PURPOSE: To methodically assess the effectiveness of augmentative plating (AP) and exchange nailing (EN) in managing nonunion following intramedullary nailing for long bone fractures of the lower extremity. METHODS: PubMed, EMBASE, Web of Science, and the Cochrane Library were searched to gather clinical studies regarding the use of AP and EN techniques in the treatment of nonunion following intramedullary nailing of lower extremity long bones. The search was conducted up until May 2023. The original studies underwent an independent assessment of their quality, a process conducted utilizing the Newcastle-Ottawa scale. Data were retrieved from these studies, and meta-analysis was executed utilizing Review Manager 5.3. RESULTS: This meta-analysis included 8 studies involving 661 participants, with 305 in the AP group and 356 in the EN group. The results of the meta-analysis demonstrated that the AP group exhibited a higher rate of union (odds ratio: 8.61, 95% confidence intervals (CI): 4.12 - 17.99, p < 0.001), shorter union time (standardized mean difference (SMD): -1.08, 95% CI: -1.79 - -0.37, p = 0.003), reduced duration of the surgical procedure (SMD: -0.56, 95% CI: -0.93 - -0.19, p = 0.003), less bleeding (SMD: -1.5, 95% CI: -2.81 - -0.18, p = 0.03), and a lower incidence of complications (relative risk: -0.17, 95% CI: -0.27 - -0.06, p = 0.001). In the subgroup analysis, the time for union in the AP group in nonisthmal and isthmal nonunion of lower extremity long bones was shorter compared to the EN group (nonisthmal SMD: -1.94, 95% CI: -3.28 - -0.61, p < 0.001; isthmal SMD: -1.08, 95% CI: -1.64 - -0.52, p = 0.002). CONCLUSION In the treatment of nonunion in diaphyseal fractures of the long bones in the lower extremity, the AP approach is superior to EN, both intraoperatively (with reduced duration of the surgical procedure and diminished blood loss) and postoperatively (with an elevated union rate, shorter union time, and lower incidence of complications). Specifically, in the management of nonunion of lower extremity long bones with non-isthmal and isthmal intramedullary nails, AP demonstrated shorter union time in comparison to EN.
Humans ; Bone Nails/adverse effects* ; Bone Plates/adverse effects* ; Femoral Fractures/surgery* ; Fracture Fixation, Intramedullary/methods* ; Fractures, Ununited/surgery* ; Lower Extremity/injuries*

PURPOSE: We carried out the study aiming to explore and analyze the risk factors, the distribution of pathogenic bacteria, and their antibiotic-resistance characteristics influencing the occurrence of surgical site infection (SSI), to provide valuable assistance for reducing the incidence of SSI after traumatic fracture surgery. METHODS: A retrospective case-control study enrolling 3978 participants from January 2015 to December 2019 receiving surgical treatment for traumatic fractures was conducted at Tangdu Hospital of Air Force Medical University. Baseline data, demographic characteristics, lifestyles, variables related to surgical treatment, and pathogen culture were harvested and analyzed. Univariate analyses and multivariate logistic regression analyses were used to reveal the independent risk factors of SSI. A bacterial distribution histogram and drug-sensitive heat map were drawn to describe the pathogenic characteristics. RESULTS: Included 3978 patients 138 of them developed SSI with an incidence rate of 3.47% postoperatively. By logistic regression analysis, we found that variables such as gender (males) (odds ratio (OR) = 2.012, 95% confidence interval (CI): 1.235 - 3.278, p = 0.005), diabetes mellitus (OR = 5.848, 95% CI: 3.513 - 9.736, p < 0.001), hypoproteinemia (OR = 3.400, 95% CI: 1.280 - 9.031, p = 0.014), underlying disease (OR = 5.398, 95% CI: 2.343 - 12.438, p < 0.001), hormonotherapy (OR = 11.718, 95% CI: 6.269 - 21.903, p < 0.001), open fracture (OR = 29.377, 95% CI: 9.944 - 86.784, p < 0.001), and intraoperative transfusion (OR = 2.664, 95% CI: 1.572 - 4.515, p < 0.001) were independent risk factors for SSI, while, aged over 59 years (OR = 0.132, 95% CI: 0.059 - 0.296, p < 0.001), prophylactic antibiotics use (OR = 0.082, 95% CI: 0.042 - 0.164, p < 0.001) and vacuum sealing drainage use (OR = 0.036, 95% CI: 0.010 - 0.129, p < 0.001) were protective factors. Pathogens results showed that 301 strains of 38 species of bacteria were harvested, among which 178 (59.1%) strains were Gram-positive bacteria, and 123 (40.9%) strains were Gram-negative bacteria. Staphylococcus aureus (108, 60.7%) and Enterobacter cloacae (38, 30.9%) accounted for the largest proportion. The susceptibility of Gram-positive bacteria to Vancomycin and Linezolid was almost 100%. The susceptibility of Gram-negative bacteria to Imipenem, Amikacin, and Meropenem exceeded 73%. CONCLUSION Orthopedic surgeons need to develop appropriate surgical plans based on the risk factors and protective factors associated with postoperative SSI to reduce its occurrence. Meanwhile, it is recommended to strengthen blood glucose control in the early stage of admission and for surgeons to be cautious and scientific when choosing antibiotic therapy in clinical practice.
