《医医琐言》价值再评价

《医医琐言》为清代徐延祚所编,当代许多医家从学术价值出发,给予该书较高评价。通过研究发现,《医医琐言》与《医断》、《续医断》具有密切关系,对于传播异邦学术具有重要价值,徐氏所增内容也具有一定的学术价值,但若言其"都是作者多年读书心得与临床经验的总结,其中不乏前人所未发之处"则言过其实。

基于证据的医学问题

更有效的方法必须结合EBM和经验丰富的医护人员的专业知识和直觉,兼取其长任何医疗体系都要平衡覆盖度、质量和成本——通常都会集中关注其中之一或之二而牺牲其他。比如,欧洲的医疗体系关注覆盖度、确保所有人都能获得医疗;与之相反,在美国,质量才是最重要的。但是,不管你认为什么才是最重要的,显然美国在所有三个方面都有改进空间。幸运的是。

General Characteristics of HIV/AIDS Patients in Ditan Hospital

Objective: To elucidate general characteristics of HIV/AIDS patients seeking care at Ditan Hospital in an attempt to guide early diagnosis in routine medical care. Materials and methods: A retrospective analysis of 185 HIV/AIDS cases from January 1990 to June 2002 was completed using SPSS statistical analysis. Results: Male to female ratio was 1.8 :1. Subjects ranged in age from 1 year old to 64 years old. 16 cases were younger than 20 years old with the median age among the younger subset at 7.7 years. 169 cases were older than 20 years old with a median age of 36 years old. 29% of the subjects were peasants. The remaining 71%, were of other unspecified occupations. 90.8% of individuals were of Han descent while 3.7% of individuals were of a minority heritage. 50.3% of subjects were married; 23.8% have never married; 8.1% were divorced; and the remaining 17.8% were of unknown marital status. Of those represented in this study, 36.8% came from the Henan province; 17.8% were from Beijing; 8.6% were from Shanxi; 31.4% from the other 20 provinces of China; and 5.4% from outside of China. Mode of transmission: 40.0% (74/185) contracted HIV through unprotected sexual contact; 29.2% (54/185) through receiving blood or plasma transfusions; 21.1%(39/185) through donating plasma; 7 cases were intravenous drug users; 7 cases were vertically transmitted. Mode of transmission was unknown in 4 cases. Clinical categories: An included 45 cases; B included 85 cases: C consisted of 76 cases. 12 cases were deceased. Initial presentation: 39 cases presented with fever ,cough and diarrhea. 37 cases had fever and cough only. 38 cases presented with chronic diarrhea. 16 cases were discovered incidentally at time of operation. 8 cases presented with fungal infection of the oral cavity or in esophagus. The common HIV associated symptoms and opportunistic infections were: weight loss and diarrhea, respiratory diseases, der-matologic diseases, anemia , neutropenia. Diseases of other organ systems were less common. Common misdiagnoses included pneumonia, the common cold, and enteritis. Conclusion: The majority of cases were of middle age (between 30-40 years old) and had contracted HIV/ AIDS sexually.Receiving contaminated blood or plasma via a transfusion accounted for the second most common mode of transmission. Donating plasma was the third most likely mode of transmission. Initial presenting symptoms were various and complicated. Even though the majority of HIV/AIDS cases present to the general hospital, many doctors working at the general hospital are still unable to recognize the symptoms of HIV/AIDS. Thus, it is imperative to identify general characteristics of the HIV/AIDS population in order to diagnose the disease at an earlier stage and halt further transmission.

Current clinical approach to achalasia

Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and conf irmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients' characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.

Tuberculous peritonitis in children:Report of nine patients and review of the literature

AIM:To present our experience with tuberculous peritonitis treated in our hospital from 2002-2007. METHODS: We reviewed the medical records of 9 children with tuberculous peritonitis. RESULTS: Nine patients (5 boys, 4 girls) of mean age 14.2 years were diagnosed with peritoneal tuberculosis. All patients presented with abdominal distention. Abdominal pain was seen in 55.5% and fever in 44.4% of the patients. Four cases had coexisting pleural effusion and two had pulmonary tuberculosis with parenchymal consolidation. Ultrasonography found ascites with septation in 7 patients. Two patients had only ascites without septation. Ascitic fluid analysis of 8 patients yielded serum-ascite albumin gradients of less than 1.1 gr/dL. Laparoscopy and laparotomy showed that whitish tuberculi were the most common appearance. Adhesions were also seen in three cases. The diagnosis of peritoneal tuberculosis was confirmed histo-pathologically in 7 patients and microbiologically in two. Two patients had been diagnosed by ascitic fluid diagnostic features and a positive response to antituberculous treatment. All patients completed the antituberculous therapy without any complications. CONCLUSION: Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. Laparoscopy and peritoneal biopsy are still the most reliable, quick and safe methods for the diagnosis of tuberculous peritonitis.

