Volume 91  ·   Issue 48  ·  2011

With the deepening of transplantation immunology and transplantation biology research and the development and clinical application of highly effective immunosuppressants, the survival rate of clinical kidney transplantation has been significantly improved in the near term, but acute rejection is still an important factor affecting the long-term survival of transplanted kidneys.At present, percutaneous transplanted kidney biopsy guided by B-ultrasound is still the "gold standard" for definitive diagnosis of acute rejection.This method is mostly adopted when the recipient has clinical symptoms of rejection, or the serum creatinine level and other biochemical indexes reflecting the function of transplanted kidneys.With the popularization and use of new immunosuppressants, many recipients lack typical symptoms and signs when acute rejection occurs, and the change of serum creatinine level reflects the non-specificity and relative lag of transplanted kidney function, which makes many subclinical rejections unable to be diagnosed in time.

Objective To observe the histopathological features of posttransplant complications for hepatic allografts and evaluate their biopsy values.Methods From January 1999 to May 2011,a total of 268 percutaneous hepatic allograft biopsies were conducted in 207 recipients and the diagnostic procedures for staining,classification and staging performed according to the Banff schema and Chinese Schema on hepatic allograft rejection. Results Among them,there were ischemia/reperfusion injury ( n =26,9.7％ ),acute T cell-mediated rejection ( n =83,31.0％ ),acute antibody-mediated rejection ( n =12,4.5％ ),chronic posttransplantation rejection (n =31,11.6％ ),immunosuppressive-induced liver injury (n =70,26.1％ )and recurrent diseases (n =18,6.7％ ). Acute T cell-mediated rejection and druginduced liver injury were two most common causes of allograft dysfunctions. Conclusion Percutaneous hepatic allograft biopsy is valuable for the diagnosis and evaluation of various posttransplantation complications.

Objective To evaluate the safety and effect of sirolimus (SIR) substitution for calcineurin inhibitors (CNI) in chronic allograft nephropathy (CAN).Methods A prospective,open-label and non-randomized comparative study was performed in 74 kidney recipients from January 2004 to June 2006 with a diagnosis of CAN at a baseline estimated glomerular filtration rate ( eGFR ) of 30 - 60 ml · min-1 · ( 1.73 m2) -1.Patients in the SIR group (n =36) received SIR at 12 hours after a cessation of CNI.For those in the CNI group ( n =38 ),a cyclosporine (CsA) -based immunosuppressive regimen was prescribed in 30 patients and a tacrolimus ( FK506)-based regimen in another 8 patients.All patients were maintained under a high level of mycophenolate mofetil and followed up for 4 years to evaluate the renal function,eGFR,blood routines,blood lipids and liver function,etc. Results The renal function and eGFR profiles of the SIR group improved significantly after substitution.The baseline eGFR was (40 ± 7 ) ml · min - 1 · ( 1.73 m2 ) - 1 in the SIR group versus ( 38 ± 6 ) ml · min - 1 · ( 1.73 m2 ) - 1 in the CNI group (P ＞ 0.05).In SIR group,the levels of eGFR were higher than those in the CNI group at months 3,12,24,36 and 48 ( all P ＜ 0.05 ). For the endpoint of serum creatinine doubling,the 4-year survival was 75.0％ in the SIR group versus 50.0％ in the CNI group ( P =0.03 ). There were 2 cases of acute rejections,1 proteinuria,1 pneumonia in the SIR group while 2 patients in the CNI group dropped out as a result of acute rejections ( P ＞ 0.05 ).The total bilirubin value of all the patients decreased significantly but serum cholesterol and triglyceride levels increase significantly after conversion ( all P ＜ 0.05 ).Conclusion The substitution of SIR for CNI is both safe and effective in renal transplant recipients with CAN.And a conversion from CNI to SIR may improve the graft survival.

Objective To explore the application of proteomics in the mechanistic analysis of acute rejection (AR).Methods Quantified proteomics with isobaric tags for relative and absolute quantitation (iTRAQ) labeling was utilized to identify the protein profiling between the transplantation patients with( n =5 )or without AR (n =8)from 2008 to 2010.Results Among the 179 identified proteins,66 proteins in AR patients had at least a 2-fold change as compared with those without AR. The results demonstrated the dominant processes and responses associated with inflammation and complement activation.It was consistent with the underlying immune rejection associated with AR. Moreover,the results also indicated that highcoagulation state existed in AR patients.A number of transcription factors were identified in AR patients,including nuclear factor-κB,signal transducer and activator of transcription 1,signal transducer and activator of transcription 3.The analysis of transcription regulation networks suggested that the cross-talks among these key transcription factors might play an important role in the acute response and activation of coagulation system.Conclusion The application of proteomics provides a new strategy of mechanistic analysis in AR.

