Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

[Clinical effects of different types of tissue flaps in repairing the wounds with steel plate exposure and infection after proximal tibial fracture surgery]

Objective: To investigate the clinical effects of different types of tissue flaps in repairing the wounds with steel plate exposure and infection after proximal tibial fracture surgery. Methods: A retrospective observational study was conducted. From January 2015 to December 2021, 11 patients with steel plate exposure and infected wounds after proximal tibial fracture surgery who met the inclusion criteria were admitted to Jiangxi Provincial General Hospital of Armed Police, including 9 males and 2 females, aged 26 to 61 years. The wounds were located on the lateral side of the proximal leg in 5 cases, on the medial side of the proximal leg in 2 cases, and on the medial side of the proximal leg and the anterior tibia below the knee in 4 cases. After debridement, the wound area was 14 cm×6 cm-22 cm×11 cm. The wounds were repaired with different types of tissue flaps, and the steel plates were removed immediately if necessary, according to the infection around the steel plates. The reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery was used in 3 cases; the medial gastrocnemius muscle flap combined with the medial half of soleus muscle flap was used in 6 cases, and the lateral gastrocnemius muscle flap combined with the anterior tibial muscle flap was used in 2 cases. After the muscle flaps had stable blood supply, the wounds were closed with thin intermediate thickness skin graft from the healthy thigh. The area of myocutaneous flap ranged from 15 cm×7 cm to 18 cm×8 cm, and the area of muscle flap ranged from 6.0 cm×4.0 cm to 18.0 cm×12.0 cm. Among the 3 patients who were treated with reverse anterolateral thigh myocutaneous flap, the wounds of flap donor site on thighs were closed by direct suturing in 2 cases, and the wound in the flap donor site of thigh in 1 case that was not closed after suture was repaired with thin intermediate thickness skin graft from healthy thigh. The incisions in the flap donor sites of 8 cases treated with calf muscle flaps were sutured directly. After surgery, the survivals of tissue flap and skin graft on the muscle flap, wound healing status and wound healing time in recipient sites of tissue flaps, suture site healing in flap donor site, and survival of skin graft were observed and recorded. Whether the steel plate was removed after operation and during follow-up was recorded. During follow-up, the shape and texture of tissue flap, whether the recipient site of tissue flap had redness, swelling, ulceration, or sinus formation were observed, the fracture healing time was recorded. At the last follow-up, the knee joint flexion and extension range of motion was measured and the knee joint function was evaluated according to Hohl's knee joint function evaluation criteria; the plantar flexor muscle strength of ankle joint was measured in 8 patients who were treated with calf muscle flaps for wound repair; the Vancouver scar scale (VSS) was used to evaluate the scar condition in the flap donor site, and whether the scar affected the movement of the affected limbs was observed. Results: Tissue flaps of 11 patients all survived after surgery. The distal end of the reverse anterolateral thigh myocutaneous flaps was necrotic in 1 patient, and the wound was healed after dressing change and grafting with thin intermediate thickness skin from healthy thigh. The distal muscle necrosis of the medial gastrocnemius muscle flap was observed in 2 patients, and the granulation tissue grew well after dressing change. The skin graft on the muscle flap survived well. All the wounds in the recipient sites of tissue flaps were healed, and the healing time was 13 to 42 days after tissue flap transplantation. The suture site of flap donor site healed, and the skin graft survived well. In 1 patient, the steel plate was removed when the wound was repaired with the medial gastrocnemius muscle flap combined with the medial half of soleus muscle flap. One patient still had exudation after 3 weeks of wound repair with the reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery, and the wound was healed after removing the steel plate. The steel plates of the other patients were preserved. During the follow-up of 6-25 months, except for 1 reverse anterolateral thigh myocutaneous flap had bloated pedicle, the other tissue flaps had good appearance and texture. One patient had redness and swelling in the recipient site of the tissue flap at 6 weeks after discharge, and the redness and swelling subsided without recurrence after anti-infection treatment. In 1 patient, repeated rupture and exudation occurred in the recipient site of tissue flap in 3 months after discharge, resulting in sinus tract formation, which was healed after the removing of steel plate. The fracture healing time of patients ranged from 6 to 15 months after injury. At the last follow-up, the knee joint function was evaluated as excellent in 4 cases, good in 6 cases, and poor in 1 case. Among the 8 patients who were treated with calf muscle flaps for wound repair, 7 patients had ankle joint plantar flexor muscle strength of grade Ⅵ, and 1 patient had ankle plantar flexor muscle strength of grade Ⅴ. The VSS scores of scars in the flap donor sites ranged from 2 to 7, and scars did not significantly affect the movement of the affected limbs. Conclusions: The reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery and the gastrocnemius muscle flap combined with soleus muscle flap or anterior tibial muscle flap are the derived types of the commonly used reverse anterolateral thigh myocutaneous flap and gastrocnemius muscle flap. Using them to repair the wounds with steel plate exposure and infection after proximal tibial fracture surgery can not only ensure the smooth operation, but also preserve the steel plate and promote fracture healing as much as possible, without significantly affecting the function of the affected limb.

IGF2/IGF2R/Sting signaling as a therapeutic target in DSS-induced ulcerative colitis

Ulcerative colitis is an inflammatory bowel disease with increasing prevalence and incidence. Current treatments for ulcerative colitis are not generally applicative and are often accompanied by side effects. IGF2 is an endogenous protein that plays roles in anti-inflammation and stemness maintenance, but little is known about its mechanism and function in the progression of ulcerative colitis. In this study, mouse recombinant IGF2 was used in a mouse model of ulcerative colitis established by DSS. IGF2 expression was reduced in colon tissues but not plasma of DSS-induced colitis mice. IGF2R expression was also decreased in colitis colons, which was then elevated by recombinant IGF2. Recombinant IGF2 alleviated colon injury in colitis, which was evaluated by colon shortening, body weight loss and DAI score. IGF2 treatment also relieved the inflammatory response in colitis, which was assessed by the spleen weight index, MPO activity and proinflammatory cytokine expression and was also detected in LPS-stimulated RAW264.7 cells in vitro. Moreover, IGF2R was predicted and further verified to interact with the Sting protein, and the cGAS-Sting pathway as a key pathway for stemness regulation, was upregulated in colonic colons, which was blocked by IGF2 treatment. Additionally, IGF2 treatment can maintain colonic stemness and further repair colonic tight junction function in DSS-induced colitis. In conclusion, IGF2/IGF2R downregulated the cGAS-Sting pathway to sustain colonic stemness and barrier integrity to protect against ulcerative colitis induced by DSS.

Complete genome sequence of carotenoid-producing Aestuariibaculum lutulentum L182T isolated from the tidal sediment

Aestuariibaculum lutulentum L182T (= KCTC 92530T = MCCC 1K08065T) was isolated from the tidal sediment collected in Beihai, People's Republic of China. The genome was sequenced and consisted of a single chromosome with the size of 3,782,725 bp and DNA G + C content of 35.1%. Genomic annotations demonstrated that it encoded 12 rRNA genes, 56 tRNA genes and 3210 ORFs. The percentages of ORFs assigned to CAZy, COG, and KEGG databases were 5.5, 86.2 and 45.5%, respectively. Comparative genomic analysis indicated that the pan- and core-genomes of the genus Aestuariibaculum consisted of 4826 and 2257 orthologous genes, respectively. Carbohydrate-active enzyme annotations of the genus Aestuariibaculum genomes revealed that they shared three polysaccharide lyase (PL) families including PL1, PL22 and PL42. Meanwhile, one carotenoid biosynthetic gene cluster related to biosynthesizing flexixanthin was found in the genus Aestuariibaculum. Furthermore, the core-genome of the genus Aestuariibaculum showed that this genus played a role in cleaving pectate, degrading ulvan, and biosynthesizing carotenoids. This study is a complete genomic report of the genus Aestuariibaculum and broadens understandings of its ecological roles and biotechnological applications.

[Visual analysis of the current research status and hotspots of electric burns at home and abroad]

Objective: To analyze the literature on electric burns published at home and abroad, and to explore the research hotspots and frontiers of electric burns. Methods: The bibliometric method was used. The Chinese and English literature related to electric burns published in China National Knowledge Infrastructure, Wanfang database, VIP database and the core collection of Web of Science database from January 1, 2013 to December 31, 2022 were searched respectively, and the CiteSpace 6.2.R2 software was used for analysis. The number of papers, authors, countries, and institutions of Chinese and English literature were counted respectively, and the co-occurrence analysis of keywords and mutation analysis and cluster analysis on the basis of the co-occurrence analysis were conducted, besides, the clustering time line figure was obtained after the keywords were sorted by time to explore the current research status and the evolution process of hotspots in the field of electric burns. Results: A total of 398 English papers were retrieved from the core collection of Web of Science database, and a total of 523 Chinese papers were retrieved from China National Knowledge Infrastructure, Wanfang database, and VIP database after duplicate check. From 2013 to 2022, the number of English literature published in the field of electric burns showed a steadily upward trend, and the number of published Chinese literature showed a downward trend and tended to be stable. In Chinese literature, a total of 302 authors as the first author published papers related to electric burns, with 17 core authors published ≥3 papers; in English literature, a total of 320 authors as the first author published papers related to electric burns. Researches on electric burns were carried out in 65 countries, with United States having the most cooperation with other countries and the largest number of papers published. A total of 512 institutions at home and abroad published papers related to electric burns, and the institutions with the largest number of Chinese and English papers were Shanghai Electric Power Hospital in China (n=14) and Hallym University in Korea (n=11), respectively. A total of 1 176 Chinese keywords and 1 068 English keywords were included for co-occurrence analysis after excluding keywords related to the searching words. The top three keywords in frequency in Chinese literature were surgical flap, wound repair, and nursing, and the top three keywords in frequency in English literature were management, epidemiology, and children. Ten clusters were obtained by keyword analysis in Chinese literature, and the largest cluster was wound healing, followed by clinical effects and surgical flaps. Seven clusters were obtained by keyword analysis in English literature, and the largest cluster was reconstructive surgical procedures, followed by chronic pain and shock. The persistent clusters in Chinese literature were wound healing and clinical outcomes, etc., and the prominent nodes in the recent two years were surgical timing, limb electric burns, and hypertrophic scars; the persistent clusters in English literature were reconstructive surgical procedures and chronic pain, etc., and the prominent nodes in the recent two years were predictors and burn management, etc. In Chinese literature, the keyword with the longest duration of mutation (2017-2021) was wrist electric burns, and the keyword with the highest intensity of mutation was flap repair; in English literature, the keyword with the longest duration of the mutation (2019-2022) was voltage, and the keyword with the highest intensity of mutation was prevention. Conclusions: There are similarities and differences in the research directions and hotspots of electric burns at home and abroad. Surgical flap repair is a common research hotspot at home and abroad. At present, domestic research focuses on wound healing, wrist electric burns, and other aspects, while international research focuses on treatment management, epidemiology, reconstruction, and other aspects.

