静脉麻醉在内镜逆行胰胆管造影中的应用

背景：内镜逆行胰胆管造影（ERCP）是一种微创技术，但相当一部分患者仍对其操作过程难以耐受。目的：探讨静脉麻醉在ERCP中的镇静作用及其临床实用性。方法：57例接受ERCP诊治的患者分为两组：麻醉组25例，在咪达唑仑、异丙酚和芬太尼静脉麻醉下行ERCP；非麻醉组32例，ERCP术前予安定镇静。比较两组患者检查前后和操作过程中生命体征的变化，分别以操作过程评分和Ramsay镇静评分评价操作的难易程度和患者的镇静程度。结果：麻醉组与非麻醉组的ERCP成功率无显著差异。麻醉组的操作过程评分和Ramsay镇静评分均显著优于非麻醉组（P〈0．01）。两组术中心率和血压较术前有显著变化（P〈0．05）．但手术前后脉搏血氧饱和度（SpO2）的变化无统计学意义结论：静脉麻醉在ERCP操作中镇静效果显著．患者耐受性好，在治疗性ERCP中尤其有利于医师操作。     

全身麻醉下经内镜逆行胰胆管造影术中低体温预测危险因素的研究

背景：术中意外低体温是全身麻醉手术的常见并发症,可引起疼痛、凝血功能障碍、伤口感染、延迟康复等不良后果。目前鲜有经内镜逆行胰胆管造影（ERCP）术中低体温的相关研究。目的：分析全身麻醉下ERCP术中低体温的危险因素,并建立预测模型。方法：选取2021年9月—2021年11月在上海市第一人民医院行全身麻醉下ERCP的患者121例,收集相关临床资料,采用Logistic回归分析筛选危险因素,构建预测模型,使用独立数据集通过ROC曲线和Hosmer-Lemeshow拟合优度检验对模型进行外部验证。结果：共114例患者纳入建模组,术中低体温发生率为11.40%(13/114)。低体温组中女性患者明显增多（P<0.05）,入手术室体温和手术室温度明显降低（P<0.05）,其中性别是全身麻醉下ERCP发生术中低体温的独立危险因素（P<0.05）。采用Logistic回归分析筛选出的性别和入手术室体温构建的预测模型具有较好的区分度和校准度,外部验证的ROC曲线下面积为0.78。结论：性别和入手术室体温可较好地预测ERCP术中低体温的发生,可协助围手术期的监护管理。     

ERCP术中镇静与麻醉的临床应用研究进展

目前,ERCP对胆胰疾病的诊断已步入成熟,ERCP的治疗操作的也广泛开展.ERCP操作过程中对胃肠道产生不适刺激和恐惧心理,会给患者带来一定痛苦,甚至不能配合完成操作;对于合并有心脏病、高血压、肺功能障碍的患者有一定风险,在某种程度上限制了ERCP应用.在ERCP术中采取镇静和麻醉可以使患者消除恐惧减轻痛苦,顺利的完成诊疗,而且麻醉监管技术的应用更加便于监测并稳定患者各项生命体征.     

瑞芬太尼靶控输注在老年人治疗性内镜逆行胰胆管造影中的应用

目的 评价瑞芬太尼靶控输注(TCI)技术在老年患者行治疗性内镜逆行胰胆管造影(ERCP)中的疗效及安全性. 方法 390例(年龄≥65岁)接受治疗性ERCP老年患者,分为两组,其中瑞芬太尼组175例采用瑞芬太尼清醒镇痛麻醉技术,利多卡因组215例采用传统利多卡因局部麻醉.持续监测并定时记录患者在治疗性ERCP过程中的血压、心率和血氧饱和度的变化,术后随访患者术中记忆和疼痛感觉及术后不良反应. 结果 两组患者术中心率和血压及血氧饱和度波动差异不明显.瑞芬太尼组165例(94.3％)麻醉效果满意,10例(5.7％)患者术中有轻度痛感,能忍受;7例(6.7％)术中出现循环及呼吸等不良反应,经对症治疗后好转.利多卡因组25例(8.6％)术中出现循环及呼吸等不良反应,2例因剧烈呃逆、呕吐而终止手术. 结论 瑞芬太尼靶控输注技术用于老年治疗性ERCP患者麻醉效果满意,不良反应少,值得临床推广应用.     

