浅议治学:治学之道需佛学禅定之静

治学之道是古今中外常谈的永恒话题，也是无数文人雅士所能亲身体会的，每个读书人都有自己的治学之道并各有千秋，观古人治学之道勉今人读书之举。在我们治学之中应当有佛学禅定之静之道方能取得更高的治学理想境界。

《轩岐救正论》治血贵静思想探析

《轩岐救正论》为明代医家肖京所著,是一部理论结合实践的专著。在书中肖氏提出了＂治血贵静＂的治疗思想,对后世血证的治疗有很好的启发作用。现对该思想进行探析,为临床诊治出血性疾病提供理论依据。1从阴阳论失血之病机肖氏论述失血的病机从阴阳和气血入手,层层剖析,逻辑严谨。他指出：＂今以失血言之,血主阴,气主阳。阳之性动,阴之体静,阳之气热,阴之性寒,而阴阳则相维,为既济之水火也。＂血本属阴,

论李清照对陶渊明的接受

李清照二个室名“归来堂”、“静治堂”一个自号“易安居士”都出自于陶渊明的作品;李清照爱喝酒,喜赏菊也与陶渊明如出一辙。在李清照的生活和作品中常常可见陶渊明的痕迹与影响。本文从室名自号与作品两个方面论述李清照对陶渊明的接受。

创伤外科学

0044292 电击伤的免疫组织化学检索[日]/大谷静治//日病理会志.-1999,88(1).-1P-PM1～103 冀医情0044293 蚊过敏的尸解1例[日]/根本启一//日病理会志.-1999,88(1).-1P-PM1～102

Clinical Study on Early Venous Glucose-free Nutrition after Hepatolobectomy

Objective： A randomized trial was designed to study the optimal nutrition after hepatolobectomy. Methods： Thirty-two patients receiving hepatolobectomy were randomly divided into 2 groups： 16 patients in the experimental group receiving high dose fat emulsion and amino acids without glucose for 7 days after hepatolobectomy, and 16 patients in the control group receiving traditional intravenous nutrition. Postoperative changes in blood glucose, lipid, amino acids and total ketone bodies were compared between two groups. Results： Postoperative glucose and lipid levels remained normal in the experimental group, while the free amino acids levels and utilization of ketone bodies were significantly higher than in the control group. Conclusion： Intravenous injection of glucose-free nutrition after hepatolobectomy could not only supply sufficient calories, but also avoid metabolic disturbance due to intravenous injection of glucose.

《金石录》与莱州

约在公元1121年,宋代著名金石学家赵明诚到莱州(今莱州市)任知事,他的妻子,女词人李清照也随到任所.这期间,他们夫妻二人正努力搜求、整理金石资料,为编纂《金石录》作各方面的准备.

Evaluation of MRI in Diagnosing Hilar Cholangiocarcinoma

Objective： To investigate the clinical application of MRI in the diagnosis and preoperative evaluation of hilar cholangiocarcinoma （HC）. Methods： Thirty-four cases of HC were examined with 1.5T super-conduct MR unit. The plain MRI and MRCP were followed by dynamic Gd-DTPA （0.1 mmol/kg） contrast-enhanced scanning, which was repeated at 30 s intervals in the first 3 min with the patient being remained in the same position. Delayed scanning was done at 5, 8, 10, 12 and 15 min respectively. 3D- DCE-MRA was performed in arterial and portal venous phase with an additional bolus injection of 15-20 mL Gd-DTPA （0.15-0.20 mmol/kg）. The contrast time-signal curve of both the liver and the tumor was drawn from DCE imaging, and both arterial and portal venous phase imaging were reconstructed with MIP. MRI findings were compared with surgical findings and pathology. Results： Hilar lesion, intrahepatic ducts dilatation and disconnect of main hepatic duct were shown in all cases. Thirty-one cases had tumor-delayed enhancement. In 3D-DCE-MRA, spiral artery deformed was displayed in 6 cases, infiltration, encasement or occlusion of portal vein was displayed in 18 cases. The accuracy of assessing tumor unresectability and resectability by preoperative MRI was 95.0% （19/20） and 78.6% （11/14） respectively. The total accuracy rate of MRI assessing was 88.2% （30/34）. Conclusion： All-in-one MR, including plain MR, MRCP, MR DCE and 3D-DCE-MRA, can accurately show the lesions and involvement of neighbouring tissues. It was of great value in diagnosis and preoperative evaluation of HC.

