有低频残余听力感音神经聋的人工耳蜗植入术

目的介绍一种有低频残余听力感音神经聋的人工耳蜗植入技术,探讨人工耳蜗植入手术对有残余听力患者的治疗效果和价值。方法15例有残余听力的患者接受了保护残余听力的人工耳蜗植入手术。术中电极植入深度在19mm～24mm左右。术后分别检测单纯使用助听器、单纯使用人工耳蜗、人工耳蜗结合助听器三种不同状态下的听力。结果15例患者中,有13例术后残余听力保存良好,仅分别丢失5～20dB听力,但另2例术后残余听力全部丧失。术后在安静、信噪比15dB和10dB三种不同状态下的言语测试结果显示,人工耳蜗结合助听器使用者测试得分始终保持在很高水平;单纯使用人工耳蜗者也有较好的成绩,但在信噪比达10dB的条件下,测试成绩下降;而单纯使用助听器者,不仅在安静状态下听力成绩不甚理想,一旦加入竞争性噪声,听力测试成绩急剧下降。结论保护和利用残余听力的人工耳蜗植入技术,使人工耳蜗植入手术对象从重度或极重度聋扩大到高频为重度或极重度聋,低频(≤500Hz)为中、轻度聋的患者。接受这项技术患者的听力和言语识别能力均明显优于其单纯配戴助听器和单纯使用人工耳蜗时的听力和言语识别能力。

Complications of newborn enterostomies

AIM To evaluate the occurrence and severity of enterostomy complications in newborns suffering from different intestinal disorders.METHODS A 10-year retrospective cohort study(2008-2017) investigated newborns that underwent enterostomy formation and reversal for different intestinal disorders. Only infants less than 28 d old at the time of enterostomy creation were included in the study(corrected age was applied in the cases of preterm neonates). The patients were divided into two groups according to their underlying diseases. Group 1 included infants suffering from necrotizing enterocolitis(NEC), whereas Group 2 included newborns diagnosed with intestinal disorders other than NEC, such as meconium obstruction, anorectal malformation, focal intestinal perforation, ileus, intestinal atresia and volvulus. The primary outcome measure was enterostomy-related morbidity. The data were analyzed statistically using Pearson's χ2 test or Fisher's exact test for categorical variables and the Wilcoxon-Mann-Whitney U-Test for continuous variables. RESULTS In total, 76 infants met the inclusion criteria and were evaluated for enterostomy-related complications. Neither group showed significant differences regarding gender, gestational age, weight at birth or weight at enterostomy formation. Infants suffering from NEC(Group 1) were significantly older at enterostomy for-mation than the neonates of Group 2 [median(range), 11(2-75) d vs 4(1-101) d, P = 0.004)]. Significantly more ileostomies were created in Group 1 [47(92.2%) vs 16(64.0%), P = 0.007], whereas colostomies were performed significantly more often in Group 2 [2(3.9%) vs 8(32.0%), P = 0.002]. The initiation of enteral nutrition after enterostomy was significantly later in Group 1 infants than in Group 2 infants [median(range), 5(3-13) vs 3(1-9), P < 0.001]. The overall rate of one or more complications in patients of both groups after enterostomy formation was 80.3%, with rates of 86.3% in Group 1 and 68.0% in Group 2(P = 0.073). Most patients suffered from two complications(23.7%). Four or more complications occurred in 21.6% of the infants in Group 1 and in 12.0% of the infants in Group 2(P = 0.365). Following enterostomy closure, at least one complication was observed in 26.0% of the patients(30.6% in Group 1 and 16.7% in Group 2, P = 0.321). The occurrence of complications was not significantly different between neonates with NEC and infants with other intestinal disorders. 48(65.8%) patients required no treatment or only pharmacological treatment for the complications that occurred [Clavien-Dindo-Classification(CDC) < Ⅲ], while 25(34.2%) required surgery to address the complications(CDC ≥Ⅲ). Early reversal of the enterostomy was performed significantly more often(P = 0.003) and the time to full enteral nutrition after closure was significantly longer [median(range), 7(3-87) d vs 12(5-93) d, P = 0.006] in infants with a CDC grading ≥Ⅲ than in infants with a CDC grading < Ⅲ. CONCLUSION Complications occur in almost all infants with enterostomies. The majority of these complications are minor and do not require surgical treatment. There is a clear trend that neonates with NEC have a higher risk for developing complications than those without NEC.

