Clinical application of targeted next-generation sequencing in severe pneumonia: a retrospective review.

BACKGROUND: The precise identification of the underlying causes of infectious diseases, such as severe pneumonia, is essential, and the development of next-generation sequencing (NGS) has enhanced the effectiveness of pathogen detection. However, there is limited information on the systematic assessment of the clinical use of targeted next-generation sequencing (tNGS) in cases of severe pneumonia. METHODS: A retrospective analysis was conducted on 130 patients with severe pneumonia treated in the ICU from June 2022 to June 2023. The consistency of the results of tNGS, metagenomics next-generation sequencing (mNGS), and culture with the clinical diagnosis was evaluated. Additionally, the results for pathogens detected by tNGS were compared with those of culture, mNGS, and quantitative reverse transcription PCR (RT-qPCR). To evaluate the efficacy of monitoring severe pneumonia, five patients with complicated infections were selected for tNGS microbiological surveillance. The tNGS and culture drug sensitisation results were then compared. RESULTS: The tNGS results for the analysis of the 130 patients showed a concordance rate of over 70% with clinical diagnostic results. The detection of pathogenic microorganisms using tNGS was in agreement with the results of culture, mNGS, and RT-qPCR. Furthermore, the tNGS results for pathogens in the five patients monitored for complicated infections of severe pneumonia were consistent with the culture and imaging test results during treatment. The tNGS drug resistance results were in line with the drug sensitivity results in approximately 65% of the cases. CONCLUSIONS: The application of tNGS highlights its promise and significance in assessing the effectiveness of clinical interventions and providing guidance for anti-infection therapies for severe pneumonia.

Evidence Supporting That C-to-U RNA Editing Is the Major Force That Drives SARS-CoV-2 Evolution.

Mutations of DNA organisms are introduced by replication errors. However, SARS-CoV-2, as an RNA virus, is additionally subjected to rampant RNA editing by hosts. Both resources contributed to SARS-CoV-2 mutation and evolution, but the relative prevalence of the two origins is unknown. We performed comparative genomic analyses at intra-species (world-wide SARS-CoV-2 strains) and inter-species (SARS-CoV-2 and RaTG13 divergence) levels. We made prior predictions of the proportion of each mutation type (nucleotide substitution) under different scenarios and compared the observed versus the expected. C-to-T alteration, representing C-to-U editing, is far more abundant that all other mutation types. Derived allele frequency (DAF) as well as novel mutation rate of C-to-T are the highest in SARS-CoV-2 population, and C-T substitution dominates the divergence sites between SARS-CoV-2 and RaTG13. This is compelling evidence suggesting that C-to-U RNA editing is the major source of SARS-CoV-2 mutation. While replication errors serve as a baseline of novel mutation rate, the C-to-U editing has elevated the mutation rate for orders of magnitudes and accelerates the evolution of the virus.

The continuing discovery on the evidence for RNA editing in SARS-CoV-2.

Recent studies have presented strong evidence that C-to-U RNA editing is the driving force that fuels severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) evolution. The findings finally ended the long-term debate on the evolutionary driving force behind SARS-CoV-2 evolution. Here, we would first acknowledge the breakthroughs made by the recent works, such as using the global SARS-CoV-2 data to demonstrate the major mutation source of this virus. Meanwhile, we would raise a few concerns on the accuracy of their interpretation on C-to-U RNA editing. By re-analysing the SARS-CoV-2 population data, we found that the editing frequency on C-to-U sites did not perfectly correlate with the binding motif of the editing enzyme APOBEC, suggesting that there might be false-positive sites among the C-to-U mutations or the original data did not fully represent the novel mutation rate. We hope our work could help people understand the molecular basis underlying SARS-CoV-2 mutation and also be useful to guide future studies on SARS-CoV-2 evolution.

Clinical Outcomes of Cardiac Shockwave Therapy in Severe Coronary Artery Disease Patients after Coronary Artery Bypass Grafting.

