Comparison of endoscopic submucosal dissection and surgery for circumferential superficial esophageal squamous cell neoplasm / 中华消化内镜杂志

Objective:To compare the efficacy of endoscopic submucosal dissection (ESD) and surgery for circumferential superficial esophageal squamous cell neoplasm.Methods:A retrospective analysis was performed on 153 patients with superficial esophageal squamous cell neoplasm who underwent ESD or surgery at Cancer Hospital, Chinese Academy of Medical Sciences from November 2013 to October 2021. There were 116 cases in ESD group and 37 cases in the surgical group. The en block resection rate, complete resection rate, operation time, perioperative complication incidence, postoperative quality of life, postoperative disease-free survival and overall survival were compared.Results:In the ESD group, the en block resection rate was 100.0% (116/116) and the complete resection rate was 96.6% (112/116). The longitudinal diameter of lesion had no significant correlation with complications or complete resection rate ( P>0.05). The operation time of the ESD group was significantly shorter than that of the surgical group (175.1±52.2 min VS 266.7±88.2 min, t=-5.991, P<0.001). There was no significant difference in the incidence of perioperative complications between the ESD group and surgical group [5.2% (6/116) VS 8.1% (3/37), P=0.452]. According to EORTC-QLQ-C30 and EORTC-QLQ-OES18, emotional function ( P=0.008),cognitive function ( P=0.013) and the total health level ( P<0.001) of the ESD group were significantly higher than those in the surgical group. Fatigue ( P=0.002), pain ( P<0.001), dyspnea ( P<0.001), insomnia ( P<0.001), anorexia ( P<0.001), diarrhea ( P<0.001) and reflux ( P<0.001) in the surgical group were significantly higher than those in ESD group. There was no significant difference in disease-free survival or overall survival between the two groups ( P>0.05). Polyglycolic acid combined with autologous esophageal mucosal transplantation combined with temporary esophageal stent implantation could reduce the rate of esophageal scar stenosis after ESD [53.3% (24/45) VS 100.0% (55/55), P<0.001] and significantly reduce the number of postoperative dilation [1.00 (0.00, 5.00) VS 9.00 (5.00, 14.00), P<0.001] compared with balloon dilation alone. Conclusion:ESD is superior to traditional surgery for the treatment of circumferential superficial esophageal squamous cell neoplasm because of high operational safety, shorter operation time, less trauma, better postoperative life quality. Postoperative esophageal stenosis can still be well cured after endoscopic treatment. Therefore, ESD can be used as the first choice for the treatment of circumferential superficial esophageal squamous cell neoplasm.

Application of artificial intelligence based on data enhancement and hybrid neural network to site identification during esophagogastroduodenoscopy / 中华消化内镜杂志

Objective:To evaluate artificial intelligence constructed by deep convolutional neural network (DCNN) for the site identification in upper gastrointestinal endoscopy.Methods:A total of 21 310 images of esophagogastroduodenoscopy from the Cancer Hospital of Chinese Academy of Medical Sciences from January 2019 to June 2021 were collected. A total of 19 191 images of them were used to construct site identification model, and the remaining 2 119 images were used for verification. The performance differences of two models constructed by DCCN in the identification of 30 sites of the upper digestive tract were compared. One model was the traditional ResNetV2 model constructed by Inception-ResNetV2 (ResNetV2), the other was a hybrid neural network RESENet model constructed by Inception-ResNetV2 and Squeeze-Excitation Networks (RESENet). The main indices were the accuracy, the sensitivity, the specificity, positive predictive value (PPV) and negative predictive value (NPV).Results:The accuracy, the sensitivity, the specificity, PPV and NPV of ResNetV2 model in the identification of 30 sites of the upper digestive tract were 94.62%-99.10%, 30.61%-100.00%, 96.07%-99.56%, 42.26%-86.44% and 97.13%-99.75%, respectively. The corresponding values of RESENet model were 98.08%-99.95%, 92.86%-100.00%, 98.51%-100.00%, 74.51%-100.00% and 98.85%-100.00%, respectively. The mean accuracy, mean sensitivity, mean specificity, mean PPV and mean NPV of ResNetV2 model were 97.60%, 75.58%, 98.75%, 63.44% and 98.76%, respectively. The corresponding values of RESENet model were 99.34% ( P<0.001), 99.57% ( P<0.001), 99.66% ( P<0.001), 90.20% ( P<0.001) and 99.66% ( P<0.001). Conclusion:Compared with the traditional ResNetV2 model, the artificial intelligence-assisted site identification model constructed by RESENNet, a hybrid neural network, shows significantly improved performance. This model can be used to monitor the integrity of the esophagogastroduodenoscopic procedures and is expected to become an important assistant for standardizing and improving quality of the procedures, as well as an significant tool for quality control of esophagogastroduodenoscopy.