Trans-arterial chemoperfusion for the treatment of liver metastases of breast cancer and colorectal cancer: Clinical results in palliative care patients

AIM To evaluate the clinical value and efficiency of transarterial chemoperfusion(TACP) in patients with liver metastases from breast cancer(BC) and colorectal cancer(CRC).METHODS We treated 36 patients with liver metastases of BC(n = 19, 19 females) and CRC(n = 17; 8 females, 9 males) with repeated TACP. The treatment interval was 4 wk. TACP was performed with gemcitabine(1000 mg/m2) and mitomycin(10 mg/m2), administered within 1 h after positioning the catheter tip in the hepatic artery. Before treatment, the size, location, tumour volume, vascularization and number of liver tumours were evaluated using magnetic resonance imaging(MRI). Tumour response was evaluated according to the Response Evaluation Criteria in Solid Tumors guidelines.RESULTS TACP using gemcitabine and mitomycin for metastases from CRC and BC was performed without any serious side effects. The follow-up MRI showed a therapeutic response in 84.2% of the BC patients-stable disease 47.4% and partial response 36.8%. A progression was seen in 15.8%.CRC patients showed a therapeutic response in 52.9% of cases. A progression of the disease was documented in 47.1% of the patients with CRC. These data show that TACP in patients with liver metastases of BC leads to a significantly better therapeutic response compared with CRC patients(P = 0.042). The median survival time was 13.2 mo for the BC patients, which is significantly longer than for CRC patients at 9.3 mo(P = 0.001).CONCLUSION TACP for liver metastases of BC appears to be a safe and effective palliative treatment with improved outcomes in comparison to patients with CRC.

Assessment of hemostatic profile in patients with mild to advanced liver cirrhosis

BACKGROUND Hemostasis of patients suffering from liver cirrhosis is challenging due to both,pro-and anticoagulatory disorders leading to hemostatic alterations with distinct abnormalities of coagulation.Pathological changes in conventional coagulation analysis and platelet count are common manifestations of decreased liver synthesis of coagulation factors and reduced platelet count in these patients.However,conventional coagulation analysis and platelet count do not reflect invivo coagulation status or platelet function.The purpose of this present observational study was therefore to assess the haemostatic profile including plasmatic coagulation using thrombelastometry and impedance aggregometry for platelet function in patients suffering from liver cirrhosis.AIM To assess the hemostatic profile of cirrhotic patients according to model for endstage liver disease(MELD)score.METHODS Our study included both in-and outpatients suffering from liver cirrhosis attending the out-and inpatient care of the department of hepatology.Demographic and biochemical data as well as medical history including cause of liver cirrhosis,end stage kidney failure and medication with anticoagulants were recorded.To assess the hemostatic profile,platelet function was analyzed by multiple electrode aggregometry(MEA)using Multiplate^■(ADP-,ASPI-and TRAP-test)and thrombelastometry using ROTEM^■(EXTEM,INTEM,FIBTEM).Data were compared using Mann-Whitney U-or χ^2-test.Spearman correlation was performed to analyze the association between MELD Score and results of thrombelastometry and MEA.RESULTS A total of 68 patients attending the out-and inpatient care suffering from liver cirrhosis were screened.Of these,50 patients were included and assigned to groups according to MELD score 6 to 11(n=25)or≥17(n=25).Baseline patient characteristics revealed significant differences for MELD score(8 vs 22,P<0.0001)and underlying laboratory parameters(international normalized ratio,bilirubine,creatinine)as well as fibrinogen level(275 mg/dL vs 209 mg/dL,P=0.006)and aPTT(30 s vs 35 s,P=0.047).MEA showed a moderately impaired platelet function(medians:AUCADP=43U,AUCASPI=71U,AUCTRAP=92U)but no significant differences between both groups.Thrombelastometry using ROTEM?(EXTEM,INTEM,FIBTEM)revealed values within normal range in both groups.No significant correlation was observed between MELD score and results of MEA/thrombelastometry.CONCLUSION Our data demonstrate a partially impaired hemostatic profile in liver cirrhosis patients unrelated to MELD score.An individual assessment of a potential coagulopathy should therefore be considered.

