[History, current situation and bottleneck of the diagnosis and treatment system of hepatic hilar cholangiocarcinoma in Japan].

Hilar cholangiocarcinoma is one of the most difficult malignant tumors to treat in the biliary system. In Japan, 5-year survival rate of the disease has increased from 32.5% to 67.1% during the past 30 years. The impressive progress reflects the solid efforts in preoperative endoscopic diagnosis, innovation in surgery such as PTPE as well as hepato-pancreatoduodenectomy and perioperative treatment including replacement of the bile and synbiotic treatment, which have finally formed a set of standardized diagnosis and treatment systems. The present review intends to report the history, current status and remaining bottlenecks of the diagnosis and treatment system of hilar cholangiocarcinoma in Japan as follows.

[Clinical effect of low-molecular-weight heparin in prevention and treatment of liver cirrhosis and portal vein thrombosis after splenectomy: a systematic review and meta-analysis].

Objective: To investigate the clinical effect of low-molecular-weight heparin (LMWH) in the treatment of liver cirrhosis and portal vein thrombosis and the value of early application of LMWH in the prevention of portal vein thrombosis after splenectomy. Methods: The databases of PubMed, Google Scholar, CNKI, Wanfang Data, and VIP were searched, and manual searching and internet searching were used to retrieve grey literature. The articles which met the inclusion criteria were included, and a systematic review and meta-analysis was performed. Results: A total of 12 randomized controlled trials were included, with 1397 patients enrolled, among whom 723 were enrolled in the LMWH group and 674 were enrolled in the control group. A meta-analysis was performed for the trials above, and the results showed that the patients with early application of LMWH had a lower rate of thrombosis compared with those in the control group (OR = 0.37, 95% CI 0.28-0.48, P < 0.001). The results of three randomized trials with the application of LMWH in the treatment of portal vein embolism showed that the patients treated with LMWH had a higher rate of recanalization of thrombus than those in the control group (OR = 5.08, 95% CI 1.74-14.84, P < 0.001). Conclusion: Early application of LMWH can reduce the rate of portal vein thrombosis after splenectomy, and LMWH for the treatment of portal vein embolism can increase the rate of recanalization of thrombus.

Monitoring the brain: processed electroencephalogram and peri-operative outcomes.

Although the brain is the target organ of general anaesthesia, the utility of intra-operative brain monitoring remains controversial. Ideally, the incorporation of brain monitoring into routine practice would promote the maintenance of an optimal depth of anaesthesia, with an ultimate goal of avoiding the negative outcomes that have been associated with inadequate or excessive anaesthesia. A variety of processed electroencephalogram devices exist, of which the bispectral index is the most widely used, particularly in the research setting. Whether such devices prove to be useful will depend not only on their ability to influence anaesthetic management but also on whether the changes they promote can actually affect clinically important outcomes. This review highlights the evidence for the role of bispectral index monitoring, in particular, in guiding anaesthetic management and influencing clinical outcomes, specifically intra-operative awareness, measures of early recovery, mortality and neurocognitive outcomes.

[Effects of modified proper digital artery island flap in repairing complex fingertip defects].

