Volume 90  ·   Issue 41  ·  2010

Vascular dementia (VaD) is one of the main causes of senile dementia, second only to Alzheimer's disease (AD), accounting for 10% ~20% of senile dementia [1-2]. The prevalence of VaD in Europeans over 65 years old is 1.6% [3]. Studies in China show that the prevalence of VaD in people over 60 years old is 0.8% [4], accounting for 26.8% of senile dementia [5].

With the deepening of understanding of dementia and the continuous renewal of diagnosis and treatment methods, the diagnostic criteria of ICD-10 and DSM-IV in the past can no longer meet the clinical needs. In 2010, the International Cognitive Impairment Group set out and launched DSM-V diagnostic criteria for cognitive impairment for global discussion and reference. The international treatment of dementia is no longer restricted to acetylcholinesterase inhibitors and NMDA receptor antagonists, but is deeply explored for the etiology and pathophysiological mechanism of the disease, and new drugs for dementia have entered clinical trials.

Objective To detect the expression change of insulin receptor under the induction of Aβ1-42 in rat hippocampus neuron and thus from the receptor level explore the disorder of central nervous insulin signaling and molecular mechanism of Alzheimer's disease. Methods Cultured primary hippocampus neuron was treated with different concentrations of Aβ1-42. Apoptosis was detected by flow cytometry. And real-time quantitative PCR(polymerase chain reaction)and Western blot were used to detect the expression of insulin receptor. Results Primary cultured cells, mature at Day 7, were identified as hippocampal cells.After the treatment with different concentrations of Aβ1-42(0 - 150 μmol/L), the ≥ 30 μmol/L treatment groups had greater early apoptosis rates(32.4 %, 36.1%, 51.0%, 53.6%)than that in the control group (13.4%)in a concentration - dependent fashion. The PCR results showed that the levels of insulin receptor gene were significantly higher in 30(2.56 ± 0. 19)and 60 μmol/L(3.44 ± 0.23)treatment groups than that the control group(regarded as 1)(P ＜ 0. 01)while the 100μmol/L group(0.74 ± 0. 15)was significantly lower than the control group(P ＜ 0. 01). And the results of Western blot had the same trend with those of PCR. The 30 and 60 μmol/L protein level of the treatment groups were 1.27 ±0. 13, 1.82 ± 0.10(P＜0.01)and 100μmol/L group was 0.82 ±0.08(P＜0.05). Conclusions Aβ1-42 induces an altered expression of insulin receptors in rat hippocampus cells and results in its functional defects. It may cause insulin resistance in center nervous system.

Objective To characterize the response of adrenocortieotropic hormone(ACTH)and cortisol in the patients with Alzheimer disease(AD)and those with mild cognition impairment(MCI).Methods The AD or MCI patients at our department from July 5, 2007 to August 31,2009 were enrolled.The levels of 8am serum ACTH and cortisol were measured by chemiluminescence in 54 AD patients, 41 MCI patients and 42 age -matched controls. Results The serum ACTH values in 3 groups were(16 ±5),(16 ±5)and(17 ±4)ng/L respectively. The serum ACTH values had insignificant changes in 3 groups(P＞0.05). The serum cortisol values were(595 ± 58),(568 ± 70)and(410 ± 81)nmol/L in 3 groups respectively. And the serum cortisol values significantly increased in AD and MCI groups(P ＜0. 01). The levels of serum cortisol in MCI group were lower than those in AD group. But there was no significant difference(P ＞ 0. 05). Through an analysis of rank correlation, the severity of AD had a positive correlation with serum concentration of cortisol(P ＜ 0.05); there was a negative correlation between the serum level of cortisol and the scores of MMSE in AD patients(P ＜ 0.05). There was no significant change of serum level of cortisol for different genders in 3 groups(P ＞ 0.05). Conclusion The level of serum ACTH has no significant change. A high level of serum cortisol is observed in AD and MCI groups. There is a positive correlation between serum level of cortisol and the severity of AD and a negative correlation between serum level of cortisol and the scores.

