Home parenteral nutrition is an important way of nutritional support for patients with short bowel syndrome at home.It can not only improve the nutritional status of patients,enhance their quality of life,but also shorten their hospital stay,save medical expenses and facilitate their return to family life.This study reviews the current situation of home parenteral nutrition,the implementation methods and follow-up management of home parenteral nutrition for patients with short bowel syndrome,and the countermeasures to promote the implementation of home parenteral nutrition for patients with short bowel syndrome,with the aim of providing references for promoting the implementation and standardizing the management of home parenteral nutrition for patients with short bowel syndrome in China.

Home parenteral nutrition is an important way of nutritional support for patients with short bowel syndrome at home.It can not only improve the nutritional status of patients,enhance their quality of life,but also shorten their hospital stay,save medical expenses and facilitate their return to family life.This study reviews the current situation of home parenteral nutrition,the implementation methods and follow-up management of home parenteral nutrition for patients with short bowel syndrome,and the countermeasures to promote the implementation of home parenteral nutrition for patients with short bowel syndrome,with the aim of providing references for promoting the implementation and standardizing the management of home parenteral nutrition for patients with short bowel syndrome in China.

Objective:To compare and study the improvement of different iterative reconstruction(IR)algorithms of the tomotherapy(TOMO)Radixact system on the image quality of megavoltage computed tomography(MVCT)imaging system,and the influence of that on the precision of automatic registration,and to explore the reconstruction algorithm that is suitable for clinical application.Methods:Using the MVCT imaging system to respectively scan the Tomo-Phantom HE phantom and the Catphan 604 phantom,and to analyze three groups of images were generated by three kinds of reconstruction algorithms,which included the Standard(STD)algorithm,IR General(IR-G)algorithm and IR Soft Tissue(IR-ST)algorithm,in MVCT image.The noise index(NI),uniformity index(UI)of image,modulation transfer function(MTF),low contrast visibility(LCV)index and contrast-to-noise ratio(CNR)of three groups of images were calculated respectively.The Lucy phantom was used to test the accuracy of automatic registration algorithm.The registration data of four dimensions,included left-right(X-axis),head-foot(Y-axis),vertical(Z-axis)and free rotation(Roll)around the Y-axis,were used to conduct verification analysis for the influences of them on the precision of automatic registration.Results:The NI values of IR-G and IR-ST reconstruction algorithms were respectively 39.58±0.10 and 14.62±0.26,which were better than 39.58±0.10 of STD algorithm,and the UI values of them were respectively 19.87±0.83 and 15.84±2.51,which were better than 24.51±1.81 of STD algorithm,and LCV values of them were respectively 2.50±0.03 and 1.74±0.11,which were better than 3.67±0.04 of STD algorithm.All of them appeared significant increase,but the resolution with high contrast of MTF were respectively 0.23 and 0.21,which were lower than 0.32 of STD.The overall image quality of the IR algorithms was superior to that of the STD algorithm.In the accuracy test of the automatic registration algorithm,the registration precisions of IR-G and IR-ST algorithms on Y-axis were respectively(0.360±0.142)mm and(0.245±0.050)mm,which were significantly higher than 0.145±0.136 of STD algorithm,and the differences of them were significant(Z=6.0,15.0,P<0.05).The differences of registration precisions of other directions were not significant(P>0.05).Conclusion:The IR algorithm has advantages in terms of noise,uniformity and resolution with low-contrast,however,it shows reduction on resolution with high-contrast.This reduction of resolution with high-contrast do not lead to the decrease of the precision of automatic registration.

