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The causes and countermeasures of non-response to anti-vascular endothelial growth factor therapy

The therapeutic response of anti-vascular endothelial growth factor (VEGF) differs among individuals. According to the changes of central retinal thickness, intraretinal fluid, subretinal fluid, best corrected visual acuity and other morphological or functional manifestations after treatment, the performance of the treated eyes can be classified as optimal response, poor response and non-response. A variety of factors could account for poor or non-response to anti-VEGF, such as genomic polymorphism and specific genomic risk alleles, lesion characteristics, vitreous and macular structural abnormalities, resistance to anti-VEGF drug, and the role of pericytes and others. The common counter measures include increasing the dosage, shortening the injection interval and replacing with another alternative drug, inhibition of pericytes, relieving vitreomacular anatomical abnormalities. It is still worthy of further exploration that how to assess individual reasons for non-response, so that we can give proper treatment to reduce the excessive use of anti-VEGF drugs and improve the clinical management of ocular neovascularization diseases.

A Clinical and Imageological Study on Endovascular Repair of Thoracic Aortic Aneurysm, Thoracic Pseudoaneurysm and Aortic Dissection

Objective To summarize the critical point of diagnosis and endovascular repairment (EVR) to thoracic aortic aneurysm (TAA), thoracic pseudoaneurysm (TPA) and aortic dissection (AD), by comparison the computerized tomography angiography (CTA) images before and after EVR to observe effects, so as to explore a unique index of imageology to assess the pathological development and evaluate therapeutically effect in dynamic and systemic reviews in pre, intra, postEVR and followup period. Methods Fortyeight patients involving aneurysm or dissection of thoracic aorta were treated with EVR based on the preoperative CTA imaging. Before and after the introducing of stentgraft, digital substation angiography (DSA) was taken place and sequential enhanced CTA was followed to evaluate the effects of the treatment. All imagings of CTA and DSA were collected and induced into e-FilmTM database to select key sections for analyses and measurement. Results Fortynine EVR were preformed and 54 stent grafts were implanted in 48 cases, with endothelial tears sealed in 42 cases of dissection, aneurismal cavities excluded in 2 cases of aortic aneurysm, and rupture site closed in 4 cases of pseudoaneurysm. Endoleakage happened in 9 cases, which were treated successfully by appropriate measures. One case suffered hemorrhage from introducing artery (iliac) which was controled by surgery, but he died of disseminated intravascular coagulation and then multiple organs failure. Fortyseven cases were followed up in 6-51 months with a satisfied clinical effect. Conclusion EVR is favorable in the effect of repairment to true, false and dissection of thoracic descending aorta. Chest pain and CTA scan is the key of early diagnosis of aortic dissection. Certain sections and leftanterior oblique viewing are the crucial profile for assessment and evaluation before and after operation.

鼻塞气道正压通气在小儿心脏手术后的应用

目的　探讨鼻塞气道正压通气 ( NCPAP)在小儿心脏手术后发生急性呼吸衰竭时的应用方法和适应证。方法　对 39例心脏手术拔管后早期并发急性呼吸衰竭患者应用 NCPAP,观察 NCPAP前后呼吸频率、心率、血压和动脉血气的变化。　结果　 39例中除 10例行二次气管内插管外 ,其余 2 9例在 NCPAP辅助下呼吸状况和动脉血气结果均改善 ,在治疗 1小时后动脉血氧分压 ( Pa O2 )升高 ,动脉血二氧化碳分压 ( Pa CO2 )降低 ,至 2小时后疗效稳定 ,总治疗时间为 2 4～ 96小时。　结论　早期合理应用 NCPAP可迅速改善心脏手术拔管后早期呼吸衰竭患者的通气和换气功能 ,可作为再次气管内插管前的补救措施之一。

法洛四联症合并单侧肺动脉缺如术后呼吸窘迫综合征

目的 回顾总结1977～1999年我院小儿ICU收治的22例法洛四联症合并单侧肺动脉缺如、术后发生急性呼吸窘迫综合征（ARDS）的治疗经验，并探讨其术后并发症的预防和治疗。方法 22例法洛四联症患者术前经肺动脉造影确诊为单侧肺动脉缺如，根治术后发生ARDS，临床表现为血痰，肺毛细血管楔压lt;18mmHg（1kPa=7.5mmHg），氧和指数PaO2/FiO2lt;200mmHg，胸部X线片示单侧为主的肺渗出。术后处理：容量控制，特定的体位疗法，相应呼吸机治疗，抗感染和全身支持治疗。结果 患者平均带管时间7±3天，二次插管5例，肺部及全身感染10例，死亡5例。结论 法洛四联症伴单侧肺动脉缺如术后易出现以单侧肺渗出为主的ARDS，术后呼吸机辅助时间延长，二次插管率高，感染及死亡率高，应采用针对性治疗：（1）及时给予血管活性药物，早期给予白蛋白提高胶体渗透压，控制容量；（2）特定体位体疗，适当延长呼吸机辅助时间及相应呼吸机治疗；（3）营养和支持治疗；（4）对部分患者采用选择性姑息手术治疗，可减少并发症，提高手术成活率。

