Current experiences with robotic surgery at Severance Hospital,Yonsei University in Korea

We started performing laparoscopic cholecystectomies in 1991. Since that time, many surgeons have been trained in laparoscopic and minimally invasive surgery, and laparoscopic surgery has been used in numerous procedures, with patients benefitting as a result. We performed the first automated surgery in Korea using Automated Endoscopic System for Optimal Positioning in June 1996. Inspired by Inbae Yoon and assisted by his generous donation, our hospital started the IB Yoon Multi‐Specialty Endoscopic Research & Training Center in 1998. Subsequently in March 2005, we started the Severance Robotic and Minimally Invasive Surgery Center. The establishment of these centers has enabled us to widen the use of laparoscopic surgery and to teach many surgeons the principles of and the techniques involved in laparoscopic and robotic surgery. We performed our first robotic surgery using the da Vinci Surgical System in July 2005. In the 4 years since introducing the da Vinci Surgical System, we have successfully performed more than 2600 robotic surgical procedures. As the collaboration between medicine and robotic engineering produces more technically advanced results, we hopefully can develop our own version of the robotic system in the near future.     

Serum hepatitis B surface antigen correlates with fibrosis and necroinflammation: A multicentre perspective in China

The kinetics of serum hepatitis B surface antigen (HBsAg) during the natural history of hepatitis B virus (HBV) infection has been studied, but the factors affecting them remain unclear. We aimed to investigate the factors affecting HBsAg titres, using data from multicentre, large‐sized clinical trials in China. The baseline data of 1795 patients in 3 multicentre trials were studied, and the patients were classified into 3 groups: hepatitis B early antigen (HBeAg)‐positive chronic HBV infection (n = 588), HBeAg‐positive chronic hepatitis B (n = 596), and HBeAg‐negative chronic hepatitis B (n = 611). HBsAg titres in the different phases were compared, and multiple linear progression analyses were performed to investigate the implicated factors. HBsAg titres varied significantly in different phases (P = .000), with the highest (4.60 log10 IU/mL [10%‐90% confidence interval: 3.52 log10 IU/mL‐4.99 log10 IU/mL]) in patients with HBeAg‐positive chronic HBV infection. In all phases, age and HBV DNA were correlated with serum HBsAg level. In HBeAg‐positive chronic hepatitis B patients, a negative correlation between HBsAg titres and fibrosis stage was observed. Alanine amonitransferase or necroinflammatory activity was also correlated with HBsAg titres in HBeAg‐negative chronic hepatitis B patients. In conclusion, decreased HBsAg titres may be associated with advancing fibrosis in HBeAg‐positive chronic hepatitis B patients or increased necroinflammation in those with HBeAg‐negative chronic hepatitis B. Our findings may help clinicians better understand the kinetics of HBsAg and provide useful insights into the management of this disease.     

艾滋病并发口腔白色念珠菌病和带状疱疹1例

1 临床资料患者,女,65岁,山西运城人,于1 a前开始出现口腔糜烂,糜烂面有白色斑片,可擦除,伴口咽疼痛. 因1985-01/1995-01在当地多次卖血(单采血浆),疑为人类免疫缺陷病毒(HIV)感染而行HIV 抗体检测,初筛试验为强阳性. 为求进一步诊治收入唐都医院全军感染病诊疗中心. 体格检查:T 36.4℃,P 120次/min,BP 12.5/7 kPa,消瘦,口腔内壁和舌面大面积糜烂,颊黏膜、舌背黏膜及咽后壁可见白色伪膜,边界尚清楚,擦去可见充血创面,触痛明显.     