Objective To observe the ratio of Tim-1 + CD19 + B cell in the peripheral blood of kidney transplantation recipients and elucidate its functions.Methods From December 2009 to June 2010,a total of 35 pairs of kidney transplant recipients were selected and divided into 3 groups:healthy donors as control ( n =35 ),pre-transplantation ( n =35 ) and post-transplantation ( n =35 ).The profiles of Tim-1 + CD19 + B cell in kidney transplantation donors and recipients were analyzed and sorted by flow cytometry (FCM). Mixed lymphocyte culture (MLC) was carried out between kidney transplantation donors and recipients.After the additions of Tim-1 + CD19 + and Tim-1 -CD19 + B cells,there were 3 groups:Tim-1 +,Tim-1 - and blank.Lymphocyte proliferation and inhibition status were evaluated by propidium iodide uptake and Annexin V binding.And the cytokine levels were detected by FCM.Results The absolute values of peripheral CD19 + B cells were ( 170 ± 90),(202 ± 99 ),( 155 ± 71 ) cells/μl in the pre-transplantation,post-transplantation and control groups respectively,post-transplantation group were higher than control group (P=0.0300).The Tim-1+CD19+ cell ratios were (2.20±0.98)％,(35.46±10.66)％ and (1.95±0.95 ) ％ in three groups.And the differences were statistically significant ( both P ＜ 0.01 ).Tim-1 + CD19 +B and Tim-1 - CD19 + B cells were added into MLC respectively.The early apoptotic cells of the Tim-1 + group were higher than those in the Tim-1 - group [ (45.31 ± 12.37 ) ％ vs ( 10.92 ± 2.14) ％,P ＜ 0.05 ] and significantly higher than the blank group [ ( 1.93 ±0.26) ％,P ＜0.01 ].Late apoptotic and dead cells of the Tim-1 + group were higher than those in the Tim-1 - group [ (21.32 ± 5.67 ) ％ vs (2.32 ± 0.31 ) ％,P＜0.01] and the blank group [(1.27 ±0.19)％,P ＜0.05].The interleukin 10 levels in MLC supematant of the Tim-1 + group were significantly higher than those in the Tim-1 - group [ (5.32 ± 0.37) pg/ml vs (2.46 ±0.25) pg/ml,P =0.0001 ].However,the interferon-γ levels were lower than those in the Tim-1- group [(1.51 ±0.22) pg/ml vs (4.69 ±0.32) pg/ml,P=0.0015].Conclusion Present in the peripheral blood of kidney transplantation recipients,Tim-1 + CD19 + B cell has the capacity of promoting lymphocytic apoptosis. As a new regulatory subset of B cells,it plays important roles in the immune responses of transplantation.

Objective To explore the feasibility of open single-branched stent graft placement for simplified total arch replacement in acute Stanford type A aortic dissection.Methods Between June 2008 and September 2009,23 patients with acute Stanford type A aortic dissection underwent total arch replacement plus open single-branched stent graft placement. When core nasophageal temperature dropped to 68 °F,the perfusion to lower body was discontinued. Left common carotid artery was transected at its ostium and its proximal stump closed.The arch was transected at a predetermined line between innominate artery and left common carotid artery.Through a transverse incision,the main stent graft of single-branched stent graft was inserted into true lumen of descending aorta.And the side arm stent graft was positioned into left subclavian artery.The transected stump of arch was reconstructed by inner proximal stent-free Dacron tube of main graft and outer Teflon felt. Subsequently continuous anastomosis was made to a 3-branched Dacron tube graft.Results Open single-branched stent graft placement was technically successful in all patients.The mean cardiopulmonary bypass time,aortic cross-clamp time,lower body arrest time and selective cerebral perfusion time were ( 161 ±32),(97 ±20),(21 ±4) and (31 ±6) min respectively.All patients were discharged from hospital without any complication.Their computed tomographic scans at 3 months postoperatively showed that all stent grafts were fully opened and not kinked.There was neither space nor blood flow surrounding the single-branched stent graft.The false lumen of descending aorta around stent graft closed with thrombus in all cases.Conclusion Open single-branched stent graft placement is a new effective technique for simplified total arch replacement in acute type A aortic dissection. With this technique,the left subclavian artery anastomosis and distal aortic anastomosis at descending aorta can be avoided.

