乙酰丙酸－十二烷基硫酸钠对结核分枝杆菌的杀灭作用及其安全性毒理学评价

目的 研究消毒剂乙酰丙酸－十二烷基硫酸钠（levulinic acid plus sodium dodecyl sulfate,LVA-SDS）对结核分枝杆菌标准株H37Rv、耐多药结核分枝杆菌临床分离株的杀灭作用;并对LVA-SDS进行安全性毒理学评价。方法 按照2002年版卫生部《消毒技术规范》要求,采用悬液定量杀菌试验和动物实验方法,分别评估LVA-SDS对结核分枝杆菌标准株H37Rv、耐多药结核分枝杆菌临床分离株菌悬液的杀灭作用以及LVA-SDS实际使用时的安全性。结果 20%（体积分数） LVA+2%（质量分数）SDS消毒剂与1 mg/mL的菌悬液作用30 min,对菌悬液内结核分枝杆菌标准株H37Rv或耐多药结核分枝杆菌临床分离株的平均杀灭对数值均>5.00。小鼠急性经口毒性试验结果为半数致死量（median lethal dose, LD₅₀）>5 000 mg/kg,蓄积系数K>5,皮肤刺激反应无红斑和水肿形成,皮肤刺激指数<0.5。结论 LVA-SDS对结核分枝杆菌标准株H37Rv、耐多药结核分枝杆菌临床分离株均有较好的杀灭作用;LVA-SDS属实际无毒级、轻度蓄积毒性作用且对皮肤无刺激性。因此,LVA-SDS是一种安全的、对结核分枝杆菌杀灭作用较好的消毒剂,具有较强的实际应用价值。     

肝门部胆管癌高位多支复杂胆道梗阻的介入引流方法探讨

目的：探讨肝门部胆管癌引起的高位多支复杂类型梗阻性黄疸的介入引流方法和临床疗效。 方法：选取因肝门部胆管癌引起的多支复杂类型梗阻性黄疸患者38例,其中男28例,女10例。Bismuth-Corlett分型Ⅱ型6例,Ⅲ型18例,Ⅳ型14例。根据胆道梗阻的部位、范围、各分支梗阻情况及胆道扩张的程度,对不同类型患者的引流方案进行个体化设计。其中30例单纯采取了引流管引流,并根据需要对引流管临时剪孔,每例放置1~3条胆道外引流管。8例Ⅳ型肝门部胆管癌根据左右肝管分支角度不同分别采取了不同的方法进行胆道双支架置入。 结果：全部病例介入引流手术过程顺利,除2例合并少量胆道出血外,无其他严重并发症发生。术后患者黄疸明显减轻或消退,皮肤瘙痒和胆管炎等症状逐渐消失。术后1~2周,血清胆红素水平由术前的（242.69±27）μmol/L降至（58.32±5.6）μmol/L,差异有统计学意义（t=9.73,P<0.05）,收到了较好的近期治疗效果。8例行胆道双支架置入患者中有3例分别于术后4~6个月发生支架再阻塞,黄疸复发,再次行经皮肝穿刺胆道引流治疗。 结论：肝门部胆管癌高位胆道梗阻病变复杂,通过引流管剪孔,可在保证引流效果的前提下尽量减少引流管的个数,减少了创伤,方便了术后生活和引流管护理,是对普通胆道外引流管的改良。双支架置入对肝门部Bismuth-Corlett Ⅳ型胆管癌近期疗效可靠,根据左右肝管分叉角度采取不同的双支架置入术式方法可行。     

B超联合DSA下急诊经皮肾穿刺造瘘治疗急性梗阻性肾盂化脓的临床效果

目的：探讨在B超联合数字减影血管造影（DSA）透视下急诊经皮肾穿刺造瘘治疗急性梗阻性肾盂化脓的临床效果。 方法：选取2015年6月至2017年6月在我科接受急诊经皮肾穿刺造瘘治疗的31例急性梗阻性肾盂化脓患者。比较治疗前后的血白细胞计数（WBC）、中性粒细胞比例（NEUR）、C反应蛋白（CRP）和降钙素原（PCT）等感染性指标变化情况。 结果：31例患者接受35次经皮肾穿刺造瘘治疗,其中单侧经皮肾穿刺造瘘27例,双侧4例。术后3 d的血WBC、NEUR、CRP和PCT较术前均明显下降,差异有统计学意义。 结论：B超联合DSA透视下急诊经皮肾穿刺造瘘治疗急性梗阻性肾盂化脓成功率高,并发症少,同时积极进行抗感染治疗,能明显改善患者的预后。     

