秦汉社会方技——医药学探析——兼论司马迁为扁鹊仓公立传的历史意义

医药学是我国古代科技的重要门类之一,在刘歆的《七略》中,医药学被称之为"方技略",医生被称之为"方者"。司马迁在《史记》中撰《扁鹊仓公列传》,开创了正史为方技立传的先河,后世因袭,遂成故事。从长沙马王堆出土的《五十二病方》来看,从春秋战国至秦汉社会,医方包括部分禁方有了很大的普及。东汉初年编成的《神农本草经》集中反映了先秦秦汉时期药物学的成就。方技中不仅方者,甚至鼓吹神仙术的方士,都对药物学作出了一定的贡献。

Chunk approach for English teaching

This paper suggests a chunk approach to solve the plateau problem among advanced English learners. The paper first discusses the extant problems and then provides a definition of the chunk approach. Based on some research results in cognitive psychology, it analyses the important role that chunks play in language acquisition and production and thus provides a cognitive foundation for implementing the chunk approach in English teaching. The paper also offers a set of classroom activities which can be easily adopted or adapted by other teachers.

Three-dimensional interpretation of sparse survey line MT data: Synthetic examples

Currently, most of MT （magnetotelluric） data are still collected on sparse survey lines and interpreted using 2D inversion methods because of the field work cost, the work area environment, and so on. However, there are some 2D interpretation limitations of the MT data from 3D geoelectrical structures which always leads to wrong geological interpretations. In this paper, we used the 3D inversion method to interpret the MT sparse lines data. In model testing, the sparse lines data are the MT full information data generated from a test model and processed using the 3D conjugate gradients inversion code. The inversion results show that this inversion method is reasonable and effective. Meanwhile, we prove that for inversion results with different element parameters, the results by joint inversion of both the impedance tensor data and the tipper data are more accurate and closer to the test model.

《韩非子》二则

以法治国，举措而已矣。法不阿贵，绳不挠曲。法之所加，智者弗能辞，勇者弗敢争。（《有度》）

Vascular access today

The number of patients with chronic kidney disease re-quiring renal replacement therapy has increased world-wide. The most common replacement therapy is hemo-dialysis （HD）. Vascular access （VA） has a key role for successful treatment. Despite the advances that have taken place in the feld of the HD procedure, few things have changed with regards to VA in recent years. Ar-teriovenous fstula （AVF）, polytetrafuoroethylene graft and the cuffed double lumen silicone catheter are the most common used for VA. In the long term, a number of complications may present and more than one VA is needed during the HD life. The most common com-plications for all of VA types are thrombosis, bleeding and infection, the most common cause of morbidity in these patients. It has been estimated that VA dysfunc-tion is responsible for 20% of all hospitalizations. The annual cost of placing and looking after dialysis VA in the United States exceeds 1 billion dollars per year. A good functional access is also vital in order to deliver adequate HD therapy. It seems that the native AVF that Brescia and Cimino described in 1966 still remains the frst choice for VA. The native forearm AVFs have the longest survival and require the fewest interventions. For this reason, the forearm AVF is the frst choice, fol-lowed by the upper-arm AVF, the arteriovenous graft and the cuffed central venous catheter is the final choice. In conclusion, VA remains the most importantissue for patients on HD and despite the technical im-provements, a number of problems and complications have to be resolved.

Therapeutic proteasome inhibition in experimental acute pancreatitis

AIM： To establish the therapeutic potential of proteasome inhibition, we examined the therapeutic effects of MG132 （Z-Leu-Leu-Leu-aldehyde） in an experimental model of acute pancreatitis. METHODS： Pancreatitis was induced in rats by two hourly intraperitoneal （ip） injections of cholecystokinin octapeptide （CCK; 2×100μg/kg） and the proteasome inhibitor MG132 （10 mg/kg ip） was administered 30 min after the second CCK injection. Animals were sacrificed 4 h after the first injection of CCK. RESULTS： Administering the proteasome inhibitor MG132 （at a dose of 10 mg/kg, ip） 90 min after the onset of pancreatic inflammation induced the expression of cell-protective 72 kDa heat shock protein （HSP72） and decreased DNA-binding of nuclear factor-κB （NF-κB）. Furthermore MG132 treatment resulted in milder inflammatory response and cellular damage, as revealed by improved laboratory and histological parameters of pancreatitis and associated oxidative stress. CONCLUSION： Our findings suggest that proteasome inhibition might be beneficial not only for the prevention, but also for the therapy of acute pancreatitis.

