In recent years, the etiology of portal hypertension has undergone many changes. In addition to the focus on viral and alcoholic liver diseases, obesity, hyperlipidemia and diabetes patients, all kinds of drugs, especially after chemotherapy with platinum drugs, bone marrow proliferative diseases, autoimmune liver disease patients, need to be included in the high-risk screening population. The change in etiology brings about complex pathological and physiological states. We need to conduct a comprehensive evaluation, understand past medical history, improve portal vein computed tomography (CT), liver elastography, gastroscopy and other examinations, clarify the etiology, and choose personalized treatment plans for patients. Through technological innovation, we aim to improve the efficacy of endoscopic therapy, combined with new concepts such as artificial intelligence, big data, and multi omics, so as to obtain more accurate prediction of portal vein pressure and clinical characteristics, refine risk stratification, and make more accurate personalized decisions for clinical diagnosis and treatment.

Objective:To explore the incidence of hepatitis B virus (HBV) reactivation in the population with HBV associated liver cancer after receiving programmed death receptor 1 (PD-1) inhibitors combined with targeted therapy, and the prognostic differences between HBV reactivation and non reactivation populations during this treatment.Methods:A retrospective analysis was conducted on patients with primary liver cancer who received PD-1 inhibitor combined with targeted drugs treatment at the Zhongshan Hospital, Fudan University (Xiamen Branch) from January 2019 to June 2021. Clinical data such as age, sex, liver function status, cirrhosis, HBV DNA level, alpha fetoprotein, tumor stage, anti-tumor program and anti HBV program, tumor treatment response, progression free survival (PFS), and total survival (OS) were collected for t test, χ 2 test and Kaplan-Meier survival analysis. Results:A total of 66 enrolled patients were enrolled, of which 17 cases experienced HBV reactivation, with an incidence rate of 25.76%; The rates of HBV reactivation at 3 months, 6 months, 1 year, 2 years, and 3 years were 6.06%(4/66), 12.12%(8/66), 19.70%(13/66), 22.73%(15/66), and 25.76%(17/66), respectively. There was no significant difference between the HBV reactivation group and the non HBV reactivation group in age, sex, liver function status, cirrhosis, HBV DNA level, alpha fetoprotein, tumor stage, anti-tumor and anti HBV programs, objective response rate (ORR) and disease control rate (DCR) (all P>0.05). However, the PFS and OS of the HBV reactivation group were significantly lower than those of the non HBV reactivation group, at 4.00 months vs 8.50 months ( P=0.002) and 12.90 months vs 19.77 months ( P=0.014), respectively. Conclusions:Patients with primary live cancer who receive PD-1 inhibitor combined with targeted therapy are at risk of HBV reactivation, and those who experience HBV reactivation have significantly poorer tumor progression and survival prognosis compared with non HBV reactivated patients.

Objective:To explore the changes of iron metabolism in patients with hepatitis B cirrhosis and esophageal and gastric varices complicated with portal vein thrombosis.Methods:This study was a cross-sectional study. 253 patients with hepatitis B cirrhosis with esophageal and gastric varices who were hospitalized in the Zhongshan Hospital, Fudan University from January 1, 2020 to December 31, 2021 were included in this study. They were divided into portal vein thrombosis group ( n=57) and non portal vein thrombosis group ( n=196) according to the presence or absence of portal vein thrombosis. The iron metabolism characteristics of the two groups were compared, and subgroups were analyzed according to the presence or absence of ascites, platelet count level, D-dimer level, and Child grade. The factors related to portal vein thrombosis were screened through multivariate logistic regression analysis. Results:The ratio of Child pugh B/C, ascites, D-dimer and platelet count in patients with hepatitis B cirrhosis and esophageal and gastric varices complicated with portal vein thrombosis was higher (all P<0.05). Patients with portal vein thrombosis had higher levels of soluble transferrin receptor [2.4(1.8, 3.6)mg/L vs 1.8(1.3, 2.7)mg/L, P=0.006], and lower levels of ferritin [33.1(18.9, 63.3)ng/ml vs 57.7(19.4, 142.5)ng/ml, P=0.038]. Layered analysis showed that ascites, platelet count levels, D-dimer levels, and Child-pugh grade did not affect the negative correlation trend between ferritin and portal vein thrombosis, and the positive correlation trend between soluble transferrin receptors and portal vein thrombosis. Moreover, soluble transferrin receptors showed a statistically significant positive correlation with portal vein thrombosis in the absence of ascites, low D-dimer levels, and Child-pugh grade A. Multivariate analysis suggested that after weighing Child-pugh grading, platelet count, and D-dimer levels, ferritin ( OR=0.943, 95% CI: 0.904-0.983, P=0.006) and soluble transferrin receptor ( OR=1.034, 95% CI: 0.001-1.067, P=0.044) were independently associated with portal vein thrombosis. Conclusions:In patients with hepatitis B cirrhosis with esophageal and gastric varices, the characteristics of iron metabolism in patients with portal vein thrombosis are different from those in patients without thrombosis, with higher levels of soluble transferrin receptor and lower levels of ferritin.

