Impact of preoperative transcatheter arterial chemoembolization (TACE) on postoperative long-term survival in patients with nonsmall hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

The purpose of this propensity score matching (PSM) analysis was to compare the effects of preoperative transcatheter arterial chemoembolization (TACE) and non-TACE on the long-term survival of patients who undergo radical hepatectomy.

METHODS

PSM analysis was performed for 387 patients with hepatocellular carcinoma (HCC) (single > 3 cm or multiple) who underwent radical resection of HCC at our centre from January 2011 to June 2018. The patients were allocated to a preoperative TACE group (n = 77) and a non-TACE group (n = 310). The main outcome measures were progression-free survival (PFS) and overall survival (OS) since the treatment date.

RESULTS

After PSM, 67 patients were included in each of the TACE and non-TACE groups. The median PFS times in the preoperative TACE and non-TACE groups were 24.0 and 11.3 months, respectively (p = 0.0117). The median OS times in the preoperative TACE and non-TACE groups were 41.5 and 29.0 months, respectively (p = 0.0114). Multivariate Cox proportional hazard regression analysis revealed that preoperative TACE (hazard ratio, 1.733; 95% CI, 1.168-2.570) and tumour thrombosis (hazard ratio, 0.323; 95% CI, 0.141-0.742) were independent risk factors significantly associated with OS.

CONCLUSIONS

Preoperative TACE is related to improving PFS and OS after resection of HCC. Preoperative TACE and tumour thrombus volume were also found to be independent risk factors associated with OS.

Extended lymphadenectomy based on the TRIANGLE for pancreatic head cancer: a single-center experience

BACKGROUND

This study was to compare the safety and efficacy of different lymphadenectomy methods in patients with pancreatic head cancer undergoing pancreaticoduodenectomy (PD).

MATERIAL AND METHODS

A total of 150 patients were included in this study. Patients were divided into Group A (n = 79), Group B (n = 44), and Group C (n = 27) according to the different lymphadenectomy methods. The clinical endpoint was time to progression (TTP) and overall survival (OS). Postoperative complications of different lymphadenectomy methods were compared respectively. TTP and OS of the three groups were compared by Kaplan-Meier curves.

RESULTS

There were no significant differences between the three groups in operative time (P = 0.300), death in the hospital (P = 0.253), postoperative hemorrhage (P = 0.863), postoperative pancreatic fistula (POPF) B/C (P = 0.306), bile leakage (P = 0.215), intestinal fistula (P = 0.177), lymphatic leakage (P = 0.267), delayed gastric emptying [(DGE) (P = 0.283)], ICU stay (P = 0.506), and postoperative hospital stay [(PHS) (P = 0.810)]. Median TTP in Groups B and C was significantly longer than in Group A (log-rank test, A vs B: P = 0.0005, A vs C: P = 0.0001). Median OS between the three groups has no statistical difference (P = 0.1546).

CONCLUSIONS

Extended lymphadenectomy methods based on the TRIANGLE do not increase perioperative complications significantly and can effectively delay tumor progression in patients with pancreatic head cancer.

Analysis of clinical significance and molecular characteristics of methionine metabolism and macrophage-related patterns in hepatocellular carcinoma based on machine learning

BACKGROUND

Increasing evidence has indicated that abnormal methionine metabolic activity and tumour-associated macrophage infiltration are correlated with hepatocarcinogenesis. However, the relationship between methionine metabolic activity and tumour-associated macrophage infiltration is unclear in hepatocellular carcinoma, and it contributes to the occurrence and clinical outcome of hepatocellular carcinoma (HCC). Thus, we systematically analysed the expression patterns of methionine metabolism and macrophage infiltration in hepatocellular carcinoma using bioinformatics and machine learning methods and constructed novel diagnostic and prognostic models of HCC.

METHODS

In this study, we first mined the four largest HCC mRNA microarray datasets with patient clinical data in the GEO database, including 880 tissue mRNA expression datasets. Using GSVA analysis and the CIBERSORT and EPIC algorithms, we quantified the methionine metabolic activity and macrophage infiltration degree of each sample. WGCNA was used to identify the gene modules most related to methionine metabolism and tumour-associated macrophage infiltration in HCC. The KNN algorithm was used to cluster gene expression patterns in HCC. Random forest, logistic regression, Cox regression analysis and other algorithms were used to construct the diagnosis and prognosis model of HCC. The above bioinformatics analysis results were also verified by independent datasets (TCGA-LIHC, ICGC-JP and CPTAC datasets) and immunohistochemical fluorescence based on our external HCC panel. Furthermore, we carried out pancancer analysis to verify the specificity of the above model and screened a wide range of drug candidates.

RESULTS

We identified two methionine metabolism and macrophage infiltration expression patterns, and their prognoses were different in hepatocellular carcinoma. We constructed novel diagnostic and prognostic models of hepatocellular carcinoma with good diagnostic efficacy and differentiation ability.

CONCLUSIONS

Methionine metabolism is closely related to tumour-associated macrophage infiltration in hepatocellular carcinoma and can help in the clinical diagnosis and prognosis of HCC.

[Research progress on distribution characteristics and health risk assessment of bioaerosols in medical institutions]

Bioaerosols in healthcare facilities are closely related to the health of medical staff and patients. Inhalation of microbial aerosol particles can lead to both infectious and non-infectious diseases. However, a systematic summary of bioaerosol types, sources, impact factors and health risk analysis is lacking.This article condutcted a literature review to understand the distribution characteristics, sources, influencing factors and health risks of bioaerosols in healthcare facilities, both domestically and internationally. The goal is to increase awareness of the distribution characteristics of bioaerosols in healthcare facilities and health risk of bioaerosols in medical institutions. This article also provides a reference for prevention and control of bioaerosols.

[Exploration of cystathionine β-synthase and cystathionine γ-lyase gene expression poor prognostic predictive value with the application of bioinformatics data mining in liver cancer]

Objective: To study the relationship between cystathionine β-synthase (CBS) and cystathionine γ-lyase (CTH) genes-related signaling pathways in liver cancer cells. Methods: We conducted a correlation analysis between the clinical features of CBS and CTH gene expression by mining the GEO (Gene Expression Omnibus) and TCGA (The Cancer Genome Atlas) databases of liver cancer. Additionally, liver cancer cell lines were verified by immunoblotting. Results: CBS and CTH expressions were significantly lower in tumors than in non-tumors (P < 0.05). COX regression result showed that CBS was an independent risk factor for the poor prognosis of liver cancer cells (HR=0.65, P = 0.02). A univariate logistic regression analysis was performed on the different tumor stages focusing on the CBS gene, which showed that TNM stage II verses I (P = 0.01, OR=0.50), stage III verses I (P = 0.03, OR=0.56), T stage T2 verses T1 (P < 0.01, OR=0.43), and T3 stage verses T1 (P = 0.02, OR=0.54) were significantly lower in liver cancer. TNM stage III verses I (P = 0.01, OR=0.50), Edmondson stage II verses I (P = 0.03, OR=0.48), stage III verses stage I (P < 0.01, OR=0.30), stage IV verses I (P = 0.03, OR=0.22), and T stage T3 verses T1(P = 0.03, OR=0.22) of the CTH gene expressions were significantly lower in liver cancer. GSEA enrichment analysis result revealed that the signaling pathway most correlated with the expression of CTH and CBS genes in liver cancer cells was cytochrome P450 (CYP450) (FDR Q < 0.01, FWER P < 0.01). Western blot results showed that the expression of the CTH downstream protein CSE was reduced in HCC cell lines such as HLE and Hep3B cells compared with the human immortalized liver cell line HL-7702. Conclusion: CBS and CTH gene expressions are lower in tumor tissue than in normal tissue groups. The CBS gene is an independent risk factor for poor prognosis in stem cell carcinoma. The cytochrome P450 is the signaling pathway most closely related to the CBS and CTH genes.

Anomalous staged hot-electron acceleration by two-plasmon decay instability in magnetized plasmas

We present a staged hot-electron acceleration mechanism of the two-plasmon decay (TPD) instability in the transverse magnetic field under the parameters relevant to inertial confinement fusion experiments. After being accelerated by the forward electron plasma wave (FEPW) of TPD, the hot-electrons can be anomalously accelerated again by the backward electron plasma wave (BEPW) of TPD and then obtain higher energy. Moreover, the surfatron acceleration mechanism of TPD in the magnetic field is also confirmed, the electrons trapped by the TPD daughter EPWs are accelerated in the direction along the wave front. Interestingly, the velocity of electrons accelerated by surfing from the FEPW is quite easily close to the BEPW phase velocity, which markedly enhances the efficiency of the staged acceleration. The coexistence of these two acceleration mechanisms leads to a significant increase of energetic electrons generated by TPD in the magnetic field. Meanwhile the EPWs are dissipated, TPD instability is effectively suppressed, and the laser transmission increases.

An alternating continuous integration system for magnetic measurements for experimental advanced superconducting tokamak

Integrators are critical instruments used for magnetic measurement systems (MMSs) in tokamaks, and, currently, the Experimental Advanced Superconducting Tokamak (EAST) has over 600 deployed. However, these integrators, designed with real-time drift compensation, will not be able to support longer pulse operations in the near future due to saturation and drift. To address these issues, this paper proposes a new alternating integration system combining analog integration with drift digital rectification. This system utilizes a microcontroller unit (MCU) to control two parallel analog integrators to work alternatively, compensate their drifts based on their respective error characteristics, and assemble the two integration segments together. The designed architecture provides highly flexible capabilities in operation modes and error correction, which make the system operation and maintenance highly automated. Performance tests on the EAST experiment site show that the prototype integrator can meet the requirements of real-time plasma control for a duration of hour-level.

Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (L-ALPPS) After Conversion Therapy for BCLC-B Hepatocellular Carcinoma: A Video Article

BACKGROUND

Despite the ALPPS technique remains a controversy, various ALPPS techniques have made many attempts.1-6 This video discusses the technical tips for L-ALPPS after conversion therapy.

