Volume 91  ·   Issue 22  ·  2011

Liver cancer is still one of the digestive tract tumors with high incidence at present, and surgical resection and liver transplantation are the main methods in the comprehensive treatment at present. As for the latter, if only from the theory of multifocal incidence of liver cancer, liver transplantation provides the only effective treatment for end-stage liver disease complicated with liver cancer. However, what has puzzled everyone for many years is the recurrence and metastasis of tumor after transplantation, which is the main reason that affects the long-term survival of recipients. With the accumulation of experience and technical improvement, the rapid development of tumor molecular biology and imaging, at present, great progress and development have been made in the indications of liver transplantation for liver cancer, the selection and individualized application of immunosuppressants, postoperative chemotherapy and the application of molecular targeted drugs.

Although the recurrence rate of hepatocellular carcinoma (HCC) patients who met the Milan criteria in Italy was lower than that of those who exceeded the Milan criteria, it also seriously hindered more HCC patients from receiving liver transplantation.In recent years, the California (UCSF) standard introduced by the transplantation community in Europe and America and the "Fudan standard" [1] and "Hangzhou standard" [2] introduced by the transplantation community in China have significantly expanded the population of HCC liver transplantation without reducing the survival rate after transplantation and tumor-free survival rate.However, the recurrence of HCC patients after liver transplantation is still the main factor affecting the prognosis.

Objective To investigate the feasibility and management of retransplantation for diffuse biliary strictures occurring after initial liver transplantation.Methods The clinical data of 53 consecutive liver retransplantation patients at our hospital from January 2001 to December 2009 were collected and analyzed retrospectively. Among them, 20 (37.7%) were due to diffuse biliary strictures.Results Diffuse biliary strictures appeared at 3-16 months after initial transplantation. The mean time was 6.3 months. The specific types included intra-hepatic diffuse biliary strictures (n=16) and multi-strictures involving both intra- & extra-hepatic biliary ducts (n=4). Retransplantation was performed after a failure of intervention or/and other comprehensive treatments. Among them, 14 were cured and 6 died from peri-operative complications including serious abdominal infection & MODS (multiple organ dysfunction syndrome) (n=3, 50%), biliary fistula (n=2, 33.3%) and hepatic artery embolism (n=1, 16.7%). These patients were followed up for a mean time of 1.8 years (range:1-5 years). The accumulative survival rates at 1, 3 and 6 months were 80.0%, 75.0% and 70.0% respectively.Conclusions Liver retransplantation is the ultimate treatment for diffuse biliary strictures after liver transplantation. The survival rate is associated with operative timing, surgical techniques and peri-operative management.

