Clinical Focus

Application and research progress of endoscopic ultrasonography in the diagnosis of pancreatic cancer

Li Shiyu, Wang Kaixuan, Jin Zhendong

2019, 34(9): 773-776. doi:10.3969/j.issn.1004-583X.2019.09.001

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Pancreatic cancer is a malignant tumor with poor prognosis, high mortality and low survival rate of five years.It is mainly because that most patients with pancreatic cancer progress to either metastatic or locally advanced disease in the asymptomatic stage, while the prognosis of patients diagnosed early and treated with interventional therapy is relatively good.Endoscopic ultrasonography and its related technologies can do a closerange multiaxial ultrasound scanning of the pancreas and biliary system, which plays a vital role in early detection, staging and preoperative evaluation, differential and pathological diagnosis of pancreatic cancer.

Principle and clinical application of endoscopic ultrasoundelastography

Liu Enshuo, Yang Fei, Sun Siyu

2019, 34(9): 777-780. doi:10.3969/j.issn.1004-583X.2019.09.002

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Endoscopic ultrasound (EUS) plays a very important role in the diagnosis of digestive system disease. Endoscopic ultrasound elastography (EUSE) can realize visualization and quantitative assessment of lesions of gastrointestinal tract and adjacent organs and improve the diagnosis efficiency of EUS. Besides, EUSE can provide additional information to endoscopic ultrasoundguided fine needle aspiration (EUSFNA), which can improve the accuracy of disease diagnosis and histological acquisition. This review mainly focused on the methodology of EUSE and its clinical applications. This paper mainly summarizes the principle, method and clinical application of EUSE.

How to improve the positive rate of endoscopic ultrasoundguided fine needle aspiration biopsy

Liu Guanyi, Cai Yunlong, Nian Weidong

2019, 34(9): 781-784. doi:10.3969/j.issn.1004-583X.2019.09.003

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EUS has been widely used in the diagnosis and staging of gastrointestinal tumors, the biliopancreatic system and other extramural organs. The development of EUSFNA changed the application scope of EUS. How to improve the positive rate of EUSFNA has always been the focus of endoscopic physicians. This article aims to make a review on the the progress of operation procedure of EUSFNA, needle selection, puncture method strategy and rapid field pathological assessment, and discuss how to improve the positive rate of EUSFNA.

Diagnostic value of endoscopic ultrasonography for spaceoccupying lesions of biliary tract

Zhang Di, Feng Zhijie, Zhao Dongqiang

2019, 34(9): 785-789. doi:10.3969/j.issn.1004-583X.2019.09.004

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The spaceoccupying lesions of biliary tract is the main cause of obstructive jaundice. Because of the special location of the biliary system, traditional imaging is difficult to diagnose. Endoscopic ultrasonography (EUS) can effectively avoid the interference of abdominal fat and intestinal gas, and clearly show the biliary system. In recent years, EUS guided fine needle aspiration and contrastenhanced endoscopic ultrasonography techniques have high diagnostic value in the spaceoccupying lesions of biliary tract and play an important role in the differential diagnosis of biliary tract diseases.

Application of the contrastenhanced endoscopic ultrasonography in diagnosis and treatment of digestive diseases

Er Limian1, Feng Zhijie2

2019, 34(9): 790-794. doi:10.3969/j.issn.1004-583X.2019.09.005

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With the development of endoscopic ultrasonography (EUS), its examination technology has undergone a great deal of progress, such as Color doppler imaging, contrastenhanced endoscopic ultrasonography, threedimensional imaging, tissue harmonic imaging, and elastography. One of the most important developments is the ability to acquire contrastenhanced images(contrastenhanced endoscopic ultrasonography, CEEUS). Enhancement technique is the use of wrapped in antioxidant shell of gas bubble as ultrasound contrast agents quickly pushed by vein injection. Microbubbles can significantly enhance doppler blood flow signal. The microvascular system in the target lesion can clearly show the abnormal perfusion area of blood flow in the tumor lesion through contrast enhancement of noninvasive observation, which is conducive to the differentiation of benign and malignant lesions and can greatly improve the accuracy of tumor diagnosis and staging. This paper is to review the advances of CEEUS in diagnosis and treatment of digestive system diseases.

