Volume 86  ·   Issue 17  ·  2006

The central idea of evidence-based medicine is that doctors should combine the current best research evidence with their own clinical experience when dealing with clinical problems, and make the best decision in diagnosis, prognosis and treatment according to the needs of patients. Evidence-based medicine emphasizes that clinicians should carefully collect medical history and physical examination, according to the problems that need to be solved in clinical practice, carry out effective literature search and evaluation, find the most suitable and powerful evidence, and through rigorous judgment, apply the most suitable diagnosis method, the most accurate prognosis estimation and the safest and effective treatment method to serve each specific patient.

Dilated cardiomyopathy (DCM) is one of the main myocardial diseases leading to heart failure. Its incidence is increasing year by year and the age is getting younger. Treatment of heart failure is the basic method of treatment for this disease. With the deepening of clinical and experimental research, it has been found that persistent virus infection, abnormal immune response and genetic factors are closely related to the occurrence of DCM. Especially, a series of anti-myocardial autoantibodies (including anti-mitochondrial ADP/ATP carrier antibody, anti-β 1-adrenergic receptor antibody, anti-myosin antibody, anti-M2-cholinergic receptor antibody, etc.) have been discovered in patients with DCM in recent ten years and their mechanism has been elucidated, which fully proves that autoimmune mechanism plays an important role in its pathogenesis.

Studies since 1990s have fully proved that in patients with chronic congestive heart failure (CHF), left ventricular remodeling caused by neuroendocrine abnormalities is the main cause of cardiac dysfunction and poor clinical prognosis. The pathological changes of left ventricular remodeling include two aspects: one is the hypertrophy, necrosis and apoptosis of cardiomyocytes, the other is the proliferation of fibroblasts and myocardial interstitial fibrosis. Previous studies mainly focused on the prevention and reversal of structural and functional abnormalities of cardiomyocytes, but in recent years, people gradually realized that myocardial fibrosis plays a very important role in the occurrence and development of heart failure, so it has become a new target in the treatment of heart failure.

Objective to investigate the birth month distribution of chronic insomnia patients. Methods the birth month distribution of 1020 chronic insomnia patients from September 2004 to November 2005 in the sleep center of Peking University Third Hospital was statistically analyzed, and the birth month distribution of 13 254 newborns born in the obstetrics department of this hospital from 1994 to 2004 was used as the background control to compare and analyze the birth month distribution of chronic insomnia patients. Results Among the 1020 chronic insomnia patients in this group, the number of patients born from January to December was 114 (11.2%), 90 (8.8%), 65 (6.4%), 67 (6.6%), 56 (5.5%), 56 (5.5%), 66 (6.5%), 78 (7.6%), 64 (6.3%), 91 (8.9%), 126 (12.4%) and 147 (14.4%), respectively. The birth month distribution of chronic insomnia patients was compared with that of 13 254 newborns as the background control. However, the number of births of 13 254 newborns in all months of the year was basically the same level, and the difference between the patient group and the control group was statistically significant (χ 2=75.098, P<0.01). Conclusion There may be some intrinsic correlation between the births from November to January and the occurrence of chronic insomnia after adulthood.

Objective to observe the effect of high mobility group protein 1 (HMGB1) on the release of cytokines from human umbilical vein endothelial cells (HUVEC) and its effect on the expression of interleukin-6 (IL-6) induced by lipopolysaccharide (LPS). Methods The changes of 11 cytokines/chemokines in HUVEC induced by recombinant HMGB1 protein (15 ng/ml) were detected by LiquiChip liquid phase protein chip system. The levels of IL-6 secreted by HUVEC at different time points (0, 1, 3, 6, 12 and 24 h) after stimulation with different concentrations of HMGB1 (0-75 ng/ml) and the effects of co-stimulation with HMGB1 (15 ng/ml) and LPS (10 ng/ml) on IL-6 secretion by HUVEC.Results After stimulation with HMGB1, the levels of granulocyte-macrophage colony stimulating factor (GM-CSF), interferon γ (IFN-γ), IL-6, IL-8 and monocyte chemotactic protein 1 (MCP-1) secreted by HUVEC were significantly increased (all P<0.01), which were 5.7, 4.2, 27.8, 12.8 and 5.4 times of those of control (without stimulation), respectively; HMGB1 protein induced the secretion of IL-6 in a time-and dose-dependent manner. The level of IL-6 began to increase from 32 pg/ml ± 21 pg/ml to 75 pg/ml ± 22 pg/ml at 6 h (P<0.01), and increased continuously from 12 h (453 pg/ml ± 78 pg/ml) to 24 h (901 pg/ml ± 184 pg/ml) (P<0.01); When the concentration of HMGB1 was 3, 15 and 75 ng/ml, the level of IL-6 was 155 pg/ml ± 33 pg/ml, 901 pg/ml ± 184 pg/ml, 1508 pg/ml ± 378 pg/ml, respectively, which was the same as the basal value of 32 pg/ml ± 21 pg/ml When HUVEC was stimulated with LPS (10 ng/ml) and HMGB1 (15 ng/ml) alone, IL-6 content increased from 32 pg/ml ± 22 pg/ml to 289 pg/ml +42 pg/ml and 901 pg/ml ± 184 pg/ml, respectively (both P<0.01); If HUVEC was co-stimulated, the production of IL-6 was greatly increased (2361 pg/ml ± 299 pg/ml), and there was a synergistic effect between the two (F =69.405, P<0.01). Conclusion HMGB1 protein can induce the release of various inflammatory cytokines in HUVEC; The upregulation of IL-6 induced by HMGB1 has a time-dependent and dose-dependent relationship, and it can cooperate with LPS to stimulate the release of IL-6 in HUVEC, which plays an important role in the occurrence and development of sepsis.