OBJECTIVE To investigate the causal association between ticagrelor and risk of infection METHODS Two-sample Mendelian randomization was adopted. Genetic instrumental variables were selected based on the results of the largest genome-wide association analysis to in vivo exposure of ticagrelor and its major active metabolite AR-C124910XX. The causal associations of ticagrelor and its major active metabolite AR-C124910XX with drug indications （coronary artery disease， unstable angina pectoris， myocardial infarction， stroke and ischemic stroke）were analyzed by inverse variance weighted Mendelian randomization model as a positive control for genetic instrumental variables. The causal relationship between ticagrelor and bacterial infection， acute lower respiratory infection， bacterial pneumoniae， pneumoniae，acute upper respiratory infection and sepsis were furtheranalyzed by using this method， and the robustness of the results was assessed by using heterogeneity tests and horizontal 202002030415） pleiotropy tests. RESULTS The increase of area under the curve at steady state （AUCss） of the genetic surrogated ticagrelor significantly reduced the risk of coronary artery disease， myocardial infarction and unstable angina pectoris （P＜0.001）. AUCss genetic instrument variables of its main active metabolite AR-C124910XX failed to pass positive control. Further analysis showed that the increase of the genetic surrogated ticagrelor exposure suggestively reduced the risk of bacterial infection [OR（95%CI）＝0.80（0.65，0.99），P＝0.040] and sepsis [OR （95%CI）＝0.84（0.73， 0.98）， P＝0.023]. The results of the heterogeneity tests showed that there was no heterogeneity in the causal association of the genetic surrogated ticagrelor AUCss with bacterial infection and sepsis （P＞0.05）. The results of horizontal pleiotropy tests showed that the causal association of genetic surrogated ticagrelor AUCss with bacterial infection and sepsis had no effects on horizontal pleiotropy （P＞0.05）. CONCLUSIONS Ticagrelor has a potential role in reducing the risk of sepsis and bacterial infections.

Objective:To investigate the effects of tamoxifen on high glucose-induced epithelial-to-mesenchymal transition of rat peritoneal mesothelial cells and the underlying mechanism.Methods:The peritoneal mesothelial cells of normal male SD rats were selected between January 2015 and June 2016 and then cultured and divided into blank control, high-glucose stimulation and drug intervention groups. High-glucose stimulation group: primary cultured rat peritoneal mesothelial cells (RPMCs) were treated with 60 mmol/L high-concentration glucose to induce epithelial-to-mesenchymal transition. Drug intervention group: (1) RPMCs were treated with 60 mmol/L high-concentration glucose and different concentrations (0.5 μmol/L, 2 μmol/L) of tamoxifen. After 72 hours of stimulation, protein was extracted. (2) RPMCs were treated with 60 mmol/L high-concentration glucose and 2 μmol/L tamoxifen with or without 2 μmol/L ER-α antagonist for 1 hour to extract protein and for 6 hours to extract RNA. (3) RPMCs were treated with high-concentration glucose and 2 μmol/L tamoxifen with or without 1 μmol/L 1 μM proteasome inhibitor for 1 hour to extract protein. Western blot analysis was performed to analyze change in E-cadherin, α-SMA, Smad2, p-Smad2, Smad3, p-Smad3 and Smad4 protein. Real-time fluorescence quantitative PCR was performed to detect the change in mRNA expression of Smad2, Smad3, connective tissue growth factor and plasminogen activator inhibitor 1.Results:Tamoxifen attenuated epithelial-to-mesenchymal transition on RPMCs induced by high-level glucose, showing increased expression of epithelial cell marker E-cadherin and decreased expression of α-SMA in a concentration-dependent manner ( tE-cadherin = 2.31, tα-SMA =-2.53, both P < 0.05).TGF-β1/R-Smad signal pathway was activated by high-concentration glucose. Phosphorylation of Smad2/3 and mRNA expression of CTGF and PAI-1 were increased. Tamoxifen remarkably reduced protein and mRNA level of above mentioned protein and related target genes ( tp-Smad2 = -3.38, tCTGF = -3.81, P < 0.05), which could be blocked by ER-α antagonist. Finally, proteasome inhibitor could weaken the inhibitory effects of tamoxifen on p-Smad2/3 and increase p-Smad2/3 protein level ( tp-Smad2 = 3.94, P < 0.05). Conclusion:Tamoxifen activates ER-α on RPMCs, weakens the activation of TGF-β1/R-Smad signal pathway through decreasing p-Smad2 protein level, and effectively inhibits the progression of high-concentration glucose-induced epithelial-to-mesenchymal transition possibly through degrading p-Smad2 protein through proteasome. The role of tamoxifen in epithelial-to-mesenchymal transition may provide a possible guide for research, prevention and treatment of peritoneal fibrosis.

