Volume 98  ·  Issue 28  ·  2018

With the rapid development of medical science and technology and the continuous renewal of health concept, the focus of people's attention in the process of diagnosing and treating diseases and maintaining health gradually shifts from whether the disease is cured to the feeling brought by the disease treatment process and the quality of life after recovery. Practice has proved that the transformation of medical quality and the improvement of teaching quality cannot be achieved through extensive expansion, but it needs to change the traditional teaching concept and realize it through technological innovation. It is under this background that the concept of accelerated rehabilitation surgery came into being as the times require, and was quickly promoted by some countries in Europe and America, especially in Europe. In our country, due to the accelerated application of rehabilitation surgery, it has brought great influence on the improvement of teaching and medical service quality, and it has been more and more accepted by the medical staff^[1]。

Von Hippel-Lindau disease, abbreviated as VHL disease, also known as Hippel-Lindau syndrome and Lindau syndrome, isVHLAn autosomal dominant disease caused by mutations in tumor suppressor genes (OMIM 193300). The patient presented with multiple organ tumor syndrome, including lesions such as central nervous system hemangioblastoma, retinal hemangioblastoma, renal cancer or renal cyst, pancreatic tumor or cyst, adrenal pheochromocytoma, inner ear lymphatic sac tumor, and reproductive system cysts^[1,2,3,4]。

The development of cellular and molecular genetics has promoted the development of human genetic research. The practicality and value of clinical gene detection have been widely accepted. The development of genomics and other omics and high-throughput sequencing technology have greatly promoted the ability of gene detection and analysis. However, the human genome contains a lot of private information about the human body. Using currently available analytical techniques, combined with the detection of specific genotypes and karyotypes, individuals can be reversely identified. In addition, traditional molecular genetics provides specific limited information. Genomic sequencing involves thousands of DNA markers. During the detection, abnormalities or changes in genetic information outside the target disease are often found, that is, accidental discovery; At present, the ability to interpret genetic information is extremely limited, and the relationship between most genetic variations and phenotypes is still unclear. Therefore, molecular genetics in the genome era not only faces serious challenges to personal privacy, group information and data security, but also faces some important management, legal and ethical issues, such as the handling of remaining samples, procedures and requirements before genetic testing, especially the qualification and ability requirements of genetic testing and genetic abnormality interpretation and interpretation personnel, the difficulty of disclosure of accidental discovery, etc^{[1,2,3,4,5,6,7,8]}。

Iron deficiency (ID) and Iron deficiency anemia (IDA) are important health problems affecting countries around the world, affecting about 2 billion people^[1], is the only common nutritional deficiency in developed countries, and the most common type of anemia in developing countries, and is more common in women of childbearing age. ID and IDA are associated with many chronic diseases, with 61% incidence of ID/IDA in tumors, inflammatory bowel disease, chronic kidney disease, and chronic heart failure, respectively^[2]、45%^[3]、24%～85%^[4]And 43% to 100%^[5]。 ID/IDA reduces quality of life and labor capacity, which is a poor prognostic factor for chronic diseases. It is an important task for clinical work to diagnose and deal with ID/IDA in time. At present, there is a lack of unified standards for the diagnosis, treatment and prevention of ID/IDA in China. Experts from relevant disciplines of the Chinese Medical Association have reached the following consensus of Chinese experts on the diagnosis, treatment and prevention of ID/IDA by referring to the diagnosis and treatment guidelines and related literatures at home and abroad in recent years.

To investigate the thickness of cranial bone in different parts of children skull during stereotactic electroencephalogram (SEEG) and its effect on electrode fixation.

From October 2016 to March 2017, 13 children with SEEG by robot of surgery assistant (ROSA) were selected. The basic case information and electrode design scheme were collected. The skull thickness of each electrode channel was measured on post-operation CT, and the loosening of the fixed screws were recorded. The thickness of skull in frontal bone, temporal bone, parietal bone and occipital bone was statistically processed by SPSS statistical software.

