Intravoxel incoherent motion diffusion-weighted imaging of solitary pulmonary lesions: initial study with gradient- and spin-echo sequences.

AIM: To evaluate the feasibility and image quality of intravoxel incoherent motion diffusion-weighted imaging (IVIM) using gradient- and spin-echo (GRASE) in solitary pulmonary lesions (SPLs) compared to echo planar imaging (EPI) and turbo spin-echo (TSE) at 3 T. MATERIALS AND METHODS: Forty-two patients with SPLs underwent lung magnetic resonance imaging (MRI) using TSE-IVIM, GRASE-IVIM, and EPI-IVIM at 3 T. Signal ratio (SR), contrast ratio (CR), and image distortion ratio (DR) of three sequences were compared. The reproducibility and repeatability of the apparent diffusion coefficient (ADC) and IVIM-derived parameters were assessed using the interclass correlation coefficient (ICC) and coefficient of variation (CV). The repeatability of the ADC and IVIM-derived parameters between all sequences was evaluated using the Bland-Altman method. RESULTS: EPI-IVIM had a higher SR, lower CR, and higher DR (p<0.05); however, there was no significant difference between TSE-IVIM and GRASE-IVIM (p>0.05). Compared to the D and f values of TSE-IVIM (ICC lower limit >0.90), GRASE-IVIM and EPI-IVIM showed poor reproducibility (ICC lower limit<0.90). The repeatability of the ADC and D values obtained by TSE-IVIM (CV, 1.93-2.96% and 2.44-3.18%, respectively) and GRASE-IVIM (CV, 2.56-3.12% and 3.21-3.51%, respectively) were superior to those of EPI-IVIM (CV, 10.03-10.2% and 11.30-11.57%). The repeatability of D∗ and f values for all sequences was poor. Bland-Altman analysis showed wide limits of agreement between the ADC and IVIM-derived parameters for all sequences. CONCLUSION: GRASE-IVIM reduced the DR, improved the stability of the ADC and D values on repeated scans, and had the shortest scanning time.

[Expert consensus on the application of critical care ultrasonography in invasive procedures].

The evolution of critical care medicine is inextricably linked to the development of critical care procedures. These procedures not only facilitate diagnosis and treatment of critically ill patients, but also provide valuable insights into disease pathophysiology. While critical care interventions offer undeniable benefits, the potential for iatrogenic complications necessitates careful consideration. The recent surge in critical care ultrasound (US) utilization is a testament to its unique advantages: non-invasiveness, real-time bedside availability, direct visualization of internal structures, elimination of ionizing radiation exposure, repeatability, and relative ease of learning. Recognizing the need to optimize procedures and minimize complications, critical care utrasound study group of Beijing critical care ultrasound research assocition convened a panel of critical care experts to generate this consensus statement. This document serves as a guide for healthcare providers, aiming to ensure patient safety and best practices in critical care.

Diagnosis of spinal dural arteriovenous fistula: a multimodal MRI assessment strategy.

AIM: To identify more specific screening indicators at magnetic resonance imaging (MRI) for the diagnosis of spinal dural arteriovenous fistulas (SDAVFs) and to determine an efficient diagnostic strategy. MATERIALS AND METHODS: This retrospective study analysed clinical and imaging data of patients diagnosed with SDAVF and alternative myelopathy who underwent conventional MRI examinations. Additionally, three-dimensional (3D) T2-weighted sampling perfection with application-optimised contrasts using different flip-angle evolutions (3D-T2-SPACE) and contrast-enhanced magnetic resonance angiography (CE-MRA) data from patients with SDAVF were compared with digital subtraction angiography (DSA) data. RESULTS: The age of onset, perimedullary flow voids (PFV), distribution of lesions, syringomyelia, degree of spinal oedema, and cauda equina disorder (CED) were factors that showed statistically significance in the identification of SDAVF with alternative myelopathy. After controlling for age, gender, PFV, degree of spinal cord swelling, and syringomyelia, the multivariable ordinal logistic regression model showed that the CED sign (OR = 32.46; 95% confidence interval [CI]: 2.47-427.15; p=0.008) was an independent predictor for SDAVF. The diagnostic model constructed using the PFV and CED signs had better diagnostic performance, with an area under the curve of 0.957 (p<0.001), maximum Youden index of 0.844, sensitivity of 92.9%, and specificity of 91.5%. Both 3D-T2-SPACE (77.8%) and CE-MRA (83.3%) sequences had good localisation values for SDAVF. Combining the two imaging examinations had better diagnostic accuracy than that of DSA. CONCLUSION: CED and PFV on conventional MRI were specific indicators for the diagnosis of SDAVF. To compensate for the lack of fistula localisation on conventional MRI, 3D-T2-SPACE and CE-MRA can be used. Together they complement each other and have good diagnostic potential.