重复肝动脉化疗栓塞治疗结直肠癌肝转移的前瞻性研究

目的 评价不同药物组合经动脉化疗栓塞治疗结直肠癌肝转移的肿瘤局控率及生存期。方法 本研究获得审查委员会批准，且获得病人知情同意。共对463例[平均年龄62．5岁，范围（34．7～88．1）岁]无法手术且全身化疗无效的结直肠肝转移病人行化疗栓塞治疗。间隔期为4周，共实施化疗栓塞2441次（5．3次／人）。

Gender-specific associations between coronary heart disease and other chronic diseases: cross-sectional evaluation of national survey data from adult residents of Germany

Background Combinations of coronary heart disease(CHD) and other chronic conditions complicate clinical management and increase healthcare costs. The aim of this study was to evaluate gender-specific relationships between CHD and other comorbidities. Methods We analyzed data from the German Health Interview and Examination Survey(DEGS1), a national survey of 8152 adults aged 18-79 years. Female and male participants with self-reported CHD were compared for 23 chronic medical conditions. Regression models were applied to determine potential associations between CHD and these 23 conditions. Results The prevalence of CHD was 9%(547 participants): 34%(185) were female CHD participants and 66%(362) male. In women, CHD was associated with hypertension(OR = 3.28(1.81-5.9)), lipid disorders(OR = 2.40(1.50-3.83)), diabetes mellitus(OR = 2.08(1.24-3.50)), kidney disease(OR = 2.66(1.101-6.99)), thyroid disease(OR = 1.81(1.18-2.79)), gout/high uric acid levels(OR = 2.08(1.22-3.56)) and osteoporosis(OR = 1.69(1.01-2.84)). In men, CHD patients were more likely to have hypertension(OR = 2.80(1.94-4.04)), diabetes mellitus(OR = 1.87(1.29-2.71)), lipid disorder(OR = 1.82(1.34-2.47)), and chronic kidney disease(OR = 3.28(1.81-5.9)). Conclusion Our analysis revealed two sets of chronic conditions associated with CHD. The first set occurred in both women and men, and comprised known risk factors: hypertension, lipid disorders, kidney disease, and diabetes mellitus. The second set appeared unique to women: thyroid disease, osteoporosis, and gout/high uric acid. Identification of shared and unique gender-related associations between CHD and other conditions provides potential to tailor screening, preventive, and therapeutic options.

虚拟去钙双能量CT检测腰椎间盘突出:与标准灰度CT比较

目的评价双能量CT重建虚拟去钙(VNCa)成像技术对腰椎间盘突出的诊断价值,并与标准CT重建影像进行比较。材料与方法回顾性研究2017年3月—2018年1月间于2周内接受第3代双源、双能量CT和3.0 T MRI的病例共41例(243个椎间盘),总体平均年龄68岁。

Severe infection with multidrug-resistant Salmonella choleraesuis in a young patient with primary sclerosing cholangitis

Massive global spread of multidrug-resistant(MDR) Salmonella spp. expressing extended-spectrum beta-lactamase(ESBL) and additional resistance to fluoroquinolones has often been attributed to high international mobility as well as excessive use of oral antibiotics in livestock farming. However, MDR Salmonella spp. have not been mentioned as a widespread pathogen in clinical settings so far. We demonstrate the case of a 25-year-old male with primary sclerosing cholangitis who tested positive for MDR Salmonella enterica serotype Choleraesuis expressing ESBL and fluoroquinolone resistance. The pathogen was supposedly acquired during a trip to Thailand, causing severe fever, cholangitis andpancreatitis. To our knowledge, this is the first report of Salmonella enterica serotype Choleraesuis in Europe expressing such a multidrug resistance pattern. ESBL resistance of Salmonella enterica spp. should be considered in patients with obstructive biliary tract pathology and travel history in endemic countries.