Objective: To investigate the surgical method and clinical effects of the modified proper digital artery island flap in repairing complex fingertip defects. Methods: A retrospective observational study was conducted. From January 2017 to December 2021, 15 patients (15 fingers) with complex fingertip defects, involving the pulp, nail bed, and lateral wall of the nail, who met the inclusion criteria were admitted into General Hospital of Northern Theater Command, including 11 males and 4 females, aged from 18 to 55 years. The area of the post debridement wound was from 2.5 cm×2.0 cm to 3.5 cm×3.5 cm, and all the wounds were repaired by using modified proper digital artery island flap (including 3 parts: main flap, tongue-shaped flap, and triangular flap), of which the main flap was used to cover the finger pulp defect, the tongue-shaped flap was used to cover the nail bed and the nail lateral wall defect, and the triangular flap was inserted into the edge of the finger pulp wound to cover the vessel pedicle. The range of the flap ranged from 3.0 cm×2.0 cm to 4.5 cm×3.0 cm. The wound at the donor site was repaired with full-thickness skin graft of the groin, and the donor site of the skin graft was sutured directly. After operation, the survival of the flap and skin graft as well as and the appearance of the affected finger were observed. During the follow-up, the fingertip morphology of the affected finger was observed, two-point discrimination distance of the affected finger pulp was measured, and the patients' satisfaction with the efficacy (including very satisfied, satisfied, and dissatisfied) was asked, and the affected finger function was evaluated by the total active movement (TAM) system evaluation standard recommended by American Academy for Surgery of Hand. Results: After operation, the main flaps and skin grafts in 15 patients all survived; but the incision at the edge of tongue-shaped flap in one patient healed poorly, and one patient developed venous stasis at the distal end of the tongue-shaped flap; the triangular flap at the pedicle was slightly bloated in the early postoperative period and became smooth after 2 to 3 months. Overall, two patients developed subcutaneous hematoma in their flaps. All the complications were healed by appropriate dressing change, suture removal, or compression bandaging. After operation, the appearance of the flap was full and formed a prominent fingertip shape. During the follow-up of 6 months to 5 years, the fingertips of the affected fingers were prominent and full; the two-point discrimination distance of the affected finger pulp was (8.6±1.4) mm; 8 patients were very satisfied with the efficacy, 6 patients were satisfied, and one patient was dissatisfied; the functional assessment of the affected fingers were all excellent. Conclusions: The modified proper digital artery island flap can repair complex fingertip defects involving the pulp, nail bed, and lateral wall of the nail. The operation is simple, and the shape and function of the fingertip are good after surgery.

Part 5. Public health and air pollution in Asia (PAPA): a combined analysis of four studies of air pollution and mortality.