[Based on CT radiomics model for predicting the response to first-line chemotherapy of diffuse large B-cell lymphoma].

Objective: To investigate the potential value of CT Radiomics model in predicting the response to first-line chemotherapy in diffuse large B-cell lymphoma (DLBCL). Methods: Pre-treatment CT images and clinical data of DLBCL patients treated at Shanxi Cancer Hospital from January 2013 to May 2018 were retrospectively analyzed and divided into refractory patients (73 cases) and non-refractory patients (57 cases) according to the Lugano 2014 efficacy evaluation criteria. The least absolute shrinkage and selection operator (LASSO) regression algorithm, univariate and multivariate logistic regression analyses were used to screen out clinical factors and CT radiomics features associated with efficacy response, followed by radiomics model and nomogram model. Receiver operating characteristic (ROC) curve, calibration curve and clinical decision curve were used to evaluate the models in terms of the diagnostic efficacy, calibration and clinical value in predicting chemotherapy response. Results: Based on pre-chemotherapy CT images, 850 CT texture features were extracted from each patient, and 6 features highly correlated with the first-line chemotherapy effect of DLBCL were selected, including 1 first order feature, 1 gray level co-occurence matrix, 3 grey level dependence matrix, 1 neighboring grey tone difference matrix. Then, the corresponding radiomics model was established, whose ROC curves showed AUC values of 0.82 (95% CI: 0.76-0.89) and 0.73 (95% CI: 0.60-0.86) in the training and validation groups, respectively. The nomogram model, built by combining validated clinical factors (Ann Arbor stage, serum LDH level) and CT radiomics features, showed an AUC of 0.95 (95% CI: 0.90-0.99) and 0.91 (95% CI: 0.82-1.00) in the training group and the validation group, respectively, with significantly better diagnostic efficacy than that of the radiomics model. In addition, the calibration curve and clinical decision curve showed that the nomogram model had good consistency and high clinical value in the assessment of DLBCL efficacy. Conclusion: The nomogram model based on clinical factors and radiomics features shows potential clinical value in predicting the response to first-line chemotherapy of DLBCL patients.

[Analysis and treatment workflow of modified seven-step approach for acute respiratory and circulatory disorders].

Acute respiratory and circulatory disorders are the most common critical syndromes, the essence of which is damage to the organs/systems of the heart and lungs. These comprise the essential manifestation of disease and injury progression to the severe stage. Its development involves the following components: individual specificity, primary disease strike, dysregulation of the host's response, and systemic disorders. Admission for acute respiratory and circulatory disorders is a clinical challenge. Based on a previously proposed flow, a critical care ultrasound-based stepwise approach (PIEPEAR) as a standard procedure to manage patients with acute cardiorespiratory compromise and practical experience in recent years, a modified seven-step analysis and treatment process has been developed to help guide clinicians with rational thinking and standardized treatment when faced with acute respiratory and circulatory disorders. The process consists of seven steps: problem-based clinical analysis, intentional information acquisition, evaluation of core disorder based on critical care ultrasound, pathophysiology and host response phenotype identification, etiology diagnosis, act treatment through pathophysiology-host response and etiology, and re-check. The modified seven-step approach is guided by a "modular analysis" style of thinking and visual monitoring. This approach can strengthen the identification of clinical problems and facilitate a three-in-one analysis. It focuses on pathophysiological disorders, body reactions, and primary causes to more accurately understand the condition's key points, and make treatment more straight forward, to finally achieve the aim of "comprehensive cognition and refined treatment".

