Preventive strategies for feeding intolerance among patients with severe traumatic brain injury:A cross-sectional survey

This study aimed to investigate the application status of preventive measures for feeding intolerance in patients with severe traumatic brain injury(STBI)in China and analysis the differences and their causes.Methods A cross-sectional survey was conducted.From December 2019 to January 2020,ICU nurses and physicians of 89 hospitals in China were surveyed by using a questionnaire on preventive strategies for feeding intolerance in patients with STBI.The questionnaire included two parts:the general information of participants(10 items)and application of preventive measures for feeding intolerance in STBI patients(18 items).Results Totally 996 nurses and physicians completed the questionnaire.Among various methods,gastrointestinal symptoms(85.0%)and injury severity(71.4%)were mostly used to assess gastrointestinal functions and risk of feeding intolerance among STBI patients,respectively.Initiating enteral nutrition(EN)within 24–48 h(61.5%),nasogastric tubes(91.2%),30°–45°of head-of-bed elevation(89.5%),continuous feeding by pump(72.9%),EN solution temperature of 38–40°C(65.5%),<500 ml initial volume of EN solution(50.0%),monitoring gastric residual volume with a syringe(93.7%),and assessing gastric residual volume every 4 h(51.5%)were mostly applied for EN delivery among STBI patients.Prokinetic agents(73.3%),enema(73.6%),probiotics(79.0%),antacid agents(84.1%),and non-nutritional preparations as initial EN formula(65.6%)were commonly used for preventing feeding intolerance among STBI patients.Conclusions The survey showed that nurses and clinicians in China have a positive attitude towards preventive strategies for feeding intolerance.However,some effective new technologies and methods have not been timely applied in clinical practice.We suggest that managers,researchers,clinicians,nurses,and other health professionals should collaborate to explore effective and standard preventive strategies for feeding intolerance among patients with STBI.

The Therapeutic Effects of Rehmannia Oral Liquid for the Syndrome of Heat Accumulation with Yin Consumption in Esophagus Cancer Patients Undergoing Radiotherapy——A Report of 60 Cases

Objective: To observe the clinical therapeutic effects of Rehmannia Oral Liquid on the syndrome of heat accumulation with Yin consumption in intermediate or late esophagus cancer patients undergoing radiotherapy. Methods: The IFN-α, TNF-α, IL-1β and TGF-β1 levels in sera were determined by the method of ABC-WLISA before and after the treatment with Rehmannia Oral Liquid. At the same time, the observation was carried out on the patient's general condition, symptoms and signs, barium meal or CT examinations, and biopsy. Another 30 cases of esophagus cancer were treated singly with radiotherapy as the control group. Results: Rehmannia Oral Liquid could obviously improve the patient's general condition, and the symptoms and signs after radiotherapy. Based on the X-ray examination and biopsy, the short-term local control rate of the treatment group and the control group was 70.0% and 40.0% respectively, showing a significant difference (P<0.05). Before the treatment, the level of serum IFN-α of both cancer groups was lower and the levels of TNF-α, IL-1β and TGF-β1 were higher than that of normal group. After treatment, the level of IFN-α in both treatment group and control group increased significantly (P<0.01), and the treatment group improved more obviously than the control group (P<0.05). The level of TNF-α of both groups decreased significantly (P<0.01) after treatment, and the level of IL-1β decreased in treatment group and increased in control group without the significant difference as compared with that before treatment. The level of TGF-β1 was significantly increased in control group (P<0.05) and decreased in treatment group (P>0.05) after treatment. The difference between groups was significant (P<0.05). Conclusion: Rehmannia Oral Liquid can obviously reduce the radiotherapy reaction, improve the quality of life, and raise the therapeutic effects. The action mechanism of the Liquid may lie in balancing the cytokine network and regulating the disordered signal transmission.

