The procalcitonin-to-cortisol ratio is a potential prognostic predictor in sepsis with abdominal source: a retrospective observational study.

BACKGROUND: The aim of the study was to investigate the procalcitonin-to-cortisol ratio (P/C ratio) as a prognostic predictor among septic patients with abdominal source. METHODS: We retrospectively enrolled 132 post-surgery patients between 18 and 90 years old with sepsis of the abdominal source. On the second day of sepsis onset, cortisol, procalcitonin (PCT), Acute Physiology and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment (SOFA) score, C-response protein (CRP), and other baseline characteristics were collected. In addition, the length of ICU stay, length of mechanical ventilation (MV) days, length of shock days, and 28-day mortality were also recorded. Univariate analysis was performed to screen potential risk factors. Stratified analysis was used to identify the interaction among the risk factors. Multivariate analysis was also utilized to demonstrate the relationship between the risk factors and mortality. The receiver operator characteristic (ROC) curve analysis was conducted to evaluate the risk factors. A restricted cubic spline (RCS) demonstrated the association between survival outcome and the P/C ratio variation. RESULTS: A total of twenty-nine patients died, and 103 patients survived within 28 d. There were significant differences in cortisol, PCT, P/C ratio, interleukin (IL)-6, SOFA, and APACHE II scores between the survival and non-survival groups. No significant interaction was observed in the stratified analysis. Logistic regression analysis revealed that P/C ratio (P=0.033) was significantly related to 28-day mortality. Based on ROC curves, P/C ratio (AUC=0.919) had a higher AUC value than cortisol or PCT. RCS analysis depicted a positive relationship between survival possibility and P/C ratio decrement. CONCLUSION: P/C ratio might be a potential prognostic predictor in septic patients with abdominal sources.

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study.

BACKGROUND: Endoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention. AIM: To assess the feasibility, efficacy and safety of EGF for WON. METHODS: Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy. RESULTS: EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients. CONCLUSION: EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

Vulvar Cancer in China: Epidemiological Features and Risk Analysis.

Objective: Describe for the first time the clinical, epidemiological features of vulvar cancer in southwest China. Identify risk factors and provide reference for the prevention of vulvar cancer. Method: We retrospectively analyzed 885 patients admitted to the West China Second University Hospital for vulvar diseases between 2006 and 2016. Vulvar cancer patients with previously diagnosed vulvar nonneoplastic epithelial disorders (n=132) were analyzed and compared to those without prior history of vulvar nonneoplastic epithelial disorders (n=219). Comparisons were also made among cancer patients and non-cancer patients with vulvar nonneoplastic epithelial disorders (n=288) and vulvar squamous intraepithelial lesions (n=246). The risk factors leading to vulvar cancer for the patients with vulvar nonneoplastic epithelial disorder were analyzed by univariate analysis. Furthermore, differences of the epidemiological features of vulvar nonneoplastic epithelial disorders, vulvar squamous intraepithelial lesion and vulvar cancer were identified. Results: According to the univariate analysis, age, first coital age, educational level, smoking, history of vaginal atrophy, HPV infection, lesion sites of the upper vulva and histo-pathological changes are strongly positively correlated with vulvar cancer. By comparing the features of vulvar cancer with those of the vulvar nonneoplastic epithelial disorder and vulvar squamous intraepithelial lesion, we found that on average patients with vulvar cancer had the highest age (ranged from 50 to 59), the lowest first coital age and the highest number of pregnancies and births. The incidences of vulvar nonneoplastic epithelial disorder and vulvar cancer were 1/1000 and 2.5/100,000 respectively with an increasing trend during last 10 years. Conclusion: Age, first coital age, educational level, smoking, atrophic vagina history, HPV infection, lesion sites of the upper vulva and histo-pathological changes are the risk factors that lead to vulvar cancer. Vulvar nonneoplastic epithelial disorder, vulvar squamous intraepithelial lesion and vulvar cancer each has distinct epidemiological features. Prompt surgical intervention and subsequent treatments are the key to a better outcome of vulvar cancer.