Cardiac shockwave therapy (CSWT) is a noninvasive treatment for patients with refractory angina or myocardial ischemia. This study aims to evaluate the potential beneficial effect and safety of CSWT in patients with severe coronary artery disease (CAD) who have undergone coronary artery bypass grafting (CABG).This was a single-arm prospective cohort study. A total of 30 patients with severe CAD who were not suitable for coronary revascularization and who had undergone CABG were enrolled. All patients received CSWT for nine sessions. Evaluation was performed before and after CSWT, including the Canadian Cardiovascular Society (CCS) classification, New York Heart Association (NYHA) classification, 6-minute walk test (6MWT), Seattle Angina Questionnaire (SAQ) score, nitroglycerin dosage, echocardiography, myocardial perfusion imaging (MPI), and safety parameters. All patients were followed up at both 1 month and 9 months after CSWT.After treatment, CSWT significantly improved CCS classification (P < 0.05), NYHA classification (P < 0.05), nitroglycerin dosage (P < 0.001), and 6MWT (P < 0.05) at 1 month and 9 months after CSWT. SAQ score (P < 0.05) and left ventricular ejection fraction (LVEF; P = 0.037) by echocardiography significantly improved at 1 month after CSWT. Significant decreases in summed stress score (SSS), summed difference score (SDS), ischemic area stress, and ischemic area difference by MPI were observed at 1 month and 9 months after CSWT (P < 0.01). There were no changes in safety parameters before and after CSWT.CSWT may have a beneficial effect on improving myocardial perfusion, clinical symptoms, exertional capacity, and quality of life and is a safe alternative treatment for patients with severe CAD who have undergone CABG.

Cataract, glaucoma, and diabetic retinopathy are independent risk factors affecting falls in the older adult with eye diseases.

OBJECTIVES: Falls are the leading cause of injury-related hospitalization in older adult, presenting a significant public health concern. To examine the specific eye diseases for risk factors of falls in the older adult. METHODS: A total of 775 older adults admitted to tertiary care hospitals were divided into a fall or non-fall group based on a questionnaire. Logistic regression analysis was used to identify factors associated with falls. RESULTS: With 208 falls, 775 participants were recruited. The major associated factors of falls were older age (Odds ratios [OR]: 1.05), female (OR: 1.91), cardiovascular diseases (OR: 1.65), more outdoor activities (OR: 2.81), cataract (OR: 1.65), glaucoma (OR: 1.63), diabetic retinopathy (OR: 2.72). CONCLUSIONS: Our study demonstrates that cataract, glaucoma, and diabetic retinopathy in the older adult with eye diseases are independent risk factors of falls, which may shed light on the prevention of falls in the older adult with eye diseases.

The Sponge Interaction Between Circular RNA and microRNA Serves as a Fast-Evolving Mechanism That Suppresses Non-small Cell Lung Cancer (NSCLC) in Humans.

Non-small cell lung cancer (NSCLC) is one of the most lethal cancer types in the world. Currently, the molecular mechanisms and pathways underlying NSCLC oncogenesis are poorly understood. Using multiple Omics data, we systematically explored the differentially expressed circular RNAs (circRNAs) in NSCLC. We also investigated potential microRNA sponges (that absorb circRNAs) in NSCLC and downstream target genes with experimental verifications. hsa_circ_0003497 was down-regulated in NSCLC and played an inhibitory role in tumorigenesis. In contrast, miR-197-3p was up-regulated in NSCLC. hsa_circ_0003497 directly interacts with miR-197-3p and releases a target gene of miR-197-3p termed CTNND1 (a known tumor suppressor gene). Evolutionary analysis reveals fast evolution of this hsa_circ_0003497-miR-197-3p-CTNND1-NSCLC axis in mammals. This work clarified the biological functions and molecular mechanisms of how hsa_circ_0003497 suppresses NSCLC through miR-197-3p and CTNND1. We discovered molecular markers for the prognosis of NSCLC and provided potential intervention targets for its treatment.

The pathological tissue expression pattern and clinical significance of m6A-regulatory genes in non-small cell lung cancer.

