous induction and maintenance of anesthesia and succinylcholine for muscle relaxation were used. The intubation was done using a modified Macintosh technique. In group 2, the total intravenous anesthesia (TIVA) or the sevoflurane inhalation anesthesia was chosen and the spontaneous breathing was reserved during anesthesia. The intubation was performed by a fiberoptic stylet laryngoscope (FOSL). The number of intubation attempts, intubation time and relative complications were observed and recorded in all patients.Results In group 1, the intubation was accomplished during the first attempt in 1279 cases (93%) and the intubation time was ＜3 minutes in 1304 cases (95%). In group 2, the intubation was completed by the first attempt in 114 patients (37%) and 123 patients had an intubation time of ＜3 minutes (40%). Tracheal intubation was successful by the second or third attempt in 96 patients in group 1 and 156 patients in group 2. Thirty-eight patients required four or more attempts which only occurred in group 2. The incidence of traumatic complication was 2.6% and 9.7% with one intubation attempt in groups 1 and 2, respectively, 12.5% and 17.0% with multiple intubation attempts (one vs multiple attempts in both groups, P＜0.001). All nontrauamatic complications occurred in group 2 and laryngospasm and hypoxemia were more common in patients using the TIVA compared to those using the sevoflurane inhalational anesthesia (P＜0.001).Conclusions This study demonstrated that with a precise airway evaluation, an adequate preoperative preparation and a pre-planned failed intubation strategy, the anesthetist who was experienced in the difficult airway management could safely perform airway control and tracheal intubation under general anesthesia in patients with scar contracture of the neck. We believe that this technique may be very valuable for the management of a known difficult airway because it is comfortable for the patient and saves time for the anesthetist。

Abstract：Background The relationship between cyclosporine-induced chronic nephrotoxicity (CAN) and renin-angiotenein Ⅱ in humans is still contradictory. This study was conducted to detect the levels of renin and angiotensin Ⅱ (ANGII) both in renal tissue and plasma from kidney transplantation patients suffering from CAN.Methods Twenty-six patients with allograft biopsy-proven CsA-related chronic nephrotoxicity (CAN group) and chronic rejection (control group) were enrolled in this study. Renal tissues were subjected to immunohistochemical staining with renin and ANGII antibodies. Renin and ANGII plasma levels were measured when the biopsy was performed. The relationship between expression of renin or ANGII and clinicopathological manifestations were also investigated. The cyclosporine plasma level was obtained 2 hours after morning dose (C2). In vitro, human umbilical vein endothelial cells (HUVEC) and rat mesangial cells (MC) were incubated with different concentrations of CsA (0, 250, 500, 1000 μg/L) for 24 hours. Secretion and expression of renin and ANGII was measured by radioimmunoassay or immunohistochemical staining.Results Renal pathological scores for renin and ANGII expression were significantly higher in specimens of CAN than in controls (P＜0.05). The plasma levels of renin, ANGII and C2 in the CAN group were higher than the control group, but no significant difference was found ((0.37±0.12) ng.ml-1·h-1 vs (0.20±0.10) ng.ml-1·h-1, P=0.076; (122.69±26.73) pg/ml vs(121.88±36.35) pg/ml, P=0.977; (719.04±55.89) ng/ml vs (658.80±90.78) ng/ml, P=0.196, respectively). In vitro, renin as well as ANGII expression increased significantly in both HUVEC and MC after the cells were incubated with CsA for 24 hours (P ＜0.05). CsA also stimulated the secretion of ANGII in HUVEC and MC in a dose-dependent manner.Conclusions Renal allograft biopsy is important to differentiate chronic CsA-related nephropathy from chronic rejection. The intrarenal renin angiotensin system plays an important role in CsA-related chronic nephropathy. The histological lesions of CsA nephrotoxicity fail to correspond spontaneously to either the change of C2 level or the change of renin and ANGII plasma level. CsA stimulates the secretion of ANGII and the expression of renin and ANGII in HUVEC and MC. Blockage of RAS may be helpful for therapeutic intervention in the progression of CsA-related chronic nephropathy。

