This article summarized Professor TU Jinwen's experience in treatment of intracranial atherosclerotic stenosis （ICAS） with principles of supplementing deficiency， resolving toxins and unblocking Collaterals. He believes that toxin damaging brain collaterals is the core pathogenesis of ICAS， and thereafter proposed supplementing deficiency， resolving toxins， and unblocking collaterals be the basic treatment method. The emptiness of brain collaterals is the source of the disease. For cases where there is spleen kidney depletion and insufficiency of original qi， the modified Sijunzi Decoction and Liuwei Dihuang Pills （四君子汤合六味地黄丸） could be used to fortify the spleen and tonify the kidneys to enrich the collaterals. The accumulation of turbidity stasis toxin in brain collaterals is essential components of the pathogenesis. For cases where turbidity and stasis combine together， inducing toxins and obstructing the colla-terals， the modified Taohong Siwu Decoction and Erchen Decoction （桃红四物汤合二陈汤） could be used to eliminate toxins and dispel knots to unblock the collaterals. Yin toxins obstructing the latent collaterals represent the gradual progression of pathogenic factors. For cases where turbid stasis transform into cold and yin toxins hide in the collaterals， the modified Buyang Huanwu Decoction and Ditan Decoction （补阳还五汤合涤痰汤） could be used to remove the toxin， warm and activate the collaterals. Heat toxins damaging the collaterals signify aggravated changes in disease. For cases where turbid stasis transforms into heat and toxins injure the brain collaterals， the modified Dachaihu Decoction and Huanglian Jiedu Decoction （大柴胡汤合黄连解毒汤） could be used to cool blood and dredge the fu viscera to clear collaterals.

Objective To construct and validate a predictive model for gastric precancerous le-sions based on urea breath test,serum pepsinogen(PG)and gastrin-17(G-17).Methods Partici-pants who underwent endoscopic screening for upper gastrointestinal tumors were retrospectively en-rolled as study subjects.Using random function,all participants were divided into training cohort of 2,788 cases(comprising 1,290 cases in precancerous lesion group and 1,498 cases in control group)and validation cohort of 1,194 cases(comprising 581 cases in precancerous lesion group and 613 cases in control group)at a ratio of 7 to 3.A simple model was established based on urea breath test,PG and G-17.Clinical data between the precancerous lesion group and the control group in the training cohort were compared.A predictive model for gastric precancerous lesions was constructed u-sing multifactorial Logistic regression analysis,and a scoring model for gastric precancerous lesions(the complete model)was developed based on this predictive model.The complete model,the simple model,the new ABC method,and the Li's score were all included in the validation cohort to compare the predictive performance of the four models.Results Multifactorial Logistic regression analysis indicated that male,smoking,positive Helicobacter pylori(Hp)infection,PG Ⅱ ≥10.19 μg/L,the ratio of PG Ⅰ to PG Ⅱ(PGR)≤11.87,and G-17 ≥3.82 pmol/L were independent risk factors for gastric precancerous lesions(P＜0.05).A predictive model for gastric precancerous lesions was constructed based on these risk factors,and the complete model was established based on the predic-tive model.The total score ranged from 0 to 12(with 6 to 12 indicating a high-risk population for gastric precancerous lesions and 0 to 5 indicating a low-risk population).When the complete model,the simple model,the new ABC method,and the Li's score were included in the validation cohort for comparison,the predictive values of the complete model and the simple model were similar.Both models demonstrated higher sensitivity,specificity,positive predictive value,negative predictive value,and accuracy compared to the new ABC method and the Li's score.Furthermore,the diag-nostic value of the simple model in the high-sensitivity region was slightly superior to that of the com-plete model.Conclusion The simple model constructed based on the urea breath test,PG and G-17 exhibits favorable predictive efficacy,calibration,and clinical utility,and is of positive signifi-cance for the early identification of patients with gastric precancerous lesions.

