Importance of risk assessment,endoscopic hemostasis,and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding(ANVUGIB)is a common medical emergency in clinical practice.While the incidence has significantly reduced,the mortality rates have not undergone a similar reduction in the last few decades,thus presenting a significant challenge.This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis.Since ANUVGIB predominantly affects the elderly population,the impact of comorbidities may be responsible for the poor outcomes.A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly.Early risk stratification plays a crucial role in deciding the line of management and predicting mortality.Emerging scoring systems such as the ABC(age,blood tests,co-morbidities)score show promise in predicting mortality and guiding clinical decisions.While conventional endoscopic therapies remain cornerstone approaches,novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives,particularly in cases refractory to traditional modalities.By integrating validated scoring systems and leveraging novel therapeutic modalities,clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.

颈前路显微外科手术治疗脊髓型颈椎病

[目的]探讨前路显微外科减压椎体融合钢板固定术治疗脊髓型颈椎病。[方法]对6l例病人实施颈椎间盘、后纵韧带及椎体后骨赘显微手术切除，保留终板，椎间融合器椎体融合，钢板固定手术。术后平均随访18．2个月。分析融合情况、融合节段的后突角度及神经功能状况。[结果]融合率100％。术后神经功能改善率（82．5±3．6）％，优良率73．7％。融合节段后突角度平均改善6．3°，有统计学意义（P〈0．01）。[结论]颈前入路显微外科手术治疗1～2个节段椎间盘突出和（或）退行性骨赘引起的脊髓型颈椎病安全可行，近期疗效满意。保留终板的椎间融合器椎体融合加钢板固定手术能恢复和维持颈椎生理曲度，促进融合。

Sternoclavicular joint dislocation and its management: A review of the literature

Dislocations of the sternoclavicular joint(SCJ) occur with relative infrequency and can be classified into anterior and posterior dislocation, with the former being more common. The SCJ is inherently unstable due to its lack of articular contact and therefore relies on stability from surrounding ligamentous structures, such as the costoclavicular, interclavicular and capsular ligaments. The posterior capsule has been shown in several studies to be the most important structure in determining stability irrespective of the direction of injury. Posterior dislocation of the SCJ can be associated with life threatening complications such as neurovascular, tracheal and oesophageal injuries. Due to the high mortality associated with such complications, these injuries need to be recognised acutely and managed promptly. Investigations such as x-ray imaging are poor at delineating anatomy at the level of the mediastinum and therefore CT imaging has become the investigation of choice. Due to its rarity, the current guidance on how to manage acute and chronic dislocations is debatable. This analysis of historical and recent literature aims to determine guidance on current thinking regarding SCJ instability, including the use of the Stanmore triangle. The described methods of reduction for both anterior and posterior dislocations and the various surgical reconstructive techniques are also discussed.

Dengue:epidemiology,prevention and pressing need for vaccine development

Dengue fever is a mosquito born viral infection,and the complicated form of dengue is dengue hemorrhagic fever(DHF).In the recent decades incidence and distribution of dengue has increased dramatically.Dengue viruses belong to family flaviviridae with four serotypes and are transmitted mainly by mosquito Aedes aegypti.Today almost two-fifth of world’s population (2.5 million) is at risk of dengue and no specific antiviral drug or vaccine is available against it.Uncontrolled population growth in Africa and South East Asia has increased number of susceptible hosts in urban and semi urban areas.About 40%of world population resides in the high risk area for dengue transmission.According to latest estimates by WHO,yearly 50 to 100 million infections occur globally,this includes around 500 000 DHF and 22 000 deaths,mostly among children.Only symptomatic treatment in the form of analgesic,antipyretics and body fluid management is provided to the patient.Prevention strategies mainly focus on two approaches, firsdy on activities to control vector and secondly on activities to protect human from mosquito bite but there is always concerns regarding their sustainably and effectiveness.Theoretically development of an effective dengue vaccine is feasible and production of an effective and affordable vaccine could be a viable option to save humans from this dreadful disease. Conceptually vaccine production is possible,but it has to be tetravalent,providing immunity against all serotypes.Few candidate vaccines are in advance stage of their development:however international cooperation is needed to make these vaccines available on cheaper rates to the poor and vulnerable countries.Objective of this review is to discuss various aspects related to dengue,its epidemiology,available preventive methods,need for vaccine and challenges in its development.

