Endoscopic Endoluminal Radiofrequency Ablation and Single-Operator Peroral Cholangioscopy System (SpyGlass) in the Diagnosis and Treatment of Intraductal Papillary Neoplasm of the Bile Duct: A Case Report and Literature Review.

Background: Intraductal papillary neoplasm of the bile duct (IPNB) is a rare biliary benign tumor with atypical clinical features and is frequently misdiagnosed. Its treatment is limited and surgical resection is thought to be the only therapeutic option in patients with IPNB. With the aim of increasing the early diagnosis rate of IPNB and providing more therapeutic options for surgeons, we innovatively put forward the concept of combined utilization of SpyGlass and endoscopic endoluminal radiofrequency ablation (ERFA) in the diagnosis and treatment of IPNB. Case Presentation: An 85-year-old woman was referred to our hospital due to right upper quadrant abdominal pain. The image examinations indicated suspicious filling defects at the upper common bile duct. Further evaluation of SpyGlass cholangioscopy showed multiple reddish villous lesions at the left hepatic duct, and SpyBite biopsy under direct visualization demonstrated papillary low-grade dysplasia. In consideration of the advanced age and preference of the patient, the novel ERFA therapy was performed. The procedure was successful without periprocedural complications; the patient recovered uneventfully and was discharged 2 days after the operation. Upon follow-up, the patient was asymptomatic and in good physical condition at 8 months postoperatively. Conclusion: Preliminarily, we demonstrate that the strategy of a combination of SpyGlass and ERAF seems to be a promising, feasible, well-tolerated, and safe management for patients with IPNB. However, more data with larger patient volumes are needed to evaluate its outcomes further.

Propensity-Matched Analysis of Clinical Relevance of the Highest Mediastinal Lymph Node Metastasis.

BACKGROUND: The clinical relevance of the highest mediastinal lymph node (HMLL) metastasis in patients with pathological N2 non-small cell lung cancer (NSCLC) is still controversial. Our study aimed to reassess the effect of HMLL metastasis on survival. METHODS: Patients with stage pT1-4N2M0 NSCLC who underwent major lung resection and systemic lymphadenectomy at Peking University People's Hospital from 2004 to 2015 were identified. Patients in the HMLL-positive group were matched to patients in the HMLL-negative group using 1:1 propensity score matching analysis. Overall survival was estimated by Kaplan-Meier method and compared using log-rank test, and multivariable Cox proportional hazard regression was constructed to identify risk factors associated with overall survival. The cumulative incidence of cancer specific mortality was evaluated through a competing risk analysis. RESULTS: A total of 266 NSCLC patients with stage pT1-4N2M0 NSCLC were enrolled. Of those, 128 cases were HMLL positive and 138 cases were HMLL negative. A higher proportion of patients in the HMLL-positive group were female (P = .034) and had a higher rate of adenocarcinoma (P = .003). Compared with the HMLL-negative, the HMLL-positive group was not associated with worse survival in unmatched cohorts (adjusted hazard ratio = 1.21; 95% confidence interval, 0.87-1.68). After propensity score matching, 109 pairs were selected. No survival difference remained in matched cohorts (adjusted hazard ratio = 1.00; 95% confidence interval, 0.70-1.42). CONCLUSIONS: Highest mediastinal lymph node metastasis does not exhibit worse survival in patients with stage pT1-4N2M0 NSCLC. The clinical relevance of HMLL metastasis needs further examination.

Lung cancer from a focal bulla into thin-walled adenocarcinoma with ground glass opacity - an observation for more than 10 years: A case report.

