Breakage and Disappearance of a Part of the Midline Catheter Tip During Insertion.

Midline catheters have been proposed as alternatives to central venous catheters and peripherally inserted central catheters. Midline catheters reduce the incidence of overall needle stick injuries during hospitalization, have lower complication rates than central venous catheters or peripherally inserted central catheters, and provide potential cost benefits for hospitals. Complications with midline catheters are similar to those of other intravenous catheters, and intravenous catheter breakage is very rare and invasive. We report a case wherein a midline catheter tip was broken during insertion and removed by open surgery. For the safe use of midline catheters, accurate and delicate insertion techniques should be practiced. More case studies are warranted to verify the usefulness and convenience of various types of midline catheters for their universal use.

[The 498th case: rash, fever and hematuria].

A 50-year-old man was admitted to the Department of Rheumatology at Peking Union Medical College Hospital with rash for 6 months, and fever and hematuria for 5 months. The main clinical manifestations included fever, fatigue, purpura, hematuria and thrombocytopenia. He was positive for antinuclear antibody (ANA), anti-neutrophil cytoplasmic antibodies (ANCA) and rheumatoid factor (RF), and had low complement levels. Initial blood culture, echocardiography and chest CT showed no signs of infection. Diagnosis of connective tissue disease was made initially. His disease improved under treatment with glucocorticoids and immunosuppressive agents, but relapsed when glucocorticoids were tapered. After admission, the diagnosis was reconsidered, and infective endocarditis was finally diagnosed with repeated positive blood cultures and vegetations detected by transesophageal echocardiography. Amoxicillin and clavulanate potassium were initiated, and surgery was performed. His symptoms finally recovered gradually.

The recurrence of phantom limb pain with spinal anesthesia.

The recurrence or exacerbation of phantom limb pain (PLP) induced by spinal anesthesia in patients with amputated limbs is rare, but it can occur in any amputee. A 76-year-old woman with an amputated right knee underwent three left knee surgeries with spinal anesthesia over a period of 6 months. She did not experience PLP in the previous two surgeries but experienced the recurrence of severe PLP after the third surgery for the left knee amputation. It is believed that this third operation caused the patient to experience even more severe psychological stress than the previous two operations. Regional blocks can induce PLP in amputees. In addition, PLP can be triggered and exacerbated by psychological factors. Therefore, we suggest that physicians check the patient's psychological state and provide adequate mental stability when performing surgeries with spinal anesthesia in amputated patients.

[Effects of plasma lipopolysaccharide changes on platelet release of vascular endothelial growth factor and thromobospondin-1 in patients with cirrhotic portal hypertension after TIPS procedure].

Objective: To investigate the effects of plasma lipopolysaccharide (LPS) concentration changes on platelet release of vascular endothelial growth factor (VEGF) and thrombospondin (TSP)-1 in patients with decompensated cirrhotic portal hypertension after transjugular intrahepatic portosystemic shunt (TIPS) procedure. Methods: 169 cases with cirrhotic portal hypertension were enrolled, of which 81 cases received TIPS treatment. LPS, VEGF, and TSP-1 concentrations with different Child-Pugh class in peripheral blood plasma of patients were measured. After pre-incubation of normal human platelets with different concentrations of LPS and stimulated by collagen in vitro, platelet PAC-1 expression rate, VEGF, and TSP-1 concentrations were detected. PAC-1 expression rate and the concentrations of LPS, VEGF and TSP-1 in peripheral blood plasma of patients before and after TIPS procedure were detected. The relationship between plasma LPS, VEGF and TSP-1 concentrations and Child-Pugh score changes in patients after TIPS procedure was analyzed. Statistical analysis was performed by t-test, one-way ANOVA or Pearson's rho according to different data. Results: Plasma LPS and TSP-1 concentrations were significantly higher in Child-Pugh class C patients than class A and B, but the concentration of plasma VEGF was significantly lower than class A and B (P < 0.01). In vitro experiments showed that concentration of LPS, TSP-1, and platelet PAC-1 expression rate was higher in the supernatant, but the difference in the concentration of VEGF in the supernatant was not statistically significant. Portal vein pressure and platelet activation were significantly decreased (P < 0.01) in patients after TIPS procedure. Portal venous pressure, platelet activation, plasma LPS, and TSP-1 levels were significantly decreased continuously, while VEGF levels were significantly increased continuously after TIPS procedure. Plasma LPS concentration was positively correlated with TSP-1 concentration (r = 0.506, P < 0.001), and negatively correlated with VEGF concentration (r = -0.167, P = 0.010). Child-Pugh score change range was negatively correlated with change range of plasma VEGF concentration (r = -0.297, P = 0.016), and positively correlated with change range of plasma TSP-1 concentration (r = 0.145, P = 0.031) after TIPS. Conclusion: Portal venous pressure gradient, plasma LPS concentration and corresponding platelet activation was decreased in cirrhotic portal hypertension after TIPS procedure, and with TSP-1 reduction and VEGF elevation it is possible to reduce the liver function injury caused by portal venous shunt.