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

AIM:To compare the incidence of early portal or splenic vein thrombosis(PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization.METHODS:We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010.Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation,respectively.Group A(153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin(LMWH) irregularly.Group B(148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery,followed by oral warfarin and aspirin for one month regularly.The target prothrombin time/international normalized ratio(PT/INR) was 1.25-1.50.Platelet and PT/INR were monitored.Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy.RESULTS:The patients' data were collected and analyzed retrospectively.Among the patients,94 developed early postoperative mural PSVT,including 63 patients in group A(63/153,41.17%) and 31 patients in group B(31/148,20.94%).There were 50(32.67%) patients in group A and 27(18.24%) in group B with mural PSVT in the main trunk of portal vein.After the administration of thrombolytic,anticoagulant and antiaggregation therapy,complete or partial thrombus dissolution achieved in 50(79.37%) in group A and 26(83.87%) in group B.CONCLUSION:Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization,and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy.Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Efficacy of different treatment strategies for hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate the efficacy of different treatment strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) and investigate factors influencing prognosis.METHODS: One hundred and seventy-nine HCC patients with macroscopic PVTT were enrolled in this study. They were divided into four groups and underwent different treatments: conservative treatment group (n = 18),chemotherapy group (n = 53), surgical resection group (n = 24) and surgical resection with postoperative chemotherapy group (n = 84). Survival rates of the patients were analyzed by the Kaplan-Meier method. A log-rank analysis was performed to identify group differences. Cox's proportional hazards model was used to analyze variables associated with survival.RESULTS: The mean survival periods of the patients in four groups were 3.6, 7.3, 10.1, and 15.1 mo respectively.There were significant differences in the survival rates among the groups. The survival rates at 0.5-, 1-, 2-, and 3-year in surgical resection with postoperative chemotherapy group were 55.8%, 39.3%, 30.4%, and 15.6% respectively, which were significantly higher than those of other groups (P＜0.001). Multivariate analysis revealed that the strategy of treatment (P＜0.001) and the number of chemotherapy cycles (P = 0.012) were independent survival predictors for patients with HCC and PVTT.CONCLUSION: Surgical resection of HCC and PVTT combined with postoperative chemotherapy or chemoembolization is the most effective therapeutic strategy for the patients who can tolerate operation.Multiple chemotherapeutic courses should be given postoperatively to the patients with good hepatic function reserve.

Hairy cell leukemia presenting as multiple discrete hepatic lesions

The involvement of hairy cell leukemia in the liver is in the form of portal and sinusoidal cellular infiltration. Here we describe the first case of hepatic hairy cell leukemia presenting as multiple discrete lesions,which was treated successfully.We suggest that in the inves- tigation of discrete hepatic lesions in cases of cancer of unknown primary,hairy cell leukemia should be consid- ered.The excellent response of hairy cell leukemia to therapy highlights the need for such a consideration.

Nutcracker syndrome

The nutcracker phenomenon [left renal vein(LRV) entrapment syndrome] refers to compression of the LRV most commonly between abdominal aorta and superior mesenteric artery.Term of nutcracker syndrome(NCS) is used for patients with clinical symptoms associated with nutcracker anatomy.LRV entrapment divided into 2 types:anterior and posterior.Posterior and right-sided NCSs are rare conditions.The symptoms vary from asymptomatic hematuria to severe pelvic congestion.Symptoms include hematuria,orthostatic proteinuria,flank pain,abdominal pain,varicocele,dyspareunia,dysmenorrhea,fatigue and orthostatic intolerance.Existence of the clinical features constitutes a basis for the diagnosis.Several imaging methods such as Doppler ultrasonography,computed tomography angiography,magnetic resonance angiography and retrograde venography are used to diagnose NCS.The management of NCS depends upon the clinical presentation and the severity of the LRV hypertension.The treatment options are ranged from surveillance to nephrectomy.Treatment decision should be based on the severity of symptoms and their expected reversibility with regard to patient's age and the stage of the syndrome.