[Expert consensus on late stage of critical care management].

We wished to establish an expert consensus on late stage of critical care (CC) management. The panel comprised 13 experts in CC medicine. Each statement was assessed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principle. Then, the Delphi method was adopted by 17 experts to reassess the following 28 statements. (1) ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management. (2) The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients (CIPs) after the rescue period, including early mobilization, early rehabilitation, nutritional support, sleep management, mental assessment, cognitive-function training, emotional support, and optimizing sedation and analgesia. (3) Disease assessment to determine the starting point of early mobilization, early rehabilitation, and early enteral nutrition. (4) Early mobilization has synergistic effects upon the recovery of organ function. (5) Early functional exercise and rehabilitation are important means to promote CIP recovery, and gives them a sense of future prospects. (6) Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation. (7) The spontaneous breathing test should be started as soon as possible, and a weaning plan should be selected step-by-step. (8) The waking process of CIPs should be realized in a planned and purposeful way. (9) Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management. (10) The spontaneous awakening trial, spontaneous breathing trial, and sleep management should be carried out together. (11) The depth of sedation should be adjusted dynamically in the late stage of CC period. (12) Standardized sedation assessment is the premise of rational sedation. (13) Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics. (14) A goal-directed minimization strategy for sedation should be implemented. (15) The principle of analgesia must be mastered first. (16) Subjective assessment is preferred for analgesia assessment. (17) Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs. (18) There must be rational use of non-opioid analgesics and non-drug-based analgesic measures. (19) Pay attention to evaluation of the psychological status of CIPs. (20) Cognitive function in CIPs cannot be ignored. (21) Delirium management should be based on non-drug-based measures and rational use of drugs. (22) Reset treatment can be considered for severe delirium. (23) Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder. (24) Emotional support, flexible visiting, and environment management are important components of humanistic management in the intensive care unit (ICU). (25) Emotional support from medical teams and families should be promoted through"ICU diaries"and other forms. (26) Environmental management should be carried out by enriching environmental content, limiting environmental interference, and optimizing the environmental atmosphere. (27) Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection. (28) ESCAPE is an excellent project for late stage of CC management.

[Human amniotic membrane plug for recurrent retinal detachment associated with pathologic myopic macular hole].

A 60-year-old woman presented with a history of "pathological myopia combined with macular hole retinal detachment, " for which she underwent vitrectomy, internal limiting membrane tamponade, and silicone oil filling surgery one year ago. Seven months ago, the silicone oil was removed. She now returned to seek medical attention as her visual acuity has declined by 10 diopters. Examination revealed a recurrence of macular hole retinal detachment. The patient was treated with combined amniotic membrane tamponade and silicone oil filling. During the surgery, the frozen amniotic membrane was cut into 2 mm × 2 mm and placed under the macular hole retina after silicone oil filling. Within 6 months after the surgery, her retina repositioned well, the macular hole closed, and her visual function improved from hand motion to 0.05. No severe complications were observed. Therefore, this surgical approach provides a new perspective for treating recurrent pathological myopia combined with macular hole retinal detachment.

Determining the lower limit of detection required for HCV viral load assay for test of cure following direct-acting antiviral-based treatment regimens: Evidence from a global data set.

