[Preliminary clinical application of novel magnetic navigation and ultrasound-guided percutaneous transhepatic cholangiography drainage through the right liver duct for malignant obstructive jaundice]

Objective: To analyze the clinical application value of a novel magnetic navigation ultrasound (MNU) combined with digital subtraction angiography (DSA) dual-guided percutaneous transhepatic biliary drainage (PTCD) through the right hepatic duct for the treatment of malignant obstructive jaundice. Methods: Randomized controlled trial. The clinical data of 64 patients with malignant obstructive jaundice requiring PTCD through the right hepatic duct at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province People's Hospital) from December 2018 to December 2021 were retrospectively analyzed. The MNU group (n=32) underwent puncture guided by a novel domestic MNU combined with DSA, and the control group (n=32) underwent puncture guided by traditional DSA. The operation time, number of punctures, X-ray dose after biliary stenting as shown by DSA, patients' tolerance of the operation, success rate of the operation, pre- and post-operative total bilirubin, and incidence of postoperative complications were compared between the two groups. Results: The operation time of the MNU group was significantly shorter than that of the control group [(17.8±7.3) vs. (31.6±9.9) min, t=-6.35,P=0.001]; the number of punctures in the MNU group was significantly lower [(1.7±0.6) vs. (6.3±3.9) times, t=-6.59, P=0.001]; and the X-ray dose after biliary stenting as shown by DSA in the MNU group was lower than that in the control group [(132±88) vs. (746±187) mGy, t=-16.81,P<0.001]; Five patients in the control group were unable to tolerate the operation, and two stopped the operation, however all patients in the MNU group could tolerate the operation, and all completed the operation, with a success rate of 100% (32/32) in the MNU group compared to 93.8%(30/32) in the control group; the common complications of PTCD were biliary bleeding and infection, and the incidence of biliary bleeding (25.0%, 8/32) and infection (18.8%, 6/32) in the MNU group was significantly lower than that in the control group, 53.1% (17/32) and 28.1% (9/32), respectively. Conclusion: Magnetic navigation ultrasound combined with DSA dual-guided PTCD through the right biliary system for the treatment of malignant obstructive jaundice is safe and feasible.

Impact of diagnostic guidelines on the diagnosis of hypersensitivity pneumonitis

Introduction

Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease from exposure to environmental antigens. Diagnosing HP could be challenging. The American College of Chest Physicians (CHEST) and American Thoracic Society/Japanese Respiratory Society/and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) have published diagnostic guidelines in 2021 and 2020 respectively. The CHEST guideline uses four grades of confidence: confident (>90%), provisional high (70-89%), provisional low (51-69%), and unlikely (≤50%). The ATS/JRS/ALAT guideline uses five grades of confidence: definite (>90%), high (80-89%), moderate (70-79%), low (51-69%) and not excluded (≤50%). In this study, we determined how these two guidelines could have affected the diagnosis of HP made before the guidelines.

Methods

Two hundred and fifty-nine adult patients from a previous cohort with HP (ICD-9:495) made between Jan. 1, 2008, and Dec. 31, 2013, at Duke University Medical Center were included. We simplified the diagnostic confidence into three categories so we could compare the guidelines: high (≥90%), intermediate (51-89%), and low (≤50%).

Results

There were 156 female and 103 male. Mean age was 58 (range: 20-90). 68.8% of the patients had restrictive defects (FVC < 80% pred) and 48.6% had lung biopsy. The CHEST guideline classified 33.6% of the patients into high, 59.5% into intermediate and 6.9% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.7% of the patients into high, 21.2% into intermediate and 49.0% into low confidence categories (p < 0.0001 vs. CHEST). Cohen's kappa was 0.331. In patients with identifiable inciting agents (IAs) (N = 168), the CHEST guideline classified 32.1% of the patients into high, 64.3% into intermediate and 3.6% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.2% of the patients into high, 20.8% into intermediate, and 50.0% into low confidence categories. Cohen's kappa was 0.314.

