Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

The median arcuate ligament syndrome(MALS)is recognized as a rare clinical entity,characterized by chronic post-prandial abdominal pain,nausea,vomiting,and unintentional weight loss.Due to its vague symptomatology,it is mainly regarded as a diagnosis of exclusion.Patients can often be misdiagnosed for several years before a correct diagnosis is established,also due to a medical team’s clinical suspicion.We present a case series of two patients who suffered from MALS and were treated successfully.The first patient is a 32-year-old woman,presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years.The second patient,a 50-year-old woman,presented with similar symptomatology,with the symptoms lasting for the last five years.Both cases were treated by laparoscopic division of the median arcuate ligament fibers,which alleviated extrinsic pressure from the celiac artery.Previous cases of MALS were retrieved from PubMed,to assemble a better diagnostic algorithm and propose a treatment method of choice.The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice,along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.

Routine lymph node dissection may be not suitable for all intrahepatic cholangiocarcinoma patients: Results of a monocentric series

AIM:To investigate the indications for lymph node dissection(LND)in intrahepatic cholangiocarcinoma patients.METHODS:A retrospective analysis was conducted on 124 intrahepatic cholangiocarcinoma(ICC)patients who had undergone surgical resection of ICC from January 2006 to December 2007.Curative resection was attempted for all patients unless there were metastases to lymph nodes(LNs)beyond the hepatoduodenal ligament.Prophylactic LND was performed in patients in whom any enlarged LNs had been suspicious for metastases.The patients were classified according to the LND and LN metastases.Clinicopathologic,operative,and long-term survival data were collected retrospectively.The impact on survival of LND during primary resection was analyzed.RESULTS:Of 53 patients who had undergone hepatic resection with curative intent combined with regional LND,11 had lymph nodes metastases.Whether or not patients without lymph node involvement had undergone LND made no significant difference to their survival(P=0.822).Five patients with multiple tumors and involvement of lymph nodes underwent hepatic resection with LND;their survival curve did not differ significantly from that of the palliative resection group(P=0.744).However,there were significant differences in survival between patients with lymph node involvement and a solitary tumor who underwent hepatic resection with LND and the palliative resection group(median survival time 12 mo vs 6.0 mo,P=0.013).CONCLUSION:ICC patients without lymph node involvement and patients with multiple tumors and lymph node metastases may not benefit from aggressive lymphadenectomy.Routine LND should be considered with discretion.

Prognosis after resection for hepatitis B virus-associated intrahepatic cholangiocarcinoma

AIM:To investigate the prognostic factors after resection for hepatitis B virus(HBV)-associated intrahepatic cholangiocarcinoma(ICC) and to assess the impact of different extents of lymphadenectomy on patient survival.METHODS:A total of 85 patients with HBV-associated ICC who underwent curative resection from January 2005 to December 2006 were analyzed.The patients were classified into groups according to the extent of lymphadenectomy(no lymph node dissection,sampling lymph node dissection and regional lymph node dissection).Clinicopathological characteristics and survival were reviewed retrospectively.RESULTS:The cumulative 1-,3-,and 5-year survival rates were found to be 60 %,18 %,and 13 %,respectively.Multivariate analysis revealed that liver cirrhosis(HR = 1.875,95%CI:1.197-3.278,P = 0.008) and multiple tumors(HR = 2.653,95%CI:1.562-4.508,P < 0.001) were independent prognostic factors for survival.Recurrence occurred in 70 patients.The 1-,3-,and 5-year disease-free survival rates were 36%,3% and 0%,respectively.Liver cirrhosis(HR = 1.919,P = 0.012),advanced TNM stage(stage Ⅲ/Ⅳ)(HR = 2.027,P < 0.001),and vascular invasion(HR = 3.779,P = 0.02) were independent prognostic factors for disease-free survival.Patients with regional lymph node dissection demonstrated a similar survival rate to patients with sampling lymph node dissection.Lymphadenectomy did not significantly improve the survival rate of patients with negative lymph node status.CONCLUSION:The extent of lymphadenectomy does not seem to have influence on the survival of patients with HBV-associated ICC,and routine lymph nodedissection is not recommended,particularly for those without lymph node metastasis.