Achieving global elimination of hepatitis C virus requires a substantial scale-up of testing. Point-of-care HCV viral load assays are available as an alternative to laboratory-based assays to promote access in hard to reach or marginalized populations. The diagnostic performance and lower limit of detection are important attributes of these new assays for both diagnosis and test of cure. Therefore, our objective was to determine an acceptable LLoD for detectable HCV viraemia as a test for cure, 12 weeks post-treatment (SVR12). We assembled a global data set of patients with detectable viraemia at SVR12 from observational databases from 9 countries (Egypt, the United States, United Kingdom, Georgia, Ukraine, Myanmar, Cambodia, Pakistan, Mozambique) and two pharmaceutical-sponsored clinical trial registries. We examined the distribution of HCV viral load at SVR12 and presented the 90th, 95th, 97th and 99th percentiles. We used logistic regression to assess characteristics associated with low-level virological treatment failure (defined as <1000 IU/mL). There were 5973 cases of detectable viraemia at SVR12 from the combined data set. Median detectable HCV RNA at SVR12 was 287,986 IU/mL. The level of detection for the 95th percentile was 227 IU/mL (95% CI 170-276). Females and those with minimal fibrosis were more likely to experience low-level viraemia at SVR12 compared to men (adjusted odds ratio AOR = 1.60 95% confidence interval [CI] 1.30-1.97 and those with cirrhosis (AOR = 1.49 95% CI 1.15-1.93). In conclusion, an assay with a level of detection of 1000 IU/mL or greater may miss a proportion of those with low-level treatment failure.

[The quality control standards and principles of the application and training of critical ultrasonography].

Critical ultrasonography is widely used in ICU and has become an indispensable tool for clinicians. However, besides operator-dependency of critical ultrasonography, lack of standardized training mainly result in the physicians' heterogenous ultrasonic skill. Therefore, standardized training as well as strict quality control plays the key role in the development of critical ultrasonography. We present this quality control standards to promote better development of critical ultrasonography.

[Development of a nomogram for predicting the risk of colorectal advanced adenomas].

Objective: To explore the risk factors of colorectal advanced adenomas (AA) and construct a nomogram to predict the risk of colorectal AAs. Methods: Clinical data of patients were retrospectively collected who underwent their first colonoscopy from January 2017 to December 2020 in the First Affiliated Hospital of Nanjing Medical University and were pathologically confirmed harboring colorectal polyps. A credible random split-sample method was used to divide data into training and validation cohorts (split ratio=7∶3). Univariate and multivariate logistic regression analysis were used to identify the predictors of colorectal advanced adenomas, and a nomogram was developed based on the above results. The validation cohort was used for internal validation of the nomogram. The discriminatory value of the nomogram was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). The consistency between actual outcomes and predicted probabilities was evaluated by the calibration curve. The clinical validity of the model was evaluated by the decision analysis curve (DCA). Results: A total of 1 936 patients with colorectal polyps were eligible. Including 1 356 patients in the training cohort (840 males and 516 females), and 580 patients in the validation cohort (379 males and 201 females), with the mean ages of (57.4±9.8) and (57.6±9.7) years, respectively. There were 1 502 (77.6%) patients without AAs and 434 [22.4%,1-9 mm 73(16.8%) cases、>9-<20 mm 271(62.5%) cases、≥20 mm 90(20.7%) cases] patients with AAs. The regression analysis found that age (OR=1.018, 95%CI:1.003-1.033), fatty liver (OR=1.870, 95%CI:1.274-2.744), low-density lipoprotein (LDL) (OR=1.378, 95%CI:1.159-1.637), fecal occult blood test (FOBT) (OR=2.597, 95%CI:1.857-3.631), and location of adenomas [proximal (OR=2.869, 95%CI:1.727-4.764), distal (OR=2.791, 95%CI:1.721-4.527)] were identified as predictors of colorectal AAs. The AUC of the nomogram was 0.664 (95%CI:0.630-0.698) in the training cohort and 0.640 (95%CI:0.587-0.693) in the validation cohort. The calibration curve showed good consistency between the predicted and actual risk, and the Hosmer-Lemeshow (H-L) test P value was 0.830 and 0.150 in the training cohort and the validation cohort. DCA demonstrated that the nomogram had a better clinical application value. Conclusions: A nomogram with five predictors, including age, fatty liver, LDL, FOBT, and location of adenomas, helped predict the risk of colorectal AAs in patients with polyps and implemented colorectcal cancer stratified screening strategy for colonoscopy in the high-risk population.

[Meta-analysis of ß-blockers for the primary prevention of liver cirrhosis with clinically significant portal hypertension with no or small esophageal varices].