BACKGROUND: In recent years, Asia has experienced rapid economic growth and a deteriorating environment caused by the increasing use of fossil fuels. Although the deleterious effects of air pollution from fossil-fuel combustion have been demonstrated in many Western nations, few comparable studies have been conducted in Asia. Time-series studies of daily mortality in Asian cities can contribute important new information to the existing body of knowledge about air pollution and health. Not only can these studies verify important health effects of air pollution in local regions in Asia, they can also help determine the relevance of existing air pollution studies to mortality and morbidity for policymaking and environmental controls. In addition, the studies can help identify factors that might modify associations between air pollution and health effects in various populations and environmental conditions. Collaborative multicity studies in Asia-especially when designed, conducted, and analyzed using a common protocol-will provide more robust air pollution effect estimates for the region as well as relevant, supportable estimates of local adverse health effects needed by environmental and public-health policymakers. SPECIFIC OBJECTIVES: The Public Health and Air Pollution in Asia (PAPA*) project, sponsored by the Health Effects Institute, consisted of four studies designed to assess the effects of air pollution on mortality in four large Asian cities, namely Bangkok, in Thailand, and Hong Kong, Shanghai, and Wuhan, in China. In the PAPA project, a Common Protocol was developed based on methods developed and tested in NMMAPS, APHEA, and time-series studies in the literature to help ensure that the four studies could be compared with each other and with previous studies by following an established protocol. The Common Protocol (found at the end of this volume) is a set of prescriptive instructions developed for the studies and used by the investigators in each city. It is flexible enough to allow for adjustments in methods to optimize the fit of health-effects models to each city's data set. It provides the basis for generating reproducible results in each city and for meta-estimates from combined data. By establishing a common methodology, factors that might influence the differences in results from previous studies can more easily be explored. Administrative support was provided to ensure that the highest quality data were used in the analysis. It is anticipated that the PAPA results will contribute to the international scientific discussion of how to conduct and interpret time-series studies of air pollution and will stimulate the development of high-quality routine systems for recording daily deaths and hospital admissions for time-series analysis. METHODS: Mortality data were retrieved from routine databases with underlying causes of death coded using the World Health Organization (WHO) International Classification of Diseases, 9th revision or 10th revision (ICD-9, ICD-10). Air quality measurements included nitrogen dioxide (NO2), sulfur dioxide (SO2), particulate matter with aerodynamic diameter < or = 10 microm (PM10), and ozone (O3) and were obtained from several fixed-site air monitoring stations that were located throughout the metropolitan areas of the four cities and that met the standards of procedures for quality assurance and quality control carried out by local government units in each city. Using the Common Protocol, an optimized core model was established for each city to assess the effects of each of the four air pollutants on daily mortality using generalized linear modeling with adjustments for time trend, seasonality, and other time-varying covariates by means of a natural-spline smoothing function. The models were adjusted to suit local situations by correcting for influenza activity, autocorrelation, and special weather conditions. Researchers in Hong Kong, for example, used influenza activity based on frequency of respiratory mortality; researchers in Hong Kong and Shanghai used autoregressive terms for daily outcomes at lag days; and researchers in Wuhan used additional smoothing for periods with extreme weather conditions. RESULTS AND DISCUSSION: For mortality due to all natural (nonaccidental) causes at all ages, the effects of air pollutants per 10-microg/m3 increase in concentration was found to be higher in Bangkok than in the three Chinese cities, with the exception of the effect of NO2 in Wuhan. The magnitude of the effects for cardiovascular and respiratory mortality were generally higher than for all natural mortality at all ages. In addition, the effects associated with PM10 and O3 in all natural, cardiovascular; and respiratory mortality were found to be higher in Bangkok than in the three Chinese cities. The explanation for these three findings might be related to consistently higher daily mean temperatures in Bangkok, variations in average time spent outdoors by the susceptible populations, and the fact that less air conditioning is available and used in Bangkok than in the other cities. However, when pollutant concentrations were incorporated into the excess risk estimates through the use of interquartile range (IQR), the excess risk was more comparable across the four cities. We found that the increases in effects among older age groups were greater in Bangkok than in the other three cities. After excluding data on extremely high concentrations of PM10 in Bangkok, the effect estimate associated with PM10 concentrations decreased in Bangkok (suggesting a convex relationship between risk and PM10, where risk levels off at high concentrations) instead of increasing, as it did in the other cities. This leveling off of effect estimates at high concentrations might be related to differences in vulnerability and exposure of the population to air pollution as well as to the sources of the air pollutant. IMPLICATIONS OF THE STUDY: The PAPA project is the first coordinated Asian multicity air pollution study ever published; this signifies the beginning of an era of cooperation and collaboration in Asia, with the development of a common protocol for coordination, data management, and analysis. The results of the study demonstrated that air pollution in Asia is a significant public health burden, especially given the high concentrations of pollutants and high-density populations in major cities. When compared with the effect estimates reported in the research literature of North America and Western Europe, the study's effect estimates for PM10 were generally similar and the effect estimates for gaseous pollutants were relatively higher. In Bangkok, however, a tropical city where total exposures to outdoor pollution might be higher than in most other cities, the observed effects were greater than those reported in the previous (i.e., Western) studies. In general, the results suggested that, even though social and environmental conditions across Asia might vary, it is still generally appropriate to apply to Asia the effect estimates for other health outcomes from previous studies in the West. The results also strongly support the adoption of the global air quality guidelines recently announced by WHO.

[Clinical effect of free thoracodorsal artery perforator flap in reconstructing large scar on the facial subunit].

