强化基层医疗卫生服务机构的服务能力,是健康中国建设的重要目标之一,对基层医院的帮扶工作是其中必不可少的环节.为提高对基层医院的帮扶效率,空军军医大学第二附属医院援富平县医疗帮扶团队将大型三甲医院MDT诊疗模式整合到基层医疗体系中,通过在基层医院开展院内MDT、县域内MDT及跨区域MDT,探索了一种行之有效的帮扶模式,为有效整合基层医疗资源提供一种新的参考,助力基层医疗水平明显提升.

Objective:To investigate the expression level and clinical significance of cellular communication network factor 4 (CCN4) gene in hepatocellular carcinoma (HCC) based on bioinformatics.Methods:The expression level of CCN4 protein in HCC tissues and its relationship with clinicopathological parameters were analyzed by TCGA database. The correlation between the expression of CCN4 protein and tumor purity and immune cell infiltration was analyzed by TIMER database. Kaplan-Meier Plotter database was used to analyze the relationship between the expression of CCN4 protein and clinical prognosis in HCC. Protein-protein interaction (PPI) network was constructed by using STRING database, and the correlation between proteins was assessed. The relationship between CCN4 expression and clinicopathological parameters was analyzed by Chi-square test. Correlation analysis was conducted by Spearman's rank correlation.Results:Clinical information and corresponding RNA sequencing data of 371 patients were obtained from TCGA HCC dataset. Data analysis showed that the expression of CCN4 protein in HCC patients was correlated with race, T stage and pathological G grade (χ2=9.055, 14.012, 17.163; P<0.05). Kaplan-Meier Plot demonstrated that HCC patients with high expression of CCN4 obtained shorter overall survival (HR=1.50, 95%CI: 1.05-2.14, P<0.05). TIMER database analysis showed that the expression level of CCN4 in HCC was negatively correlated with tumor purity (rs=-0.397, P<0.05), whereas positively correlated with the infiltration levels of B cells, CD8+T cells, CD4+T cells, macrophages, neutrophils, dendritic cells and M2 macrophages (rs=0.306, 0.279, 0.460, 0.490, 0.465, 0.404, 0.532; P<0.05). PPI network analysis indicated that decorin was the main protein interacting with CCN4 (score=0.953).Conclusions:The expression level of CCN4 protein is associated with race, T stage and pathological G grade, which can be used as a biomarker for poor prognosis of HCC. The underlying mechanism may be related to the infiltration of immune cells, the polarization of M2 macrophages and the formation of stromal fibers.

目的:评价单纯新辅助化疗治疗进展期低位直肠癌的疗效,同时探索新辅助化疗对直肠癌患者术后低位前切除综合征(low anterior resection syndrome,LARS)发生率的影响.方法:回顾性分析 2012 年 01月01 日至2021 年01 月01 日,我院普通外科治疗的临床进展期且接受腹腔镜根治术的60 例直肠癌患者临床资料.根据患者是否接受新辅助化疗分为新辅助化疗(NACT)组和辅助化疗(ACT)组.回顾性分析对比各组病人的一般临床资料、化疗不良反应、手术并发症、手术时长、手术出血量、住院时长、住院费用、肿瘤标志物转阴率、肿瘤缓解率、肿瘤降期率、化疗后肿瘤反应等级、术后无病生存曲线、总生存曲线,术后1、3、6、12 个月的LARS评分.结果:NACT组与ACT组相比,两组在手术并发症、术后排气时间、住院时长上均没有统计学差异(P>0.05);在化疗不良反应、术后CEA、CA19-9 转阴率、手术时长、手术出血量、住院费用上NACT组要明显优于ACT组(P<0.05);在DFS、OS生存曲线上,随着时间的延长,NACT生存曲线下降的幅度小于ACT组,其中DFS生存曲线有明显统计学差异(P<0.05),OS生存曲线无明显统计学差异(P>0.05);NACT组患者术后不同阶段的LARS评分与ACT组均无明显统计学差异(P>0.05),两组患者在术后1 年的LARS评分下降最为明显(P>0.05).结论:仅用新辅助化疗同样可明显改善直肠癌患者的预后,同时并不会影响术后LARS的发生率以及严重程度.