Objective To evaluate the correlation between retinal artery atherosclerosis and renal dysfunction and compare their risk factors in an urban population of Beijing.Methods The non-diabetic adults ＞40 years old undergoing annual physical examinations during June 2010 and February 2011 at one medical center were evaluated.Pearson correlation coefficient was calculated between retinal artery atherosclerosis and renal dysfunction.The analyses of multivariate Logistic regression were performed to compare the risk factors of these two diseases.Results Among 10 191 subjects included,retinal artery atherosclerosis was diagnosed in 1287 ( 12.6％ ) and renal dysfunction in 434 (4.3％ ). And 1.0％ of subjects had both two diseases versus 12.2％ with retinal artery atherosclerosis alone and 3.3％ with renal dysfunction alone.Correlation coefficient was low between two diseases (r =0.21 ; P ＜ 0.01 ).According to the analyses of multivariate Logistic regression,the strongest predictors of retinal artery atherosclerosis were obesity (OR=2.5,95％CI 2.0-3.2) and hypertension (OR=2.2,95％CI 2.0-2.6) while advanced age (OR =3.1,95％ CI 2.8 - 3.5 per 10 year increment ) was the strongest factor for renal dysfunction.Conclusion The low-level correlation and different risk factor profiles between retinal artery atherosclerosis and renal dysfunction indicate different pathogenic mechanisms of two diseases and suggest different preventive strategies.

Objective To explore the correlations of serum alanine aminotransferase (ALT),insulin resistance and pancreatic B-cell function.Methods A total of 351 first-degree relatives of type 2 diabetes mellitus received a standard oral glucose tolerance test (OGTT) at our outpatient clinic.All subjects were analyzed for the parameters of body mass index ( BMI),waist-hip ratio,blood pressure ( BP),serum lipids,ALT,aspartate aminotransferase (AST),plasma glucose (PG),true-insulin and proinsulin.Homeostasis model assessment (HOMA) was applied to assess the status of insulin resistance and pancreatic B-cell function. They were divided into 4 groups according to the quartiles of ALT:ALT1 group (＜12.9 U/L),ALT2 group (12.9- 17.3 U/L),ALT3 group (17.4-24.2 U/L) and ALT4 group ( ≥24.2 U/L).The diagnosis of metabolic syndrome was made according to the definition of Chinese Diabetic Society.Results With the rising serum ALT levels (ALT4 vs ALT1 ),the levels of BMI [ (26.3 ± 2.9) kg/m2 vs (23.2±3.7) kg/m2,P＜0.01],HOMA-IR [1.93(1.21 -3.26) vs 1.06(0.65 -1.54),P＜0.01] and LnHOMA-beta (2.00 ±0.32 vs 1.87 ±0.28,P＜0.05) were elevated; BP,serum lipids,PG,true-insulin and proinsulin also increased ( P ＜ 0.05 or P ＜ 0.01 ).The levels of serum ALT [ 23.3(16.3-37.6) vs 14.3 (10.3-18.5) U/L,P＜0.01] and AST [21.5 (18.3-32.8) U/L vs 17.9( 15.5 -22.1 ) U/L,P ＜0.01 ] increased with the rising number of metabolic disorders (0 vs 3 -4 metabolic disorders).After adjustments for gender,age,BMI and waist-hip ratio,serum ALT were still positively correlated with BP,serum lipids,PG,fasting true-insulin,2 h proinsulin,2 h proinsulin/true-insulin,HOMA-IR and the numbers of metabolic disorder (r=0.117 -0.236,P＜0.05 or P＜0.01).After adjustments for gender,age,BMI,waist-hip ratio and HOMA-IR,the serum ALT level remained positively correlated with the numbers of metabolic disorders (r =0.120,P ＜ 0.05).Multiple stepwise regression analysis showed that triglyceride,HOMA-IR,total cholesterol and 2 h-proinsulin were the independent risk factors for the level of serum ALT ( P ＜ 0.05 or P ＜ 0.01 ).Conclusion The elevated levels of serum ALT are significantly correlated with metabolic syndrome,insulin resistance and compensatory increases of pancreatic B-cell function.Independently of insulin resistance,the serum ALT level is correlated with metabolic syndrome.