Objective to investigate the clinical characteristics of mycoplasma pneumoniae (MP) infection. Methods the clinical data of 13 patients with MP infection with double serum MP antibody (particle agglutination test) titer increased 4 times or more from April 2003 to April 2004 were retrospectively analyzed. All patients were aged 17-34 years old. Results the time when the MP antibody titer increased 4 times or more was found to be on the 6th to 17th day of the disease course; The most common symptoms were fever (13/13), cough (11/13), sore throat (5/13) and mild headache (5/13). There was no nasal congestion, sneezing, rash, earache, pharyngeal congestion, and the total number of peripheral blood leukocytes was not high. 10 cases of pneumonia were diagnosed by X-ray chest radiography. Appropriate amount of macrolide + quinolone antibiotics had good therapeutic effect, and there was no obvious difference between azithromycin and erythromycin. Conclusion MP mainly infects adolescents and easily leads to pneumonia. Extrapulmonary complications are rare. One positive serum specific antibody should not be used as the clinical diagnostic criterion of MP infection.

Objective to observe and evaluate the pathological changes and pathological rules of ethmoid sinus bone in chronic sinusitis (CRS). Methods the ethmoid sinus mucosa samples of 40 patients with CRS and 16 normal controls were retrospectively analyzed. The pathological changes of ethmoid sinus mucosa and bone were observed by HE, tartrate-resistant acid phosphatase, alkaline phosphatase and Van Gieson staining, and the mucosal inflammation, histological changes of mucoperiosteum and ethmoid bone and bone tissue remodeling activity were observed and scored respectively.Results the mean score of mucosal inflammation in CRS ethmoid sinus samples was 2.30±0.88, which was significantly higher than that in the control group (1.38±0.81) (P =0.001); The score of pathological changes of mucoperiosteum and bone tissue in CRS ethmoid sinus specimens was 1.65±0.84, which was significantly higher than that in the control group (1.00±0.73) (P =0.004); The score of bone remodeling activity in CRS ethmoid sinus specimens was 2.15±0.74, which was significantly higher than that in the control group (1.56±0.63) (P =0.007). The score of mucosal inflammation in CRS patients was not significantly correlated with the score of mucoperiosteum and bone histopathology (R =0.047, P =0.772) and the remodeling activity of bone tissue (R =0.021, P =0.897). Conclusion The histological observation of CRS ethmoid bone showed significant characteristics of fibrosis, remodeling and woven bone structure. The pathological changes of CRS ethmoid bone were similar to chronic osteomyelitis, among which bone resorption, new bone formation and fibrosis were prominent.

