Objective:To evaluate the efficacy and safety of hypomethylating agents (HMA) in patients with myelodysplastic syndromes (MDS) .Methods:A total of 409 MDS patients from 45 hospitals in Zhejiang province who received at least four consecutive cycles of HMA monotherapy as initial therapy were enrolled to evaluate the efficacy and safety of HMA. Mann-Whitney U or Chi-square tests were used to compare the differences in the clinical data. Logistic regression and Cox regression were used to analyze the factors affecting efficacy and survival. Kaplan-Meier was used for survival analysis. Results:Patients received HMA treatment for a median of 6 cycles (range, 4-25 cycles) . The complete remission (CR) rate was 33.98% and the overall response rate (ORR) was 77.02%. Multivariate analysis revealed that complex karyotype ( P=0.02, OR=0.39, 95% CI 0.18-0.84) was an independent favorable factor for CR rate. TP53 mutation ( P=0.02, OR=0.22, 95% CI 0.06-0.77) was a predictive factor for a higher ORR. The median OS for the HMA-treated patients was 25.67 (95% CI 21.14-30.19) months. HMA response ( P=0.036, HR=0.47, 95% CI 0.23-0.95) was an independent favorable prognostic factor, whereas complex karyotype ( P=0.024, HR=2.14, 95% CI 1.10-4.15) , leukemia transformation ( P<0.001, HR=2.839, 95% CI 1.64-4.92) , and TP53 mutation ( P=0.012, HR=2.19, 95% CI 1.19-4.07) were independent adverse prognostic factors. There was no significant difference in efficacy and survival between the reduced and standard doses of HMA. The CR rate and ORR of MDS patients treated with decitabine and azacitidine were not significantly different. The median OS of patients treated with decitabine was longer compared with that of patients treated with azacitidine (29.53 months vs 20.17 months, P=0.007) . The incidence of bone marrow suppression and pneumonia in the decitabine group was higher compared with that in the azacitidine group. Conclusion:Continuous and regular use of appropriate doses of hypomethylating agents may benefit MDS patients to the greatest extent if it is tolerated.

Objective:To analyze the factors influencing the success rate of external cephalic version (ECV) and to create a preoperative scoring scale for stratified management of pregnant women who were preparing for ECV.Methods:This prospective study was conducted on singleton pregnant women who underwent ECV without anesthesia in Fujian Maternity and Child Health Hospital from January 1, 2017, to December 31, 2019. Univariate (two independent samples t-test, Mann-Whitney U test, and Chi-square test) and multivariate logistic regression were used to screen the clinical characteristics affecting the success of ECV, and receiver operating characteristic (ROC) curve was used to determine the cut-off value and convert quantitative variables into dichotomous variables. The independent variables were scored according to the regression coefficient in multivariate logistic regression analysis, and then a preoperative scoring scale was created. The ROC curve was used to calculate the cut-off value for the scoring scale. The subjects were divided into low and high score groups according to the cut-off value. The area under the ROC curve was used for evaluating the effectiveness of the scale in predicting the success of ECV. The success rate of ECV, difficulty of the operation and mode of delivery were compared between the two groups. Results:A total of 1 338 pregnant women met the inclusion criteria during the study period. After the exclusion of 885 women, 165 refused ECV in favor of direct cesarean section, 27 spontaneously converted to cephalic position before ECV, 261 who voluntarily accepted ECV were finally enrolled. ECV succeeded in 202 cases and failed in 59. (1) Favorable factors for ECV without anesthesia were the distance between the fetal breech and ischial spine <－3.5 cm ( OR=0.177, 95% CI: 0.071-0.438, P=0.009), the sum of the fundal height and the station of the fetal breech based on the ischial spine <30.25 cm ( OR=0.225, 95% CI: 0.094-0.537, P=0.001), amniotic fluid index ≥12 cm ( OR=0.399, 95% CI: 0.164-0.969, P=0.042), the surgeon's ability to hold the fetal head or breech with one hand ( OR=0.241, 95% CI: 0.098-0.589, P=0.002; OR=0.219, 95% CI: 0.087-0.546, P=0.001), and the fetal head located on the right or left upper abdomen of the mother ( OR=0.184, 95% CI: 0.059-0.568, P=0.003; OR=0.253, 95% CI: 0.084-0.760, P=0.014). (2) The area under the ROC curve of the preoperative score for predicting the success of ECV was 0.881 (95% CI: 0.821-0.941) and the cut-off value was 5.5. The subjects were divided into low (0-5 scores) and high (6-11 scores) score groups and the area under the ROC curve for predicting the success of ECV by grouping was 0.843 (95% CI: 0.774-0.912). Compared with the low score group, the high score group had a shorter ECV duration [2.0 min (0.5-10.0 min) vs 10.0 min (0.9-25.8 min), Z=－6.83, P<0.001], less attempts [1.0 times (1.0-4.0 times) vs 3.0 times (1.0-5.0 times), Z=－8.41, P<0.001], higher success rate [92.7% (190/205) vs 21.4% (12/56), χ2=127.64, P<0.001], higher rate of vaginal birth [75.4% (147/195) vs 18.5% (10/54)] and lower cesarean section rate [24.6% (48/195) vs 81.5% (44/54)] ( χ2=58.70, P<0.001). Conclusions:Preoperative scoring based on the factors influencing the success rate of ECV (the distance between the fetal breech and ischial spine, the sum of the fundal height and the station of the fetal breech based on the ischial spine <30.25 cm, amniotic fluid index ≥12 cm, the surgeon's ability to hold the fetal head or breech with one hand, and the fetal head locating on the right or left upper abdomen of the mother) is conducive to the individualized evaluation of the difficulty and the success rate of ECV as well as the success rate of vaginal delivery after ECV, which can provide a reference for clinical stratified management of ECV patients.