Humans ; Surgical Wound Infection/epidemiology* ; Male ; Female ; Risk Factors ; Retrospective Studies ; Middle Aged ; Adult ; Case-Control Studies ; Fractures, Bone/surgery* ; Aged ; Drug Resistance, Bacterial ; Logistic Models ; Anti-Bacterial Agents/therapeutic use* ; Incidence ; Bacteria/drug effects*

Nonobstructive azoospermia (NOA), one of the most severe types of male infertility, etiology often remains unclear in most cases. Therefore, this study aimed to detect four biallelic detrimental variants (0.5%) in the minichromosome maintenance domain containing 2 ( MCMDC2 ) genes in 768 NOA patients by whole-exome sequencing (WES). Hematoxylin and eosin (H&E) demonstrated that MCMDC2 deleterious variants caused meiotic arrest in three patients (c.1360G>T, c.1956G>T, and c.685C>T) and hypospermatogenesis in one patient (c.94G>T), as further confirmed through immunofluorescence (IF) staining. The single-cell RNA sequencing data indicated that MCMDC2 was substantially expressed during spermatogenesis. The variants were confirmed as deleterious and responsible for patient infertility through bioinformatics and in vitro experimental analyses. The results revealed four MCMDC2 variants related to NOA, which contributes to the current perception of the function of MCMDC2 in male fertility and presents new perspectives on the genetic etiology of NOA.
Humans ; Male ; Azoospermia/genetics* ; Meiosis/genetics* ; Spermatogenesis/genetics* ; Adult ; Exome Sequencing ; Microtubule-Associated Proteins/genetics* ; Alleles ; Infertility, Male/genetics*

Objective:To analyze the efficacy and safety of nalbuphine for analgesia in patients with non-mechanical ventilation in intensive care unit (ICU).Methods:From December 2018 to August 2021, a multicenter randomized controlled clinical study was conducted to select non-mechanical ventilation patients with analgesic needs admitted to ICU of four hospitals in Henan Province and Guizhou Province. Patients were randomly assigned to nalbuphine group and fentanyl group. The nalbuphine group was given continuous infusion of nalbuphine [0.05~0.20 mg/(kg·h)], and the fentanyl group was given continuous infusion of fentanyl [0.5~2.0 μg/(kg·h)]. The analgesic target was critical-care pain observation tool (CPOT) score<2. The observation time was 48 hours. The primary endpoint was CPOT score, the secondary endpoints were Richmond agitation-sedation score (RASS), ICU length of stay, adverse events, and proportion of mechanical ventilation. The quantitative data of the two groups were compared by t test or Mann-Whitney U test. The enumeration data were compared by chi square test or Fisher exact probability method. The data at different time points between groups were compared by repeated measures analysis of variance. Results:A total of 210 patients were enrolled, including 105 patients in the nalbuphine group and 105 patients in the fentanyl group. There was no significant difference in baseline data between the two groups (all P>0.05). There was no significant difference in CPOT score between nalbuphine group and fentanyl group at each time point after medication ( P>0.05), the CPOT score of both groups at each time point after medication was significantly lower than that before medication, and the analgesic target could be achieved and maintained 2 hours after medication. There was no significant difference in RASS between the two groups at each time point after medication ( P>0.05), which was significantly lower than that before medication, and the target sedative effect was achieved 2 hours after medication. There was no significant difference in ICU length of stay between nalbuphine group and fentanyl group [5.0(4.0,7.5) d vs. 5.0(4.0,8.0) d, P=0.504]. The incidence of delirium, nausea and vomiting, abdominal distension, pruritus, vertigo and other adverse events in the nalbuphine group was lower than that in the fentanyl group (all P<0.05). There was no significant difference in the incidence of other adverse events such as deep sedation, hypotension and bradycardia between the two groups (all P>0.05). The incidence of respiratory depression in nalbuphine group was not significantly different from that in fentanyl group ( P>0.05), but the proportion of mechanical ventilation was significantly lower than that in the fentanyl group [1.9% (2/105) vs. 8.6%(9/105), P=0.030]. Conclusions:Nalbuphine could be used for analgesia in ICU patients with non-mechanical ventilation. The target analgesic effect could be achieved within 2 hours, and it had a certain sedative effect with a low incidence of adverse reactions.