There were total 113 electrodes in 13 children with epilepsy. There were 45 electrodes at frontal bone, of which the thickness was (5.7±2.8)mm. There were 34 electrodes at temporal bone, of which the thickness was (3.5±1.3)mm.There were 16 electrodes at parietal bone, of which the thickness was (6.0±2.5)mm.There were 18 electrodes at occipital bone, of which the thickness was (6.9±0.5)mm. Statistics showed that there was significant difference between differnt bone (F=15.340, P<0.01). There were 4 electrodes loosening, 1 at frontal bone and 3 at temporal bone, when the screws were removed. There was no adverse event related to the implantation of electrodes.

The children′s skull thickness is thinner than adults. The screw loosening is exist in some cases, but it has no effect on SEEG recording. No SEEG related adverse events are found in this group. Therefore, ROSA guided SEEG is safe and reliable in children with epilepsy.

To discover frequently mutated new gastric cancer-related genes by exome sequencing technology and to analyze mutated their relationships with different clinicopathological phenotypes of gastric cancer.

Tumor samples of gastric cancers and preoperative peripheral blood samples from 30 patients were collected respectively from January to March, 2016 in the department of general surgery, Chinese PLA General Hospital. Exome sequencing on samples were performed. Using peripheral bloods as control, mutations in tumor samples were discovered by Mutect and Varscan. Frequently mutated gastric cancer-related genes were defined as genes mutated more frequently than TP53. Difference between the mutant and wild-type of certain genes were compared on common clinicopathological phenotypes, such as age, gender, tumor position, differentiation, metastasis lymph nodes, etc.

There were 27 frequently mutated genes were founded, most of which showed no relationship with clinicopathological phenotypes of gastric cancer. Cases with mutant and wild-type TAS2R43 showed statistically significant difference in gastric body cancer(55.6% vs 9.5%, P=0.022). Cases with mutant and wild-type ANKRD36C showed statistically significant difference in gastric body cancer (62.5% vs 9.1%, P=0.005). Cases with mutant and wild-type ANKRD36 showed statistically significant difference in proximal gastric cancer (8.33% vs 44.4%, P=0.049). Cases with mutant SYNE1 suffer from less metastatic lymph nodes than those with wild types(2.1±2.4 vs 8.8±9.5, P=0.006). Cases with mutant ADAR are younger than those with wild types(50.7±11.5 year vs 64.0±9.8 year, P=0.006).

Mutant TAS2R43, ANKRD36 and ANKRD36C were related to location of gastric cancer. Mutant SYNE1 was related to gastric cancer with less lymph nodes metastasis. Mutant ADAR may lead to gastric cancers in younger groups.

To investigate the efficacy and safety of Compound Lactobacillus Tablets or Saccharomyces boulardii Sachets combining with bismuth quadruple therapy for Helicobacter pylori(H.pylori) eradication.

A total of 360 H. pylori- infected patients were enrolled and randomly assigned into three groups. Group A received esomeprazole 20 mg bid+ bismuth potassium citrate 220 mg bid+ amoxicillin 1 000 mg bid+ furazolidone 100 mg bid for 10 days. Group B or group C received the same quadruple therapy for 10 days as group A, as well as Compound Lactobacillus Tablets 1 000 mg tid or Saccharomyces boulardii Sachets 500 mg bid for 14 days. Drug-related side effects and adverse reactions were collected during the therapy, and H. pylori eradication results were confirmed by ¹³C/¹⁴C-UBT at least 4 weeks after cessation of therapy.

The H. pylori eradication rates in group A, B and C were 81.7%, 84.2% and 85.0% by ITT analysis (P=0.768) and 92.5%, 90.1% and 93.6% by PP analysis (P=0.770), respectively. The overall side effects and adverse reactions rates (P=0.008) and occurrence of diarrhea (P<0.001) were significantly lower in group B than group A. The overall side effect rates (P=0.003) and occurrence of diarrhea (P<0.001), abdominal distension (P=0.004) and constipation(P=0.002) were significantly lower in group C than group A. There was no significant difference in side effects and adverse reactions rates between the two probiotics groups.

Both Compound Lactobacillus Tablets and Saccharomyces boulardii Sachets, combining with bismuth quadruple therapy, reduced the overall side effects and adverse reactions rates for H. pylori eradication. Moreover, the former can reduce the incidence of diarrhea, and the latter can reduce the incidence of diarrhea, abdominal distension and constipation.

To observe the effect of hydromorphone on emergence agitation of children anesthetized by Sevoflurane.

