Objective:To investigate the correlation between heart rate variability (HRV) and cerebral small vessel disease (CSVD) in patients with obstructive sleep apnea (OSA).Methods:Patients with OSA received polysomnography and brain MRI examination in Weihai Municipal Hospital from July 2019 to July 2020 were consecutively collected for cross-sectional analysis. The 5 min HRV before sleep (awake state) was analyzed. The patients were divided into CSVD group and non-CSVD group according to the overall burden of CSVD. The demographic data, clinical data, polysomnography parameters and HRV time domain and frequency domain parameters were compared between the two groups. Multivariate logistic regression analysis was used to determine the correlation between the HRV parameters and CSVD in patients with OSA. Results:A total of 100 patients with OSA were enrolled, including 79 males (79.0%), aged 52.36±8.66 years, apnea hypopnea index (AHI) 38.70±24.65/h. There were 46 patients (46.0%) in the CSVD group and 54 (54.0%) in the non-CSVD group. Univariate analysis showed that there were significant differences in age, AHI, oxygen desaturation index (ODI), percentage of blood oxygen saturation <90% in total sleep time (T90), square root of the mean of the sum of the squares of the difference between adjacent RR intervals (RMSSD), power in high frequency range (HF), power in low frequency range (LF) to HF ratio (LF/HF) between the CSVD group and the non-CSVD group (all P<0.05). Multivariate logistic regression analysis showed that after adjusting for age, body mass index, systolic blood pressure, AHI, ODI, and T90, RMSSD (odds ratio 0.625, 95% confidence interval 0.389-0.981; P=0.041) and LF/HF ratio (odds ratio 1.429, 95% confidence interval 1.011-2.020; P=0.043) were the independent influencing factors of CSVD in patients with OSA. Conclusion:Increased LF/HF and decreased RMSSD in OSA patients with CSVD suggest that the increased sympathetic excitability and decreased vagus function, which may be one of the pathophysiological mechanisms of occurring CSVD in patients with OSA.

Objective:To investigate the correlation between heart rate variability (HRV) and cognitive impairment in patients with obstructive sleep apnea (OSA).Methods:Patients received polysomnography in Weihai Municipal Hospital from June 2019 to November 2020 were enrolled as the subjects of cross-sectional analysis. According to the Montreal Cognitive Assessment score, the patients with OSA were divided into a cognitive impairment group and a non-cognitive impairment group. Multivariate logistic regression analysis was used to determine whether HRV parameters were the independent influencing factors of cognitive impairment in patients with OSA. Multiple linear regression analysis was used to determine the independent correlation between HRV parameters and overall cognition as well as each cognitive domain in patients with OSA. Results:A total of 115 patients with OSA were included, including 80 males (69.6%), aged 58.25±9.88 years. Among them, there were 61 in the cognitive impairment group (53.0%) and 54 in the non-cognitive impairment group (47.0%). The standard deviation of the R-R interval in normal sinus beats (SDNN), the square root of the mean of the sum of the squares of the difference between adjacent NN intervals (RMSSD), the percentage of the number of pairs of adjacent R-R intervals differing by more than 50 ms (pNN50) and the power in high-frequency range (HF; 0.15-0.40 Hz) in the cognitive impairment group were significantly lower than those in non-cognitive impairment group (all P<0.05). Multivariate logistic regression analysis showed that SDNN (odds ratio [ OR] 0.551, 95% confidence interval [ CI] 0.380-0.798; P=0.002), RMSSD ( OR 0.516, 95% CI 0.342-0.779; P=0.002), pNN50 ( OR 0.900, 95% CI 0.834-0.971; P=0.006), LF ( OR 0.821, 95% CI 0.687-0.982; P=0.030) and HF ( OR 0.687, 95% CI 0.525-0.899; P=0.006) were the independent protective factors of cognitive impairment in patients with OSA. Multiple linear regression analysis showed that SDNN ( β=0.208, P=0.023), RMSSD ( β=0.228, P=0.011), pNN50 ( β=0.186, P=0.040), HF ( β=0.235, P=0.010) is independently correlated with overall cognitive function in patients with OSA. Conclusion:The decline of HRV parameters SDNN, RMSSD, pNN50 and HF is independently correlated with cognitive impairment in patients with OSA, suggesting that the decline of vagus nerve function may be involved in the mechanism of cognitive impairment in patients with OSA.