[Establishment and validation of a predictive clinical model for postoperative surgical site infection in patients with colorectal surgery]

Objective: To investigate the risk factors of surgical site infection (SSI) after colorectal surgery, and to establish and validate a risk prediction model nomogram. Methods: An observational study was conducted to retrospectively collect data of 6527 patients aged ≥16 years who underwent colorectal surgery in 56 domestic hospitals from March 1, 2021 to February 28, 2022 from the national Surgical Site Infection Surveillance network. The incidence of SSI after surgery was 2.3% (149/6527). According to the ratio of 7:3, 6527 patients were randomly divided into the modeling cohort (4568 cases) and the validation cohort (1959 cases), and there was no statistically significant difference between the two datasets (P>0.05). Univariate analysis was performed using t test /Mann-Whitney U test /χ2 test. Multivariate analysis was performed using binary logistic regression to establish a preliminary model and select variables using Lasso analysis to establish an optimized model nomogram. The discrimination and calibration of the model were evaluated by ROC curve, calibration curve, and Hosmer-Lemeshow test. AUC value>0.7 is considered a good discrimination of the model. The Bootstrap method (repeated self-sampling 1000 times) was used to verify the constructed model internally and externally to evaluate the accuracy of the constructed model. Results: Multivariate analysis showed that history of chronic liver disease (OR=3.626, 95%CI: 1.297-10.137, P<0.001) and kidney disease (OR=1.567,95%CI:1.042-2.357,P=0.038), surgical antibiotic prophylaxis (OR=1.564, 95%CI:1.038-2.357,P=0.035), and emergency surgery (OR=1.432,95%CI: 1.089-1.885, P=0.021), open surgery (OR=1.418, 95%CI:1.045-1.924, P=0.042), preoperative stoma (OR=3.310, 95%CI:1.542-7.105,P<0.001), postoperative stoma (OR=2.323,95%CI: 1.537-8.134,P<0.001), surgical incision type above grade II (OR=1.619,95%CI:1.097-2.375,P=0.014), and each unit increase in total bilirubin (OR=1.003,95%CI:-0.994-1.012, P=0.238), alanine aminotransferase (OR=1.006, 95%CI:1.001-1.011,P=0.032), blood urea nitrogen (OR=1.003,95%CI:0.995-1.011,P=0.310), blood glucose (OR=1.024, 95%CI:1.005-1.043,P=0.027), C-reactive protein (OR=1.007, 95%CI:1.003-1.011,P<0.001), length of incision (OR=1.042, 95%CI:1.002-1.087,P=0.031), surgical duration (OR=1.003,95%CI:1.001-1.005,P=0.017), and surgical blood loss (OR=1.001,95%CI: 1.000-1.002,P=0.045) were risk factors for SSI after colorectal surgery. Each unit increase in albumin level (OR=0.969,95%CI:0.941-0.998,P=0.036) was an independent protective factor for SSI after colorectal surgery. The area under the curve of the optimized model obtained by internal and external validation were 0.768 (95%CI: 0.723-0.813) and 0.753 (95%CI: 0.680-0.832), respectively. The predicted value of the calibration curve was basically consistent with the actual value. Conclusions: The risk prediction model for SSI after colorectal surgery constructed in this study has good discrimination and calibration. The nomogram created in this model can provide an evaluation basis for the observed rate and expected event rate of SSI after clinical colorectal surgery.

[Influence of work engagement and self-efficacy of nurses on clinical practice ability in burn intensive care unit]

Objective: To analyze the influence of work engagement and self-efficacy of nurses on clinical practice ability in burn intensive care unit (BICU), and to explore its potential pathways of action. Methods: A cross-sectional survey was conducted. From May to October 2020, a total of 30 hospitals with BICU in China were selected by stratified sampling method. Among BICU nurses who met the inclusion criteria, their clinical practice ability, work engagement, and self-efficacy were evaluated by self-evaluation scale of oriented problem-solving behavior in nursing practice (OPSN), Utrecht work engagement scale (UWES), and general self-efficacy scale (GSES), respectively. The total scale scores of each index and the average item scores were recorded. The self-designed general data questionnaire was used to investigate the nurses' gender, age, marital status, education background, working years, professional title, and the economic region of the hospital that they belonged to. The total scale scores of the above-mentioned three evaluation indexes were compared after the classification of nurses according to general data, and the data were statistically analyzed with independent sample t test or one-way analysis of variance. Pearson correlation analysis was used to analyze the correlation between the total scale scores of the three evaluation indexes. Based on the total scale scores of the above-mentioned three evaluation indexes, a structural equation model was established, the mediation analysis of the relationship among the three evaluation indexes and the pathway analysis of the structural model were conducted, and the Bootstrap method was used to verify the pathways of action. Results: A total of 401 questionnaires were distributed, and 337 valid questionnaires were returned, with a valid return rate of 84.04%. The total scale scores of clinical practice ability, work engagement, and self-efficacy of 337 nurses were 98.2±11.7, 67.7±18.6, and 26.6±5.6, respectively, and the average item scores were 3.9±0.5, 4.5±1.2, and 2.7±0.6, respectively. Among the 337 nurses, the majority were female, aged 40 or below, married, and had a bachelor's degree with work experience of ≤10 years; both nurses with professional nurse title and nurses from the Southeast region accounted for about 50%. There were statistically significant differences in the total scale score of clinical practice ability among nurses with different ages, education backgrounds, working years, and professional titles (with F values of 3.26, 4.36, 3.12, and 2.80, respectively, P<0.05). There was statistically significant difference in the total scale score of work engagement among nurses with different working years (F=4.50, P<0.05). There were statistically significant differences in the total scale score of self-efficacy among nurses with different ages, working years, and professional titles (with F values of 4.91, 4.50, and 2.91, respectively, P<0.05). The total scale score of nurses' work engagement was significantly positively correlated with the total scale score of clinical practice ability and the total scale score of self-efficacy (with r values of 0.30 and 0.51, respectively, P<0.05). The total scale score of nurses' self-efficacy was significantly positively correlated with the total scale score of clinical practice ability (r=0.37, P<0.05). The model had good adaptability, and the intermediary model was established. Nurses' work engagement had a significantly positive effect on both self-efficacy and clinical practice ability (with β values of 0.54 and 0.16, respectively, P<0.05), and nurses' self-efficacy had a significantly positive effect on clinical practice ability (β=0.29, P<0.05). Work engagement had a direct effect on self-efficacy and clinical practice ability, and self-efficacy had a direct effect on clinical practice ability and played a mediating role between work engagement and clinical practice ability. Bootstrap validation showed that self-efficacy played a significantly mediating role in the influence of work engagement on clinical practice ability (with effect size of 0.16, with 95% confidence interval of 0.08-0.24, P<0.05), accounting for half of the total effect of work engagement on clinical practice ability (with effect size of 0.32). Conclusions: BICU nurses have an above-average level of clinical practice ability, a medium level of self-efficacy, and a high level of work engagement. Work engagement and self-efficacy are positively correlated with clinical practice ability. Work engagement can directly affect clinical practice ability or indirectly affect clinical practice ability through the mediating role of self-efficacy.

[A case of poisoning caused by head and face bite of Deinagkistrodon acutus]

Snake bites kill and maim many people every year. Head and face venomous snake bite is rare, easy to misdiagnose and miss diagnosis, and the fatality rate is high. In this paper, 1 case of head and face venomous snake bite poisoning was reported and 10 similar cases were reviewed. The clinical characteristics of head and face venomous snake bite poisoning were summarized to provide guidance for clinical diagnosis and treatment. Head and face venomous snake bites may lead to airway injury, edema, and airway obstruction is the main cause of early death. Timely intubation or tracheotomy to maintain oxygen supply and early use of antivenin can improve prognosis.

HC067047 Ameliorates Sepsis-associated Encephalopathy by Suppressing Endoplasmic Reticulum Stress and Oxidative Stress-Induced Pyroptosis in the Hippocampi of Mice

Sepsis-associated encephalopathy (SAE) is a common neurological complication of sepsis and is characterized by hyperneuroinflammation. NLRP3 inflammasome-mediated pyroptosis can induce an inflammatory cascade response and plays a key role in SAE. TRPV4 is involved in the hyperinflammatory response associated with inflammation; however, whether TRPV4 inhibition might alleviate SAE-related brain damage is still unknown. Therefore, we aimed to investigate the role and mechanism of HC067047, a potent inhibitor of TRPV4, in hyperneuroinflammation and blood-brain barrier (BBB) dysfunction in a lipopolysaccharide (LPS)-induced SAE mouse model. We found that HC067047 administration significantly inhibited the expression of TRPV4 and p-CamkIIα in the hippocampi of SAE mice. Furthermore, HC067047 treatment attenuated LPS-induced endoplasmic reticulum (ER) stress and oxidative stress (OS), thus remarkably preventing NLRP3 inflammasome-mediated pyroptosis, as well as the expression of proinflammatory factors (IL-1β and IL-18). Additionally, we found that HC067047 selectively prevented pyroptosis in hippocampal cells, mainly the neurons, oligodendrocytes and the resident microglia. The disruption of BBB integrity in SAE mice was also rescued by HC067047 intervention. Thus, we can conclude that the TRPV4 inhibitor HC067047 could protect against hippocampal cell pyroptosis, which might be due to the attenuation of the NLRP3 inflammasome-mediated pyroptosis pathway caused by ER stress and OS. Our findings suggest a potential preventive role for HC067047 in SAE.