Objective:To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application.Methods:This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis.Results:The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group ( χ2=5.560, P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group ( χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion:SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Objective To compare clinical efficacy and complication rate of percutaneous endoscopic transforaminal discec-tomy(PETD),percutaneous endoscopic interlaminar discectomy(PEID)and unilateral biportal endoscopic(UBE)in treating single-segment lumbar disc herniation(LDH).Methods From October 2019 to August 2021,121 LDH patients with single-segment treated by spinal endoscopy were retrospectively analyzed and divided into three groups.In PETD group,there were 48 patients,including 19 males and 29 females,aged from 18 to 72 years old with an average of(44.0±13.9)years old;3 patients with L3,4 segments,27 patients with L4,5 segments,and 18 patients with L5S1 segments.In PEID group,there were 43 patients,including 23 males and 20 females,aged from 20 to 69 years old with an average of(40.1±12.1)years old;1 patient with L3.4 segments,15 patients with L4.5 segments,and 27 patients with L5S1 segments.In UBE group,there were 30 patients,including 12 males and 18 females,agedfrom29 to 72 years old with an average of(41.2±15.0)years old;1 patient with L3,4 segments,18 patients with L4,5 segments,and 11 patients with L5S1 segments.Operation time,blood loss,fluoroscopy times and complica-tions among three groups were observed and compared.Before opertaion,3 months after operation and at the latest follow-up,visual analogue scale(VAS)was used to evaluate low back pain and lower extremity pain,Oswestry disfunction index(ODI)was used to evaluate lumbar function,and modified MacNab was used to evaluate clinical efficacy at the latest follow-up.Re-sults All patients were performed endoscopic spinal surgery completely and were followed up for at least 12 months.One patient occurred dural sac rupture both in PETD and PEID group,and dural sac rupture was small,and there was no obvious discomfort after operation.Two patients were occurred intraoperative rupture of dural sac in UBE group.One patient was occurred cere-brospinal fluid leakage after operation,and was improved after rest in supine position and fluid rehydration.One patient without no significant postoperative discomfort.(1)There were no significant difference in operating time,blood loss and hospital stay between PETD and PEID group(P＞0.05),while UBE group was higher than those of PETD and PEID group(P＜0.05).There was no statistical significance in fluoroscopy times between PEID and UBE group(P＞0.05),but PETD group was higher than that of PEID and UBE group(P＜0.05).(2)VAS of low back pain at 3 months after operation in UBE group was higher than that in PETD and PEID group(P＜0.05),but there was no significant difference between PETD and PEID group(P＞0.05).At the latest follow-up,there was no significant difference in VAS of low back pain among three groups(P＞0.05).(3)Lower ex-tremity pain of VAS and ODI among 3 groups after operation were significantly improved at all time points compared with those before opertaion(P＜0.05),and there were no statistical significance between groups(P＞0.05),and there were no statistical significance in interaction between different time points and operation groups(P＞0.05).(4)At the latest follow-up,according to the modified MacNab standard,the results of PETD group were excellent in 27 patients,good in 16 patients,moderate in 4 patients,poor in 1 patient;in PEID group,27 patients got excellent result,12 good,3 moderate,and 1 poor;in UBE group,16 patients got excellent,10 good,2 moderate,and 2 poor.There was no significant difference among three groups(x2=0.308,P＞0.05).Recurrence of lumbar disc herniation occurred in 1 patient among each three groups,symptoms were improved in 2 pa-tients after symptomatic treatment,and 1 patient was treated in other hospitals.Conclusion PETD,PEID and UBE techniques could achieve good early clinical effects in treating lumbar disc herniation with similar complication rates.Both of PETD and PEID are single-channel minimally invasive surgery,with mild intraoperative tissue damage and quick postoperative recovery;while intraoperative fluoroscopy of PETD was relatively more frequent,and PEID was more suitable for L5S1 segment;UBE is a two-channel surgery,in which the intraoperative soft tissue damage is more severe,but exposure is broad,which is more suit-able for complex cases.

