The incidence of bile duct injury in laparoscopic cholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladde...The incidence of bile duct injury in laparoscopic cholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladder was divided into two parts above the Hartmann pouch and all contents were aspirated. Then, the distal part was dissected for short distance. The proximal part was dissected dome down until reaching to cystic duct which was tied or clipped and cut. J-vac drain was put in peritoneal cavity. Between September 2012 and October 2013, overall 77 patients (53 females and 24 males) with mean age of 49 years (between 23 and 67 years) underwent bipartite laparoscopic cholecystectomy. The mean operative time was 60 minutes (between 40 and 90 minutes). The dissection of both parts of gall bladder was safe and easy as close as possible from its wall. No biliary tract injuries were recorded during or after procedure and also at follow-up period (20 months). Bipartite laparoscopic cholecystectomy is safe, easy to do, and can avoid all complications especially bile duct injuries in difficult cases.展开更多
Evidence-based practice(EBP)has been the gold standard in healthcare for nearly three centuries and aims to assist physicians in providing the safest and most effective healthcare for their patients.The well-establish...Evidence-based practice(EBP)has been the gold standard in healthcare for nearly three centuries and aims to assist physicians in providing the safest and most effective healthcare for their patients.The well-established hierarchy of evidence lists systematic reviews and meta-analyses at the top however these methodologies are not always appropriate or possible and in these instances case-control studies,case series and case reports are utilised to support EBP.Case-control studies allow simultaneous study of multiple risk factors and can be performed rapidly and relatively cheaply.A recent example was during the Coronavirus pandemic where case-control studies were used to assess the efficacy of personal protective equipment for healthcare workers.Case series and case reports also play a role in EBP and are particularly useful to study rare diseases such as inflammatory bowel disease in transgender and gender non-conforming individuals.They are also vital in generating and disseminating early signals and encouraging further research.Whilst these methodologies have weaknesses,particularly with regards to bias and loss of patient confidentiality for rare pathologies,they have an important part to play in EBP and when appropriately utilised can significantly impact upon clinical practice.展开更多
Edge devices,due to their limited computational and storage resources,often require the use of compilers for program optimization.Therefore,ensuring the security and reliability of these compilers is of paramount impo...Edge devices,due to their limited computational and storage resources,often require the use of compilers for program optimization.Therefore,ensuring the security and reliability of these compilers is of paramount importance in the emerging field of edge AI.One widely used testing method for this purpose is fuzz testing,which detects bugs by inputting random test cases into the target program.However,this process consumes significant time and resources.To improve the efficiency of compiler fuzz testing,it is common practice to utilize test case prioritization techniques.Some researchers use machine learning to predict the code coverage of test cases,aiming to maximize the test capability for the target compiler by increasing the overall predicted coverage of the test cases.Nevertheless,these methods can only forecast the code coverage of the compiler at a specific optimization level,potentially missing many optimization-related bugs.In this paper,we introduce C-CORE(short for Clustering by Code Representation),the first framework to prioritize test cases according to their code representations,which are derived directly from the source codes.This approach avoids being limited to specific compiler states and extends to a broader range of compiler bugs.Specifically,we first train a scaled pre-trained programming language model to capture as many common features as possible from the test cases generated by a fuzzer.Using this pre-trained model,we then train two downstream models:one for predicting the likelihood of triggering a bug and another for identifying code representations associated with bugs.Subsequently,we cluster the test cases according to their code representations and select the highest-scoring test case from each cluster as the high-quality test case.This reduction in redundant testing cases leads to time savings.Comprehensive evaluation results reveal that code representations are better at distinguishing test capabilities,and C-CORE significantly enhances testing efficiency.Across four datasets,C-CORE increases the average of the percentage of faults detected(APFD)value by 0.16 to 0.31 and reduces test time by over 50% in 46% of cases.When compared to the best results from approaches using predicted code coverage,C-CORE improves the APFD value by 1.1% to 12.3% and achieves an overall time-saving of 159.1%.展开更多