Analysis of Lymph Node Metastases of 1,526 Cases with Thoracic Esophageal and Cardiac Carcinomas: A Random Sampling Report froni the Fourth Hospital of Hebei Medical University from 1996 to 2004

OBJECTIVE To summarize the regular pattern and state oflymph node metastasis of patients with esophageal and cardiaccarcinomas,so as to analyze factors influencing lymph nodemetastasis.METHODS Clinical data collected from 1,526 thoracicesophageal and cardiac carcinoma patients who were admitted inthe Fourth Hospital of Hebei Medical University during a periodfrom January 1996 to December 2004,were randomly selectedand an Access Database of the patient's information was set up.Eight clinico-pathologic factors,including the patient's age,tumorlocation and size,pathological classification,the depth of tumorinvasion,vascular tumor embolus (VTE),the state of surroundingorgan encroachment and the status of tumor residues,wereidentified.A correlation between these factors and metastases wasstatistically analyzed using SPSS13.0 software.RESULTS Lymph node metastatic sites from esophagealcarcinomas included the thoracic and abdominal cavity.Lymphnode metastasis from the superior esophageal carcinomasmainly occurred in the neck and thoracic cavity.There was atwo-way lymph node metastasis in the patients with the middleesophageal carcinoma.The inferior esophageal carcinomas mainlymetastasized to the paraesophageal,paragastric cardia,and leftgastric artery lymph nodes.The rate and degree of the metastasisfrom the inferior esophageal carcinomas were significantly highercompared to those of the superior and the middle esophagealcarcinomas (P<0.0125).The degree of abdominal lymph node metastasis fromcarcinomas of the gastric cardia was significantly higher comparedwith that of esophageal carcinomas.In the group with carcinomaof the gastric cardia,the rate and degree of the lymph nodemetastases in the paragastric cardia and left gastric artery weresignificantly higher compared to the group with esophagealcarcinoma (P<0.05).Paraesophageal lymph node metastasis fromcarcinomas of the gastric cardia in the thoracic cavity frequentlyoccurred,too,and the degree of the metastasis was similar to thatof esophageal carcinoma.There was no significant difference inthe rate and degree of the paraesophageal lymph-node metastasisbetween the group with carcinoma of the gastric cardia comparedto those with esophageal carcinoma (P>0.05).Multifactoriallogistic regression analysis showed that the tumor size,depth oftumor encroachment,VTE,and tumor residues could all bringabout obvious impact on lymph-node metastases (P<0.05).CONCLUSION Lymph node metastasis from superioresophageal carcinomas mainly occurs in the neck and thoraciccavity.The middle esophageal carcinomas presented a two-waylymph-node metastasis (both the upwards and the downwards),and the lymph node metastasis from inferior esophagealcarcinomas mainly occurred in the thoracic and abdominal cavities.The metastases of carcinoma of the gastriccardia were most commonly found in the abdominalcavity,with frequent paraesophageal lymph-nodemetastasis.The sufficient attention should be paidto neck lymph node clearance in cases of esophagealcarcinoma.What is of the greatest concern is theclearance of the left gastric artery lymph nodes,andalso in cases of gastric cardia carcinoma,clearance,the paraesophageal lymph nodes.With an increasein the tumor size and depth of tumor encroachment,and occurrence of VTE and tumor residual cells,therisk of lymph node metastasis is significantly raised (P<0.05).

Defensins couple dysbiosis to primary immunodeficiency in Crohn's disease

Antimicrobial peptides,including defensins,are essential effectors in host defence and in the maintenance of immune homeostasis.Clinical studies have linked the defective expression of both α-and β-defensin to the reduced killing of certain microorganisms by the intestinal mucosa of patients suffering from ileal and colonic Crohn's disease(CD),respectively.Only recently have the events leading to defective expression of defensins in CD been further elucidated,and are discussed herein.These events may account for CD-associated alterations in the microbiome and may subsequently precipitate the development of granulomatous inflammatory lesions in genetically-predisposed patients.We also address how these discoveries may pave the way for the development of a molecular medicine aimed at restoring gut barrier function in CD.