丙泊酚联合咪达唑仑静脉麻醉在老年患者ERCP中的应用

在适度镇静下施行ERCP已成为内镜医生共识,越来越多文献报道丙泊酚单用或联合咪达唑仑正逐步代替传统的安定联用哌替啶或芬太尼方案,即使在80岁以上的老年患者中,应用丙泊酚麻醉也是安全的。我院自2004年起对老年患者应用丙泊酚联合咪达唑仑静脉麻醉下行ERCP术,麻醉效果满意,报道如下。     

小儿经内镜逆行胰胆管造影术45例的麻醉分析

目的 评价小儿经内镜逆行胰胆管造影术（ERCP）术中不同静脉麻醉方式的安全性和有效性,为小儿ERCP提供较为理想的静脉麻醉方式。方法 2013年8月至2016年7月,南京医科大学附属杭州医院45例次小儿ERCP纳入回顾性研究分析,汇总静脉麻醉方式和ERCP手术的完成情况、不良反应发生情况、苏醒时间等。结果 静脉麻醉下45例次治疗性ERCP均顺利完成,其中17例次（37.8％）患儿（初次行ERCP且体重≥20.0 kg或因再次行ERCP且预计手术时间＜30.0 min）采用深度镇静方式,其余28例次（62.2％）患儿（初次行ERCP且体重＜20.0 kg或因再次行ERCP且预计手术时间≥30.0 min）采用气管插管全麻。深度镇静组的患儿,平均苏醒时间（7.2±6.3）min,术中出现1例次（5.9％）体动和2例次（11.8％）脉搏血氧饱合度一过性下降（均保持在95％以上）;气管插管全麻组的患儿,平均苏醒时间（10.5±8.7）min,无麻醉相关不良反应发生。结论 深度镇静和气管内插管全麻均可安全有效地用于小儿ERCP的术中麻醉。相比深度镇静方式,气管内插管全麻可确保ERCP操作期间患儿的气道安全和充分氧供,可能是初次行ERCP且体重＜20.0 kg或再次行ERCP且预计手术时间≥30.0 min的患儿较为理想的静脉麻醉方式。     

双镜联合一次性治疗胆囊结石并发胆总管结石的临床研究

目的 探讨应用腹腔镜、十二指肠镜联合同期一次性治疗胆囊结石合并胆总管结石的可行性.方法 2009年11月至2012年3月,对150例胆囊结石合并胆总管结石的患者采用双镜同期治疗.即在手术室在全身麻醉下先行腹腔镜胆囊切除术(LC),随后行内镜逆行胆胰管造影(ERCP),采用乳头括约肌切开(EST)或球囊扩张(EPBD)取石,然后放置鼻胆管引流(ENBD).观察疗效和并发症发生情况.结果 150例患者均成功完成LC和ERCP操作,术中术后未发生出血、穿孔、重症胰腺炎等严重的并发症.术后胃肠功能恢复时间及住院时间短.术后随访期间行腹部B超检查,均未发现胆总管残留结石或再生结石.结论 在同一次麻醉下同期完成LC和ERCP是安全可行的,具有创伤小、恢复快等优点.     

咪唑安定、异丙酚及芬太尼复合静脉麻醉在ERCP检查中的应用

目的研究咪唑安定、异丙酚及芬太尼复合静脉麻醉在ERCP检查中的临床效果。方法60例拟行ERCP患者(ASAⅠ～Ⅱ级),依次静注咪唑安定0.05mg.Kg-1,芬太尼0.05～0.1mg,异丙酚0.5～1.5mg.Kg-1及异丙酚3.5～7.5mg.Kg-1h-1泵注维持复合静脉麻醉,记录麻醉前10min和麻醉后10min MAP、HR、SPO2变化、入睡时间、操作时间、呼之睁眼时间、正确应答时间及患者术后感受等。结果麻醉后10min MAP、HR、SPO2比麻醉前10min略有下降,但无统计学意义。患者苏醒时间短,遗忘程度100%,患者感觉愉悦多言,占95%。结论咪唑安定、异丙酚及芬太尼复合静脉麻醉在ERCP检查中是一种既安全又有效的方法。     