[Surgical site infection after colorectal surgery in China from 2018 to 2020]

Objective: This study aims to survey the incidence of surgical site infection (SSI) in China and to analyze its risk factors, so as to prevent and control SSI after colorectal surgery. Methods: An observative study was conducted. Based on a program of Chinese SSI Surveillance from 2018 to 2020, the clinical data of all adult patients undergoing colorectal surgery during this time period were extracted. These included demographic characteristics and perioperative clinical parameters. Minors, pregnant women, obstetric or gynecological surgery, urological system surgery, retroperitoneal surgery, resection of superficial soft tissue masses, and mesh or other implants were excluded. A total of 2122 patients undergoing colorectal surgery from 50 hospitals were included, including 1252 males and 870 females. The median age was 63 (16) years and the median BMI was 23 (4.58) kg/m². The primary outcome was the incidence of SSI within 30 days after colorectal surgery. The secondary outcomes were mortality within 30 days postoperatively, length of ICU stays and postoperative hospital stays, and cost of hospitalization. Patients were divided into the SSI group and non-SSI group based on the occurrence of SSI. Multivariable logistic regression was performed to analyze risk factors of SSI after colorectal surgery, and subgroup analysis was conducted for open and laparoscopic surgery. Results: The incidence of SSI after colorectal surgery was 5.6% (119/2122), including 47 cases (47/119, 39.5%) with superficial incisional infections, 24 cases (24/119, 20.2%) with deep incisional infections, and 48 cases (48/119, 40.3%) with organ/space infections. The occurrence of SSI significantly increased mortality [2.5% (3/119) vs. 0.1%(3/2003), χ²=22.400, P=0.003], the length of ICU stay [0 (1) day vs. 0(0) day, U=131 339, P<0.001], postoperative hospital stay [18.5 (12.8) days vs. 9.0 (6.0) days, U=167 902, P<0.001], and medical expenses [75 000 (49 000) yuan vs. 60 000 (31 000) yuan, U=126 189, P<0.001] (P<0.05). Multivariate analysis revealed that hypertension (OR=1.782, 95%CI: 1.173-2.709, P=0.007), preoperative albumin level (OR=1.680, 95%CI: 1.089-2.592, P=0.019), a contaminated or infected incision (OR= 1.993, 95%CI: 1.076-3.689, P=0.028), emergency surgery (OR=2.067, 95%CI: 1.076-3.972, P=0.029), open surgery (OR=2.132, 95%CI: 1.396-3.255, P<0.001), and surgical duration (OR=1.804, 95%CI: 1.188-2.740, P=0.006) were risk factors for SSI, while preoperative skin preparation (OR=0.478, 95%CI: 0.310-0.737, P=0.001) was a protective factor for SSI. Subgroup analysis was performed on patients undergoing open or laparoscopic surgery. The incidence of SSI in the open surgery group was 10.2%, which was significantly higher than that in the laparoscopic or robotic group (3.5%, χ²=39.816, P<0.001). Subgroup analysis identified that a contaminated or infected incision (OR=2.168, 95%CI: 1.042-4.510, P=0.038) and surgical duration (OR=2.072, 95%CI: 1.171-3.664, P=0.012) were risk factors for SSI after open surgery, while mechanical bowel preparation (OR=0.428, 95%CI: 0.227-0.807, P=0.009) and preoperative skin preparation (OR=0.356, 95%CI: 0.199-0.634, P<0.001) were protective factors for SSI after open surgery. In laparoscopic surgery, diabetes mellitus (OR= 2.292, 95%CI: 1.138-4.617, P=0.020) and hypertension (OR=2.265, 95%CI: 1.234-4.159, P=0.008) were risk factors for SSI. Conclusions: The incidence of SSI after colorectal surgery is 5.6%. Minimally invasive surgery should be selected to reduce the occurrence of postoperative SSI. To prevent the occurrence of SSI after open surgery, skin preparation and mechanical bowel preparation should be performed before the operation, and the duration of the operation should be shortened as much as possible. In the perioperative period, care of patients with hypertension, diabetes, and contaminated or infected incisions should be given particular attention.

[Investigation on the growth factor regulatory network of dermal fibroblasts in mouse full-thickness skin defect wounds based on single-cell RNA sequencing]

Objective: To explore the heterogeneity and growth factor regulatory network of dermal fibroblasts (dFbs) in mouse full-thickness skin defect wounds based on single-cell RNA sequencing. Methods: The experimental research methods were adopted. The normal skin tissue from 5 healthy 8-week-old male C57BL/6 mice (the same mouse age, sex, and strain below) was harvested, and the wound tissue of another 5 mice with full-thickness skin defect on the back was harvested on post injury day (PID) 7. The cell suspension was obtained by digesting the tissue with collagenase D and DNase Ⅰ, sequencing library was constructed using 10x Genomics platform, and single-cell RNA sequencing was performed by Illumina Novaseq6000 sequencer. The gene expression matrices of cells in the two kinds of tissue were obtained by analysis of Seurat 3.0 program of software R4.1.1, and two-dimensional tSNE plots classified by cell group, cell source, and gene labeling of major cells in skin were used for visual display. According to the existing literature and the CellMarker database searching, the expression of marker genes in the gene expression matrices of cells in the two kinds of tissue was analyzed, and each cell group was numbered and defined. The gene expression matrices and cell clustering information were introduced into CellChat 1.1.3 program of software R4.1.1 to analyze the intercellular communication in the two kinds of tissue and the intercellular communication involving vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), epidermal growth factor (EGF), and fibroblast growth factor (FGF) signal pathways in the wound tissue, the relative contribution of each pair of FGF subtypes and FGF receptor (FGFR) subtypes (hereinafter referred to as FGF ligand receptor pairs) to FGF signal network in the two kinds of tissue, and the intercellular communication in the signal pathway of FGF ligand receptor pairs with the top 2 relative contributions in the two kinds of tissue. The normal skin tissue from one healthy mouse was harvested, and the wound tissue of one mouse with full-thickness skin defect on the back was harvested on PID 7. The multiple immunofluorescence staining was performed to detect the expression and distribution of FGF7 protein and its co-localized expression with dipeptidyl peptidase 4 (DPP4), stem cell antigen 1 (SCA1), smooth muscle actin (SMA), and PDGF receptor α (PDGFRα) protein. Results: Both the normal skin tissue of healthy mice and the wound tissue of full-thickness skin defected mice on PID 7 contained 25 cell groups, but the numbers of cells in each cell group between the two kinds of tissue were different. Genes PDGFRα, platelet endothelial cell adhesion molecule 1, lymphatic endothelial hyaluronic acid receptor 1, receptor protein tyrosine phosphatase C, keratin 10, and keratin 79 all had distinct distributions on two-dimensional tSNE plots, indicating specific cell groups respectively. The 25 cell groups were numbered by C0-C24 and divided into 9 dFb subgroups and 16 non-dFb groups. dFb subgroups included C0 as interstitial progenitor cells, C5 as adipose precursor cells, and C13 as contractile muscle cells related fibroblasts, etc. Non-dFb group included C3 as neutrophils, C8 as T cells, and C18 as erythrocytes, etc. Compared with that of the normal skin tissue of healthy mice, the intercellular communication in the wound tissue of full-thickness skin defected mice on PID 7 was more and denser, and the top 3 cell groups in intercellular communication intensity were dFb subgroups C0, C1, and C2, of which all communicated with other cell groups in the wound tissue. In the wound tissue of full-thickness skin defected mice on PID 7, VEGF signals were mainly sent by the dFb subgroup C0 and received by vascular related cell groups C19 and C21, PDGF signals were mainly sent by peripheral cells C14 and received by multiple dFb subgroups, EGF signals were mainly sent by keratinocyte subgroups C9 and C11 and received by the dFb subgroup C0, and the main sender and receiver of FGF signals were the dFb subgroup C6. In the relative contribution rank of FGF ligand receptor pairs to FGF signal network in the normal skin tissue of healthy mice and the wound tissue of full-thickness skin defected mice on PID 7, FGF7-FGFR1 was the top 1, and FGF7-FGFR2 or FGF10-FGFR1 was in the second place, respectively; compared with those in the normal skin tissue, there was more intercellular communication in FGF7-FGFR1 signal pathway, while the intercellular communication in FGF7-FGFR2 and FGF10-FGFR1 signal pathways decreased slightly or did not change significantly in the wound tissue; the intercellular communication in FGF7-FGFR1 signal pathway in the wound tissue was stronger than that in FGF7-FGFR2 or FGF10-FGFR1 signal pathway; in the two kinds of tissue, FGF7 signal was mainly sent by dFb subgroups C0, C1, and C2, and received by dFb subgroups C6 and C7. Compared with that in the normal skin tissue of healthy mouse, the expression of FGF7 protein was higher in the wound tissue of full-thickness skin defected mouse on PID 7; in the normal skin tissue, FGF7 protein was mainly expressed in the skin interstitium and also expressed in the white adipose tissue near the dermis layer; in the two kinds of tissue, FGF7 protein was co-localized with DPP4 and SCA1 proteins and expressed in the skin interstitium, co-localized with PDGFRα protein and expressed in dFbs, but was not co-localized with SMA protein, with more co-localized expression of FGF7 in the wound tissue than that in the normal skin tissue. Conclusions: In the process of wound healing of mouse full-thickness skin defect wound, dFbs are highly heterogeneous, act as potential major secretory or receiving cell populations of a variety of growth factors, and have a close and complex relationship with the growth factor signal pathways. FGF7-FGFR1 signal pathway is the main FGF signal pathway in the process of wound healing, which targets and regulates multiple dFb subgroups.

Mesenchymal stem cell-derived exosomes: A novel and potential remedy for cutaneous wound healing and regeneration

Poor healing of cutaneous wounds is a common medical problem in the field of traumatology. Due to the intricate pathophysiological processes of wound healing, the use of conventional treatment methods, such as chemical molecule drugs and traditional dressings, have been unable to achieve satisfactory outcomes. Within recent years, explicit evidence suggests that mesenchymal stem cells (MSCs) have great therapeutic potentials on skin wound healing and regeneration. However, the direct application of MSCs still faces many challenges and difficulties. Intriguingly, exosomes as cell-secreted granular vesicles with a lipid bilayer membrane structure and containing specific components from the source cells may emerge to be excellent substitutes for MSCs. Exosomes derived from MSCs (MSC-exosomes) have been demonstrated to be beneficial for cutaneous wound healing and accelerate the process through a variety of mechanisms. These mechanisms include alleviating inflammation, promoting vascularization, and promoting proliferation and migration of epithelial cells and fibroblasts. Therefore, the application of MSC-exosomes may be a promising alternative to cell therapy in the treatment of cutaneous wounds and could promote wound healing through multiple mechanisms simultaneously. This review will provide an overview of the role and the mechanisms of MSC-derived exosomes in cutaneous wound healing, and elaborate the potentials and future perspectives of MSC-exosomes application in clinical practice.

Establishing a rabbit model of perianal fistulizing Crohn’s disease

BACKGROUND

Crohn's disease (CD) is a chronic nonspecific intestinal inflammatory disease. The aetiology and pathogenesis of CD are still unclear. Anal fistula is the main complication of CD and is a difficult problem to solve at present. The main limitation of developing new therapies is bound up with the short of preclinical security and effectiveness data. Therefore, an ideal animal model is needed to establish persistent anal fistula and an inflamed rectal mucosa.

AIM

To improve the induction method of colitis and establish a reliable and reproducible perianal fistulizing Crohn’s disease animal model to evaluate new treatment strategies.

