内镜黏膜下剥离术治疗胃间质瘤的临床疗效及术后出血的危险因素分析

摘要 目的：探讨内镜黏膜下剥离术（ESD）治疗胃间质瘤的临床疗效及术后出血的危险因素。方法：选取2018年2月至2020年3月我院诊治的135例胃间质瘤患者作为研究对象,统计其ESD治疗后的各项临床指标,比较治疗前后患者的细胞免疫功能和胃肠激素变化,根据患者ESD治疗后是否发生出血将其进一步分为术后出血组12例和术后未出血组123例,分析胃间质瘤患者ESD术后出血的危险因素。结果：135例患者平均手术时间为（45.89±8.79）min,平均术后进食时间为（3.05±0.98）d,平均住院时间为（6.11±0.95）d,完整切除率为96.30%,术后出血发生率为8.89%,术后穿孔发生率为5.19%,术后感染发生率为9.63%。经单因素分析发现,ESD治疗胃间质瘤术后出血与高血压、糖尿病、血小板（PLT）、血清降钙素原（PCT）和C反应蛋白（CRP）有关（P<0.05）。与治疗前相比,患者治疗后CD3⁺、CD4⁺、CD4⁺/CD8⁺、血清胃动素（MTL）、胃泌素（GAS）和生长激素释放肽(Ghrelin)水平明显下降,而CD8⁺明显升高（P<0.05）。进一步多因素Logistic回归分析表明,胃间质瘤患者ESD术后出血的危险因素包括高血压、糖尿病、PCT＞2.73 ng/mL以及CRP＞62.19 ng/mL（P<0.05）,而保护因素则为PLT＞151.38×109/L（P<0.05）。结论：ESD治疗胃间质瘤患者的疗效确切,安全性较好,但其会引起胃间质瘤患者的细胞免疫功能和胃肠激素分泌下降。同时,高血压、糖尿病、PCT＞2.73 ng/mL和CRP＞62.19 ng/mL是胃间质瘤患者ESD术后出血的危险因素。     

Higher frequency of septic shock in septic patients with the 47C allele (rs4880) of the SOD2 gene

Aim

To analyze the effect of the two different versions of the manganese superoxide dismutase gene (SOD2) on sepsis. The SOD2 gene presents the 47C > T single nucleotide polymorphism (SNP; ID: rs4880) which produces MnSOD with different activities. The − 9Val MnSOD (47T allele) is less efficient than the − 9Ala version (47C allele). During sepsis there are abundance of ROS, high SOD2 expression and excess of H₂O₂ synthesis. High concentrations of H₂O₂ could affect the sepsis scenario and/or the sepsis outcome.

Methods

We determined the 47C > T single nucleotide polymorphism (SNP) frequencies in 529 critically ill patients with or without sepsis, facing outcome. To collect information on population frequencies, we obtained a pilot 47C > T genotypic and allelic frequencies in a random group of 139 healthy subjects.

Results

We compared the 47C allele carriers (47CC + 47CT genotypes) with 47TT homozygotes and noticed a significant association between 47C allele carriers and septic shock in septic patients (P = 0.025). With an adjusted binary multivariate logistic regression, incorporating 47C > T SNP and the main clinical predictors, we showed high SOFA scores [P < 0.001, OR = 9.107 (95% CI = 5.319–15.592)] and 47C allele [P = 0.011, OR = 2.125 (95% CI = 1.190–3.794)] were significantly associated with septic shock outcome. With this information we presented a hypothesis suggesting that this negative outcome from sepsis is possibly explained by effects on cellular stress caused by 47C allele.

Conclusion

In our population there was a significant higher frequency of septic shock in septic patients with the 47C allele of the SOD2 gene. This higher 47C allele frequency in septic patients with negative outcome could be explained by effects of higher activity MnSOD on cellular stress during the sepsis.     