Biochemical markers for non-invasive assessment of disease stage in patients with primary biliary cirrhosis

AIM: To evaluate different biochemical markers and their ratios in the assessment of primary biliary cirrhosis (PBC) stages. METHODS: This study included 112 patients with PBC who underwent a complete clinical investigation. We analyzed the correlation (Spearman's test) between ten biochemical markers and their ratios with different stages of PBC. The discriminative values were compared using areas under receiver operating characteristic (ROC) curves. RESULTS: The mean age of patients included in the study was 53.88 ± 10.59 years, including 104 females and 8 males. We found a statistically significant correlation between PBC stage and Aspartate aminotransferase (AST), Alanine aminotransferase (ALT) to platelet ratio (APRI), ALT/platelet count, AST/ALT, ALT/AST and ALT/Cholesterol ratios, with the values of Spearman's rho of 0.338, 0.476, 0.404, 0.356, 0.351 and 0.325, respectively. The best sensitivity and specificity was shown for AST/ALT, with an area under ROC of 0.660. CONCLUSION: Biochemical markers and their ratios do correlate with different sensitivity to and specificity of PBC disease stage. The use of biochemical markers and their ratios in clinical evaluation of PBC patients may reduce, but not eliminate, the need for liver biopsy.

Gastroenterology service in a teaching hospital in rural New Zealand, 1991-2003

AIM: To retrospectively collect inpatient and outpatient data and to assess the use of endoscopic procedures during the years 1991, 1997 and 2003 to analyse for trends. METHODS: This retrospective survey was conducted in a University-associated Gastroenterology Unit offering secondary and tertiary health care services for a population of approximately 182 000 people in Southern New Zealand. Data collected included patient contacts (inand outpatients), gastroscopic and colonoscopic investigations. RESULTS: We observed a significant increase in the absolute numbers of patient contacts over the years (1991: 2308 vs 1997: 2022 vs 2003: 2783, P < 0.0001) with inflammatory bowel disease, other diseases of the colon, anus and rectum and iron studies related disorders decreasing significantly but liver disease and constipation increasing linearly over time. The use of endoscopy services remained relatively stable but colonoscopic investigations for a positive family history of colorectal cancer increased significantly while more gastroscopies were performed for unexplained anaemia. CONCLUSION: The whole spectrum of gastroenterology contacts was studied. A substantial proportion of colonoscopies and outpatient consultations were undertaken to screen for colorectal cancer. This proportion is likely to grow further. Our fi ndings have implications for the recruitment and training of the next generation of gastroenterologists.

Clinical Intelligent Diagnosis Path Based on the Chief Complaint

Goals of traditional Chinese medicine(TCM)include precision,accuracy,and recognition by clinical practice.Establishment of a diagnosis and treatment system that closely conforms to the principle-method-recipe-medicines system and derivation of an accurate diagnosis and treatment plan should be considerations of TCM.Artificial intelligence research based on computer technology is one of the effective ways to solve this problem.In the research of intelligent diagnosis path,reflecting the characteristics of the overall view and dialectical treatment of TCM such as"Combination of four diagnostic methods""overall examination""combination of disease and syndrome"and"treatment individualized to patient,season and locality"are key for successful research of artificial intelligence in TCM diagnosis or recognition by clinical practice.

Small bowel capsule endoscopy in 2007:Indications,risks and limitations

Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn＇s disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool （which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions）.The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions （i.e. obscure GI bleeding）, the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way （with capsule endoscopy） and to define and treat the lesions identified （with double balloon enteroscopy）.

