[Perioperative management of non-thyroid surgery in patients with thyroid dysfunction].

Thyroid diseases are relatively common in clinical practice. Surgery and use of related drugs may exacerbate the underlying thyroid diseases, increasing the difficulty of perioperative management. However, there is a lack of guidelines and consensus for non-thyroid surgery in patients with thyroid dysfunction. This review mainly summaries the perioperative management of non-thyroid surgery in patients with hypothyroidism and hyperthyroidism to provide clinical treatment suggestions and reduce the risk of perioperative complications.

[Clinical effect of modified vertical rectus abdominis myocutaneous flap in repairing skin and soft tissue defects after abdominoperineal resection for rectal cancer].

Objective: To investigate the clinical effect of the modified vertical rectus abdominis myocutaneous flap in repairing the skin and soft tissue defect after abdominoperineal resection for rectal cancer. Methods: This study was a retrospective observational study. From June 2019 to July 2022, five male patients with low rectal cancer who were conformed to the inclusion criteria were admitted to the Department of Basic Surgery of Xiangya Hospital of Central South University, with ages ranging from 65 to 70 years and the sizes of the perianal skin ulcers ranging from 5 cm×4 cm to 11 cm×9 cm, and all of them underwent abdominoperineal resection. The secondary skin and soft tissue defects in the perineum with an area of 8 cm×6 cm-14 cm×12 cm (with the depth of pelvic floor dead space being 10-15 cm) were repaired intraoperatively with transplantation of modified vertical rectus abdominis myocutaneous flaps with the skin area being 9 cm×7 cm-16 cm×12 cm, the volume of the muscle being 18 cm×10 cm×5 cm-20 cm×12 cm×5 cm, and the vessel pedicle being 18-20 cm in length. During the operation, most of the anterior sheath of the rectus abdominis muscle was retained, the flap was transferred to the recipient area through the abdominal cavity, the remaining anterior sheaths of the rectus abdominis muscle on both sides of the donor area were repeatedly folded and sutured, the free edge of the transverse fascia of the abdomen was sutured with the anterior sheath of the rectus abdominis muscle, and the donor area skin was directly sutured. After the operation, the survival of the transplanted myocutaneous flap was observed. The occurrence of complications in the perineal recipient area was recorded within 2 weeks after the operation. The recovery of the perineal recipient area and the abdominal donor area was observed during follow-up, and the occurrence of complications in the donor area of the abdomen as well as the recurrence of tumors and metastasis were recorded. Results: All transplanted myocutaneous flaps in 5 patients survived after surgery. One patient had dehiscence of the incision in the perineal recipient area 2 days after surgery, which healed after 7 d with intermittent dressing changes and routine vacuum sealing drainage treatment. In the other 4 patients, no complications such as incisional rupture, incisional infection, or fat liquefaction occurred in the perineal recipient area within 2 weeks after surgery. Follow-up for 6-12 months after discharge showed that the skin of the perineal recipient area had good color, texture, and elasticity, and was not bloated in appearance; linear scars were left in the perineal recipient area and the abdominal donor area without obvious scar hyperplasia or hyperpigmentation; no complications such as incisional rupture, incisional infection, intestinal adhesion, intestinal obstruction, or weakening of the abdominal wall strength occurred in the abdominal donor area, and the abdominal appearance was good with no localized bulge or formation of abdominal hernia; there was no local recurrence of tumor or metastasis in any patient. Conclusions: The surgical approach of using the modified vertical rectus abdominis myocutaneous flap to repair the skin and soft tissue defects after abdominoperineal resection for rectal cancer is relatively simple in operation, can achieve good postoperative appearances of the donor and recipient areas with few complications, and is worthy of clinical promotion.

[A brief discussion on the harvest of thinned perforator flap, detection of perforator vessels, and evaluation of flap blood supply].

Repair and reconstruction surgery is not just a simple repair and reconstruction of tissue and organ defects in different parts, but also requires perfect repair that matches the defect and confuses the real. The thinning strategy of perforator flap is one of its main contents. In recent years, the concept of pure skin perforator flap and its clinical application have overturned the traditional concept that flaps must carry subdermal vascular plexus and improved our understanding of flap surgery, and it is expected to enhance the level of repair and reconstruction. This article explores the harvest of thinned perforator flaps, especially the harvest of innovative pure skin perforator flap with the thickness similar to full thickness skin, as well as the preoperative detection of perforator vessels, blood supply evaluation of perforator flaps, and their clinical applications. It proposes a "Jinshan" repair that perfectly matches the recipient area defect, and also prospects research on the perforasome and three-dimensional visualized digital anatomy of pure skin perforator flaps.

[Repair methods of complex facial defect wounds involving paranasal sinuses and their clinical effectiveness].