Objective To explore the factors associated with the pathogenesis of gastric ulcer and mechanism of inflammatory response in a mouse model.Methods A total of 31 patients with gastric ulcer were enrolled in the ulcer group,and 31 healthy individuals undergoing physical exami-nations during the same period were included in healthy group.The infection status of Helicobacter pylori(Hp),serum levels of inflammatory cytokines and T-lymphocyte subset indicators were com-pared between the two groups.Logistic regression analysis was employed to screen for the influencing factors of gastric ulcer onset.A lipopolysaccharide(LPS)-induced gastric injury mouse model was constructed,and the levels of relevant inflammatory cytokines after chlorogenic acid intervention were measured.Results The Hp infection level in the healthy group was lower than that in the ulcer group,and the difference was statistically significant(t=5.95,P＜0.001).The levels of interleu-kin(IL)-2,IL-5,IL-8,IL-12p70,IL-17A,interferon-α(IFN-α)and tumor necrosis factor-α (TNF-α)in the ulcer group were higher than those in the healthy group,with statistically significant differences(P＜0.05).The counts of cluster of differentiation 45-positive lymphocytes(CD45+Lym),T-lymphocytes(CD3+),helper/inducer T-lymphocytes(CD3+CD4+),suppressor/cytotoxic T-lymphocytes(CD3+CD8+)and the percentages of helper/inducer T-lymphocytes(CD3+CD4+％)in the ulcer group were lower than those in the healthy group,and the differences were statistically significant(P＜0.05).Logistic multivariate regression analysis revealed that Hp infec-tion,elevated IL-12p70 and elevated TNF-α were independent risk factors for the onset of gastric ul-cer(P＜0.05).In the LPS-induced gastric injury mouse model,chlorogenic acid intervention sig-nificantly inhibited increase in the expression levels of IL-6,IL-1β,IL-12 and TNF-α in mouse plasma(P＜0.05).Conclusion Patients with gastric ulcer exhibit high expression of Hp,IL-12p70 and TNF-α,which are important influencing factors for the pathogenesis of gastric ulcer.In addition,chlorogenic acid can effectively inhibit the elevation of inflammatory cytokine levels in mice with LPS-induced gastric injury.

Objective:To investigate the correlation between cardiac polyps and gastroesophageal flap valve (GEFV).Methods:The clinical, endoscopic and pathological data of 349 patients with cardiac polyps (the cardiac polyp group) visiting Affiliated Hospital of Yangzhou University from January 1, 2016 to December 31, 2021 were retrospectively collected, and the same number of non-cardiac polyp patients (the non-cardiac polyp group) were matched in the same period as control according to the propensity score. The clinical, endoscopic and pathological data of the two groups were compared.Results:After matching with propensity score, there were 296 patients in each group, with no significant differences in smoking, acid reflux, heartburn, Helicobacter pylori infection, bile reflux, reflux esophagitis or pancreatitis between the two groups ( P>0.05). Compared with the non-cardiac polyp group, the risk of cardiac polyps increased in GEFV Ⅱ patients ( OR=3.046, 95%CI: 2.100-4.419, P<0.001) and GEFV Ⅲ patients ( OR=4.202, 95%CI: 2.299-7.681, P<0.001). Compared with the non-cardiac polyp group, the risk of cardiac polyps increased in patients with GEFV abnormalities ( OR=2.822, 95%CI: 1.615-4.931, P<0.001). GEFV abnormalities was associated with the cardiac polyp site ( χ2=22.169, P=0.003) and was not significantly associated with cardiac polyp size, number, morphology, intestinal metaplasia of the surrounding mucosa or intraepithelial neoplasia ( P>0.05). Conclusion:The occurrence of cardiac polyps is related to GEFV, and the patients with GEFV abnormalities are more likely to develop cardiac polyps.