Discussion

In our HP cohort with two-thirds of the patients with restrictive defects, we found the two guidelines had fair agreement in diagnosing HP with or without identifiable IAs. They agreed more when the diagnostic confidence was high. When the diagnostic confidence was lower, however, the ATS/JRS/ALAT guideline was more stringent. Clinicians should be aware of the differences between the two guidelines when evaluating patients suspicious of HP.

[Resting-state functional magnetic resonance imaging analysis of abnormal directional functional connectivity of the nucleus accumbens in patients with chronic tinnitus]

Objective: To investigate abnormal directional functional connectivity of the nucleus accumbens (NAc) in chronic tinnitus patients using resting-state functional magnetic resonance imaging (fMRI), and to determine the relationship between the degree of this connectivity and tinnitus characteristics. Methods: The resting-state fMRI data of 40 patients with bilateral chronic tinnitus (12 males and 28 females, aged from 26 to 63(50.6±11.6) years) and 40 healthy controls with normal hearing (16 males and 24 females, aged from 26 to 70(45.9±12.4)years) were retrospectively enrolled from the Department of Otolaryngology, Nanjing First Hospital from January 2017 to January 2020. The bilateral NAc were selected as seeds to detect the directional functional connectivity with the whole brain, then the effective connectivity values between the two groups were compared using Granger Causality Analysis (GCA), and the correlation between the effective connectivity and the characteristics of tinnitus was calculated. Results: Compared with healthy controls, the effective connectivity from the left NAc to left middle frontal gyrus in patients with bilateral chronic tinnitus was increased [(1.0±0.2)vs(0.6±0.3)], the effective connectivity from the right NAc to left inferior frontal gyrus was enhanced [(0.9±0.3)vs(0.6±0.4)], the effective connectivity from the right middle temporal gyrus to left NAc was enhanced [(1.0±0.2)vs(0.5±0.3)], the effective connectivity from the right middle frontal gyrus to right NAc was also enhanced[(1.0±0.2)vs(0.5±0.3)](all P<0.05). After adjusting for age, gender, education level, and gray matter volume, positive correlations was observed between the Tinnitus Handicap Questionnaire (THQ) scores and increased effective connectivity values from the left NAc to the left middle frontal gyrus (r=0.386, P=0.020). Additionally, enhanced effective connectivity values from the right middle frontal gyrus to the right NAc was also positively associated with tinnitus duration (r=0.390, P=0.019). Conclusion: The directional functional connectivity between the NAc and prefrontal cortex in patients with chronic tinnitus is enhanced.

Chronic hypersensitivity pneumonitis in the southeastern United States: an assessment of how clinicians reached the diagnosis

Background

Chronic hypersensitivity pneumonitis (cHP) is a disease caused by exposure to inhaled environmental antigens. Diagnosis of cHP is influenced by the awareness of the disease prevalence, which varies significantly in different regions, and how clinicians utilize relevant clinical information. We conducted a retrospective study to evaluate how clinicians in the Southeast United States, where the climate is humid favoring mold growth, diagnosed cHP using items identified in the international modified Delphi survey of experts, i.e., environmental exposure, CT imaging and lung pathology,

Methods

We searched Duke University Medical Center database for patients over the age of 18 with a diagnosis of cHP (ICD-9 code: 495) between Jan. 1, 2008 to Dec. 31, 2013 using a query tool, Duke Enterprise Data Unified Content Explorer (DEDUCE).

Results

Five hundred patients were identified and 261 patients had cHP confirmed in clinic notes by a pulmonologist or an allergist. About half of the patients lived in the Research Triangle area where our medical center is located, giving an estimated prevalence rate of 6.5 per 100,000 persons. An exposure source was mentioned in 69.3% of the patient. The most common exposure sources were environmental molds (43.1%) and birds (26.0%). We used Venn diagram to evaluate how the patients met the three most common cHP diagnostic criteria: evidence of environmental exposures (history or precipitin) (E), chest CT imaging (C) and pathology from lung biopsies (P). Eighteen patients (6.9%) met none of three criteria. Of the remaining 243 patients, 135 patients (55.6%) had one (E 35.0%, C 3.3%, P 17.3%), 81 patients (33.3%) had two (E + C 12.3%, E + P 17.3%, C + P 4.9%), and 27 patients (11.1%) had all three criteria (E + C + P). Overall, 49.4% of patients had pathology from lung biopsy compared to 31.6% with CT scan.