Clinical effect of different plastic biliary stent indwelling methods on managing obstructive jaundice in unresectable hilar cholangiocarcinoma / 中华消化内镜杂志

Objective:To compare the clinical effect of three indwelling methods of plastic biliary stent on relieving obstructive jaundice caused by unresectable hilar cholangiocarcinoma.Methods:A retrospective study was performed on data of 61 patients with obstructive jaundice caused by unresectable hilar cholangiocarcinoma from April 2014 to December 2020 in Cancer Hospital, Chinese Academy of Medical Sciences. Plastic biliary stent placement was used to relieve jaundice, including 18 cases of intragastric indwelling at the end of biliary stent, 31 cases of duodenal papilla indwelling at the end of biliary stent, and 12 cases of horizontal portion of duodenum indwelling at the end of biliary stent. Incidence of fever within 2 weeks, perioperative mortality, 90-day obstruction rate, and median stent patency period were followed up and the results were analyzed.Results:The incidence of fever within 2 weeks of the three groups were significantly different [66.7% (12/18), 58.1% (18/31) and 16.7% (2/12), χ2=7.30, P=0.026]. There were no statistically differences in the perioperative mortality [0 (0/16), 3.2% (1/31) and 0 (0/10), χ2=1.09, P=1.000], 90-day obstruction rate [52.9% (9/17), 48.3% (14/29) and 40.0% (4/10), χ2=1.91, P=0.589], or median stent patency period (66.0 d, 91.5 d and 94.0 d, Z=4.96, P=0.084) among three groups. Conclusion:Patients with biliary plastic stents with ends placed at the horizontal portion of the duodenum show lower incidence of fever within two weeks after implantation, and similar median stent patency period, 90-day obstruction rate and perioperative mortality compared with intragastric indwelling and duodenal papilla indwelling groups. Therefore, biliary plastic stents with ends placed at the horizontal portion of the duodenum should be recommended as the preferred procedure.

Endoscopic submucosal dissection for early hypopharyngeal carcinoma and precancerous lesions / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for early hypopharyngeal carcinoma and precancerous lesions.Methods:Clinical data of 41 patients who received ESD for early hypopharyngeal carcinoma and precancerous lesions from August 2013 to August 2019 in the Department of Endoscopy of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively analyzed. Main outcome measurements included operation completion rate, operation time, en bloc resection rate, R0 resection rate, complication rate and recurrence.Results:ESD was successfully completed in all 41 cases, with a success rate of 100.0% and a mean time of 49.1 min (ranged 10-110 min). Fifty-four lesions underwent en bloc resection, with an en bloc resection rate of 98.2% (54/55), of which 41 had negative horizontal and vertical margins, and the R0 resection rate was 74.5% (41/55). During the operation of 55 lesions, there was a small amount of blood oozing on the wound surface, and electrocoagulation with thermal biopsy forceps could successfully stop the bleeding. No perforation occurred, and 2 cases (4.3%) had delayed bleeding after ESD, and hemostasis was successful under emergency endoscopy. Postoperative endoscopy showed that 1 case (2.2%) had esophageal entrance stenosis, and the obstruction was relieved after repeated water balloon dilatation. The follow-up period ranged from 3 to 72 months, and the median time was 18 months. One case was found to have mucosal lesions in the same part of the hypopharynx and received ESD treatment again. Follow-up to October 2020, no residual lesions and recurrence were found.Conclusion:ESD is a safe and effective option for the treatment of early hypopharyngeal carcinoma and precancerous lesions, which is worthy of clinical application.

Mechanism of Qihuang Yiqi Shexue Prescription in Treatment of ITP Model Mice Based on Autophagy Mediated by AMPK/mTOR/ULK1 Signaling Pathway / 中国实验方剂学杂志

ObjectiveTo explore the mechanism of Qihuang Yiqi Shexue prescription （QHYQSX） in the treatment of immune thrombocytopenia （ITP） model mice based on the autophagy mediated by the adenosine monophosphate-activated protein kinase （AMPK）/mammalian target of rapamycin （mTOR）/Unc-51-like kinase 1 （ULK1） signaling pathway. MethodFifty BALB/c mice were randomly divided into normal group， model group， high- and low-dose QHYQSX groups， and prednisone group， with 10 mice in each group. The ITP model was induced by intraperitoneal injection of anti-platelet serum （APS） of guinea pig. On the 8th day of the APS injection， drugs were administered by gavage for 14 days. Peripheral blood platelet （PLT） count and hemoglobin （Hb） concentration were detected. Spleen and thymus were separated， weighed， and the organ index was calculated. Sternum was sampled for bone marrow smear， and bone marrow megakaryocytes were classified under a microscope. Thrombopoietin （TPO）， interleukin-6 （IL-6）， IL-10， tumor necrosis factor-α （TNF-α）， transforming growth factor-β1 （TGF-β1）， and interferon-γ （IFN-γ） in the serum were detected by enzyme-linked immunosorbent assay（ELISA）. AMPK， mTOR， ULK1， microtubule-associated protein light chain 3 （LC3）， Beclin1， and p62 mRNA expression levels in the spleen were detected by Real-time fluorescence-based quantitative polymerase chain reaction （Real-time PCR）. The protein expression of AMPK， p-AMPK， p-mTOR， p-ULK1， LC3Ⅱ/LC3Ⅰ， Beclin1， and p62 in the spleen was detected by Western blot. ResultCompared with the normal group， the model group showed reduced peripheral blood PLT count， Hb， and TPO levels （P<0.05，P<0.01）， increased spleen and thymus indexes （P<0.01）， decreased number of bone marrow megakaryocytes （P<0.01）， elevated serum levels of IL-6， TNF-α， and IFN-γ （P<0.01）， and reduced IL-10 and TGF-β1 levels （P<0.01）. Compared with the model group， the groups with drug intervention showed increased PLT counts and TPO levels （P<0.01）， decreased spleen and thymus indexes （P<0.05， P<0.01）， elevated number of bone marrow megakaryocytes （P<0.05， P<0.01）， reduced serum levels of IL-6， TNF-α， and IFN-γ （P<0.05， P<0.01）， and up-regulated IL-10 and TGF-β1 levels （P<0.05，P<0.01）. Compared with the low-dose QHYQSX group， the high-dose QHYQSX group and the prednisone group showed different degrees of significant differences in improving PLT counts and levels of cellular inflammatory factors （P<0.05， P<0.01）. Real-time PCR and Western blot results showed that compared with the normal group， the model group showed up-regulated mRNA expression of AMPK， LC3， and Beclin1 and protein expression of p-AMPK/AMPK， LC3Ⅱ/LC3Ⅰ， and Beclin1 in the spleen （P<0.05， P<0.01）， and down-regulated mRNA expression of mTOR， ULK1， and p62 and protein expression of p-mTOR， p-ULK1， and p62 （P<0.05， P<0.01）. Compared with the results in the model group， high- and low-dose QHYQSX and prednisone could down-regulate the mRNA expression of AMPK， LC3， and Beclin1 and protein expression of p-AMPK/AMPK， LC3Ⅱ/LC3Ⅰ， and Beclin1 in the spleen （P<0.05， P<0.01）， and up-regulate the mRNA expression of mTOR， ULK1， and p62 and protein expression of p-mTOR， p-ULK1， and p62 （P<0.05， P<0.01）. ConclusionQHYQSX may inhibit excessive autophagy by regulating the AMPK/mTOR/ULK1 signaling pathway， thereby regulating immune intolerance and playing a role in the treatment of ITP.

