Narrative medicine first entered China in 2011 and has developed rapidly since then. The patient-centered care, shared decision making and relational medicine in the medical sphere, together with patients narrating their illness and narratology contributed to the rise of narrative medicine. Through listening to patients' narratives, paying attention to their emotions, and representing their stories in various ways, clinicians can connect with patients and empathize with them. In this way, affiliation and mutual trust with patients can be established. Patients will feel good in the doctor-patient encounter because of such humane care, and clinicians may get satisfaction from their work. Narrative medicine courses characterized by close reading of literature and writing should be added to the curriculum of medical education as the major content of medical humanities, so as to train narrative competence for the future doctors.

Objective: To explore the feasibility of enhanced recovery after surgery (ERAS) in treatment of children with congenital choledochal cyst. Methods: One hundred and thirty children with congenital choledochal cysts admitted in the Children's Hospital of Zhejiang University from June 2017 to June 2019 were divided into ERAS group (n=65) and control group (n=65) according to admission order. The intestinal tract condition during operation, time of operation, surgical results, time for eating after operation, abdominal drainage after operation, length of hospital stay after operation, total hospital expenses and complications were compared between two groups. Results: Compared with the control group, the satisfaction of intestinal operation field, recovery of gastrointestinal function after operation, time required for the volume of peritoneal drainage fluid to be less than 50 mL, time of abdominal drainage tube removal, and length of hospital stay were all improved in ERAS group (P < 0.05 or P < 0.01).ERAS group had more peritoneal effusion after removal of abdominal drainage tube (P < 0.01), but the incidence of edema after operation was lower (P < 0.05). The satisfaction of parents in the two groups was similar, but the cooperation of parents in the ERAS group was improved (P < 0.05) and the total cost of hospitalization was reduced (P < 0.01). Conclusion: ERAS has advantages over the traditional scheme and can be used in the clinical treatment of children with congenital choledochal cyst.

Objective: To analyze clinical manifestations, diagnosis and treatment of annular pancreas in neonates. Methods: Clinical data of 114 neonates with annular pancreas admitted in the Children's Hospital of Zhejiang University from January 2009 to December 2018 were reviewed. The demographic parameters (gestational age, birth weight), clinical manifestations, onset time, results of antenatal examination, associated anomalies, radiological findings, operations, postoperative complications were analyzed. Results: One hundred and two cases were examined by abdominal echography, in which 68 cases showed duodenal obstruction, 4 cases showed annular pancreas. Plain abdomen X-ray examination performed in 113 cases before operation, 76 cases presented double-bubble sign, 12 cases presented single-bubble sign and 5 cases had high-position intestinal obstruction. Upper gastrointestinal radiography (UGI) was performed in 103 cases, which suggested duodenal obstruction in 102 cases. Operations were performed in all cases, of which 69 cases were operated under laparoscopy including 1 case converted to open laparotomy. The mean fasting time after surgery was (7.8±2.7) d, and the mean length of hospital stay was (16.9±10.1) d. Five patients had postoperative complications. The incidence of postoperative complications in antenatal abnormal group was lower than that in the antenatal non-abnormal group (P < 0.05); the average fasting time in laparoendscopic surgery group was shorter than that in traditional laparotomy group (P < 0.05). Conclusions: Neonates with recurrent vomiting early after birth should be highly suspected to have annular pancreas. The fetal chromosome examination should be performed with abnormal antenatal screening. Surgery is the only effective way to diagnose and treat annular pancreas, and laparoscopic surgery could be the first choice for experienced doctors.

Objective: To summarize the clinical characteristics and treatment of type Ⅲ-b congenital intestinal atresia (CIA). Methods: The clinical data of 12 type Ⅲ-b CIA treated in the Children's Hospital of Zhejiang University School of Medicine from January 2015 to December 2017 were analyzed retrospectively. Results: Of the 12 patients diagnosed as type Ⅲ-b CIA in operation, treatment was refused during operation by their parents in 2 cases. For one child, only the proximal intestine was partly resected in the first operation, dilatation and dysplasia of the duodenum was diagnosed and total duodenum was resected and sutured in the second operation, as the child had postoperative intestinal obstruction. For one child, due to the long distal normal intestine, distal apple-peel like intestine was partly resected without mesenteric reformation. For the rest 8 children total duodenum resection and mesenteric reformation were performed. During the postoperative follow-up, one case was early rejected for further treatment by parents, one case died from complex congenital heart disease, 5 cases had the complication of short bowel syndrome. All 8 survival children received parenteral nutrition support after operation, 5 of whom received parenteral nutrition support for more than 42 days, and they were followed up for 1-3 years after discharge. The short-time efficacy was satisfactory. Conclusions: For children with type Ⅲ-b CIA, the distal apple-peel like intestine should be preserved as much as possible, the mesenteric reformation should be performed and the proximal dilated bowel should be partly resected and sutured. Postoperative nutritional support and early intestinal rehabilitation contribute to the compensation for rest intestines.