Conclusions

Environmental mold was the most common exposure for cHP in the Southeast United States. Lung pathology was available in more than half of cHP cases in our tertiary care center, perhaps reflecting the complexity of referrals. Differences in exposure sources and referral patterns should be considered in devising future diagnostic pathways or guidelines for cHP.

Knowledge and Perceptions Regarding Palliative Care Among Religious Leaders in Uasin Gishu County, Kenya: Survey and Focus Group Analysis

Spirituality and religion are at the core of Kenyan life. Pastoral leaders play a key role in shaping the individual and community’s response to living with chronic and life-threatening illnesses. Involvement of religious leaders would therefore be critical in advocacy and education efforts in palliative care (PC) to address the needs of this population. The goal of this study was to evaluate the knowledge and perceptions of religious leaders in Western Kenya regarding PC. This was a mixed-methods study with 86 religious leaders utilizing a 25-question survey followed by 5-person focus group discussions. Eighty-one percent of participants agreed that pastors should encourage members with life-threatening illnesses to talk about death and dying. However, almost a third of participants (29%) also agreed with the statement that full use of PC can hasten death. The pastors underscored challenges in end-of-life spiritual preparation as well as the importance of traditional beliefs in shaping cultural norms. Pastors supported the need for community-based PC education and additional training in PC for religious leaders. The results of this study confirm the dominant role of religion and spirituality in PC in Kenya. This dominant role in shaping PC is tied closely to Kenyan attitudes and norms surrounding death and dying.

[Stent placement for filter-related chronic occlusion of the inferior vena cava]

Objective: To assess the technical success rate, stent patency, clinical efficacy and complications of stent placement for filter-related chronic occlusion of the inferior vena cava. Methods: A retrospective analysis was carried out for 12 patients with filter-related chronic occlusion of the inferior vena cava associated with severe post-thrombotic syndrome, who underwent stent placement after ineffective conservative therapy at Nanjing First Hospital from March 2016 to December 2018,9 males and 3 females, aged from 48 to 77 years, mean age 60 years, six had bilateral lower extremity symptoms and six had unilateral lower extremity symptoms.Technical success rate, stent patency, clinical efficacy and complications of stent placement were recorded. Clinical success was defined as relief of symptoms and a decrease in clinical, etiology, anatomy, and pathophysiology (CEAP) score for at least grade 1. Results: Stent placement in the unilateral or bilateral iliocaval occlusion was successful in 11 patients. The cause of technical failure in the single patient with failed stent placement was an inability to cross the occluded left iliacvein and the patient was treated with stent placement in the right iliocaval vein.There were 7 patients with inferior vena cava and unilateral iliocaval stent placement; 5 patients with inferior vena cava and bilateral iliocaval stent placement. Acute stent thrombosis occlusion occurred in 1 case after the operation, the blood flow recanalized after catheter-directed thrombolysis and re-stenting. All patients were followed up for 6 to 24 months, with an average of (13±6) months. During the follow-up period, CTV or venography of lower limbs showed that the blood flow in the stent was unobstructed. At the last follow-up, 12 patients were evaluated as clinically effective. Three patients had transient treatment of lateral lumbar pain during operation, which alleviated by themselves.No significant abdominal pain, severe hemorrhage, symptomatic pulmonary embolism and other complications related to treatment occurred in all patients during perioperative period and follow-up. Conclusion: Stent placement is safe and feasible in the treatment of filter-related chronic occlusion of the inferior vena cava, which can alleviate the clinical symptoms of severe post-thrombotic syndrome.