Endoscopic ultrasonography technique in diagnosis and treatment of pancreatic cystic lesions

Zhang Lixian1, Mi Jianwei2, Zhao Dongqiang2

2019, 34(9): 795-798. doi:10.3969/j.issn.1004-583X.2019.09.006

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Endoscopic ultrasonography, as a new examination method, plays an important role in the diagnosis and treatment of the pancreatic cystic lesions (PCL). We aim to give a report by summarizing the advances in the diagnosis and treatment of PCL.

Value of endoscopic ultrasonography in the diagnosis of lowgrade appendix mucinous neoplasm

Zhang Jingchao, Ma Yangyang, Li Shuangbiao, Lan Yongzhen, Wang Xiao

2019, 34(9): 799-801. doi:10.3969/j.issn.1004-583X.2019.09.007

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The incidence of lowgrade appendix mucinous neoplasms (LAMN) is low, and it is often manifested as appendicitis and abdominal mass. Due to the lack of specific clinical features, preoperative diagnosis is difficult. With the popularization of colonoscopy and application of endoscopic ultrasound (EUS) in the colon, the detection rate of LAMN is rising.At the same time, more doubts and problems need further exploration and solution. For example, the features of LAMN in EUS, the advantages of EUS compared with other imaging examinations, its differential diagnosis of other appendic diseases, the significance and accuracy of preoperative staging. More research and summary need to select which kind of ultrasound endoscope (Linerarray echoendoscope, radialarray echoendoscope and miniprobe) more suitable for detecting appendix diseases.

Predictive value of musculoskeletal ultrasonography in clinical remission of disease recurrence in patients with rheumatoid arthritis

Zhao Xuegang1, Liu Xiaomin1, Li Li1, Zhou Wei2

2019, 34(9): 802-804. doi:10.3969/j.issn.1004-583X.2019.09.008

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Objective To investigate the relapses of rheumatoid arthritis(RA) and the correlation with musculoskeletal ultrasound.Methods A total of 63 RA patients whose erythrocyte sedimentation rate（DAS28ESR） were continuously ≤2.6 were followed up strictly for at least 3 months. The clinical data and ultrasound results of 28 articular musculoskeletal specimens were recorded.With the persistence of the original treatment, patients' 3month clinical information were collected.Patients with disease recurrence (DAS28ESR) were divided into the disease recurrence group, patients with disease continuous remission （DAS28ESR≤2.6） were divided into the continuous remission group. The differences of clinical indexes and ultrasonography images between disease recurrence group and continuous remission group were compared by logistic regression analysis. Results A total of 26 cases with disease recurrence (41.3%) and 37 cases with continuous remission(58.7%) were observed within 3 months. Detection rate of subclinical synovitis of disease recurrence group was obviously higher than that of continuous remission group,while it was lower in depth remission rate（DAS28ESR<1.6）. Subclinical synovitis was an independent risk factor for the recurrence of RA, while the deep remission was a protective factor for the recurrence of RA. Conclusion The recurrence of RA was related to high disease activity and subclinical synovitis.

Expressions and clinical significance of aquaporins in Sjogren’s syndrome

Fan Lipinga, Huang Chunyana, Gong Sijinga, Wang Lifangb, Guo Huifanga, Gao Lixiaa