Abstract：Background Colon cancer is a common malignant tumor in the clinic with an incidence rate that is increasing in recent years. The key point for improving the survival rate is the diagnosis and treatment at an early stage. The purpose of this study was to compare the difference of the Fuji Intelligent Chromo Endoscopy (FICE) and staining technique for the diagnosis of colon tumors and non-tumor lesions.Methods From March to November 2007, 654 patients were examined with ordinary colonoscopy. Among them 223 patients with colon neoplasm or polypoid lesion were included. The patients were examined with a magnifying ordinary colonoscopy, a magnifying FICE technique and magnifying staining technique. The pit pattern and blood capillary form of the lesion were examined, an endoscopic diagnosis was made and it was compared with the pathologic diagnosis.Results Four hundred and fifty-one neoplasms were detected in the 223 patients, among those 91.1% (411/451) were detected with the magnifying ordinary endoscopy while 99.1% (447/451) were detected with the FICE technique; there was a significant difference between the two methods. FICE could clearly show the structure and form of mucosal blood capillaries (P＜0.01) but there was no significant difference between the two methods for showing the pit pattern. The coincident rate of FICE for the diagnosis of tumor and non-tumor lesions was 91.6% (413/451), that of the magnifying staining technique was 82.0% (370/451) (P＜0.05).Conclusions Magnifying FICE could show the mucosal microstructure and blood capillary form and it had a superiority of high coincident rate, high sensitivity and specificity when compared with ordinary magnifying colonoscopy and magnifying staining endoscopy. In addition, it was easy to operate and a biopsy could be taken from the target, so it has a satisfactory clinical practical value。

Abstract：Background In China,transthoracic echocardiography(TTE)is popularly used for pre-intervention examination for atrial septal defect(ASD)and for guiding ASD closure.However,the ability to determine ASD size and the safety and efficacy of TTE for guiding ASD closure still has not been widely accepted This study aimed to evaluate the efficacy and safety of TTE used before,during and after transcatheter ASD closure with Amplatzer septal occluders(ASO).Methods Sixty-eight subjects(15 men and 53 women;mean age(33.7±17.3)years)were enrolled.TTE was used to measure the diameters and guide transcatheter closure of ASD.The ASD was examined by long-axis view,basal short-axis view,apical four-chamber view and the subcostal view to observe position.diameter and reIation with neighbouring structures.The largest diameter was selected as the reference diameter.Patients were divided into 3 groups according to the ASD reference diameter:22 subjects with ASD diameter 4-14 mm(group A):21 subjects with ASD diameter 15-20 mm(group B);and 25 subjects with ASD diameter 21-33 mm(group C).Results ASD was occluded successfully in groups A and B.In group C.occlusion failed in 2 cases;1 case remained with a 3-mm residual shunt sustained untiI 6-month follow-up.However,at 6-month follow-up,no case of thromboembolism,ASO dislocation or death occurred in the three groups.The diameter of ASD measured bv TTE could accurately predict the ASO size that could successfully occlude the ASD.especially in patients with ASD＜20 mm.The ASD diameter measured by TTE correlated well with ASO size(r=0.925,P＜0.001:r=0.976,P＜0.001;r=0.929,P＜0.001 respectively).Conclusions ASD diameter measured by TTE can accurately estimate the size of the ASO needed for successful closure of ASD.The larger the ASD,the much larger the ASo needed.TTE is a satisfactory guiding imaging tool for ASD closure。

