Objective·To explore the value of combined diaphragm and intercostal muscle ultrasound assessment compared with conventional diaphragm ultrasound in predicting the weaning outcome in mechanically ventilated patients with sepsis.Methods·Mechanically ventilated patients with sepsis,consecutively admitted to the Department of Critical Care Medicine of Affiliated Hospital of Nantong University from October 2022 to December 2023,were selected.During the peri-weaning period,after the patient's sepsis condition improved and the patient passed the spontaneous breathing trial(SBT),ultrasound evaluation of respiratory muscles was performed by ultrasound qualified personnel with ultrasound qualification and experience in bedside ultrasound examination.Diaphragm excursion(DE),thickening fraction of diaphragm(TFD),and thickening fraction of intercostal muscle(TFic)were measured,respectively.The patients were divided into a successful weaning group(n=114)and a failed weaning group(n=24)according to the weaning results.Receiver operating characteristic(ROC)curves were used to analyze the value of diaphragm ultrasound and intercostal muscle ultrasound,alone and in combination,in predicting ventilator weaning outcome.Results·TFic and TFic/TFD were significantly higher in the failed weaning group during SBT than in the successful weaning group(all P<0.05).The areas under the ROC curve(AUROC)of DE,TFD,and TFic to predict weaning failure in mechanically ventilated patients with sepsis during the period of SBT were 0.689(0.591?0.776),0.657(0.557?0.747),and 0.769(0.676?0.846),respectively,whereas the combined indexes TFic/TFD and TFic&TFD_mix had AUROCs of 0.867(0.786?0.925)and 0.860(0.778?0.920),respectively.TFic/TFD with a cutoff value of>0.95 had a sensitivity of 86.7%and a specificity of 75.3%in predicting weaning failure,and TFic&TFD_mix with a cutoff value of>0.13 had a sensitivity of 86.6%and a specificity of 80.9%in predicting weaning failure.Moreover,the intercostal muscle ultrasonography method had an intra-observer intraclass correlation coefficient(ICC)of 0.890 and an extra-observer ICC of 0.876 for measurement reliability,which were both rated as good(P<0.001).Conclusion·Combined diaphragm and intercostal muscle ultrasonography provides a more comprehensive picture of the patient's overall respiratory muscles,and has a higher guiding value in predicting the weaning outcomes in mechanically ventilated patients with sepsis than diaphragm ultrasound alone.

Objective·To explore the value of combined diaphragm and intercostal muscle ultrasound assessment compared with conventional diaphragm ultrasound in predicting the weaning outcome in mechanically ventilated patients with sepsis.Methods·Mechanically ventilated patients with sepsis,consecutively admitted to the Department of Critical Care Medicine of Affiliated Hospital of Nantong University from October 2022 to December 2023,were selected.During the peri-weaning period,after the patient's sepsis condition improved and the patient passed the spontaneous breathing trial(SBT),ultrasound evaluation of respiratory muscles was performed by ultrasound qualified personnel with ultrasound qualification and experience in bedside ultrasound examination.Diaphragm excursion(DE),thickening fraction of diaphragm(TFD),and thickening fraction of intercostal muscle(TFic)were measured,respectively.The patients were divided into a successful weaning group(n=114)and a failed weaning group(n=24)according to the weaning results.Receiver operating characteristic(ROC)curves were used to analyze the value of diaphragm ultrasound and intercostal muscle ultrasound,alone and in combination,in predicting ventilator weaning outcome.Results·TFic and TFic/TFD were significantly higher in the failed weaning group during SBT than in the successful weaning group(all P<0.05).The areas under the ROC curve(AUROC)of DE,TFD,and TFic to predict weaning failure in mechanically ventilated patients with sepsis during the period of SBT were 0.689(0.591?0.776),0.657(0.557?0.747),and 0.769(0.676?0.846),respectively,whereas the combined indexes TFic/TFD and TFic&TFD_mix had AUROCs of 0.867(0.786?0.925)and 0.860(0.778?0.920),respectively.TFic/TFD with a cutoff value of>0.95 had a sensitivity of 86.7%and a specificity of 75.3%in predicting weaning failure,and TFic&TFD_mix with a cutoff value of>0.13 had a sensitivity of 86.6%and a specificity of 80.9%in predicting weaning failure.Moreover,the intercostal muscle ultrasonography method had an intra-observer intraclass correlation coefficient(ICC)of 0.890 and an extra-observer ICC of 0.876 for measurement reliability,which were both rated as good(P<0.001).Conclusion·Combined diaphragm and intercostal muscle ultrasonography provides a more comprehensive picture of the patient's overall respiratory muscles,and has a higher guiding value in predicting the weaning outcomes in mechanically ventilated patients with sepsis than diaphragm ultrasound alone.

