BACKGROUND Nocardiosis is a rare bacterial infection with unclear epidemiology,pathogenesis,and characteristics.Its clinical manifestations are diverse and nonspecific,making diagnosis prone to errors,including misdia...BACKGROUND Nocardiosis is a rare bacterial infection with unclear epidemiology,pathogenesis,and characteristics.Its clinical manifestations are diverse and nonspecific,making diagnosis prone to errors,including misdiagnosis and missed diagnosis.Additionally,this disease is difficult to treat,often requiring months or even years of antibacterial therapy,and can be fatal in patients with underlying conditions.CASE SUMMARY A 93-year-old male patient with chronic renal insufficiency sustained a skin injury at the tip of his right thumb.As a result of an initial misdiagnosis and inadequate treatment,the infection progressed,resulting in multiple rashes on his right upper limb.Local incision and drainage of pus,combined with oral antibiotics administered at a different hospital,yielded no significant improvement.Upon hospitalization,the patient’s immune function was assessed,and further local incision and drainage were performed.Cultures of the pus identified Nocardia brasiliensis.Treatment involved intravenous infusion of piperacillin-tazobactam sodium and oral administration of sulfamethoxazole-trimethoprim,leading to the patient’s recovery.After discharge,the patient continued to take sulfamethoxazole tablets for 6 months,with complete healing of the skin lesions and no recurrence.CONCLUSION Nocardiosis should be considered in patients with underlying conditions and compromised immunity.Prompt and accurate diagnosis is crucial.展开更多
PURPOSE:To investigate the differences in gut microbial characteristics between two traditional Chinese syndromes of premature ovarian insufficiency(POI).METHODS:Forty women with POI were recruited from the Department...PURPOSE:To investigate the differences in gut microbial characteristics between two traditional Chinese syndromes of premature ovarian insufficiency(POI).METHODS:Forty women with POI were recruited from the Department of Traditional Chinese Medicine at Shenzhen Maternity and Child Healthcare Hospital between June and December 2020.Women with POI were divided into the kidney deficiency and blood stasis syndrome(SDBS)and Qi and blood deficiency syndrome(QBDS)groups.Gut microbial community profiles were analyzed by 16S rRNA gene sequencing using an Illumina Mi Seq system.A retrospective study comparing hormone levels and gut microbiota information was performed between the SDBS and QBDS groups.RESULTS:Compared with the QBDS group,the serum levels of estradiol(E2)and anti-Müllerian hormone(AMH)were significantly decreased in the SDBS group.The quantities of Adlercreutzia,Eggerthella,Klebsiella,and Paraprevotella significantly increased in the SDBS group,whereas Lactobacillus decreased significantly.Moreover,alterations in the microbiome in the SDBS and QBDS groups were closely related to the levels of E2 and AMH.The area under the receiver operating characteristic curve for the classification of the two syndromes by the gut microbiome was 0.71.CONCLUSIONS:There were significant differences in the dominant microbiota between the SDBS and QBDS groups,and the change in Proteobacteria in the QBDS group was more significant.The characteristics of gut microbiota help us differentiate between the SDBS and QBDS groups,which may provide a basis for the objectification of TCM syndrome types.展开更多
This letter discusses the critical yet underrecognized intersection of chronic renal insufficiency and Nocardia brasiliensis skin infection in the case reported by Zhang et al,emphasizing the diagnostic challenges and...This letter discusses the critical yet underrecognized intersection of chronic renal insufficiency and Nocardia brasiliensis skin infection in the case reported by Zhang et al,emphasizing the diagnostic challenges and therapeutic complexities in the context of advanced age,comorbidities,and immunocompromised populations.The study’s strengths included its integration of immunological profiling and precision medicine,demonstrating that a tailored low-dose trimethoprimsulfamethoxazole regimen with pharmacokinetic monitoring can improve outcomes in geriatric patients with chronic renal insufficiency while mitigating nephrotoxicity risks.However,its limitations included a single-case design,reliance on phenotypic diagnostics,and the lack of information regarding comorbidity interactions.The findings support the use of advanced molecular tools for rapid pathogen identification and identification of co-infection.Future studies should prioritize elucidating the synergistic effects of chronic kidney disease-uremia and immunosuppression on Nocardia colonization,developing biomarkers for early detection,and conducting global epidemiological studies in endemic regions.This case underscores the importance of interdisciplinary collaboration and innovative diagnostics to optimize management of nocardiosis in vulnerable populations.展开更多
BACKGROUND In open heart surgery requiring cardiopulmonary bypass(CPB),ventricular fibrillation(VF)is common,but refractory recurrent VF is uncommon but perilous.CASE SUMMARY This article reports a 58-year-old male pa...BACKGROUND In open heart surgery requiring cardiopulmonary bypass(CPB),ventricular fibrillation(VF)is common,but refractory recurrent VF is uncommon but perilous.CASE SUMMARY This article reports a 58-year-old male patient with an ascending aortic aneurysm who presented for a Bentall procedure and subsequently experienced multiple occurrences of unexplained VF after weaning from CPB.The recurrent episodes of VF in this case were felt to be related to coronary insufficiency after reconstruction of the aortic root.Coronary artery bypass grafting(CABG)of the proximal right coronary artery and the left anterior descending artery successfully resolved VF.Finally,this patient was safely transferred to the postoperative intensive care unit,and was discharged successfully after subsequent supportive treatment.CONCLUSION In aortic root replacement,coronary insufficiency is a potential cause of VF episodes and should be considered in the differential diagnosis.CABG is the sole effective treatment for VF caused by coronary insufficiency.展开更多
BACKGROUND Pancreatic exocrine insufficiency(PEI)leads to fat malabsorption and maldigestion and is most commonly treated with pancreatic enzyme replacement therapy(PERT).Patients suffering from PEI in China are more ...BACKGROUND Pancreatic exocrine insufficiency(PEI)leads to fat malabsorption and maldigestion and is most commonly treated with pancreatic enzyme replacement therapy(PERT).Patients suffering from PEI in China are more likely not to receive adequate treatment as this drug is not part of the Chinese national essential medicine list.AIM To examine the cost-effectiveness of PERT for patients suffering from PEI in China.METHODS A decision analytical Markov model was constructed to simulate the progress of patients with PEI in China.The population included in the analyses were patients suffering from PEI with advanced(non-resectable)pancreatic cancer,who have undergone surgery due to pancreatic cancer and who have undergone endoscopic treatment due to chronic pancreatitis.The cost-effectiveness analyses were undertaken from a Chinese societal perspective comparing PERT with no PERT.The incremental cost-effectiveness ratio in United States dollars per quality adjusted life year(QALY)gained is the main outcome.Input was informed by publicly available data supplemented with expert clinical advice.RESULTS The cost-effectiveness analyses estimated that PERT resulted in additional 0.45 to 2.93 QALYs at discounted costs of between 4315 dollars to 15193 dollars.This resulted in an incremental cost-effectiveness ratio of 5178 dollars to 9533 dollars per QALY.The one-way sensitivity analyses showed that the main drivers of the model were the cost of PERT and overall survival.CONCLUSION This study demonstrates that PERT is a cost-effective treatment for patients suffering from PEI in China.展开更多