Low grade dysplasia in Barrett's esophagus:Should we worry?

The optimal management for low-grade dysplasia(LGD)in Barrett’s esophagus is unclear.In this article the importance of LGD is discussed,including the significant risk of progression to esophageal adenocarcinoma.Endoscopic surveillance is a management option but is plagued by sampling error and issues of suboptimal endoscopy.Furthermore endoscopic surveillance has not been demonstrated to be cost-effective or to reduce cancer mortality.The emergence of endoluminal therapy over the past decade has resulted in a paradigm shift in the management of LGD.Ablative therapy,including radiofrequency ablation,has demonstrated promising results in the management of LGD with regards to safety,cost-effectiveness,durability and reduction in cancer risk.It is,however,vital that a shareddecision making process occurs between the physician and the patient as to the preferred management of LGD.As such the management of LGD should be"individualised."

Cholesterol crystal embolism leading to perforation of the gallbladder

BACKGROUND: Cholesterol crystal embolism (CCE) from atherosclerotic arterial disease leading to perforation of the gallbladder is rare. We describe our experience of managing a patient with perforation of gallbladder caused by CCE. METHODS: A 64-year-old man was admitted to this hospital because of acute abdominal pain with clinical features suggestive of peritonitis. He was known to suffer from atherosclerotic peripheral arterial disease and had undergone aortobifemoral bypass 17 years ago. A CT scan showed a collection of peri-hepatic fluid. The gallbladder was normal in appearance but contained multiple calculi. At laparotomy, free bile was observed in the peritoneal cavity, leaking from a pin-hole size peroration of the fundus of the gallbladder. Hence cholecystectomy was performed. RESULTS: The patient made an uneventful recovery. Histological study of the gallbladder showed chronic cholecystitis and obliteration of the lumen of the mural arteries with cholesterol crystals within, indicating CCE. CONCLUSIONS: Although perforation of the gallbladder following CCE of its mural arteries is rare, the diagnosis should be considered in patients with abdominal pain and known atherosclerotic arterial disease. Management should include an early recognition of this condition, prompt institution of treatment, prevention of further insults by discontinuing or avoiding predisposing factors, and modification of cardiovascular risk factors.

Combined Effects of Capsaicin and HA14-1 in Inducing Apoptosis in Melanoma Cells

Abnormal regulation of apoptosis is an important aspect of tumour development. Capsaicin, an extract of red chilli peppers, has been shown to inhibit growth of melanoma and other malignant cell lines and HA14-1 is an organic compound that directly induces apoptosis by binding to Bcl-2 protein. The aim of this work was to investigate whether combination therapy with capsaicin and HA14-1 might hold any promise for the treatment of melanoma. Three melanoma cell lines of a range of aggressive potential, melanocytes and fibroblasts were examined, looking at the effects of both drugs singly and in combination on cell viability and induction of apoptosis. This comparative study showed that melanoma cells and melanocytes have a similar sensitivity to capsaicin while fibroblasts are more resistant to it. HA14-1, as expected, induced apoptosis in all cells at relatively low concentrations. A combination of the two agents produced the expected results of an additive effect for 2 (HBL and A375SM) out of 3 melanoma cell lines in inducing apoptosis, but encouragingly for the most metastatically aggressive cancer cell line (C8161), a combination of the two showed a synergistic induction of apoptosis.

Is cardiac MRI an effective test for arrhythmogenic right ventricular cardiomyopathy diagnosis?

