Objective To explore the value of high-frequency ultrasound in the detection of metastatic hepatocellular carcinoma and displaying lesion characteristics. Methods A total of 38 paitients with hepatocellular carcinoma satellite lesions within 40 mm of subcutaneous tissue were underwent low-frequency (1-5 MHz) and high-frequency (6-9 MHz) ultrasound. Detection rates and ultrasonic features were compared. Results High-frequency grayscale ultrasound had a higher detection rate (71.1% vs. 36.8%, P＜0.001). Subgroup analysis showed higher detection rates with chemotherapy history (88.9% vs. 33.3%, P＝0.002), fatty liver (71.9% vs 31.3%, P＜0.001) or superficial lesion (within 20 mm, 76.5% vs 41.2%, P＝0.031). High-frequency ultrasound also showed clearer margins (P＝0.004) and more arterial-phase rim enhancement (P＝0.007). Conclusions 6-9 MHz ultrasound detects metastatic hepatocellular carcinoma, especially superficial lesions, more effectively than 1-5 MHz ultrasound and better visualizes characteristics.

Objective:To establish a nomogram for preoperative differentiating intrahepatic cholangiocarcinoma (ICC) from hepatocellular carcinoma (HCC) based on clinical, ultrasound, and contrast-enhanced ultrasound (CEUS) data.Methods:A retrospective analysis was conducted on ultrasound and CEUS data of 462 patients who underwent hepatectomy in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from January 2016 to December 2023, including 262 cases of HCC (56.7%) and 200 cases of ICC (43.3%). The data were randomly divided into training set ( n=324) and validation set ( n=138) in a 7∶3 ratio. Univariate analysis was used to initially screen for variables with statistically significant differences between HCC and ICC groups in the training set, and LASSO regression was performed to select the variables with higher coefficients. Logistic regression analyses were then used to predict independent risk factors for ICC. A nomogram was drawn using R software. The performance of the nomogram was then validated using ROC curve, calibration curve, and decision curve analysis (DCA). Results:Univariate analysis showed that there were significant differences in age, gender, liver cirrhosis, HBsAg (+ ), ALP >185 U/L, CA19-9 >27 kU/L, CA242>10 kU/L, irregular shape, border, cholangiectasis, portal vein tumor thrombus, enhanced pattern in arterial phase, clearance time <60 s, intra-tumoral vein between ICC and HCC groups (all P<0.05). The top 10 features were selected for LASSO regression analysis. Logistic regression analysis revealed that gender, cirrhosis, CA19-9>27 kU/L, CA242>10 kU/L, cholangiectasis, clearance time <60 s, intra-tumoral vein and enhanced pattern in arterial phase were risk factors for ICC (all P<0.05). The area under the ROC curve in the training and validation groups were 0.963 and 0.914, respectively. In the training group, the specificity and sensitivity of the nomogram were 0.926 and 0.917, respectively, and in the validation group, they were 0.875 and 0.871, respectively. The calibration curve showed that the prediction effect of the model was in good agreement with the actual situation. DCA showed that the nomogram could increase the net benefit to the different diagnosis of ICC in patients. Conclusions:The nomogram based on clinical, ultrasound and CEUS features has a good predictive value for preoperative identification of ICC and provides reliable evidence for clinical practice.