Genistein inhibits invasive potential of human hepatocellular carcinoma by altering cell cycle, apoptosis, and angiogenesis

AIM： To study the in vitro and in vivo inhibitory effects of genistein on invasive potential of Bel 7402 hepatocellular carcinoma （HCC） cells and to explore the underlying mechanism. METHODS： Bel 7402 HCC cells were exposed to genistein. The invasive activity of tumor cells was assayed in transwell cell culture chamber, p125^FAK expression and cell cycle were evaluated by a functional assay. Cell apoptosis analysis was performed with TUNEL method. In addition, bilateral subrenal capsule xenograft transplantation of HCC was performed in 10 nude mice. Genistein was injected and the invasion of HCC into the renal parenchyma was observed. Nicrovessels with immunohistochemical staining were detected. RESULTS： Genistein significantly inhibited the growth of Bel 7402 cells, the inhibitory rate of tumor cells was 26 -42%. The invasive potential of Bel 7402 cells in vitro was significantly inhibited, the inhibitory rate was 11- 28%. Genistein caused G2/M cell cycle arrest, S phase decreased significantly. The occurrence of apoptosis in genistein group increased significantly. The expression of p125^FAK in 5 μg/mL genistein group （15.26±0.16%） and 10 μg/mL genistein group （12.89±0.36%） was significantly lower than that in the control group （19.75± 1.12%, P〈0.05）. Tumor growth in genistein-treated nude mice was significantly retarded in comparison to control mice, the inhibitory rate of tumor growth was about 20%. Genistein also significantly inhibited the invasion of Bel 7402 cells into the renal parenchyma of nude mice with xenograft transplant. The positive unit value of microvessels in genistein-treated group （10.422 ±0.807） was significantly lower than that in control group （22.330 ± 5.696, P〈 0.01）. CONCLUSION： Genistein can effectively inhibit the invasive potential of Bel 7402 HCC cells by altering cell cycle, apoptosis and angiogenesis, inhibition of focal adhesion kinase may play a significant role in this process.

Plasma microRNAs as potential new biomarkers for early detection of early gastric cancer

BACKGROUND Early gastric cancer(EGC), compared with advanced gastric cancer(AGC), has a higher 5-year survival rate. However, due to the lack of typical symptoms and the difficulty in diagnosing EGC, no effective biomarkers exist for the detection of EGC, and gastroscopy is the only detection method.AIM To provide new biomarkers with high specificity and sensitivity through analyzed the differentially expressed microRNAs(miRNAs) in EGC and AGC and compared them with those in benign gastritis(BG).METHODSWe examined the differentially expressed miRNAs in the plasma of 30 patients with EGC, AGC, and BG by miRNA chip analysis. Then, we analyzed and selected the significantly different miRNAs using bioinformatics. Reverse transcription quantitative real-time polymerase chain reaction(RT-qPCR)confirmed the relative transcription level of these miRNAs in another 122 patients, including patients with EGC, AGC, Helicobacter pylori(H. pylori)-negative gastritis(Control-1), and H. pylori-positive atrophic gastritis(Control-2).To establish a diagnostic model for the detection of plasma miRNA in EGC, we chose miRNAs that can be used to determine EGC and AGC from Control-1 and Control-2 and miRNAs in EGC from all other groups.RESULTS Among the expression profiles of the miRNA chips in the three groups in the discovery set, of 117 aberrantly expressed miRNAs, 30 confirmed target prediction, whereas 14 were included as potential miRNAs. The RT-qPCR results showed that 14 potential miRNAs expression profiles in the two groups exhibited no differences in terms of H. pylori-negative gastritis(Control-1) and H. pyloripositive atrophic gastritis(Control-2). Hence, these two groups were incorporated into the Control group. A combination of four types of miRNAs,miR-7641, miR-425-5 p, miR-1180-3 p and miR-122-5 p, were used to effectively distinguish the Cancer group(EGC + AGC) from the Control group [area under the curve(AUC) = 0.799, 95% confidence interval(CI): 0.691-0.908, P < 0.001].Additionally, miR-425-5 p, miR-24-3 p, miR-1180-3 p and miR-122-5 p were utilized to distinguish EGC from the Control group(AUC = 0.829, 95%CI: 0.657-1.000, P =0.001). Moreover, the miR-24-3 p expression level in EGC was lower than that in the AGC(AUC = 0.782, 95%CI: 0.571-0.993, P = 0.029), and the miR-4632-5 p expression level in EGC was significantly higher than that in AGC(AUC = 0.791,95%CI: 0.574-1.000, P = 0.024).CONCLUSION The differentially expressed circulatory plasma miR-425-5 p, miR-1180-3 p, miR-122-5 p, miR-24-3 p and miR-4632-5 p can be regarded as a new potential biomarker panel for the diagnosis of EGC. The prediction and early diagnosis of EGC can be considerably facilitated by combining gastroscopy with the use of these miRNA biomarkers, thereby optimizing the strategy for effective detection of EGC. Nevertheless, larger-scale human experiments are still required to confirm our findings.