One hundred patients without any analgetic, aged 3 to 7 years, ASA Ⅰ-Ⅱ, undergoing strabismus surgery in Beijing Tongren Hospital from March, 2017 to December, 2017 were selected and they were randomly divided into two groups(n=50), H group and F group by random number table. After standardized tidal volume method induction by 8% sevoflurane and oxygen, suiltable laryngeal mask was inserted, and each patient was left spontaneously breathing anesthetized by 2.5%-3.0% sevoflurane.Ten minutes before the surgery, patients in H group were administered a dose of 0.01 mg/kg hydromorphone (diluted to 5 ml with normal saline) by pump control injection in 10 min, whereas patients in F group administered a dose of 1 μg/kg fentanyl in the same way. After the surgery , the patient was sent to postanesthesia care unit. A nurse who was blinded measured the vital signs, pediatric anesthesia emergence delirium(PAED) score, face legs activity cry consolability behavioral pain assessment tool(FLACC) score, the time of opening the eyes and departing from postanesthesia care unit(PACU), and the occurence rates of hypoxemia, swirl or nausea, drowsiness, and other scores.

The incidence of emergence agitation(EA) in H group was lower than in F group, whether EA was defined as PAED>10 (18.0% vs 28.0%,P>0.05) or PAED>12(12.0% vs 24.0%,P>0.05), there were not significant differences between them. The ratio of patients whose PAED>15 in F group was 12.0%, while the ratio of H group was 0, there was significant difference between the two groups(P=0.027). The occurrence rates of swirl, glossocoma in H group were 0 and 10.0% while those of F group were all 6.0%, there were no significant differences between the two groups(P>0.05).

Comparing with fentanyl, hydromorphone can prevent the occurrence rate of EA of the children anesthetized by sevoflurane equally, even decrease the occurrence rate of the severe EA more observably, and reduce postoperation pain more significantly with less occurrence rate of swirl or nausea. Glossocoma need be paid attention to when HM is administered.

To evaluate the safety and flexibility of uncut Roux-en-Y esophagojejunostomy in totally laparoscopic total gastrectomy (TLTG).

Between July 2016 to November 2016, 15 patients received totally laparoscopic total gastrectomy plus uncut Roux-en-Y esophagojejunostomy in the Sir Run Run Shaw hospital. Clinical data of those patients, including operative indexes, post-operative indexes and fellow-up data, were analyzed respectively.

A total of 15 patients were enrolled in this study, ten were corpus carcinoma and five were esophagogastric junction carcinoma. The total operative time and anastomosis time was (25.0±4.3) min and (25.0±4.3) min, the blood loss during operation was (133.3±121.2) ml. All the operations were performed successfully, and no one was transferred to open surgery. All the patients were encouraged to off-bed activity at first day after surgery. The first time to flatus, the first time to liquid food intake and the length of stay in hospital were (4.1±0.8) days, (5.1±0.9) days and (9.3±1.6) days, respectively. The pathological staging of these patients was stage Ⅰb in 1 case, stage Ⅱa in 3 cases, stageⅡb in 2 cases, stage Ⅲb in 3 cases, stage Ⅲc in 6 cases. The lymph node harvest was (36.0±12.3). Cutting margins in all patients were negative. Pulmonary infection occurred in one patient postoperatively and recovered after antibiotic treatment. No death and severe complication was found. Liver metastasis occurred in one patient eight months after operation. One patient was found recurrence in anastomotic site. No Roux-en-Y stasis syndrome was found.

Uncut Roux-en-Y esophagojejunostomy in TLTG is safe and flexible.

To observe the effect of human umbilical cord mesenchymal stem cells (hUC-MSCs) on airway remodeling in asthma model of rat and its possible mechanism.

hUC-MSCs were isolated and cultured, and surface markers of hUC-MSCs were identified by flow cytometry. Forty Wistar male rats were divided into 4 groups: Control, Model, MSCs, Budesonide. The rats of Control group were sensitized and challenged by normal saline. The rats of Model, MSCs and Budesonide group were sensitized and challenged by ovalbumin (OVA) for 8 weeks. The MSCs group rats were given a tail vein injection of MSCs 0.2 ml (1×10⁶ /ml) on days 35, 45, and 55 half an hour befor each OVA exposure. The Budesonide group rats were given aerosol inhalation of budesonide 2 mg two hours before each OVA exposure. Specimens were collected within 24 hours after the last OVA challenge. The parameters of airway morphological changes and the degree of airway remodeling were analyzed using Image-pro plus computer graphics. The levels of transformation growth factor (TGF) -β₁ in bronchoalveolar lavage fluid (BALF) and serum were detected by enzyme linked immunosorbent assay (ELISA). The expressions of E-cadherin, α-smooth muscle actin (α-SMA) and fibronectin (Fn) were measured by immunohistochemistry.