METHODS

Twenty male New Zealand rabbits underwent rectal enema with different doses of 2,4,6-trinitrobenzene sulfonic acid to induce proctitis. Group A was treated with an improved equal interval small dose increasing method. The dosage of group B was constant. Seven days later, the rabbits underwent surgical creation of a transsphincteric fistula. Then, three rabbits were randomly selected from each group every 7 d to remove the seton from the fistula. The rabbits were examined by endoscopy every 7 days, and biopsy forceps were used to obtain tissue samples from the obvious colon lesions for histological analysis. The disease activity index (DAI), colonoscopy and histological scores were recorded. Perianal endoscopic ultrasonography (EUS) was used to evaluate the healing of fistulas.

RESULTS

Except for the DAI score, the colonoscopy and histological scores in group A were significantly higher than those in group B (P < 0.05). In the ideal model rabbit group, on the 7^th day after the removal of the seton, all animals had persistent lumens on EUS imaging, showing continuous full-thickness high signals. Histological inspection of the fistula showed acute and chronic inflammation, fibrosis, epithelialization and peripheral proctitis of the adjoining rectum.

CONCLUSION

The improved method of CD colitis induction successfully established a rabbit perianal fistula CD preclinical model, which was confirmed by endoscopy and pathology.

[Research advances on mesenchymal stem cell-derived extracellular vesicles in promoting angiogenesis of diabetic ulcers]

Extracellular vesicles are nanoparticles secreted by most eukaryotic cells and play important roles in material transport and information transmission between cells, involved in inflammation, angiogenesis, antigen presentation, cell apoptosis, cell differentiation, and other biological processes. The culture supernatant of mesenchymal stem cells is rich in extracellular vesicles, and the extracellular vesicles can regulate the formation of new blood vessels, a key step in wound healing and tissue repair. The persistence of diabetic ulcers is closely related to the blocked formation of wound vascular network. This article reviews the role of extracellular vesicles derived from mesenchymal stem cells in promoting angiogenesis of diabetic ulcers, in order to provide a new idea for the treatment of diabetic ulcers.

[Incidence of leptospirosis in Fujian province, 2015-2020]

Objective: To analyze the incidence of leptospirosis in Fujian province from 2015 to 2020 and provide the scientific evidences for the risk assessment, prevention and control of leptospirosis. Methods: The incidence data of leptospirosis in Fujian during 2015-2020 were collected from China Information System for Disease Control and Prevention for a descriptive analysis, and software ArcGIS 10.3.1 was used for spatial autocorrelation analysis, and rats were captured in 17 surveillance areas during the same period, and the rat organs were collected for pathogen culture, the level of Leptospira antibody was detected in serum samples of rats, healthy population and the serum samples of patients sent by the hospitals. The infection status of Leptospira in human and rats were analyzed. Results: The incidence of leptospirosis in Fujian showed a downward trend from 2015 to 2020. A total of 176 cases of leptospirosis were reported. There were obvious seasonality and bimodal distribution. The majority of cases were farmers, accounting for 49.43% (87/176). Most cases were aged 30-69 years (85.80%, 151/176). The male to female ratio of the cases was 3.51∶1 (137∶39). Spatial autocorrelation analysis showed that leptospirosis had high or low clustering areas. From 2015 to 2020, the average capture rate of rats in 17 surveillance areas was 6.96% (1 519/21 838), Rattus losea, Rattus flavipectus and Niviventer fulvescens were the main species. The average positive rate of Leptospira antibody in rats was 28.64% (252/880). Java and Autumnalis were the predominant serogroups, accounting for 56.75% (143/252) and 17.46% (44/252), respectively. The average positive rate of Leptospira antibody in healthy population was 16.13% (254/1 575), and Autumnalis and Australis were the predominant serogroups, accounting for 71.65% (182/254). The confirmation rate of leptospirosis in patient serum samples sent by the hospitals was 2.23% (188/8 431), Autumnalis (56.38%, 106/188) and Hebdomadis (19.68%, 37/188) were the major serogroups. Conclusions: The incidence of leptospirosis in Fujian showed a downward trend from 2015 to 2020, there were obvious area clustering and seasonality. The high clustering areas were mainly distributed in northern, western and central Fujian. Java and Autumnalis were the predominant serogroups in rats. The infection rate in healthy population decreased year by year. Autumnalis and Hebdomadis were the main serogroups in population in Fujian.

[Establishment of morphological reference values for the differential count of white blood cells in peripheral blood smear, as well as nucleated cells and megakaryocytes in bone marrow smear]

Objective: To establish the morphological reference values for the differential count of white blood cells in peripheral blood smear as well as nucleated cells and megakaryocytes in bone marrow smear. Methods: From April 2012 to June 2020, 4 221 healthy donors for hematopoietic stem cell transplantation in Hebei Yanda Lu Daopei Hospital were selected. The median age was 36 (3-72) years old, including 2 520 males and 1 701 females. They were divided into four groups according to age: children group, with age≤14 years old [n=334, 11 (3-14) years old], youth group, with age >14 years old and <45 years old [n=2 855, 33 (15-44) years old], middle-aged adult group, with age ≥45 years old and < 60 years old [n=929, 49 (45-59) years old], and older adult group, with age ≥60 years old [n=103, 62 (60-72) years old]. Gender subgroups were established in each age group. According to different hematopoietic characteristics, the children group were divided into two subgroups: children group 1 [n=48, 6 (3-7) years old] and children group 2 [n=286, 11 (8-14) years old]. According to the clinical routine, 100 white blood cells in peripheral blood, 200 nucleated cells in bone marrow, and cell numbers/4.5 cm² for megakaryocytes were classified and counted. The results of cell count in different age and gender groups were compared, and the reference values of morphological classification were established for different groups with statistical or clinical significance. Results: Due to the existence of statistically significant differences between children and adult groups and different gender subgroups in adults (all P<0.05), the reference values were established for children group and adult gender subgroups. The counts of segmented neutrophils and lymphocytes in peripheral blood were 46.65(43.97-49.32)% and 44.00(10.60-65.10)% in children group 1, 50.73(49.50-51.96)% and 39.55 (38.36-40.74)% in children group 2, and 57.00 (39.00-75.23) % and 33.00 (17.00-52.00) % in adult group, respectively. Bone marrow segmented neutrophils, orthochromatic erythroblasts, and mature lymphocytes were 11.54 (10.68-12.41)%, 14.20 (13.19-15.21)%, and 23.99 (22.06-25.92)% in children group 1, 12.50 (7.00-21.50)%, 15.00(9.50-25.50)%, and 21.02 (20.24-21.81)% in children group 2, 13.50 (7.50-21.00)%, 16.50 (10.50-26.00)%, and 15.50 (7.50-26.00)% in adult male group, and 14.50 (8.00-24.50)%, 14.50 (9.00-23.00)%, and 17.50 (8.50-29.00)% in adult female group, respectively. The myelopoiesis/erythropoiesis ratio in children group, adult male group and adult female group was 1.86∶1 (1.14∶1-3.23∶1), 1.96∶1 (1.12∶1-3.19∶1), 2.22∶1 (1.30∶1-3.69∶1), respectively. The numbers of granular megakaryocytes and thromocytogenic megakaryocytes were 138 (25-567) cells/4.5cm² and 86 (13-328) cells/4.5 cm² in children group, and 92 (13-338) cells/4.5 cm² and 38 (3-162) cells/4.5 cm² in adult group, respectively. Conclusion: The morphological reference values for the differential count of white blood cells in peripheral blood smear as well as nucleated cells and megakaryocytes in bone marrow smear are successfully established, which is helpful to improve the application of morphological examination in disease screening, diagnosis and monitoring.

Distribution, Phylogeny and Evolution of Clinical and Environmental Vibrio vulnificus Antibiotic-Resistant Genes

Vibrio vulnificus is an emergent marine pathogen and is the cause of a deadly septicemia. However, the evolution mechanism of antibiotic-resistant genes (ARGs) is still unclear. Twenty-two high-quality complete genomes of V. vulnificus were obtained and grouped into 16 clinical isolates and 6 environmental isolates. Genomic annotations found 23 ARG orthologous genes, among which 14 ARGs were shared by V. vulnificus and other Vibrio members. Furthermore, those ARGs were located in their chromosomes, rather than in the plasmids. Phylogenomic reconstruction based on single-copy orthologous protein sequences and ARG protein sequences revealed that clinical and environmental V. vulnificus isolates were in a scattered distribution. The calculation of non-synonymous and synonymous substitutions indicated that most of ARGs evolved under purifying selection with the Ka/Ks ratios lower than one, while h-ns, rsmA, and soxR in several clinical isolates evolved under the positive selection with Ka/Ks ratios >1. Our result indicated that V. vulnificus antibiotic-resistant armory was not only confined to clinical isolates, but to environmental ones as well and clinical isolates inclined to accumulate beneficial non-synonymous substitutions that could be retained to improve competitiveness.

[Application of electric tube stapler in laparoscopic colorectal tumor surgery]

Objective: To investigate the application of electric tube stapler in laparoscopic colorectal tumor surgery. Methods: A descriptive case series study was conducted. Clinical data of patients who underwent laparoscopic colorectal surgery in Peking Union Medical College Hospital in August 2021 using domestic electric tube stapler were collected to analyze the occurrence of postoperative anastomotic leakage, anastomotic bleeding and other complications as well as postoperative intestinal function recovery. Results: A total of 11 patients with colorectal tumor were enrolled in this study, including 8 males and 3 females. Eight patients underwent laparoscopic low anterior resection (1 patient underwent protective ileostomy), and three patients underwent laparoscopic sigmoid carcinoma radical resection. During operation, power system failure of stapler occurred in 1 patient, and the replacement manual device was used to complete the anastomosis. No anastomotic leakage or bleeding occurred in the cohort of patients. There was no conversion to laparotomy or conventional anastomosis. One patient developed acute myocardial infarction 2 days after surgery. The average time to the first flatus after surgery was (2.4±0.8) days and the average length of hospital stay was (10.0±6.1) days. Conclusions: The application of electric tube stapler in laparoscopic colorectal tumor surgery has many advantages, such as safe and effective anastomosis, low morbidity of postoperative complications, and rapid recovery of intestinal function. Domestic electric tube stapler can be applied in minimally invasive surgery for colorectal tumor.

