Objective:To compare the effects of different positioning and puncture methods for epidural anesthesia in obese parturients undergoing cesarean section.Methods:In this prospective, randomized, controlled study, 175 obese parturients, of American Society of Anesthesiologists Physical Status classification Ⅰ or Ⅱ, with a body mass index of > 30 kg/m 2, who underwent elective cesarean section with epidural anesthesia at Henan Provincial People′s Hospital from July 2023 to April 2024, were selected and assigned into 4 groups using a random number table method: palpation positioning + median approach to puncture group (PM group, n=44), body surface marker positioning + paramedian approach to puncture group (BP group, n=43), ultrasound-assisted positioning + paramedian approach to puncture group (UP group, n=45), and ultrasound-assisted positioning + ultrasound-guided in-plane approach to puncture group (UU group, n=43). The procedures were performed by anesthesiology residents skilled in the four different epidural anesthesia positioning and puncture methods. Main observation indicators: success rate of puncture at first attempt and total success rate of puncture. Secondary observation indicators: the number of puncture, changes in puncture interspaces, positioning time, puncture time, anesthesia operation time, postoperative nausea and vomiting, sensory abnormalities at the puncture site, bleeding at the puncture site, maternal satisfaction rates, and occurrence of low back pain at day 7, 1 month, 2 months, and 3 months postoperatively. Results:In this study, 2 cases were excluded from PM group, 2 from BP group, 2 from UP group, and 2 from UU group. The total success rates of puncture were as follows: 95% (40/42) in PM group, 98% (40/41) in BP group, 93% (40/43) in UP group, and 98% (40/41) in UU group. There was no significant difference in the total success rates of puncture among the four groups ( P>0.05). Compared to PM group, the success rate of puncture at first attempt was significantly increased, the rate of changes in puncture interspaces was decreased, the positioning time was shortened, the incidence of nausea and vomiting was decreased, satisfaction rates were increased, and the incidence of low back pain was reduced at 7 days after operation in BP group; the success rate of puncture at first attempt was significantly increased, the number of puncture was reduced, the rate of changes in puncture interspaces was decreased, the positioning time, puncture time and anesthesia operation time were shortened, the satisfaction rates were increased, and the incidence of low back pain was decreased at 7 days after operation in UP group; the rate of changes in puncture interspaces was significantly decreased, and the positioning time was shortened in UU group ( P<0.05). Compared to BP group, the puncture time was significantly shortened in UP group, and the number of puncture was significantly increased, the anesthesia operation time was prolonged, the incidence of nausea and vomiting was increased, and the satisfaction rate was decreased in UU group ( P<0.05). Compared to UP group, the success rate of puncture at first attempt was significantly decreased, the number of puncture was increased, the puncture time and anesthesia operation time were prolonged, the incidence of nausea and vomiting was increased, and the satisfaction rates were decreased in UU group ( P<0.05). Conclusions:Ultrasound-assisted positioning combined with the paramedian approach to puncture can raise the success rate of puncture at first attempt, reduce the development of puncture-related complications, and increase the maternal satisfaction in obese parturients undergoing cesarean section.