患者男，49岁，主因体检发现胆囊结石6年余入院。既往无腹胀、腹痛等不适。查体：面色暗沉，巩膜轻度黄染，未见肝掌、蜘蛛痣；腹部无压痛、反跳痛及肌紧张，肝脾肋下未触及，肝区叩痛阴性。患者自诉体检发现胆红素升高20余年，因无任何不适症状，未进一步检查及治疗。实验室检查提示总胆红素26.48 μmol/L，结合胆红素19.59 μmol/L，尿胆红素1+，其余指标未见明显异常。既往无肝炎病史，感染八项提示乙肝表面抗体定量、e抗体定量阳性。腹部B超提示肝脏大小正常，肝右叶钙化灶，空腹胆囊内部液性暗区消失，可见数处强回声光斑，最大直径约1.8 cm。脂餐后30 min再次探查，胆囊未见明显变化，提示胆囊收缩功能差。核素肝胆动态显像检查静脉注射显影剂后90 min，胆囊始终未见显影，提示胆囊功能明显受损。其他术前检查无明显异常。

目的 分析肝动脉化疗栓塞(TACE)联合射频消融术(RFA)治疗原发性肝癌的临床效果及对免疫功能、KPS评分和预后的影响.方法 收集2016年12月—2020年12月收治的原发性肝癌104例的临床资料.根据治疗方法分为联合组53例和单一组51例.单一组仅给予TACE治疗,联合组在单一组基础上联合RFA治疗.比较2组临床疗效、免疫功能、KPS评分、甲胎蛋白(AFP)水平,观察并发症及复发发生情况.结果 联合组总有效率高于单一组(P<0.05).2组治疗后CD3+、CD4+、CD4+/CD8+、KPS评分均高于治疗前,AFP水平、CD8+低于治疗前,且联合组上述指标优于单一组(P<0.05,P<0.01).2组并发症发生率比较差异无统计学意义(P>0.05).联合组复发率低于单一组(P<0.05).结论 TACE联合RFA治疗原发性肝癌效果显著,可改善免疫功能,降低复发率,且安全性较高.

医学检验技术专业旨在培养从事医学检验工作的技术应用型人才,其专业课教学内容具有涉及学科知识较广,各学科相互渗透并与临床医学对接的特点.基于目前教学中存在的学生临床医学知识相对欠缺,基本教材内容陈旧等问题,作者所在单位以微课作为信息化的主要手段,辅助移动教学互动软件,探索建立了适合于医学检验技术专业课的新的混合式教学模式.该模式可促进医学检验技术专业学生的深度学习.其中教学内容与教学活动的重构为混合式教学模式能有效实施的关键.

目的 分析胆囊结石合并胆总管结石(CBDS)的老年患者行腹腔镜胆囊切除术(LC)联合内镜逆行胰胆管造影术(ERCP)的临床疗效.方法 选取2019年1月-2021年3月于该院治疗的104例胆囊结石合并CBDS的老年患者作为试验对象,随机纳入对照组和试验组,各52例.对照组行LC联合腹腔镜胆总管探查取石术(LCBDE),试验组行LC联合ERCP.比较两组患者手术情况、术前和术后1 d应激反应和凝血功能指标、术前和术后3d肝功能水平以及术后并发症发生情况.结果 试验组住院总费用高于对照组(P<0.05),住院时间短于对照组(P<0.05),结石残留率低于对照组(0.00％和13.46％,P<0.05).术后1 d,两组患者血清去甲肾上腺素(NE)、皮质醇(Cor)、促肾上腺皮质激素(ACTH)水平及血浆纤维蛋白原(FIB)、D-二聚体水平均较术前升高,且试验组低于对照组(P<0.05).术后1 d,两组患者凝血酶原时间(PT)和活化部分凝血活酶时间(APTT)均较术前延长,且试验组短于对照组(P<0.05).与术前比较,两组患者术后3 d血清谷丙转氨酶(GPT)、γ-谷氨酰转肽酶(GGT)和谷草转氨酶(GOT)水平明显降低,且试验组低于对照组(P<0.05).试验组并发症发生率为3.85％,与对照组的13.46％比较,差异无统计学意义(P>0.05).结论 对胆囊结石合并CBDS的老年患者实施LC联合ERCP治疗,不仅可以减轻机体应激反应,改善凝血功能及肝功能,促进术后康复,还可提高结石清除效果,安全性高,值得临床推广应用.