Objective:To evaluate the safety and effectiveness of rubber band-assisted endoscopic submucosal excavation (RB-ESE) for gastric submucosal tumors (SMT).Methods:A retrospective study was conducted on data of gastric SMT patients who underwent ESE in Affiliated Hospital of Yangzhou University from January 2017 to August 2022. A total of 48 patients were selected and divided into two groups: RB-ESE group ( n=20) and the conventional ESE (C-ESE) group ( n=28). The operation time, bleeding rate and perforation rate during operation, the retention rate of the mucosal cap, the number of clips, postoperative complications, and the hospitalization time were analyzed. Additionally, correlations between complications and tumor size/location and between bleeding and perforation were evaluated. Results:No significant difference was found in the general conditions between the two groups ( P>0.05). The operation time of RB-ESE group (14.82±2.31 min) was significantly shorter than that of C-ESE group (23.70±3.67 min) ( t=-9.539, P<0.001). The intraoperative bleeding rates were 20.0% (4/20) and 42.9% (12/28) in the RB-ESE group and C-ESE group respectively ( χ2=2.743, P=0.098), while the intraoperative perforation rates were 25.0% (5/20) and 46.4% (13/28) respectively ( χ2=2.286, P=0.131). Furthermore, the mucosal cap preservation rate was notably higher in the RB-ESE group at 60.0% (12/20) compared with 7.1% (2/28) in the C-ESE group ( χ2=15.777, P<0.001). The number of clips applied to close the wound was 8.05±1.40 and 10.43±1.96 in the RB-ESE group and C-ESE group respectively ( t=4.925, P<0.001). The postoperative hospital stays were 4.35±0.75 days and 5.00±0.86 days respectively in two groups ( t=2.724, P=0.009). No postoperative bleeding or perforation occurred in either group. The results showed that the occurrence of perforation and bleeding were associated with tumor diameter. Patients with tumor size ≥2 cm showed increased proportions of intraoperative bleeding [68.4% (13/19), P<0.001] and perforation [78.9% (15/19), P<0.001]. There was a correlation between intraoperative bleeding and perforation ( P<0.001). Conclusion:RB-ESE proves to be an effective and safe approach for managing gastric SMT, offering advantages such as reduced operation time and hospital stays, improved retention of the mucosal cap post-operation, and less clips use. The results suggest that RB-ESE could be widely adopted for treating SMT.

Objective To explore the efficacy and safety of endoscopic retrograde appendicitis therapy (ERAT) for pediatric acute appendicitis. Methods Thirty-five pediatric patients with acute simple appendicitis admitted between June 2021 and November 2023 were selected as study subjects. Relevant perioperative data including clinical manifestations, diagnostic and therapeutic processes, as well as treatment and follow-up outcomes were collected. Results All 35 patients successfully underwent ERAT with an operation time ranging from 24 to 75 min. Intubation of the appendiceal lumen was successful in all patients, with pus flushed out or stones removed. After contrast administration and flushing, 16 patients were found to have pus only in the appendiceal lumen with no appendicoliths, while 19 patients had both pus and visible appendicoliths with diameters ranging from 2 to 5 mm. Of 19 patients, 17 appendicoliths were loose and 2 were well-formed. Abdominal pain symptoms were alleviated within a short period, with the average VAS score decreasing from 6.6 preoperatively to 1.7 at 3 hours postoperatively and to 0.2 at 24 hours postoperatively. There was a statistically significant difference in Visual Analogue Scale(VAS) scores before and after surgery (P < 0.05). During follow-up ranging from 3 to 11 months postoperatively, appendicitis recurred in one patient one week after ERAT, while no surgery-related complications occurred in the other patients during follow-up. Conclusion ERAT is a safe and effective endoscopic treatment for pediatric acute appendicitis, with advantages including reduced trauma and shorter recovery time. It is particularly suitable for pediatric patients with acute simple appendicitis complicated by appendicoliths, appendiceal lumen stenosis, or intra-appendiceal abscesses.

Objective:To investigate the effect of intravenous anesthesia on the detection rate of lesions in diagnostic gastroscopy.Methods:A total of 9 071 subjects who underwent diagnostic gastroscopy at the Digestive Endoscopy Center of Yangzhou University Affiliated Hospital from March 2021 to February 2022 were selected. Data were collected from the gastroscopy quality control system, including age, gender, examination physician, Helicobacter pylori infection, examination method, withdrawal time, number of images left, number of biopsies, biopsy site, gastroscopy diagnosis, pathological diagnosis, etc. They were divided into anesthesia group and general group based on the examination method, and propensity score matching (PSM) was performed on the two groups of subjects. Excluding confounding factors, the detection of lesion location and lesion type in two groups of subjects was analyzed; Simultaneously, univariate and multivariate logistic regression analysis was used to analyze the influencing factors of the detection rate of precancerous lesions and malignant tumors in the upper gastrointestinal tract.Results:After PSM, 1 655 subjects were included in both groups. In terms of lesion location, the detection rate of gastric body lesions in the anesthesia group was higher than that in the general group ( P<0.05), and the detection rate of esophageal lesions in the anesthesia group was lower than that in the general group ( P<0.05); In terms of lesion types, the detection rate of precancerous lesions such as gastric polyps, mucosal protrusions, mucosal atrophy, and intestinal metaplasia in the anesthesia group was higher than that in the general group (all P<0.05). The results of logistic regression analysis showed that intravenous anesthesia was an independent influencing factor for the detection rate of precancerous lesions and malignant tumors in diagnostic gastroscopy ( OR=1.338, 95% CI: 1.070-1.674, P<0.05). Conclusions:Intravenous anesthesia is an independent influencing factor for the detection rate of precancerous lesions and malignant tumors in diagnostic gastroscopy, and can improve the detection rate of upper gastrointestinal lesions.

