[Annual review of progress in research on chronic obstructive pulmonary disease(2022-2023)].

Chronic obstructive pulmonary disease (COPD) is the most common chronic airway disease, with a high prevalence and high disease burden. Clinical questions have driven advances in clinical research that continue to deepen our understanding of COPD. At the same time, new perspectives, evidence, and strategies have emerged. Studies since 2022 have increased knowledge of the impact of risk factors, such as low-to-moderate income and ambient ozone, on the prevalence of COPD. The effect of preterm birth on obstructive lung function deficits and COPD in the sixth decade of life was investigated for the first time. Screening studies for COPD in developed and low- and middle-income countries suggest the importance of tailoring screening strategies to local conditions. Developments in artificial intelligence provide a general framework for using machine-learning-based methods and medical record-based labels to improve disease prediction. New perspectives on endotypes/phenotypes and prognostic assessment of COPD were provided by lifetime spirometry patterns of obstruction and limitation, sensitisation to recombinant Aspergillus fumigatus allergens, airway-occluding mucus plugs and exacerbation history in COPD group A and B patients. Clinical trials focusing on inflammatory mediators, comorbidity treatment, non-pharmacological treatments, and environmental interventions shed light on some crucial and long-debated issues. Further research is needed for individualised diagnosis and treatment of COPD.

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

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

[Effects of three-dimensional computed tomography angiography-assisted free medial sural artery perforator flap in repairing foot wounds].

Objective: To investigate the effects of three-dimensional computed tomography angiography (3D-CTA)-assisted free medial sural artery perforator flap in repairing foot wounds. Methods: A retrospective observational study was conducted. From May 2018 to August 2021, 18 patients with foot soft tissue defects who met the inclusion criteria were admitted to the Department of Spine and Trauma Orthopedics of the Yidu Central Hospital of Weifang, including 13 males and 5 females, aged 19 to 55 years, with a wound area of 4.0 cm×3.0 cm-9.0 cm×8.0 cm at admission. Before the operation, CT scanner was used to scan the area from the supracondylar femur to the middle segment of the fibula of patients, and the obtained data were extracted into the Mimics16.0 software and analyzed to determine the pre-selected perforator, and then the image data of the pre-selected perforator side were analyzed further, and the body surface projection position of the perforating point of the medial sural artery in the calf region was marked. Based on the above examination, the flap was designed and cut according to the shape and area of the patient's foot tissue defect, and the area of flaps ranged from 5.0 cm×4.0 cm to 10.0 cm×9.0 cm. The donor sites were sutured directly or covered by skin grafting. The type of perforator, the diameters of perforator at the beginning and outlet point, and the location of the outlet point of perforator of the medial sural artery were observed under 3D-CTA examination before operation and compared to see if they were consistent with the observation under intraoperative condition. The survival of the flaps after operation was recorded. During follow-up, the satisfaction of patients with the wound repair effects, the sensory recovery of the recipient flaps, the healing of the donor wound, and whether there were complications affecting limb functions were recorded. Data were statistically analyzed with Kappa consistency test and equivalence test, and the 95% confidence intervals of measurement difference of perforator diameter and outlet point position of perforator were -0.50-0.50 mm and -2.0-2.0 cm, respectively. Results: The types of medial sural artery perforators observed during operation were type Ⅰ in 3 cases, type ⅡA in 6 cases, type ⅡB in 8 cases, and type Ⅲ in 1 case, which was consistent with the results of 3D-CTA before operation (Kappa=1.00, P<0.05). The blood vessel diameter detected by 3D-CTA before operation at the beginning of perforator of medial sural artery was (1.81±0.39) mm, and the blood vessel diameter at the outlet point of the perforator was (0.83±0.21) mm, which were close to the actual intraoperative measurement of (1.83±0.43) and (0.86±0.22) mm, respectively; equivalence test showed that the 95% confidence intervals of the measurement differences of diameter of medial sural artery perforator at beginning and outlet point were -0.18-0.22 and -0.08-0.14 mm, respectively, with both P values <0.05. The preoperative 3D-CTA detected that the perforating position at the deep fascia of the perforator of the medial sural artery, namely the vertical distance with the popliteal fold was (12.2±1.4) cm, and the horizontal distance with the posterior midline was (2.6±0.7) cm, which were respectively close to the actual intraoperative measurement of (12.4±1.4) and (2.6±0.7) cm; equivalence test showed that the 95% confidence intervals of the measurement differences in the vertical distance with the popliteal fold and the horizontal distance with the posterior midline of the outlet point of medial sural artery perforator were -1.06-1.26 and -0.46-0.66 cm, respectively, with both P values <0.05. After surgery, all flaps of 18 patients survived without vascular crisis. After 1 year of follow-up, the satisfaction degree of 16 patients was excellent and 2 patients was good with the wound repair effects, with a satisfaction ratio of 16/18; the sensory recovery of flap was evaluated as S3 in 11 cases and S2 in 7 cases; the donor wounds healed well without obvious scar or contracture, with no effect on limb joint functions. Conclusions: The medial sural artery perforator flap achieved good results in repairing foot wound with high degree of patient satisfaction. Preoperative application of 3D-CTA can realize the standardization, systematization, and visualization of artery perforator flap.