BACKGROUND Glucose imbalance is common in total parenteral nutrition(TPN).Hypoglycemia seems to be less frequent than hyperglycemia,but it influences the clinical outcome to a greater extent.Therefore,it should be eff...BACKGROUND Glucose imbalance is common in total parenteral nutrition(TPN).Hypoglycemia seems to be less frequent than hyperglycemia,but it influences the clinical outcome to a greater extent.Therefore,it should be effectively prevented and treated.However,there is no relevant report on how to treat hypoglycemia caused by TPN in patients with liver cell injury.CASE SUMMARY We present three patients with liver cell injury who developed severe hypo-glycemia during or after TPN infusion.The causes of severe hypoglycemia and glucose-raising strategies were discussed.According to the physiological charac-teristics of the hepatocellular injury,the ratio of nutrition components prescribed in TPN was appropriately adjusted for the three cases.We simultaneously reduced the dose of insulin and fat emulsion,and increased the dose of glucose in TPN.The blood glucose level was restored to normal range and clinical symptoms were eliminated.CONCLUSION When hypoglycemia occurs during or after TPN in patients with hepatocellular injury,physicians need to simultaneously reduce insulin and fat emulsion,and increase glucose,and correct severe hypoglycemia in time to reduce its adverse consequences.展开更多
BACKGROUND In this study,we retrospectively analysed macrophage infiltration and podocyte injury in three patients with diffuse proliferative lupus nephritis(LN)who un-derwent repeated renal biopsy.CASE SUMMARY Clinic...BACKGROUND In this study,we retrospectively analysed macrophage infiltration and podocyte injury in three patients with diffuse proliferative lupus nephritis(LN)who un-derwent repeated renal biopsy.CASE SUMMARY Clinical data of three diffuse proliferative LN patients with different pathological characteristics(case 1 was LN IV-G(A),case 2 was LN IV-G(A)+V,and case 3 was LN IV-G(A)+thrombotic microangiopathy)were reviewed.All patients underwent repeated renal biopsies 6 mo later,and renal biopsy specimens were studied.Macrophage infiltration was assessed by CD68 expression detected by immunohistochemical staining,and an immunofluorescence assay was used to detect podocin expression to assess podocyte damage.After treatment,Case 1 changed to LN III-(A),Case 2 remained as type V LN lesions,and Case 3,which changed to LN IV-S(A),had the worst prognosis.We observed reduced macro-phage infiltration after therapy.However,two of the patients with active lesions after treatment still showed macrophage infiltration in the renal interstitium.Before treatment,the three patients showed discontinuous expression of podocin.Notably,the integrity of podocin was restored after treatment in Case 1.CONCLUSION It may be possible to reverse podocyte damage and decrease the infiltrating ma-crophages in LN patients through effective treatment.展开更多
BACKGROUND Fulminant type 1 diabetes mellitus(FT1DM)that occurs during pregnancy or the perinatal period is known as pregnancy-related FT1DM(PF),always without history of abnormal glucose metabolism.Here,we present fo...BACKGROUND Fulminant type 1 diabetes mellitus(FT1DM)that occurs during pregnancy or the perinatal period is known as pregnancy-related FT1DM(PF),always without history of abnormal glucose metabolism.Here,we present four patients who developed FT1DM during treatment but were first diagnosed with gestational diabetes mellitus(GDM).CASE SUMMARY The clinical data of four patients with GDM combined with FT1DM admitted to our hospital between July 2018 and April 2021 were collected,and the patients and their infants were followed up.All patients were diagnosed with GDM during the second trimester and were treated.The blood glucose level elevated suddenly during the third trimester and then were diagnosed with FT1DM.Two patients had an insulin allergy,and two had symptoms of upper respiratory tract infection before onset.One patient developed ketoacidosis,and three developed ketosis.Two patients had cesarean section deliveries,and two had vaginal deliveries.The growth and development of the infants were normal.C-peptide levels were lower than those at onset,suggesting progressive impairment of islet function.The frequencies of the DRB109:01,DQB103:03,DQA103:02,DPA101:03,DPA102:02,DPB105:01,DRB401:03,G 01:01,and G 01:04 human leukocyte antigen(HLA)-G alleles were high in the present study.CONCLUSION In comparison with pregnancy-associated FT1DM(PF),patients with GDM combined with FT1DM had an older age of onset,higher body mass index,slower onset,fewer prodromal symptoms,and less acidosis.The pathogenesis may be due to various factors affecting the already fragileβ-cells of GDM patients with genetically susceptible class II HLA genotypes.We speculate that GDM combined with FT1DM during pregnancy,referred to as“double diabetes,”is a subtype of PF with its own unique characteristics that should be investigated further.展开更多