BACKGROUND: Aberrant expression of m6A-related proteins contributes to the occurrence and progression of non-small cell lung cancer (NSCLC). Current studies mainly focus on single m6A regulatory genes and their underlying mechanisms, and the expression of multiple m6A regulatory proteins in NSCLC remains unclear. Therefore, it is necessary to systematically examine these proteins, particularly in clinical specimens. METHODS: Bioinformatic analysis was used to determine the expression of m6A regulatory genes and their correlation with common gene mutations, such as TP53, EGFR and KRAS, using The Cancer Genome Atlas (TCGA) and the AE-meta databases. Immunohistochemistry was employed to analyze the protein expression of m6A regulatory proteins in 61 benign lung tissues and 316 NSCLC tissues. Statistical analysis was performed to calculate the correlation between the expression of m6A regulatory proteins and clinicopathological features, survival, and common gene mutations in lung carcinoma patients. RESULTS: Analysis of the mRNA levels of 13 core m6A regulators, using information from TCGA and the AE-meta databases, revealed that YTHDF1 levels were upregulated in NSCLC compared to those in adjacent normal tissues. Immunohistochemical staining showed that the expression of METTL3, ALKBH5, YTHDC2 and YTHDF1 was significantly upregulated in NSCLC tissues. Further analyses demonstrated a positive correlation between differentially expressed m6A regulatory proteins, including METTL3, ALKBH5, YTHDC2 and YTHDF1, and the poor clinicopathological features and survival of NSCLC patients. According to the statistics of NSCLC patients enrolled in the present study, the protein levels of METTL3 in patients with EGFR exon-19 mutation were higher than those in patients with wild-type EGFR. CONCLUSIONS: Our results indicate that m6A regulators, including METTL3, ALKBH5, YTHDC2 and YTHDF1, could serve as predictive markers of NSCLC, which will facilitate the early detection and diagnosis of NSCLC.

Efficacy and safety of cardiac shock wave therapy for patients with severe coronary artery disease: A randomized, double-blind control study.

BACKGROUND: Previous studies proved the efficacy of cardiac shock wave therapy (CSWT) for coronary artery disease (CAD) patients who are not candidate for reperfusion therapy. Randomized control trials are limited. We try to explore the efficacy and safety of CSWT for patients with severe CAD. METHODS: Thirty patients with severe CAD who had obvious ischemia on myocardial perfusion imaging (MPI) were enrolled and randomly assigned to the CSWT group or the control group. They had received optimal medication treatment for at least three months. Nine sessions of shock wave therapy were conducted over 3 months. CSWT group received the real treatment, while the control group received the pseudo-treatment. Clinical symptom, imaging outcomes and safety parameters were compared between two groups. RESULTS: After treatment, regional stress score (P = .023), improvement rate (IR) of ischemic area (IA) stress (P < .001) and IR of IA difference (P < .001) were significantly favor CSWT group. The interaction of summed rest score (P < .001), summed stress score (P = .004), summed difference score (P = .036) were significantly improved in the CSWT group compared to the control group. Seattle angina questionnaire, quality of life (QOL) and the distance of six-minute walking test (6MWT) were improved in both groups without significant difference between them. Hemodynamic parameters were stable during procedure. Myocardial injury markers showed no changes in two groups. CONCLUSIONS: Our study demonstrated CSWT could effectively and safely improve myocardial perfusion in patients with severe CAD. Clinical symptom, QOL and 6MWT were all improved after treatment, but no significant difference between two groups.

Identification of Candidate Genes and Pathways in Nonsegmental Vitiligo Using Integrated Bioinformatics Methods.