Abstract：Background Among the deaths due to trauma,about one half of the patients suffer from road traffic injury(RTI).Most of RTI patients complicate acute respiratory distress syndrome(ARDS)and severe multiple injuries.ARDS is a major contributor to morbidity and mortality in trauma patients.Although many injuries and conditions are believed to be associated with ARDS independent risk factors in trauma patients.their relative importance in development of the syndrome are undefined.We hypothesize that not all of the traditionaI risk factors impacting mortality are independently associated with patients strictly identified by traffic injury.This study aimed to sieve distinctive risk factors in our RTI population,meanwhile,we also hypothesize that there may exist significantly different risk factors in these patients.Methods This was a retrospective cohort study regarding RTI as a single cause for emergency intensive care unit (EICU)admission.Patients identified as severe RTI with post-traumatic ARDS were enrolled in a prospectively maintained database between May 2002 and April 2007 and observed.Twenty-three items of potential risk impacting mortality were calculated by univariate and multivariate Logistic analyses in order to find distinctive iterns in these severe RTI patients.Results There were 247 RTI patients with post-traumatic ARDS admitted to EICU during the study period.The unadjusted odds ratio(OR)and 95％ confidence intervals(CI) of mortality were associated with six risk factors out of 23:APACHE Ⅱ score,duration of trauma factor,pulmonary contusion,aspiration of gastric contents,sepsis and duration of mechanical ventilation.The adjusted ORs with 95％ CI were denoted with respect to surviving beyond 96 hours EICU admission(APACHE Ⅱ score,duration of trauma factor,aspiration of gastric contents),APACHE Ⅱ score beyond 20 EICU admission(duration of trauma factor,sepsis,duration of mechanical ventilation)and mechanicaI ventilation beyond 7 days EICU admission fduration of trauma factor and sepsis).Conclusions We have retrospectively demonstrated an adverse effect of six different risk factors out of 23 items in mortality of post-traumatic ARDS within severe RTI patients and,moreover,gained distinct outcomes in stratified patients under real emergency trauma circumstance.An impact of APACHE Ⅱ score and pulmonary contusion contributing to prediction of mortality may exist in prophase after traffic injury.Sepsis is still a vital risk factor referring to systemic inflammatory response syndrome,infection,and secondary multiple organs dysfunction.Eliminating trauma factors as early as possible becomes the critical therapeutic measure.Aspiration of gastric contents could lead to incremental mortality due to severe ventilation associated pneumonia.Long-standing mechanical ventilation should be constrained on account of severe refractory complications。

Abstract：Background Many treatment options for lower limb ischemia are difficult to apply for the patients with poor arterial outflow or with poor general conditions.The effect of medical treatment alone is far from ideal.especially in patients with diabetic foot.A high level amputation is inevitable in these patients.This study aimed to explore the effect of transplantation of autologous bone marrow mononuclear cells on the treatment of lower limb ischemia and to compare the effect of intra-artedal transplantation with that of intra-muscular transplantation.Methods In this clinical trial,32 patients with lower limb ischemia were divided into two groups.Group 1 (16 patients with 18 affected limbs) received transplantation of autologous bone marrow mononuclear cells by intra-muscular injection into the affected limbs;and group 2(16 patients with 17 affected limbs)received transplantation of autologous bone marrow mononucJear cells by intra-arterial injection into the affected limbs.Rest pain,coldness,ankle/brachial index (ABI),claudication,transcutaneous oxygen pressure(tcPO2)and angiography(15 limbs of 14 patients)were evaluated before and after the mononuclear cell transplantation to determine the effect of the treatment.Results Two patients died from heart failure.The improvement of rest pain was seen in 76.5%(13/17)of group 1 and 93.3%(14/15)of group 2.The improvement of coldness was 100%in both groups.The increase of ABI was 44.4%(8/18)in group 1 and 41.2%(7,17)in group 2.The value of tcPO2 increased to 20 mmHg or more in 20 limbs.Nine of 15 limbs which underwent angiography showed rich collaterals.Limb salvage rate was 83.3%(15,18)in group 1 and 94.1%(16/17)in group 2.There was no statistically significant difference in the effectiveness of the treatment between the two groups.Conclusions Transplantation of autologous bone marrow mononucJear cells is a simple,safe and effective method for the treatment of lower limb ischemia,and the two approaches for the implantation,intra-muscular injection and intra-arterial injection,show similar results。

Abstract：Background As with many studies carried out in European countries, a quality assurance program has been established by the National Center for Clinical Laboratories in China (NCCL). The results showed that the external quality assessment significantly improves laboratory performance for quantitative evaluation of hepatitis C virus (HCV) RNA.Methods Serum panels were delivered twice annuatly to the clinical laboratories which performed HCV RNA detection in China. Each panel made up of 5 coded samples. All laboratories were requested to carry out the detection within the required time period and report on testing results which contained qualitative and/or quantitative test findings, reagents used and relevant information about apparatus. All the positive samples were calibrated against the first International Standard for HCV RNA in a collaborative study and the range of comparison target value (TG) designated as ±0.5 log.Results The numbers of laboratories reporting on qualitative testing results for the first and second time external quality assessment were 168 and 167 in the year of 2003 and increased to 209 and 233 in 2007; the numbers of laboratories reporting on quantitative testing results were 134 and 147 in 2003 and rose to 340 and 339 in 2007. Deviation between the mean value for quantitative results at home in 2003 and the target value was above 0.5 log, which was comparatively high.By 2007, the target value was close to the national average except for the low concentrated specimens (103 IU/ml). The percentage of results within the range of GM±0.5 log10 varied from 8.2% to 93.5%. Some laboratories had some difficulties in the exact quantification of the lowest (3.00 log IU/ml) as well as of the highest viral levels (6.37 log IU/ml) values, very near to the limits of the dynamic range of the assays.Conclusions The comparison of these results with the previous study confirms that a regular participation in external quality assessment (EQA) assures the achievement of a high proficiency level in the diagnosis of HCV infection. During the 5-year external quality assessment, sensitivity and accuracy of detection in most of the clinical laboratories have been evidently improved and the quality of kits has also been substantially improved。