Vascular calcification in chronic kidney disease: Pathogenesis and clinical implication

Cardiovascular disease is the leading cause of deathamong patients with chronic kidney disease （CKD）.Vascular calcification （VC） is one of the independentrisk factors associated with cardiovascular disease andcardiovascular mortality in both the general populationand CKD patients. Earlier evidence revealed substan-tially higher prevalence of VC in young adults on chron-ic hemodialysis compared to the general population inthe same age range, indicating the infuence of CKD-related risk factors on the development of VC. Patho-genesis of VC involves an active, highly organized cel-lular transformation of vascular smooth muscle cells tobone forming cells evidenced by the presence of bonematrix proteins in the calcifed arterial wall. VC occursin both the intima and the media of arterial wall withmedial calcification being more prevalent in CKD. Inaddition to traditional cardiovascular risks, risk factorsspecific to CKD such as phosphate retention, excessof calcium, history of dialysis, active vitamin D therapy in high doses and deficiency of calcification inhibitors play important roles in promoting the development of VC. Non-contrast multi-slice computed tomography has often been used to detect coronary artery calcif-cation. Simple plain radiographs of the lateral lumbar spine and pelvis can also detect VC in the abdominal aorta and femoral and iliac arteries. Currently, there is no specifc therapy to reverse VC. Reduction of calcium load, lowering phosphate retention using non-calcium containing phosphate binders, and moderate doses of active vitamin D may attenuate progression. Parenteral sodium thiosulfate has also been shown to delay VC progression.

Contrast-induced acute kidney injury:A review of practical points

Contrast-induced acute kidney injury(CI-AKI) is oneof the most common causes of AKI in clinical practice.CI-AKI has been found to be strongly associated with morbidity and mortality of the patients.Furthermore,CI-AKI may not be always reversible and it may be associated with the development of chronic kidney disease.Pathophysiology of CI-AKI is not exactly understood and there is no consensus on the preventive strategies.CI-AKI is an active research area thus clinicians should be updated periodically about this topic.In this review,we aimed to discuss the indications of contrastenhanced imaging,types of contrast media and their impact on nephrotoxicity,major pathophysiological mechanisms,risk factors and preventive strategies of CI-AKI and alternative non-contrast-enhanced imaging methods.

Surgical treatment of anal stenosis

Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anoplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.

Patients' quality of life after laparoscopic or open cholecystectomy

Objective: This study was aimed at evaluating and comparing the quality of life in patients who underwent laparo-scopic and open cholecystectomy for chronic cholecystolithiasis. Methods: The study included 25 patients with laparoscopic cholecystectomy (LC group) and 26 with open cholecystectomy (OC group). The quality of life was measured with the Gastrointestinal Quality of Life Index (GLQI) preoperatively, thereafter regularly at 2, 5, 10 and 16 weeks after the operation. Results: The mean preoperative overall GLQI scores were 112.5 and 110.3 in LC and OC group respectively (P>0.05). In the LC group, the mean overall GLQI score reduced slightly to 110.0 two weeks after the operation (P>0.05). The LC group showed significant improvement in overall score and in the aspects of symptomatology, emotional and physiological status from 5 to 16 weeks postoperatively. In the OC group, the GLQI score reduced to 102.0 two weeks after surgery (P<0.05). Significant reductions were shown in the aspects of symptomatology, physiological and social status. The GLQI scores returned to the preoperative level of 115.6 ten weeks after the operation (P>0.05). The patients experienced significant improvements of GLQI sixteen weeks after OC operation (P<0.01-0.05). Within the 10 postoperative weeks, the LC group had significantly higher GLQI scores than the OC group (P<0.05). Conclusions: LC can improve the quality of life postoperatively better and more rapidly than OC. The assessment of quality of life assessment is a valid method for measuring the effects of surgical treatment.