[The diagnostic value of low dose of dual-source CT venography for deep venous thrombosis]

Objective: To investigate the diagnostic value of low dose of dual-source CT venography examination for DVT (deep venous thrombosis). Methods: A total of 60 patients from Nanjing First Hospital with suspected DVT underwent indirect low dose CTV examination and treatment of DSA from January to December, 2017, and recording the radiation dose for CTV.DSA as the gold standard, calculate the sensitivity, specificity of CTV, kappa consistency test was used to exam the results of CTV and DSA.McNemar test was used to check statistical difference between two examinations. Results: A total of 60 patients, 780 blood vessels took CTV examinations, 326 were positive; 420 blood vessels took DSA examinations, 332 were positive.DSA as the gold standard, the sensitivity, specificity, of DVT detection by CTV were 96.2% and 92.6%, kappa=0.860, P<0.05, and the result of McNemar test was P=0.263. Conclusion: Low dose of dual-source indirect CTV examination for DVT can not only reduce radiation dose for the patients, but also has a high clinical value in the diagnosis of DVT.

[Time-dependent Protein Expressions of MMP-2 and MMP-9 in Liver Contusion Rats after Impact]

OBJECTIVES

To observe the protein expression patterns of matrix metalloproteinase （MMP）-2 and MMP-9 in the liver tissue of liver contusion rats at different time after impact.

METHODS

Fifty healthy adult male SD rats were randomly and evenly divided into control group and experimental groups （1 h, 3 h, 6 h, 12 h, 18 h, 24 h, 3 d, 5 d, 7 d after liver contusion）. A rat liver contusion model was established by a free-falling device. The rats were killed at corresponding time, and the contused hepatic lobes were extracted. The protein expressions of MMP-2 and MMP-9 in contused liver tissue of the rats in each group were observed by immunohistochemical staining （SP method） and Western blotting.

RESULTS

After the liver contusion, the expression of positive cell and the protein semiquantitative result showed that the protein expression of MMP-2 enhanced at 6 h and peaked at 24 h, then decreased gradually at 3-5 d, and returned to normal levels at 7 d. The difference of expression between group and its previous adjacent group after 6 h （except 18 h） had statistical significance （P<0.05）. The protein expression of MMP-9 rose obviously at 1 h after liver contusion and peaked at 18 h, then decreased gradually at 3-7 d which still higher than control group. The expression difference between group and its previous adjacent group （except 12 h and 24 h） had statistical significance （P<0.05）.

CONCLUSIONS

The protein expressions of MMP-2 and MMP-9 in contused liver tissue after impact show good time-dependent patterns, which may provide important reference indicators for the time estimation of liver contusion.

[Application of percutaneous AngioJet thrombectomy in patients with acute symptomatic portal and superior mesenteric venous thrombosis]

Objective: To evaluate the clinical value of percutaneous AngioJet thrombectomy in treatment of acute symptomatic portal and superior mesenteric venous thrombosis venous thrombosis (PVMVT) . Method: From January 2014 to January 2016, a total of 8 patients in Nanjing First Hospital with PVMVT verified by color Doppler ultrasound and computed tomographic angiography (CTA) were analyzed retrospectively. Under ultrasound guidance , the branch of the right portal vein(PV) was punctured with a micropuncture set and a 4-F infusion catheter was advanced to the superior mesenteric vein(SMV). The venogram demonstrated the thrombosis in the PV/SMV and a 6-F AngioJet Xpeeedior catheter was advanced over the guidewire and positioned in the distal SMV. Percutaneous thrombectomy was performed after a mixture of 250 000 U of urokinase in 100 ml of normal saline for mechanical pulse spray of thrombus in all patients for approximately 15 minutes. 2 patients underwent PTA and stent implantation after the thrombectomy procedure, 1 of them and the others 6 patients received continuous transcatheter infusion of urokinase (500 000 U/d) for 24 or 48 hours until the thrombosis was completely dissolved confirmed by angiography at 24 and 48 hours.After procedure and the thrombolytic therapy was discontinued, removal of the infusion catheter and the sheath from the liver, the transhepatic tract was embolized with coils or gelfoam to reduce the risk of bleeding. The patency rate of PV /SMV was assessed by CTA at 1 and 6 months after the procedure. Patients were discharged with oral anticoagulation regimen for at least 6 months.The following criteria were used in evaluation of thrombolysis: grade Ⅰ<50% thrombus removal; grade Ⅱ 50%~90% thrombus removal, and grade Ⅲ>90% thrombus removal. Results: All 8 patients with PVMVT were treated by AngioJet thrombectomy. Angiography after the thrombectomy procedure showed complete thrombus removal (>90%) was in 3 cases, substantial thrombus removal (50%~90%) in 5 cases. Grade Ⅲ (complete) thrombolysis was achieved in 7 cases and grade Ⅱ (50%~90%) lysis in 1 case post thrombolytic therapy for 24 or 48 hours. 2 patients had underwent PTA and stent implantation. Large volume intraperitoneal hemorrhage was discovered in 1 patient after removal of the catheter and sheath from the liver. The patient restored stability after a blood transfusion.Venous patency was comfirmed in all 8 patients at 1 or 6 months after the treatment. There was no patient with major complications death related to the procedure. Conclusion: Percutaneous AngioJet thrombectomy with adjunctive thrombolytic therapy is an effective and safe treatment modality in patients with acute symptomatic PVMVT.

