Steroid-induced osteonecrosis of the femoral head （SONFH） is a severe musculoskeletal disorder often induced by the prolonged or excessive use of glucocorticoids. Characterized by ischemia of bone cells， necrosis， and trabecular fractures， SONFH is accompanied by pain， femoral head collapse， and joint dysfunction， which can lead to disability in severe cases. The pathogenesis of SONFH involves hormone-induced osteoblast apoptosis， bone microvascular endothelial cell （BMEC） apoptosis， oxidative stress， and inflammatory responses. The phosphatidylinositol 3-kinase/protein kinase B （PI3K/Akt） signaling pathway plays a pivotal role in the development of the disease. Modulating the PI3K/Akt signaling pathway can promote Akt phosphorylation， thereby stimulating the osteogenic differentiation of bone marrow mesenchymal stem cells and osteoblasts， promoting angiogenesis in BMECs， and inhibiting osteoclastogenesis. The research on the treatment of SONFH with traditional Chinese medicine （TCM） has gained increasing attention. Recent studies have shown that TCM monomers and compounds have potential therapeutic effect on SONFH by intervening in the PI3K/Akt signaling pathway. These studies not only provide a scientific basis for the application of TCM in the treatment of SONFH but also offer new ideas for the development of new therapeutic strategies. This review summarized the progress in Chinese and international research on the PI3K/Akt signaling pathway in SONFH over the past five years. It involved the composition and transmission mechanisms of the signaling pathway， as well as its regulatory effects on osteoblasts， mesenchymal stem cells， osteoclasts， BMECs， and other cells. Additionally， the review explored the TCM understanding of SONFH and the application of TCM monomers and compounds in the intervention of the PI3K/Akt pathway. By systematically analyzing and organizing these research findings， this article aimed to provide references and point out directions for the clinical prevention and treatment of SONFH and promote further development of TCM in this field. With in-depth research on the PI3K/Akt pathway and the modern application of TCM， it is expected to bring safer and more effective treatment options for patients with SONFH.

This study aimed to comprehensively examine the association of gallstones, cholecystectomy, and cancer risk. Multivariable logistic regressions were performed to estimate the observational associations of gallstones and cholecystectomy with cancer risk, using data from a nationwide cohort involving 239 799 participants. General and gender-specific two-sample Mendelian randomization (MR) analysis was further conducted to assess the causalities of the observed associations. Observationally, a history of gallstones without cholecystectomy was associated with a high risk of stomach cancer (adjusted odds ratio (aOR)=2.54, 95% confidence interval (CI) 1.50-4.28), liver and bile duct cancer (aOR=2.46, 95% CI 1.17-5.16), kidney cancer (aOR=2.04, 95% CI 1.05-3.94), and bladder cancer (aOR=2.23, 95% CI 1.01-5.13) in the general population, as well as cervical cancer (aOR=1.69, 95% CI 1.12-2.56) in women. Moreover, cholecystectomy was associated with high odds of stomach cancer (aOR=2.41, 95% CI 1.29-4.49), colorectal cancer (aOR=1.83, 95% CI 1.18-2.85), and cancer of liver and bile duct (aOR=2.58, 95% CI 1.11-6.02). MR analysis only supported the causal effect of gallstones on stomach, liver and bile duct, kidney, and bladder cancer. This study added evidence to the causal effect of gallstones on stomach, liver and bile duct, kidney, and bladder cancer, highlighting the importance of cancer screening in individuals with gallstones.
Humans ; Mendelian Randomization Analysis ; Gallstones/complications* ; Female ; Male ; Cholecystectomy/statistics & numerical data* ; Middle Aged ; Risk Factors ; Aged ; Adult ; Neoplasms/etiology* ; Stomach Neoplasms/epidemiology*