Premature ovarian insufficiency(POI)is characterized by irreversible loss of ovarian function before 40 years of age and affects 3.7%of women worldwide(Golezar et al.,2019;Huang et al.,2021).Raised serum follicle-stim...Premature ovarian insufficiency(POI)is characterized by irreversible loss of ovarian function before 40 years of age and affects 3.7%of women worldwide(Golezar et al.,2019;Huang et al.,2021).Raised serum follicle-stimulating hormone(FSH)levels,menstrual disturbance,and estrogen deficiency are the main symptoms of POl(European Society for Human Reproduction et al.,2016).Besides infertility,patients have an increased risk of long-term complications due to the early deficiency of ovarian steroids,such as osteoporosis,cardiovascular disease,and metabolic disorders(lshizuka,2021).Due to the lack of biomarkers for prediction or early diagnosis,most patients are not diagnosed until the failure stage(serum levels of FSH above 25 IU/L and amenorrhea),missing opportunities for intervention.Therefore,developing sensitive biomarkers for diminished ovarian reserves is paramount for timely treatment to improve reproductive outcomes and prevent long-term complications.展开更多
BACKGROUND Gastrectomy is recognized as a potential cause of exocrine pancreatic insufficiency(EPI).However,limited data are available regarding the incidence and impact of EPI on quality of life(QoL)following gastric...BACKGROUND Gastrectomy is recognized as a potential cause of exocrine pancreatic insufficiency(EPI).However,limited data are available regarding the incidence and impact of EPI on quality of life(QoL)following gastric surgery.AIM To evaluate incidence and severity of EPI after gastrectomy and its effect on QoL at least one year after surgery.METHODS EPI was assessed using fecal elastase measurement and classified into:(1)No-EPI(fecal elastase>200μg/g);(2)Moderate EPI(fecal elastase 100–200μg/g);and(3)severe EPI(fecal elastase<100μg/g).QoL was measured using the Gastrointestinal Quality of Life Index(GIQLI)questionnaire.RESULTS Sixteen out of 44(36.4%)patients developed EPI post-operatively:9(56.2%)patients had moderate EPI while 7(43.8%)patients had severe EPI.Severe EPI was more frequently observed in younger patients(5/7:71.4%;P=0.05),in more advanced disease stages(7/7:100%;P=0.05),lymph nodes metastases(7/7:100%;P=0.04)and in the mixed histotypes(4/7:66.7%;P=0.02)compared to the no-EPI and moderate EPI groups.QoL analysis showed that severe EPI was associated with a significantly lower overall GIQLI score[65(59–92)]compared to the no-EPI/moderate EPI groups[89(84–100)](P=0.002).Lower scores were particularly evident in the core(P<0.0001)and disease-specific symptoms domains(P=0.002)in the severe EPI group compared to the no-EPI/moderate EPI groups.CONCLUSION Gastrectomy is a cause of EPI.Younger patients,aggressive disease and advanced stages are significant risk factors for more severe EPI.Severe EPI worsens QoL,being associated with a higher rate of gastrointestinal symptoms.展开更多
Resection of the terminal ileum and ileocecal valve remains the most commonly performed procedure in patients with Crohn's disease.However,despite radical treatment,there is a risk of disease recurrence at the sit...Resection of the terminal ileum and ileocecal valve remains the most commonly performed procedure in patients with Crohn's disease.However,despite radical treatment,there is a risk of disease recurrence at the site of the intestinal ana-stomosis in some cases.Therefore,long-term postoperative management is crucial and requires systematic clinical assessment,endoscopic surveillance,and pharma-cological support when indicated.A key challenge is identifying the risk factors associated with the recurrence of anastomotic failure and defining the principles of follow-up care to prevent secondary intestinal insufficiency.This paper focuses on both surgical and non-surgical factors that may play a role in preventing complications in patients undergoing ileocecal resection,providing a compre-hensive approach to postoperative management.展开更多
OBJECTIVE:To investigate the potential mechanism of electroacupuncture(EA)in alleviating premature ovarian insufficiency(POI)and to provide a theoretical basis for EA treatment of POI.METHODS:For this purpose,a POI mi...OBJECTIVE:To investigate the potential mechanism of electroacupuncture(EA)in alleviating premature ovarian insufficiency(POI)and to provide a theoretical basis for EA treatment of POI.METHODS:For this purpose,a POI mice model was developed by injecting 12 mg/kg busulfan and 120 mg/kg cyclophosphamide intraperitoneally to induce POI.It was then proceeded by EA intervention at Guanyuan(CV4)acupoint on the second day following modeling.Similarly,apoptosis in ovarian granulosa cells was detected by terminal deoxynucleotidyl transferase d UTP nick end labeling staining,while enzyme-linked immunosorbent assay was employed for measuring serum folliclestimulating hormone(FSH),luteinizing hormone(LH),estrogen(E_(2)),and anti-müllerian hormone(AMH)levels.Moreover,transmission electron microscopy(TEM)was employed for examining mitochondrial morphology,while autophagy and hippo-yes-associated protein/transcriptional co-activator with postsynaptic density protein,drosophila disc large tumor suppressor,and zonula occludens-1 protein binding motif(YAP/TAZ)pathway related protein levels in ovarian tissue were detected via Western blotting.RESULTS:Analysis of serum levels of various hormones indicated that serum FSH and LH were reduced in EA compared to the POI group,while E_(2) and AMH levels were found to be elevated in EA compared to the POI group.The EA was found to inhibit apoptosis in granulosa cells in POI model mice,in addition to improved mitochondrial damage and significantly improved mitophagy.Pathway analysis revealed that EA was involved in activating the hippo-YAP/TAZ pathway,followed by reversing EA effects on granulosa cell apoptosis and mitophagy with the use of verteporfin,an autophagy and YAP-T-cell factor/enhancer of split and activator of transcription domain family member interaction inhibitor.CONCLUSIONS:EA at the Guanyuan(CV4)acupoint protected the granulosa cell by inhibiting cell apoptosis and promoting mitophagy,which was mediated by the Hippo-YAP/TAZ pathway.展开更多
Nocardiosis remains a rare and often underdiagnosed bacterial infection,particularly in immunocompromised individuals.The case report by Zhang et al highlights the diagnostic and therapeutic challenges in managing Noc...Nocardiosis remains a rare and often underdiagnosed bacterial infection,particularly in immunocompromised individuals.The case report by Zhang et al highlights the diagnostic and therapeutic challenges in managing Nocardia brasiliensis skin infection in a 93-year-old patient with chronic renal insufficiency.This editorial explores the importance of timely diagnosis,microbiological confirmation,and tailored antibiotic therapy.Emphasis is placed on the role of immune status evaluation,drug concentration monitoring,and the necessity of long-term antimicrobial therapy.Improved clinician awareness and adherence to evidencebased management protocols are essential to achieving better outcomes in nocardiosis cases.展开更多
Objective: To study clinical features of the patients with multiple myeloma(MM) accompanied by renal insufficiency and investigate the related risk factors of renalimpairment. Methods: A control study of clinical char...Objective: To study clinical features of the patients with multiple myeloma(MM) accompanied by renal insufficiency and investigate the related risk factors of renalimpairment. Methods: A control study of clinical characteristics was performed between 91 patientswith renal insufficiency due to MM and 165 patients with normal renal function in MM during the sameperiod. The data were statistically analyzed by chi-square test and logistic regression analysis.Results: Renal insufficiency was the initial presentation in 48 (52.7%) of the 91 patients, and 30(62.5%) of the 48 patients were misdiagnosed. The prognosis of group with renal insufficiency wassignificantly poorer than that of group with normal renal function: mortality in 3 months, 3months-1 year was 26/91 vs 14/165 (P 【 0.0001), 14/91 vs 12/165 (P 【 0.05) respectively, andpatients survived 】 1 year was 18/91 vs 95/165 (P 【 0.0001). The incidence of hypercalcemia,hyperuricemic, severe anemia, high serum M-protein concentration and lytic bone lesions weresignificantly higher in renal insufficiency group than those in control group (P 【 0.05). Logisticregression analysis identified 5 risk factors of renal impairment, including, severe anemia(Exp(β)=13.819, P 【 0.0001), use of nephrotoxic drugs (Exp(β)=6.217, P = 0.001), high serumM-protein concentration (Exp(β) = 5.026, P = 0.001), male (Exp(β)=3.745, P=0.006), andhypercalcemia (Exp(β)=3A72, P=0.006), but age, serum density of uric acid, type of serum M-protein,and Bence Jones proteinuria were not significantly associated with renal insufficiency. Conclusion:Renal insufficiency was a common early complication of MM, which often resulted in misdiagnosis.The status of these patients tended to be very bad, with many other complications, when MM wasdiagnosed, so their prognosis was poor. The occurrence of renal insufficiency in patients with MMand hypercalcemia, severe anemia, high serum M-protein concentration, especially use of nephrotoxicdrugs should be alert.展开更多