持续血液滤过及内毒素吸附治疗外科感染性多器官衰竭(英文)

目的 :探索持续血液滤过及内毒素直接吸附治疗外科感染性多器官衰竭的有效性。方法 :为 1例外科感染性多器官衰竭患者进行血液持续滤过 ,并利用多粘菌素B结合纤维 (PMX)进行内毒素吸附。PMX治疗每 2 /d ,共 8d。结果 :用上述方法治疗后 ,内毒素和IL 6水平下降 ,病情好转并停用血管活性药物。结论 :持续血液滤过并用PMX吸附内毒素是治疗外科感染性多器官衰竭的有效方法。

Melatonin protects liver from intestine ischemia reperfusion injury in rats

AIM: To investigate the protective effect of melatonin on liver after intestinal ischemia-reperfusion injury in rats. METHODS: One hundred and fifty male Wistar rats, weighing 190-210 g, aged 7 wk, were randomly divided into melatonin exposure group, alcohol solvent control group and normal saline control group. Rats in the melatonin exposure group received intraperitoneal (IP) melatonin (20 mg/kg) 30 min before intestinal ischemia-reperfusion (IR), rats in the alcohol solvent control group received the same concentration and volume of alcohol, and rats in the normal saline control group received the same volume of normal saline. Serum samples were collected from each group 0.5, 1, 6, 12, and 24 h after intestinal IR. Levels of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured with an auto-biochemical analyzer. Serum TNF-α was tested by enzyme-linked immunosorbent assay (ELISA). Malondialdehyde (MDA) in liver was detected by colorimetric assay. Pathological changes in liver and immunohistochemical straining of ICAM-1 were observed under an optical microscope. RESULTS: The levels of ALT measured at various time points after intestinal IR in the melatonin exposure group were significantly lower than those in the other two control groups (P < 0.05). The serum AST levels 12 and 24 h after intestinal IR and the ICAM-1 levels (%) 6, 12 and 24 h after intestinal IR in the melatonin exposure group were also significantly lower than those in the other two control groups (P < 0.05). CONCLUSION: Exotic melatonin can inhibit the activity of ALT, AST and TNF-α, decrease the accumulation of MDA, and depress the expression of ICAM-1 in liver after intestinal IR injury, thus improving the liver function.

Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation

BACKGROUND Different types of periampullary diverticulum(PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography(ERCP) cannulation,but the clinical significance of the two current PAD classifications for cannulation is limited.AIM To verify the clinical value of our newly proposed PAD classification.METHODS A new PAD classification(Li-Tanaka classification) was proposed at our center.All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.RESULTS A total of 3564 patients with native papillae were enrolled, including 967(27.13%)PAD patients and 2597(72.87%) non-PAD patients. In the Li-Tanaka classification, type Ⅰ PAD patients exhibited the highest difficult cannulation rate(23.1%, P = 0.01), and type Ⅱ and Ⅳ patients had the highest cannulation success rates(99.4% in type Ⅱ and 99.3% in type Ⅳ, P < 0.001). In a multivariableadjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio(OR) = 1.87, 95% confidence interval(CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group,the difficulty of cannulation in the type Ⅰ PAD group according to the Li-Tanaka classification was greater(OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower(OR = 0.27, 95%CI: 0.11-0.66, P < 0.001),while it was higher in the type Ⅱ PAD group(OR = 4.44, 95%CI: 1.61-12.29, P <0.01).CONCLUSION Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.

Fault diagnosis method of hydraulic system based on fusion of neural network and D-S evidence theory

According to fault type diversity and fault information uncertainty problem of the hydraulic driven rocket launcher servo system（HDRLSS） , the fault diagnosis method based on the evidence theory and neural network ensemble is proposed. In order to overcome the shortcomings of the single neural network, two improved neural network models are set up at the com-mon nodes to simplify the network structure. The initial fault diagnosis is based on the iron spectrum data and the pressure, flow and temperature（PFT） characteristic parameters as the input vectors of the two improved neural network models, and the diagnosis result is taken as the basic probability distribution of the evidence theory. Then the objectivity of assignment is real-ized. The initial diagnosis results of two improved neural networks are fused by D-S evidence theory. The experimental results show that this method can avoid the misdiagnosis of neural network recognition and improve the accuracy of the fault diagnosis of HDRLSS.