辽东楤本化学成分的研究

从辽东楤本(Aralia elata)的根皮中分得8个化合物,利用理化和光谱方法鉴定分别为胡萝卜甙-6’-棕榈酸酯(6’-O-palmitoyl-β-sitosterol-3-O-β-D-glucoside,A₅)、罗盘草甙A(silphioside A,A₉)、楤木皂甙A甲酯(araloside A methyl ester,A₁₀)、竹节人参甙I_b(chikusetusaponin I_b,A₁₁)、楤木皂甙A(araloside A,A₁₂)、楤木皂甙C(araloside C,A₁₅、楤木皂甙G(araloside G,A₁₆)、无梗五加甙D(acanthoside D,B₁)。化合物A₅,A₉,A₁₁和B₁为首次从该植物中分得,A₁₀为新天然产物,A₁₆为新化合物命名为楤木皂甙G,归属了化合物A₉,A₁₅的¹³C-NMR化学位移。     

Agonist desensitisation of α1 adrenoceptors and endothelin-1 receptors coupled to phosphatidylinositol metabolism

Summary— Agonist desensitisation of responses coupled to phosphatidylinositol metabolism were studied. Responses mediated by two different agonists, endothelin-1 and noradrenaline were investigated. In vivo pressor responses were examined in conscious male New Zealand white rabbits, while effects on inositol phosphate formation were studied in rings of freshly isolated aorta and in cultured aortic vascular smooth muscle cells. No desensitisation of responses to noradrenaline were observed in vivo despite a 10-day infusion under conditions which cause desensitisation of α₂ and β-adrenoceptor mediated responses. In contrast, responses to endothelin-1 were attenuated within 5 min of commencing endothelin-1 infusions. No reduction in noradrenaline stimulated inositol phosphate was observed in cultured vascular smooth muscle cells after pre-incubation with noradrenaline up to 10⁻⁴M, whereas with endothelin-1 pre-incubation a dose and time-related reduction in endothelin-1 stimulated inositol phosphate formation was observed. Thus, differences in the pattern of desensitisation of both pressor responses and phosphatidylinositol metabolism were observed for noradrenaline and endothelin-1 suggesting that the nature of the 2nd messenger involved in signal transduction is not the only determinant of agonist desensitisation. In addition, differences in the rate of desensitisation and sensitivity to endothelin-1, but not noradrenaline, were observed when responses in cultured cells were compared with in vivo responses or responses to freshly isolated tissues. These differences are discussed in relation to possible modifications of the endothelin receptor or its coupling to phosphatidylinositol metabolism during culture.     

Evaluation of four methods of flexor tendon repair for postoperative active mobilization

Evaluation of four methods of flexor tendon repair for postoperative active mobilization@Gu YT @Rice K @Chen F @Pan CZ     

Human neutrophil degranulation during extracorporeal circulation

Cardiopulmonary bypass, especially when prolonged, may result in hemostatic failure and pulmonary dysfunction, which has been attributed to changes in platelets and leukocytes, respectively. It has been well documented that contact of blood with synthetic surfaces causes platelet activation. In this report, we explore mechanisms of the activation of neutrophils during simulated in vitro extracorporeal circulation and document the release of neutrophil lactoferrin and elastase during clinical cardiopulmonary bypass (CCB). Inhibition in the simulated circuit by prostaglandin E1 (PGE1) and lidocaine suggests different mechanisms for release of neutrophil-specific proteins. During CCB with a bubble oxygenator it was observed that platelet counts fell to 42% +/- 2% of baseline. In addition, beta- thromboglobulin antigen (beta TG), a platelet-specific, alpha-granule protein marker reflecting the release reaction, increased from 0.15 +/- 0.05 to 0.84 +/- 0.11 microgram/mL. Neutrophil counts decreased to 67% +/- 7% of prebypass levels but then gradually rose as bypass continued. Both lactoferrin, a neutrophil-specific granule marker, and neutrophil elastase, an azurophilic granule marker, increased in plasma threefold to 1.66 +/- 0.33 micrograms/mL and 1.65 +/- 0.68 microgram/mL, respectively, just before bypass was stopped. When fresh heparinized human blood was recirculated within an extracorporeal membrane oxygenator bypass circuit for 120 minutes, plasma beta-TG rose to 5.13 micrograms/mL, lactoferrin increased from 0.13 +/- 0.04 to 1.62 +/- 0.22 micrograms/mL, and neutrophil elastase rose from 0.05 +/- 0.02 to 1.86 +/- 0.41 micrograms/mL. At 120 minutes, lidocaine (100 mumol/L), which inhibits neutrophil activation, delayed release of lactoferrin (1.33 +/- 0.26 micrograms/mL) and markedly inhibited release of elastase (0.24 +/- 0.05 microgram/mL) but did not inhibit release of beta-TG antigen (5.66 micrograms/mL at 120 minutes). PGE1 (0.3 mumol/L) inhibited significantly the release of beta-TG (0.31 microgram/mL) and elastase (0.52 +/- 0.11 microgram/mL) and attenuated the release of lactoferrin (1.57 +/- 0.45 micrograms/mL).     