[Coiled tube of femoral anterolateral flap for repair of circumferential defect after operation of advanced hypopharyngeal carcinoma].

Objective: To investigate the clinical application value of coiled tube of femoral anterolateral flap in the repair of circumferential defect after resection of advanced hypopharyngeal carcinoma. Methods: Clinical data of 42 patients with advanced hypopharyngeal cancer admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to April 2022 were retrospectively analyzed, including 41 males and 1 female, aged from 33 to 82 years old. All patients received surgical treatment, including total laryngectomy plus total laryngopharyngectomy in 20 cases, total laryngectomy, total laryngopharyngectomy and resection of partial tongue base in 8 cases, total laryngectomy, total laryngopharyngectomy and resection of cervical esophagus in 9 cases, total laryngectomy, total laryngopharyngectomy, and resection of partial tongue base and cervical esophagus in 5 cases. The postoperative circumferential defects were repaired with the coil tube of anterolateral femoral skin flap in phase Ⅰ, and the healing status of the flap, wound healing and swallowing function were observed. All cases were followed up. Results: The lengths of the hypopharyngeal defects were 7-18 cm and the sizes of the harvested flaps were 6 cm×9.5 cm-10 cm×20 cm. Flaps survived in 41 cases, flap necrosis occurred in one case, and the survival rate of flaps was 97.6%. One artery and one vein were anastomosed in 40 cases, and one artery and two veins were anastomosed in 2 cases. Postoperative cervical wound infection occurred in 5 cases, and pharyngeal fistula occurred in 2 cases. Three months of follow-up after surgery, 31 cases had normal diet, 9 cases presented with semi-liquid diet and 2 cases with liquid diet. Following up for 6-65 months, recurrence and metastasis occurred in 14 patients (33.3%), including primary site recurrence in 4 cases (9.5%), cervical lymph node recurrence in 6 cases (14.3%), and distant metastasis in 4 cases (9.5%). The 1-year and 3-year overall survival rates were respectively 79.4% and 60.5%. Conclusion: Coiled tube of femoral anterolateral flap is an ideal skin flap for repair of circumferential defects after resection of advanced hypopharyngeal carcinoma.

[Efficacy and safety of extracorporeal membrane oxygenation-supported percutaneous coronary intervention in chronic coronary total occlusion patients with reduced left ventricular ejection fraction].