OBJECTIVE：To screen the effective compo nent in antioxi dant active fraction of Pueraria lobata . METHODS ：The antioxidant active fraction sample （S1-S20） of 20 batches of P. lobata were prepared. HPLC method was adopted. The determination was performed on SepaxBio-C 18 column with mobile phase consisted of methanol-water （gradient elution ）at the flow rate of 0.6 mL/min. The column temperature was set at 25 ℃，and detection wavelength was set at 250 nm. HPLC fingerprints of 20 batches of P. lobata were established by the Similarity Evaluation System of TCM Chromatographic Fingerprints （2012 edition），and common peaks were identified. Cluster analysis ，principal component analysis （PCA）and orthogonal partial least squares discriminant analysis （OPLS-DA）were used to screen the effective components in antioxidant active fraction of P. lobata . RESULTS：There were 18 common peaks in HPLC fingerprints of 20 batches of antioxidant active fraction in P. lobata ，and the similarity was more than 0.99. Eight common peaks were identified ，which were 3′-hydroxypuerarin（peak 2），puerarin（peak 3）， 3′-methoxypuerarin（peak 4），daidzein（peak 5），genistein（peak 7），formononetin（peak 11），daidzein（peak 13）and genistein （peak 16）. The results of cluster analysis and PCA analysis showed that samples S 1，S3，S4，S6，S8，S18 and S 19 were clustered into one category ，and samples S 2，S5，S7，S9-S17 and S 20 were clustered into one category ；peak 2，peak 3，peak 10，peak 11 and peak 13 had great influence on principal component 1；peak 8 and peak 9 had great influence on principal component 2. OPLS-DA analysis showed that peak 4，peak 3，peak 2，peak 16，peak 13 and peak 11 had great influence on the quality of antioxidant active fraction of P. lobata . CONCLUSIONS ： HPLC fingerprint for active fraction of P. lobata is established in the study and 8 components are identified ；among them ， com puerarin，3′-hydroxypuerarin，daidzein and formononetin maybe the material basis of antioxidant fraction of P. lobata .

Objective:To explore the association between the spontaneous neural activity and memory function in depressive patients with different sleep quality.Methods:Totally 58 patients with depressive disorder and 58 gender-, age-, education-matched healthy controls (HC) completed 3.0 T MRI Scanning and clinical assessment including Wechsler memory scale (WMS), 24 Hamilton depression scale(HAMD-24) and Pittsburgh sleep quality index (PSQI). According to the score of PSQI, patients were divided into poor sleep quality group (PS, n=38) and good sleep quality group (GS, n=20). Amplitude of low frequency fluctuations (ALFF) were calculated and compared among three groups.Correlation analyses between the brain activity and the score of WMS were conducted as well. Results:Memory quotient of WMS showed differences among three groups( F=14.163, P<0.01), and the lowest score was found in patients with low sleep quality.The brain areas showed significant differences among three groups located in the left medial superior frontal gyrus (lmSFG, MNI: x=-10, y=30, z=58; K=56), right orbital inferior frontal gyrus (roIFG, MNI: x=26, y=20, z=-26; K=24) and left middle frontal gyrus (lMFG, MNI: x=-40 y=32, z=42; K=25) (voxel size P<0.001, cluster size P<0.05, GRF corrected). Compared with GS group, the ALFF of PS group showed significantly increased in the lmSFG, which was negatively correlated with memory quotient ( r=-0.327, P=0.045) and short term memory( r=-0.388, P=0.016). Compared with HC group, the ALFF of PS group showed increased in the lmSFG and lMFG, GS group showed increased ALFF in the roIFG. Conclusion:The impairment of memory function is more serious in patients with depression of low sleep quality, and the activity of frontal lobe is abnormally increased, which is related to memory function.Their association suggests that poor sleep quality in depressive patients may impair memory function by disrupting neural plasticity and synaptic pruning in the frontal lobes.

