Endoscopic identification of endoluminal esophageal landmarks for radial and longitudinal orientation and lesion location

AIM To characterize esophageal endoluminal landmarks to permit radial and longitudinal esophageal orientation and accurate lesion location.METHODS Distance from the incisors and radial orientation were estimated for the main left bronchus and the left atrium landmarks in 207 consecutive patients using white light examination. A sub-study was also performed using white light followed by endoscopic ultrasound(EUS) in 25 consecutive patients to confirm the findings.The scope orientation throughout the exam was maintained at the natural axis,where the left esophageal quadrant corresponds to the area between 6 and 9 o'clock. When an anatomical landmark was identified, it was recorded with a photograph and its quadrant orientation and distance from the incisors were determined. The reference points to obtain the distances and radial orientation were as follows: the midpoint of the left main bronchus and the most intense pulsatile zone of the left atrium. With the video processor system set to moderate insufflation, measurements were obtained at the end of the patients' air expiration.RESULTS The left main bronchus and left atrium esophageal landmarks were identified using white light in 99% and 100% of subjects at a mean distance of 25.8 cm(SD2.3), and 31.4 cm(SD 2.4) from the incisors, respectively. The left main bronchus landmark was found to be a tubular, concave, non-pulsatile, esophageal external compression, occupying approximately 1/4 of the circumference. The left atrium landmark was identified as a round, convex, pulsatile, esophageal external compression, occupying approximately 1/4 of the circumference. Both landmarks were identified using white light on the anterior esophageal quadrant. In the substudy, the left main bronchus was identified in 24(92%) patients at 25.4 cm(SD2.1) and 26.7 cm(SD 1.9) from the incisors, by white light and EUS, respectively.The left atrium was recognized in all patients at 30.5 cm(SD 1.9), and 31.6 cm(SD2.3) from the incisors, by both white light and EUS, respectively. EUS confirmed that the landmarks corresponded to these two structures, respectively, and that they were located on the anterior esophageal wall. The Bland-Altman plot demonstrated high agreement between the white light and EUS measurements.CONCLUSION This study provides an endoscopic characterization of esophageal landmarks corresponding to the left main bronchus and left atrium, to permit radial and longitudinal orientation and accurate lesion location.     

湖南省永州市华支睾吸虫病高度流行区的流行病学调查

目的 了解湖南省永州市华支睾吸虫病的流行现状和流行因素。 方法 于2006年11～12月对湖南省永州市冷水滩区和祁阳县各1个自然村的1周岁以上常住居民,采用改良加藤厚涂片法（一粪三检）检查华支睾吸虫的感染情况,并进行问卷调查。调查保虫宿主（狗和鼠类）和中间宿主的感染情况。 结果 共调查777人,华支睾吸虫感染率为75.4%（586/777）;平均克粪虫卵数451个,轻、中、重度构成比分别为85.5%（501/586）、14.0%（82/586）和0.5%（3/586）;其中男性感染率为76.9%（316/411）、女性为73.8%（270/366）,两者差异无统计学意义（χ²＝1.013, P＞0.05）。各年龄组均有感染,感染率随年龄增长而升高,其中以70～79岁组感染率最高,为85.7%（30/35）。不同职业人群均有感染,农民、医生、教师和干部分别为82.5%（447/542）、 79.3%（42/53）、 73.7%（28/38）和73.5％（25/34）。 中间宿主和保虫宿主的调查结果显示,纹沼螺（Parafossarulus striatulus）和长角涵螺（Alocinma longicornis）的感染率分别为17.4％（29/167）和7.4%（2/27）; 鲫鱼（Carassius auratus）和鲤鱼（Cyprinus carpio）的感染率分别为69.2%（9/13）和5.3%（1/19）;剖检3只家犬均有感染。居民的问卷调查结果显示,80%以上的居民不知晓食生鱼会感染华支睾吸虫,95.6%（153/160）的农民和56.7%（349/616）的学生有食生鱼片史;当地使用未经处理的粪便施肥和在鱼塘洗刷粪桶的现象较普遍。 结论 湖南省祁阳县和冷水滩区为华支睾吸虫病高度流行区。居民普遍有食生鱼片和使用未经处理的粪便施肥等习惯,是华支睾吸虫病流行的主要因素。     

结膜吸吮线虫实验室感染大绕眼果蝇

在安徽黄山地区捕捉有绕眼习性的果蝇,将结膜吸吮线虫初产蚴混于果汁中,实验室喂饲感染果蝇,常温饲养20 d后,检查果蝇的感染情况。结果显示,大绕眼果蝇（Amiota magna）和冈田绕眼果蝇（A. okadai）的阳性率分别为30%（30/100）和21.6%（55/255）,两者间的差异无统计学意义（χ²=0.058 4, P>0.05）。将采自大绕眼果蝇的结膜吸吮线虫感染期幼虫接种家兔,35 d后在兔结膜囊内检获结膜吸吮线虫成虫及其初产蚴,表明在实验室条件下,结膜吸吮线虫可感染大绕眼果蝇。     