Objective:To compare the effects of different positioning and puncture methods for epidural anesthesia in obese parturients undergoing cesarean section.Methods:In this prospective, randomized, controlled study, 175 obese parturients, of American Society of Anesthesiologists Physical Status classification Ⅰ or Ⅱ, with a body mass index of > 30 kg/m 2, who underwent elective cesarean section with epidural anesthesia at Henan Provincial People′s Hospital from July 2023 to April 2024, were selected and assigned into 4 groups using a random number table method: palpation positioning + median approach to puncture group (PM group, n=44), body surface marker positioning + paramedian approach to puncture group (BP group, n=43), ultrasound-assisted positioning + paramedian approach to puncture group (UP group, n=45), and ultrasound-assisted positioning + ultrasound-guided in-plane approach to puncture group (UU group, n=43). The procedures were performed by anesthesiology residents skilled in the four different epidural anesthesia positioning and puncture methods. Main observation indicators: success rate of puncture at first attempt and total success rate of puncture. Secondary observation indicators: the number of puncture, changes in puncture interspaces, positioning time, puncture time, anesthesia operation time, postoperative nausea and vomiting, sensory abnormalities at the puncture site, bleeding at the puncture site, maternal satisfaction rates, and occurrence of low back pain at day 7, 1 month, 2 months, and 3 months postoperatively. Results:In this study, 2 cases were excluded from PM group, 2 from BP group, 2 from UP group, and 2 from UU group. The total success rates of puncture were as follows: 95% (40/42) in PM group, 98% (40/41) in BP group, 93% (40/43) in UP group, and 98% (40/41) in UU group. There was no significant difference in the total success rates of puncture among the four groups ( P>0.05). Compared to PM group, the success rate of puncture at first attempt was significantly increased, the rate of changes in puncture interspaces was decreased, the positioning time was shortened, the incidence of nausea and vomiting was decreased, satisfaction rates were increased, and the incidence of low back pain was reduced at 7 days after operation in BP group; the success rate of puncture at first attempt was significantly increased, the number of puncture was reduced, the rate of changes in puncture interspaces was decreased, the positioning time, puncture time and anesthesia operation time were shortened, the satisfaction rates were increased, and the incidence of low back pain was decreased at 7 days after operation in UP group; the rate of changes in puncture interspaces was significantly decreased, and the positioning time was shortened in UU group ( P<0.05). Compared to BP group, the puncture time was significantly shortened in UP group, and the number of puncture was significantly increased, the anesthesia operation time was prolonged, the incidence of nausea and vomiting was increased, and the satisfaction rate was decreased in UU group ( P<0.05). Compared to UP group, the success rate of puncture at first attempt was significantly decreased, the number of puncture was increased, the puncture time and anesthesia operation time were prolonged, the incidence of nausea and vomiting was increased, and the satisfaction rates were decreased in UU group ( P<0.05). Conclusions:Ultrasound-assisted positioning combined with the paramedian approach to puncture can raise the success rate of puncture at first attempt, reduce the development of puncture-related complications, and increase the maternal satisfaction in obese parturients undergoing cesarean section.

Objective:To provide insight into the diagnosis for clinicians, the clinical characteristics, diagnosis and treatment history of 3 patients with 21-hydroxylase deficiency (21-OHD) and testicular adrenal rest tumors (TART) were analyzed.Methods:The clinical, laboratory and imaging data of 3 male patients with 21-OHD and TART, confirmed with CYP21 gene sequencing, from May 2010 to May 2021 in the First Medical Center of Chinese PLA General Hospital were analyzed retrospectively. The treatment strategy and clinical outcome were followed up.Results:All the 3 patients were first diagnosed with bilateral adrenal mass at the age of 27-42 years old. They were 145-162 cm tall. The levels of progesterone, 17-hydroxyprogesterone, and adrenocorticotropic hormone (ACTH) of the 3 patients were relatively high, and that of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) of the 3 patients were low. Testosterone level of 1 patient was significantly elevated, and that of the other 2 patients was below the lower limit of normal range. Testicular ultrasound showed heterogeneous hyperechoic masses in both testes. CT of the adrenal glands showed bilateral adrenal enlargement with mass. All 3 patients were treated with dexamethasone. After 4-96 months of follow-up, 17-hydroxyprogesterone level was kept above the median normal level. One of the patients got married and had a baby after treatment. The sizes of adrenal hyperplasia and testicular masses reduced to various degrees with the change of the testicular masses being proportional to that of adrenal hyperplasia.Conclusions:Patients with 21-OHD are prone to have TART, leading to the impaired testicular function. Early glucocorticold therapy is beneficial to the reduction of TART and restoration of testicular function.

