As a fundamental principle of medical ethics,informed consent shares a critical role in medical ethics research,while its specific enforcement is not optimistic at present.Possible reasons are analyzed as follows: the impact of traditional culture,the limited health resources,the imperfect health system and legislation,drawbacks of the education system and professional barriers.The principle of informed consent can be implemented well only by tackling all the above problems.

Esophageal gastric variceal bleeding(EGVB)is a serious complication of cirrhotic portal hypertension with high mortality rate. Prevention of EGVB is an important mean to improve the survival of patients. Non-selective beta-blockers(NSBBs)is one of the first-line drugs for primary and secondary prevention of EGVB,however,only about 1 / 3 of cirrhotic patients respond to this treatment when evaluated by hepatic venous pressure gradient( HVPG). This may be related to the genetic polymorphisms of NSBBs’receptors and the metabolic enzymes. This article reviewed the progress in study on therapeutic efficacy of NSBBs and its influencing factors for preventing EGVB in cirrhotic patients.

Objective To observe the effect of propofol on phosphorylation of a-amino-3-hydroxy-5-methyl-4-isoxa-zolep-propionate receptors (AMPARs) GluR1 subunit and long-term potentiation (LTP) in cultured hippocampal neurons in aged rats.Methods A total of 30 18-month-old rats were decapitated,the brains were rapidly removed and hippocampal slice were prepared.The slices were randomly divided into control group (perfused with artificial cerebrospinal fluid,n=10),propofol-treated group (perfused with propofol in artificial cerebrospinal fluid,n=10)and propofol+ phorbol-12-myristate-13-acetate (PMA)-treated group (perfused with propofol and phorbol ester in artificial cerebrospinal fluid,n=10).Extracellular excitatory postsynaptic potentials (EPSP) were recorded from the CA1 region of hippocampal slices.After perfusion for 20 min,LTP was induced using higher-frequency stimulation (HFS,100Hz,400 pulse) by the Schaffer-collateral pathway.The phosphorylation of AMPA-GluR1 subunit was assayed in cultured rat neurons by Western blot.Results The value of EPSP in propofol-treated group (105.50 ± 3.77) was much lower than in control group (242.10±14.68) and in propofol+ PMA-treated group (239.40±8.98) (F=2.90,P＜0.05),and there was no significant difference in the value of EPSP between control group and propofol+ PMA-treated group (P＞0.05).The level of P-Glu1/Glu1in propofol-treated group (0.68±0.15) was much lower than in control group (1.67±0.20) and in propofol+PMA-treated group (1.57±0.18) (F=6.84,P＜0.05),while there was no difference in the level of P-Glu1/Glu1 between control group and propofol + PMA-treated group (P ＞ 0.05).There was no difference in the value of GluR1/β-actin among the three groups (F=0.31,P＞0.05).Conclusions Propofol possesses the ability to inhibit LTP induction and attenuate AMPA receptor GluR1 subunit phosphorylation through modulation of PKC pathway.

Complex regional pain syndrome (CRPS) is a neuropathic pain disorder, characterized with persistent and severe pain after trauma or surgery. This paper would review the epidemiology, mechanisms and pathophysiology of CRPS.

OBJECTIVETo observe the clinical effects of acupuncture method of "Huoxue Sanfeng, Shugan Jianpi" (activating blood and eliminating wind, soothing liver and strengthening spleen) on morning blood pressure in patients with cerebral infraction combined with essential hypertension.

METHODSSixty-eight patients were randomly divided into an observation group and a control group, 34 cases in each one. The patients in the two groups were treated with acupuncture method of "Xingnao Kaiqiao" (consciousness-restoring resuscitation) and oral administration of nifedipine. In addition, patients in the observation group were treated with acupuncture method of "Huoxue Sanfeng, Shugan Jianpi" that met the criteria of standard manipulation, in which bilateral Renying (ST 9), Quchi (LI 11), Hegu (LI 4), Zusanli (ST 36) and Taichong (LR 3) were selected. The treatment was given once a day, five times a week, for totally six weeks. The improvement and control rate of morning blood pressure in the two groups were observed.

RESULTS(1) After treatment, the morning blood pressures were decreased significantly in the two groups (all P < 0.05); after 15 treatments, the reduction of systolic pressure and diastolic pressure in the observation group was superior to that in the control group, but the difference was not significant (both P > 0.05); after 30 treatments, the reduction of systolic pressure and diastolic pressure in the observation group was significantly superior to that in the control group (both P < 0.05). (2) After 30 treatments, the control rate of morning blood pressure in the observation group was significantly higher than that in the control group [82.4% (28/34) vs 58.8% (20/34), P < 0.05].