ObjectiveTo investigate the value of aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 (FIB-4) score, and gamma-glutamyl transpeptidase-to-platelet ratio (GPR) in diagnosis of liver inflammation grade in patients with chronic hepatitis B (CHB). MethodsA total of 545 patients with CHB who underwent percutaneous liver biopsy and routine laboratory examinations during hospitalization in Shanghai Public Health Clinical Center Affiliated to Fudan University from October 2016 to October 2019 were enrolled. Inflammation grade (G) was determined according to the Scheuer scoring system, and APRI, FIB-4, and GPR were calculated based on related clinical indicators. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. A Spearman correlation analysis was used to investigate the correlation between two variables. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance of the three serum noninvasive diagnostic models in determining liver inflammation grade, and the Delong test was used for comparison of the area under the ROC curve (AUC). ResultsAmong the 545 patients, 224 had grade G0-1 liver inflammation, 209 had grade G2 liver inflammation, and 112 had grade G3 liver inflammation. The Spearman correlation analysis showed that APRI, FIB-4, and GPR were positively correlated with liver inflammation grade (r=0.611, 0.470, and 0.563, all P＜0.001). APRI, FIB-4, and GPR had an AUC of 0.820, 0.719, and 0782, respectively, in the diagnosis of G≥2 liver inflammation, with optimal cut-off values of 0.53, 1.48, and 0.20, respectively; for the diagnosis of G≥2 liver inflammation, GPR had a better performance than FIB-4 (P=0.01) and a slightly lower performance than APRI (P=0.048). The stratified analysis based on alanine aminotransferase (ALT) level showed that in the ≤1×upper limit of normal (ULN) group, the (1-2)×ULN group, and the (2-5)×ULN group, APRI had an AUC of 0.847, 0.786, and 0.724, respectively, in the diagnosis of G≥2 liver inflammation, FIB-4 had an AUC of 0.777, 0.729, and 0.626, respectively, and GPR had an AUC of 0.801, 0.781, and 0.607, respectively; the subgroup analysis showed that GPR had a similar diagnostic performance to APRI and FIB-4 in all ALT stratification groups except the (2-5)×ULN group, in which GPR had a lower diagnostic performance than APRI (P=0.042). APRI, FIB-4, and GPR had an AUC of 0.791, 0.725, and 0.801, respectively, in the diagnosis of G≥3 liver inflammation, with optimal cut-off values of 0.66, 1.49, and 0.25, respectively; in the diagnosis of G≥3 liver inflammation, GPR had a similar diagnostic performance to APRI and a better diagnostic performance than FIB-4 (P=0.006). The stratified analysis based on ALT level showed that in the ≤1×ULN group, the (1-2)×ULN group, and the (2-5)×ULN group, APRI had an AUC of 0.900, 0.742, and 0.693, respectively, in the diagnosis of G≥3 liver inflammation, FIB-4 had an AUC of 0.874, 0.683, and 0.644, respectively, and GPR had an AUC of 0.890, 0.805, and 0.668, respectively. The subgroup analysis showed that GPR had a similar diagnostic performance to APRI and FIB-4 in all ALT stratification groups except the (1-2)×ULN group, in which GPR had a better diagnostic performance than FIB-4(P=0.015). ConclusionAPRI, FIB-4, and GPR may accurately diagnose liver inflammation grade in CHB patients, which helps to monitor the progression of CHB and determine the timing of antiviral therapy.