BACKGROUND:It has been suggested that CT multiplanar reconstruction should be performed prior to the placement of axial pedicle screws to determine the anatomy of the C2 pedicle in each patient,to design the appropriate screw locus and diameter,and to evaluate the feasibility of screw placement to reduce the incidence of surgery-related complications. OBJECTIVE:To evaluate the feasibility of axis pedicle screw placement by morphologic classification of pediculoisthmic component with CT multiplanar reconstruction. METHODS:The CT data of 200 patients(400 axial pedicle screws)with cervical spine were retrospectively studied by using Siemens Syngo.Via software.According to the direction of the axis of the pedicle,the CT multiplanar reconstruction positioning line was adjusted to reconstruct the sectional image of the narrowest part of the pediculoisthmic component.According to its morphological characteristics,the narrowest part of the pediculoisthmic component was divided into three types:type 1,"hook"type:Type 1a outer diameter width(a1)>0.4 cm,type 1b outer diameter width(a1)≤0.4 cm;type 2,"like circle/ellipse"type;type 3,"horizontal ellipse"type.The outer diameter width of the narrowest part of pediculoisthmic component(d1),medullary cavity width(d2),outer diameter height(a1),and medullary cavity height(a2)were compared among the three types,and the feasibility of pedicle screw placement of the three types was evaluated. RESULTS AND CONCLUSION:(1)A total of 400 axial pedicles included 269 cases of type 1,130 cases of type 2,and 1 case of type 3.(2)The mean external diameter height between types 1 and 2 was not significantly different(P>0.05).The mean medullary cavity height,mean outer diameter widths,and mean medullary cavity width were significantly different(P<0.001).There were 42 cases(15.6%)of type 1 and 0 cases(0.00%)of type 2 with mean external diameter width≤0.4 cm,and the difference was significant(P<0.001).There was only one case of type 3,whose external diameter height,medullary cavity height,outer diameter width and medullary cavity width were 1.20 cm,0.84 cm,0.64 cm and 0.31 cm,respectively.(3)These results confirm that axial pedicle screws can be safely inserted in patients with types 1a,2 and 3,which requires no further measurement and assessment.Pedicle screw insertion should be performed with caution in type 1b patients.Therefore,in type 1 patients,the width of the narrowest outer diameter of the pediculoisthmic component should be further measured to evaluate the feasibility of axial pedicle screw placement.