AIM:To compare and analyse the diagnostic efficacy of the College of Optometrists Vision Development Quality of Life Questionnaire(COVD-QOL)and the Convergence Insufficiency Symptom Survey(CISS)in detecting convergenc...AIM:To compare and analyse the diagnostic efficacy of the College of Optometrists Vision Development Quality of Life Questionnaire(COVD-QOL)and the Convergence Insufficiency Symptom Survey(CISS)in detecting convergence insufficiency and to compare their diagnostic value in clinical applications.METHODS:Using the diagnostic test method,62 adult patients with convergence insufficiency(age:24.74±3.75y)and 62 normal participants(age:23.61±3.13y)who visited the Optometry Clinic of West China Hospital of Sichuan University from April 2021 to January 2023 were included.All subjects completed the CISS and COVD-QOL.Statistical analysis of the sensitivity and specificity of the CISS and COVD-QOL and comparison and joint experimental analysis of their diagnostic efficacy were performed.RESULTS:The sensitivity of the CISS and COVD-QOL for convergence insufficiency was 64.5%and 71.0%,respectively,while the specificity was 96.8%and 67.7%,respectively.Compared to the CISS alone,the combination of the CISS and COVD-QOL demonstrated lower sensitivity and specificity.The areas under the receiver operating characteristic curve of CISS,COVD-QOL and CISS combined with COVD-QOL were 0.806,0.694 and 0.782,respectively.CONCLUSION:Considering the low sensitivity of the CISS and the low specificity of the COVD-QOL,it is recommended to supplement these questionnaires with other screening tests for the detection of convergence insufficiency.展开更多
AIM:To investigate the risk factors for postoperative liver insufficiency in patients with Child-Pugh class A liver function undergoing liver resection.METHODS:A total of 427 consecutive patients undergoing partial he...AIM:To investigate the risk factors for postoperative liver insufficiency in patients with Child-Pugh class A liver function undergoing liver resection.METHODS:A total of 427 consecutive patients undergoing partial hepatectomy from October 2007 to April 2011 at a single center(Department of Hepatic SurgeryⅠ,Eastern Hepatobiliary Surgery Hospital,Shanghai,China) were included in the study.All the patients had preoperative liver function of Child-Pugh class A and were diagnosed as having primary liver cancer by postoperative histopathology.Surgery was performed by the same team and hepatic resection was carried out by a clamp crushing method.A clamp/unclamp time of 15 min/5 min was adopted for hepatic inflow occlusion.Patients' records of demographic variables,intraoperative parameters,pathological findings and laboratory test results were reviewed.Postoperative liver insufficiency and failure were defined as prolonged hyperbilirubinemia unrelated to biliary obstruction or leak,clinically apparent ascites,prolonged coagulopathy requiring frozen fresh plasma,and/or hepatic encephalopathy.The incidence of postoperative liver insufficiency or liver failure was observed and the attributing risk factors were analyzed.A multivariate analysis was conducted to determine the independent predictive factors.RESULTS:Among the 427 patients,there were 362 males and 65 females,with a mean age of 51.1 ± 10.4 years.Most patients(86.4%) had a background of viral hepatitis and 234(54.8%) patients had liver cirrhosis.Indications for partial hepatectomy included hepatocellular carcinoma(391 patients),intrahepatic cholangiocarcinoma(31 patients) and a combination of both(5 patients).Hepatic resections of ≤ 3 and ≥ 4 liver segments were performed in 358(83.8%) and 69(16.2%) patients,respectively.Seventeen(4.0%) patients developed liver insufficiency after hepatectomy,of whom 10 patients manifested as prolonged hyperbilirubinemia unrelated to biliary obstruction or leak,6 patients had clinically apparent ascites and prolonged coagulopathy,1 patient had hepatic encephalopathy and died on day 21 after surgery.On univariate analysis,age ≥ 60 years and prealbumin < 170 mg/dL were found to be significantly correlated with postoperative liver insufficiency(P = 0.045 and P = 0.009,respectively).There was no statistical difference in postoperative liver insufficiency between patients with or without hepatitis,liver cirrhosis and esophagogastric varices.Intraoperative parameters(type of resection,inflow blood occlusion time,blood loss and blood transfusion) and laboratory test results were not associated with postoperative liver insufficiency either.Age ≥ 60 years and prealbumin < 170 mg/dL were selected on multivariate analysis,and only prealbumin < 170 mg/dL remained predictive(hazard ratio,3.192;95%CI:1.185-8.601,P = 0.022).CONCLUSION:Prealbumin serum level is a predictive factor for postoperative liver insufficiency in patients with liver function of Child-Pugh class A undergoing hepatectomy.Since prealbumin is a good marker of nutritional status,the improved nutritional status may decrease the incidence of liver insufficiency.展开更多
This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas(AISP).We covered the main diseases a...This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas(AISP).We covered the main diseases associated with exocrine pancreatic insufficiency(EPI)which are of common interest to internists/gastroenterologists,oncologists and surgeons,fully aware that EPI may also occur together with many other diseases,but less frequently.A preliminary manuscript based on an extended literature search(Medline/PubMed,Cochrane Library and Google Scholar)of published reports was prepared,and key recommendations were proposed.The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012.Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached.The final draft of the manuscript was then sent to the AISP Council for approval and/or modification.All concerned parties approved the final version of the manuscript in June 2013.展开更多
Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of ...Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of digestive enzymes by pancreatic acinar cells,a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food.Failure in any of these steps may result in pancreatic exocrine insufficiency,which leads to steatorrhea,weight loss and malnutrition-related complications,such as osteoporosis.Methods evaluating digestion,such as fecal fat quantification and the13C-mixed triglycerides test,are the most accurate tests for pancreatic exocrine insufficiency,but the probability of the diagnosis can also be estimated based on symptoms,signs of malnutrition in blood tests,fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging.Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption,dietary consultation,enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment.Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicro-spheres during meals.The dose should be in proportion to the fat content of the meal,usually 40-50000 lipase units per main meal,and half the dose is required for a snack.In cases that do not respond to initial treatment,the doses can be doubled,and proton inhibitors can be added to the treatment.This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.展开更多