Objective To prospectively compare the clinical efficacy and radiographic outcomes between interlaminar per-cutaneous endoscopic lumbar decompression(IL-PELD)and transforaminar percutaneous endoscopic lumbar decompression(TF-PELD)in the treatment of single-segment lumbar lateral recess stenosis.Methods From April 2018 to July 2021,85 pa-tients with single-segment lumbar lateral recess stenosis underment percutaneous endoscopic lumbar decompression.There were 44 males and 41 females,aged from 49 to 81 years old with an average of(65.5±8.3)years old,duration of lumbar lateral re-cess stenosis ranging from 3 to 83 months with an average of(26.7±16.5)months.They were divided into IL-PELD group and TF-PELD group according to the different operation methods.There were 47 patients in the IL-PELD group,including 28 males and 19 females aged from 50 to 80 yeaes old with an average age was(66.7±9.3)years old.The disease duration ranged from 3 to 65 months with an average of(25.7±15.0)months.There were 38 patients in the TF-PELD group,including 16 males and 22 females,aged from 51 to 78 years old with an average of(64.1±7.6)years old.The disease duration ranged from 4 to 73 months with an average of(27.9±18.3)months The operation time,intraoperative blood loss,intraoperative fluoroscopy,hospi-talization day and complications of the two groups were recorded.Visual analogue scale(VAS)to evaluate low back pain and lower limb pain,Oswestry disability index(ODI)to evaluate lumbar function in preoperative and postoperative period(1 month,6 months and last follow-up)were recorded.the sagittal diameter of the lateral recess of the responsible intervertebral space in preoperative and 1 week after the operation were recorded.Results The operation was successfully completed in both groups without serious complications such as vascular injury,dural sac tear and nerve injury.The operation time in IL-PED group(69.3±19.3)min was significantly longer than that in TF-PELD group(57.5±14.5)min(P＜0.05).There was no significant dif-ference in the intraoperative blood loss between the two groups(P＞0.05).The number of intraoperative fluoroscopy in TF-PELD group(8.8±2.6)times was significantly higher than that in IL-PED group(4.8±1.2)times(P＜0.05).The hospitalization days of the two groups were not statistically significant(P＞0.05).VAS for low back and lower extremity pain and ODI were(5.1±2.2),(6.9±1.3)scores and(71.4±12.6)％in IL-PELD group,and(4.7±1.8),(6.9±1.3)scores and(68.4±13.9)％in TF-PELD group.In the IL-PELD group,the VAS of low back pain was(2.4±1.5),(1.6±0.8),(1.4±0.9)scores,and the VAS of lower extremity pain was(3.0±1.2),(1.6±0.7),(1.5±1.0)scores,ODI was(32.6±11.9)％,(17.4±6.5)％,(19.3±9.3)％;In TF-PELD group,the VAS of low back pain was(2.6±1.4),(1.5±0.6),(1.4±1.0)scores,and the VAS of lower extremity pain was(2.8±1.2),(1.6±0.6),(1.5±1.2)scores,The ODI was(32.0±11.2)％,(15.0±6.1)％,and(20.0±11.3)％.The VAS and ODI of the two groups at each time point after operation were significantly improved compared with those before operation(P＜0.05),but there was no statistically significant difference between the groups(P＞0.05),and there was no statistically sig-nificant difference in the interaction between different time points and groups(P＞0.05).At 1 week after operation,the sagittal diameter of lateral recess in both groups was significantly increased compared with that before operation(P＜0.05),but there was no significant difference between the two groups at each time point(P＞0.05).According to the modified Macnab criteria,IL-PELD group was rated as excellent in 24 cases,good in 19 cases and fair in 4 cases.In TF-PELD group the results were ex-cellent in 19 cases,good in 15 cases,fair in 3 cases and poor in 1 case.There was no significant difference between the two groups(P＞0.05).Conclusion IL-PELD and TF-PELD can expand the lateral recess in the treatment of single level lumbar lateral recess stenosis,and have achieved good clinical effects.