Objective:To investigate the workflow, feasibility and advantages of respiratory navigator-guided stereotactic body radiation therapy (SBRT) of liver malignancies on the magnetic resonance linear accelerator (MR-linac).Methods:Clinical data of 10 patients with liver cancer treated with respiratory navigator-guided SBRT on the MR-linac from September to December 2021 were analyzed retrospectively. All patients underwent CT and MR simulated localization, and plain, enhanced and 4D CT scan, and T 1 3D MR and T 2 3D MR images were collected. The expiratory 4D CT was chosen to design the reference plan. The T 2 3D navigator MR image (end-exhalation) was collected before treatment, the target position was adjusted or the target shape was modified in combination with the real-time monitoring 2D MR image and appropriate online adaptive planning process was selected. Then, the ability of CT, T 2 3D and T 2 3D navigator MR images to display the tumor was evaluated by naked eye. The changes of target volume were calculated. Dosimetric differences between the adaptive and reference plans were compared. The efficacy and adverse reactions of patients were evaluated. Results:In the free breathing state, the T 2 3D navigator MR image was significantly better than T 2 3D MR image to clearly display the tumor and its boundary. The adaptive plans of adapt-to-position (ATP) and adapt-to-shape (ATS) adopted by 10 patients was 37 times and 22 times respectively. The tumor subsided significantly in 3 patients. The average target conformal index (CI) of the adaptive plans was no different from that of the reference plans, but the gradient index (GI) was higher ( P<0.05), especially in the ATS plans. Compared to the reference plans, the normal liver V 5 Gy, V 10 Gy and D mean were almost the same, but the average MU was increased with a significant difference in the ATP adaptive plans ( P<0.05). The average of MU, segments and normal liver D mean and V 10 Gy in the ATS adaptive plans were lower than those in the reference plans, and the liver V 5 Gy was slightly increased. Seven patients were evaluated after 1 month and 3 months. The local control of lesions was promising. Toxicities were mild and no grade 3 or higher toxicities were observed. Conclusion:Respiratory navigator on MR-linac improves the visual clarity of tumors and online MR images, and shows its advantages to guide the adaptive precision radiotherapy of liver tumors, especially in SBRT.

Objective:To evaluate the effects of intraoperative fluid therapy guided by different stroke volume variation (SVV)s on bleeding during laparoscopic hepatolobectomy and postoperative renal function.Methods:A total of 135 American Society of Anesthesiologists physical status Ⅰ-Ⅲ patients of both sexes, aged 25-64 yr, scheduled for elective laparoscopic hepatolobectomy under general anesthesia, were divided into 3 groups ( n=45 each) using a random number table method: low SVV group (group L), medium SVV group (group M) and high SVV group (group H). In group L, group M and group H, SVVs were maintained at 10%-15%, 16%-20% and more than 21%, respectively.Before surgery and at 1, 3 and 5 days after the surgery, blood samples from the peripheral vein were taken for determination of serum blood urea nitrogen, creatinine and procalcitonin (PCT) concentrations.The occurrence of conversion to laparotomy, intraoperative volume of blood loss, volume of blood transfused, urine volume, operation duration, length of hospital stay and time to first flatus were recorded.On admission to the operating room (T 0), at skin incision (T 1), at the beginning of resection of the liver (T 2), after resection of the lobes of the liver (T 3) and at the end of the surgery (T 4), mean arterial pressure (MAP), heart rate (HR) and lactic acid (Lac) were recorded.The consumption of intraoperative norepinephrine, hypotension, arrhythmia and postoperative adverse reactions were recorded. Results:Compared with group L, the intraoperative volume of blood loss and consumption of intraoperative norepinephrine in group M and intraoperative volume of blood loss, the total amount of fluid infused and urine volume in group H were significantly decreased, consumption of furosemide and nitroglycerin in group H and the total amount of red blood cells infused in M and H groups were increased, length of hospital stay and time to first flatus in group M were shortened, concentration of serum PCT at 1 day after surgery was decreased in group M, MAP at T 3, 4 was increased in group M, and Lac at T 2-4 was increased in group H ( P<0.05). Compared with group M, the intraoperative volume of blood loss, consumption of intraoperative norepinephrine and consumption of furosemide and nitroglycerin were significantly increased, the total amount of fluid infused and urine volume were decreased, length of hospital stay and time to first flatus in group M were prolonged, concentration of serum PCT at 1 day after surgery was increased, MAP at T 3, 4 was decreased in group M, and Lac at T 2-4 was increased in group H ( P<0.05). There was no significant difference in the incidence of postoperative adverse reactions and intraoperative hypotension and arrhythmia among the 3 groups ( P>0.05). Conclusion:Intraoperative fluid therapy guided by SVV at 16%-20% during laparoscopic hepatolobectomy can decrease the intraoperative volume of blood loss and has less effect on renal function, which is helpful for postoperative outcomes.