Objective To investigate the role of IL-6/STAT3 pathway in the proliferation of cholangiocytes after liver transplantation and determine whether or not rapamycin (RPM) depresses the regeneration of cholangiocytes by blocking the activation of STAT3.Methods Rats were randomized into OLT-1 h and OLT-12 h groups (supplied livers preserved for 1 or 12 h), anti-sIL-6R group (rats of the OLT-12 h group injected intravenously with 16.7 μg/kg anti-rat sIL-6R antibody at 1 hour pre-operation and daily post-operation), RPM group (rats of the OLT-12 h group injected intraperitoneally with 0.05 mg/kg RPM for 3 days pre-operation and daily post-operation) and sham group (transverse laparotomy and closure without liver manipulation). At 1, 3, 7, 14 d post-operation, the IL-6 concentration in liver homogenate and cholangiocytic proliferation were detected by ELISA (enzyme linked immunosorbent assay) and histochemistry respectively. The expressions of IL-6 mRNA, phophorylated-STAT3 and cyclin D1 protein in cholangiocytes were determined by real-time RT-PCR (reverse transcription-polymerase chain reaction) or Western blot. The DNA binding activity of STAT3 was determined by electrophoretic mobility shift assay. The serum concentrations of ALP (alkaline phosphatase) and GGT (γ-glutamyltransferase) were also measured.Results The minimal expressions of IL-6, p-STAT3, cyclin D1 and DNA binding activity of STAT3 were detected in OLT-1h group. And a slight increase of IOD (integral optical density) ratio (38±10 and 22±7) indicated a mild cholangiocytic proliferation. The concentrations of GGT were(69±6)U/L,(34±4)U/L and ALP(86±9)U/L,(45±3)U/L. The expression of IL-6 in liver homogenate were(273±20)ng/g, (159±18)ng/g and 0.40±0.04, 0.23±0.04 in cholangiocytes. The expressions of P-STAT3 were 0.420±0.023 and 0.230±0.040 in cholangiocytes and cyclin D1 0.580±0.023 and 0.420±0.015 respectively. Cholangiocytes responded to extended cold preservation with severe bile duct injures and marked increases in IL-6 secretion, p-STAT3 and cyclin D1 protein expression and DNA binding activity of STAT3, followed by compensatory cholangiocytic regeneration. Meanwhile biochemical index and morphology indicated that bile duct injury recovered at 14 d post-operation. The IOD ratios were 38±10 and 22±7 respectively. The expressions of IL-6 were(659±28)and(446±23)ng/g in liver homogenate and 0.73±0.06 and 0.54±0.04 in cholangiocytes. The expression of P-STAT3 were 0.72±0.04 and 0.58±0.06 in cholangiocytes and cyclin D1 0.88±0.04 and 0.74±0.07 respectively. However, anti-sIL-6R inhibited the cholangiocytic proliferation and reduced the expressions of IL-6, STAT3 and cyclin D1. The DNA binding activity of STAT3 with cellular injury and the increases of serum ALP or GGT were also abrogated by the administration of anti-sIL-6R. With similar results, the RPM treatment had insignificant effects on the expression of IL-6.Conclusion The IL-6/STAT3 pathway initiates the cholangiocytic regeneration after liver transplantation so as to accelerate the biliary recovery. However RPM represses the cholangiocytic regeneration by inhibiting the STAT3 activation. It may have a negative effect on the healing and recovery of bile ducts in grafts with extended cold preservation.

Objective To analyze the negative impact of preoperative neutrophil-lymphocyte ratio (NLR) on the tumor recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation.Methods The clinical data of HBV (hepatitis B virus)-associated HCC patients undergoing liver transplantation were retrospectively analyzed. Their clinical and pathological risk factors for tumor-free survival were evaluated by univariate analysis. The analysis of Cox multiple regression was performed to determine the parameters of predicting the HCC recurrence. NLR≥2.5 was considered to be elevated.Results A total of 76 patients were identified. Among them, 37 had an elevated NLR. The 1, 3 and 5-year tumor-free survival rates were 69.2%, 52.7% and 50.9% respectively. The disease-free survival for patients with high NLR was significantly worse than that for those with normal NLR (1, 3, and 5 year survivals at 56.3%, 37.6% and 37.6% vs 81.1%, 66.9% and 63.3% respectively;P=0.011). Univariate analysis of factors revealed that tumor size＞5 cm, tumor number＞3, vascular invasion, serumα-fetoprotein level≥400 μg/L and NLR≥2.5 were preoperative predictors of disease-free survival. Cox regression analysis showed that the presence of vascular invasion, tumor number＞3 and NLR≥2.5 were independent prognostic factors of worse disease-free survival.Conclusion An elevated NLR significantly increases the risk for tumor recurrence in HCC patients undergoing liver transplantation.

Objective To systematically review the advantages of tubeless percutaneous nephrolithotomy.Methods The randomized controlled trials (RCTs) of tubeless and standard percutaneous nephrolithotomy were retrieved and their included references investigated. Data analyses of literatures fulfilling the inclusion criteria were performed with the Cochrane ColLaboration' s RevMan 5.0 software.Results Seven literatures were finally retrieved after screening. A total of 1365 patients were included for a meta-analysis. The results showed that, as compared with the control group(standard percutaneous nephrolithotomy), the patients in the trial group(tubeless percutaneous nephrolithotomy) had the following features. (1) There was no significant difference in mean operative duration and change of hemoglobin(95%CI -15.16 to 0.13, P=0.05;95%CI -0.16 to 0.19, P=0.90 respectively). (2) The hospitalization stay was shortened an average of 23.86 hours (95%CI -32.35 to -15.36, P=0.000). (3) The postoperative analgesic dose was lowered by 69.02 mg(95%CI-107.67 to -30.36, P=0.000).(4)There was a remarkable improvement of the stone-free rate (95%CI 1.25 to 2.95, P=0.003).Conclusion Tubeless percutaneous nephrolithotomy may shorten the hospitalization stay, lower the postoperative analgesic dose and improve the stone-free rate. It is significantly superior to standard percutaneous nephrolithotomy.