[PD-1 is associated with CD8(+)T lymphocyte dysfunction in patients with acute and chronic liver failure]

Objective: To explore whether peripheral blood CD8(+)T lymphocyte dysfunction is correlated with the programmed death receptor-1 (PD-1) expression in patients with acute-on-chronic liver failure (HBV-ACLF). Methods: Peripheral blood mononuclear cells (PBMC) were collected from patients with HBV-ACLF and healthy controls. CD8(+)T lymphocytes number and PD-1 expression condition in CD8(+)T lymphocytes were detected by flow cytometry. CD8(+)T lymphocytes isolated from peripheral blood of HBV-ACLF patients were further cultured in vitro. One group was added with PD-L1-IgG fusion protein (ACLF+PD-1 group), and the other group was added with IgG fusion protein (ACLF group). Proliferation ability (ki67), cell viability (CD69), and secretion ability of effector cytokines (IL-2, IFN-γ, TNF-α) were analyzed. Results: 30 cases with HBV-ACLF and healthy controls were enrolled. CD8(+)T lymphocytes absolute number was significantly lower in the peripheral blood of patients with ACLF group (333.88 ± 147.74)/μl than healthy controls (872.50 ± 206.64)/μl (P < 0.001). PD-1 expression in peripheral blood CD8(+)T lymphocytes were significantly increased in ACLF group (13.33% ± 2.52%), (P = 0.027) than healthy controls (7.02% ± 2.12%). In in vitro culture, compared with healthy controls, the peripheral blood CD8(+)T lymphocytes cell viability (CD69), proliferation ability (ki67) (all P ​​< 0.001), and the level of cytokine production (IL-2, IFN-γ, TNF-α) (all P < 0.05) were equally weakened in patients with ACLF group. Compared with ACLF group, CD8(+)T cell viability (CD69), proliferation ability (KI67) (all P < 0.05), and the level of cytokine production were weakened in ACLF+PD-1 group (all P < 0.05). Conclusion: HBV-ACLF patients have CD8(+)T lymphocyte dysfunction. Therefore, PD-1 may have correlation in the regulation of CD8(+)T lymphocyte dysfunction in ACLF patients.

Various myosteatosis selection criteria and their value in the assessment of short- and long-term outcomes following liver transplantation

Body composition and myosteatosis affect clinical outcomes in orthotopic liver transplantation (OLT). Here we aimed to compare the value and limitations of various selection criteria to define pre-transplant myosteatosis in the assessment of short- and long-term outcomes following OLT. We retrospectively analyzed the data of 264 consecutive recipients who underwent deceased donor OLT at a German university medical centre. Myosteatosis was evaluated by preoperative computed-tomography-based segmentation. Patients were stratified using muscle radiation attenuation of the whole muscle area (L3Muslce-RA), psoas RA (L3Psoas-RA) and intramuscular adipose tissue content (IMAC) values. L3Muslce-RA, L3Psoas-RA and IMAC performed well without major differences and identified patients at risk for inferior outcomes in the group analysis. Quartile-based analyses, receiver operating characteristic curve and correlation analyses showed a superior association of L3Muslce-RA with perioperative outcomes when compared to L3Psoas-RA and L3IMAC. Long-term outcome did not show any major differences between the used selection criteria. This study confirms the prognostic role of myosteatosis in OLT with a particularly strong value in the perioperative phase. Although, based on our data, L3Muscle-RA might be the most suitable and recommended selection criterion to assess CT-based myosteatosis when compared to L3Psoas-RA and L3IMAC, further studies are warranted to validate these findings.

Effectiveness of Herbal Medicine for Leukopenia/Neutropenia Induced by Chemotherapy in Adults with Colorectal Cancer: A Systematic Review and Meta-analysis

Objective:

To evaluate the effectiveness of Chinese Herbal Medicine (CHM) on leukopenia/neutropenia induced by chemotherapy in adults with colorectal cancer (CRC).

Methods:

Eight electronic databases were searched from their inception to June 2020. Randomized controlled trials with clarified sequence generation were qualified. Two reviewers independently conducted the screening and data extraction. Methodological quality was assessed using the Risk of Bias tool. RevMan 5.4 was applied to the meta-analysis.

Results:

Twenty-seven studies involving 1867 participants were qualified, of which 26 were included in the quantitative synthesis. Meta-analysis showed that CHM significantly reduced the incidence of leukopenia induced by chemotherapy (RR = 0.69; 95% CI 0.59-0.82), as well as the grade 3/4 leukopenia (RR = 0.71; 95% CI 0.55-0.90). Meanwhile,CHM decreased the occurrence of neutropenia (RR = 0.52, 95% CI 0.35-0.77), especially for the grades 3/4 neutropenia (RR = 0.42, 95% CI 0.27-0.64). Twenty-six of the included studies focused on the adverse events related to CHM.

Conclusion:

CHM may relieve neutropenia/leukopenia induced by chemotherapy in adults with colorectal cancer.

UV response characteristics of mixed-phase MgZnO thin films with different structure distributions, high Iuv/Idark ratios, and fast speed MgZnO UV detectors with tunneling breakdown mechanisms

High-performance ultraviolet (UV) detectors with both high responses and fast speeds are hard to make on homogeneous crystal semiconductor materials. Here, the UV response characteristics of mixed-phase MgZnO thin films with different internal structure distributions are studied. The mixed-phase MgZnO-based detector with the given crystal composition has a high response at both deep UV light (96 A W-1 at 240 nm) and near UV light (80 A W-1 at 335 nm). Meanwhile, because of the quasi-tunneling breakdown mechanism within the device, the high-response UV detector also shows a fast response speed (tr = 0.11 μs) and recovery speed (td1 = 26 μs) at deep UV light, which is much faster than both low-response mixed-phase MgZnO-based UV detectors with other structure constitutions and reported high-response UV devices on homogenous crystal materials. The Idark of the device is just 4.27 pA under a 5 V bias voltage, so the signal-to-noise ratio of the device reached 23852 at 5.5 uW cm-2 235 nm UV light. The new quasi-tunneling breakdown mechanism is observed in some mixed-phase MgZnO thin films that contain both c-MgZnO and h-MgZnO parts, which introduce a high response, signal-to-noise ratio, and fast speed into mixed-phase MgZnO-based UV detectors at weak deep UV light.

[Etiological survey and traceability analysis of five cases of typhoid fever during the same period in Yantai city]

Objective: To analyze the etiological characteristics and molecular epidemiological correlation of five cases of typhoid fever during the same period in yantai city. Methods: Six S. Typhis strains were isolated from 5 typhoid patients and epidemiological samples in Yantai city in 2018. The onset time of the cases were from May 26, 2018 to July 24, 2018, distributed in Shuidao Town of Muping District, Dengzhou Street of Penglai District, Donglai Street of Longkou District, Wenhua Street of Muping District and Fulaishan Street of zhifu District. S. Typhis strains were analyzed by conventional bacterial isolation method and XbaⅠ/BlnⅠ double-enzyme digestion pulse-field gel electrophoresis (PFGE). Meanwhile, ViaB virulence gene detection and 27 common antibiotics sensitivity tests were conducted to study the etiology of S. Typhis. Results: Six strains of S. Typhi were isolated from 5 patients and the domestic egg of one patient, which were divided into 4 PFGE patterns by PFGE-XbaⅠ and PFGE-BlnⅠ and among which 3 strains had the same PFGE patterns.One multi-drug resistant strain (foreign patient), one single-drug resistant strain (patient with a history of provincial retention), and one completely sensitive strain were detected. The three strains of the same PFGE pattern exhibit the same drug-sensitive phenotype which were intermediate against aminoglycosides and quinolones and susceptibility against the other antibiotics.All of the strains carried the ViaB virulence factor except the strain from the foreign patient. Conclusion: Local S. Typhi is susceptibility or intermediate against antibiotics commonly used in clinic.Sporadic cases of typhoid fever and typhoid imported infections still need attention.

Decrease of renal resistance during hypothermic oxygenated machine perfusion is associated with early allograft function in extended criteria donation kidney transplantation

Hypothermic oxygenated machine perfusion (HOPE) was recently tested in preclinical trials in kidney transplantation (KT). Here we investigate the effects of HOPE on extended-criteria-donation (ECD) kidney allografts (KA). Fifteen ECD-KA were submitted to 152 ± 92 min of end-ischemic HOPE and were compared to a matched group undergoing conventional-cold-storage (CCS) KT (n = 30). Primary (delayed graft function-DGF) and secondary (e.g. postoperative complications, perfusion parameters) endpoints were analyzed within 6-months follow-up. There was no difference in the development of DGF between the HOPE and CCS groups (53% vs. 33%, respectively; p = 0.197). Serum urea was lower following HOPE compared to CCS (p = 0.003), whereas the CCS group displayed lower serum creatinine and higher eGFR rates on postoperative days (POD) 7 and 14. The relative decrease of renal vascular resistance (RR) following HOPE showed a significant inverse association with serum creatinine on POD1 (r = − 0.682; p = 0.006) as well as with serum urea and eGFR. Besides, the relative RR decrease was more prominent in KA with primary function when compared to KA with DGF (p = 0.013). Here we provide clinical evidence on HOPE in ECD-KT after brain death donation. Relative RR may be a useful predictive marker for KA function. Further validation in randomized controlled trials is warranted.

Trial registration: clinicaltrials.gov (NCT03378817, Date of first registration: 20/12/2017).

Low Postoperative Platelet Counts Are Associated with Major Morbidity and Inferior Survival in Adult Recipients of Orthotopic Liver Transplantation

BACKGROUND

Platelets (PLT) play an essential functional role in cellular injury and liver regeneration following partial hepatectomy and orthotopic liver transplantation (OLT). Here, we investigated the association of postoperative PLT counts with short- and long-term outcomes in adult OLT recipients.

METHODS

Three hundred consecutive patients from our prospective OLT database were analyzed retrospectively (May 2010-November 2017). Ninety-day post-OLT complications were graded using the Clavien-Dindo (CD) classification and quantified by the comprehensive complication index (CCI). To determine the prognostic accuracy of PLT counts, the area under the receiver operating characteristic curve (AUROC) was calculated for major complications (CD ≥ 3b). Parametric and non-parametric tests were applied for subgroup analyses. Uni- and multivariable logistic regression analyses were performed to identify risk factors for major complications. Graft and patient survival were analyzed using the Kaplan-Meier method as well as uni- and multivariable Cox regression analyses.

RESULTS

Postoperative day 6 PLT counts < 70 × 10⁹/L (POD6-70) were identified as the best cutoff for predicting major complications (AUROC = 0.7; p < 0.001; Youden index 0.317). The stratification of patients into low- (n = 113) and high-PLT (n = 187) groups highlighted significant differences in major complications (CCI 68 ± 29 vs. 43 ± 28, p < 0.001); length of hospital and intensive care unit (ICU) stay (53 ± 43 vs. 31 ± 25, p < 0.001; 21 ± 29 vs. 7 ± 11, p < 0.001, respectively) and estimated procedural costs. POD6-70 was associated with inferior 5-year graft survival. Multivariable logistic regression analysis identified POD6-70 as an independent predictor of major complications (odds ratio 2.298, confidence intervals 1.179-4.478, p = 0.015).

