Objective:To analyze the prognostic factors of patients with liver cirrhosis and portal vein thrombosis (PVT), and to construct a prognostic prediction model based on machine learning methods.Methods:The clinical data of 388 patients with liver cirrhosis and PVT admitted to the Fifth Medical Center of PLA General Hospital from January 2022 to April 2024 were retrospectively collected and analyzed, including 243 males and 145 females, aged (56.9±10.9) years. A total of 388 patients were randomly divided into the training set ( n=310) and the testing set ( n=78) in a 4∶1 ratio. The Boruta algorithm was used to screen the key features in the training set, and then four machine learning algorithms, including random forest, support vector machine, generalized linear model and Bayesian, were used to establish a survival prediction model. Model performance was evaluated by the receiver operating characteristic (ROC) curves of the test set and the training set. The patients were followed up for 1 year for survival. Sort the importance of features based on the SHAP value. Results:There were 250 patients (80.6%) who survived and 60 (19.4%) who died. The model for end-stage liver disease score, total bilirubin, serum creatinine, prothrombin time, international normalized ratio, D-dimer, white blood cell count, severe ascites ratio, and Child-Pugh grade C ratio of liver function in the death group were higher than those in the survival group, and the red blood cell count and hematocrit were lower than those in the survival group, and the differences were statistically significant (all P<0.05). The areas under the ROC curve for predicting survival by random forest, support vector machine, generalized linear model and Bayesian model were 0.92, 0.78, 0.81 and 0.71 in the training set, and the area under the ROC curve in the testing set were 0.81, 0.72, 0.67 and 0.68, respectively. Random forest had the best prediction performance, with an accuracy of 81.7%, a sensitivity of 84.6%, and a specificity of 76.9% in the testing set. In the analysis of the importance of characteristic parameters of the random forest model, total bilirubin, red blood cells, hematocrit, serum creatinine, ascites classification, etc. had a relatively high contribution to the model. Conclusion:In the survival prediction model of patients with liver cirrhosis and PVT based on machine learning algorithm, the random forest model had high prediction performance, and total bilirubin may be the most important factor affecting the survival prognosis of patients.

Objective Pelvic fracture urethral distraction defect(PFUDD)is relatively rare among boys and difficult to manage.This study aims to explore the efficacy of progressive urethral anastomosis in the treatment of this disease.Methods A total of 34 male children with PFUDD who were admitted to our hospitals during Jan.2008 and Dec.2022 were collected.The therapeutic effects and the occurrence of postoperative complications were observed and analyzed.Results All cases were traumatic pelvic fractures,including fall injuries in 3 cases,traffic-related impact injuries in 21 cases,and pelvic crush injuries in 10 cases.Urethroplasty was performed at least 3 months after the initial trauma or after the failure of the last intervention.The mean length of the urethral defect was 3.0 cm,with a range of 1.5 to 5.5 cm.Three cases complicated with urethrorectal fistula underwent urethroplasty concomitant with fistula repair.All children were followed up for an average of 65.5 months,with a range of 5.0 to 155.0 months,with 32 cases(94.1％)achieving successful treatment.Two cases with stricture recurrence were cured by a second operation.Three cases with mild urinary incontinence were improved after half a year of pelvic floor muscle rehabilitation training.Conclusion The progressive urethral anastomosis strategy can yield a relatively high success rate.The trans-inferior-pubic resection or simpler approaches can be adopted for the treatment of PFUDD in over 90％of male children.

Objective Pelvic fracture urethral distraction defect(PFUDD)is relatively rare among boys and difficult to manage.This study aims to explore the efficacy of progressive urethral anastomosis in the treatment of this disease.Methods A total of 34 male children with PFUDD who were admitted to our hospitals during Jan.2008 and Dec.2022 were collected.The therapeutic effects and the occurrence of postoperative complications were observed and analyzed.Results All cases were traumatic pelvic fractures,including fall injuries in 3 cases,traffic-related impact injuries in 21 cases,and pelvic crush injuries in 10 cases.Urethroplasty was performed at least 3 months after the initial trauma or after the failure of the last intervention.The mean length of the urethral defect was 3.0 cm,with a range of 1.5 to 5.5 cm.Three cases complicated with urethrorectal fistula underwent urethroplasty concomitant with fistula repair.All children were followed up for an average of 65.5 months,with a range of 5.0 to 155.0 months,with 32 cases(94.1％)achieving successful treatment.Two cases with stricture recurrence were cured by a second operation.Three cases with mild urinary incontinence were improved after half a year of pelvic floor muscle rehabilitation training.Conclusion The progressive urethral anastomosis strategy can yield a relatively high success rate.The trans-inferior-pubic resection or simpler approaches can be adopted for the treatment of PFUDD in over 90％of male children.