BACKGROUND: Thin-walled lung cancer manifests as a cystic lesion, mostly adenocarcinoma. It is often misdiagnosed as a benign lesion in clinical practice, thus delaying the diagnosis and surgical treatment. Its natural course is rarely recorded and observed; thus, the pathogenesis and diagnosis need to be clarified and improved. CASE SUMMARY: A 66-year-old man developed a mass in the upper lobe of the right lung and a small, thin-walled cavity in the lower lobe of the right lung in 2007. The right upper lobe mass was confirmed to be adenocarcinoma after surgery. The cavity diameter increased from 11 mm to 31 mm over 10 years, and a ground glass opacity lesion appeared around the bulla on computed tomography. A second operation confirmed that the lesion was lepidic predominant adenocarcinoma. Here we report a rare case of lung cancer developing from a focal bulla to a thin-walled adenocarcinoma for more than 10 years and confirm that the check-valve mechanism explains the pathogenesis. CONCLUSION: Solitary thin-walled lung adenocarcinoma is a rare tumor in terms of its clinical manifestations, pathogenesis, and disease progression. The check-valve mechanism can explain the cause of thin-walled lung cancer. Close follow-up and accurate imaging are necessary.

Author Correction: Levels of Faecal Calprotectin and Magnetic Resonance Enterocolonography Correlate with Severity of Small Bowel Crohn's Disease: A Retrospective Cohort Study.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Fecal calprotectin is a strong predictive marker of relapse in Chinese patients with Crohn's disease: a two-year prospective study.

OBJECTIVE: To evaluate the predictive value of fecal calprotectin (FC) for clinical relapse in Chinese patients with quiescent Crohn's disease (CD) and to further investigate the correlation between FC and intestinal inflammation. METHODS: Sixty-two patients with a diagnosis of quiescent CD were consecutively enrolled in this prospective study. Fecal samples were collected and enteroscopy were performed to detect mucosal lesions at the beginning of the study. Patients were followed until the first relapse or by the end of the two-year follow-up. The calprotectin concentration was measured using a quantitative enzyme-linked immunoassay. RESULTS: Of the 62 CD patients, 29 had a relapse (median time of relapse: 8.44 months). The median follow-up months was 8.16 (4.98-13.59). The cut off level of 225 µg/g provided the maximal area under the receiver operating characteristic curve (AUC) of .775 for detecting the relapse of CD patients. Meanwhile, fecal occult blood had an added value. The multivariate Cox regression model showed that FC was the strongest predictor of the risk of relapse (risk ratio (RR): 6.315; p = .001). FC correlated most closely with the simple endoscopic score for Crohn's disease (SES-CD) (r = 0.524, p < .001). CONCLUSIONS: FC correlated significantly with gut inflammation and could be a reliable predictor of relapse in Chinese patients with CD.

Identifying patients at higher risk of pneumonia after lung resection.

BACKGROUND: Pneumonia is considered as one of the most common and serious complications after lung resection. The purpose of this study was to identify the risk factors associated with postoperative pneumonia (POP) after lung resection and to develop a scoring system to stratify patients with increased risk of POP. METHODS: A retrospective review of a prospective database of patients between September 2014 and June 2016 was carried out. Logistic regression analysis was used to examine the risk factors for POP. Bootstrap resampling analysis was used for internal validation. Regression coefficients were used to develop weighted risk scores for POP. RESULTS: Results revealed that age ≥64 years, smoking (current or previous), high pathological stage, and extent of excision of more than one lobe as risk factors. Logistic regression analysis showed that the predictors of POP were as follows: age ≥64 years, smoking, extent of excision of more than one lobe. A weighted score based on these factors was developed which was follows: smoking (three points), age ≥64 years (four points), and extent of excision of more than one lobe (five points). POP score >5 points offered the best combination of sensitivity (64.7%) and specificity (83.3%), and an area under receiver operating characteristic (ROC) curve (AUC) of 0.830 [95% confidence interval (CI): 0.746-0.914]. CONCLUSIONS: Patients with older age, smoking and extent of excision of more than one lobe have a higher risk for pneumonia after lung cancer surgery. Also, the scoring system helps to guide decision making of POP risk reduction.

Levels of Faecal Calprotectin and Magnetic Resonance Enterocolonography Correlate with Severity of Small Bowel Crohn's Disease: A Retrospective Cohort Study.