Objective To study the difference of immunological and inflammatory indices between mild type and severe type of adult pandemic(H1N1)patients. Methods White blood cell, lymphocyte,monocyte, CD4+ and CD8 + T lymphocyte counts, level of C3 and C4, CH50, immunoglobulin A/G/M and CRP from 166 pandemic(H1N1)patients during acute and recovery phases were recorded and analyzed.Results A lowered lymphocyte count and an elevated monocyte count were observed in both groups during acute phase. And both were corrected during recovery phase. The absolute values of CD4 + and CD8 + T lymphocytes were much lower in severe group than those in mild group. During acute phase, the level of creactive protein(CRP)was elevated in both groups while it was higher in the severe group than that in the mild group. During recovery phase, the CRP level fell after a rise in both groups while it was quicker in the severe group than that in the mild group. During acute phase, the majority of CH50 became mildly elevated.And it was higher in severe patients than mild ones. Conclusion Lymphocyte count, CD4 + & CD8 + T lymphocyte counts and CRP & CH50 values provide useful information for the diagnosis of pandemic (H1N1)and the evaluation of its severity.

Objective To build a three-dimensional finite element model of thoracolumbar spine with osteoporotic vertebral compression fracture(OVCF)and analyze its biomechanical change. Methods The T10-L2 segment data were obtained from computed tomography(CT)scans of an elderly female with a single T12 OVCF. A three-dimensional finite element model of thoracolumbar spine was constructed with the MIMICS and ABAQUS software. The model was composed of bony vertebrae, articulating facets,intervertebral disc and associated ligaments. The basic stress analysis of T10-L2 motion segment was made for different material properties of bone, ligaments and facet joints contacting frictional property. The stress on the annulus fiber, nucleus pulposus, endplate and facet joints under axial pressure(0. 3 MPa, 1.0 MPa,4. 0 MPa)were analyzed. Results A three-dimensional finite element model of human T12-L2 motion segment had 617468 elements. And the stress was higher in vertebral body than posterior structure. The distribution of pressure stresses in intervertebral disc was asymmetrical. The stress increased with a rising axial pressure. Conclusion 3D finite element model of thoracolumbar OVCF and adjacent segments are successfully established. The results of stress analysis are both feasible and reliable.

Objective To detect the single nucleotide polymorphisms(SNPs)in exon 6 of tissue inhibitor of metalloproteinase-1(TIMP-1)in young men in North China and to investigate the relationship between these polymorphisms and lumbar intervertebal disc degeneration. Methods The recruited subjects aged from 18 to 40 years old were divided by MRI into degeneration group(n = 48)and non-degeneration group(n = 49). The genomic DNA was collected from blood. After PCR amplification, the SNPs of TIMP-1 exon 6 were detected by DNA sequencing. Results Only the TIMP-1 666C ＞ T(rs11551797)polymorphism was observed and the genotype was of homozygote(CC/TT). The difference between two group was statistically significant(x2= 4. 571,P = 0. 033). Although the polymorphism was a synonymous mutation, the TT genotype mutant type was one of the risk factors for lumbar intervertebal disc degeneration(OR = 3. 269,95% CI 1. 063-10. 047). In the degeneration group, no significant correlation was found between the polymorphism, extent, level and number of degenerated intervertebal discs. Conclusion TIMP-1 666C ＞ T polymorphism present in north Chinese young men may lead to lumbar intevertebal disc degeneration. However it has no effect on the degree, level and number of degenerated intervertebal discs.

Objective To investigate the clinical values of blood pressure, heart rate and central venous pressure before and after fluid challenge to predict volume responsiveness. Methods A total of 86 fluid challenges in 39 patients with hemodynamic monitoring were retrospectively analyzed. Fluid challenges were separated into responder group and control group based on whether a 10% increase in cardiac output was achieved by fluid challenge. Such physiologic variables as systolic blood pressure(SBP), diastolic blood pressure(DBP), pulse pressure(PP), mean arterial pressure(MAP), heart rate(HR)and central venous pressure(CVP)were recorded before and after fluid challenges. Results △SBP, △DBP, △PP and △MAP before and after fluid challenge were significantly higher in responder group than control group.Logistic regression analysis identified △PP as the only independent predictor of fluid responsiveness(OR1. 100, 95%CI 1. 037-1. 167). Fluid responsiveness was predicted by △PP ≥5 mm Hg with sensitivity 78.4%, specificity 75.7%, positive predict value 76. 3% and negative predict value 77.8%. Only △PP correlated with △CO by Pearson correlation analysis(r=0.417, P＜0.001). Conclusion △PP before and after fluid challenge can predict volume responsiveness while HR and CVP can not.