Objective:To explore the risk factors for lymphoproliferative disorders (PTLD) in children with thalassemia major (TM) after allogeneic hematopoietic stem cell transplantation (allo-HSCT).Methods:This was a retrospective case-control study.A total of 482 children with TM who underwent allo-HSCT at Shenzhen Children′s Hospital between January 2020 and December 2022 were selected and classified into the PTLD and non-PTLD groups according to the occurrence of PTLD.The risk factors for PTLD after allo-HSCT in children with TM were analyzed, and the diagnostic efficiency of relevant risk factors for PTLD was analyzed by receiver operating characteristic (ROC) curve.Results:A total of 25 out of 482 patients (5.2%, 25/482) developed PTLD about 114 (54-271) days after allo-HSCT.Among them, 12 cases (12/25, 48.0%) occurred within 100 days, and 22 cases (22/25, 88.0%) occurred within 1 year after allo-HSCT.Univariate analysis showed that there were significant differences in gender composition, type of transplant donor, number of natural killer cells and B lymphocytes in peripheral blood at 30 days after allo-HSCT, positive rate of plasma Epstein-Barr virus deoxyribonucleic acid (EBV-DNA) and incidence rate of acute graft-versus-host disease (aGVHD) between the 2 groups (all P<0.05).Multivariate Logistic regression analysis showed that female ( OR=3.196, 95% CI: 1.144-8.929), positive plasma EBV-DNA ( OR=17.523, 95% CI: 5.449-56.344) and aGVHD ( OR=3.156, 95% CI: 1.161-8.575) were independent risk factors for PTLD after allo-HSCT in TM children (all P<0.05).The ROC curve analysis showed that positive plasma EBV-DNA had an excellent accuracy in predicting the occurrence of PTLD after allo-HSCT (sensitivity was 0.796, specificity was 0.800, area under the curve was 0.803).If combined with aGVHD and gender, the area under the curve for the prediction of PTLD increased to 0.831. Conclusions:Female, positive plasma EBV-DNA and aGVHD are independent risk factors for PTLD after allo-HSCT in children with TM.It provides useful early warnings for the prediction and prevention of PTLD.

Objective:To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application.Methods:This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis.Results:The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group ( χ2=5.560, P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group ( χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion:SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Patients with severe trauma require an extremely timely treatment and transfusion plays an irreplaceable role in the emergency treatment of such patients. An increasing number of evidence-based medicinal evidences and clinical practices suggest that patients with severe traumatic bleeding benefit from early transfusion of low-titer group O whole blood or hemostatic resuscitation with red blood cells, plasma and platelet of a balanced ratio. However, the current domestic mode of blood supply cannot fully meet the requirements of timely and effective blood transfusion for emergency treatment of patients with severe trauma in clinical practice. In order to solve the key problems in blood supply and blood transfusion strategies for emergency treatment of severe trauma, Branch of Clinical Transfusion Medicine of Chinese Medical Association, Group for Trauma Emergency Care and Multiple Injuries of Trauma Branch of Chinese Medical Association, Young Scholar Group of Disaster Medicine Branch of Chinese Medical Association organized domestic experts of blood transfusion medicine and trauma treatment to jointly formulate Chinese expert consensus on blood support mode and blood transfusion strategies for emergency treatment of severe trauma patients ( version 2024). Based on the evidence-based medical evidence and Delphi method of expert consultation and voting, 10 recommendations were put forward from two aspects of blood support mode and transfusion strategies, aiming to provide a reference for transfusion resuscitation in the emergency treatment of severe trauma and further improve the success rate of treatment of patients with severe trauma.