METHODS

A 56-year-old, HCC patient who performed the abdominal CT showed a 6.0*5.7-cm-sized mass with intrahepatic metastasis. After four cycles of conversion therapy, the patient achieved a radiologic complete response. However, the standardized, remnant liver volume ratio (SRLVR) was only 34%. Thus, L-ALPPS was contemplated.

RESULTS

After full mobilization, intraoperative ultrasonography marked the main trunk of MHV. The concept of "Laennec membrane anatomy" was introduced.7 The anterior pedicle (AP) and the posterior pedicle (PP) were elastically suspended along the Laennec membrane. The conventional hilar dissection approach was used to isolate and suspend RHA and the right portal vein (RPV). Then, IRHV and short hepatic vein were clipped and cut. The Pringle maneuver was used intermittently during the parenchymal transection. Hepatic resection was performed from the caudal to the cranial side along MHV after RPV was ligated. The RHV was elastically suspended after hepatic resection. The omentum was used to cover the resection surface. Stage 2, preoperative SRLVR increased to 68.3%. The adhesion of the right hemiliver was bluntly separated. AP, PP, and RHV were divided by the stapler respectively. Operation time and bleeding volume for stage-1 surgery and stage-2 surgery were 240 min and 80 min, 200 ml and 250 ml, respectively. The postoperative recovery was uneventful.

CONCLUSIONS

L-ALPPS as a surgical option seems to be feasible and safe for intermediate-advanced HCC after conversion therapy.

A novel nomogram based on the hematological prognosis risk scoring system can predict the overall survival of patients with hepatocellular carcinoma

BACKGROUND

This study aimed to establish and validate a nomogram based on a hematological prognostic risk scoring system to predict the overall survival in patients with unresectable hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Patients diagnosed with unresectable HCC undergoing transcatheter arterial chemoembolization (TACE) in 2012-2016 and 2017-2018 were included in the development set and validation set, respectively. The clinical outcome was overall survival (OS). The LASSO regression analysis was used to construct a hematological prognostic risk scoring system (HPR) by using the 18 hematological markers of patients in the development set. Combining the features of oncology on the basis of HPR to construct a nomogram for OS. In the development set and validation sets, the C-index, calibration curve, and decision curve analysis (DCA) were used to evaluate the prediction performance of the nomogram.

RESULTS

Multiple markers of immunity, coagulation, liver function, and nutrition, including red blood cell distribution width-coefficient of variation (RDW-CV), platelet (PLT), aspartate transferase (AST), alkaline phosphatase (ALP), prognostic nutritional index (PNI), and fibrinogen (Fib), construct the HPR. HPR was an independent risk factor for OS in patients with HCC. The C-index of the nomogram was 0.731 (95% confidence interval (CI) 0.712-0.749) and 0.696 (95% CI 0.668-0.725) in the development set and the validation set, respectively.

CONCLUSIONS

HPR was a complement to the clinical features of patients with unresectable HCC. The nomogram based on HPR proved to be a practical and effective method for prognosticating HCC patients who undergo TACE.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223 min (range 181-260 min). The median blood loss was 200 ml (range 150-310 ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

[Clinical effects of anterolateral thigh flap with blood supply source of medial femoral perforator in repairing the wounds on extremities]

Objective: To investigate clinical effects of anterolateral thigh flap with blood supply source of medial femoral perforator in repairing the wounds on extremities. Methods: A retrospective observational study was conducted. From October 2018 to June 2021, Suzhou Ruihua Orthopedic Hospital admitted 12 patients (11 males and 1 female, aged 24-64 years) who met the inclusion criteria, and did not have the lateral circumflex femoral artery during anterolateral thigh flap resection, or changed to medial femoral perforator as a source of blood supply due to small perforator to repair the wound with flap transplantation. The wounds were on the upper limbs in 7 cases and on the lower limbs in 5 cases. The wound area after debridement was 8.0 cm×5.0 cm-24.0 cm×6.5 cm, and the applied flap area was 9 cm×6 cm-25 cm×7 cm. During transplantation, the perforating branch or source artery of the flap was anastomosed end to end with the vascular pedicle of the recipient area. Subcutaneous beauty suture was performed on all the donor wounds. After operation, the survival of the flap and vascular crisis were observed; and the wound healing at the donor site was observed. During follow-up, the texture of the flap and complications at the donor site were observed. At the last follow-up, the effect of flap repair was evaluated by using the modified self-made comprehensive efficacy rating table. Results: After operation, all the flaps of patients survived without vascular crisis; the wounds in the donor site healed smoothly. During follow-up of 6 to 26 months, the flaps had good texture; only linear scars remained in the donor area without scar contracture, pain or other discomfort. At the last follow-up, the total score of flap repair effect of 12 patients was 75-95, with an average of 87, of which 5 cases were rated as excellent, 6 cases as good, and 1 case as fair, and the proportion of excellent and good patients was 11/12. Conclusions: The application of anterolateral thigh flap with blood supply from the medial femoral perforator to repair wounds on extremities is an alternative method for the vascular variations such as no descending branch, oblique branch, or small perforator of the lateral circumflex femoral artery during the resection of the anterolateral thigh flap. This operation has the advantages of simple operation, small trauma, and others, which effectively ensures the smooth operation.

[ Ⅲ ]

Objective: To assess maxillary sagittal and vertical as well as upper airway changes immediately after mini-screw assisted rapid maxillary expansion (MARME) in class Ⅲ patients. Method: A consecutive sample of 48 class Ⅲ patients with maxillary transverse deficiency who visited the Department of Orthodontics, School & Hospital of Stomatology, Wuhan University between January 2013 and March 2023 was retrospectively collected. The sample was comprised of 24 growing patients (cervical vertebra maturation, CVM 1-4) and 24 nongrowing patients (CVM 5-6). Cone-beam CT scans before (T0) and immediately after MARME (T1) were imported into Dolphin Imaging software, and then voxel-based superimposition was conducted on the basis of the anterior cranial base. Sagittal and vertical changes of the maxillary landmarks (A, ANS, PNS, UI and Spr), as well as upper airway changes after MARME were measured on multiplanar reconstruction views. Wilcoxon signed-rank test was employed to analyze the changes after MARME. Mann-Whitney U test was employed to compare the changes between growing and non-growing patients. Results: Some class Ⅲ patients exhibited significant maxillary sagittal and vertical changes immediately after MARME. The amount of changes in midpalatal suture was 4.03 (2.99, 4.87) mm in growing patients, significantly larger than that in non-growing patients [2.27 (1.49, 3.64) mm] (U=3.18, P=0.001). In growing class Ⅲ patients, the forward changes of A, ANS, PNS, UI and Spr were 0.35 (0.06, 0.80), 0.48 (0.11, 0.88), 0.48 (0.13, 0.99), 0.53 (-0.33, 1.04) and 0.40 (0.03, 0.69) mm, respectively. Vertically, the downward changes of A, ANS, PNS, UI and Spr were 1.45 (0.99, 2.13), 1.18 (0.61, 1.95), 1.30 (0.91, 1.96), 1.20 (0.71, 1.83) and 1.30 (0.81, 1.73) mm, respectively. All changes were significantly different from 0 after treatment (P<0.05). In nongrowing patients, PNS moved forward by 0.18 (-0.08, 0.39) mm while other sagittal changes were statistically insignificant (P>0.05); vertically, the downward changes of A, ANS, PNS, UI and Spr were 0.90 (0.51, 1.39), 0.73 (0.41, 1.21), 0.70 (0.55, 1.08), 0.60 (0.36, 1.19) and 0.70 (0.55, 1.23) mm, respectively. Significant immediate increase of the nasopharynx volume and nasal width was obtained in both groups (P<0.05), and the changes of oropharynx volume and minimum cross-sectional area (MCA) presented as statistically insignificant (P>0.05). Conclusions: For growing class Ⅲ patients, besides transverse expansion, significant forward and downward changes of maxilla were obtained immediately after MARME. For non-growing patients, significant downward changes were observed, while sagittal changes were negligible. The nasopharynx volume increased in both growing and nongrowing class Ⅲ patients immediately after MARME, whereas, the changes of oropharynx volume and MCA presented as statistically insignificant.

Laparoscopic left hemihepatectomy guided by real-time indocyanine green fluorescence imaging using the arantius-first approach

BACKGROUND AND OBJECTIVE

Laparoscopic hepatectomy approaches, including major hepatectomy, were rapidly developed in the past decade. However, standard laparoscopic left hemihepatectomy (LLH) is still only performed in high-volume medical centres. In our series, we describe our technical details and surgical outcomes of LLH.

METHODS

Thirty-nine patients who underwent LLH in our institute were enrolled in the study. Among these, 13 patients underwent LLH guided by real-time ICG fluorescence imaging using the Arantius-first approach (ICG-LLH group), and the other 26 underwent conventional LLH (conventional LLH group). Demographic characteristics and perioperative data were retrospectively collected and analysed. We compared the technical and postoperative short-term outcomes of the two groups.

RESULTS

There were no significant differences in the demographic or clinicopathological characteristics of the patients in the two groups. ICG-LLH required significantly fewer pringle manoeuvres (1 vs. 3 times, p < 0.0001), had a shorter parenchyma dissection time (26 vs. 78 min, p < 0.001), and required fewer vessel clips (18 vs. 28, p < 0.001). Although there was no significant difference, the ICG-LLH group had less bile leakage (0 vs. 5, p = 0.09) and less blood loss (120 vs. 165, p = 0.119). There were no significant differences in the overall complication or R0 resection rates between the two groups.

CONCLUSION

Our data demonstrate that laparoscopic left hemihepatectomy guided by real-time ICG fluorescence imaging using the Arantius-first approach is safe and feasible in selected patients, thus improving the fluency of the surgical procedure and postoperative short-term outcomes.

