Endoscopic retrograde stent drainage therapies for malignant biliary obstruction: the distal opening of stent location above or across the duodenal papilla? A systematic review and meta-analysis.

OBJECTIVE: To systematically evaluate the efficacy and safety of the method of placing the distal stent opening above the duodenal papilla (hereinafter referred to Above method) for endoscopic retrograde stent internal drainage in MBO patients. METHODS: PubMed, Embase, Web of science and Cochrane databases were searched to identify clinical studies comparing the stent distal opening mounted above the papilla and across the papilla (hereinafter referred to Across method), Comparison indicators included stent patency, stent occlusion rate, clinical success rate, overall complication rate, postoperative cholangitis rate, and overall survival. Revman5.4 software was used for meta-analysis, funnel plot and publication bias and Egger's test were completed by Stata14.0 software. RESULTS: A total of 11 clinical studies (8 case-control studies, 3 RCT studies) were included, with a total of 751 patients (318 cases in the Above group and 433 cases Across group). The overall patency of Above method was longer than that of Across method (HR = 0.60, 95%CI [0.46-0.78], p < 0.001). Subgroup analysis showed statistical difference using plastic stent (HR = 0.49, 95%CI [0.33,0.73], p < 0.001). Inversely, there didn't exist significant difference in which metal stent were adopted (HR= 0.74, 95%CI [0.46,1.18], p = 0.21). Similarly, there also without statistical difference between patients with plastic stent placed above the papilla and metal stent mounted Across the papilla (HR = 0.73, 95%CI [0.15,3.65], p = 0.70). Moreover, the overall complication rate of the Above method was lower than that of the Across method (OR = 0.48,95%CI [0.30,0.75], p = 0.002). On the contrary, the differences of stent occlusion rate (OR = 0.86,95%CI [0.51,1.44], p = 0.56), overall survival (HR = 0.90, 95%CI [0.71,1.13]), p = 0.36), the clinical success rate (OR = 1.30, 95%CI [0.52,3.24], p = 0.57) and postoperative cholangitis rats (OR = 0.73, 95%CI [0.34,1.56], p = 0.41) were not statistically significant. CONCLUSIONS: The distal opening of the stent can be placed above the duodenal main papilla for eligible MBO patients who receiving endoscopic retrograde stent drainage treatment, which can effectively prolong the patency duration when plastic stent is used, and reduce the overall risk of complications.

Nucleobindin-2/nesfatin-1 enhances the cell proliferation, migration, invasion and epithelial-mesenchymal transition in gastric carcinoma.

Nesfatin-1, a newly discovered adipokine derived from nucleobindin-2 (NUCB2), has been described as a new prognostic marker in cancers. This study aimed to explore the functional role of NUCB2/nesfatin-1 in the cell proliferation, migration and invasion in gastric carcinoma (GC). The expressions of NUCB2/nesfatin-1 in GC tissues and normal adjacent tissues (NATs) were compared, and the effect of inhibition of NUCB2/nesfatin-1 on the cell proliferation, migration, invasion and epithelial-mesenchymal transition (EMT) in GC cell line SGC-7901 was investigated. Cell transfection was conducted to inhibit NUCB2/nesfatin-1 by short hairpin RNA. Cell proliferation, migration and invasion abilities were determined using cell counting kit-8 (CCK-8), 5-ethynyl-2'-deoxyuridine (EdU), wound healing and transwell assays, respectively. The expressions of EMT markers E-Cadherin and N-Cadherin were determined using western blotting. The expression of NUCB2/nesfatin-1 protein in GC tissues was significantly increased compared with that in NATs. Consistently, the serum concentrations of NUCB2/nesfatin-1 were significantly higher in patients with GC as compared with those in the control group. Moreover, the results of CCK-8 assay and EdU assay indicated that knockdown of NUCB2/nesfatin-1 could markedly decrease SGC-7901 proliferation. Furthermore, the results of wound healing assay and transwell assay demonstrated that knockdown of NUCB2/nesfatin-1 significantly suppressed SGC-7901 migration and invasion abilities. Additionally, knockdown of NUCB2/nesfatin-1 decreased the expressions of N-Cadherin and increased the expressions of E-Cadherin in SGC-7901 cells. These findings suggest that knockdown of NUCB2/nesfatin-1 suppressed the proliferation, migration, invasion and EMT of SGC-7901 cells, suggesting a potentially promising therapeutic target for GC.