Environmental pollution has caused wide social concern,and it demands immediate attention to striking at the crime in the environmental pollution. At present,there are difficulties of putting a case on file,collecting...Environmental pollution has caused wide social concern,and it demands immediate attention to striking at the crime in the environmental pollution. At present,there are difficulties of putting a case on file,collecting evidence,judicial identification,and presumption of causal relationship in investigation of environmental pollution cases. In accordance with current situations,it came up following recommendations:(i) widely collecting case clues to solve the difficulty of putting a case on file;(ii) improving the ability of collecting evidence and standardizing the evidence collection,to solve the difficulty of evidence collection.(iii) including the environmental pollution judicial identification system,and unifying the identification standards,to solve the difficulty in identification. It is recommended to use the epidemiological causal relationship theory combined with enough high-quality evidences to solve the difficulty in presumption of causal relationship.展开更多
BACKGROUND Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise.CASE SUMMARY A 64-year-old woman was admitted to the h...BACKGROUND Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise.CASE SUMMARY A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications.CONCLUSION Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction.Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.展开更多
BACKGROUND Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce.In addition to relatively more difficulties in the technique of endotracheal intubation,the time for ma...BACKGROUND Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce.In addition to relatively more difficulties in the technique of endotracheal intubation,the time for manipulation is restricted compared to adults.Securing the airways safely and avoiding the occurrence of hypoxemia in these patients are of significance.CASE SUMMARY A 9-year-old boy with spastic cerebral palsy,severe malnutrition,thoracic scoliosis,thoracic and airway malformation,laryngomalacia,pneumonia,and epilepsy faced the risk of anesthesia during palliative surgery.After a thorough preoperative evaluation,a detailed scheme for anesthesia and a series of intu-bation tools were prepared by a team of anesthesiologists.Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways.Given the age and medical condition of the patient,we kept him sedated with spontaneous breathing during endotracheal intubation.The endotracheal intubation was completed on the second attempt after the failure of the first effort.Fortunately,the surgery was successful without postoperative complications.CONCLUSION Dealing with difficult airways in the pediatric population,proper sedation allows time to intubate without interrupting spontaneous breathing.The appropriate endotracheal intubation method based on the patient’s unique characteristics is the key factor in successful management of these rare cases.展开更多
Airway ultrasound allows for precise airway evaluation,particularly for assessing the difficult airway and the potential for front of neck access.Many studies have shown that identification of the cricothyroid membran...Airway ultrasound allows for precise airway evaluation,particularly for assessing the difficult airway and the potential for front of neck access.Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation.However,no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy.This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making.The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed.The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.展开更多
When narrative medicine(NM)was introduced into China,traditional Chinese medicine scholars found that the core concepts advocated by NM are manifested in Chinese yi’an.But why NM echoes with ancient Chinese yi’an?Ho...When narrative medicine(NM)was introduced into China,traditional Chinese medicine scholars found that the core concepts advocated by NM are manifested in Chinese yi’an.But why NM echoes with ancient Chinese yi’an?How can we better integrate NM into Chinese medical practices?To answer those questions,this article first investigates how NM establishes itself as a remedy to biomedicine by taking traditional healing models including TCM as its ideal Other.Then,the narrative traditions of both case histories and yi’an are examined respectively.This article argues that NM is searching for a lost tradition of narrative case histories,but yi’an functions as a living tradition of TCM.The Parallel Chart in NM,designed as a complement to the dehumanized hospital chart,is still based on a dichotomy of science and art and a conflictual doctor-patient model.But yi’an exemplifies the holistic and humane healthcare that NM hopes to achieve.A comparison of both genres also inspired us to rethink the genre of yi’an in NM.Thus,it is concluded that yi’an should be viewed as an epistemic genre integrating individualization and generalization,a bridge linking medicine and literature.And narrative yi’an can well serve as a tool for NM in China.It is also proposed that a thick description of yi’an be encouraged to further promote a pluralistic NM in China.展开更多
Necrotic feet secondary to vascular compromise in the diabetic patient may require an emergent guillotine amputation. Unrecognized, retained hardware in a distal ankle years after fracture repair may complicate the in...Necrotic feet secondary to vascular compromise in the diabetic patient may require an emergent guillotine amputation. Unrecognized, retained hardware in a distal ankle years after fracture repair may complicate the intraoperative guillotine amputation at the transtibial/fibula level. Troubleshooting such an unexpected surgical problem is not necessarily straightforward depending on the clinical situation. Presented is a case report where a patient with a necrotic burned foot failed to inform the burn team that he had implanted ankle hardware, prior to his surgical intervention. A successful amputation was completed after proceeding down a specific algorithm devised for such a scenario.展开更多