[Current status of occupational stress among medical staff in Shenzhen, China and related influencing factors].

Objective: To investigate the current status of occupational stress in medical staff in Shenzhen, China, and to provide a reference for developing health administrative policy and reducing occupational stress in medical staff. Methods: From January to June, 2018, a cross-sectional survey was performed in 992 medical workers who were selected from 2 municipal hospitals and 2 district hospitals by stratified random sampling. General information was collected, Occupational Stress Inventory-Revised Edition was used to investigate occupational stress, and univariate and multivariate analyses were performed based on a descriptive analysis of related results. Results: For the medical staff in Shenzhen, the scores of Occupational Role Questionnaire, Personal Stress Questionnaire, and Personal Resources Questionnaire were 185.67±17.55, 108.45±15.56, and 122.74±16.56, respectively. Age, degree of education, type of work, job title, professional title, and permanent or temporary job were influencing factors for occupational task (P<0.05) ; age, working years, type of work, and night shift were influencing factors for personal stress response (P<0.05) ; working years, type of work, professional title, and weekly working hours were influencing factors for personal coping resources (P<0.05) . Conclusion: There is a high degree of occupational stress among medical staff in Shenzhen, and it is recommended to improve medical resources in Shenzhen, reduce occupational stress among medical staff, and increase coping resources.

Cardiac µ-opioid receptor contributes to opioid-induced cardioprotection in chronic heart failure.

BACKGROUND: The therapeutic potential of cardiac µ-opioid receptors in ischaemia-reperfusion (I/R) injury during opioid-modulating diseases, such as heart failure, is unknown. We aimed to explore the changes of cardiac µ-opioid receptor expression during heart failure, and its role in opioid-induced cardioprotection. METHODS: Rats received doxorubicin (DOX) or were subjected to coronary artery ligation to induce heart failure, or received normal saline (NS) as control. Hearts from NS or DOX rats were isolated and subjected to myocardial ischaemia and reperfusion in an in vitro perfusion system. The opioid [D-Ala,2N-MePhe,4 Gly-ol]-enkephalin (DAMGO), with a high µ-opioid receptor specificity, morphine, and remifentanil were administrated before I/R with or without opioid receptor antagonists, or an extracellular signal-regulated kinase (ERK) inhibitor. RESULTS: Cardiac µ-opioid receptor mRNA concentrations were 3.2 times elevated in DOX-treated rats compared with NS rats, while cardiac µ-opioid receptor protein concentrations showed 6.1- and 3.5-fold increases in DOX-treated and post-infarcted rats, respectively. DAMGO reduced I/R-caused infarct size, expressed as the ratio of area at risk, from 0.50 (0.04) to 0.25 (0.03) in failing rat hearts, but had no effect on infarct size in control hearts. DAMGO promoted phosphorylation of ERK and glycogen synthase kinase (GSK)-3ß only in failing hearts. DAMGO-mediated cardioprotection was blocked by an ERK inhibitor. The µ-opioid receptor antagonist D-Pen-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2 (CTOP) prevented morphine- and remifentanil-induced cardioprotection and phosphorylation of ERK and GSK-3ß in failing hearts. In contrast, δ- and κ-opioid receptor selective antagonists were less potent than CTOP in the failing hearts. CONCLUSIONS: Cardiac µ-opioid receptors were substantially up-regulated during heart failure, which increased DAMGO-induced cardioprotection against I/R injury.