Objective:To observe the clinical characteristics and prognosis of patients with rapidly progressive glomerulonephritis (RPGN) caused by lupus nephritis, antineutrophil cytoplasmic antibodies (ANCA) - associated vasculitis, or primary glomerulonephritis who were treated with peritoneal dialysis (PD) and then withdrew PD because of renal recovery.Methods:Data of the above patients were retrospectively analyzed. The patients were diagnosed as RPGN and received PD therapy in Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University from February 2009 to August 2018. The patients were divided into early withdrawal group (PD time≤183 days, n=24) and late withdrawal group (PD time>183 day, n=24). The differences of clinical characteristics between the two groups were compared. The cumulative incidence of adverse events in both groups was analyzed using Kaplan-Meier curves. Cox proportional hazards model was used to analyze the risk factors influencing the prognosis of patients. Results:Forty-eight RPGN patients were included. The median time of maintaining PD was 178(76, 378) days. Compared with the late withdrawal group, the patients in early withdrawal group had lower levels of urine volume, serum albumin and parathyroid hormone, and lower rates of gross hematuria and hypertension at the beginning of PD, and received higher rates of methylprednisolone impulse, combined immunosuppressive agents, and hemodialysis or continuous renal replacement therapy (all P<0.05). At the time of PD withdrawal, the levels of serum creatinine, serum calcium, serum albumin and parathyroid hormone in the early withdrawal group were significantly lower than those in the late withdrawal group (all P<0.05). The Kaplan-Meier curves showed that there was no significant difference in the cumulative survival of patients in both groups (log-rank test χ2=3.485, P=0.062). Cox regression analysis revealed serum creatinine≥209 μmol/L at the time of PD withdrawal was an independent risk factor for poor prognosis ( HR=5.253, 95% CI 1.757-15.702, P=0.003). Conclusions:PD can be used for RPGN patients caused by lupus nephritis, ANCA-associated vasculitis and primary nephritis. Serum creatinine≥209 μmol/L at the time of PD withdrawal is an independent risk factor for poor prognosis.

Objective To explore the diagnosis and treatment of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.Methods The retrospective cross-sectional study was conducted.The clinical data of 36 patients with mesenteric venous thrombosis secondary to long-term ischemic enteropathy who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2009 to June 2017 were collected.Diagnostic methods:history inquiry,physical examination,laboratory test and image finding.Treatment methods:parenteral nutrition support,selective stage 1 bowel resection with anastomosis or stage 1 bowel resection and colostomy,definitive stage 2 operation for recovering digestive tract.Anticoagulation therapy was performed.Observation indicators:(1) clinical characteristics;(2) treatment;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to December 2017.Measurement data with skewed distribution were described as M (P25,P75) and M (range).Results (1) Clinical characteristics:① the main clinical manifestations:34,33,27,20,17 and 14 patients showed respectively discomfort after meal,abdominal pain,abdominal distension,nausea with vomiting,stop of analis exhaust and defecation and weight loss of different degree,and the worst patient lost 20 kg within 1 month.The clinical manifestations of 30 patients were more than 3.② The score of acute physiology and chronic health evaluation (APACHE)Ⅱ in 36 patients was 4 (2,6).③ Laboratory test:total protein (TP),albumin and prealbumin were 55.8 g/L (45.2 g/L,59.1 g/L),30.6 g/L (27.3 g/L,37.5 g/L) and 100.0 g/L (86.0 g/L,132.0 g/L),respectively,showing a decreased trend.④ Imaging finding:enhanced scans of abdominal CT showed the portal cavernous in 16 patients,the absence of main trunk of superior mesenteric vein with extensive collaterals in 12 patients,and dovelopment of portal vein and main trunk of superior mesenteric vein in 8 patients.One patients had intestinal edema and stenosis.X-ray contrast examination of digestive tract showed intestinal stenosis with mucosal erosion in 28 patients and complete intestinal obstruction in 8 patients.(2) Treatment:of 36 patients,24 underwent stage 1 bowel resection with anastomosis and other 12 received stage 1 bowel resection and colostomy (11 undergoing definitive stage 2 operation for recovering digestive tract and 1 refusing stage 2 operation due to advanced age).The length of resected bowel was 30 cm (15 cm,80 cm).One patient with stage 1 bowel resection with anastomosis was complicated with small bowel fistula,and was cured by conservative treatment.There was no complication in other patients.(3) Follow-up:all 36 patients were followed up for 3-10 months,with a median time of 6 months.During the follow-up,7 patients were complicated with secondary portal hypertension,5 of 7 were improved by symptomatic treatment,and 2 died of severe digestive tract bleeding;other patients had no related complications.Conclusions The discomfort after meal and bowel obstruction are the main clinical manifestations of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.The abdominal CT with X-ray contrast examination benefits to diagnosis of patients with poor nutrition status and mild infection.The main strategy includes early surgical resection and postoperative anticoagulation therapy after bleeding risk evaluation.