Objective To explore the influence of rs1360780 T risk allele of FK506-binding protein 5 (FKBP5) gene on the brain function under resting-state and its association with clinical symptoms as well as immune function in patients with major depressive disorder (MDD).Methods Totally 147 MDD patients and 61 gender-,age-,and education-matched healthy controls were scanned with 3.0T MRI Scanner and genotyped.The peripheral serum immunoglobulin and complement were measured.The main effect of the disease,the genotype and their interaction effects were analyzed using regional homogeneity (ReHo) by two-way ANOVA.Abnormal brain activity was identified in T risk allele carriers of rs1360780 and non-risk CC individuals in MDD using post hoc analyses.Correlation analyses were performed between ReHo values of significant brain regions and the total score,five-factor scores of Hamilton rating scale for depression (HAMD-17),serum levels of immunoglobulin and plasma complement component in MDD patients.Results (1) The results of 2x 2 ANOVA showed the interaction effects located in the left opercular part of inferior frontal gyrus (MNI:x,y,z =-42,6,9;F=10.83),right opercular part of inferior frontal gyrus (MNI:x,y,z =30,6,33;F=15.05),left medial superior frontal gyrus (MNI:x,y,z=-9,54,0;F=9.17) and left pallidum (MNI:x,y,z =-12,6,-6;F=11.37) (Alphasim corrected,P＜ 0.05).(2) In post-hoc analyses for the main effect of genotype,T+ carriers with MDD showed increased ReHo values in the right opercular part of inferior frontal gyrus (MNI:x,y,z=60,12,6;t=2.88) compared with CC carriers;for the effect of diseaseby-genotype interaction,T+ carriers with MDD showed increased ReHo values in the right opercular part of inferior frontal gyrus (MNI:x,y,z=30,6,33;t=2.96) and decreased ReHo values in the left orbital part of inferior frontal gyrus (MNI:x,y,z =-21,9,-18;t =-3.21) (Alphasim corrected,P＜ 0.05) in contrast to CC carriers.(3)Pearson's correlation showed that the average ReHo values of the right opercular part of inferior frontal gyrus negatively correlated with the content of immunoglobulin G (r=-0.528,P=O.0016,Bonferroni corrected) and positively correlated with anxiety/somatization factor score (r=0.421,P＜0.001,Bonferroni corrected) in T + carrìers with MDD.Conclusion The results of this study suggest that rs1360780 T-risk allele of FKBP5 gene is involved in the changes of local neural activity in the right opercular part of inferior frontal gyrus of depressed patients and could potentially indicate a neuropathological mechanism of anxiety somatic symptoms and immune dysfunction in depression.

Objective To evaluate the value of nested polymerase chain reaction (PCR) for the rap-id detection of pathogens in children with severe pneumonia. Methods We prospectively enrolled the pa-tients with severe community-acquired pneumonia admitted to pediatric intensive care unit (PICU) in Shang-hai Children′s Hospital from January 2017 to June 2018. The sputum for PCR were collected within 24 h after PICU admission. Both nested PCR and routine microbiological methods were performed. Respiratory Panel (R-Panel) based on nested PCR could detect 17 kinds of respiratory pathogen at the same time. Results A total of 65 patients were enrolled in this study and the samples were detected using both R-Panel and routine microbiological method. (1) A total of 15 patients (23. 08 %) showed positive routine microbiological de-tection including 13 cases with virus-positive and 2 cases with mycoplasma-positive; (2) A total of 38 pa-tients (58. 46%) showed positive results using R-Panel within 2 h including 46 cases with virus-positive and 5 cases with mycoplasma-positive. The mainly primary infection was human rhinovirus and enterovirus in 15 cases (23. 08%),followed by adenovirus in 10 cases (15. 38%); and the positive rate of 2 or more patho-gens was 18. 46% (12/65);(3) The rate of adenovirus-positive using R-Panel was significantly higher than that using routine microbiological methods (15. 38 % vs. 4. 62%,χ2 ＝4. 188,P＝0. 041); the sensitivity of R-Panel for detection of adenovirus,respiratory syncytial virus,and parainfluenza virus was significantly high-er than those of routine microbiological methods (100% vs. 30%,χ2 ＝107. 692;50. 00% vs. 16. 67%,χ2 ＝ 24. 442;100% vs. 80%,χ2 ＝22. 222;100% vs. 40%,χ2 ＝85. 714; all P <0. 001). Conclusion R-Panel using nested PCR is a rapid,sensitive,and specific method for the detection of pathogens in children with severe community acquired pneumonia,which is valuable for targeted therapy in time.