Restitution of normal fat absorption in exocrine pancreatic insufficiency remains an elusive goal. Although many patients achieve satisfactory clinical results with enzyme therapy, few experience normalization of fat ...Restitution of normal fat absorption in exocrine pancreatic insufficiency remains an elusive goal. Although many patients achieve satisfactory clinical results with enzyme therapy, few experience normalization of fat absorption, and many, if not most, will require individualized therapy. Increasing the quantity of lipase administered rarely eliminates steatorrhea but increases the cost of therapy. Enteric coated enzyme microbead formulations tend to separate from nutrients in the stomach precluding coordinated emptying of enzymes and nutrients. Unprotected enzymes mix well and empty with nutrients but are inactivated at pH 4 or below. We describe approaches for improving the results of enzyme therapy including changing to, or adding, a different product, adding non-enteric coated enzymes,(e.g., giving unprotected enzymes at the start of the mealand acid-protected formulations later), use of antisecretory drugs and/or antacids, and changing the timing of enzyme administration. Because considerable lipid is emptied in the first postprandial hour, it is prudent to start therapy with enteric coated microbead prior to the meal so that some enzymes are available during that first hour. Patients with hyperacidity may benefit from adjuvant antisecretory therapy to reduce the duodenal acid load and possibly also sodium bicarbonate to prevent duodenal acidity. Comparative studies of clinical effectiveness of different formulations as well as the characteristics of dispersion, emptying, and dissolution of enteric-coated microspheres of different diameter and density are needed; many such studies have been completed but not yet made public. We discuss the history of pancreatic enzyme therapy and describe current use of modern preparations, approaches to overcoming unsatisfactory clinical responses, as well as studies needed to be able to provide reliably effective therapy.展开更多
Liver cirrhosis is a major cause of mortality worldwide,often with severe sepsis as the terminal event.Over the last two decades,several studies have reported that in septic patients the adrenal glands respond inappro...Liver cirrhosis is a major cause of mortality worldwide,often with severe sepsis as the terminal event.Over the last two decades,several studies have reported that in septic patients the adrenal glands respond inappropriately to stimulation,and that the treatment with corticosteroids decreases mortality in such patients.Both cirrhosis and septic shock share many hemodynamic abnormalities such as hyperdynamic circulatory failure,decreased peripheral vascular resistance,increased cardiac output,hypo-responsiveness to vasopressors,increased levels of proinflammatory cytokines [interleukine(IL)-1,IL-6,tumor necrosis factor-alpha] and it has,consequently,been reported that adrenal insufficiency(AI) is common in critically ill cirrhotic patients.AI may also be present in patients with stable cirrhosis without sepsis and in those undergoing liver transplantation.The term hepato-adrenal syndrome defines AI in patients with advanced liver disease with sepsis and/or other complications,and it suggests that it could be a feature of liver disease per se,with a dif-ferent pathogenesis from that of septic shock.Relative AI is the term given to inadequate cortisol response to stress.More recently,another term is used,namely "critical illness related corticosteroid insufficiency" to define "an inadequate cellular corticosteroid activity for the severity of the patient's illness".The mechanisms of AI in liver cirrhosis are not completely understood,although decreased levels of high-density lipoprotein cholesterol and high levels of proinflammatory cytokines and circulatory endotoxin have been suggested.The prevalence of AI in cirrhotic patients varies widely according to the stage of the liver disease(compensated or decompensated,with or without sepsis),the diagnostic criteria defining AI and the methodology used.The effects of corticosteroid therapy on cirrhotic patients with septic shock and AI are controversial.This review aims to summarize the existing published information regarding AI in patients with liver cirrhosis.展开更多
Objective To investigate the association between vitamin D deficiency and risk of gestational diabetes rnellitus （GDM） in pregnant Chinese women. Methods A nested case-control study was conducted. Clinical and bioch...Objective To investigate the association between vitamin D deficiency and risk of gestational diabetes rnellitus （GDM） in pregnant Chinese women. Methods A nested case-control study was conducted. Clinical and biochemical data were analyzed for 200 subjects with GDM and 200 subjects with normal glucose tolerance （NGT）. Results The median （interquartile range） serum 25-hydroxyvitamin D （25OHD） levels were 22.39 （17.67, 29.38） and 25.86 （19.09, 34.88） nmol/L in the GDM and NGT groups, respectively. Rates of 25OHD deficiency or insufficiency were significantly higher in the GDM group than in the NGT group. Subjects with 25OHD levels 〈25 nmol/L had a 1.g-fold higher risk of GDM compared with subjects with higher vitamin D levels. In the GDM group, serum 25OHD was independently associated with HbAlc and insulin resistance after adjusting for confounding factors. In the NGT group, serum 25OHD was independently associated with fasting plasma glucose and systolic blood pressure after adjusting for maternal age and other confounding factors. Conclusion 2SOHD insufficiency is very common in Chinese women. Low 25OHD status may be associated with insulin resistance and act as a risk factor for GDM.展开更多
AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma (HCC). METHODS: In a cohort of 565 cons...AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma (HCC). METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 x 10(9)/L and patients with platelet count >= 100 x 10(9)/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis. RESULTS: Patients with a low immediate postoperative platelet count (< 100 x 10(9)/L) had more grade III-V. complications (20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure (6.8% vs 2.6%, P = 0.02), hepatic insufficiency (31.5% vs 21.2%, P < 0.001) and mortality (6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count >= 100 x 10(9)/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency. CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.展开更多
Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences.In the recent decade,the recommendations for managing symptomatic varicose ...Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences.In the recent decade,the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques.The literature was systematically searched on Medline without language restrictions.All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed.Endovenous laser ablation(EVLA)and radiofrequency ablation(RFA)both are same safe and effective in terms of occlusion rate,and time to return to normal activity.In comparison with RFA or EVLT,Cure conservatrice et Hemodynamique de l’Insufficience Veineuse en Ambulatoire(CHIVA)may cause more bruising and make little or no difference to rates of limb infection,superficial vein thrombosis,nerve injury,or hematoma.In terms of recurrence of varicose veins,there is little or no difference between CHIVA and stripping,RFA,or EVLT.Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy(FS)group(51%)during 1 year of follow-up.The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy.Although the mechanochemical endovenous ablation(MOCA)is a non-thermal,non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage,the overall success rate of MOCA is lower than those of other procedures such as EVLA,RFA,or high ligation and stripping.EVLA is the most cost-effective therapeutic option,with RFA being a close second for the treatment of patients with varicose veins.Endovenous thermal ablation(EVLA or RFA)is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins.Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures.MOCA and cyanoacrylate embolization appear promising,but evidence of their effectiveness is required.展开更多
基金Supported by Zhejiang Provincial Traditional Chinese Medicine Science and Technology Program,No.2023ZF075.