瑞芬太尼复合丙泊酚静脉麻醉在老年人ERCP中的应用

目的观察瑞芬太尼复合丙泊酚静脉麻醉在老年人内镜下逆行胰胆造影（ERCP）中的麻醉效果。方法 112例接受ERCP的老年患者,随机分为P组（50例）、R组（62例）。两组均以丙泊酚1.5 mg/kg作为诱导,注药时间不少于2 min,R组诱导时即以瑞芬太尼0.025μg/（kg.min）微泵泵入,诱导后微泵持续泵入丙泊酚维持麻醉,两组均在睫毛反射消失、脑电双频指数（BIS）在50时开始进镜,术中调节丙泊酚速度使BIS维持在60左右,术中患者有肢体抖动时静注丙泊酚20 mg/次。结果两组麻醉效果优良率均为100%,丙泊酚用量R组少于P组（P〈0.01）,苏醒时间R组短于P组（P〈0.01）。结论丙泊酚复合瑞芬太尼在老年人ERCP中的麻醉效果好,丙泊酚用量少,患者苏醒时间短。     

丙泊酚靶控输注应用于老年患者ERCP的安全性探讨

目的 评价丙泊酚靶控输注在老年患者内镜逆行胰胆管造影术（ERCP）中的应用价值；探讨该类患者ERCP操作过程中麻醉的处理。方法麻醉下行ERCP患者的2081例，根据年龄分成非老年组（1025例）和老年组（1056例），比较两组问操作过程中丙泊酚靶控输注血药浓度，血压变化，氧饱和度变化及不良事件发生率的差异。结果两组患者麻醉后血压、氧饱和度、心率均有所下降，两组间差异不明显，操作时老年组丙泊酚的血药浓度更低。两组问不良事件发生率没有差异没有统计学意义。结论通过完善的术前评价和准备，高龄患者麻醉下行ERCP是安全、可行的。     

Control of intraabdominal hemorrhage and shock: a comparison of fluid resuscitation, MAST, and balloon occlusion

Our study examined the efficacy of four treatment modalities in controlling hemorrhage and achieving hemodynamic stabilization in hemorrhagic shock: intravenous fluid replacement (IV); military antishock trousers used concomitantly with fluids (MAST); balloon occlusion at the level of the diaphragm with concomitant fluid replacement (balloon); and a combination of MAST inflation, balloon occlusion, and fluid resuscitation (MAST and balloon). Twenty-eight mongrel dogs were anesthetized, and the spleen was exposed and completely crushed. The abdomen was closed, and treatment was initiated and continued for four hours or until the dog died. For all conditions the hematocrit dropped during the course of the experiment; balloon occlusion was effective at slowing this drop (P less than .0001), but MAST had no statistically significant effect. Animals with balloons bled more slowly into the abdominal cavity than did animals in the other two groups (P less than .0001). MAST also were effective at slowing the bleeding (P less than .05). Of the balloon and the MAST and balloon dogs, all except one survived the entire four hours; this difference between balloon and nonballoon dogs is significant (P = .002). MAST did not have a statistically significant effect on survival. Perfusion pressure (PP) declined during the course of the experiment, and the balloon was effective at slowing this decline (P less than .0001); none of the other comparisons was statistically significant.     

Interplay between interferon-mediated innate immunity and porcine reproductive and respiratory syndrome virus

Innate immunity is the first line of defense against viral infection, and in turn, viruses have evolved to evade host immune surveillance. As a result, viruses may persist in host and develop chronic infections. Type I interferons (IFN-α/β) are among the most potent antiviral cytokines triggered by viral infections. Porcine reproductive and respiratory syndrome (PRRS) is a disease of pigs that is characterized by negligible induction of type I IFNs and viral persistence for an extended period. For IFN production, RIG-I/MDA5 and JAK-STAT pathways are two major signaling pathways, and recent studies indicate that PRRS virus is armed to modulate type I IFN responses during infection. This review describes the viral strategies for modulation of type I IFN responses. At least three non-structural proteins (Nsp1, Nsp2, and Nsp11) and a structural protein (N nucleocapsid protein) have been identified and characterized to play roles in the IFN suppression and NF-κB pathways. Nsp's are early proteins while N is a late protein, suggesting that additional signaling pathways may be involved in addition to the IFN pathway. The understanding of molecular bases for virus-mediated modulation of host innate immune signaling will help us design new generation vaccines and control PRRS.     