Abstract：Background In recent years, interventional tumor therapy, involving implantation of intra-cholangial metal stents through percutaneous trans-hepatic punctures, has provided a new method for treating cholangiocarcinoma, 103Pd cholangial radioactive stents can concentrate high radioactive dosages into the malignant tumors and kill tumor cells effectively, in order to prevent re-stenosis of the lumen caused by a relapsed tumor. The aim of the present study was to investigate the efficacy of y-rays released by the 103Pd biliary duct radioactive stent in treating cholangiocarcinoma via induction of biliary cholangiocarcinoma cell apoptosis.Methods A group of biliary duct cancer cells was collectively treated with a dose of y-rays. Cells were then examined by the 3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyl terazolium-bromide (MTT) technique for determining the inhibition rate of the biliary duct cancer cells, as well as with other methods including electron microscopy, DNA agarose gel electrophoresis, and flow cytometry were applied for the evaluation of their morphological and biochemical characteristics. The growth curve and the growth inhibition rate of the cells were determined, and the changes in the ultrastructure of the cholangiocarcinoma cells and the DNA electrophoresis bands were examined under a UV-lamp.Results The y-ray released by 103Pd inhibited cholangiocarcinoma cell growth, as demonstrated when the growth rate of the cells was stunned by a γ-ray with a dosage larger than 197.321 MBq. Typical features of cholangiocarcinoma cell apoptosis were observed in the 197.321 MBq dosage group, while cell necrosis was observed when irradiated by a dosage above 245.865 MBq. DNA agarose gel electrophoresis results were different between the 197.321 MBq irradiation dosage group, the 245.865 MBq irradiation dosage group, and the control group.Conclusions 103Pd radioactive stents which provide a radioactive dosage of 197.321 MBq are effective in the treatment of cholangiocarcinoma; 103Pd radioactive stents should be useful for the clinical treatment of cholangiocarcinoma。

Abstract：Background Glaucoma can cause progressive damage to retinal ganglion cells. These cells can be classified as cells projecting to the superior colliculus and melanopsin-containing retinal ganglion cells, which project to the suprachiasmatic nucleus. This study was to investigate the effects of chronic intraocular pressure elevation on melanopsin-containing retinal ganglion cells in rats.Methods Chronic intraocular pressure elevation was induced in one eye of adult Wistar rats by cauterization of three episcleral veins. Intraocular pressure was measured at different intervals with a rebound tonometer. Superior collicular retinal ganglion cells were retrogradely labeled from the superior colliculus with Fluorogold. Melanopsin-containing retinal ganglion cells were visualized by free-floating immunohistochemistry on whole-mount retinas. The number of labeled superior collicular and melanopsin-containing retinal ganglion cells were counted in the sample areas on flat-mounted retinas.Results Compared with contralateral control eyes, the numbers of both superior collicular and melanopsin-containing retinal ganglion cells were significantly reduced after 12 weeks of experimental intraocular pressure elevation ((2317.41±99.96)/mm2 vs (1815.82±2.4.25)/mm2; (26.20±2.10)/mm2 vs (20.62±1.52)/mm2, respectively). The extent of cell loss of the two types of retinal ganglion cells was similar. However, no morphologic changes were found in melanopsin-containing retinal ganglion cells.Conclusion Both melanopsin-containing and superior collicular retinal ganglion cells were damaged by chronic ocular hypertension, indicating that glaucomatous neural degeneration involves the non-image-forming visual pathway。

