Objective:To investigate the safety and feasibility of the CHESS endoscpic ruler (CHESS ruler), and the consistency between the measured values and the interpretation values by endoscopic physician experience.Methods:From January 2021 to January 2022, a total of 105 liver cirrhosis patients with portal hypertension were prospectively enrolled from General Hospital, Xixia Branch Hospital, Ningnan Hospital of People′s Hospital of Ningxia Hui Autonomous Region (29 cases), and the First People′s Hospital of Yinchuan (25 cases), General Hospital of Ningxia Medical University (18 cases), Wuzhong People′s Hospital (10 cases), the Fifth People′s Hospital of Ningxia Hui Autonomous Region (10 cases), Shizuishan Second People′s Hospital (6 cases), Yinchuan Second People′s Hospital (5 cases), and Zhongwei People′s Hospital (2 cases) 8 hospitals. The clinical characteristics of all the patients, including gender, age, nationality, etiolog of liver cirrhosis, and Child-Pugh classification of liver function were recorded. A big gastroesophageal varices was defined as diameter of varices ≥5 mm. Endoscopist (associated chief physician) performed gastroscopy according to the routine gastroscopy procedures, and the diameter of the biggest esophageal varices was measured by experience and images were collected, and then objective measurement was with the CHESS ruler and images were collected. The diameter of esophageal varices of 10 randomly selected patients (random number table method) was determined by 6 endoscopists (attending physician or associated chief physician) with experience or measured by CHESS ruler. Kappa test was used to test the consistency in the diameter of esophageal varices between measured values by CHESS ruler and the interpretation values by endoscopic physician experience.Results:Among 105 liver cirrhosis patients with portal hypertension, male 65 cases and female 40 cases, aged (54.8±12.2) years old, Han nationality 82 cases, Hui nationality 21 cases and Mongolian nationality 2 cases. The etiology of liver cirrhosis included chronic hepatitis B (79 cases), alcoholic liver disease (7 cases), autoimmune hepatitis (7 cases), chronic hepatitis C (2 cases), and other etiology (10 cases). Liver function of 32 cases was Child-Pugh A, Child-Pugh B 57 cases, and Child-Pugh C 16 cases. All 105 liver cirrhosis patients with cirrhotic portal hypertension were successfully measured the diameter of gastroesophageal varices by CHESS ruler, and the success rate of application of CHESS ruler was 100.0% (105/105). The procedure time from the CHESS ruler into the body to the exit of the body after measurement was (3.50±2.55) min. No complications happened in all the patients during measurement. Among 105 liver cirrhosis patients with cirrhotic portal hypertension, 96 cases (91.4%) were recognized as big gastroesophageal varices by the endoscopists. Totally 93 cases (88.6%) were considered as big gastroesophageal varices by CHESS ruler. Eight cases were recognized as big gastroesophageal varices by the endoscopist, however not by the CHESS ruler; 5 cases were recognized as big gastroesophageal varices by the CHESS ruler, but not by the endoscopists; 4 cases were not recognized as big gastroesophageal varices both by the endoscopists and CHESS ruler; 88 cases were recognized as big gastroesophageal varices both by the endoscopists and CHESS ruler. The missed diagnostic rate of big gastroesophageal varices by the endoscopists experience was 5.4% (5/93), and the Kappa value of consistency coefficient between the measurement by the CHESS ruler and the interpretation by endoscopists experience was 0.31 (95% confidence interval 0.03 to 0.60). The overall Kappa value of consistency coefficient by 6 endoscopists measured by CHESS ruler in big gastroesophageal varices diagnosis was 0.77 (95% confidence interval 0.61 to 0.93).Conclusion:As an objective measurement tool, CHESS ruler can make up for the deficiency of subjective judgment by endoscopists, accurately measure the diameter of gastroesophageal varices, and is highly feasible and safe.