目的 研究结直肠腺瘤合并幽门螺杆菌(Hp)阳性者的血清胃泌素(GAS)、炎症因子水平和肠道菌群变化情况.方法 选择2019年6月至2021年12月西安凤城医院收治的125例结直肠腺瘤患者进行研究,按照是否伴有Hp感染分为研究组(Hp阳性,50例)和对照组(Hp阴性,75例).比较两组患者的血清GAS、炎性细胞因子[白细胞介素-1(IL-1)、白细胞介素-6(IL-6)、白细胞介素-10(IL-10)、肿瘤坏死因子-α(TNF-α)]水平及粪便菌群(乳酸杆菌、双歧杆菌、大肠埃希菌)含量.结果 研究组患者的血清GAS水平为(65.87±9.32)pg/mL,明显高于对照组的(51.05±4.94)pg/mL,差异有统计学有意义(P<0.05);研究组患者的血清IL-1、IL-6和TNF-α水平分别为(206.17±54.98)ng/L、(40.56±11.94)ng/L、(403.65±104.96)pg/mL,明显低于对照组的(315.09±87.24)ng/L、(101.72±31.84)ng/L、(527.59±139.87)pg/mL,IL-10水平为(110.93±25.78)ng/L,明显高于对照组的(86.74±18.51)ng/L,差异均有统计学意义(P<0.05);两组患者粪便中大肠埃希菌、嗜酸乳杆菌含量比较差异均无统计学意义(P>0.05),但研究组患者粪便中长双歧杆菌的含量为(11.67±1.16)个/100 g,明显高于对照组患者的(10.43±0.54)个/100 g,差异有统计学意义(P<0.05).结论 Hp阳性结直肠腺瘤患者血清促炎性炎细胞因子水平明显下调,血清GAS、抗炎性细胞因子及肠道有益菌种相应上调.

以"糖的有氧氧化"微课设计为例,把生物化学的课程内容、医学生自身知识能力和科学精神交互融合进行微课教学设计,采用视频、图片、语音和文字等多种信息整合,进而生动形象表达教学内容,使科研情景、理论知识、知识与实践应用、思考与小结依次呈现,探讨微课设计在生物化学教学中的应用,以期让微课设计在提高生物化学教学质量中发挥积极作用.

Objective To investigate the application value of TACE combined with sorafenib in the treatment of primary liver cancer (PLC) from the perspective of clinical trials. Methods Four randomized controlled trials of TACE combined with sorafenib for PLC with the highest evidence level from 2010 to 2018 were selected globally, named Post-TACE, SPACE, TACE-2, TACTICS study respectively. Using the method of comparative description, the number of patients, tumor condition, liver function, general condition, TACE operation, duration of medication, primary endpoint, evaluation method and median follow-up time were analyzed. The clinical benefits of patients were further compared between different combinations of TACE with sorafenib to explore the optimal one and most eligible patients. In the literature review, the survival curve was delineated by Kaplan-Meier method. The survival status between two groups was analyzed by Cox's proportional hazards regression model. Results Negative results were obtained in Post-TACE, SPACE and TACE-2 studies. TACTICS study showed that the median vascular invasion time, median extrahepatic metastasis time and TACE time interval in the TACE combined with sorafenib group were 31.3 months, 15.7 months and 21.1 weeks, respectively, significantly longer than 4.0 months, 6.9 months and 16.9 weeks in the single TACE group (HR=0.26, 0.21, 0.59; P=0.008, 0.006, 0.018). Conclusions From the perspective of clinical trials, TACE combined with sorafenib may prolong the progression-free survival of patients with unresectable early and middle stage PLC and play a role in stabilizing the tumor progression. Key words: Carcinoma, hepatocellular; Transarterial chemoembolisation; Sorafenib; Clinical trial