CONCLUSIONAcupuncture method of "Huoxue Sanfeng, Shugan Jianpi", characterized with standard manipulation criteria, can effectively control morning blood pressure in patients with cerebral infraction combined with essential hypertension.

Acupuncture Points ; Acupuncture Therapy ; Adult ; Aged ; Blood Pressure ; Cerebral Infarction ; physiopathology ; therapy ; Essential Hypertension ; Female ; Humans ; Hypertension ; physiopathology ; therapy ; Liver ; physiopathology ; Male ; Middle Aged ; Spleen ; physiopathology ; Treatment Outcome

Objective To discuss the surgical treatment of primary pigmented nodular adrenocortical disease(PPNAD).Methods twenty-four cases of PPNAD were treated in our hospital from January 2005 to December 2017.Clinical data of these patients were reviewed.It included 8 males and 16 females with a mean age of 23 years old (range 14 to 58).23 cases presented with typical symptoms of Cushing syndrome, 1 case presented with hypertension.Eight cases could be diagnosed with Carney complex.All cases were confirmed as ACTH-independent Cushing syndrome.Adrenal imaging showed bilateral multiple nodules in 11 cases, unilateral multiple nodules in 4 cases, unilateral single mass or nodule in 3 cases, normal adrenals in 6 cases.Results All of the 24 cases received laparoscope unilateral adrenalectomy or laparoscope unilateral mass resection.After the operation, 8 cases underwent secondary operation because of symptom recurrence and the elevated 24-hour urinary free cortisol.Among them, 5 cases received contralateral subtotal adrenalectomy, 3 cases received contralateral total adrenalectomy.Seven cases with a slightly elevated 24-hour urinary free cortisol but a good recovery of Cushing symptoms were followed-up.Nine cases recovered well after the first operation and they didn't undergo secondary surgical treatment, but 1 of the 9 cases needed glucocorticoid replacement.Conclusions Bilateral adrenalectomy followed with long-term glucocorticoid replacement is the standard treatment of PPNAD.Unilateral adrenalectomy or subtotal adrenalectomy may be suitable for elected patients, but appropriate criteria need to be explored.

Objective To explore the effects of different treatments on prognosis of patients with Gynura segetum caused hepatic vein occlusion disease (HVOD).Methods From July 2008 to January 2016,85 patients with Gynura segetum caused HVOD were enrolled and received treatment of liver function protection and microcirculation improvement.According to different treatment options,patients were divided into non-anticoagulation group,nowanticoagulation transfered to transjugular intrahepatic portosystem stent-shunt (TIPS) group,anticoagulation group,anticoagulation transfered to TIPS group and anticoagulation-TIPS step-by-step treatment group.The efficacy of each group was observed.Chi square test was performed for statistical analysis.Results Among 22 patients who received nonanticoagulation treatment,six (27.3％) patients were cured and 14 (63.6％) patients died during the treatment period;besides two (9.1 ％) patients received TIPS because of ineffective treatment and achieved longterm survival.Among 63 patients treated with combination of low-molecular-weight heparin and warfarin,six (9.5％) patients died and 36(57.1％) patients were cured.The cure rate was higher than that of nonanticoagulation group (x2 =5.820,P=0.016).Other 21 patients received TIPS treatment,achieved longterm survival except one patient died from surgical complications.The cure rate of anticoagulation-TIPS step treatment group was 88.9 ％ (56/63) which was higher than that of non-anticoagulation group,and the difference was statistically significant (x2 =31.350,P＜0.01).Conclusions Compared to conventional liver function protection treatment and symptomatic treatment,anticoagulation therapy significantly increases the cure rate of patients with Gynura segetum caused HVOD.Anticoagulation-TIPS step-by-step treatment further improves the cure rate.

Objective To investigate the type,clinical and imaging features of iatrogenic bile duct injury and the efficacy and safety of endoscopic and interventional radiology therapy.Methods A total of 48 patients with iatrogenic bile duct injury who have undergone endoscopic and/or interventional therapy from January 1st 2013 to June 30th 2016 were enrolled.Patients' general information,causes of injury,clinical manifestations,treatment methods,efficacy and complications were retrospectively analyzed.Results The causes of iatrogenic bile duct injury were cholecystectomy(45.8％,22/48),liver transplantation (35.4％,17/48),transjugular intrahepatic portosystemic shunt (8.3％,4/48),Roux-en-Y anastomosis (6.3％,3/48) and endoscopic retrograde cholangiopancreatography (4.2％,2/48).The most common type of iatrogenic bile duct injury was stenosis of intra/extra bile ducts (66.7％,32/48).Other types included biliary fistula(18.8％,9/48),hemobilia (10.4％,5/48) and stenosis of anastomotic stoma (4.2％,2/48).The most common clinical manifestations were jaundice (37.5％,18/48) and abdominal pain (29.2％,14/48).Other clinical manifestations were fever (14.6％,7/48),hematemesis or melena (8.3％,4/48) and abnormal drainage fluid (8.3％,4/48).Diagnosis was confirmed by angiography,cholangiography or endoscopy.The overall effective rate of minimally invasive therapy was 91.7％ (44/48) and the most common complications were fever (16.7％,8/48) and pancreatitis (10.4％,5/48).Other complications were hemobilia (2.1％,1/48),cardia dilaceration (2.1％,1/48) and biliary fistula caused by catheter shedding(2.1％,1/48).Conclusion Iatrogenic bile duct injury could occur after upper abdominal surgeries,endoscopic or interventional procedures.Early diagnosis and treatment with endoscopic or vascular interventional methods can achieve satisfying efficacy and safety.