Objective: To explore the repair methods of complex facial defect wounds involving paranasal sinuses and their clinical effectiveness. Methods: A retrospective observational study was conducted. From January 2020 to May 2022, 5 patients admitted to the Department of Burns and Plastic Surgery of Xiangya Hospital of Central South University and 4 patients admitted to the Department of Burns and Plastic Surgery of Chenzhou First People's Hospital with complex facial defect wounds involving paranasal sinuses met the inclusion criteria, including 6 males and 3 females, aged 35-69 years, including 4 patients with titanium mesh exposure combined with paranasal sinuses injury and 5 patients with tumor involving paranasal sinuses. After an adequate assessment of the damage by a multiple discipline team, titanium mesh removal, paranasal sinus debridement, and paranasal sinus mucosa removal were performed in patients with exposed titanium mesh, and radical tumor resection was performed in patients with tumors, with postoperative skin and soft tissue defects areas of 5.0 cm×2.5 cm to 18.0 cm×7.0 cm, anterior paranasal sinus wall defects/absence areas of 3 cm×2 cm to 6 cm×4 cm, and sinus cavity depths of 1 to 4 cm. Depending on the perforator course of the descending branch of the lateral circumflex femoral artery, the anterolateral femoral chimeric flap or anterolateral femoral myocutaneous flap (with flap area of 9 cm×4 cm to 19 cm×8 cm, muscle size of 5 cm×3 cm×3 cm to 11 cm×6 cm×3 cm) was transplanted to repair the defect, and the donor site wound was sutured directly. The type of tissue flap transplanted, the blood vessel of the recipient area, and the vascular anastomosis way during the operation, the recovery of the donor and recipient areas and the occurrence of complications after operation were observed. The appearance and blood supply of the recipient area and the recurrence of ulcers and tumors were followed up. Results: The anterolateral femoral myocutaneous flap transplantation was performed in 6 patients, and the anterolateral femoral chimeric flap transplantation was performed in 3 patients. The blood vessels in recipient areas were facial arteries and veins in 3 cases and superficial temporal arteries and veins in 6 cases. The superficial temporal arteries and veins were bridged with blood vessels in tissue flaps by flow-through way in 2 patients, and end-to-end anastomosis of blood vessels in donor and recipient areas was performed in 7 patients. After operation, all the tissue flaps survived, and the facial defect wounds were well repaired without cerebrospinal fluid leakage or paranasal sinus secretion leakage, no intracranial infection occurred, and the wounds in donor areas were healed well. Follow-up of 6-35 months after operation showed that all the patients had good blood supply in the recipient area, and the shape was acceptable; 4 patients with exposed titanium mesh had no recurrence of ulceration, and 5 patients with tumor had no local tumor recurrence or metastasis. Conclusions: Based on an adequate assessment of the extent of paranasal sinuses involved in the facial wound and the nature of the defect, good clinical effects can be achieved by using the anterolateral femoral muscle flap or the anterolateral femoral chimeric flap transplantation to repair complex facial defect wounds with open paranasal sinuses.

[Clinical and laboratory features compared between JAK2 exon12 and JAK2 V617F mutated polycythemia vera].

Objective: To compare clinical and laboratory features between JAK2 exon12 and JAK2 V617F mutated polycythemia vera (PV) . Method: We collected data from 570 consecutive newly-diagnosed subjects with PV and JAK2 mutation, and compared clinical and laboratory features between patients with JAK2 exon12 and JAK2 V617F mutation. Results: 543 (95.3%) subjects harboured JAK2 V617F mutation (JAK2 V617F cohort) , 24 (4.2%) harboured JAK2 exon12 mutations (JAK2 exon12 cohort) , and 3 (0.5%) harboured JAK2 exon12 and JAK2 V617F mutations. The mutations in JAK2 exon12 including deletion (n=10, 37.0%) , deletion accompanied insertion (n=10, 37.0%) , and missense mutations (n=7, 25.9%) . Comparing with JAK2 V617F cohort, subjects in JAK2 exon12 cohort were younger [median age 50 (20-73) years versus 59 (25-91) years, P=0.040], had higher RBC counts [8.19 (5.88-10.94) ×10(12)/L versus 7.14 (4.11-10.64) ×10(12)/L, P<0.001] and hematocrit [64.1% (53.7-79.0%) versus 59.6% (47.2%-77.1%) , P=0.001], but lower WBC counts [8.29 (3.2-18.99) ×10(9)/L versus 12.91 (3.24-38.3) ×10(9)/L, P<0.001], platelet counts [313 (83-1433) ×10(9)/L versus 470 (61-2169) ×10(9)/L, P<0.001] and epoetin [0.70 (0.06-3.27) versus 1.14 (0.01-10.16) IU/L, P=0.002] levels. We reviewed bone marrow histology at diagnosis in 20 subjects with each type of mutation matched for age and sex. Subjects with JAK2 exon12 mutations had fewer loose megakaryocyte cluster (40% versus 80%, P=0.022) compared with subjects with JAK2 V617F. The median follow-ups were 30 months (range 4-83) and 37 months (range 1-84) for cohorts with JAK2 V617F and JAK2 exon12, respectively. There was no difference in overall survival (P=0.422) and thrombosis-free survival (P=0.900) . Conclusions: Compared with patients with JAK2 V617F mutation, patients with JAK2 exon12 mutation were younger, and had more obvious erythrocytosis and less loose cluster of megakaryocytes.

[Sternal bone marrow cell morphology evaluation utility for diagnostic categorization in patients with acquired hypocellular bone marrow failure syndromes].

Objective: Diagnostic value assessment of sternal bone marrow cell morphology in patients with acquired hypocellular bone marrow failure syndromes (BMFS) characterized by normal cytogenetics. Methods: A total of 194 eligible patients with an acquired hypocellular BMFS pre-sternum diagnosis in Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College from June 2014 to January 2019 were reviewed. Sternal bone marrow evaluation was performed, and a post-sternum diagnosis was made. Clinical characteristics and overall survival (OS) were then compared among patients with different post-sternum diagnosis. Binary logistic regression was used to develop a predictive scoring system. Results: In 152 patients with pre-sternum AA diagnosis, 29 patients with a pre-sternum idiopathic cytopenia of undetermined significance (ICUS) diagnosis, and 13 patients with a pre-sternum clonal cytopenia of undetermined significance (CCUS) diagnosis, sternal bone marrow evaluation resulted in a change of diagnosis to hypocellular myelodysplastic syndrome (hypo-MDS) in 42.8% (65/152) , 24.1% (7/29) , and 30.8% (4/13) , respectively. Patients with a post-sternum hypo-MDS diagnosis showed a significant difference in OS compared with patients with a post-sternum AA diagnosis (P=0.005) . Patients with ICUS/CCUS showed no difference in OS compared with AA and hypo-MDS (P=0.095 and P=0.480, respectively) . A 4-item predictive scoring system to identify hypocellular BMFS patients that need sternal bone marrow evaluation was developed, including age > 60 years old (OR=6.647, 95% CI 1.954-22.611, P=0.002, 2 points) , neutrophil alkaline phosphatase score ≤ 160 (OR=2.654, 95% CI 1.214-5.804, P=0.014, 1 point) , abnormal erythroid markers evaluated by flow cytometry on iliac bone marrow (OR=6.200, 95% CI 1.165-32.988, P=0.032, 2 points) , and DAT (DNMT3A, ASXL1, TET2) genes mutation (OR=4.809, 95% CI 1.587-14.572, P=0.005, 1 point) . The Akaike information criterin (AIC) was 186.1. Conclusion: Patients with a pre-sternum acquired hypocellular BMFS diagnosis characterized by normal cytogenetics may not reach accurate diagnostic categorization without sternal bone marrow cell morphology evaluation, which could be considered a diagnostic tool for this patient population. A predictive scoring system was developed, and when the total score is ≥ 2 points, sternal bone marrow evaluation should be performed for accurate diagnostic categorization that is critical to optimal patient care.

