Objective To compare the clinical efficacy of abdominal ultrasound-guided endoscopic retrograde appendicitis therapy(ERAT)with laparoscopic appendectomy(LA)for acute uncomplicated appendicitis using propensity score matching.Methods The clinical data of 441 patients with acute uncomplicated appendicitis admitted to the Third People's Hospital of Yunnan Province from March 2020 to April 2023 were collected.The cases were classified based on the differences in surgical method and divided into the ERAT group(n = 30)and LA group(n = 411).The clinical efficacy of patients was compared between the two groups after reducing confounding bias by propensity score matching(PSM).Results After PSM,a total of 30 pairs of patients in the two groups were successfully matched,and the baseline data of the two groups met the requirements for comparability.At 24 hours after the operation,the ERAT group exhibited lower white blood cells,neutrophil counts,and C-reactive protein levels compared to the LA group,and these differences were statistically significant(P<0.05).There was no significant difference in the operation time and total effective rate between the ERAT group and the LA group(P>0.05).However,the ERAT group had lower intraoperative blood loss and shorter pain relief time compared to the LA group,and these differences were statistically significant(P<0.05).Conclusion Abdominal ultrasound-guided endoscopic retrograde appendicitis treatment is an effective,safe,and feasible technique with good prospects for the treatment of acute uncomplicated appendicitis.

Objective:To explore the effect of early intermittent enteral nutrition (EN) in critically ill patients after cardiac surgery.Methods:We developed an early EN feeding regimen for critically ill patients after cardiac surgery. A prospective analysis was conducted on 178 critically ill patients admitted to the Cardiothoracic Surgery Intensive Care Unit of a tertiary hospital in Shanghai from May 2022 to May 2023. They were divided into the control group ( n=88) and the observation group ( n=90) using a random number table method. The control group received routine EN feeding, while the observation group received early intermittent EN feeding. Comparison between groups was performed in terms of the tolerability and interruption of EN administration, nutrition related outcome indicators, and prognosis indicators. Results:The observation group had significantly lower rates of abdominal distension, diarrhea, nausea and vomiting (or reflux), and EN interruption, as well as shorter duration of EN interruption, compared to the control group ( P<0.05). After 7 days of early EN, 87.8% of patients in the observation group met the calorie goal, which was significantly higher than that of 22.5% in the observation group ( P<0.05). The nutritional related indicators (serum prealbumin, hemoglobin, actual intake of nutritional fluids) were also better in the observation group patients compared to the control group ( P<0.05). The duration of mechanical ventilation and length of ICU stay in the observation group were significantly shorter than those in the control group, with statistical significance ( P<0.05). There was no significant difference in the length of hospital stay between the two groups. Conclusion:Early EN program can improve the symptoms of feeding intolerance in patients, reduce the occurrence and duration of feeding interruption, increase the rate of calorie goal fulfillment, improve nutritional status,and promote patient recovery and outcome in critically ill patients after cardiac surgery.

Objective:To explore the value of a nomogram model based on the CT enterography (CTE) signs for prediction of intestinal penetrating lesions in patients with Crohn disease (CD).Methods:The clinical and CTE data of CD patients who underwent at least two CTE examinations from January 2010 to June 2020 in the First Affiliated Hospital of Sun Yat-sen University were retrospectively collected. A total of 112 patients were enrolled, and according to whether there was intestinal wall penetration in the last CTE observation were divided into non-penetration group (84 cases) and penetration group (28 cases). First, the clinical and CTE data for the first examination was analyzed by using univariate and multivariate Cox proportional hazards regression to screen out high-risk factors that could effectively predict intestinal wall penetrating lesions in CD patients and established a nomogram model. Then the change trend of CTE data (ΔCTE) between the first and last clinical and CTE signs was analyzed by using univariate and multivariate Cox proportional hazards regression, and built a nomogram model to sort out ΔCTE that may accompany the development of penetrating lesions in CD patients. The Harrell concordance index was used to evaluate the discriminative ability of the nomogram model.Results:In the first time clinical and CTE signs, multivariate Cox proportional hazards regression results showed that numbers of diseased bowel segments (HR=0.686, 95%CI 0.475-0.991, P=0.045) and the shortest diameter of the largest lymph node (HR=0.751, 95%CI 0.593-0.949, P=0.017) were independent protection factors for penetrating lesions, and rough bowel wall surface (HR=5.626, 95%CI 2.466-12.839, P<0.001) was an independent risk factor for penetrating lesions. The specificity and sensitivity of the nomogram model to predict non-penetration lesions were 82.1% and 59.5% respectively, and the Harrell concordance index was 0.810 (95%CI 0.732-0.888). In the ΔCTE signs, multivariate Cox proportional hazards regression showed that Δrough bowel wall surface (always rough bowel wall surface HR=12.344, 95%CI 2.042-74.625, P=0.006; slide bowel wall surface becomes rough bowel wall surface HR=28.720, 95%CI 4.580-180.112, P<0.001) and Δthe shortest diameter of the largest lymph node (HR=1.534, 95%CI 1.091-2.157, P=0.014) were independent risk factors for penetrating lesions. The specificity and sensitivity of the nomogram model were 89.3% and 79.2% respectively, and the Harrell concordance index was 0.876 (95%CI 0.818-0.934). Conclusion:The nomogram based on CTE signs of numbers of diseased bowel segments, the shortest diameter of the largest lymph node and rough bowel wall surface and ΔCTE can effectively predict the intestinal wall penetrating lesions of CD patients.

