AIM: To explore the factors influencing heart rate(HR)changes during small incision lenticule extraction(SMILE)surgery by monitoring HR trends at different time points of the procedure.METHODS: Prospective cohort study. A total of 69 patients who underwent SMILE surgery at the Laser Vision Correction Center of Xi'an No.1 Hospital from April to May 2024 were enrolled. Before the surgery, patients completed the State Anxiety Inventory(S-AI, questions 1-20)to assess their preoperative anxiety scores related to the next day's surgery. Baseline HR was recorded using medical pulse oximeter, and real-time HR was recorded during patient positioning, lenticule scanning, lenticule separation and extraction, and the application of postoperative eye drops.RESULTS: The HR during patient positioning was 83.61±13.87 bpm, which was significantly different from the baseline HR(77.52±10.88 bpm), HR during lenticule separation and extraction(75.54±12.52 bpm), and HR during postoperative eye drop application(76.65±10.54 bpm; all P<0.001). When stratified by median age, older patients(>26 years)had the HR during lenticule separation and extraction 76.27±9.93 bpm, which differed from the HR at positioning(84.82±14.10 bpm)and at lens scanning(82.76±13.72 bpm; all P<0.005). Stratified by gender, the HR of male patients at positioning was the highest(85.31±16.61 bpm), which differed significantly from the baseline HR(78.26±12.63 bpm), HR during lenticule separation and extraction(77.14±14.59 bpm), and HR during postoperative eye drop application(77.11±12.49 bpm; all P<0.005). There was no correlation between HR during positioning and preoperative anxiety scores(r=0.124, P=0.418).CONCLUSION: HR changes during SMILE surgery vary with different procedural stages, peaking during patient positioning and reaching the lowest point during lenticule separation and extraction. Older patients showed higher HR during positioning, and male patients exhibited higher HR during positioning.

AIM: To investigate the decentration of the treatment zone(TZ)and the early impact on corneal higher-order aberrations(HOAs)induced by orthokeratology(OK)lenses fitted with digital corneal topography.METHODS: A retrospective longitudinal clinical study was conducted on 28 patients(28 right eyes)who were digitally fitted with OK lenses at the Laser Vision Center of Xi'an No.1 Hospital since 2023. Longitudinal measurements were taken at baseline, 1 wk, 1 and 3 mo post-treatment to assess changes in TZ diameter, decentration magnitude and direction. Furthermore, changes in corneal HOAs were observed, and correlations of decentration with each HOAs were also analyzed.RESULTS: The mean age of patients was 10.29±2.00 years, with 15 males and 13 females, and the average baseline spherical equivalent was -2.92±0.94 D. The average TZ diameters at 1 wk, 1, and 3 mo were 3.64±0.58, 3.83±0.57, and 3.69±0.55 mm, respectively, with no statistically significant differences between 1 wk and 3 mo. Horizontal decentration values were -0.43±0.28, -0.38±0.33, and -0.31±0.37 mm after wearing lenses for 1 wk, 1 and 3 mo, respectively, while vertical decentration values were -0.33±0.20, -0.33±0.23, and -0.36±0.23 mm across the same time points. The TZ consistently decentered inferotemporally, and changes in both horizontal and vertical decentration over time were not statistically significant(Fhorizontal=1.416, Phorizontal=0.252; Fvertical=0.126, Pvertical=0.882). Significant increases in total corneal HOAs, coma, and spherical aberration were observed at 5 mm optical zone post-wear(F=45.695, 33.401, and 45.091, all P<0.001). Vertical decentration at 1 wk and 1 mo was negatively correlated with total HOAs and coma(all P<0.05), while horizontal decentration at 3 mo showed a weak negative correlation with spherical aberration(P=0.037).CONCLUSION: Digitally-fitted OK lenses achieved stable TZ diameter by 1 wk post-wear, with minor inferotemporal decentration. Early post-wear corneal total HOAs, coma and sphercal aberration increased significantly, and vertical downward decentration was associated with elevated total HOAs and coma. However, correlations between decentration and HOAs weakened by 3 mo.

