The European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) have recently updated and published the 2024 ESC guidelines for the management of atrial fibrillation. Based on the latest evidences, the guidelines have been updated in many aspects, such as diagnostic criteria for atrial fibrillation, AF-CARE treatment principles, comorbidities and risk factor management. In particular, there are significant changes in the recommendations for surgical management of atrial fibrillation in the guidelines. Therefore, this paper aims to interpret the content updates of the guidelines in AF-CARE treatment principles, diagnostic criteria and surgical treatment of atrial fibrillation, especially highlighting the updates and new suggestions about surgical treatment of atrial fibrillation.

Objective: To assess the association between the metabolic score for insulin resistance index (METS-IR) and overactive bladder (OAB) in the US population，so as to explore the potential of METS-IR as a predictive tool for OAB risk and to provide insights for early screening and intervention strategies. Methods: Based on the data from the National Health and Nutrition Examination Survey (NHANES) 2005-2018，a cross-sectional design was employed，and multivariate logistic regression models were used to analyze the association between METS-IR and OAB. METS-IR was analyzed both as a continuous variable and categorized into quartiles. To further validate the association between METS-IR and OAB across diverse populations，subgroup analyses were conducted in participants stratified by clinical characteristics. Smooth curve fitting was employed to test the linearity of the METS-IR-OAB relationship. Results: Elevated METS-IR was associated with an increased risk of OAB (P<0.001)，and this positive correlation remained stable when METS-IR was categorized into quartiles (P<0.001). Subgroup analyses revealed that the association between METS-IR and OAB was more pronounced in females，participants younger than 55 years，and non-diabetic individuals (P<0.05). Furthermore，smooth curve fitting confirmed a linear positive correlation between METS-IR and OAB，with this linear relationship observed in both diabetic and non-diabetic groups. Conclusion: This study，based on the NHANES 2005-2018 database，found a linear positive correlation between METS-IR and OAB.

OBJECTIVE To evaluate the cost-effectiveness of dapagliflozin and empagliflozin in the treatment of type 2 diabetic kidney disease from the perspective of healthcare system in China. METHODS Based on the data from the two multicenter clinical trials， DECLARE-TIMI 58 and EMPA-REG OUTCOME， a Markov model was constructed according to the urinary albumin-to-creatinine ratio （UACR） of the patients with type 2 diabetic kidney disease with a cycle of 1 year， simulating until 99% of patients died. The model outputs were total costs and quality-adjusted life year （QALY）. The cost-effectiveness of the two treatment regimens was assessed by comparing their incremental cost-effectiveness ratio （ICER） and the willingness-to-pay threshold （WTP，set at three times China’s 2023 per capita gross domestic product， i.e.， 268 074 yuan/QALY）. Additionally， oneway sensitivity analysis and probabilistic sensitivity analysis were performed to test the robustness of the base analysis results. RESULTS Compared with dapagliflozin， the ICER for empagliflozin regimen was 44 334.82 yuan/QALY， which was below the WTP ， indicating its cost-effectiveness. The results of the oneway sensitivity analysis indicated that the incidence of non-fatal myocardial infarction in both groups and the utility values associated with the microalbuminuria state had the most significant impact on the outcomes， but did not change the base-case conclusion. The probabilistic sensitivity analysis indicated that the results of the base-case analysis were robust. CONCLUSIONS With a WTP of three times China’s per capita gross domestic product in 2023， empagliflozin is more cost-effective than dapagliflozin in treating type 2 diabetic kidney disease.