Objective To investigate the effects of serum uric acid (SUA) on all?cause death and cardiovascular death in patients of maintaining peritoneal dialysis (PD). Methods One thousand and sixty?three PD patients in the First Affiliated Hospital of Zhejiang University Medical College were included. The SUA levels at 6 months after PD start were measured. Patients with SUA≥420 μmol/L were grouped in hyperuricemia group (492 cases) and patients with SUA<420 μmol/L were grouped in normal uric acid group (571 cases). The effects on all ? cause mortality and cardiovascular mortality were retrospectively analyzed. Results The median age of the patients was 51(41, 62) years; 557 cases were male (52.40％); the median follow?up time was 33(20, 54) months (6?96 months); 167 cases (15.71％) died during the follow?up period, including 64 cases (6.02％) withcardiovascular causes. The mortality in hyperuricemia group was 19.11％(94/492) and the cardiovascular mortality was 7.93％(39/492), both rates were higher than those in normal uric acid group, and the differences were statistically significant (P=0.005, P=0.015, respectively). Hyperuricemia (SUA≥420μmol/L) at 6 months after PD start (HR=1.572, 95％CI 1.155-2.141, P=0.004), high uric acid level (continuous variable) at 6 months after PD start (HR=1.002, 95％CI 1.001-1.004, P=0.008), and age≥65 years (HR=3.571, 95％CI 2.556-4.990, P<0.001), serum albumin≤30 g/L (HR=1.907, 95％CI 1.278-2.845, P=0.002), high Charlson comorbidity index (HR=1.209, 95％CI 1.032-1.417, P=0.019) at the beginning of PD start were independent risk factors for all ? causes death in PD patients. Hyperuricemia (SUA≥420 μmol/L) at 6 months after PD start (HR=1.734, 95％CI 1.033-2.912, P=0.037) and age≥65 years (HR=1.761, 95％CI 1.024-3.209, P=0.041), with diabetes (HR=2.775, 95％CI 1.358-5.671, P=0.005) at the beginning of PD start were independent risk factors for cardiovascular death in PD patients. Conclusions SUA at 6 months after PD is an independent risk factor for all?cause death and cardiovascular death in PD patients.

Objective To investigate the risk factors and prognosis of peritoneal dialysis (PD)related bacterial peritonitis.Methods The clinical data of patients with PD related bacterial peritonitis from January 2006 to September 2016 in our hospital were retrospectively analyzed and followed up until December 2016.Patients were divided into two groups according to the frequency of peritonitis,single episode group and multiple episodes group (no less than two episodes of peritonitis).According to efficacy of therapy,the episodes of peritonitis were divided into two groups,cured group (no relapse,recurrence or repeat episodes) and failure group (relapse,recurrent or repeat infection after the therapy of initial episode).Logistic regression and Cox regression were used to analyze the risk factors for outcomes.Results Five hundred and fifty-nine patients had PD related bacterial peritonitis,including 339 patients in the single episode group and 220 patients in the multiple episodes group.Logistic analysis showed low serum albumin level (OR=787,P ＜ 0.001) and malnutrition (OR=0.422,P ＜ 0.001) at baseline were independent risk factors for multiple episodes (P ＜ 0.001).The technical survival was better in the single episode group than that in the multiple episodes group (75.2％ vs 36.2％,P=0.001) while the difference of survival rate was not significant between the two groups (48.2％ vs 24.1％,P=0.592).Five hundred and thirteen episodes of peritonitis were analyzed,including 147 episodes in failure group (88 relapse episodes,16 recurrent episodes and 43 repeat episodes) and 366 episodes in cured group.There were 78 patients in failure group and 253 patients in cured group.Logistic analysis showed prolonged response time (OR=1.200,P ＜ 0.001),Gram-positive bacteria infection (OR=1.736,P=0.022),higher hs-CRP level (OR=1.004,P=0.013),lower serum albumin level (OR=0.936,P=0.008) were independent risk factors for failure of therapy.Multivariate Cox regression showed prolonged response time (HR=1.120,P=0.032),Gram-positive bacteria infection (HR=2.462,P=0.002),higher hs-CRP level (HR=1.007,P=0.009) were independent risk factors for failure of therapy and higher serum albumin level (HR=0.942,P=0.048) was an independent protection factor.Conclusions Low serum albumin level and malnutrition at baseline are independent risk factors for patients with multiple peritonitis episodes.Prolonged response time,Gram-positive bacteria infection,the high hs-CRP level are independent risk factors for relapse or recurrent or repeat episodes while high serum albumin level was an independent protection factor.