Few studies have evaluated the usefulness of fecal calprotectin (FC) or magnetic resonance enterography (MRE) in diagnosing active Crohn's disease (CD) of the small bowel. In the study, we investigated the reliability of FC and MRE in assessing the activity of ileal CD and further explored the relationship between levels of FC and MRE scores. A total of 221 patients were diagnosed with ileal or ileo-colitis CD in our department between July 2012 and October 2016. The global magnetic resonance index of activity (MaRIA) correlated with the simple endoscopic score for CD (SES-CD) (r = 0.527, P = 0.005). When analysed segment-by-segment, a significant correlation was still observed (r = 0.590, P < 0.001). The SES-CD correlated closest with FC (r = 0.503), followed by CRP (r = 0.461), ESR (0.377) and the CDAI (r = 0.320). In receiver operating characteristic (ROC) analyses, the FC cut-off value of mucosal healing was 213.1 µg/g, with 76.1% sensitivity and 66.7% specificity. As for MaRIA, a cut-off value of 6.8 for each segment provided a sensitivity of 100% and a specificity of 79.2%. No agreement between MaRIA and FC levels was found. In conclusion, a combination of FC levels and MaRIA could be effective in monitoring mucosal activity in patients with small bowel CD.

Confusing untypical intestinal Behcet's disease: Skip ulcers with severe lower gastrointestinal hemorrhage.

Behcet's disease (BD) is a rare and life-long disorder characterized by inflammation of blood vessels throughout the body. BD was originally described in 1937 as a syndrome involving oral and genital ulceration in addition to ocular inflammation. Intestinal BD refers to colonic ulcerative lesions documented by objective measures in patients with BD. Many studies have shown that over 40% of BD patients have gastrointestinal complaints. Symptoms include abdominal pain, diarrhea, nausea, anorexia and abdominal distension. Although gastrointestinal symptoms are common, the demonstration of gastrointestinal ulcers is rare. This so-called intestinal BD accounts for approximately 1% of cases. There is no specific test for BD, and the diagnosis is based on clinical criteria. The manifestations of intestinal BD are similar to those of other colitis conditions such as Crohn's disease or intestinal tuberculosis, thus, it is challenging for gastroenterologists to accurately diagnose intestinal BD in patients with ileo-colonic ulcers. However, giant ulcers distributed in the esophagus and ileocecal junction with gastrointestinal hemorrhage are rare in intestinal BD. Here, we present a case of untypical intestinal BD. The patient had recurrent aphthous ulceration of the oral mucosa, and esophageal and ileo-colonic ulceration, but no typical extra-intestinal symptoms. During examination, the patient had massive acute lower gastrointestinal bleeding. The patient underwent ileostomy after an emergency right hemicolectomy and partial ileectomy, and was subsequently diagnosed with incomplete-type intestinal BD by pathology. The literature on the evaluation and management of this condition is reviewed.

A single leaf of Camellia oleifera has two types of carbon assimilation pathway, C(3) and crassulacean acid metabolism.

The C(4) plants, whose first product of photosynthetic CO(2) fixation is a four-carbon acid, have evolved independently many times. Crassulacean acid metabolism (CAM) is a biological mechanism known to exhibit some C(4) characteristics such as the C(3) cycle during daylight and demonstrates the C(4) cycle at night. There are also various C(3)-CAM intermediates, whose CAM pathway can be induced by environmental changes. However, neither fungus-induced CAM nor Theaceae CAM have been reported previously. Here, we show that CAM could be generated by fungus infection in Camellia oleifera Abel. young leaves, even at a location of a single leaf where the upper part had been transformed into a succulent one, while the lower part remained unchanged. The early photosynthetic products of dark-grown C. oleifera succulent leaves were malate, whereas C. oleifera normal leaves and light-grown succulent leaves incorporated most of (14)C into the primary photosynthetic product 3-phosphoglycerate. Camellia oleifera succulent leaves have a lower absolute δ(13)C value, much lower photorespiration rates and lower transpiration rates during the day than those of C. oleifera normal leaves. Like a typical CAM plant, stomata of C. oleifera succulent leaves closed during the daylight, but opened at night, and therefore had a detectable CO(2) compensation point in darkness. Net photosynthetic rates (P(n)) fluctuated diurnally and similarly with stomatal aperture. No light intensity saturation could be defined for C. oleifera succulent leaves. C(4) key enzymes in C. oleifera succulent leaves were increased at both the transcriptional/translational levels as well as at the enzyme activity level.