Initial empiric antibiotic therapy for community-acquired pneumonia in Chinese hospitals.

OBJECTIVES: Studies on treatment of community-acquired pneumonia (CAP) in China are scarce. We performed a study to investigate empiric antibiotic practices for patients hospitalized with CAP in China and the risk factors for treatment failure. METHODS: Data were collected from a national Chinese hospitalization database. Adult patients who were diagnosed with CAP between 1 October 2014 and 30 September 2015 were identified. We studied initial empiric antibiotic regimens, microbiologic sampling, treatment failure, in-hospital mortality and length of hospital stay. RESULTS: We included 18 043 adult patients from 185 hospitals who met all the study inclusion criteria. The most common initial antibiotic regimen for CAP was monotherapy with a fluoroquinolone (14.8%, 2671/18 043). The most common initial antibiotic (used alone or in combination with other antibiotics) was levofloxacin (15.7%, 4597/29 278 (this denominator represents the total number of initial antibiotics)). The microbiologic sampling rate was 26.9% (4851/18 043). A total of 4050 (22.4%) of 18 043 patients experienced treatment failure. Multivariate logistic regression demonstrated that older age, male sex, coexisting lung cancer and use of regimens not covering atypical pathogens were risk factors for treatment failure. In-hospital mortality was 2.1% (380/18 043). The median hospital length of stay was 11 days (interquartile range, 8-15 days). CONCLUSIONS: Patients receiving Chinese guideline-adherent regimens had better outcomes, and atypical pathogen active regimens were associated with a lower treatment failure rate and shorter length of hospital stay.

Solid pseudopapillary neoplasm of the pancreas with liver metastasis initially misinterpreted as benign haemorrhagic cyst.

Solid pseudopapillary neoplasm (SPN) of the pancreas is considered a low-malignant neoplasm with a good prognosis. However, 5% to 15% of patients with SPNs develop metastatic disease, most commonly in the liver. Metastatic hepatic malignancies that show pseudocystic features are rare. Here we describe the case of a middle-aged female with a cystic liver metastasis from SPN. To the best of our knowledge, SPN with a single cystic liver metastasis has not been described, although these tumours frequently undergo haemorrhagic-cystic degeneration. Thus, in these patients the marked cystic change could be misinterpreted as a benign lesion.

Morphology of Labronemella major n. sp. (Nematoda: Dorylaimida), a soil-dwelling nematode from China, including a revised key to species of the genus.

One new species from Qinghai Province, China, Labronemella major n. sp., is described. The new species is characterized by a body length of 3.03-3.34 mm; lip region wide, offset by a distinct depression, disc-like with six separated inner liplets; amphid fovea funnel-shaped, distinctly bulged on body surface in scanning electron micrographs; odontostyle long (35-39 µm) with distinct lumen, aperture about 39-47% of its length; odontophore rod-like and long; guiding ring double; pharyngeal basal expansion about half of the total neck length; uterus relatively long and tripartite; vulva transverse and sclerotized; spicules 81-90 µm long; ventromedial supplements 19-23; tail short, rounded to conoid. It can be differentiated from all other species of the genus by its relatively longer body, odontostyle and spicules, and wider lip region. Due to the lip region being offset by a deep constriction, and the long (three or more times the body diameter at mid-body) tripartite uterus, the new species is close to Labronemella czernowitzensis (Micoletzky, 1922) Andrássy, 2002 and Labronemella labiata Andrássy, 1985. An improved key to the genus including the new species is provided.