BACKGROUND:Irisin,a myokine isolated from the transmembrane protein FNDC5 by muscle cells during exercise,has the function of inducing the browning of white adipose tissue,but its effect on lipotoxicity-induced osteogenic differentiation and the mechanism is unclear. OBJECTIVE:To investigate the effect of irisin on the osteogenic ability of palmitic acid-induced bone marrow mesenchymal stem cells and the mechanism of action. METHODS:CCK-8 assay was used to detect the effect of different concentrations of palmitic acid on the proliferation of mouse bone marrow mesenchymal stem cells and the effect of irisin on the proliferation of mouse bone marrow mesenchymal stem cells in the presence of palmitic acid.After pretreatment with irisin and palmitic acid for 24 hours,osteogenic differentiation of mouse bone marrow mesenchymal stem cells was induced by alkaline phosphatase staining as well as qRT-PCR was performed to detect the expression of osteogenesis-related genes on day 7 of osteogenic induction culture.The expression of proteins related to the AMPK/BMP2/SMAD signaling pathway was detected by western blot assay.Alizarin red staining was conducted on day 21 to detect osteogenic differences. RESULTS AND CONCLUSION:(1)The CCK-8 assay results suggested that the amplification of bone marrow mesenchymal stem cells was inversely proportional to the concentration of palmitic acid,but at 0.02 mmol/L concentration,palmitic acid had no significant effect on the amplification of bone marrow mesenchymal stem cells,and irisin did not affect the proliferation of bone marrow mesenchymal stem cells when its mass concentration was in the range of 0.1-20 μg/L.(2)Alkaline phosphatase staining and alizarin red staining showed that palmitic acid inhibited the osteogenic differentiation ability of bone marrow mesenchymal stem cells.Irisin improved palmitic acid-induced osteogenic inhibition of bone marrow mesenchymal stem cells.qRT-PCR results showed that palmitic acid could cause the downregulation of osteogenic-related genes,and irisin could inhibit this trend.(3)Western blot assay results showed that compared with the palmitic acid intervention group,irisin treatment enhanced AMPK/BMP2/SMAD signal transduction in bone marrow mesenchymal stem cells.It is found that irisin can improve the osteogenic differentiation ability of bone marrow mesenchymal stem cells pretreated with palmitic acid,and proposed that the specific mechanism might be mediated by AMPK/BMP/SMAD signaling pathway.

BACKGROUND:At present,the treatment methods for necrotizing fasciitis mostly use negative pressure sealing suction after thorough debridement.This method requires repeated debridement to completely remove necrotic infected tissue,causing serious physical and economic burdens to patients. OBJECTIVE:To introduce a rare clinical case of calf compartment syndrome caused by diabetic foot necrotizing fasciitis,and summarize the clinical experience of using antibiotic-loaded bone cement for treatment and comprehensive management. METHODS:A total of 6 patients with calf compartment syndrome caused by diabetic necrotizing fasciitis admitted to Wuxi 9th Affiliated Hospital of Soochow University from August 2017 to August 2020 were selected,including 5 males and 1 female with an average age of 54 years.During the perioperative period,the patients'general condition was evaluated and systemic nutritional support treatment was given.In the first stage,all patients received complete debridement to control infection,antibiotic-loaded bone cement packing,and negative pressure sealed drainage.In the second stage,bone cement was removed and wound repair was performed.The wound healing,as well as the occurrence of redness,swelling,and exudation was observed during the follow-up. RESULTS AND CONCLUSION:(1)The wounds of four patients were fresh after twice antibiotic-loaded bone cement packing,and the membrane formation was good,and one patient was good after three times of antibiotic-loaded bone cement packing,and the wounds of all five patients healed well after the second stage of skin grafting.Due to the difficulty in maintaining intraoperative blood pressure and infection in all four compartments of the lower leg,a patient underwent emergency knee amputation.Meanwhile,the stump wound was placed with antibiotic-loaded bone cement.The wound was closed directly after the secondary bone cement was removed,and the wound healed in the first stage.(2)The six patients were followed up for 6-24 months after discharge.At the last follow-up,all six patients had good wound healing and no symptoms such as redness,swelling,and exudation.The quality of life of the patients was significantly improved,and all of them were satisfied with the curative effect.(3)The occurrence of calf compartment syndrome should be vigilant when diabetic foot necrotizing fasciitis is highly suspected.Early diagnosis and timely incision decompression are of great importance.Besides,the application of antibiotic-loaded bone cement in the treatment of calf compartment syndrome caused by diabetic necrotizing fasciitis has a good short-term effect.