Arrhythmic risk stratification in ischemic,non-ischemic and hypertrophic cardiomyopathy:A two-step multifactorial,electrophysiology study inclusive approach

Annual arrhythmic sudden cardiac death ranges from 0.6%to 4%in ischemic cardiomyopathy(ICM),1%to 2%in non-ischemic cardiomyopathy(NICM),and 1%in hypertrophic cardiomyopathy(HCM).Towards a more effective arrhythmic risk stratification(ARS)we hereby present a two-step ARS with the usage of seven non-invasive risk factors:Late potentials presence(≥2/3 positive criteria),premature ventricular contractions(≥30/h),non-sustained ventricular tachycardia(≥1episode/24 h),abnormal heart rate turbulence(onset≥0%and slope≤2.5 ms)and reduced deceleration capacity(≤4.5 ms),abnormal T wave alternans(≥65μV),decreased heart rate variability(SDNN<70ms),and prolonged QT_(c)interval(>440 ms in males and>450 ms in females)which reflect the arrhythmogenic mechanisms for the selection of the intermediate arrhythmic risk patients in the first step.In the second step,these intermediate-risk patients undergo a programmed ventricular stimulation(PVS)for the detection of inducible,truly high-risk ICM and NICM patients,who will benefit from an implantable cardioverter defibrillator.For HCM patients,we also suggest the incorporation of the PVS either for the low HCM Risk-score patients or for the patients with one traditional risk factor in order to improve the inadequate sensitivity of the former and the low specificity of the latter.

Associations between serum uric acid and hepatobiliary-pancreatic cancer:A cohort study

BACKGROUND Uric acid is the end product of purine metabolism.Previous studies have found that serum uric acid(SUA)levels are associated with the total cancer risk.However,due to the dual effect of uric acid on cancer,the relationship between the SUA levels and most specific-site cancer remains unclear.AIM To investigate the associations between the SUA levels and incidence of hepatobiliary-pancreatic cancer.METHODS In this prospective cohort study,444462 participants free of cancer from the UK Biobank were included.The SUA levels were measured at baseline,and the incidence of hepatobiliary-pancreatic cancer was determined by contacting the cancer registry.The hazard ratios(HRs)and 95%confidence intervals(CIs)between the SUA levels and hepatobiliary-pancreatic cancer were investigated using multiple adjusted Cox regression models adjusted for potential confounders.RESULTS In total,920 participants developed liver,gallbladder,biliary tract or pancreatic cancer during a median of 6.6 yrs of follow-up.We found that the HR of pancreatic cancer in the highest SUA group was 1.77(95%CI:1.29-2.42)compared with that in the lowest group.After stratifying by gender,we further found that SUA was associated with an increased risk of pancreatic cancer only among the females(highest quartile vs lowest quartile HR 2.04,95%CI:1.35-3.08).Among the males,the SUA levels were positively associated with the gallbladder cancer risk(highest quartile vs lowest quartile HR 3.09,95%CI:1.28-7.46),but a U-shaped association with the liver cancer risk was observed(P-nonlinear=0.03).CONCLUSION SUA is likely to have gender-specific effects on hepatobiliary-pancreatic cancer.High SUA levels are a risk factor for pancreatic cancer in females and gallbladder cancer in males.A U-shaped association with the liver cancer risk was identified.

Astragaloside Ⅳ Improves Angiogenesis and Promotes Wound Healing in Diabetic Rats via the Activation of the SUMOylation Pathway

Radix astragali is the dried root of the legume Mongolian Astragalus or Astragalus membranaceus~([1]). Modern research has found that the main active ingredients in astragalus are astragalus polysaccharides, astragaloside, and astragalus isoflavones. Astragaloside IV(AS-IV) has been used internationally as a standard for evaluating the quality of astragalus medicinal materials.

An ongoing dispute in the management of severe pancreatic fistula:Pancreatospleenectomy or not?