Liver biochemistry profile,significance and endoscopic management of biliary tract complications post orthotopic liver transplantation

AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy. METHODS: Patients who developed biliary complications were analysed in detail for the clinical information,laboratory tests,treatment offered,response to it,follow up and outcomes. The profile of liver enzymes was determined. The safety,efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed. RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be > 3 times (388.1 ± 70.9 U/mL vs 168.5 ± 34.2 U/L,P = 0.007) and SAP > 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L,P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic strictures in 28 (40%). Sustained success was achieved in 26 (81%) patients. CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early,non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.

Abdominal cocoon in children: A case report and review of literature

BACKGROUND Abdominal cocoon or“encapsulating peritoneal sclerosis”(EPS)is an uncommon and rare cause of intestinal obstruction.Only a few cases have been reported in paediatric patients.Typically,EPS is described as the primary form in young adolescent girls from tropical and subtropical countries because of viral peritonitis due to retrograde menstruation or a history of peritoneal dialysis.Most patients are asymptomatic or present with abdominal pain,which is likely to occur secondary to subacute bowel obstruction.Findings at imaging,such as ultrasound,computed tomography,and magnetic resonance imaging,are often nonspecific.When diagnosed,EPS is characterized by total or partial encasement of the bowel within a thick fibrocollagenous membrane that envelopes the small intestine in the form of a cocoon because of chronic intraabdominal fibroinflammatory processes.The membrane forms a fibrous tissue sheet that covers,fixes,and finely constricts the gut,compromising its motility.CASE SUMMARY We present a case of EPS in a 12-year-old boy 8 wk after primary surgery for resection of symptomatic jejunal angiodysplasia.There was no history of peritoneal dialysis or drug intake.CONCLUSION In this report,we sought to highlight the diagnostic,surgical,and histopathological characteristics and review the current literature on EPS in paediatric patients.

Comparison of outcomes between complete and incomplete congenital duodenal obstruction

BACKGROUND Congenital duodenal obstruction (CDO) can be complete (CCDO) or incomplete (ICDO). To date there is no outcome analysis available that compares both subtypes. AIM To quantify and compare the association between CCDO and ICDO with outcome parameters. METHODS We retrospectively reviewed all patients who underwent operative repair of CCDO or ICDO in our tertiary care institution between January 2004 and January 2017. The demographics, clinical presentation, preoperative diagnostics and postoperative outcomes of 50 patients were compared between CCDO (n = 27;atresia type 1-3, annular pancreas) and ICDO (n=23;annular pancreas, web, Ladd′s bands). RESULTS In total, 50 patients who underwent CDO repair were enrolled and followed for a median of 5.2 and 3.9 years (CCDO and ICDO, resp.). CCDO was associated with a significantly higher prenatal ultrasonographic detection rate (88% versus 4%;CCDO vs ICDO, P<0.01), lower gestational age at birth, lower age and weight at operation, higher rate of associated congenital heart disease (CHD), more extensive preoperative radiologic diagnostics, higher morbidity according to Clavien-Dindo classification and comprehensive complication index (all P≤0.01). The subgroup analysis of patients without CHD and prematurity showed a longer time from operation to the initiation of enteral feeds in the CCDO group (P<0.01). CONCLUSION CCDO and ICDO differ with regard to prenatal detection rate, gestational age, age and weight at operation, rate of associated CHD, preoperative diagnostics and morbidity. The degree of CDO in mature patients without CHD influences the postoperative initiation of enteral feeding.

