Objective To validate the efficacy of the prediction model for difficulty of peroral endoscopic myotomy (POEM) through an independent cohort. Methods A total of 617 patients with achalasia who underwent POEM at the Endoscopy Center of Zhongshan Hospital, Fudan University from January 2021 to December 2023 were included. The general data of patients were collected, and the predictive value of the prediction model for POEM difficulty in the validation cohort was estimated. The stratified analysis was undergone according to the difficulty risk scores. Results In 617 consecutive patients, technical difficulty was observed in 90 cases (14.6%). The predictive model demonstrated moderate discriminatory capacity with an area under the receiver operating characteristic curve (AUC) of 0.711 (95%CI 0.643-0.780). Patients were stratified into three risk categories according to the difficulty risk scores: low-risk (＜0.1), medium-risk (0.1-0.25), and high-risk (≥0.25). The corresponding technical difficulty rates were 7.3%, 16.9%, and 51.6%, respectively. Conclusion The prediction model for POEM difficulty built by our center shows good stability and discrimination, and has good clinical application value.

Objective: To explore the changes of mechanosensitive channels Piezos (Piezo 1 and Piezo 2) in neurogenic bladder (NB) of young rats and their effects，so as to provide reference for clinical search of new therapeutic targets. Methods: A total of 30 female young SD rats were divided into 5 groups based on random number table method：sham operation group (sham)，2-week nerve transection group (NB-2W)，6-week nerve transection group (NB-6W)，2-week nerve transection + Piezos inhibitor group (NB-P-2W) and 6-week nerve transection + Piezos inhibitor group (NB-P-6W)，with 6 rats in each group.The NB models were constructed by transecting the L6 and S1 spinal nerves of young rats.The NB-2W and NB-6W groups were not intervened after modeling，while the NB-P-2W and NB-P-6W groups were intraperitoneally injected with Piezos inhibitor GsMTx4 (10 mg/kg) every 2 days after modeling.Bladder cystometry and ultrasound were performed after 2 and 6 weeks of transection.The expressions of Piezos and fibrosis-related indexes (Collagen Ⅰ and α-smooth muscle actin) were detected in bladder tissues. Results: The results of bladder cystometry showed that the basal bladder pressure in NB-2W group was significantly increased，while it was slightly decreased but was still higher in NB-6W group than in the sham group (P<0.05).Basal bladder pressure was lower in NB-P-2W group than in NB-2W group，but was higher than that in the sham group; basal bladder pressure was lower in NB-P-6W group than in NB-6W group，but higher than that in the sham group (P<0.05).Compared with the sham group，the NB-2W and NB-6W groups had firstly increased and then decreased maximum cystometric capacity (MCC) (P<0.05).Compared with NB-2W group，NB-P-2W group had lower bladder leakage point pressure (BLPP)，but higher MCC and bladder compliance (BC) (P<0.05).Compared with NB-6W group，NB-P-6W group had significantly lower BLPP but higher MCC and BC (P<0.05).HE and MASSON staining and ultrasound results showed that，with the extension of nerve transection time，bladder fibrosis gradually worsened，the bladder wall became rough and thickened，calculi were visible inside，and hydronephrosis gradually appeared; the degree of fibrosis in NB-P-2W and NB-P-6W groups was less than that in NB-2W and NB-6W groups，and no hydronephrosis was observed in the upper urinary tract.In addition，Western blotting and immunohistochemical results showed that NB-2W and NB-6W groups had significantly higher relative expression levels of Piezos，Collagen Ⅰ and α-SMA than the sham group (P<0.01)，while NB-P-2W and NB-P-6W groups had lower relative expression levels of Piezos,Collagen Ⅰ and α-SMA than NB-2W and NB-6W groups (P<0.01). Conclusion: The increased expressions of mechanosensitive channels Piezos in NB young rats may be involved in the progression of bladder fibrosis，but its mechanism needs further study.

Gastrointestinal tumors are a serious and threatening public health concern.Endoscopic minimally invasive treatment is an im-portant way to achieve early diagnosis and treatment of gastrointestinal tumors.Here,we summarize the history and current status of en-doscopic minimally invasive resection of early-stage gastrointestinal tumors,and explain the application of the new ERBEC concepts of endo-scopic minimally invasive surgery for the treatment of gastrointestinal tumors,which include elements,reservation-resection,bilateral-bene-fit,expansion,and collaboration.We also discuss the future direction of endoscopic minimally invasive resection for gastrointestinal tumors.