Objective To explore the clinical features, diagnosis, treatment and prognosis of central nervous system lymphoma(CNSL).Methods Retrospective analysis was conducted for 31 CNSL cases from January 2007 to December 2009 in our hospital. Their clinical data were analyzed by statistical software package SPSS 16.0.Results Accounting for around 4.7% of all lymphomas at our institution, the present cohort had 21 males and 10 females with a median age of 38 years old. The major clinical manifestations were focal neurological deficits associated with the site of disease or increased intracranial pressure. Most patients were treated with chemotherapy-based regimens. The overall response rate was 67.7% (21/31) with 32.3% (10/31) complete remission rate (CR) and 35.5% (11/31) partial remission rate (PR). Involvement outside CNS or bone marrow, high international prognostic index (IPI) and B symptoms had significant effects on the therapeutic efficacy (P<0.05). The overall survival rates were 80.7%,74.2%,64.5% and 58.1% at 3, 6, 12, 24 months respectively. The median survival time was 22.5 months. Univariate analysis showed that the clinical efficacy had significant effects on the overall survival of patients(OR=0.030,95%CI:0.003-0.270,P=0.000).Conclusion The prognosis of CNSL remains poor. New diagnostic tools and treatment modality need to be explored.

Objective To explore the characteristics of ST-segment deviation in patients with acute ST elevation myocardial infarction (STEMI) having only one vessel lesion in either left circumflex artery (LCX) or right coronary artery (RCA).Methods All AMI (acute myocardial infarction) patients were admitted into Peking Union Medical College Hospital from January 1996 to March 2009. They underwent coronary angiography (CAG). And the IRA (infarction-related artery) was either LCX or RCA without other coronary artery stenosis. Their ST-segments deviations on electrocardiogram (ECG ) were analyzed quantitatively. Results Among 2503 AMT cases undergoing CAG during hospitalization, 75 cases had LCX ( n = 16) or RCA( n =59)-related STEMI. The RCA group was further divided into the proximal subgroup (n =21) and the distal subgroup (n =38). RCA as IRA was diagnosed when ST I depression <0, ST V1 elevation ≥0 or ST I and aVL depression <0 with the sensitivities of 55. 9% , 74. 6% and 54. 2% and the specificities of 81.3%, 62.5% and 81.3% respectively. LCX as IRA was diagnosed when ST aVR depression ≥0.1 mv, ST I elevation ≥0 or ST V5 and V6 elevation ≥0 with (he sensitivities of 68. 8% , 81. 3% and 31. 3% and the specificities of 76. 3% , 59. 3% and 91. 5% respectively. Proximal occlusion of RCA was diagnosed when there was no ST depression in V1 and depression in V2, Max precordial ST depression in V1 - V3 with the sensitivities of 47. 6% and52. 4% and the specificities of 78. 9% and 84. 2% . Conclusion While discriminating IRA in STEMI patients with single LCX or RCA lesion, it is necessary to assess all ST-segments deviations on ECG.