Objective:To explore whether the application of combined multimodal ultrasound parameters of heart, lung and diaphragm can predict the weaning outcome in critically ill patients.Methods:A total of 53 patients mechanically ventilated > 48 hours and prepared for spontaneous breathing trial (SBT), were prospectively selected from the Department of Critical Care Unit, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from December 2022 to December 2023. The patients were eligible for weaning extubation and prepared to undergo a 30-minute SBT, during which the doctors examined the patient′s heart, lungs and diaphragm with ultrasound probes.According to the weaning outcomes, the patients were divided into successful group and failed group. The ultrasound parameters with statistical significance in the univariate analysis were incorporated into the binary logistic regression model to explore the independent influencing factors of weaning outcomes, and the ROC curve was plotted and the area under the curve (AUC) was calculated for statistical analysis.Results:Thirteen of the 53 patients failed weaning.There were significant differences in diaphragm excursion (DE), diaphragm thickening fraction (DTF), bilateral lung ultrasound score (LUS), total LUS and left ventricular ejection fraction (LVEF) between successful and failed groups (all P<0.05). The AUC for LVEF was 0.709 (95% CI=0.534-0.883, P=0.025) with the cutoff value 57.95%, the sensitivity 85.0%, and the specificity 61.5%. The AUC for the total LUS score was 0.878 (95% CI=0.772-0.984, P<0.001), with the cutoff value 17.50, the sensitivity 77.5%, and the specificity 92.3%. The AUC for the DE was 0.876 (95% CI=0.777-0.975, P<0.001) with the cutoff value 1.205 cm, the sensitivity 80.0%, and the specificity 92.3%. The AUC for DTF was 0.902 (95% CI=0.818-0.986, P<0.001) with the cutoff value 18.1%, the sensitivity 82.5%, and the specificity 92.3%. The AUC for the combination plotting of statistically significant ultrasound parameters, consisting of LVEF, LUS, DE and DTF, was 0.948 (95% CI=0.889-1.000, P<0.001) with the sensitivity 85.0% and the specificity 92.3%. Conclusions:Ultrasound parameters of the heart, lungs, and diaphragm provide critical information on cardiopulmonary and diaphragmatic function during SBT. Weaning failure is more common in patients with increased LUS and decreased LVEF, DE and DTF. The combination of four aspects can improve the accuracy of the prediction of weaning outcome.

Objective:To establish and evaluate a clinical and ultrasound parameters-based nomogram for the preoperative differentiating diagnosis of intrahepatic cholangiocarcinoma (ICC).Methods:A total of 723 patients undergoing hepatectomy in Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University from January 2016 to August 2022 were retrospectively screened. A total of 399 patients with hepatocellular carcinoma (HCC, 198 cases) or ICC (201 cases) were enrolled in this study, including 284 males and 115 females, aged (60.5±10.5) years. Through random sampling using computer-generated random numbers, patients were divided into training ( n=279) and validation groups ( n=120) in a ratio of 7∶3. Univariate and multivariate logistic regression were performed to identify factors differentiating ICC, and a nomogram was established using R software based on independent risk factors for ICC. The accuracy of the nomogram was evaluated by receiver operating characteristic curve and calibration curves. Decision curve analysis was performed to assess the net benefit of the model. Results:Multivariate logistic regression analysis showed that irregular shape, cholangiectasis, female, cirrhosis, carbohydrate antigen 242 >10 U/ml, carbohydrate antigen 125 >30 U/ml and alpha-fetoprotein >10 μg/L were independent differentiating factors for ICC (all P<0.05). A nomogram was constructed based on those factors. The nomogram showed a better discrimination between ICC and HCC. The area under the curve of the training group and the validation group were 0.966 and 0.956, respectively. The calibration curve showed that the prediction effect of the model is in good agreement with the actual situation. Decision curve analysis showed that the nomogram was more effective than diagnosing all patients as either HCC or ICC, which yielded a net benefit at the most reasonable threshold probabilities. Conclusion:The nomogram for the preoperative diagnosis of ICC based on clinical and ultrasound features showed a good diagnostic performance.

