Objective:To explore the influencing factors of early postoperative complications after radical resection of congenital choledochal cyst (CCC) in a single center and provide some clinical basis and guidance for reducing postoperative complications.Methods:Case control study.Clinical data of 124 children (29 boys and 95 girls) with CCC diagnosed and radically treated at the Affiliated Hospital of Zunyi Medical University from September 2010 to October 2019 were analyzed.According to postoperative complications (bile leakage, gastrointestinal anastomotic fistula, bleeding, incision dehiscence, cholangitis, abdominal infection, pancreatitis, and lymphatic fistula), these children were divided into the complication group (group A) and non-complication group (group B). Age, laboratory indicators[preoperative white blood cell (WBC) count, hemoglobin, glutamic pyruvic transaminase, prealbumin, and postoperative albumin], and clinical factors, such as operation method, operation time, intraoperative blood loss, cyst type, cyst diameter, hepatic duct diameter, abdominal operation history, biliary sludge and calculus, hepatic duct anatomic variation, and pancreaticobiliary maljunction were statistically analyzed between the two groups.The t-test was performed for normal distribution of the measurement data, and the non-parametric rank sum test for non-normal distribution.Multivariate analysis was made using Logistic regression. Results:Among the 124 children, 25(20.16%) had complications, and 99(79.84%) had no complications.Bile leakage occurred in 14 children (11.29%), of whom 7 received operation again and 7 received conservative treatment.Gastrointestinal anastomotic fistula occurred in 2 children (1.61%), of whom 1 was re-operated and 1 was cured conservatively.One child (0.81%) was complicated with bleeding and cured by re-operation.Two children (1.61%) were complicated with incision dehiscence, of whom 1 was cured by re-operation and 1 was cured by conservative treatment.Cholangitis in 2 children (1.61%), abdominal infection in 2 children (1.61%), pancreatitis in 1 child (0.81%), and lymphatic fistula in 1 child (0.81%) were all conservatively cured.No significant difference was found in non-normal distribution indicators-age and WBC count-between the two groups (all P>0.05). Blood loss volume and cyst diameter were significantly different between the two groups (all P<0.05). Postoperative albumin[(27.84±4.62) g/L vs.(32.45±3.72) g/L] meeting the normal distribution showed a statistically significant difference between the two groups ( t=5.254, P<0.05). Logistic multivariate regression analysis suggested that preoperative anemia ( OR=7.922, 95% CI: 1.468-42.757) and biliary sludge and calculus ( OR=1.295, 95% CI: 1.075-4.359) were independent risk factors for postoperative complications; postoperative albumin ( OR=0.055, 95% CI: 0.012-0.244) was a protective factor for postoperative complications, and the differences were statistically significant (all P<0.05). Conclusions:The larger the cyst diameter, the more the intraoperative bleeding, and the higher the risk of operation.Treating anemia before operation, clearing sludge in the hepatic duct during operation, reducing bleeding, and strengthening the monitoring of albumin and hemoglobin during the perioperative period can prevent and reduce early complications after radical resection of CCC in children.

Chronic hepatitis B virus (HBV) infection will greatly contribute to raising the occurrence probability of cirrhosis and hepatocellular carcinoma in patients. Although existing antiviral treatment regimens have a certain effect on delaying disease progression and improving prognosis, it is still not effective in attaining functional cures. Hepatitis B virus DNA integration may be one of the reasons for this phenomenon. Therefore, this paper reviews the possible mechanisms of HBV DNA integration in maintaining chronic inflammation of the liver, evading existing antiviral treatment methods, and inducing hepatocellular carcinoma so as to further deepen the understanding of the role of HBV DNA integration in the occurrence and development of chronic hepatitis B, providing ideas and references for formulating better treatment strategies.