Effect of biliary drainage on inducible nitric oxide synthase, CD14 and TGR5 expression in obstructive jaundice rats.

AIM: To investigate the effect of biliary drainage on inducible nitric oxide synthase (iNOS), CD14 and TGR5 expression in rats with obstructive jaundice (OJ). METHODS: Male adult Sprague-Dawley rats were randomly assigned to four groups: OJ, sham operation (SH), internal biliary drainage (ID) and external biliary drainage (ED). Rat models were successfully established by two operations and succumbed for extraction of Kupffer cells (KCs) and liver tissue collection on the 8(th) and 15(th) day. KCs were isolated by in situ hepatic perfusion and digested with collagen IV, density gradient centrifuged by percoll reagent and purified by cell culture attachment. The isolated KCs were cultured with the endotoxin lipopolysaccharide (LPS) with and without the addition of ursodeoxycholic acid (UDCA). The expression of iNOS, CD14 and bile acid receptor-TGR5 protein in rat liver tissues was determined by immunohistochemistry. The expression of iNOS and CD14 messenger RNA (mRNA) on the isolated KCs was detected by reverse transcription polymerase chain reaction (PCR) and the TGR5 mRNA level in KCs was measured by real-time quantitative PCR. RESULTS: The iNOS protein was markedly expressed in the liver of OJ rats, but rare expressed in SH rats. After relief of OJ, the iNOS expression was decidedly suppressed in the ID group (ID vs OJ, P < 0.01), but obviously increased in rats of ED (ED vs OJ, P = 0.004). When interfered only with LPS, the expression of iNOS mRNA by KCs was increased in the OJ group compared with the SH group (P = 0.004). After relief of biliary obstruction, the iNOS mRNA expression showed slight changes in the ED group (ED vs OJ, P = 0.71), but dropped in the ID group (ID vs OJ, P = 0.001). Compared with the simple intervention with LPS, the expressions of iNOS mRNA were significantly inhibited in all four groups after interfered with both LPS and UDCA (P < 0.01, respectively). After bile duct ligation, the CD14 protein expression in rat liver was significantly strengthened (OJ vs SH, P < 0.01), but the CD14 mRNA level by KCs was not up-regulated (OJ vs SH, P = 0.822). After relieving the OJ, the expression of CD14 protein was reduced in the ID group (ID vs OJ, P < 0.01), but not reduced in ED group (ED vs OJ, P = 0.591). And then the CD14 mRNA expression was aggravated by ED (ED vs OJ, P < 0.01), but was not significantly different between the ID group and the SH and OJ groups (ID vs SH, P = 0.944; ID vs OJ, P = 0.513, respectively). The expression of TGR5 protein and mRNA increased significantly in OJ rats (OJ vs SH, P = 0.001, respectively). After relief of OJ, ID could reduce the expression of TGR5 protein and mRNA to the levels of SH group (ID vs SH, P = 0.22 and P = 0.354, respectively), but ED could not (ED vs SH, P = 0.001, respectively). CONCLUSION: ID could be attributed to the regulatory function of activation of KCs and release of inflammatory mediators.

Natural Orifice Translumenal Endoscopic Surgery (NOTES): patients' perceptions and attitudes.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has generated a surge of enthusiasm among researchers by virtue of its challenge to the dogma and potential benefits. However, no data is available in the medical literature about NOTES' acceptance by patients in Asia. The aim of the study is to survey patients' perceptions and attitudes towards NOTES. METHODS: It is a questionnaire-based multi-center study on inpatient subjects with various gastrointestinal disorders from 14 hospitals in 12 cities of China. Procedural details with the benefits and risks of NOTES, laparoscopic surgery, and conventional surgery were explained to all registered candidates. They were required to choose and cite reasons for adopting one of the above three surgical techniques as the preferred mode of treatment. The reasons for selection of the surgical treatment were: safety, efficacy, cost, postoperative pain, abdominal wounds, and scarring. RESULTS: There were 1,797 cases, including 976 (54.3%) males and 821 females (45.7%). Based on their comprehension of the procedure, 802 (44.6%) patients opted for NOTES, 757 (42.1%) for laparoscopic surgery, and 238 (13.2%) for conventional surgery. NOTES was mainly selected by the young and educated persons, especially females and by those with past exposure to laparoscopy or conventional surgery. The choice of treatment was significantly correlated with age (P=0.0021), education (P=0.0209), past medical history (laparoscopy, P=0.0134; open surgery, P<0.0001), and department of admission (P=0.0173). The preference for NOTES was based on safety (37.3%), cost (17.6%), elimination of postoperative scars (16.1%), abdominal wounds (16.0%), and efficacy (13.1%). CONCLUSIONS: The vast majority of patients prefer mini-invasive surgery to conventional surgery. The potential recipients of NOTES are educated and younger age groups. However, a few consider NOTES as a safe and effective intervention at present.

