Objectives:The combined technology of laparoscopy, choledochoscope and gastroscope was used in the treatment of gallbladder stones combined with common bile duct stones, which consists of laparoscopic cholecystectomy (LC), laparoscopic common bile duct exploration with primary closure (LCBDE-PC) and combined gastroscopic and choledochoscopic transabdominal nasobiliary drainage (GC-NBD). The clinical effects of the combined technology were evaluated based on hospital stay, hospital costs, postoperative complications, recurrence of stones, and overall patient satisfaction. Methods:From July 2017 to December 2020, 206 patients with gallbladder stones combined with common bile duct stones were reviewed retrospectively. According to the surgical method, the patients were divided into Triple-Scope group (LC + LCBDE-PC + GC-NBD), (n = 38), ERCP + LC group [endoscopic retrograde cholangiopancreatography (ERCP) followed by LC], (n = 96) and T tube group (LC + LCBDE + T tube drainage), (n = 72). The differences in stone size, hospital stay, hospital cost, postoperative gallstone recurrence rate and postoperative complications were compared among three groups. Results:No postoperative bile leak occurred in Triple-Scope group, and patients were discharged successfully, and the abdominal drain was removed around 3 days after surgery, and the nasobiliary drainage was removed around 5 days after surgery with a hospital stay of 9.5 ± 2.65 days. The length of hospital stay and hospital cost in the Triple-Scope group were lower than those in the ERCP + LC group (P < 0.01), but not significantly different from those in the T tube group (P > 0.05). The diameter of common bile duct and stone size were significantly larger in the Triple-Scope group and T-tube group than in the ERCP + LC group (P = 0.001; P = 0.004), and the recurrence rate of stones in the Triple-Scope group was not significantly different compared with those in the other two groups (P = 0.43). Conclusions:For patients with gallbladder stones combined with common bile duct stones, the triple-scope combination is safe and effective with fast recovery, and it is worthy of clinical promotion and application.

OBJECTIVE:To establish a two-port minimally invasive laparoscopic cholecystectomy (LC) technique that minimises surgical scarring and alleviates post-operative pain. METHODS:A cohort study was conducted, enrolling patients meeting the inclusion criteria to undergo two-port minimally invasive LC. The outcomes were compared with those of patients who underwent conventional LC performed by other medical teams. The clinical and pathological data were collected. Visual Analogue Scale scores were used to assess incision pain on post-operative days 1 and 15. Statistical analyses were performed to compare pain scores between the groups. RESULTS:Between November 2020 and June 2021, 56 patients met the screening criteria and were enrolled in the study group. Of these, 42 patients successfully underwent two-port LC, while 14 cases were converted to conventional three-port LC. No post-operative complications, such as bleeding or bile leakage, occurred, and all patients were discharged without incident. On day 1 post-surgery, the average incision pain score in the two-port LC group was 1.4 ± 0.95, significantly lower than 1.8 ± 1.32 in the conventional LC group (P = 0.02). On day 15 post-surgery, 13 patients (23.2%) in the two-port LC group reported subxiphoid incision pain, compared to 63 patients (41.4%) in the conventional LC group. CONCLUSION:For patients meeting indications for conventional LC, early implementation of two-port minimally invasive LC achieved a success rate of 75%. Compared to conventional LC, this technique did not significantly shorten operative time or reduce the complication rates. However, it decreased the number of incisions to two, reduced scar size from 10 mm to 3 mm and significantly alleviated post-operative pain. It is worthy of clinical application and promotion.

Our research is dedicated to combating HIV by targeting its Matrix (MA) domain, which is crucial for viral assembly and replication. This strategy specifically aims to interrupt early-stage infection and deter drug resistance by focusing on this essential domain. Due to the MA domain’s conservation across different HIV strains, our approach promises broad-spectrum efficacy, which is particularly crucial in regions marked by significant genetic diversity and resistance issues. In our study, we introduce CNP0269688, a natural product that exhibits high affinity for the HIV-1 Matrix. Through detailed molecular dynamics simulations, we have assessed the compound’s structural stability and interaction dynamics, particularly its potential to hinder Protein-tRNA interactions. This analysis lays the groundwork for future experimental investigations. Our efforts are steps toward enhancing HIV treatment, reducing viral transmission, and curbing drug resistance, with the ultimate aim of controlling and eradicating the pandemic, thereby contributing significantly to public health and scientific advancement.