Objective To evaluate the feasibility of clinical application for genetic based dosing algorithm in the predication of warfarin maintenance dose in Chinese population.Methods The clinical data were collected and blood samples harvested from a total of 126 patients undergoing heart valve replacement.The genotypes of VKORC1 and CYP2C9 were determined by melting curve analysis after PCR.They were divided randomly into the study and control groups.In the study group,the first three doses of warfarin were prescribed according to the predicted warfarin maintenance dose while warfarin was initiated at 2.5 mg/d in the control group.The warfarin doses were adjusted according to the measured international normalized ratio (INR) values.And all subjects were followed for 50 days after an initiation of warfarin therapy.Results At the end of a 50-day follow-up period,the proportions of the patients on a stable dose were 82.4％ (42/51)and 62.5％ (30/48) for the study and control groups respectively.The mean durations of reaching a stable dose of warfarin were (27.5 ± 1.8) and ( 34.7 ± 1.8 ) days and the median durations were ( 24.0 ± 1.7 ) and (33.0±4.5)days in the study and control groups respectively. Significant differences existed in the durations of reaching a stable dose between the two groups (P =0.012).Compared with the control group,the hazard ratio (HR) for the duration of reaching a stable dose was 1.786 in the study group (95％ CI 1.088 - 2.875,P =0.026).Conclusion The predicted dosing algorithm incorporating genetic and nongenetic factors may shorten the duration of achieving efficiently a stable dose of warfarin.And the present study validates the feasibility of its clinical application.

Objective To explore the efficacies and toxicities in multiple myeloma (MM) patients on the maintenance therapies of thalidomide and interferon-α so as to seek the optimal chemotherapeutic regimen.Methods A retrospective analysis was conducted for 57 MM patients on the maintenance therapies of thalidomide and interferon-α after introduction and consolidation.And 56 MM patients without maintenance therapy were enrolled as the control group.Results The values of progression-free survival (PFS) and overall survival (OS) were significantly longer in the maintenance group and this translated into an improved estimated 3-year PFS of 75.4％ (71.8％,83.3％ ) versus 23.2％ in the control group ( P ＜ 0.01 ).The estimated 4-year OS was higher in the maintenance group [ 89.5％ ( 89.7％,88.9％ ) vs 33.9％,P ＜ 0.01 ].No statistically significant differences existed among different maintenance groups in terms of PFS and OS.The administration of maintenance therapy extended both PFS and OS for MM patients of various M-proteins (P ＜0.05).However,in the thalidomide group,PFS and OS were extended only in MM of immunoglobulin G (IgG) and immunoglobulin A (IgA) but not in light-chain patients.Furthermore,the MM patients of Durie-Salmon (DS) stages Ⅱ and Ⅲ and international staging system (ISS) stages Ⅱ and Ⅲ extended PFS and OS through maintenance ( P ＜ 0.05 ). While in those of ISS stage Ⅰ,the differences were insignificant in terms of PFS and OS between two groups.The results were similar between the thalidomide and control groups.The patients achieving a partial remission (PR) or higher response level benefited from the maintenance therapy in terms of PFS and OS (P ＜ 0.05 ).In the thalidomide group,the patients with below PR prolonged OS( P =0.031 )but did not achieve a longer PFS( P =0.091 ).Both PFS and OS were extended through maintenance therapy after either stem cell transplantation or consolidation chemotherapies(P ＜ 0.05).There was no significant difference in terms of PFS and OS between MM patients without maintenance therapy after transplantation and those without transplantation. The adverse effects of thalidomide,milder than those of interferon-α,could be tolerated in most patients.The incidence and severity of adverse effects showed no significant difference between the combination maintenance and single agent therapies. Conclusion The maintenance therapies of thalidomide and interferon-α could improve the profiles of PFS and OS in MM patients.And there was no significant difference between them in terms of PFS and OS. However,the maintenance therapy of thalidomide is a better option due to its convenient application,milder adverse effects,reasonable cost and better efficacies in MM patients not achieving PR or receiving induction therapy without bortezomib or without transplantation.