Objective To explore the changes and clinical significances of plasma D-dimer, factor X and tissue factor in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and analyze the in-depth changes of these indicators in AECOPD with co-current deep venous thrombosis (DVT).Methods A total of 56 AECOPD patients were divided into the DVT and non-DVT subgroups (n=28 each). And 60 normal control subjects were recruited according to age and gender. For each subject, 2.7 ml whole blood was drawn and then the plasma levels of D-dimer, factor X and tissue factor were detected. The results were statistically analyzed with the software SPSS 13.0. And the analysis of variance was performed between the groups.Results There was no significant difference between the distribution of the AECOPD group and the control group by gender and age. Therefore two groups were comparable. And in the AECOPD group, there was no significant difference between the distribution of DVT and non-DVT subgroups by gender and age. Therefore these two subgroups were comparable as well. The value of D-dimer in the AECOPD patients was significantly higher than that in the normal control[(0.76±0.30) vs (0.29±0.11) mg/L, P<0.01];and in the AECOPD group, the value of D-dimer in the DVT subgroup was significantly higher than that in the non-DVT subgroup[(0.85±0.29) vs (0.67±0.28) mg/L, P<0.05]. In the AECOPD group, the value of tissue factor was (238±68) mg/L and the value of factor X (1181±337) mg/L. While in the normal control group, the values were (124±30) and (998±260) mg/L respectively. As for tissue factor and factor X, there were significant differences between two groups (all P<0.01). Yet in AECOPD patients, neither indicator had significant differences between the DVT and non-DVT subgroups (all P>0.05).Conclusion The blood of AECOPD patients is in a hypercoagulatory state. And an obvious rise in their plasma level of D-dimer suggests that it may be complicated with DVT.

Objective To explore the relationship between HMGB1 (high mobility group box-1) protein and receptor for advanced glycosylation end products (RAGE) and the nosogenesis and severity of bronchial asthma.Methods Based on the criteria, the asthma group included 64 acute-onset asthma patients while the control group had 20 healthy cases. The asthma group received a 4-week combination inhalation therapy of budesonide and formoterol. Lung functions and induced sputum examinations were conducted before and after treatment. The percentage of a second forced expiratory volume in the predicted value (FEV1%) was recorded. A differential count of neutrophilic leukocyte in reduced sputum was performed. And the sputum levels of HMGB1 and RAGE were detected by ELISA (enzyme linked immunosorbent assay).Results Prior to treatment, the neutrophilic leukocyte percentage and the levels of HMGB1 and RAGE were all higher than those of control group (P<0.01). The induced sputum of severe asthma patients had higher levels of neutrophilic leukocyte percentage and HMGB1 than those of mild cases (P<0.01). But the level of RAGE showed no statistical significance among mild, moderate or severe asthma cases (P>0.05). The post-treatment levels of neutrophilic leukocyte percentage, HMGB1 and RAGE were lower as compared with the pre-treatment ones (P<0.01). These three parameters in uncontrolled cases were higher than those in completely controlled cases (P<0.05);in asthma group, both HMGB1 and RAGE had a negative correlation with FEV1% (r=-0.830, r=-0.632, P<0.01);in induced sputum, both HMGB1 and RAGE had a positive correlation with FEV1% (r=0.820, r=0.623, P<0.01). The levels of HMGB1 and RAGE were positively correlated (r=0.929, P<0.01).ConclusionBoth HMGB1 and RAGE participate in the inflammatory process of asthmatic airway. HMGB1 is correlated with the severity of asthma. And the levels of HMGB1 and RAGE in induced sputum may be employed as reference indices for the observation of therapeutic effects.

Objective To study the correlation and influencing factors between the St. George respiratory questionnaire (SGRQ) and lung functions in chronic obstructive pulmonary disease (COPD) patients.Methods Sixty-three stable COPD patients received pulmonary function tests and SGRQ. A correlation analysis of the results was performed.They were divided into two groups according to GOLD (global initiative for chronic obstructive lung disease) classification scheme, 32 patients were in stage Ⅱ (moderate) and 31 in stages Ⅲ and Ⅳ(severe & very severe). And the inter-group SGRQ scores were compared. According to age, they were divided into <70 years group(n=31)and ≥ 70 years group (n=32). The correlations between the SGRQ score and pulmonary functions were analyzed in different age groups. Thirty-six patients willing to participate in treatment and a 3-month follow-up were randomly divided into two groups of treatment with either salmeterol/fluticasone (50 μg/500 μg)(n=18) or salbutamol/ipratropium bromide (120 μg/21 μg)(n=18). The post-therapeutic changes of SGRQ score and pulmonary functions were analyzed.Results There were no significant differences in SGRQ total score and all section score between two groups according to GOLD classification scheme. There were mild to moderate correlations in the <70 years group between lung functions including FVC%, FEV1%, FEFMAX%, SVC% and the SGRQ score including total score, symptoms section score and activity section score. The range of correlation coefficients was -0.341 to -0.534. However, the score only had some correlation with IC% in the ≥70 years group. Compared with the salbutamol/ipratropium bromide treatment group, the SGRQ score of the salmeterol/fluticasone treatment group decreased significantly after therapy (P=0.001).ConclusionInfluenced by age, the SGRQ score can be used to evaluate the clinical efficacy of medications in COPD patients.