Objective: To investigate the feasibility and safety of extracorporeal membrane oxygenation (ECMO)-supported percutaneous coronary intervention (PCI) in chronic coronary total occlusion (CTO) patients with reduced left ventricular ejection fraction (LVEF). Methods: The CTO patients with LVEF≤35% and undergoing CTO-PCI assisted by ECMO in the General Hospital of Northern Theater Command from December 2018 to March 2022 were enrolled in this study. The post-procedure complications, changes of LVEF from pre-procedure to post-procedure during hospitalization, and the incidence of all-cause mortality and changes of LVEF after discharge were assessed. Results: A total of 17 patients aged (59.4±11.8) years were included. There were 14 males. The pre-procedure LVEF of these patients were (29.00±4.08)%. Coronary angiography results showed that there were 29 CTO lesions in these 17 patients. There was 1 in left main coronary artery, 7 in left anterior descending artery, 11 in left circumflex artery, and 10 in right coronary artery. ECMO was implanted in all patients before procedure. Among 25 CTO lesions attempted to cross, 24 CTO were successfully implanted with stents. All patients underwent successful PCI for at least one CTO lesion. The number of drug-eluting stents implantation per patient were 4.6±1.3. After procedure, there were 8 patients with hemoglobin decreased>20 g/L, and 1 patient with ECMO-access-site related bleeding. The LVEF value at a median duration of 2.5 (2.0-5.5) days after procedure significantly increased to (38.73±7.01)% (P<0.001 vs. baseline). There were no in-hospital deaths. Patients were followed up for 360 (120, 394) days after discharge, 3 patients died (3/17). The LVEF value was (41.80±7.32)% at 155 (100, 308) days after discharge, which was significantly higher than the baseline value (P<0.001). Conclusion: The results of present study demonstrate that it is feasible, efficient and safe to perform ECMO)-supported CTO-PCI in CTO patients with reduced LVEF.

Could immune-related hepatitis rapidly progress to immune-related cirrhosis?

BACKGROUND: Immune-related hepatitis is one of the prevalent adverse events associated with immunotherapy, especially immune checkpoint inhibitors (ICIs). For patients without a history of liver disease, autoimmune disease, or alcohol consumption, it is not clear whether immune-related hepatitis could rapid progress to immune-related cirrhosis. CASE REPORT: We report the case of a 54-year-old female with stage IIIB primary pulmonary lymphoepithelioma-like carcinoma (PLELC) diagnosed with immune-related hepatitis. After 15 months, a liver biopsy demonstrated the rapid progression of liver cirrhosis although systematic corticosteroid administration. CONCLUSIONS: Long-term immune activation caused by ICIs may exacerbate the process of cirrhosis. Great attention should be paid to the rapid progression to liver cirrhosis of immune-related hepatitis in the clinic.

[A survey on the practice of bronchoscopy in county-level hospitals of China].

Objective: To investigate the bronchoscopy resource allocation and technology application in county-level hospitals in China. Methods: A cross-sectional survey was conducted. In 2021, 12 provinces were sampled from all provinces in China according to the regional Gross Domestic Product (GDP) and the number of counties, in which a total of 291 county-level hospitals were randomly enrolled. Two county-level hospitals which carried out bronchoscopy technology in each province were randomly sampled to investigate the status of bronchoscopy resources, technical application, decontamination and anesthesia by using questionnaires. Independent sample t test or two related sample nonparametric test were used for comparison between groups. Spearman correlation analysis was used to explore the correlation. Bilateral P<0.05 was considered statistically significant. Results: According to the sampling results, it was estimated that in the county-level hospitals, the proportion of those performing bronchoscopy was 11.4% (9.9%, 13.8%), which was significantly correlated with the population in the province (r=0.64, P=0.025) and the regional GDP (r=0.65, P=0.025).The 24 county-level hospitals interviewed were equipped with (1.6±1.0) bronchoscopes on average, and the number of hospitals with electronic bronchoscopes and fiberoptic bronchoscopes was 22 (91.7%) and 6 (25.0%), respectively. Six (25.0%) hospitals performed bronchoscopy every working day. Twelve (50.0%) hospitals had relatively permanent physicians and nurses. All operating doctors had received special training. There was a significant increase in the number of bronchoscopy cases per hospital in 2020 compared to 2019 [140(70, 335) vs. 100(29, 254), P=0.001]. All hospitals used standard cleaning and sterilization workbenches, cleaning agents and disinfectants. Surface anesthesia was available in 24 hospitals, and bronchoscopy techniques under sedation and analgesia were performed in 10 (41.7%) hospitals. Atropine was still used to prevent airway secretions in 2 (8.3%) hospitals,although not recommended by guidelines. Conclusions: There was a large gap between the current status of bronchoscopy technology in county-level hospitals and the standards of the National Health Commission, together with regional disparities. Bronchoscopist training in the standardization and the decontamination work met the requirements. In some hospitals, the use of complementary medicines was not standardized or the sedatives were not given routinely according to the guidelines. We should promote the popularization and standardization of bronchoscopy technology, and strengthen the allocation of related resources in China's county hospitals.