AIM:To evaluate the referrals with suspected arrhythmogenic right ventricular cardiomyopathy(ARVC)and compare cardiac MR(cMR)findings against clinical diagnosis.METHODS:A retrospective analysis of 114(age range16 to 83,males 55%and females 45%)patients referred for cMR with a suspected diagnosis of ARVC between May 2006 and February 2010 was performed after obtaining institutional approval for service evaluation.Reasons for referral including clinical symptoms and family history of sudden death,electrocardiogram and echo abnormalities,cMR findings,final clinical diagnosis and information about clinical management were obtained.The results of cMR were classified as major,minor,non-specific or negative depending on both functional and tissue characterisation and the cMR results were compared against the final clinical diagnosis.RESULTS:The most common reasons for referral included arrhythmias(30%)and a family history of sudden death(20%).Of the total cohort of 114 patients:4 patients(4%)had major cMR findings for ARVC,13patients(11%)had minor cMR findings,2 patients had non-specific cMR findings relating to the right ventricle and 95 patients had a negative cMR.Of the 4 patients who had major cMR findings,3(75%)had a positive clinical diagnosis.In contrast,of the 13 patients who had minor cMR findings,only 2(15%)had a positive clinical diagnosis.Out of the 95 negative patients,clinical details were available for 81 patients and none of them had ARVC.Excluding the 14 patients with no clinical data and final diagnosis,the sensitivity of the test was 100%,specificity 87%,positive predictive value29%and the negative predictive value 100%.CONCLUSION:CMR is a useful tool for ARVC evaluation because of the high negative predictive value as the outcome has a significant impact on the clinical decision-making.

Cholecystocolocutaneous fistula: a case report

BACKGROUND: Cholecystocolocutaneous fistula (CCCF) is a rare complication of gallstone disease resulting from spillage of gallstones from perforation of an empyema of the gallbladder, which can pose diagnostic dilemmas. We describe a patient, who presented initially with a swelling followed by discharging sinuses on her right flank where a diagnosis of CCCF was made and was treated surgically with satisfactory outcome. METHODS: A computed tomography (CT) scan showed an ill-defined soft tissue mass in the right subhepatic space and a fistulogram demonstrated passage of contrast into the gallbladder fossa and hepatic flexure of colon. At laparotomy,a cutaneous fistula containing two pigment stones led to the gallbladder fossa and hepatic flexure of colon. RESULTS: Debridement of infected granulation tissues which had replaced the gallbladder, closure of the cystic duct stump and colonic fistula followed by excision of the fistula tract led to complete resolution. CONCLUSIONS: CCCF is a rare complication of perforated gallbladder with spillage of calculi, and a fistulogram is helpful in establishing the diagnosis. This case highlights the importance of retrieving spilled stones following interventions in the gallbladder to prevent the complication.

Recursive Fuzzy Predictions of Future Patient Paths to Support Clinical Decision Making in ICU

In this paper, we propose a new architecture that combines prediction and decision-making in the form of a hybrid framework aimed at providing clinicians with transparent and accurate maps, or charts, to guide and to support treatment decisions, and to interrogate the clinical patients’ course as it develops. These maps should be patient-specific, with options displayed of possible treatment pathways. They would suggest the optimal care pathways, and the shortest routes to the most efficient care, by predicting clinical progress, testing the ensuing suggestions against the developing clinical state and patient condition, and suggesting new options as necessary. These maps should also mine an extensive database of accumulated patient data, modelled diseases, and modelled patient-responses based on expert-derived rules. These individualized hierarchical targets, which are implemented in order to prevent life-threatening illnesses, will also have to “adapt” to the patient’s altering clinical condition. Therapies that support one system can destabilize others and selecting which specific support to prioritize is an uncertain process, the prioritization of which can vary between clinical experts. Whilst clinical therapeutic decisions can be made with some degree of anticipation of the “likely” outcome (based on the experts’ opinion and judgment), treatment is essentially rooted in the present, and is dependent on analyzing the current clinical condition and available data. The recursive learning approach presented in this paper, allows decision rules to predict the possible future course, and reflects back derived information from such projections to the present time and thus support proactive clinical care rather than reactive clinical care. The proposed framework for such a patient map supports and enables an optimized choice from available options and also ensures that decisions are based on both the available evidence and a database of best clinical practice. Preliminary results are encouraging and it is hoped to validate the approach clinically in the near future.

