Objective:To analyze the cause of varicocele (VC) recurrence and investigate the efficacy of sub-inguinal microsurgical varicocelectomy (MV) for recurrent VC.Methods:All of 16 inpatients diagnosed as recurrent VC, in the Department of Andrology of the Affiliated Hospital of Qingdao University from 2015 April to 2019 April, were performed sub-inguinal MV. The age of the inpatients was 18-36 years old, median 27 years old.5 cases were originally performed retroperitoneal high ligation of spermatic vein and other 11 cases were originally performed laparoscopic varicocelectomy. During the review one to three years after the previous operation, all of 16 patients were diagnosed as VC recurrence. The complains of these patients during the review included male subfertility (10 cases) and scrotal pain (12 cases), in which 6 cases’ complains were male subfertility with scrotal pain. After admission, 13 patients were classified as Grade Ⅲ (left in 8 cases, bilateral in 5 cases) and 3 patients as Grade Ⅱ (all left). The median of their visual analogue scale (VAS) was 2.5. Color doppler flow imaging (CDFI) grading showed: Grade Ⅲ in 12 cases (left in 7 cases, bilateral in 5 cases), Grade Ⅱ in 4 cases (all left). Particularly, 12 of them were Graded as Ⅲ simultaneously accompanying with Nut-cracker Phenomenon (NCP). Preoperative tests showed that the average serum testosterone was (16.2±4.9)nmol/ml, the average sperm concentration was (11.8±3.9)×10 6/ml and the progressive motility rate (PR) was (24.4±4.2)%. All of the patients were performed sub-inguinal MV using general anesthesia and supine position. The spermatic cords were clearly exposed and padded up by inserting gauze strips under them. During the operation, the field was magnified 4-6 times with the microscope. Then all of the dilated external and internal spermatic veins were ligated, at the same time the internal spermatic artery and lymph vessels were well preserved. During these operations, 11 patients underwent left-side MV, while other 5 did bilateral MVs. During these MVs, we found twisted and dilated external and internal spermatic veins in all cases and well preserved the internal spermatic arteries and lymph vessels. The number of ligated left and right external spermatic veins were(2.1±0.6) and (1.4±0.5)respectively and the number of ligated left and right internal spermatic veins were (10.1±1.1) and (6.6±0.5) respectively. We also found out(1.3±0.5) internal spermatic arteries and (3.0±1.0)lymph-vessels on left side. On right side, there were (1.4±0.5) internal spermatic arteries and (2.6±0.5) lymph-vessels respectively. At last, we summarily analyzed the pre-operative and post-operative VAS, serum testosterone, CDFI and semen analysis data. Results:All of the 16 sub-inguinal MVs were successfully performed. All patients were reviewed comprehensively 6 months after MV. The reviewed results showed that the post-operative VAS was significantly reduced ( Z=-2.994, P<0.05), palpable scrotal vessels disappeared and Valsalva tests were negative. No obvious reflux of internal spermatic veins were detected by CDFI. Interestingly, the sperm concentration and motility were both significantly improved 6 months after MV ( P<0.05), while there was not remarkable increase of the serum testosterone after MV ( P>0.05). During the follow up, no testicular atrophy, hydrocele and other complications were found. Up to submission, five of the ten patients who presented for male subfertility have impregnated their wives. Conclusions:The most possible cause of VC recurrence could be the omission of the external and internal spermatic veins, particularly in the grade Ⅲ VC patients or VC accompanied with NCP. The sub-inguinal MV, which can discover more twisted spermatic veins and at the same time preserve the spermatic artery and lymph-vessels, shows better clinical efficacy than other procedures.