Objective: To comprehensively evaluate and analyze the transfusion outcomes of patients with acute upper gastrointestinal bleeding (UGIB). Methods: The transfusion management system and hospital information system (HIS) were used to retrospectively collect clinical data of 230 patients with UGIB admitted to Zhejiang Provincial People's Hospital and its branches from June 2018 to June 2021. 101 cases were screened and categorized into transfusion group (n=56) and non-transfusion group (n=45) based on transfusion outcomes. The cohort comprised 68 males and 33 females. A univariate model based on the AIMS65 score, a logistic multiple regression model, and multivariate transfusion models using machine learning methods (including Random Forest, Support Vector Machine, and Artificial Neural Network) were established. The sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curves of each model were compared. Results: For the univariate model based on the AIMS65 scoring, the optimal threshold was 1.5. This model demonstrated a sensitivity of 0.446, a specificity of 0.822, an AUC of 0.67, an accuracy (ACC) of 0.614, a Kappa value of 0.256, and an F1-score of 0.655. For logistics regression model (optimal critical probability: 0.459), the sensitivity was 0.929, specificity was 0.889, AUC was 0.96, ACC was 0.911, Kappa was 0.819, and F1-score was 0.899. For the Random Forest model (optimal critical probability: 0.458), the sensitivity was 0.964, specificity was 0.956, AUC was 0.99, ACC was 0.960, Kappa was 0.920, and F1-score was 0.956. For the Support Vector Machine model (optimal critical probability: 0.474), the sensitivity was 0.875, specificity was 0.933, AUC was 0.94, ACC was 0.901, Kappa was 0.801, and F1-score was 0.894. For the Artificial Neural Network model (optimal critical probability: 0.797), the sensitivity was 0.804, specificity was 0.956, AUC was 0.96, ACC was 0.871, Kappa was 0.745, and F1-score was 0.869. Ten-fold cross validation also confirmed the reliability of the results. Conclusion: Based on integrated various clinical test indicators of patients, we could establish logistic regression model and multiple machine learning models. These models hold significant value for predicting the need for blood transfusion in patients, indicating a promising application prospect for machine learning algorithms in transfusion prediction.

Objective:To analyze the efficacy and feasibility of performing a new surgical procedure, tunnel esophagogastrostomy, to perform proximal gastrectomy.Methods:The study cohort comprised 10 consecutive patients who had undergone esophagogastrostomy by the tunnel technique in Jiangsu Cancer Hospital between October 2019 and July 2022. All patients were male. Their average age was (64.2±8.1) years and body mass index (25.5±3.2) kg/m2. Nine had upper gastric body adenocarcinoma, the remaining one having signet ring cell carcinoma. TNM staging of the tumors showed that seven were Stage IA, one Stage IB, one Stage IIA, and one Stage IIIA. Briefly, tunnel esophagogastrostomy is performed as follows: After performing a proximal gastrectomy, a rectangular seromuscular flap (3.0 cm × 3.5 cm) is created. The posterior esophageal wall is sutured to the gastric wall at the orad end of the seromuscular flap 5 cm from the stump with three to four stitches. Next, the stump of the esophagus is opened, the posterior esophageal wall is sutured to the gastric mucosa and submucosa, and the anterior esophageal wall is sutured to the full layer of the stomach. Finally, the caudad end of the seromuscular flap is closed. Data on surgical safety, postoperative morbidity, and postoperative reflux esophagitis were analyzed. All enrolled patients completed endoscopic follow-up 1 year and 2 years after surgery.Results:All procedures were completed. They comprised four cases of laparoscopic assisted surgery, four of DaVinci robotic surgery, and two of open surgery. The mean operation time was 212.7±33.2 mins, mean anastomosis time (51.6±5.3) minutes, mean tunnel preparation time (20.0±3.5) minutes, and mean operative blood loss (90.0±51.6) mL. The time to first postoperative passage of flatus was (64.8±11.5) hours. The mean hospital stay after surgery was (9.2±1.7) days. There were no postoperative complications above Clavien-Dindo Grade II. The mean preoperative Reflux Disease Questionnaire score was (3.3± 0.4) before the surgery, (3.8±1.0) 1 month postoperatively, and (3.3±0.4) 12 months postoperatively. All patients underwent endoscopic follow-up; no anastomotic stenoses were found. However, one patient had Grade A reflux esophagitis 1 year after surgery and another Grade B reflux esophagitis 2 years after surgery.Conclusion:Esophagogastrostomy by the tunnel technique is a safe and feasible means of performing proximal gastrectomy.