Risk factors for esophageal refractory stenosis after large-scale endoscopic submucosal dissection of superficial esophageal neoplasms / 中华消化内镜杂志

Objective:To determine risk factors for postoperative esophageal refractory stenosis after endoscopic submucosal dissection (ESD) of large-scale early esophageal carcinomas and precancerous lesions.Methods:Two hundred and twelve early esophageal carcinomas or precancerous lesions in 186 patients who underwent ESD larger than 3/4 the total esophageal circumference in Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, between July 2013 and December 2017 were divided into two groups according to session number of endoscopic balloon dilatation (EBD), the refractory stenosis group ( n=69, ≥6 EBD sessions) and non-refractory stenosis group ( n=117, ≤5 EBD sessions). Student′s t-test or Mann-Whitney U test was used for univariate analysis and χ2 test and Fisher exact test were used for comparison of categorical variables. Logistic regression was used for multivariate analysis. Results:Compared with the non-refractory stenosis group, the refractory stenosis group had statistically significant differences in the longitudinal diameter of lesions, the longitudinal diameter of artificial ulcer, lesion location, the circumferential range of lesions and the composition of the muscular layer injury (all P<0.05). After eliminating the factor of the vertical diameter of artificial ulcer (because there was significant correlation between the vertical diameter of artificial ulcer and the longitudinal diameter of lesion in clinical practice), multivariate logistic regression analysis showed that the longitudinal diameter of lesion>5 cm (VS ≤5 cm: P=0.003, OR=3.531, 95% CI:1.547-8.060), the location of lesion in the upper thoracic segment (VS lower thoracic segment: P=0.001, OR=36.720, 95% CI:4.233-318.551), in the cervical segment (VS lower thoracic segment: P=0.003, OR=24.959, 95% CI:2.927-212.795), the whole circumferential lesion (VS ≥3/4 but not the whole circumference: P<0.001, OR=10.082, 95% CI:4.196-24.226) and the presence of muscular layer injury ( P<0.001, OR=7.128, 95% CI:2.748-18.486) were more likely to lead to esophageal refractory stenosis after ESD. Conclusion:The longitudinal lesion diameter of more than 5 cm, the circumferential extent of esophageal ESD, cervical or upper-thoracic esophageal lesions, and muscular layer damage are independent risk factors for postoperative esophageal refractory stenosis after ESD for large-scale esophageal cancer and precancerous lesions.

Submucosal tunneling endoscopic resection for submucosal tumors originating from muscularis propria layer at esophagogastric junction / 中华肿瘤杂志

Objective@#To evaluate the short-term outcomes and safety of submucosal tunneling endoscopic resection (STER) for submucosal tumors (SMT) originating from muscularis propria (MP) layer at esophagogastric junction.@*Methods@#The clinical data of 31 patients with SMT originating from MP layer at esophagogastric junction underwent STER were collected and retrospectively analyzed.@*Results@#The success rate of STER of the thirty-one patients was 100%. The mean tumor size was (2.5±1.3) cm and the average operative time was (95.9±56.7) min. Perforation occurred in 3 patients and was successfully clipped by endo-clips during operation. One patient developed delayed bleeding and the bleeding was stopped by endoscopic hemostasis. Twenty-nine leiomyomas and two stromal tumors (GIST) were finally pathologically diagnosed. No local recurrence and distant metastasis were noted during the mean 15.4 months follow-up of 20 cases. According to the lesion size, 31 patients who received STER were divided into two groups. The operation time of maximum diameter ≥3.5 cm group was (134.0±70.6) min, significantly longer than (80.3±42.6) min of maximum diameter <3.5 cm group (P=0.014). However, the en bloc removal rate, postoperative hospital stay and the complication incidence between the two groups had no obvious differences (P>0.05). Univariate analysis showed that the piecemeal removal group had longer tumor diameter, higher incidence of irregular tumor morphology, and longer operative time than the en bloc removal group (all P<0.05). Stepwise logistic regression analysis showed that irregular shape was a risk factor for failure of en bloc removal (OR=18.000, 95% CI: 1.885~171.88, P=0.012).@*Conclusion@#As a new method of minimally invasive treatment, STER technology appears to be a safe and effective option for patients with SMT originating from MP layer at esophagogastric junction.