Objective: To explore whether NSBB is suitable for the primary prevention of liver cirrhosis accompanied by CSPH with no or small esophageal varices. Methods: Relevant literatures were retrieved from Cochrane library, PubMed, EMBASE, SinoMed, CNKI and Wanfang databases until December 12, 2020. All randomized controlled trials (RCTs) on NSBB use for primary prevention of cirrhosis accompanied by CSPH with no or small esophageal varices were collected. The literature was strictly screened according to the established inclusion and exclusion criteria, odds ratio (OR), and 95% confidence interval (CI) combined effect size. The development of esophageal varices and the initial upper gastrointestinal bleeding were the primary outcome measures. Death (with a maximum average follow-up of about five years) and adverse events (adverse drug reactions, etc.) were the secondary outcome measures. Results: A total of 9 RCTs with 1396 cases were included. Meta-analysis results showed that, compared with placebo, NSBB significantly reduced the incidence of liver cirrhosis accompanied by CSPH with no or small esophageal varices to large esophageal varices progression (OR=0.51, 95%CI: 0.29-0.89, P=0.02), and mortality (with maximum average follow-up of about five years) (OR=0.64, 95%CI: 0.44-0.92, P=0.02); however, there was no statistically significant difference in the initial upper gastrointestinal bleeding rate between the two groups (OR=0.82, 95%CI: 0.44-1.52, P=0.53). Adverse event incidence was greater in the NSBB than the placebo group (OR=1.74, 95%CI: 1.27-2.37, P=0.0005). Conclusions: NSBB use cannot reduce the initial upper gastrointestinal bleeding rate or adverse event incidence in patients with liver cirrhosis accompanied by CSPH with no or small esophageal varices, but it can delay the progression of gastroesophageal varices and reduce patient mortality.

Association Between Minimum Inhibitory Concentration, Beta-lactamase Genes and Mortality for Patients Treated With Piperacillin/Tazobactam or Meropenem From the MERINO Study.

INTRODUCTION: This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial. METHODS: Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations. RESULTS: In total, 320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam nonsusceptible breakpoint (MIC >16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% confidence interval [CI] 2.8-87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3%-15%) and 8% (95% CI 2%-15%) for the original PA population and the post hoc MA populations, which reduced to 5% (95% CI -1% to 10%) after excluding strains with piperacillin/tazobactam MIC values >16 mg/L. Isolates coharboring extended spectrum ß-lactamase (ESBL) and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-day mortality of 14% (95% CI 2%-28%). CONCLUSIONS: After excluding nonsusceptible strains, the 30-day mortality difference from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA coharboring ESBLs suggests that meropenem remains the preferred choice for definitive treatment of ceftriaxone nonsusceptible Escherichia coli and Klebsiella.

Y-shaped airway self-expanding covered metallic stent removal via the interventional technique.

AIM: To review the removal of Y-shaped airway self-expanding covered metallic stents using the interventional technique under fluoroscopy. MATERIALS AND METHODS: The clinical data of 33 patients who underwent removal of Y-shaped airway self-expanding covered metallic stents from March 2011 to August 2019 were analysed retrospectively. RESULTS: A total of 35 Y-shaped stents were removed. The average indwelling duration of the tracheal stents was 101.7 ± 105.4 days. Four cases were removed via the conventional method (grasping the upper tip of the stent to collapse and adduct the proximal end of the stent), whereas 31 cases were removed using the reversal method (grasping the distal end of the stent to invert and strip out the stent). The duration of stent removal was 24.3 ± 12.4 minutes (median time, 20 minutes). CONCLUSION: The interventional radiology technique is a feasible, safe, and effective method for removing Y-shaped airway self-expanding covered metallic stents, and can be considered for use in the clinical setting.

[A birth cohort study on the effect of chronotype during pregnancy on small for gestational age and the mediating effect of glucose-lipid metabolism].