[Repair methods and clinical effects of full-thickness burn wounds deep to tendon or even bone in fingers].

Objective: To explore the repair methods and clinical effects of full-thickness burn wounds deep to tendon or even bone in fingers. Methods: A retrospective non-randomized controlled trial was conducted on the 98 patients with full-thickness finger burns deep to tendon or even bone who met the inclusion criteria and were hospitalized in Xiangya Hospital of Central South University from January 2010 to December 2019. Among the 98 patients, there were 81 males and 17 females, aged from 1 to 72 years, with 160 fingers involved. The wound area of each of affected fingers ranged from 2.0 cm×1.5 cm to 12.0 cm×3.5 cm, and the maximum wound area after merging the affected fingers was 12.0 cm×10.0 cm. For adult hands with multiple full-thickness burn wounds deep to tendon or even bone in multiple fingers or children with full-thickness finger burns deep to tendon or even bone, pedicled abdominal flaps were selected. For adults with single or two fingers with full-thickness burns deep to tendon or even bone, the pedicled internal hand flaps and free tissue flaps were selected. The free tissue flap repair requires good vascular conditions in the recipient area with arteries and veins available for anastomosis. For thumb nail burns deep to tendon or even bone or partial absence of the thumb after burns, the thumbs were reconstructed with the first toenail flap or dorsal foot flap with the second toe. In this study, 45 pedicled abdominal flaps were used to repair the wounds in 91 fingers, 37 pedicled internal hand flaps were used to repair the wounds in 37 fingers, 26 free tissue flaps were used to repair the wounds in 28 fingers, 3 first toenail flaps were used to reconstruct 3 patients' thumb nails and to repair hand wounds, and 1 dorsal foot flap with the second toe was used to reconstruct 1 patient's thumb and to repair hand and wrist wounds. The tissue flap area was from 2.0 cm×1.5 cm to 20.0 cm×10.0 cm. The wound in the donor site was repaired by direct suture or full-thickness skin grafting from the medial upper arm of the affected limb or split-thickness skin grafting from the outer thigh. The postoperative survival of the tissue flap, postoperative complications, and appearance and function of the flap donor site were observed. For the patients who were followed up, their finger functions were evaluated at the last follow-up using the trial criteria for replantation function evaluation of the amputated finger issued by the Hand Surgery Society of the Chinese Medical Association, and the satisfaction of the patients was investigated using the Efficacy Satisfaction Scale. Data were statistically analyzed with Kruskal-Wallis H test and Nemenyi test. Results: Of the 112 tissue flaps, 104 tissue flaps survived completely and had good blood circulation; 1 pedicled thumb dorsal ulnar reverse island flap, 1 pedicled finger artery cutaneous branch reverse island flap, and 1 free grafted anterolateral thigh perforator flap were slightly necrotic at the end, which were repaired with outer thigh split-thickness skin graft after dressing change and granulation tissue growth; 2 free grafted tarsal external artery flaps and 1 pedicled thumb dorsal ulnar reverse island flap suffered from postoperative venous return obstruction, which survived after partial suture removal and heparin saline cleansing of the wound; 1 pedicled modified dorsal metacarpal artery retrograde island flap and 1 free grafted peroneal artery perforator flap were necrotic, which were repaired by a pedicled abdominal flap and a lateral upper arm flap free transplantation respectively in stage Ⅱ. After transplantation, the tissue flaps had good shape, soft texture, and good elasticity, without bloating. There was no functional disorder in the flap donor site, and only slight scar remained. A total of 117 fingers of the 72 patients received 3-24 months of outpatient or telephone follow-up. At the last follow-up, the excellent and good rates of function evaluation of fingers repaired with pedicled abdominal flap, pedicled internal hand flap, and free tissue flap were respectively 77.3% (51/66), 96.3% (26/27), and 95.8% (23/24). The function of fingers repaired with free tissue flap and pedicled internal hand flap was significantly better than that with pedicled abdominal flap (P<0.01). The satisfaction of patients with fingers repaired by free tissue flaps was significantly higher than that by pedicled abdominal flap (P<0.05). Conclusions: According to the specific situation of full-thickness burn wounds deep to tendon or even bone in fingers, the pedicled abdominal flap is used to repair the multiple full-thickness burn wounds deep to tendon or even bone in multiple fingers of adult or the full-thickness burn wounds deep to tendon or even bone in fingers of children, the pedicled internal hand flap or free tissue flap is used to repair the full-thickness burn wounds deep to tendon or even bone in single or two fingers of adult patients, and the first toenail flap or the dorsal foot flap with the second toe is used to reconstruct the thumbs with full-thickness burn deep to tendon or even bone, with high postoperative tissue flap survival rate and few complications. The functional recovery of the affected finger is better after repair with free tissue flap and pedicled internal hand flap, and the patients' satisfaction is the highest after free tissue flap repair.

[Clinical effects of axillary propeller flaps in reconstructing the axillary fold scar contracture].