Persistent methicillin-sensitive staphylococcus aureus(MSSA)bacteremia is usually defined as persistent bacteremia despite 7 days of appropriate antibiotic therapy.While nafcillin,cefazolin,or oxacillin are excellent ...Persistent methicillin-sensitive staphylococcus aureus(MSSA)bacteremia is usually defined as persistent bacteremia despite 7 days of appropriate antibiotic therapy.While nafcillin,cefazolin,or oxacillin are excellent antimicrobial options,persistent MSSA is a commonly encountered phenomenon in clinical practice for which further guidelines on appropriate management are necessitated.Here we highlight two cases of MSSA bacteremia requiring salvage therapy with ertapenem.展开更多
Dear Editor,Two cases of primary angle-closure glaucoma(PACG)with persistent shallow anterior chamber after phacoemulsification,intraocular lens(IOL)implantation and goniosynechialysis(GSL)were presented.PACG,which ma...Dear Editor,Two cases of primary angle-closure glaucoma(PACG)with persistent shallow anterior chamber after phacoemulsification,intraocular lens(IOL)implantation and goniosynechialysis(GSL)were presented.PACG,which mainly presents with mechanical obstruction of the trabecular meshwork,is clinically characterized by elevated intraocular pressure(IOP)secondary to the apposition of peripheral iris or a synechial closure of the angle[1].A previous study reported that angle-closure glaucoma eyes experienced widening and deepening of anterior chamber angles following cataract extraction and IOL implantation,which could probably normalize the IOP[2].A randomized controlled trial demonstrated that in comparison with laser peripheral iridotomy(LPI),clear-lens extraction showed greater advantages in efficacy and cost-effectiveness and could be proposed as the first-line initial treatment for PACG[3].展开更多
Public health strategies have resulted in declines in some respiratory infectious viruses during the COVID-19 pandemic[1],while the way to assess the extent of public health measures and their impacts on respiratory i...Public health strategies have resulted in declines in some respiratory infectious viruses during the COVID-19 pandemic[1],while the way to assess the extent of public health measures and their impacts on respiratory infectious diseases varies[2-4].During the pandemic,Thailand has implemented a strong and rapid governmental response according to its incidence rate[3],and we attempted to investigate the association between the extent of public health measures and other respiratory infectious diseases cases amidst the COVID-19 pandemic in Thailand.In this way,the level of public health measures and their impacts on other kinds of non-SARS-CoV-2 respiratory infections will help the government formulate more efficient policies.展开更多
During endoscopy,an endoscopist is inevitably faced with the occasional“difficult colonoscopy,”in which the endoscopist finds it challenging to advance the endoscope to the cecum.Beyond optimization of technique,wit...During endoscopy,an endoscopist is inevitably faced with the occasional“difficult colonoscopy,”in which the endoscopist finds it challenging to advance the endoscope to the cecum.Beyond optimization of technique,with minimized looping,minimal insufflation,sufficient sedation,and abdominal splinting when needed,sometimes additional tools may be needed.In this review,we cover available techniques and technologies to help navigate the difficult colonoscopy,including the ultrathin colonoscope,rigidizing overtube,balloon-assisted colonoscopy and the abdominal compression device.展开更多
BACKGROUND Eosinophilic fasciitis(EF)is a rare connective tissue disease that can cause swelling and sclerosis of the extremities,and special attention is needed to differentiate EF from systemic sclerosis.Misdiagnosi...BACKGROUND Eosinophilic fasciitis(EF)is a rare connective tissue disease that can cause swelling and sclerosis of the extremities,and special attention is needed to differentiate EF from systemic sclerosis.Misdiagnosis or omission markedly delays treatment of EF,and severe skin sclerosis in advanced stages can cause joint contracture and tendon retraction,worsening the patient's prognosis and quality of life.CASE SUMMARY We report a case of EF in a young woman diagnosed by tissue biopsy,confirming the difficulty of differential diagnosis with scleroderma.CONCLUSION Focusing on skin manifestations,completing tissue biopsy and radiography can help diagnose EF effectively.Clinicians should enhance their understanding of the differences between EF and scleroderma,and early diagnosis and standardized treatment can improve the prognosis of patients with EF.展开更多