2019, 34(9): 805-808. doi:10.3969/j.issn.1004-583X.2019.09.009

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Objective To analyze the expression level and clinical value of aquaporins (AQPs) in peripheral blood of patients with Sjogren's syndrome(SS).Methods Twentythree SS patients of clinically confirmed were selected as experimental group. While 14 patients with autoimmune diseases (AIDs) were selected as experimental control group and 20 healthy subjects were selected as healthy control group.The expressions of AQP5 and AQP8 in peripheral blood were detected by enzymelinked immunosorbent assay (ELISA).Results AQP5 in SS group was higher than that in healthy control group（Z=1.826, P=0.041）, and there was no significant difference in the level of AQP8（P＞0.05）. There was no significant difference in the expression levels of AQP5 and AQP8 between SS group and experimental control group（P＞0.05）.The level of AQP5 was correlated with that of AQP8 in peripheral blood of SS patients（r=0.991, P＜0.01）. The levels of AQP5 （r=0.4805, P=0.032） and AQP8（r=0.5357, P=0.0149） in peripheral blood of patients with SS correlated with peripheral blood IgM. And neither had relationship with IgG, IgA, ESR, CRP, RF and leukocytes, hemoglobin and platelets（P＞0.05）.The SS patients were separated into different subgroups by with or without interstitial lung disease, with or without hematological involvement, antiSSB antibody negative and positive, and salivary gland pathological grade, there were no significant differences in subgroup analysis of patients（P＞0.05）.Conclusion The expression of AQP5 was higher in SS patients than in healthy people, which may have certain value for the diagnosis and the studies for pathogenesis of SS.The expression level of AQP8 related to the level of AQP5 in SS patients.And their significance for SS need further study.

Distribution and drug resistance characteristics of bronchoalveolar lavage fluid in hospitalized children with pneumonia in Soochow 2013-2018

He Ping, Feng Tao, Xu Jun, Hua Shenghao, Huang Lili, Shao Xuejun, Zhu Hong, Ji Xueqiang

2019, 34(9): 809-813. doi:10.3969/j.issn.1004-583X.2019.09.010

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Objective The distribution of pathogenic bacteria and characteristics of drug resistance changes of bronchoalveolar lavage in hospitalized children with pneumonia in Suzhou 2013 to 2018 were retrospectively analyzed, to provide a basis for the rational use of antimicrobial agents to effectively control related infections. Methods For the children with pneumonia who were hospitalized from January 2013 to December 2018, bronchoalveolar lavage(BALF) was extracted to detect the pathogen for the need of diagnosis and treatment.Results A total of 3 242 BALF samples were collected, from which 418 samples of pathogens were isolated.The positive rate of pathogen isolation was 12.89%. The main strains were Streptococcus pneumoniae and Haemophilus influenzae, with the detection rates of 38.28% and 21.05%, respectively. Streptococcus pneumoniae was significantly resistant to erythromycin, compound neostigmine, clindamycin and tetracycline, and the drug resistance rate was not significantly changed (P>0.05). Haemophilus influenzae was highly sensitive to ceftriaxone, metopenan and ceftapexin, and the drug resistance rate to ampicillin increased yearly (P<0.05).The positive rate of βlactamase was also significantly increased (P<0.05).Conclusion BALF etiological test can be used to detect children with pneumonia at a young agebecause of the refractory pneumonia with treatment difficulties and no clear etiological data.The distribution and drug resistance rate of BALF pathogenin Soochow have their own characteristics, so drug resistance monitoring and analysis should be strengthened. The clinical rational drug use should be duided according to the characteristics of the drug use in children.

Clinical value of serum protein electrophoresis (α2+β)/Alb ratio combined with CysC in diagnosis of early stage of diabetic nephropathy

Chen Jiaa, Xu Huab

2019, 34(9): 814-818. doi:10.3969/j.issn.1004-583X.2019.09.011

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Objective To investigate the clinical value of serum protein electrophoresis (α2+β) / Alb ratio in the early screening of diabetic nephropathy and its combination with serum CysC for early diagnosis of diabetic nephropathy. Methods According to urinary microalbumin/creatinine ratio (ACR), a total of 70 patients with type 2 diabetes were divided into normal albuminuria group and early diabetic nephropathy group with 35 cases in each group.At the same time, a total of 35 subjects for health check were selected as a control group. The serum protein electrophoresis, estimated glomerular filtration rate (eGFR), serum CREA, α1MG, β2MG, CysC level and serum protein electrophoresis (α2+β) /Alb ratio were compared among experimental groups, and the diagnostic value of each index was evaluated by ROC curve. Results With the increase of ACR level in diabetic patients, serum protein electrophoresis changed significantly, there were significant differences among experient groups in (α2+β)/ Alb ratio (P<0.01). ROC curve analysis showed that the AUC of (α2+β)/Alb ratio in differentiating microalbuminuria, controls and normal albuminuria was 0.860 with the sensitivity of 91.4% and the specificity of 75.7% in the optimal cutoff value of 0.32, superior to eGFR, CREA, α1MG, β2MG and CysC; The AUC of the combination of (α2+β)/Alb and CysC for diagnosis of early stage of diabetic kidney disease was 0.911 with the sensitivity of 91.4% and the specificity of 82.9%.Conclusion The serum protein components of diabetic nephropathy changed in the early stage. The (α2+β)/Alb ratio has certain clinical significance for early screening of diabetic nephropathy, and its combination with CysC is helpful in the early diagnosis of diabetic nephropathy.