Objective: To explore the clinical effects of axillary propeller flaps in reconstructing the axillary fold scar contracture. Methods: A retrospective cohort study was conducted. From July 2016 to January 2020, 11 patients with anterior axillary fold or anterior and posterior axillary fold scar contractures after burns were admitted to Xiangya Hospital of Central South University, including 7 males and 4 females, aged 8 to 48 years. The lesions involved unilateral axilla in 9 cases and bilateral axilla in 2 cases, with the joint abduction angle of the affected shoulder ranging from 25 to 100°. The axillary fold contracture scars were excised and released, resulting in wound of 8 cm×5 cm-24 cm×20 cm. According to the condition of the residual normal skin in axilla, 2, 3, and 4-leaf propeller flaps with area of 5 cm×3 cm-24 cm×10 cm were designed to repair the wounds after scar excision and release. The donor site wound was closed by suturing directly, and the residual wound that could not be completely sutured was transplanted with free full-thickness skin grafts from the inner thigh or abdomen. The application of 2, 3, and 4-leaf propeller flaps, the joint abduction angle of the affected shoulder immediately after operation, and the survival of the flaps and skin grafts after operation were recorded. The recurrence of scar contracture, the appearance of the flaps, the joint abduction angle of the affected shoulder, and the functional recovery of the affected shoulder joint and upper arm were observed through a follow-up. Results: Among the 13 axillary propeller flaps transplanted in the 11 patients in this group, there were 9 double-leaf propeller flaps, two 3-leaf propeller flaps, and two 4-leaf propeller flaps. The joint abduction angle of the affected shoulder reached 110-165° immediately after operation. All the flaps survived after operation. Nine flap donor sites were repaired with free skin grafts, with skin grafts survived in 7 flap donor sites after operation. Scar erosion in incision and small area of skin graft necrosis developed in 2 flap donor sites. One of the wounds was debrided and repaired by transplantation of split-thickness skin grafts from inner thigh, and the other wound was healed after dressing changes. A follow-up of 6 to 24 months was conducted after surgery, and all the patients had no recurrence of axillary scar contracture; the color of the flap matched the receiving area; the elasticity of flap was good; the joint abduction angle of the affected shoulder reached 120-165°, and the joint pronation and supination, upper arm lifting and circular rotation of the affected shoulder were all good. Conclusions: Reconstruction of the axillary fold scar contracture with axillary propeller flaps has good result, with better flap appearance and recovery of the shoulder joint activity and upper arm function after operation.

[Overall survival and prognosis of patients with polycythemia vera: an analysis based on 906 patients from a single center].

Objective: To explore predictors of overall survival (OS) in Chinese patients with polycythemia vera (PV) . Methods: A total of 906 consecutive newly diagnosed patients with PV seen at the Blood Diseases Hospital, Chinese Academy of Medical Sciences, from June 2007 to February 2020 were included, and their data were collected. PV was diagnosed according to 2016 World Health Organization (WHO) diagnostic definitions. OS and prognostic factors were retrospectively analyzed. Results: Among the 906 patients, 439 were male (48.5%) and 467 were female (51.5%) . The median age was 57 years (range: 18-91 years) . 31.6% (276/874) of the patients had a thrombosis history at diagnosis, and 4.6% (25/541) of the patients had abnormal cytogenetics. The median follow-up was 54 months (95% confidence interval [CI] 8-130 months) . The 5- and 10-year cumulative deaths were 5.8% (95% CI 4.8%-6.7%) and 11.1% (95% CI 9.3%-12.9%) , respectively. Univariate analysis showed that age ≥60 years, thrombosis history, white blood cells (WBC) ≥15×10(9)/L, platelet (PLT) ≥450×10(9)/L, and platelet distribution width (PDW) ≥15 fl significantly correlated with worse OS, and palpable spleen correlated with better OS. Multivariate analysis showed that age ≥60 years (HR=4.3, 95% CI 2.1-9.2, P<0.001) and PDW ≥15 fl (HR=2.1, 95% CI 1.1-4.0, P=0.023) were independent prognostic factors for worse OS. The 5-year cumulative death for patients with PDW ≥15 fl or PDW<15 fl was 8.6% (95% CI 5.9%-11.3%) or 4.4% (95% CI 3.4%-5.4%) , respectively. The 5-year cumulative death for patients defined as low-, intermediate-, and high-risk patients by international working group score system for PV (IWG-PV) were 0.8% (95 CI 0.2%-1.4%) , 4.0% (95% CI 2.7%-5.3%) , and 12% (95% CI 9.6%-14.4%) , respectively, with a significant difference among the three cohorts (P<0.05) . PDW ≥ 15 fl significantly affected OS for intermediate- and high-risk patients (HR=2.3, 95% CI 1.2-4.2, P=0.009) defined by IWG-PV score system, but not for low-risk patients (HR=3.1, 95% CI 0.2-52.0, P=0.405) . Conclusions: Age ≥60 years and PDW ≥15 fl were independent prognostic factors for worse OS in PV. IWG-PV score system effectively predicted OS for Chinese patients with PV.

[Pathological characteristics of megakaryocytes in myeloproliferative neoplasms and their correlation with driver gene mutations].