文摘BACKGROUND Nocardiosis is a rare bacterial infection with unclear epidemiology,pathogenesis,and characteristics.Its clinical manifestations are diverse and nonspecific,making diagnosis prone to errors,including misdiagnosis and missed diagnosis.Additionally,this disease is difficult to treat,often requiring months or even years of antibacterial therapy,and can be fatal in patients with underlying conditions.CASE SUMMARY A 93-year-old male patient with chronic renal insufficiency sustained a skin injury at the tip of his right thumb.As a result of an initial misdiagnosis and inadequate treatment,the infection progressed,resulting in multiple rashes on his right upper limb.Local incision and drainage of pus,combined with oral antibiotics administered at a different hospital,yielded no significant improvement.Upon hospitalization,the patient’s immune function was assessed,and further local incision and drainage were performed.Cultures of the pus identified Nocardia brasiliensis.Treatment involved intravenous infusion of piperacillin-tazobactam sodium and oral administration of sulfamethoxazole-trimethoprim,leading to the patient’s recovery.After discharge,the patient continued to take sulfamethoxazole tablets for 6 months,with complete healing of the skin lesions and no recurrence.CONCLUSION Nocardiosis should be considered in patients with underlying conditions and compromised immunity.Prompt and accurate diagnosis is crucial.
基金Sanming Project of Medicine in Shenzhen:the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine,Luo Songping National Famous Chinese Medicine Practitioner Female Reproductive Disorders Prevention and Treatment Team(SZZYSM202311010)Guangdong Provincial Administration of Traditional Chinese Medicine:Investigation of the Mechanism of Regulating Ren-Tong-Du Acupuncture on Ovarian Granulosa Cells in Polycystic Ovary Syndrome based on Activin A/Smads Signalling Pathway(No.20181229)+1 种基金Guangdong Provincial Administration of Traditional Chinese Medicine:Evaluation of the Efficacy of Menstrual Regulation and Pregnancy Promotion by Acupuncture in the Treatment of Premature Ovarian Insufficiency(No.20201294)Shenzhen Science and Innovation Commission:Investigating the Mechanism of Action of Acupuncture in Regulating the Gut Microbiome to Inhibit Apoptosis of Ovarian Granulosa Cells in Premature Ovarian Insufficiency Mice based on the Rictor/Torepamycin Target Protein C2 Pathway(No.JCYJ20210324130001004)。
文摘PURPOSE:To investigate the differences in gut microbial characteristics between two traditional Chinese syndromes of premature ovarian insufficiency(POI).METHODS:Forty women with POI were recruited from the Department of Traditional Chinese Medicine at Shenzhen Maternity and Child Healthcare Hospital between June and December 2020.Women with POI were divided into the kidney deficiency and blood stasis syndrome(SDBS)and Qi and blood deficiency syndrome(QBDS)groups.Gut microbial community profiles were analyzed by 16S rRNA gene sequencing using an Illumina Mi Seq system.A retrospective study comparing hormone levels and gut microbiota information was performed between the SDBS and QBDS groups.RESULTS:Compared with the QBDS group,the serum levels of estradiol(E2)and anti-Müllerian hormone(AMH)were significantly decreased in the SDBS group.The quantities of Adlercreutzia,Eggerthella,Klebsiella,and Paraprevotella significantly increased in the SDBS group,whereas Lactobacillus decreased significantly.Moreover,alterations in the microbiome in the SDBS and QBDS groups were closely related to the levels of E2 and AMH.The area under the receiver operating characteristic curve for the classification of the two syndromes by the gut microbiome was 0.71.CONCLUSIONS:There were significant differences in the dominant microbiota between the SDBS and QBDS groups,and the change in Proteobacteria in the QBDS group was more significant.The characteristics of gut microbiota help us differentiate between the SDBS and QBDS groups,which may provide a basis for the objectification of TCM syndrome types.
文摘This letter discusses the critical yet underrecognized intersection of chronic renal insufficiency and Nocardia brasiliensis skin infection in the case reported by Zhang et al,emphasizing the diagnostic challenges and therapeutic complexities in the context of advanced age,comorbidities,and immunocompromised populations.The study’s strengths included its integration of immunological profiling and precision medicine,demonstrating that a tailored low-dose trimethoprimsulfamethoxazole regimen with pharmacokinetic monitoring can improve outcomes in geriatric patients with chronic renal insufficiency while mitigating nephrotoxicity risks.However,its limitations included a single-case design,reliance on phenotypic diagnostics,and the lack of information regarding comorbidity interactions.The findings support the use of advanced molecular tools for rapid pathogen identification and identification of co-infection.Future studies should prioritize elucidating the synergistic effects of chronic kidney disease-uremia and immunosuppression on Nocardia colonization,developing biomarkers for early detection,and conducting global epidemiological studies in endemic regions.This case underscores the importance of interdisciplinary collaboration and innovative diagnostics to optimize management of nocardiosis in vulnerable populations.
文摘BACKGROUND In open heart surgery requiring cardiopulmonary bypass(CPB),ventricular fibrillation(VF)is common,but refractory recurrent VF is uncommon but perilous.CASE SUMMARY This article reports a 58-year-old male patient with an ascending aortic aneurysm who presented for a Bentall procedure and subsequently experienced multiple occurrences of unexplained VF after weaning from CPB.The recurrent episodes of VF in this case were felt to be related to coronary insufficiency after reconstruction of the aortic root.Coronary artery bypass grafting(CABG)of the proximal right coronary artery and the left anterior descending artery successfully resolved VF.Finally,this patient was safely transferred to the postoperative intensive care unit,and was discharged successfully after subsequent supportive treatment.CONCLUSION In aortic root replacement,coronary insufficiency is a potential cause of VF episodes and should be considered in the differential diagnosis.CABG is the sole effective treatment for VF caused by coronary insufficiency.
文摘BACKGROUND Pancreatic exocrine insufficiency(PEI)leads to fat malabsorption and maldigestion and is most commonly treated with pancreatic enzyme replacement therapy(PERT).Patients suffering from PEI in China are more likely not to receive adequate treatment as this drug is not part of the Chinese national essential medicine list.AIM To examine the cost-effectiveness of PERT for patients suffering from PEI in China.METHODS A decision analytical Markov model was constructed to simulate the progress of patients with PEI in China.The population included in the analyses were patients suffering from PEI with advanced(non-resectable)pancreatic cancer,who have undergone surgery due to pancreatic cancer and who have undergone endoscopic treatment due to chronic pancreatitis.The cost-effectiveness analyses were undertaken from a Chinese societal perspective comparing PERT with no PERT.The incremental cost-effectiveness ratio in United States dollars per quality adjusted life year(QALY)gained is the main outcome.Input was informed by publicly available data supplemented with expert clinical advice.RESULTS The cost-effectiveness analyses estimated that PERT resulted in additional 0.45 to 2.93 QALYs at discounted costs of between 4315 dollars to 15193 dollars.This resulted in an incremental cost-effectiveness ratio of 5178 dollars to 9533 dollars per QALY.The one-way sensitivity analyses showed that the main drivers of the model were the cost of PERT and overall survival.CONCLUSION This study demonstrates that PERT is a cost-effective treatment for patients suffering from PEI in China.