New Progress in Basic Research of Macrophages in the Pathogenesis and Treatment of Low Back Pain.

Low back pain (LBP) is quite common in clinical practice, which can lead to long-term bed rest or even disability. It is a worldwide health problem remains to be solved. LBP can be induced or exacerbated by abnormal structure and function of spinal tissue such as intervertebral disc (IVD), dorsal root ganglion (DRG) and muscle; IVD degeneration (IVDD) is considered as the most important among all the pathogenic factors. Inflammation, immune response, mechanical load, and hypoxia etc., can induce LBP by affecting the spinal tissue, among which inflammation and immune response are the key link. Inflammation and immune response play a double-edged sword role in LBP. As the main phagocytic cells in the body, macrophages are closely related to body homeostasis and various diseases. Recent studies have shown that macrophages are the only inflammatory cells that can penetrate the closed nucleus pulposus, expressed in various structures of the IVD, and the number is positively correlated with the degree of IVDD. Moreover, macrophages play a phagocytosis role or regulate the metabolism of DRG and muscle tissues through neuro-immune mechanism, while the imbalance of macrophages polarization will lead to more inflammatory factors to chemotaxis and aggregation, forming an "inflammatory waterfall" effect similar to "positive feedback," which greatly aggravates LBP. Regulation of macrophages migration and polarization, inhibition of inflammation and continuous activation of immune response by molecular biological technology can markedly improve the inflammatory microenvironment, and thus effectively prevent and treat LBP. Studies on macrophages and LBP were mainly focused in the last 3-5 years, attracting more and more scholars' attention. This paper summarizes the new research progress of macrophages in the pathogenesis and treatment of LBP, aiming to provide an important clinical prevention and treatment strategy for LBP.

Hsa-miR-557 Inhibits Osteosarcoma Growth Through Targeting KRAS.

Objective: Osteosarcoma is the most common malignancy in the skeletal system; studies showed an important role of miRNAs in tumorigenesis, indicating miRNAs as possible therapeutic molecules. This study found abnormal hsa-miR-557 expression levels in osteosarcoma and tried to explore the potential function and the mechanism. Methods: Differential expression genes of osteosarcoma were analyzed using GSE28423 from the GEO database. Survival analysis of miRNAs was conducted with data obtained from the TARGET-OS database. STRING and miRDIP were used to predict target genes of hsa-miR-557; KRAS was then verified using dual-luciferase reporter assay. Expression of genes was detected by qPCR, and levels of proteins were detected by Western blot. The proliferation ability of cells was detected by CCK-8 and cell cycle analysis. Tumor formation assay in nude mice was used to detect the influence of osteosarcoma by hsa-miR-557 in vivo. Results: Analysis from the GEO and TARGET databases found 12 miRNAs that are significantly related to the osteosarcoma prognosis, 7 downregulated (hsa-miR-140-3p, hsa-miR-564, hsa-miR-765, hsa-miR-1224-5p, hsa-miR-95, hsa-miR-940, and hsa-miR-557) and 5 upregulated (hsa-miR-362-3p, hsa-miR-149, hsa-miR-96, hsa-miR-744, and hsa-miR-769-5p). CCK-8 analysis and cell cycle analysis found that hsa-miR-557 could significantly inhibit the proliferation of osteosarcoma cells. The tumor formation assay in nude mice showed that tumor sizes and weights were inhibited by hsa-miR-557 transfection. Further studies also proved that hsa-miR-557 could target the 3'UTR of KRAS and modulate phosphorylation of downstream proteins. Conclusion: This study showed that hsa-miR-557 could inhibit osteosarcoma growth both in vivo and in vitro, by modulating KRAS expression.

Progressive halo-vest traction preceding posterior occipitocervical instrumented fusion for irreducible atlantoaxial dislocation and basilar invagination.