Objective: To assess the value of fetal anteroposterior renal pelvic diameter (APD) in predicting antenatal hydronephrosis requiring surgical treatment after birth. Methods: A total of 525 cases of antenatal hydronephrosis detected by prenatal ultrasonography (ultrasound index APD ≥ 4 mm in the second trimester and APD ≥ 7 mm in the third trimester) in Zhejiang Prenatal Diagnosis Center from June 2007 to June 2018 were retrospectively analyzed. ROC curve was used to analyze the relationship between these ultrasound indicators and the requirement for surgical treatment after birth. Results: There were 162 cases (30.9%) diagnosed in the second trimester and 363 cases (69.1%) diagnosed in the third trimester; 131 cases were diagnosed pathologically after birth, of which 121 finally underwent surgical treatment. The area under ROC curve (AUC) of APD in middle pregnancy for prediction of requiring surgery 1-12 years after birth was 0.910; the cut-off value of APD was 8.45 mm with a sensitivity of 97.1%, specificity of 70.9%, positive predictive value (PPV) of 47.9%, and negative predictive value (NPV) of 98.9%. The AUC of APD in late pregnancy for prediction of requiring surgery 1-12 years after birth was 0.800; the cut-off value of APD was 12.25 mm with a sensitivity of 66.7%, specificity of 81.2%, PPV of 51.7%, and NPV of 89.1%. Conclusion: APD in pregnancy can be used to predict whether the fetus with hydronephrosis needs surgical treatment after birth, and the prediction value of APD in the middle pregnancy is better.

Objective: To improve the method of vermillion flap and orbicularis oris bundle anastomosis in repair of transverse facial cleft. Methods: Based on the precise fixed point, the modified vermillion flap was designed slender at the new corner of the upper lip, and was inserted into the lower lip after removing part tissue. The orbicularis oris was divided into two bands and cross-stitched. Results: Fifteen patients with unilateral transverse facial cleft form the Children's Hospital of Zhejiang University during September 2016 and December 2018 were operated, and the position and shape of the commissure were almost normal. Conclusion: The cosmetic effect and oral function are satisfactory when the modified vermillion flap and bundle anastomosis of orbicularis oris is used to repair transverse facial cleft.

Objective: To assess the application of probe-based confocal laser endomicroscopy (pCLE) in diagnosis of gastric carcinoma and precancerous lesions. Methods: Patients underwent pCLE in the First Affiliated Hospital of Zhejiang University School of Medicine during December 2013 and November 2014 and in the First Affiliated Hospital of Zhejiang Chinese Medical University during January 2014 and December 2017 were enrolled. The consistency between pCLE diagnosis and pathological diagnosis of gastric lesions, including atrophic gastritis, gastric intestinal metaplasia, low-grade intraepithelial neoplasia and high-grade intraepithelial neoplasia (including gastric carcinoma) was analyzed. Results: Totally 154 gastric lesions from 119 patients were detected by pCLE. Using pathological diagnosis as gold standard, the sensitivity, specificity, coincidence rate and κ value of pCLE diagnosis for atrophic gastritis were 94.34%, 91.09%, 92.21%and 0.83; those indicators for gastric intestinal metaplasia were 84.47%, 92.16%, 87.01% and 0.72. The coincidence rate and κ value of pCLE diagnosis of complete gastric intestinal metaplasia were 0.75 and 0.49; for incomplete gastric intestinal metaplasia were 0.79 and 0.48, respectively. The sensitivity, specificity, coincidence rate and κ value of pCLE diagnosis for low-grade intraepithelial neoplasia were 85.29%, 87.50%, 87.01%and 0.66; those for high-grade intraepithelial neoplasia (including gastric carcinoma) were 95.83%, 97.17%, 96.75%and 0.92. Conclusion: pCLE can be used for diagnosis of gastric carcinoma and pericancerous lesions and also for typing of gastric intestinal metaplasia.