Objective:To investigate the feasibility and clinical effects of the application of augmented reality (AR) navigation on assisted design of the chimeric twin-paddled anterolateral thigh perforator flap (ALTPF) in reconstruction of soft tissue defects in extremities.Methods:From June 2017 to June 2023, 8 patients with soft tissue defects in extremities received reconstruction of chimeric twin-paddled ALTPF designed with the assistance of AR navigation in Department of Hand & Foot Microsurgery Orthopaedics, Guigang City People’s Hospital. All of them were traffic accidents or machine injuries, with 3 cases of calf, 2 cases of ankle, 1 case of foot, and 2 cases of hand defects. All the wounds were wide or irregular (defect sized 14 cm×14 cm-25 cm×13 cm). The images of bilateral thighs were acquired by CT angiography preoperatively. The dominant side and dominant perforators were selected. Three dimensional reconstruction was performed by Mimics software. AR technology was applied to guide the design and harvest of the chimeric twin-paddled ALTPF. Flap area was 15 cm × 16 cm to 26 cm × 14 cm. The donor site was sutured directly. Follow-up with outpatient visits or WeChat images and videos at 1, 3, 6 and 12 months postoperatively to record the appearance, colour, texture, recurrence of infection, and knee extension function of the flap donor site.Results:According to the preoperative design, the perforator flaps were harvested and transferred in all the 8 patients. All flaps survived and the recipient and donor sites healed in one stage. All patients entered postoperative follow-up for 3 to 12 (mean, 8.6)months. The colour and texture of the flaps were excellent, and the appearance of donor and recipient sites was satisfactory. Two patients with hand injuries were evaluated using the brief Michigan Hand Outcomes Questionnaire (MHQ), with scores of 43.74 and 81.25, respectively. Six patients with lower limb injuries were evaluated using the Maryland foot score, with scores of 2 excellent, 3 good and 1 fair.Conclusion:The application of AR navigation can effectively assist the design of a chimeric twin-paddled ALTPF. It also provides an effective basis for clinical personalised flap design.

Objective:To construct an assessment tool for laparoscopic left lateral sectionectomy skills.Methods:From November 2023 to January 2024, 22 clinical experts in hepatopancreatobiliary surgery from different regions of China were selected for this study. A preliminary indicator system was established through literature review, and the indicators and their weights at each level were determined using the Delphi method and analytic hierarchy process (AHP).Results:In the two rounds of consultation, the expert positive coefficients were 100.00% and 90.91%, authority coefficients were 0.984 and 0.985, Kendall coefficients were 0.231 and 0.193 ( P<0.001), and Cronbach's α coefficients were 0.905 and 0.865, respectively. A skill assessment tool for laparoscopic left lateral sectionectomy skills was constructed consisting of 5 primary indicators and 23 secondary indicators. AHP analysis showed that the concordance rate of each matrix of the secondary indicators was <0.1, meeting the consistency test requirements. Conclusions:The assessment tool for laparoscopic left lateral sectionectomy skills developed in this study is objective and reliable for evaluating the surgical skills of novice surgeons.

Objective To explore the clinical application value of deep learning image reconstruction(DLIR)-based technique for radiation dose reduction with different noise index(NI)in CT-guided percutaneous transthoracic needle biopsy(PTNB).Methods Thirty-two patients undergoing PTNB were selected,and three sets of CT images with NI of 15,30,and 45 sequentially were obtained after adjusting the puncture needle using the scanning parameters of a small range(40 mm),tube voltage 100 kV,and automatic tube cur-rent modulation(ATCM).Group A was 50％weight of adaptive statistical iterative reconstruction-Veo(ASIR-V)scanned with NI 15,and group B and C were the DLIR-high reconstructed images with NI 30 and NI 45 respectively.The CT value and standard devia-tion(SD)value of paraspinal muscles,subcutaneous fat,and arterial vessels were measured at the puncture center point and its upper and lower 10 mm sclices,respectively,and the signal-to-noise ratio(SNR)and the contrast-to-noise ratio(CNR)were also calculated.Then the images were subjectively scored by two physicians,meanwhile the effective dose(ED)among the three groups was com-pared.Results According to the subjective evaluation,the image quality of group A,B,and C all met the clinical requirement for puncture.The SD and SNR of the images in group B were better than those in groups A and C.The SD and SNR of paraspinal mus-cles and sudcutaneous fat were significantly different between groups A and B,and between groups B and C(P＜0.05),however those of paraspinal muscles and subcutaneous fat between groups A and C were not significant.The differences in ED among the three groups were all statistically significant(P＜0.05).Compared with group A,the ED in groups B and C were reduced by 82.86％and 93.90％respectively,and the ED in group C was reduced by 64.44％compared with group B.Conclusion Increasing the NI combined with the DLIR technique can significantly reduce the radi-ation dose during CT-guided PTNB.

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.

Replantation of traumatic amputation in children has its own characteristics. This consensus primarily focuses on the issues related to the treatment of traumatically amputated limb injuries in children. Organised along a timeline, the consensus summarises domestic and international clinical experiences in emergency care and injury assessment of traumatic limb amputation limbs, indications and contraindications for replantation surgery, principles and procedures of replantation surgery, postoperative medication and management, as well as rehabilitation in children. The aim of this consensus is to propose standardise the treatment protocols for limb replantation for children therefore to serve as a reference for clinical practitioners in medical practices, and further improve the treatment and care for the traumatic limb amputations in children.