Analysis of prognostic value of hematological indexes in patients with malignant ascites

Liu Yingying, Zheng Guoqi, Liang Yufei, Su Shanshan, Yin Wenjie, Zhang Guozun

2019, 34(9): 819-822. doi:10.3969/j.issn.1004-583X.2019.09.012

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Objective To investigate the differences of the blood parameters in malignant ascites(MA), and evaluate their influence on relationship with clinical prognosis. Methods 249 patients with pathologically proven MA were retrospectively reviewed. Investigation was performed in the changes of hematological indexes between MA group and control group, also between malignant peritoneal mesothelioma（MPeM） group and peritoneal carcinomatosis(PC) group. Age, sex, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) and monocyte/lymphocyte ratio (MLR) were analyzed.Influenceofblood lactic dehydrogenase(LDH), chemotherapy and viscera transfer on prognosis were analyzed.Results Of the 249 MA patients who were initially difficult to identify benign/malignant ascites， MPeM accounted for 41%, and PC accounted for 59%. The single factor analysis indicated that gender, NLR, PLR, MLR, LDH, chemotherapy, other organ metastasis were factors affecting OS of MA patients, but multivariate analysis indicated that LDH, other organ metastasis and NLR were independent factors affecting OS of MA patients.Conclusion MA patients with lower LDH and NLR have a better prognosis. Early active treatment is of great significance for improving the survival rate of MA.

Application value of CT targeted scan combined with multiple plane reconstruction in diagnosis of groundglass nodules(<1 cm) in lung

Chi Hongwei, Men Ming, Xu Qian, Feng Wenqiu, Ren Jinjun, Chen Yanfang, Guo Zhijun

2019, 34(9): 823-826. doi:10.3969/j.issn.1004-583X.2019.09.013

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Objective To explore the application value of targeted scan combined with multiple plane reconstruction(MPR) in diagnosis of ground glass nodules (<1 cm) in the lung.Methods A total of 71 groundglass nodules of lung from 62 patients with conventional CT scanning and targeted scan simultaneously in our hospital were selected. The analysis of nodules with MPR and volume rendering (VR) was performed. The morphological features of the nodules was evaluated by doubleblind method. Results The images obtained by targeted scans were superior significantly to that of conventional scans in showing the density, margin and lobulation sign of the ground glass nodules. There was statistical significance in the difference between the clearness of the images of air bronchial signs and vascular bundle signs obtained by targeted scan combined with MPR and that obtained byconventional scans. Compared with the conventional scans, the targeted scan can enhance diagnostic confidence (P=0.000) and diagnostic accuracy (P=0.039) of physicians,increase thenumber of nodule surgeries and decrease the number of followup cases. Conclusion The images of targeted scanning combined with MPR can clearly show the internal structure,the change of margin and the other key details of the groundglass nodules (<1 cm). For the groundglass nodules(<1 cm) which are difficult to be diagnosed by conventional CT, it is suggested to use target scan combined with MPR for further examination.