结直肠支架序贯联合腹腔镜手术在左半结肠癌伴肠梗阻中的应用

目的探讨结直肠支架联合腹腔镜根治手术治疗左半结肠癌伴肠梗阻患者的临床有效性及安全性。 方法回顾性分析2012年1月至2016年12月江门市中心医院收治的可根治性切除左半结肠癌伴肠梗阻患者90例,根据治疗方式不同分为联合治疗组（33例,先行肠道支架置入术后行腹腔镜下一期切除吻合术）和单纯手术组（57例,行急诊开腹手术）。对比分析两组患者的临床成功率、安全性和疗效。 结果联合治疗组中3例导丝无法通过狭窄处而放置肠道支架失败,未出现支架置入相关的穿孔、支架移位、出血及术后肠穿孔,技术成功率及临床成功率均为90.9%（30/33）。30例术后3~5 d均顺利施行腹腔镜下肿瘤根治术而不需施行预防性肠道造瘘术。联合治疗组以及单纯手术组的平均手术时间分别为（274.6±58.4）min、（294.3±54.2）min,两组比较差异无统计学意义（t=1.569,P=0.120）。联合治疗组术中出血量为（35.4±20.4）ml,明显低于单纯手术组的（135.5±26.9）ml,差异有统计学意义（t=17.84,P<0.001）。两组患者均未发生围手术期死亡,总体并发症、感染性并发症、非感染性并发症发生率均差异无统计学意义。 结论结直肠支架在左半结肠癌伴肠梗阻中的应用安全、有效。结直肠支架可作为腹腔镜根治手术术前准备的"桥梁",并发症发生率低,避免预防性肠道造口,临床短期疗效相近。     

Carbohydrate antigen 19-9 as a novel prognostic biomarker in distal cholangiocarcinoma

BACKGROUNDDistal cholangiocarcinoma (DCC) presents as one of the relatively rare malignant tumors in the digestive system and has a poor long-term prognosis. Curative resection is currently the most appropriate therapy for patients with DCC because of the lack of effective adjuvant therapies. Therefore, it is important to accurately predict the prognosis for formulating a reasonable treatment plan and avoiding unnecessary surgical trauma.AIMTo minimize the interference of obstructive jaundice on carbohydrate antigen 19-9 (CA19-9) level by adapting CA19-9 to γ-glutamyltransferase (GGT) as an indicator, to determine the strong associations between CA19-9/GGT and postoperative neoplasm recurrence and long-term outcome of DCC.METHODSWe enrolled 186 patients who were diagnosed with DCC between January 2010 and December 2019 and performed radical excision with strict criteria as follows in our hospital. Receiver operating characteristic curves were drawn according to preoperative CA19-9/GGT and 1-year survival. Based on this, patients were divided into two groups (group 1, low-ratio, n = 81; group 2, high-ratio, n = 105). Afterwards, by the way of univariate and multivariate analysis, the risk factors influencing postoperative tumor recrudesce and long-term prognosis of patients with DCC were screened out.RESULTSOptimum cut-off value of CA19-9/GGT was 0.12. Patients in group 2 represented higher CA19-9 and lymphatic metastasis rate accompanied by lower GGT, when compared with group 1 (P < 0.05). The 1-, 3- and 5-year overall survival rates of patients in groups 1 and 2 were 88.3%, 59.2% and 48.1%, and 61.0%, 13.6% and 13.6%, respectively (P = 0.000). Multivariate analysis indicated that CA19-9/GGT, lymphatic metastasis and tumor differentiation were independent risk factors for tumor recurrence and long-term prognosis of DCC.CONCLUSIONElevation of CA19-9/GGT performed better as a biomarker of aggressive carcinoma and predictor of poor clinical outcomes by reducing the effect of obstruction of biliary tract on CA19-9 concentration in patients with DCC.     

终末期肝病模型及MELD-Na评分在肝移植应用中的研究进展

终末期肝病模型（MELD）被认为能较好地评价终末期肝病患者的疾病状态,并且已应用于肝移植的器官分配。本文简要介绍了MELD和MELD-Na评分与等待肝移植患者的死亡率,以及肝移植患者术中输血、术后生存和并发症、再移植的关系。     

Comparison of short-term complications between Onlay and Duckett urethroplasty and the analysis of risk factors

Aims

To compare the short-term complications between Onlay and Duckett urethroplasty and to analyze the various risk factors cause the complications.

Methods

The children with hypospadias who underwent treatment with Onlay or Duckett urethroplasty from November 2014 to June 2016 were followed up. The difference in complications between the two groups was analyzed. Moreover, a single-factor ANOVA was performed to analyze the length and curvature of the penis and the length of the urethral defect.