Objective: To investigate the pathological characteristics of megakaryocytes in myeloproliferative neoplasms(MPN)and their correlations with driver gene mutations. Methods: Trephine specimens administered for 160 patients with MPN from February 2012 to October 2017 were reevaluated according to the World Health Organization(WHO)'s(2016)diagnostic criteria. Results: This cohort of patients included 72(45.0%)men, with the median age of 59(range, 13-87)years, comprising 39 with polycythemia vera(PV), 33 with essential thrombocythemia(ET), 37 with prefibrotic/early-primary myelofibrosis(pre-PMF), 37 with overt PMF, 1 with post-ET MF, 2 with post-PV MF, and 11 with MPN-unclassifiable(MPN-U)after the re-diagnosis. With PV, ET, pre-PMF, and overt PMF changes, proportions of dense clusters, hypolobulated nuclei, and naked nuclei of megakaryocytes gradually increased, whereas erythropoiesis gradually decreased. Proportions of reticulin, collagen, and osteosclerosis grades of ≥1 also increased. Dense clusters, hypolobulated nuclei, and naked nuclei of megakaryocytes were negatively correlated with erythropoiesis and positively correlated with granulopoiesis and fibrosis. In patients with pre- and overt PMF, dense clusters and naked nuclei of megakaryocytes were positively correlated with fibrosis. Patients with JAK2V617F MPN had significantly increased erythropoiesis(P=0.022). Patients with CALR-mutated MPN were characterized by increased loose and dense clusters; paratrabecular distribution and naked nuclei of megakaryocytes(P=0.055, P=0.002, P=0.018, P=0.008); and increased reticulin, collagen, and osteosclerosis(P=0.003, P<0.001, P=0.001). In patients with pre- and overt PMF, patients with JAK2V617F had increased cellularity(P=0.037). CALR-mutated patients had increased dense clusters and giant sizes of megakaryocytes, collagen, and osteosclerosis(P=0.055, P=0.059, P=0.011, P=0.046). Conclusion: Megakaryocytes showed abnormal MPN morphology and distribution, which were related to fibrosis. CALR mutation was probably associated with abnormal morphology and distribution of megakaryocytes and fibrosis.

[Establishment and test results of an artificial intelligence burn depth recognition model based on convolutional neural network].

Objective: To establish an artificial intelligence burn depth recognition model based on convolutional neural network, and to test its effectiveness. Methods: In this evaluation study on diagnostic test, 484 wound photos of 221 burn patients in Xiangya Hospital of Central South University (hereinafter referred to as the author's unit) from January 2010 to December 2019 taken within 48 hours after injury which met the inclusion criteria were collected and numbered randomly. The target wounds were delineated by image viewing software, and the burn depth was judged by 3 attending doctors with more than 5-year professional experience in Department of Burns and Plastic Surgery of the author's unit. After marking the superficial partial-thickness burn, deep partial-thickness burn, or full-thickness burn in different colors, the burn wounds were cut according to 224×224 pixels to obtain 5 637 complete wound images. The image data generator was used to expand images of each burn depth to 10 000 images, after which, images of each burn depth were divided into training set, verification set, and test set according to the ratio of 7.0∶1.5∶1.5. Under Keras 2.2.4 Python 2.8.0 version, the residual network ResNet-50 of convolutional neural network was used to establish the artificial intelligence burn depth recognition model. The training set was input for training, and the verification set was used to adjust and optimize the model. The judging accuracy rate of various burn depths by the established model was tested by the test set, and precision, recall, and F1_score were calculated. The test results were visualized to generate two-dimensional tSNE cloud chart through the dimensionality reduction tool tSNE, and the distribution of various burn depths was observed. According to the sensitivity and specificity of the model for the recognition of 3 kinds of burn depths, the corresponding receiver operator characteristics (ROC) curve was drawn, and the area under the ROC curve was calculated. Results: (1) After the testing of the test set, the precisions of the artificial intelligence burn depth recognition model for the recognition of superficial partial-thickness burn, deep partial-thickness burn, or full-thickness burn were 84% (1 095/1 301), 81% (1 215/1 499) and 82% (1 395/1 700) respectively, the recall were 73% (1 095/1 500), 81% (1 215/1 500) and 93% (1 395/1 500) respectively, and the F1_scores were 0.78, 0.81, and 0.87 respectively. (2) tSNE cloud chart showed that there was small overlapping among different burn depths in the test results for the test set of artificial intelligence burn depth recognition model, among which the overlapping between superficial partial-thickness burn and deep partial-thickness burn and that between deep partial-thickness burn and full-thickness burn were relatively more, while the overlapping between superficial partial-thickness burn and full-thickness burn was relatively less. (3) The area under the ROC curve for 3 kinds of burn depths recognized by the artificial intelligence burn depth recognition model was ≥0.94. Conclusions: The artificial intelligence burn depth recognition model established by ResNet-50 network can rather accurately identify the burn depth in the early wound photos of burn patients, especially superficial partial-thickness burn and full-thickness burn. It is expected to be used clinically to assist the diagnosis of burn depth and improve the diagnostic accuracy.

[Clinical effectiveness of simultaneous reconstructions of multiple joint scar contracture deformity of limb].

Objective: To explore the clinical effects of simultaneous reconstruction of multiple joint scar contracture deformity of limb. Methods: From January 2010 to June 2018, 24 patients with multiple joint scar contracture deformity of the same limb were reconstructed in simultaneous operations in Xiangya Hospital of Central South University, including 16 males and 8 females, aged 3-42 years, with 15 patients having deformities in the upper limbs and 9 patients having deformities in the lower limbs. One operation was performed to repair contracture deformity of axillary fossa and elbow in 3 patients, cubital fossa and palmar of wrist in 4 patients, cubital fossa and hand in 5 patients, palmar of wrist, palm, and palmar of finger in 3 patients, groin and medial knee in 2 patients, popliteal fossa and posterior ankle in 1 patient, and anterior ankle and dorsum of foot in 6 patients. After the release of various joint scar contractures, the area of skin defect was 140 to 580 cm(2). Autologous full-thickness skin grafts were used in 7 patients, autologous medium-thickness skin grafts were used in 4 patients, autologous full-thickness skin grafts combined with local skin flaps were used in 9 patients, and allogeneic acellular dermal matrix and autologous thin skin grafts were used in 4 patients. Comprehensive measures for rehabilitation were taken and the survival of the skin graft was observed after operation. Six months to eight years after the operation, all the patients were followed up for the functions of the affected limbs, among which the functions of the upper limbs were evaluated according to the trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association. The joint mobility, walking, and squatting function of lower extremity were examined after operation. Recurrence of contractures in all the affected limbs and reoperation were recorded. Results: The grafts survived after operation in 22 patients. Two patients had necrosis in small full-thickness skin area, of which one was healed by skin grafting after debridement, and the other one was healed after dressing changes. The deformity of scar contracture at each repaired joint was completely or partially corrected. During a follow-up for 6 to 96 months, the upper limb functions of 15 patients were rated excellent in 12 patients and good in 3 patients. Among the 9 patients of lower limb scar contractures, except for one 3-year-old child who experienced recurrence of medial knee scar contracture and underwent surgical release and skin grafting 5 years later, the remaining 8 patients basically recovered normal joint functions with pretty good outcomes. Conclusions: For continuous scar contracture deformity of multiple joints of the same limb, simultaneous surgical release and skin grafting can reduce operation frequency and obtain better outcomes of surgical operation.