Personal Experience in TCM Treatment of Reflux Esophagitis

Reflux esophagitis falls into the category of reflux gastroesophagopathy. It is characterized by inflammation, erosion, ulcer formation and fibrosis of the esophageal mucous membrane due to reflux of the content of the stomach and duodenum into the esophagus.

Respiratory Virus Multiplex RT-PCR Assay Sensitivities and Influence Factors in Hospitalized Children with Lower Respiratory Tract Infections

Multiplex RT-PCR assays have been widely used tools for detection and differentiation of a panel of respiratory viral pathogens. In this study, we evaluated the Qiagen ResPlex lI V2.0 kit and explored factors influencing its sensitivity. Nasopharyngeal swab （NPS） specimens were prospectively collected from pediatric inpatients with lower respiratory tract infections at the time of admission in the Shenzhen Children＇s Hospital from May 2009 to April 2010. Total nucleic acids were extracted using the EZ1 system （Qiagen, Germany） and 17 respiratory viruses and genotypes including influenza A virus （FluA）, FluB, parainfluenza virus 1 （PIV1）, PIV2, PIV3, PIV4, respiratory syncytial virus （RSV）, human metapneumovirus （hMPV）, rhinoviruses （RhV）, enteroviruses （EnV）, human bocaviruses （hBoV）, adenoviruses （AdV）, four coronaviruses （229E, OC43, NL63 and HKU1）, and FluA 2009 pandemic H1NI（H1NI-p） were detected and identified by the ResPlex II kit. In parallel, 16 real-time TaqMan quantitative RT-PCR assays were used to quantitatively detect each virus except for RhV. Influenza and parainfluenza viral cultures were also performed. Among the total 438 NPS specimens collected during the study period, one or more viral pathogens were detected in 274 （62.6%） and 201（45.9%） specimens by monoplex TaqMan RT-PCR and multiplex ResPlex, respectively. When results from monoplex PCR or cell culture were used as the reference standard, the multiplex PCR possessed specificities of 92.9-100.0%. The sensitivity of multiplex PCR for PIV3, hMPV, PIV1 and BoV were 73.1%, 70%, 66.7% and 55.6%, respectively, while low sensitivities （11.1%-40.0%） were observed for FluA, EnV, OC43, RSV and H1N1. Among the seven viruses/genotypes detected with higher frequencies, multiplex PCR sensitivities were correlated significantly with viral loads determined by the TaqMan RT-PCR in FluA, H 1N 1-p and RSV （p=0.011-0.000） The Qiagen ResPlex II multiplex RT-PCR kit possesses excellent specificity for simultaneous detection of 17 viral pathogens in NPS specimens in pediatric inpatients at the time of admission. The sensitivity of multiplex RT-PCR was influenced by viral loads, specimen process methods, primer and probe design and amplification condition.

Effect improvement of drug pricing reform based on multi-channel coordination

To improve the effect of the drug pricing reform,a business model of pharmaceutical e-commerce is introduced into the pharmaceutical supply chain.First,based on the measures of the drug pricing reform,a dual-channel model is established,consisting of a drugstore and a hospital.The analysis of the model indicates that the reform leads to higher costs for patients.Then,an e-pharmacy is added to the dual-channel supply chain.Meanwhile,to reduce the home-delivery cost of the e-pharmacy,a multi-channel coordination strategy called“order online,delivery by drugstore”is proposed.By comparing the optimal values under the two models with and without coordination strategy,respectively,the results show that the profits of the e-pharmacy and the drugstore increase while the retail prices of drugs drop,and a large number of patients are diverted from the hospital.Therefore,the business model of pharmaceutical e-commerce with multi-channel coordination can greatly improve the effect of the drug pricing reform.