目的 探讨三维可视化技术在肝切除中应用及其在半肝离断面设计中的误差分析.方法 回顾性分析《肝脏外科名家手术精粹》一书中的59例病例资料.其中男37例,女22例;平均年龄(54±14)岁.肝恶性肿瘤46例,肝门部胆管癌1例,肝囊腺瘤2例,肝血管瘤3例,肝局灶性结节性增生1例,肝胆管结石3例,肝包虫病1例,活体供肝切取2例.筛选半肝离断的手术视频及相应的术前三维可视化技术设计的半肝离断面,将术中肝离断面与术前设计离断面对比分析,总结术前设计的误差及原因.结果 共18例术前采用三维重建技术,其中14例纳入分析.术前设计离断面与术中不符10例,术前、术中基本相符4例.不按Cantlie线切割9例,其中沿肝中静脉纵轴切割7例,沿下腔静脉右侧壁切割1例,切割线偏离胆囊切迹中点1例;按Cantlie线切割但设计离断面未避开肝癌1例.结论 三维重建技术在肝切除中使用率不高.术前离断面的设计需要具有资质的技术人员实施,高年资肝脏外科医师与影像科医师或相关技术人员共同审查和核对.半肝离断平面设计应按照Cantlie线走行切割,还需结合肝癌切除原则.

目的 探讨胸腺法新联合阿德福韦对慢性乙型肝炎患者肝功能及乙型肝炎e抗原(HBeAg)转阴率的影响.方法 将105例慢性乙型肝炎随机分为对照组(n=52)和研究组(n=53),对照组给予阿德福韦治疗,研究组给予胸腺法新联合阿德福韦治疗,观察比较两组治疗后的临床疗效,AST、ALT复常情况,HBeAg、HBV-DNA转阴率,以及治疗期间不良反应.结果 经治疗后,研究组治疗总有效率,AST、ALT复常率,HBeAg、HBV-DNA转阴率明显高于对照组(P＜0.05);两组治疗期间不良反应发生率无明显差异(P＞0.05).结论 胸腺法新联合阿德福韦能提高慢性乙型肝炎患者临床疗效,改善患者肝功能与病毒转阴率,且具有较高的用药安全性.

Objective:To explore whether CT image post-processing software can accurately measure (associating liver partition and portal vein ligation for staged hepatectomy, ALPPS) related (future liver remnant, FLR).Methods:Clinical data of 9 liver cancer patients undergoing ALPPS were retrospectively analyzed in the Second Affiliated Hospital of Air Force Military Medical University from Mar 2015 to May 2019. All cases were divided into 2 groups by measurement: CT′s image post-processing software, or Myrian software. Two groups were compared with each other by paired t-test. Results:FLR from group CT′s image post-processing software was larger than that by Myrian software, there was statistical difference ( t=2.512, P=0.019). The mistakes of FLR measurements by the radiologist using CT′s image post-processing software couldbe caused by: (1)Lacking theoretical knowledge of liver surgery; (2) Adding devitalized tissue of hepatic section into future liver remnant; (3) Concept confusion about liver anatomy; (4) Lack of precision measurement. Conclusions:The inaccuracies generated during the ALPPS related future liver remnant measurements in CT′s image post-processing technique are all caused by human factors. These problems could be solved if the radiologist who operates 3D reconstruction receives liver surgery training or works with liver surgeons.