Background: Identifying biomarkers may lead to easier detection and a better understanding of pathogenesis of pancreatic ductal adenocarcinoma (PDAC). Methods: Plasma small extracellular vesicles (sEV) from 106 participants, including 20 healthy controls (HC), 12 chronic pancreatitis (CP) patients, 12 benign pancreatic tumour (BPT) patients, and 58 PDAC patients, were profiled for microRNA (miRNA) sequencing. Three machine learning methods were applied to establish and evaluate the diagnostic model. Results: The plasma sEV miRNA diagnostic signature (d-signature) selected using the three machine learning methods could distinguish PDAC patients from non-PDAC individuals, HC, and benign pancreatic disease (BPD, CP plus BPT) both in training and validation cohort. Combining the d-signature with carbohydrate antigen 19-9 (CA19-9) performed better than with each model alone. Plasma sEV miR-664a-3p was selected by all methods and used to predict PDAC diagnosis with high accuracy combined with CA19-9. Plasma sEV miR-664a-3p was significantly positively associated with the presence of vascular invasion, lower surgery ratio, and poor differentiation. MiR-664a-3p was mainly distributed in the PDAC cancer stroma, including fibers and vessels, and was accompanied by VEGFA expression. Overexpression of miR-664a-3p could promote the epithelial-mesenchymal transition (EMT) and angiogenesis. Conclusion: In conclusion, our study demonstrated the potential utility of the sEV-miRNA d-signature in the diagnosis of PDAC via machine learning methods. A novel sEV biomarker, miR-664a-3p, was identified for the diagnosis of PDAC. It can also potentially promote angiogenesis and metastasis, provide insight into PDAC pathogenesis, and reveal novel regulators of this disease.

BackgroundPancreatic cancer stem cells (CSCs) promote pancreatic ductal adenocarcinoma (PDAC) tumorigenesis and chemoresistance. Cyclin-dependent kinase 1 (CDK1) plays an important role in tumor initiation in other tumors, but the function of CDK1 in PDAC remains unclear. Fisetin is a bioactive flavonoid with anti-tumor properties in multiple tumors, while its function in CSCs remains elusive.ResultsIn this study, we demonstrated that CDK1 was correlated with prognosis and was highly expressed in pancreatic cancer tissue and gemcitabine-resistant cells. Silencing CDK1 impaired tumor stemness and reduced a subset of CSCs. We found that fisetin blocked the kinase pocket domain of CDK1 and inhibited pancreatic CSC characteristics. Using acetylation proteomics analysis and phosphorylation array assay, we confirmed that fisetin reduced CDK1 expression and increased CDK1 acetylation at lysine 33 (K33), which resulted in the suppression of CDK1 phosphorylation. Silencing CDK1 or STAT3 suppressed tumor stemness properties, while overexpressing CDK1 or STAT3 showed the opposite effect. Mutation or acetylation of CDK1 at K33 weakened STAT3 phosphorylation at Y705, impairing the expression of stem-related genes and pancreatic cancer stemness. In addition, lack of histone deacetylase 3 (HDAC3), which deacetylates CDK1, contributed to weakening STAT3 phosphorylation by regulating the post-translational modification of CDK1, thereby decreasing the stemness of PDAC. Moreover, our results revealed that fisetin enhanced the effect of gemcitabine through eliminating a subpopulation of pancreatic CSCs by inhibiting the CDK1-STAT3 axis in vitro and in vivo.ConclusionOur findings highlight the role of post-translational modifications of CDK1-STAT3 signaling in maintaining cancer stemness of PDAC, and indicated that targeting the CDK1-STAT3 axis with inhibitors such as fisetin is a potential therapeutic strategy to diminish drug resistance and eliminate PDAC.