Cell sheet technology for regeneration of esophageal mucosa

The progress of tissue-engineering technology has realized development of new therapies to treat various disorders by using cultured cells. Cell-and tissue-based therapies have been successfully applied to human patients, and several tissue-engineered products have been approved by the regulatory agencies and are commercially available. In the review article, we describe our experience of development and clinical application of cell sheet-based regenerative medicine.Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been shown to be useful for removal of gastrointestinal neoplasms with less invasiveness compared with open surgery, especially in esophageal surgery. However, postoperative inflammation and stenosis are major complications observed after intensive mucosal resection. Therefore, we have developed novel regenerative medicine to prevent such complications and promote wound healing of esophageal mucosa after EMR or ESD. Transplantable oral mucosal epithelial cell sheets were fabricated from patients' own oral mucosa. Immediately after EMR or ESD, fabricated autologous cell sheets were endoscopically transplanted to the ulcer sites. We performed a preclinical study with a canine model. In human clinical settings, cell culture and cell sheet fabrication were performed in clean rooms according to good manufacturing practice guidelines, and pharmaceutical drugs were used as supplements to culture medium in place of research regents used in animal study. We believe that cell-based regenerative medicine would be useful to improve quality of life of patients after EMR or ESD.

Targeting key signalling pathways in oesophageal adenocarcinoma:A reality for personalised medicine?

Cancer treatments are rapidly changing.Curative treatment for oesophageal adenocarcinoma currently involves surgery and cytotoxic chemotherapy or chemoradiotherapy.Outcomes for both regimes are generally poor as a result of tumor recurrence.We have reviewed the key signalling pathways associated with oesophageal adenocarcinomas and discussed the recent trials of novel agents that attempt to target these pathways.There are many trials underway with the aim of improving survival in oesophageal cancer.Currently,phase 2 and 3 trials are focused on MAP kinase inhibition,either through inhibition of growth factor receptors or signal transducer proteins.In order to avoid tumor resistance,it appears to be clear that targeted therapy will be needed to combat the multiple signalling pathways that are in operation in oesophageal adenocarcinomas.This may be achievable in the future with the advent of gene signatures and a combinatorial approach.

Investigations and thoughts of the ethics in genetic discrimination

A questionnaire research in ethics was conducted to get the view of students of medical universities in Shanghai on genomics and genetic discrimination. We find that 66% respondents indicated their willingness to understand the genetic information and 79% of respondents mind their own genetic information be aware of by other people. In contrast, 77% of the respondents believe that medical organization are not able to protect personal genetic information from disclose. Hence, it is significant to take some measures to preserve citizen's genetic information privacy. Depending on our results, we put forward our suggestion to this problem.

Doctors' faith

We make some efforts to find some connections between religion and medical science. Medical science can be regarded as sacred and holy as a religion for doctors to believe. The common points between them are the basis to successfully integrate them into doctors' faith. Furthermore, we explain that doctors need a faith to believe so as to meet the demand of humanitarian traits we should have and to do better in the scientific work and win in the battles with the diseases.

EFFECT OF ELECTROACUPUNCTURE AND CALCIUM-CHANNEL INHIBITORS ON CYTOPLASMIC FREE CALCIUM CONCENTRATION OF MOUSE BRAIN CELLS

Objective: To study the effect of electroacupuncture (EA) and Verapamil and Nifedipine (calcium channel inhibitors) on free calcium concentrations of cells and intrasynaptosomes in hypothalamus (HT), periaqueductual grey matter (PAG) and hippocampus (HIP) of mice. Methods: The female ICR mice were randomly divided into control, EA, CaCl2 and CaCl2+EA groups (n=8 in each group). Pain threshold was detected by using radiation-heat irradiation-induced tail flick method. EA (8 Hz, a suitable stimulating strength, dense-sparse waves and duration of 30 min) was applied to“Shuigou” (水沟 GV 26) and “Chengjiang” (承浆CV 24). CaCl2 (10 μL, 0.2 μmol/L) was injected into the lateral cerebral ventricle of mice after EA. The concentrations of cytosolic free calcium ([Ca 2+]i) in HIP, PAG, HT cell suspension specimen and hippocampal intrasynaptosome suspension of mice were determined by the fluorescent calcium indicator Fura-2-AM and a spectrofluorometer. Results: During EA analgesia, the intracellular free [Ca 2+]i in HT and PAG specimens and intrsynaptosomal [Ca 2+]i of the 3 cerebral regions decreased considerably (P<0.05～0.01), but that in hippocampal cell suspension increased significantly (P<0.01) in comparison with control group. The concentrations of hippocampal intrasynaptosomal free [Ca 2+]i decreased significantly after adding Verapamil and Nifedipine to the extracted hippocampal intrasynaptosomal specimen. Microinjection of CaCl2 into lateral ventricle had no apparent influence on degree of analgesia (DA)% and intracellular and intrasynapsotomal [Ca 2+]i, but significantly lower DA% and reduce changes of cytosolic and intrasynaptosomal [Ca 2+]i induced by EA stimulation. Conclusion: Calcium ion in the neurons and intrasynaptosome of HT, PAG and HIP is involved in electroacupuncture analgesia.