Diabetes mellitus increases the prevalence of anemia in patients with chronic kidney disease:A nested case-control study

AIM: To compare anemia prevalence between matched chronic kidney disease(CKD) patients with and without diabetes mellitus(DM) and to assess factors associated with anemia development.METHODS: This is a nested case-control study of 184 type-2 diabetic and 184 non-diabetic CKD patients from a prospectively assembled database of a Nephrology outpatient clinic, matched for gender, age and estimated glomerular filtration rate(eG FR). Prevalence of anemia(hemoglobin: Men: < 13 g/dL, women: < 12 g/dL and/or use of recombinant erythropoietin) was examined in comparison, in the total population and by CKD Stage. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with anemia.RESULTS: The total prevalence of anemia was higher in diabetics(47.8% vs 33.2%, P = 0.004). Accordingly, prevalence was higher in diabetics in CKD Stage 3(53.5% vs 33.1%, P < 0.001) and particularly in Stage 3a(60.4% vs 26.4%, P < 0.001), whereas it was nonsignificantly higher in Stage 4(61.3% vs 48.4%; P = 0.307). Serum ferritin was higher in diabetics in total and in CKD stages, while serum iron was similar between groups. In multivariate analyses, DM(OR = 2.206, 95%CI: 1.196-4.069), CKD Stages 3a, 3b, 4(Stage 4: OR = 12.169, 95%CI: 3.783-39.147) and serum iron(OR = 0.976, 95%CI: 0.968-0.985 per mg/d L increase) were independently associated with anemia.CONCLUSION: Prevalence of anemia progressively increases with advancing stages of CKD and is higher in diabetic than matched non-diabetic CKD patients and diabetes is independently associated with anemia occurrence. Detection and treatment of anemia in diabetic CKD patients should be performed earlier than non-diabetic counterparts.

Aortic valve stenosis： treatments options in elderly high-risk patients

In the last decades, a trend towards a worldwide aging has been reported and diseases which are common in the elderly people would have important implications in clinical practice. Aortic stenosis （AS） is perhaps the most common and most often cause of sudden death among valvular heart diseases. Its prevalence is low among adults aged 〈 60 years, but increases to almost 10% in adults ≥ 80 years.[2] Since the degenerative calcific disease represents the lead- ing cause of AS in developed countries, the improved understanding on its pathogenesis （atherosclerotic processes and/or skeleton key） may offer potentially new targets for preventing and inhibiting AS development and progres- sion.[3] Patients with AS are generally asymptomatic for a prolonged period and the development of symptoms is a critical point in the natural history. Indeed, the prognosis changes dramatically with the onset of symptoms of angina,

Targeting cannabinoid signaling for peritoneal dialysisinduced oxidative stress and fibrosis

Long-term exposure to bioincompatible peritoneal dialysis(PD) solutions frequently results in peritoneal fibrosis and ultrafiltration failure,which limits the life-long use of and leads to the cessation of PD therapy.Therefore,it is important to elucidate the pathogenesis of peritoneal fibrosis in order to design therapeutic strategies to prevent its occurrence.Peritoneal fibrosis is associated with a chronic inflammatory status as well as an elevated oxidative stress(OS) status.Beyond uremia per se,OS also results from chronic exposure to high glucose load,glucose degradation products,advanced glycation end products,and hypertonic stress.Therapy targeting the cannabinoid(CB) signaling pathway has been reported in several chronic inflammatory diseases with elevated OS.We recently reported that the intra-peritoneal administration of CB receptor ligands,including CB_1 receptor antagonistsand CB_2 receptor agonists,ameliorated dialysis-related peritoneal fibrosis.As targeting the CB signaling pathway has been reported to be beneficial in attenuating the processes of several chronic inflammatory diseases,we reviewed the interaction among the cannabinoid system,inflammation,and OS,through which clinicians ultimately aim to prolong the peritoneal survival of PD patients.

Real-world characteristics of hospitalized frail elderly patients with atrial fibrillation： can we improve the current prescription of anticoagulants？