Objective To make a clear distinction of intrasellar cystic lesions: craniopharyngioma (CR), Rathke's cleft cyst(RCC), cystic pituitary adenoma(PA)and intrasellar arachnoid cyst(AC).Methods A total of 72 adult patients underwent transsphenoidal approach for the removal of intrasellar cystic lesions. The authors conducted a study to(1)investigate preoperative clinical, biochemical and radiographic features of patients with CR, RCC, PA and AC;(2)identify clinicopathological features of independently predicting recurrence in CR, PA and RCC in adults. These adult patients included CR(n =10), RCC(n = 27), cystic PA(n=32)and 1 patient with AC(n = 1). Results The CR patients presented with hypopituitarism in 80% of cases. According to the biochemical criteria, the percentage of patients with a slight prolactin increase happened in PA(55.6%)and RCC(44. 4%). Cystic PA had postcontrasting enhancement in cyst wall because of rumor tissue. Calcification detectable on computed tomographic scanning was present in 70% of CR patients. It was a significantly greater proportion compared to other diseases. Typical RCC was located between anterior and posterior pituitary and the contents in RCC were variable. Mass effects vanished post-operatively in all kinds of lesions. Long-term hormone replacement therapy was administered more in CR patients(60%)and diabetes insipidus than other lesions. One PA patient and 2 CR patients had recurrence during a follow-up of 12-52 months(mean: 34). RCC and AC had no recurrence. Conclusion Craniopharyngioma, Rathke's cleft cyst, cystic pituitary adenoma and intrasellar arachnoid cyst are a spectrum of diseases with different therapeutic strategies. An accurate diagnosis of these lesions is essential so as to determine the type of treatment to improve outcome.

Objective To evaluate values of MR perfusion weighted imaging(PWI)in the grading of intracranial gliomas by a meta-analysis. Methods All English and Chinese literatures published before November 2009 in PUBMED and CNKI(China National Knowledge Infrastructure)were searched.Literature searching requirements:(1)MR PWI with region of interest(ROI)must have been applied in the grading of gliomas;(2)histopathological results must have been used as the reference standards. In addition, after data extraction, a bivariate random-effect model and hierarchical weighted symmetric summary receiver-operating curve must have been utilized to pool the data. Furthermore, a meta regression method must have been applied to detect and analyze the factors that affected the diagnostic accuracy. Results Overall, fourteen studies were included with a total amount of 1021 patients. The pooled sensitivity,specificity and diagnostic odds ratio with 95% of CI were 93%(89%-96%), 81%(73%-87%)and 55(28-107), respectively. The factors that affected the diagnostic accuracy were the sample size, the ratio of malignant glioma, the injection rate of contrast agents, the repetition time and the cutoff value.Heterogeneity did exist among the results obtained from different studies. Conclusion the relative cerebral blood volume(rCBV)of MR PWI can be referred to differentiate malignant cerebral gliomas from benign ones with sound sensitivity and specificity. However, there is not a unified threshold applied in the researches that have been conducted so far, and techniques used differ among the studies. In summary,clinical application values of rCBV of MR PWI are to be corroborated by further studies with a larger sample size.

Objective To evaluate the apparent diffusion coefficient(ADC)value features of the lesions after transcatheter arterial chemoembolization(TACE)plus radiofrequency ablation in hepatocellular carcinoma(HCC)with 3.0T magnetic resonance imaging(MRI)and diffusion-weight imaging(DWI)and analyze the value of 3.0T DWI in detecting the pathological lesion features of post-TACE plus radiofrequency ablation in HCC. Methods Twenty-eight HCC patients were enrolled to receive TACE firstly. Then all viable rumors around the lesions underwent radiofrequency ablation. At 1-4 months after radiofrequency ablation, 3.0T MRI and DWI(b = 600 sec/mm2)were performed to measure the ADC values of different lesions of post-TACE plus radiofrequency ablation. The features of MRI and ADC values of different lesions,the difference of contrast enhancement sequence and DWI in evaluating the lesions of post-TACE plus radiofrequency ablation were analyzed. Results Viable tumors occurred in 14 of 28 HCC patients after TACE plus radiofrequency ablation. The ADC values of necrotic tissues with lipiodol, necrotic tissues without lipiodol, viable tumors and normal liver tissues were 1.905±0.487, 0.726±0.116, 1.449±0.054and 1.777±0.094(10-3 mm2/sec)respectively. There was no significant difference of ADC values between necrotic tissues with lipiodol and normal tissues(P =0. 115). But there were significant differences of ADC values among necrotic tissues with lipiodol, necrotic tissues without lipiodol and viable tumors(P ＜0. 05). The viable tumor tissues after TACE plus radiofrequency ablation appeared as nodular lesions with slightly heightened signal intensities around the necrotic tissues, the lesions with heterogeneous enhancement during arterial phase, portal vein phase and parenchymal phase. Necrotic tissues without lipiodol occurred outside necrotic tissues without lipiodol, around normal liver tissues, with low signal intensities on T2WI,without enhancement during arterial phase, portal vein phase and parenchymal phase. There were no significant difference between contrast enhancement and DWI sequence in detecting viable tumors after TACE plus radiofrequency ablation(P ＞0. 05). Conclusion The ADC values of 3.0T MR DWI may be used to distinguish the viable residue or recurrent tumor tissues, necrotic tissues in HCC after TACE plus radiofrequency ablation.