基金supported by the National Key Research&Developmental Program of China(2022YFC2703800,2022YFC2703000)the National Natural Science Foundation of China(82125014,82371646,32070847)+1 种基金Basic Science Center Program of NSFC(31988101)the Natural Science Foundation of Shandong Province(ZR202105250005,ZR2022YQ69,tsqn202211371).
文摘Premature ovarian insufficiency(POI)is characterized by irreversible loss of ovarian function before 40 years of age and affects 3.7%of women worldwide(Golezar et al.,2019;Huang et al.,2021).Raised serum follicle-stimulating hormone(FSH)levels,menstrual disturbance,and estrogen deficiency are the main symptoms of POl(European Society for Human Reproduction et al.,2016).Besides infertility,patients have an increased risk of long-term complications due to the early deficiency of ovarian steroids,such as osteoporosis,cardiovascular disease,and metabolic disorders(lshizuka,2021).Due to the lack of biomarkers for prediction or early diagnosis,most patients are not diagnosed until the failure stage(serum levels of FSH above 25 IU/L and amenorrhea),missing opportunities for intervention.Therefore,developing sensitive biomarkers for diminished ovarian reserves is paramount for timely treatment to improve reproductive outcomes and prevent long-term complications.
文摘BACKGROUND Gastrectomy is recognized as a potential cause of exocrine pancreatic insufficiency(EPI).However,limited data are available regarding the incidence and impact of EPI on quality of life(QoL)following gastric surgery.AIM To evaluate incidence and severity of EPI after gastrectomy and its effect on QoL at least one year after surgery.METHODS EPI was assessed using fecal elastase measurement and classified into:(1)No-EPI(fecal elastase>200μg/g);(2)Moderate EPI(fecal elastase 100–200μg/g);and(3)severe EPI(fecal elastase<100μg/g).QoL was measured using the Gastrointestinal Quality of Life Index(GIQLI)questionnaire.RESULTS Sixteen out of 44(36.4%)patients developed EPI post-operatively:9(56.2%)patients had moderate EPI while 7(43.8%)patients had severe EPI.Severe EPI was more frequently observed in younger patients(5/7:71.4%;P=0.05),in more advanced disease stages(7/7:100%;P=0.05),lymph nodes metastases(7/7:100%;P=0.04)and in the mixed histotypes(4/7:66.7%;P=0.02)compared to the no-EPI and moderate EPI groups.QoL analysis showed that severe EPI was associated with a significantly lower overall GIQLI score[65(59–92)]compared to the no-EPI/moderate EPI groups[89(84–100)](P=0.002).Lower scores were particularly evident in the core(P<0.0001)and disease-specific symptoms domains(P=0.002)in the severe EPI group compared to the no-EPI/moderate EPI groups.CONCLUSION Gastrectomy is a cause of EPI.Younger patients,aggressive disease and advanced stages are significant risk factors for more severe EPI.Severe EPI worsens QoL,being associated with a higher rate of gastrointestinal symptoms.
文摘Resection of the terminal ileum and ileocecal valve remains the most commonly performed procedure in patients with Crohn's disease.However,despite radical treatment,there is a risk of disease recurrence at the site of the intestinal ana-stomosis in some cases.Therefore,long-term postoperative management is crucial and requires systematic clinical assessment,endoscopic surveillance,and pharma-cological support when indicated.A key challenge is identifying the risk factors associated with the recurrence of anastomotic failure and defining the principles of follow-up care to prevent secondary intestinal insufficiency.This paper focuses on both surgical and non-surgical factors that may play a role in preventing complications in patients undergoing ileocecal resection,providing a compre-hensive approach to postoperative management.
基金Shenzhen Science and Innovation Commission:Investigating the Mechanism of Action of Acupuncture in Regulating the Gut Microbiome to Inhibit Apoptosis of Ovarian Granulosa Cells in Premature Ovarian Insufficiency Mice based on the Rictor/Torepamycin Target Protein c2 Pathway(No.JCYJ20210324130001004)Sanming Project of Medicine in Shenzhen:the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine,Luo Songping National Famous Chinese Medicine Practitioner Female Reproductive Disorders Prevention and Treatment Team(SZZYSM202311010)。
文摘OBJECTIVE:To investigate the potential mechanism of electroacupuncture(EA)in alleviating premature ovarian insufficiency(POI)and to provide a theoretical basis for EA treatment of POI.METHODS:For this purpose,a POI mice model was developed by injecting 12 mg/kg busulfan and 120 mg/kg cyclophosphamide intraperitoneally to induce POI.It was then proceeded by EA intervention at Guanyuan(CV4)acupoint on the second day following modeling.Similarly,apoptosis in ovarian granulosa cells was detected by terminal deoxynucleotidyl transferase d UTP nick end labeling staining,while enzyme-linked immunosorbent assay was employed for measuring serum folliclestimulating hormone(FSH),luteinizing hormone(LH),estrogen(E_(2)),and anti-müllerian hormone(AMH)levels.Moreover,transmission electron microscopy(TEM)was employed for examining mitochondrial morphology,while autophagy and hippo-yes-associated protein/transcriptional co-activator with postsynaptic density protein,drosophila disc large tumor suppressor,and zonula occludens-1 protein binding motif(YAP/TAZ)pathway related protein levels in ovarian tissue were detected via Western blotting.RESULTS:Analysis of serum levels of various hormones indicated that serum FSH and LH were reduced in EA compared to the POI group,while E_(2) and AMH levels were found to be elevated in EA compared to the POI group.The EA was found to inhibit apoptosis in granulosa cells in POI model mice,in addition to improved mitochondrial damage and significantly improved mitophagy.Pathway analysis revealed that EA was involved in activating the hippo-YAP/TAZ pathway,followed by reversing EA effects on granulosa cell apoptosis and mitophagy with the use of verteporfin,an autophagy and YAP-T-cell factor/enhancer of split and activator of transcription domain family member interaction inhibitor.CONCLUSIONS:EA at the Guanyuan(CV4)acupoint protected the granulosa cell by inhibiting cell apoptosis and promoting mitophagy,which was mediated by the Hippo-YAP/TAZ pathway.
文摘Nocardiosis remains a rare and often underdiagnosed bacterial infection,particularly in immunocompromised individuals.The case report by Zhang et al highlights the diagnostic and therapeutic challenges in managing Nocardia brasiliensis skin infection in a 93-year-old patient with chronic renal insufficiency.This editorial explores the importance of timely diagnosis,microbiological confirmation,and tailored antibiotic therapy.Emphasis is placed on the role of immune status evaluation,drug concentration monitoring,and the necessity of long-term antimicrobial therapy.Improved clinician awareness and adherence to evidencebased management protocols are essential to achieving better outcomes in nocardiosis cases.