Objective : To provide an experimental basis for predicting the sample size needed for animal experiments by studying the survival of SD rats after buccal mucosal biopsy with arecoline administered at different concentrations with different methods. Methods : In all, 48 rats were divided into 8 groups, with 6 in each group, as follows: rats in groups A-D were treated with arecoline at different concentrations (0, 0.5, 2, 8 mg/mL); rats in groups E-H were treated with arecoline at different concentrations (0, 0.5, 2, 8 mg/mL), followed by stimulation of the buccal mucosa by mechanical rubbing. After 16 weeks, a 6-mm-diameter sample of the buccal mucosa was collected, and the wound was closed with interrupted sutures. The survival time of the rats was recorded, and the relationship between the survival time and the concentration of arecoline and mechanical stimulation was analyzed. Results: No rats died during the first 16 weeks after treatment or after biopsy. The success rate of the arecoline stimulation model was 66.7%. The average observation time of all SD rats after biopsy was 42.5 days. Up to 120 days after biopsy, the cumulative survival rate in the eight groups was 50%, 33%, 17%, 0%, 33%, 17%, 0% and 0%, respectively (in alphabetical order). The cumulative survival rate in the groups administered 0 mg/mL (groups A and E), 0.5 mg/mL (groups B and F), 2 mg/mL (groups C and G), and 8 mg/mL (groups D and H) was 42%, 25%, 8% and 0%, respectively. Cox survival analysis showed that moderate and high concentrations of arecoline (2, 8 mg/mL) significantly affected the survival duration (P < 0.05), while mechanical stimulation had no significant effect on the survival duration (P > 0.05). The chi-squared test showed that the survival rate of rats showing wound healing (33.3%) was significantly higher than that of rats showing incomplete wound healing (0.0%) (P=0.003). Conclusion The success rate of the rat buccal submucosal fibrosis model was higher than moderate and high concentrations of arecoline, but the survival duration was significantly reduced after biopsy. Mechanical stimulation did not lead to a significant decrease in the survival duration, and impaired wound healing may be a cause of death in this model.

Objective To summarise the best evidence for postpartum follow-up acquired from patients with gestational diabetes mellitus so as to provide an evidence-based reference for establishment of a postpartum follow-up program.Methods Literature on postpartum blood glucose follow-up in patients with gestational diabetes mellitus was retrieved from 17 major databases including BMJ Best Practice,UpToDate,Joanna Briggs Institute(JBI),International Guide Collaboration Network,National Institute for Health and Care Excellence(NICE),American Diabetes Association website,Medlive,Cochrane Library,Embase,OVID,PubMed,Web of Science,Quanfang local PubMed,CNKI,Wanfang Data,VIP,and Sinomed from the inception of databases to July 2023.The literature to be retrieved included guidelines,expert consensus,evidence summaries,systematic reviews,clinical decisions,and the original studies.Results A total of 9 articles,five practice guidelines,a systematic review,an evidence summaries,an expert consensus and a clinical decisions,were included.Totally,17 pieces of best evidence were summarised from the five aspects:postpartum blood glucose,lifestyle guidance,breastfeeding,drug treatment and health education.Conclusions The summarised best evidences can provide evidence-based references for postpartum follow-up of patients with gestational diabetes.Nursing staff in hospitals and community health centres should formulate relevant follow-up plans according to the actual postpartum conditions of patients in order to prevent the incidence of postpartum Type Ⅱ diabetes.