Effect of dapagliflozin on electrolytes in hematuria in patients with type 2 diabetes

Pang Qiqi, Gao Qian, Su Junping, Ma Ying, Chen Yunxia

2019, 34(9): 827-831. doi:10.3969/j.issn.1004-583X.2019.09.014

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Objective To observe the patients with type 2 diabetes mellitus (T2DM) who had poor glycemiccontrol (glycosylated hemoglobin, HbA1c>7.5%) with metformin alone and the application effects of dapagliflozinon blood electrolytes (serum sodium, serum potassium, serum calcium), urinary electrolytes(24 hours urinary sodium, 24 hours urinary potassium, 24 hours urinary calcium), urine osmolality and other metabolic indicators were evaluated for safety after administration.Methods During the period from September 2017 to April 2019, 103 patients with T2DM who were treated in the hospital were randomly divided into control group (n=55) and experimental group (n=48). The control group was treated with metformin, and the experimental group was given dapagliflozinmore. The changes of blood electrolytes, urinary electrolytes, urine osmolality and other metabolic indexes were compared with the baseline and those in the control group after 24 weeks of treatment, and the safety of the medication was evaluated.Results After 24 weeks of treatment, the levels of urinary electrolyte and urine osmolality in the experimental group were higher than those in the baseline and the control group(P<0.05). The blood glucose parameters, TC, TG, 24hour urinary protein, BMI and body weight in the experimental group were lower than those in the baseline and the control group(P<0.05). The levels of serum electrolyte, urinary pH, LDLC, HDLC and eGFR in the experimental group were the same as those in the baseline and control group(P>0.05).Conclusion In patients with poorly controlled T2DM treated with metformin alone, the combination of dapagliflozin can reduce blood glucose, improve blood lipids, reduce body weight and reduce urinary protein. Although it may cause an increase in urinary electrolytes and inurine osmolality, but there were no significant change in blood electrolyte levels. No serious adverse events occurred, and it was safe to use.

Risk factors of Mycoplasma pneumonia infection with incomplete Kawasaki disease

Zhang Jingjing1a, Wang Chengyi1a，2, Song Chaomin1b, Liu Guanghua1a, Wang Shibiao1c, Liu Yijun1a

2019, 34(9): 832-836. doi:10.3969/j.issn.1004-583X.2019.09.015

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Objective To investigate the high risk factors of Mycoplasma pneumonia infection with incomplete Kawasaki disease.Methods A total of 68patients having M.pneumonia infection with incomplete Kawasaki disease were collected from January 2015 to December 2018. At the same time ,a total of 136 patients having M.pneumonia infection without Kawasaki disease were selected as a control group. The risk factors of M.pneumonia infection with incomplete Kawasaki disease were analyzed by univariate and multivariate binary logistic regression analysis, and the ROC curve analysis was carried out for relevant indicators with statistical significance in binary Logistic regression analysis.Results Binary logistic regression analysis showed hemoglobin and albumin were protective factors, and the fever duration >7 d. The mixed infection of two or more pathogensand platelet countwere high risk factors of M. pneumonia infection with incomplete Kawasaki disease. The ROC curve analysis showed that the cutoff values of the 5 predictors were hemoglobin＜101 g/L, area under curve (AUC=0.869, 95%CI 0.8140.912, platelet count＞403×109/L(AUC=0.840, 95%CI 0.7830.888), albumin＜40.5 g/L(AUC=0.830, 95%CI 0.7720.879), fever duration >7 d(AUC=0.761, 95%CI 0.6960.818), and the mixed infection of two or more pathogens (AUC=0.551, 95%CI 0.4800.621).Conclusion The reduced hemoglobin and albumin, increased platelet count, fever duration >7 d and mixed infection of two or more pathogens are risk factors for M. pneumonia infection with incomplete Kawasaki disease.

Comparative analysis of the risks and benefits of endoscopic treatment in patients with colorectal polyps in hospital, daycare and outpatient settings