Objective: To assess the predictive value of myocardial scar mass in malignant ventricular arrhythmia (MVA) after myocardial infarction. Methods: Thirty myocardial infarction patients with complete electrophysiology and cardiac MRI data admitted from January 2012 to August 2017 were enrolled in the study. According to the results of intracavitary electrophysiological study, MVA developed in 16 patients (MVA group) and not developed in 14 patients (non-MVA group). The qualitative and quantitative analysis of left ventricular ejection fraction (LVFE) and scar mass was performed with CV^I42 post-processing software and predictive value of myocardial scar and LVEF for MVA after myocardial infarction was analyzed using ROC curves. Results: LVEF in MVA group was significantly lower than that in non-MVA group, and scar mass in MVA group was significantly higher than that in non-MVA group (all P < 0.05). Regression analysis showed that LVEF (OR=1.580) and scar mass (OR=6.270) were risk factors for MVA after myocardial infarction. For predicting MVA, the area under ROC curve (AUC) of LVEF was 0.696 with a sensitivity of 0.786 and the specificity of 0.685; the AUC of the scar mass was 0.839 with a sensitivity was 0.618 and the specificity of 0.929; the AUC of LVEF combined with scar mass was 0.848 with a sensitivity of 0.688 and specificity of 0.857. Conclusion: Myocardial scar assessed by late gadolinium enhancement MRI is more effective than LVEF in predicting MVA after myocardial infarction.

Objective: To investigate the effect and mechanism of mechanical stress on cartilage repair in inflammatory environment. Methods: The chondrogenic progenitor cells (CPCs) were isolated from the knee joint cartilage of patients with osteoarthritis (OA) undergoing total knee arthroplasty. The CPCs were cultured and expanded in a 3-D scaffold constructed with alginate. Intermittent hydrostatic pressure (IHP) was applied in a inflammatory environment induced by IL-1β, and Western blot was used to detect the expression of MAPK signaling pathway proteins. Cell proliferation was detected by CCK-8 method, and the expression of related genes like matrix metallo-proteinases 13 (MMP-13) and a disintegrins and metalloproteinase with thrombospondin motif 5 (ADAMTS-5) was detected by real-time RT-PCR. The anterior cruciate ligament of the rats was cut to construct the knee joint OA model, and the appropriate mechanical stress was constructed with external fixation to distract the knee joint in order to observe the repair of the cartilage and to explore its mechanism. Results: Adding 0.01 ng/ml IL-1β in cell culture inhibited the proliferation of CPCs. After IHP application, the expression of MAPK pathway protein was decreased, the mRNA expression of MMP-13 and ADAMTS-5 was reduced. The inhibition of IL-1β on CPCs was counteracted by IHP. Four weeks after the anterior cruciate ligament resected, the articular cartilage degeneration was observed in rats. The Mankin score in the OA treatment (joint distraction) group was lower, and the cartilage repair was better than that of the control group (P < 0.01). Animal experiments found that the suitable mechanical stress reduced the expression of P-p38, MMP-13 and COLL-X, inhibited cartilage cells apoptosis and promoted the repair of OA cartilage. Conclusion: Mechanical stress can promote the proliferation of CPCs, reduce the expression of matrix degrading enzymes, and promote the repair of OA cartilage by inhibiting MAPK signaling pathway.

Objective: To investigate the effect of bilateral superior cervical sympathetic ganglion occlusion (SCG) on aortic dissection and its possible mechanism. Methods: Forty-five SD rats were randomly divided into three groups with 15 in each:blank control group, sham operation group and SCG group. β-aminopropione (666 mg·kg^-1·d^-1) was given by subcutaneous injection for 4 weeks to establish the aortic dissection model. Rats in SCG group were given SCG before the injection of β-aminopropione. Blood pressure and heart rate of the rats were monitored using noninvasive tail artery blood pressure measuring instrument; sympathetic activity was monitored using drug block method; the structure of aortic wall was observed using HE staining; collagen fibers in aortic wall was observed using Sirius red staining; protein expression of Apelin was detected by immunohistochemistry; and the protein expression of matrix metalloproteinase (MMP)-2, 9 was detected by Western blotting. Results: During the experiment, the body mass of the sham operation group and SCG group was smaller than that of the blank control group (all P < 0.05), and the body mass of the SCG group was larger than that of the sham operation group (all P < 0.05). The heart rate and sympathetic activity of the sham operation group were higher than those of the blank control group (all P < 0.05), while the SCG group were lower (all P < 0.05). Compared with the blank control group, the aortic wall in the sham operation group was thickening, while that in the SCG group was improved. A large number of collagen-1 in the aortic wall of the blank control group was stained brown by Sirius red, which was lighter in SCG group, and the staining in the sham operation group was the lightest. Compared with the blank control group, the expression of Apelin, MMP-2 and MMP-9 protein in the sham operation group increased (all P < 0.05), while those in the SCG group decreased (all P < 0.05). Conclusion: SCG can effectively reduce the incidence and mortality of aortic dissection in rats, which may be related to the inhibition of sympathetic activity and the decrease of collagen-1, Apelin, MMP-2 and MMP-9 expression.