心肌血流储备分数指导下药物治疗冠状动脉临界病变患者的远期疗效

目的研究心肌血流储备分数(FFR)指导下药物治疗冠状动脉临界病变患者的安全性。方法 2010年4月至2011年9月武汉亚洲心脏病医院介入中心行冠状动脉造影提示临界病变同时行冠状动脉内压力导丝测定FFR≥0.8的连续15例患者,规范冠心病二级预防药物治疗。随访≥1年,包括主要不良事件(包括死亡、心肌梗死、再次靶病变血运重建术、卒中)及再发心绞痛、再次住院、出血发生情况。结果 15例患者平均(61±7.49)岁。其中男性7例(46.7%),冠状动脉造影病变平均(1.2±0.5)支。15例患者冠状动脉造影提示19处临界病变:左前降支15处、回旋支3处,右冠状动脉1处;其中单支病变者11例(73.3%),双支病变者4例(26.7%),均合并前降支病变;FFRmyo均值(0.88±0.06)。15例患者平均随访(23.6±5.67)个月,其中1例(6.7%)失访。2例(13.3%)不稳定型心绞痛患者随访期间出现心绞痛,症状较前无明显加重,含服硝酸甘油可缓解,余心肌梗死、再次靶病变血运重建术、卒中、全因死亡、再次住院率、出血等不良事件无发生。对入选患者心绞痛发生情况采用Kaplan-Meier法做生存分析,FFR术后平均再发心绞痛时间为术后(29.12±0.67)个月。结论初步验证了FFR指导下药物治疗冠状动脉临界病变患者是可行的。     

纤维蛋白原与冠状动脉临界病变血流储备分数的相关性

目的探讨血浆纤维蛋白原水平与冠状动脉临界病变血流储备分数(FFR)的相关性及其临床意义。方法入选经冠状动脉造影检查为冠状动脉临界病变(冠状动脉狭窄程度为50%~70%)并行FFR检查的患者,根据冠状动脉FFR测得值分为FFR≥0.8组(23例)和FFR0.8组(14例)。入选患者均于入院后检测纤维蛋白原、总胆固醇、甘油三酯、尿酸、肌酐、血糖等指标。采用相关分析和ROC曲线分析纤维蛋白原与FFR的相关性。结果应用偏相关分析控制可能影响纤维蛋白原及冠状动脉血管病变的因素包括年龄、性别、血脂、血糖水平等,结果显示FFR0.8组患者血浆纤维蛋白原水平明显高于FFR≥0.8组(3.50±0.72 g/L比2.68±0.63 g/L,P0.05),纤维蛋白原水平与FFR值呈负相关(r=-0.477,P0.01);ROC曲线分析显示,最适宜的截断点为2.692 g/L,应用FFR值=0.8作为判断冠状动脉临界病变有无缺血的敏感度为92.9%,特异度为65.2%。结论血浆纤维蛋白原可用于检测冠状动脉临界病变心肌有无缺血,与冠状动脉临界病变心肌缺血程度相关,可作为预测冠状动脉临界病变心肌有无功能性缺血及支架植入的影响因素。     

冠状动脉临界病变血管内超声检查参数与定量血流分数的相关性研究

目的探讨冠状动脉临界病变血管内超声(IVUS)检查参数与定量血流分数(QFR)的相关性。方法前瞻性连续入选2018年9月至2019年9月于同济大学附属东方医院接受QFR和IVUS检查的116例患者(117处冠状动脉临界病变)。根据QFR评估结果,将患者分为QFR≤0.80组(25处病变)和QFR>0.80组(92处病变),比较两组IVUS检查参数的差异。应用Poisson线性相关性分析以及受试者工作特征(ROC)曲线评估IVUS与QFR的相关性,应用logistic多元回归分析QFR≤0.80的预测因素。结果IVUS检查发现,QFR≤0.80组最小管腔面积(MLA)[(3.1±0.8)mm²比(3.6±1.1)mm²,P=0.040]、最小管腔直径(MLD)[(1.8±0.3)mm比(2.0±0.3)mm,P=0.012]显著小于QFR>0.80组,而斑块负荷[(73.5±5.6)%比(68.0±8.4)%,P=0.002]、面积狭窄率[(69.8±8.8)%比(63.8±9.8)%,P=0.007]、斑块偏心指数[(0.83±0.12)比(0.73±0.19),P=0.008]及回声消减斑块比例(52.0%比23.9%,P=0.003)显著高于QFR>0.80组,差异均有统计学意义。Poisson线性相关分析显示,MLA(r=0.259,P=0.005)、MLD(r=0.300,P=0.001)与QFR正相关,而斑块负荷(r=–0.357,P<0.001)以及斑块偏心指数(r=–0.247,P=0.008)与QFR负相关。logistic多因素回归分析表明斑块负荷>70%(OR 4.531,95%CI 1.443~14.222,P=0.010)和斑块偏心指数(OR 1.066,95%CI 1.014~1.121,P=0.012)为QFR≤0.80的独立预测因素。结论冠状动脉临界病变IVUS检查结果中斑块负荷>70%以及斑块偏心指数是QFR≤0.80的独立预测因子。     