The higher expression levels of dehydroascorbate reductase and glutathione reductase in salicylic acid-deficient plants may contribute to their alleviated symptom infected with RNA viruses.

Salicylic acid (SA) is a critical signal for activation of both local and systemic resistance responses. However, SA-deficient plants adapt to RNA virus infections better, which show a less-severe symptom and less reactive oxygen species (ROS) accumulation. The higher levels of reduced glutathione (GSH) and reduced ascorbic acid (AsA) in SA-deficient plants may contribute to their alleviated symptoms, which are consistent with their higher expression levels of dehydroascorbate reductase gene (DHAR) and glutathione reductase gene (GR). High-dose AsA or GSH treatment could alleviate the symptom and inhibit virus replication after 20 days, but ROS eliminators could not imitate the effect of AsA or GSH. The data show a new link between SA and AsA/GSH-mediated redox homeostasis.

The roles of ascorbic acid and glutathione in symptom alleviation to SA-deficient plants infected with RNA viruses.

Salicylic acid (SA) is required for plant systemic acquired resistance (SAR) to viruses. However, SA-deficient plants adapt to RNA virus infections better, which show a lighter symptom and have less reactive oxygen species (ROS) accumulation. The virus replication levels are higher in the SA-deficient plants during the first 10 days, but lower than the wild-type seedlings after 20 dpi. The higher level of glutathione and ascorbic acid (AsA) in SA-deficient plants may contribute to their alleviated symptoms. Solo virus-control method for mortal viruses results in necrosis and chlorosis, no matter what level of virus RNAs would accumulate. Contrastingly, early and high-dose AsA treatment alleviates the symptom, and eventually inhibits virus replication after 20 days. ROS eliminators could not imitate the effect of AsA, and could neither alleviate symptom nor inhibit virus replication. It suggests that both symptom alleviation and virus replication control should be considered for plant virus cures.

A broad-spectrum, efficient and nontransgenic approach to control plant viruses by application of salicylic acid and jasmonic acid.

Plant viruses cause many diseases that lead to significant economic losses. However, most of the approaches to control plant viruses, including transgenic processes or drugs are plant-species-limited or virus-species-limited, and not very effective. We introduce an application of jasmonic acid (JA) and salicylic acid (SA), a broad-spectrum, efficient and nontransgenic method, to improve plant resistance to RNA viruses. Applying 0.06 mM JA and then 0.1 mM SA 24 h later, enhanced resistance to Cucumber mosaic virus (CMV), Tobacco mosaic virus (TMV) and Turnip crinkle virus (TCV) in Arabidopsis, tobacco, tomato and hot pepper. The inhibition efficiency to virus replication usually achieved up to 80-90%. The putative molecular mechanism was investigated. Some possible factors affecting the synergism of JA and SA have been defined, including WRKY53, WRKY70, PDF1.2, MPK4, MPK2, MPK3, MPK5, MPK12, MPK14, MKK1, MKK2, and MKK6. All genes involving in the synergism of JA and SA were investigated. This approach is safe to human beings and environmentally friendly and shows potential as a strong tool for crop protection against plant viruses.

Difference of physiological characters in dark green islands and yellow leaf tissue of Cucumber mosaic virus (CMV)-infected Nicotiana tabacum leaves.

Dark green islands (DGIs) are a common symptom of plants systemically infected with the mosaic virus. DGIs are clusters of green leaf cells that are free of virus but surrounded by yellow leaf tissue that is full of virus particles. In Cucumber mosaic virus (CMV)-infected Nicotiana tabacum leaves, the respiration and photosynthesis capabilities of DGIs and yellow leaf tissues were measured. The results showed that the cyanide-resistant respiration was enhanced in yellow leaf tissue and the photosynthesis was declined, while in DGIs they were less affected. The activities of the oxygen-scavenging enzymes catalase (CAT), peroxidase (POD), and superoxide dismutase (SOD) in infected leaves were significantly higher than those in the healthy leaves, and the enzyme activities in DGIs were always lower than in the yellow leaf tissues. Reactive oxygen species (ROS) staining showed that the hydrogen peroxide content in yellow leaf tissues was apparently higher than that in DGIs, while the superoxide content was on the contrary. Formation of DGIs may be a strategy of the host plants resistance to the CMV infection.