Objective:To evaluate the safety and efficacy of enhanced recovery after surgery(ERAS) in the perioperative period of congenital choledochal cysts in children.Methods:This is a multicenter prospective randomized controlled study. The clinical data of 273 pediatric congenital choledochal cysts(CCC) patients who underwent surgery at 14 medical centers with complete follow-up data were collected through the medical data analysis platform. Among them, 123 cases in ERAS group were managed perioperatively in strict accordance with ERAS mode, and 150 cases in conventional group were managed according to traditional mode. The length of hospital stay,time to first farting, time to complete feeding, the incidence of complications, cost and readmission rate within 30 days,stress indexes and liver function were compared between the two groups.Results:Compared with the conventional group, median time to start farting (2.0 d vs. 3.0 d, P<0.001), median time to complete feeding (5.0 d vs. 7.0 d, P<0.001), median postoperative hospitalization time (6.0 d vs. 9.0 d, P<0.001),the median total length of stay(13.0 d vs. 15.0 d, P<0.001) were shorter,the median hospitalization cost (37,000 yuan vs.43,000 yuan P<0.001) was lower, and stress indexes recovered quickly. The incidence of postoperative hospital stay and readimission rate within 30 d were not statistically different between the two groups. Conclusion:It is safe and feasible to implement ERAS for children with CCC in the perioperative period, which can reduce stress response, speed up recovery,and save medical costs.

Background/Aims: Acute-on-chronic liver failure (ACLF) is a catastrophic illness. Few studies investigated the prognostic value of vitamin D-binding protein (VDBP) for hepatitis B virus (HBV)-related ACLF (HBV-ACLF) resulted in conflicting results. Methods: Two prospective HBV-ACLF cohorts (n=287 and n=119) were enrolled to assess and validate the prognostic performance of VDBP. Results: VDBP levels in the non-survivors were significantly lower than in the survivors (P<0.001). Multivariate Cox regression demonstrated that VDBP was an independent prognostic factor for HBV-ACLF. The VDBP level at admission gradually decreased as the number of failed organs increased (P<0.001), and it was closely related to coagulation failure. The areas under the receiver operating characteristic curve (AUCs) of the Child-Pugh-VDBP and chronic liver failuresequential organ failure assessment (CLIF–SOFA)-VDBP scores were significantly higher than those of Child-Pugh (P<0.001) and CLIF-SOFA (P=0.0013). The AUCs of model for end-stage liver disease (MELD)-VDBP were significantly higher than those of MELD (P= 0.0384) only in the case of cirrhotic HBV-ACLF patients. Similar results were validated using an external multicenter HBV-ACLF cohort. By longitudinal observation, the VDBP levels gradually increased in survivors (P=0.026) and gradually decreased in non-survivors (P<0.001). Additionally, the VDBP levels were found to be significantly decreased in the deterioration group (P=0.012) and tended to be decreased in the fluctuation group (P=0.055). In contrast, they showed a significant increase in the improvement group (P=0.036). Conclusions The VDBP was a promising prognostic biomarker for HBV-ACLF. Sequential measurement of circulating VDBP shows value for the monitoring of ACLF progression.

Objective:To investigate the clinical features of Epstein-Barr virus associated lymphoproliferative disease in children and to improve the understanding of this disease.Methods:This study included the children with Epstein-Barr virus associated lymphoproliferative disease admitted to the First Affiliated Hospital of College of Medicine of Zhejiang University from January 2014 to December 2018.Data of these children were collected, including age, clinical manifestations, laboratory results, treatment and outcome.The clinical features and therapeutic effects were analyzed.Results:A total of 114 cases(mean age 6 years, 0~17 years)were enrolled in this study, including 53 males and 61 females.There were 107 cases(93.86%) in the mild group (38 cases of EBV infection and 69 cases of infectious mononucleosis) and 7 cases in the severe group (6.14%). Six cases of the severe group were T cell or NK cell proliferation.Compared with the mild group, the load of EBV-DNA was higher in the severe group, but there was no significant difference( χ2=0.957, P>0.05). The IgM in severe group was significantly lower( Z=-2.041, P<0.05). But the differences in the level of immune function including IgA, IgG, CD4 + cell and CD8 + cell between the severe group and the mild group were not significant.The cases in the mild group had improved after antiviral treatments.Among the severe group, 3 cases survived after treatment, another 1 case was diagnosed as hydroa vacciniforme-like EBV-related proliferative disease (HV-like LPD). After antiviral treatment, the effect was not good, then after high-dose IVIG treatment and Bortezomib combined with methylprednisolone treatment, the EBV-DNA load decreased and the condition improved.While 1 case lost to follow-up, there were 2 cases with EBV-associated hemophagocytic syndrome and 1 case with EBV-associated lymphoma died after chemotherapy or transplantation. Conclusion:EBV-associated lymphoproliferative disease may manifest as a condition similar to infectious mononucleosis.High IgE, low IgM or high DNA load may indicate poor prognosis.Immune function after EBV infection may have different effects on prognosis.When the infected lymphocyte types are NK or T cells, it may indicate poor prognosis.The efficacy of transplantation and chemotherapy in severe cases is still uncertain.