OBJECTIVES: Surgical treatment of irreducible atlantoaxial dislocation (IAAD) with basilar invagination (BI) is associated with high rates of severe complications, including mortality. This retrospective study investigated the safety and efficacy of progressive halo-vest traction for IAAD with BI prior to posterior occipitocervical instrumented fusion. PATIENTS AND METHODS: Between 2009 and 2013, 39 patients with IAAD with BI underwent preoperative reduction by progressive halo-vest traction for 20.82±4.21days. Instrumented fusion was then performed through a posterior approach. Clinical outcomes were based on pain scale and Japanese Orthopedic Association (JOA) scores. Radiographic analysis evaluated changes in atlantodental distance, McGregor's line violation, spinal canal width at the craniocervical junction, cervicomedullary angle, C2-C7 lordosis angle, and the occiput-C2 angle. RESULTS: Follow-ups ranged from 48 to 96 months. Both atlantodental distance and BI significantly improved in all patients. The rates of complete anatomical reduction were 85% for IAAD, and 95% for BI. Most of the patients reported satisfactory pain relief and improvement in daily activity; the mean JOA scores at baseline and last follow-up were 9.10 and 15.92, respectively. Although complications occurred in 10 patients (25.64%), all of which healed uneventfully. The bony fusion rate was 100%. CONCLUSION: Progressive halo-vest traction before surgery is safe and effective for reduction of IAAD with BI. The technique we describe is a promising method for treatment of complex craniocervical junction deformity.

One-stage Posterior Spinal Osteotomy in Severe Spinal Deformities: A Total of 147 Cases.

STUDY DESIGN: This is a retrospective study. OBJECTIVES: The treatment of severe spinal deformities is still a difficult surgical challenge. It is generally significant to identify the related complications performed to a consecutive series of patients with severe spinal deformity and managed by 1-stage posterior spinal osteotomy. SUMMARY OF BACKGROUND DATA: We investigated data from 147 consecutive patients (75 males and 72 females) with severe deformity and managed by Smith-Petersen osteotomy, pedicle subtraction osteotomy, or vertebral column resection between years 2006 and 2012 with >2-year follow-up. Mean age was 21.2 (range, 14-51 y) years at operation. MATERIALS AND METHODS: The patients underwent standing anteroposterior and lateral radiography before and after scoliosis surgery. Age, sex, diagnosis, surgical approach and centrum, all the related complications, treatment, and preoperative and postoperative Cobb angle in the coronal and sagittal planes were recorded at final follow-up. RESULTS: There were 17 (11.6%) cases with complications in 147 patients, including spinal cord-related complications in 7 cases (4.8%), superior mesenteric artery syndrome in 5 cases (3.4%), broken rod and unstable screw hat in 3 cases (2.0%), and infection in 2 cases (1.4%). Among the 17 cases, 15 cases recovered completely and 2 cases recovered partially. CONCLUSIONS: The total complication rate of severe spinal deformity after 1-stage posterior spinal osteotomy without fusion was about 11.6%. Except for the major complication of neurological deficit, spine surgeon should also pay more attention on other related complications, especially superior mesenteric artery syndrome. Large-scale and long-term follow-up was warranted to find out more subjective complication rates. LEVEL OF EVIDENCE: Level IV-prognostic study (see the guidelines for a complete description of levels of evidence).

[Value of predicting preoperative risk in orthopedic surgery by using POSSUM].

OBJECTIVE: To assess the use of Physical and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system in predicting outcomes of patients undergoing orthopedic surgery and provide guidance for operation treatment decisions. METHODS: From April 2009 to September 2010, a total of 779 cases went operation in Beijing Hospital were collected.They were divided into two groups according to the presence or absence of complications.The patients' postoperative complications were predicted by POSSUM and compared to the actual morbidity to verify the effectiveness of the equation.Logistic regression was taken to make appropriate improvements for the POSSUM equation.ROC curve was drawn to describe the compliance of the original and new equations. RESULTS: In the 779 cases, the morbidity predicted by POSSUM is 212 cases while the actual morbidity is 65 cases.Of all risk factors, echocardiography ejection fraction showed a close relationship with postoperative complications (P<0.01). In the original equation, actual complication group compared with non-complication group, the difference was statistically significant (P<0.01). In the modified equation, complication group compared with non-complication group, the difference was statistically significant (P<0.01). Compared with the original one , the modified POSSUM had better predictive value on postoperative morbidity, and the comparison of AUC between the two groups was statistically significant ((0.67 ± 0.12) vs (0.75 ± 0.08), P<0.01). CONCLUSION: POSSUM over predicted morbidity of patients undergoing orthopedic surgery, it can be more accurate when modified appropriately.

Risk assessment and decision-making for patients undergoing orthopedic surgery.