Objective:To establish a nomogram prediction model for recurrence within 2 years after radical resection of hepatocellular carcinoma (HCC) based on clinical and ultrasonographic characteristics.Methods:Clinical data from 405 HCC patients (including 327 males and 78 females), aged 60 (53, 66) years old, who underwent radical hepatectomy in the Zhongshan Hospital, Fudan University, from January to December 2021, were retrospectively collected. The patients were divided into two groups: the training group ( n=283) and the validation group ( n=122). Based on recurrence within 2 years after surgery, the 283 patients in the training group were further categorized into the recurrence group ( n=73) and the non-recurrence group ( n=210). Among the 122 patients in the validation group, 33 had recurrence within 2 years, while 89 did not. Data on age, microvascular invasion, alpha-fetoprotein (AFP), AFP lentil lectin-reactive fraction (AFP-L3), protein induced by vitamin K absence or antagonist-II (PIVKA-II), tumor number, and enhancement homogeneity were collected. Logistic regression analysis was performed on the training group to identify risk factors associated with postoperative recurrence, and a nomogram model for predicting HCC recurrence was constructed based on these factors. Calibration curves were used to compare the consistency between predicted and actual outcomes in both the training and validation groups. Results:Multivariate logistic regression analysis revealed that younger age ( OR=0.976, 95% CI: 0.953-1.000, P=0.004), higher AFP-L3 ( OR=1.066, 95% CI: 1.014-1.120, P=0.012), higher PIVKA-II ( OR=1.000, 95% CI: 1.000-1.001, P=0.042), multiple tumors ( OR=0.399, 95% CI: 0.225-0.706, P=0.038), and heterogeneous enhancement ( OR=0.472, 95% CI: 0.243-0.916, P=0.045) were significant risk factors for recurrence after partial hepatectomy in HCC patients. The nomogram constructed based on these variables had a C-index of 0.87 (95% CI: 0.81-0.93) in the training group and 0.83 (95% CI: 0.77-0.89) in the validation group. The calibration curves for predicting recurrence within 2 years after partial hepatectomy in HCC patients showed a high degree of fit in both the training and validation groups, indicating a good agreement between predicted and actual outcomes. Conclusion:The nomogram model constructed based on preoperative clinical and ultrasonographic characteristics can effectively predict the risk of recurrence within 2 years after radical resection of HCC.