Objective To investigate the features and incidence of severe anti-N-methyl-D-aspartate receptor ( NMDAR) encephalitis in pediatric intensive care unit ( PICU) treated with therapeutic plasma exchange(TPE). Methods A retrospective study was conducted of children with severe anti NMDAR encephalitis admitted to PICU of Shanghai Children′s Hospital from July 2015 to June 2018. Demographic data,therapeutic regimens,clinical and laboratory data were analyzed. The one dose of replacement plasma was 50-70 ml/kg. The laboratory biomarkers, anti-NMDAR in serum and cerebrospinal fluid ( CSF) were measured before and after TPE treatment. Results Thirteen cases with anti-NMDAR encephalitis were analyzed. The main clinical features were seizures, unconsciousness, motor dysfunctions organ dysfunction included respiratory failure in 3 (23. 1%) patients and shock in 4 (30. 8%) cases. The average levels of PICU stays were[11. 0(5. 5,19. 0)] days. The conventional therapy included methylprednisolone,intrave-nous immunoglobulin (IVIG),antiepileptic,and immune-suppressants. Seven patients received conventional treatment,and 6 (46. 2%) cases combined TPE after unsatisfactory effect on 3 to 7 days conventional treat-ment. TPE dosage was 50-70 ml/kg body weight per times for 3-5 dosages. The Glasgow coma score(GCS) and pediatric risk of mortality Ⅲ( PRISM Ⅲ) of children after TPE treatment were signifcantly improved compared with those before TPE treatment[ GCS:7. 5(6. 0,9. 3) vs. 12. 5 (11. 5,13. 5),PRISM Ⅲ:15. 5 (9. 5,17. 5) vs. 11. 0(4. 5,12. 3),all P<0. 05]. The levels of anti-NMDAR antibody in both serum and CSF decreased significantly after TPE(all P<0. 05). Three cases (50. 0%) had anaphylaxis during TPE. Conclusion TPE could decease the levels of anti-NMDAR antibody in CSF and serum,improve psychiatric and neurologic symptoms. TPE may be a potential therapy in pediatric severe NMDAR encephalitis.

Objective To investigate the diagnostic value of knee skin temperature and serum soluble intercellular adhesion molecule-1 (sICAM-1) level in peri-prosthetic infection after total knee arthroplasty (TKA).Methods Thirty patients (11 males and 19 females,aged 59.3±9.5 years old) underwent primary TKA during November 2012 and October 2015.Ten patients with peri-prosthetic infection (3 males and 7 females,aged 60.9±8.2 years old) underwent two-stage revision TKA from November 2012 to October 2015.The interleukin-6 (IL-6),C-reactive protein (CRP),erythrocyte sedimentation rate (ESR),sICAM-1 in serum and the skin temperature in knee joint were recorded preoperatively (revision patients on diagnosis),at days 1,7 and at 1,3,6,12 months post-operatively.Results All of the 40 patients were followed up for 12 months.The serum CRP,IL-6 and ESR levels in the primary TKA group were normal preoperatively and increased after operation,reaching their peaks at 1-7 days postoperatively.These indexes then returned slowly to the normal levels within 3 months.The serum sICAM-1 level in the primary TKA group did not change significantly during the follow up.The serum levels of CRP,IL-6,ESR,and sICAM-1 in the revision group were significantly higher than that in the primary TKA group preoperatively (P＜0.05),IL-6,CRP,ESR returned slowly to the normal levels within 3 months after the second-stage revision,while the level of sICAM-1 returned to normal within 3 months after the first-stage revision.During whole follow-up after the second-stage revision,the level of sICAM-1 didn't change significantly.The preoperative mean differential temperature (MDT) in the primary TKA group was 0.73±0.62 ℃ preoperatively and elevated to 4.37±1.06 ℃ at 7 days postoperatively,which returned to the baseline within 6 months after primary TKA.The preoperative MDT in the revision group was 5.03±0.81 ℃,which was significantly higher than that in the primary TKA group (P＜0.05).The MDT returned to the normal level within 6 months after the second-stage revision TKA.Conclusion The change of MDT is in accordance with serum CRP,IL-6,and ESR,which together may predict the occurrence of infection.Serum sICAM-1 level may also be valuable in the diagnosis of peri-prosthetic infection.