[PIK3CA gene mutations in Chinese women with HR+/HER2- breast cancer].

Objective: To investigate the spectrum of PIK3CA gene mutations in Chinese women with hormone receptor positive and HER2 negative (HR+/HER2-) breast cancer, to provide the genetic evidence for identifying potential beneficiaries from specific PI3K isoform inhibitors in Chinese women with breast cancer and to develop detection strategies. Methods: A total of 365 breast cancer specimens archived at the Peking Union Medical College Hospital, Beijing, China from January 2017 to October 2017 were screened. Among these patients, 186 HR+/HER2- women with invasive breast cancer were collected. PIK3CA gene mutations were detected using next generation sequencing technology. The gene variant features were then analyzed and compared with reported data. Results: Among the 186 HR+/HER2- breast cancer cases, 40 (21.5%,40/186) cases harbored PIK3CA gene mutations. Exons 9 and 20 of PIK3CA mutations occurred in 92.5%(37/40)of the tumors, which included E545K, E545G, Q546K, E542K, Q546R, P539R, E547D, H1047R, H1047L, H1047Q and N1044Y. Only one case harbored the exon 7 C420R mutation. Additionally, exons 1 (F83C) and 5 (G364R) uncommon mutations were discovered respectively in 2 cases. Based on the finding, 85.0% (34/40) of cases with known mutations could be detected using companion diagnostic methods. Moreover, 25.0% (10/40) of patients had two or three variants, which were composed of E726K/N345K, H1047Q/N345K, H1047R/G364R, H1047R/E453K, E545G/E726K, E542K/E726K, E542K/H1047R, E545K/H1047R/H1047L and E545K/E547D. The lymph node positive rate in these patients with PIK3CA mutation was remarkably higher than those without (i.e., wild type, P<0.05). Conclusions: In this group of HR+/HER2- breast cancer patients, common PIK3CA gene mutations account for the vast majority of the mutations. New rare variants in PIK3CA are also identified while their clinical significance needs to be further studied in a large cohort and/or multi-center study.

[One-year follow-up results of atrial fibrillation patients who undergoing transcatheter aortic valve implantation].

Objective: To investigate whether atrial fibrillation (AF) before transcatheter aortic valve implantation (TAVI) will affect the prognosis of patients post TAVI. Methods: This is a single center retrospective study. A total of 115 patients with severe aortic stenosis (AS) who were admitted to General Hospital of Northern Theater Command from May 2016 to November 2020 and successfully received TAVI treatment were included. According to absence or accompaniment of AF pre-TAVI, they were divided into AF group (21 cases) and non-AF group (94 cases). The patients were followed up for postoperative antithrombotic treatment and the occurrence of the net adverse clinical and cerebrovascular events (NACCE) at 12 months post TAVI, including cardiogenic death, readmission to hospital for heart failure, nonfatal myocardial infarction, ischemic stroke and severe bleeding (BARC levels 3-5). Univariate logistic regression was used to analyze the related factors of NACCE. Results: Among the 115 selected patients, age was (73.8±6.9) years, there were 63 males. And 21 cases (18.2%) were diagnosed as AFbefore TAVI. In terms of postoperative antithrombotic therapy, 48.9% (46/94) of the patients in the non-AF group received monotherapy and 47.9% (45/94) received dual antiplatelet therapy. In the AF group, 47.6% (10/21) received anticoagulants and 33.3% (7/21) received dual antiplatelet therapy. The proportion of patients in the AF group taking non-vitamin K antagonist oral anticoagulants (NOAC) was higher than that in the non-AF group (38.1% (8/21) vs. 2.1% (2/94), P<0.001). Patients in both groups were followed up to 12 months after TAVI. During the 12 months follow-up, the incidence of NACCE after TAVI was 14.3% (3/21) in the AF group, which was numerically higher than that in the non-AF group (6.4% (6/94)), but the difference was not statistically significant (P=0.441). The incidence of severe bleeding was significantly higher in the AF group than in the non-AF group (9.5% (2/21) vs. 0, P=0.032). Univariate logistic regression analysis showed that hypertension was associated with the risk of NACCE (OR=8.308, P=0.050), while AF was not associated with the risk of NACCE (P=0.235). Conclusion: The incidence of severe bleeding after TAVI is higher in patients with AF than in patients without AF prior TAVI, and there is a trend of increased risk of NACCE post TAVI in AF patients.