Ministry of Health Clinical Practice Guidelines: Diabetes Mellitus

The Ministry of Health (MOH) have updated the clinical practice guidelines on Diabetes Mellitus to provide doctors and patients in Singapore with evidence-based treatment for diabetes mellitus. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Diabetes Mellitus, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

1.1 Objectives and scope of guideline

The first edition of the MOH clinical practice guidelines on diabetes mellitus for Singapore was published in 1999. Since that time, more facts about this important condition have emerged, not only with regard to its diagnosis and treatment, but also about whether or not type 2 diabetes may be prevented, and, if so, how this may be achieved.As diabetes mellitus has great public health significance in developed countries and developing nations alike, managing it properly involves a consideration, not just of clinical issues, but also of health economics. This second edition of the guidelines attempts to address some of these complex issues wherever evidence-based information pertaining to them is available.

1.2 Target group

The main aim of these guidelines is to help physicians make sound clinical decisions about diabetes mellitus by presenting up-to-date information about diagnosis, classification, treatment, outcomes, and follow-up.These guidelines are developed for all health care professionals in Singapore. We hope they would be helpful especially to primary care physicians who care for patients with diabetes mellitus.

1.3 Guideline development

These guidelines have been produced by a committee of endocrinologists, family practitioners and primary care specialists, ophthalmologist, dietitian, social worker, and patient representative, appointed by the Ministry of Health. They were developed by the adaptation of existing guidelines, by the review of relevant literature and by expert clinical consensus with consideration of local practice. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

1.4 What’s new in the revised guidelines

The following is a list of the major revisions and additions to the previous guidelines:

• In Chapter 3, we have explained the rationale for criteria in diagnosing diabetes. In particular, for asymptomatic patients with a first test that meets criteria, we have attempted to provide more clarity on how to choose a second test, and how to interpret the findings.
• Chapter 4 is a new chapter which brings emphasis to two areas contributing towards positive outcomes in diabetes care: diabetes self-management education, and psychosocial assessment and holistic care of the person with diabetes.
• Chapter 5 on pharmacotherapy in diabetes mellitus has been updated to take into account recent clinical trial evidence of the efficacy of the newer classes of pharmacological agents.
• Chapter 6 focuses on glycaemic control, and emphasizes the importance of individualised targets, balancing the benefits of achieving targets without incurring undue risk of hypoglycaemia or other adverse effects, and considering the risk profile of the patient.
• In Chapter 7 on prevention of cardiovascular disease in diabetes mellitus, recommendations on decision-making in the area of therapeutics have been updated and harmonised with current local guidance on lipid, blood pressure and cardiovascular management. Target blood pressure ranges and LDL levels are discussed, as well as the role of antiplatelet therapy.
• Chapter 8 on prevention and management of diabetic nephropathy has been revised to present recent clinical trial evidence regarding the efficacy of, and indications for, the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers.
• Chapter 9 on the prevention and management of eye complications has been updated to include developments such as intravitreal injection of anti-vascular endothelial growth factor in patients with diabetic macular oedema.
• Chapter 11 on pre-gestational and gestational diabetes has been updated. Women at high risk for gestational diabetes, but who are not found to have glucose intolerance in early pregnancy, are now recommended to be re-evaluated with a 75 gram OGTT at 24–28 weeks gestation.
• Chapter 13 is a new chapter outlining key principles in the management of the adult with type 1 diabetes, relevant to the primary care healthcare professional.

1.5 Review of guidelines

Evidence-based clinical practice guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review four years after publication, or earlier if new evidence emerges that necessitates substantive changes to the recommendations.Future revisions may include management of hypoglycaemia in persons with diabetes, and evolving areas like bariatric surgery and pancreas/islet cell transplantation.