[Genetic characteristics and prognostic values of RAS mutations in patients with myelofibrosis].

Objective: To explore the genetic characteristics, clinical features, and prognostic values of RAS mutations in patients with myelofibrosis (MF) . Methods: We analyzed 112-gene targeted sequencing data from 226 patients who had a diagnosis of either primary myelofibrosis (PMF) or post-polycythemia vera/post-essential thrombocythemia (post-PV MF and post-ET MF) from December 2011 to December 2019. A retrospective analysis of the genetic characteristics, clinical features, and prognosis of RAS mutations was performed. Results: Among 266 patients diagnosed PMF or post-PV/ET MF, RAS mutations were found in 14 (6.2%) cases, including 9 (4.0%) cases of NRAS mutations, 8 (3.5%) cases of KRAS mutations, and 3 (1.3%) cases of both NRAS and KRAS mutations. All of the NRAS mutations were located in codons 12 and 13. The median VAFs of RAS mutations were significantly lower than those of the driver mutations, confirming that they represent sub-clonal events that are acquired during the disease course. SETBP1, SRSF2, and MPL tended to be clustered with RAS mutations. Patients with RAS mutations had a higher number of additional oncogenic mutations (median, 3.36 vs 1.17, P<0.001) . RAS mutations had a statistically significant association with elevated monocyte cell counts (P=0.003) , lower platelet counts (P=0.026) , higher bone marrow blasts (P=0.022) , splenomegaly (P=0.005) , and very high-risk (VHR) karyotype abnormality percentage (P=0.031) . In univariate analysis, the OS of patients with NRAS mutations were significantly inferior in the entire MF and PMF cohorts (P=0.001, P=0.008) . In a multivariate model, NRAS retained an independent negative prognostic factor in PMF. Conclusion: RAS gene mutations were constantly related to elevated monocyte cell counts, lower platelet counts, higher bone marrow blasts, and VHR karyotype abnormality percentage that usually defined high-risk disease and often occurred as sub-clonal events. NRAS mutation is an independent poor prognostic factor in PMF.

[Fibrosis-driving cells in patients with primary myelofibrosis and myelodysplastic syndromes with myelofibrosis].

Objective: To compare fibrosis-driving cells in patients with primary myelofibrosis (PMF) and patients with myelodysplastic syndromes (MDS) with myelofibrosis (MF) (MDS-MF) . Methods: Bone marrow biopsy sections of patients with newly diagnosed PMF and MDS (10 each randomly selected for MF-0/1, MF-2, and MF-3) were stained with specific immunofluorescence antibodies to label Gli1, LeptinR, alpha smooth muscle actin (α-SMA) , CD45, and ProcollagenⅠ. Images captured by confocal microscopy were analyzed by Fiji-ImageJ to calculate the cell counts of Gli1(+), LeptinR(+) cells, and fibrosis-driving cells including α-SMA(+), α-SMA(+)/Gli1(+), α-SMA(+)/LeptinR(+), and ProcollagenⅠ(+)/CD45(+) cells. Results: Patients with PMF and MDS with MF-2/3 had higher LeptinR(+), α-SMA(+), α-SMA(+)/Gli1(+), and Procollagen Ⅰ(+)/CD45(+) cell counts compared with those with MF-0/1 (all P values<0.05) . However, patients with PMF with MF-2/3 presented with higher Gli1(+) and α-SMA(+)/LeptinR(+) cell counts than those with MF-0/1 (P=0.001 and 0.006) , whereas these cells were similar between patients with MDS with MF-0/1 and MF-2/3 (P=0.169 and 0.067) . In patients with MF-0/1, all fibrosis-driving cells did not differ between PMF and MDS (all P>0.05) . However, in patients with MF-2/3, Procollagen Ⅰ(+)/CD45(+) cell counts were higher in patients with PMF compared with those with MDS (P=0.007) , while other fibrosis-driving cell counts were similar between these two groups (all P>0.05) . MF grade and fibrosis-driving cell counts were not correlated with overall survival in patients with either PMF or MDS. Conclusion: α-SMA(+) cells in patients with PMF originated from both Gli1(+) and LeptinR(+) cells, whereas α-SMA(+) cells in patients with MDS-MF only originated from Gli1(+) cells; patients with PMF had higher ProcollagenⅠ(+)/CD45(+) cell counts than those with MDS-MF.

[Clinical characteristics and repair effect of 136 patients with electric burns of upper limb].