Objective:To discuss the perioperative management strategy of the HeartCon left ventricular assist device in the treatment of adult patients with end-stage heart failure and evaluate the effectiveness of blood pump.Methods:Ten consecutive patients with end-stage heart failure treated with the LVAD HeartCon at the Department of Cardiovascular Surgery, Jiangsu Province Hospital from July 2021 to July 2023 were enrolled in this study. The clinical data and follow-up results were retrospectively analyzed. Blood pump parameter, cardiac function classification, liver and kidney function, coagulation, myocardial markers, N-terminal pro-B-type natriuretic peptide, von Willebrand factor antigen, echocardiography, cardiothoracic ratio, and 6-minute walking distance test (6MWT) were evaluated before and after implantation of LVAD in 30, 60, 90, 180, 360, 540, and 720 days. EQ-5D-5L questionnaire was used to evaluate the quality of life.Results:There were 9 males and 1 female with a mean age of (53.7±9.7) years. All patients survived. Renal insufficiency occurred in 1 patient and recurrent aseptic granuloma occurred in 1 patient. There were no significant differences in aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), serum creatinine (Scr), blood urea nitrogen (BUN), right ventricular fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) between pre-operation and 30, 60 and 90 days post-operation( P>0.05). The levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), von Willbrand factor (vWF) antigen, left ventricular end-diastolic diameter (LVDd) and cardiothoracic ratio decreased significantly on the 30th, 60th and 90th day after operation ( P<0.05). The left ventricular ejection fraction (LVEF), 6MWT and EQ-5D-5L scores were significantly increased at 30, 60 and 90 days after operation compared with those before operation ( P<0.05). Conclusion:With the left ventricular assist device HeartCon, the cardiac function and quality of life of patients were significantly improved within 3 months after operation, and no serious complications were observed, proving that the device is safe and effective.

Objective:By comparing the changes of metabolic parameters before and after laparoscopic sleeve gastectomy (LSG) in patients with type 2 diabetes mellitus (T2DM) and obesity, the insulin resistance index (HOMA-IR) and atherogenic index of plasma (AIP) were calculated to evaluate the effect of metabolic surgery on insulin resistance and atherosclerosis in patients with type 2 diabetes mellitus (T2DM) and obesity.Methods:LSG treatment were retrospectively analyzed in 54 patients with type 2 diabetes mellitus and obesity, detection of preoperative and postoperative 1 month, 6 month of fasting plasma glucose (FPG), fasting insulin (FINS), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), measuring blood pressure, body weight, calculating body mass index, and according to the steady state evaluation model and the formula for calculating HOMA-IR and AIP. Before and after surgery, paired t test was used, and Pearson correlation analysis and multiple stepwise regression analysis.Results:FPG, FINS, TG, HOMA-IR and AIP were (6.38±2.03) mmol/L and (5.36±1.33) mmol/L, (20.42±25.77) uU/mLand (11.22±3.62) uU/mL, (1.94±2.81) mmol/Land (1.70±2.33) mmol/L, (5.60±7.52) and (2.58±0.80), (0.15±0.27) and (0.08±0.25) ,which were significantly lower than those before surgery ( P<0.05) ,HDL-C was (1.04±0.20) mmol/L and (1.10±0.18) mmol/L at 1 and 6 months after operation, respectively, which was higher than that before operation ( P<0.05) .Preoperative correlation analysis showed that AIP was positively correlated with FPG, TG and HOMA-IR ( P<0.05), and negatively correlated with HDL-C ( P<0.05) .The results of multiple stepwise regression analysis showed that FPG, TG and HDL-C were independent influencing factors of AIP ( P<0.05) . Conclusion:LSG surgery can effectively reduce the blood glucose and lipid levels in patients with type 2 diabetes complicated with obesity, improve insulin resistance and reduce the plasma atherosclerosis index.