在英国人群中编码血管紧张素转换酶的基因插入/缺失多态现象与泛发型白癜风无关

Vitiligo is an acquired hypomelanotic skin disorder characterised by circumscribed depigmented macules resulting from the loss of functional melanocytes from the cutaneous epidermis and autoimmunity has been suggested to play a role in th e pathogenesis of the disease. Recently, an insertion/deletion (I/D) polymorphis m of a 287-base pair repetitive sequence in intron 16 of the angiotensin conver ting enzyme (ACE) gene has been associated with autoimmune disease and with the development of vitiligo. In this study, the distribution of ACE gene I/D genotyp es was investigated in a population of 106 English patients with generalised (no n-segmental) vitiligo and 174 ethnically matched healthy controls using a restriction fragment length polymorphism-polymerase chain reaction genotyping method. No significant difference in the frequ encies of II, ID and DD genotypes was detected between vitiligo patients and con trol subjects (P=0.35). The same result was evident for the genotype distributio n in vitiligo patients with an autoimmune disease and for those without when com pared with controls (P=0.33 and P=0.53, respectively). In addition, the results indicated that the D allele was not significantly over-represented in the group of patients with vitiligo compared with controls (P=0.42) and that this was als o the case for patients with and without associated autoimmunity (P=0.40 and P=0 .62, respectively).

Emergency Treatment of Acute Decompensated Severe Aortic Stenosis with Transcatheter Aortic Valve implantation under the Coplane View Using J-Tipped Wires Fluoroscopy

Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks,leading to high postoperative mortality rates.However,for some patients eligible for transcatheter aortic valve implantation(TAVI),computed tomography angiography for assessing the aortic root and coronary artery might be challenging before the TAVI procedure.This case highlights a patient who underwent emergency TAVI guided by coplane view generated using J-tipped wires fluoroscopy without computed tomography evaluation before the TAVl.This approach reduces contrast usage during the TAVI procedure,significantly mitigating the risks of renal injury and heart function deterioration.

关节镜下髌韧带与腘绳肌腱重建前交叉韧带的疗效比较

目的比较分析膝关节镜下自体髌韧带与腘绳肌腱移植重建前交叉韧带(ACL)的疗效. 方法回顾分析49例膝关节镜下自体髌韧带移植重建ACL及54例自体腘绳肌腱移植重建ACL的情况,随访24～48个月,平均31.6个月.采用Lysholm膝关节评分、国际膝关节文献编制委员会分级评估标准和KT-1000关节测量仪测定稳定性评价疗效. 结果两组间患者满意度、关节稳定性及功能差异均无统计学意义.髌韧带重建组膝痛发生率较腘绳肌腱组高(37%比11%). 结论关节镜下髌韧带与腘绳肌腱移植重建ACL的疗效相同.ACL重建中等长重建、牢固固定及早期康复锻炼对疗效更有决定作用.

The effect of L-arginine on the progression of chronic renal scarring in remnant kidney

OBJECTIVE: To investigate the effect of L-arginine (L-arg) on early compensatory renal growth (CRG), tubulointerstitial accumulation of extracellular matrix (ECM), long term survival rate and renal scarring in rats with 5/6 nephrectomy (SNx). METHODS: The experiment included four groups of rats (n = 5 each group): (1) Sham group, (2) SNx group, (3) SNx + L-arg group, and (4) Sham + L-arg group (L-arg 1% in drinking water). Parameters related with CRG and early tubulointerstitial expression of ECM and alpha smooth muscle actin (alphaSMA) were evaluated by immunohistochemistry at day 30. The survival rate and the extent of renal scarring in the rats were observed at day 120. RESULTS: L-arg significantly increased the early CRG of SNx rats as determined by the wet kidney weight (P

Turning cross-cultural medical education on its head:Learning about ourselves and developing respectful curiosity