Objective To explore the gene mutation characteristics and detailed clinical presentations of hyperglycemia caused by GCK mutations in 10 patients.Methods The clinical and follow-up data of 10 patients with hyperglycemia caused by mutation of GCK gene were reviewed.The patients were ascertained between January 1,2014 and August 31,2018 at the Department of Pediatrics,the First Affiliated Hospital of Zhejiang University and Ningbo Women & Children's Hospital.Clinical data were collected,including age,gender,main complaint,family history,fasting blood glucose,fasting blood insulin,2-hour blood glucose,2-hour blood insulin after oral glucose tolerance test,glycosylated hemoglobin,anti-glutamic acid decarboxylase antibody and body mass index.Mutations of GCK gene were detected by Sanger sequencing or high-throughput sequencing of diabetes-related genes in the patients and their family members.Results There were ten patients,8 of them were male,2 were female.The ages at diagnosis varied between 4.7 to 12.3 years.The patients usually did not have obvious clinical symptoms of diabetes mellitus.Most of them were unexpectedly found to have hyperglycemia and with impaired glucose metabolism in three consecutive generations.The fasting blood glucose of patients was 6.8-7.7 mmol/L,2-hour postprandial blood glucose was 7.8-11.6 mmol/L.Fasting blood insulin was 0.5-8.5 mU/L,glucose tolerance test results showed that 2 h postprondial blood insulin was 1.3-55.4 mU/L.The level of glycosylated hemoglobin was 6.1％-6.8％.Anti-glutamic acid decarboxylase antibody was negative in all patients.The GCK mutations identified in patients and one of their parents were located at exon5 (4 cases),exon9 (2 cases),exon2 (1 case),exon4 (1 case),exon6 (1 case) and exon7 (1 case).Conclusions Most of the hyperglycemia patients caused by GCK mutations did not have typical clinical symptoms of diabetes.The fasting blood glucose was slightly elevated.Abnormal glucose tolerance test results were found in all 10 patients.Three consecutive generations of family had impaired glucose metabolism.GCK mutations located at exon 5 were common in 10 cases.There was no correlation between type of mutations and plasma glucose levels in domestic and international researches.When fasting glucose was found abnormal in clinic,a complete family history should be taken and the GCK gene should be sequenced to confirm the diagnosis in time.

Biliary atresia (BA) is a common neonatal liver disease characterized by inflammation and fibrosis of the extrahepatic biliary ducts,leading to cholestasis and biliary cirrhosis.It is also a severe liver disease in infants.The pathogenesis of BA is associated with multiple genes and gene polymorphism,virus infections,epigenetic,immune abnormalities,and so on.With the development of genetic technology,it provides a new method to determine the susceptibility genes in BA.Now,more and more doctors pay attention to the change and regulation of genes in BA.

In order to improve the quality of medical records written by interns of clinical medicine in hematology department,we evaluated and analyzed 100 medical records written by the interns.The main reasons that affect the quality of medical record written by interns are the writing defects that are history of present illness,past history,personal history,the record of the clinical operation,blood transfusion and chemotherapy.There are other reasons for affecting the quality of medical records,such as students in clinical practice not paying attention to the writing of medical records,the relative lag of teaching management,the particularity of the diseases in the department of hematology and the weak legal consciousness.Therefore,we should strengthen the teaching management,improve the comprehensive quality of the clinical teaching teachers,carry out the pre job training of the medical records for the interns,train the interns' inquiries and the ability to communicate with the doctors and patients,and make use of the typical medical records of the Department of Hematology to combine the discussion and other ways,so as to strengthen the interns' clinical disease writing skills and legal consciousness as well as the quality of their writing medical records.