[Effects of tibial second toe free flap bridged with blood flow and nerve in the treatment of severe flexion contracture of the proximal interphalangeal joint]

Objective: To investigate the effects of tibial second toe free flap bridged with blood flow and nerve in the treatment of severe flexion contracture of the proximal interphalangeal joint. Methods: A retrospective observational study was conducted. From March 2013 to October 2019, 9 patients with severe flexion contracture (type Ⅲ) of the proximal interphalangeal joint after trauma operation, conforming to the inclusion criteria, were hospitalized in Suzhou Ruihua Orthopaedic Hospital, including 5 males and 4 females, aged from 17 to 62 years. After the contracture tissue affecting the extension of the proximal interphalangeal joint was cut off, and the scar tissue was resected, the size of the volar wound near the proximal interphalangeal joint in extended position was 2.0 cm×1.0 cm-2.5 cm×1.5 cm, with the length of proper digital artery and nerve defect being 1.0-1.5 cm. A free flap of the same size as the wound was cut from the tibial side of the second toe and transplanted to repair the wound, and the defective proper digital artery and nerve was repaired by bridging with the tibial proper plantar digital artery and nerve of about 1.5 cm in length. The full-thickness skin graft was taken from the proximal tibial side of the lower leg to repair the wound at flap donor site. The wound at skin graft donor site was sutured directly. The survival of flap and skin graft was observed after operation. The patients were followed up, and at the last follow-up, the recovery of the affected finger and the second toe, including the donor and recipient areas were observed, the two-point discrimination distances of the flap repaired site and the pulp of the affected finger were observed and measured at the same time, the blood flow patency of bridged vessel of the affected finger was examined by Allen test, and the function of the proximal interphalangeal joint of the affected finger was evaluated according to Chinese Medical Association's standard for the range of motion of proximal interphalangeal joint. Results: The flaps and skin grafts survived smoothly after operation. The follow-up after operation lasted for 5 to 22 months, with a mean of 10 months. At the last follow-up, the flap repaired site had good shape, good color and texture, with the two-point discrimination distance being 9-12 mm, and the two-point discrimination distance of the pulp of the affected finger was 6-10 mm; the Allen test results of the affected fingers were all negative (i.e., the bridged vessels had good blood flow patency), with no recurrence of flexion contracture, and the function of the proximal interphalangeal joint was evaluated as excellent; the skin graft area of the second toe was not ruptured but was a little pigmented, and the flexion and extension activities of toe were good. Conclusions: The tibial second toe free flap bridged with blood flow and nerve has reliable therapeutic effect in the treatment of severe flexion contracture of the proximal interphalangeal joint, and the color and texture of the flap repaired area are good. Bridging to repair the severely contracted proper digital artery and nerve is beneficial to improve the blood supply of the finger body and rebuild the sensation.

Kinetic model and Vlasov simulation verification of two-ion decay instability

A kinetic theory is developed to describe the longitudinal decay of two-ion decay (TID): The pump ion-acoustic wave (IAW) decays into two daughter IAWs with a longer wavelength. The instability growth rate and threshold are given by the theory. Both the simulations of full kinetic Vlasov and hybrid Vlasov (kinetic ions and Boltzmann electrons) are employed to verify the theory and have a high quantitative agreement with the theory for 8≤ZT_{e}/T_{i}≤15, where Z is the ion charge number and T_{i}(T_{e}) is the ion (electron) temperature. The kinetic model developed here solves a long-standing problem that the simple fluid theory underestimates growth rate by a factor of 2∼3. Also, a reasonable explanation is given to the typical characteristics of TID that the dependence curves of subharmonic growth rate γ and wave number k.

[Effects of bilobated superficial peroneal artery perforator flap in repairing two adjacent wounds of the fingers]

Objective: To investigate the therapeutic efficacy of bilobated superficial peroneal artery perforator flap in repairing two adjacent wounds of the fingers. Methods: A retrospective observational study was conducted. From January 2021 to January 2022, 15 patients with two adjacent wounds of the fingers who met the inclusion criteria were hospitalized in Suzhou Ruihua Orthopaedic Hospital, including 10 males and 5 females, aged 25 to 51 years. The area of single wound after debridement was from 2.5 cm×2.0 cm to 7.5 cm×2.5 cm. All the wounds were repaired by the bilobated superficial peroneal artery perforator flap from the lower leg. The single lobe area of bilobated flap was from 3.0 cm×2.0 cm to 8.0 cm×3.0 cm. The wounds in all the donor sites were sutured directly. During the operation, the number of resected flaps, the number and type of carried perforators were recorded, and the calibers of perforator and superficial peroneal artery and the length of vascular pedicle were measured. The survival of flap and the wound healing in the donor and recipient sites were recorded after operation. The recovery of donor and recipient sites were recorded during follow-up. At the last follow-up, the repair effect of flap was evaluated by the comprehensive evaluation scale, and the sensory function of flap was evaluated by the sensory function evaluation standard of British Medical Research Association. Results: During the operation, 15 bilobated flaps were successfully resected, carrying 36 superficial peroneal artery perforators, all of which were septocutaneous perforators with the caliber of 0.2-0.8 mm. The caliber of superficial peroneal artery was 0.4-1.1 mm and the length of vascular pedicle was 3-8 cm. After operation, all the flaps survived with no vascular crisis occurred, and the wounds in donor and recipient sites healed well. During the follow-up of 6 to 12 months, the color and texture of flaps were similar to those of normal tissue in the hand and the appearance of flap was good in 10 cases; the other 5 cases underwent the stage Ⅱ flap thinning and plastic surgery 6 months after operation due to the bloated appearance of flaps. There was only linear scar in the donor site of lower leg, with no obvious scar hyperplasia or pigmentation, and there was no obvious adverse effect on the sensation or motor function of the distal limbs in the donor area. At the last follow-up, the repair effect of flap of 15 patients was excellent in 11 cases and good in 4 cases, and the sensory function of the flap was evaluated as grade S2 in all cases. Conclusions: The bilobated superficial peroneal artery perforator flap has high proportion of septocutaneous perforator, and the blood supply is sufficient and reliable. Using this flap to repair two adjacent wounds of the fingers causes minimal damage to the donor area, only one group of blood vessels is needed to be anastomosed to repair two wounds, the difficulty of microoperation is reduced, and good flap repair effect and sensory function can be obtained.

[Investigate of the etiology and prevention status of liver cirrhosis]

Objective: To investigate the etiology, prevention and treatment status, and their corresponding regional differences of the patients with liver cirrhosis in China, in order to provide scientific basis for the development of diagnosis and control strategies in China. Methods: Clinical data of patients diagnosed with liver cirrhosis for the first time through January 1, 2018 to December 31, 2020 from 50 hospitals in seven different regions of China were collected and analyzed retrospectively, and the difference of etiology, treatment, and their differences in various regions were analyzed. Results: A total of 11 861 cases with liver cirrhosis were included in the study. Thereinto, 5 093 cases (42.94%) were diagnosed as compensated cirrhosis, and 6 768 cases (57.06%) had decompensated cirrhosis. Notably, 8 439 cases (71.15%) were determined as chronic hepatitis B-caused cirrhosis, 1 337 cases (11.27%) were alcoholic liver disease, 963 cases (8.12%) were chronic hepatitis C, 698 cases (5.88%) were autoimmune liver disease, 367 cases (3.09%) were schistosomiasis, 177 cases (1.49%) were nonalcoholic fatty liver, and 743 cases (6.26%) of other types of liver disease. There were significant differences in the incidence of chronic hepatitis B, chronic hepatitis C, alcoholic liver disease, fatty liver, schistosomiasis liver disease, and autoimmune liver disease among the seven regions (P<0.001). Only 1 139 cases (9.60%) underwent endoscopic therapy, thereinto, 718 cases (6.05%) underwent surgical therapy, and 456 cases (3.84%) underwent interventional therapy treatment. In patients with compensated liver cirrhosis, 60 cases (0.51%) underwent non-selective β receptor blockers(NSBB), including 59 cases (0.50%) underwent propranolol and 1 case (0.01%) underwent carvedilol treatment. In patients with decompensated liver cirrhosis, 310 cases (2.61%) underwent NSBB treatment, including 303 cases (2.55%) underwent propranolol treatment and 7 cases (0.06%) underwent carvedilol treatment. Interestingly, there were significant differences in receiving endoscopic therapy, interventional therapy, NSBB therapy, splenectomy and other surgical treatments among the seven regions (P<0.001). Conclusion: Currently, chronic hepatitis B is the main cause (71.15%) of liver cirrhosis in several regions of China, and alcoholic liver disease has become the second cause (11.27%) of liver cirrhosis in China. The three-level prevention and control of cirrhosis in China should be further strengthened.