Objective:To evaluate the feasibility of using two-dimensional shear wave elastography (2D-SWE) based liver and spleen elastic hardness (L/S-SWE) in patients with liver cirrhosis, and to determine the exclusion and diagnostic thresholds for early identification of liver cirrhosis.Methods:A total of 574 patients with chronic hepatitis B (hepatitis B for short) were included in this study. The clinical characteristics, L-SWE and S-SWE of the patients were collected, and the differences between cirrhosis group ( n=311) and non cirrhosis group ( n=263) were analyzed. The success rate and stability of liver and spleen elastic surgery were evaluated in two groups. The receiver operating characteristic (ROC) curve was used to analyze the efficacy of L-SWE, S-SWE, aspartate aminotransferase to platelet ratio index (APRI) alone and in combination in diagnosing liver cirrhosis. By analyzing the ROC curve, the double threshold for excluding and diagnosing liver cirrhosis was determined. Results:There was a statistically significant difference in platelet count and APRI between the cirrhosis group and the non cirrhosis group (all P<0.05). In the feasibility assessment of 2D-SWE technology, the success rate and stability of liver and spleen elastic operation were relatively high (success rate: 97.2% vs 81.3%; stability: 0.92 vs 0.84), and the success rate and stability of L-SWE operation were slightly better than S-SWE. The success rate of S-SWE operation in the cirrhosis group was higher than that in the non cirrhosis group ( P<0.05). The correlation analysis results showed that L-SWE, S-SWE, APRI were positively correlated with liver tissue pathological grading ( r=0.677, 0.528, 0.149, all P<0.05). The areas under the ROC curve for identifying liver cirrhosis using L-SWE, S-SWE, and APRI were 0.959, 0.896, and 0.706, respectively. When L-SWE and S-SWE were combined, the area under the ROC curve was 0.987, the sensitivity was 92.6%, and the specificity was 96.0%. The Delong test showed that the combined diagnosis of L-SWE and S-SWE had the same diagnostic efficacy as using L-SWE alone for liver cirrhosis ( P>0.05). Further analysis of the ROC curve showed that the likelihood of liver cirrhosis was low when L-SWE was less than 9.4 kPa, and high when L-SWE was greater than 12.0 kPa. Patients between 9.4 and 12.0 kPa can undergo further S-SWE testing; If the S-SWE was between 17.5 and 29.3 kPa, it was classified as 2D-SWE, which was difficult to determine whether there was liver cirrhosis, and further liver puncture and other examinations were needed. Conclusions:2D-SWE technology has high operational feasibility in the diagnosis of liver cirrhosis, and combined with S-SWE, it helps to improve the diagnostic efficiency of early non-invasive identification of liver cirrhosis, enabling more patients to avoid unnecessary liver puncture examinations.