Supplementary Table S1 and Supplementary Figure S1 to S11

The microRNAs (miRNAs) are potent regulators of tumorigenesis in various cancers, especially pancreatic cancer. The abnormal expression of miRNAs can be observed in tumor cells. Noteworthy, miRNAs could be transferred by exosomes as small extracellular vesicles in regulation of carcinogenesis. This research focused on exploring the roles and mechanisms of exosomal miR-484, derived from human bone marrow mesenchymal stem cells (hBMSCs), in the context of molecular interactions and regulation of mitochondrial metabolism. Exosomes were isolated for the examination of miR-484 expression. The impacts of hBMSCs-derived exosomal miR-484 on pancreatic cancer cells were studied using various assays. Evaluation of mitochondrial function and metabolism was performed. Wnt/MAPK pathway-related protein expression was assessed, and an in vivo tumor xenograft model was utilized to examine the functions. Our findings demonstrated a decreased miR-484 expression in pancreatic cancer cells. However, hBMSCs-derived exosomal miR-484 inhibited the proliferation and migration of these cells, while inducing apoptosis. Moreover, miR-484 led to an upsurge in reactive oxygen species production, a decrease in ATP levels, and a disruption in mitochondrial metabolism. In vivo analyses showed that hBMSCs-derived exosomal miR-484 lessened tumor size and weight, while also suppressing the expression of mitochondrial biomarkers. Further, there was a decline in β-catenin and p-p38 protein levels both in vitro and in vivo. The addition of LiCl restored the disrupted mitochondrial metabolism. Conclusively, our results suggest that hBMSCs-derived exosomal miR-484 mitigates the malignant transformation and mitochondrial metabolism of pancreatic cancer by deactivating the Wnt/MAPK pathway.

Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant tumor with a poor prognosis. As a tumor inhibitor, the specific tumor suppressor mechanism of Sirtuin4(SIRT4) in PDAC remains elusive. In this study, SIRT4 was found to inhibit PDAC by impacting mitochondrial homeostasis. SIRT4 deacetylated lysine 547 of SEL1L and increased the protein level of an E3 ubiquitin ligase HRD1. As a central member of ER-associated protein degradation (ERAD), HRD1-SEL1L complex is recently reported to regulate the mitochondria, though the mechanism is not fully delineated. Here, we found the increase in SEL1L-HRD1 complex decreased the stability of a mitochondrial protein, ALKBH1. Downregulation of ALKBH1 subsequently blocked the transcription of mitochondrial DNA-coded genes, and resulted in mitochondrial damage. Lastly, a putative SIRT4 stimulator, Entinostat, was identified, which upregulated the expression of SIRT4 and effectively inhibited pancreatic cancer in vivo and in vitro.

Traumatic neuroma mostly results from nerve injury caused by surgery or trauma. Traumatic neuroma of the gallbladder without prior abdominal surgery is extremely rare, and we termed it “idiopathic traumatic neuroma of the gallbladder.” Due to its rarity and a lack of specific clinical and radiological features, it is most commonly misdiagnosed. In our case, the patient was admitted to our hospital for cholangiocarcinoma. Repeated abdominal contrast-enhanced computed tomography scans preoperatively indicated hilar cholangiocarcinoma. Due to insufficient future liver remnant, we planned preoperative percutaneous transhepatic cholangiodrainage and percutaneous transhepatic portal vein embolization based on multidisciplinary team consultation. The patient was then admitted 1 month later for surgery. We performed a laparoscopic cholecystectomy and an extensive laparoscopic right hepatectomy as gallbladder carcinoma was strongly suspected intraoperatively. However, the final diagnosis was traumatic neuroma of the gallbladder confirmed by pathological examination. Traumatic neuroma of the gallbladder is very rare, and we hope to provide some references for diagnosis by reporting our case and reviewing the literature on this topic so that extensive treatment can be avoided, thus improving patients’ quality of life. To the best of our knowledge, this is the first reported case of traumatic neuroma without prior surgery in the English literature since 1996.