CONCLUSION

In OLT patients, a PLT count on POD6 of less than 70 × 10⁹/L bears a prognostic significance warranting further investigations.

Orthotopic Kidney Auto-Transplantation in a Porcine Model Using 24 Hours Organ Preservation And Continuous Telemetry

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for kidney transplantation (KT). Even though, the use of allografts from extended criteria donors (ECD) could partially ease the shortage of organ donors, ECD organs carry a potentially higher risk for inferior outcomes and postoperative complications. Dynamic organ preservation techniques, modulation of ischemia-reperfusion and preservation injury, and allograft therapies are in the spotlight of scientific interest in an effort to improve allograft utilization and patient outcomes in KT. Preclinical animal experiments are playing an essential role in translational research, especially in the medical device and drug development. The major advantage of the porcine orthotopic auto-transplantation model over ex vivo or small animal studies lies within the surgical-anatomical and physiological similarities to the clinical setting. This allows the investigation of new therapeutic methods and techniques and ensures a facilitated clinical translation of the findings. This protocol provides a comprehensive and problem-oriented description of the porcine orthotopic kidney auto-transplantation model, using a preservation time of 24 hours and telemetry monitoring. The combination of sophisticated surgical techniques with highly standardized and state-of-the-art methods of anesthesia, animal housing, perioperative follow up, and monitoring ensure the reproducibility and success of this model.

[Meta-analysis of clinical effects of microskin grafting and Meek microskin grafting in repairing extensively deep burn wounds]

Objective: To systematically evaluate the clinical effects of microskin grafting and Meek microskin grafting in repairing extensively deep burn wounds using meta-analysis. Methods: Foreign language databases including PubMed and Cochrane Library were searched with the terms of " Meek micrografting, burn" , and Chinese databases including Chinese Journal Full-Text Database, Chinese Biomedical Database, VIP database, and Wanfang Data were searched with the terms in Chinese version of ", Meek," to retrieve the publicly published randomized controlled trials on the microskin grafting and Meek microskin grafting in repairing extensively deep burn wounds from the establishment of each database to March 20, 2019. The outcome indexes included the survival rate of skin graft, primary healing rate, operation time, and surgical treatment cost after the first operation, as well as the wound healing time and length of hospital stay. RevMan 5.3 and Stata 14.0 statistical software were used to conduct a meta-analysis of eligible studies. Results: A total of 821 patients with extensively deep burns were included in 15 studies, including 410 patients in microskin group who received microskin grafting and 411 patients in Meek microskin group who received Meek microskin grafting. The bias risks of the 15 studies included were uncertain. Compared with those of microskin group, the survival rate of skin graft and primary healing rate of patients in Meek microskin group were significantly increased, with relative risks of 0.76 and 0.66 (95% confidence interval=0.66-0.88, 0.50-0.88, P<0.01), the surgical treatment cost was significantly reduced, with a standardized mean difference of 3.19 (95% confidence interval=1.36-5.01, P<0.01), and the operation time, wound healing time, and length of hospital stay were significantly shortened, with standardized mean differences of 6.05, 2.39, and 2.35 (95% confidence interval=3.66-8.44, 1.43-3.35, 2.03-2.68, P<0.01). Subgroup analysis showed that microskin grafting combined with allogenic skin graft might be a heterogeneous source of operation time. Sensitivity analysis showed that the combined effect size was stable in the operation time, surgical treatment cost, and wound healing time. There was no publication bias in the survival rate of skin graft, operation time, wound healing time, and length of hospital stay (P>0.05), while the primary healing rate and surgical treatment cost had publication bias (P<0.01). Conclusions: Compared with microskin grafting, Meek microskin grafting improves the rates of skin graft survival and primary healing, shortens operation time, wound healing time, and length of hospital stay, and reduces the treatment cost in treating extensively deep burn wounds.

Spatial distribution of perfluoroalkyl acids (PFAAs) and their precursors and conversion of precursors in seawater deeply affected by a city in China

Conversion of perfluoroalkyl acid (PFAA) precursors in the environment has been a hotspot research in recent years. This study firstly determined the spatial distribution of PFAAs and their precursors including 8:2 fluorotelomer unsaturated acid (8:2 FTUCA), perfluorooctane sulfoneamide (FOSA), and diperfluorooctane sulfonamido ethanol-based phosphate (di-SAmPAP), then investigated the conversion of the potential precursors in the seawater and sewage treatment plants (STPs) effluents. The results indicated that the target pollutants showed a typical concentration gradient from nearshore to offshore. And the obviously increased concentration of perfluorinated carboxylic acids (△[PFCAs]) after oxidation treatment can verify the existence of PFAA precursors in the seawater and STP effluents. The concentrations of PFCAs with carbon atom numbers 4-9 (PFCA_C4-C9) revealed the most increase. Moreover, the levels of △[PFCAs] and the ratios of △[PFCAs] to their concentration before oxidation (△[PFCA]/[PFCA]_{before oxidation}) indicated obvious spatial variations in the seawater and STP effluents. The higher levels of △[PFCA_C4-C12] and the lower ratios of ∑△[PFCA_C4-C12]/∑[PFAA]_{before oxidation} were observed in the STP effluents, which implied that precursors might be decomposed during the sewage treatment process. These results suggested the STP effluents might have an important effect on the PFAAs levels of seawater.

[WITHDRAWN: Potential false-positive rate among the 'asymptomatic infected individuals' in close contacts of COVID-19 patients]

Editor office’s response for Ahead of Print article withdrawn The article “Potential false-positive rate among the ‘asymptomatic infected individuals’ in close contacts of COVID-19 patients” was under strong discussion after pre-published. Questions from the readers mainly focused on the article’s results and conclusions were depended on theoretical deduction, but not the field epidemiology data and further researches were needed to prove the current theory. Based on previous discussions, the article was decided to be offline by the editorial board from the pre-publish lists. Objective: As the prevention and control of COVID-19continues to advance, the active nucleic acid test screening in the close contacts of the patients has been carrying out in many parts of China. However, the false-positive rate of positive results in the screening has not been reported up to now. But to clearify the false-positive rate during screening is important in COVID-19 control and prevention. Methods: Point values and reasonable ranges of the indicators which impact the false-positive rate of positive results were estimated based on the information available to us at present. The false-positive rate of positive results in the active screening was deduced, and univariate and multivariate-probabilistic sensitivity analyses were performed to understand the robustness of the findings. Results: When the infection rate of the close contacts and the sensitivity and specificity of reported results were taken as the point estimates, the positive predictive value of the active screening was only 19.67%, in contrast, the false-positive rate of positive results was 80.33%. The multivariate-probabilistic sensitivity analysis results supported the base-case findings, with a 75% probability for the false-positive rate of positive results over 47%. Conclusions: In the close contacts of COVID-19 patients, nearly half or even more of the 'asymptomatic infected individuals' reported in the active nucleic acid test screening might be false positives.

[Imaging classification diagnosis and maxillary sinus floor augmentation of maxillary sinus cystic lesions]

Maxillary sinus cystic lesions can often be found in cone-beam computed tomography (CBCT) images. However, whether this change affects the implementation of maxillary sinus floor augmentation remains unclear. Combining the common cystic change performance of CBCT, image classification diagnosis of maxillary sinus cystic change was introduced, and the indications and surgical methods of maxillary sinus floor augmentation and postoperative radiographic changes of mucous were analyzed. This procedure may help clinicians evaluate the feasibility and methods of maxillary sinus augmentation in maxillary sinus cystic changes.

[Risk factor analysis on anastomotic leakage after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy and establishment of a nomogram prediction model]

Objective: To investigate the risk factors of anastomotic leakage (AL) after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy and construct a nomogram prediction model. Methods: This study was a retrospective case-control study that collected and reviewed the clinicopathological data of 359 patients who underwent laparoscopic surgery from January 2012 to January 2018, including 202 patients from the Department of General Surgery, Nanfang Hospital of Southern Medical University and 157 patients from the Department of Gastrointestinal Surgery of Fujian Provincial Cancer Hospital. Inclusion criteria: (1) age ≥ 18 years old; (2) diagnosis as rectal cancer by biopsy before treatment; (3) distance from tumor to anus within 12 cm; (4) locally advanced stage (T3-T4 or N+) diagnosed by imaging (CT, MRI, PET or ultrasound); (5) standardized neoadjuvant therapy followed by laparoscopic radical operation. Exclusion criteria: (1) previous history of colorectal cancer surgery; (2) short-term or incomplete standardized neoadjuvant therapy; (3) Miles, Hartmann, emergency surgery, palliative resection; (4) conversion to open surgery. Clinicopathological data, including age, gender, body mass index (BMI), preoperative albumin, distance from tumor to anus, operation hospital, American Society of Anesthesiologists score (ASA score), operation time, T stage, N stage, M stage, TNM stage, pathological complete response (pCR) were analyzed with univariate analysis to identify predictors for AL after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy. Then, incorporated predictors of AL, which were screened by multivariate logistic regression, were plotted by the "rms" package in R software to establish a nomogram model. According to the scale of the nomogram of each risk factor, the total score could be obtained by adding each single score, then the corresponding probability of postoperative AL could be acquired. The area under ROC curve (AUC) was used to evaluate the predictive ability of each risk factor and nomogram on model. AUC > 0.75 indicated that the model had good predictive ability. The Bootstrap method (1000 bootstrapping resamples) was applied as internal verification to show the robustness of the model. The discrimination of the nomogram was determined by calculating the average consistency index (C-index) whose rage was 0.5 to 1.0. Higher C-index indicated better consistency with actual risk. The calibration curve was used to assess the calibration of prediction model. The Hosmer-Lemeshow test yielding a non-significant statistic (P>0.05) suggested no departure from the perfect fit. Results: Of 359 cases, 224 were male, 135 were female, 189 were ≥ 55 years old, 98 had a BMI > 24 kg/m(2), 176 had preoperative albumin ≤ 40 g/L, 128 had distance from tumor to anus ≤ 5 cm, 257 were TNM 0-II stage, 102 were TNM III-IV stage, and 84 achieved pCR after neoadjuvant therapy. The incidence of postoperative AL was 9.5% (34/359). Univariate analysis showed that gender, preoperative albumin and distance from tumor to the anus were associated with postoperative AL (All P<0.05). Multivariate logistic regression analysis revealed that male (OR=2.480, 95% CI: 1.012-6.077, P=0.047), preoperative albumin ≤40 g/L (OR=5.319, 95% CI: 2.106-13.433, P<0.001) and distance from tumor to anus ≤ 5 cm (OR=4.339, 95% CI: 1.990-9.458, P<0.001) were significant independent risk factors for postoperative AL. According to these results, a nomogram prediction model was constructed. The male was for 55 points, the preoperative albumin ≤ 40 g/L was for 100 points, and the distance from tumor to the anus ≤ 5 cm was for 88 points. Adding all the points of each risk factor, the corresponding probability of total score would indicated the morbidity of postoperative AL predicted by this nomogram modal. The AUC of the nomogram was 0.792 (95% CI: 0.729-0.856), and the C-index was 0.792 after internal verification. The calibration curve showed that the predictive results were well correlated with the actual results (P=0.562). Conclusions: Male, preoperative albumin ≤ 40 g/L and distance from tumor to the anus ≤ 5 cm are independent risk factors for AL after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy. The nomogram prediction model is helpful to predict the probability of AL after surgery.