Objective:To investigate whether discontinuation of previous targeted immunotherapy increases the risk of rebleeding in patients with advanced liver cancer complicated with esophageal and gastric variceal bleeding after endoscopic treatment.Methods:A retrospective cohort study was conducted to include advanced liver cancer patients who were diagnosed with esophageal and gastric variceal bleeding through endoscopic examination and treated under endoscopy at Zhongshan Hospital, Fudan University from March 1, 2020 to March 1, 2022, due to upper gastrointestinal bleeding. We collected clinical data from patients and divided them into targeted immunotherapy group and non targeted immunotherapy group based on whether they received targeted immunotherapy before bleeding; Follow up observation was conducted for 6 months to evaluate the patient′s re bleeding and survival status.Results:A total of 55 patients were included, of which 24 had previously received targeted immunotherapy and 31 had not received targeted immunotherapy. There was no significant difference between the two groups in gender distribution, etiology, hypertension and diabetes (all P>0.05). The age of the target immunotherapy group was younger than that of the non target immunotherapy group, and the level of fibrinogen was higher than that of the non target immunotherapy group, with statistical significance ( P=0.002, 0.017). There was no statistically significant difference in the 6-month re bleeding rate (20.83% vs 22.58%, P=0.269) and 6-month mortality rate (45.83% vs 29.03%, P=0.199) between the targeted and non targeted groups of patients. Further Cox regression multivariate analysis revealed that Child-pugh grading was an independent risk factor for 6-month survival in patients with advanced liver cancer with esophageal and gastric varices ( HR=2.64, P=0.009). Conclusions:Targeted immunotherapy does not increase the rate of rebleeding in patients with advanced unresectable liver cancer after endoscopic treatment of esophageal and gastric varices. Child-pugh grading is a factor that affects the 6-month survival of advanced liver cancer patients after bleeding, and the poorer the liver function, the shorter the survival period.

Objective:To explore the influencing factors of esophageal and gastric varices (EGV) in patients with liver cirrhosis, and to construct a column chart prediction model for EGV occurrence.Methods:A cross-sectional study was conducted to select patients ( n=127) who underwent gastroscopy at Minhang Hospital, Fudan University from January 2022 to April 2023 due to liver cirrhosis. Patients were divided into EGV group ( n=74) and non EGV group ( n=53) based on the presence of EGV. Clinical and auxiliary examination data of the two groups were compared. Univariate and multivariate logistic regression analysis were used to explore the independent influencing factors of EGV occurrence, and a column chart prediction model was further constructed to evaluate its predictive efficacy. Results:Multivariate logistic regression analysis showed that splenomegaly ( OR=28.38, 95% CI: 6.30-127.89, P<0.001), schistosomiasis infection ( OR=0.05, 95% CI: 0.01-0.28, P=0.001), and fatty liver ( OR=0.09, 95% CI: 0.02-0.33, P<0.001) were independent influencing factors for the occurrence of EGV in patients with liver cirrhosis. Based on this model, a column chart was constructed to predict the probability of EGV occurrence in patients with liver cirrhosis. The column chart model showed good consistency and discrimination (area under the curve was 0.927, 95% CI: 0.883-0.972), and was internally validated using the Bootstrap method, showing an average absolute error of 0.029. Conclusions:Spleen enlargement, schistosomiasis infection, and fatty liver are independent influencing factors for the occurrence of EGV in patients with liver cirrhosis. The Nomogram column chart prediction model for the occurrence of EGV in patients with liver cirrhosis has good predictive performance and can provide scientific basis for non-invasive risk screening and prevention strategies for EGV in liver cirrhosis.