Background In elderly patients, especially those older than 80 years, atrial fibrillation （AF） is associated with an almost 25% in- creased risk of stroke. Stroke prophylaxis with anticoagulants is therefore highly recommended. The prevalence of factors that have been associated with a lower rate of prescription and adherence to anticoagulant therapy in these patients is little known. The objective of this study was to explore the clinical characteristics of elderly subjects, with and without AF, consecutively admitted to an acute geriatric unit, discussing factors that may decrease the persistence on stroke prophylaxis therapy. We also highlight possible strategies to overcome the barriers conditioning the current underuse of oral anticoagulants in this segment of the population. Methods A retrospective observational study was performed on a cohort of elderly patients with and without AF admitted to the Acute Geriatric Unit of San Gerardo Hospital （Monza, Italy）. Results Compared to patients without AF （n = 1216）, those with AF （n = 403） had a higher Charlson Comorbidity Index （3 vs. 2, P 〈 0.001）, number of administered drugs （4 vs. 3, P 〈 0.001）, rate of heart failure （36.5% vs. 12%, P 〈 0.001） and chronic kidney disease （20.6 vs. 13.2, P 〈 0.001）. Many patients with AF were frail （54%） or pre-frail （29%）. Conclusions Elderly patients with AF have higher rates of conditions that affect adherence to traditional anticoagulant therapy （vitamin K antagonists, VKA）. New direct oral anticoagulants （DOAs） can help overcome this problem. In order to prescribe the most appropriate VKA or DOAs, with the best efficacy/safety profile and the highest compliance, a comprehensive geriatric assessment should always accompany the scores for thrombotic and hemorrhagic risk stratification.

Silent diabetic nephropathy

AIM： To examine the risk of renal events in patients with biopsy-proven diabetic nephropathy （DN） and its possible associated factors.METHODS： Clinical and histological data of 60 pa-tients diagnosed with diabetic nephropathy were retro-spectively collected. Patients with evidence or suspicion of other nephropathies were excluded from the study. The fnal event was defned as renal replacement ther-apy （RRT） initiation or progression of chronic kidney disease （CKD）, according to the KDIGO 2012 defnition of a decrease in CKD category and a decrease in GFR of 25% or more. RESULTS： A total of 45 patients with a follow-up of at least 3 mo were included. Most of the patients presented type 2 DM, with a mean age of 58.3 years old. The time of evolution of DM was 9.6 ± 7.8 years, al-though in 13 patients, it was less than 5 years. A total of 62% of patients reached the fnal event in a mean period of 3.4 years （95%CI： 2.1-4.7）, with 21 of them requiring dialysis. The factors that were indepen-dently associated with renal survival were estimated glomerular fltration rate （eGFR） at the time of biopsy, cardiovascular disease （CVD） history and HbA1c less than 7%. Therefore, for each 10 mL/min per 1.73 m2 reduction in eGFR, we obtained a DN progression risk of HR = 2 （1.3-3.0） （P = 0.001）; patients with CVD were at greater risk for DN progression （HR = 2.8, 1.1-7.1, P = 0.032）, and CKD patients with HbA1c 〈 7% demonstrated greater renal risk than patients with HbA1c ≥ 7%, with an HR of 2.9 （1.0-8.4） （P = 0.054）.CONCLUSION： A past history of CVD is a risk fac-tor for DN progression. Levels of HbA1c less than 7% could favor an eGFR decrease in these patients.

Erectile dysfunction in chronic kidney disease:From pathophysiology to management

Chronic kidney disease(CKD) is encountered in millions of people worldwide,with continuously rising incidence during the past decades,affecting their quality of life despite the increase of life expectancy in these patients.Disturbance of sexual function is common among men with CKD,as both conditions share common pathophysiological causes,such as vascular or hormonal abnormalities and are both affected by similar coexisting comorbid conditions such as cardiovascular disease,hypertension and diabetes mellitus.The estimated prevalence of erectile dysfunction reaches 70% in end stage renal disease patients.Nevertheless,sexual dysfunction remains under-recognized and under-treated in a high proportion of these patients,a fact which should raise awareness among clinicians.A multifactorial approach in management and treatment is undoubtedly required in order to improve patients' quality of life and cardiovascular outcomes.

Comparison of four proton pump inhibitors for the short-term treatment of esophagitis in elderly patients