Irritable bowel syndrome: Physicians' awareness and patients' experience

AIM: To study if and how physicians use the irritable bowel syndrome (IBS) diagnostic criteria and to assess treatment strategies in IBS patients. METHODS: A questionnaire was sent to 191 physicians regarding IBS criteria, diagnostic methods and treatment. Furthermore, 94 patients who were diagnosed with IBS underwent telephone interview. RESULTS: A total of 80/191 (41.9%) physicians responded to the survey. Overall, 13 patients were diag-nosed monthly with IBS by specialists in gastroenterology (SGs) and 2.5 patients by general practitioners (GPs). All the SGs knew of the criteria to diagnose IBS, as did 46/70 (65.7%) GPs. Seventy-nine percent used the patient's history, 38% used a physical examination, and 38% exclusion of other diseases to diagnose IBS. Only 18/80 (22.5%) physicians used specific IBS criteria. Of the patients interviewed, 59/94 (62.8%) knew they had experienced IBS. Two out of five patients knew IBS and had seen a physician because of IBS symptoms. Half of those received a diagnosis of IBS. A total of 13% were satisfied with treatment. IBS affected daily activities in 43% of cases. CONCLUSION: Half of the patients with IBS who consulted a physician received a diagnosis. Awareness and knowledge of diagnostic criteria for IBS differ between SGs and GPs.

Research on Text Mining of Syndrome Element Syndrome Differentiation by Natural Language Processing

Objective Natural language processing (NLP) was used to excavate and visualize the core content of syndrome element syndrome differentiation (SESD). Methods The first step was to build a text mining and analysis environment based on Python language, and built a corpus based on the core chapters of SESD. The second step was to digitalize the corpus. The main steps included word segmentation, information cleaning and merging, document-entry matrix, dictionary compilation and information conversion. The third step was to mine and display the internal information of SESD corpus by means of word cloud, keyword extraction and visualization. Results NLP played a positive role in computer recognition and comprehension of SESD. Different chapters had different keywords and weights. Deficiency syndrome elements were an important component of SESD, such as "Qi deficiency""Yang deficiency" and "Yin deficiency". The important syndrome elements of substantiality included "Blood stasis""Qi stagnation", etc. Core syndrome elements were closely related. Conclusions Syndrome differentiation and treatment was the core of SESD. Using NLP to excavate syndromes differentiation could help reveal the internal relationship between syndromes differentiation and provide basis for artificial intelligence to learn syndromes differentiation.

Abstraction of Data Elements of Clinical Symptoms in Chinese Medicine

This report analyzes the existing problems in terminology referring to clinical symptoms of traditional Chinese medicine(TCM)from the viewpoint of data sharing and elaborates the necessity of establishing a standard directory of clinical data elements of TCM.We evaluated the principles and methods of data element extraction according to the status quo of the clinical information system and characteristics of symptoms for TCM and consequently proposed a three-layer model for optimal extraction.

Outlier Detection in Near Infra-Red Spectra with Self-Organizing Map

A new method to detect multiple outliers in multivariate data is proposed. It is a combination of minimum subsets, resampling and self-organizing map (SOM) algorithm introduced by Kohonen,which provides a robust way with neural network. In this method, the number and organization of the neurons are selected by the characteristics of the spectra, e.g., the spectra data are often changed linearly with the concentration of the components and are often measured repeatedly, etc. So the spatial distribution of the neurons can be arranged by this characteristic. With this method, all the outliers in the spectra can be detected, which cannot be solved by the traditional method, and the speed of computation is higher than that of the traditional neural network method. The results of the simulation and the experiment show that this method is simple, effective, intuitionistic and all the outliers in the spectra can be detected in a short time. It is useful when associated with the regression model in the near infra-red research.

Endoscopic treatment of chronic pancreatitis

Treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as a primary therapeutic option. Initially performed for drainage of pancreatic cysts and pseudocysts, endoscopic treatments were adapted to biliary and pancreatic ducts stenosis. Pancreatic sphincterotomy which allows access to pancreatic ducts was firstly reported. Secondly, endoscopic methods of stenting, dilatation, and stones extraction of the bile ducts were applied to pancreatic ducts. Nevertheless, new improvements were necessary： failures of pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic stenosis was improved by forage with a new device; moreover endosonography allowed guidance for celiac block, gastro-cystostomy, duodeno-cystostomy and pancreatico-gastrostomy. Although endoscopic treatments are more and more frequently accepted, indications are still debated.