Abstract：Background Estrogen is involved in suppression of colon cancer development and exerts its function via estrogen receptors α and β (ERα, ERβ). The recently identified ERα46 resulted from exon 1-deletion from the 66-kDa full length form of ERα66 is devoid of the transactivation domain AF-1, whose function remains largely unknown.Methods In this study, we compared the expression of ERα46 mRNA in 32 normal colorectal tissues and their matched colorectal cancer tissues by real-time quantitative polymerase chain reaction (PCR). Human colon adenocarcinoma cell HT-29, that has low endogenous expression of ERα46, was transfected with ERα46-expression vector; methyl thiazolyl tetrazolium (MTT) assay, flow cytometry, DNA fragmentation and TUNEL staining were used to evaluate the proliferation and apoptosis status of the cells in the presence of 17β-oestradiol.Results Higher ERα46 mRNA levels were observed in normal colorectal tissues than in the corresponding cancer tissues. ERα46-transfected cells showed a significantly decreased growth rate than control cells and an accumulation of cells in the G0/1 phase and a reduced proportion of cells in G2/M phase after exposed to 10-8 mol/L 17β-oestradiol. There were also more positive TUNEL stained cells in ERα46-transfected cells than the control cells in the presence of 1713-oestradiol (P＜0.05).Conclusions These data suggest that ERα46 may be involved in the development and/or progression of colorectal cancer via mediating growth inhibition and apoptosis of cancer cells in the presence of 17β-oestradiol。

In the world between 1 and 2 billion people have obesity.1 In the United States, which has the highest obesity rate in the world, one in three people have obesity.2 Obesity rates are increasing in every country in which it has taken hold.1 Obesity rates also affect all ages from the growing elderly-obese population3 to the dramatic increase in pediatric obesity,4,5 for example in the United States it is predicted that by the end of the decade one in two US children will have obesity.Obesity similarly affects all races and both sexes.6 As a consequence of the co-morbidities of obesity and of the associated costs such as days off work, obesity costs the US economy about 100-200 billion dollars per year.7

Hemangioma is a common benign vascular tumor,with an incidence of 2%-3% in the neonate and 10% in baby after 1 year.1 The incidence of hemangiomas is approximately 22%-30% of preterm infants with birthweight less than 1000 g. The development of hemangioma is therefore supposed to be related to various intra- and extra-uterine factors。

Hematospermia is a rare condition, but often causes frustration. The reason for this frustration is that the exact incidence of hematospermia remains unknown and its cause is difficult to determine.1 Many reports in the past decades have focused on the etiology of hematospermia.2 Hematospermia is treated initially by administration of antibiotics, coagulants, and sex steroid hormones. However, some cases may prove resistant to this therapy and the condition may continue. For some intractable and agnogenic cases, the therapeutic strategy mentioned above is not very effective. Recently, we treated 63 such nonresponsive patients by direct continuous antibiotic irrigation into the bilateral seminal vesicles through puncture under transrectal ultrasonography (TRUS) guidance.…… Biography：Correspondence to: Dr. XU Yue-min, Department of Urology, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, China (Tel: 86-21-64369181-8382. Fax: 86-21-64083783. Email: urology600@gmail. com)

Acute and chronic subdural hygromas are common postoperative clinical complications of ventricular shunting, arachnoid cyst marsupialization and arachnoid cyst resection.1 This article introduces a case of subdural hygroma after resection of a space-occupying lesion in the left lateral ventricle that resulted in compressive brainstem deformation and reviewed the recent related literature. The conclusion is that in related surgical procedures, prevention of rapid cerebrospinal fluid loss and excessive fluctuations in intracranial pressure are especially important。

To the Editor: In former times, traditional Chinese medicine (TCM) individualized its treatment protocol or clinical practice without considering the principles of modern medicine.The standard methodology of random selection, blinding and placebo control, followed by statistical analysis was generally overlooked. This had a negative effect on the development of TCM.Recently, the volume of applied research in Chinese medicine is growing rapidly and the quality is improving.1 There is good evidence supporting the use of some Chinese patent medicine treatments.2-4 Further, there is a more open attitude to Chinese medicine among conventional health professionals, partly explained by the rise of evidence-based medicine (EBM)。