A Call to Action to Enhance Filovirus Disease Outbreak Preparedness and Response

The frequency and magnitude of recognized and declared filovirus-disease outbreaks have increased in recent years, while pathogenic filoviruses are potentially ubiquitous throughout sub-Saharan Africa. Meanwhile, the efficiency and effectiveness of filovirus-disease outbreak preparedness and response efforts are currently limited by inherent challenges and persistent shortcomings. This paper delineates some of these challenges and shortcomings and provides a proposal for enhancing future filovirus-disease outbreak preparedness and response. The proposal serves as a call for prompt action by the organizations that comprise filovirus-disease outbreak response teams, namely, Ministries of Health of outbreak-prone countries, the World Health Organization, Médecins Sans Frontières, the Centers for Disease Control and Prevention—Atlanta, and others.     

Disease Pandemics and Major Epidemics Arising From New Encounters between Indigenous Viruses and Introduced Crops

Virus disease pandemics and epidemics that occur in the world’s staple food crops pose a major threat to global food security, especially in developing countries with tropical or subtropical climates. Moreover, this threat is escalating rapidly due to increasing difficulties in controlling virus diseases as climate change accelerates and the need to feed the burgeoning global population escalates. One of the main causes of these pandemics and epidemics is the introduction to a new continent of food crops domesticated elsewhere, and their subsequent invasion by damaging virus diseases they never encountered before. This review focusses on providing historical and up-to-date information about pandemics and major epidemics initiated by spillover of indigenous viruses from infected alternative hosts into introduced crops. This spillover requires new encounters at the managed and natural vegetation interface. The principal virus disease pandemic examples described are two (cassava mosaic, cassava brown streak) that threaten food security in sub-Saharan Africa (SSA), and one (tomato yellow leaf curl) doing so globally. A further example describes a virus disease pandemic threatening a major plantation crop producing a vital food export for West Africa (cacao swollen shoot). Also described are two examples of major virus disease epidemics that threaten SSA’s food security (rice yellow mottle, groundnut rosette). In addition, brief accounts are provided of two major maize virus disease epidemics (maize streak in SSA, maize rough dwarf in Mediterranean and Middle Eastern regions), a major rice disease epidemic (rice hoja blanca in the Americas), and damaging tomato tospovirus and begomovirus disease epidemics of tomato that impair food security in different world regions. For each pandemic or major epidemic, the factors involved in driving its initial emergence, and its subsequent increase in importance and geographical distribution, are explained. Finally, clarification is provided over what needs to be done globally to achieve effective management of severe virus disease pandemics and epidemics initiated by spillover events.     

Barrett's Esophagus: Where Do We Stand?

Barrett''s esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.     

The Technology Transfer from Europe to China in the 17th–18th Centuries: Non-Invasive On-Site XRF and Raman Analyses of Chinese Qing Dynasty Enameled Masterpieces Made Using European Ingredients/Recipes