AIM: To evaluate the clinical outcomes of using the cross-positioning method for correcting low and moderate astigmatism during small incision lenticule extraction(SMILE)surgery with Alpins vector analysis.METHODS: A total of 50 patients(81 eyes)with low and moderate astigmatism with the rule ≤1.50 D who underwent SMILE surgery at the laser myopia treatment center of Xi'an No.1 Hospital from May 2022 to November 2022 were included in the prospective randomized controlled study, and they were divided into two groups according to the random table, with 25 case(41 eyes)in cross-positioning group and 25 cases(40 eyes)in control group. In the cross-positioning group, the patients' head position was adjusted based on the cross intersection lines before the standard SMILE procedure, aligning the lateral canthi with the horizontal line and the midpoint of the eyebrows and the nose bridge with the vertical line. Postoperative visual acuity and refractive results at 3 mo were observed in both groups, and astigmatic changes were analyzed and evaluated using the Alpins vector analysis method.RESULTS: During the follow-up period, 6 cases(11 eyes)in the cross-positioning group were lost to follow-up, while in the control group, 8 cases(14 eyes)were lost to follow-up, with 19 cases(30 eyes)and 17 cases(26 eyes)finally included in the cross-positioning group and the control group, respectively. At 3 mo postoperatively, the uncorrected visual acuity(UCVA)of both groups' operated eyes was ≥1.0, and no serious complications occurred, with no significant differences in UCVA, best corrected visual acuity(BCVA), spherical power, and spherical equivalent between the cross-positioning group and the control group(all P>0.05). The cylindrical power in the cross-positioning group was 0.00(0.00, 0.00)D, which was lower than -0.13(-0.50, 0.00)D in the control group(P=0.01). The vector analysis results showed that the difference vector(DV)in the cross-positioning group was lower than that in the control group [0.00(0.00, 0.00)vs 0.13(0.00, 0.50), P=0.01], and the index of success(IOS)was better than that of the control group [0.00(0.00, 0.00)vs 0.18(0.00, 0.77), P<0.01]. At 3 mo postoperatively, 26(87%)and 15(58%)eyes in the cross-positioning group and control groups achieved an angle of error(AE)within ±5°, respectively.CONCLUSION: The cross positioning method was used to calibrate the patients' head position during SMILE surgery, which reduced the axial position error and improved the accuracy of SMILE in correcting low and moderate astigmatism.

Myopia is becoming more and more common all over the world, and the incidence of myopia is gradually increasing. Many treatments have been used to prevent and control myopia, including optics, drugs, environment or behavior, but the results are different and lack standardization. At present, many experiments have proved that peripheral defocus technology has a certain effect on myopia control. Based on this technology, three kinds of framed eyeglass lenses with peripheral defocus design, namely defocus incorporated multiple segments(DIMS), highly aspherical lenslets(HAL)and cylindrical annular reactive elements(CARE), are commonly used in medical and optometry institutions in China. These lenses provide not only clear vision in the central area, but also a certain amount of myopic defocus in the periphery to control the progression of myopia. This paper aims to focus on the design principle and myopia prevention and control effect of the above three peripheral defocus lenses, and evaluate their effectiveness in clinical practice.

Objective:To investigate the safety and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis and treatment of pediatric pancreaticobiliary maljunction (PBM).Methods:Data of 40 pediatric patients under 14 with PBM diagnosed and treated by ERCP at Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from November 2012 to September 2022 were collected. PBM types, ERCP-related diagnosis and treatment, adverse events and prognosis were retrospectively analyzed.Results:Nineteen cases were P-B type (joining of common bile duct with pancreatic duct), 17 were B-P type (joining of pancreatic duct with common bile duct), and 4 were complex type. Forty children with PBM underwent 50 ERCP-related operations, among which 48 procedures succeeded. One case failed during cannulation of ERCP, replaced by rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP) afterwards. There were no serious postoperative adverse events such as bleeding, perforation or death. Thirty-four patients (85%) were followed up successfully, among which 14 underwent further surgery and 20 continued conservative treatment.Conclusion:ERCP is the golden standard to diagnose pediatric PBM, and it is also safe and effective treatment for PBM.

Objective This study aimed to investigate the potential relationship between urinary metals copper (Cu), arsenic (As), strontium (Sr), barium (Ba), iron (Fe), lead (Pb) and manganese (Mn) and grip strength. Methods We used linear regression models, quantile g-computation and Bayesian kernel machine regression (BKMR) to assess the relationship between metals and grip strength.Results In the multimetal linear regression, Cu (β=-2.119), As (β=-1.318), Sr (β=-2.480), Ba (β=0.781), Fe (β= 1.130) and Mn (β=-0.404) were significantly correlated with grip strength (P < 0.05). The results of the quantile g-computation showed that the risk of occurrence of grip strength reduction was -1.007 (95％ confidence interval:-1.362, -0.652; P < 0.001) when each quartile of the mixture of the seven metals was increased. Bayesian kernel function regression model analysis showed that mixtures of the seven metals had a negative overall effect on grip strength, with Cu, As and Sr being negatively associated with grip strength levels. In the total population, potential interactions were observed between As and Mn and between Cu and Mn (Pinteractions of 0.003 and 0.018, respectively).Conclusion In summary, this study suggests that combined exposure to metal mixtures is negatively associated with grip strength. Cu, Sr and As were negatively correlated with grip strength levels, and there were potential interactions between As and Mn and between Cu and Mn.