Repeat hepatic resection versus radiofrequency ablation for recurrent hepatocellular carcinoma: retrospective multicentre study.

BACKGROUND: The therapeutic value of repeat hepatic resection (rHR) or radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma (HCC) is unknown. This study aimed to investigate the safety and efficacy of rHR or RFA. METHODS: This was a retrospective multicentre study of patients with recurrent HCC within the Milan criteria who underwent rHR or RFA at nine university hospitals in China and Italy between January 2003 and January 2018. Survival after rHR or RFA was examined in unadjusted analyses and after propensity score matching (1 : 1). RESULTS: Of 847 patients included, 307 and 540 underwent rHR and RFA respectively. Median overall survival was 73.5 and 67.0 months after rHR and RFA respectively (hazard ratio 1.01 (95 per cent c.i. 0.81 to 1.26)). Median recurrence-free survival was longer after rHR versus RFA (23.6 versus 15.2 months; hazard ratio 0.76 (95 per cent c.i. 0.65 to 0.89)). These results were confirmed after propensity score matching. RFA was associated with lower morbidity of grade 3 and above (0.6 versus 6.2 per cent; P < 0.001) and shorter hospital stay (8.0 versus 3.0 days, P < 0.001) than rHR. CONCLUSION: rHR was associated with longer recurrence-free survival but not overall survival compared with RFA.

[Perioperative serious complications in patients undergoing transcatheter aortic valve replacement: a single-center experience].

Objective: To observe the incidence of perioperative severe complications in aortic stenosis (AS) patients undergoing transcatheter aortic valve implantation (TAVR), and to explore the influence of the accumulated experience of the operators on the incidence of complications. Methods: This is a single-center retrospective study. Patients with AS who underwent TAVR from May 2016 to November 2020 in General Hospital of Northern Theater Command were included. The occurrence of severe complications during perioperative period was recorded. Severe complications included all-cause death, surgical transfer to thoracotomy, coronary artery occlusion, peripheral vascular approach complications, severe cerebrovascular events, moderate or above perivalvular leakage, valve displacement (implanted valve middle valve), pacemaker implantation, etc. In order to observe the influence of the accumulated experience of the operators on the occurrence of postoperative complications, the complications in each stage of the patients were counted and the bar chart was drawn with interval of every 30 patients. Results: A total of 119 patients were included, including 64 males and 55 females, the mean age was (73.9±6.9) years. The valve implantation was unsuccessful in 3 out of 119 patients (2.5%). There were 39 cases of severe complications during perioperative period, including 1 death (0.8%), 2 cases of thoracotomy (1.7%), 2 cases of coronary artery occlusion (1.7%), 8 cases of peripheral vascular approach complications (6.7%), and 1 case of new severe cerebrovascular event (0.8%), 3 cases of moderate or higher perivalvular leakage (2.5%), 8 cases of valve displacement leads to midvalvular implantation (6.7%), 14 cases of permanent pacemaker implantation due to new atrioventricular block (11.8%). The bar chart showed that the incidence of permanent pacemaker implantation and in-valve implantation did not significantly decrease with the accumulation of experience, while the incidence of other complications showed a decreasing trend after 30 cases. Conclusions: Most serious complications occurred in the early stage of TAVR in our center. The incidence of all cause death, coronary artery occlusion and peripheral vascular approach complications in the perioperative period post TAVR could be reduced in the TAVR center in the learning stage through the accumulation of procedure-related experience, but the incidence of pacemaker placement and the implanted valve within the valve dose not significantly decrease over time.

[Analysis of microsatellite instability in endometroid carcinoma with deficient mismatch repair].