威猛联合方案治疗中高度恶性及难治非何杰金恶性淋巴瘤的观察

目的为探讨威猛联合方案对中、高度恶性及难治复发非何杰金淋巴瘤（ＮＨＬ）的治疗效果。方法应用ＣＨＶＰ方案（环磷酰胺、阿霉素、威猛及强的松）或ＣＯＶＰＰ（环磷酰胺、长春新硷、强的松、威猛及顺铂）方案治疗４２例中、高度恶性及难治复发ＮＨＬ,其中Ⅲ期１２例,Ⅳ期３０例,２６例为初治恶性程度较高的病人,１６例为难治复发病例。结果完全缓解（ＣＲ）１８例（４２．９％）,部分缓解（ＰＲ）１５例（３５．７％）,总有效率为７８．６％,其中２６例初治病例中ＣＲ１２例（４６．２％）,ＰＲ９例（３４．６％）,１６例难治复发病例中ＣＲ６例（３７．５％）,ＰＲ６例（３７．５％）。主要毒性反应为骨髓抑制,但经间歇期及Ｇ ＣＳＦ治疗后均能恢复。结论这两方案是治疗中、高度恶性及难治复发ＮＨＬ的较有效而安全选择。     

中危人群双源CT冠脉显像检测冠状动脉狭窄的可靠性

目的探讨冠状动脉(冠脉)双源CT(DSCT)评价冠状动脉性心脏病(冠心病)中危人群冠脉狭窄的准确性。方法选择2006-07-2009-05至我院行冠状动脉造影(冠脉造影)的冠心病中危患者67例,男42例,女25例,分别给予双源CT和冠脉造影检查(不予心率控制)。双盲法对图像资料结果进行比较分析。结果66例获得了清晰的图像。在至少有一处狭窄>50%的患者16例中,15例由双源CT准确发现,敏感性93.8%。在无狭窄>50%的患者50例中,45例由双源CT准确排除,特异性90.0%。双源CT诊断冠脉狭窄≥50%的敏感性为94.3%,特异性98.8%,阳性预测值75.0%,阴性预测值99.8%;诊断冠脉狭窄≥75%的敏感性为94.1%,特异性99.4%,阳性预测值76.2%,阴性预测值99.9%。kappa一致性分析发现双源CT与冠脉造影的结果有较好的一致性(κ=0.79,P<0.01)。结论双源CT判断冠心病中危人群冠脉狭窄情况的敏感性及特异性均较高,可作为此人群筛查的安全、可靠方法。     

Risk factors for transfer from Respiratory Intermediate Care Unit to Intensive Care Unit in COVID-19

BackgroundPatients hospitalized for COVID-19-related pneumonia often need several degrees of ventilatory support, which are performed between Respiratory Intermediate Care Units (RICUs) and Intensive Care Units (ICUs), and which depend on the severity of acute respiratory distress syndrome. There is no firm consensus on transfer predictors from the RICU to the ICU.MethodsIn this retrospective observational single center study, we evaluated 96 COVID-19 patients referred to the RICU for acute respiratory failure (ARF) according to their transferal to the ICU or their stay at the RICU. We compared demographic data, baseline laboratory profile, and final clinical outcomes to identify early risk factors for transfer.ResultsThe best predictors for transfer to the ICU were elevated C-reactive protein and lymphopenia. The mortality rate was lower in the RICU than in the ICU, where transferred patients who died were mostly younger men and with less comorbidities than those in the RICU.ConclusionsFew inflammatory markers can predict the need for transfer from the RICU to the ICU. Due to the ongoing COVID-19 pandemic, we urge better clinical stratification by early and meaningful profiles in patients admitted to the RICU who are at risk of transferal to the ICU.     

Rethinking the Barcelona clinic liver cancer guidelines: Intermediate stage and Child-Pugh B patients are suitable for surgery?

According to Barcelona Clinic Liver Cancer recommendations, intermediate stage hepatocellular carcinomas (stage B) are excluded from liver resection and are referred to palliative treatment. Moreover, Child-Pugh B patients are not usually candidates for liver resection. However, many hepatobiliary centers in the world manage patients with intermediate stage hepatocellular carcinoma or Child-Pugh B cirrhosis with liver resection, maintaining that hepatic resection is not contraindicated in selected patients with non–early-stage hepatocellular carcinoma and without normal liver function. Several studies demonstrate that resection provides the best survival benefit for selected patients in very early/early and even in intermediate stages of Barcelona Clinic Liver Cancer classification, and this treatment gives good results in the setting of multinodular, large tumors in patients with portal hypertension and/or Child-Pugh B cirrhosis. In this review we explore this controversial topic, and we show through the literature analysis how liver resection may improve the short- and long-term survival rate of carefully selected Barcelona Clinic Liver Cancer B and Child-Pugh B hepatocellular carcinoma patients. However, other large clinical studies are needed to clarify which patients with intermediate stage hepatocellular carcinoma are most likely to benefit from liver resection.