BACKGROUND Microsatellite instability(MSI)is a predictive biomarker for cancer immunotherapy.The tumor-agnostic nature of MSI makes it a denominator for immunotherapy in several solid tumors.It can be assessed using n...BACKGROUND Microsatellite instability(MSI)is a predictive biomarker for cancer immunotherapy.The tumor-agnostic nature of MSI makes it a denominator for immunotherapy in several solid tumors.It can be assessed using next-generation sequencing(NGS),fluorescent multiplex PCR,and immunohistochemistry(IHC).CASE SUMMARY Here,we report 3 cases with discordant MSI results detected using different methods.A cholangiocellular carcinoma case revealed proficient mismatch repair(MMR)by IHC but high MSI(MSI-H)by liquid NGS.A cervical cancer case revealed deficient MMR by IHC,microsatellite stable by PCR,and MSI-H by NGS.Lastly,an endometrial cancer case revealed proficient MMR by IHC but MSI-H by NGS.CONCLUSION IHC for MMR status is the first choice due to several advantages.However,in cases of indeterminate IHC results,molecular testing by MSI-PCR is preferred.Recently,NGS-based MSI assays are being widely used to detect MSI-H tumors.All three methods have high accuracy;however,the inconsistencies between them may lead to misdiagnosis.展开更多
文摘The incidence of bile duct injury in laparoscopic cholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladder was divided into two parts above the Hartmann pouch and all contents were aspirated. Then, the distal part was dissected for short distance. The proximal part was dissected dome down until reaching to cystic duct which was tied or clipped and cut. J-vac drain was put in peritoneal cavity. Between September 2012 and October 2013, overall 77 patients (53 females and 24 males) with mean age of 49 years (between 23 and 67 years) underwent bipartite laparoscopic cholecystectomy. The mean operative time was 60 minutes (between 40 and 90 minutes). The dissection of both parts of gall bladder was safe and easy as close as possible from its wall. No biliary tract injuries were recorded during or after procedure and also at follow-up period (20 months). Bipartite laparoscopic cholecystectomy is safe, easy to do, and can avoid all complications especially bile duct injuries in difficult cases.
文摘Evidence-based practice(EBP)has been the gold standard in healthcare for nearly three centuries and aims to assist physicians in providing the safest and most effective healthcare for their patients.The well-established hierarchy of evidence lists systematic reviews and meta-analyses at the top however these methodologies are not always appropriate or possible and in these instances case-control studies,case series and case reports are utilised to support EBP.Case-control studies allow simultaneous study of multiple risk factors and can be performed rapidly and relatively cheaply.A recent example was during the Coronavirus pandemic where case-control studies were used to assess the efficacy of personal protective equipment for healthcare workers.Case series and case reports also play a role in EBP and are particularly useful to study rare diseases such as inflammatory bowel disease in transgender and gender non-conforming individuals.They are also vital in generating and disseminating early signals and encouraging further research.Whilst these methodologies have weaknesses,particularly with regards to bias and loss of patient confidentiality for rare pathologies,they have an important part to play in EBP and when appropriately utilised can significantly impact upon clinical practice.
文摘Edge devices,due to their limited computational and storage resources,often require the use of compilers for program optimization.Therefore,ensuring the security and reliability of these compilers is of paramount importance in the emerging field of edge AI.One widely used testing method for this purpose is fuzz testing,which detects bugs by inputting random test cases into the target program.However,this process consumes significant time and resources.To improve the efficiency of compiler fuzz testing,it is common practice to utilize test case prioritization techniques.Some researchers use machine learning to predict the code coverage of test cases,aiming to maximize the test capability for the target compiler by increasing the overall predicted coverage of the test cases.Nevertheless,these methods can only forecast the code coverage of the compiler at a specific optimization level,potentially missing many optimization-related bugs.In this paper,we introduce C-CORE(short for Clustering by Code Representation),the first framework to prioritize test cases according to their code representations,which are derived directly from the source codes.This approach avoids being limited to specific compiler states and extends to a broader range of compiler bugs.Specifically,we first train a scaled pre-trained programming language model to capture as many common features as possible from the test cases generated by a fuzzer.Using this pre-trained model,we then train two downstream models:one for predicting the likelihood of triggering a bug and another for identifying code representations associated with bugs.Subsequently,we cluster the test cases according to their code representations and select the highest-scoring test case from each cluster as the high-quality test case.This reduction in redundant testing cases leads to time savings.Comprehensive evaluation results reveal that code representations are better at distinguishing test capabilities,and C-CORE significantly enhances testing efficiency.Across four datasets,C-CORE increases the average of the percentage of faults detected(APFD)value by 0.16 to 0.31 and reduces test time by over 50% in 46% of cases.When compared to the best results from approaches using predicted code coverage,C-CORE improves the APFD value by 1.1% to 12.3% and achieves an overall time-saving of 159.1%.