Objective:To investigate the diagnostic accuracy of serological indicators and evaluate the diagnostic value of a new established combined serological model on identifying the minimal hepatic encephalopathy (MHE) in patients with compensated cirrhosis.Methods:This prospective multicenter study enrolled 263 compensated cirrhotic patients from 23 hospitals in 15 provinces, autonomous regions and municipalities of China between October 2021 and August 2022. Clinical data and laboratory test results were collected, and the model for end-stage liver disease (MELD) score was calculated. Ammonia level was corrected to the upper limit of normal (AMM-ULN) by the baseline blood ammonia measurements/upper limit of the normal reference value. MHE was diagnosed by combined abnormal number connection test-A and abnormal digit symbol test as suggested by Guidelines on the management of hepatic encephalopathy in cirrhosis. The patients were randomly divided (7∶3) into training set ( n=185) and validation set ( n=78) based on caret package of R language. Logistic regression was used to establish a combined model of MHE diagnosis. The diagnostic performance was evaluated by the area under the curve (AUC) of receiver operating characteristic curve, Hosmer-Lemeshow test and calibration curve. The internal verification was carried out by the Bootstrap method ( n=200). AUC comparisons were achieved using the Delong test. Results:In the training set, prevalence of MHE was 37.8% (70/185). There were statistically significant differences in AMM-ULN, albumin, platelet, alkaline phosphatase, international normalized ratio, MELD score and education between non-MHE group and MHE group (all P<0.05). Multivariate Logistic regression analysis showed that AMM-ULN [odds ratio ( OR)=1.78, 95% confidence interval ( CI) 1.05-3.14, P=0.038] and MELD score ( OR=1.11, 95% CI 1.04-1.20, P=0.002) were independent risk factors for MHE, and the AUC for predicting MHE were 0.663, 0.625, respectively. Compared with the use of blood AMM-ULN and MELD score alone, the AUC of the combined model of AMM-ULN, MELD score and education exhibited better predictive performance in determining the presence of MHE was 0.755, the specificity and sensitivity was 85.2% and 55.7%, respectively. Hosmer-Lemeshow test and calibration curve showed that the model had good calibration ( P=0.733). The AUC for internal validation of the combined model for diagnosing MHE was 0.752. In the validation set, the AUC of the combined model for diagnosing MHE was 0.794, and Hosmer-Lemeshow test showed good calibration ( P=0.841). Conclusion:Use of the combined model including AMM-ULN, MELD score and education could improve the predictive efficiency of MHE among patients with compensated cirrhosis.

Objective:To compare the differences in the prevalence of mild micro-hepatic encephalopathy (MHE) among patients with cirrhosis by using the psychometric hepatic encephalopathy score (PHES) and the Stroop smartphone application (Encephal App) test.Methods:This prospective, multi-center, real-world study was initiated by the National Clinical Medical Research Center for Infectious Diseases and the Portal Hypertension Alliance and registered with International ClinicalTrials.gov (NCT05140837). 354 cases of cirrhosis were enrolled in 19 hospitals across the country. PHES (including digital connection tests A and B, digital symbol tests, trajectory drawing tests, and serial management tests) and the Stroop test were conducted in all of them. PHES was differentiated using standard diagnostic criteria established by the two studies in China and South Korea. The Stroop test was evaluated based on the criteria of the research and development team. The impact of different diagnostic standards or methods on the incidence of MHE in patients with cirrhosis was analyzed. Data between groups were differentiated using the t-test, Mann-Whitney U test, and χ2 test. A kappa test was used to compare the consistency between groups. Results:After PHES, the prevalence of MHE among 354 cases of cirrhosis was 78.53% and 15.25%, respectively, based on Chinese research standards and Korean research normal value standards. However, the prevalence of MHE was 56.78% based on the Stroop test, and the differences in pairwise comparisons among the three groups were statistically significant (kappa = -0.064, P < 0.001). Stratified analysis revealed that the MHE prevalence in three groups of patients with Child-Pugh classes A, B, and C was 74.14%, 83.33%, and 88.24%, respectively, according to the normal value standards of Chinese researchers, while the MHE prevalence rates in three groups of patients with Child-Pugh classes A, B, and C were 8.29%, 23.53%, and 38.24%, respectively, according to the normal value standards of Korean researchers. Furthermore, the prevalence rates of MHE in the three groups of patients with Child-Pugh grades A, B, and C were 52.68%, 58.82%, and 73.53%, respectively, according to the Stroop test standard. However, among the results of each diagnostic standard, the prevalence of MHE showed an increasing trend with an increasing Child-Pugh grade. Further comparison demonstrated that the scores obtained by the number connection test A and the number symbol test were consistent according to the normal value standards of the two studies in China and South Korea ( Z = -0.982, -1.702; P = 0.326, 0.089), while the other three sub-tests had significant differences ( P < 0.001). Conclusion:The prevalence rate of MHE in the cirrhotic population is high, but the prevalence of MHE obtained by using different diagnostic criteria or methods varies greatly. Therefore, in line with the current changes in demographics and disease spectrum, it is necessary to enroll a larger sample size of a healthy population as a control. Moreover, the establishment of more reliable diagnostic scoring criteria will serve as a basis for obtaining accurate MHE incidence and formulating diagnosis and treatment strategies in cirrhotic populations.