[Combined transgastric and transcolonic endoscopic salpingectomy: experiment with pigs].

OBJECTIVE: To compare the feasibility and safety of combined transgastric and transcolonic dual approach and those of transgastric single approach in endoscopic salpingectomy. METHODS: Two female Chinese Nongda miniature pigs underwent gastric and colonic lavage with tap water followed by disinfection of mucosa with 1:10 iodophor. An endoscope was inserted and the colonic wall was punctured with a needle knife, dilated with a balloon-dilator and a double-channel endoscope was advanced into the peritoneal cavity. Under direct observation through this endoscope, a trans-gastric entrance was made with the second double-channel endoscope. With the help of transcolonic endoscope, the left Fallopian tube was ligated and partially resected using the transgastric endoscope. With the help of transgastric endoscope, liver biopsy was performed using the transcolonic endoscope. Finally, the gastric incision was closed with 3 clips and the colonic incision was closed with a loop and a clip. Antibiotics were used for 3 days following the procedures. Seventeen days later laparotomy was performed to observe the infection, visceral damage and adhesion, healing of the incisions of gastrointestinal duct, etc. RESULTS: Compared with the single route, the dual routes were more convenient to perform the liver biopsy and salpingectomy. The pigs drank and ate normally soon after the resuscitation. The pigs looked well and gained weight during 2 weeks after the operation. Repeat endoscopy in 2 weeks showed a well-healed gastric incision with 2 clips still in place and a healed colonic incision with 1 clip still attached. The necropsy revealed a complete transmural healing of the gastric incision with minimal adhesion and a complete healing of the colonic incision without any adhesion. Few adhesions were found around the liver biopsy site and the salpingectomy site without any intraperitoneal infection or organ damage. CONCLUSION: Combined transgastric and transcolonic approach appears safe and feasible and facilitates translumenal intraperitoneal interventions.

Treatment of patients with rhegmatogenous retina detachment combined with non-secondary glaucoma / 中南大学学报(医学版)

OBJECTIVE@#To discuss the cause of disease, treatment and therapeutic effect in patients with rhegmatogenous retina detachment (RRD) combined with non-secondary glaucoma.@*METHODS@#Clinical data of 28 patients with RRD combined with primary or congenital glaucoma were retrospectively analyzed.@*RESULTS@#Twenty-five out of the 28 patients succeeded with one operation (89.3%). The intraocular pressure of post-operation:on the 1st day was 10 approximately 46 (28.1+/-6.5) mmHg, on the 7th day was (18.9+/-7.2) mmHg, and on the last re-examination day was (17.6+/-6.2) mmHg. Anti-glaucoma operation was performed in 10 patients after the retinal operation. Chroidal hemorrhage was found in 2 patients and 2 chroidal exudations were found after the retinal operation.@*CONCLUSION@#The proportion of primary open angle glaucoma is higher than that of primary angle closure glaucoma, and trauma or surgery before the retinal operation is an important cause in glaucoma patients with RRD. There is no obvious difference in the ratio of surgical success between non-secondary glaucoma with RRD and those RRD patients without glaucoma. Vitreotomy+ silicon oil injection or drainage of subretinal fluid+air injection+cryocoagulation+explants is recommended. Chroid is easily involved. It is important to control the intraocular pressure during and after the surgery. The final visual acuity is rather poor, which may be related to the glaucoma and intraocular pressure.