Anemia and digestive diseases: An update for the clinician

Anemia and iron deficiency are so common in digestive diseases that often are underestimated and undertreated. Our goal is to review from classif ication to treatment of the diverse types of anemias in different digestive diseases to update our knowledge on diagnosis and treatment. With the goal of improving the prognosis and quality of life of digestive diseases patients, we will review current transfusion, intravenous iron, and erythropoietin roles in the treatment of anemia.

Satisfaction with patient-doctor relationships in inflammatory bowel diseases:Examining patient-initiated change of specialist

AIM:To assess the reasons for,and factors associated with,patient-initiated changes in treating specialist in inflammatory bowel diseases(IBD).METHODS:Prospectively identified IBD patients(n = 256) with ≥ 1 encounter at a metropolitan hospital were surveyed,including whether they had changed treating specialist and why.Negative reasons included loss of confidence,disagreement,and/or personality clash with the specialist.RESULTS:Of 162 respondents,70(43%) had ever changed specialists;30/70(43%) for negative reasons,52/70(74%) in the preceding year.Patients with negative reasons for changing(n = 30) were younger(median,35.2 years vs 45.3 years),had higher IBD knowledge(median,5.0 years vs 4.0 years),yet had lower medication adherence and satisfaction scores(median,19.0 years vs 22.0 years,14.0 years vs 16.0 years respectively,Mann-Whitney tests,all P < 0.05),compared to all other responders(n = 132).Patients with a recent change(for any reason) were more likely to have Crohn's disease,currently active disease,previous bowel resection and recent hospitalization [OR 2.6,95% CI(1.3-5.4),2.2(1.0-4.7),5.56(1.92-16.67),2.0(1.3-3.0),eachP < 0.05].CONCLUSION:Changing specialist appears associated with patient-related(age,nonadherence) and contemporaneous disease-related factors(recent relapse) which,where modifiable,may enhance patient-doctor relationships and therefore quality of care.

Metachronous bile duct cancer nine years after resection of gallbladder cancer

We report a rare case of a 74-year-old man with metachronous gallbladder cancer and bile duct cancer who underwent curative resection twice, with the operations nine years apart. At the age of 65 years, the patient underwent a cholecystectomy and resection of the liver bed for gallbladder cancer. This was a welldifferentiated adenocarcinoma, with negative resection margins （T2NOM0, stage Ⅰ B）. Nine years later, during a follow-up examination, abdominal computed tomography and MRCP showed an enhanced 1.7 cm mass in the hilum that extended to the second branch of the right intrahepatic bile duct. We diagnosed this lesion as a perihilar bile duct cancer, Bismuth type Ⅲ a, and performed bile duct excision, right hepatic Iobectomy and Roux-en-Y hepaticojejunostomy. The histological diagnosis was a well-differentiated adenocarcinoma with one regional lymph node metastasis （TINIM0, stage Ⅱ B）. Twelve months after the second operation, the patient is well, with no signs of recurrence. This case is compared with 11 other cases of metachronous biliary tract cancer published in the world medical literature.

Magnets, children and the bowel: A dangerous attraction?