A large human natural single-chain fragment variable (scFv) phage library was constructed based on Cre-LoxP recombination, and used to successfully identify antibodies against proprotein convertase subtilisin/kexin type 9 (PCSK9). The library was derived from 400 blood samples, 30 bone marrow samples, and 10 cord blood samples from healthy donors. Lymphocytes were isolated from each sample and cDNA was synthesized using reverse transcription-quantitative PCR. Two-step overlap PCR was then used for scFv synthesis using a LoxP peptide as the linker. The scFv gene was inserted into the phagemid vector pDF by enzymatic digestion and ligation, and then transformed into Escherichia coli (E. coli) SS320 to establish a primary antibody library in the form of scFvs. A primary antibody library consisting of 5×107 peripheral blood and umbilical cord blood sources, as well as a primary antibody library of 5×107 bone marrow samples were obtained. By optimizing the recombination conditions, the primary phage library was used to infect E. coliBS1365 strain (which expresses the Cre enzyme), and a human scFv recombinant library with a size of 1×1011 was obtained through Cre-LoxP enzyme-mediated heavy and light chain replacement and recombination. This constructed recombinant library was employed to screen for antibodies against recombinant PCSK9. After four rounds of selection, a fully human antibody (3D2) was identified with a binding affinity of 1.96±1.56ⅹ10−10 M towards PCSK9. In vitro, the PCSK9/low-density lipoprotein receptor (LDLR) pathway of Hep-G2 cells was inhibited by 3D2 treatment, thereby increasing LDL uptake in these cells. In addition, combination treatment with 3D2 and statin was more effective at increasing LDLR levels than treatment with 3D2 or statin alone. Furthermore, 3D2 resulted in a 3-fold increase in hepatic LDLR levels, and lowered total serum cholesterol by up to 61.5% in vivo. Taken together, these results suggest that the constructed human Cre-LoxP scFv phage display library can be used to screen fully human scFv, and that 3D2 may serve as a candidate hypolipidemic therapy.

Objective To explore the application value of preoperative accurate define of liver transection plane with three-dimensional (3D) visualization technology in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Methods Clinical data of 9 patients undergoing ALPPS in the Second Affiliated Hospital of Air Force Medical University from March 2015 to May 2019 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 7 patients were male and 2 female, aged (54±10) years on average. 3D model of liver of the patients was reconstructed using Myrian software. The future liver remnant (FLR) was assessed before operation by liver division of Robin Smithuis & Eduard E. De Lange imaging (RE division) and precise division, respectively. Precise division focuses on the tumor cutting margin on the base of RE division. The FLR obtained by two methods was statistically compared by using paired t test. Results The FLR of RE division was (419±144) ml, significantly larger than (403±135) ml of precise division (t=2.51, P=0.036). The FLR difference value between two methods accounted for 0.2%-4.5% of standard liver volume (SLV). For1 patient, the FLR/SLV ratio was calculated as 44.3% (above 40%) by RE division, while 39.8% (below 40%) by precise division. Among 9 patients, 7 cases underwent ALPPS successfully including 6 cases of extended right hepatectomy and 1 case of right hepatectomy. The remaining 2 cases failed to undergo the second-stage operation. Conclusions The single imaging liver division method may have some errors. Prior to ALPPS, surgeons should combine imaging liver plane with the dividing line of liver lobes and follow the principle of liver cancer resection in order to accurately define the transection plane based on 3D visualization technology. Key words: Hepatectomy; Imaging, three-dimensional; Carcinoma, hepatocellular; Bile duct neoplasms

目的 探讨内镜鼻胆管引流术与经皮肝穿刺胆道引流术治疗急性梗阻性化脓性胆管炎的临床疗效.方法 选择2012年1月～2015年12月在我科治疗的164例急性梗阻性化脓性胆管炎患者,根据引流方式不同分为对照组和观察组,对照组采用经皮肝穿刺胆道引流术共81例,观察组采用内镜鼻胆管引流术共83例,观察两组患者治疗有效率、临床指标及并发症发生率.结果 观察组患者的治疗有效率为91.57％,对照组患者的治疗有效率为90.12％,虽然观察组的有效率高于对照组,但不具有统计学意义(P＞0.05);比较两组患者术后7d临床症状,观察组患者的血清总胆红素水平(62.54±11.23) μmol/L、腹痛缓解时间(5.67±1.16)d、住院时间(10.56±3.29)d均明显低于对照组的(79.36±17.68) μmol/L、(7.54±1.43)d、(16.82 ±4.71)d(P ＜0.05);观察组患者的引流量(343.18±53.46) ml/d明显高于对照组(312.45±51.27)ml/d(P ＞0.05);观察组的不良反应发生率为6.02％明显低于对照组的16.05％ (P ＜0.05).结论 内镜鼻胆管引流术与经皮肝穿刺胆道引流术在治疗急性梗阻性化脓性胆管炎方面均疗效显著,但内镜鼻胆管引流术操作简单,缓解症状更快,术后并发症更少,安全性更高.