Objective:To explore the effects of sleep disorders on clinical symptoms, anxiety/depression, acid reflux, and esophageal motility in patients with gastroesophageal reflux disease (GERD).Methods:Patients who were diagnosed with GERD at the Gastroenterology Department of the First Affiliated Hospital with Nanjing Medical University from June 2020 to March 2023 were included in the study. Esophageal 24-hour pH impedance monitoring and high-resolution esophageal manometry (HRM) were performed simultaneously. They were divided into a sleep disorder group and a normal sleep group based on the Pittsburgh Sleep Quality Index (PSQI). The GerdQ score, endoscopic esophagitis degree, Anxiety/Depression Score (SAS/SDS), 24-hour pH impedance monitoring, and HRM parameters were compared between the two groups. The relationship between age, body mass index (BMI), SAS/SDS, PSQI, and acid exposure time (AET) was analyzed. Logistic regression analysis was used to evaluate the influencing factors of abnormal acid reflux in GERD patients.Results:A total of 92 patients with GERD were included, including 39 cases (42.4%) in the sleep disorder group and 53 cases (57.6%) in the normal sleep group. Compared to the normal sleep group, the GerdQ score of the sleep disorder group was higher ( P<0.01), and the sleep disorder group had higher reflux, heartburn symptoms, and additional medication frequency (all P<0.05). The SAS score of the sleep disorder group was significantly higher than that of the normal sleep group ( P=0.009). Compared with the normal sleep group, the sleep disorder group had a higher proportion of abnormal acid reflux (AET>6%) and mean AET, with a significant increase in acid reflux frequency and total reflux frequency (all P<0.05). There was no statistically significant difference in the resting pressure of the upper esophageal sphincter (UES), lower esophageal sphincter (LES), LES length, abdominal LES length, percentage of ineffective swallowing, proportion of ineffective esophageal motility patients, and gastroesophageal junction contraction score (EGJ-CI) between the two groups of patients (all P>0.05). BMI and PSQI scores were positively correlated with AET (all P<0.05). The results of multivariate logistic analysis showed that high BMI and sleep disorders were independent risk factors for abnormal acid reflux ( OR=1.223, 1.139, all P<0.05). Conclusions:Sleep disorders are associated with acid reflux and heartburn symptoms in patients, and are independent of increased acid exposure in patients with anxiety/depression, but do not affect esophageal motility.

Objective:To explore the effects of midazolam oral solution on preoperative sedation, hemodynamics, and awakening agitation in children undergoing tonsillectomy combined with adenoidectomy.Methods:A total of 267 pediatric patients who underwent tonsillectomy combined with adenoidectomy at the Children′s Hospital Affiliated to Zhejiang University School of Medicine from January to September 2022 were randomly divided into a low-dose group ( n=89), a high-dose group ( n=89), and a control group ( n=89) using a random number table method. 30 minutes before anesthesia, the low-dose group received 0.25 mg/kg of midazolam orally, the high-dose group received 0.5 mg/kg of midazolam orally, and the control group received 5 ml of 10% glucose mixture orally. We compared the extubation time and post anesthesia recovery room (PACU) retention time among three groups of pediatric patients; Mean arterial pressure (MAP) and heart rate (HR) levels before administration and 10, 20, and 30 minutes after administration; The Yale Modified Perioperative Anxiety Scale (mYPAS) score and restlessness incidence were measured before administration and 10 and 60 minutes after administration. Results:The retention time of PACU in the low-dose group was shorter than that in the high-dose group ( P<0.05), and there was no statistically significant difference between the low-dose group and the control group ( P>0.05). At 10, 20, and 30 minutes after administration, the levels of MAP and HR in the low-dose and high-dose groups were lower than before administration (all P<0.05), and at 10, 20, and 30 minutes after administration, the levels of MAP and HR in the low-dose and high-dose groups were lower than those in the control group (all P<0.05). Before administration, there was no statistically significant difference in mYPAS scores among the three groups (all P>0.05); At 10 and 60 minutes after administration, the mYPAS scores of the low-dose and high-dose groups were lower than before administration, and the mYPAS scores of the low-dose and high-dose groups were lower than those of the control group (all P<0.05); At 10 and 60 minutes after administration, there was no statistically significant difference in mYPAS scores between the control group and before administration (all P>0.05), while there was no statistically significant difference in mYPAS scores between the low-dose and high-dose groups (all P>0.05). There was no statistically significant difference in the incidence of agitation among the three groups ( P>0.05). Conclusions:Preoperative oral administration of 0.25 mg/kg or 0.5 mg/kg midazolam can effectively alleviate preoperative anxiety and improve hemodynamics in children undergoing tonsillectomy combined with adenoidectomy. However, due to the fast metabolism of midazolam, its effect on improving postoperative restlessness during the recovery period is not significant. The 0.25 mg/kg dose of midazolam can reduce the retention time of PACU compared to the 0.5 mg/kg dose, which is worthy of clinical recommendation.