BACKGROUND: Nonsegmental vitiligo (NSV) is an acquired depigmentation disorder of unknown origin. Enormous interests focus on finding novel biomarkers and pathways responsible for NSV. METHODS: The gene expression level was obtained by integrating microarray datasets (GSE65127 and GSE75819) from the Gene Expression Omnibus database using the sva R package. Differentially expressed genes (DEGs) between each group were identified by the limma R package. The interaction network was constructed using STRING, and significant modules coupled with hub genes were identified by cytoHubba and molecular complex detection. Pathway analyses were conducted using generally applicable gene set enrichment and further visualized in R environment. RESULTS: A total of 102 DEGs between vitiligo lesional skin and healthy skin, 14 lesion-specific genes, and 29 predisposing genes were identified from the integrated dataset. Except for the anticipated decrease in melanogenesis, three major functional changes were identified, including oxidative phosphorylation, p53, and peroxisome proliferator-activated receptor (PPAR) signaling in lesional skin. PPARG, MUC1, S100A8, and S100A9 were identified as key hub genes involved in the pathogenesis of vitiligo. Besides, upregulation of the T cell receptor signaling pathway was considered to be associated with susceptibility of the skin in NSV patients. CONCLUSION: Our study reveals several potential pathways and related genes involved in NSV using integrated bioinformatics methods. It might provide references for targeted strategies for NSV.

DETECTION OF MORPHOLOGIC PATTERNS OF DIABETIC MACULAR EDEMA USING A DEEP LEARNING APPROACH BASED ON OPTICAL COHERENCE TOMOGRAPHY IMAGES.

PURPOSE: To develop a deep learning (DL) model to detect morphologic patterns of diabetic macular edema (DME) based on optical coherence tomography (OCT) images. METHODS: In the training set, 12,365 OCT images were extracted from a public data set and an ophthalmic center. A total of 656 OCT images were extracted from another ophthalmic center for external validation. The presence or absence of three OCT patterns of DME, including diffused retinal thickening, cystoid macular edema, and serous retinal detachment, was labeled with 1 or 0, respectively. A DL model was trained to detect three OCT patterns of DME. The occlusion test was applied for the visualization of the DL model. RESULTS: Applying 5-fold cross-validation method in internal validation, the area under the receiver operating characteristic curve for the detection of three OCT patterns (i.e., diffused retinal thickening, cystoid macular edema, and serous retinal detachment) was 0.971, 0.974, and 0.994, respectively, with an accuracy of 93.0%, 95.1%, and 98.8%, respectively, a sensitivity of 93.5%, 94.5%, and 96.7%, respectively, and a specificity of 92.3%, 95.6%, and 99.3%, respectively. In external validation, the area under the receiver operating characteristic curve was 0.970, 0.997, and 0.997, respectively, with an accuracy of 90.2%, 95.4%, and 95.9%, respectively, a sensitivity of 80.1%, 93.4%, and 94.9%, respectively, and a specificity of 97.6%, 97.2%, and 96.5%, respectively. The occlusion test showed that the DL model could successfully identify the pathologic regions most critical for detection. CONCLUSION: Our DL model demonstrated high accuracy and transparency in the detection of OCT patterns of DME. These results emphasized the potential of artificial intelligence in assisting clinical decision-making processes in patients with DME.

Clinical Application of the Musculoperiosteal Iliac Flap for Osteonecrosis of the Femoral Head.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) often affects young, active patients, and the femoral head's preservation is the primary goal of treatment for this disease. Vascularized iliac crest bone grafting is one of the many vascularized procedures used in treating ONHF. In some cases, we selectively performed this procedure using the musculoperiosteal iliac flap with the ascending branch of the lateral femoral circumflex artery for ONFH treatment. METHODS: Twelve patients (12 hips) with nontraumatic femoral head necrosis underwent musculoperiosteal iliac flap transfer with the ascending branch of the lateral femoral circumflex artery. The Harris Hip Score (HHS), visual analog scale score, and double-hip X-ray findings were used to analyze hip function changes within 10 days preoperatively and 6 and 12 months postoperatively. RESULTS: The mean HHS increased from 52.33 ± 3.34 preoperatively to 65.92 ± 5.04 6 months postoperatively and 79.75 ± 3.84 12 months postoperatively, and the data showed a statistical significance difference between preoperative and postoperative (F = 131.90, P < 0.01). The HHS at 6 and 12 months after surgery were significantly different (P < 0.01). The visual analog scale score showed the same trend. The x-ray of hip joints at 6 and 12 months after surgery showed that the femoral heads' shape and contour were good, femoral heads did not collapse, and the transferred bone flaps healed well. CONCLUSIONS: Musculoperiosteal iliac flap transfer with the ascending branch of the lateral femoral circumflex artery may be an effective method with a high clinical success rate for treating young patients with early to midstage ONFH.