Objective:To investigate the feasibility and clinical efficacy of laparoscopic radical cholecystectomy(LRC) for gallbladder cancer.Methods:The clinical data of 247 patients with gallbladder cancer who underwent radical resection from Jan 2013 to Dec 2019 at Department of General Surgery, Sir Run Run Shaw Hospital affiliated to Zhejiang University School of Medicine was analyzed retrospectively. After propensity score matching, 54 patients were included in laparoscopic group and 103 in laparotomy group. The clinicopathological characteristics and the short- and long-term outcomes were compared.Results:Compared to the laparotomy group, patients in the laparoscopic group had less intraoperative blood loss [100(50,200)ml vs. 200(100,300) ml, Z=4.105, P<0.001], earlier postoperative oral diet[1.0(1.0,2.0) d vs. 2.0(1.0,4.0) d, Z=4.157, P<0.001]and drainage removal[6.5(4.0,12.5) d vs. 9.0(6.0,16.0) d, Z=2.769, P=0.006], shorter hospital stay[7.0(5.0,9.3) d vs. 9.0(8.0,14.0) d, Z=3.923, P<0.001]. The number of lymph node dissection in laparoscopic group was significantly lesser than that in open group [6(4,9) vs. 8(5,12), Z=2.639, P=0.008]. There were no significant differences between the two groups in postoperative complications, short-term and long-term survival outcomes. Conclusions:Laparoscopic radical surgery for gallbladder cancer is as safe and feasible, and identical survival prognosis as open surgery, and moreover a less traumatic procedure.

Abstract Background Laparoscopic pancreatic tumor enucleation (LPE) is a viable option for the removal of non-malignant pancreatic masses leading to maximally preservation of organ function. However, postoperative pancreatic fistula (POPF) is a concern, particularly when the mass is close to the main pancreatic duct (MPD). Pancreatic duct stents are used to treat refractory pancreatic leakage, Preoperative stenting of the MPD might prevent its injury when performing LPE. Aimas To explore the application value of pancreatic duct stents in laparoscopic pancreatic tumor enucleation. Methods We reviewed the clinical data of patients who underwent either Laparoscopic pancreatic enucleation with pancreatic stenting (LPE + PS) or LPE from January 2016 to December 2019. The patients were divided into two groups as LPE + PS and LPE. Results Twenty (9 LPE and 11 LPE + PS) were included in the final analysis. The 2 groups were equivalent in baseline characteristics and pathologic variables. LPE + PS group showed shorter hospital stay (p = 0.045), lower Grade B/C postoperative pancreatic fistula rates than the LPE group (p = 0.047). Intraoperative and postoperative outcomes, including operating time (p = 0.124), estimated blood loss (p = 0.258), were similar in the two groups. No local recurrence and no patients presented exocrine or endocrine insufficiency was detected in either group. Conclusion This procedure is associated with acceptable morbidity and it is safe. The preoperative stenting of the MPD may facilitates to identify the main pancreatic duct intraoperatively, might avoid the occurrence of Grade B/C POPF.

DNA damage repair is a major barrier for chemotherapy efficacy of pancreatic ductal adenocarcinoma (PDAC), including the efficacy of platinum-based and gemcitabine/nab-paclitaxel treatments. N6-methyladenosine modifications (m6A) have recently been reported to play a role in homologous recombination (HR) repair of DNA double strand breaks (DSBs); however, the mechanism of action remains unknown. Our previous work indicated that fisetin may be a promising anti-tumour agent that induces DNA damage. In this study, we reported that fisetin induced DSBs and suppressed HR repair through m6A modification in PDAC cells. The m6A writer ZC3H13 and PHF10, which is a subunit of the PBAF chromatin remodelling complex, were identified as the main molecules affected by fisetin treatment. To our knowledge, it's the first time that PHF10 was found and involved in the DNA damage response. PHF10 loss-of-function resulted in elevated recruitment of γH2AX, RAD51, and 53BP1 to DSB sites and decreased HR repair efficiency. Moreover, ZC3H13 knockdown downregulated the m6A methylation of PHF10 and decreased PHF10 translation in a YTHDF1-dependent manner. In conclusion, our study demonstrates that fisetin enhanced DSBs via ZC3Hl3-mediated m6A modification of PHF10, which may provide insight into novel therapeutic approaches for PDAC.