Objective: To explore the clinical effect of free transplantation of thoracodorsal artery perforator flap in reconstructing large scar on the facial subunit. Methods: From April 2014 to March 2018, 7 patients with large facial scar were admitted to Ningbo NO.6 Hospital, including 3 males and 4 females, aged from 31 to 49 years, 4 with frontal involvement and 3 with chin and neck. Color Doppler ultrasound was used for the positioning of the thoracodorsal artery perforating vessel, and scar resection was performed according to the principle of facial subunit repair. The wound area was 8 cm×6 cm-21 cm×8 cm, and the wound was repaired with the free thoracodorsal artery perforator flap in the area of 9 cm×7 cm-22 cm×9 cm. The donor site was closed directly by suturing. The consistency of the location of the perforating vessel explored during the operation with its preoperative positioning and the flap survival were recorded. The color, texture, and appearance of the flap and the healing condition, scar formation, and function of the donor area were observed during follow-up. Results: The locations of the perforating vessels of 7 patients explored during the operation were consistent with those positioned by color Doppler ultrasound before the operation. All the flaps of the 7 cases survived successfully after operation. Postoperative follow-up of 12-18 months showed that the flap color was similar to the surrounding skin of the recipient area, with soft texture and no obvious contracture. Slight bloated appearance was observed in the flaps of 4 cases. All the 7 patients had postoperative healing of the flap donor site without obvious scar hyperplasia or influence on shoulder joint function. Conclusions: The anatomy of the perforating vessel of the thoracodorsal artery perforator flap is relatively constant and the flap can be cut in large area with soft texture, good appearance, and concealed donor area, which is a good choice for reconstructing large scar on the facial subunit.

A randomized study of pomalidomide vs placebo in persons with myeloproliferative neoplasm-associated myelofibrosis and RBC-transfusion dependence.

RBC-transfusion dependence is common in persons with myeloproliferative neoplasm (MPN)-associated myelofibrosis. The objective of this study was to determine the rates of RBC-transfusion independence after therapy with pomalidomide vs placebo in persons with MPN-associated myelofibrosis and RBC-transfusion dependence. Two hundred and fifty-two subjects (intent-to-treat (ITT) population) including 229 subjects confirmed by central review (modified ITT population) were randomly assigned (2:1) to pomalidomide or placebo. Trialists and subjects were blinded to treatment allocation. Primary end point was proportion of subjects achieving RBC-transfusion independence within 6 months. One hundred and fifty-two subjects received pomalidomide and 77 placebo. Response rates were 16% (95% confidence interval (CI), 11, 23%) vs 16% (8, 26%; P=0.87). Response in the pomalidomide cohort was associated with ⩽4 U RBC/28 days (odds ratio (OR)=3.1; 0.9, 11.1), age ⩽65 (OR=2.3; 0.9, 5.5) and type of MPN-associated myelofibrosis (OR=2.6; 0.7, 9.5). Responses in the placebo cohort were associated with ⩽4 U RBC/28 days (OR=8.6; 0.9, 82.3), white blood cell at randomization >25 × 109/l (OR=4.9; 0.8, 28.9) and interval from diagnosis to randomization >2 years (OR=4.9; 1.1, 21.9). Pomalidomide was associated with increased rates of oedema and neutropenia but these adverse effects were manageable. Pomalidomide and placebo had similar RBC-transfusion-independence response rates in persons with MPN-associated RBC-transfusion dependence.

[Combination treatment for craniopharyngiomas with stereotactic intracavitary irradiation and gamma knife surgery].