AIM: To compare efficacy and tolerability of four proton pump inhibitors (PPIs) commonly used in the short-term therapy of esophagitis in elderly patients.METHODS: A total of 320 patients over 65 years with endoscopically diagnosed esophagitis were randomly assigned to one of the following treatments for 8 wk: (1) omeprazole 20 mg/d; (2) lansoprazole 30 mg/d; (3) pantoprazole 40 mg/d, or (4) rabeprazole 20 mg/d. Major symptoms, compliance, and adverse events were recorded. After 8 wk, endoscopy and clinical evaluation were repeated.RESULTS: Per protocol and intention to treat healing rates of esophagitis were: omeprazole = 81.0% and 75.0%, lansoprazole = 90.7% (P = 0.143 vs omeprazole) and 85.0%, pantoprazole = 93.5% (P = 0.04 vs omeprazole) and 90.0% (P = 0.02 vs omeprazole), rabeprazole = 94.6% (P = 0.02 vs omeprazole) and 88.8% (P = 0.04 vs omeprazole). Dividing patients according to the grades of esophagitis, omeprazole was significantly less effective than the three other PPIs in healing grade 1 esophagitis (healing rates: 81.8% vs 100%, 100% and 100%, respectively, P = 0.012). Pantoprazole and rabeprazole (100%) were more effective vs omeprazole (89.6%, P = 0.0001)and lansoprazole (82.4%, P = 0.0001) in decreasing heartburn. Pantoprazole and rabeprazole (92.2% and 90.1%, respectively) were also more effective vs lansoprazole (75.0%, P < 0.05) in decreasing acid regurgitation. Finally, pantoprazole and rabeprazole (95.2% and 100%) were also more effective vs lansoprazole (82.6%, P < 0.05) in decreasing epigastric pain.CONCLUSION: In elderly patients, pantoprazole and rabeprazole were significantly more effective than omeprazole in healing esophagitis and than omeprazole or lansoprazole in improving symptoms. H pylori infection did not influence the healing rates of esophagitis after a short-term treatment with PPI.

Epidemiology, pathophysiology, clinical characteristics and management of childhood cardiorenal syndrome

Cardiorenal syndrome(CRS) is a new term recently introduced to describe the acute or chronic comorbid state of the heart and kidney that has been long known and frequently managed in very sick individuals. The tight and delicate coordination of physiological functions among organ systems in the human body makes dysfunction in one to lead to malfunction of one or more other organ systems. CRS is a universal very common morbidity in the critically ill, with a high mortality rate that has received very little research attention in children. Simultaneous management of heart and renal failures in CRS is quite challenging; the therapeutic choice made for one organ must not jeopardize the other. This paper reviews the epidemiology, pathophysiology, clinical characteristics and management of acute and chronic CRS in children.

Reliability of a Novel Cobb Protractor for Measuring the Cobb Angle of Radiograph in Scoliosis

Objective To introduce a novel Cobb protractor and assess its reliability and rapidity for measuring Cobb angle in scoliosis patients. Methods The novel Cobb protractor had two endplate markers. A measurement was performed just to align the two markers to each endplate of the curve. The Cobb angle on the posteroanterior radiographs of 24 patients clinically diagnosed with adolescent idiopathic scoliosis was measured by three orthopedic surgeons with both standard Cobb method and the new technique, and the time of measurement was recorded. Intraclass correlation coefficients(ICCs) were calculated to assess the reliability of the new method. Results The time for a measurement with the new tool was approximately 10 seconds less than the time that used to finish a measurement with the standard method(P<0.05). The overall mean Cobb angle for the major curve of the 24 patients was 47.8°. The mean overall intraobserver and interobserver ICC was 0.971 and 0.971 for the Cobb method group, while the overall intraobserver ICC and the interobserver was 0.985 and 0.979 for the new tool group. Conclusions The novel Cobb protractor could perform quick measurement and measure almost all forms of radiographs. The Cobb protractor might be an ideal instrument to measure the Cobb angle.

艾司氯胺酮对不孕症患者腹腔镜手术后疼痛程度、焦虑及抑郁情绪的影响

目的探讨艾司氯胺酮对不孕症患者腹腔镜手术后疼痛程度、焦虑及抑郁情绪的影响。方法选取100例不孕症行腹腔镜手术患者,根据随机数字表法分为对照组与研究组,每组50例。研究组在全身麻醉诱导后静脉缓慢注射盐酸艾司氯胺酮注射液,对照组给予等量0.9%氯化钠注射液。比较两组患者术后恢复效果。结果术后48h研究组前列腺素E_(2)(PGE_(2))水平(123.14±16.43)ng/L及视觉模拟评分法(VAS)评分(3.52±1.32)分均分别低于对照组的(143.14±20.34)ng/L、(6.05±1.59)分(P<0.05)。术后48h研究组焦虑自评量表(SAS)、抑郁自评量表(SDS)评分均明显低于对照组(P<0.05)。术后48h研究组去甲肾上腺素(NE)、肾上腺素(E)指标均较对照组低(P<0.05)。结论艾司氯胺酮可够减轻不孕症患者腹腔镜手术后疼痛程度,改善焦虑、抑郁情绪,还能减轻术后应激反应程度,值得临床推广。