Objective:To systematically review and evaluate the predictive efficacy of various derived indicators of sequential organ failure assessment (SOFA) in mortality rate of sepsis patients.Methods:Literature on sepsis and SOFA scores were searched in PubMed, Embase and Cochrane Library. The retrieval time will be set to the time of database-building to February, 2023. The main outcome measures included 28-day mortality, 30-day mortality, in-hospital mortality, intensive care unit (ICU) mortality and long-term mortality. Literature screening, data extraction and quality evaluation were carried out independently by 2 researchers. Data were analyzed by Revman 5.3.5, Meta-disc and Stata software. Deek funnel plots were used to assess publication bias in the included studies.Results:A total of 40 articles including 51 trials were included. Of these, 32 were in English and 8 in Chinese, 17 were in prospective trials and 34 were in retrospective trials, 38 were in initial SOFA-related trials and 9 were in the change of SOFA score (ΔSOFA)-related studies, a total of 59?962 patients were enrolled. ① The area under the receiver operator characteristic curve (AUC) of initial SOFA and ΔSOFA for predicting outcome in sepsis was 0.773 and 0.787 ( Z = 0.115, P > 0.05), respectively. There was no significant difference between the two indexes in predicting the outcome of patients with sepsis. ② In subgroup analysis, due to limitations in the number of literature articles, the 28-day mortality rate and 30-day mortality rate were merged for discussion. The predictive power of ΔSOFA for 28-day or 30-day mortality was significantly higher than that of initial SOFA (AUC was 0.854, 0.787, Z = 2.603, P ≤ 0.01). ③ There were few studies onΔSOFA in predicting in-hospital mortality, ICU mortality and long-term mortality of sepsis patients. The AUC of the initial SOFA for predicting the study endpoints described above was: ICU mortality (0.814) > 28-day or 30-day mortality (0.787) > in-hospital mortality (0.697) > long-term mortality (0.646). ④ Initial SOFA and ΔSOFA in patients with sepsis of non-Han original had good predictive performance and there was no significant difference between them (AUC was 0.766, 0.811, respectively). However, the pooled sensitivity of ΔSOFA was higher (92%). ⑤ In prospective studies, initial SOFA was better at predicting outcomes in patients with sepsis (AUC was 0.804, pooled sensitivity 64%). The sensitivity of ΔSOFA indicators in predicting the outcome of sepsis patients was significantly higher than the initial SOFA (78% vs. 64%). The funnel plot showed that there was no significant publication bias in the included literature. Conclusion:ΔSOFA has a relatively high diagnostic efficacy in predicting short-term (28-day or 30-day) mortality in patients with sepsis.

Case-based reasoning is a method of reasoning from experience to solve current problems in the field of cognitive science， which has the advantages of easy acquisition of knowledge， simple operation steps， and the ability to improve the efficiency of reasoning with the growth of experience. Formula-syndrome differentiation is a method of differentiation and treatment based on the scope of the adapted disease， disease mechanism， therapeutic methods， and contraindications of the formula. Analysed from the perspectives of concept， applicable field， and implementation steps， it is believed that the concept of formula-syndrome differentiation belongs to the scope of case-based reasoning， the clinical diagnosis and treatment of traditional Chinese medicine belongs to the applicable field of case-based reasoning， and the steps of formula-syndrome differentiation are consistent with the process of case-based reasoning. Based on the characteristics of case-based reasoning， we analyse the advantages， limitations and problems to be noted in the process of formula-syndrome differentiation， and put forward four strategies to improve the ability of formula-syndrome differentiation， including accumulating experience on formulas and syndromes， cultivating the ability to grasp the main symptoms， accumulating a rule base to improve the ability to modify formulas according to the symptoms， and improving the ability to assess the effect of treatment plans and obtain corresponding feedback， with a view to promoting the clinical application of formula-syndrome differentiation.