Home vs hospital narrowband UVB treatment by a hand-held unit for new-onset vitiligo: A pilot randomized controlled study.

PURPOSE: To compare the efficacy and safety of narrowband ultraviolet B (NB-UVB) phototherapy in home vs in hospital for the management of limited new-onset vitiligo. METHODS: Patients with new-onset vitiligo (<3 months) with <5% body surface area involvement were recruited and randomly assigned to either a home-based or a hospital-based treatment group. Both groups were administered NB-UVB phototherapy thrice a week. The body surface area (BSA) involved with vitiligo, Vitiligo Area Scoring Index (VASI), the effectiveness of repigmentation, Vitiligo Quality of Life index (VitiQoL), and the cost of treatment were examined. RESULTS: A total of 100 patients completed the study. Patients in both groups exhibited improvements demonstrated by BSA and VSAI decrease. No significant differences were found between the two groups in terms of skin repigmentation (P > 0.05). Improvements in the VitiQoL scores were reduced to the greatest degree at week 8 for all patients in both groups. Adverse events, such as painful erythema, burning, blistering, and excessive hyperpigmentation, were more frequently observed in the home-based treatment group than in the hospital-based treatment group. The cost of phototherapy in hospital exceeded the cost of home phototherapy after 7 weeks of treatment. CONCLUSIONS: Home NB-UVB phototherapy treatment was as effective as treatment in hospital, but exhibited cost-effective and a better compliance. However, the education of the patients should be strengthened to avoid excessive UVB exposure and related adverse events.

Transient ocular surface non-perfusion during cataract phacoemulsification surgery.

BACKGROUND: Complete non-perfusion of the anterior segment vasculature during cataract phacoemulsification surgery is rarely reported. CASE PRESENTATION: We present two cases of transient ocular surface non-perfusion (TOSN) during cataract phacoemulsification surgery. The TOSN happened during intraocular lens (IOL) implantation with complete vanish of blood flow in the conjunctival, episcleral and limbal vessels. Reperfusion started within 30 s and part of the blood supply of the conjunctiva and episclera was restored within 2 min. However, the blood flow in the limbal vessels was not restored until 5 min later. The postoperative examination of both eyes was normal. These two rare cases are the TOSN during cataract surgery. We speculated that the significantly increased intraocular pressure during IOL implantation might be the cause of this rare phenomenon. CONCLUSION: Non-perfusion of the ocular structures may occur if the IOP peak during IOL injection exceeds the perfusion pressure of the anterior vasculature.

Retinal microvasculature impairment in patients with congenital heart disease investigated by optical coherence tomography angiography.

IMPORTANCE: A high prevalence of retinal abnormalities have been reported in congenital heart disease (CHD), but quantitative analysis of retinal vasculature is scarce. Optical coherence tomography angiography (OCTA) is a noninvasive method to quantitatively assess the retinal microvasculature. BACKGROUND: To investigate the retinal microvasculature changes in CHD patients by using OCTA. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 158 participants including 57 cyanotic CHD (CCHD) patients, 60 acyanotic CHD (ACHD) patients and 41 control subjects were included. METHODS: All participants underwent a comprehensive ophthalmologic examination, including refraction measurement, intraocular pressure measurement and OCTA. MAIN OUTCOME MEASURES: Vessel density (VD) was measured within the radial peripapillary capillary (RPC), superficial capillary plexus (SCP) and deep capillary plexus (DCP) of the macula. RESULTS: CCHD patients had significantly lower VD in the RPC, SCP and DCP (all P < .01) compared to control subjects, and significantly lower VD in the RPC and DCP (both P < .05) compared to ACHD patients. Besides, among the CHD group, VD in the RPC was positively correlated with oxygen saturation (whole image, ρ = 0.45; peripapillary, ρ = 0.48) and negatively correlated with haematocrit (whole image, ρ = 0.55; peripapillary, ρ = 0.55) (all P < .001). CONCLUSIONS AND RELEVANCE: Retinal VD might be a surrogate to reflect the effect of chronic systemic hypoxemia in CHD patients. OCTA could be a convenient and noninvasive tool to evaluate the retinal structure and function in CHD patients.