Objective:To explore the efficacy and safety of ABO-incompatible (ABO-I) liver transplantation for hepatocellular carcinoma.Methods:Forty-four ABO-I liver transplantation recipients were matched with ABO-compatible (ABO-C) recipients by propensity score matching in a ratio of 1: 2. The cumulative overall survival (OS) rate, disease-free survival (DFS) rate and complications were compared between two groups.Results:Compared with ABO-C group, the levels of serum creatinine (sCr) were significantly higher in ABO-I group at Days 7 and 14 post-operation (89.1±36.9 vs 74.8±26.2 umol/L, P=0.001; 77.9±27.6 vs 67.6±18.6 umol/L, P=0.002). The incidence of hepatic arterial thrombosis (9.1% vs 1.1%, P=0.024), biliary complications (25.0% vs 8.0%, P=0.007), early allograft dysfunction (52.3% vs 31.8%, P<0.001) and acute kidney injury(68.1% vs 36.4%, P<0.001) also significantly spiked in ABO-I group. The postoperative cumulative OS, DFS and graft survival rate of ABO-C group were significantly higher than those of ABO-I group ( P<0.001). No inter-group difference existed in survival rate or complication incidence in accordance with the Hangzhou criteria. However, OS, DFS and graft survival rates of ABO-I group were significantly lower than those of ABO-C group ( P<0.001) and the incidence of hepatic artery thrombosis (6.7% vs 0.0%, P=0.043), biliary complications (30.0% vs 6.7%, P=0.003), early allograft dysfunction (53.3% vs 28.3%, P=0.020) and acute kidney injury (63.3% vs 28.3%, P<0.001) significantly rose exceeding the Hangzhou criteria. Conclusions:ABO-I liver transplantation does not affect the OS rate, graft survival rate and postoperative complications in accordance with the Hangzhou criteria. For HCC recipients exceeding the Hangzhou criteria, the prognosis of ABO-I liver transplantation is significantly inferior to that of ABO-C liver transplantation. Careful implementations and accurate evaluations should be performed for ABO-I liver transplantation. Patients exceeding the Hangzhou criteria may receive down-staging treatment so as to obtain transplantation opportunities and yield a better prognosis.

Objective:To evaluate the effect of esketamine on extremity ischemia-reperfusion-induced lung injury in elderly patients undergoing total knee replacement.Methods:Sixty elderly patients of both sexes, aged 65-80 yr, with body mass index <35 kg/m 2, of American Society of Anesthesiologists Physical Status classification Ⅱ or Ⅲ, scheduled for elective unilateral total knee replacement under neuraxial anesthesia, were divided into 2 groups according to the random number table method: control group (C group) and esketamine group (S group), with 30 cases in each group. Esketamine 0.3 mg/kg was intravenously infused before tourniquet inflation in group S. Immediately after the end of operation, the two groups received adductor block with 0.5% ropivacaine 15 ml under ultrasound guidance. And then patient-controlled intravenous analgesia was performed, patient-controlled intravenous analgesia solution included sufentanil 1.5 μg/kg in 100 ml of normal saline in group C and sufentanil 1.5 μg/kg and esketamine 0.75 mg/kg in 100 ml of normal saline in group S. The background infusion rate was 1.5 ml/h, the patient-controlled analgesia dose was 1.5 ml, and the lockout interval was 15 min in the two groups. When the visual analogue scale score at rest≥ 4 points within 3 days after surgery, ketorolac tromethamine 30 mg was intravenously injected for rescue analgesia. Blood samples from the radial artery were collected for blood gas analysis at 30 min before tourniquet inflation(T 0), 30 min after tourniquet inflation(T 1), and 3 min, 30 min and 24 h (T 4) after tourniquet release (T 2-4), and PaO 2 and PaCO 2 were recorded. The alveola-arterial oxygen partial pressure difference, oxygenation index and respiratory index were calculated. Peripheral venous blood samples were collected at T 0, T 3 and T 4 for determination of serum endothelin-1 and malondialdehyde by enzyme-linked immunosorbent assay. The requirement for rescue analgesia and occurrence of dizziness, hallucinations and pulmonary complications within 3 days after surgery were recorded. Results:Compared with group C, alveola-arterial oxygen partial pressure difference was significantly decreased at T 1-3, respiratory index was decreased, oxygenation index was increased at T 2, 3, and serum endothelin-1 and malondialdehyde concentrations were decreased at T 3, 4, and the rate of postoperative rescue analgesia was decreased in group S( P<0.05). There was no significant difference in the incidence of postoperative dizziness, hallucinations, and pulmonary complications between the two groups ( P>0.05). Conclusions:Esketamine can reduce extremity ischemia-reperfusion-induced lung injury in elderly patients undergoing total knee replacement, and the mechanism may be related to regulating vascular endothelial function and reducing lipid peroxidation.