Objective To evaluate the clinical efficacy and survival rate of transarterial chemoembolization(TACE)alone or plus radiofrequency ablation(RFA)in patients with intermediate or advanced stage primary hepatocellular carcinoma(HCC). Methods In this retrospective study, 467 cases received RFA or TACE plus RFA. Among them, 167 cases with strict clinical procedure(TACE alone or plus RFA)and complete follow-up data were included. Eighty-seven cases received TACE and 80 cases had TACE plus RFA between January 2000 and December 2006. Hierarchical analyses were performed using logrank tests and survival curve was estimated by Kaplan-Meier method. Results A total of 167 patients received TACE alone or plus RFA for a follow-up period of 1 to 89 months. In the TACE alone group, the time-to-progression(TTP)was an average of 3.6 months. The median survival was 13 months, one-year survival rate 52. 9%, three-year survival rate 11.5% and five-year survival rate 4. 6%. In the TACE plus RFA group, the TTP time was an average of 10. 8 months. The median survival time was 30 months, oneyear survival rate 85.0%, three-year survival rate 45.0% and five-year survival rate 11.3%. In the TACE alone group, the median survival of intermediate stage HCC was 14 months, one-year survival rate 62. 2%,three-year survival rate 13. 3% and five-year survival rate 4. 4%; In the TACE plus RFA group, the median survival of intermediate stage HCC was 14 months, one-year survival rate 90. 1%, three-year survival rate 52.9% and five-year survival rate 13. 7%. AIl differences of two groups has statistical significance(P ＜0. 05). In intermediate stage HCC, the median survival of TACE alone group was 14 months, one-year survival rate 62. 2%, three-year survival rate 13.3%, five-year survival rate 4.4% versus 32 months,90. 1%, 52. 9% , 13.7% in the TACE plus RFA group respectively. For the advanced stage HCC, the median survival time was 12 months, one-year survival rate 35%, three-year survival rate 7. 1% and fiveyear survival rate 0 in the TACE alone group versus 28 months, 62. 1% , 24. 1% and 6. 9% in the TACE plus RFA group(P =0. 00). There was significantly statistic difference between both groups in intermediate and advanced staging HCC. Among them, 60/485(12. 4%)patients required a therapy of post-TACE hepatic dysfunctions versus 13/168(7. 7%)in the TACE plus RFA group(P =0. 004, ANOVA method).Conclusion The regimen of TACE plus RFA has the advantages of tumor control, liver function protection and survival extending in the treatment of HCC than TACE alone in intermediate or advanced stage HCC.

Objective The objective of this study was to evaluate the performance of 320-row multidetector CT(MDCT)in the detection and grading of esophageal varices and to evaluate the ability of MDCT in predicting the risk of hemorrhage in comparison with upper endoscoy in patients with portal hpyertension.Methods A total of 69 patients , with clinically confirmed portal hypertension, underwent epigastric triphasic enhancement scans using 320-row MDCT 1 weeks or less before upper endoscopies were performed.Two blinded abdominal imagers retrospectively interpreted all CT images to detect the presence of esophageal varices and divided EV into large EV(≥ 5 mm)and small EV(＜ 5 mm). The correlation between CT measurements and endoscopic grading was assessed by kappa values. With endoscopy as standard, the sensitivity, specifity, accuracy, positive predictive value and negative predictive value of the two radiologists in detection of EV were calculated. Correlations between CT measurements of varix size and red color sign were asscessed by correlation analysis. Results Of the total of 69 patients, 56 patients had esophageal varices, 41 had large EV, and 15 had small EV according to the endoscopic findings. MDCT showed an excellent interobserver reliability with regard to the diagnosis of the EV(k =0. 94). Agreement between CT and endoscopy with regard to the grading of EV were excellent(k = 0. 77). The sensitivity, specificity,accuracy, positive predictive value and negative predictive value of radiologist 1 in the detection of EV was 95%, 69%, 87%, 93% and 75% respectively; the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of radiologist 2 in the detection of EV was 93%, 77%, 87%, 95% and 71%, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the two radiologists in the detection of large EV was 95%, 100%, 97%, 100% and 93%,respectively. CT variceal grading showed a strong correlation with endoscopic grading for both observers (P ＜0. 01). Correlations between CT measurements of varix size and red color sign were significant in both radiologists with a correlation coefficient r of 0. 731 for radiologist 1(P ＜ 0. 01)and 0. 718 for radiologist 2(P＜0. 01). Conclusion 320-row MDCT is useful for the detection and grading of EV, and it is useful in evaluation of EV for predicting a risk of hemorrhage.