Results

40 patients were treated by Duckett, while 54 by Onlay. In comparison to the Onlay group, the Duckett group showed the initial penile length was shorter (P?=?0.044), the initial urethral defect (P?=?0.024) and after the correction of chordee was longer (P?<?0.001), and the initial penile curvature (P?<?0.001) and after degloving (P?<?0.001) was greater. Furthermore, the incidence of urethra percutaneous fistula (P?=?0.041) and urethral stenosis (P?<?0.001) in Duckett group was significantly higher. The analysis of risk factors showed that the age at the time of surgery, the initial penile curvature, the initial urethral defect, and the urethral defect after the correction of chordee were not correlated with the complications. The degree of penile curvature after skin degloving and urethra stenosis was significantly correlated (P?=?0.019).

Conclusion

The incidence of complications of urethra percutaneous fistula and urethral stenosis after 1 year of Duckett was higher than that by Onlay approach. The greater the curvature of the penis after skin degloving, the more likely the occurrence of urethral stenosis after surgery.

     

The risk of cytomegalovirus infection after treatment of acute rejection in renal transplant recipients

The risk of cytomegalovirus infection (CMV) after rejection treatment is poorly understood. To investigate this, we conducted a case/control (1:2) analysis of adult renal transplant recipients between January 1, 2005 and December 31, 2015, via incidence density sampling and survival analysis. Our objective was to evaluate the association of prior acute rejection with subsequent CMV, including epidemiology and outcomes. There were 2481 eligible renal transplants within the study period and 251 distinct CMV infections. Despite the use of antiviral prophylaxis rejection was a significant risk factor for CMV on unadjusted (HR 1.73 [1.34, 2.24] P < 0.05) and adjusted analysis (HR 1.46 [1.06, 2.04] P < 0.05). When matching cases to controls patients with CMV had significantly more rejection prior to CMV diagnosis (26.7% vs 14.2%, P < 0.01). CMV was associated with a twofold increased risk of prior rejection on unadjusted (OR 1.94, 95%CI: 1.28‐2.96, P < 0.01) and adjusted analysis (OR 2.16, 95% CI: 1.31‐3.58, P < 0.01). Patients with rejection preceding CMV had significantly increased graft loss (HR 2.89, 95% CI: 1.65‐5.09, P < 0.01) and mortality (HR 1.82, 95% CI: 1.12‐4.24, P = 0.03) as compared to those CMV cases without rejection. In conclusion, rejection is a risk factor for CMV infection that appears to persist for 1 year. Preceding rejection events increased risk of graft loss and mortality in CMV patients. Given this, prolonged surveillance monitoring for CMV after rejection may be warranted. Studies are needed investigating optimal monitoring strategies.     

Systematic review of clinical practice guidelines for kidney disease in China: application of the Appraisal of Guidelines Research and Evaluation-China

Objective To evaluate the quality of clinical practice guidelines for kidney diseases in China and provide reference for selecting suitable high-quality guidelines for primary care and developing standardized guidelines. Methods The China Guideline Clearinghouse, China Biology Medicine disc, VIP Database, Wanfang Database and CNKI, and other resources were searched from January 2013 to July 2018. In accordance with the criteria for inclusion and exclusion, the published guidelines for kidney diseases were screened. The Appraisal of Guidelines Research and Evaluation-China (AGREE-China) was used to systematically assess the current status of domestic guidelines for kidney diseases. Results A total of 18 guidelines for kidney diseases were included, covering different types of kidney disease such as glomerulonephritis, nephrotic syndrome, end-stage renal disease and other diseases. The overall score ranged from 30 to 68, with an average score of 47.3. The average scores of these guidelines were 20.1, 12.8, 0.5, 9.9 and 3.9 in five review fields including scientificity/rigorism, effectiveness/safety, economy, availability/feasibility, and conflicts of interest, respectively. Of these 18 guidelines, 8(44.4%) guidelines were strongly recommended, and 10(55.6%) guidelines were weakly recommended. Conclusions There are still deficiencies in scientificity/rigorism and economy in current guidelines for kidney diseases in China. The AGREE-China can be used as an evaluation tool for guidelines for kidney diseases in accordance with China's situation, while its practicability and feasibility still need further verification and improvement.     

腹膜后肿瘤外科治疗进展和争议

腹膜后肿瘤,主要是软组织肉瘤是一类来源于结缔组织的少见恶性肿瘤,异质性高,病理类型复杂,推荐应在具备多学科协作团队的区域性肉瘤中心进行综合治疗。对局部肿瘤施以切缘阴性的完整手术切除是对原发性腹膜后肉瘤（RPS）患者标准的、潜在根治性治疗,可以说外科治疗是RPS综合治疗的基础。近年来,腹膜后肿瘤的外科治疗取得了一些进展,同时存在一些争议。外科治疗在进展和争议中逐步成熟。