Objective:To explore the surgical strategies and clinical efficacy for aortic dissection combined with refractory superior mesenteric artery (SMA) ischemia.Methods:This is a retrospective case series study. Clinical data of 24 patients with aortic dissection and refractory SMA ischemia admitted to the Department of Vascular Surgery, Zhongshan Hospital, Fudan University from August 2010 to August 2020 were retrospectively collected. Of the 24 patients, 21 were males and 3 were females, with an age of (50.3±9.9) years (range: 44 to 72 years).Among them, 9 cases were Stanford type A aortic dissection, and 15 cases were type B. All patients underwent CT angiography upon admission, and based on imaging characteristics, they were classified into three types. Type Ⅰ: severe stenosis/occlusion of the SMA true lumen only; Type Ⅱ: stenosis of the true lumens in the descending aorta and SMA (isolated type); Type Ⅲ: stenosis of the true lumens in the thoracoabdominal aorta and SMA (continuation type). Surgical procedures, complications, mortality, and reintervention rates were recorded.Results:Among the 24 patients, 17 (70.8%) were classified as Type Ⅰ, 4 (16.7%) as Type Ⅱ, and 3 (12.5%) as Type Ⅲ. Fourteen cases of Type Ⅰ underwent thoracic endovascular aortic repair combined with SMA stent implantation. Additionally, 3 Type Ⅰ and 1 Type Ⅱ patients underwent only SMA reconstruction (with one case of chronic TAAD treated with iliac artery-SMA bypass surgery). Moreover, 3 Type Ⅱ and 3 Type Ⅲ patients underwent descending aorta combined with SMA stent implantation. There were 5 patients (20.8%) who underwent small bowel resection, either in the same sitting or in a staged procedure. During hospitalization, 4 patients died, resulting in a mortality rate of 16.7%. Among these cases, two patients succumbed to severe intestinal ischemia resulting in multiple organ dysfunction syndrome. The follow-up duration was (46±9) months (range: 13 to 72 months). During the follow-up, 2 patients died, unrelated to intestinal ischemia. The 5-year freedom from reintervention survival rate was 86.1%, and the 5-year cumulative survival rate was 82.6%.Conclusions:Patients with aortic dissection and refractory SMA ischemia have a high perioperative mortality. However, implementing appropriate surgical strategies according to different clinical scenarios can reduce mortality and alleviate intestinal ischemia.

Objective:To evaluate the clinical outcomes of thoracic endovascular aortic repair (TEVAR) in the treatment of Stanford type B aortic dissection (TBAD) in Marfan syndrome patients who had no history of aortic arch replacement.Methods:This is a retrospective case-series study. From January 2009 to December 2019,the clinical data of Marfan syndrome patients who underwent TEVAR for TBAD at the Department of Vascular Surgery were collected. A total of 23 patients were enrolled,including 15 males and 8 females. The age was (38.0±11.0) years (range:24 to 56 years). Among them,12 patients had history of ascending aortic surgery. Details of TEVAR,perioperative complications and reintervention were recorded and survival rate was analyzed by Kaplan-Meier curve.Results:Technical success was 91.3% (21/23). Two patients with technical failure were as follows:one patient had type Ⅰa endoleak at the completion angiography,which healed spontaneously during the follow-up,and the other patient suffered aortic intimal intussusception after the deployment of the first stent-graft, and the second stent-graft was deployed. However, type Ⅲ endoleak was detected,which disappeared during the follow-up. One patient died during hospitalization. The median follow-up time ( M(IQR)) was 60 (48) months (range:12 to 132 months). Reintervention was performed on 7 patients,including 3 distal stent-graft-induced new entry,2 distal aortic dilation,1 Ⅰa endoleak and 1 retrograde type A aortic dissection,respectively. Five-year cumulative survival rate was 86.7% (95% CI:86.6% to 86.8%) and the 5-year freedom from reintervention rate was 81.8% (95% CI:61.8% to 92.8%). Conclusions:TEVAR is feasible in the treatment of TBAD in Marfan syndrome patients who has no history of aortic arch replacement. It has high technical success rate and low perioperative complication.

Chronic pain is a subjective experience that is difficult to accurately and objectively assess.Electroencephalography(EEG)can record physiological electrical signals generated during brain activity,and time signals reflect brain activity during task processing.The frequency signals reflect quiet brain activity.This paper reviews changes of event-related potential in EEG time signal,changes of different frequency bands in frequency signal and changes of event-related synchronization or desynchronization between the two signals in patients with chronic pain.