Natural history of colorectal cancer: a Meta-analysis on global prospective cohort studies / 中华流行病学杂志

Objective@#To acknowledge the availability and rates of annual transition of outcomes during the progression and regression stages of colorectal cancer (CRC) and related diseases, by pooling global follow-up studies on the natural history of CRC.@*Methods@#Till March, 2017, data was collected through systematic literature review over multiple databases, including PubMed, Embase, Cochrane and Chinese Biology Medicine (CBM) disc. Information regarding the characteristics, classification system of health states, related outcomes and incidence rates on CRC or high-risk adenoma for the surveillance cohorts of the studies, were extracted and summarized. Both Meta and sensitivity analyses were performed on those outcomes if they appeared in more than 3 studies, using the random effects model. Annual transition rate with 95%CI was used to estimate each of the outcomes, Quality of the studies was assessed, using the Newcastle-Ottawa Scale.@*Results@#A total of 29 cohort studies were included, with the mean follow-up period as 5.7 years. All studies except one, focused on adenoma-carcinoma pathway and reported the outcome parameters of adenomas by different risk, and some reported the findings on different sizes (n=6) of adenomas. These cohorts were divided into three groups (normal status, with low-risk or high-risk adenoma) according to the status of baseline endoscopic pathologic findings. Their available outcome parameters, corresponding number of involved articles, aggregated sample size and pooled annual transition rates were presented. Six parameters were obtained in the normal cohorts, including those from normal to low-risk adenoma (16 articles, 58 235, 0.030: 0.024-0.037), to high-risk adenoma (17 articles, 62 089, 0.003: 0.002-0.004), to diminutive adenoma (<5 mm, 4 articles, 1 277, 0.021: 0.013-0.029), to small adenoma (6-9 mm, 4 articles, 1 277, 0.006: 0.001-0.010), to large adenoma (≥10 mm, 7 articles, 3 531, 0.002: 0.000-0.003) and to CRC (19 articles, 104 836, 0.000 3: 0.000 2-0.000 5). Three parameters were obtained in low-risk adenoma in cohorts with polypectomy findings, including recurrence (9 articles, 4 788, 0.109: 0.062-0.157) from low-risk adenoma after polypectomy to high-risk adenoma (10 articles, 5 736, 0.009: 0.004-0.013) and to CRC (12 articles, 11 347, 0.000 6: 0.000 4-0.000 8). Three parameters were obtained on high-risk adenoma from cohorts with polypectomy findings, including recurrence (12 articles, 7 030, 0.038: 0.028-0.048) from high-risk adenoma after polypectomy to low-risk adenoma (8 articles, 2 489, 0.133: 0.081-0.185) and CRC (14 articles, 14 899, 0.002: 0.001-0.003). Except for normal to low-risk adenomas, results from the sensitivity analysis for the other parameters showed stable. Of the included studies, two presented incidence rates of CRC in different clinical stages and the another two were focusing on the parameters related to serrated pathway.@*Conclusions@#Globally, follow-up studies reported data on natural history of colorectal cancer is of paucity. Compared to the "adenoma-carcinoma" pathway, transition parameters of the serrated lesion pathway are more limited. This Meta-analysis provided convincing evidence for optimizing the strategies regarding follow-up program on the disease, using the baseline endoscopic findings from global CRC Screening Program. These results also offered strong data-related support for Chinese population- specific interventional model on colorectal cancer.

Clinical value of18F-FDG-PET/CT in recurrent and metastatic breast cancer / 肿瘤

Objective: To explore the clinical significance of18F-fluorodeoxyglucose (FDG) PET/CT for the treatment of recurrent and metastatic breast cancer. Methods: From January 1, 2010 to December 31, 2017, all of 45 patients with breast invasive ductal carcinoma were selected by pathological diagnosis. According to the results of progesterone receptors (PR), estrogen receptor (ER), human epidermal growth factor receptor-2 (HER-2) and Ki-67, all patients were divided into Luminal A, Luminal B, HER-2 over expression and Basal-like types. All patients underwent18F-FDG PET/CT, then the correlations of the maximum standard uptake value (SUVmax) of glucose with the different ER, PR, HER-2 status, molecular subtype and tumor grade of breast cancer were analyzed. Of 18 patients underwent18F-FDG PET/CT again after chemotherapy, and these patients were divided into metabolic reaction group (SUVmax change rate ≥20%, n = 12) and no metabolic response group (SUVmax change rate < 20%, n = 6), then the overall survival time of the two groups of patients was analyzed. Results: The18F-FDG PET/CT SUVmax in ER negative group (n = 19), PR negative group (n = 27) or HER-2 positive group (n = 7) was higher than that in corresponding ER positive group (n = 26), PR positive group (n = 18) or HER-2 negative group (n = 38) (all P < 0.05), respectively. The18F-FDG PET/CT SUVmax in Basal-like and HER-2 over expressed groups were higher than that in Luminal A group (P < 0.001, P = 0.010). The18F-FDG PET/CT SUVmax in Basal-like group was higher than that in Luminal B group (P = 0.011). The18F-FDG PET/CT SUVmax in G3 group was higher than those in G2 and G1 groups (both P < 0.05). The median survival time of patients with breast cancer in metabolic reaction group was longer than that in no metabolic response group (P = 0.001). Conclusion: Different ER, PR, HER-2 status, tumor grading, and molecular typing all affect18F-FDG PET/CT SUVmax.18F-FDG PET/CT SUVmax is correlated with the overall survival time of patients with recurrent metastatic breast cancer.