Objective: To explore the key technique and outcome of transoral radiofrequency ablation microsurgery for early stage of glottic carcinoma with anterior commissure involvement (ACI). Methods: A retrospective analysis was conducted on 31 patients, who were diagnosed as early stage glottic carcinoma during January 2010 to March 2016 in ENT Department. According to whether the anterior commissure was involved or not, two groups were divided. There were eleven cases with ACI (stages T1a, T1b, and T2). Twenty cases without ACI (stages Tis, T1a, and T2). All the patients received transoral radiofrequency ablation microsurgery and followed up closely.Only one case received radiotheraphy after surgery. SPSS19.0 software was used to analyze data. Results: The follow-up time was 12-67 months, and the median follow-up time was 30 months. Nine among 11 cases with ACI obtained good oncologic outcomes, initial local recurrence was identified in 2/11 cases, including 2 cases of T2. Two cases ultimately required salvage total laryngectomy. Meanwhile, initial local recurrence was identified in 2/20 cases without ACI, including 1 case of T1a and 1 case of T2. One case underwent elective neck dissection, and another one received salvage total laryngectomy.Compared to the patients without ACI, it seemed that the cases with ACI always accomponied with a little higher initial local recurrence and lower overall laryngealpreservation, but the difference had no significance (P>0.05). Conclusions Transoral radiofrequency ablation microsurgery is an effective treatment for glottic carcinoma with ACI. Its advantages, such as more flexibility and deformability, make it more feasible to operate at the narrow space of anterior commissure assisted with laryngeal endoscopy.Good oncologic outcomes can be obtained by this technique with lower initial local recurrence as well as higher overall laryngeal preservation rate.

This paper summarized nursing points for caring 12 cases undergoing endoscopic ultrasonography guided biliary drainage(EUS-BD) in the treatment of malignant obstructive jaundice.All patients received EUS-BD after unsuccessful endoscopic retrograde cholangiopancreatography,including 5 patients undergoing EUS guided hepaticogastrostomy(EUS-HGS) and 7 patients undergoing EUS guided choledochoduodenostomy(EUS-CDS).Nursing points included:preoperative assessment,psychological care,preoperative gastrointestinal preparation,intraoperative cardiopulmonary function monitoring,collaboration in operation,postoperative monitoring,observation and nursing care for complications such as bleeding,bile leakage and the others.The average hospital stay was 10～16 d.Two patients developed complications(16.67％).A patient undergoing EUS-HGS developed bile leakage,biliary peritonitis,and pneumoperitoneum after the procedure,but was successfully recovered by placement of a second fully covered self-expendable metal stent in the primary metal stent,percutaneous abdominal drainage and antibiotic treatment.A patient undergoing EUS-CDS developed gastrointestinal bleeding,and was successfully treated with radiological intervention.

Objective To analyze the efficacy of endoscopic ultrasonography-guided biliary drainage ( EUS-BD) for malignant obstructive jaundice and the management of adverse events. Methods Clinical data of 12 patients with malignant obstructive jaundice, who underwent EUS-BD between April 2016 and January 2017, were retrospectively analyzed. All patients received EUS-BD after unsuccessful ERCP, including EUS-guided hepaticogastrostomy ( EUS-HGS ) , EUS-guided antegrade stenting ( EUS-AS ) , and EUS-guided choledochoduodenostomy(EUS-CDS). Procedure outcomes, serum bilirubin and liver enzyme levels before the procedure and 1 week after, complications, treatment results, hospitalization time and follow-up were recorded. Results Two patients underwent EUS-HGS, 3 underwent EUS-AS, and 7 underwent EUS-CDS. Total bilirubin ( t=3. 462, P=0. 005 ) , direct bilirubin ( t=3. 351, P=0. 006 ) , alanine transaminase (t=2. 399, P=0. 037), γ-glutamate transpeptidase (t=3. 256, P=0. 031) reduced significantly after the procedure. Two patients ( 16. 67％) developed complications. A patient undergoing EUS-HGS developed bile leakage, biliary peritonitis, and pneumoperitoneum. A patient undergoing EUS-CDS developed upper gastrointestinal bleeding. Both patients were successfully treated. There were no other adverse events, such as acute pancreatitis, subcutaneous emphysema, pneumothorax and emphysema. No procedure-related death occurred. The mean hospital stay was 13. 75 ± 6. 92 days ( range 5-26 days ) . Conclusion EUS-BD is a safe substitute after unsuccessful ERCP when performed by experienced biliary endoscopists. However, intensive care is necessary after the procedure for early detection and management of complications.