Objective:To explore the effect of long-chain fat emulsion in parenteral nutrition therapy on the perioperative nutritional status of patients with low rectal cancer.Methods:A total of 204 patients who underwent rectal cancer surgery in the Third Hospital of Shanxi Medical University from January 2017 to June 2020 were retrospectively analyzed. The patients were divided into two groups according to the specific nutritional treatment methods, 100 cases in the study group used long-chain fat emulsion for parenteral nutrition support, and 104 cases in the control group used medium- and long-chain fat emulsion injection. After admission, the nutritional status of patients were evaluated according to the results of Scored Patient-Generated Subjective Global Assessment (PG-SGA) and related laboratory tests. At 7th day before the operation, the patients were treated with nutrition and electrolyte support. Parenteral nutrition and enteral nutrition combined treatment and early enteral nutrition were given after the operation. The albumin, prealbumin, retinol-binding protein, total cholesterol and body mass index (BMI) at 7th day before the operation, 1st day after the operation and 7th day after the operation and the patient's first exhaust time after surgery, occurrence of postoperative complications, postoperative fever and total hospital stay were recorded and compared between the two groups.Results:Postoperative first exhaust time [(42±11) h vs. (54±10) h], fever time [(48±8) h vs. (57±7) h], total hospital stay [(16.0±0.7) d vs. (18.0±0.9) d)], resting energy expenditure at the 7th day after surgery [(5 326±589) kJ/d vs. (5 840±599) kJ/d] and total cholesterol at the 7th day after surgery [(4.8±0.3) mmol/L vs. (5.0± 0.4) mmol/L] in the study group were lower than those in the control group, and albumin [(33±3) g/L vs. (28± 3) g/L], prealbumin [(0.189±0.041) g/L vs. (0.164±0.037) g/L] and retinol-binding protein [(0.039±0.016) g/L vs. (0.032±0.013) g/L] at the 7th day after surgery in the study group were higher than those in the control group, and the differences between the two groups were statistically significant (all P < 0.05). There was no statistical difference in other detection indexes between the two groups (all P > 0.05). Conclusion:The use of long-chain fat emulsion in low rectal cancer patients with malnutrition during the perioperative period may be more conducive to the recovery of the body.

The clinical data of 15 patients with duodenal trauma who were admitted to Shanxi Bethune Hospital from January 2012 to June 2019 were retrospectively analyzed. There were 13 patients with blunt injury and 2 with penetrating injury. The surgical procedure was selected by patient′s condition and extent of injury combined with the clinical symptoms, imaging examination and the Organ Injury Scale grading system of the American Association for the Surgery of Trauma (AAST-OIS). All patients were followed up through outpatient examination and telephone interview till February 2020. Ten patients were diagnosed as duodenal trauma by CT scan before operation, and 5 patients were diagnosed during the operation. According to the AAST-OIS, 1 patient was with grade Ⅰ injury, 6 in grade Ⅱ, 5 in grade Ⅲ, 2 in grade Ⅳ and 1 in grade Ⅴ. All 15 patients received surgical treatment, including 1 with simple suture, 5 with break suture and duodenal diverticularization, 6 with break suture and biliary drainage (3 with hepatocystic duct drainage and 3 with cholecystostomy), 2 with pancreaticoduodenectomy. Postoperative complications occurred in 3 patients with Clavien system classification of Ⅲ b, Ⅱ and Ⅱ. One patient with duodenal stricture and severe abdominal infection was cured after gastrectomy and Billroth Ⅱ gastrojejunostomy 6 months after operation, and 2 cases with duodenal fistula were cured after conservative treatment. One patient who underwent pancreaticoduodenectomy was followed up for 6 months in the outpatient department, and 14 patients were followed up for 6-24 months. For emergency abdominal trauma patients with suspected duodenal injury, surgical exploration should be carried out actively. The site and range of intestinal wall injury should be considered in order to select a reasonable operation. Effective duodenal decompression and complete peritoneal drainage are important for the success of surgery. Early postoperative enteral nutrition support is one of the key measures for successful wound healing.