Objective: To evaluate the efficacy of ultrasound or fluoroscopic-guided percutaneous transluminal angioplasty (PTA) combined with thrombolysis for the treatment of acutely thrombosed arteriovenous fistula (AVF) or grafts (AVG). Methods: One hundred and ninety-two hemodialysed patients, in whom the thrombosed arterio-venous AVF or AVG developed less than 72 h and there were no contraindications for thrombolysis and PTA, underwent PTA combined with thrombolysis therapy in Sir Run Run Shaw Hospital of Zhejiang University from October 2014 to October 2017. Under ultrasound and/or fluoroscopic guidance, balloon catheter was introduced to thrombosis sites along a guide wire. Then the balloon was inflated and normal saline mixed with urokinase and heparin was injected for thrombolysis. After blood flow was restored, angioplasty was performed on vascular stenosed sites. Results: A total of 274 endovascular interventional operations were performed for 192 patients. The procedure success rate was 98.2%, clinical success rate was 93.8%and complication rate was 1.46%. The post-intervention primary patency rates for AVF group were 87.4%, 76.7%and 63.9%at 3, 6 and 12 months, respectively; while the post-intervention secondary patency rates were 93.7%, 91.6%and 83.0%, respectively. The post-intervention primary patency rates for AVG group were 60.7%, 51.5%and 43.1%at 3, 6 and 12 months, while the post-intervention secondary patency rates were 82.7%, 77.1%and 70.8%, respectively. Conclusion: PTA combined with thrombolysis is an effective and safe therapeutic option for AVF and AVG thrombosis, which would prolong hemodialysis access and save vascular resources for hemodialyzed patients.

Objective: To evaluate the outcome of re-pregnancy in women with uterine artery embolization(UAE)for postpartum hemorrhage(PPH). Methods: Clinical data of 117 pregnant women with previous PPH admitted in Ningbo Women and Children's Hospital from January 2010 to January 2016 were retrospectively analyzed. Among them 40 cases were treated with UAE (UAE group) and 77 cases were not treated with UAE (control group). The outcomes of re-pregnancy were followed up and compared between two groups. Results: There were significant differences in the incidence of induced abortion in early pregnancy and cesarean scars pregnancy (CSP) between the two groups (P < 0.05 or P < 0.01). In the UAE group, the incidence of PPH, placental accretion and hysterectomy rate was significantly higher than that of control group (P < 0.05 or P < 0.01). Multivariate analysis showed that UAE was independent risk factor for CSP, placenta accretion, PPH and hystere-ctomy (P < 0.05 or P < 0.01). Conclusions: The overall fertility and re-pregnant outcomes in women with previous UAE for PPH are favorable. However, the risk of CSP, placenta accretion and associated recurrence of PPH and hysterectomy is higher in women receiving UAE during subsequent pregnancy.

Objective: To analyze risk factors of pelvic ischemia after occlusion of the internal iliac artery during endovascular aneurysm repair (EVAR) surgery. Methods: The clinical data, preoperative CT angiography (CTA) findings and follow-up results of 82 patients with unilateral embolization of internal iliac artery undergoing EVAR were analyzed retrospectively. Among 82 patients, pelvic ischemic symptoms were developed in 20 patients (ischemia group) and the remaining patients served as control group. The risk factors for pelvic ischemia after occlusion of internal iliac artery during EVAR surgery were explored using univariate and multivariate analysis, and the clinical value was evaluated using ROC curves. Results: The univariate analysis showed that the numbers of the contralateral internal iliac artery and the ipsilateral deep femoral artery stenosis in the pelvic ischemia group were less than those in the control group (both P < 0.05). Multivariate Logistic regression analysis showed that the decreased number of internal iliac artery branches (OR=8.383, 95%CI:1.469-47.841, P < 0.05) was an independent risk of pelvic ischemia. The ROC curve analysis showed that AUC of the decreased number of contralateral internal iliac artery branches for predicting the incidence of pelvic ischemia was 0.816; when the number of 3.5 was taken as cut-off value, the corresponding sensitivity was 0.861 and the specificity was 0.167. Conclusion: The decrease in number of the contralateral internal iliac artery branches on preoperative CTA is an independent risk factor for pelvic ischemia after occlusion of the internal iliac artery during EVAR surgery, but it does not show enough clinical value.