Objective:To analyze the prognostic factors of patients with liver cirrhosis and portal vein thrombosis (PVT), and to construct a prognostic prediction model based on machine learning methods.Methods:The clinical data of 388 patients with liver cirrhosis and PVT admitted to the Fifth Medical Center of PLA General Hospital from January 2022 to April 2024 were retrospectively collected and analyzed, including 243 males and 145 females, aged (56.9±10.9) years. A total of 388 patients were randomly divided into the training set ( n=310) and the testing set ( n=78) in a 4∶1 ratio. The Boruta algorithm was used to screen the key features in the training set, and then four machine learning algorithms, including random forest, support vector machine, generalized linear model and Bayesian, were used to establish a survival prediction model. Model performance was evaluated by the receiver operating characteristic (ROC) curves of the test set and the training set. The patients were followed up for 1 year for survival. Sort the importance of features based on the SHAP value. Results:There were 250 patients (80.6%) who survived and 60 (19.4%) who died. The model for end-stage liver disease score, total bilirubin, serum creatinine, prothrombin time, international normalized ratio, D-dimer, white blood cell count, severe ascites ratio, and Child-Pugh grade C ratio of liver function in the death group were higher than those in the survival group, and the red blood cell count and hematocrit were lower than those in the survival group, and the differences were statistically significant (all P<0.05). The areas under the ROC curve for predicting survival by random forest, support vector machine, generalized linear model and Bayesian model were 0.92, 0.78, 0.81 and 0.71 in the training set, and the area under the ROC curve in the testing set were 0.81, 0.72, 0.67 and 0.68, respectively. Random forest had the best prediction performance, with an accuracy of 81.7%, a sensitivity of 84.6%, and a specificity of 76.9% in the testing set. In the analysis of the importance of characteristic parameters of the random forest model, total bilirubin, red blood cells, hematocrit, serum creatinine, ascites classification, etc. had a relatively high contribution to the model. Conclusion:In the survival prediction model of patients with liver cirrhosis and PVT based on machine learning algorithm, the random forest model had high prediction performance, and total bilirubin may be the most important factor affecting the survival prognosis of patients.

The principles for surgical treatment of femoral neck fracture are anatomical reduction, rigid fixation and reduction of iatrogenic tissue damage to maintain sufficient blood supply and reduce the risk of complications such as avascular necrosis of the femoral head. In the evolution of internal fixation structures for femoral neck fracture, a variety of new products have been developed, such as the neck-shaft angle stabilization structure represented by dynamic hip screw, the multi-screw structure represented by three cannulated screws, and the plate-screw structure represented by multi-screw structure combined with a locked plate. These internal fixation structures have their own advantages and disadvantages in terms of stability and reduced risk of complications. However, none of them can perfectly meet the requirements of all the surgical principles. Femoral neck system (FNS) was firstly applied in clinic practice in 2017 to further improve the internal fixation of femoral neck fracture. In recent years, its mechanical properties and clinical effects have been widely reported in an attempt to further improve the implantation of this internal fixation device. This article reviews the researches on the mechanical properties and clinical efficacy of FNS and the suggestions put forward by orthopedic surgeons to improve the implantation methods of FNS.

ObjectiveTo investigate the efficacy and safety of N-acetylcysteine （NAC） in the treatment of severe alcoholic hepatitis （SAH）， and to provide a basis for clinical medication for SAH. MethodsA prospective randomized controlled trial was conducted among 172 SAH patients with a Maddrey discriminant function score of >32 points who were recruited by The Fifth Medical Center of Chinese PLA General Hospital from June 2015 to June 2018， and these patients were divided into NAC group with 84 patients and control group with 86 patients. NAC （8 g/day， 28 days） was assessed in terms of its safety in SAH patients， its impact on 28-day biochemical parameters， and its role in improving 28- and 180-day survival rates. A further analysis was performed to investigate the effect of NAC on the 28- and 180-day survival rates of SAH patients with acute-on-chronic liver failure （ACLF-SAH patients） and those without acute-on-chronic liver failure （non-ACLF-SAH patients）. The independent-samples t test was used for comparison of normally distributed continuous data between two groups， and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The Kaplan-Meier method was used to plot survival curves， and the Log-rank test was used for comparison of survival curves. Univariate and multivariate Cox proportional-hazards regression model analyses were used to investigate independent influencing factors. ResultsNo serious adverse events were observed during NAC treatment， suggesting that NAC had a good safety profile. Compared with the control group， NAC did not significantly improve the 28-day biochemical parameters （all P>0.05） and survival rate of SAH patients （P=0.081）， but it could improve the 180-day survival rate of SAH patients （67.4% vs 81.0%， χ²=4.280， P=0.039）. NAC did not improve the 28- and 180-day survival rates of ACLF-SAH patients （both P>0.05）； NAC did not improve the 28-day survival rate of non-ACLF-SAH patients （P>0.05）， but it could improve the 180-day survival rate of these patients （68.4% vs 88.9%， χ²=4.883， P=0.027）. The multivariate Cox regression survival analysis showed that NAC treatment （hazard ratio ［HR］=2.530， 95% confidence interval ［CI］： 1.334‍ ‍— 4.796， P=0.004，）， Maddrey discriminant function score （HR=3.852， 95%CI： 2.032 — 7.304， P<0.001）， and serum sodium level （HR=1.948， 95%CI： 1.079‍ ‍—‍ ‍3.517， P=0.027） were independent influencing factors for 180-day survival rate in SAH patients. ConclusionNAC has a good safety profile in the treatment of SAH and can improve the 180-day survival rate of SAH patients， and in particular， non-ACLF-SAH patients can benefit from NAC treatment in terms of middle- and long-term survival rates.