PURPOSE: Physical and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring system was designed to predict the postoperative morbidity and mortality mainly in general surgery. The purpose of this study was to assess the value of POSSUM scoring system in predicting outcomes of patients undergoing orthopedic surgery, and to do some modifications to make the system more accurate in predicting postoperative complication rates. METHODS: This is a retrospective clinical study involving 779 patients between April 1, 2009 and September 1, 2010. The postoperative complication rates were predicted by POSSUM, and then compared with the actual morbidity. Logistic regression was taken to improve the POSSUM equation. RESULTS: In the 779 cases, the predicted morbidity was 27.2% (212 cases) by POSSUM, while the actual morbidity is 8.3% (65 cases). CONCLUSION: POSSUM excessively predicted the morbidity of patients undergoing orthopedic surgery, and it could be more accurate with appropriate modification. Of all risk factors, echocardiography ejection fraction showed a close relationship with postoperative complications.

A novel compound WISP3 mutation in a Chinese family with progressive pseudorheumatoid dysplasia.

BACKGROUND: Progressive pseudorheumatoid dysplasia (PPD) is an extremely rare autosomal recessive genetic disease caused by mutation of the Wnt1-inducible signaling pathway protein 3 (WISP3) gene. Here, we characterize the clinical manifestations and features of PPD and screen for WISP3 mutations. MATERIALS AND METHODS: We performed genetic testing for PPD in a Chinese family, after investigating the clinical particulars and family history, in addition to 200 healthy individuals, who served as the controls for this study. All 5 exons and the exon-intron boundaries of the WISP3 gene were amplified by polymerase chain reaction (PCR) and sequenced directly. RESULTS: We identified a missense mutation (c.667T>G, p.C223G) in the maternal allele and a nonsense mutation (c.756C>A, p.C252X) in the paternal allele in the two affected individuals. To our knowledge, the mutation c.756C>A has not been reported previously. In these patients, there was a specific period when their condition markedly improved after having been very serious. Moreover, severe compression of lumbar spinal cord led to conspicuous spinal disorders in the proband. CONCLUSIONS: Our study suggests that novel C223G and C252X mutations in exon 4 of the WISP3 gene are responsible for PPD in Chinese patients. Furthermore, we report certain unique phenotypic characteristics in our patients.

Spinal osteotomy techniques in management of severe pediatric spinal deformity and analysis of postoperative complications.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To compare radiographical analysis and clinical outcomes of spinal osteotomy techniques, including Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR), and analyze the relationship between preoperative evaluation and postoperative complication incidence. SUMMARY OF BACKGROUND DATA: These 3 techniques have been extensively reported previously, whereas, few literatures are available on comparing these 3 techniques in management of severe pediatric spinal deformity. METHODS: In all the 34 pediatric patients, 14 were treated with SPO, 12 were treated with PSO, and 8 were treated with VCR. All operations were performed by the senior author (L. X.) between 2005 and 2009 in the Institute of Spinal Deformity, The First Affiliated Hospital of Zhengzhou University. Preoperative Halo-gravity traction was applied for 2 weeks in all patients; patients were evaluated by using standing radiographs taken before and after traction and after operation and a prospectively collected database with outcomes questionnaires. The postoperative complications and its relationship to preoperative assessment were also analyzed in this study. RESULTS: All the 34 patients' severe pediatric spinal deformity (22 females and 12 males) was diagnosed, with an average age of 11.97 years (range, 6-17 yr) and an average follow-up of 66.38 months (range, 48-97 mo). The mean preoperative major curve for each group was 103.43º in the SPO group, 108.08º in the PSO group, and 117.00º in the VCR group, and was corrected to 15.21º, 16.83º, and 25.88º, respectively. The apical vertebral translation was corrected by 73.29% by SPO, 73.35% by PSO, and 59.71% by VCR. The coronal balance was improved from 16.57 mm to 1.50 mm in the SPO group, 17.33 mm to 3.83 mm in the PSO group, and 29.38 mm to 3.63 mm in the VCR group. The mean correction of the kyphotic angle for single SPO was 19.00º, for those with 2 and 3 SPOs, the average correction was 34.40º and 47.5º, and 33.83º for the PSO group, 47.38º for the VCR group. There were significant improvements in the overall clinical outcomes. The overall complication rate was 35.3%. The complication rate was high in patients with respiratory insufficiency and rigid spine. CONCLUSION: There was no significant difference in coronal correction among these 3 techniques, whereas, the average corrections in the sagittal plane were progressively higher from single SPO to 2 SPOs or PSO to 3 SPOs or VCR. Preoperative respiratory insufficiency and rigidity of the spinal deformity are associated with a high complication rate. LEVEL OF EVIDENCE: 3.