Background Hepatocellular carcinoma (HCC) is a highly malignant tumor with a very poor prognosis. Pyroptosis is an inflammatory form of cell death and plays an important role in cancer development. The prognostic value of pyroptosis-related genes (PRGs) in HCC has not been studied extensively. Methods Unsupervised consensus clustering analysis was performed to identify two subtypes based on the expression profiles of prognostic PRGs in the The Cancer Genome Atlas (TCGA) database, and the differences between the two subtypes were compared. A prognostic model based on four PRGs was established by further least absolute shrinkage and selection operator (LASSO) Cox regression analysis and multivariate Cox regression analysis. Results Two subtypes (clusters 1 and 2) were identified by consensus clustering based on prognostic PRGs in HCC. Survival outcomes, biological function, genomic alterations, immune cell infiltration, and immune checkpoint genes were compared between the subtypes. Cluster 2 had a worse survival outcome than cluster 1. Cluster 2 was enriched for hallmarks of cancer progression, TP53 mutation, tumor-promoting immune cells, and immune checkpoint genes, which may contribute to the poor prognosis. A prognostic risk signature that predicted the overall survival (OS) of patients was constructed and validated. Consequently, a risk score was calculated for each patient. Combined with the clinical characteristics, the risk score was found to be an independent prognostic factor for survival of HCC patients. Further analysis revealed that the risk score was closely associated with the levels of immune cell infiltration and the expression profiles of immune checkpoint genes. Conclusions Collectively, our study established a prognostic risk signature for HCC and revealed a significant correlation between pyroptosis and the HCC immune microenvironment.

十四五规划指出"加快培养理工农医类专业紧缺人才"和"加强基础研究人才培养".在职临床医生申请同等学位已经成为研究生教育不可或缺的一部分,是提高在职临床医师教育层次的重要途径之一,为医疗人员继续医学教育提供了一个重要平台,是医院提高医疗水平和科研水平的重要途径之一,可有效提高医疗卫生水平.但由于临床医生的工作特点,申请同等学力的在职临床医生科研意识薄弱、科研能力差是不争的事实,因此,提高其科研能力是培养高素质临床医生的重点之一.文章分析了培养临床医生在职攻读硕士学位的过程中存在的问题,并结合当前实际情况,对申请同等学位的在职临床医生的毕业要求、课程学习、沟通、实验时间和导师培养方式提出了建设性的意见,以期为改进同等学力在职研究生的培养工作提供参考,以适应当前医学教育改革的需要,确保同等学力在职研究生的培养质量.

目的 探讨腹腔镜肝切除术治疗肝内胆管结石的安全性、有效性以及临床应用价值.方法 回顾性分析浙江大学医学院附属邵逸夫医院普外科2015年1月至2019年12月收治的肝内胆管结石行肝切除术治疗的208例病人,其中95例病人行开腹肝切除术(open hepatectomy,OH),113例行腹腔镜肝切除术(laparoscopic hepatectomy,LH).术后随访6～40个月,记录病人术前情况、手术结果、术后情况、随访情况.结果 95例行O H病人中,手术时间为(239.9±77.6)min,术中出血(308.9±211.6)mL,术中输血率为21.1％(20/95),切口感染率为15.8％(15/95),术后镇痛药使用时间为(4.1±1.9)d,术后抗生素使用时间为(8.5±5.1)d,术后禁食时间为(3.3±1.7)d,术后下床活动所需时间为(2.5±1.7)d,住院费用为(68932.2±16852.7)元.113例行LH病人中,手术时间为(219.2±68.9)min,术中出血(211.2±205.9)mL,术中输血率为9.7％(11/113),切口感染率为7.1％(8/113),术后镇痛药使用时间为(1.5±0.9)d,术后抗生素使用时间为(4.3±2.7)d,术后禁食时间为(2.4±0.8)d,术后下床活动所需时间为(1.9±1.3)d,住院费用为(56005.9±15376.9)元.以上指标LH与OH比较,差异均有统计学意义(均P<0.05).两组即时结石清除率、最终结石清除率、结石复发率差异均无统计学意义(均P>0.05).结论 LH作为治疗肝内胆管结石的术式,与OH相比手术时间短、术中出血量少、术中输血率低,切口感染率低,术后镇痛药、抗生素使用时间更短,术后禁食、下床活动所需时间、住院时间更短,住院费用更低.同时,LH即时结石清除率、最终结石清除率及结石复发率与OH相当.