Morphology and morphometrics of Heterodorus qinghaiensis n. sp. (Dorylaimida, Nordiidae) from soil samples in China.

One new species of the family Nordiidae Jairajpuri & Siddiqi, 1964 from the enclosure grassland of Qinghai Province, China, Heterodorus qinghaiensis n. sp., is described and illustrated. The new species is characterized by the slender body, 1.29-1.46 mm in length; the granular lateral chord with numerous large depression plaques throughout its entirety; the lip region offset by a distinct depression; amphid goblet-shaped with aperture about half to two-thirds of corresponding body diameter; odontostyle 11-13 µm long; rod-like odontophore without basal flanges; pharyngeal basal expansion about one-third of the total neck length; didelphic genital system containing sperm; ovaries generally not reaching the sphincter level; vulva transversed and sclerotized; female tail conoid with round terminus; 3-5 spaced ventromedial supplements and spicule 32-41 µm long. It is close to H. liangi (Ahmad, Wu & Shaheen, 2002) Andrássy, 2009, H. brevidentatus (Thorne, 1939) Andrássy, 2009, H. monticola Andrássy, 2011, H. morgensis (Loof, 1988) Andrássy, 2009 and H. meghalayensis (Mushtaq, Baniyamuddin & Ahmad, 2007) Andrássy, 2009 in having inconspicuous or no lateral body pores, smaller odontostyle and ventrally curved tail.

Duplication polymorphisms in exon 4 of κ-casein gene in yak breeds/populations.

The objective of this study was to compare 12 bp-duplication polymorphisms in exon 4 of the κ-casein gene among 3 breeds/populations of yak (Bos grunniens). Genomic DNA was extracted from yak blood or muscle samples (N = 211) and a partial sequence of exon 4 of κ-casein gene was amplified by polymerase chain reaction. A polyacrylamide gel electrophoresis assay of the products (169 bp) revealed 2 variants. These variants differed in a 12-bp duplication of the nucleotide sequence corresponding to amino acids 147-150 (Glu-Ala-Ser-Pro) or 148-151 (Ala-Ser-Pro-Glu). The genotype frequency and gene frequency of the 2 κ-casein variants differed among the 3 yak breeds/populations. The long form of the κ-casein gene was the predominant allele, and the Jiulong yak showed the highest frequency of the short form variant of the κ-casein gene. In addition, 2 nucleotide differences resulting in amino acid substitutions were also identified in yaks. These results are significant for designing a breeding strategy to improve the genetic makeup of yak herds.

Correlation between carbonic anhydrase IX (CA-9), XII (CA-12) and hypoxia inducible factor-2α (HIF-2α) in breast cancer.

Hypoxia inducible factor 2α (HIF-2α) can trigger the expression of several genes related to many aspects of tumor progress under hypoxia. As an independent factor, the role of HIF-2α is different from other hypoxia-mediated elements, including HIF-1α. Carbonic anhydrase (CA) were also regarded as important enzymes that involve in the tumor microenvironment pH. To find clinical-pathological features of breast cancer in plateau and explore the impact of CAIX, XII (CA-9, CA-12) and HIF-2α on patients with breast cancer. Clinical data were collected and summarized in 94 patients with breast cancer. The expression of HIF-2α, CA-9 and CA-12 were detected, using immunohistochemistry of specimens. The relation between expressions and clinical-pathology was analyzed. Under normoxia, hypoxia, and after being pretreated with the JNK inhibitor SP600125, HIF- 2α, CA-9 and CA-12 expressions were detected, and adhesion and invasion assays were performed in MCF-7 cells and HIF- 2α shRNA cells, respectively. There are higher expressions of HIF-2α in tumor classification 2 and clinical stage 2 (P < 0.05). High expression of CA-12 was observed in clinical stage 2 (P < 0.05). CA-9 expression is significantly correlated with CA-12 expression (r = 0.376, P = 0.0001). HIF-2α expression is not correlated with both CA-9 expression (P = 0.21) and CA-12 expression (P = 0.27). Breast cancer cells in vitro showed that HIF-2α, CA-9 or CA-12 had an increase expression under hypoxia (1% O2). CA-9 or CA-12 expression was observed in HIF-2α shRNA cells. JNK inhibitor SP 600125 reduced the HIF-2α expression and inhibited the adhesion and invasion of breast cancer cell. Slight inhibition effect on CA-9 and CA-12 expression was found. In conclusion, HIF-2α, CA-9 and CA-12 are important hypoxia responsive elements in breast cancer. HIF-2α was involved in metastasis and invasion of breast cancer cells under hypoxia, by the involvement of c-Jun NH2-terminal kinase (JNK) signal pathway. CA-9 and CA-12 may tend to be regulated by HIF-1α more often than by HIF-2α under hypoxia.