Objective:To investigate the prognosis and influencing factors of liver transplantation (LT) for hepatocellular carcinoma (HCC) using steatotic donor liver.Methods:The retrospective cohort study was conducted. The clinicopathological data of 152 pairs of donors and the corresponding recipients undergoing LT for HCC in the two medical centers [89 pairs in Shulan (Hangzhou) Hospital and 63 pairs in the First Affiliated Hospital of Zhejiang University School of Medicine] from January 2015 to December 2019 were collected. Of 152 donors, there were 131 males and 21 females, aged (48±12)years, and there were 130 cases with liver mild steatosis and 22 cases with liver moderate steatosis. Of 152 recipients, there were 138 males and 14 females, aged (52±9)years. Observation indicators: (1) follow-up, overall survival and tumor recurrence free survival of recipients; (2) influencing factors for overall survival and tumor recurrence free survival of recipients; (3) construction and validation of nomogram prediction model for overall survival and tumor recurrence free survival of recipients. Follow-up was conducted using outpatient examination and telephone interview to detect survival and tumor recurrence of recipients up to December 2020. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( IQR). Count data were described as absolute numbers. The Kaplan-Meier method was used to calculate the survival time and draw survival curve, and the Log-Rank test was used for survival analysis. The COX regression model was used for univariate and multivariate analysis. The independent risk factors were brought into the R 3.6.2 software to construct nomogram prediction model and draw the receiver operating characteristic (ROC) curve. The accuracy and discrimination of the nomogram prediction model were evaluated using the area under curve (AUC) and the calibration curve. Results:(1) Follow-up, overall survival and tumor recurrence free survival of recipients. All the 152 recipients undergoing LT for HCC using steatotic donor liver were followed up for 45.8(27.6)months, with the overall survival time and tumor recurrence free survival time of 36.5(32.3)months and 30.4(34.6)months. The 1-year, 3-year overall survival rates and tumor recurrence free rates of the 152 recipients were 73.4%, 55.8% and 62.2%, 43.4%, respectively. (2) Influencing factors for overall survival and tumor recurrence free survival of recipients. Results of univariate analysis showed that the donor liver cold ischemia time (CIT), the donor liver warm ischemia time (WIT), graft-to-recipient weight ratio (GRWR), ABO compatibility, recipient body mass index (BMI), recipient tumor diameter, recipient tumor number, recipient tumor differentiation degree, recipient preoperative alpha fetoprotein (AFP) were related factors influencing the overall survival of recipients ( hazard ratio=6.26, 1.90, 2.47, 4.08, 0.55, 5.16, 3.62, 5.28, 2.65, 95% confidence interval as 3.01?13.03, 1.07?3.38, 1.36?4.49, 2.07?8.03, 0.31?0.98, 2.56?10.42, 1.95?6.72, 1.60?17.42, 1.48?5.01, P<0.05) and the donor liver CIT, GRWR, ABO compatibility, recipient tumor diameter, recipient tumor number, recipient tumor differentiation degree, recipient preoperative AFP were related factors influencing the tumor recurrence free survival of recipients ( hazard ratio=4.24, 2.53, 4.05, 3.39, 3.10, 5.19, 2.63, 95% confidence interval as 2.50?7.21, 1.54?4.17, 2.12?7.72, 2.04?5.62, 1.91?5.03, 2.04?13.18, 1.61?4.30, P<0.05). Results of multivariate analysis showed that donor liver CIT ≥8 hours, GRWR ≥2.5%, recipient tumor diameter ≥8 cm and recipient preoperative AFP ≥400 μg/L were independent risk factors influencing the overall survival of recipients ( hazard