Compliance rate of screening colonoscopy and its associated factors among high-risk populations of colorectal cancer in urban China / 中华预防医学杂志

Objective@#To evaluate the compliance rate of screening colonoscopy and associated factors in high-risk populations of colorectal cancer (CRC) in urban China.@*Methods@#CRC screening data from the Program of Cancer Screening in Urban China conducted in 12 provinces in 2012-2014 was used in the present study. All 97 445 participants were asked to take epidemiological questionnaire survey to evaluate their cancer risk. Participants who were evaluated as "high risk for CRC" were recommended to receive colonoscopy at designated hospitals. Chi-square tests were used to compare the differences of participation rates between groups. Multivariate logistic regression models were applied to explore the potential factors associated withthe compliance rate of screening colonoscopy.@*Results@#Overall, 97 445 participants of CRC high-risk were included in this analysis, and 14 949 of them took screening colonoscopy, yielding a participation rate of 15.3%. The participation rate varied greatly across provinces, ranging from 25.2% (2 785/11 071) in Heilongjiang to 9.7% (1 698/17 515) in Liaoning. Moreover, the participation rate in 2013-2014 was significantly higher than that in 2012-2013 (17.1%(9 766/57 280) vs 12.9% (5 183/40 165), χ2=57.67, P<0.001) . The multivariate logistic regression analyses showed that: compared with individuals of 40-49 years old, individuals of 50-59 or 60-69 years old were more willing to accept screening colonoscopy, with OR of 1.17 (95% CI: 1.12-1.22) and 1.13 (95% CI: 1.08-1.19), respectively; compared with uneducated individuals, individuals with good educational background of equivalent to high school or higher (OR=1.29, 95% CI:1.10-1.50) were more willing to accept screening colonoscopy; compared with individuals who never took fecal occult blood tests (FOBT) before, individuals with previous positive FOBT results (OR=1.40, 95% CI:1.31-1.50) were more willing to accept screening colonoscopy; compared with individuals with no inflammatory bowel diseases (IBD), individuals with IBD (OR=1.63, 95%CI:1.56-1.69) were more willing to accept screening colonoscopy; Compared with individuals without polyp history, individuals having history of previous polyp detection (OR=1.43, 95% CI:1.37-1.50) were more willing to accept screening colonoscopy; compared to individuals with no family history of CRC, individuals with history of CRC (OR=1.60, 95% CI:1.53-1.66) were more willing to accept screening colonoscopy.@*Conclusion@#The overall participation rate of screening colonoscopy among high-risk population of CRC in the 12 participating sites was 15.3%. The study findings indicated that age, education level, history of past fecal occult blood test, IBD, history of polyp, family history of CRC were associated with the compliance rate of colonoscopy in this population-based CRC screening program.

Applied research of appointment checkup process optimization based on the theory of constraints / 中华医院管理杂志

Objective To discuss the effect of the appointment checkup process optimized with the theory of constraints in shortening the appointment waiting time. Methods The patients who underwent ultrasonography, magnetic resonance imaging examination, and CT examinations were selected from the First Hospital of Shanxi Medical University from March 2017 to February 2018. Firstly, we applied the theory of constraints to investigate and analyze the status of medical technology examinations. Secondly, we optimized the process according to the results of the investigation. Finally, we compared the appointment duration of medical examinations before and after the optimization. Results Thanks to support of departments involved, the longest ultrasonography appointment waiting time was reduced from 3. 74 days to 1. 32 days. The longest appointment time for magnetic resonance imaging examination was reduced from 3. 74 days to 1. 33 days. The longest appointment waiting time for CT was reduced from 2. 62 days to 1. 55 days, and the goal of completing the checkup the day after the prescription was reached in the continuous improvement phase. Conclusions The optimization of the medical technology examination appointment process based on the constraint theory can effectively shorten the checkup appointment duration, maximize utilization of medical resources and optimize the services.

Risk factors analysis of the early colorectal carcinoma after endoscopic non-curative resection: A retrospective clinical study of 56 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the risk factors contributing to the progression-free survival rate of patients undergoing endoscopic non-curative resection.</p><p><b>METHODS</b>Clinicopathological data of patients with early colorectal carcinoma and intraepithelial neoplasia undergoing endoscopic resection in our department from January 2009 to January 2015 were collected. Associated factors affecting the progression-free survival rate of the early colorectal carcinoma after endoscopic non-curative resection were analyzed. Any of the following conditions was defined as endoscopic non-curative resection: (1) positive lateral or vertical cutting margin; (2) submucosa invasion depth ≥1 000 μm; (3) vascular or lymphatic invasion; (4) low differentiation, including signet ring cell carcinoma or mucinous adenocarcinoma; (5) high grade tumor budding.</p><p><b>RESULTS</b>Clinicopathological data of 840 cases were collected. According to China's Endoscopic Screening, Diagnosis and Treatment Guidelines for Early Colorectal Cancer, 56(56/840, 6.7%) cases were defined as the non-curative resection, the metastasis or recurrence rate was 14.3%(8/56), 3-year progression-free survival rate was 85.7%(48/56), and 3-year overall survival rate was 94.6%(53/56). Univariate prognostic analysis showed that 3-year progression-free survival rate in low and moderate-high differentiation adenocarcinoma was 25.0% and 90.4%(χ=6.711, P=0.010), in patients with submucosa invasion depth ≥2 000 μm and <2 000 μm was 75.0% and 93.8%(χ=6.745, P=0.009), and in patients with and without vascular or lymphatic invasion was 60.0% and 88.2%(χ=7.708, P=0.005), whose differences were all significant. Multivariate Cox regression analysis revealed that low differentiation adencarcinoma (P=0.015, HR=8.021, 95%CI: 1.499-42.921), invasion depth ≥2 000 μm (HR=6.823, 95%CI: 1.299-35.848) and vascular or lymphatic invasion (HR=18.143, 95%CI: 2.079-158.358) were independent risk factors for the progression-free survival rate of the early colorectal carcinoma after endoscopic non-curative resection.</p><p><b>CONCLUSION</b>Pathology after endoscopic non-curative resection for early colorectal carcinoma indicates that low differentiation adenocarcinoma, submucosa invasion depth ≥2 000 μm and vascular or lymphatic invasion are independent risk factors of poor prognosis.</p>