Allografts ; COVID-19 ; China/epidemiology* ; Disease Outbreaks ; Humans ; Kidney Transplantation/adverse effects* ; SARS-CoV-2

Objective:To evaluate the performance of the European Evidence-based Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP) Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN).Methods:A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤ acyst diameter ≥40 mm,⑤ bcyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results:Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly ( P<0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail, OR=3.284,95% CI:1.268-8.503, P=0.014),thickened/enhancement cyst wall (with vs.without, OR=2.713,95% CI:1.177-6.252, P=0.019),CA19-9(≥37 U/L vs.<37 U/L, OR=5.086,95% CI:2.05-12.62, P<0.01) and NLR(≥2 vs.<2, OR=2.380,95% CI:1.043-5.434, P=0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤ b⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤ a⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤ b⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions:Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.

Objective:To evaluate the performance of the European Evidence-based Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP) Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN).Methods:A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤ acyst diameter ≥40 mm,⑤ bcyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results:Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly ( P<0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail, OR=3.284,95% CI:1.268-8.503, P=0.014),thickened/enhancement cyst wall (with vs.without, OR=2.713,95% CI:1.177-6.252, P=0.019),CA19-9(≥37 U/L vs.<37 U/L, OR=5.086,95% CI:2.05-12.62, P<0.01) and NLR(≥2 vs.<2, OR=2.380,95% CI:1.043-5.434, P=0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤ b⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤ a⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤ b⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions:Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.

Objective To study and prepare the monoclonal antibody library against human FXYD6 functional region,to screen the hybridoma cell lines secreting the monoclonal antibodies against intracellular or extracellular region of human FXYD6,and to identify the biological function of monoclonal antibody against extracellular domain.Methods FXYD6 functional region recombinant protein which did not contain the transmembrane region was prokaryotically expressed,purified,and FXYD6 recombinant protein was used to immunize BALB/c mice.Then splenocytes after immunization were fused with myeloma cells SP2/0.After several rounds of screening and cloning,the hybridomas which secreted the antibodies against the extracellular domain or the intracellular domain of human FXYD6 were established.The antibody specificity and subtype were identified with indirect ELISA,western blot and immunohistochemistry.The monoclonal antibodies against the extracellular domain which recognized the native conformation were screened with flow cytometry.The antibody against extracellular region was prepared with the ascites revulsion method and purified.The affinity constants were measured with indirect ELISA.The function of extracellular monoclonal antibody was detected by HepG2 cell line with high expression of FXYD6.Results The hybridoma cell library which secreted the monoclonal antibody against extracellular domain or the intracellular domain of human FXYD6 was successfully obtained,and extracellular region monoclonal antibodies with the functional blocking were prepared.Conclusion The prepared anti-human FXYD6 extracellular monoclonal antibodies could inhibit HepG2 cell proliferation.

A 7-year-old female patient presented with frontal bossing and exophthalmos complicated by skin pigmentation all over the body for 7 years.Pigmentation was seen on the flexor aspects of the bilateral elbows 1 week after birth,and skin pigmentation gradually appeared at multiple body sites 1 year later.She had suffered from lacrimal duct obstruction since childhood,and repeated dredging of the duct was ineffective.Parents of the child were healthy and non-consanguineous marriage,and had no family history of the same disease.Physical examination showed square-shaped skull,frontal bossing,maxillary hypoplasia,mandibular prognathism,exophthalmos,ocular hypertelorism,depressed nasal bridge,dental malocclusion,and irregular dentition.Skin examination showed dark brown skin all over the body,coarse skin on the neck,axillary and inguinal regions,papillomatous cutaneous thickening,with velvet-like appearance.The patient was diagnosed with Crouzon syndrome complicated by acanthosis nigricans (CAN).Polymerase chain reaction (PCR)and DNA sequencing were performed to detect mutations in the FGFR3 gene in the patient with CAN,her parents and 100 unrelated healthy controls.A heterozygous missense mutation (C.1172 C ＞ A) was identified in the FGFR3 gene in the proband,but not in her parents or the 100 unrelated healthy controls.The missense mutation in the FGFR3 gene may be a causative mutation leading to the clinical manifestations of the patient.