Objective To investigate the correlation between liver and spleen stiffness measured by acoustic radiation force impulse (ARFI) and hepatic venous pressure gradient (HVPG),and to evaluate its efficiency in the diagnosis of portal hypertension.Methods From April 2014 to March 2016,20 cases underwent HVPG measurement because of liver cirrhosis were enrolled.Before HVPG measurement,liver and spleen stiffness were assessed with ARFI.The correlation between HVPG and age,alanine aminotransferase (ALT),aspartate aminotransferase (AST),total hilirubin,serum albumin,platelet count,prothrombin time,aspartate aminotransferase to platelet ratio index (APRI) score,Child-Pugh score,model for end-stage liver disease (MELD) score,liver stiffness and spleen stiffness were analyzed.Pearson correlation and Spearman rank correlation were performed for statistical analysis.Results HVPG,liver and spleen stiffness were successfully measured in all 20 patients.The mean liver stiffness was (1.78±0.29) m/s,the mean spleen stiffness was (3.37±0.44) m/s and HVPG was (16.10±5.14) mmHg (1 mmHg=0.133 kPa).Age,ALT,AST,total bilirubin,serum albumin,platelet count,prothrombin time,APRI score,Child-Pugh score and MELD score were all not correlated with HVPG (all P＞0.05).But HVPG was positively correlated with liver and spleen stiffness (r=0.449,P=0.047;r=0.487,P=0.030).In the diagnosis of HVPG≥12 mmHg,the area under curve (AUC) of liver stiffness was 0.875,the optimal cut-off value was 1.77 m/s,the sensitivity was 68.6 ％ and the specificity was 100.0％.In the diagnosis of HPVG≥20 mmHg,the AUC of liver stiffness was 0.798,the optimal cut off value was 1.85 m/s,the sensitivity was 100.0％ and the specificity was 68.8％.The AUC of spleen stiffness was 0.820,the optimal cut-off value was 3.23 m/s,the sensitivity was 100.0 ％ and the specificity was 56.3％.Conclusion In patients with liver cirrhosis,liver stiffness and spleen stiffness assessed by ARFI are positively correlated with HVPG and therefore ARFI has certain application value in the noninvasive diagnosis of portal hypertension.

Objective To explore the correlation between wedged hepatic vein pressure (WHVP) and directly measured portal vein pressure (PVP) and further analyze the correlation between hepatic venous pressure gradient (HVPG) and portal pressure gradient (PPG).Methods From December 2012 to April 2014,the related data including WHVP,free hepatic venous pressure (FHVP),inferior vena cava pressure (IVCP) and PVP of patients who received transjugular interahepatic portosystem stentshunt (TIPS) treatment were collected,and HVPG and PPG were calculated.The correlations between WHVP and PVP,between FHVP and IVCP,between HVPG and PPG were analyzed.Pearson's correlation analysis were performed for correlation analysis.Results Twenty two patients matched the criteria were enrolled during the December 2012 to April 2014.The mean pressures of PVP and WHVP were (28.07±4.43) mmHg (1 mmHg=0.133 kPa) and (26.22±5.91) mmHg,respectively.PVPand WHVP were positively correlated,the correlation coefficient of them was 0.431 (P=0.045) and slope was0.323.The mean pressures of FHVP and IVCP were (7.31±3.37) mmHg and (6.82±4.01) mmHg,respectively.FHVP and IVCP were positively correlated,the correlation coefficient of them was 0.845 (P＜0.01) and slope was 0.711.The mean pressures of PPG and HVPG was (21.02±3.76) mmHg and (18.90±4.86) mmHg,respectively.There was no correlation between PPG and HVPG,the correlation coefficient of them was 0.014 (P=0.951).Conclusions There is a good correlation between PVP and WHVP,and so is the correlation between FHVP and IVCP.However,there is no good correlation between HVPG and PPG in this study because of the effects of many factors.