Evaluation of a new closure technique of large defects after endoscopic full-thickness resection / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the security and efficacy of a new endoscopic closure method of large defects after endoscopic full-thickness resection (EFTR) double purse-string suture using two endoloops and metallic clips via single-channel endoscopy.</p><p><b>METHODS</b>Clinical data of 23 cases with submucosal tumors (SMT) who received endoscopic resection from June 2015 to July 2016 in our National Cancer Center were collected. For gastric and esophageal SMTs or the mucosa layer injured during submucosal tunneling endoscopic resection (STER), double purse-string suture was conducted after EFTR. The key steps of closure were as follows: the endoloop was installed onto the delivery system and inserted into the gastric cavity to the defect location with endoscopy and then opened; the clips were transported into the gastric cavity from the biopsy channel; the endoloop was fixed onto the full thickness of gastric wall along the edge of the defect by clips one by one between the interval of about 5 mm; the endoloop was tightened slowly till the entire circumference of the defect was sutured, thus, one purse-string suture was done; in accordance with the operation above, another endoloop was released, and the second endoloop was fixed at 5-10 mm to the outer edge of the original one, and tied the endoloop gently; this sequence was continued till there was no gap, thus, the double-purse string suture was finished. A total of 23 patients were enrolled in the study, including 18 with gastric tumor and 5 with esophageal tumor, 15 males and 8 females, with the average age of 56 (19 to 76) years.</p><p><b>RESULTS</b>Eighteen cases of gastric SMT were successfully treated by endoscopic EFTR and double purse-string suture. The esophageal mucosa layer of all the 5 cases of esophageal SMT, including tumors of 3 cases located in cervical esophagus at 15-20 cm from the fore-tooth, 1 esophageal leiomyoma case complicated with squamous cell carcinoma in situ, and 1 case of mucosal layer injury during submucosal tunneling endoscopic resection (STER), was successfully repaired by using double purse-string suture. The mean maximum diameter of tumor was 2.3 cm, and the average suture time was 22.8 min. Postoperative pathology showed that 13 cases were gastrointestinal stromal tumors (GIST), 7 cases were leiomyoma, 2 cases were neurilemmoma, and 1 case was leiomyoma complicated with early squamous cell carcinoma in situ. No severe complications occurred during or after the operation.</p><p><b>CONCLUSIONS</b>The double purse-string suture by using metallic clips and endoloops with single channel endoscope is a relatively safe, easy, and reliable technique for repairing large gastric defect after EFTR. For cervical esophageal SMT, or the SMT combined with superficial mucosal lesions, and for the mucosa layer injury during submucosal tunneling endoscopic resection(STER), double purse-string suture is helpful to perform the closure.</p>

Combined treatment with apatinib for relapsed and refractory breast cancer: A report of 2 cases and related literature review / 肿瘤

Objective: To observe the efficacy and safety of apatinib combined with chemotherapy or endocrine therapy in the treatment of relapsed and refractory breast cancer. Methods: The clinical records of two patients with relapsed and refractory breast cancer treated with apatinib combined with chemotherapy or endocrine therapy were analyzed, and the related literatures were reviewed. Results: Two patients with relapsed and refractory breast cancer were treated with apatinib combined with chemotherapy or endocrine therapy and followed up for 10 months. The treatment outcome was stable disease. Major adverse reaction was hypertension, and the use of antihypertensive drugs could control the blood pressure in a normal range. Conclusion: Apatinib combined with chemotherapy or endocrine therapy in the treatment of relapsed and refractory breast cancer is effective, and the adverse effects are tolerated. Large-scale studies should be implemented to further determine the efficacy of this treatment protocol.

Risk factors and survival analysis for synchronous esophageal carcinoma in patients with hypopharyngeal carcinoma / 中华耳鼻咽喉头颈外科杂志

Objective@#To investigate the risk factors and survival status of hypopharyngeal carcinoma with synchronous second primary carcinoma of the esophagus.@*Methods@#One hundred and sixty patients with newly diagnosed hypopharyngeal carcinoma from January 2009 to December 2012 were retrospectively reviewed. The clinical data, tumor-related information and follow-up results were collected and analyzed.@*Results@#Forty-three synchronous esophageal carcinomas (27%) were detected in 160 patients with hypopharyngeal carcinoma, and most patients (72%) were at an early stage. On univariate analysis, the median age of less than 55 years old (χ2=4.525, P=0.033), excessive alcohol consumption (χ2=6.942, P=0.008) and invasion site more than 3 anatomical regions (χ2=21.503, P=0.000) had a significant correlation with the occurrence of synchronous esophageal carcinomas. Multivariate analysis showed that excessive alcohol consumption (OR=4.787, P=0.029) and invasion site more than 3 anatomical regions (OR=14.391, P=0.000) were independent risk factors. The median survival time was 26 months in 43 patients with synchronous esophageal carcinomas, which was significantly lower than that (58 months) in patients without secondary primary esophageal carcinomas (χ2=11.981, P=0.001).@*Conclusions@#There is a high incidence of synchronous esophageal carcinoma in hypopharyngeal carcinoma patients, affecting the prognosis of hypopharyngeal carcinoma. Surveillance for esophageal carcinomas in patients with hypopharyngeal carcinoma, especially in excessive alcohol drinkers, is warranted.