患者男,37 岁,1 周前行腹部 CT 示肝左叶占位性病变,考虑肝癌可能,无恶心、呕吐,无寒战、高热,无腹痛、纳差、头晕,无皮肤、巩膜黄疸,为进一步治疗,门诊以"肝占位性病变待查"收入院.病后精神较可,食欲可,体重无下降.患者既往体健,无牧区生活史.偶吸烟,现已戒烟,无酗酒史.体检:体温 36.5℃,血压 120/60 mmHg(1 mmHg=0.133 kPa),体重 60 kg.心肺未见明显异常,腹平软,全腹无压痛、反跳痛,肝肋下可触及,质软,肝区无叩击痛,脾肋下未触及,肠鸣音正常,双下肢无水肿.实验室检查:血常规、尿常规、大便常规、肝肾功能、电解质、肝炎系列、凝血系列、肿瘤标志物均正常,CEA 0.94 μg/L,AFP 2.98 μg/L,CA19-96.67 kU/L.增强 CT 检查示:肝左叶占位性病变,考虑恶性肿瘤,并侵犯门静脉左支,肝左叶胆管扩张,肝右叶稍低密度影,考虑转移瘤.MRI 检查示:肝左叶占位性病变,考虑肝癌(纤维板层型)合并病变内少量出血,并侵犯门静脉左支,肝左叶胆管扩张,不除外间叶组织来源的恶性肿瘤;肝右叶多发小囊肿.初步诊断:肝占位性病变.

目的 对抗人中性粒细胞明胶酶相关脂质运载蛋白(NGAL)单克隆抗体H5识别的抗原表位区域进行鉴定.方法 设计4个NGAL截短体,通过PCR扩增截短体DNA片段并克隆到PET42a质粒中表达GST-NGAL截短体融合短肽.以此为抗原鉴定H5识别的抗原表位区域.随后根据生物信息学预测结果,化学合成2段潜在B细胞表位肽,用ELISA和Western blot方法进一步鉴定.结果 H5能与NGAL蛋白分子第20～36位氨基酸结合.结论 单克隆抗体H5的抗原表位结合位点存在于成熟NGAL蛋白分子氨基末端第20～36位氨基酸处,其深入研究为建立高效灵敏的NGAL免疫学检测体系和进一步研究NGAL分子抗原表位结构奠定基础.

Acute lung injury (ALI), with the hallmarks of vascular integrity disruption and neutrophil recruitment, is associated with high morbidity and mortality. Enhanced actomyosin assembly contributes to endothelial cell contact dysfunction. However, the roles and mechanisms of actomyosin assembly in ALI are not totally clear. We investigated the dynamic alterations and roles of actomyosin in ALI in vivo and in vitro models induced by LPS. Pulmonary levels of E-cadherin, vascular endothelial-cadherin, occludin, myosin phosphatase target subunit 1, and thymosin 4 were decreased, and the number and activity of neutrophils and the levels of actomyosin, p--associated protein kinase, p-myosin light-chain kinase, and profilin1 were increased within 3 d after LPS administration, and then, those alterations were recovered within the next 4 d, which was consistent with the alterations of lung histology, vascular permeability, edema, and serum levels of IL-6 and TNF-. Direct or indirect inhibition of increased F-actin or myosin assembly ameliorated the reduction of intercellular junction molecules, the activation and migration of neutrophils, and the degree of lung injury. Moreover, neutrophil activation further promoted actomyosin assembly and aggravated lung injury. Conclusively, the enhancement of self-organized actomyosin contributes to alveolar-capillary barrier disruption and neutrophil recruitment in inflammatory response, which is a potential therapeutic target for ALI.Chen, B., Yang, Z., Yang, C., Qin, W., Gu, J., Hu, C., Chen, A., Ning, J., Yi, B., Lu, K. A self-organized actomyosin drives multiple intercellular junction disruption and directly promotes neutrophil recruitment in lipopolysaccharide-induced acute lung injury.