The aim of this manuscript is to review controversies in managing severe pancreatic fistula after pancreatic surgery.Significant progress in surgical technique and perioperative care has reduced the mortality rate of pancreatic surgery.However,leakage of the pancreatic stump still accounts for the majority of surgical complications after pancreatic resection.Various strategies have been employed in order to manage pancreatic fistula.Nonetheless high grade pancreatic fistula evokes controversy in relation to the choice of treatment.A Medline search was performed,with regard to conservative treatment options versus completion pancreatectomy for the management of pancreatic fistula grade C.Pancreatic fistula rates remain unchanged with an incidence ranging from 5%-20% and this is considered as the most important cause of postoperative death.Many authors claim that completion pancreatectomy has probably lost its role in favour of interventional radiology procedures,while others believe that completion pancreatectomy continues to have a place in the management of patients with severe clinical deterioration after pancreatic fistula who do not respond to non-surgical interventions.There is no agreement on the best clinical management of severe pancreatic fistula after pancreatic surgery.Completion pancreatectomy is reserved for patients not improving with conventional measures.

The prognostic significance of ALI,PLR,and Ki-67 expression in stageⅢ–Ⅳinoperable non-small cell lung cancer

Objective The aim of the study was to investigate and compare the prognostic value of advanced inflammatory index,platelet/lymphocyte ratio(PLR),and Ki-67 expression in stageⅢ–Ⅳinoperable non-small cell lung cancer(NSCLC)before treatment.Methods The clinical data of 98 inoperable patients with stageⅢ–ⅣNSCLC in our hospital(Fifth Department of Oncology,Hebei General Hospital,Shijiazhuang,China)before treatment were retrospectively analyzed,and advanced lung cancer inflammation index(ALI)was calculated using body mass index(BMI)×serum albumin(ALB)÷neutrophil/lymphocyte ratio(NLR).he optimal cutoff values of ALI and PLR for predicting prognosis is determined.Chi-square test was used to analyze the relationship between patients and clinical characteristics.Kaplan-Meier method was used to calculate the total survival of patients,and log-rank test was used for comparison.Independent prognostic factors were assessed by univariate and multivariate analyses.Spearman correlation was used to analyze the relationship among ALI,PLR,and Ki-67.Results In our study of the 98 cases,the survival time of the patients with ALI<18 was significantly lower than that of patients with ALI>18(P<0.001),with a median survival time of 10 months and 25 months,respectively.The survival time of patients with a PLR<185 was significantly higher than that of patients with a PLR>185(median survival time was 27 months vs.10 months,P<0.001).The higher the Ki-67 expression,the shorter the survival time(P<0.005).The combined ALI and PLR detection results indicated that the survival time of patients with high ALI and low PLR was significantly longer than that of patients with low ALI and high PLR(P<0.001).Univariate analysis showed that smoking history,degree of differentiation,KPS score,Ki-67 expression,ALI value,and PLR affected the prognosis of patients.Multivariate analysis showed that KPS score,ALI value,and Ki-67 expression were independent prognostic factors.Conclusion ALI,PLR,and Ki-67 expression are important predictors of stage III-IV inoperable NSCLC.In terms of the prognostic value,ALI seems to have the best ability to predict patient survival.In addition,the combined detection of ALI and PLR levels before treatment seems to be more helpful in improving our prediction of patient prognosis.Moreover,it is expected to play a role in future clinical applications.

Effects of ethanol on the properties of platelets and endothelial cells in model experiments

AIM: To investigate effects of ethanol on activity markers of atherosclerosis in an in vitro endothelial cell model. METHODS: After 24 h incubation with ethanol (0.0095%), human umbilical vein endothelial cells were stimulated for 1 h with lipopolysaccharide, and were then incubated in direct contact with activated platelets. Following this incubation, the expression of CD40L and CD62P on platelets, and the expression of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), urokinase plasminogen activator receptor (uPAR), and membrane-type 1 matrix metalloproteinase (MT1-MMP) on endothelial cells were measured by flow cytometry. RESULTS: The increased expression of VCAM-1 and uPAR on endothelial cells by proinflammatory stimulation with activated platelets was significantly reduced through pre-incubation with ethanol (P < 0.05). Furthermore, platelets in direct contact with ethanol and with endothelial cells pre-incubated in ethanol showed a significant reduction in their CD40L expression (P < 0.05). Ethanol had no significant effect on ICAM-1 and MT1-MMP expression on endothelial cells. CONCLUSION: Ethanol directly attenuates platelet activation and has significant endothelial cell-mediated effects on selected markers of atherosclerosis in vitro. These findings underline possible protective effects of ethanol on atherosclerosis.