Clinical Follow-up Study of the Reconstruction of the Femoral Head With Transferred Vascularized Greater Trochanter Bone Graft for Association Research Circulation Osseous III-IV Osteonecrosis of the Femoral Head.

PURPOSE: The aim of the study was to investigate the curative efficacy of osteonecrosis of the femoral head (ONFH) in a hip-preserving operative approach, by transferring a vascularized greater trochanter graft combined with osteotomy of the upper third of femoral head, in an attempt to seek an innovative approach for patients who experienced middle- to late-stage ONFH with femoral head's weight-bearing area severely collapsed. METHOD: Our research included a total of 23 patients (23 hips) who accepted hip-preserving surgery by reconstructing the femoral head with transferred vascularized greater trochanter bone graft for ONFH from January 2013 to December 2017. The definition of reconstructing the femoral head is that we do the osteotomy on the upper third of the femoral head with weight-bearing area severely collapsed, and the remnant femoral head requires a hemispherical bone graft to recover the shape. A vascularized greater trochanter bone graft was next transferred and fixed at the upper portion of the remnant femoral head, and then, the shape and vascular supply of the femoral head are successfully reconstructed. The clinical assessment was performed with Harris Hip Score system. Kaplan-Meier survival curves with femoral head collapse as the end point showing the probability of progression in collapsed femoral head based on the gender, age and body mass index. RESULTS: Twenty-three patients (23 hips) were eventually contacted by telephone for an outpatient clinic follow-up, with a mean follow-up time of 41.35 months (varied from 16 to 72 months), no patients lost contact. Seven patients (7 hips) had radiographic stage progress. One patient (1 hip) had conversion to total hip arthroplasty at 24 months postoperatively because of progressive femoral head collapse and severely pain. The image success rate was 69.6%, clinical success rate was 65.2%, and the clinical survival rate was 96%. The average Harris Hip Score was 82.5 ± 5.5 points at the last follow-up, representing a great improvement compared with the 51.9 ± 7.2 points obtained preoperatively (P<0.05). Kaplan-Meier survival curves with femoral head collapsed as the end point showing the probability of progression in collapsed femoral head based on the sex, age, and body mass index. CONCLUSIONS: Reconstructing the femoral head with transferred vascularized greater trochanter bone graft provides a new method for the treatment of the young Association Research Circulation Osseous stage III-IV ONFH patients with severely femoral head collapsed, which can better improve the patient's symptoms, the quality of life, and delay the age of undergoing arthroplasty in young patients.

Comparison of clinical outcomes of different components of diabetic macular edema on optical coherence tomography.