OBJECTIVE To determine the prevalence of frontal recess cells variations in patients with frontal sinus associated headache according to the International Frontal Sinus Anatomy Classification(IFAC).METHODS A retrospective study was conducted on the CT scans of sinuses in patients with frontal sinus associated headache.We reviewed 46 patients with frontal sinus-related headache who had clinical symptoms and were relieved after nasal endoscopic surgery.The development of frontal recess cells in the frontal recess drainage area was analyzed,and the variation of middle meatus and sinus involvement were analyzed in the same time.The Anatomical variations and imaging characteristics of frontal recess cells development in patients with frontal sinus associated headache were analyzed.RESULTS A total of 92 sinus CT profiles were analyzed in 46 patients.The most common cells were agger nasi cell(ANC)(100%,92/92),followed by supra bulla cell(SBC)(78.3%,72/92),supra agger cell(SAC)(67.4%,62/92),supra bulla frontal cell(SBFC)(27.2%,25/92),supra agger frontal cell(SAFC)(20.7%,19/92),frontal septal cell(FSC)(8.7%,8/92)and supraorbital ethmoid cell(SOEC)(0%,0/92).In the conventional frontal sinus drainage area,SAFC(P=0.0108),SAC(P=0.0104)and SAFC(P=0.0088)in the IFAC classification were significantly associated with the occurrence of frontal sinus associated headache.At the same time,the middle concha bullosa also showed a significant correlation with the occurrence of frontal sinus associated headache in the lower segment of the frontal recess drainage channel(P=0.0390).CONCLUSION In the frontal recess drainage channel,the abnormal development of SAC,SAFC,SBFC and the middle concha bullosa are significantly correlated with frontal sinus associated headache.

Heme, which exists widely in living organisms, is a porphyrin compound with a variety of physiological functions. Bacillus amyloliquefaciens is an important industrial strain with the characteristics of easy cultivation and strong ability for expression and secretion of proteins. In order to screen the optimal starting strain for heme synthesis, the laboratory preserved strains were screened with and without addition of 5-aminolevulinic acid (ALA). There was no significant difference in the heme production of strains BA, BAΔ6 and BAΔ6ΔsigF. However, upon addition of ALA, the heme titer and specific heme production of strain BAΔ6ΔsigF were the highest, reaching 200.77 μmol/L and 615.70 μmol/(L·g DCW), respectively. Subsequently, the hemX gene (encoding the cytochrome assembly protein HemX) of strain BAΔ6ΔsigF was knocked out to explore its role in heme synthesis. It was found that the fermentation broth of the knockout strain turned red, while the growth was not significantly affected. The highest ALA concentration in flask fermentation reached 82.13 mg/L at 12 h, which was slightly higher than that of the control 75.11 mg/L. When ALA was not added, the heme titer and specific heme production were 1.99 times and 1.45 times that of the control, respectively. After adding ALA, the heme titer and specific heme production were 2.08 times and 1.72 times higher than that of the control, respectively. Real-time quantitative fluorescent PCR showed that the expressions of hemA, hemL, hemB, hemC, hemD, and hemQ genes at transcription level were up-regulated. We demonstrated that deletion of hemX gene can improve the production of heme, which may facilitate future development of heme-producing strain.
Gene Deletion ; Bacillus amyloliquefaciens/metabolism* ; Aminolevulinic Acid/metabolism* ; Heme/metabolism* ; Fermentation

The meniscus in the knee joint plays an important role in bearing load,shock absorption,joint lubrication,and increasing the stability of the knee joint in various directions.Meniscal injury is a common ailment in knee joint injuries,which can cause severe knee pain and limited knee joint movement,significantly affecting the patient's quality of life.Arthroscopic minimally invasive treatment has become the main approach for treating meniscal injuries,with the consensus being to preserve the meniscus morphology and structure as much as possible.By introducing the structure and function of the meniscus,the mechanism of injury,and focusing on several suture techniques for arthroscopic meniscal injury treatment,analyzing their advantages and disadvantages,it aims to provide some reference for clinical research on arthroscopic suture of the meniscus.