[Curative effects of the superficial peroneal artery perforator flap carrying multiple perforators in repairing hand and foot wounds]

Objective: To investigate the curative effects of the superficial peroneal artery perforator flap carrying two and more homologous perforators in repairing hand and foot wounds. Methods: A retrospective observational study was conducted. From January to September 2021, 23 patients with hand and foot wounds combined with bone or tendon exposure who met the inclusion criteria were admitted to Suzhou Ruihua Orthopaedic Hospital, including 16 males and 7 females, aged 23 to 68 years. After expansion of the wound, the wound area was 3.0 cm×2.0 cm to 11.0 cm×4.0 cm. All the wounds were repaired with the superficial peroneal artery perforator flap carrying two and more homologous perforators. The area of the resected flap was 4.0 cm×2.0 cm to 12.0 cm×5.0 cm. All the wounds in donor areas were sutured directly. During the operation, the resection of the flap, the number and caliber of carried perforators, the caliber of superficial peroneal artery, the length of vascular pedicle, and the number of accompanying veins of the superficial peroneal artery were recorded. The survival of the flap, the occurrence of complications, and the wound healing in the donor area were observed after operation. The recovery of the donor and recipient areas was followed up. At the last follow-up, the comprehensive evaluation scale was used to evaluate the curative effect of flap repair, and the sensory grading scale was used to evaluate the sensory function of the recipient area. Results: Totally 24 flaps were successfully resected in surgical operations, carrying 56 superficial peroneal artery perforators in total, with the caliber of perforators of 0.20-0.70 mm. The calibers of all perforators carried by 7 flaps were smaller than 0.40 mm. Nineteen flaps carried 2 perforators each, 3 flaps carried 3 perforators each, 1 flap carried 4 perforators, and 1 flap carried 5 perforators. During the operation, the superficial peroneal artery was resected with a caliber of 0.40-1.50 mm, the vascular pedicle was 2-6 cm in length, and each superficial peroneal artery had two accompanying veins. After operation, all the flaps survived smoothly, no vascular crisis or distal necrosis occurred, and the wounds healed well in the donor area. During the follow-up of 6 to 10 months after operation, the color, texture, and elasticity of the recipient area were good. Among them, 6 recipient areas were thinned and reshaped because of bloating. There was only linear scar and no obvious scar hyperplasia or pigmentation in the donor area, without significant change in sensory or motor function. At the last follow-up, the curative effect evaluation of flap repair was excellent in 22 flaps and good in 2 flaps, and the sensory function evaluation of the recipient area was grade S3 in 1 area and grade S2 in 23 areas. Conclusions: The superficial peroneal artery perforator flap with two and more homologous perforators has sufficient and reliable blood supply and is effective in repairing hand and foot wounds. It provides an ideal solution for the clinical problem in which the original operation scheme is abandoned due to the existence of only multiple slender perforators of caliber smaller than 0.40 mm, and only a single perforator in the operative field that cannot satisfy the needs of the flap blood supply and recipient area.

Strategic Approach to Aberrant Hepatic Arterial Anatomy during Laparoscopic Pancreaticoduodenectomy: Technique with Video

BACKGROUND

It is critical for every pancreatic surgeon to determine how to protect the aberrant hepatic artery intraoperatively in order to safely implement laparoscopic pancreatoduodenectomy (LPD). "Artery-first" approaches to LPD are ideal procedures in selected patients with pancreatic head tumors. Here, we described our surgical procedure and experience of aberrant hepatic arterial anatomy-LPD (AHAA-LPD) in a retrospective case series. In this study, we also sought to confirm the implications of the combined SMA-first approach on the perioperative and oncologic outcomes of AHAA-LPD.

METHODS

From January 2021 to April 2022, the authors completed a total of 106 LPDs, of which 24 patients underwent AHAA-LPD. We evaluated the courses of the hepatic artery via preoperative multi-detector computed tomography (MDCT) and classified several meaningful AHAAs. The clinical data of 106 patients who underwent AHAA-LPD and standard LPD were retrospectively analyzed. We compared the technical and oncological outcomes of the combined SMA-first approach, AHAA-LPD, and the concurrent standard LPD.

RESULTS

All the operations were successful. The combined SMA-first approaches were used by the authors to manage 24 resectable AHAA-LPD patients. The mean age of the patients was 58.1 ± 12.1 years; the mean operation time was 362 ± 60.43 min (325-510 min); blood loss was 256 ± 55.72 mL (210-350 mL); the postoperation ALT and AST were 235 ± 25.65 IU/L (184-276 IU/L) and 180 ± 34.43 IU/L (133-245 IU/L); the median postoperative length of stay was 17 days (13.0-26.0 days); the R0 resection rate was 100%. There were no cases of open conversion. The pathology showed free surgical margins. The mean number of dissected lymph nodes was 18 ± 3.5 (14-25); the number of tumor-free margins was 3.43 ± 0.78 mm (2.7-4.3 mm). There were no Clavien-Dindo III-IV classifications or C-grade pancreatic fistulas. The number of lymph node resections was greater in the AHAA-LPD group (18 vs. 15, p < 0.001). Surgical variables (OT) or postoperative complications (POPF, DGE, BL, and PH) showed no significant statistical differences in both groups.

CONCLUSIONS

In performing AHAA-LPD, the combined SMA-first approach for the periadventitial dissection of the distinct aberrant hepatic artery to avoid hepatic artery injury is feasible and safe when performed by a team experienced in minimally invasive pancreatic surgery. The safety and efficacy of this technique need to be confirmed in large-scale-sized, multicenter, prospective randomized controlled studies in the future.

Transradial versus transfemoral approach for TACE: a retrospective study

OBJECTIVE

Transcatheter arterial chemoembolization (TACE) has been widely applied in the treatment of hepatocellular carcinoma (HCC). Our study aimed to investigate the feasibility and efficacy of transradial access as an alternative to transfemoral access for TACE.

METHODS

Patients undergoing TACE were divided into the radial artery (RA) route group or the femoral artery (FA) route group according to the operation approach, namely, transradial or transfemoral access. We retrospectively analysed the clinical characteristics, technical outcomes, clinical efficacy and incidence of adverse events to compare the two technologies for intervention for HCC.

RESULTS

Transradial access was found to achieve superior technical outcomes and clinical efficacy, as the patients in the RA group had a lower rate of hepatic arterial spasm, a higher partial response rate and a lower progression rate than the patients in the FA group according to the mRECIST evaluations. In contrast, the liver function indices and VAS (visual analogue scale) pain scores were consistent across the two groups. Moreover, patients in the RA group had a shorter length of stay than those in the FA group, despite similar hospitalization expenses. The total adverse events were significantly reduced by transradial access for TACE (72.5% vs. 84.1%, P = 0.027).

CONCLUSION

Our study suggested that transradial access is an effective and feasible alternative to transfemoral access for TACE. Large-scale prospective randomized controlled studies are expected.

NAMPT inhibition reduces macrophage inflammation through the NAD+/PARP1 pathway to attenuate liver ischemia-reperfusion injury

BACKGROUND

Liver ischemia-reperfusion injury (IRI) is a major complication in the perioperative period and often leads to liver failure and even systemic inflammation. Previous studies have suggested that the inflammatory response participated in the liver damage during liver IRI. Nicotinamide phosphoribosyl transferase (NAMPT) is required for the maintenance of cellular nicotinamide adenine dinucleotide (NAD+) levels, catalyzing the rate-limiting step in the NAD + salvage pathway. NAMPT is strongly upregulated during inflammation and constitutes an important mechanistic link between inflammatory, metabolic, and transcriptional pathways. The aim of our study was to investigate the role of NAMPT in liver IRI.

METHODS

We investigated the effect of pharmacological inhibition of NAMPT with FK866 in models of liver IRI. Liver damage was assessed by HE staining, serum ALT/AST, and TUNEL staining. To examine the mechanism, primary hepatocytes, liver macrophages and RAW264.7 cells were treated with or without NAMPT inhibitors before hypoxia-reoxygenation. Liver macrophages and RAW 264.7 cells activation in vitro was evaluated by western blotting, flow cytometry, and ELISA.

RESULT

We found that NAMPT was upregulated in liver IRI. Treatment with the NAMPT inhibitor FK866 ameliorated liver IRI and suppressed inflammation in mice. Although NAMPT plays an important role both in hepatocytes and liver macrophages, we focused on the impact of NAMPT on liver macrophages. The mechanism revealed that FK866 potently inhibited NAMPT activity, as demonstrated by reduced liver NAD+ and intracellular NAD+, resulting in reduced abundance and activity of NAD + -dependent enzymes, including poly (ADP-ribose) polymerase 1 (PARP1), thus inhibiting macrophage M1 polarization by reducing CD86, iNOS, TNF-α, and interleukin (IL)-1β. Taken together, our data suggested that NAMPT can regulate macrophage polarization through NAD+/PARP1 to ameliorate liver injury, and that FK866-mediated NAMPT blockade may be a therapeutic approach in liver IRI.

Enhanced strong-coupling stimulated Brillouin amplification assisted by Raman amplification

Higher intensity of strong-coupling stimulated Brillouin scattering (SC-SBS) amplification is achieved by supplementary Raman amplification. In this scheme, a Raman pump laser first amplifies the seed pulse in the homogeneous plasma, and then a SC-SBS pump laser continues the amplification in the inhomogeneous plasma in order to suppress the spontaneous instability of pump lasers. The intensity of the seed laser gets higher and the duration of the seed laser gets shorter than that in the pure SC-SBS scheme with the same incident energy, while the energy conversion efficiency is not significantly reduced. We also found that the SC-SBS amplification is seeded by the leading pulse of Raman amplification. The results obtained from envelope coupling equations, Vlasov simulations, and two-dimensional particle-in-cell simulations agree with each other. This scheme offers a possible way to improve the SC-SBS amplification in experiments.

Risk of waning humoral responses after inactivated or subunit recombinant SARS-CoV-2 vaccination in patients with chronic diseases: Findings from a prospective observational study in China

Heterogeneity of antibody responses has been reported in SARS-CoV-2 vaccination recipients with underlying diseases. We investigated the impact of the presence of comorbidities on the humoral response to SARS-CoV-2 vaccination in patients with chronic disease (PWCD) and assessed the effect of the number of comorbidities on the humoral response to vaccination. In this study, neutralizing antibodies (NAbs) and IgG antibodies against the receptor-binding domain (RBD-IgG) were monitored following a full-course vaccination. In total, 1400 PWCD (82.7%, inactivated vaccines; 17.3%, subunit recombinant vaccine) and 245 healthy controls (65.7% inactivated vaccines, 34.3% subunit recombinant vaccine) vaccinated with inactivated or subunit recombinant SARS-CoV-2 vaccines, were included. The seroconversion and antibody levels of the NAbs and RBD-IgG were different in the PWCD group compared with those in the control group. Chronic hepatitis B (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.46-0.93), cancer (OR: 0.65; 95% CI: 0.42-0.99), and diabetes (OR: 0.50; 95% CI: 0.28-0.89) were associated with lower seroconversion of NAbs. Chronic kidney disease (OR: 0.29; 95% CI: 0.11-0.76), cancer (OR: 0.38; 95% CI: 0.23-0.62), and diabetes (OR: 0.37; 95% CI: 0.20-0.69) were associated with lower seroconversion of RBD-IgG. Only the presence of autoimmune disease showed significantly lower NAbs and RBD-IgG titers. Patients with most types of chronic diseases showed similar responses to the controls, but humoral responses were still significantly associated with the presence of ≥2 coexisting diseases. Our study suggested that humoral responses following SARS-CoV-2 vaccination are impaired in patients with certain chronic diseases.