Objective:To evaluate the effect of remimazolam combined with remifentanil used for painless gastroscopy.Methods:A total of 150 patients of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, aged 18-64 yr, with body mass index of 18-30 kg/m 2, scheduled for elective painless gastroscopy, were divided into 3 groups ( n=50 each) using a random number table method: propofol combined with remifentanil group (group P), remimazolam 0.3 mg/kg combined with remifentanil group (group R1) and remimazolam 12 mg combined with remifentanil group (group R2). Drugs were administrated according to body weight, and calculation was carried out according to ideal body weight.Remifentanil 0.25 μg/kg was injected intravenously, propofol 1.5 mg/kg was then injected intravenously in group P, remimazolam 0.3 mg/kg was injected intravenously in group R1, and remimazolam 12 mg was injected intravenously in group R2.When Modified Observer′s Assessment/Alertness and Sedation (MOAA/S) score was≤3, gastroscopy was performed.It was defined as sedation failure when MOAA/S score was still ≥4 at 3 min after administration of propofol or remimazolam.When intraoperative body movement occurred, 1/4 of the initial dose of propofol was injected intravenously in group P, 1/4 of the initial dose of remimazolam was injected intravenously in group R1, and remimazolam 2.5 mg was injected intravenously in group R2 to maintain MOAA/S score ≤3.It was defined as sedation failure when sufficient sedation was not maintained after the additional drugs were given more than 3 times within 15 min.The success of sedation, time for gastroscopy, emergence time and discharge time were recorded.The occurrence of intraoperative body movement, bradyeardia, hypotension, respiratory depression, hiccup, coughing and injection pain was recorded. Results:Compared with group P, no significant change was found in the success rate of sedation ( P>0.05), and the incidence of intraoperative body movement, bradyeardia, hypotension, respiratory depression, hiccup, coughing and injection pain was decreased in group R1, and the success rate of sedation was significantly decreased, the incidence of intraoperative body movement, bradyeardia, hypotension, respiratory depression, coughing and injection pain was decreased, and the incidence of hiccup was increased in group R2 ( P<0.05). Compared with group R2, the success rate of sedation was significantly increased, and the incidence of intraoperative body movement, coughing and hiccup was decreased in group R1 ( P<0.05). Conclusion:Remimazolam 0.3 mg/kg combined with remifentanil can be safely and effectively used for painless gastroscopy.

Objective To assess the diagnostic performance of liver stiffness measurement(LSM)and serum markers on hepatic fibrosis in chronic hepatitis B(CHB)patients with alanine aminotransferase(ALT)less than or equal to two times the upper limit of normal(≤2×ULN).Methods A total of 284 CHB patients with ALT≤2×ULN who were treated in Department of Hepatobiliary Medicine,Public Health Clinical Center,Shanghai from October 2015 to December 2017 were analyzed.FibroScan,routine blood tests and serum fibrosis markers were conducted on the day or one day before liver biopsy.The Scheuer scoring system was used for liver histologic assessment.Aspartate aminotransferase to platelet ration index(APRI)and FIB-4 were calculated.Based on the results of liver pathology,the area under receiver operating characteristic curve(AUROC)was used to evaluate the value of LSM and serum markers in the diagnosis of liver fibrosis stage.Non-normal distribution variables were expressed as M(QR)as appropriate,and compared by analysis of Kruskal-Wallis test as appropriate.The correlation between two variables was analyzed by Spearman correlation analysis.Results Of 284 CHB patients,175 were male and 109 were female.For inflammatory grading,175 cases were G1 grade,88 cases were G2,and 21 cases were G3.For fibrosis grading,153 cases were S1,53 cases were S2,34 cases were S3,and 44 cases were S4.Spearman correlation analysis showed that LSM,APRI and FIB-4 were positively correlated with hepatic fibrosis stage(r=0.650,0.484,and 0.317,respectively,all P<0.01).The AUC of LSM for predicting fibrosis≥S2,≥S3,and S4 were 0.840,0.902,and 0.942,respectively.The cut-off of LSM values were 6.10,8.40,and 10.10 kPa,respectively.The values of AUC of APRI and FIB-4 for predicting fibrosis≥S2 were 0.755 and 0.638,respectively,those for predicting fibrosis≥S3 were 0.737 and 0.657,respectively,and those for S4 were 0.804 and 0.694,respectively.The AUCs of LSM for predicting fibrosis≥S2 in patients with ALT≤1×ULN and those with ALT>1 -≤2×ULN were 0.857 and 0.813,respectively,those for fibrosis≥S3 were 0.890 and 0.892,respectively,and those for S4 were 0.925 and 0.908,respectively.The cut-off of LSM were 5.90 and 7.80 kPa,8.10 and 9.50 kPa,8.40 and 10.40 kPa,respectively.Conclusions LSM could accurately assess the degree of liver fibrosis in CHB patients with ALT≤2×ULN,which is superior to serum markers for predicting liver fibrosis stage.