Methods Thirty-four children with brachial plexus injury were treated from March 1998 to April 2001. They were divided into groups of 0-12 months (17 cases), 13-36 months (11 cases) and 37-60 months (6 cases) according to the age at the time of operation. All phrenic nerve translocation was used in the operation methods, and the follow-up was 3-7 years, with an average of 4.03 years. At the follow-up, 34 healthy children of the same age were used as controls for paired study (height, weight and sex). Routine physical examination, pulmonary function (tidal, ventilatory function and pulse oscillation examination), blood gas analysis and chest X-ray were performed to observe the diaphragm activity. Results Compared with the control group, the lung volume and lung compliance of children aged 0-12 and 13-36 months at the time of phrenic nerve translocation were lower (the maximum vital capacity was 0.9 L ± 0.2 L, 1.2 L ± 0.4 L vs. 1.3 L ± 0.3 L, 1.4 L ± 0.5 L, and the volume in one second was 0.8 L ± 0.1 L, 0.9 L ± 0.1 L vs. 1.0 L ± 0.1 L, 1.0 L ± 0.1 L However, there was no significant difference in lung function between the 37-60 month group and the control group (the maximum vital capacity was 1.6 L ± 0.4 L vs. 1.8 L ± 0.5 L, and the one-second volume was 1.5 L ± 0.1 L vs. 1.6 L ± 0.3 L, all P>0.05) There was no significant difference in blood gas analysis between the three groups and the control group.The incidence of recurrent respiratory tract infection was 47.1% (8/17 cases) and 27.3% (3/11 cases), and the incidence of thoracic deformity was 41.2% (7/17 cases) and 9.1% (1/11 cases), respectively. The incidence of thoracic deformity was 41.2% (7/17 cases) and 9.1% (1/11 cases), respectively, and 17.6% (3/17 cases) of children aged 0-12 months had different degrees of digestive symptoms, while the children aged 37-60 months did not have the above clinical manifestation.Conclusion The phrenic nerve transposition may have adverse effects on respiratory system, thoracic development and digestive system in children aged less than 3 years, the younger the operation age, the more significant the effect, while the phrenic nerve transection in children aged over 3 years did not have the above effects.

Public health emergency refers to major infectious diseases, mass diseases of unknown origin, major food and occupational poisoning and other events that seriously affect public health that suddenly occur, cause or may cause serious damage to public health. The correctness of decision-making is directly related to people's health and life safety. Because this kind of crisis occurs suddenly, comes fiercely, has various types and is highly concentrated in critical cases, it is a severe challenge not only to disease prevention and control institutions, but also to the level of urban medical management and government administration. At the same time, due to the limited response time, decision-making must be made immediately, the information is unreliable or incomplete, and the manpower and material resources needed to deal with the crisis may exceed the actual reserve, etc. This makes the decision-making of public health emergency extremely complicated and difficult [1]. Public health emergency is an issue that must be paid attention to at the present stage of social development. As a public health manager, In order to improve the level of scientific decision-making, we should know what factors may influence the decision-making of public health emergencies.

Objective to investigate the therapeutic value of sarcoplasmic reticulum calcium ATPase 2a (SERCA2a) transgene in non-ischemic and ischemic heart failure. Methods Recombinant adenovirus and adeno-associated virus vectors containing SERCA2a cDNA were constructed to prepare two models of heart failure in rats with abdominal aortic coarctation and myocardial infarction. The virus was injected into the pericardial cavity through the diaphragm (2×1011 virus particles), and the virus was introduced into the left ventricle by local myocardial injection. The hemodynamics of recombinant adeno-associated virus rAAV2-SERCA2a was detected by cannulation into the left ventricle through the carotid artery 10-30 days after operation. Results Compared with the control group (rAAV2-EGFP), the hemodynamics of rAAV2-SERCA2a were significantly improved 10 days and 30 days after the rAAV2-EGFP was introduced into the pericardial cavity of rats with aortic ligation. The left ventricular systolic blood pressure (LVSP), the maximum increase rate of left ventricular pressure (+ dp/dt) and the maximum decrease rate of left ventricular pressure (-dp/dt) were increased at 30 days, respectively 57% (94 mm Hg vs 147 mm Hg), 110% (5350 mm Hg/s vs 11225 mm Hg/s) and 99.8% (4198 mm Hg/s vs 8390 mm Hg/s), Left ventricular end-diastolic pressure (LVEDP) decreased by 60% (22 mm Hg vs 9 mm Hg). After transduction of SERCA2a, the expression of SERCA2a protein in the rAAV-SERCA2a group was significantly higher than that in the heart failure group and rAAV2-EGFP group at 30 days, and reached the level of the control group. The hemodynamics of recombinant adenovirus rAV-SERCA2a was significantly better than that in the rAAV2-EGFP group at 21 days after transduction, and LVSP, + dp/dt and-DP/dt were increased respectively 28% (86 mm Hg vs 110 mm Hg), 41% (4272 mm Hg/s vs 6026 mm Hg/s) and 71% (2789 mm Hg/s vs 4756 mm Hg/s), LVEDP decreased by 70% (3.89 mm Hg vs-5.34 mm Hg), Conclusion the recombinant adeno-associated virus rAAV2-SERCA2a and adenovirus rAV-SERCA2a mediate the overexpression of SERCA2a in rat myocardium, which can effectively improve the hemodynamic status of rat model of heart failure.