[Anatomical characteristics and clinical application of anterolateral thigh perforator flap pedicled with oblique branch trunk of lateral circumflex femoral artery in the muscular septum]

Objective: To explore the anatomical characteristics of the anterolateral thigh perforator flap pedicled with oblique branch trunk of lateral circumflex femoral artery in the muscular septum and the clinical effect of this flap in repairing skin and soft tissue defects in the extremities. Methods: A retrospective observational study was conducted. From December 2020 to April 2021, 59 patients with skin and soft tissue defects in the extremities admitted to the Department of Hand Surgery of Suzhou Ruihua Orthopaedic Hospital met the inclusion criteria, including 46 males and 13 females, aged 20 to 81 years. The wound area after debridement ranged from 8 cm×5 cm to 38 cm×20 cm. According to the condition of the wound, the perforators in the anterolateral femoral region on the unaffected side were located by color Doppler ultrasound. The anterolateral thigh perforator flap with the oblique branch of lateral circumflex femoral artery as the source artery was designed, and the wound was repaired by unilateral flap or series combination of bilateral flaps (with the area of unilateral flap ranging from 7 cm×5 cm to 37 cm×11 cm). The wound of the donor site was sutured directly. The following items were recorded, including the number of perforators in the anterolateral femoral region marked before operation, the course characteristics of oblique branch trunk of lateral circumflex femoral artery and its perforators, and the number, origin, and type of perforators observed during operation, the flap repair mode and the flap harvest time. After operation, the survival condition of the flap, the wound healing time in the recipient site, and the suture healing in the donor area were observed, and the recovery of the donor and recipient areas was followed up. At the last follow-up, the sensation function evaluated by sensory rating scale of British Medical Research Association and two-point discrimination of the area transplanted with flap were recorded, and the improved comprehensive curative effect evaluation scale of flap was used to evaluate the repair effect of the flap. Results: A total of 156 perforators were marked in the anterolateral femoral region before operation, and 144 perforators were observed during the operation, of which 98 came from the oblique branch of the lateral circumflex femoral artery, and the first perforator of the oblique branch was the intermuscular septal perforator. Once formed, most oblique branch trunk of lateral circumflex femoral artery in the muscular septum could be divided into the deep branch and the superficial branch at the middle and upper 1/3 junction of the line between the anterior superior iliac spine and the lateral edge of the patella, the deep branch mainly ran in the muscle of vastus intermedius and vastus lateralis, and rarely developed the skin perforators, while the superficial branch mainly ran in the muscular septum between the rectus femoris and the vastus lateralis, and grew out the perforators to the proximal skin of the anterolateral femoral region. Fifty-six patients were repaired with unilateral flap and 3 patients with bilateral flap in series combination, with the harvesting time of the unilateral flap ranged from 9 to 99 min. Three patients developed arterial crisis within 48 hours after operation and survived after timely exploration; the flap of 1 patient developed necrosis 11 days after operation and was repaired by abdominal split-thickness skin graft; the other flaps survived smoothly. The wound healing time in the recipient area was 10 to 42 days after operation, and the sutures in the donor area healed well. During the follow-up of 6 to 10 months, 8 patients underwent thinning and plastic surgery 6 months after operation because of bloating in the flap transplantation area, while the other patients had a good shape of the flap transplantation area, with no deep tissue infection such as osteomyelitis, with soft texture, good elasticity, no pain, and good blood circulation; all the donor areas were left with linear scars, normal blood circulation in the distal extremities, no limitation of knee joint motion or quadriceps muscle strength. At the last follow-up, the sensation function was restored in the flap transplantation area of the affected limb, including 14 cases of S1 grade and 45 cases of S2 grade; there was only one point of two-point discrimination; the curative effect evaluation of flap repair included excellent in 24 cases, good in 35 cases, and general in 3 cases. Conclusions: The anterolateral thigh perforator flap pedicled with oblique branch trunk of lateral circumflex femoral artery in the muscular septum has the advantages of relatively concealed donor area, large cutting width, and simple operation during surgery. It protects the donor area to the greatest extent while repairing skin and soft tissue defects in the extremities, and is a useful supplement to the classic anterolateral thigh perforator flap.

[Association study between the KCNE family gene polymorphisms of potassium channel gene and the susceptibility of atrial fibrillation]

Objective: To investigate the relationship between KCNE family gene polymorphisms of potassium channel gene and the susceptibility of atrial fibrillation (AF). Methods: In the case-control study, a total of 648 subjects were studied, of which 338 patients with atrial fibrillation were selected from the Department of Cardiovascular Medicine, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine from January 2019 to December 2019, and 310 healthy people were selected from the physical examination population during the same period. DNA sequencing technology and polymerase chain reaction (PCR) were used to detect the genotype and allele frequency of rs1805127 of KCNE1, rs9984281 of KCNE2, rs9516, rs626930 of KCNE3 and rs12621643 of KCNE4. Results: The ages of subjects in atrial fibrillation group and control group were (69±13) and (73±8) years, respectively (P=0.077). Men subjects accounted for 57.70% (195 men) and 40.00% (124 men) in the two groups, respectively (P=0.092). The distribution frequencies of the allele C at rs1805127 of gene KCNE1, the allele A at rs9984281 of gene KCNE2 and the allele G at rs12621643 of gene KCNE4 were significantly different between groups (P<0.05). After adjustment for sex, smoking, hypertension, cardiac insufficiency and other factors, it was found that the increase in the frequency of the above three loci would increase the risk of atrial fibrillation (rs1805127 OR=7.064, 95%CI:1.559-31.997; rs9984281 OR=4.210, 95%CI:1.118-15.850; rs12621643 OR=2.679, 95%CI:1.025-6.998). Conclusion: The rs1805127 of KCNE1, the rs9984281 of KCNE2,the rs12621643 of KCNE4 were significantly associated with the susceptibility to atrial fibrillation.

[Safety and feasibility of stereotactic radiation therapy on porcine ventricular septum: a preliminary study]

Objective: To explore the safety and feasibility of stereotactic radiation therapy (SBRT) strategy for irradiating porcine ventricular septum, see if can provide a preliminary experimental evidence for clinical SBRT in patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods: Five male pigs (39-49 kg, 6 months old) were used in this study. Pigs were irradiated at doses of 25 Gy (n=2) or 40 Gy (n=3). Delineation of the target volume was achieved under the guidance of 3-dimensional CT image reconstruction, and SBRT was then performed on defined target volume of porcine ventricular septum. Blood biomarkers, electrocardiogram and echocardiography parameters were monitored before and after SBRT. Pathological examination (HE staining, Masson staining) was performed on the target and non-target myocardium at 6 months post SBRT. Results: SBRT was successful and all animals survived to the designed study endpoint (6 months) after SBRT. Serum cardiac troponin T (cTnT) level was significantly higher than the baseline level at 1 day post SBRT, and reduced at 1 week after SBRT, but was still higher than the baseline level(P<0.05). Serum N-terminal pro-B type natriuretic peptide (NT-proBNP) was also significantly increased at 1 day post SBRT (P<0.05) and returned to baseline level at 1 week post SBRT. The serum NT-proBNP level was (249±78), (594±37) and (234±46) pg/ml, respectively, and the cTnT was (14±7), (240±40) and (46±34) pg/ml, respectively at baseline, 1 day and 1 week after SBRT in the 40 Gy dose group. The serum NT-proBNP level was (184±20), (451±49) and (209±36) pg/ml, respectively, the cTnT values ​​were (9±1), (176±29) and (89±27) pg/ml, respectively at baseline, 1 day and 1 week after SBRT in the 25 Gy dose group. Both NT-proBNP and cTnT values tended to be higher post SBRT in the 40 Gy dose group as compared with the 25 Gy dose group, but the difference was not statistically significant (P>0.05). The left ventricular ejection fraction and the left ventricular end-diastolic diameter remained unchanged before and after SBRT (P>0.05). The interventricular septum thickness showed a decreasing trend at 6 months after SBRT, but the difference was not statistically significant ((9.54±0.24) mm vs. (9.82±8.00) mm, P>0.05). The flow velocity of the left ventricular outflow tract, and the valve function and morphology were not affected by SBRT. At 6 months after SBRT, HE staining revealed necrosis in the irradiated target area of ​​the myocardium in the 40 Gy dose group and the 25 Gy dose group, and the degree of necrosis in the irradiated interventricular septum was more obvious in the 40 Gy dose group as compared with the 25 Gy group. The combined histological analysis of the two groups showed that the necrotic area of ​​the irradiated target area accounted for (26±9)% of the entire interventricular septum area, which was higher than that of the non-irradiated area (0) (P<0.05). There was no damage or necrosis of myocardial tissue outside the target irradiation area in both groups. The results of Masson staining showed that the percentage area of myocardial fibrosis was significantly higher in the irradiated target area than non-irradiated area ((12.6±5.3)% vs. (2.5±0.8)%, P<0.05). Conclusion: SBRT is safe and feasible for irradiating porcine ventricular septum.