Objective To examine the relationship between single nucleotide polymorphism (SNP) of adiponectin (APN) locus +45T/G and Han male patients with premature coronary artery heart disease (pCAD).Methods A total of 423 male patients of Han ethnic group ( ＜55 yr old) undergoing coronary arteriography were recruited.Among them,358 patients were diagnosed as pCAD while another 65 normal control (NC).All subjects were genotyped for adiponectin gene SNP + 45 by polymerase chain reactionrestriction fragment length polymorphism (PCR-RFLP) assay.Results Statistical differences of TG/GG genotype ratio were observed between two groups.The TG/GG genotype ratio in the pCAD group was 51.1％ versus 35.4％ in the NC group ( x2 =5.45,P =0.022).After an adjustment of conventional risk factors,such as age,body mass index (BMI) and hypertension,the adiponectin gene SNP + 45 TG/GG genotype was strongly associated with Han ethnic group male pCAD by binary logistic regression analysis ( OR =1.843,P =0.035,95％ CI:1.045 ～3.250).And there were statistical differences between TT genotype and TG/GG genotype among pCAD subjects in the following factors:BMI,total cholesterol (TC),low-density lipoprotein-C (LDL-C) and APN level (P ＜0.05).By Pearson correlation analysis,APN was negatively correlated with TC,LDL-C and SNP + 45T/G polymorphism. Conclusion The SNP of adiponectin locus +45T/G is associated with male pCAD.And TG/GG genotype is a possible predisposing gene for Han ethnic group male pCAD.

Objective To compare the short- and long-term outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients with severe left ventricular dilatation (LVD).Methods From July 2003 to September 2005,we enrolled 251 patients with severe LVD to undergo coronary revascularization with either PCI ( n =101 ) or CABG ( n =150 ) and analyzed the effects of different revascularization strategies on the in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE).Results Compared with those in the CA BG group,the patients in the PCI group had lower incidence of in-hospital MACCE events [ 3.0％ ( 3/101 ) vs10.7％ ( 16/150 ),P =0.024 ],due mainly to a lower in-hospital mortality (2.0％ vs 8.7％,P =0.028 ).Ninty-nine ( 98.0％ )patients in the PCI group and 136(90.7％ ) patients in the CABG group were followed up for (516 ± 182) days and (515 ± 231 ) days,respectively.Although no difference existed in the follow-up incidence of MACCE between two groups,the PCI patients had a trend of a higher incidence of MACCE events [ 18.2％ (18/99) vs 9.6％ ( 13/136 ),P =0.054 ],due mainly to a higher rate of repeat revascularization [ 14 (14.1％ )vs(0.7％ ),P＜0.01 ].Two patients groups had the comparable follow-up rates of mortality [4 (4.0％)vs 12(8.8％ ),P =0.151 ],myocardial infarction [2(2.0％ ) vs 1 (0.7％),P =0.781 ] and stroke [ 2 (2.0％) vs 0 (0.0％ ),P =0.176 ].Conclusion For the patients with severe LVD.PCI is both safe and feasible.And it has a lower rate of in-hospital mortality,and a comparable incidence of follow-up MACCE events.However,the rate of follow-up repeat revascularization is higher.

Objective To explore the roles of BCG-depleted immunodominant antigens derived from M.tuberculosis in serological tests for tuberculosis(TB).Methods Four different combinations of current mainstream antigens used for serological diagnosis of TB were selected:Reagent A [ Mycobacterium TB immunoglobulin G (IgG) antibody assay kit]; Reagent B (Mycobacterium TB detection kit); Reagent C (M.tuberculosis-specific antibody detection kit) ; Reagent D [ Active TB antibody detection enzyme-linked immunosorbent assay (ELISA) system].Immunological methods of Western blot,colloidal gold and ELISA were developed to test the antibodies in 109 patients with active tuberculosis (TB) and 97 healthy populations.They were divided into purified protein derivative of tuberculin (PPD) positive and negative groups.Bayesian statistical analysis was used to analyze the influences of variable combinations of different antigens on the detection accuracy of TB.Results For Reagent A,B,C,D,the detection rates of IgG antibodies in the patients with active TB were 80.0％,66.7％,80.7％,56.0％ versus 23.9％,8.9％,6.6％ and 1.0％ respectively in healthy populations.The TB antibody detection rates in four TB patient populations were all higher than that in healthy populations ( x2 =47.53,51.59,90.48,69.68,all P ＜0.01 ).The TB antibody detection rates of Reagents A and B increased with the intensity of positive reaction to PPD in healthy populations (x2 =2.124,2.220,all P ＜0.05 ) while those of Reagents C,D in healthy populations were irrelevant to PPD reaction.( x2 =0.122,0.479,all P ＞0.05 ).Reagent D has the highest accuracy.The immunoglobulin M ( lgM ) antibody detection rate of Reagent D was only 2.1 ％ in the patients with active TB.Conclusions The detecting sensitivity of TB IgG antibodies is associated with antigen selection.And it is also positively correlated with the number of combined antigens. High-sensitivity detection is often accompanied by a loss of specificity.With the BCG-depleted antigens derived from M.tuberculosis,the specificity of serological test for TB may significantly improve.

