Hilar cholangiocarcinoma is a malignant disease in the main left or right hepatic ducts,ductus hepaticus communis or their confluence.The treatment for hilar cholangiocarcinoma remains a challenge because of the aggressive nature of the disease and the absence of effective treatments besides surgical resection.Hilar cholangiocarcinoma is diagnosed by its clinical manifestations,tumor markers and results of imaging studies.Problems as the necessity of preoperative hepatic bile drainage and decision making of proper treatment remain controversial.Here,we will review the current advances in the management of hilar cholangiocarcinoma,so as to provide theoretical basis and new ideas for clinical treatment.

The reoperation for biliary diseases is usually unplanned, and the major reasons leading to this situation include:(1) The initial operation was performed under emergency situation and radical procedure could not be carried out.(2) The surgical procedure was inadequate.( 3 ) The operator was unqualified for the operation. In order to avoid repeated operations,the following principles must be obeyed strictly.Firstly,once the initial operation was failed,the patients must be transferred to large medical center and the reoperation must be performed by hepatobiliary specialists.Secondly,the operator must realize that most of the patients were in poor condition because of the previous operation,and they needed careful evaluation of organ function and adequate supportive treatment before reoperation.Thirdly,various measures must be taken to avoid unplanned operation and ensure the successful implement of radical operation at a time:( 1 ) Operator must learn all the details of previous operation,which include operation procedure,findings during operation and postoperative complications.( 2 ) Cholangiogram of the whole biliary tree is important for surgical planning,ultrasonography,computed tomography (CT),endoscopic retrograde cholangiopancreatography,magnetic resonance cholangiopancreatography, percutaneous transhepatic cholangiography (PTC),or PTC-CT should be performed solely or comprehensively to determine the nature and location of lesions.For bile duct injury,additional examination including CT angiography,magnetic resonance angiography or digital subtraction angiography is necessary to ascertain the accompanied vessel injury.(3) Making individual surgical procedure according to patien's condition and distribution of lesions.

Objective To study the image features and clinical significance of 3-dimensional (3-D)and multiplanar reconstruction with spiral CT(SCT) in cervical spinal fractures.MethodPlain film radiography and spiral CT scanning were taken for 26 cases of cervical spinal fractures.The type of fractures, diagnositic successful rate, parameter of scanning and late stage managing methods were investigated retrospectively to find out the effective difference between the diagnosis of plain X-ray and SCT. The imagin location of fractures,sequence of cenrum, heighth of centrum, fracture line, auxillary structure and rotation/dislocation of the fractures were emphasized to evaluate the advantages of 3-D imaging.ResultIn the 26 cases, there were 4 Jefferson fractures, (in which 1 combined with articular dislocations), 17 C2 spinous process fractures, (in which 1 had failure of plain X-ray diagnostic), 1 Hangman fracture, 2 C1～2 imbalance, (in which 1 had failure of plain X-ray diagnostic).There were 2 cases of axoid longitudinal fractures without obvious dislocation. The diagnositic successful rate were 100% in SCT group, while 65% in X-ray group in which 6 cases had diagnostic failure and 3 cases had fracture mis-diagnozing as dislocation.The anatomical structure of upper cervical spine was complicated and was significantly different from other cervical spine constructions. Spiral CT could reveal high resolution images of the upper cervical spine, morphosis of vertibral canal, dislocation information of fracture mass and its relation with neighbouring tissues. Especially in C1 burst fracture,C2 dens fracture and C1～2 dislocation, SCT could provide clear 3-D information of the size of collateral mass and the dislocation degree, furthermore, images could be rotated freely to observe the fracture in any proper section. That provides important information for the decision of operation, selection of operation types and evaluation of operation dager.ConclusionThe spiral CT scan and 3D reconstruction can reveal fracture better.The advantages of SCT are suggested that this diagnostic modality may be the standard method for the initial evaluation of the upper cervical spine injury.

AIM: Tumor necrosis factor-?(TNF-?) participates in the establishment of inflammatory lesions in pneumonia.High production of TNF-? may relate to the severity of pneumonia.There have already been several studies examining the association between pneumonia and single nucleotide polymorphisms(SNPs) that affect cytokine productivity.SNPs of TNF-?,-1 031,-863,-857,-308 and-238 have been identified.The variant alleles of these SNPs have suggested to be related to high TNF-? production and the severity of pneumonia.Therefore,the aim of this study is to examine the association between the severity of pneumonia in Chinese and the following SNPs: five in the TNF-? gene promoter(-1 031,-863,-857,-308,-238).METHODS: A total of 117 Chinese individuals were enrolled in this study.They were 67 patients with pneumonia and 50 healthy subjects.TNF-? was genotyped by polymerase chain reaction-restriction fragment length polymorphism for all subjects.The frequency distributions of genotypes in different groups were analyzed by SPSS 11.5 program.RESULTS: Frequency of subjects who carried at least one variant allele in TNF-?-1 031,-863,-857,-308,-238 SNPs among pneumonia patients was significantly higher than that in healthy subjects.And frequency of subjects who carried variant allele in TNF-?-863,and-308 SNPs among severe adult community acquired pneumonia patients was significantly higher than that in common pneumonia patients.CONCLUSION: TNF-?-863 and-308 SNPs appear to be associated with severe adult community acquired pneumonia in Chinese populations.