文摘Objective: To study clinical features of the patients with multiple myeloma(MM) accompanied by renal insufficiency and investigate the related risk factors of renalimpairment. Methods: A control study of clinical characteristics was performed between 91 patientswith renal insufficiency due to MM and 165 patients with normal renal function in MM during the sameperiod. The data were statistically analyzed by chi-square test and logistic regression analysis.Results: Renal insufficiency was the initial presentation in 48 (52.7%) of the 91 patients, and 30(62.5%) of the 48 patients were misdiagnosed. The prognosis of group with renal insufficiency wassignificantly poorer than that of group with normal renal function: mortality in 3 months, 3months-1 year was 26/91 vs 14/165 (P 【 0.0001), 14/91 vs 12/165 (P 【 0.05) respectively, andpatients survived 】 1 year was 18/91 vs 95/165 (P 【 0.0001). The incidence of hypercalcemia,hyperuricemic, severe anemia, high serum M-protein concentration and lytic bone lesions weresignificantly higher in renal insufficiency group than those in control group (P 【 0.05). Logisticregression analysis identified 5 risk factors of renal impairment, including, severe anemia(Exp(β)=13.819, P 【 0.0001), use of nephrotoxic drugs (Exp(β)=6.217, P = 0.001), high serumM-protein concentration (Exp(β) = 5.026, P = 0.001), male (Exp(β)=3.745, P=0.006), andhypercalcemia (Exp(β)=3A72, P=0.006), but age, serum density of uric acid, type of serum M-protein,and Bence Jones proteinuria were not significantly associated with renal insufficiency. Conclusion:Renal insufficiency was a common early complication of MM, which often resulted in misdiagnosis.The status of these patients tended to be very bad, with many other complications, when MM wasdiagnosed, so their prognosis was poor. The occurrence of renal insufficiency in patients with MMand hypercalcemia, severe anemia, high serum M-protein concentration, especially use of nephrotoxicdrugs should be alert.
文摘AIM:To compare and analyse the diagnostic efficacy of the College of Optometrists Vision Development Quality of Life Questionnaire(COVD-QOL)and the Convergence Insufficiency Symptom Survey(CISS)in detecting convergence insufficiency and to compare their diagnostic value in clinical applications.METHODS:Using the diagnostic test method,62 adult patients with convergence insufficiency(age:24.74±3.75y)and 62 normal participants(age:23.61±3.13y)who visited the Optometry Clinic of West China Hospital of Sichuan University from April 2021 to January 2023 were included.All subjects completed the CISS and COVD-QOL.Statistical analysis of the sensitivity and specificity of the CISS and COVD-QOL and comparison and joint experimental analysis of their diagnostic efficacy were performed.RESULTS:The sensitivity of the CISS and COVD-QOL for convergence insufficiency was 64.5%and 71.0%,respectively,while the specificity was 96.8%and 67.7%,respectively.Compared to the CISS alone,the combination of the CISS and COVD-QOL demonstrated lower sensitivity and specificity.The areas under the receiver operating characteristic curve of CISS,COVD-QOL and CISS combined with COVD-QOL were 0.806,0.694 and 0.782,respectively.CONCLUSION:Considering the low sensitivity of the CISS and the low specificity of the COVD-QOL,it is recommended to supplement these questionnaires with other screening tests for the detection of convergence insufficiency.
基金Supported by The Grants of National Science and Technology Major Project,No.2008ZX10002-025Scientific Research Fund of Shanghai Health Bureau,No.2009Y066
文摘AIM:To investigate the risk factors for postoperative liver insufficiency in patients with Child-Pugh class A liver function undergoing liver resection.METHODS:A total of 427 consecutive patients undergoing partial hepatectomy from October 2007 to April 2011 at a single center(Department of Hepatic SurgeryⅠ,Eastern Hepatobiliary Surgery Hospital,Shanghai,China) were included in the study.All the patients had preoperative liver function of Child-Pugh class A and were diagnosed as having primary liver cancer by postoperative histopathology.Surgery was performed by the same team and hepatic resection was carried out by a clamp crushing method.A clamp/unclamp time of 15 min/5 min was adopted for hepatic inflow occlusion.Patients' records of demographic variables,intraoperative parameters,pathological findings and laboratory test results were reviewed.Postoperative liver insufficiency and failure were defined as prolonged hyperbilirubinemia unrelated to biliary obstruction or leak,clinically apparent ascites,prolonged coagulopathy requiring frozen fresh plasma,and/or hepatic encephalopathy.The incidence of postoperative liver insufficiency or liver failure was observed and the attributing risk factors were analyzed.A multivariate analysis was conducted to determine the independent predictive factors.RESULTS:Among the 427 patients,there were 362 males and 65 females,with a mean age of 51.1 ± 10.4 years.Most patients(86.4%) had a background of viral hepatitis and 234(54.8%) patients had liver cirrhosis.Indications for partial hepatectomy included hepatocellular carcinoma(391 patients),intrahepatic cholangiocarcinoma(31 patients) and a combination of both(5 patients).Hepatic resections of ≤ 3 and ≥ 4 liver segments were performed in 358(83.8%) and 69(16.2%) patients,respectively.Seventeen(4.0%) patients developed liver insufficiency after hepatectomy,of whom 10 patients manifested as prolonged hyperbilirubinemia unrelated to biliary obstruction or leak,6 patients had clinically apparent ascites and prolonged coagulopathy,1 patient had hepatic encephalopathy and died on day 21 after surgery.On univariate analysis,age ≥ 60 years and prealbumin < 170 mg/dL were found to be significantly correlated with postoperative liver insufficiency(P = 0.045 and P = 0.009,respectively).There was no statistical difference in postoperative liver insufficiency between patients with or without hepatitis,liver cirrhosis and esophagogastric varices.Intraoperative parameters(type of resection,inflow blood occlusion time,blood loss and blood transfusion) and laboratory test results were not associated with postoperative liver insufficiency either.Age ≥ 60 years and prealbumin < 170 mg/dL were selected on multivariate analysis,and only prealbumin < 170 mg/dL remained predictive(hazard ratio,3.192;95%CI:1.185-8.601,P = 0.022).CONCLUSION:Prealbumin serum level is a predictive factor for postoperative liver insufficiency in patients with liver function of Child-Pugh class A undergoing hepatectomy.Since prealbumin is a good marker of nutritional status,the improved nutritional status may decrease the incidence of liver insufficiency.
基金Supported by An unrestricted grant from Abbott Italia s.r.l
文摘This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas(AISP).We covered the main diseases associated with exocrine pancreatic insufficiency(EPI)which are of common interest to internists/gastroenterologists,oncologists and surgeons,fully aware that EPI may also occur together with many other diseases,but less frequently.A preliminary manuscript based on an extended literature search(Medline/PubMed,Cochrane Library and Google Scholar)of published reports was prepared,and key recommendations were proposed.The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012.Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached.The final draft of the manuscript was then sent to the AISP Council for approval and/or modification.All concerned parties approved the final version of the manuscript in June 2013.