Serum cholinesterase(ChE)level is important for the diagnosis and prognostic evaluation of various diseases such as liver diseases and toxic diseases,and butyrylcholinesterase(BuChE)is an important component of ChE.Mutations in the BCHE gene can cause a significant reduction in the level of BuChE,with extensive reports in European and American populations and relatively few reports in Eastern countries,particularly China.This study describes a male patient,aged 35 years,who was misdiagnosed with organophosphorus pesticide poisoning due to an extreme reduction in ChE level and was given detoxification therapy,but such diagnosis was excluded by various biochemical examinations.Finally whole-exome sequencing and Sanger sequencing revealed the complex heterozygous mutations of c.1027dup and c.401dup at exon 2 of the BCHE gene,and hereditary BuChE deficiency due to these mutations is the cause of the extreme reduction in ChE level.

Objective:To compare the parameters for infra-acetabular screw placement between men and women using a digital Chinese anatomical model of the pelvis and acetabulum.Methods:The normal pelvic CT data were collected from the 163 adult patients who had been admitted to the Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous Region from January 2018 to December 2021. There were 61 males and 102 females with an age of 53.0 (45.0, 60.0) years. Mimics 21.0 software was used to reconstruct the three dimensional pelvis which was then imported into Autodesk maya 2022 software before the model was flattened. Polygonal modeling tools were used to create a cylinder to simulate an infra-acetabular screw for length and angle measurements of the screw. The diameters of the infra-acetabular screws were measured by axial fluoroscopy in Mimics 21.0 software. The maximum diameters and maximum lengths of the infra-acetabular bone channel were compared between males and females, and the angles between the axis of the infra-acetabular screw and the anterior pelvic plane and the median sagittal plane were also compared between genders.Results:The maximum diameters of the left and right infra-acetabular corridors were 5.24 (4.26, 6.38) mm and 5.04 (4.50, 6.57) mm in males, and 3.99 (3.81, 4.51) mm and 3.89 (3.65, 4.90) mm in females; the maximum lengths of the left and right infra-acetabular corridors were (98.43±4.42) mm and (98.01±5.08) mm in males and 87.73 (84.22, 90.98) mm and 87.51 (84.59, 90.15) mm in females. The left and right angles between the infra-acetabular screw axis and the median sagittal plane were -0.98°±4.79° and -1.08°±4.91° in men, and 6.20° (3.34°, 11.16°) and 6.44° (3.77°, 11.85°) in women. The differences in the above data between men and women were statistically significant ( P<0.05). There was no statistically significant difference between men and women in the angle between the infra-acetabular screw axis and the anterior pelvic plane ( P>0.05). Conclusions:The length and diameter of the infra-acetabular corridor in males are greater than those in females, the angle between the infra-acetabular corridor and the sagittal plane in males is smaller than that in females, and the infra-acetabular corridor in males is more parallel to the sagittal plane. Therefore, the fluoroscopy angle should be adjusted for males to reduce the difficulty in screw placement when an infra-acetabular screw is placed during surgery.