Objective To explore the related influencing factors of androgenic alopecia(AGA)in young women(FAGA).Methods A total of 296 cases of FAGA initially diagnosed in the dermatology clinic of this hospital from January 2022 to January 2023 were selected as the observation group,and 296 young women without suffering from FAGA in the physical examination of this hospital at the same time were selected as the control group.The clinical data were compared between the two groups and the influencing factors causing FAGA in young women were analyzed.Results The familial inheritance history,often staying up,sleep disor-der,like to eat high carbohydrate food,like to eat high fat food,high mental stress,going on a diet,irregular menstruation,childbearing history and complicating other diseases had statistical differences between the two groups(P＜0.05).The multivariate logistic regression analysis results showed that the familial inheritance history,often staying up,sleep disorder,like to eat high carbohydrate food,like to eat high fat food,high men-tal stress,going on a diet,irregular menstruation,childbearing history and complicating other diseases were the independent risk factors leading to FAGA(P＜0.05).Conclusion It is necessary to do a good job in the complicating disease screening of young female hair loss groups and pay attention to the related risk factors.

Objective To perform structural analysis on the homogeneous polysaccharide SP800301 isolated from Saposhnikoviae Radix to determine its chemical structure.Methods Polysaccharides were separated and purified from Saposhnikoviae Radix using column chromatography,such as DEAE-cellulose and Sephadex G-75.The molecular weight distribution,monosaccharide composition,oligosaccharide fragments,sugar residue types,and glycosidic bond connection of the isolated homogeneous polysaccharide SP800301 from Saposhnikoviae Radix were analyzed using electrospray ionization multistage mass spectrometry,gas chromatography-mass spectrometry,and nuclear magnetic resonance to determine its structure.The appearance characteristics of the Saposhnikoviae Radix polysaccharide were characterized using electron and atomic force microscopy.Results Polysaccharide SP800301 extracted from Saposhnikoviae Radix had good homogeneity with a molecular weight of 9.1×104 g/mol.The uronic acid content was 52.72%.The monosaccharide group comprised rhamnose,galacturonic acid,glucose,galactose,and arabinose,with a molar ratio of 4.3:58.1:25.4:5.0:7.3.The polysaccharide was mainly composed of polygalacturonic acid as the primary chain.The branched chain was comprised of rhamnose,galacturonic acid,galactose,glucose,and arabinose,with arabinose at the end of the branched chain and part of the galacturonic acid in the sugar chain forming a methyl ester.Conclusion This study clarified the chemical structure of the homogeneous polysaccharide SP800301 from Saposhnikoviae Radix,enriched the chemical composition of Saposhnikoviae Radix polysaccharides,laid the foundation for further research on the immune regulatory mechanism of Saposhnikoviae Radix polysaccharides,and provided a scientific basis for clinically using Saposhnikoviae Radix.