Objective:To investigate the epidemiological data of maternal sepsis in intensive care unit (ICU), analyze the common causes, outcomes of maternal sepsis, and the risk factors of multi-drug resistant (MDR) bacteria.Methods:A retrospective cohort study. Maternal sepsis cases admitted to ICUs of Peking University Third Hospital, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, and Beijing Friendship Hospital Affiliated to Capital Medical University from January 2008 to September 2022 were enrolled. The following data were recorded: demographic characteristics, sequential organ failure assessment (SOFA) during infection, infection time, infection sites, invasive intervention measures before infection, microbial culture results, blood routine test during infection, body temperature, and clinical outcomes caused by infection. According to the time of sepsis occurrence, the patients were divided into pre-ICU sepsis group and ICU sepsis group, and the causes of sepsis in the two groups were analyzed. According to whether MDR occurred, the patients were divided into MDR group and non-MDR group, and clinical outcomes were analyzed. Multivariate Logistic regression was used to analyze the risk factors of MDR bacteria infection in obstetrics with sepsis.Results:160 patients were enrolled, among which 104 cases of sepsis happened before ICU and 56 cases of sepsis happened during ICU, 53 cases were with MDR bacteria and 107 cases were without MDR bacteria. The median age of the patients was 30.5 (28.0, 34.0) years old, the median temperature was 38.8 (38.2, 39.5) ℃, and the median white blood cell count (WBC) was 17.2 (13.2, 21.3)×10 9/L, the median SOFA score was 5.0 (3.0, 8.0), and 130 cases (81.2%) were referred from other hospitals. The main infection sites were uterine cavity in 64 cases (40.0%), lung in 48 cases (30.0%), abdominal and pelvic cavity in 30 cases (18.8%), urinary system in 27 cases (16.9%). Sepsis led to hysterectomy in 6 cases (3.8%), stillbirth in 8 cases (5.0%), and neonatal death in 2 cases (1.3%). The main surgical intervention measures were cesarean section (44 cases, accounting for 27.5%), followed by exploratory laparotomy (19 cases, 11.9%). The median length of ICU stay was 5.0 (3.0, 10.0) days, and the median hospital length was 14.0 (10.0, 20.8) days. Intrauterine infection was the primary cause of sepsis happened during ICU, accounting for 50.0% (28/56), of which postpartum hemorrhage accounted for 85.7% (24/28). The proportion of diabetes [28.3% (15/53) vs. 14.0% (15/107)], intrauterine operation [41.5% (22/53) vs. 23.4% (25/107)], intrauterine infection [50.9% (27/53) vs. 34.6% (37/107)] and bacteremia [18.9% (10/53) vs. 2.8% (3/107)] in the MDR group were significantly higher than those in the non-MDR group (all P < 0.05). Multivariate Logistic regression analysis showed that diabetes [odds ratio ( OR) = 2.348, 95% confidence interval (95% CI) was 1.006-5.480, P = 0.048] and intrauterine operation ( OR = 2.541, 95% CI was 1.137-5.678, P = 0.023) were independent risk factors for MDR bacterial infection in obstetrics with sepsis. Conclusions:Intrauterine infection is the common cause of maternal sepsis in ICU, and postpartum hemorrhage is the common cause of secondary intrauterine infection in ICU. MDR bacteria can lead to serious clinical outcomes. Diabetes and intrauterine operation are independent risk factors for MDR bacteria' infection.