Objective:To investigate the effect of gracilis flap in repair of radiation-induced vesicovaginal fistula.Methods:The data of 18 patients with radiation-induced vesicovaginal fistula treated in the Sixth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2021 to August 2022 were retrospectively reviewed. Their age was (57.3±10.4) years. All patients underwent radical surgery for cervical cancer, and received (24.6±2.8)(range from 20 to 30)times of radiotherapy after surger. The median time between the end of radiotherapy and the onset of vesicovaginal fistula was 14.0(7.8, 18.2)months. The median duration of fistula urine was 12.0(9.8, 18.0)months. All patients were required to use median 19.5(15.8, 27.5) pads per day before surgery. The life quality score(QOL)of 18 cases was median 5.0(5.0, 6.0) points. Three cases had performed laparoscopic vesicovaginal fistula repair, two cases had underwent transvaginal vesicovaginal fistula repair, one case had underwent transvaginal and laparoscopic vesicovaginal fistula repair successively, and the remaining 12 cases were new vesicovaginal fistulas. Two cases were combined with rectovaginal fistulas. All patients underwent the repair of vesicovaginal fistula with gracilis flap interposition in prone and folded knife position, by transvaginal route, the vesicovaginal fistula was mobilized and the two layers were closed, and the vascular pedicle gracilis flap of left inner leg was romoved under the skin tunnel to repair the vesicovaginal fistula. Meanwhile, two cases combined rectovaginal fistulas were repaired and closed the rectovaginal fistulas. The urinary catheters were removed at 3 weeks after the operation and urination was recorded.Results:All patients underwent smooth surgery in (96.6±13.2) minutes. The median follow-up was 13.0(9.8, 20.2)(range from 6 to 24)months. The median number of urine pads used per day in 18 patients was 2.0(1.0, 11.8), and significantly reduced ( P<0.01).QOL score was median 1.0(0, 4.2) point and significantly reduced ( P<0.01).Successful outcome was achieved in 12 patients with no leakage of urine in the vagina. Two cases developed urinary incontinence and required conservative treatment, but the curative effect was poor. Two cases still had vaginal urine leakage performed vesicovaginal fistula repair again. One case was successfully repaired without significant urine leakage.The other case still had significant urine leakage and the QOL score was 3 points. She refused further treatment for self-satisfied. Two cases still had vesicovaginal fistula and rectovaginal fistula after the surgery, and refused further surgery. Conclusions:Repair with gracilis flap interposition is a surgical method with few complications and reliable surgical effect for patients with radiation-induced vesicovaginal fistula.

Objective:To explore the efficacy of pedicled bladder muscle flap in the repair of urinary tract obstruction.Methods:The data of 26 patients with urinary tract obstruction admitted to Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2016 to June 2021 were retrospectively reviewed. There were 14 males and 12 females, with the age ranged from 2 to 75 years old. Refractory bladder neck obstruction after prostatic hyperplasia surgery in 12 cases, with the age of (70.0±3.5) years old.They all experienced at least 2 times of transurethral stenosis incisionor resection. Transpubic cystostomy tube was placed in 9 patients. Posttraumatic pelvic fractures lead to bladder neck atresia and urethral injury in 6 girls, with the age of (10.5±2.1) years old. The bladder neck atresia and urethral obliteration length was 1-2 cm determined by urethrography. Eight cases suffered ureteral strictures after gynecological myomectomy or ureteroscopy holmium laser lithotripsy(4 cases of each type), including two males and six females, with the age of (55.0±3.2) years old. The length of ureteral stricture or defect was 5-6 cm determined by intravenous urography(IVU) or CT urography(CTU). The patients with bladder neck obstruction underwent the following surgery: The "Y" incision of the bladder and stenosis of the prostate urethra was performed and the pedicled bladder muscle flap was inserted into the normal urethral mucosa to complete the Y-V plasty. In the 6 girl patients, pedicled bladder muscle flap(2-4 cm) augmented reconstruction were performed. All above 18 patients, whose urethral catheter was indwelled for 3-4 weeks, urinary flow rate and urethroscopy examination were performed to evaluate the effect of surgery 4 weeks and 3 months after the operation. As the 8 cases with ureteral strictures, the pedicled bladder muscle flap (7-8 cm) ureteroplasty was performed and the ureteral stent was retained for 4 weeks. Ultrasonography and IVU/CTU were performed 4 weeks and 3 months postoperatively. The patency of the ureteral lumen and whether it is accompanied by hydronephrosis, lower back pain, and urinary tract infection were assessed.Results:All patients underwent pedicled bladder muscle flap reconstructive surgery successfully and no serious complications occurred postoperatively. The patients were followed up for (8.2± 2.2) months. As urethral catheters were removed, 10 patients with refractory neck obstruction could return to normal urination with the urinary flow Q max (17.2±2.8)ml/s, while 2 patient had dysuria and were treated with regular urethral dilatation. The catheter was removed 4 weeks after the reconstructive surgery in 6 girls with bladder neck atresia and urethral injury after posttraumatic pelvic fracture. Five could successfully urinate with the urinary flow Q max of (16.7±1.1)ml/s, and one girl had urinary incontinence, waiting for further operation.The ureteral stent was removed after ureteroplasty in 8 patients. CTU and IVU examination showed no ureters with obstruction.No one had low back pain, discomfort, or urinary tract infection. Conclusions:The reconstruction using the pedicled bladder muscle flap was a convenient, minimally invasive and effective technique for the management of adjacent lower ureters, bladder neck, and proximal urethra.