ALKBH5/MAP3K8 axis regulates PD-L1+ macrophage infiltration and promotes hepatocellular carcinoma progression

Hepatocellular carcinoma is one of the most common malignant tumors.M6A is a novel epigenetic modification that have been emerged as vital regulators for the progression of HCC. However, the regulatory role, clinical significance and the details of the modification, such as the impact on the local tumor environment, remain largely unclear. Our study showed that ALKBH5 was highly expressed in HCC and high ALKBH5 expression predicted a worse prognosis of HCC patients. Prediction of ALKBH5 function by tissue samples and single cell sequencing Gene Set Variation Analysis. Primary CD3 + T lymphocytes and bone marrow-derived macrophages were used to evaluate the effect of ALKBH5 on immune microenvironment. The results indicated that ALKBH5 promote HCC cell proliferation, metastasis and PD-L1+macrophage recruitment. Mechanistically the results showed that ALKBH5 regulates MAP3K8 expression in a m6A dependent manner which mediates the proliferation and metastasis of HCC cells. ALKBH5 also promotes the activation of JNK and ERK pathways through upregulating MAP3K8, thus regulating the expression of IL-8 and promoting macrophage recruitment. Taken together, these data show that ALKBH5 promotes HCC growth, metastasis and macrophage recruitment through ALKBH5/MAP3K8 axis and it may serve as a potential diagnostic marker and target for treatment of HCC patients.

[Clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux]

Objective: To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods: A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results: A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S3 in 2 cases, grade S2 in 9 cases, and grade S1 in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions: The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.

Effects of a combination of fibrolytic and amylolytic enzymes on ruminal enzyme activities, bacterial diversity, blood profile and milk production in dairy cows

We hypothesised that adding a combination of fibrolytic and amylolytic enzymes to the diet of early-lactation dairy cows would improve rumen enzyme activity and bacterial diversity, promote energy metabolism, and benefit milk production in cows. Twenty multiparous early-lactation (90 ± 5 d) Holstein cows with similar body conditions were randomly allocated to control (CON, n = 10) and experimental (EXP, n = 10) groups in a completely randomised single-factor design. The CON was fed only a basal total mixed ration diet, and the diet of the EXP was supplemented with a combination of fibrolytic and amylolytic enzymes at 70 g/cow/d (cellulase 3 500 CU/g, xylanase 2 000 XU/g, β-glucanase 17 500 GU/g, and amylase 37 000 AU/g). The experiment lasted 28 days, with 21 days for adaptation and 7 days for sampling. Enzyme addition increased the activity levels of α-amylase and xylanase, and the ammonia-N concentration (P < 0.05) tended to increase the activity of β-glucanase (P = 0.08) in rumen fluid. However, there was no significant difference in the rumen bacterial richness and diversity, phylum (richness > 0.1%) or genus (richness > 1%) composition between the CON and EXP groups (P > 0.05). A tendency of difference was found between CON and EXP (R = 0.22, P = 0.098) in principal component analysis. Ten genera showed different abundances across the CON and EXP groups (linear discriminant analysis effect size, linear discriminant analysis > 2). EXP increased the ratio of albumin to globulin and the concentrations of total cholesterol and low-density lipoprotein cholesterol (P < 0.05) and tended to increase triglycerides (P = 0.09) in blood. Milk yield, 3.5% fat-corrected milk yield and energy-corrected milk yield increased with enzyme supplementation (P < 0.05). The production levels of milk fat and lactose increased, but the percentage of solids, not fat and protein, decreased in EXP (P < 0.05). Although the DM intake was not affected, the feed efficiency tended to increase (P = 0.07) in EXP. In conclusion, dietary supplementation with a mixture of fibrolytic and amylolytic enzymes on multiparous early-lactation dairy cows increased α-amylase and xylanase activity levels in rumen fluid, enhanced milk performance and tended to improve the feed efficiency in cows.

[Value of dual-layer spectral detector CT in preoperative prediction of lymph node metastasis of gastric cancer]

Objective: To investigate the value of dual-layer spectral detector CT(SDCT) in preoperative prediction of lymph node (LN) metastasis of gastric cancer. Methods: From January 2019 to January 2021, the clinical and imaging data of 130 gastric cancer patients(93 males and 37 females, aged from 37 to 84 years)confirmed by pathology in the Zhongshan hospital of Xiamen University were retrospectively collected. According to the status of lymph node metastasis, those patients were divided into metastatic LNs group (n=104) and nonmetastatic LNs group (n=26). The maximum diameter of gastric cancer on spectral CT images, CT Values of lesions in 40, 50, 60, 70. KeV monoenergetic image of arterial and Venous phase (CT_{40 keV}, CT_{50 keV}, CT_{60 keV}, CT_{70 keV}), iodine concentration (IC) and effective atomic number (Z_eff) were measured, then the normalized IC(NIC) and spectral curve(K_(40-70)) value were calculated. The differences of each parameter derived from spectral CT between the two groups were compared, and a logistic regression model was constructed. The ROC curves and area under the curve (AUC) were conducted to evaluate the diagnostic performance of each parameter and Delong test was used to compare the difference of each AUC. Results: Compared to nonmetastatic LNs group, metastatic LNs group had higher maximum diameter of tumor, CT_{40 keV}, CT_{50 keV}, CT_{60 keV}, CT_{70 keV}, IC, NIC, Zeff, and K_(40-70) values on venous phase (the representative parameter is Z_eff: 8.4 (8.2, 8.5) vs 8.2 (8.1, 8.3)) (all P<0.05). The proportion of patients with lower histology differentiated degree, higher T grade and positive carcino embryonic antigen (CEA)were higher than that in nonmetastatic LNs (the representative parameter was CEA: 34.6%(36/104) vs 7.7%(2/26) (all P<0.05). The regression model constructed by CEA and Zeff had the highest predictive value in predicting metastatic LNs, with an AUC of 0.835(0.759-0.894), sensitivity and specificity of 83.65% and 73.08%, respectively. Conclusion: SDCT quantitative parameters on venous phase and CEA facilitate the accurate prediction of metastatic LNs in patients with gastric cancer, and the multi-parameter regression model has the highest diagnostic performance.

LncRNA Snhg1 Plays an Important Role via Sequestering rno-miR-139-5p to Function as a ceRNA in Acute Rejection After Rat Liver Transplantation Based on the Bioinformatics Analysis

In order to explore the molecular mechanism of acute rejection after liver transplantation (ARLT) in rats, we employed the GSE36798 data set in the Gene Expression Omnibust (GEO) database to construct a related ceRNA network. This dataset contained a total of 16 samples (8 graft samples and 8 plasma samples). Each kind of sample was divided into acute rejection (AR) groups and non-acute rejection (NR) groups, and each group had 4 replicates. First, we performed principal component analysis (PCA) with downloaded data to compare the difference between samples in a macroscopic way. Then, we used the “limma” R package to screen out differentially expressed miRNAs among different groups and used the “pheatmap” R package to perform bidirectional hierarchical clustering analysis for these differentially expressed miRNAs. The miRWalk database and the LncBase V.2 database were applied to predict downstream target genes and upstream-related lncRNAs, respectively. Meanwhile, the String database was used to predict the relationship between target genes, and the aforementioned results were processed for visualization by Cytoscape software. In addition, we exhibited the ultimate ceRNA network, including two lncRNAs, two miRNAs, and 77 mRNAs. Finally, we constructed a rat model of ARLT and applied graft specimens to relevant experimental verification. We found that the lncRNA Snhg1/rno-miR-139-5p axis might be involved in the regulation of ARLT in rats. In short, we demonstrated the differentially expressed miRNA profile, constructed a related ceRNA network, and screened out a possible regulatory axis. In view of the conservation of genes among species, this work was expected to provide a new strategy for the treatment and prevention of ARLT in the clinical setting.

Negative pressure wound therapy for managing the open abdomen in non-trauma patients

BACKGROUND

Management of the open abdomen is a considerable burden for patients and healthcare professionals. Various temporary abdominal closure techniques have been suggested for managing the open abdomen. In recent years, negative pressure wound therapy (NPWT) has been used in some centres for the treatment of non-trauma patients with an open abdomen; however, its effectiveness is uncertain.

OBJECTIVES

To assess the effects of negative pressure wound therapy (NPWT) on primary fascial closure for managing the open abdomen in non-trauma patients in any care setting.

SEARCH METHODS

In October 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL EBSCO Plus. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared NPWT with any other type of temporary abdominal closure (e.g. Bogota bag, Wittmann patch) in non-trauma patients with open abdomen in any care setting. We also included RCTs that compared different types of NPWT systems for managing the open abdomen in non-trauma patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection process, risk of bias assessment, data extraction, and GRADE assessment of the certainty of evidence.