文摘Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of digestive enzymes by pancreatic acinar cells,a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food.Failure in any of these steps may result in pancreatic exocrine insufficiency,which leads to steatorrhea,weight loss and malnutrition-related complications,such as osteoporosis.Methods evaluating digestion,such as fecal fat quantification and the13C-mixed triglycerides test,are the most accurate tests for pancreatic exocrine insufficiency,but the probability of the diagnosis can also be estimated based on symptoms,signs of malnutrition in blood tests,fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging.Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption,dietary consultation,enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment.Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicro-spheres during meals.The dose should be in proportion to the fat content of the meal,usually 40-50000 lipase units per main meal,and half the dose is required for a snack.In cases that do not respond to initial treatment,the doses can be doubled,and proton inhibitors can be added to the treatment.This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.
基金Supported by The Office of Research and Development Medical Research Service Department of Veterans Affairs,Public Health Service grants No.DK067366 and No.DK56338 which funds the Texas Medical Center Digestive Diseases Center
文摘Restitution of normal fat absorption in exocrine pancreatic insufficiency remains an elusive goal. Although many patients achieve satisfactory clinical results with enzyme therapy, few experience normalization of fat absorption, and many, if not most, will require individualized therapy. Increasing the quantity of lipase administered rarely eliminates steatorrhea but increases the cost of therapy. Enteric coated enzyme microbead formulations tend to separate from nutrients in the stomach precluding coordinated emptying of enzymes and nutrients. Unprotected enzymes mix well and empty with nutrients but are inactivated at pH 4 or below. We describe approaches for improving the results of enzyme therapy including changing to, or adding, a different product, adding non-enteric coated enzymes,(e.g., giving unprotected enzymes at the start of the mealand acid-protected formulations later), use of antisecretory drugs and/or antacids, and changing the timing of enzyme administration. Because considerable lipid is emptied in the first postprandial hour, it is prudent to start therapy with enteric coated microbead prior to the meal so that some enzymes are available during that first hour. Patients with hyperacidity may benefit from adjuvant antisecretory therapy to reduce the duodenal acid load and possibly also sodium bicarbonate to prevent duodenal acidity. Comparative studies of clinical effectiveness of different formulations as well as the characteristics of dispersion, emptying, and dissolution of enteric-coated microspheres of different diameter and density are needed; many such studies have been completed but not yet made public. We discuss the history of pancreatic enzyme therapy and describe current use of modern preparations, approaches to overcoming unsatisfactory clinical responses, as well as studies needed to be able to provide reliably effective therapy.
文摘Liver cirrhosis is a major cause of mortality worldwide,often with severe sepsis as the terminal event.Over the last two decades,several studies have reported that in septic patients the adrenal glands respond inappropriately to stimulation,and that the treatment with corticosteroids decreases mortality in such patients.Both cirrhosis and septic shock share many hemodynamic abnormalities such as hyperdynamic circulatory failure,decreased peripheral vascular resistance,increased cardiac output,hypo-responsiveness to vasopressors,increased levels of proinflammatory cytokines [interleukine(IL)-1,IL-6,tumor necrosis factor-alpha] and it has,consequently,been reported that adrenal insufficiency(AI) is common in critically ill cirrhotic patients.AI may also be present in patients with stable cirrhosis without sepsis and in those undergoing liver transplantation.The term hepato-adrenal syndrome defines AI in patients with advanced liver disease with sepsis and/or other complications,and it suggests that it could be a feature of liver disease per se,with a dif-ferent pathogenesis from that of septic shock.Relative AI is the term given to inadequate cortisol response to stress.More recently,another term is used,namely "critical illness related corticosteroid insufficiency" to define "an inadequate cellular corticosteroid activity for the severity of the patient's illness".The mechanisms of AI in liver cirrhosis are not completely understood,although decreased levels of high-density lipoprotein cholesterol and high levels of proinflammatory cytokines and circulatory endotoxin have been suggested.The prevalence of AI in cirrhotic patients varies widely according to the stage of the liver disease(compensated or decompensated,with or without sepsis),the diagnostic criteria defining AI and the methodology used.The effects of corticosteroid therapy on cirrhotic patients with septic shock and AI are controversial.This review aims to summarize the existing published information regarding AI in patients with liver cirrhosis.
基金partially supported by grants from the National Natural Science Foundation Project of China(grants 30971369,81170674,and 81070630)
文摘Objective To investigate the association between vitamin D deficiency and risk of gestational diabetes rnellitus （GDM） in pregnant Chinese women. Methods A nested case-control study was conducted. Clinical and biochemical data were analyzed for 200 subjects with GDM and 200 subjects with normal glucose tolerance （NGT）. Results The median （interquartile range） serum 25-hydroxyvitamin D （25OHD） levels were 22.39 （17.67, 29.38） and 25.86 （19.09, 34.88） nmol/L in the GDM and NGT groups, respectively. Rates of 25OHD deficiency or insufficiency were significantly higher in the GDM group than in the NGT group. Subjects with 25OHD levels 〈25 nmol/L had a 1.g-fold higher risk of GDM compared with subjects with higher vitamin D levels. In the GDM group, serum 25OHD was independently associated with HbAlc and insulin resistance after adjusting for confounding factors. In the NGT group, serum 25OHD was independently associated with fasting plasma glucose and systolic blood pressure after adjusting for maternal age and other confounding factors. Conclusion 2SOHD insufficiency is very common in Chinese women. Low 25OHD status may be associated with insulin resistance and act as a risk factor for GDM.
基金Supported by Grants from the National Science and Technology Major Project of China,No.2012ZX10002-016 and No.2012ZX10002-017
文摘AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma (HCC). METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 x 10(9)/L and patients with platelet count >= 100 x 10(9)/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis. RESULTS: Patients with a low immediate postoperative platelet count (< 100 x 10(9)/L) had more grade III-V. complications (20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure (6.8% vs 2.6%, P = 0.02), hepatic insufficiency (31.5% vs 21.2%, P < 0.001) and mortality (6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count >= 100 x 10(9)/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency. CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.
文摘Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences.In the recent decade,the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques.The literature was systematically searched on Medline without language restrictions.All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed.Endovenous laser ablation(EVLA)and radiofrequency ablation(RFA)both are same safe and effective in terms of occlusion rate,and time to return to normal activity.In comparison with RFA or EVLT,Cure conservatrice et Hemodynamique de l’Insufficience Veineuse en Ambulatoire(CHIVA)may cause more bruising and make little or no difference to rates of limb infection,superficial vein thrombosis,nerve injury,or hematoma.In terms of recurrence of varicose veins,there is little or no difference between CHIVA and stripping,RFA,or EVLT.Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy(FS)group(51%)during 1 year of follow-up.The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy.Although the mechanochemical endovenous ablation(MOCA)is a non-thermal,non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage,the overall success rate of MOCA is lower than those of other procedures such as EVLA,RFA,or high ligation and stripping.EVLA is the most cost-effective therapeutic option,with RFA being a close second for the treatment of patients with varicose veins.Endovenous thermal ablation(EVLA or RFA)is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins.Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures.MOCA and cyanoacrylate embolization appear promising,but evidence of their effectiveness is required.