The thickness of airway wall and smooth muscle of Model, MSCs and Budesonide group rats were significantly thicker than Control group. The levels of TGF-β₁ in both BALF and serum of Model, MSCs and Budesonide group rats were significantly higher than Control group. The expression of E-cadherin of Model, MSCs and Budesonide group rats was significantly lower than Control group, while the expression of α-SMA and Fn were significantly higher. The thickness of airway wall and smooth muscle of MSCs and Budesonide group rats were significantly lower than Model group[(38.40±2.50, 45.34±0.33) vs (80.18±1.75) μm and (15.71±0.89, 18.57±0.67) vs (40.97±0.90) μm]. The levels of TGF-β ₁ in both BALF and serum of MSCs and Budesonide group were significantly lower than Model group[(3.53±0.43, 3.11±0.05) vs (20.88±0.37) μg/L and (31.07±0.89, 31.12±0.50) vs (70.58±0.39)μg/L](all P<0.01). The expressions of α-SMA, Fn of MSCs and Budesonide group rats were significantly lower than Model group[(0.438±0.057, 0.445±0.027) vs (0.521±0.030) and (0.459±0.041, 0.458±0.029) vs (0.527±0.022)], While the expression of E-cadherin was significantly higher[(0.308±0.023, 0.296±0.010) vs (0.256±0.087)](allP<0.01).

MSCs could alleviate asthmatic airway remodeling, the mechanism of which may be associated with the inhibition of TGF-β₁ induced epithelial-mesenchymal transition.

To investigate the effect of cigarette smoke exposure on the expression of CC Chemokine receptor 7 (CCR7) and levels of Th1/Th2 cytokines in asthmatic rats.

Forty Wistar rats were randomly divided into four groups: control group, asthma group, smoke exposure group, asthma-smoke exposure group. The asthma group were sensitized with ovalbumin (OVA) and Aluminum hydroxide at day 1, 8 and challenged with OVA at day 15 by atomization for 8 weeks.While control group was sensitized and challenged with normal saline instead of OVA.The smoke exposure group was sensitized and challenged with normal saline instead of OVA followed passive smoking for 8 weeks. The asthma-smoke exposure group was challenged with OVA followed passive smoking. The pathological changes of different groups were observed by HE-staining. CCR7 was semiquantitatively analyzed in lungs by immunohistochemistry.The concentration of CC chemokine ligand (CCL)19, CCL21, interferon (IFN)-γ and interleukin (IL)-4 in peripheral blood and CCL19 and CCL21 in bronchoalveolar lavage fluid (BALF) were measured by enzyme-linked immunosorbent (ELESA) assay.

In asthma group, smoke exposure group and asthma-smoke exposure group, the various degrees of inflammatory reaction appeared in lung tissue and the asthma-smoke exposure group was with the most significant reaction. In the lung tissues of the rats from asthma group, smoke exposure group and asthma-smoke exposure group, the average optical density (AOD) of CCR7 were significantly higher than those in control group (0.350±0.023, 0.252±0.022, 0.400±0.029 vs 0.180±0.020, all P<0.01). The AOD of CCR7 of asthma-smoke exposure group was much higher than both that in asthma group and in smoke exposure group (bothP<0.01). In asthma group, smoke exposure group and asthma-smoke exposure group, the concentrations of both CCL19 and CCL21 in peripheral blood and BALF were significantly higher than that in control group (allP<0.01). The concentrations of both CCL19 and CCL21 in peripheral blood and BALF of asthma-smoke exposure group were significantly higher than the results in asthma group and in smoke exposure group (allP<0.01). The concentrations of IFN-γ in peripheral blood of asthma group and asthma-smoke exposure group were lower than those in control group [(33±3), (17±3) vs (70±4) pg/ml], but asthma-smoke exposure group was much lower than the results in asthma group (allP<0.01). The concentration of IFN-γ in peripheral blood of smoke exposure group[(100±5)pg/ml]was higher than that in control group and asthma-smoke exposure group (bothP<0.01). In asthma group, smoke exposure group, asthma-smoke exposure group, the concentrations of IL-4 in peripheral blood were significantly higher than those in control group [(54±4), (42±4), (76±4) vs (30±4) pg/ml, allP<0.01]. The concentrations of IL-4 in peripheral blood of asthma-smoke exposure group was significantly higher than those in asthma group and in smoke exposure group (bothP<0.01).