Objective To investigate the effects of rhGH on hypoalbuminemia in cirrhotic rats after partial hepatectomy. Methods Thirty rats were randomly divided into normal control group ( n =6), liver cirrhosis group (LC group, n =6), liver cirrhosis and hepatectomy group (LCH group, n =6), PN (parenteral nutrition) group ( n =6, given PN after hepatectomy) and rhGH+PN group ( n =6,given rhGH and PN after hepatectomy). Liver function and blood glucose were measured. The expression of ALB mRNA was detected by RT PCR. Liver Ki67 immunohistochemistry was studied. Results Compared with PN group, serum ALP was lower; serum ALB and blood glucose were higher in rhGH+PN group. The expression of hepatic ALB mRNA was higher, and hepatic Ki67 labeling index was higher as well in this group. Conclusion rhGH can improve hypoalbuminemia after partial hepatectomy in cirrhotic rats with partial hepatectomy.

Objective To investigate the inhibitory effect of dauricine on the growth of human bladder cancer T-24 cell and its mechanism.Methods The T-24 cells were treated with dauricine(Dau) at different concentrations.The proliferation of T-24 cells was assayed with MTT colorimetric method.The apoptosis of T-24 cells induced by Dau was studied by fluorescent staining,flow cytometry(FCM) and DNA agarose gel electrophoresis.Results Dau effectively inhibited the proliferation of T-24 cells in a concentration dependent manner.A characteristic DNA ladder was observed in Dau treated groups.Dau at the concentration of 5-30 ?g/ml induced the apoptosis of T-24 cells and the apoptosis rate increased in a time-dependeut manner.Cell cycle was arrested at G_0/G_1 phase.The expression of bcl-2 was inhibited and the expression of bax was up-regulated.Conclusion Dauricine significantly inhibits the growth of bladder cancer cells.Cell cycle arrest and apoptosis might be the functional mechanisms.

In recent years , with dramatic increase of the number of clinical studies , researchers and ethical committees face with the new challenge of ethical issues about protection of subjects .Based on the experience of previous ethical review , this article summed up a few typical cases of clinical research , involving the practical ethi-cal issues, such as the goal of research , informed consent, and compensation for damage caused by research .And then it analyzed the ethical issues in these cases , and proposed some suggestions for the reference of clinical re-searchers , ethical committees and policy makers .

This article selected several typical clinical cases, analyzed many factors affect the doctor-patient relationship of ethical issues and new technology of differentiating the ethical dilemma for clinical application, and put forward some suggestions for the reference of medical staff , hospital ethics committees and health policy makers.

Objective To analyze the perioperative complications and prognosis of surgical treatment of pancreatic ductal stones.Methods 60 patients diagnosed to have pancreatic ductal stones and were admitted into our hospital from January 2009 and December 2014 were enrolled into this retrospective study.There were 47 males and 13 females.The average age was (44.1 ± 12.0).Results All patients underwent surgical operation and there was no perioperative death.Perioperative complications occurred in 7 patients (11.7％), including pancreatic fistula in 4 patients, delayed gastric emptying in 1 patient, abdominal infection in 1 patient, anastomotic bleeding in 1 patient.Eight patients developed elevated amylase levels.The fasting time was 3.4 ± 1.2 days and the hospital stay was 10.0 ±4.0 days.The follow-up rate was 88.3％ (53/60), at a mean follow-up of 27 months.In 51 patients who presented with abdominal pain, 43 patients (84.3％) had complete pain relief and 7 patients (13.7％) had partial pain relief.In 14 patients with preoperative diabetes mellitus, 1 patient had improvement and 2 patients recovered from diabetes.Two additional patients were diagnosed to have diabetes two years after the operation.Of the 2 patients who were shown to have pancreatic cancer on histopathological study, 1 patient was lost to follow-up while another patient died at 27 months after the operation.The patients diagnosed to have epithelial dysplasia were followed-up and none developed pancreatic cancer.Conclusions The relationship between chronic pancreatitis and pancreatic ductal stones was very close.Chronic pancreatitis also caused exocrine and endocrine dysfunction.Surgical operation plays an important role in symptomatic relief and in delaying pancreatic dysfunction.