文摘BACKGROUND Glucose imbalance is common in total parenteral nutrition(TPN).Hypoglycemia seems to be less frequent than hyperglycemia,but it influences the clinical outcome to a greater extent.Therefore,it should be effectively prevented and treated.However,there is no relevant report on how to treat hypoglycemia caused by TPN in patients with liver cell injury.CASE SUMMARY We present three patients with liver cell injury who developed severe hypo-glycemia during or after TPN infusion.The causes of severe hypoglycemia and glucose-raising strategies were discussed.According to the physiological charac-teristics of the hepatocellular injury,the ratio of nutrition components prescribed in TPN was appropriately adjusted for the three cases.We simultaneously reduced the dose of insulin and fat emulsion,and increased the dose of glucose in TPN.The blood glucose level was restored to normal range and clinical symptoms were eliminated.CONCLUSION When hypoglycemia occurs during or after TPN in patients with hepatocellular injury,physicians need to simultaneously reduce insulin and fat emulsion,and increase glucose,and correct severe hypoglycemia in time to reduce its adverse consequences.
基金Supported by National Natural Science Foundation of China,No.81960136the Science and Technology Department of Yunnan Province,No.202101AT070243.
文摘BACKGROUND In this study,we retrospectively analysed macrophage infiltration and podocyte injury in three patients with diffuse proliferative lupus nephritis(LN)who un-derwent repeated renal biopsy.CASE SUMMARY Clinical data of three diffuse proliferative LN patients with different pathological characteristics(case 1 was LN IV-G(A),case 2 was LN IV-G(A)+V,and case 3 was LN IV-G(A)+thrombotic microangiopathy)were reviewed.All patients underwent repeated renal biopsies 6 mo later,and renal biopsy specimens were studied.Macrophage infiltration was assessed by CD68 expression detected by immunohistochemical staining,and an immunofluorescence assay was used to detect podocin expression to assess podocyte damage.After treatment,Case 1 changed to LN III-(A),Case 2 remained as type V LN lesions,and Case 3,which changed to LN IV-S(A),had the worst prognosis.We observed reduced macro-phage infiltration after therapy.However,two of the patients with active lesions after treatment still showed macrophage infiltration in the renal interstitium.Before treatment,the three patients showed discontinuous expression of podocin.Notably,the integrity of podocin was restored after treatment in Case 1.CONCLUSION It may be possible to reverse podocyte damage and decrease the infiltrating ma-crophages in LN patients through effective treatment.
基金Supported by National Natural Science Foundation of China,No.82270864.
文摘BACKGROUND Fulminant type 1 diabetes mellitus(FT1DM)that occurs during pregnancy or the perinatal period is known as pregnancy-related FT1DM(PF),always without history of abnormal glucose metabolism.Here,we present four patients who developed FT1DM during treatment but were first diagnosed with gestational diabetes mellitus(GDM).CASE SUMMARY The clinical data of four patients with GDM combined with FT1DM admitted to our hospital between July 2018 and April 2021 were collected,and the patients and their infants were followed up.All patients were diagnosed with GDM during the second trimester and were treated.The blood glucose level elevated suddenly during the third trimester and then were diagnosed with FT1DM.Two patients had an insulin allergy,and two had symptoms of upper respiratory tract infection before onset.One patient developed ketoacidosis,and three developed ketosis.Two patients had cesarean section deliveries,and two had vaginal deliveries.The growth and development of the infants were normal.C-peptide levels were lower than those at onset,suggesting progressive impairment of islet function.The frequencies of the DRB109:01,DQB103:03,DQA103:02,DPA101:03,DPA102:02,DPB105:01,DRB401:03,G 01:01,and G 01:04 human leukocyte antigen(HLA)-G alleles were high in the present study.CONCLUSION In comparison with pregnancy-associated FT1DM(PF),patients with GDM combined with FT1DM had an older age of onset,higher body mass index,slower onset,fewer prodromal symptoms,and less acidosis.The pathogenesis may be due to various factors affecting the already fragileβ-cells of GDM patients with genetically susceptible class II HLA genotypes.We speculate that GDM combined with FT1DM during pregnancy,referred to as“double diabetes,”is a subtype of PF with its own unique characteristics that should be investigated further.