Objective:The investigation and research on the application status of Hepatic Venous Pressure Gradient (HVPG) is very important to understand the real situation and future development of this technology in China.Methods:This study comprehensively investigated the basic situation of HVPG technology in China, including hospital distribution, hospital level, annual number of cases, catheters used, average cost, indications and existing problems.Results:According to the survey, there were 70 hospitals in China carrying out HVPG technology in 2021, distributed in 28 provinces (autonomous regions and municipalities directly under the central Government). A total of 4 398 cases of HVPG were performed in all the surveyed hospitals in 2021, of which 2 291 cases (52.1%) were tested by HVPG alone. The average cost of HVPG detection was (5 617.2±2 079.4) yuan. 96.3% of the teams completed HVPG detection with balloon method, and most of the teams used thrombectomy balloon catheter (80.3%).Conclusion:Through this investigation, the status of domestic clinical application of HVPG has been clarified, and it has been confirmed that many domestic medical institutions have mastered this technology, but it still needs to continue to promote and popularize HVPG technology in the future.

Objective:To investigate the long-term outcomes of minimally invasive Oxford phase Ⅲ unicompartmental knee arthroplasty (UKA) for patients with medial compartment osteoarthropathy.Methods:The clinical data of 594 patients (701 knees) who underwent minimally invasive UKA with Oxford phase Ⅲ unicompartmental prosthesis at Department of Orthopedics,the Affiliated Hospital of Qingdao University from January 2007 to January 2016 were retrospectively analyzed.There were 155 males and 439 females,aged (62.6±10.9) years (range: 44 to 81 years),with a body mass index of (26.9±3.8) kg/m 2 (range: 21.1 to 36.2 kg/m 2).There were 359 left knees and 342 right knees,676 knees with osteoarthritis and 25 knees with idiopathic osteonecrosis of the medial femoral condyle.There were 487 cases underwent UKA (66 cases underwent UKA on one side and total knee arthroplasty on the other) and 107 cases underwent bilateral UKA.Patients′ prosthetic survival,complications,range of motion(ROM) of the knee,visual analogue score (VAS),Western Ontario and McMaster University (WOMAC) osteoarthritis index,and American knee society score (KSS) were collected to assess clinical outcomes.Paired sample t test was used to compare the data before and after operation. Results:All patients completed the surgery successfully.There was no intraoperative fractures,postoperative infections or symptomatic vascular embolic disease occurred.The postoperative complications,including mobile bearing dislocation,prosthesis loosening,tibial plateau collapse,the lateral compartment degeneration and postoperative pain were occurred in 18 cases (3.0%,18/594).Thirteen patients suffered complications were transferred to total knee arthroplasty,4 underwent partial revision,if this was used as the endpoint of the study,the surgical success rate was 97.1% (577/594) and the prosthetic revision rate was 2.9%.The ROM was improved from(105.9±11.8)°preoperatively to (114.0±13.3)° at the last follow-up ( t=10.796, P<0.01);the KSS clinical score was increased from 54.3±3.6 to 90.1±6.0 ( P<0.01) and the functional score was increased from 55.9±3.9 to 87.5±5.7( t=124.325, P<0.01; t=110.985, P<0.01).The WOMAC osteoarthritis index was decreased from 54.8±6.7 to 9.2±3.1 at the last follow-up( t=150.860, P<0.01) and the VAS was decreased from 6.1±1.1 to 1.5±1.0 at the last follow-up( t=74.941, P<0.01). Conclusions:Minimally invasive Oxford phase Ⅲ UKA for medial compartment knee osteoarthritis has a favorable prosthesis survival rate,low revision rate,and few complications at long-term follow-up.Patients have significant improvement in knee function with satisfactory clinical outcomes.