Objective:To analyze the risk factors and prognosis for early acute kidney injury (AKI) after orthotopic liver transplantation (OLT).Methods:The retrospective study was conduc-ted. The clinicopathological data of 340 pairs of donor and recipients undergoing OLT in The First Affiliated Hospital of Nanjing Medical University from January 2016 to January 2020 were collected. There were 262 males and 78 females of donors. There were 268 males and 72 females of recipients, aged (51±11)years. Of 340 recipients, 217 cases without postoperative early AKI were divided into the non-AKI group and 123 cases with postoperative early AKI were divided into the AKI group. 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 distri-bution were represented as M( IQR), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was conducted using the non-parameter test. Multivariate analysis was conducted using the binary Logistic regre-ssion model with forward method. The nomogram predictive model was constructed using the R software with its RMS package (R3.6.1). The efficacy of the predictive model was validated using the area under curve (AUC) of the receiver operating characteristic (ROC) curve, and internal validation of the predictive model was performed using the Bootstrap method. The Kaplan-Meier method was used to draw survival curves, and Log-rank test was used for survival analysis. Results:(1) Com-parison of preoperative clinical characteristics between donors and recipients of the non-AKI group and the AKI group. There was a significant difference in overweight of donors between the non-AKI group and the AKI group ( P<0.05). There were significant differences in preoperative hypertension, viral hepatitis, pathological types, international normalized ratio, fibrinogen levels, platelet (PLT), hemoglobin, and anemia of recipients between the non-AKI group and the AKI group ( P<0.05). (2) Comparison of surgical situations between recipients of the non-AKI group and the AKI group. There were significant differences in intraoperative urine output, volume of intraoperative blood loss, peak serum potassium after reperfusion, massive transfusion, plasma infusion, cryoprecipitate infusion, and aminocaproic acid use of recipients between the non-AKI group and the AKI group ( P<0.05). (3) Influencing factors for postoperative early AKI and construction and evaluation of the nomogram predictive model for postoperative early AKI. Results of multivariate analysis showed that donors of overweight, recipients of preoperative hypertension, recipients of non-viral hepatitis, recipients of preoperative severe PLT reduction, recipients of less intraoperative urine output, recipients of severe post-reperfusion hypotension, recipients of high peak serum potassium after reperfusion, recipients with intraoperative plasma infusion were independent risk factors for postoperative early AKI ( odds ratio=1.982, 3.365, 0.519, 3.615, 0.169, 2.480, 1.500, 1.001, 95% confidence interval as 1.160-3.388, 1.649-6.865, 0.293-0.917, 1.358-9.621, 0.061-0.464, 1.246-4.934, 1.003-2.243, 1.000-1.001, P<0.05). The nomogram predictive model for postoperative early AKI was constructed based on the results of multivariate analysis. Results of ROC curve showed the AUC was 0.769 (95% confidence interval as 0.717-0.820). Results of the calibration curve showed that the predictive results of nomogram predictive model fitted well with the actual situation, with a mean absolute error of 0.016. (4) Comparison of prognosis between recipients of the non-AKI group and the AKI group. There were significant differences in postopera-tive peak creatinine, peak brain natriuretic peptide, duration of intensive care unit stay, mechanical ventilation time, re-intubation of recipients between the non-AKI group and the AKI group ( Z=-4.836, -5.652, -5.861, -6.533, χ2=14.676, P<0.05). All 340 recipients were followed up. For recipients of hepatocellular carcinoma, the 6-month survival rates after surgery were 87.8% and 75.6% of the non-AKI group and the AKI group, respectively, showing a significant difference between them ( χ2=4.010, P<0.05), and the overall survival rates were 46.7% and 56.1% of the non-AKI group and the AKI group, respectively, showing no significant difference between them ( χ2=0.047, P>0.05). For recipients of benign liver disease, the 6-month survival rates after surgery were 89.8% and 78.0% of the non-AKI group and the AKI group, respectively, showing a significant difference between them ( χ2=6.401, P<0.05), and the overall survival rates were 81.4% and 68.0% of the non-AKI group and the AKI group, respectively, showing a significant difference between them ( χ2=4.452, P<0.05). Conclusions:Donors of overweight, recipients of preoperative hypertension, recipients of non-viral hepatitis, recipients of preoperative severe PLT reduction, reci-pients of less intraoperative urine output, recipients of severe post-reperfusion hypotension, recipi-ents of high peak serum potassium after reperfusion, recipients with intraoperative plasma transfu-sion were independent risk factors for postoperative early AKI. Nomogram predictive model has well clinical application value. For recipients of benign liver disease, the 6-month survival rate after surgery and overall survival rate of recipients in the non-AKI group are superior to those of the AKI group.

Objective:This study aimed to assess left atrial function in adults across various age groups using 4-dimensional automated left atrial quantification(4D Auto LAQ)technology.The study also aimed to compare the differences in two-dimensional(2D)and four-dimensional(4D)strains of the left atrium among different age groups, with the goal of enhancing the clinical utility of 4D Auto LAQ.Methods:A total of 409 healthy volunteers were recruited for the research.Two-dimensional and four-dimensional images were obtained using a GE Vivid E95 ultrasound system with a 4Vc four-dimensional probe.The study examined variations in 2D and 4D ultrasound parameters across various age groups.Furthermore, the relationship between left atrial reservoir strain(LASr), Left atrial conduit strain(LAScd), left atrial contraction strain(LASct), and age was explored.Results:The study involved 409 volunteers, with 217 males and 192 females, who were categorized into three age groups: young(18-45 years, n=56), middle-aged(46-65 years, n=202), and elderly(>65 years, n=151).Conventional ultrasound measurements indicated changes in left atrial anterior-posterior diameter with age progression: (31.70±3.65)mm for the young group, (34.02±3.91)mm for the middle-aged group, and(35.2±4.37)mm for the elderly group( P<0.01).The 2D and 4D left atrial parameters across the age groups were as follows: LASr(2D)(%): 37.48±7.51, 30.95±8.23, 26.9±7.56( P<0.01); LA VImax(ml/m 2): 23.54±5.79, 26.33±7.6, 28.99±8.15( P<0.01); LASr(%): 31.2±17.07, 22.5±8.59, 19.49±7.47( P<0.01).Both 2D and 4D left atrial parameters exhibited significant associations with age.Specifically, the correlations between LASr(2D)(%), LAScd(2D)(%), LASr(%), LAScd(%), and age were -0.429, 0.580, -0.354, 0.298, respectively( P<0.01). Conclusions:The 4D Auto LAQ technology is efficient in assessing left atrial function across various age groups, with age playing a significant role in influencing left atrial parameters.When compared to other ultrasound parameters, both 2D and 4D left atrial strain parameters have the ability to detect differences at an early stage, making them suitable for the early screening, evaluation, and monitoring of age-related left atrial dysfunction, especially in the elderly population.