Objective: To analyze the microsatellite instability (MSI) status in endometrioid endometrial carcinoma (EEC) with deficient mismatch repair (dMMR) and to explore the concordance between MSI next generation sequencing (NGS)/PCR and MMR immunohistochemistry (IHC) results. Methods: Sixty dMMR EEC cases by IHC from November 2017 to February 2019 were selected in the Department of Pathology, Peking Union Medical College Hospital. Two pathologists reviewed the IHC results. The MSI status and the germline/somatic mutational status of MMR genes were analyzed by NGS. MLH1 promoter methylation status was determined by methylation-specific PCR (MSP) in cases with MLH1 protein deficiency. In cases with discrepant results between MMR IHC and MSI NGS, the MSI status was detected again by PCR, and the reasons for the discrepancy were discussed with gene mutation and MLH1 promoter methylation results. Results: Among 60 dMMR EEC specimens, 3 samples were re-assigned as proficient mismatch repair (pMMR) after pathological review, and identified as MSS by NGS. Another 3 dMMR cases showed MSI-uncertainty (MSI-U) by NGS due to insufficient tumor content. In the remaining 54 cases, the concordance between MMR IHC and MSI NGS was 87% (47/54). The seven discrepant cases was further analyzed: in 5 discrepant cases with MLH1/PMS2 protein loss, one case did not have enough samples for detection, one case was MSI-H, and the remaining three cases were MSS by PCR. All these 5 cases with MLH1/PMS2 protein loss showed the MLH1 promoter hypermethylation, two of which also had a somatic mutation in the MSH2 gene. The two discrepant cases with MSH6 protein loss were both MSS by PCR, one of which was considered to have Lynch syndrome with germline mutation in MSH6 gene. Conclusions: Although the overwhelming majority of dMMR EEC cases by IHC shows MSI-H by NGS/PCR, there are uncommon discrepant dMMR EEC cases with MSS. They are mostly found in cases with MLH1/PMS2 protein loss caused by MLH1 promoter hypermethylation and rarely related to Lynch syndrome. Both MMR IHC and MSI NGS/PCR tests have their advantages and disadvantages, complimentary to each other.

[Short-term outcomes of single incision plus one port laparoscopic surgery for colorectal cancer].

Objective: Although single port laparoscopic surgery has achieved good clinical results, many surgeons are discouraged by the difficulties of operation, conflict of instruments, lack of antagonistic traction, and straight-line perspective. Therefore, some surgeons have proposed a single incision plus one hole laparoscopic surgery (SILS+1) surgical method. This study explored the safety and feasibility of SILS+1 for radical resection of colorectal cancer. Methods: A descriptive cohort study was carried out. The clinical data, including the operation, pathology and recovery situation, of 178 patients with colorectal cancer undergoing SILS+1 at Department of General Surgery, Nanfang Hospital, Southern Medical University from March 2018 to January 2019 were prospectively collected and retrospectively analyzed. Clavien-Dindo criteria was used for postoperative complication evaluation and visual analog scale was used for pain standard. Follow-up studies were conducted through outpatient service or telephone and the follow-up period was up to May 2019. Results: A total of 178 patients with colorectal cancer underwent SILS+1, including 111 male patients (62.4%) with an average age of 59 years. Eleven (6.2%) patients received added 1-3 operation ports during operation, and 1 patient was converted to open surgery due to ileocolic artery hemorrhage. The operative time was (135.2±42.3) minutes. The intraoperative blood loss was (34.6±35.5) ml. The number of harvested lymph nodes was 33.1±17.6. The distal margin was (4.7±17.8) cm. The proximal margin was (10.2±5.3) cm. Operation-related complications were observed in 16 patients (9.0%) within 30 days after the operation, of whom 6 had Clavien-Dindo III complications (3.4%). The postoperative pain scores were lower than 3. The average postoperative hospital stay was (5.6±2.6) days. Three patients (1.7%) returned to hospital within 30 days after operation due to intestinal obstruction and infection around stoma. The cosmetic evaluation of all the patients was basically satisfied. Conclusion: SILS+1 is safe and feasible in the treatment of colorectal cancer, and can reduce the postoperative pain.