Objective: To explore the therapeutic role of bedside continuous blood purification(CBP) in children with severe acute pancreatitis(SAP). Method: The clinical and laboratory data of 11 children with SAP who were admitted to Pediatric Intensive Care Unit (PICU) of Shanghai Children′s Hospital from June 2013 to May 2016 were analyzed, including using pediatric critical illness score (PCIS) and pediatric risk of score mortality (PRISM)-Ⅲ score to assessing the severity of the disease.For those patients with severe organ dysfunction, CBP treatment was used when conventional therapy was not efficient.The evolution and prognosis of the disease were observed and analyzed.The measurement data were analyzed by Wilcoxon signed rank test. Result: From June 2013 to May 2016, 11 cases with SAP were treated in PICU, of whom 7 cases had combined multiple organ dysfunction syndrome(MODS). After conservative treatment for 12-24 h, 6 cases with SAP deteriorated aggressively and were treated with CBP.PRISMA and PRISMA flex machines were used with Gambro PRISMA filter, and continuous venovenous hemodiafiltration(CVVHDF) or high volume hemofiltration (HVHF) were chosen as the therapy model.All 6 SAP patients survived after bedside CBP treatment(the median time spent on CBP were 48.5(48.0, 55.5) h). The serum concentration of amylase before and after the CBP treatment were respectively 675(495, 1 334)vs.176(136, 246) U/L, lipase 551(385, 1 075)vs.143(117, 185) U/L, CRP 168(125, 192) vs. 67(28, 87) mg/L, and inflammatory cytokines(TNF alpha 67.2(51.0, 72.9)vs. 22.6(19.3, 31.0) ng/L, IL-6 47.8(35.2, 88.4)vs. 23.6(20.3, 42.9) ng/L, IL-10 21.3(16.8, 23.9)vs. 35.6(26.5, 38.6) ng/L), which were obviously improved after CBP treatment(all P<0.05). And after CBP treatment, partial pressure of oxygen(PaO₂)/fraction of inspiration O₂(FiO₂) (192(101, 208)and 240(207, 267) mmHg, 1 mmHg=0.133 kPa), MAP (58.3(56.3, 62.5) and 83.3(74.0, 87.4) mmHg) and PCIS scores (66(62.5, 72)and 92(89, 94) scores) were higher (all P<0.05). Conclusion CBP in critically ill with SAP can rapidly reduce blood amylase and lipase, help to keep the stable internal environment, block the systemic inflammatory response, improve the organ functions and maintain the fluid balance.CBP treatment may be a potential therapy in children with SAP.

Objective To investigta e the efficayc of bedside plasma exchange( PE) combined con-tinuous veno-venous hemodiafiltration ( CVVHDF ) in childer n with critical hemo lty ic uremic syndrome ( HUS) .Method s Eight patients with HUS from Pediatric Intensive Care Unit of Shanghai Ch ildren′s Hos-pitalw ere included in the present stuyd .The seveir ty of children was gar ded accordni g to peid atric critiac l ill-ness soc re and pediatric riks ofs core mortalityⅢ.Four of them received continuuo s blood purification treat-me nt.Meanwhile,the clinical manifestation and outcom e of HUS weer analyzed.Results Eight children with HUS weer ni itially trae ted with diuretic and blood transfusion for 12-24 hours.Four ac ses who deteriora-ted aggressively were ep rofr med PE and CVVHDF.Plasauto iQ21 and Prisma flex wereu sed with Pir sma TPE 2000 membrna e plasma separator and AN69 M60 membrane filter respectively.All the 4 patients with critical HUS survived after bedside continuous blood purification treatment.Clinical symptoms and serum bio-chemistry were improved sing ificantly as follows.The average levels of serum creatinine and lactate dehydro-genase decreased obviously(318μmol/L vs.162μmol/L;1 963 U/L vs.407 U/L,respectively).In addi-tion,platelet count increased significantly(40 ×109/L vs.97 ×109/L) .Eventually,symptoms disappeared in these 4 patients.Conclusion The combined therapy of PE and CVVHDF in HUS could stabilize fluid acid-base equilibrium,prevent hemolysis and improve the renal function.