Objective:To explore the classification performance of combined model constructed from CT signs combined with radiomics for discriminating COVID-19 pneumonia and other viral pneumonia.Methods:The clinical and CT imaging data of 181 patients with viral pneumonia confirmed by reverse transcription-polymerase chain reaction in 15 hospitals of Yunnan Province from March 2015 to March 2020 were analyzed retrospectively. The 181 patients were divided into COVID-19 group (89 cases) and non-COVID-19 group (92 cases), which were further divided into training cohort (126 cases) and test cohort (55 cases) at a ratio of 7∶3 using random stratified sampling. The CT signs of pneumonia were determined and the radiomics features were extracted from the initial unenhanced chest CT images to build independent and combined models for predicting COVID-19 pneumonia. The diagnostic performance of the models were evaluated using receiver operating characteristic (ROC) analysis, continuous net reclassification index (NRI) calibration curve and decision curve analysis.Results:The combined models consisted of 3 significant CT signs and 14 selected radiomics features. For the radiomics model alone, the area under the ROC curve (AUC) were 0.904 (sensitivity was 85.5%, specificity was 84.4%, accuracy was 84.9%) in the training cohort and 0.866 (sensitivity was 77.8%, specificity was 78.6%, accuracy 78.2%) in the test cohort. After combining CT signs and radiomics features, AUC of the combined model for the training cohort was 0.956 (sensitivity was 91.9%, specificity was 85.9%, accuracy was 88.9%), while that for the test cohort was 0.943 (sensitivity was 88.9%, specificity was 85.7%, accuracy was 87.3%). The AUC values of the combined model and the radiomics model in the differentiation of COVID-19 group and the non-COVID-19 group were significantly different in the training cohort ( Z=-2.43, P=0.015), but difference had no statistical significance in the test cohort ( Z=-1.73, P=0.083), and further analysis using the NRI showed that the combined model in both the training cohort and the test cohort had a positive improvement ability compared with radiomics model alone (training cohort: continuous NRI 1.077, 95 %CI 0.783-1.370; test cohort: continuous NRI 1.421, 95 %CI 1.051-1.790). The calibration curve showed that the prediction probability of COVID-19 predicted by the combined model was in good agreement with the observed value in the training and test cohorts; the decision curve showed that a net benefit greater than 0.6 could be obtained when the threshold probability of the combined model was 0-0.75. Conclusion:The combination of CT signs and radiomics might be a potential method for distinguishing COVID-19 and other viral pneumonia with good performance.