Ischemic colitis due to obstruction of mesenteric and splenic veins: A case report

Ischemic injury to the bowel is a well known disease entity that has a wide spectrum of pathological and clinical findings. A sudden drop in the colonic blood supply is essential to its development. We encountered a 41-year-old male patient, who presented with abdominal pain and bloody diarrhea. A colonoscopy showed markedly edematous mucosa with tortuous dilatation of the veins and a deep ulceration at the rectosigmoid junction. On an abdominal computed tomography (CT) scan and CT angiography, the mesenteric and splenic veins were absent with numerous venous collaterals for drainage. The patient gradually responded to oral aminosalicylate therapy, and was in remission after nine months. In most cases, non-occlusive ischemic injury is caused by idiopathic form and occlusive ischemia is caused by abnormalities of arteries and acute venous thrombosis. However, chronic venous insufficiency due to obstruction of macrovascular mesenteric vein rarely causes ischemia of the bowel. This report describes the first case of ischemic colitis caused by obstruction of the mesenteric and splenic veins.

Altered blood-brain barrier permeability in rats with prehepatic portal hypertension turns to normal when portal pressure is lowered

AIM： To study the blood-brain barrier integrity in prehepatic portal hypertensive rats induced by partial portal vein ligation, at 14 and 40 dafer ligation when portal pressure is spontaneously normalized. METHODS： Adult male Wistar rats were divided into four groups： Group Ⅰ： Sham14d, sham operated; Group Ⅱ： PHil, portal vein stenosis, （both groups were used 14 days after surgery）; Group Ⅲ： Sham4od, Sham operated and Group Ⅳ： PH4od Portal vein stenosis （Groups Ⅱ and Ⅳ used 40 d afer surgery）. Plasma ammonia, plasma and cerebrospinal fluid protein and liver enzymes concentrations were determined. Trypan and Evans blue dyes, systemically injected, were investigated in hippocampus to study blood-brain barrier integrity. Portal pressure was periodically recorded. RESULTS： Forty days afer stricture, portal pressure was normalized, plasma ammonia was moderately high, and both dyes were absent in central nervous system parenchyma. All other parameters were reestablished. When portal pressure was normalized and ammonia level was lowered, but not normal, the altered integrity of blood-brain barrier becomes reestablished. CONCLUSION： The impairment of blood-brain barrier and subsequent normalization could be a mechanism involved in hepatic encephalopathy reversibility. Hemodynamic changes and ammonia could trigger blood-brain barrier alterations and its reestablishment.

Portal venous stent placement for treatment of portal hypertension caused by benign main portal vein stenosis

AIM: To evaluate the value of endovascular stent in the treatment of portal hypertension caused by benign main portal vein stenosis.METHODS: Portal vein stents were implanted in six patients with benign main portal vein stenosis (inflammatory stenosis in three cases, postprocedure of liver transplantation in another three cases). Changes in portal vein pressure, portal vein patency, relative clinical symptoms, complications, and survival were evaluated.RESULTS: Six metallic stents were successfully placed across the portal vein stenotic or obstructive lesions in six patients. Mean portal venous pressure decreased significantly after stent implantation from (37.3±4.7) cm H2O to (18.0±1.9) cm H2O. The portal blood flow restoredand the symptoms caused by portal hypertension were eliminated. There were no severe procedure-related complications. The patients were followed up for 1-48 mo. The portal vein remained patent during follow-up. All patients survived except for one patient who died of other complications of liver transplantation. CONCLUSION: Percutaneous portal vein stent placement for the treatment of portal hypertension caused by benign main portal vein stenosis is safe and effective.