Objective: To analyze clinical characteristics and wound repair methods and effects of patients with upper limb electric burns. Methods: Medical records of 136 patients with upper limb electric burn who met the inclusion criteria and hospitalized in our unit from January 2015 to March 2019 were retrospectively analyzed. Proportion in patients with electric burns in the same period, gender, age, admission time, categories, injury causes, injury voltage, burn area and depth of upper limb, simultaneous injury of both upper limbs, and early wound treatment measure of patients with upper limb electric burn were recorded. The main repair methods of each affected limb were classified and recorded. The overall efficacy of the patients was recorded, including postoperative wound complications and healing condition. The patients repaired with distal pedicled flaps and those with free flaps were followed up for 3 to 6 months. The survival rate of flaps were recorded, the function of affected limbs after operation was evaluated, and the satisfaction degree of patients was investigated by Curative Effect Score Table. The amputation rate, age, and burn area of upper limbs of patients caused by high-voltage and low-voltage electricity were compared. Data were processed with Wilcoxon rank sum test, chi-square test, or Fisher's exact probability test. Results: (1) The number of upper limb electric burn patients accounted for 88.3% of 154 patients with electric burns hospitalized in the same period, including 117 males and 19 females, aged 1 year and 2 months to 72 years [(34±18) years], admitted 1 h to 48 d after injury, including 51 electricians, 32 rural migrant workers, 31 students and preschool children, and 22 patients belonging to other categories. Patients of the first two categories were mainly injured by work accidents, and those of the latter two categories mainly suffered from touching power source or power leakage. Among all the patients, 75 cases were injured by high-voltage electric burn, and 61 cases were injured by low-voltage electric burn, with burn area of upper limb from 0.2% to 16.0% [2% (1%, 5%)] total body surface area (TBSA) and area of wounds deep to bone from 0.2% to 15.0% [2% (1%, 5%)] TBSA. Two upper limbs in 54 cases were simultaneously injured, accounting for 39.7%. Early fasciotomy was performed for 73 limbs. (2) Thirteen affected limbs were treated with dressing change, 2 affected limbs were sutured directly after debridement, 56 affected limbs were repaired by skin grafting, 12 affected limbs were repaired by local flap, 45 affected limbs were repaired by distal pedicled flap, 22 affected limbs were repaired by free flap, and 40 affected limbs were amputated (accounting for 21.1%). (3) One case died of pulmonary infection, sepsis, and multiple organ failure after operation, and the rest patients were all cured. One case with avulsion of abdominal flap was repaired by skin grafting after dressing change. The anterolateral thigh flap in one case necrotized after transplantation, which was replaced by pedicled abdominal flap. Seven cases had small erosion on the pedicle or margin after transplantation of abdominal flap and were healed by dressing change. Six cases had local bruising at the distal end after transplantation of abdominal flap and were healed after conservative treatment such as hyperbaric oxygen. The other flaps survived well. (4) The survival rate of distal pedicled flap grafting was 97.8% (44/45), which was close to that of free flap grafting (95.5%, 21/22, P>0.05). The function recovery of affected limb after free flap grafting was better than that of distal pedicled flap grafting (Z=-3.054, P<0.01), but their satisfaction degree of patients was similar (Z=-0.474, P>0.05). (5) Patients with high-voltage electric burn had higher amputation rate, older age, and larger upper limb burn area than those with low-voltage electric burn (χ(2)=4.743, Z=-2.801, -6.469, P<0.05 or P<0.01). Conclusions: Upper extremity electric burn often occurs in children, electricians, and rural migrant workers with high rate of amputation. Teachers and parents should strengthen safety education for children and manage power source of life well. Workers should improve safety awareness and operate standardly. Fasciotomy for relaxation should be performed for electric burn wound as soon as possible, and flap grafting can effectively repair wound after early debridement. The function recovery of affected upper limb repaired with free flap grafting is better.

[A study of clinical characteristics and prognosis of primary myelofibrosis patients with thrombocytopenia in varied degrees].

Objective: To evaluate clinical characteristics and prognosis of primary myelofibrosis (PMF) patients with thrombocytopenia in varied degrees. Methods: Clinical features and survival data of 1 305 Chinese patients with PMF were retrospectively analyzed. The prognostic value of thrombocytopenia in patients with PMF was evaluated. Results: 320 subjects (47%) presented severe thrombocytopenia (PLT<50×10(9)/L), 198 ones (15.2%) mild thrombocytopenia [PLT (50-99)×10(9)/L] and 787 ones (60.3%) without thrombocytopenia (PLT ≥ 100×10(9)/L). The more severe the thrombocytopenia, the higher the proportions of HGB<100 g/L, WBC<4×10(9)/L, circulating blasts ≥ 3%, abnormal karyotype and unfavourable cytogenetics (P<0.001, P<0.001, P=0.004, P<0.001 and P<0.001, respectively) were observed in this cohort of patients. The more severe the thrombocytopenia, the lower the proportion of JAK2V617F positive (P<0.001) was also noticed. Platelet count was positively correlated with splenomegaly, HGB and WBC (P<0.001, correlation coefficients were 0.131, 0.445 and 0.156, respectively). Platelet count was negative correlated with constitutional symptoms and circulating blasts (P=0.009, P=0.045, respectively; correlation coefficients were -0.096 and -0.056, respectively). The median survival of patients with severe thrombocytopenia, mild thrombocytopenia and without thrombocytopenia were 32, 67 and 89 months, respectively (P<0.001). Multivariate analysis identified thrombocytopenia in varied degrees (HR=1.693, 95%CI 1.320-2.173, P<0.001) and Dynamic Internation Prognostic Scoring System(DIPSS) prognostic model (HR=2.051, 95%CI 1.511-2.784, P<0.001) as independent risk factors for survival. Conclusion: PMF patients with severe thrombocytopenia frequently displayed anemia, leucopenia, circulating blasts and short survival, so active treatment measures should be taken especially in these patients.

[Retrospect of development and progress over the past 60 years and going further while carrying out practice].

This article briefly describes the establishment and development of Department of Burns and Reconstructive Surgery of Xiangya Hospital of Central South University. Over the past 60 years, our department has achieved great achievements in the treatment of burns by the combination of traditional Chinese medicine with western medicine, treatment of severe burns, and burn wounds repaired by flaps, and established Hunan burn rescue medical collaboration network. With the development of society and the change of disease spectrum, the future development direction of our department mainly focuses on treatment of severe burns, scar prevention, and treatment of acute and chronic wounds.

[Analysis of prognostic factors in Chinese patients with post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis].