Objective:To investigate the efficacy and safety of kidney sparing treatment based on Thulium laser ablation and systematic therapy in localized high-risk upper urinary tract urothelial carcinoma (UTUC).Methods:The data of 10 patients with UTUC who received combined treatment based on Thulium laser and systematic treatment from January 2020 to December 2021 in West China Hospital were retrospectively analysed. There were 5 males and 5 females with a median age of 76 (range 52 to 87)years old. Three cases were renal pelvis tumor and 7 cases were ureter tumor including 5 cases in lower ureter and 2 cases in upper and middle ureter. Five cases were with positive urine cytology and 6 cases were with hydronephrosis. One case was muscular invasion UTUC confirmed by biopsy(cT 2+), 7 cases were high-grade invasive urothelial carcinoma (cT 1+), and 2 cases were high-grade papillary urothelial carcinoma (cT a). Among 10 cases, 5 patients refused radical nephroureterectomy(RUN), among whom 3 patients were too old or in poor general condition to tolerate RNU. One case had a solitary kidney and 1 case had bilateral tumours. Patients were treated with Thulium laser tumor ablation under ureteroscopy combined with systemic therapy. The perioperative systemic treatment included platinum-based chemotherapy±immunotherapy, RC48+ immunotherapy, and immunotherapy alone. The postoperative treatment was immunotherapy maintenance±local radiotherapy. Strict follow-up was conducted after the completion of treatment. Results:Nine patients received systemic therapy before ablation. Four cycles of platinum-based chemotherapy (cisplatin in 2 cases, carboplatin in 1 case) were used in 3 cases, and platinum-based chemotherapy + immunotherapy (6 cycles of cisplatin + toripalimab in 1 case, 4 cycles of cisplatin + toripalimab in 1 case, 4 cycles of carboplatin+ trelizumab in 1 case) was used in 3 cases, four cycle of RC48 + immunotherapy (toripalimab or trelizumab) were used in 2 cases, and four cycles of immunotherapy (toripalimab) were used in 1 case. The operations of 10 cases were successfully completed without serious complications during the perioperative period and the laser working time (42.4 ± 15.2) min. Of the 10 cases, 4 achieved complete ablation at the first ablation, and 6 patients had incomplete ablation. Among them, 2 patients achieved clinical complete remission after 1-2 cycles of systemic therapy, and 4 patients achieved complete ablation after Thulium laser ablation again.All the 10 patients were treated with immunotherapy for 1 year, and 2 of them received additional adjuvant radiotherapy. The patients were followed-up for median 40 months(range 26 to 53 months). Recurrence occurred in 5 cases, of which 3 cases underwent salvage nephroureterectomy and 2 cases underwent Thulium laser ablation under ureteroscopy again. Five patients had no tumor recurrence. None of the 10 patients had distant metastasis. At the last follow-up, 1 patient died of complications and 6 patients kept the affected kidney alive. Perioperative complications including macroscopic hematuria (8 cases), fever (3 cases), the long-term complications of ureter stenosis (4 cases).Conclusions:For localized high-risk UTUC, local Thulium laser ablation combined with systemic therapy can achieve good tumor control while preserving the affected kidney in selected patients, and its potential application value should be further evaluated.