Objective to observe the effect of cardiac sympathetic nerve block on left ventricular diastolic function in patients with severe heart failure. Methods 39 patients with dilated cardiomyopathy with severe heart failure and left ventricular ejection fraction<35% were randomly selected and divided into cardiac sympathetic nerve block group (TEB group) and control group. The control group was given conventional anti-heart failure therapy, while the TEB group was given TEB at the same time as drug therapy. Echocardiography was performed before and 1 month after treatment. Left atrial diameter (Lad), left ventricular diameter (LVEDd), left ventricular ejection fraction (EF), early diastolic velocity and late diastolic velocity (Em and Am) of myocardial tissue at 6 sites of mitral annulus were measured, and the mean values (MEm and MAm) were taken to compare the changes of the above indexes between the two groups. Results Lad and LVEDd were significantly reduced in TEB group (LVEDd: 66mm±6 mm vs 71 mm±6 mm, P<0.05), EF was significantly increased (35%±7% vs 23%±6%, P<0.05), Em at 6 sites and Am at 3 sites of mitral annulus were significantly increased, MEm and MAm were also Conclusion Compared with conventional therapy, TEB can significantly improve left ventricular diastolic function while reducing left ventricular diameter and enhancing ejection function in patients with severe heart failure.

Objective to evaluate the diagnostic value of B-type natriuretic peptide (BNP) in patients with left heart failure. Methods 243 patients with left heart failure and 111 normal subjects were measured by fluorescence immunoassay. The patients with left heart failure were subdivided into left ventricular ejection fraction (LVEF) ≤40% (n =111) and>40% (n =132) groups; The results showed that BNP was significantly higher in the left heart failure group than in the normal group (292.0 ng/L vs 17.9 ng/L, P<0.001), in the LVEF ≤40% group than in the LVEF>40% group (471.0 ng/L vs 138.5 ng/L, P<0.001), and in the decompensated heart failure group than in the compensated heart failure group (579.0 ng/L vs 84.8 ng/L, P<0.001). BNP was the highest in the area under the working characteristic curve (AUC) =0.927, in the LVEF ≤40% group (AUC =0.989), in the decompensated heart failure group (AUC =0.991) and in the distinguishing between compensated and decompensated heart failure group (AUC =0.941), with good diagnostic accuracy. 50.0 ng/L was used as the diagnostic threshold for LVEF>40% and compensated heart failure.

In 1972, Delgado et al. [1] first reported the real tissue microdialysis technology. Eklund et al. [2] first applied the microdialysis technology to the study of kidney in 1991. Since then, with the efforts of scientific researchers, the renal microdialysis technology has been developed continuously. In 1994, Baranowski et al. [3] first applied the microdialysis technology to the sampling of adenosine in renal interstitial fluid (RIF). Because this technology is directly sampled from living renal interstitial fluid, the adenosine concentration in the sample can more truly reflect the adenosine content in the kidney.

nesiritide (nesiritide) is a new drug for the treatment of heart failure, which has been spread rapidly after being approved for use in 2001. However, in recent months, the safety of nesiritide has been questioned.

Clinical data A 28-year-old female was admitted to the hospital on March 4, 2004, mainly due to progressive skin yellowing, oliguria and holding breath for 12 days after cesarean section. The patient had 1 pregnancy and 1 delivery, and all examinations during pregnancy were normal. On February 15, 2004, she was admitted to the Department of Obstetrics and Gynecology of a hospital in Hebei Province due to full-term pregnancy with increased fetal movement. On February 17, 2004, she underwent cesarean section due to cephalopelvic disproportion (macrosomia), and successfully gave birth to a 4.5 kg male baby. The blood pressure was stable during the operation, the bleeding was not much, and the postoperative urine output was normal. Since February 20, 2004, the patient gradually developed skin itching, yellowing all over the body, soy sauce-colored urine, palpitation and fatigue, upper abdominal discomfort with nausea and vomiting. The vomit was stomach content, and the urine output gradually decreased to 500~800 ml/d. By February 25, the patient's body temperature increased to 38.5 ℃, urine output decreased to 100 ml/d, heart rate 120 beats/min, accompanied by chest tightness, holding breath, and edema of both lower limbs. Blood routine examination: white blood cells 19.5×109/L, hemoglobin 58g/L, platelets 85×109/L, neutrophils 0.88, peripheral blood Urea nitrogen was 22 mmol/L and creatinine was 624.3 μ mol/L.