Objective:To investigate the feasibility and safety of laparoscopic pancreatic tumor enucleation combined with intraoperative pancreatic duct stenting.Methods:The clinical data of a case of pancreatic solid pseudopapillary neoplasms who underwent laparoscopic pancreatic tumor resection combined with pancreatic duct stenting in Sir Run Run Shaw Hospital affiliated to Medical School of Zhejiang University in May 2021 were retrospectively analyzed.Results:The operation was successful, with the endoscopic operation time of 240 minutes and intraoperative blood loss of about 20 ml. 12 days after surgery, the patient was discharged with abdominal drainage tube. The drainage tube was removed half a month after surgery, and the pancreatic duct stent was removed by reexamination one month later. Postoperative pathology was considered as pancreatic solid pseudopapillary neoplasms.Conclusions:Laparoscopic pancreatic neck tumor resection combined with pancreatic duct stenting is feasible and safe without obvious pancreatic fistula.

Pancreatic cancer (PC) has a poor prognosis due to the lack of effective molecular biomarkers for early diagnosis. Recent studies have investigated the use of exosomal microRNAs (exmiRs) as diagnostic biomarkers in cancer. The present study examined exmiR-21, exmiR-10b and exmiR-212-3p expression in patients with PC and healthy individuals. The expression levels of exmiR-21, exmiR-10b and exmiR-212-3p were examined in the peripheral blood plasma of 36 patients with PC and 65 healthy controls, using tethered cationic lipoplex nanoparticle biochip. The levels of exmiR-21 in the plasma of 34 mice were also evaluated. The expression levels of exmiR-21 and exmiR-10b were significantly greater in patients with PC compared with the control group. The receiver operating characteristic (ROC) analysis indicated that exmiR-21 had better diagnostic performance (P=0.0003; AUC, 0.7171) compared with the other two exmiRs. The diagnostic value of exmiR-21 improved when combined with exmiR-10b (P<0.0001; AUC, 0.791). Furthermore, exmiR-21 was capable of distinguishing patients with early-stage PC from controls and advanced-stage PC (P<0.05, early stage vs. healthy; P<0.001, early stage vs. advanced stage). The results of the present study revealed that the plasma levels of exmiR-21 and exmiR-10b were upregulated in patients with PC. The ROC analyses indicated that exmiR-21 had the best diagnostic performance among the three exmiRs. Furthermore, exmiR-21 was capable of discriminating patients with early-stage PC from healthy controls. These findings indicate the potential of determining the expression of exmiR-21 from serum using a tethered cationic lipoplex nanoparticle biochip as a novel non-invasive strategy for the early diagnosis of PC.

Immunotherapy in pancreatic ductal adenocarcinoma (PDAC) treatment faces serious challenges, due particularly to the poor immunogenicity. Cancer cell-derived small extracellular vesicles (sEVs) play important roles in damaging the immune system. However, the effects of pancreatic cancer-derived sEVs on T lymphocytes are unknown. Here we investigated changes in phenotypes and signal transduction pathways in sEVs-treated T lymphocytes. We identified the overexpression of immune checkpoint proteins PD-1, PD-L1, CTLA4, and Tim-3 and the enrichment of FOXP3+ Treg cluster in sEVs-treated T lymphocytes by CyTOF. Gene set enrichment analysis revealed that DNA damage response and metabolic pathways might be involved in sEVs-induced Tregs. ATM, AMPK, SIRT1, SIRT2, and SIRT6 were activated sequentially in sEVs-treated T lymphocytes and essential for sEVs-upregulated expressions of FOXO1A, FOXO3A, and FOXP3. Our study reveals the impact and mechanism of pancreatic cancer cell-derived sEVs on T lymphocytes and may provide insights into developing immunotherapy strategies for PDAC treatment.