OBJECTIVE: To evaluate the effectiveness of the combination treatment for craniopharygiomas with stereotactic intracavitary irradiation and gamma knife surgery. METHODS: Combination treatment of stereotactic instillation of radioisotopes and gamma knife surgery was performed in 46 patients with craniopharyngioma between October 1996 and June 1999. There were 24 men and 22 women, with age ranging from 3 to 60 years (average 38.6 years). There were 13 solid tumors and 33 mixed solid and cystic tumors. Twenty-eight patients had undergone prior caraniotomies with total or partial resection of tumors, with or without followed external beam radiation therapy. Gamma knife surgery was done in solid tumors and the combination treatment was done in mixed tumors: the cyst being treated with stereotactic intracavitary radiation and the solid part with Gamma knife. RESULTS: Thirty-eight patients (10 solid and 28 mixed) were followed up from 6 months to two years (averaged 16 months). The tumor control rate (disappeared, decreased and unchanged) was 90% in solid tumor, 85.7% in mixed tumors, and 92.1% in solid segment and the total control rate was 89.5%. CONCLUSION: The combination treatment is a simple, safe and effective method for craniopharyngiomas, especially for the recurrent mixed solid and cystic tumors. Gamma knife surgery plays an important role in the treatment of solid component of the craniopharyngiomas.

Schistosomiasis control in China.

Well-organized programmes combining local involvement and major government projects have been successful in controlling schistosomiasis to a large extent in China. The task is far from complete, however, especially in some lacustrine and mountainous areas, where conditions are highly favourable for the vector snails, and difficult to modify. A long-term programme of health education, medical care and infrastructure development is needed.

PIP: Archeological studies have shown schistosomiasis to be present in China for at least 2100 years. Large-scale surveys undertaken after the founding of the People's Republic of China found approximately 14,000 square kilometers to be infested with the Oncomelania snail vectors and the disease endemic in 380 counties of twelve provinces south of the Yangtze river. 100 million people were exposed to infection, of whom 12 million were already infected. A schistosomiasis control campaign was thus launched in 1956, and has since eradicated the disease in Fujian, Guangdong, Guangzi, and Shanghai provinces. The prevalence of infection has also been reduced in many other provinces with the disease eradicated in 158 counties and effectively controlled in 101. The area which serves as an habitat for the infected snails has been reduced by 74% to 3700 square kilometers, while the number of people infected has been reduced 87% to 1.6 million. These achievements may be attributed to the success of well-organized programs combining local involvement and major government projects. Much work remains, however, especially in some lacustrine and mountainous areas where conditions are highly favorable for the snail vectors and difficult to modify, to eradicate schistosomiasis across China. A long-term program of health education, medical care, and infrastructure development is called for.

The effect of extract of ginkgo biloba added to haloperidol on superoxide dismutase in inpatients with chronic schizophrenia.

The purpose of the study was to evaluate the effect of the classic antipsychotic haloperidol plus extract of ginkgo biloba (EGb) on treatment-resistant chronic schizophrenia and on blood superoxide dismutase (SOD) levels. Eighty-two patients with chronic refractory schizophrenia were studied. Forty-three patients were treated with haloperidol plus extract of ginkgo biloba (group 1), and 39 received haloperidol plus placebo (group 2). SOD levels of these patients were measured before and after treatment and were compared with SOD levels of 30 healthy volunteers. Therapeutic efficiency was equated with a change in clinical rating scores assessed by standardized measurement tools that included the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms (SANS) over this period. Patients in group 1 improved significantly as demonstrated by scores from these two assessment instruments; those in group 2 improved significantly only as shown by scores on SANS. SOD levels before treatment in all patients were significantly higher than those in healthy controls; after treatment, the SOD level decreased significantly in group 1 but not in group 2. These results suggest that EGb may enhance the efficiency of the classic antipsychotic haloperidol in patients with schizophrenia, especially on their positive symptoms, and that EGb may work through an antioxidant effect that is involved in the therapeutic mechanism in patients with chronic refractory schizophrenia.

Studies on social medicine and leprosy in east China.

Leprosy is a disease in which the social, economic, cultural and environmental factors play an important role in occurrence, spread, control, eradication and rehabilitation. Eliminating the unfavourable factors hindering leprosy control can make achieving the goal of basic eradication of leprosy in China before the end of this century possible. For this reason, since 1984 we have carried out systematic studies of the social aspects of leprosy in Baoying County, a former high-endemic area in Jiangsu Province of East China, where the endemicity of leprosy is nearing full control.