AIM: To study the effect of calcium sensing receptor (CaSR) on icariin (ICA) induced mouse embryonic stem cells ( mESCs) to differentiate into cardiomyocytes in vitro.METHODS:mESCs were cultured to embry-oid bodies ( EBs) by direct suspension method and the differentiation of EBs into cardiomyocytes was induced by ICA.The expression of cardiac specific proteinsα-actinin and cardiac troponin-I ( cTnI) was analyzed by Western blot and immuno-fluorescence.The differentiation rate was determined by flow cytometry.The ultrastructure of the derived cardiomyocytes was further characterized by transmission electron microscopy.The expression of cardiac-specific transcription factors Nkx2.5 and GATA-4,as well as CaSR was detected by Western blot.RESULTS: After induction with ICA, the positive characteristics of myocardial cells appeared in the EBs cultured for 2 d.The expression of cardiac-specific sarcomeric pro-tein actinin (α-actinin) and cTnI showed an overall upward trend by Western blot in different phases of ICA induced differ-entiation.The expression of CaSR, Nkx2.5 and GATA-4 was the highest at an early stage of ICA-induced differentiation. Neomycin (an activator of CaSR) up-regulated CaSR, NKx2.5 and GATA-4 expression in the EBs at early stage of ICA-in-duced differentiation, all of which were reversed by NPS2390 ( an inhibitor of CaSR) .CONCLUSION:CaSR is function-ally expressed in mESC-derived cardiomyocytes, and activation of CaSR is involved in the differentiation of mESCs into car-diomyocytes by facilitating the expression of NKx2.5 and GATA-4.

AIM: Ischemic post-conditioning ( PC) plays an important role in cardioprotection from ischemia /reperfusion ( I/R) injury in the young heart but not in the aging hearts .The physiological and pathological roles of hydrogen sulfide ( H2 S) in the regulation of cardio-vascular functions have been recognized .Whether H2 S is involved in the recovery of PC-induced cardioprotection in the aging hearts is unclear.METHOD:The male Wistar young rats (3-month-old), the aging rats (24-month-old), primary cultured cardiomyocytes and the aging cardiomyocytes induced by D-galactose suffered from I/R (or H/R) and PC.RESULTS:I/R (or H/R) decreased H2S production rate and cystathionine γ-lyase (CSE) expression, aggravated cardiomyocyte damage , apoptosis, myocardial infarct size and oxidative stress, reduced cardiac function, increased the levels of Bcl-2, cleaved caspase-3 and caspase-9 mRNA and proteins, promo-ted the release of cytochrome c and mPTP opening, down-regulated the phosphorylation of ERK 1/2, PI3K, Akt and GSK-3βand mito-chondrial membrane potential , up-regulated the phosphorylation of IκBα, NF-κB, JNK2 and STAT3, and inhibited PKC-ε transloca-tion and mitochondrial ATP-sensitive K channels (mitoKATP) in isolated young and aging hearts as well as normal and aging cardiomyo-cytes.PC suppressed myocardial I/R injury in the young heart but not in the aging hearts .Supply of NaHS not only increased PC-in-duced cardioprotection in the young hearts and cardiomyocytes , but also attenuated I/R injury and significantly recovered the cardiopro-tective role of PC in the aging hearts and cardiomyocytes .CONCLUSION:The exogenous H 2 S restores PC-induced cardioprotection through inhibiting oxidative stress via the down-regulation of NF-κB and JAK2-STAT3 pathways and mPTP opening by the up-regulation of ERK1/2-GSK-3β, PI3K-Akt-GSK-3βand PKC-ε-mitoKATP pathways in the aging hearts and cardiomyocytes .These findings provide a novel potential target for the treatment of aging ischemic cardiomyopathy .

Objective To study the effects of health management on blood pressure and lifestyle of hypertensive outpatients.Methods A total of 319 hypertensive outpatients were randomly assigned to the control group (n =160) or the health management group (n =159).Pharmacologic therapy was given to the control group,while in the health management group,intensive health management combined with pharmacologic therapy was conducted.Blood pressure,height,body weight (BW),total cholesterol (TC),and fasting blood glucose (FBG) of the participants were measured and compared at baseline and 12 months.Results There were no significant differences of clinical characteristics between two groups at baseline.After 12 months' intervention,more significant decrease of systolic blood pressure and diastolic blood pressure was found in the health management group (t values were 2.701 and 2.306,respectively;both P ＜ 0.05).There were statistically significant differences of body mass index (BMI) and serum TC levels between the control and the health management group (t values were 2.111 and 2.227,respectively ;P ＜ 0.05).After the intervention,two groups showed no significant difference in current cigarette smoking (x2=2.787,P ＞ 0.05).The participants in the health management group showed improved physical exercises,diet,and adherence to treatment at the end of the observation (x2 values were 59.459,52.018,6.321 and 5.392,respectively; all P ＜ 0.05).Conclusion Compared with pharmacologic therapy,health management combined with pharmacologic therapy could significantly improve clinical parameters and life style of hypertensive patients.