胰腺结核一例

Clinical Analysis of Gastroesophageal Reflux Disease Manifested Mainly as Stubborn Pharyngitis

ObjectiveTo explore and analyze the clinical diagnosis and treatment of gastroesophageal reflux disease (GERD) which is manifested mainly as stubborn pharyngitis. MethodsFrom February 2010 to December 2012, 79 cases were diagnosed as stubborn pharyngitis and otolaryngology standard treatment was invalid. GERD questionnaire ratings and conventional endoscopy were performed for patients with obvious manifestations of stubborn pharyngitis shown on the laryngoscopy. They were randomly divided into treatment group (n=40) and control group (n=39). Patients in the treatment group accepted esomeprazole 40 mg, qd, for 12 weeks; and patients in the control group had sucralfate suspension 15 mL bid for 12 weeks. At the three observation points which are 4, 8, and 12 weeks after treatment began, clinical symptom score and pharyngeal inflammatory changes were recorded, and at the end of the treatment, all patients underwent endoscopy, and esophageal mucosal healing was observed. ResultsThere was no significant difference between the two groups of patients in terms of general data. After the treatment, the symptom scores were significantly decreased in the treatment group at the three observation points (P<0.05). The same situation happened also in the control group, but the difference was not significant (P>0.05). The symptom scores between the two groups after treatment were significantly different (P<0.5). And the effective rate for local pharyngeal infection was 83.9% and 41.4% in the treatment group and the control group respectively (P<0.05). ConclusionSome atypical GERDs feature by the symptoms of stubborn pharyngitis. Clinically, patients with long-term stubborn pharyngitis should be screened to exclude the possibility of GERD. esomeprazole therapy can significantly improve the pharyngitis symptoms and relieve local inflammation.

Clinical observation of physical exercise with low intensity in patients with cirrhosis

Objective To evaluate the efficiency and security of physical exercise with low intensity against malnutrition and sarcopenia in patients with cirrhosis. Methods Between December 2014 and October 2015, 37 patients with cirrhosis were divided into two groups according to their willings, with 19 in the exercise group and 18 in the control group. Endurance of the exercise for 3 months were recorded. Mid-arm circumference, " up and go” time, width of portal vein and Child-Pugh score were compared before and after the research between the two groups. Results Three months later, the mid-arm circumference and the " up and go” time of the exercise group [(33.99±2.15) cm, (9.17±0.35) s] were better than those before the exercise [(32.09±2.58) cm, (9.77±0.46) s] and those in the control group [(31.93±2.04) cm, (9.76±0.30) s], and the differences above were all statistically significant (P<0.05). The change of the width of portal vein was positively correlated with pre-exercise body mass index in overweight patients (r=0.93, P=0.007). Conclusions Physical exercise with low intensity is safe and effective against malnutrition and sarcopenia in patients with cirrhosis. Overweitht patiens or malnutrition at the early stage may benefit more.

Clinical analysis of 426 emmetropia patients with unilateral rhegmatogenous retinal detachment and retinal lesions in the contralateral eyes