文摘Environmental pollution has caused wide social concern,and it demands immediate attention to striking at the crime in the environmental pollution. At present,there are difficulties of putting a case on file,collecting evidence,judicial identification,and presumption of causal relationship in investigation of environmental pollution cases. In accordance with current situations,it came up following recommendations:(i) widely collecting case clues to solve the difficulty of putting a case on file;(ii) improving the ability of collecting evidence and standardizing the evidence collection,to solve the difficulty of evidence collection.(iii) including the environmental pollution judicial identification system,and unifying the identification standards,to solve the difficulty in identification. It is recommended to use the epidemiological causal relationship theory combined with enough high-quality evidences to solve the difficulty in presumption of causal relationship.
基金Supported by Key Clinical Projects of Peking University Third Hospital,No. BYSYZD2021013Beijing Haidian District Innovation and transformation project,No. HDCXZHZB2021202。
文摘BACKGROUND Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise.CASE SUMMARY A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications.CONCLUSION Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction.Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.
文摘BACKGROUND Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce.In addition to relatively more difficulties in the technique of endotracheal intubation,the time for manipulation is restricted compared to adults.Securing the airways safely and avoiding the occurrence of hypoxemia in these patients are of significance.CASE SUMMARY A 9-year-old boy with spastic cerebral palsy,severe malnutrition,thoracic scoliosis,thoracic and airway malformation,laryngomalacia,pneumonia,and epilepsy faced the risk of anesthesia during palliative surgery.After a thorough preoperative evaluation,a detailed scheme for anesthesia and a series of intu-bation tools were prepared by a team of anesthesiologists.Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways.Given the age and medical condition of the patient,we kept him sedated with spontaneous breathing during endotracheal intubation.The endotracheal intubation was completed on the second attempt after the failure of the first effort.Fortunately,the surgery was successful without postoperative complications.CONCLUSION Dealing with difficult airways in the pediatric population,proper sedation allows time to intubate without interrupting spontaneous breathing.The appropriate endotracheal intubation method based on the patient’s unique characteristics is the key factor in successful management of these rare cases.
文摘Airway ultrasound allows for precise airway evaluation,particularly for assessing the difficult airway and the potential for front of neck access.Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation.However,no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy.This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making.The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed.The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.
基金This study was financed by the grant from 2022 Liaoning Social Sciences Research Funds(No.L22CWW002).
文摘When narrative medicine(NM)was introduced into China,traditional Chinese medicine scholars found that the core concepts advocated by NM are manifested in Chinese yi’an.But why NM echoes with ancient Chinese yi’an?How can we better integrate NM into Chinese medical practices?To answer those questions,this article first investigates how NM establishes itself as a remedy to biomedicine by taking traditional healing models including TCM as its ideal Other.Then,the narrative traditions of both case histories and yi’an are examined respectively.This article argues that NM is searching for a lost tradition of narrative case histories,but yi’an functions as a living tradition of TCM.The Parallel Chart in NM,designed as a complement to the dehumanized hospital chart,is still based on a dichotomy of science and art and a conflictual doctor-patient model.But yi’an exemplifies the holistic and humane healthcare that NM hopes to achieve.A comparison of both genres also inspired us to rethink the genre of yi’an in NM.Thus,it is concluded that yi’an should be viewed as an epistemic genre integrating individualization and generalization,a bridge linking medicine and literature.And narrative yi’an can well serve as a tool for NM in China.It is also proposed that a thick description of yi’an be encouraged to further promote a pluralistic NM in China.
文摘Necrotic feet secondary to vascular compromise in the diabetic patient may require an emergent guillotine amputation. Unrecognized, retained hardware in a distal ankle years after fracture repair may complicate the intraoperative guillotine amputation at the transtibial/fibula level. Troubleshooting such an unexpected surgical problem is not necessarily straightforward depending on the clinical situation. Presented is a case report where a patient with a necrotic burned foot failed to inform the burn team that he had implanted ankle hardware, prior to his surgical intervention. A successful amputation was completed after proceeding down a specific algorithm devised for such a scenario.