Objective To explore the effects of secretary leukocyte protease inhibitor (SLPI)-transfected bone marrow mesenchymal stem cells (BMSCs) transplantation on airway inflammation and mucus secretion in chronic obstructive pulmonary disease (COPD) rats.Methods Sixty rats were equally and randomly divided into negative contol,COPD model,BMSCs and SLPI-transfected BMSCs groups.The COPD rat model was established in all rats with the exception of the negative control rats by smoking and intratracheal instillation of lipopolysaccharide (LPS). BMSCs with or without transfection of plasmid containing SLPI gene were delivered through caudal vein of rats at 30 days post-induction.The expression of SLPI was examined with Western blot.The levels of interleukin (IL)-8 and tumor necrosis factor (TNF)-α were detected by enzyme-linked immunosorbent assay (ELISA).Goblet cell hyperplasia of lung pathological section was observed on. Results Compared with the negative control group,the expression of SLPI increased significantly after the administration of SLPI-transfected BMSCs (0.79 ± 0.06 vs 0.24 ± 0.02,P＜0.05).The levels of IL-8 and TNF-α in BMSCs and SLPI-transfected BMSCs group were lower than those in the COPD model group. Compared with the negative control group,the administration of SLPI-transfected BMSCs resulted in a further decrease in IL-8 and TNF-α in bronchoalveolar lavage fluid [ ( 17.6 ± 1.7 ) vs ( 36.6 ± 4.0 ) ng/L,P ＜ 0.05 ].SLPI-transfected BMSCs transplantation also significantly attenuated goblet cell hyperplasia in rats ( P ＜ 0.05 ).Conclusion There is a potential role for cell-based SLPI gene therapy in the treatment of COPD.

A 32-year-old female, weight 63 kg, height 159 cm, was transferred to Peking University Third Hospital 6 days after cesarean section due to multiple organ dysfunction. The patient underwent cesarean section 6 days ago due to intrauterine pregnancy of 40 weeks, fetal distress and amniotic fluid III contamination, and gave birth to a healthy boy. After delivery, the fetus developed atonic postpartum hemorrhage. After 2 hours after the operation, laparotomy was performed. The bleeding reached 5120ml, and hemorrhagic shock occurred. The lowest blood pressure was 75/50 mm Hg (1 mm Hg =0.133 kPa). The hemodynamics gradually stabilized, but the pulse oxygen saturation (SpO2) decreased progressively, accompanied by cough, cough of pink foamy sputum, macroscopic hematuria, oliguria, poor response to furosemide and abnormal coagulation function. It was considered as acute respiratory distress syndrome (ARDS), acute renal failure, diffuse vascular

Medical Record Abstract A 43-year-old male was admitted to the Department of Respiratory Medicine of Peking Union Medical College Hospital on February 11, 2011 due to fever and cough for more than 1 month and hemoptysis for more than 20 days. The patient developed fever without inducement in mid-December 2010, with the highest body temperature of 38℃, accompanied by cough, without fear of cold, chills and expectoration. The fever subsided after self-administration of cephalosporin antibiotics for 3~4 days, and the above symptoms were alleviated. At the end of December 2010, he developed fever again, with the highest body temperature of 39.3℃, accompanied by dry cough and dull pain in the right chest. Self-administration of antipyretic drugs and antibiotics (details unknown) was not effective. The patient went to the local county hospital on January 5, 2011, and the chest CT examination showed consolidation in the middle lobe of the right lung (Figure 1). Considering "pneumonia", he was given ceftriaxone (3 g/d) + levofloxacin (0.4 g/d) for 14 days, and the highest body temperature once dropped to 37.5℃. On January 13, the body temperature rose again to 38.5℃, accompanied by cough and a small amount of yellow phlegm, and the original regimen was continued. On January 20th, the highest body temperature reached 39.3℃, and the cough worsened, coughed a lot of brown pus and odorous sputum (100~200 ml/d), so he was admitted to the local hospital. Blood test routine: white blood cells 11.3×109/L, neutrophils 0.789, hemoglobin and platelets were normal; Sputum culture (1), chest CT showed that the consolidation shadow and cavity in the middle lobe of the right lung were smaller than before (Figure 2).