Objective: To evaluate the performances of the prognostic scoring systems devised for primary myelofibrosis(PMF)and the new developed MYSEC- PM(Mysec Prognostic Model)and investigate the risk factors in Chinese patients with post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis(post- PV/ET MF). The most widely used prognostic scoring systems in PMF included the International Prognostic Scoring System(IPSS), dynamic International Prognostic Scoring System(DIPSS), refined DIPSS(DIPSS plus), modified IPSS for Chinese(IPSS-Chinese), and modified DIPSS for Chinese(DIPSS- Chinese). Methods: The clinical and hematologic information of 55 consecutive patients diagnosed with post- PV/ET MF from March 1984 to December 2013 were retrospectively collected. All post-PV/ET MF patients were categorized according to IPSS, DIPSS, DIPSS plus, IPSS-Chinese, DIPSS-Chinese and MYSEC-PM, and the possible prognostic factors were statistically analyzed. Results: Fifty five patients diagnosed with post-PV MF(n=32)or post-ET MF(n=23)were analyzed with a median age of 59(range: 20- 88)years old, including 20 males and 35 females. Median time from original diagnosis to myelofibrosis was 7.8(range: 1.1- 23.4)years. With a median follow up from post-PV/ET MF diagnosis of 37(range: 1-156)months, 44(80.0%)patients were censored alive, 11(20.0%)patients died. Median survival was 110(95% CI 87.5-132.8)months. Using IPSS, DIPSS, DIPSS plus, IPSS- Chinese and MYSEC- PM criteria, there were no statistically significances in survival among different risk groups(P>0.05). In univariate analyses HGB<100 g/L(P=0.003)was the only factor associated with poorer overall survival. The prognosis in subjects with HGB≥100 g/L was significantly better than that with HGB<100 g/L(median OS: not reached vs 47 months, P=0.003). Conclusion: IPSS, DIPSS, DIPSS plus, IPSS- Chinese and MYSEC- PM did not accurately discriminate different risk categories in post PV/ET MF patients. HGB< 100 g/L was associated with poor outcome in post-PV/ET MF patients.

[Prognostic value of JAK2, MPL and CALR mutations in Chinese patients with primary myelofibrosis].

OBJECTIVE: To evaluate the prognostic value of JAK2, MPL and CALR mutations in Chinese patients with primary myelofibrosis (PMF). METHODS: Four hundred and two Chinese patients with PMF were retrospectively analyzed. The Kaplan-Meier method, the Log-rank test, the likelihood ratio test and the Cox proportional hazards regression model were used to evaluate the prognostic scoring system. RESULTS: This cohort of patients included 209 males and 193 females with a median age of 55 years (range: 15- 89). JAK2V617F mutations were detected in 189 subjects (47.0% ), MPLW515 mutations in 13 (3.2%) and CALR mutations in 81 (20.1%) [There were 30 (37.0%) type-1, 48 (59.3%) type-2 and 3 (3.7%) less common CALR mutations], respectively. 119 subjects (29.6%) had no detectable mutation in JAK2, MPL or CALR. Univariate analysis indicated that patients with CALR type-2 mutations or no detectable mutations had inferior survival compared to those with JAK2, MPL or CALR type- 1 or other less common CALR mutations (the median survival was 74vs 168 months, respectively [HR 2.990 (95% CI 1.935-4.619),P<0.001]. Therefore, patients were categorized into the high-risk with CALR type- 2 mutations or no detectable driver mutations and the low- risk without aforementioned mutations status. The DIPSS-Chinese molecular prognostic model was proposed by adopting mutation categories and DIPSS-Chinese risk group. The median survival of patients classified in low risk (132 subjects, 32.8% ), intermediate- 1 risk (143 subjects, 35.6%), intermediate- 2 risk (106 subjects, 26.4%) and high risk (21 subjects, 5.2%) were not reached, 156 (95% CI 117- 194), 60 (95% CI 28- 91) and 22 (95% CI 10- 33) months, respectively, and there was a statistically significant difference in overall survival among the four risk groups (P<0.001). There was significantly higher predictive power for survival according to the DIPSS-Chinese molecular prognostic model compared with the DIPSS-Chinese model (P=0.005, -2 log-likelihood ratios of 855.6 and 869.7, respectively). CONCLUSION: The impact of the CALR type- 2 mutations or no detectable driver mutation on survival was independent of current prognostic scoring systems. The DIPSS- Chinese molecular prognostic model based on the molecular features of Chinese patients was proposed and worked well for prognostic indication.

One-stage posterior procedure in treating active thoracic spinal tuberculosis: a retrospective study.

PURPOSE: To investigate the clinical efficacy and feasibility of surgical treatment for thoracic spinal tuberculosis with neurological deficit by one-stage posterior instrumentation, proper transpedicular debridement, without anterior instrumentation and without anterior or posterior bone graft. METHODS: A total of 19 cases with thoracic tuberculosis, neurological deficit and bone destruction (without severe kyphosis) admitted to the hospital from May 2005 to January 2010 were treated by internal fixation, transpedicular debridement without bone graft via the isolated posterior approach. Operating time, blood loss, complications, neurological function, deformity correction, pain relief, and inter-body fusion were investigated. RESULTS: The average mean operating time was 168.9 ± 21.1 min. The average blood loss during operation was 655.8 ± 82.8 ml. All patients were followed for 28-46 months post-operation (average, 36.8 ± 5.8 months). All patients had significant postoperative improvement in ASIA classification scores and VAS scores. The thoracic kyphotic angle was significantly decreased to 11.6°-20.2° after operation (average, 15.6° ± 2.2°), and the angle was 12.3°-21.6° (average, 16.4° ± 2.2°) at final follow-up. No severe complications or spinal cord injury occurred. The erythrocyte sedimentation rate and C-reactive protein recovered to normal within 3 months after operation in all patients. All patients have got spontaneous bony fusion within 6-9 months after surgery. CONCLUSIONS: One-stage posterior instrumentation, transpedicular debridement without bone graft can be an effective and feasible treatment method for selected thoracic spinal tuberculosis.