MAIN RESULTS

We included two studies, involving 74 adults with open abdomen associated with various conditions, predominantly severe peritonitis (N = 55). The mean age of the participants was 52.8 years; the mean proportion of women was 39.2%. Both RCTs were carried out in single centres and were at high risk of bias. Negative pressure wound therapy versus Bogota bag We included one study (40 participants) comparing NPWT with Bogota bag. We are uncertain whether NPWT reduces time to primary fascial closure of the abdomen (NPWT: 16.9 days versus Bogota bag: 20.5 days (mean difference (MD) -3.60 days, 95% confidence interval (CI) -8.16 to 0.96); very low-certainty evidence) or adverse events (fistulae formation, NPWT: 10% versus Bogota: 5% (risk ratio (RR) 2.00, 95% CI 0.20 to 20.33); very low-certainty evidence) compared with the Bogota bag. We are also uncertain whether NPWT reduces all-cause mortality (NPWT: 25% versus Bogota bag: 35% (RR 0.71, 95% CI 0.27 to 1.88); very low-certainty evidence) or length of hospital stay compared with the Bogota bag (NPWT mean: 28.5 days versus Bogota bag mean: 27.4 days (MD 1.10 days, 95% CI -13.39 to 15.59); very low-certainty evidence). The study did not report the proportion of participants with successful primary fascial closure of the abdomen, participant health-related quality of life, reoperation rate, wound infection, or pain. Negative pressure wound therapy versus any other type of temporary abdominal closure There were no randomised controlled trials comparing NPWT with any other type of temporary abdominal closure. Comparison of different negative pressure wound therapy devices We included one study (34 participants) comparing different types of NPWT systems (Suprasorb CNP system versus ABThera system). We are uncertain whether the Suprasorb CNP system increases the proportion of participants with successful primary fascial closure of the abdomen compared with the ABThera system (Suprasorb CNP system: 88.2% versus ABThera system: 70.6% (RR 0.80, 95% CI 0.56 to 1.14); very low-certainty evidence). We are also uncertain whether the Suprasorb CNP system reduces adverse events (fistulae formation, Suprasorb CNP system: 0% versus ABThera system: 23.5% (RR 0.11, 95% CI 0.01 to 1.92); very low-certainty evidence), all-cause mortality (Suprasorb CNP system: 5.9% versus ABThera system: 17.6% (RR 0.33, 95% CI 0.04 to 2.89); very low-certainty evidence), or reoperation rate compared with the ABThera system (Suprasorb CNP system: 100% versus ABThera system: 100% (RR 1.00, 95% CI 0.90 to 1.12); very low-certainty evidence). The study did not report the time to primary fascial closure of the abdomen, participant health-related quality of life, length of hospital stay, wound infection, or pain.

AUTHORS' CONCLUSIONS

Based on the available trial data, we are uncertain whether NPWT has any benefit in primary fascial closure of the abdomen, adverse events (fistulae formation), all-cause mortality, or length of hospital stay compared with the Bogota bag. We are also uncertain whether the Suprasorb CNP system has any benefit in primary fascial closure of the abdomen, adverse events, all-cause mortality, or reoperation rate compared with the ABThera system. Further research evaluating these outcomes as well as participant health-related quality of life, wound infection, and pain outcomes is required. We will update this review when data from the large studies that are currently ongoing are available.

Development of explicit formulations of G45-based gas kinetic scheme for simulation of continuum and rarefied flows

In this work, the explicit formulations of the Grad's distribution function for the 45 moments (G45)-based gas kinetic scheme (GKS) are presented. Similar to the G13 function-based gas kinetic scheme (G13-GKS), G45-GKS simulates flows from the continuum regime to the rarefied regime by solving the macroscopic governing equations based on the conservation laws, which are widely used in conventional Navier-Stokes solver. These macroscopic governing equations are discretized by the finite volume method, where the numerical fluxes are evaluated by the local solution to the Boltzmann equation. The initial distribution function is reconstructed by the G45 distribution function, which is a higher order truncation of the Hermite expansion of distribution function compared with the G13 distribution function. Such high order truncation of Hermite expansion helps the present solver to achieve a better accuracy than G13-GKS. Moreover, the reconstruction of distribution function makes the development of explicit formulations of numerical fluxes feasible, and the evolution of the distribution function, which is the main reason why the discrete velocity method is expensive, is avoided. Several numerical experiments are performed to examine the accuracy of G45-GKS. Results show that the accuracy of the present solver for almost all flow problems is much better than G13-GKS. Moreover, some typical rarefied effects, such as the direction of heat flux without temperature gradients and thermal creep flow, can be well captured by the present solver.

Suprathermal electrons from the anti-Stokes Langmuir decay instability cascade

The study of parametric instabilities has played a crucial role in understanding energy transfer to plasma and, with that, the development of key applications such as inertial confinement fusion. When the densities are between 0.11n_{c}≲n_{e}≲0.14n_{c} and the electron temperature is in inertial confinement fusion-relevant temperatures, anomalous hot electrons with kinetic energies above 100keV are generated. Here a new electron acceleration mechanism-the anti-Stokes Langmuir decay instability cascade of forward stimulated Raman scattering-is investigated. This mechanism potentially explains anomalous energetic electron generation in indirectly driven inertial confinement fusion experiments, it also provides a new way of accelerating electrons to higher energy for applications such as novel x-ray sources.

Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain.

OBJECTIVES

To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques.

SEARCH METHODS

We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes.

MAIN RESULTS

We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.

[Predictive value of impedance of leadless pacemaker during implantation on trend changes of pacing threshold]

Objective: To explore the predictive value of the impedance measured during leadless pacemaker Micra implantation on the trend of changes of pacing threshold post implantation. Methods: This is a retrospective cross-sectional study. Patients who received implantation of leadless pacemaker Micra at the Second Xiangya Hospital of Central South University from December 2019 to August 2020 were enrolled. The clinical data and the intraoperative electrical parameters during leadless pacemaker implantation were collected. The impedance and pacing threshold data were analyzed at three time points: immediate release, 5-10 min after release, and after traction test. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to analyze the value of the impedance at immediate release on predicting the trend of changes of pacing threshold post implantation. Results: A total of 21 patients (mean age: (72.2±12.5) years, 12 males) were included. The impedance of 21 patients was (798.1±35.3) Ω immediately after implantation, (800.9±35.6) Ω after 5-10 minutes of release, and (883.6±31.7) Ω after traction test. Impedance was similar between the three time points (P>0.05). The threshold was (0.97±0.11) V/0.24 ms immediately after implantation, (0.95±0.12) V/0.24 ms at 5-10 min after the release, and (0.59±0.06) V/0.24 ms after the traction test. The threshold was significantly lower after the traction test than that immediately after release (P=0.003) and than that at 5-10 minutes after release (P=0.008), suggesting a decreased tendency of the threshold over time. According to the analysis of the ROC curve, the immediate impedance after the release ≥680 Ω could predict the ideal pacing threshold after the traction test (AUC=0.989, 95%CI 0.702-0.964, P<0.001), the prediction sensitivity was 87%, and the specificity was 100%. The pacing threshold would be not ideal with the immediate impedance ≤ 520 Ω (95%CI 0.893-1.000, P<0.001), the sensitivity was 100%, and the specificity was 80%. Conclusions: The impedance immediately after the release has predictive value for the changing trend of threshold post leadless pacemaker Micra implantation. Impedance ≥680 Ω immediately after release is often related with ideal pacing threshold after the traction test. In contrast, the impedance ≤ 520 Ω pacing is often related with unsatisfactory threshold after the traction test, therefore, it is recommended to find a new pacing site to achieve the impedance ≥680 Ω immediately after release during leadless pacemaker Micra implantation.

Polarization conversion in the caviton driven by linearly polarized lasers

In one-dimensional particle-in-cell simulations of a plasma irradiated by linearly polarized lasers from both sides of boundaries, it is found that there is an appreciable growth of the electromagnetic field in cavitons in the transverse direction perpendicular to the direction of polarization, which indicates the polarization conversion of the electromagnetic field in cavitons. This paper demonstrates the mechanism of this phenomenon based on parametric resonance induced by ponderomotive force with twice the frequency of the electromagnetic radiation in the caviton. We develop a theoretical model and verify it with simulation results. This phenomenon contributes to the heating and acceleration of particles and traps more EM energy in cavitons.

Variant of gas kinetic flux solver for flows beyond Navier-Stokes level

In this paper, a variant of gas kinetic flux solver (GKFS) is presented for simulation of flows beyond the Navier-Stokes (NS) level. The method retains the framework of GKFS and reconstructs the numerical fluxes by the moments of distribution function at the cell interface, which is given from the local solution of the Boltzmann equation. In the conventional GKFS, the first-order Chapman-Enskog (CE) expansion is utilized to approximate the initial distribution function. By using the differential chain rule, it was found that the CE expansion form could be linked to the stress tensor and the heat flux. For flows in the NS level, the stress tensor and heat flux can be simply calculated from the linearized constitutive relationship and Fourier's law, respectively. However, for flows beyond the NS level, due to the strong nonequilibrium effect, the linearized constitutive relationship and Fourier's law are insufficient to predict the stress tensor and the heat flux. To overcome this difficulty, this paper introduces correction terms to the stress tensor and heat flux in the initial distribution function. These correction terms will take effect in the strong nonequilibrium region for flows beyond the NS level. To avoid finding complex expressions or solving complicated partial differential equations for the correction terms, a simple and iterative procedure is proposed to update the correction terms based on the framework of GKFS. The proposed method is validated by three benchmark cases which cover the flow from the continuum regime to the transition regime. Numerical results show that the present solver can provide accurate solution in the continuum regime. It is indeed the correction terms that take effect in the strong nonequilibrium region for flows beyond the NS level, which enables the present solver to capture the nonequilibrium phenomenon with reasonable accuracy for rarefied flows at moderate Knudsen number.

Prophylactic abdominal drainage for pancreatic surgery

BACKGROUND

The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. This is the third update of a previously published Cochrane Review to address the uncertain benifits of prophylactic abdominal drainage in pancreatic surgery.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal.

SEARCH METHODS

In this updated review, we re-searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and the Chinese Biomedical Literature Database (CBM) on 08 February 2021.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We conducted the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) or standardized mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. We used GRADE to assess the certainty of the evidence for important outcomes.