Objective To explore the protein expressions of PYK2 (protein-rich tyrosine kinase-2) and caveolin-1 in alcoholic cardiomyopathy (ACM) dog model and the effect of early drug intervention.Methods A total of 28 adult dogs were randomly divided into 4 groups: (i): alcohol-fed;(ii): alcohol plus valsartan, an angiotensin receptor blocker (ARB);(iii): alcohol plus carnitine;(iv): control group. At Month 6, the cardiac functions of all animals were evaluated by echocardiography. The concentrations of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and malondialdehyde (MDA) in cardiac tissue were detected by chromometry. The protein expressions of collagen typesⅠand Ⅲ were determined by ELISA (enzyme-linked immunosorbent assay) while those of PYK2 and caveolin-1 evaluated by immunohistochemistry. The internal relationship of PYK2, caveolin-1, MDA and collagen typesⅠ& Ⅲ was analyzed.Results Compared with the control group, the contents of SOD and GSH-Px significantly decreased in the alcohol, valsartan and carnitine groups while MDA significantly increased in the alcohol and carnitine groups. The relative contents in each group were as follows: MDA[alcohol: (28±5)U/mg Pro;valsartan: (33±13)U/mg Pro;carnitine:(33±10)U/mg Pro], GSH-Px[alcohol:(188±37)U/g Pro;valsartan:(362±29)U/g Pro;carnitine:(282±29) U/g Pro and MDA [alcohol:(19.4±3.0)nmol/mg Pro;carnitine:(10.8±2.1)nmol/mg Pro].Compared with the control group, the concentration of collagen typeⅠsignificantly increased in the alcohol, valsartan and carnitine groups. In the alcohol-fed group, theprotein expression of PYK2 gradually increased with the progression of ACM while that of caveolin-1 stayed at a low level. Through the interventions of valsartan and carnitine, the protein expression of PYK2 significantly increased while that of caveolin-1 significantly decreased (all P<0.01). Conclusion Alcohol promotes the myocardial oxidative stress and fibrosis through an elevated expression of PYK2 and a lowered expression of caveolin-1. Then a deterioration of cardiac structures and functions occur

Abstract of medical records `` The patient was a 10-year-old male. He was admitted to the Department of Endocrinology of Peking Union Medical College Hospital in December 2009 due to paroxysmal skin flushing and palpitation for 7 years, intermittent fever for 5 months, and retroperitoneal space was found to occupy 2 weeks. The patient was 3 years old (2002) and began to develop paroxysmal facial and chest skin flushing, accompanied by palpitation, without headache and excessive sweating, which lasted for 20~30 minutes and could alleviate by itself, more often than during activity. The blood pressure was not measured at the time of attack, 1~2 times a week or once a day. The above symptoms did not attract the attention of the parents of the child. By July 2009, he developed fever, with the highest body temperature of 38.5 ℃, and it was in the afternoon, accompanied by night sweats, nausea, fatigue and general muscle pain, and the anti-infective treatment effect was not good. In November 2009, the hemoglobin was examined at 102 g/L in another hospital due to fever. Blood lactate dehydrogenase 375 U/L (114~240 U/L; reference range in parentheses, same below), α hydroxybutyrate dehydrogenase 312 U/L (72~200 U/L), erythrocyte sedimentation rate (ESR) 78 mm/1 h, CRP 64.5 mg/L. Abdominal CT showed retroperitoneal soft tissue mass, about 9.0 cm ×5.0 cm in size, uneven density, annular enhancement, and density changes in multiple vertebral bodies.