Comparative analysis for clinical efficacy and life quality between endoscopic submucosal dissection and surgical treatment of patients with early gastric cancer / 中华消化内镜杂志

Objective To compare the efficacy, safety, and the life quality of patients with early gastric cancer ( EGC) between endoscopic submucosal dissection ( ESD) and surgical treatment. Methods A total of 460 cases with EGC receiving endoscopic therapy or surgical treatment were collected from October 2009 to January 2015 in the Cancer Hospital, Chinese Academy of Medical Sciences. The clinical efficacy and life quality of ESD and surgical treatment for EGC patients were retrospectively analyzed. Results There were 434 cases collected in the study, including 208 cases ( 229 lesions) in the ESD group and 226 cases in the surgery group. For the short-term clinical outcomes of the ESD group, the hospitalization time ( 7. 85 ± 3. 18 d VS 16. 68±5. 89 d, P<0. 001), hospitalization cost (3782. 30±1898. 84 CNY VS 9685. 60± 3643. 97 CNY, P<0. 001 ) and complications [ 0 ( 0/208 ) VS 6. 2% ( 14/226 ) , P<0. 001 ] were statistically different compared with those of the surgery group. For the long-term clinical outcomes, there was no statistical significance on recurrence rate[0. 4%(1/229) VS 0. 9% (2/226), P=0. 622] between the two groups. The cumulative multiple hazard probability curve showed that the ESD group had a significantly higher risk of multiple primary lesions than the surgery group ( P=0. 004) after the same follow-up period. In order to exclude the influence of confounding factors, COX regression model was used to control the age and other factors, and multiple primary risks of the two groups were also statistically significant ( P=0. 013) . The health score of self-evaluation and life quality between the two groups were statistically significant ( P<0. 001) . Conclusion For the short-term clinical outcomes, the ESD group was better than the surgery group. For the long-term clinical outcomes, multiple primary risks were higher in the ESD group than those in the surgery group, but most of the multiple primary cases were successfully treated with a second ESD. The health score of self-evaluation and life quality were better in the ESD group than those in the surgery group.

Comparative analysis for clinical efficacy and life quality between endoscopic submucosal dissection and surgical treatment of patients with early gastric cancer / 中华消化内镜杂志

Objective To compare the efficacy, safety, and the life quality of patients with early gastric cancer ( EGC) between endoscopic submucosal dissection ( ESD) and surgical treatment. Methods A total of 460 cases with EGC receiving endoscopic therapy or surgical treatment were collected from October 2009 to January 2015 in the Cancer Hospital, Chinese Academy of Medical Sciences. The clinical efficacy and life quality of ESD and surgical treatment for EGC patients were retrospectively analyzed. Results There were 434 cases collected in the study, including 208 cases ( 229 lesions) in the ESD group and 226 cases in the surgery group. For the short-term clinical outcomes of the ESD group, the hospitalization time ( 7. 85 ± 3. 18 d VS 16. 68±5. 89 d, P<0. 001), hospitalization cost (3782. 30±1898. 84 CNY VS 9685. 60± 3643. 97 CNY, P<0. 001 ) and complications [ 0 ( 0/208 ) VS 6. 2% ( 14/226 ) , P<0. 001 ] were statistically different compared with those of the surgery group. For the long-term clinical outcomes, there was no statistical significance on recurrence rate[0. 4%(1/229) VS 0. 9% (2/226), P=0. 622] between the two groups. The cumulative multiple hazard probability curve showed that the ESD group had a significantly higher risk of multiple primary lesions than the surgery group ( P=0. 004) after the same follow-up period. In order to exclude the influence of confounding factors, COX regression model was used to control the age and other factors, and multiple primary risks of the two groups were also statistically significant ( P=0. 013) . The health score of self-evaluation and life quality between the two groups were statistically significant ( P<0. 001) . Conclusion For the short-term clinical outcomes, the ESD group was better than the surgery group. For the long-term clinical outcomes, multiple primary risks were higher in the ESD group than those in the surgery group, but most of the multiple primary cases were successfully treated with a second ESD. The health score of self-evaluation and life quality were better in the ESD group than those in the surgery group.