ratio=4.21, 2.58, 4.10, 2.27, 95% confidence interval as 1.98?8.96, 1.24?5.35, 1.35?12.43, 1.13?4.56, P<0.05) and donor liver CIT ≥8 hours, GRWR ≥2.5%, recipient tumor diameter ≥8 cm, recipient tumor number ≥3 and recipient preoperative AFP ≥400 μg/L were independent risk factors influencing the tumor recurrence free survival of recipients ( hazard ratio=3.37, 2.63, 2.42, 2.12, 2.22, 95% confidence interval as 1.70?6.67, 1.40?4.96, 1.04?5.66, 1.08?4.18, 1.26?3.90, P<0.05). (3) Construction and validation of nomogram prediction model for overall survival and tumor recurrence free survival of recipients. The donor live CIT, GRWR, recipient tumor diameter, recipient preoperative AFP were used to construct nomogram prediction model for overall survival of recipients and the donor liver CIT, GRWR, recipient tumor diameter, recipient tumor number, recipient preoperative AFP were used to construct nomogram prediction model for tumor recurrence free survival of recipients. The ROC curve showed that the AUC of the nomogram prediction model for overall survival of recipients was 0.84 (95% confidence interval as 0.76?0.92, P<0.05), with the optimal diagnostic value as 7.3 and the specificity and sensitivity as 87.6% and 70.0%. The AUC of the nomogram prediction model for tumor recurrence free survival of recipients was 0.79 (95% confidence interval as 0.71?0.87, P<0.05), with the optimal diagnostic value as 5.8 and the specificity and sensitivity as 97.4% and 52.5%. The calibration curve showed that the nomogram prediction model had good distinction for high risk recipients in overall survival and tumor recurrence free survival. Conclusion:Donor liver CIT ≥8 hours, GRWR ≥2.5%, recipient tumor diameter ≥8 cm and recipient preoperative AFP ≥400 μg/L are independent risk factors influencing the overall survival of recipients who underwent LT for HCC using steatotic donor liver and donor liver CIT ≥8 hours, GRWR ≥2.5%, recipient tumor diameter ≥8 cm, recipient tumor number ≥ 3 and recipient preoperative AFP ≥400 μg/L are independent risk factors influencing the tumor recurrence free survival of recipients.

Methods:From Jan 2019 to Nov 2021, 20 patients underwent 3D printed template assisted pre-fenestration of stent graft with reducing-diameter tie technique and branched stents for the EVAR at the three hospitals. The clinical data patients were collected and analyzed.Results:All the 20 cases underwent 3D printed template assisted pre-fenestration of stent graft according to the data of pre-operative the computed tomographic angiography (CTA). EVAR was successfully performed in all patients(included 2 cases with one fenestration,5 cases with 2 fenestration,10 cases with 3 fenestration and 3 cases with 4 fenestration). Fifty-four reinforced fenestrations (20 in right renal artery, 18 in left renal artery, 13 in superior mesenteric artery and 3 in celiac artery) were performed. During the follow-up period (mean 14.6 months), 1 case died, and the one-stage patency rate of splanchnic artery branch stent was 98.1%. Four patients had endoleak, 1 patient died of intracranial hemorrhage during postoperative period. None of patients had postoperative paraplegia or organ ischemia.Conclusions:3D printed template assisted pre-fenestration of stent graft with reducing-diameter tie technique is feasible for EVAR in the treatment of complex abdominal aortic aneurysms and dissections. The technique is capable to reinforce the blood supply of visceral arteries with satisfied short-term effectiveness.Ojective:To evaluate 3D printed template assisted pre-fenestration of stent graft with reducing-diameter tie technique and branched stents for the endovascular aortic aneurysm repair (EVAR).