Case abstract The patient was a 49-year-old female. Physical examination showed that the stomach wall occupied sex space for 10 days. She was admitted to hospital in January 2010. The patient had no anorexia, nausea and vomiting, abdominal distension and abdominal pain, hematemesis and hematochezia, fatigue and weight loss. Physical examination did not show swollen lymph nodes, no yellowing staining of skin and sclera, no abdominal mass, and negative signs of ascites. Routine blood, urine and stool tests were negative; Tumor marker examination: carcinoembryonic antigen (CEA) 1.40 μ g/L, CA125 186.9 U/ml, alpha-fetoprotein (AFP) 3.49 μ g/L, human chorionic gonadotropin β (HCG-β) 0.220 mU/ml. Chest X-ray and pelvic B-mode ultrasound showed no mass. Abdominal and pelvic CT showed a 2.4 cm ×3.0 cm mass under the gastric antrum mucosa (no gastric wall lesions were found on CT examination on April 4, 2008), which was considered as gastric stromal tumor (Figure 1A, B); Upper gastrointestinal angiography showed tumor Figure 1 CT image showed a 2.4 cm ×3.0 cm bulge posterior wall of gastric antrum with smooth surface, which was considered as submucosal tumor, possibly gastrointestinal stromal tumor located under the mucosa of gastric antrum with small mucosal ulcer (Figure 2).

Autophagy is a dynamic process of removing wastes and invading microorganisms in cells. Autophagy is involved in many physiological and pathological processes of cells by encapsulating these substances to form autophagy phagosomes and combining them with lysosomes. Autophagy is divided into macromolecular autophagy, small molecule autophagy and chaperone-mediated autophagy [1]. Autophagy refers to macromolecular autophagy, which is a process of isolating and removing damaged organelles and intracellular substances in eukaryotic cells and reusing their components to provide nutrition [2].

In recent 20 years, with the improvement of clinical treatment methods, especially the progress of anti-rejection reaction, the number of patients waiting for transplantation has increased rapidly, and the problem of donor shortage has become increasingly prominent. The huge contradiction between supply and demand has prompted the clinic to seek various solutions to expand the source of donors. Because of the shortage of donors, people have turned their attention to the donors that were once considered unsuitable in order to make them use to the maximum extent. There is no strict concept of borderline donor heart. In a broad sense, any heart that is not suitable for routine donor heart may become borderline donor heart, which usually includes the donor being viral infected, the donor being elderly, accompanied by coronary heart disease or other cardiac structural abnormalities, the donor being ischemic for a long time, the donor being mismatched in blood type or body weight, the donor having a history of drug abuse, etc.

It is well known that hyperuricemia is closely related to cardiovascular diseases. The former is widespread in patients with nephropathy, metabolic syndrome and diabetes, while metabolic syndrome is often associated with inflammatory state and thrombotic state. So, what is the relationship between uric acid and renal insufficiency? Rare report.The study published on January 26, 2011 in the journal Kardiologia Polsia analyzed the relationship between renal function, blood uric acid, and markers of inflammation and thrombosis in patients with diabetes mellitus, metabolic syndrome, and coronary heart disease.

Acute exacerbation of chronic obstructive pulmonary disease (COPD) indicates the deterioration of clinical condition and disease progression of patients, and is related to the occurrence of complications, which increases the risk of acute exacerbation, decreases the health status and physical activity of patients, decreases the pulmonary function and increases the risk of death. Therefore, prevention of acute exacerbation has become the main treatment goal of COPD. For patients with moderate to severe COPD, relevant clinical guidelines recommend the use of long-acting anticholinergic drugs or long-acting β 2 receptor agonists as first-line maintenance therapy, but it is not clear which drugs are more effective and can be used first.

Published by the Riordan Clinic in March 2011<The journal Translational Medicine published the research collaboration of oncologists, alternative medicine physicians and basic researchers: a new use of vitamin C-intravenous injection for the treatment of cancer. Intravenous injection of vitamin C may be useful in the following conditions of cancer patients: loss of weight (cachexia), immunosuppression and improvement of quality of life. This paper cites 246 articles, synthesizes the existing knowledge on the use of intravenous vitamin C in many medical conditions, and re-evaluates the role of intravenous vitamin C in routine tumor diagnosis and treatment.