Objective:To evaluate the application effect of non opioid anesthesia using ketamine in endoscopic submucosal dissection under general anesthesia of gastroscopy and laryngeal mask.Methods:Sixty patients who underwent elective endoscopic submucosal dissection under general anesthesia gastroscopy and laryngeal mask at Nanjing Medical University Affiliated Nanjing Hospital from January to December 2022 were randomly divided into a conventional anesthesia group and a non opioid anesthesia group using a random number table method, with 30 cases in each group. The conventional anesthesia group used opioid drugs, while the non opioid anesthesia group used ketamine instead of opioid drugs. We recorded the incidence of postoperative nausea and vomiting in two groups of patients; Recorded the mean arterial pressure (MAP) and heart rate (HR) of two groups of patients before anesthesia (T 0), during intubation (T 1), at the start of surgery (T 2), and after surgery (T 3); We also recorded the lowest pulse oxygen saturation (SpO 2) after extubation in two groups of patients; At the same time, the surgical time, propofol dosage, extubation time, monitoring time in the anesthesia and resuscitation unit (PACU), incidence of postoperative nausea and vomiting, patient satisfaction, and other adverse reactions were recorded. Results:The difference in surgical time, MAP and HR from T 0 to T 3, and the lowest SpO 2 after extubation between the conventional anesthesia group and the non opioid anesthesia group was not statistically significant (all P>0.05); Compared with the conventional anesthesia group, the non opioid anesthesia group had a lower incidence of postoperative nausea and vomiting, lower dosage of propofol, shorter extubation time and PACU monitoring time, and higher patient satisfaction (all P<0.05); Both groups of patients had no serious adverse reactions. Conclusions:The application of ketamine in endoscopic submucosal dissection during non opioid anesthesia of gastroscopy laryngeal mask has certain advantages over conventional use of opioid drugs, including fast postoperative recovery, low incidence of nausea and vomiting, and high patient satisfaction.

Objective:To explore the mechanism of anti anxiety (AD) effect of Shenqi Schisandra chinensis using network pharmacology and molecular docking technology.Methods:The main active ingredients of S-Q-W-W-Z (Shenqi Schisandra chinensis) were screened through the TCMSP database. The corresponding targets of the active ingredients were obtained through the TCMSP database and SymMap database. The drug active ingredient target relationship network was visualized using Cytoscape. Utilize TTD, OMIM, NCBI, Drugbank, and GeneCards databases to directly identify potential targets for anxiety. We constructed interaction diagrams of potential targets based on the String database, and used Cytoscape tool to obtain key target proteins. Gene ontology (GO) enrichment analysis and Tokyo Encyclopedia of Genomes (KEGG) signaling pathway analysis were used to identify key targets and signaling pathways for anti anxiety effects of Schisandra chinensis. AutodockTools software was used to perform molecular docking on key active ingredients and key target proteins, and their binding energies were calculated. The molecular docking results were visualized using PyMol software.Results:The 63 effective ingredients in Shen-Qi-Wu-Wei-Zi (Shenqi Schisandra chinensis) can act on anxiety disorder through 69 targets. Among them, quercetin, luteolin, and stigmasterol are the main active ingredients, and serine threonine protein kinase 1 (AKT1) protein and interleukin-6 (IL-6) protein are key target proteins. Molecular docking technology has verified the good binding ability between these key active ingredients and key target proteins. Shenqi Schisandra mainly exerted therapeutic effects on anxiety disorders by regulating Toll like receptor signaling pathways, tumor necrosis factor (TNF) signaling pathways, cancer pathways, and other pathways.Conclusions:The Shenqi Schisandra may exert anti anxiety effects by regulating related targets such as AKT1 and IL-6, regulating inflammatory reactions, cell apoptosis, and other processes.