Objective:To explore the value of aspartate aminotransferase(AST)and platelet (PLT)ratio index(APRI)in the prognosis of liver transplantation(LT)for hepatocellular carcinoma and establish a nomogram model for evaluating its clinical application potential.Methods:From January 2015 to December 2019, retrospective review was conducted for clinical data of LT for hepatocellular carcinoma(HCC)at First Affiliated Hospital of Zhejiang University School of Medicine and Shulan(Hangzhou)Hospital(601 cases). They were randomized into two groups of modeling (399 cases)and validation(202 cases)and then divided into low and high APRI groups according to the APRI value at Month 1 post-transplantation. The independent risk factors of recurrence and prognosis post-LT were screened in modeling group using univariate and multivariate Cox regression analyses and were further used for constructing a nomogram prediction model. The receiver operating characteristic curve(ROC)and survival curve were utilized for verifying the accuracy of nomogram prediction model.Results:Univariate and multivariate Cox regression analyses revealed that independent risk factors for the prognosis of HCC-LT included cold ischemic time(CIT) >8 h, beyond Hangzhou criteria, surgical bleeding volume >1 000 ml and APRI >1.5. The AUC of HCC-LT recurrence prediction model was 0.734(95%CI: 0.681~0.787)and 0.749(95%CI: 0.671~0.817)in modeling and validation groups; the AUC of HCC-LT mortality prediction model was 0.735(95%CI: 0.679~0.790)and 0.758(95%CI: 0.682~0.834)in modeling and validation groups.Conclusions:APRI>1.5 is an independent risk factor for postoperative recurrence and mortality after HCC-LT. The nomogram prediction model based upon CIT, Hangzhou criteria, intraoperative bleeding volume and APRI can effectively predict the recurrence and overall survival of LT for HCC.

Objective:To investigate the types, incidences, and clinical characteristics of shock in polytrauma patients at different stages after polytrauma.Methods:A retrospective study was conducted on polytrauma patients admitted to multiple trauma centers from June 2020 to December 2021. The inclusion criteria were patients >18 years old and treated due to polytrauma. Exclusion criteria included an admission time of more than 48 h after trauma, a history of malignancy, or metabolic, consumptive, and immunological diseases. The early stage was defined as the period of ≤48 h after polytrauma, and the middle stage was defined as the period between 48 h and 14 days. The patient’s medical history, clinical manifestations, laboratory tests, imaging examination, injury severity score (ISS), and Glasgow coma scale (GCS) were collected. The types, incidences, and clinical characteristics of shock in different stages after polytrauma were analyzed, according to the diagnostic criteria of each type of shock. The differences between the groups were compared by Student’s t test, χ2 test or Mann-Whitney U test. Results:The incidence of the early and middle stage shock after polytrauma were 73.1% and 36.4%, respectively, with statistically significant difference between stages ( P<0.01). There were significant differences in the incidence of hypovolemic shock (83.6% vs. 28.4%), distributed shock (13.7% vs. 80.9%) and cardiogenic shock (3.5% vs. 6.6%) between stages (all P<0.05). The incidence of obstructive shock (8.4% vs. 9.7%, P>0.05) was similar between stages. The incidence of undifferentiated shock was 1.6% and 1.2%, respectively. There were 9.5% patients with multifactorial shock in the early stage and 14.4% in the middle stage. Totally 7 combinations of multifactorial shock were found in different stages after polytrauma. In the early stage, the combination of HS and DS accounted the highest ratio (42.3%) and followed by HS and OS for 28.8%. In the middle stage, the combination of HS and DS was the most common (48.6%) and followed by DS and OS (24.3%). Conclusions:The incidence of shock in polytrauma patients is high. Different types of shock can occur simultaneously or sequentially. Therefore a comprehensive resuscitation strategy is significant to improve the success rate of treatment.