Cigarette smoke could enhance the expression of CCR7 and its ligand, and it can also result in exacerbations of asthma by reducing the expression level of IFN-γ (the representative of Th1 cytokine) and increasing the expression level of IL-4 (the representative of Th2 cytokine).

To investigate pulmonary vascular remodeling in rat model of pulmonary hypertension in left heart disease (PH-LHD).

A total of 66 male minor Sprague-Dawley (SD) rats were randomly divided into control group (n=6), sham operation group (n=6) and model group (n=54). The rats in the control group entered the experimental procedure immediately without any treatment, and the rats in the sham operation group entered the experimental procedure 64 days after sham operation, and the rats in model group entered the experimental procedure (6 rats each) on day 1, day 3, day 5, day 8, day 15, day 22, day 36, day 50 and day 64 respectively after supracoronary aortic banding successfully. The lung tissue was fixed and cut and made into pathological sections to observe the characteristics of pulmonary vascular remodeling.

Medial thickening was mainly observed in pulmonary arterioles with diameter <100 μm [(11.17±1.03)%]. Additionally, medial thickening was seen in pulmonary arterioles with diameter 50-100 μm and 20-50 μm from day 15 [(12.73±1.15)%] and day 50 [(14.53±1.53)%], respectively. Medial muscularize of pulmonary arterioles were mainly observed in arterioles with diameter 20-50 μm, and deteriorated with time. Reduced pulmonary arteriole lumen size were observed with diameter 20-50 μm since day 50 ( P<0.05).

Pulmonary arteries with diameter >100 μm have little effect on the reconstruction of pulmonary vessels in PH-LHD rat model. However, arterioles with diameter 20-50 μm and 50-100 μm are the most important vessels involved in the formation of pulmonary hypertension, especially 20-50 μm.

To investigate the influence of thermal cycling on the mechanical properties of resin-ceramic composites.

The different groups of resin-ceramic composites A (Lava Ultimate, 3M ESPE, USA), B (block HC, Shofu, Japan), C (Hyramic, Upcera, China), D (Vita Enamic, Vita, German), and the feldspar ceramic E (Mark Ⅱ, Vita, German) were included in this study. The properties of these groups (with 30 samples in each group), including flexural strength, flexural modulus and Vickers hardness were tested before and after thermal cycling (0, 10 000 and 20 000 cycles, respectively). The data were statistically analyzed.

Before thermal cycling, the flexural strength of groups A, B and C [(166.28±13.78) MPa, (170.21±11.36) MPa and (202.04±16.55) MPa] were higher than those of groups D and E [(137.09±8.83) MPa and (119.35±5.98) MPa], and the flexural modulus [(62.39±3.40) GPa] and Vickers hardness [(406.97±14.73) HV] of E group were higher than those of other groups (P<0.05). The flexural strength, flexural modulus and Vickers hardness of groups D and E did not change after thermal cycling (allP>0.05), while those of groups A, B and C decreased (allP<0.05).

After thermal cycling, the mechanical properties of the A, B and C groups decreased, while those of the groups D and E were stable.