Long-term result of endoscopic Histoacryl （N-butyl-2-cyanoacrylate）injection for treatment of gastric varices

AIM:To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl for treatment of gastric variceal bleeding and prophylaxis.METHODS:Between January 1994 and March 2010 at SoonChunHyang University Hospital,a total of 127 patients with gastric varices received Histoacryl injections endoscopically.One hundred patients underwent endoscopic Histoacryl injections because of variceal bleeding,the other 27 patients received such injections as a prophylactic procedure.RESULTS:According to Sarin classification,56 patients were GOV1,61 patients were GOV2 and 10 patients were IGV.Most of the varices were large(F2 or F3,111 patients).The average volume of Histoacryl per each session was 1.7±1.3 cc and mean number of sessions was 1.3±0.6.(1 session-98 patients,2 sessions-25 patients,≥3 sessions-4 patients).Twenty-seven patients with high risk of bleeding(large or fundal or RCS+or Child C) received Histoacryl injection as a primary prophylactic procedure.In these patients,hepatitis B virus was the major etiology of cirrhosis,25 patients showed GOV1 or 2(92.6%)and F2 or F3 accounted for 88.9%(n=24).The rate of initial hemostasis was 98.4%and recurrent bleeding within one year occurred in 18.1%of patients.Successful hemostasis during episodes of rebleeding was achieved in 73.9%of cases.Median survival was 50 mo (95%CI 30.5-69.5).Major complications occurred in 4 patients(3.1%).The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions.None of the 27 subjects who were treated prophylactically experienced treatment-related complications.Cumulative survival rates of the 127 patients at 6 mo,1,3,and 5 years were 92.1%,84.2%,64.2%,and 45.3%,respectively.The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%.CONCLUSION:Histoacryl injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.

New methods for the management of gastric varices

Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.

Septic thrombophlebitis of the porto-mesenteric veins as a complication of acute appendicitis

Pylephlebitis, a rare complication of acute appendicitis, is defined as thrombophlebitis of the portal venous system. Pylephlebitis usually occurs due to secondary infection in the region drained into the portal system. We report a case of pylephlebitis caused by acute appendicitis. The patient was transferred from a private clinic 1 wk after appendectomy with the chief complaints of high fever and abdominal pain. He was diagnosed with pylephlebitis of the portal vein and superior mesenteric vein by CT-scan. The patient was treated with antibiotics and anticoagulation therapy, and discharged on the 25th day and follow-up CT scan showed a cavernous transformation of portal thrombosis.

Combined functional and anatomical diagnostic endpoints for assessing arteriovenous fistula dysfunction

Failure of arteriovenous fistulas(AVF) to mature and thrombosis in matured fistulas have been the major causes of morbidity and mortality in hemodialysis patients. Stenosis, which occurs due to adverse remodeling in AVFs, is one of the major underlying factors under both scenarios. Early diagnosis of a stenosis in an AVF can provide an opportunity to intervene in a timelymanner for either assisting the maturation process or avoiding the thrombosis. The goal of surveillance strategies was to supplement the clinical evaluation(i.e., physical examination) of the AVF for better and earlier diagnosis of a developing stenosis. Surveillance strategies were mainly based on measurement of functional hemodynamic endpoints, including blood flow(Q a) to the vascular access and venous access pressure(VAP). As the changes in arterial pressure(MAP) affects the level of VAP, the ratio of VAP to MAP(VAPR = VAP/MAP) was used for diagnosis. A Q a < 400-500 m L/min or a VAPR > 0.55 is considered sign of significant stenosis, which requires immediate intervention. However, due to the complex nature of AVFs, the surveillance strategies have failed to consistently detect stenosis under different scenarios. VAPR has been primarily developed to detect outflow stenosis in arteriovenous grafts, and it hasn't been successful in accurate diagnosis of outflow lesions in AVFs. Similarly, AVFs can maintain relatively high blood flow despite the presence of a significant outflow stenosis and thus, Q a has been found to be a better predictor of only inflow lesions. Similar shortcomings have been reported in the detection of functional severity of coronary stenosis using diagnostic endpoints that were based on either flow or pressure. This limitation has been associated with the fact that both pressure and flow change in the presence of a stenosis and thus, hemodynamic diagnostic endpoints that employ only one of these parameters are inherently prone to inaccuracies. Recent attempts have resulted in development of new diagnostic endpoints that can combine the effects of pressure and flow. These new hemodynamic diagnostic endpoints have shown to be better predictors of functional severity of lesions as compared to either flow or pressure based counterparts. In this review article, we discussed the advantages and limitations of current functional and anatomical diagnostic endpoints in AVFs.