Effect of dexmedetomidine on emergence agitation after general anesthesia in children undergoing odontotherapy in day-surgery operating room / 华西口腔医学杂志

<p><b>OBJECTIVE</b>To study the effectiveness of dexmedetomidine used for general anesthesia maintenance in children undergoing odontotherapy in day-surgery operating room in reducing the incidence of emergence agitation (EA).</p><p><b>METHODS</b>Eighty children undergoing odontotherapy and under general anesthesia in day-surgery operating room were randomized into two groups, group A (n=40) and group B (n=40). Each patient in group A was administered with a bolus dose of dexmedetomidine (1.0 μg·kg⁻¹, saline diluted to 10 mL) pump-infused after intubation and a maintenance dose of 0.1-0.4 mL·(kg·h)⁻¹ followed-up until 45 min before the end of operation. Each patient in group B was administered with a bolus dose of normal saline 10 mL pump-infused after intubation and maintenance dose of 0.1-0.4 mL·(kg·h)⁻¹ followed-up until 45 min before the end of operation. Gender, age, weight, physical status according to the American Society of Anesthesiologists, perioperative heart rate (HR), mean arterial pressure (MAP), pulse oxygen saturation (SpO₂), sufentanil dosage, duration of surgery, time of extubation, time of regaining consciousness, and time to reach modified Aldrete's score≥12 were recorded. Behavior in postanesthesia care unit was rated on the four-point agitation scale.</p><p><b>RESULTS</b>Compared with group B, decreases were observed in HR and MAP at the beginning of operation, in 10 and 30 min, 1 and 2 h after the beginning of operation, and after extubation of group A (P<0.05). Sufentanil dosage and incidence of EA during recovery of group A were also lower than those of group B (P<0.05). Time to regain consciousness and time to reach modified Aldrete's score≥12 of group A were longer than those of group B (P<0.05). No statistical difference was observed between other indexes of the two groups.</p><p><b>CONCLUSIONS</b>As an anesthetic used for general anesthesia maintenance in children undergoing odontotherapy in day-surgery operating room, dexmedetomidine results in low incidence of EA during recovery and more stable vital signs.</p>

Cannabinoid receptor 1 regulates the spatial learning and memory function and the expression of NR1 subunit of N-methyl-D-aspartic acid receptor in medial prefrontal cortex of neuropathic pain model rat / 中华神经科杂志

Objective To investigate the effect of cannabinoid receptor 1 ( CBR1 ) on spatial learning and memory function of neuropathic pain ( NP ) model rats and the expression of N-methyl-D-aspartic acid receptor 1(NR1) subunit in medial prefrontal cortex (mPFC).Methods Thirty-six healthy male Wistar rats were randomly divided into 4 groups, with 9 rats in each group: the sham operated group (SO group), the neuropathic pain model group (NP group), the NP model group with an mPFC injection of saline ( NS group ) , and the NP model group with an mPFC injection of the CBR 1 antagonist AM251 ( AM251 group).The NP model was prepared using the operation of chronic constriction injury ( CCI) of the right sciatic nerve.The mechanical withdrawal threshold ( MWT ) and the thermal withdrawal latency (TWL) of the rats in each group were detected at 3, 7, 14, 21 and 28 days after the operation.At 29 days after the operation , 18 rats of NP model were randomly selected and given an mPFC injection of saline or AM251 using a three-dimensional brain puncture.At days 30-37 after operation , the eight-arm maze test was performed to detect the spatial learning and memory function of the rats , and the rats were sacrificed immediately after this test.The expression levels of CBR1, NR1 and phosphorylated-N-methyl-D-aspartic acid receptor 1 ( p-NR1 ) ( Ser896 ) in the mPFC brain region were detected by Western blotting , RT-PCR and immunofluorescence.Results Compared with the SO group , the pain thresholds and the spatial learning and memory function of the rats in the NP group were significantly lower ( both P <0.05 ).Compared with the NS group , the rats in the AM251 group showed improvement about spatial learning and memory function ( P<0.05).Compared with the SO group ( the mRNA and protein level of CBR 1:0.23 ± 0.06,0.42 ±0.03), the mRNA(0.43 ±0.12) and protein (0.53 ±0.05) level of CBR1 in NP group increased (both P<0.05).Compared with the NS group (the mRNA and protein level of CBR1:0.42 ± 0.11,0.52 ±0.10), the mRNA (0.53 ±0.05) and protein (0.98 ±0.17) level of CBR1 in AM251 group increased (both P<0.05).Compared with the SO group (the mRNA and protein level of NR1 and the protein level of p-NR1:1.50 ±0.15,0.65 ±0.05,0.79 ±0.15), the mRNA (0.94 ±0.07) and protein (0.24 ±0.05) level of NR1 in NP group decreased (both P<0.05), the protein level of p-NR1 (0.33 ± 0.04) decreased (P<0.05).Compared with the NS group (the mRNA and protein level of NR1 and the protein level of p-NR1:1.09 ±0.14,0.26 ±0.06,0.31 ±0.08), the mRNA(1.58 ±0.10) and protein (1.42 ±0.10) level of NR1 in AM251 group increased (both P<0.05), the protein (0.95 ±0.15) level of p-NR1 increased ( P<0.05).Conclusion CBR1 can decrease the expression level of NR 1 and p-NR1 in the mPFC brain region of NP model rats and induce the spatial learning and memory impairment.

Mechanism progress of bronchial asthma cured by PPARγagonists / 中国基层医药

Peroxisome proliferators -activated receptors γ(PPARγ)agonist is a kind of drugs that is widely used in the treatment of type 2 diabetes,also shows effects on hypertensive disease,regulating blood lipid metabolism, anti -atherosclerosis and inhibiting inflammatory response.In recent years,good effects of PPARγagonist have been found on different animal models of asthma,and production of proinflammatory cytokines can significantly be reduced. Airway remodeling can be reduced,and airway hyper responsiveness can be inhibited by PPARγagonist that provide theoretical basis on new drugs for asthma.The mechanism of bronchial asthma cured by PPARγagonists are reviewed briefly.