Objective To evaluate the clinical outcomes of total ProlifiTM system surgery for the repair of recurrent severe pelvic organ prolapse. Methods The clinical records of 13 cases of recurrent severe pelvic organ prolapse were retrospectively analyzed. The characteristic was vaginal vault prolapse in combination with anterior and posterior wall prolapse. Anatomic effect(according to POP-Q score),functional effect(according to prolapse quality of life)and sexual life(according to sexual life score)of each patient were assessed. All subjects were post-menopausal with a mean age(60 ±9)years and a mean BMI of(25. 6 ±2.9)kg/m2. Results All operations were accomplished successfully without any impairment of bladder, urethra, rectum, great vessels or nerves or blood transfusion. The mean operation time was (61 ± 18)minutes and the mean blood loss(155 ±84)ml. All patients were followed up for a medium of 19(15-30)months. Except for one post-operative urinary retention for a period of 7 days, 12 patients were able to micturate spontaneously 1 -2 d post-operatively with a residual urine volume of less than 100 ml.During follow-up, mesh erosion(n = 1), de novo overactive bladder(n = 1), one algopareunia(n = 1)and dyspareunia(n = 1)occurred. Postoperative Quality of Life Scores improved significantly(P ＜ 0. 01).However, sexual life scores was impaired(P ＜ 0. 05). The anatomic cure rate was 92. 3% and the patient subjective satisfactory rate 84. 6%. Conclusion The total ProliftTM system surgery represents a safe, simple and useful treatment for recurrent severe pelvic organ prolapse with satisfactory objective clinical outcomes.However, the level of patient subjective satisfaction is lower than objective cure rate. Meanwhile, harmful effects on sexual life remain a main concern.

A 40-year-old male was admitted to hospital in December 2009 due to "multiple joint swelling and pain for 15 years, subcutaneous nodules for 9 years, and intermittent fever for 3 months". After exertion 15 years ago, the patient developed redness, swelling, heat and severe pain at the first metatarsophalangeal joint of both feet. The local hospital diagnosed it as "gouty arthritis" and was treated with dexamethasone and Tibetan medicine, and the symptoms were relieved. Since then, the above symptoms were often induced by exertion, the duration of joint swelling and pain was gradually prolonged, and other joints of both feet, ankles, knees, elbows and hands were involved, and the treatment effect of Tibetan medicine was not good.

A 53-year-old male was admitted to the hospital on July 28, 2009 due to intrahepatic mass found on physical examination for 10 days. He had a history of chronic hepatitis B for 28 years, no history of peptic ulcer, and no history of special food and drug allergies. Physical examination: No positive signs were found. Abdominal MRI showed an irregular mass at the apex of the liver, 9.6 cm ×6.5 cm ×8.2 cm, tumor thrombus formed in the left branch of the portal vein, the diameter of the main portal vein was 12 mm, and there was no establishment of splenic and gastric collateral circulation in the portal vein stage (Figure 1). Gastroscopy showed no abnormalities in esophagus and stomach. Pathological return of liver biopsy guided by B-ultrasound: differentiated adenocarcinoma in the bile duct.

Case 1: A 28-year-old female was admitted to the emergency department on September 20, 2009 due to "lumbar and abdominal distension and pain accompanied by fever for 6 days and rash for 3 days". Three days ago, she developed scattered congestive rash all over her body due to lumbar and abdominal distension and pain and fever after intravenous infusion of norfloxacin. She was in good health and had no history of allergy. Urinary routine showed that white blood cells (WBC) were>100/ml. She was proposed to be diagnosed as "urinary tract infection? Drug allergy?". She was given anti-infective treatment with cefuroxime. A few minutes after administration, the patient developed dizziness, sweating, nausea and vomiting, and was transferred to the emergency room for treatment.

In recent years, the research on the concept, criteria, diagnosis and treatment of mild cognitive impairment (MCI) has been progressing continuously, which provides the basis for the formulation of the guidelines. This guideline aims to make recommendations on the clinical classification, diagnosis process, prevention and treatment of MCI in combination with clinical practice.