Objective:To explore the value of multiphasic CT-based radiomics signature in predicting the invasive behavior of pancreatic solid pseudopapillary neoplasm (pSPN).Methods:The multiphasic CT images of patients with pSPN confirmed by postoperative pathology in the First Affiliated Hospital of Zhengzhou University from January 2012 to January 2021 were analyzed retrospectively. There were 23 cases of invasiveness and 59 cases of non-invasiveness. The region of interest(ROI) was artificially delineated layer by layer in the plain scan, arterial-phase and venous-phase images, respectively. The 1 316 image features were extracted from each ROI. The data set was divided into training and validation sets with a ratio of 7∶3 by stratified random sampling, and synthetic minority oversampling technique (SMOTE) algorithm was used for oversampling in the training set to generate invasive and non-invasive balanced data for building the training model. The constructed model was validated in the validation set. The receiver operating characteristic(ROC) analysis was used to evaluate model performance and the Delong′s test was applied to compare the area under the ROC curve (AUC) of different predict models. The improvement for classification efficiency of each independent model or their combinations were also assessed by net reclassification improvement (NRI) and integrated discrimination improvement (IDI) indices.Results:After feature extraction, 2, 6 and 3 features were retained to construct plain-scanned model, arterial-phase and venous-phase models, respectively. Seven independent-phase and combined-phase models were established. Except the plain-scanned model, the AUC values of other models were greater than 0.800. The arterial-phase model had the best efficiency for classification among all independent-phase models. The AUC values of arterial-phase model in the SMOTE training and validation sets were 0.913 and 0.873, respectively. By combining the radiomics signature of the arterial-phase and venous-phase models, the AUC values of training and validation sets increased to 0.934 and 0.913 respectively. There were no significant differences of the AUC values between the scan-arterial venous-phase model and arterial venous-phase model in both training and validation sets (both P>0.05). The NRI and IDI indexes showed that the combined form of plain-scan model and arterial-venous-phase model could not significantly improve the classification efficiency in the validation set (both NRI and IDI<0). Conclusions:The arterial-phase CT-based radiomics model has a good predictive performance in the invasive behavior of pSPN, and the combination with a venous-phase radiomics model can further improve the model performance.

Objective:To develop a mesenteric creeping fat index (MCFI) based on CT enterography (CTE) to characterize the degree of creeping fat wrapping around the inflamed gut in Crohn disease (CD), and to assess the relationship between MCFI and the inflammatory intestinal stricture.Methods:From December 2018 to July 2019, the patients with CD who underwent surgery in the First Affiliated Hospital of Sun Yat-Sen University were prospectively collected. The extent of perienteric mesenteric vessels wrapping around the gut was reconstructed to develop MCFI based on CTE images. The intestinal stricture index was obtained by calculating the ratio of the maximal upstream luminal diameter divided by the minimum luminal diameter apparent within the stricturing region. Using region-by-region correlation between CTE and surgical specimen, creeping fat score in intestinal specimen was obtained by assessing the extent of creeping fat wrapping around the resected bowel segment, and HE staining was performed on the bowel specimen corresponding to creeping fat to obtain the pathological inflammatory score. The Spearman correlation analysis was used to evaluate the correlation between MCFI, creeping fat score in intestinal specimen, and inflammatory score, intestinal stricture index. The ROC curve analysis was used to assess the accuracy of MCFI in distinguishing moderate-severe and mild inflammatory bowel walls.Results:Totally 30 CD patients were enrolled. The creeping fat score in intestinal specimen positively correlated with pathological inflammatory score ( r s=0.403, P=0.027) and with intestinal stricture index ( r s=0.642, P<0.001). MCFI positively correlated with creeping fat score in intestinal specimen ( r s=0.840, P<0.001), with pathological inflammatory score ( r s=0.497, P=0.005), and with intestinal stricture index ( r s=0.599, P<0.001). ROC analysis showed that the area under the curve of MCFI for differentiating moderate-severely from mildly inflammatory bowel walls was 0.718 (95%CI 0.522-0.913). Using MCFI≥4 as a cutoff value, the sensitivity and specificity were 81.8% and 47.4%, respectively. Conclusions:There was a correlation between creeping fat and inflammatory intestinal strictures in CD. MCFI can non-invasively depict the degree of creeping fat wrapping around the gut and assess the inflammatory intestinal stricture.