Two masterpieces of the Qing Dynasty (1644–1912 CE), one in gilded brass (incense burner) decorated with cloisonné enamels stylistically attributed to the end of the Kangxi Emperor’s reign, the other in gold (ewer offered by Napoleon III to the Empress as a birthday present), decorated with both cloisonné and painted enamels bearing the mark of the Qianlong Emperor, were non-invasively studied by optical microscopy, Raman microspectroscopy and X-ray microfluorescence spectroscopy (point measurements and mapping) implemented on-site with mobile instruments. The elemental compositions of the metal substrates and enamels are compared. XRF point measurements and mappings support the identification of the coloring phases and elements obtained by Raman microspectroscopy. Attention was paid to the white (opacifier), blue, yellow, green, and red areas. The demonstration of arsenic-based phases (e.g., lead arsenate apatite) in the blue areas of the ewer, free of manganese, proves the use of cobalt imported from Europe. The high level of potassium confirms the use of smalt as the cobalt source. On the other hand, the significant manganese level indicates the use of Asian cobalt ores for the enamels of the incense burner. The very limited use of the lead pyrochlore pigment (European Naples yellow recipes) in the yellow and soft green cloisonné enamels of the Kangxi incense burner, as well as the use of traditional Chinese recipes for other colors (white, turquoise, dark green, red), reinforces the pioneering character of this object in technical terms at the 17th–18th century turn. The low level of lead in the cloisonné enamels of the incense burner may also be related to the use of European recipes. On the contrary, the Qianlong ewer displays all the enameling techniques imported from Europe to obtain a painted decoration of exceptional quality with the use of complex lead pyrochlore pigments, with or without addition of zinc, as well as cassiterite opacifier.     

Formoterol Delivered via the Dry Powder Aerolizer® Inhaler Versus Albuterol MDI and Placebo in Mild-to-Moderate Asthma: A Randomized, Double-Blind, Double-Dummy Trial

The objectives of this study were to compare the efficacy and tolerability of twice-daily formoterol dry powder 12 µg and 24 µg (Foradil) delivered via Aerolizer inhaler with four times daily albuterol (salbutamol) 180 µg delivered via metered dose inhaler (MDI) and placebo. A total of 554 adolescents and adults (ages 12-75 years) with mild-to-moderate asthma were randomized to this 12-week, multicenter, double-blind, double-dummy, placebo-controlled, parallel-group study. Twelve-hour spirometry measurements were taken at weeks 0, 4, 8, and 12. A total of 484 patients completed the study (122, 116, 127, and 119 given formoterol 12 µg, formoterol 24 µg, albuterol, and placebo, respectively). For the primary efficacy variable, the forced expiratory volume in 1 second (FEV₁), both formoterol 12 µg and 24 µg were statistically superior to placebo at all time points on all test days (p ≤ 0.017) and to albuterol at most time points on all test days (p ≤ 0.001). The onset of improvement in FEV₁ was rapid, with 15% increase within 5 min in 57%, 71%, and 65% of formoterol 12 µg, formoterol 24 µg, and albuterol patients, respectively. Formoterol was also superior to placebo and albuterol in terms of secondary efficacy variables: FEV₁ area under the curve, percentage of predicted FEV₁, forced vital capacity and forced expiratory flow, asthma symptom scores, and peak expiratory flows. In conclusion, both formoterol doses were superior to placebo in all lung function measurements. Overall, compared with albuterol, both formoterol doses produced superior bronchodilation. Formoterol and albuterol were safe and well-tolerated.     

Liver enzymes,metabolomics and genome-wide association studies:From systems biology to the personalized medicine

For several decades,serum levels of alanine(ALT) and aspartate(AST) aminotransferases have been regarded as markers of liver injury,including a wide range of etiologies from viral hepatitis to fatty liver.The increasing worldwide prevalence of metabolic syndrome and cardiovascular disease revealed that transaminases are strong predictors of type 2 diabetes,coronary heart disease,atherothrombotic risk profile,and overall risk of metabolic disease.Therefore,it is plausible to suggest that aminotransferases are surrogate biomarkers of "liver metabolic functioning" beyond the classical concept of liver cellular damage,as their enzymatic activity might actually reflect key aspects of the physiology and pathophysiology of the liver function.In this study,we summarize the background information and recent findings on the biological role of ALT and AST,and review the knowledge gained from the application of genome-wide approaches and "omics" technologies that uncovered new concepts on the role of aminotransferases in human diseases and systemic regulation of metabolic functions.Prediction of biomolecular interactions between the candidate genes recently discovered to be associated with plasma concentrations of liver enzymes showed interesting interconnectivity nodes,which suggest that regulation of aminotransferase activity is a complex and highly regulated trait.Finally,links between aminotransferase genes and metabolites are explored to understand the genetic contributions to the metabolic diversity.