Osteoporotic proximal humeral fracture (OPHF) is one of the common osteoporotic fractures in the aged, with an incidence only lower than vertebral compression fracture, hip fracture, and distal radius fracture. OPHF, secondary to osteoporosis and characterized by poor bone quality, comminuted fracture pattern, slow healing, and severely impaired shoulder joint function, poses a big challenge to the current clinical diagnosis and treatment. In the field of diagnosis, treatment, and rehabilitation of OPHF, traditional Chinese and Western medicine have accumulated rich experience and evidence from evidence-based medicine and achieved favorable outcomes. However, there is still a lack of guidance from a relevant consensus as to how to integrate the advantages of the two medical systems and achieve the integrated diagnosis and treatment. To promote the diagnosis and treatment of OPHF with integrated traditional Chinese and Western medicine, relevant experts from Orthopedic Expert Committee of Geriatric Branch of Chinese Association of Gerontology and Geriatrics, Youth Osteoporosis Group of Orthopedic Branch of Chinese Medical Association, Osteoporosis Group of Orthopedic Surgeon Branch of Chinese Medical Doctor Association, and Osteoporosis Committee of Shanghai Association of Integrated Traditional Chinese and Western Medicine have been organized to formulate Expert consensus on the diagnosis and treatment of osteoporotic proximal humeral fracture with integrated traditional Chinese and Western medicine ( version 2024) by searching related literatures and based on the evidences from evidence-based medicine. This consensus consists of 13 recommendations about the diagnosis, treatment and rehabilitation of OPHF with integrated traditional Chinese medicine and Western medicine, aimed at standardizing, systematizing, and personalizing the diagnosis and treatment of OPHF with integrated traditional Chinse and Western medicine to improve the patients ′ function.

Objective:To investigate the mid-to-long term therapeutic effects of allogeneic bone composite prosthesis reconstruction in patients with large bone defects after the resection of distal femoral tumors.Methods:From June 2013 to December 2018, a total of 19 patients with malignant tumors of the distal femur who underwent reconstruction with allogeneic bone composite prosthesis in the Department of Bone Tumor, Shanghai General Hospital were retrospectively collected. There were 10 males and 9 females, aged 22.3±11 years (range, 11-42 years). The mean body mass index was 19.3±3.4 kg/m 2 (range, 14-27 kg/m 2). There were 18 cases of osteosarcoma and 1 case of Ewing's sarcoma. According to Ennecking staging, there were 17 cases of stage IIB and 2 cases of stage III. The intraoperative blood loss and operation time were recorded, and the prosthesis and patient survival conditions and postoperative complications were observed. The limb function was evaluated by the Musculoskeletal Tumor Society (MSTS) 93 function score. Results:All patients successfully completed the operation. The operation time was 187.3±39.8 min (range, 110-260 min), the intraoperative blood loss was 284.9±87.0 ml (range, 200-500 ml), and the blood transfusion volume was 327±213 ml (range, 100-800 ml). The remaining length of the proximal femur was 153.7±26.6 mm (range, 93-190 mm), and the length of allogeneic bone was 84.1±24.6 mm (range, 39-134 mm). Among the 19 patients, 9 patients (47%) achieved bony union with an average healing time of 16.7±4.8 months (range, 10-25 months), and 7 patients had delayed healing with an average healing time of 18.4±4.0 months (range, 15-25 months). The remaining 10 cases were nonunion between allogeneic bone and host bone. All patients were followed up for 80.7±20.2 months (range, 56-121 months). During the follow-up, 3 cases died due to pulmonary metastasis of bone tumors, and the time of death was 57 months, 63 months, and 59 months after surgery, respectively. At the last follow-up, the patient survival rate was 84% (16/19), and the MSTS 93 function score of the 16 patients was (24.3±2.4) points (range, 21-28 points), with an excellent rate of 100% (16/16). Seven patients underwent revision surgery, 3 cases were aseptic loosening, 3 cases were prosthesis stem fracture at the junction of the allograft bone and the host bone, and 1 case was periprosthetic infection, among which the patient with periprosthetic infection had poor local soft tissue conditions due to preoperative radiotherapy, and the infection was controlled after two revision surgeries. Five cases were revised with allogeneic bone composite prosthesis, and 2 cases were revised with short-stem giant prosthesis with cortical steel plate or locking nail. After revision, the remaining length of the proximal femur was 143.4±31 mm (range, 91-175 mm), and the length of the allograft bone was 92.6±26.6 mm (range, 61-123 mm). The 7 revised patients were still in follow-up. There were no cases of pulmonary infection, nerve injury, deep vein thrombosis or other complications after surgery.Conclusion:The survival period of patients after the surgery to reconstruct large bone defects following the resection of malignant tumors at the distal end of the femur using allogeneic bone composite prosthesis is satisfactory, and the limb function is good. However, the incidence of prosthesis complications is high, which can be reconstructed through revision.