术前AGR、NLR、FOXQ1联合检测对低位直肠癌根治性切除手术患者术后复发的预测价值

摘要 目的：探讨术前白蛋白-球蛋白比值（AGR）、中性粒细胞-淋巴细胞比值（NLR）、叉头框蛋白Q1（FOXQ1）联合检测对低位直肠癌根治性切除手术患者术后复发的预测价值。方法：选取2017年3月至2019年4月重庆市第九人民医院就诊的拟行低位直肠癌根治性切除手术患者110例,术前均检测血清AGR、NLR、FOXQ1水平。随访3~48个月,中位随访时间为25.5个月,失访9例,101例根据术后复发情况将患者分为复发组（n=16）和未复发组（n=85）。比较两组患者术前血清AGR、NLR、FOXQ1水平,收集患者的临床资料,以Logistic回归分析探讨低位直肠癌患者术后复发的危险因素,绘制受试者工作曲线（ROC）判定术前血清AGR、NLR、FOXQ1水平对低位直肠癌患者术后复发的预测价值。结果：复发组术前血清AGR水平低于未复发组,术前血清NLR、FOXQ1水平高于未复发组（P<0.05）;复发组患者肿瘤细胞分化程度为低分化、TNM分期为Ⅲ期、糖链抗原19-9（CA19-9）阳性占比高于未复发组（P<0.05）,复发组术后化疗占比低于未复发组（P<0.05）;Logistic回归分析结果显示,TNM分期为Ⅲ期、细胞分化程度为低分化、术前血清AGR降低、NLR升高、FOXQ1升高均为低位直肠癌患者术后复发的危险因素（P＜0.05）;ROC曲线结果显示,术前血清AGR、NLR、FOXQ1水平及三者联合对低位直肠癌患者术后复发的预测的曲线下面积（AUC）值分别为0.738、0.747、0.731、0.842。结论：术前检测血清AGR、NLR、FOXQ1水平对低位直肠癌根治性切除术患者术后复发预测具有一定的价值,且联合的预测价值更高。     

颈静脉孔区肿瘤各手术入路的选择及对比分析

颈静脉孔区肿瘤位置深,结构复杂,周围有重要的神经血管走形,此区域肿瘤类型较多,常见的有颈静脉球瘤,其次为神经鞘瘤和脑膜瘤。由于此区域位置深,结构复杂,手术显露困难,切除此区域肿瘤难度较大,选择合适的手术入路以及术中正确的处理是该区域肿瘤手术成功的关键。此区域的手术入路可分为三种:后方入路、侧方入路、前方入路;各自又有新型的改良术式。手术入路的选择取决于病变性质、生长范围、受累结构、患者的功能状态及术者的个人经验。术中保护重要的神经血管是此手术的关键。尽管如此,术后出现的并发症在所难免,其主要的并发症有:脑神经损伤后功能障碍、脑脊液漏和脑膜炎等。     

Plasma Kallikrein Promotes Epidermal Growth Factor Receptor Transactivation and Signaling in Vascular Smooth Muscle through Direct Activation of Protease-activated Receptors

The kallikrein-kinin system, along with the interlocking renin-angiotensin system, is a key regulator of vascular contractility and injury response. The principal effectors of the kallikrein-kinin system are plasma and tissue kallikreins, proteases that cleave high molecular weight kininogen to produce bradykinin. Most of the cellular actions of kallikrein (KK) are thought to be mediated by bradykinin, which acts via G protein-coupled B1 and B2 bradykinin receptors on VSMCs and endothelial cells. Here, we find that primary aortic vascular smooth muscle but not endothelial cells possess the ability to activate plasma prekallikrein. Surprisingly, exposing VSMCs to prekallikrein leads to activation of the ERK1/2 mitogen-activated protein kinase cascade via a mechanism that requires kallikrein activity but does not involve bradykinin receptors. In transfected HEK293 cells, we find that plasma kallikrein directly activates G protein-coupled protease-activated receptors (PARs) 1 and 2, which possess consensus kallikrein cleavage sites, but not PAR4. In vascular smooth muscles, KK stimulates ADAM (a disintegrin and metalloprotease) 17 activity via a PAR1/2 receptor-dependent mechanism, leading sequentially to release of the endogenous ADAM17 substrates, amphiregulin and tumor necrosis factor-α, metalloprotease-dependent transactivation of epidermal growth factor receptors, and metalloprotease and epidermal growth factor receptor-dependent ERK1/2 activation. These results suggest a novel mechanism of bradykinin-independent kallikrein action that may contribute to the regulation of vascular responses in pathophysiologic states, such as diabetes mellitus.     

Preoperative statin therapy and infectious complications in cardiac surgery

AimTo assess whether preoperative statin therapy is associated with the risk of postoperative infection in patients undergoing cardiac surgery.Methods520 patients undergoing cardiac surgery in 2010 were retrospectively examined. Data regarding statin and antibiotic use prior to and after surgery were available from the hospital pharmacy information system. Cultures and clinical data of patients on postoperative antibiotics other than standard prophylactic therapy were studied to identify postoperative infections up to 30 days from day of surgery.Results370 (71.2 %) patients were on preoperative statin therapy. Overall, 82 patients (15.8 %) suffered from postoperative infection of which 11 were surgical site infections. In multivariable regression analysis, statin therapy was associated with a reduced risk of postoperative infection (adjusted odds ratio: 0.329, 95 %: CI 0.19–0.57; P < 0.001).ConclusionsPreoperative statin use was associated with a considerable reduced risk of postoperative infections following cardiac surgery. Randomised controlled trials are required to clarify the role of statin therapy in the prevention of postoperative infections.     