[Efficacy comparison of interventional treatment by anterograde or retrograde catheterization for acute lower extremity deep venous thrombosis]

Objective: To compare the clinical efficacy differences between anterograde and retrograde catheterization interventional treatment for acute low extremity deep venous thrombosis(DVT). Methods: The clinical data of 217 patients with acute low extremity DVT between January 2009 and December 2014 were analyzed retrospectively. Group A: 67 patients underwent treated with anterograde catheterization interventional treatment. Group B: 150 patients underwent treated with retrograde catheterization interventional treatment. The degree of thrombolysis in different anatomical sites, clinical effective rate, femoral-popliteal vein valve reflux and the incidence of post-thrombotic syndrome(PTS) were all analyzed. Results: There were no statistical differences in the degree of thrombolysis (≥50%) of common iliac vein, external iliac vein and common femoral vein between group A (83.6%, 88.1%, 91.0%)and B (80.7%, 82.0%, 88.0%)(all P>0.05). The degree of thrombolysis (≥50%) of superficial femoral vein in group A(94.0%) was significantly higher than that of group B (75.3%)(P=0.001). There was no significantly difference in the clinical effective rate at discharged between group A (80.6%) and B(76.7%)( P=0.519). During follow-up of 44±15 months, There was no statistical difference in the patency rate of the iliofemoral vein, the valvular regurgitation of patent femoropopliteal vein and the incidence of PTS between group A(70.2%, 25.4%, 35.8%) and B (60.0%, 31.5%, 40.0%)(all P>0.05). The incidence of PTS in patients with iliofemoral vein patency(13.1%) was significantly lower than that in patients with iliofemoral vein occlusion (82.5%)(P<0.01). Conclusions: The anterograde or retrograde catheterization interventional treatment can be used for treating acute low extremity DVT and get comparable clinical effect.The retrograde catheterization does not increase venous valve damage. The recovery of iliofemoral vein lumen patency is the main task in the treatment of DVT and can significantly reduce the incidence of PTS.

[Clinical application and prognostic analysis of interventional treatment for cesarean scar pregnancy]

OBJECTIVE

To analyze the clinical value and prognosis of cesarean scar pregnancy (CSP) treated by uterine artery embolization (UAE).

METHODS

In the study, 492 cases of patients in Nanjing Maternal and Child Health Care Hospital Affiliated to Nanjing Medical University diagnosed as CSP between January 2011 and December 2014 were chosen, of which 283 were of high-risk group and 209 of low-risk group. According to whether to take UAE, the high-risk group was subdivided into high-risk UAE group(UAE+laparoscopic group), 167 cases, and high-risk non UAE group (chemotherapy+laparoscopic group), 116 cases, while the low-risk group was subdivided into low-risk UAE group (UAE+curettage group), 113 cases, and low-risk non UAE group(chemotherapy+curettage group), 96 cases. The differences of the intraoperative bleeding, length of stay, blood beta human chorionic gonadotropin (β-HCG) dropped to normal time, menstruation recovery time and the hospitalization expenses were compared. And multivariate regression analysis was used to predict the recurrence risk of CSP.