Background::Pulmonary embolism (PE) is a severe and acute cardiovascular syndrome with high mortality among patients with autoimmune inflammatory rheumatic diseases (AIIRDs). Accurate prediction and timely intervention play a pivotal role in enhancing survival rates. However, there is a notable scarcity of practical early prediction and risk assessment systems of PE in patients with AIIRD.Methods::In the training cohort, 60 AIIRD with PE cases and 180 age-, gender-, and disease-matched AIIRD non-PE cases were identified from 7254 AIIRD cases in Tongji Hospital from 2014 to 2022. Univariable logistic regression (LR) and least absolute shrinkage and selection operator (LASSO) were used to select the clinical features for further training with machine learning (ML) methods, including random forest (RF), support vector machines (SVM), neural network (NN), logistic regression (LR), gradient boosted decision tree (GBDT), classification and regression trees (CART), and C5.0 models. The performances of these models were subsequently validated using a multicenter validation cohort.Results::In the training cohort, 24 and 13 clinical features were selected by univariable LR and LASSO strategies, respectively. The five ML models (RF, SVM, NN, LR, and GBDT) showed promising performances, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.962-1.000 in the training cohort and 0.969-0.999 in the validation cohort. CART and C5.0 models achieved AUCs of 0.850 and 0.932, respectively, in the training cohort. Using D-dimer as a pre-screening index, the refined C5.0 model achieved an AUC exceeding 0.948 in the training cohort and an AUC above 0.925 in the validation cohort. These results markedly outperformed the use of D-dimer levels alone.Conclusion::ML-based models are proven to be precise for predicting the onset of PE in patients with AIIRD exhibiting clinical suspicion of PE.Trial Registration::Chictr.org.cn: ChiCTR2200059599.

Background::Hypothermia therapy has been suggested to attenuate myocardial necrosis; however, the clinical implementation as a valid therapeutic strategy has failed, and new approaches are needed to translate into clinical applications. This study aimed to assess the feasibility, safety, and efficacy of a novel selective intracoronary hypothermia (SICH) device in mitigating myocardial reperfusion injury.Methods::This study comprised two phases. The first phase of the SICH was performed in a normal porcine model for 30 minutes ( n = 5) to evaluate its feasibility. The second phase was conducted in a porcine myocardial infarction (MI) model of myocardial ischemia/reperfusion which was performed by balloon occlusion of the left anterior descending coronary artery for 60 minutes and maintained for 42 days. Pigs in the hypothermia group ( n = 8) received hypothermia intervention onset reperfusion for 30 minutes and controls ( n = 8) received no intervention. All animals were followed for 42 days. Cardiac magnetic resonance analysis (five and 42 days post-MI) and a series of biomarkers/histological studies were performed. Results::The average time to lower temperatures to a steady state was 4.8 ± 0.8 s. SICH had no impact on blood pressure or heart rate and was safely performed without complications by using a 3.9 F catheter. Interleukin-6 (IL-6), tumor necrosis factor-α, C-reactive protein (CRP), and brain natriuretic peptide (BNP) were lower at 60 min post perfusion in pigs that underwent SICH as compared with the control group. On day 5 post MI/R, edema, intramyocardial hemorrhage, and microvascular obstruction were reduced in the hypothermia group. On day 42 post MI/R, the infarct size, IL-6, CRP, BNP, and matrix metalloproteinase-9 were reduced, and the ejection fraction was improved in pigs that underwent SICH.Conclusions::The SICH device safely and effectively reduced the infarct size and improved heart function in a pig model of MI/R. These beneficial effects indicate the clinical potential of SICH for treatment of myocardial reperfusion injury.