Objective To observe the fundus lesions in the unilateral rhegmatogenous retinal detachment (RRD) eyes and contralateral eyes in non-traumatic emmetropia patients, and explore the risks of lateral eyes. Methods This is a retrospective case analysis. A total of 426 patients of unilateral RRD diagnosed by clinical examination were enrolled in this study. There were 273 males and 74 females. The average age of onset was 54.7 years. 81.46% of them (347 patients) were 51 - 70 years old. The average detachment time was 2.12 months. They were divided into two groups, equal or lesser than 50 years old group and more than 50 years old group. A total of 100 patients (200 eyes) with ocular surface disorders were randomly selected as control. The lattice-like degeneration, cystic degeneration and dry retinal holes were treated with prophylactic laser photocoagulation. Follow-up period was 6 to 24 months. The age, gender, proliferative vitreous retinopathy (PVR) grading, best corrected visual acuity (BCVA), distribution and quantity of retinal holes, and posterior vitreous detachment (PVD) were retrospectively analyzed. The incidence of PVD among different age groups was compared with Chi square. Results Among 426 RRD eyes, there were 239 eyes (56.10%) with PVD. Among them, there were 30 eyes with age equal or lesser than 50 years old (12.55%) and 209 eyes with age more than 50 years old (84.75%). There were 187 eyes (43.90%) without PVD, which including 38 eyes with age equal or lesser than 50 years old (20.32%) and 149 eyes with age more than 50 years old (79.68%). The incidence of PVD among different age groups was statistically significant (χ2=4.72, P＜0.05). There were 10, 254, 40 and 5 eyes in class A, B, C and D of PVR, respectively; 117 eyes without PVR. The retinal hole was located in superior temporal, inferior temporal, superior nasal, inferior nasal and macular in 305, 91, 22, 4 and 4 eyes, respectively. The number of holes was 1, 2, and more than 3 in 297, 89 and 40 eyes, respectively. The retinal detachment range of 1, 2, 3 quadrants and total dissociation were 92, 230, 71, 33 eyes, respectively. The fundus lesion was found in 47 eyes (11.03%) in the lateral eyes. There were 20 RRD eyes in class B of PVR, and 27 RRD eyes in class C of PVR. Retinal degenerated area was found. Among them, the degeneration of 41 eyes was located in the temporal retina, 45 eyes involved in a quadrant. There were 16 eyes with peripheral retinal dry holes; the holes diameter was less than 1, 1 - 2, greater than 2 optic-discs in 6, 11 and 5 retinal holes. At the end of the follow-up, there were 47 eyes with almost normal visual field, 16 eyes with decreased visual acuity, no eyes with retinal detachment. In the control group, 4 patients (5 eyes, 2.50%) had fundus lesions. Conclusion The unilateral RRD in non-traumatic emmetropia mostly occurs in elderly patients; 11.03% of patients had fundus lesions in the contralateral eyes, higher than the general population.

Diagnosis of Esophageal and Gastric Varices by CT Portography or Endoscopy

目的　比较CT门静脉血管成像（CTP）与内镜诊断肝硬化胃食管静脉曲张的效果，探讨CTP对肝硬化门静脉高压侧支循环血管的显示及其在随访中的价值。 方法　对2010年1月－2011年12月收治的43例肝硬化患者行多排螺旋CT增强扫描门静脉血管成像，观察胃食管静脉曲张程度，及有无其他侧支开放，并在4周内行内镜检查，了解胃食管静脉曲张的程度。 结果　43例患者中有33例经胃镜确诊食管静脉曲张，其中CTP诊断与胃镜相符29例；胃镜诊断胃底静脉曲张14例，其中有12例CTP诊断与之相符；CTP诊断胃食管静脉曲张与内镜有较好的相关性和一致性，但在判断食管静脉曲张部位上与胃镜一致性较差。 结论　对肝硬化患者可采用CTP进行随访，以评估胃食管静脉曲张出血风险，可减少不必要的内镜随访。

Research on the Relationship among the Esophageal Varices, the Diameter of Portal Vein and Spleen Vein, and Child-Pugh’s Score in Patients with Liver Cirrhosis

【摘要】　目的　探讨肝硬化食管静脉曲张程度与门脾静脉内径、肝功能Child-Pugh分级间的关系。　方法　对2007年1月-2010年1月间56例肝硬化患者行增强CT，测量门静脉主干及脾门部脾静脉直径，采用Child-Pugh分级标准进行肝功能分级，并行胃镜了解食管静脉曲张的程度。　结果　食管静脉曲张程度与门、脾静脉内径呈正相关，而Child-Pugh分级与门脾静脉内径、食管静脉曲张程度无相关性。　结论　根据门、脾静脉内径可预测肝硬化上消化道出血的可能性；在Child-Pugh分级基础上对患者上消化道出血的风险进行评估显得尤为重要。【Abstract】　Objective　To discuss the relationship among the esophageal varices, the diameter of portal vein and spleen vein, and Child-Pugh score in patients with liver cirrhosis.　Methods　The study included 56 patients who had liver cirrhosis between January 2007 and January 2010. We measured their portal vein and spleen vein diameter with CT; used Child-Pugh score to grade their hepatic function; and detected the degree of the esophageal varices by endoscopy.　Results　There was a positive correlation between the degree of esophageal varices and diameter of portal vein and spleen vein, while no correlation showed between portal vein and spleen vein diameter, degree of esophageal varices, and Child-Pugh score.　Conclusion　The upper gastrointestinal bleeding in patients with liver cirrhosis can be predicted by the diameter of portal vein and spleen vein, assessment of upper gastrointestinal bleeding based on Child-Pugh score should also be taken into account.