[The change in expression of Toll-like receptor 4 on peripheral blood mononuclear cell after continuous renal replacement therapy in patients with sepsis].

OBJECTIVE: To explore the change in Toll-like receptor 4 (TLR4) of peripheral blood mononuclear cell (PBMC) and the expression of cytokines in patients with sepsis, and to investigate the role of continuous renal replacement therapy (CRRT) in its modulation. METHODS: A clinical study was performed in 13 patients with sepsis which were divided into improved group (n=7) and healing group (n=6), according to their outcome. Another 6 healthy individuals served as normal control. The mRNA expression of TLR4 on PBMC was detected by reverse transcription-polymerase chain reaction (RT-PCR), the protein expression of TLR4 on PBMC was assayed with flow cytometry, the expressions of IL-6 and TNF-alpha were measured by enzyme linked immunoadsorbent assay (ELISA). RESULTS: TLR4 mRNA, IL-6, TNF-alpha, and TLR4 protein expressions were upregulated markedly in patients suffering from sepsis. The above parameters were decreased significantly after CRRT (all P<0.05) and in the same time, the clinic condition turn up, in the meanwhile, the expression of TLR4 went down, but it still have some expression on monocyte in improved group. CONCLUSION: The down regulation of TLR4 through CRRT may imply an important mechanism in the CRRT on patients with sepsis.

Thoraco-umbilical flap: experience with 33 cases.

From August, 1996 to June, 2000, 33 patients received transfer of free thoraco-umbilical flaps for repair of various soft-tissue defects. The size of the flaps ranged from 10 to 40 cm in length and 8 to 25 cm in width, with blood supply of the flaps derived from the largest periumbilical perforating branch of the deep inferior epigastric vessels. The indications of this flap included complex extremity trauma or large skin loss resulted from soft tissue tumor resection, either acute or postprimary. The overall success rate was 100% in the 33 cases. The donor area was closed directly with 10- to 12-cm-wide flaps, leaving an inconspicuous scar, whereas larger flaps required skin grafting. A 2-year follow-up found uneventful healing of all the flaps with minimal donor abdominal morbidity.

Thoracoumbilical flap: experience with 33 cases.

From August 1996 to June 2000, 33 free thoracoumbilical flaps were transferred to reconstruct a variety of soft-tissue defects. The size of the flaps ranged from 10 to 40 cm in length and 8 to 25 cm in width. The blood supply to the skin island came from the largest periumbilical perforator of the deep inferior epigastric vessels. The main indications were complex extremity trauma or soft-tissue tumor resection with extensive skin loss, either acute or postprimary. The overall success rate was 100 percent (33/33). The donor area was closed directly in 10- to 12-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. After a 2-year follow-up, all flaps have healed uneventfully and donor abdominal morbidity is minimal.

[CPP32 expression and its significance in multidrug-resistant tumor cells and their parent cells].

OBJECTIVE: To study the expression difference of CPP32 in multidrug-resistant (mdr) tumor cells and their parent cells and to understand the possible effect of CPP32 in apoptosis induction in the 2 cell lines. METHODS: Sequence analysis of CPP32 mRNA extracted form mdr gastric cancer cell line SGC7901/VCR08 and naive cell line SGC7901 was performed by means of reverse transcriptase-polymerase chain reaction (RT-PCR), and the protein expression of CPP32 in the 2 cell lines assayed by way of Western blotting. RESULTS: The expressions of CPP32 mRNA was comparable in the 2 cell lines, and sequence analysis found consistent sequence of CPP32 in both cell lines with previous report. No differences was identified in the protein expression, either. CONCLUSION: The apoptosis resistance of mdr cells is not related to the abnormality of CPP32 but the upstream of caspase, the fact of which indicates promising prospect of the research on reversion of mdr cells using CPP32 as target.