Risk Factors for 3-Year-Mortality and a Tool to Screen Patient in Dialysis Population

Introduction

Clinical parameters especially co-morbidities among end stage renal disease (ESRD) patients are associated with mortality. This study aims to determine the risk factors that are associated with mortality within three years among prevalent patients with ESRD.

Methods

This is a cohort study where prevalent ESRD patients' details were recorded between May 2012 and October 2012. Their records were matched with national death record at the end of year 2015 to identify the deceased patients within three years. Four models were formulated with two models were based on logistic regression models but with different number of predictors and two models were developed based on risk scoring technique. The preferred models were validated by using sensitivity and specificity analysis.

Results

A total of 1332 patients were included in the study. Majority succumbed due to cardiovascular disease (48.3%) and sepsis (41.3%). The identified risk factors were mode of dialysis (P < 0.001), diabetes mellitus (P < 0.001), chronic heart disease (P < 0.001) and leg amputation (P = 0.016). The accuracy of four models was almost similar with AUC between 0.680 and 0.711. The predictive models from logistic regression model and risk scoring model were selected as the preferred models based on both accuracy and simplicity. Besides the mode of dialysis, diabetes mellitus and its complications are the important predictors for early mortality among prevalent ESRD patients.

Conclusions

The models either based on logistic regression or risk scoring model can be used to screen high risk prevalent ESRD patients.

[Effect of preservation of left colic artery on postoperative anastomotic leakage of patients with rectal cancer after neoadjuvant therapy]

Objective: To evaluate the effect of preservation of left colic artery (LCA) on postoperative anastomotic leakage in patients with rectal cancer after neoadjuvant therapy. Methods: A retrospective cohort study was conducted to collect data of rectal cancer patients at Department of Gastrointestinal Surgery of Fujian Cancer Hospital from September 2014 to August 2017. Inclusion criteria: (1) age of 18 to 79 years; (2) rectal adenocarcinoma confirmed by postoperative pathology; (3) patients without preoperative serious cardiovascular and cerebrovascular disease receiving preoperative neoadjuvant radiotherapy or chemoradiotherapy; (4) laparoscopic-assisted anterior rectal resection and distal ileostomy were performed simultaneously; (5) complete clinical data. Exclusion criteria: patients with extensive abdominal metastasis, or distant organ metastasis during operation, and combined organ resection. According to whether LCA was retained during operation, the patients were divided into two groups, then the intraoperative and postoperative clinical outcomes were compared. Moreover, univariate analysis and multivariate logistic regression were used to analyze risk factors of postoperative anastomotic leakage. Results: A total of 125 patients were included in this study, including 56 patients in the retained LCA group and 69 patients in the non-retained LCA group. Differences in baseline data, such as gender, age, diabetes mellitus, body mass index, hemoglobin, distance between tumor and anal margin, maximum diameter of tumor, preoperative neoadjuvant therapy, and ypTNM stage, between retained LCA group and non-retained LCA group were not statistically significant (all P>0.05), indicating that two groups were comparable. Meanwhile there were no significant differences in operation time, intraoperative blood loss, total number of lymph node harvested, number of harvested lymph node at the root of inferior mesenteric artery, circumferential margin, anastomotic bleeding, or postoperative hospital stay between two groups (all P>0.05). Thirteen patients in the non-retained LCA group (18.8%) developed postoperative anastomotic leakage, including 7 cases of grade A, 5 cases of grade B and 1 case of grade C, while in the retained LCA group, only 5.4% (3/56) of patients developed postoperative anastomotic leakage, including 1 case of grade A and 2 cases of grade B without case of grade C, whose difference was statistically significant (U=1674.500, P=0.028). Univariate analysis showed that preoperative hemoglobin <120 g/L and non-retained LCA were associated with postoperative anastomotic leakage (both P<0.05). Multivariate analysis cofirmed that preoperative hemoglobin < 120 g/L (OR=3.508, 95% CI: 1.158 to 10.628, P=0.017) and non-retained LCA (OR=4.065, 95%CI: 1.074 to 15.388, P=0.031) were independent risk factors for postoperative anastomotic leakage. Median follow-up time was 31 months (16 to 51 months), and no long-term complication was found. Local recurrence and distant metastasis were found in 1 case (1.8%) and 7 case (12.5%) in the retained LCA group, while those were found in 2 cases (2.9%) and 5 cases (7.2%) respectively, in the non-retained LCA group, whose differences were not statistically significant (P=1.000, P=0.321 respectively). Conclusion: Preservation of left colic artery not only can ensure radical lymph node dissection efficacy under the condition of similar operation time and blood loss, but also can effectively reduce the incidence of postoperative anastomotic leakage for rectal cancer patients after neoadjuvant therapy.

Synthesis of high quality silver nanowires and their applications in ultrafast photonics

Silver nanowires are widely used in catalysts, surface enhanced Raman scattering, microelectronic equipment, thin film solar cells, microelectrodes and biosensors for their excellent conductivity, heat transfer, low surface resistance, high transparency and good biocompatibility. However, the optical nonlinearity of silver nanowires has not been further explored yet. In this paper, three silver nanowire samples with different concentrations are produced via a typical hydrothermal method. Their applications to fiber lasers are implemented to prove the optical nonlinearity of silver nanowires for the first time. Based on three kinds of silver nanowires, the mode-locked operation of fiber lasers is successfully realized. Moreover, the fiber laser based on the silver nanowire with a concentration of 2 mg/L demonstrates the shortest pulse duration of 149.3 fs. The experiment not only proves the optical nonlinearity of silver nanowires, but also has some enlightenment on the selection of the optimum concentration of silver nanowires in the consideration of ultrashort pulse output.

Artesunate exerts protective effects against ulcerative colitis via suppressing Toll‑like receptor 4 and its downstream nuclear factor‑κB signaling pathways

Artesunate (ART) is a semi-synthetic derivative of artemisinin used in the treatment of patients with malaria, which has also been reported to have immunoregulatory, anticancer and anti-inflammatory properties. The aim of the present study was to investigate the possible beneficial effects of ART on ulcerative colitis (UC) rats and to detect the possible mechanisms underlying these effects. A UC rat model was established using dextran sulfate sodium (DSS). Rats were randomly divided into the following groups: Normal control, UC model group, UC rats treated with a low, medium or high dose of ART (10, 30 and 50 mg/kg/day, respectively), and the positive control group (50 mg/kg/day 5-aminosalicylic acid). The damage status of colonic mucosal epithelial tissue was investigated by hematoxylin and eosin staining, and then the weight, colon length and disease activity index (DAI) were measured. Western blotting and reverse transcription-quantitative polymerase chain reaction analysis were used to detect the levels of cytokines associated with UC and proteins associated with Toll-like receptor 4 (TLR4)-nuclear factor (NF)-κB pathway. ELISA was also performed to measure the levels of inflammatory cytokines. In addition, the viability and infiltration of RAW264.7 cells were examined using Cell Counting Kit-8 and Transwell assays. The results demonstrated that treatment with ART significantly alleviated the UC symptoms induced by DSS in the rat model, lowered the DAI, ameliorated pathological changes, attenuated colon shortening, inhibited the levels of pro-inflammatory mediators and myeloperoxidase activity, and increased hemoglobin expression. Additionally, inflammatory and apoptotic markers were found to be significantly downregulated following treatment with ART in UC rats and RAW264.7 cells. To the best of our knowledge, the present study is the first to demonstrate that ART exerts anti-inflammatory effects via regulating the TLR4-NF-κB signaling pathway in UC.

Potential value and limitations of different clinical scoring systems in the assessment of short- and long-term outcome following orthotopic liver transplantation

BACKGROUND

In an attempt to further improve liver allograft utilization and outcome in orthotopic liver transplantation (OLT), a variety of clinical scoring systems have been developed. Here we aimed to comparatively investigate the association of the Balance-of-Risk (BAR), Survival-Outcomes-Following-Liver-Transplant (SOFT), Preallocation-Survival-Outcomes-Following-Liver-Transplant (pSOFT), Donor-Risk-Index (DRI), and the Eurotransplant-Donor-Risk-Index (ET-DRI) scores with short- and long-term outcome following OLT.

METHODS

We included 338 consecutive patients, who underwent OLT in our institution between May 2010 and November 2017. For each prognostic model, the optimal cutoff values were determined with the help of the Youden-index and their diagnostic accuracy for 90-day post OLT-mortality and major postoperative complications was measured by the area under the receiver operating characteristic curve (AUROC). Patient- and graft survival were analyzed using the Kaplan-Meier method and the log-rank test. Morbidity was assessed using the Clavien-Dindo classification and the Comprehensive-Complication-Index.

RESULTS

BAR, SOFT, and pSOFT performed well above the conventional AUROC-threshold of 0.70 with good prediction of early mortality. Only BAR showed AUC>0.70 for both mortality and major morbidity. With the cutoffs of 14, 31, and 22 respectively for BAR, SOFT, and pSOFT, subgroup analysis showed significant differences (p<0.001) in morbidity and mortality, length of intensive care- and hospital-stay and early allograft dysfunction rates. Five-years patient survival was inferior in the high BAR, pSOFT, and SOFT groups.

CONCLUSIONS

Out of all scores tested, the BAR-score had the best value in predicting both 90-day morbidity and mortality after OLT showing the highest AUCs. The pSOFT and SOFT scores demonstrated an acceptable accuracy in predicting 90-day morbidity and mortality. The used BAR, SOFT, and pSOFT cutoffs allowed the identification of patients at risk in terms of five-year patient survival. The DRI and ET-DRI scores have failed to predict recipient outcomes in the present setting.