Reports of magnet ingestion are increasing rapidly globally. However, multiple magnet ingestion, the subsequent potential complications and the importance of the early identification and proper management remain both under-recognized and underestimated. Published literature on such cases could possibly represent only the tip of an iceberg with press reports, web blogs and government documents highlighting further occurrence of many more such incidents. The increasing number of complications worldwide being reported secondary to magnet ingestion point not only to an acute lack of awareness about this condition among the medical profession but also among parents and carers who will be in most cases the first to pick up on magnet ingestion. There still seems to be no consensus on the management of magnet ingestion with several algorithms being proposed for management. Prevention of this condition remains a much better option than cure. Proper education and improved awareness among parents and carers and frontline medical staff is key in addressing this rapidly emerging problem. The goal of managing such cases of suspected magnet ingestion should be aimed at reducing delays between ingestion time, diagnosis time and intervention time.

Systemic therapy of non-colorectal gastrointestinal malignancies in the elderly

In the coming years life expectancy is expected to increase and with this the percentage of the population above age 65 will grow. Patients above 65 make up more than two thirds of those currently diagnosed with gastrointestinal malignancies. Available evidence based medicine does not focus on the average patient, above the age 70, encountered in every day practice. Most guidelines and clinical trials are not designed to take into account the special considerations needed when treating the elderly such as functional status, comorbidities, polypharmacy, life expectancy, and social support. The majority of available data is based on retrospective reviews or subset analyses of larger studies where the elderly represent a fraction of the studied population. This review focuses on the toxicities and tolerability of current standard therapies for noncolorectal gastrointestinal malignancies, including gastroesophageal, pancreatic, bile duct and hepatocellular cancers in the elderly. With careful patient selection and geriatric assessment the elderly can safely benefit from standard therapies offered to younger patients.

Giant vesical diverticulum:A rare cause of defecation disturbance

Vesical diverticula frequently result from bladder outlet obstructions. However, giant vesical diverticula which cause acute abdomen or intestinal obstruction are very rare. Our review of the English medical literature found 3 cases of bladder diverticula which caused gastrointestinal symptoms. Here, we present a 57-yearold man with a giant diverticulum of the urinary bladder who complained of abdominal pain, nausea and vomiting, constipation, no passage of gas or feces, and abdominal distension for 3 d. A 20 cm x 15 cm diverticulum was observed upon laparotomy. The colonic obstruction was secondary to external compression of the rectum against the sacrum by a distended vesical diverticulum. We performed a diverticulectomy and primary closure. Twelve months postoperatively, the patient had no difficulty with voiding or defecation.

YINDARA-4 relieves visceral hypersensitivity in irritable bowel syndrome rats via regulation of gut microbiota and serotonin levels

Objective:The present study aims to evaluate the in vivo efficacy of YINDARA-4 in improving the symptoms of irritable bowel syndrome(IBS)in a rat model and investigate the impact of YINDARA-4 on potential targets of IBS management,such as the serotonin level in intestinal tissues and the structure and composition of the gut microbiota.Methods:We developed an IBS rat model by combining stress from maternal separation,acetic acid administration,and restraint.We administered YINDARA-4 water extract to the IBS rat model for 10 consecutive days.The fecal water content,visceral sensitivity,gut microbiota,and serotonin levels in the colonic tissue were then analyzed and compared between the control group,IBS model group,and YINDARA-4–treated groups.Results:Treatment with YINDARA-4 reversed visceral hypersensitivity in a dose-dependent manner in the experimental rat model of IBS.The relief of visceral hypersensitivity upon treatment with YINDARA-4 involved regulation of the gut microbiota structure and composition,and normalization of elevated serotonin levels in the colon.The decrease in colonic serotonin levels with YINDARA-4 treatment might be associated with a reduction in the abundance of Helicobacter and enrichment of Butyricimonas.Conclusions:Treatment with YINDARA-4 was beneficial against visceral hypersensitivity in a rat model of IBS.The improved symptoms exhibited in IBS rats were associated with favorably altered gut microbiota and normalization of serotonin levels in the colon.