Objective:To investigate the surgical efficacy and prognosis influencing factors of hilar cholangiocarcinoma based on multidisciplinary diagnosis and treatment.Methods:The retrospective cohort study was conducted. The clinicopathological data of 91 patients with hilar cholangiocarcinoma who underwent surgery in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from April 2004 to April 2021 were collected. There were 59 males and 32 females, aged (61±10)years. Patients who were admitted from April 2004 to March 2014 underwent traditional surgical diagnosis and treatment, and patients who were admitted from April 2014 to April 2021 underwent multidisciplinary diagnosis and treatment. Observation indica-tors: (1) surgical situations; (2) postoperative situations; (3) postoperative pathological examina-tions; (4) postoperative prognosis analysis; (5) influencing factors of postoperative prognosis. Follow-up was conducted using telephone interview and outpatient examination. Patients were followed up once every 6 months after surgery to detect survival. The follow-up was up to April 2023. Measure-ment data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Comparison of ordinal data was conducted using the rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Kaplan-Meier method was used to draw survival curve and calculate survival rate. The Log-Rank test was used for survival analysis. Univariate and multivariate analyses were conducted using the COX proportional hazard model. Results:(1) Surgical situations. Of the 91 patients, there were 65 cases receiving hemi- or expanded hemi-hepatectomy, 13 cases receiving tri-hepatectomy, 9 cases receiving partial hepatectomy, 4 cases receiving extrahepatic bile duct resection. There were 24 cases receiving combined vein resection and reconstruction, 8 cases receiving combined pancreaticoduodenectomy, 6 cases receiving com-bined hepatic artery resection and reconstruction, including 24 cases receiving extended radical surgery (tri-hepatectomy, hepatic artery resection and reconstruction, hepatopancreaticoduodenec-tomy). The operation time, volume of intraoperative blood loss and intraoperative blood transfusion rate of 91 patients was (590±124)minutes, 800(range, 500?1 200)mL and 75.8%(69/91), respectively. Of the 91 patients, cases receiving extended radical surgery, the volume of intraoperative blood loss were 4, 650(range, 300?1 000)mL in the 31 patients who were admitted from April 2004 to March 2014, versus 20, 875 (range, 500?1 375)mL in the 60 patients who were admitted from April 2014 to April 2021, showing significant differences between them ( χ2=4.39, Z=0.31, P<0.05). (2) Post-operative situations. The postoperative duration of hospital stay and cases with postoperative infectious complications were (27±17)days and 50 in the 91 patients. Cases with abdominal infection, cases with infection of incision, cases with bacteremia and cases with pulmonary infection were 43, 7, 5, 8 in the 91 patients. One patient might have multiple infectious complications. Cases with bile leakage, cases with delayed gastric emptying, cases with chylous leakage, cases with liver failure, cases with pancreatic fistula, cases with intraperitoneal hemorrhage, cases with reoperation, cases dead during the postoperative 90 days were 30, 9, 9, 6, 5, 3, 6, 3 in the 91 patients. Cases with abdominal infection was 10 in the 31 patients who were admitted from April 2004 to March 2014, versus 33 in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( χ2=4.24, P<0.05). Cases dead during the postoperative 90 days was 3 in the 31 patients who were admitted from April 2004 to March 2014, versus 0 in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( P<0.05). (3) Post-operative pathological examinations. Of the 91 patients, cases with Bismuth type as type Ⅰ?Ⅱ, type Ⅲ, type Ⅳ, cases with T staging as Tis stage, T1 stage, T2a?2b stage, T3 stage, T4 stage, cases with N staging as N0 stage, N1 stage, N2 stage, cases with M staging as M0 stage, M1 stage, cases with TNM staging as 0 stage, Ⅰ stage, Ⅱ stage, Ⅲ stage, ⅣA stage, ⅣB stage, cases with R 0 radical resection, cases with R 1 or R 2 resection were 15, 46, 30, 1, 9, 25, 30, 26, 49, 36, 6, 85, 6, 1, 7, 13, 58, 6, 6, 63, 28. Cases with R 0 radical resection, cases with R 1 or R 2 resection were 15, 16 in the 31 patients who were admitted from April 2004 to March 2014, versus 48, 12 in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( χ2=9.59, P<0.05). (4) Postoperative prognosis analysis. Of the 91 patients, 3 cases who died within 90 days after surgery were excluded, and the 5-year overall survival rate and median overall survival time of the rest of 88 cases were 44.7% and 55 months. The 5-year overall survival rate was 33.5% in the 28 patients who were admitted from April 2004 to March 2014, versus 50.4% in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( χ2=5.31, P<0.05). Results of further analysis showed that the corresponding 5-year overall survival rate of cases without lymph node metastasis was 43.8% in the 16 patients who were admitted from April 2004 to March 2014, versus 61.6% in the 31 patients who were admitted from April 2014 to April 2021. There was a significant difference in the 5-year overall survival rate between these patients without lymph node metastasis ( χ2=3.98, P<0.05). The corresponding 5-year overall survival rate of cases with lymph node metastasis was 18.5% in the 12 patients who were admitted from April 2004 to March 2014, versus 37.7% in the 29 patients who were admitted from April 2014 to April 2021. There was no significant difference in the 5-year overall survival rate between these patients with lymph node metastasis ( χ2=2.25, P>0.05). (5) Influencing factors of postoperative prognosis. Results of multivariate analysis showed that poorly differentiated tumor and R 1 or R 2 resection were inde-pendent risk factors influencing prognosis after surgical treatment of hilar cholangiocarcinoma ( hazard ratio=2.62, 2.71, 95% confidence interval as 1.30?5.29, 1.30?5.69, P<0.05). Conclusions:Compared with traditional surgical diagnosis and treatment, treatment of hilar cholangiocarcinoma based on multidisciplinary diagnosis and treatment can expand surgical indications, reduce proportion of dead patients within 90 days after surgery, improve proportation of radical resection and long-term survival rate. Poorly differentiated tumor and R 1 or R 2 resection are independent risk factors influencing prognosis after surgical treatment of hilar cholangiocarcinoma.

Objective:In Shanghai Advanced Proton Therapy Facility (SAPT) of Ruijin Hospital Proton Therapy Center, the calculation accuracy of the commercial proton treatment planning system RayStation (V10), especially the accuracy of the proton range calculation, was measured and verified, aiming to provide reference for the clinical application of the treatment planning system.Methods:A head phantom was used to verify the calculation accuracy of RayStation. The phantom CT was imported into treatment planning system (TPS). The phantom was followed closely by a water tank with a one-liter cubic target. A single field verification plan with the prescribed dose of 200 cGy (relative biological effectiveness) was designed and implemented. Then, the measured distribution results were compared with the calculation results.Results:When the verification plan of the phantom was designed with the default settings of RayStation, the measured longitudinal dose distribution was approximately 4 mm deeper than that of TPS, indicating that RayStation overestimated the water equivalent thickness (WET) of the tissue substitute materials in the phantom. To study the range error, the actual beam was used to measure the WET of the soft tissue substitute material. The default setting of RayStation was fine-tuned according to the measured results. It was found that the error between the measured SOBP and TPS calculations was reduced to only 2 mm.Conclusions:Using the default setting of RayStation to calculate the stopping power of the phantom may cause a large range error. A method that combines tissue segmentation with the measured WET of the tissue substitute material is proposed to improve the range calculation accuracy of the TPS. The results show that the proposed method can improve the dose and range accuracy of the commercial TPS including RayStation for tissue substitute materials.