Objective: To explore the relationship between maternal sleep time and the risk of small for gestational age (SGA), and to evaluate the role of glucose-lipid metabolism in the association. Methods: A total of 6 821 women who was second pregnancy were recruited from pregnancies consulted at Hefei First People's Hospital, Anhui Province Maternity & Child Health Hospital and the First Affiliated Hospital of Anhui Medical University from March 2015 to April 2019, and a face-to-face questionnaire survey was conducted to collect general demographic characteristics, dietary habits and routine lifestyles. Sleep information including bedtime, getup and sleep duration were reported by pregnant woman herself, and this survey as well as the third trimester of gestation. Pregnancy and birth outcomes were collected at delivery. A total of 5 488 mother-pairs with complete data were obtained in the final data. The non-linear relationship between chronotype and SGA risk was explored by restricted cubic spline regression model, and the role of glucose-lipid metabolism in the association between sleep midpoint and SGA was explored by using the mediating model based on bootstrap method. Results: The incidence of SGA was 8.4% (459/5 488) in eligible pregnant women. Compared with the pregnant women who went to bed before 21∶00, the risk of SGA of women who went to bed after 23∶00 am (OR=1.54, 95%CI: 1.01-2.34) was significantly higher in the multivariate logistic regression model. Additionally, the risk of SGA in pregnant women who got up after 8∶00 am was significantly higher than those women who got up before 8 o'clock (OR=1.31, 95%CI:1.05-1.62). However, the significant association between sleep duration and SGA was not found. In the restricted cubic spline regression, the risk of SGA was significantly increased from the specific midpoint of 02∶45 am (P<0.05). Moreover, mediation model showed that the negative effect of late sleep in the second trimester on SGA may be partially explained through glucose-lipid metabolism(all P<0.05). Conclusion: Maternal sleep status at the second trimester of gestation may be more susceptible to SGA. Lately sleep midpoint may be a potential independent risk factor for increased risk of SGA, and furtherly affect the occurrence of SGA by changing the level of glucose and lipid metabolism.

[In situ semiconductor laser fenestration of type A aortic dissection during thoracic endovascular aortic repair].

Objective: To investigate the feasibility, efficacy and safety of semiconductor laser in situ fenestration of type A aortic dissection during thoracic endovascular aortic repair. Methods: The clinical data of 68 patients with type A aortic dissection treated by semiconductor laser in situ fenestration from June 2016 to January 2020 in Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiaotong University were analyzed retrospectively. Of the patients, 45 were male, 23 were female, the mean age was (52±14) years. The technical success rate and complication rates were assessed. Results: The technical success rate of 68 patients was 92.6% (63/68), only 5 patients failed due to the complex aortic arch type, 3 patients underwent chimney stent implantation, 2 patients underwent artificial vessel bypass. During the perioperative period, 1 patient died due to severe pulmonary infection, 4 patients developed neurological symptoms such as cerebral infarction after surgery, and the remaining patients had no related complications. Postoperative CTA follow-up indicated that the primary intercalation rupture was completely closed, and the main and branch stents were patency, 8 (8.8%) type Ⅰ leakage were occurred. Conclusion: It showed that in situ semiconductor laser fenestration is a feasible, effective and safe method to treat type A aortic dissection.

Removal of covered metallic stents with a bullet head for bronchopleural fistula using a fluoroscopy-assisted interventional technique.

AIM: To investigate the feasibility and safety of a fluoroscopy-assisted interventional technique for removal of bullet-shaped self-expanding covered metallic stents from bronchopleural fistulas (BPFs). MATERIALS AND METHODS: Clinical data for 49 consecutive patients who underwent removal of bullet-shaped self-expanding covered metal stents from October 2010 to November 2019 were analysed retrospectively. Fifty-one stents were removed in all, including 29 large Y-shaped bullet stents, 10 small Y-shaped bullet stents, and 12 branched bullet-shaped stents. The average duration for which tracheal stents were in place was 99.4±8.5 days. RESULTS: Fifty-one stents were removed successfully, of which 49 were directly removed on the first attempt. The time required for stent removal ranged from 7-60 minutes (median time, 22 minutes). In eight cases, the stent was removed by the conventional method (i.e., grasping the upper tip of the stent to collapse and adduct the proximal end), and in 43 by the eversion method (i.e., grasping the distal end of the stent to invert and peel out). CONCLUSIONS: Interventional radiology is a simple, safe, and effective method to extract self-expanding covered metallic bullet-shaped stents, with no need for general anaesthesia and tracheal intubation. It has a short operation time, is well tolerated by patients, and is worthy of clinical application.