A carcinoid tumour arising within a tailgut cyst: a diagnostic challenge.

A 49-year-old man was referred with constipation that had lasted for a few months. On colonoscopy, a subepithelial tumour more than 4 cm in size was seen in the rectum. He underwent endoscopic ultrasound and pelvic magnetic resonance imaging. He was preoperatively diagnosed with a rectal duplication cyst based on imaging studies. However, the final histopathologic diagnosis after transanal excision of the rectal mass was rectal carcinoid tumour with tailgut cyst. Tailgut cysts are very rare congenital lesions in the presacral area and are most often discovered incidentally in middle-aged women. It is difficult to distinguish the imaging appearance of tailgut cysts from that of many other retrorectal cysts. Malignant transformation of tailgut cysts has been estimated to occur in 2 to 13% of cases. We report the diagnostic difficulties encountered in a case of carcinoid tumour arising from a tailgut cyst in a male patient.

Endoscopic submucosal dissection with sentinel node navigation surgery for early gastric cancer.

We combined endoscopic submucosal dissection (ESD) and sentinel node navigation surgery with the purpose of achieving complete resection of early gastric cancer while preserving the organ and assessing pathological nodal status. A total of 13 patients with cT1( ≤ 3 cm)N0 early gastric cancer underwent combined ESD and sentinel node navigation surgery (ESN) at a single tertiary referral center. Sentinel node navigation surgery using indocyanine green was performed during ESD and all suspected sentinel nodes were removed laparoscopically and examined intraoperatively. ESN was converted to gastrectomy with D2 dissection if there was evidence of metastasis on frozen section. ESN was completed in 12 patients and in 1 patient was converted to gastrectomy after sentinel node navigation surgery. En bloc tumor resection was achieved in all cases. Two patients underwent additional gastrectomy because they had tumor-positive vertical margins. In all cases ESN was conducted without intraoperative or postoperative adverse events. ESN is a feasible minimally invasive procedure that allows en bloc tumor resection to be achieved while assessing the pathological status of the lymph nodes.

Differences in mitochondrial gene expression profiles, enzyme activities and myosin heavy chain types in yak versus bovine skeletal muscles.

Hypoxia can affect energy metabolism. We examined gene expression and enzyme activity related to mitochondrial energy metabolism, as well as myosin heavy chain (MyHC) types in yaks (Bos grunniens) living at high altitudes. Real-time quantitative PCR assays indicated that the yak has significantly lower levels of carnitine palmitoyltransferase (CPT) mRNA in the biceps femoris and lower levels of uncoupling protein 3 (UCP3) mRNA in both biceps femoris and longissimus dorsi than in Yellow cattle. No significant differences between yak and Yellow cattle were observed in the activities of mitochondrial ß-hydroxyacyl-CoA dehydrogenase, isocitrate dehydrogenase and cytochrome oxidase in the same muscles. Semi-quantitative RT-PCR analysis showed that the MyHC 1 mRNA levels in yak biceps femoris was lower than in Yellow cattle. We conclude that the yak has significantly lower mRNA levels of CPT, UCP3, and MyHC 1 in biceps femoris than in Yellow cattle, suggesting that the yak biceps femoris has lower fatty acid oxidation capacity and greater glycolytic metabolic potential.