Objective To study the effect of human CCR4-NOT transcription complex subunit 7 (CNOT7) gene knockdown on the immune microenvironment of HepG2 cells and explore its significance. Methods We designed a cell transfection protocol and performed the experiment with three groups:CNOT7-targeted knockdown group, control group, and CNOT7 overexpression group. The transfection efficiency was assessed using inverted fluorescence microscopy, and the expression level of CNOT7, transforming growth factor-β1 (TGF-β1), and nuclear factor-kappa B (NF-κB) p65 proteins was determined by Western blotting. The concentration of TGF-β1 secreted in the cell culture supernatant was measured by ELISA. The sensitivity of tumor cells to the killing function of natural killer (NK) cells was detected by flow cytometry. Results Compared with the control group, the expression level of TGF-β1 and NF-κB p65 proteins was significantly decreased in the CNOT7-targeted knockdown group, and the TGF-β1 concentration in the culture supernatant was also significantly reduced. However, in the CNOT7 overexpression group, the expression level of the two proteins and TGF-β1 concentration were significantly increased. NK cells were co-cultured with tumor cells, and the apoptosis rate of HepG2 cells transfected with CNOT7-specific shRNA was significantly increased. However, in the CNOT7 overexpression group, the apoptosis rate was significantly decreased. Conclusion CNOT7 forms the immune microenvironment of hepatocellular carcinoma. Targeted knockdown of CNOT7 can reduce TGF-β1 secretion and enhance the killing function of NK cells toward HepG2 cells.

Objective To analyze tumor immune microenvironment and related mechanisms in liver cancer.Methods We included 10 cases of hepatocellular carcinoma,hepatitis B patients and healthy volunteers from January 2015 to December 2017 in Shanxi Grand Hospital.We first detected the peripheral and local GM-CSF level in each group,detected myeloid-derived suppressor cells (MDSCs) GM-CSF and pathway-related protein expression.from liver cancer,tumor margin and normal liver tissue through flow cytometry and immunohistochemistry,Finally,we transfected the CCR4-NOT transcriptional complex subunit 7 (CNOT7) recombinant plasmid in the hepatoma cell line,and then detected the related protein expression.Results There was no significant difference for peripheral blood GM-CSF level between liver cancer group,hepatitis group and control group (P＞0.05).The level of local GM-CSF was (32.2±8.9) ng/L,which was higher than that of hepatocellular carcinoma (9.7±2.7) ng/L and normal liver tissue (11.6±2.9) ng/L.The difference was statistically significant (P＜0.05).The proportion of MDSCs at the edge of the tumor was (9.9 ±3.6) ％,which was higher than that of liver cancer (4.0± 1.5) ％ and normal liver tissue (6.3±2.3) ％,and the difference was statistically significant (P＜0.05).Immunohistochemistrydata was consistent with previous data.Compared with normal liver tissue,CNOT7 and STAT3 were highly expressed in liver cancer tissues,while STAT1 was lowly expressed.HepG2 human hepatoma cells were selected for transfection.Compared with the empty plasmid group,CNOT7 expression was decreased in the knocking out group at the same time STAT1 expression was increased,STAT3 and GM-CSF expression was decreased.Conclusion In hepatocellular carcinoma,the secretion of GM-CSF increased and the number of MDSCs increased.Knocking out CNOT7 reduced GM-CSF secretion and activate the JAK/STAT signaling pathway.

Objective To study the regulation of dendritic cells by recombinant glycated polylysine-coupled MIP-3α-FL double-gene targeting expression vector in liver cancer immune microenvironment.Methods H22 hepatocarcinoma cells were transfected with recombinant plasmid of MIP-3α-FL (shMIP-3α-FL) and injected into hepatoma model mice.The survival time,tumor size were compared.Flow cytometry was used to measure the number and phenotype of tumor infiltrating DCs.Results Western blot and ELISA demonstrated that the secretion of MIP-3α and FL in H22 cells was significantly increased after transfection with MIP-3α-FL.The survival time of the mice in the experimental group was significantly prolonged,the tumor size decreased.Flow cytometry showed that the number of tumor-infiltrating DCs in the experimental group was significantly higher than that in the control group;the expression of CD80 and CD86 in the infiltrating dendritic cells (TIDCs) was significantly higher than that of the control group.Conclusions The co-action of MIP-3α and FL can significantly promote DC accumulation,maturation,and conjugate glycosylated polylysine carriers increase the precision of targeting and enhance the antigenpresentation of the DCs.