Objective To explore the sensitivity of new activated clotting time (ACT) reagent for laboratory monitoring of low molecular weight heparin (LMWH).Methods Blood samples were collected from 30 healthy volunteers and different doses of LMWH (dalteparin) added. The dalteparin concentration of final blood samples was 0.1-1.8 U/ml. ACT and clot rate (CR) were measured with traditional reagent kaolin and new reagent magbar. Linear regression analysis was performed and a regression equation established between different dalteparin concentrations and their corresponding ACT and CR values.ResultsWith rising dalteparin concentrations, the ACT values became gradually extended and the CR values were gradually reduced by both kaolin and magbar. Analysis of dose-response curves was obtained in vitro. And an excellent linear relationship was observed between the ACT and dalteparin concentrations for two reagents (P<0.01). An exponential relationship was observed between the CR and dalteparin concentrations (P<0.01). Differences in slope of regression curves of ACT were observed with the tested reagents (magbar 1097.6 s/U vs kaolin 59.3 s/U, P<0.01).Conclusion This in vitro study has shown that the sensitivity of new ACT test reagent (magbar) is good for laboratory monitoring of dalteparin. The new reagent magbar may be used for bedside monitoring of anticoagulant activity of LMWH.

Case 1: A 46-year-old male was admitted to the hospital on October 13, 2005 because of a mass in the left kidney found on physical examination for 10 days. The isoechoic mass in the left kidney was found on physical examination by B-ultrasound. There was no lumbar discomfort, no macroscopic hematuria, frequent urination and painful urination, etc. Blood pressure: 140/90 mm Hg (1 mm Hg =0.133 kPa). Urinary routine was normal. Intravenous pyelography showed branched renal pelvis of the left kidney, with intermediate solid occupation of the left kidney (Figure 1A). CT scan of isodensity mass in the left kidney showed a CT value of 32 Hu, which was significantly enhanced after enhancement, suggesting the possibility of renal cancer (Figure 1B). On October 10, 2005, PET-CT examination in a foreign hospital showed that the left kidney was visualized with speckled dense condensation, with an SUV value of 4.7, and primary renal cancer was diagnosed (Figure 1C).

Klippel-Feil syndrome (KFS) is a congenital malformation characterized by cervical fusion, which is extremely rare in clinic, and its anesthetic treatment has corresponding particularities. The patient was an 18-year-old male, weighing 57 kg and height 163cm. He came to the Department of Neurosurgery of Wuhan Union Medical College Hospital on November 10, 2009 due to dizziness for 6 months and was diagnosed with cerebellar teratoma. There was no special history in the past. Physical examination showed short neck, obvious limitation of head tilt, Mallampati score Ⅱ, distance between nail and chin ≥4 transverse fingers, and other systematic examinations were not special. Cervical X-ray and cervical CT scan showed abnormal cervical spine morphology, vertebral body fusion into two pieces, upper vertebral body slipped slightly backward compared with lower vertebral body, atlas and occipital fusion (Figure 1). There was no obvious abnormality in electrocardiogram and chest X-ray. B-ultrasound and blood biochemical examination of heart, liver and kidney were normal. Diagnosis: KFS complicated with cerebellar teratoma.

A 49-year-old male was returned to the hospital on September 22, 2009 due to "pain in the body stump after traumatic hemiectomy for more than 5 years". On March 9, 2004, the patient suffered from severe crushing and damage between 15 cm below the umbilicus and the upper segment of both thighs due to a traffic accident. The abdomen and whole pelvis below the level of S1 were completely crushed and dissected, and the intestines were exposed. The sigmoid colon, rectum, bladder and other organs and external genitals in the pelvic cavity were seriously damaged. Only the right iliac lumbar had 7 cm wide skin connected to the pelvis and lower limbs, so he was used as a pedicled transfer flap to cover the lower abdominal stump. A large area of flap necrosis appeared on the trunk stump 1 week after operation. After dressing change, staged scab excision and drainage, the stump wound was covered with granulation, and the scalp was free skin grafted with medium-thickness skin. On the 247th day after the injury, the lower abdominal stump wound healed, and he was discharged on December 19, 2005. In 2007, he underwent rehabilitation treatment in a hospital in Beijing, and achieved uprightness through the "receiving cavity" (Figure 1). He took care of himself at home and assisted his family in running convenience stores. The patient has survived for more than 5 years after hemiectomy, and his general health is in good condition, but he has been troubled by postoperative pain.