[Recommendations for the treatment of severe coronavirus disease 2019 based on critical care ultrasound].

Severe patients with coronaviras disease 2019 (COVID-19) are characterized by persistent lung damage, causing respiratory failure, secondary circulatory changes and multiple organ dysfunction after virus invasion. Because of its dynamic, real-time, non-invasive, repeatable and other advantages, critical ultrasonography can be widely used in the diagnosis, assessment and guidance of treatment for severe patients. Based on the recommendations of critical care experts from all over the country who fight against the epidemic in Wuhan, this article summarizes the guidelines for the treatment of COVID-19 based on critical ultrasonography, hoping to provide help for the treatment of severe patients. The recommendations mainly cover the following aspects: (1) lung ultrasound in patients with COVID-19 is mainly manifested by thickened and irregular pleural lines, different types of B-lines, shred signs, and other consolidation like dynamic air bronchogram; (2) Echocardiography may show right heart dysfunction, diffuse cardiac function enhancement, stress cardiomyopathy, diffuse cardiac depression and other multiple abnormalities; (3) Critical ultrasonography helps with initiating early treatment in the suspect patient, screening confirmed patients after intensive care unit admission, early assessment of sudden critical events, rapid grading assessment and treatment based on it; (4) Critical ultrasonography helps to quickly screen for the etiology of respiratory failure in patients with COVID-19, make oxygen therapeutic strategy, guide the implementation of lung protective ventilation, graded management and precise off-ventilator; (5) Critical ultrasonography is helpful for assessing the circulatory status of patients with COVID-19, finding chronic cardiopulmonary diseases and guiding extracorporeal membrane oxygenation management; (6) Critical ultrasonography contributes to the management of organs besides based on cardiopulmonary oxygen transport; (7) Critical ultrasonography can help to improve the success of operation; (8) Critical ultrasonography can help to improve the safety and quality of nursing; (9) When performing critical ultrasonography for patients with COVID-19, it needs to implement three-level protection standard, pay attention to disinfect the machine and strictly obey the rules from nosocomial infection. (10) Telemedicine and artificial intelligence centered on critical ultrasonography may help to improve the efficiency of treatment for the patients with COVID-19. In the face of the global spread of the epidemic, all we can do is to share experience, build a defense line, We hope this recommendations can help COVID-19 patients therapy.

[Effects of comorbid gestational diabetes mellitus and depression on glucose metabolism during pregnancy and neonatal morphological outcome].

Objective: To estimate the effect of comorbid gestational diabetes mellitus (GDM) and depression on glucose metabolism and neonatal morphology. Methods: From March 2015 to October 2018, recruited 18 to 28 weeks pregnant women who met the criteria in the Hefei First People's Hospital or First Affiliated Hospital of Anhui Medical University or Anhui Maternal and Child Health Hospital, including a total of 4 380 study subjects, of which the birth outcome information of 3 827 newborns were collected. The self-made questionnaire "Maternal Health Questionnaire for Hefei City" and Edinburgh Postpartum Depression Scale were used to obtain basic demographic characteristics and emotional state of depression. Data from the 75-g oral-glucose-tolerance test were obtained at 24-28 weeks of gestation. After delivery, delivery outcome information were collected from the hospital medical records. Covariance analysis was used to analyze the differences in glucose metabolism indicators and neonatal outcome indicators in pregnant women with different GDM and depression status. Multiple logistic regression model was used to analyze the correlation between GDM and depression, with different groups of GDM and depression status (no GDM and depression, simple depression, simple GDM, comorbid GDM and depression)as independent variables and whether they were large for gestational age as dependent variables. The interaction between GDM and depression was also analyzed. Results: The 4 380 pregnant women were (28.8±4.2) years old. The incidence of GDM was 19.5% (852/4 380), and the detection rates of depression in the second and third trimesters were 12.1% (526/4 380) and 12.3% (536/4 367). PG-1h and AUC in the comorbid GDM and depression group were significantly higher than those in the group with no GDM and depression (P<0.05) and the single GDM group (P<0.05). After adjusting for factors such as the childbirth age, education level, family's main economic income, BMI before pregnancy, parity, number of physical activities, and weight gain during pregnancy, compared with the group with no GDM and depression, the RR(95%CI) of LGA occurred in the single depression group, the single GDM group and the comorbid group were 1.31(0.89-1.91), 1.51(1.14-2.00) and 2.43(1.29-4.57), respectively. Further analysis showed that the association between GDM pregnant women with depression and newborn LGA ï¼»RR (95%CI): 2.12 (1.01-4.49)ï¼½ was stronger than that between GDM pregnant women without depression and newborn LGA ï¼»RR (95%CI): 1.50 (1.12-1.99)ï¼½, the P interaction value was<0.05. Conclusion: The status of comorbid GDM and depression can impair glucose metabolism and increase the risk of LGA.