Xu Peng, Wang Yifei, Zhang Lihang, Wang Shanjuan

2019, 34(9): 837-842. doi:10.3969/j.issn.1004-583X.2019.09.016

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Objective To study the complications，relative risk factors and economic efficiency ratio in patients undergoing endoscopic resection of colorectal polyps (polyps) with different perioperative treatment scheme.Methods A retrospective analysis was conducted on 1 720 endoscopic polyp patients admitted to our hospital from December 2015 to December 2018, and according to the random number table method, the patients were divided into inpatient group(588 cases，performed selective operation after perfect inspection), patients with only routine blood tests performed resection directly were divided into two subgroups, daycare group(659 cases，postoperative admission to daycare ward)，and outpatient group(473 cases，postoperative followup observation outside the hospital). The incidence of complications, related risk factors, bed use and cost were analyzed.Results The postoperative fever in the inpatient group was higher than the other two groups (P<0.01). Abdominal discomfort was the lowest in the outpatient group with statistically significant difference compared with the other two groups (P<0.01). The outpatient group was followed by the day care group, and there was tatistically significant difference between day care group and inpatient group (P<0.05). The outpatient group had the least intestinal function recovery time and hypoglycemic reaction, and the difference was statistically significant compared with the other two groups(P<0.05 or P<0.01). Intraoperative bleeding in ascending colon and ileocecal junction was the most common, followed by rectum.Delayed polypectomy bleedingin rectumwas the most common,followed by ascending colon and ileocecal junction. The risk of bleeding increased with the increase of adaxial polyp diameter, the risk of bleeding with pedicle or apically raised polyp in the range of 1.02.0 cm was the highest, while in the range that＞2.0 cm was the lowest, especially with delayed polypectomy bleeding, which was significantly different compared with oter types (P<0.01). Age significantly increased the risk of bleeding, followed by systolic blood pressure level and polyp diameter, while high diastolic blood pressure level, surgical history and general anesthesia were protective factors for bleeding risk.Conclusion Polyp endoscopic therapy performed in outpatient department did not increase the risk of complications, only highrisk groups need day care wards, which is beneficial for improving patients' satisfication and compliance with endoscopic review, saving medical insurances and reducing medical costs.

Effect of computerized cognitive training in elderly with mild cognitive impairment: a metaanalysis

Wang Xuemei, Zhang Yuanyuan, Yu Hong, Yang Fengjuan, Li Yujie, Li Yan

2019, 34(9): 843-849. doi:10.3969/j.issn.1004-583X.2019.09.017

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Objective To evaluate the effect of computerized cognitive training on elderly with mild cognitive impairment.Methods A randomized controlled trial on the effect of computerized cognitive training on elderly with mild cognitive impairment was searched in Chinese and English databases, and metaanalysis was performed using RevMan 5.2 software．Results A total of 12 articles were included, involving 488 patients.Metaanalysis showed that the improvement of MMSE and MoCA in the intervention group was better than that in the control group after the intervention (MD=1.78, 95%CI 0.41，3.15，P<0.05; MD=4.02, 95%CI 1.33，6.70, P<0.05), the improvement of DSF and DSB in the intervention group was better than that in the control group after the intervention(MD=1.01, 95%CI 0.39，1.64, P<0.05; MD=0.67, 95%CI 0.16，1.17, P<0.05), the improvement of delay recall in the intervention group was better than that in the control group after the intervention(MD=1.20, 95%CI 1.00，1.39 , P<0.05), But, it had no obvious effect on SF, GDS and ADL. Conclusion Computerized cognitive training can improve the global cognitive function of the elderly with mild cognitive impairment, especially attention and shortterm memory, as well as delayed memory. But, it has no obvious effect on language abilities, depressive and everyday activities. Largesample, highquality randomized controlled study still needs more verification.

A case report and literature review：ornithine transcarbamylase deficiency caused by mutation of c.1006-3c>G#br#

Xu Yuping, Yu Yu, Wang Tuanjie, Li Shujun

2019, 34(9): 850-854. doi:10.3969/j.issn.1004-583X.2019.09.018

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The child started with digestive system discomfort as the primary symptom,resulting in intracranial hemorrhage and brain death due to high blood ammonia.The results of gene test during hospitalization indicated that the mutation ofc.10063C>G was responsible. The clinical manifestation of this disease is lack of specificity,mainly relying on the tandem mass spectrometry analysis of hematuria,and the gold standard(genetic detection)for the diagnosis of the disease. Ornithine transcarbamylase deficiency（OTCD） patients have a high mortality rate and a poor prognosis.There is no clinical standard treatment plan at present.Clinicians need to improve the awareness,diagnosis,treatment level,andearly detection of high blood ammonia.Early blood purification techniques may alleviate symptoms.

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