Objective:To explore the diagnostic efficacy of nomogram based on multi-parameter MRI for assessment of bowel fibrosis in patients with Crohn disease（CD).Methods:The clinical and imaging data of CD patients diagnosed by surgical histopathology in the First Affiliated Hospital of Sun Yat-sen University from June 2015 to March 2018 were prospectively collected. All the patients underwent conventional MRI and diffusion kurtosis imaging（DKI) within 2 weeks before surgery. Patients who underwent surgery between June 2015 and September 2017 were included in the model building group, and those who underwent surgery between October 2017 and March 2018 were included in the model validation group. We measured the apparent diffusion coefficient（ADC) from monoexponential model of diffusion-weighted imaging（DWI), apparent diffusional kurtosis（K app), and apparent diffusion for non-Gaussian distribution（D app) from non-Gaussian DKI model, and observed T 2WI signal intensity and enhancement pattern of the same segment. One to three intestinal specimens per patient were stained with Masson′s trichrome for the histological grading of fibrosis. Correlations between qualitative/quantitative MRI indexes and histological grades were evaluated using the Spearman rank test. Multivariate logistic regression analysis was performed to identify independent factors to be included into the nomogram for predicting the degree of bowel fibrosis and its diagnostic performance was assessed by internal and external validation. Results:A total of 40 CD patients were included, including 31 in the model construction group and 9 in the model verification group. A total of 81 intestinal specimens from 31 patients were graded as none-to-mild bowel fibrosis（ n=32) and moderate-to-severe bowel fibrosis（ n=49) according to a scoring system of fibrosis. In the training cohort, the K app value of moderate-to-severely fibrotic bowel walls was significantly higher than that of none-to-mildly fibrotic bowel walls, and the D appand ADC values of moderate-to-severely fibrotic bowel walls were significantly lower than those of none-to-mildly fibrotic bowel walls（ Z=-5.999, -4.521 and -3.893; P<0.001). There was no significant difference in T 2WI signal intensity or enhancement pattern between these two groups（χ2=1.571 and 0.103; P>0.05). Moderate and mild correlations of histological fibrosis grades with K appand D app( r=0.721 and -0.483; P<0.001), and a mild correlation with ADC（ r=-0.445, P<0.001) were found. Independent factors derived from multivariate logistic regression analysis to predict the degree of bowel fibrosis were K app and D app. Internal and external validation revealed good performance of the nomogram with concordance index of 0.901（95% confidence interval, 0.824-0.978) and 1.000, respectively, for differentiating none-to-mild from moderate-to-severe fibrosis. Conclusion:The DKI-based nomogram can be used to evaluate the bowel fibrosis in CD patients and provides a visual and simple prediction method for clinic.

OBJECTIVE: To establish a novel standardized magnetization transfer ratio (MTR) parameter which considers the element of the normal bowel wall and to compare the efficacy of the MTR, normalized MTR, and standardized MTR in evaluating intestinal fibrosis in Crohn's disease (CD).MATERIALS AND METHODS: Abdominal magnetization transfer imaging from 20 consecutive CD patients were analyzed before performing elective operations. MTR parameters were calculated by delineating regions of interest in specified segments on MTR maps. Specimens with pathologically confirmed bowel fibrosis were classified into one of four severity grades. The correlation between MTR parameters and fibrosis score was tested by Spearman's rank correlation. Differences in MTR, normalized MTR, and standardized MTR across diverse histologic fibrosis scores were analyzed using the independent sample t test or the Mann-Whitney U test. The area under the receiver operating characteristic curve (AUC) was computed to test the efficacies of the MTR parameters in differentiating severe intestinal fibrosis from mild-to-moderate fibrosis.RESULTS: Normalized (r = 0.700; p < 0.001) and standardized MTR (r = 0.695; p < 0.001) showed a strong correlation with bowel fibrosis scores, followed by MTR (r = 0.590; p < 0.001). Significant differences in MTR (t = −4.470; p < 0.001), normalized MTR (Z = −5.003; p < 0.001), and standardized MTR (Z = −5.133; p < 0.001) were found between mild-to-moderate and severe bowel fibrosis. Standardized MTR (AUC = 0.895; p < 0.001) had the highest accuracy in differentiating severe bowel fibrosis from mild-to-moderate bowel wall fibrosis, followed by normalized MTR (AUC = 0.885; p < 0.001) and MTR (AUC = 0.798; p < 0.001).CONCLUSION: Standardized MTR is slightly superior to MTR and normalized MTR and therefore may be an optimal parameter for evaluating the severity of intestinal fibrosis in CD.
Crohn Disease ; Fibrosis ; Humans ; Magnetic Resonance Imaging ; ROC Curve