OBSERVATION OF THE EFFICACY OF ACUPUNCTURE AND MOXIBUSTION IN 62 CASES OF CHRONIC COLITIS

62 patients with chronic colitis were randomly divided into two groups. Acupuncture and moxibustion at acupoints such as Tianshu (St 25), Guanyuan (Ren 4) were applied in the treatment group, and western drugs were applied in the control group. The results showed that acupuncture and moxibustion had a marked curative effective with few side effects, and therefore was readily acceptable to the patients.

Medical Foreign Bodies in Urinary Bladder: a Case Report

RETAINED foreign bodies in the urinary tract after surgical or diagnostic procedure, named iatrogenic foreign bodies, are rarely reported, though the estimated incidence was as high as 1/1500 cases.1 Prompt and proper retrieval is required due to potential complications. We report a case of iatrogenic foreign body into the bladder.

Prevalence of depressive and anxiety disorders in Chinese gastroenterological outpatients

AIM:To investigate the prevalence and physicians' detection rate of depressive and anxiety disorders in gastrointestinal(GI)outpatients across China. METHODS:A hospital-based cross-sectional survey was conducted in the GI outpatient departments of 13 general hospitals.A total of 1995 GI outpatients were recruited and screened with the Hospital Anxiety and Depression Scale(HADS).The physicians of the GI departments performed routine clinical diagnosis and management without knowing the HADS score results.Subjects with HADS scores≥8 were subsequently interviewed by psychiatrists using the Mini International Neuropsy-chiatric Interview(MINI)to make further diagnoses. RESULTS:There were 1059 patients with HADS score ≥8 and 674(63.64%)of them undertook the MINI interview by psychiatrists.Based on the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th edition),the adjusted current prevalence for depressive disorders,anxiety disorders,and comorbidity of both disorders in the GI outpatients was 14.39%, 9.42%and 4.66%,respectively.Prevalence of depressive disorders with suicidal problems[suicide attempt or suicide-related ideation prior or current;module C (suicide)of MINI score≥1]was 5.84%in women and 1.64%in men.The GI physicians'detection rate of depressive and anxiety disorders accounted for 4.14%. CONCLUSION:While the prevalence of depressive and anxiety disorders is high in Chinese GI outpatients, the detection rate of depressive and anxiety disorders by physicians is low.

Supplementary tests for confirmation of brain death

In 1959, the concept of brain death （BD） or irreversible coma was described by Mollaret and Goulon （1959）. The first guideline （the Harvard criteria） for deciding BD was established in 1968 （Ad Hoc Committee of the Harvard Medical School, 1968）. This concept has been accepted worldwide although its fundamental meaning is not exactly globally uniform yet. Some countries （e.g., the US） view BD as ＂whole brain death＂, while others （e.g., the UK） as brain-stem death. The guidelines for the diagnosis of BD also differ among countries, even among hospitals in the same country.

Hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation

Here, we present the case of a 53-year-old man with a hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation. On admission, the patient complained of severe acute abdominal pain, with physical examination findings suspicious for a perforated peptic ulcer. Of note, the patient had no history of other medical conditions or recent trauma, and the initial chest radiography and laboratory findings were not specific. A subsequent abdominal computed tomography revealed intrathoracic displacement of the liver, gallbladder, transverse colon and omentum through a right diaphragmatic defect. The patient then underwent an explorative laparotomy that confirmed duodenal ulcer perforation. A primary repair of the duodenal perforation was performed, and the diaphrag-matic defect was repaired using a polytetrafluoroeth-ylene patch after the organs were reduced and the cavity irrigated. This particular case proves interesting as right-sided spontaneous diaphragmatic ruptures are very rare and difficult to diagnose. Additionally, the best treatment for such large diaphragmatic defects is still controversial, especially in cases of intrathoracic or intra-abdominal contamination.

Mirizzi Syndrome: Our Experience with 27 Cases in PUMC Hospital

Objective To retrospectively evaluate the diagnosis and treatment of Mirizzi syndrome （MS）. Methods Patients who received elective or emergency cholecystectomies in our center during 23 years were retrospectively evaluated. The data reviewed included demography, clinical presentations, diagnostic methods, surgical procedures, postoperative complications, and follow-up.