MAIN RESULTS

We identified a total of nine RCTs with 1892 participants. Drain use versus no drain use We included four RCTs with 1110 participants, randomised to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. Low-certainty evidence suggests that drain use may reduce 90-day mortality (RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants). Compared with no drain use, low-certainty evidence suggests that drain use may result in little to no difference in 30-day mortality (RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants), wound infection rate (RR 0.98, 95% CI 0.68 to 1.41; four studies, 1055 participants), length of hospital stay (MD -0.14 days, 95% CI -0.79 to 0.51; three studies, 876 participants), the need for additional open procedures for postoperative complications (RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants), and quality of life (105 points versus 104 points; measured with the pancreas-specific quality of life questionnaire (scale 0 to 144, higher values indicating a better quality of life); one study, 399 participants). There was one drain-related complication in the drainage group (0.2%). Moderate-certainty evidence suggests that drain use probably resulted in little to no difference in morbidity (RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants). The evidence was very uncertain about the effect of drain use on intra-abdominal infection rate (RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-certainty evidence), and the need for additional radiological interventions for postoperative complications (RR 0.87, 95% CI 0.40 to 1.87; three studies, 660 participants; very low-certainty evidence). Active versus passive drain We included two RCTs involving 383 participants, randomised to the active drain group (N = 194) and the passive drain group (N = 189) after pancreatic surgery. Compared with a passive drain, the evidence was very uncertain about the effect of an active drain on 30-day mortality (RR 1.23, 95% CI 0.30 to 5.06; two studies, 382 participants; very low-certainty evidence), intra-abdominal infection rate (RR 0.87, 95% CI 0.21 to 3.66; two studies, 321 participants; very low-certainty evidence), wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; two studies, 321 participants; very low-certainty evidence), morbidity (RR 0.97, 95% CI 0.53 to 1.77; two studies, 382 participants; very low-certainty evidence), length of hospital stay (MD -0.79 days, 95% CI -2.63 to 1.04; two studies, 321 participants; very low-certainty evidence), and the need for additional open procedures for postoperative complications (RR 0.44, 95% CI 0.11 to 1.83; two studies, 321 participants; very low-certainty evidence). There was no drain-related complication in either group. Early versus late drain removal We included three RCTs involving 399 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 200) and the late drain removal group (N = 199) after pancreatic surgery. Compared to late drain removal, the evidence was very uncertain about the effect of early drain removal on 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; three studies, 399 participants; very low-certainty evidence), wound infection rate (RR 1.32, 95% CI 0.45 to 3.85; two studies, 285 participants; very low-certainty evidence), hospital costs (SMD -0.22, 95% CI -0.59 to 0.14; two studies, 258 participants; very low-certainty evidence), the need for additional open procedures for postoperative complications (RR 0.77, 95% CI 0.28 to 2.10; three studies, 399 participants; very low-certainty evidence), and the need for additional radiological procedures for postoperative complications (RR 1.00, 95% CI 0.21 to 4.79; one study, 144 participants; very low-certainty evidence). We found that early drain removal may reduce intra-abdominal infection rate (RR 0.44, 95% CI 0.22 to 0.89; two studies, 285 participants; very low-certainty evidence), morbidity (RR 0.49, 95% CI 0.30 to 0.81; two studies, 258 participants; very low-certainty evidence), and length of hospital stay (MD -2.20 days, 95% CI -3.52 to -0.87; three studies, 399 participants; very low-certainty evidence), but the evidence was very uncertain. None of the studies reported on drain-related complications.

AUTHORS' CONCLUSIONS

Compared with no drain use, it is unclear whether routine drain use has any effect on mortality at 30 days or postoperative complications after pancreatic surgery. Compared with no drain use, low-certainty evidence suggests that routine drain use may reduce mortality at 90 days. Compared with a passive drain, the evidence is very uncertain about the effect of an active drain on mortality at 30 days or postoperative complications. Compared with late drain removal, early drain removal may reduce intra-abdominal infection rate, morbidity, and length of hospital stay for people with low risk of postoperative pancreatic fistula, but the evidence is very uncertain.

Absolute stimulated Brillouin side scattering in an inhomogeneous flowing plasma

Theory of absolute stimulated Brillouin side scattering in an inhomogeneous flowing plasma is presented and verified numerically. The linearized coupling equations are transformed into a Schrödinger equation in k space and solved as an eigenvalue problem. Analytic threshold, growth rate, and scattering geometry are obtained for the pump laser with arbitrary incidence angle. Numerical solutions of the coupling equations show good agreements between the theoretical and numerical absolute thresholds when ion-acoustic wave damping is not too large, and thus an old but famous threshold in [Phys. Fluids 17, 1211 (1974)PFLDAS0031-917110.1063/1.1694867] is corrected. It also indicates that the theoretical analysis is not accurate for strong dampings, since it will overestimate the absolute threshold. Possibility of finding such instability in the current experiments is also discussed.

The protective effect of isoflurane pretreatment on liver IRI by suppressing noncanonical pyroptosis of liver macrophages

BACKGROUND

Liver ischaemia-reperfusion injury (IRI) is a major complication in the perioperative period and often leads to liver failure and even systemic inflammation. Sufficient evidence has demonstrated that isoflurane has anti-inflammatory effects. We aimed to determine whether isoflurane pretreatment protects against liver IRI and to investigate the mechanisms involved in this protection.

METHODS

Male C57BL/6 mice were pretreated with or without isoflurane and subjected to 90 min of 70% liver ischaemia, followed by reperfusion for 6 h. Liver tissues and serum were analysed to assess liver IRI. To probe the mechanisms, liver macrophages isolated from C57BL/6 mice were pretreated with or without emulsified isoflurane for 30 min before incubation with 1 µg/ml lipopolysaccharide (LPS) for 24 h. Inflammatory cytokine production, intracellular Ca²⁺ levels, caspase-11 expression, NF-κB transcription, and NLRP3 inflammasome activation were assessed by ELISA, an intracellular Ca²⁺ concentration assay, immunohistochemistry, or Western blotting.

RESULTS

Isoflurane preconditioning significantly relieved liver IRI in mice and LPS-induced inflammation in liver macrophages. Additionally, isoflurane pretreatment inhibited caspase-11 expression and noncanonical pyroptosis-related production of cytokines (IL-1β and IL-18). Interestingly, isoflurane preconditioning reduced intracellular Ca²⁺ levels, NF-κB translocation, and NLRP3 inflammasome activation in LPS-induced macrophages. Our results indicated that isoflurane preconditioning ameliorated liver IRI by suppressing noncanonical pyroptosis in liver macrophages. These findings suggest that isoflurane could be a pharmacological agent for liver IRI prevention and thus deserves more attention and further investigation.

Development and Validation of Epigenetic Modification-Related Signals for the Diagnosis and Prognosis of Hepatocellular Carcinoma

Background

Increasing evidence has indicated that abnormal epigenetic factors such as RNA m6A modification, histone modification, DNA methylation, RNA binding proteins and transcription factors are correlated with hepatocarcinogenesis. However, it is unknown how epigenetic modification-associated genes contribute to the occurrence and clinical outcome of hepatocellular carcinoma (HCC). Thus, we constructed the epigenetic modification-associated models that may enhance the diagnosis and prognosis of HCC.

Methods

In this study, we focused on the clinical value of epigenetic modification-associated genes for HCC. Our gene expression data were collected from TCGA and HCC data sets from the GEO database to ensure the reliability of the data. Their functions were analyzed by bioinformatics methods. We used lasso regression, Support vector machine (SVM), logistic regression and Cox regression to construct the diagnostic and prognostic models. We also constructed a nomogram of the practicability of the above-mentioned prognostic model. The above results were verified in an independent liver cancer data set from the ICGC database and clinical samples. Furthermore, we carried out pan-cancer analysis to verify the specificity of the above model and screened a wide range of drug candidates.

Results

Many epigenetic modification-associated genes were significantly different in HCC and normal liver tissues. The gene signatures showed a good ability to predict the occurrence and survival of HCC patients, as verified by DCA and ROC curve analysis.

Conclusion

Gene signatures based on epigenetic modification-associated genes can be used to identify the occurrence and prognosis of liver cancer.

[Clinical effects of bilateral overlength anterolateral femoral perforator flaps connected in series or parallel in repairing large area of wounds in limbs]

Objective: To explore the clinical effects of bilateral overlength anterolateral femoral perforator flaps connected in series or parallel in repairing large area of wounds in limbs. Methods: From January 2017 to July 2019, 9 patients with large area of skin and soft tissue defects in limbs were admitted to the Departments of Hand Surgery and Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 8 males and 1 female, aged 36 to 63 years. The retrospective cohort study was conducted. The wound areas of patients after debridement were 20 cm×15 cm to 30 cm×25 cm, and the wounds were repaired with bilateral overlength anterolateral femoral perforator flaps. One main artery defect in the receiving area of 4 patients was repaired with bilateral flaps connected in series. Two main artery defects in the receiving area of 5 patients were repaired with bilateral flaps connected in parallel. A total of 18 flaps were excised, and the area of a single flap ranged from 20 cm×8 cm to 46 cm×9 cm. The donor sites of 17 flaps were sutured directly, and the donor site of 1 flap was repaired with free full-thickness skin graft from hypogastrium. Harvesting time of flaps, survival condition of flaps after surgery, and wound healing time, and flap observation, two-point discrimination distance of flaps, functional recovery of joint and appearance of recipient site, and recovery of donor site during follow-up were recorded. Results: In this group of 9 patients, the flap harvesting time was 1.0 to 4.5 hours, and all the 18 flaps survived. The wound healing time of recipient site was 18 to 72 days after flap transplantation. They were followed up for 6 to 34 months. The shape of the recipient site was satisfactory, with no deep tissue infection such as osteomyelitis. Four flaps in 2 patients were bloated and were thinned in 6 months after operation; 4 flaps in 2 patients had skin pigmentation on the edge of the flap; the flap of one patient was scalded but healed by dressing change, with patchy scar being observed during follow-up. The rest of the flaps were soft, elastic, and painless with good blood supply. All the flaps restored with protective sensation, with only one point in two-point discrimination. Only linear scars remained in the donor sites of 17 flaps. All the limbs had good blood supply in the distal end of donor sites, and no restriction occurred in range of motion of knee joint and quadriceps muscle strength. Conclusions: The bilateral overlength anterolateral femoral perforator flaps connected in series or parallel have constant anatomy, reliable blood supply, and flexible combination. It is an ideal surgical method for repairing large area of skin and soft tissue defects in limbs at one time.