Objective:To observe the effect of noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula oxygen therapy (HFNC) on the prognosis of patients with coronavirus disease 2019 (COVID-19) accompanied with acute respiratory distress syndrome (ARDS).Methods:A retrospective study was conducted in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology when authors worked as medical team members for treating COVID-19. COVID-19 patients with pulse oxygen saturation/fraction of inspiration oxygen (SpO 2/FiO 2, S/F) ratio < 235, managed by medical teams [using S/F ratio instead of oxygenation index (PaO 2/FiO 2) to diagnose ARDS] from February to April 2020 were included. The patients were divided into NIPPV group and HFNC group according to their oxygen therapy modes. Clinical data of patients were collected, including general characteristics, respiratory rate (RR), fraction of FiO 2, SpO 2, heart rate (HR), mean arterial pressure (MAP), S/F ratio in the first 72 hours, lymphocyte count (LYM), percentage of lymphocyte (LYM%) and white blood cell count (WBC) at admission and discharge or death, the duration of dyspnea before NIPPV and HFNC, and the length from onset to admission. The differences of intubation rate, all-cause mortality, S/F ratio and RR were analyzed, and single factor analysis and generalized estimation equation (GEE) were used to analyze the risk factors affecting S/F ratio. Results:Among the 41 patients, the proportion of males was high (68.3%, 28 cases), the median age was 68 (58-74) years old, 28 cases had complications (68.3%), and 34 cases had multiple organ dysfunction syndrome (MODS, 82.9%). Compared with HFNC group, the proportion of complications in NIPPV group was higher [87.5% (21/24) vs. 41.2% (7/17), P < 0.05], and the value of LYM% was lower [5.3% (3.4%-7.8%) vs. 10.0% (3.9%-19.7%), P < 0.05], the need of blood purification was also significantly lower [0% (0/24) vs. 29.4% (5/17), P < 0.05]. The S/F ratio of NIPPV group gradually increased after 2 hours treatment and RR gradually decreased with over time, S/F ratio decreased and RR increased in HFNC group compared with baseline, but there was no significant difference in S/F ratio between the two groups at each time point. RR in NIPPV group was significantly higher than that in HFNC group after 2 hours treatment [time/min: 30 (27-33) vs. 24 (21-27), P < 0.05]. There was no significant difference in rate need intubation and hospital mortality between NIPPV group and HFNC group [66.7% (16/24) vs. 70.6% (12/17), 58.3% (14/24) vs. 52.9% (9/17), both P > 0.05]. Analysis of the factors affecting the S/Fratio in the course of oxygen therapy showed that the oxygen therapy mode and the course of illness at admission were the factors affecting the S/F ratio of patients [ β values were -15.827, 1.202, 95% confidence interval (95% CI) were -29.102 to -2.552 and 0.247-2.156, P values were 0.019 and 0.014, respectively]. Conclusion:Compared with HFNC, NIPPV doesn't significantly reduce the intubation rate and mortality of patients with COVID-19 accompanied with ARDS, but it significantly increases the S/F ratio of those patients.

Objective:To compare the clinical characteristics of critically ill pregnant women admitted to the intensive care unit (ICU) with different admission methods, in order to make more effective and rational use of ICU resources.Methods:A retrospective study was conducted. The clinical data of critically ill pregnant women admitted to ICU of Peking University Third Hospital from January 2006 to July 2019 were analyzed. According to the admission mode to ICU, the pregnant women were divided into emergency admission group (transferred to ICU on the same day or the next day due to critical illness) and planned admission group (transferred to ICU 2 days after admitting in obstetric ward). The clinical characteristics of ICU critical pregnant women, such as the incidence, causes of admission, severity of the disease, main treatment measures, mortality, and medical expenses were collected, and a comparative analysis between the two groups was performed.Results:During the nearly 14 years, a total of 576 critical pregnant women in ICU were enrolled, accounting for 0.8% (576/71 790) of the total number of obstetric inpatients and 4.6% (576/12 412) of the total number of ICU inpatients. Seven maternal deaths accounted for 1.2% of all critically pregnant women transferred to ICU, and the overall mortality of pregnant women was 10/100 thousand. Of the 576 critically pregnant women, there were 327 patients (56.8%) in the emergency admission group and 249 patients (43.2%) in the planned admission group. Compared with the planned admission group, the proportion of elective cesarean section in the emergency admission group was significantly lower (17.7% vs. 94.0%, P < 