Portal vein tumor thrombus is a bottleneck in the treatment of hepatocellular carcinoma

The effect of portal vein tumor thrombus(PVTT) on the prognosis of patients with hepatocellular carcinoma has become clear over the past several decades. However, identifying the mechanisms and performing the diagnosis and treatment of PVTT remain challenging. Therefore, this study aimed to summarize the progress in these areas. A computerized literature search in Medline and EMBASE was performed with the following combinations of search terms: "hepatocellular carcinoma" AND "portal vein tumor thrombus." Although several signal transduction or molecular pathways related to PVTT have been identified, the exact mechanisms of PVTT are still largely unknown. Many biomarkers have been reported to detect microvascular invasion, but none have proved to be clinically useful because of their low accuracy rates. Sorafenib is the only recommended therapeutic strategy in Western countries. However, more treatment options are recommended in Eastern countries, including surgery, radiotherapy(RT), transhepatic arterial chemoembolization(TACE), transarterial radioembolization(TARE), and sorafenib. Therefore, we established a staging system based on the extent of portal vein invasion. Our staging system effectively predicts the long-term survival of PVTT patients. Currently, several clinical trials had shown that surgery is effective and safe in some PVTT patients. RT,TARE, and TACE can also be performed safely in patients with good liver function. However, only a few comparative clinical trials had compared the effectiveness of these treatments. Therefore, more randomized controlled trials examining the extent of PVTT should be conducted in the future.

Transjugular intrahepatic portosystemic shunt vs endoscopic therapy in preventing variceal rebleeding

AIM:To compare early use of transjugular intrahepatic portosystemic shunt(TIPS) with endoscopic treatment(ET) for the prophylaxis of recurrent variceal bleeding.METHODS:In-patient data were collected from 190 patients between January 2007 and June 2010 who suffured from variceal bleeding.Patients who were older than 75 years;previously received surgical treatment or endoscopic therapy for variceal bleeding;and complicated with hepatic encephalopathy or hepatic cancer,were excluded from this research.Thirty-five cases lost to follow-up were also excluded.Retrospective analysis was done in 126 eligible cases.Among them,64 patients received TIPS(TIPS group) while 62 patients received endoscopic therapy(ET group).The relevant data were collected by patient review or telephone calls.The occurrence of rebleeding,hepatic encephalopathy or other complications,survival rateand cost of treatment were compared between the two groups.RESULTS:During the follow-up period(median,20.7 and 18.7 mo in TIPS and ET groups,respectively),rebleeding from any source occurred in 11 patients in the TIPS group as compared with 31 patients in the ET group(Kaplan-Meier analysis and log-rank test,P = 0.000).Rebleeding rates at any time point(6 wk,1 year and 2 year) in the TIPS group were lower than in the ET group(Bonferroni correction α' = α/3).Eight patients in the TIPS group and 16 in the ET group died with the cumulative survival rates of 80.6% and 64.9%(Kaplan-Meier analysis and log-rank test c2 = 4.864,P = 0.02),respectively.There was no significant difference between the two groups with respect to 6-wk survival rates(Bonferroni correction α' = α/3).However,significant differences were observed between the two groups in the 1-year survival rates(92% and 79%) and the 2-year survival rates(89% and 64.9%)(Bonferroni correction α' = α/3).No significant differences were observed between the two treatment groups in the occurrence of hepatic encephalopathy(12 patients in TIPS group and 5 in ET group,KaplanMeier analysis and log-rank test,c2 = 3.103,P = 0.08).The average total cost for the TIPS group was higher than for ET group(Wilcxon-Mann Whitney test,52 678 RMB vs 38 844 RMB,P < 0.05),but hospitalization frequency and hospital stay during follow-up period were lower(Wilcxon-Mann Whitney test,0.4 d vs 1.3 d,P = 0.01;5 d vs 19 d,P < 0.05).CONCLUSION:Early use of TIPS is more effective than endoscopic treatment in preventing variceal rebleeding and improving survival rate,and does not increase occurrence of hepatic encephalopathy.