Sonographic signs of neutropenic enterocolitis

瞄准：与 neutropenic 小肠结肠炎在病人在诊断和后续的时间调查 sonographic 特征。方法：在有 neutropenic 小肠结肠炎的 14 个病人的 sonographic 调查结果被描述并且评估了考虑症状和临床的结果。结果：在有 neutropenic 小肠结肠炎的所有病人， ileocoecal 区域涉及墙变厚 】10 公里。一个透壁的煽动性的模式，变厚的肠墙的亢奋的由脉管形成和免费腹的液体是普通调查结果。肠墙的 sonographically 揭示的厚度与致命的结果(P【0.03 ) 被联系。在 11 个幸存病人，临床的症状的改进被肠的墙厚度的进步减小伴随。结论：肠的高端 sonography 是为诊断的一个有用工具，对预后的评价和有 neutropenic 小肠结肠炎的病人的后续。ultrasonographically 揭示的肠厚度反映严厉和疾病的功课，并且似乎为临床的结果预兆。

Colon capsule endoscopy: Current status and future directions

Colon capsule endoscopy(CCE; Pill Cam Colon; Given Imaging; Yoqneam, Israel) is a minimally invasive wireless technique for the visualization of the colon. With the recent introduction of the second generation colon capsule the diagnostic accuracy of CCE for polyp detection has significantly improved and preliminary data suggest it may be useful to monitor mucosal inflammation in patients with inflammatory bowel disease. Limitations include the inability to take biopsies and the procedural costs. However, given the potentially higher acceptance within an average risk colorectal cancer(CRC) screening population, its usefulness as a screening tool with regard to CRC prevention should be further evaluated.

Persistent bowel dysfunction after surgery for Hirschsprung’s disease:A neuropathological perspective

Hirschsprung’s disease(HD)is a congenital disorder,characterized by aganglionosis in the distal part of the gastrointestinal tract.Despite complete surgical resection of the aganglionic segment,both constipation and fecal incontinence persist in a considerable number of patients with limited treatment options.There is growing evidence for structural abnormalities in the ganglionic bowel proximal to the aganglionosis in both humans and animals with HD,which may play a role in persistent bowel dysfunction.These abnormalities include:(1)Histopathological abnormalities of enteric neural cells;(2)Imbalanced expression of neurotransmitters and neuroproteins;(3)Abnormal expression of enteric pacemaker cells;(4)Abnormalities of smooth muscle cells;and(5)Abnormalities within the extracellular matrix.Hence,a better understanding of these previously unrecognized neuropathological abnormalities may improve follow-up and treatment in patients with HD suffering from persistent bowel dysfunction following surgical correction.In the long term,further combination of clinical and neuropathological data will hopefully enable a translational step towards more individual treatment for HD.

Iatrogenic atrial septal defects after transseptal puncture for percutaneous left atrial appendage occlusion and their hemodynamic effects

Background Percutaneous left atrial appendage occlusion(LAAO)requires puncture of the interatrial septum.The immediate hemodynamic effects of iatrogenic atrial septal defects(iASD)after LAAO have not been examined so far.We aimed at evaluat-ing these effects through invasive measurements of pressure and oxygen saturation.Moreover,we assessed the incidence of per-sistent iASD at three months.METHODS Forty-eight patients scheduled for percutaneous LAAO were prospectively included in the study.Pressure and oxygen saturation were measured(1)in the right atrium(RA)before transseptal puncture,(2)in the left atrium(LA)through the transseptal sheath after transseptal puncture,(3)in the LA after removal of introducer sheath,and(4)in the RA after removal of introducer sheath.Transesophageal echocardiography was performed at three months to detect iASD.RESULTS Pressure in the RA increased significantly after removing the introducer sheath(P=0.034),whereas no difference was found in oxygen saturation in the RA(P=0.623).Pressure measurement in the LA showed no significant difference after re-moving the introducer sheath(P=0.718).Oxygen saturation in the LA also showed no significant difference(P=0.129).Follow-up transesophageal echocardiogram at 3 months revealed a persistent iASD in 4 patients(8.5%).CONCLUSIONS Our study suggests that iASD after percutaneous LAAO does not result in significant shunts directly after the procedure,although a significant increase of mean right atrial pressure can be observed.Persistent iASDs after percutaneous LAAO seem to be relatively rare at three months.

Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Chronic intestinal failure(CIF)is a rare but feared complication of Crohn’s disease.Depending on the remaining length of the small intestine,the affected intestinal segment,and the residual bowel function,CIF can result in a wide spectrum of symptoms,from single micronutrient malabsorption to complete intestinal failure.Management of CIF has improved significantly in recent years.Advances in home-based parenteral nutrition,in particular,have translated into increased survival and improved quality of life.Nevertheless,60%of patients are permanently reliant on parenteral nutrition.Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy.The outcomes of patients with CIF could be greatly improved by more effective prevention,understanding,and treatment.In complex cases,the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation,nutritional support,and an improved quality of life.Here,we summarize current literature on CIF and short bowel syndrome,encompassing epidemiology,pathophysiology,and advances in surgical and medical management,and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.

患者-人工瓣膜不匹配和主动脉瓣设计对主动脉瓣置换术后患者冠状动脉血流储备的影响

目的：本前瞻性随机研究旨在调查主动脉狭窄（AS）患者中，主动脉瓣设计和患者一人工瓣膜不匹配（PPM）对机械或生物主动脉瓣置换术（AVR）后冠状动脉血流储备（CFR）的影响。背景：CFR可能是AS患者AVR后长期存活的一个重要参数。CFR减少可以导致心血管事件和死亡率的增加。方法：48例行AVR的患者在术前、术后5d和随访6个月时进行磁共振检查。测定冠状动脉血流，并在随访6个月时测定CFR。拟行机械瓣AVR的患者被随机分为侧倾碟瓣（n=12）或双叶瓣组（n=12）。

Delayed diagnosis of isolated alar ligament rupture:A case report

Ligament disruptions at the craniovertebral junction are typically associated with atlantoaxial rotatory dislocation during upper cervical spine injuries and require external orthoses or surgical stabilization. Only in few patients isolated ruptures of the alar ligament have been reported. Here we present a further case, in which the diagnosis was initially obscured by a misleading clinical symptomatology but finally established six month following the trauma, demonstrating the value of contrast-enhanced high resolution 3 Tesla magnetic resonance imaging in identifying this particular lesion.

Extravascular use of drug-eluting beads: A promising approach in compartment-based tumor therapy

Intraperitoneal carcinomatosis(PC)may occur with several tumor entities.The prognosis of patients suffering from PC is usually poor.Present treatment depends on the cancer entity and includes systemic chemotherapy,radiation therapy,hormonal therapy and surgical resection.Only few patients may also benefit from hyperthermic intraperitoneal chemotherapy with a complete tumor remission.These therapies are often accompanied by severe systemic side-effects.One approach to reduce side effects is to target chemotherapeutic agents to the tumor with carrier devices.Promising experimental results have been achieved using drug-eluting beads(DEBs).A series of in vitro and in vitro experiments has been conducted to determine the suitability of their extravascular use.These encapsulation devices were able to harbor CYP2B1producing cells and to shield them from the hosts immune system when injected intratumorally.In this way ifosfamide-which is transformed into its active metabolites by CYP2B1-could be successfully targeted into pancreatic tumor growths.Furthermore DEBs can be used to target chemotherapeutics into the abdominal cavity for treatment of PC.If CYP2B1 producing cells are proven to be save for usage in man and if local toxic effects of chemotherapeutics can be controlled,DEBs will become promising tools in compartmentbased anticancer treatment.

Thrombolysis in acute stroke under dual antiplatelet therapy: perspectives arising from translational studies

We have recently established a mouse model of focal stroke under dual antiplatelet therapy(DAPT)to study tissue plasminogen activator(tPA)-associated hemorrhagic transformation.The purpose of this short perspective is to discuss the rationale for establishing the model,highlighting its relevance for addressing unresolved clinical questions.Hemorrhagic conversion of the ischemic stroke remains one of the major liabilities of thrombolytic therapy with tPA,contributing to unfavorable outcomes and failed regeneration.This was recognized early on,and the resulting restrictions on tPA usage have led to only a minor percentage of stroke patients receiving any kind of drug treatment to limit ischemic injury.