Objective To determine the correlation between intravoxel incoherent motion (IVIM) parameters and both histologic inflammatory and fibrotic grades of Crohn disease (CD) in adults. Methods Prospectively, 17 patients (77 lesions) with a clinical and pathological diagnosis of CD in the first affiliated hospital of sun yat-sen university from July 2015 to June 2016 underwent MRE 15 days before surgery. All patients underwent T2WI, IVIM and enhanced MRI and calculated IVIM parameters include diffusion-related coefficient (D), perfusion-related coefficient (D*) and perfusion-related fraction (f). Histological intestinal inflammation and fibrosis was scored using the surgical histopathology as reference standard and further divided into mild-moderate (score 1 to 2) and severe (score 3 to 4) groups. Intestinal microvessel density (MVD) were also analyzed. Differences in IVIM parameters among different histological inflammation and fibrosis grades were assessed with the Kruskal-Wallis test. The Wilcoxon test was used for assessing differences in f between mild-moderate and severe fibrosis. The bivariate correlations between IVIM parameters and histological inflammation and fibrosis grades were analyzed using partial correlation . The bivariate correlations between IVIM parameters and MVD were analyzed using Spearman rank correlation. The areas under the receiver operating characteristics curves (AUROC) were analyzed to evaluate the efficacy for distinguishing severe from mild-moderate fibrosis. Results Of 77 surgical specimens, there were 41 mild-moderate and 36 severe inflammatory bowel segments, along with 22 mild-moderate and 55 severe fibrotic bowel segments. Positive correlation was shown between histologic inflammatory and fibrotic scores (r=0.592, P<0.01). MVD (42.7 ± 39.9)/HP presented weak positive correlation with histologic inflammatory scores (r=0.332, P=0.003) while no correlation with histologic fibrotic scores (r=0.129, P=0.262) was presented. Neither the D nor the D* values significantly correlated with histologic inflammation or fibrosis (P>0.05) while the f value significantly correlated with both histologic inflammation and fibrosis (P<0.05). Significant correlation was present between the f value and histologic inflammatory and fibrotic scores, respectively (r=-0.280, -0.520;P<0.05). There was significant difference in the f value between mild-moderate and severe fibrosis(Z=-5.255,P<0.01). The AUROC for the f value to distinguish between patients with mild-moderate fibrosis and severe fibrosis were 0.885. Using a threshold fractional perfusion of 0.33, the sensitivity and specificity values were 95.5％ and 81.8％, respectively. No correlation between f, D and D*value with histologic fibrotic scores (r=0.129, P=0.262) was presented. Conclusion The f value derived from IVIM could help to evaluate the severity of intestinal inflammation and fibrosis CD in adults.

Objective To assess the diagnostic value of magnetization transfer MRI (MTI) for bowel inflammation and fibrosis in humans with Crohn disease (CD). Methods From July 2014 through April 2017, 31 patients with a confirmed diagnosis of CD were prospectively recruited from the First Affiliated Hospital of Sun Yat Sen University. They were scheduled for elective surgery due to bowel obstruction and other complications, and underwent preoperative MR enterography (MRE) and MTI within 15 days of surgery. All cases had available intestinal specimens identified on MRE and resected bowel segments for region by region matching. All patients underwent breath hold conventional MRE and MTI examinations, and then the magnetization transfer ratios (MTRs) of pathological bowel segments were measured. Using region by region correlation between MTI and surgical specimen, the bowel segments were resected to stain with HE for evaluating bowel inflammation, Masson for bowel fibrosis, and typeⅠcollagen staining for the deposition of typeⅠcollagen within the bowel walls. The histologic sections from the most severe areas were scored as 0 (normal), 1 (mild), 2 (moderate) and 3 (severe). The correlations between MTR and histologic scores were analyzed by using Spearman rank correlation or partial correlation. The differences in MTR among different grades of bowel fibrosis were analyzed by one way ANOVA. The efficacy of MTR for predicting bowel fibrosis was evaluated by receiver operating characteristic curves analysis. The difference in MTRs between purely inflammatory bowel walls and mixed fibrotic and inflammatory bowel walls was analyzed by Student s t test. Results Sixty two resected bowel specimens from 31 patients including 9 purely inflammatory bowel walls and 53 mixed fibrotic and inflammatory bowel walls were obtained in this study. There were significant differences in MTR among non fibrotic [(21.45 ± 2.65)%], mildly [(30.88 ± 6.14)%], moderately [(35.14 ± 4.31)%] and severely [(35.14 ± 4.31)%] fibrotic walls (F=38.397,P<0.01). MTRs strongly correlated with fibrosis scores (r=0.681, P<0.01). High accuracy of MTRs was shown (curve under area=0.905, P<0.01) for differentiating moderately severely fibrotic from non fibrotic and mildly fibrotic bowel walls. Using MTR of 31.50% as a cutoff value, the sensitivity and specificity were 93.6% and 80.0%, respectively. The MTRs of purely inflammatory bowel walls [(21.45 ± 2.65)%] were significantly higher than that of mixed fibrotic and inflammatory [(36.28±5.21)%] bowel walls (t=-13.052,P<0.01). MTRs correlated with the scores of type Ⅰ collagen (r=0.325, P=0.044) but did not correlate with inflammation scores (r=-0.024, P=0.857). Conclusions MTI enables quantitative evaluation of bowel fibrosis in patients with CD and can be used to differentiate purely inflammatory CD from mixed fibrotic and inflammatory CD.