External Validation of SENIC and NNIS Scores for Predicting Wound Infection in Colorectal Surgery

Objective: We aimed to identify the ratio of Surgical Site Infection (SSI) and also the validity of the National Nosocomial Infection Survellance (NNIS) and Study on the Efficacy of Nosocomial Infection Control (SENIC) risk indexes in colorectal surgery, among Turkish population. Background: Some problems have been reported with the power of NNIS risk index to predict the risk of surgical site infection. We aimed to validate theNNIS and SENIC risk indexes in colorectal surgery. Methods: Between January 2003 and December 2006, surgical site ?nfection survellance was performed to 107 patient who undergo colorectal surgery with NNIS and SENIC risk scales. The mean patient age was 48 years (range, 17 to 86), and 61.7% of the group (66) was female. For this patient cohort, 6 (5.6%) were diagnosed with incisional SSI. While the mean Body Mass Index (BMI) of all patients was 26.6;mean value of BMI among the patiens with SSI was 27.8.Results: 6 insicional surgical site infection were observed during the study. According to Receiver Operating Characteric (ROC) curve analyze neither NNIS with avalue of 0.70, nor SENIC with a value of 0.67 are perfect risk indexes. Conclusion: As a result both NNIS and SENIC ?s a good risk indexes but not perfect. Scarcely when NNIS and SENIC is used together to predict the SSI they forecast the development of infection better. But there is a lot of other factors that effect the development of SSI, so for excellent surveillance risk index those factors known by everyone must be added to risk index scales.

Hypoglycemic encephalopathy caused by overdose of metformin in an adolescent

To the Editor:Hypoglycemic encephalopathy is an acute brain dysfunction caused by hypoglycemia.Its clinical manifestations are complex,and sometimes its symptoms are not typical.Therefore,it can be misdiagnosed.This article shares a case of hypoglycemic encephalopathy caused by excessive ingestion of metformin for a suicide attempt in an adolescent.

Emergent Endoscopic Retrograde Cholangiopancreatography with Placement of Biliary Double Stents to Salvage Endoscopic Retrograde Cholangiopancreatography-lnduced Stapfer＇s Type Ⅱ Perforation

To the Editor：Endoscopic retrograde cholangiopancreatography （ERCP） plays a vital role in the management ofpancreaticobiliary diseases in recent years and it concomitantly carries a risk of complications including post-ERCP pancreatitis,cholangitis,bleeding,and perforation.The incidence of primary post-ERCP complications ranges from 5.4% to 23.0%,and ERCP-induced perforation can occur in 0.3-1.0% of cases,but the associated mortality is high ranging from 8% to 23%.[1] Because of the confluence of the bile duct and pancreatic duct meet at the papilla in proximity to the site of perforation in the duodenum,there is a potential risk of leakage of bile and pancreatic juice into the retroperitoneal space or peritoneum.Patients with Stapfer＇s Type Ⅱ perforation （perivaterian perforation） generally suffered from systemic inflammatory response syndrome,which could progress rapidly to acute lung injury and acute renal insufficiency and even multiple organ failure.All of these contribute to the significantly high mortality.A timely recognition and appropriate treatment are crucial to the management of ERCP-induced perforation to reduce the overall mortality.Conventionally,surgery remains the primary treatment for iatrogenic perforations.With the improvement in endoscopic technique and development of new accessories,nonsurgical management with endoscopic treatment of perforation is increasingly being reported.[2] We report a retrospective analysis of ERCP-induced Stapfer＇s Type Ⅱ perforations over a 5-year period managed with nonsurgical approach combined with salvage ERCP.

Segmentation multi-dimensional crest factor reduction for multi-service supporting digital radio over fibre system

A segmentation multi-dimensional crest factor reduction （SMD-CFR） algorithm is proposed for multi-service supporting digital radio over fibre （DRoF） system. Benefit from segmentation dynamic clipping threshold and clipping factor got basing on characteristics of all service bands, the SMD-CFR is able to get better peak clipping and peak to average power ratio （PAPR） reduction for multi-band combined signal. Simulation results show that SMD-CFR gets more than 2.3 reduction in PAPR for two-bands combined signal of long term evolution （LTE） , which is much better than traditional one dimensional （1D）-CFR. Meanwhile, for 64-quadrature amplitude modulation （QAM） modulation and demodulation link, it has very small effect on bit error rate （BER） and error vector magnitude （EVM） , which are controlled less than 0. 1% and 0.2% respectively. For hardware experiment, SMD-CFR obtains 4.5% increase in drain efficiency and about 4 dBc increase in adjacent channel leakage ratio （ACLR）. These are very significant for the wide band power amplifier （PA） in multi-service supporting DRoF system.