Nonlinear optical properties of MoS2-WS2 heterostructure in fiber lasers

As a saturable absorption material, the heterostructure with the van der Waals structure has been paid much attention in material science. In general, the heterogeneous combination is able to neutralize, or even exceed, the individual material's advantages in some aspects. In this paper, which describes the magnetron sputtering deposition method, the tapered fiber is coated by the MoS₂-WS₂ heterostructure, and the MoS₂-WS₂ heterostructure saturable absorber (SA) is fabricated. The modulation depth of the prepared MoS₂-WS₂ heterostructure SA is measured to be 19.12%. Besides, the theoretical calculations for the band gap and carrier mobility of the MoS₂-WS₂ heterostructure are provided. By employing the prepared SA, a stable and passively erbium-doped fiber laser is implemented. The generated pulse duration of 154 fs is certified to be the shortest among all fiber lasers based on transition mental dichalcogenides. Results in this paper provide the new direction for the fabrication of ultrafast photon modulation devices.

[Effects of GBR and Delayed Loading on Bone Ring Grafting with Simultaneous Implant Insertion: an Experimental Study on Beagle Dogs]

OBJECTIVE

To determine the effects of guided bone regeneration (GBR) and delayed loading on autogenous bone ring grafting.

METHODS

Autogenous bone ring augmentation with simultaneous implant insertion was performed in the mandibular premolars region of six Beagle dogs. The Bone quality of four mandibular premolars [second premolar (P2) and fourth premolar (P4)] were detected using cone beam CT (CBCT). The P2s and P4s of bilateral mandible were extracted, with three extracting sites being randomly selected to create buccal defects and the remaining one serving as control. GBR and bone ring grafting with simultaneous implant insertion was performed on two of the three experimental sites with buccal defects 3 months later, while the other one was treated with bone ring grafting with simultaneous implant insertion. Routine implant placement was performed in the control group. Vertical bone resorption and sulcus deep around the implants were measured three months after occlusal loading with abutment.

RESULTS

Three months after operations, 83.3% of bone rings grafts were successful and 100% of implants survived. Delayed healing appeared more in the dogs with GBR compared those treated with bone ring grafting with simultaneous implant insertion, resulting in an increase in vertical bone resorption. Compared with the control group, delayed loading had no effects on vertical bone resorption and the health of gingiva tissues after autogenous bone ring transplant.

CONCLUSION

GBR is not a preferred procedure for bone ring grafts, which may increase the risk of delayed healing and site infections, leading to failure of implants. Healed bone ring grafts can resist loadings as normal.

A sub-megavolt anti-scattering grid: Fabrication, testing, and Monte Carlo simulation

X-ray flash radiography is an effective diagnostic in implosive research. While scattering reduces the contrast of radiography, the anti-scattering grids can effectively intercept the scattered radiation and acquire better images. A focused sub-megavolt grid is elaborately manufactured with the combination of lithography, etching, and laser drilling. The consistency of Monte Carlo simulations and radiographic experiments suggests a transmission of about 36% and a 1000 times improvement for the signal to scatter ratio of the grid.

[Meta analysis on effectiveness of epidermal growth factor in treating patients with inhalation injury]

Objective: To systematically evaluate the effectiveness of epidermal growth factor (EGF) in treating patients with inhalation injury by meta analysis. Methods: Databases including PubMed, Cochrance Library, and Embase were searched using key words " inhalation injury, smoke inhalation injury, epidermal growth factor, and EGF" , and Chinese Journals Full-text Database, China Biology Medicine disc, VIP Database, and Wanfang Database were searched using key words in Chinese version "," to obtain the randomized controlled trails about EGF published publicly in the treatment of patients with inhalation injury from the establishment of each database to December 2017. The measurement indexes included content of total protein and albumin, colloid osmotic pressure (COP), the number of total cells, percentages of neutrophils, lymphocytes, and fibroblasts in bronchoalveolar lavage fluid (BALF), the time of disappearance of pulmonary symptoms, the time of exfoliation of necrotic mucous membrane, the time of removal of tracheal tube, the amount of respiratory secretions, and the incidence of lung infection. Meta-analysis was conducted by RevMan 5.3 statistical software. Results: A total of 6 trials involving 375 patients were included, with 182 patients in group EGF who received EGF treatment and 173 patients in conventional treatment group who received conventional treatment. All of the 6 trails had unclear risk of bias. The content of total protein and albumin and COP in BALF of patients in group EGF were lower than those in conventional treatment group, with standardized mean differences (SMDs) respectively -9.37, -26.77 , and -8.13 [with 95% confidence intervals (CIs) respectively -14.11--4.63, -41.85--11.69, -9.54--6.73, P<0.001]. The number of total cells and percentages of neutrophils and lymphocytes in BALF of patients in group EGF were lower than those in conventional treatment group, while the percentage of fibroblasts in BALF of patients in group EGF was higher than that in conventional treatment group, with SMDs respectively -20.22, -13.08, -12.28, 2.99 (with 95% CIs respectively -22.27--17.66 , -14.76--11.40, -13.86--10.70, 2.48-3.50, P<0.001). The time of disappearance of pulmonary symptoms, the time of exfoliation of necrotic mucous membrane, and the time of removal of tracheal tube of patients in group EGF were shorter than those in conventional treatment group, with SMDs respectively -1.05, -1.22 , -1.11 (with 95% CIs respectively -1.36--0.74, -1.54--0.91, -1.39--0.82, P<0.001). The amount of respiratory secretions of patients in group EGF was lower than that in conventional treatment group, with SMD -1.44 (with 95% CI -1.90--0.98, P<0.001). The incidence rate of pulmonary infection of patients in group EGF was lower than that in conventional treatment group, with relative risk 0.46 (with 95% CI 0.24-0.89, P<0.05). There may be publication bias in the content of total protein, albumin, and COP in BALF (P<0.05), while the time of disappearance of pulmonary symptoms, the time of exfoliation of necrotic mucous membrane, and the time of removal of tracheal tube showed no significant publication bias (P>0.05). Conclusions: Conventional treatment combined with EGF therapy can reduce respiratory inflammation of inhalation injury, promote restoration of respiratory epithelium, shorten the time of removal of tracheal tube, reduce the incidence of pulmonary infection of patients, and therefore has good effect on inhalation injury.

[Effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography on repair of electrical burn wounds of head with skull exposure and necrosis]

Objective: To explore the effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography (CTA) on repair of electrical burn wounds of head with skull exposure and necrosis. Methods: Seven patients with head electrical burns accompanied by skull exposure and necrosis were admitted to our burn center from March 2016 to December 2017. Head CTA was performed before the operation. The diameters of the facial artery and vein or the superficial temporal artery and vein were measured, and their locations were marked on the body surface. Preoperative CTA for flap donor sites in lower extremities were also performed to track the descending branch of the lateral circumflex femoral artery with the similar diameter as the recipient vessels on the head, and their locations were marked on the body surface. Routine wound debridement and skull drilling were performed successively. The size of the wounds after debridement ranged from 12 cm×8 cm to 20 cm×12 cm, and the areas of skull exposure ranged from 8 cm×6 cm to 15 cm×10 cm. Anteriolateral thigh perforator flaps with areas from 13 cm×9 cm to 21 cm×13 cm containing 5-10 cm long vascular pedicles were designed and dissected accordingly. The fascia lata under the flap with area from 5 cm×2 cm to 10 cm×3 cm was dissected according to the length of vascular pedicle. The fascia lata was transplanted to cover the exposed skull, and the anteriolateral thigh perforator flap was transplanted afterwards. The descending branch of the lateral circumflex femoral artery and its accompanying vein of the flap were anastomosed with superficial temporal artery and vein or facial artery and vein before the suture of flap. The flap donor sites were covered by intermediate split-thickness skin graft collected from contralateral thigh or abdomen. Results: The descending branch of the lateral circumflex femoral artery and its accompanying vein were anastomosed with superficial temporal artery and vein in six patients, while those with facial artery and vein in one patient. All the flaps survived after the operation, and no vascular crisis was observed. Wound healing was satisfactory. One patient was lost to follow up. Six patients were followed up for 6 to 10 months. The patients were bald in the head operation area with acceptable appearance. No psychiatric symptom such as headache or epileptic seizure was reported. The flap donor sites were normal in appearance. The muscle strength of the lower extremities all reached grade V. The sensation and movement of the lower extremities were normal. Conclusions: Anterolateral thigh perforator flap with fascia lata transplantation can effectively repair electrical burn wounds of head with skull exposure and necrosis. The fascia lata can be used to protect the vascular pedicle of flaps, which is beneficial to the survival of the flap. Preoperative head and lower extremities CTA can provide reference for intraoperative vascular exploration in donor site and recipient area, so as to shorten operation time.

Delivery of bevacizumab by intracranial injection: assessment in glioma model

Background

Many reports have indicated that the intravenous administration of bevacizumab produces a number of systemic side effects. Therefore, we investigated the therapeutic effects of intratumoral bevacizumab administration using a glioma animal model.

Methods

The glioma cell lines U251 and U87 that carried luciferase were implanted into the brains of mice to develop glioma models. Glioma-bearing mice were treated with bevacizumab intravenously or intratumorally by Alzet micro-osmotic pumps, and the survival time of mice was monitored. Tumor volumes and location were observed by fluorescence imaging and histological analysis. Levels of microvessel marker, cancer stem cell marker as well as angiogenesis-, invasion-, and inflammation-related factors in tumors were examined by immunohistochemical staining.

Results

Mice treated with intratumoral low-dose bevacizumab had smaller tumor volumes, longer survival time, lower microvessel density, and fewer cancer stem cells as compared with untreated and intravenously treated mice. Furthermore, expression levels of inflammation-related factors increased signifiwhereas that of angiogenesis- and invasion-related factors decreased in intratumorally treated animals, compared with intravenously treated mice.

Conclusion

These results implied bevacizumab delivery by intratumoral injection via Alzet micro-osmotic pumps may be a more effective and safer protocol for treating gliomas.

Direct Growth of Al2O3 on Black Phosphorus by Plasma-Enhanced Atomic Layer Deposition

Growing high-quality and uniform dielectric on black phosphorus is challenging since it is easy to react with O₂ or H₂O in ambient. In this work, we have directly grown Al₂O₃ on BP using plasma-enhanced atomic layer deposition (PEALD). The surface roughness of BP with covered Al₂O₃ film can reduce significantly, which is due to the removal of oxidized bubble in BP surface by oxygen plasma. It was also found there is an interfacial layer of PO _x in between amorphous Al₂O₃ film and crystallized BP, which is verified by both X-ray photoelectron spectroscopy (XPS) and transmission electron microscopy (TEM) measurements. By increasing temperature, the PO _x can be converted into fully oxidized P₂O₅.