The 47-year-old female was admitted to the Department of Endocrinology of Peking Union Medical College Hospital in June 2017 due to "polyuria and polydipsia for 10 months, fatigue, anorexia and loss of sexual desire for 8 months". The patient developed polyuria, polydipsia, polydipsia without obvious trigger 10 months ago, liked cold drinks, had a daily urine output of 5~6 L, clear urine color, nocturia increased to 2 times, and the urine output was equivalent day and night. The longest persistence was 2 hours without drinking water, which was not paid attention to. Eight months ago, weakness of both lower limbs, anorexia, fear of cold, laziness, loss of sexual desire and pubic hair loss gradually appeared. Visited the local hospital, serum potassium was 3.87 mmol/L, serum sodium was 154 mmol/L, and creatinine was 198 μ mol/L. Positive desmopressin test. Enhanced magnetic resonance imaging (MRI) of the head: suprasellar pituitary stalk running area nodule, considering pituitary stalk origin, benign may be large. Thyroid function: free triiodothyronine (FT₃) 2.96 pmol/L (reference value: 3.1-6.8 pmol/L), free tetraiodothyronine (FT₄) 8.3 pmol/L (reference: 12-22 pmol/L), and thyroid stimulating hormone (TSH) 2.61 mU/L (reference: 0.27-4.20 mU/L). Blood cortisol_8：00204.2 nmol/L (reference value: 115.9-1 059.8 nmol/L). Consider "central diabetes insipidus; pituitary stalk occupation, possible lymphocytic hypophysitis; secondary hypothyroidism". 50 μ g desmopressin acetate tablets (coagulation) were administered orally, once before bedtime; Levothyroxine sodium tablets 12.5 μ g orally, once a day as replacement therapy. The symptoms of self-conscious polydipsia and polyuria were not significantly relieved, so we went to our hospital for further diagnosis and treatment. Deny headache, nausea, vomiting, loss of vision, deny fever, rash, joint swelling and pain, deny chest pain, dyspnea, deny bone pain, history of fracture. During the course of the disease, the spirit and sleep are good, the stool is once every 1 to 2 days, and the weight has lost 4 kg in the past six months. Past history: Right breast fibroadenoma resection was performed in 2016. Menstrual history: Menarche at the age of 15, regular menstruation, menopause at the age of 46. Personal history and family history are no different.

A 77-year-old female was admitted to the Department of Oncology Surgery of Jiaxing No.1 Hospital on June 8, 2012 due to "upper abdominal discomfort for more than 2 months". On May 5, 2012, the patient went to an external hospital for "upper abdominal discomfort". Abdominal CT showed that a mass was seen on the outside of the great curvature of the stomach. First, gastric malignant stromal tumor was considered, and histological examination was recommended. Gastroscopy suggests that the stomach occupies space. Pathology: Malignant tumor of the stomach body, poorly differentiated carcinoma is likely, and immunohistochemistry is recommended for further diagnosis. For further diagnosis and treatment, we came to our hospital, and no obvious abnormalities were found in the physical examination and laboratory examination. Previous hypertension for more than 10 years, self-stated oral antihypertensive drugs can be controlled.

Neuroendocrine tumors of bile duct can be divided into highly differentiated neuroendocrine tumors (NET, also divided into G1, G2, G3 stages), differentiated neuroendocrine carcinomas (NEC, large-cell and small-cell), and mixed gonadal-neuroendocrine carcinomas (MANEC) with both adenocarcinoma and neuroendocrine tumor components according to the degree of differentiation. Rare types include goblet cell carcinoid, tubular carcinoid, etc^[1,2]。 Clinically, NET mostly occurs in gastrointestinal and pancreatic tissues, while NET occurring in bile ducts, especially extrahepatic bile ducts, is extremely rare. This paper reports a case of neuroendocrine tumor, which occurred in the middle section of the common bile duct. The tumor volume (5.5 cm ×4.5 cm ×4 cm) is the larger NET volume of the common bile duct so far compared with the reports retrievable by PubMed today. The report is as follows.

Lymphoma is one of the common malignant tumors. According to the China Cancer Registry Annual Report, the incidence rate of lymphoma in China from 2003 to 2013 was about 5/100,000, of which Hodgkin's lymphoma (HL) accounted for about 10%^[1]。 In the United States, approximately 9 000 people are expected to be diagnosed with HL each year^[2]。 HL is a curable malignancy, but approximately 20% of patients still experience treatment failure, and approximately the same proportion of patients may have overtreatment, resulting in an increase in the incidence of near-term or long-term adverse reactions^[3]。 Therefore, accurately identifying patients with different relapse risks and individualizing treatment plans to improve the cure rate and avoid overtreatment has become a hot spot in current HL research. This article reviews the progress of the prognostic factors of HL.