ObjectiveTo study the effects of health management on elderly patients with metabolic syndrome and lower extremity arterial disease.Methods A total of 118 metabolic syndrome( MS ) patients with ankle-brachial index (ABI) ＜ 0.9 and no intermittent claudication were randomly assigned to the control group( n =60,receiving pharmacologic therapy ) or health management group ( n =58,receiving intensive health management + pharmacologic therapy).Blood pressure,ABI,total cholesterol (TC),and fasting blood glucose(FBS) were tested before and 12 after the intervention.Results Clinical data were comparable between the two groups at baseline.After 12-months' intervention,systolic blood pressure(SBP) and FBS in both groups were significantly decreased,especially in the health management group[SBP:(141 ± 10)mm Hg(1 mm Hg=0.133 kPa) vs(146±11) mm Hg,t =2.581,P=0.011; FBS:(5.32 ±1.33) mmol/L vs ( 5.92 ± 1.61 ) mmol/L,t =2.231,P =0.028].TC ( 5.51 ± 0.51 ) mmol/L vs ( 5.11 ± 0.49 ) mmol/L,(t=4.307,P=0.000) and ABI(0.77 ±0.17 vs 0.84 ±0.19,t=2.091,P=0.039) of the health management group were significantly improved at 12 months.Patients in the health management group also showed higher SF-36 scores than those in the control group( physical functioning:72.2 ± 12.4 vs 65.2 ±20.1,t =2.268,P =0.025 ; emotion:73.9 ± 18.0 vs 65.6 ± 21.1,t =2.295,P =0.023 ; mental health:63.9 ± 13.3vs 58.3 ± 12.5,t =2.358,P =0.020 ).Conclusion Compared with medication,health management and pharmacologic therapy could significantly improve clinical parameters and quality of life of elderly MS patients combined with peripheral arterial disease.

Objective To study the effects of health management on cardiovascular events in the elderly patients with hypertension. Methods A total of 182 elderly patients with hypertension were randomly assigned to the control group (n = 61 ), pharmacologic therapy group (n = 61 ) or health management group ( n = 60). Serum biomarkers, brachial-ankle pulse wave velocity ( baPWV ), and blood pressure were tested at baseline and after intervention. Results There were no differences between the 2 groups in clinical characteristics at baseline. The average following-up period was (21 ± 7 ) months. The improvement of systolic blood pressure ( t = 3.915, P = 0. 000 ), pulse pressure ( t = 3. 966, P = 0. 000), and baPWV ( t = 3. 093, P = 0. 002) in the health management group was more significant than the control group;the systolic blood pressure ( t = 2. 008, P= 0. 046 ) was bitterly improved than the pharmacologic therapy group. The accumulative survival rate of the health management group (96. 7% ) was higher than the control group (83.6%; x2 =5. 921 ,P =0. 015) ,similar to the pharmacologic therapy group (93.3%; x2 =2. 821,P=0.091 ). Decreased systolic blood pressure, diastolic blood pressure, pulse pressure and baPWV were protective factors. After adjusted by age and gender,the improvement of systolic blood pressure was found to be an independent protective factors ( RR = 0. 75, P ＜ 0. 05 ). Conclusion Health management in elderly patients with hypertension could more significantly reduce the risk of cardiovascular diseases.

Objective To evaluate the effectiveness and safety of needle-knife fistulotomy (NKF)for difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP). Methods Data of patients, who received NKF on the back of major papilla when bile duct could not be accessed by conventional cannulation and/or other pre-cut methods during ERCP, were retrospectively reviewed. The success rate of deep cannulation and its complications were observed and analyzed. Results NKF was performed in 108patients due to difficult cannulation, which succeeded in 97 (91.2%) in access to the bile duct and failed in 11 patients with malignant biliary strictures. The failure rate in patients with distal malignant obstruction was higher (25. 8%, 8/31) than those with proximal lesions (5.3%, 3/57) (P = 0. 014, χ2 = 5. 983).Post-ERCP pancreatitis occurred in 5 cases (4. 6%), with the incidence significantly higher in NKF-failure group (18. 2%, 2/11) than that in NKF-suocess group (3.1% ,3/97) (P = 0. 006, χ2 = 7.418). Intestinal perforation occurred in 1 patient and cholangitis developed in 4 others, which all recovered after conservative managements. Conclusion NKF for difficult cannulations in ERCP is safe and effective, especially in hands of experienced operators, but cannulation success rate is relatively low in distal malignant biliary obstruction.