[Differences in the bone marrow histopathology between pediatric acquired aplastic anemia and refractory cytopenia of childhood].

Objective: To study the differences in the bone marrow histopathology between acquired aplastic anemia (AAA) in children and refractory cytopenia of childhood (RCC) to facilitate their diagnoses and differential diagnosis. Methods: The clinical data and bone marrow biopsies of the RCC and AAA cases diagnosed from January 2008 to December 2018 in Xinhua Hospital, Shanghai Jiaotong University School of Medicine and Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine were analyzed. Results: A total of 71 AAA and 79 RCC cases were analyzed. There were 52 males and 19 females, age ranged 1.0-15.0 years (median, 8.9 years) in the AAA group, and 53 males and 26 females, age ranged 0.5-16.0 years (median, 5.0 years) in the RCC group. All the biopsy specimens of AAA patients had severe hypocellularity; the cellularity of 88.7% (63/71) specimens was under 5.0%, and 11.3%(8/71) was 5%-24%. None of the AAA specimens showed any dysplastic change. All the biopsy specimens of RCC patients had hypocellularity, including 94.9%(75/79) of the specimens with a cellularity of 5%-50%. All of the RCC specimens showed a patchy distribution of hematopoiesis. A dysplastic change of erythroid cells and micromegakaryocytes was found in 40.5% (32/79) and in 60.8% (48/79) of the RCC cases, respectively. Conclusions: The degree of hypocellularity, the distribution pattern of hematopoiesis, the cell composition and localization of erythroid cell clusters and the appearance of micromegaryocytes could help the diagnosis and differential diagnosis of AAA and RCC.

[Application of the pathological classification of "CCCG-WT-2016" (2019 revision) for treatment of Wilms tumors].

Objective: To describe our experiences in application of the 2019 revision of "CCCG-WT-2016" for the diagnosis of Wilms tumors. Methods: Ninety-one cases of Wilms tumor diagnosed at Shanghai Children's Medical Center from January 2015 to December 2018 were collected. All cases were reviewed by two senior pathologists, including one from China and the other from Singapore, according to the 2019 revision of "CCCG-WT-2016." Results: The specimens were obtained by core biopsy (n=21), primary nephrectomy (n=41), post-chemotherapy nephrectomy/resection (n=18), or biopsy/resection of metastatic/relapse/post-chemotherapy metastatic lesion(s) (n=11). The specimens of core biopsy and primary nephrectomy (n=62) all had favorable histology.Twelve post-chemotherapy nephrectomy cases were subdivided into three risk groups: low risk (n=0), intermediate risk (n=10) and high risk (n=2). Six post-chemotherapy resection cases were subdivided into 3 risk groups:low risk (n=0), intermediate risk (n=5) and high risk (n=1). The remaining 11 cases were comprised of metastatic, relapse, and post-chemotherapy metastatic lesions. The concordance rate of the two senior pathologists was 100%(91/91). Conclusions: The 2019 revision of "CCCG-WT-2016" is clearly written and easy to use. It can serve as the basis of accurate classification for clinical treatment.