麻醉方式对老年髋关节置换术患者的影响

目的:观察和比较腰硬联合麻醉与全麻对行择期髋关节置换术老年患者的生命体征、简易智力状况检查量表(Mini-mental State Examinatlon,MMSE)评分、认知功能障碍(postoperative cognitive dysfunction,POCD)发生率的影响。方法:选取2015年1月-2017年6月于我院行择期髋关节置换术的80例老年患者为研究对象,随机分为腰硬联合麻醉组和全麻组,每组各40例。全麻组患者术前应用全身麻醉,腰硬联合麻醉组患者术前应用腰硬联合麻醉。观察两组患者麻醉前后的生命体征、MMSE评分变化及POCD的发生情况。结果:腰硬联合麻醉组患者麻醉后收缩压(Systolic pressure,SP)、舒张压(diastolic pressure,DP)、心率(heart rate,HR)、呼吸频率(Respiratory rate,RR)均低于全麻组(P0.05),两组患者血氧饱和度(Pulse Oxygen Saturation,Sp O2)比较差异无统计学意义(P0.05)。腰硬联合麻醉组患者麻醉起效时间、运动阻滞恢复时间以及麻醉药用量均低于全麻组(P0.05)。术后6 h、24 h、72 h,腰硬联合麻醉组的MMSE评分均高于全麻组患者(P0.05)。术后1 d,全麻组的患者出现19例POCD,腰硬联合麻醉组出现4例,发生率显著低于全麻组(P0.05);两组在术后3 d的POCD发生率比较差异无统计学意义(P0.05)。结论:腰硬联合麻醉用于择期行髋关节置换术的老年患者具有良好的临床效果,麻醉起效快,缩短了完全阻滞时间,明显改善了患者的生命体征,降低术后认知功能障碍的发生,麻醉药物用量少。     

Postoperative analysis of the mechanical interaction between stent and host tissue in patients after transcatheter aortic valve implantation

The analysis is based on a finite element procedure to extract the contact forces between an implanted Nitinol stent and the surrounding host tissue using postoperative CT images. The methodology was applied for patients (N=46) which have undergone a TAVI procedure with the Medtronic CoreValve Revalving System (MCRS) to obtain corresponding deformation and force maps. The postoperative CT data were recorded for each patient in both systolic and diastolic phase of the heart cycle. Scalar parameters were defined, which map deformed geometry and contact force field to mechanically relevant quantities: radial dilatation, radial shape distortion, non-convex points, mean force, a force deviation measure and a pressure equivalent. The latter demonstrates that in the area of the aortic root, the added circumferential loading is of the same order as the baseline average blood pressure, thus leading to a doubling of the local mechanical load. Generally the force distribution along the stent is non-homogeneous. A comparison of systolic and diastolic data revealed slightly higher contact forces during the diastole, indicating that the stent has to carry more load in this phase. The geometrical and mechanical parameters were compared for two types of clinical complication: para-valvular leakage (PVL) and permanent pacemaker requirement (PPM). It was found that an increase in mean force can be associated with both complications; significantly for PVL and as a trend for PPM.     

剖宫产术后镇痛策略的研究进展

剖宫产术后疼痛会对产妇带来一系列不良影响。术后的急性疼痛会使产妇处于高水平的应激状态,增加术后并发症的发生率,不利于产妇的快速康复,并且可能导致慢性疼痛及产后抑郁的发生。良好的术后镇痛一方面可以消除体内的不良刺激,维持内环境的稳定,为机体康复提供有利条件,另一方面可以减轻产妇的心理负担,使其能尽早开始哺乳,并且更好的与新生儿互动。椎管内或静脉注射阿片类药物是目前常用的镇痛方法,但其不良反应较多,并且可以转移至母乳,对新生儿有潜在风险,因此,联合应用其他药物或手段进行多模式镇痛或许是更好的选择。本文对剖宫产术后镇痛药物及镇痛方式的研究进展进行综述,以期为剖宫产术后产妇提供高质量、个体化的镇痛有所帮助。     

Marine Conservation versus International Free Trade: Reconciling Dolphins with Tuna and Sea Turtles with Shrimp

During the 1990s, the World Trade Organization (WTO) rejected as impermissible unilateral efforts by the United States to promote conservation of endangered marine species through trade sanctions against other governments. These acts of unilateral economic coercion were held to be discriminatory tactics done in unfair restraint of international trade. But in so doing, the WTO findings aroused the ire of environmentalists worldwide. These findings by the WTO became portrayed not as decisions upholding free trade, but as mandates against marine conservation and environmental protection. Even so, this denial of lawful permissibility to use unilateral economic coercion to protect endangered species internationally does not signal the demise of national efforts to conserve living marine resources. Rather, these WTO findings point up the manner in which potential trade and marine conservation disputes should be handled, i.e., through means of peaceful settlement. The key to future international marine conservation relies on a multilateral rather than a unilateral approach. Thus, environmentally conscious governments, such as the United States, should continue to encourage global adoption of marine conservation policies without impinging on international norms and standards of international commercial transactions.