Objective:To investigate the strategies and clinical effects of free tissue flaps in repairing massive destructive burn wounds.Methods:This study was a retrospective observational study. From June 2014 to October 2023, 51 burn patients with 53 massive destructive burn wounds which met the inclusion criteria were admitted to Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 47 males and 4 females, aged 21 to 77 years. After debridement, the wound area needed to be repaired by tissue flaps ranged from 20.0 cm×12.5 cm to 50.0 cm×15.0 cm. Emergency, early, or delayed transplantation of tissue flaps was performed to repair the wounds. Six head, face, and neck wounds, 5 upper limb wounds, and 1 lower limb wound were repaired with latissimus dorsi myocutaneous flaps. Eleven upper limb wounds and 6 lower limb wounds were repaired with anterolateral thigh flaps. Seven upper limb wounds, 5 lower limb wounds, and 2 face and neck wounds were repaired with paraumbilical perforator flaps. One lower limb wound was repaired with lower abdominal flap. Two face and neck wounds, 2 upper limb wounds, and 1 lower limb wound were repaired with inguinal flaps. One upper limb wound was repaired with scapular flap. One trunk wound was repaired with the "fillet flap" from the abandoned upper limb after amputation. Three head, face, and neck wounds, 3 lower limb wounds, and 1 upper limb wound were repaired with omental flaps. Four wounds were repaired by combined transplantation of the above-mentioned tissue flaps. Three wounds were repaired by fractional transplantation of the above-mentioned tissue flaps. The size of a single harvested tissue flap ranged from 15.0 cm×5.0 cm to 45.0 cm×25.0 cm. The arterial and venous anastomoses were added as the circumstances might require to improve tissue flap circulation. The wounds in the flap donor sites were sutured directly or repaired by split-thickness skin grafts from head. The general condition of patients during treatment was recorded. After surgery, the survival of tissue flaps, the healing of wounds in the recipient sites, limb salvage, the healing of wounds in the flap donor sites, and the survival of skin grafts were observed. The healing of wounds in the recipient sites was observed during follow-up. At the last follow-up, the upper limb function after successful limb salvage was evaluated by the Arm, Shoulder, and Hand Disability Scoring Scale, the weight-bearing walking ability of patients with successful lower limb salvage was evaluated by the Holden walking ability classification, and the patient's satisfaction with the efficacy was assessed by 5-grade Likert scale.Results:During treatment, one case with electrical burn of the head suffered from aggravated cerebral edema, cerebral hernia and coma recurred. After dehydration, hormone therapy, and so on, the patient recovered and incomplete hemiplegia on the right limb was left. The shock symptoms of 4 patients got worse, which were gradually controlled after anti-shock with fluid supplement and colloid injection. One patient developed hemorrhagic shock after tissue flap transplantation, which was corrected by fluid infusion and red blood cell suspension transfusion. Vascular crisis occurred in 3 tissue flaps after surgery, of which 2 survived and 1 eventually became necrotic after exploration. Partial necrosis occurred in 2 tissue flaps and slight necrosis occurred at the edge of 5 tissue flaps, which all healed after tissue flap trimming, vacuum sealing drainage (VSD), and skin grafting treatment. All the other tissue flaps survived. There were 12 recipient wounds with residual necrotic tissue after surgery, which healed after debridement, VSD, and skin grafting treatment. The remaining 41 wounds healed well. Among the 40 limb wounds of 39 patients, 5 patients had 3 upper limb and 2 lower limb amputations. The remaining 35 limbs of 34 patients were successfully salvaged. The donor site wounds healed well, and the skin grafts survived well. During the follow-up of 6 to 52 months, all the head, face, neck, and trunk wounds were well repaired. The fester recurred in 7 limb wounds 3 to 9 months after surgery and healed after debridement, drainage, and tissue flap repair. At the last follow-up, the functional scores of 22 upper limbs after successful limb salvage ranged from 0 to 100 (with an average of 50), and the Holden walking ability classification of 12 patients with 13 lower limbs after successful limb salvage was level Ⅴ in 8 cases, level Ⅳ in 2 cases, and level Ⅲ in 2 cases. The patients were very satisfied with the efficacy in 33 cases, relatively satisfied in 12 cases, and not quite satisfied in 6 cases.Conclusions:Systematic evaluation and treatment of the whole body condition, choosing the appropriate repair time, and using appropriate tissue flaps to repair massive destructive burn wounds will help ensure the safety of treatment, improve the repair effect, and reduce the injury of donor sites, thus optimizing the repair effect.