Vascular smooth muscle cells (VSMC) are the main cellular component of vessel wall. The changes of VSMC functions including phenotypic transformation and apoptosis play a critical role in the pathogenesis of intracranial aneurysm (IA). Autophagy can participate in the regulation of vascular function by regulating cell function. In the initial stage of IA, the activation of autophagy can accelerate the phenotypic transformation of VSMC and inhibit VSMC apoptosis. With the progress of IA, the relationship between autophagy and apoptosis changes from antagonism to synergy or promotion, and a large number of apoptotic VSMC lead to the rupture of IA. In this review, we describe the role of autophagy regulating the function of VSMC in the occurrence, development and rupture of IA, for further understanding the pathogenesis of IA and finding molecular targets to prevent the formation and rupture of IA.

Uniparental disomy (UPD) refers to a chromosome defect that an individual's homologous chromosome or segments are inherited from one parent. UPD can cause either aberrant patterns of genomic imprinting or homozygosity of mutations, leading to various diseases, including cancer. The mechanisms of UPD formation are diverse but largely due to the incorrect chromosome separation during cell division. UPD does not alter the number of gene copies, thus is difficult to be detected by conventional cytogenetic techniques effectively. Assisted by the new techniques such as single nucleotide polymorphism arrays, more and more UPD-related cases have been reported recently. UPD events are non-randomly distributed across cancer types, which play important role in the occurrence, development and metastasis of cancer. Here we review the research progress on the formation mechanisms, detection methods, the involved chromosomal regions and genes, and clinical significance of UPD; and also discuss the directions for future studies in this field.

Severe adenovirus pneumonia has a high mortality and incidence of sequelae. Fever and cough are the main symptoms of children's severe adenovirus pneumonia, but such clinical manifestations are lack of specificity. For children with persistent high fever who are in the epidemic age and season, the adenovirus etiology detection, blood routine, cytokines, T cell subsets and imaging examinations are suggested. Children with early manifestations of infiltration of lung segment and lobar parenchyma, obvious emphysema, interstitial pneumonia or a large amount of pleural effusion should be alerted to have severe adenovirus pneumonia. This article reviews the epidemiological characteristics and risk factors of adenovirus pneumonia in different seasons, regions and serology, and the laboratory findings and imaging features of severe adenovirus pneumonia, which would be helpful for the early identification of the disease.

Congenital heart disease (CHD) is the most common birth defect at present. In recent years, the application of 3D printing in the diagnosis and treatment of CHD has been widely recognized, which presents CHD lesions in 3D solid model and provides a better understanding of the anatomy of CHD. In the future, 3D printing technology would improve the surgical proficiency, shorten the operation time, reduce the occurrence of perioperative complications, and create more personalized cardiovascular implants, therefore promote the precision of diagnosis and treatment for congenital heart disease. This article reviews the application of 3D printing technology in preoperative planning, intraoperative navigation and personalized implants of CHD, in surgical training and medical education, as well as in promoting doctor-patient communication and better understanding their condition for patients.

In vitro fertilization and embryo transplantation (IVF-ET) technology is one of the main treatments for infertility. But IVF-ET is expensive and has not be covered by health insurance in most developing countries. Therefore, how to obtain the maximum success rate with the minimum cost is a common concern of clinicians and patients. At present, the economic studies on IVF-ET mainly focus on different ovulation stimulating drugs, different ovulation stimulating protocols, different transplantation methods and the number of transplants. But the process of IVF-ET is complex, the relevant methods of economic study are diverse, and there are no unified standard for outcome indicators, so there is no unified conclusion for more economical and effective protocol by now. Therefore, to analyze the economic studies of IVF-ET, and to explore appropriate evaluation methods and cost-effective protocols will be helpful for reasonable allocation of medical resources and guidance of clinical selection. It would provide policy reference to include the costs of IVF-ET treatment in health insurance in the future.