Objective:To investigate the long-term outcomes of minimally invasive Oxford phase Ⅲ unicompartmental knee arthroplasty (UKA) for patients with medial compartment osteoarthropathy.Methods:The clinical data of 594 patients (701 knees) who underwent minimally invasive UKA with Oxford phase Ⅲ unicompartmental prosthesis at Department of Orthopedics,the Affiliated Hospital of Qingdao University from January 2007 to January 2016 were retrospectively analyzed.There were 155 males and 439 females,aged (62.6±10.9) years (range: 44 to 81 years),with a body mass index of (26.9±3.8) kg/m 2 (range: 21.1 to 36.2 kg/m 2).There were 359 left knees and 342 right knees,676 knees with osteoarthritis and 25 knees with idiopathic osteonecrosis of the medial femoral condyle.There were 487 cases underwent UKA (66 cases underwent UKA on one side and total knee arthroplasty on the other) and 107 cases underwent bilateral UKA.Patients′ prosthetic survival,complications,range of motion(ROM) of the knee,visual analogue score (VAS),Western Ontario and McMaster University (WOMAC) osteoarthritis index,and American knee society score (KSS) were collected to assess clinical outcomes.Paired sample t test was used to compare the data before and after operation. Results:All patients completed the surgery successfully.There was no intraoperative fractures,postoperative infections or symptomatic vascular embolic disease occurred.The postoperative complications,including mobile bearing dislocation,prosthesis loosening,tibial plateau collapse,the lateral compartment degeneration and postoperative pain were occurred in 18 cases (3.0%,18/594).Thirteen patients suffered complications were transferred to total knee arthroplasty,4 underwent partial revision,if this was used as the endpoint of the study,the surgical success rate was 97.1% (577/594) and the prosthetic revision rate was 2.9%.The ROM was improved from(105.9±11.8)°preoperatively to (114.0±13.3)° at the last follow-up ( t=10.796, P<0.01);the KSS clinical score was increased from 54.3±3.6 to 90.1±6.0 ( P<0.01) and the functional score was increased from 55.9±3.9 to 87.5±5.7( t=124.325, P<0.01; t=110.985, P<0.01).The WOMAC osteoarthritis index was decreased from 54.8±6.7 to 9.2±3.1 at the last follow-up( t=150.860, P<0.01) and the VAS was decreased from 6.1±1.1 to 1.5±1.0 at the last follow-up( t=74.941, P<0.01). Conclusions:Minimally invasive Oxford phase Ⅲ UKA for medial compartment knee osteoarthritis has a favorable prosthesis survival rate,low revision rate,and few complications at long-term follow-up.Patients have significant improvement in knee function with satisfactory clinical outcomes.

BACKGROUND:At present, dexamethasone has been widely used in the perioperative period of major surgery in the orthopedics for reducing postoperative pain and nausea and vomiting, but the study on the application of methylprednisolone to reducing postoperative nausea and vomiting and pain after unilateral total knee arthroplasty is rarely reported.OBJECTIVE:To evaluate the effects and safety assessment of the application of methylprednisolone on postoperative nausea and vomiting and pain after unilateral total knee arthroplasty. METHODS:A total of 86 patients undergoing unilateral total knee arthroplasty were randomly assigned to two groups. Patients in the methylprednisolone group were given methylprednisolone 40 mg in intravenous drip within 24 hours during and after replacement. Patients in the control group were given an equal volume of saline in intravenous drip at the same time. The incidence of postoperative nausea and vomiting was observed and recorded at 0-6 hours, 6-24 hours, 24-48 hours, and 48-72 hours after surgery, as wel as the total incidence was recorded in both groups. Pain visual analogue scale (VAS) score at 6, 24, 48 and 72 hours after replacement, and knee joint scoring system (KSS) score at 3 days after replacement were recorded. C-reactive protein and fasting blood glucose were determined. The occurrence of adverse reactions postoperatively was recorded in 6-month fol ow-up in both groups. RESULTS AND CONCLUSION:(1) The total incidence rate of postoperative nausea and vomiting during 0-72 hours after surgery, and incidence rates of nausea and vomiting at 6 and 24 hours were significantly lower in the methylprednisolone group than in the control group (P<0.05). (2) Pain VAS score was significantly lower in the methylprednisolone group than in the control group at 6 and 24 hours after surgery (P<0.05). (3) KSS scores were significantly higher in the methylprednisolone group than in the control group after surgery (P<0.05). (4) C-reactive protein and fasting blood glucose were not significantly different between two groups before and after surgery (P>0.05). (5) The surgical incision was found to heal in 3-month fol ow-up and no postoperative infection occurred in both groups. (6) Results show that methylprednisolone can obviously reduce postoperative nausea and vomiting and pain in unilateral total knee arthroplasty, and did not increase the incidence of postoperative infection.