Objective:To explore the surgical strategies and clinical efficacy for aortic dissection combined with refractory superior mesenteric artery (SMA) ischemia.Methods:This is a retrospective case series study. Clinical data of 24 patients with aortic dissection and refractory SMA ischemia admitted to the Department of Vascular Surgery, Zhongshan Hospital, Fudan University from August 2010 to August 2020 were retrospectively collected. Of the 24 patients, 21 were males and 3 were females, with an age of (50.3±9.9) years (range: 44 to 72 years).Among them, 9 cases were Stanford type A aortic dissection, and 15 cases were type B. All patients underwent CT angiography upon admission, and based on imaging characteristics, they were classified into three types. Type Ⅰ: severe stenosis/occlusion of the SMA true lumen only; Type Ⅱ: stenosis of the true lumens in the descending aorta and SMA (isolated type); Type Ⅲ: stenosis of the true lumens in the thoracoabdominal aorta and SMA (continuation type). Surgical procedures, complications, mortality, and reintervention rates were recorded.Results:Among the 24 patients, 17 (70.8%) were classified as Type Ⅰ, 4 (16.7%) as Type Ⅱ, and 3 (12.5%) as Type Ⅲ. Fourteen cases of Type Ⅰ underwent thoracic endovascular aortic repair combined with SMA stent implantation. Additionally, 3 Type Ⅰ and 1 Type Ⅱ patients underwent only SMA reconstruction (with one case of chronic TAAD treated with iliac artery-SMA bypass surgery). Moreover, 3 Type Ⅱ and 3 Type Ⅲ patients underwent descending aorta combined with SMA stent implantation. There were 5 patients (20.8%) who underwent small bowel resection, either in the same sitting or in a staged procedure. During hospitalization, 4 patients died, resulting in a mortality rate of 16.7%. Among these cases, two patients succumbed to severe intestinal ischemia resulting in multiple organ dysfunction syndrome. The follow-up duration was (46±9) months (range: 13 to 72 months). During the follow-up, 2 patients died, unrelated to intestinal ischemia. The 5-year freedom from reintervention survival rate was 86.1%, and the 5-year cumulative survival rate was 82.6%.Conclusions:Patients with aortic dissection and refractory SMA ischemia have a high perioperative mortality. However, implementing appropriate surgical strategies according to different clinical scenarios can reduce mortality and alleviate intestinal ischemia.

Objective:To evaluate the clinical outcomes of thoracic endovascular aortic repair (TEVAR) in the treatment of Stanford type B aortic dissection (TBAD) in Marfan syndrome patients who had no history of aortic arch replacement.Methods:This is a retrospective case-series study. From January 2009 to December 2019,the clinical data of Marfan syndrome patients who underwent TEVAR for TBAD at the Department of Vascular Surgery were collected. A total of 23 patients were enrolled,including 15 males and 8 females. The age was (38.0±11.0) years (range:24 to 56 years). Among them,12 patients had history of ascending aortic surgery. Details of TEVAR,perioperative complications and reintervention were recorded and survival rate was analyzed by Kaplan-Meier curve.Results:Technical success was 91.3% (21/23). Two patients with technical failure were as follows:one patient had type Ⅰa endoleak at the completion angiography,which healed spontaneously during the follow-up,and the other patient suffered aortic intimal intussusception after the deployment of the first stent-graft, and the second stent-graft was deployed. However, type Ⅲ endoleak was detected,which disappeared during the follow-up. One patient died during hospitalization. The median follow-up time ( M(IQR)) was 60 (48) months (range:12 to 132 months). Reintervention was performed on 7 patients,including 3 distal stent-graft-induced new entry,2 distal aortic dilation,1 Ⅰa endoleak and 1 retrograde type A aortic dissection,respectively. Five-year cumulative survival rate was 86.7% (95% CI:86.6% to 86.8%) and the 5-year freedom from reintervention rate was 81.8% (95% CI:61.8% to 92.8%). Conclusions:TEVAR is feasible in the treatment of TBAD in Marfan syndrome patients who has no history of aortic arch replacement. It has high technical success rate and low perioperative complication.