Cross-cultural education is often understood to mean acquiring cultural knowledge about different cultural groups in order to serve people from diverse groups equitably.However,this article argues that to work effectively in cross-cultural situations,we need to learn about our own culture and develop an approach of respectful curiosity.The first goal of cross-cultural education is to understand how culture influences our thoughts,perceptions,biases,and values at an unconscious level.The second goal is to understand the nature of individual cultural identity as a multidimensional and dynamic construct through exploration of our own cultural identity.This exploration helps us understand the limitations of learning about‘others’through learning categorical information and helps us limit the effect of our implicit biases on our interactions.The approach of respectful curiosity is recommended to question our assumptions,understand each unique individual patient,connect with each patient,and build the therapeutic relationship.

一名胸痛伴宽QRS波心动过速的男性患者

一名50岁"严重"胸痛的男性患者因心电图(ECG)呈现宽QRS波心动过速被紧急从当地区级医院转诊到心胸中心。胸痛为间歇性,始于就诊前2小时。患者平素吸烟,病史包括哮喘和8年前的心肌梗死,未进行介入治疗。在过去的一年里,他经常出现清晨胸痛发作,但并无劳力性心绞痛。检查发现患者心动过速,心率160次/分,但血压正常,125/75 mmHg。体检其他未发现明显异常。转诊后描记了ECG。图1显示的是患者胸痛发作时的ECG,图2为患者胸痛缓解后的ECG。

Combination of ablative fractional carbon dioxide laser and platelet-rich plasma treatment to improve hypertrophic scars:a retrospective clinical observational study

Background:Hypertrophic scars are one of the main complications that affect the quality of life of patients after burns.Many methods have been shown to be effective in the treatment of hypertrophic scars,such as ablative fractional CO_(2) laser(AFCL)and platelet-rich plasma(PRP).However,there are few studies on the effect of the combined application of these measures.The purpose of this study was to explore the therapeutic effect of AFCL combined with PRP on hypertrophic burn scars.Methods:A retrospective clinical observation study was conducted on 50 patients with hypertrophic burn scars.The AFCL+PRP group included 31 patients who received AFCL combined with PRP treatment;the AFCL group included 19 patients who received AFCL treatment only.The University of North Carolina 4P Scar Scale(UNC4P)and the Vancouver Scar Scale(VSS)scores that were collected before each treatment were used as indicators of the effectiveness of the previous treatment.The scores recorded at the second,fourth and seventh months were analysed.Results:The demographic data of the 2 groups were not significantly different.Before treatment,therewas no difference in the UNC4P and VSS scores between the 2 groups.Therewas a significant decline in the UNC4P and VSS total scores over 6 months in both groups(p<0.05)and scores in the 2 groups were comparable after 3 and 6 months(p<0.05).UNC4P scores in the AFCL+PRP group decreased from a mean of 8.26 to 2.61(p<0.05)with a concomitant drop in VSS scores from a mean of 11.74 to 6.06(p<0.01).In the AFCL group UNC4P and VSS scores decreased from 7.68 to 4.63(p<0.05)and from 10.89 to 8.16(p<0.05),respectively.The sub-items of these 2 assessments were analysed and the results suggest that AFCL combined with PRP can comprehensively improve scarring.Conclusions:This study shows that PRP is an effective adjunct for AFCL in the treatment of hypertrophic burn scars and that the combination of PRP and AFCL proved to be more useful than AFCL alone.This combination may be a new and effective clinical practice for the treatment of scars.However,larger and higher-level clinical studies are still needed to determine its efficacy and possible mechanisms.

The challenges of cross-cultural research and teaching in primary care

Introduction This special issue of Family Medicine and Community Health is focused on some of the challenges that we face when undertaking cross-cultural academic studies in primary care.It includes both research and teaching studies conducted in several different coun-tries around the world.It highlights some of the challenges we need to address when under-taking such academic work in widely different contexts and cultures.The authors have used a wide variety of methods-chosen to match not only the questions they have asked but also the methods they have chosen which take into account the context in which the studies have been undertaken.