Objectives:To examine the functional outcomes of robot-assisted radical prostatectomy (RARP) with preservation of pelvic floor stabilized structure and early elevated retrograde liberation of the neurovascular bundle (PEEL).Methods:This study was a retrospective cohort study. Between June 1, 2022, and March 20, 2023, 27 cases of RARP with PEEL and 153 cases of RARP with preservation of pelvic floor stabilized structure (PPSS) were included in this study. All patients were males, aged (62.5±5.2) years (range: 50 to 73 years). There were 18 cases of ≤T2b stage and 9 cases of T2c stage. After 1∶1 propensity score matching, the postoperative functional outcomes of 27 cases of RARP with PEEL and 27 cases of RARP with PPSS were compared. All surgeries were performed by a single surgeon and included patients were clinically staged as cT1-2N0M0 without preoperative urinary incontinence or erectile dysfunction. In RARP with PEEL, the prostate was cut near the midline at the front when dissecting the neurovascular bundle, dissection was performed between the visceral layer of the pelvic fascia and the prostatic fascia, preserving the parietal layer and the visceral layer of the pelvic fascia, and the neurovascular bundle was retrogradely released from the apex. The cumulative probability curve was plotted using the Kaplan-Meier method and the Log-rank test was used to compare the differences in functional outcomes between the two groups. Univariate and multivariate analysis with the Cox proportional hazards model was used to compare postoperative urinary continence and sexual function.Results:The recovery time of continence and potency was significantly longer in the PPSS group than in the PEEL group (all P<0.05). The continence rate of the PEEL group was significantly higher than that of the PPSS group (92.59% vs. 68.10%, P=0.026) at 3 months after surgery. The potency rate of the PEEL group was also significantly higher than that of the PPSS group (40.70% vs. 15.10%, P=0.037) at 3 months after surgery. In the univariate analysis, compared to the PPSS technique, the PEEL technique was associated with a shorter recovery time of continence ( HR=1.94, 95% CI: 1.08 to 3.48, P=0.027) and a shorter recovery time of potency ( HR=2.06, 95% CI: 1.03 to 4.13, P=0.042). In the multivariate analysis, the PEEL technique was an independent prognosis factor for postoperative recovery of continence ( HR=2.05, 95% CI: 1.01 to 4.17, P=0.047) and potency ( HR=3.57, 95% CI: 1.43 to 8.92, P=0.007). All the cases of the PPSS group and the PEEL group were performed successfully with negative surgical margins. Conclusion:Compared with PPSS, PEEL may be more conducive to the recovery of urinary continence and sexual function after RARP.

Objective:To investigate the effect of dexmedetomidine on the intraoperative and early postoperative complications of patients undergoing orthotopic liver transplantation.Methods:This is a retrospective cohort study. The clinical data of 399 patients who underwent orthotopic liver transplantation at the First Affiliated Hospital of Nanjing Medical University from January 2016 to September 2020 were retrospectively collected. There were 319 males and 80 females, aged (50.9±10.2) years (range: 10 to 73 years). These patients were divided into the control group (369 cases) and the dexmedetomidine group (30 cases) according to whether dexmedetomidine was continuously pumped intravenously during the operation until the operation ended. The 1∶2 propensity score matching was used to match the preoperative and intraoperative conditions of the two groups of patients, and the caliper width was 0.2. Outcome indicators included intraoperative postreperfusion syndrome, acute kidney injury and pulmonary complications within 7 days after surgery, length of hospital stay, time of stay in ICU, duration of assisted mechanical ventilation, rate of reintubation, 6-month and 1-year survival and recurrence-free survival rate after surgery. The independent sample t test, χ2 test, Mann-Whitney U test or Fisher exact test was used to statistically analyze the data of the two groups of patients, respectively. Survival curves of overall survival and disease-free-survival were plotted by Kaplan-Meier method, and the survival rate and recurrence-free survival rate were compared by Log-rank test. Results:A total of 78 patients were included after propensity score matching, including 26 in the dexmedetomidine group and 52 in the control group. The incidence of acute kidney injury in the dexmedetomidine group within 7 days after surgery was 0 (0/26), significantly lower than that of the control group (21.2%,11/52)(corrected χ2=4.776, P=0.029). There were no significant differences in the incidence of intraoperative postreperfusion syndrome and pulmonary complications within 7 days after surgery, length of hospital stay, ICU time, the duration of assisted mechanical ventilation, rate of reintubation, 6-month and 1-year survival, and recurrence-free survival rate after surgery between the two groups (all P>0.05). Conclusion:Continuous infusion of dexmedetomidine via intravenous pump during operation may be beneficial in reducing the incidence of acute kidney injury within 7 days after orthotopic liver transplantation.