0.01), and the proportion of emergency cesarean section was significantly higher (65.1% vs. 2.4%, P < 0.01), the acute physiology and chronic health evaluation (APACHE Ⅱ, APACHE Ⅲ) scores, simplified acute physiology score Ⅱ (SAPS Ⅱ) and Marshall score were significantly higher [APACHE Ⅱ score: 6.0 (4.0, 9.8) vs. 4.0 (3.0, 7.0), APACHE Ⅲ score: 14.0 (11.0, 20.3) vs. 12.0 (9.0, 16.0), SAPS Ⅱ score: 8 (0, 12) vs. 3 (0, 8), Marshall score: 2 (1, 4) vs. 1 (1, 3), all P < 0.01]. The length of ICU stay in the emergency admission group was significantly longer than that in the planned admission group [days: 2 (1, 5) vs. 2 (1, 3), P < 0.01], and the total length of hospital stay was significantly shorter [days: 9 (7, 13) vs. 13 (10, 18), P < 0.01]. Both in the emergency admission group and the planned admission group, obstetric factors were the main reason for admission, 60.9% (199/327) and 70.3% (175/249), respectively. The proportion of postpartum hemorrhage was the highest [35.2% (115/327) and 57.0% (142/249)], followed by preeclampsia/eclampsia [7.0% (23/327) and 7.6% (19/249)]. Only 7 of the 19 critically pregnant women with puerperal infection were planned admission. All 21 patients with acute fatty liver of pregnancy (AFLP) during pregnancy were emergency admission. Among the emergency and planned admission patients, 73 patients (22.3%) and 42 patients (16.9%) required mechanical ventilation (duration of mechanical ventilation > 24 hours), 99 patients (30.3%) and 35 patients (14.1%) needed vasoactive agents, 67 patients (20.5%) and 20 patients (8.0%) received hemodynamic monitoring, and 123 patients (37.6%) and 154 patients (61.8%) were given anticoagulation therapy, respectively. In terms of severity score of critical pregnant women, there were significant differences in APACHE Ⅱ, APACHE Ⅲ, SAPS Ⅱ and Marshall scores of pregnant women with different diseases. Among them, the APACHE Ⅲ, SAPS Ⅱ and Marshall scores of AFLP were the highest [21.0 (15.0, 32.5), 12.0 (6.0, 16.5) and 6.0 (3.5, 8.0), respectively]. The APACHE Ⅱ and APACHE Ⅲ scores of postpartum hemorrhage were the lowest [4.0 (3.0, 7.0), 12.0 (10.0, 16.0)]. The SAPS Ⅱ score of pneumonia was the lowest [2.0 (0, 14.0)]. The Marshall score for puerperal infection was the lowest [1.0 (0, 3.0)]. In terms of the total medical expenses, the cost in the emergency admission group was significantly lower than that in the planned admission group [10 thousand Yuan: 3.1 (2.0, 4.7) vs. 4.1 (2.9, 5.8), P < 0.05]. Conclusions:Compared with the critically ill pregnant women who planned to be admitted to ICU, the patients emergency admitted to ICU were more complicated and urgent, and the severity of the condition was scored higher. At present, the severity scoring system commonly used in ICU can only partly evaluate the severity of critically ill pregnant women, therefore, it is necessary to design the specific severity scoring system for critically ill pregnant women to effectively and rationally use the precious ICU resources.

Objective To explore the clinical efficacy of the gap above the splenic pedicle in laparoscopic splenectomy (LS).Methods The retrospective cohort study was conducted.The clinical data of 189 patients who underwent LS in the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between August 2012 and March 2015 were collected.Among 189 patients receiving splenic pedicle division,42 without the application of the gap above the splenic pedicle were allocated into the group A and 147 with the application of the gap above the splenic pedicle were allocated into the group B.Observation indicators included:(1) operation situations:combined operation,operation time (excluding combined operation time),volume of intraoperative blood loss (excluding blood volume of spleen),cases with conversion to open surgery;(2) postoperative situations:time to initial anal exsufflation,time for fluid diet intake,occurrence of postoperative complications and duration of hospital stay;(3) follow-up.Patients were followed up by telephone interview and outpatient examination up to August 2016.Follow-up included routine blood test,coagulation function,liver function,with or without long-term complications.Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed using the t test.Comparisons of count data were analyzed by the chi-square test.Results (1) Operation situations:of 189 patients undergoing LS,136 combined with laparoscopic pericardial devascularization,13 combined with laparoscopic cholecys-tectomy,9 combined with laparoscopic radio frequency ablation (RFA) of liver tumors and 26 combined with pathological examination using laparoscopic liver tissues sampling.Operation time,volume of intraoperative blood loss and cases with conversion to open surgery were (118±31) minutes,(80±38) mL,2 in the group A and (70± 22) minutes,(50± 28) mL,1 in the group B,respectively,with statistically significant differences between the 2 groups (t =12.579,-8.516,x2=4.912,P＜0.05).