PURPOSE: To evaluate the edema reduction after intravitreal injection of ranibizumab (IVR) in two diabetic macular edema (DME) components in the same eye using optical coherence tomography (OCT). METHODS: Totally 113 eyes with mixed OCT pattern of DME were included. All the eyes underwent best-corrected visual acuity (BCVA) examination and OCT scanning at baseline and follow-up visits (1, 3, and 6 months after 3 monthly consecutive IVR). The mixed OCT pattern of DME was classified into 2 OCT components: serous retinal detachment (SRD) component and non-SRD component. Foveal thickness of the SRD component (SRDFT) and the non-SRD component (NSRDFT) was compared between baseline and follow-up visits. Reduction and reduction ratio of the SRDFT and the NSRDFT at each follow-up were compared. When calculating the NSRDFT reduction ratio, we innovatively optimized a commonly used formula by subtracting the normal foveal thickness from the baseline NSRDFT. RESULTS: SRDFT was 265.6 ± 175.4 µm at baseline and was significantly decreased to 126.7 ± 114.4 µm at 1 month, to 110.5 ± 103.4 µm at 3 months, and to 110.4 ± 89.6 µm at 6 months (all P < 0.001). NSRDFT was 409.5 ± 173.1 µm at baseline and was significantly decreased to 274.1 ± 140.4 µm at 1 month, to 249.1 ± 95.9 µm at 3 months, and to 254.1 ± 90.4 µm at 6 months (all P < 0.001). There was no significant difference in reduction or reduction ratio between NSRDFT and SRDFT during follow-up (all P > 0.05). The correlation between BCVA and SRDFT was most significant at baseline (r = 0.366, P < 0.001) and the correlation between BCVA and NSRDFT was most significant at 6 months (r = 0.426, P < 0.001). BCVA improvement was more significantly correlated with reduction or reduction ratio of SRDFT at each follow-up timepoint (r = 0.271-0.426, all P < 0.01). CONCLUSIONS: IVR was effective in reducing both the SRD and non-SRD components of DME according to our optimized formula. The association between BCVA improvement and edema reduction was more significant in the SRD component.

The Combined Therapy of Tantalum Rod Implantation and Vascularized Bone Transplantation for Femoral Head Osteonecrosis: A Retrospective Long-Term Follow-Up Survival Analysis.

Tantalum rod implantation with vascularized bone transplantation has been reported to be an effective method for the treatment of osteonecrosis of the femoral head (ONFH). However, long-term follow-up results were unclear. Sixty-five patients (71 hips) with ONFH treated with this technique were retrospectively reviewed. According to the Association Research Circulation Osseous (ARCO) classification, 21 hips were stage II, 30 were stage III, and 15 were stage IV. Sixty-one patients (66 hips) were followed for more than 10 years. Fifteen hips had to be converted to total hip arthroplasty (THA), the proportion of THA conversion surgery over 10 years postoperative was 4.76% for stage II, 16.7% for stage III, and 60% for stage IV, respectively. The 10-year joint-preserving success rate of the entire group was 77.2%. The Harris Hip Score (HHS) in the patients not receiving THA therapy increased from a mean of 51.35 points (ranged from 32 to 62 points) to 90.12 points (ranged from 72 to 99 points). The technique of tantalum rod implantation with vascularized bone grafting was an effective joint-preserving method for the treatment of ARCO stage II-III ONFH.

Early diagnosis and treatment of steroid-induced osteonecrosis of the femoral head.

OBJECTIVE: This study aims to investigate the early diagnosis and treatment of steroid-induced osteonecrosis of the femoral head. PATIENTS AND METHODS: From January 2010 to January 2014, a total of 350 patients, who required the use of large amounts of hormones, were enrolled into the study. These patients were followed up every three months after starting the hormone therapy. A total of 62 cases were screened, among which nine cases were asymptomatic. Furthermore, 38 patients were diagnosed as stage I and were given low-molecular weight heparin (LMWH) and vasodilator drugs. Moreover, 22 cases were diagnosed as stage IIa/b and underwent core decompression. In addition, two cases were diagnosed as stage IIc and underwent pedicled bone transplantation. During the follow-up period, ARCO staging was used for radiological evaluation, the HHS score was applied to evaluate for clinical efficacy, and SPSS 22.0 statistical software was used for the data analysis. RESULTS: A total of 60 patients were followed up for 24 months. Among these patients, 38 patients were diagnosed with ARCO stage I and underwent systematic therapy. No progress was found in 29 cases (76.3%). Furthermore, three cases progressed to stage IIb (7.8%), four cases progressed to stage IIc (10.5%), two cases progressed to stage III and IV, respectively (2.6%), and 16 cases (80%) did not progress after core decompression. In the 16 cases at stage IIa and four cases at stage IIb, and four cases (20%) progressed in stage III. The HHS score of stage I was 80.42 ± 3.25 before follow-up, while the HHS score was 86.46 ± 8.54 after follow-up, and the difference was statistically significant (P < 0.05). Furthermore, the HHS score of patients with stage IIa/b was 70.38 ± 4.62 before follow-up, while the HHS score was 80.28 ± 6.72 after follow-up, and the difference was statistically significant (P < 0.01). CONCLUSION: MRI remains as the most effective method for the non-invasive diagnosis of osteonecrosis, at present. Enhanced MRI may be able to detect early osteonecrosis, but further research is needed. Drug treatment and core decompression can achieve satisfactory results at the early stage.