Objective:To investigate the effect of logistic regression model based on virtual touch tissues quantification (VTQ) and fibrosis index based on four factors (FIB-4) in assessing impaired liver reserve function (LFR) in hepatic surgery patients before surgical resection.Methods:From January 2016 to October 2018, 173 patients including 135 males and 38 females with the mean age of 58.6 years old, scheduled for potential hepatectomy in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, were enrolled in our retrospective study. According to indocyanine green retention test at 15 minutes (ICG R15), the patients were divided into two groups, LFR-impaired group ( n=11, ICG R15≥20%) and control group ( n=162, ICG R15 < 20%). VTQ, FIB-4, platelet count and other parameters were compared between two groups. The multivariate logistic regression model was used to establish a risk model to access the impaired LFR. Receiver operating characteristic (ROC) curve was used to analyze the efficacy of each parameter in LFR-impaired. Results:The platelet count in LFR-impaired group was lower than that in control group, VTQ and FIB-4 were higher than that in control group (all P<0.05). Logistic regression showed that VTQ ( OR=4.382, 95% CI: 1.380-13.918)) and FIB-4 ( OR=2.112, 95% CI: 1.342-3.325) were risk factors for LFR-impaired. The final prediction model of LFR-impaired group was Logit (P)=-6.185+ 0.748×FIB-4+ 1.477×VTQ. The cut-off point (sensitivity, specificity, accuracy) of logistic model, FIB-4 and VTQ were 0.098 (72.8%, 90.1%, 89.0%), 0.990 (90.9%, 79.0%, 79.8%) and 1.8 m/s (81.8%, 77.8%, 78.0%), respectively. The specificity, accuracy of logistic model was higher than FIB-4 or VTQ. Conclusions:Logistic regression model based on VTQ and FIB-4 may improve the specificity and accuracy in the diagnosis of significant LFR impairment. VTQ can further assist clinicians in preoperative evaluation of LFR.

The objective is to deal with brain effective connectivity among epilepsy electroencephalogram (EEG) signals recorded by use of depth electrodes in the cerebral cortex of patients suffering from refractory epilepsy during their epileptic seizures. The Wiener-Granger Causality Index (WGCI) is a well-known effective measure that can be useful to detect causal relations of interdependence in these kinds of EEG signals. It is based on the linear autoregressive model, and the issue of the estimation of the model parameters plays an important role in the calculation accuracy and robustness of WGCI to do research on brain effective connectivity. Focusing on this issue, a modified Akaike's information criterion algorithm is introduced in the computation of the WGCI to estimate the orders involved in the underlying models and in order to advance the performance of WGCI to detect brain effective connectivity. Experimental results support the interesting performance of the proposed algorithm to characterize the information flow both in a linear stochastic system and a physiology-based model.

Muscle atrophy of the residual limb after lower-limb amputation is a disadvantage of amputees' rehabilitation. To investigate the biomechanics mechanism of muscle atrophy of the residual limb, we built a finite element model of a residual limb including muscle, skeletons and main vessels based on magnetic resonance images of a trans-femoral amputee, and studied the biomechanics effects of the socket of the lower-limb prosthesis on the soft tissue and vessels in the residual limb. It was found that the descending branch of the lateral femoral circumflex artery suffered the most serious constriction due to the extrusion, while that of the deep femoral artery was comparatively light. Besides, the degree of the constriction of the descending branch of the lateral femoral circumflex vein, femoral vein and deep femoral vein decreased in turn, and that of the great saphenous vein was serious. The stress-strain in the anterior femoral muscle group were highest, while the stress concentration of the inferior muscle group was observed at the end of the thighbone, and other biomechanical indicators at the inferior region were also high. This study validated that the extrusion of the socket on the vessels could cause muscle atrophy to some degree, and provided theoretical references for learning the mechanism of muscle atrophy in residual limb and its effective preventive measures.