BACKGROUND: How to effectively and rapidly induce the osteogenic differentiation of human umbilical cord mesenchymal stem cells is the focus of the current stem cell research. Increasing evidence has demonstrated some growth factors, such as bone morphogenetic protein-2, have important effects on the transdifferentiation of umbilical cord mesenchymal stem cels into osteoblasts in vitro. However, widespread use of growth factors is limited because of high cost. Insulin is widely used in the cell culture and induction, but there is no report about the effect of insulin on the osteogenic differentiation of human umbilical cord mesenchymal stem cells. OBJECTIVE:To observe the effect of insulin on osteogenic differentiation of human umbilical cord mesenchymal stem cels and to explore the feasibility of human umbilical cord mesenchymal stem cell transplantation in the treatment of diabetic delayed fracture healing. METHODS:The passage 3 human umbilical cord mesenchymal stem cells were inoculated in two flasks, denoted as experimental group and control group. The insulin (10-7mmol/L) was added to the experimental group but not to the control group. The proliferative capacity of human umbilical cord mesenchymal stem cels was evaluated by cell count kit-8 and alkaline phosphatase activity. The osteogenic differentiation capacity of human umbilical cord mesenchymal stem cells was evaluated by measuring the protein and mRNA expressions of type I colagen as well as osteocalcin mRNA level. RESULTS AND CONCLUSION: After 1-2 weeks of induction, compared with the control group, insulin could significantly increase the number of human umbilical cord mesenchymal stem cells in the experimental group, the activity of alkaline phosphatase and expressions of type I collagen osteocalcin mRNA (P< 0.05). These data indicate that insulin can promote the proliferation and osteogenic differentiation of human umbilical cord mesenchymal stem cells.

BACKGROUND: Studies have shown that tranexamic acid can effectively reduce postoperative blood loss in patients with total knee arthroplasty. There are many means to inject tranexamic acid (intra-articular injection, intravenous injection and their combination). Which is the best way has no conclusion.
OBJECTIVE: To explore whether all three ways (intra-articular injection, intravenous injection and their combination) to inject tranexamic acid can all effectively reduce the bleeding after total knee arthroplasty.
METHODS:103 patients undergoing unilateral total knee arthroplasty from December 2014 to December 2015 were enrolled in this study. The patients were allocated into four groups according to injection way. In the intra-articular injection group, 2 000 mg of tranexamic acid was given through the intra-articular injection after incision suture. In the intravenous injection group, 1 000 mg of tranexamic acid was given through the intravenous injection at 15 minutes before the use of tourniquet. In the combined modality therapy group, above methods were used. In the blank control group, tranexamic acid was not given.
RESULTS AND CONCLUSION:(1) Total blood loss and blood transfusion rate were less in the intra-articular injection group and combined modality therapy group than in the intravenous injection group (P < 0.05). The total blood loss was more in the intra-articular injection group than in the combined modality therapy group (P > 0.05). The blood transfusion rate was 0% in the intra-articular injection group and combined modality therapy group. (2) Adverse reaction: deep vein thrombosis, pulmonary embolism, wound infection, hematoma or gangrene was not observed in al groups. (3) Results confirmed that intra-articular combined with intravenous injection can reduce effectively postoperative blood loss and the effect is better than separate administration.

BACKGROUND:The blood loss and the need of blood transfusion after bilateral total knee arthroplasty are very high. Therefore, the use of medicine such as tranexamic acid in total knee arthroplasty is overheated in recent years. Tranexamic acid has been proved to be able to decrease the blood loss after total knee arthroplasty, while the study of its use in bilateral total knee arthroplasty is seldom. OBJECTIVE:To observe the effect and safety of tranexamic acid on perioperative blood loss and the change of hemoglobin in patients undergoing bilateral total knee arthroplasty. METHODS: We selected 69 patients who received bilateral total knee arthroplasty and divided them into two different groups randomly. The patients in the experimental group were given 1 g of tranexamie acid dissolved in 100 mL of 5% glucose solution through intravenous infusion. Those in control group were only given 5% glucose solution 100 mL. Total blood loss, intraoperative blood loss, the hidden blood loss, amount of postoperative drainage, the ratio of blood transfusion, hemoglobin, D-dimer, prothrombin time and activated partial thromboplastin time were studied and compared between the two groups. We also observed the incidence of thrombotic events between the two groups. RESULTS AND CONCLUSION:The blood loss of the experimental group was significantly lower compared to the control group (t=2.194-2.908,P < 0.05). The blood transfusion rate of experimental group was significantly lower compared to the control group (χ2=5.219,P=0.022). The hemoglobin of the experimental group was significantly higher than that of the control group at 3 and 5 days after replacement (t=-3.481, 2.319,P < 0.05). No significant difference in prothrombin time and activated partial thromboplastin time was detectable between the two groups before and after replacement (P > 0.05). Thrombotic events were not visible in both groups. Venous ultrasonography in the lower extremity did not reveal deep venous thrombosis. Above results suggest that tranexamic acid can significantly reduce intraoperative blood loss in patients undergoing bilateral total knee arthroplasty, decreases the requirement of blood transfusion and the dynamic change of hemoglobin, and does not increase the risk of thrombosis.