The urinary system and the reproductive system are homologous in embryonic development and have close anatomical relationship.Female urethra and bladder have estrogen receptor distribution.Postmenopausal women are also the high incidence of lower urinary tract symptoms.Therefore,the relationship between estrogen and bladder has been paid attention to all times.The bladder is mainly composed of smooth muscle and collagen, and the collagen fibers of bladder are mainly type Ⅰ and type Ⅲ [1]. In particular, the content of type Ⅲ collagen is the determinant of bladder compliance.The increase of its content will lead to loss of bladder wall elasticity and decrease of smooth muscle function [2]. In this study, the expression of type Ⅰ and type Ⅲ collagen genes in bladder tissue was detected by comparing the urodynamic parameters of normal control, ovariectomized and ovariectomized rats supplemented with estrogen and phytoestrogen respectively, and further evaluated the effects of estrogen phytoestrogen on bladder function and collagen that may be related to these functions.

Pluripotent neural stem cells (NSC) have become a cell substitute for repairing central nervous system damage, providing a new way for the treatment of nervous system diseases [1]. Although a large number of animal experiments have proved that NSC transplantation can effectively treat Parkinson's disease [2, 3], there are many problems in clinical application [4]. At present, there is still a lack of effective monitoring means to observe the condition of NSC after transplantation in vivo. Among many imaging methods, magnetic resonance can provide images with near cell-level (about 25~50 μ m) resolution simultaneously, and its distribution in the host can be understood by tracing the transplantation of magnetized labeled cells [5]. We used superparamagnetic iron oxide (SPIO) to label NSC in the brain of rats with Parkinson's disease, and used magnetic resonance imaging to observe the distribution and migration of NSC after transplantation.

At present, most scholars advocate right atrial maze surgery, right atrial isolation surgery and various atrial maze surgery to treat organic heart disease complicated with atrial flutter/fabrilation (AF), but this kind of surgery is more complicated, and other postoperative surgical complications and perioperative mortality increased significantly [1, 2]. From October 2001 to January 2005, we tried to treat organic heart disease complicated with persistent AF with modified atrial incision method, and compared with conventional atrial incision surgery, to analyze the therapeutic effect of this method on AF and other atrial reentrant arrhythmias.

Subarachnoid hemorrhage (SAH) accounts for about 5% ~10% of all strokes, and 85% of them are caused by rupture of intracranial aneurysm [1, 2]. Hydrocephalus, as a common complication after SAH, can lead to obvious neurological impairment, accelerate the progression of the disease and even lead to death.

Arnold-Chiari malformation is a group of congenital diseases, and its pathogenesis is not very clear at present. There are many surgical treatments for this disease, but the results are inconsistent. We summarized 98 cases of Arnold-Chiari malformation treated by microsurgery in Beijing Tiantan Hospital from January 1997 to December 2003, and the results are reported as follows.

A 35-year-old male was admitted to the hospital on February 12, 2003 due to repeated frequent urination and urgency for 1 and a half years, low back pain, numbness and weakness of left lower limb for half year.One and a half years ago, he had frequent urination, urgency, prolonged urination time, joint pain and fever, and found facial butterfly erythema, acral erythema and necrotizing skin lesions. Blood routine white blood cells 2.6×109/L; Immunological examination: anti-nuclear antibody negative, anti-double-stranded DNA antibody 1:20, anti-SS-A antibody and anti-SS-B antibody positive; After oral administration of methylprednisolone 40 mg/d, the symptoms were relieved, and the dose was reduced to 20 mg/d for maintenance. Six months ago, I gradually felt low back pain, which was obvious when I moved, numbness and weakness in my left lower limb, and feeling of ant crawling from time to time, which gradually progressed to my right lower limb; Sometimes urination is difficult to solve, and sometimes urinary incontinence; Stool sometimes incontinence.

The prevalence of migraine and obesity (including overweight) is 12% and 64% respectively in the United States. Both of them are independent risk factors for cardiovascular diseases. The risk of chronic daytime headache in obese patients is 5 times higher than that in normal weight people, which is a risk factor for chronic daytime headache. Is obesity a risk factor for migraine? Experts led by Dr. M. E. Bigal of the Albert Einstein School of Medicine conducted a multicenter population survey in major cities in the United States, including Baltimore, Atlanta and Philadelphia. The results were published recently<In Neurology, 2006, 66:545-550.

A new study, conducted by Dr. Helen H. Hobbs of the University of Texas Southwestern Medical Center in Dallas, USA, published in March 2006, showed that long-term lowering of density lipoprotein cholesterol (LDL cholesterol) levels can reduce the risk of coronary heart disease (CHD) by 88%. This finding also points to a possible new target for lipid-lowering treatment<N Engl JMed, 2006, 354: 1264-1272).