Transplantation of exogenous stem/progenitor cells or promoting more involvement of endogenous stem cells in tissue repair is the therapy of myocardial regeneration after ischemic injury. More than 10 years ago, the use of monopotent cardiac precursor cells and terminally differentiated cardiomyocytes derived from skeletal muscle began to be used, and now it has developed to use pluripotent and multidirectional stem/progenitor cells [1]. The research of stem/progenitor cell type selection and transplantation methods is a hot spot in cardiac stem cell repair research [2]. Previous studies have evaluated the safety, feasibility and effectiveness of various types of cells. The discovery, in vitro isolation and expansion of cardiac stem/progenitor cells in situ have further advanced the research in the field of stem cells [3]. Embryonic stem cells are also one of the promising candidates in the field of cardiac repair therapy. With the opening of embryonic stem cell research policy, the application research of embryonic stem cells in the medical field has obviously strengthened. It can be predicted that embryonic stem cells can be used as the source of cardiomyocytes and endothelial cells for clinical transplantation. They can be transformed into intracardiac cell phenotype, However, teratogenicity and immune rejection associated with tissue origin are the most major concerns in clinical application; Currently, there are strategies to transform embryonic stem cells into tumor-free cardiac cell lines [4].

Inflammatory response is a kind of defensive response of the body, which can induce further physiological adaptive response, which can cause localized tissue damage or promote the clearance of proinflammatory factors.The development of inflammation involves a series of complex events, including arteriole dilation,increased permeability of venules and capillaries, fluid exudation, and migration of plasma proteins and leukocytes to the inflammatory site, etc. The mechanism of inflammation is closely related to the production of many inflammatory mediators, including prostaglandins, leukotrienes, histamine, bradykinin, platelet activating factor and pro-inflammatory cytokines including interleukin (IL) -1,IL-8 and tumor necrosis factor α (TNF-α) [1].

A 60-year-old male was admitted to hospital due to hematemesis for 2d and fever for 1d. The volume of hematemesis was about 500 ml, accompanied by chills and fever, the highest body temperature was 38.7℃, and there was no cough, hemoptysis or chest pain. Aortic stent was placed due to type Ⅲ aortic dissection aneurysm 2 months ago. Physical examination on admission showed that body temperature was 38 4℃, blood pressure was 90/60 mm Hg (1 mm Hg =0 133 kPa), anemia appearance, and no abnormal signs of heart and lung. Blood routine showed that white blood cells were 10.32×109/L, neutrophil ratio was 0.75, red blood cells were 2 99×1012/L, hemoglobin was 90 g/L, and platelets were 180×109/L. Chest X-ray showed a liquid-gas plane in the mediastinum (Figure 1). Chest CT showed extensive gas density and liquid density shadow around the esophagus in the mediastinum, the fat space around the normal esophagus disappeared, the boundary between the thoracic esophagus and the surrounding lesions was unclear, and stents were found in the descending segment of the aortic arch and the lumen of the left subclavian artery, with normal appearance and no collapse. No contrast overflow was found in enhanced CT (Figure 2). Considering the existence of aortoesophageal fistula, emergency gastroscopy showed a large fistula at the distance of 34~37 cm from the incisors in the lower segment of the esophagus, and fresh blood gushed out of the mediastinum, and a large amount of purulent secretion was seen in the mediastinum after blood suction (Figure 3). Final diagnosis: aortoesophageal fistula (AEF), mediastinal abscess, upper gastrointestinal hemorrhage, and aortic dissection aneurysm after stent placement. The patient was given total parenteral nutrition, intravenous anti-infective treatment with vancomycin, cephaloperazone and sulbactam sodium. The peak body temperature of the patient gradually decreased, and there was no hematemesis and melena. On the 5th day after admission, the patient was transferred to another hospital for conservative treatment. 20 days after being transferred to another hospital, he was due to hematemesis