文摘Persistent methicillin-sensitive staphylococcus aureus(MSSA)bacteremia is usually defined as persistent bacteremia despite 7 days of appropriate antibiotic therapy.While nafcillin,cefazolin,or oxacillin are excellent antimicrobial options,persistent MSSA is a commonly encountered phenomenon in clinical practice for which further guidelines on appropriate management are necessitated.Here we highlight two cases of MSSA bacteremia requiring salvage therapy with ertapenem.
基金Supported by National Natural Science Foundation of China(No.61634006)the National Key R&D Program of China(No.2020YFC2008200)the Beijing Science and Technology Plan Project(No.Z191100007619045)。
文摘Dear Editor,Two cases of primary angle-closure glaucoma(PACG)with persistent shallow anterior chamber after phacoemulsification,intraocular lens(IOL)implantation and goniosynechialysis(GSL)were presented.PACG,which mainly presents with mechanical obstruction of the trabecular meshwork,is clinically characterized by elevated intraocular pressure(IOP)secondary to the apposition of peripheral iris or a synechial closure of the angle[1].A previous study reported that angle-closure glaucoma eyes experienced widening and deepening of anterior chamber angles following cataract extraction and IOL implantation,which could probably normalize the IOP[2].A randomized controlled trial demonstrated that in comparison with laser peripheral iridotomy(LPI),clear-lens extraction showed greater advantages in efficacy and cost-effectiveness and could be proposed as the first-line initial treatment for PACG[3].
文摘Public health strategies have resulted in declines in some respiratory infectious viruses during the COVID-19 pandemic[1],while the way to assess the extent of public health measures and their impacts on respiratory infectious diseases varies[2-4].During the pandemic,Thailand has implemented a strong and rapid governmental response according to its incidence rate[3],and we attempted to investigate the association between the extent of public health measures and other respiratory infectious diseases cases amidst the COVID-19 pandemic in Thailand.In this way,the level of public health measures and their impacts on other kinds of non-SARS-CoV-2 respiratory infections will help the government formulate more efficient policies.
文摘During endoscopy,an endoscopist is inevitably faced with the occasional“difficult colonoscopy,”in which the endoscopist finds it challenging to advance the endoscope to the cecum.Beyond optimization of technique,with minimized looping,minimal insufflation,sufficient sedation,and abdominal splinting when needed,sometimes additional tools may be needed.In this review,we cover available techniques and technologies to help navigate the difficult colonoscopy,including the ultrathin colonoscope,rigidizing overtube,balloon-assisted colonoscopy and the abdominal compression device.
基金Supported by National Natural Science Foundation of China,No.81704050National High Level Hospital Clinical Research Funding,No.2022-NHLHCRF-LX-02-0103 and No.2022-NHLHCRF-LX-02-0104.
文摘BACKGROUND Eosinophilic fasciitis(EF)is a rare connective tissue disease that can cause swelling and sclerosis of the extremities,and special attention is needed to differentiate EF from systemic sclerosis.Misdiagnosis or omission markedly delays treatment of EF,and severe skin sclerosis in advanced stages can cause joint contracture and tendon retraction,worsening the patient's prognosis and quality of life.CASE SUMMARY We report a case of EF in a young woman diagnosed by tissue biopsy,confirming the difficulty of differential diagnosis with scleroderma.CONCLUSION Focusing on skin manifestations,completing tissue biopsy and radiography can help diagnose EF effectively.Clinicians should enhance their understanding of the differences between EF and scleroderma,and early diagnosis and standardized treatment can improve the prognosis of patients with EF.
文摘BACKGROUND Microsatellite instability(MSI)is a predictive biomarker for cancer immunotherapy.The tumor-agnostic nature of MSI makes it a denominator for immunotherapy in several solid tumors.It can be assessed using next-generation sequencing(NGS),fluorescent multiplex PCR,and immunohistochemistry(IHC).CASE SUMMARY Here,we report 3 cases with discordant MSI results detected using different methods.A cholangiocellular carcinoma case revealed proficient mismatch repair(MMR)by IHC but high MSI(MSI-H)by liquid NGS.A cervical cancer case revealed deficient MMR by IHC,microsatellite stable by PCR,and MSI-H by NGS.Lastly,an endometrial cancer case revealed proficient MMR by IHC but MSI-H by NGS.CONCLUSION IHC for MMR status is the first choice due to several advantages.However,in cases of indeterminate IHC results,molecular testing by MSI-PCR is preferred.Recently,NGS-based MSI assays are being widely used to detect MSI-H tumors.All three methods have high accuracy;however,the inconsistencies between them may lead to misdiagnosis.