A novel lift-off method for fabricating patterned and vertically-aligned W18O49 nanowire arrays with good field emission performance.

A novel lift-off method has been developed for fabricating patterned W(18)O(49) nanowires in vertical arrays and on a large scale. These W(18)O(49) nanowire arrays have an average diameter of about 30 nm, and their lengths range from 2-3 µm. In every pattern of a 2 inch sample, the nanowires exhibit the same morphology and growth density. They are single crystals with monoclinic structure and grow along the [010] direction. Field emission (FE) measurements show that they have a turn-on field of 6.2 V µm(-1) and their emission current density can reach 500 µA cm(-2) at an electric field of 10.9 V µm(-1). Because the W(18)O(49) nanowire patterns synthesized by this simple method still have good FE performance, comparable to many cathode nanostructures with excellent FE properties, it suggests that it may provide an effective and simple preparation technique for patterned growth of nanowire arrays in future FE applications.

Hybrid natural orifice transluminal endoscopic surgery: endoscopic full-thickness resection of early gastric cancer and laparoscopic regional lymph node dissection--14 human cases.

BACKGROUND AND STUDY AIM: Minimally invasive treatment has become a mainstay management strategy for early gastric cancer (EGC). Full-thickness incision of the gastric wall using natural orifice transluminal endoscopic surgery (NOTES) has been reported but is not easily applicable in clinical settings at present. The aim of the current study was to assess the feasibility of hybrid NOTES, which consists of endoscopic full-thickness gastric resection and a laparoscopic lymphadenectomy. PATIENTS AND METHODS: This was a prospective, pilot study at a single tertiary care referral center. A total of 14 patients with EGC located above the lower third of the stomach underwent hybrid NOTES. Clinically, the patients had contraindications to exclusive treatment using endoscopic submucosal dissection (ESD). The main outcome measure was technical success of hybrid NOTES. RESULTS: All cases were resected en bloc with negative surgical margins. Histologically, four cases were mucosal cancers, and 10 cases were submucosal cancers. The median tumor size was 26 mm (range 12 - 90 mm). Lymphatic vessel invasion was found in four cases without lymph node metastasis (LNM). The median number of obtained lymph nodes was 18 (range 7 - 67). LNM was discovered in one case of undifferentiated submucosal cancer without lymphovascular invasion. Hybrid NOTES was conducted without intraoperative or postoperative adverse events in nine cases. The median operating time and estimated blood loss of successful cases were 143 minutes (range 110 - 253 minutes) and 16 mL (range 5 - 30 mL), respectively. The median hospital stay was 6 days (range 4 - 10 days). Five cases were converted to a subtotal gastrectomy for various reasons. CONCLUSIONS: Hybrid NOTES could be a bridge between endoscopic resection and laparoscopic surgery and may prevent extensive gastrectomy in patients with EGC.

Effect of drug-eluting metal stents in benign esophageal stricture: an in vivo animal study.

BACKGROUND AND STUDY AIMS: The aim of this study in canines was to investigate the effectiveness and safety of self-expandable metal stents, which were coated with paclitaxel to minimize the tissue response. MATERIALS AND METHODS: 14 dogs (5-10 kg) were randomly allocated to two groups. Drug-eluting stents (DES, n = 7) or nondrug-eluting stents (non-DES, n = 7) were endoscopically inserted and fixed in the esophagus of healthy dogs. Every 2 weeks, for a maximum period of 8 weeks, an endoscopic examination was performed to evaluate the status of stent insertion, the grade of tissue hyperplasia, and mucosal change at both ends of the stent. RESULTS: One case of stent migration was observed after 4 weeks in the non-DES group. In this group, tissue reaction and hyperplasia remained for more than 4 weeks after stent insertion. By contrast, an endoscopic examination of the surrounding esophageal mucosa in the DES group showed very little tissue reaction, and the stent was easily separated from the esophageal tissue. CONCLUSION: Although further studies are required to confirm our results, we suggest that these newly designed DES may provide an alternative tool to manage refractory benign esophageal stricture.