RESULTS

The high-risk UAE group was better than the high-risk non UAE group in comparison of intraoperative bleeding [(36.5±14.8) mL vs.(76.5±39.7) mL], length of stay [(5.9±0.9) d vs.(9.6±1.3) d], blood β-HCG dropped to normal time [(17.9±8.7) d vs.(28.7±10.1) d] and menstruation recovery time [(18.1±1.6) d vs.(24.3±1.8) d],while the low-risk UAE group was better than the low-risk non UAE group in comparison of intraoperative bleeding [(93.2±43.3) mL vs.(284.8±110.5) mL], length of stay [(10.2±1.4) d vs. (30.7±9.6) d], blood β-HCG dropped to normal time [(50.1±17.6)d vs.(67.5±22.9)d] and menstruation recovery time[(56.3±6.7)d vs.(65.9±9.3) d], all P<0.05. The high-risk UAE group was higher than the high-risk non UAE group in comparison of hospitalization expenses [(20 140±1 520 )Yuan vs.(13 510±1 013) Yuan], and the low-risk group UAE was also higher than the low-risk non UAE group in comparison of hospitalization expenses [(10 095±962 )Yuan vs.(3 890±457) Yuan], all P<0.01. Multivariate Logistic regression analysis showed that the treatment method was independent predictor of CSP recurrence risk (OR 2.407, 95%CI 1.176-5.092, P<0.05), and using the comprehensive treatment including UAE could reduce the risk of recurrent CSP.

CONCLUSION

As the efficacy of interventional therapy for CSP was rapid and reliable, fewer complications, faster recovery and lower recurrence, hospitalization with good conditions, and particularly for those patients with CSP who want to fertility again, the comprehensive treatment including UAE treatment should be the first choice.

[Genetic analysis on litter size in pigs]

Genetic analysis was conducted on the data of 3 populations with 1,686 litters including Erhualian pig, Large White and first cross. The results indicated that the heritability estimates for the total number of piglets born, the number of piglets born alive, the number of piglets at 20 d and at 45 d were 0.081, 0.156, 0.402 and 0.419, respectively. The major gene index analysis indicated that the prolificacy of Erhualian pig was influenced by major genes.

[Genetic analysis of sow productivity traits]

Genetic analysis was conducted on the data of 3 populations with 1686 litters including Erhualian pigs, Large White and first cross. The phenotypic and genetic parameters among litter weight at birth (LW), average piglet weight at birth (APW), litter weight at 20 days (LW20), average piglet weight at 20 days (APW20), litter weight at 45 days (LW45), average piglet weight at 45 days (APW45) were estimated by sire model. The results indicated that Erhualian pigs had stronger maternal ability and slower growth rate compared to Large White. The first four traits (LW, APW, LW20, APW20) had larger maternal effects, while LW45 and APW45 had smaller maternal effects. The heritabilities of LW, APW, LW20, APW20, LW45, APW45 were 0.251, 0.277, 0.341, 0.330, 0.235, 0.186, respectively. The results indicated that direct selection was effective. According to our results, we considered that it was fit to select two traits (LW, LW20) out of these six traits to reflect sow productivity. Litter weight at birth could reflect the prolificacy of sow, litter weight at 20 days could reflect the maternal ability of sow.

[Changes of potassium and sodium content in erythrocyte of rabbit cardiac blood after death and timing of death]

We studied the changes of potassium and sodium contents in erythrocytes and the activity of erythrocyte membrane Na(+)-K(+)-ATPase in 40 cardiac blood samples of rabbit corpses at different postmortem intervals (PMI). The erythrocyte potassium content (RBCK) decreased linearly as the PMI increased (R = -0.829, P < 0.025). during postmortem 48 hours. The erythrocyte potassium content and the time after death had significant correlation. The activity of erythrocyte membrane Na(+)-K(+)-ATPase had no significant changes over postmortem 48 hours.