Pedicled iliac crest bone flap transfer for the treatment of upper femoral shaft fracture nonunion: An anatomic study and clinical applications.

PURPOSE: We present the results of a study on the anatomy of the ascending branch of the lateral circumflex femoral artery (AB-LCFA) and the use of the pedicled iliac bone flap transfer perfused by AB-LCFA combined with external fixation for the treatment of the nonunion of upper femoral shaft fractures. METHODS: The orientation, diameter, length, and distribution of the AB-LCFA from 40 lower limbs of adult cadavers were dissected and measured. From 2000 to 2012, 13 patients with nonunion of upper femoral shaft fractures underwent pedicled iliac bone flap transfer perfused by the AB-LCFA combined with external fixation. The time of bone fracture union was recorded based on X-ray examination. The functional results of the femoral shaft were evaluated by the Klemm classification. RESULTS: The lateral circumflex femoral artery (LCFA) divided into ascending, transverse, and descending branches in 32 specimens (80%). The diameter of the AB-LCFA at the origin was 3.15 ± 0.9 mm and the length of the AB-LCFA was 8.51 ± 3.06 cm. The postoperative course of the procedure was uneventful in all 13 patients. The average follow-up was 15 months. Bone union was achieved in all patients and the average union time was 5.3 months. 12 patients achieved excellent or good functional results based on the Klemm classification. CONCLUSION: The AB-LCFA has a consistent orientation and abundant blood flow. The transfer of the iliac crest bone flap perfused by the AB-LCFA while combined with external fixation could be an option for treating the nonunion of upper femoral shaft fractures.

Management of osteonecrosis of the femoral head with pedicled iliac bone flap transfer: A multicenter study of 2190 patients.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) often affects young active adults and leads to destruction of the hip joint and disabling arthritis. Several procedures have been developed to arrest the progress of osteonecrosis and postpone the procedure of total hip replacement especially in young patients. The aim of this multicenter study was to analyze the results of the use of the vascularized iliac bone flap transfer for management of ONFH. METHODS: From January 1985 to December 2012, a total of 2190 patients (2690 hips) with the mean age of 43.15 years (ranging from 18 to 65 years) underwent hip-preserving surgery with the pedilced iliac bone flap transfer for management of ONFH with Ficat and Arlet stage II-IV in 8 hospitals. There were 1733 hips in stage II, 776 hips in stage III, and 181 hips in stage IV preoperatively. The complications were recorded. The outcomes were evaluated by radiograph, the Harris hip-scoring system (HHS). RESULTS: Postoperative complications occurred in 128 patients (5.84%). Among them, 25 patients had deep venous thromboses, 16 patients had sensory deficits, 40 patients had superficial infection and hematoma, and 47 patients had wound dehiscence. A total of 1912 patients (2179 hips) were followed up with a median time of 12 years (ranging from 5 to 25 years). There were 1787 hips with no radiographic osteonecrotic progress during follow-up, while osteonecrosis progress was observed in 186 hips with stage II (13.1%), 170 hips with stage III (25.6%) and 36 hips with stage IV (36.4%; P < .001). Two hundred fifteen hips (9.87%) in 203 patients were converted to THA during follow-up, including 19 hips with stage II (1.34%), 162 hips with stage III (24.4%), and 34 hips with stage IV (34.3%).The mean HHS at the end of follow-up was significantly improved when compared to preoperative mean HHS (83.63 ± 5.03 vs. 66.54 ± 6.05, P < .001). CONCLUSIONS: In this evaluation of a large series of cases, the vascularized iliac bone flap transfer showed good results for arresting the osteonecrosis progress and improving the hip function of patients with pre-collapse stages of ONFH.