(2) Postoperative situations:time to initial anal exsufflation,time for fluid diet intake,number of patients with postoperative complications and duration of hospital stay were (22± 10)hours,(3.1 ± 1.3) days,8,(9±3)days in the group A and (23±11)hours,(3.8±1.8)days,13,(8±3)days in the group B,respectively.Pancreatic fistula,intra-abdominal hemorrhage,asymptomatic portal vein thrombosis,pulmonary infection and intraperitoneal infection were respectively detected in 2,2,2,1,1 patients in the group A and 1,2,5,2,3 patients in the group B.There was no significant difference in time to initial anal exsufflation,time for fluid diet intake and duration of hospital stay between the 2 groups (t =1.102,0.745,0.583,P＞0.05),and a statistically significant difference in number of patients with postoperative complications between the 2 groups (x2 =7.259,P＜ 0.05).There were statistically significant differences in cases with pancreatic fistula and intra abdominal hemorrhage (x2=16.021,5.812,P＜0.05) and no significant difference in cases with asymptomatic portal vein thrombosis,pulmonary infection and intraperitoneal infection (x2 =1.391,0.396,0.865,P＞0.05).Patients with postoperative complications were cured by symptomatic treatment.(3) Follow-up:156 of 189 patients (33 in the group A and 123 in the group B) were followed up for 1-18 months,with an average time of 12 months.During the follow-up,13 patients had recurrent hematemesis and melena,including 3 in the group A and 10 in the group B.Eight patients stopped bleeding after conservative treatment,3 stopped bleeding after proxial gastrectomy and 2 died of excessive bleeding and organ failure.Conclusion Splenic pedicle division using Endo-GIA through the gap above the splenic pedicle in LS can reduce operation time,volume of intraoperative blood loss,rate of conversion to open surgery and postoperative complications.

Objective To compare the clinical effects of combined anterolateral and posterolateral approach,lateral incision via double intermuscular spatia approach,and posterolateral transfibular approach in the treatment of fractures of anterolateral and posterolateral columns of tibial plateau.Methods A retrospective analysis was done of the 18 patients with fracture of anterolateral and posterolateral columns of tibial plateau who had been treated at our hospital from January 2012 to January 2015.They were 10 men and 8 women,aged from 28 to 58 years (mean,35.5 years).They were divided into 3 equal groups.Group A was treated with combined anterolateral and posterolateral approach,group B with lateral incision via double intermuscular spatia approach and group C with posterolateral transfibular approach.Operation time,surgical blood loss and complications were recorded.At the final follow-ups,Rasmussen score was used to evaluate the fracture reduction and Hospital for Special Surgery (HSS) knee score to assess functions of the involved knees.Results The 18 patients were followed up for 10 to 18 months (average,13.3 months).No such early complications as incision infection or deep vein thrombosis occurred.The operation time (89.5 min and 79.3 min,respectively) and surgical blood loss (151.7 mL and 207.8 mL,respectively) for groups A and B were obviously less than those for group C (102.5 min;260.2 mL);the incision length for group A (10.5 cm) was shorter than that for group B (17.4 cm) and for group C (16.3 cm);group C had more cases of excellent reduction (6) than groups A and B (4 for both).There were no obvious differenc es between groups A,B and C in the Rasmussen score (16.8,17.0 and 16.3) or HSS score (86.3,86.0 and 85.7).One case of delayed incision healing due to partial necrosis occurred in group B.At the final follow-ups in group C,the varus stress test showed 2 cases of laxation of degree Ⅱ and 2 cases of laxation of degree Ⅰ.Conclusions In the treatment of fractures of anterolateral and posterolateral columns of tibial plateau,all the 3 approaches can lead to good exposure,fine reduction,rigid fixation and satisfactory outcomes.Although the combined anterolateral and posterolateral approach and lateral incision via double intermuscular spatia approach can lead to similar exposure ranges and fixation effects,the latter is easier in operation while the former exposes the anterior and posterior spatia more fully,allowing the anterior and posterior plates to be better positioned.The posterolateral transfibular approach can lead to the largest exposure range and more precise reduction,but it has risks of damage to the lateral ligamentous structure,greater invasion,postoperative lateral instability and injury to the common peroneal nerve.