Aim To investigate the effect of salvianolic acid B (Sal B)on c-Jun N-terminal kinase (JNK)ac-tivation and apoptosis of INS-1 cells induced by inter-mittent high glucose.Methods INS-1 cells were pre-incubated with Sal B for 24 h,followed by exposure to intermittent high glucose (IHG,11.1 mmol·L-1 12 h,33. 3 mmol·L-1 12 h)for 72 h.Cell viability was assessed by MTT assay and cell apoptosis was evalua-ted by flow cytometry.Glucose induced insulin secre-tion capacity and intracellular reactive oxygen species (ROS)contents were measured by enzyme linked im-munosorbent assay (ELISA)and a fluorescent probe DCFH-DA,respectively.Levels of JNK activation and PDX-1 protein expression were determined by Western blot analysis.Results Sal B significantly alleviated IHG-induced cell injury and apoptosis,with glucose induced insulin secretion capacity improved evidently (P<0.05 or P<0.01).Preincubation with Sal B no-tably decreased intracellular ROS and JNK activation in INS-1 cells,while the level of PDX-1 protein was in-creased markedly (P<0.05 or P<0.01 ).Conclu-sion Sal B is capable of ameliorating IHG-induced cell injury and apoptosis in INS-1 cells,which might be derived from suppression of JNK activation and up-regulation of PDX-1 protein expression.

Objective To investigate association of the paired box 4 (PA X 4) gene rs3824004 (574C>A; R192S) and rs2233580 (575G>A; R192H) polymorphism with obesity and metabolic markers in children and adolescents. Methods A total of 103 obese children were randomly selected, and an average age was (10.82±2.57) years, and body mass index (BMI) was (26.82±4.57) kg/m2. At the same period, 100 normal weight children were selected as the control group, and an average age of (10.60±2.84) years, and BMI was (16.79±2.13) kg/m2. The blood pressure, physical measurements, and blood metabolic parameters were measured and compared. The oral glucose tolerance test (OGTT) and insulin release test were performed in the obesity group. The homeostasis model insulin resistance index (HOMA-IR) and the overall insulin sensitivity index (WBISI) were calculated. PA X 4 rs3824004 and rs2233580 polymorphism were detected by PCR.The differences of allele frequency and genotype frequency of polymorphic loci were analyzed, and the correlation between different genotypes and metabolic indexes was analyzed. Results The height, weight, BMI, systolic blood pressure, diastolic blood pressure, waist circumference, hip circumference, waist to height ratio (WHtR), fasting blood glucose (FPG), total cholesterol (TC), low density lipoprotein (LDL), triacylglycerol (TG), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) in the obesity group were significantly higher than those in the control group, and the high density lipoprotein (HDL) was significantly lower than that in the control group (all P<0.05). The frequency of gene distribution was in accordance with the Hard-Weinberg balance. The frequencies of A allele of rs3824004 in obesity and control groups were 4.9% and 5.0%, respectively, and the frequencies of CA genotype were 9.7% and 10.0%, respectively, and there was no significant difference between two groups (P>0.05). The frequency of GA allele of rs2233580 in obesity group was 25.2%, which was significantly higher than that in control group (P<0.05). The BMI and waist in rs2233580 GA genotype were significantly higher than those in GG genotype (all P <0.05). However,logistic regression analysis showed that there was no correlation between PA X 4 rs2233580 genotype and metabolic markers (all P>0.05).There were no significantly differences in HOMA-IR and WBISI among different genotypes of PA X 4 rs2233580 in obesity group(all P>0.05).Conclusions PA X 4 rs2233580 affects children's BMI and waist circumference and may be involved in the development of childhood obesity, but it is not an independent risk factor for obesity in children and adolescents.