Objective:To analyze clinical characteristics of patients within 48 hours in pediatric intensive care unit（PICU）,and investigate causes and prognosis of extubation failure in reintubation children.Methods:A single-center retrospective study was conducted.Patients who were reintubated within 48 hours after extubation in PICU at Children's Hospital of Fudan University from January 1，2019 to December 31，2022 were retrospectively enrolled.Patients with unplanned extubation for various reasons which include re-intubation due to surgery and replacement of tracheal intubation were excluded.We analyzed the clinical characteristics，causes of extubation failure and prognosis.Main outcome measures included principal diagnosis，pediatric critical illness score（PCIS），the reason of intubation，the glasgow coma scale（GCS），the direct cause of reintubation，aeration time，hospitalization period，outcomes at PICU discharge and whether to extubate successfully.Results:During the study period，a total of 2 652 patients were extubated in PICU,and a total of 87 children were enrolled.Finally，63（72.4%）patients survived at PICU，nine（10.3%）patients died in hospital，and 15（17.2%）patients were discharged automatically.In the survival group，38（60.3%）patients were decannulated and 25（39.7%）patients underwent tracheotomy.The top three principal diagnosis in 87 cases were central nervous system disease[34（39.1%）cases]，lower airway disease[18（20.7%）cases] and sepsis[nine（10.3%）cases].Of the 87 children，28（32.2%）patients were reintubated due to central respiratory failure，21（24.1%）patients were reintubated due to lower airway disease，20（23.0%）patients were reintubated due to upper airway obstruction，14（16.1%）patients were reintubated due to cough weakness and/or swallowing disturbance，and four（4.6%）patients were reintubated for other reasons.In children with mechanical ventilation duration ≥7 days before first extubation，central nervous system diseases were the most common primary diseases，and it accounts for 55.6%.Central respiratory failure was the main direct cause of reintubation，accounting for 40.0%，and more patients(40.0%) had GCS scores＜8 before the first intubation.Compared with the successful decannulation group，the extubation failure group had the higher proportion of children with GCS＜8（32.7% vs.10.5%， P＜0.05），the longer median duration of mechanical ventilation before the first extubation[239（123，349）h vs.68.5（19，206）h， P＜0.05]and the longer median length of ICU stay[38（23，54）d vs.24（12，43）d， P＜0.05].After comparing the three groups including survival group，in-hospital death group and automatic discharge group，the PCIS score of the survival group was the highest，and the in-hospital death group was the lowest( P＜0.05). Conclusion:The rate of reintubation at 48 h after extubation in PICU is 3.3%.The immediate causes of reintubation mainly included central respiratory failure，lower airway disease，upper airway obstruction，cough weakness and/or dysphagia.The mortality rate of reintubation in critically ill children is high and the prognosis is poor.

[Objective]Taking the theory of"sinew meridan-channel-viscera"as the context,to explain the pathogenesis of visual fatigue from a new perspective,and to provide a new diagnosis and treatment idea for the clinical treatment of visual fatigue.[Methods]By summarizing with teachers,sorting out medical cases,reading relevant ancient books and documents,the application of the theory of"sinew meridian-channel-viscera"in the occurrence,development and treatment of visual fatigue is deeply discussed.[Results]The basic pathogenesis of visual fatigue is in the formation of nodules,so the treatment should take"adjusting the meridians and regulating viscera,dispersing and reinforcing"as the general guidelines,emphasize the overall concept in the process of treatment,pay attention to dredge the nodules,get through the meridian system,adjust the body system,according to the degree of the progress of different,using flexible adjustment of"dredge the nodules""get through the meridian system""adjust the body function"three aspects of related drugs.In the attached medical records,using the experience of the team,embodying the core principles of"adjusting the meridians and regulating viscera,dispersing and reinforcing",and it achieved good clinical curative effect.[Conclusion]Based on this theory,firmly grasping the overall concept,connecting with all parties,and using drugs flexibly provide a new idea for the treatment of visual fatigue,which is worth promoting.

Objective:To analyze the clinical situation of critically ill children with Montgomery T-tube，aiming to summarize the characteristics of T-tube application in pediatric and the experience of postoperative airway management in PICU.Methods:The etiology，clinical characteristics，complications and ICU admissions of patients with Montgomery T-tube admitted to the Pediatric Hospital of Fudan University from April 2019 to December 2021 were analyzed，and the application of T-tube in patients with critical conditions requiring long-term mechanical ventilation was described in the light of clinical experience.Results:During the study period,seven children were admitted to the PICU after T-tube insertion,including three males and four females,aged 9~75 months.Five children received mechanical ventilation.Among them,there were five cases with congenital laryngeal malformations,one case with tracheoesophageal fistula,and one case with laryngeal papilloma.The main complications were sputum blockage,infection,and granulation proliferation.One child died of secretion blockage,while the other children were successfully evacuated from the T-tube.The longest retention time of the T-tube was 367 days.Five patients experienced hoarseness after removing the T-tube,and upon re-examination with fiberoptic bronchoscopy,no recurrence of subglottic stenosis was observed.There was no respiratory distress or wheezing,and there were no abnormalities observed during regular outpatient follow-up after discharge.After discharge,the quality of life of the six surviving children improved compared to preoperative,and they all resumed oral feeding.There were no complaints of swallowing difficulties or aspiration during outpatient follow-up.But they were all combined with malnutrition.Conclusion:The Montgomery T-tube is a secure and dependable airway stent utilized for airway remodeling and the maintenance of airway patency following interventional surgery.For critically ill children,early management of airway clearance and infection prevention are imperative.

To investigate the efficacy and safety of total oral regimen containing ixazomib in multidrug-resistant relapsed and refractory multiple myeloma(RRMM). A total of 38 patients were retrospectively analyzed from August 2018 to January 2020 in the First Affiliated Hospital of Soochow University. The overall response rate (ORR)was 36.8%. Among them, the very good partial response (VGPR) or better rate was 23.7%, and the complete response (CR) rate was 5.3%. The ORR was 41.7% in patients receiving ixazomib-lenalidomide-dexamethasone (IRD) regimen. Median PFS was 5 months and median OS was 7.5 months. The ORR was 50% after second-line therapy, 40% after third-line therapy and 12.5% after forth-line therapy or more. The ORR was 29.0% in bortezomib-refractory patients, 38.0% in lenalidomide-refractory patients, 21.4% in bortezmoib & lenalidomide dual refractory patients. Grade 3-4 hematological adverse events (AEs) were reported in 21% patients. Common hematological AEs included lymphopenia, neutropenia, thrombocytopenia. Other usual AEs were fatigue and diarrhea. No grade 3-4 peripheral neuropathy was recorded. In the treatment of relapsed/refractory multiple myeloma patients with multidrug resistance, the total oral regimens containing ixazomib demonstrate reliable efficacy and safety. Early administration of ixazomib at first or second relapse is suggested for more favorable clinical outcome.

Objective:To investigate the clinical epidemiological data of children with prolonged mechanical ventilation (PMV) in pediatric intensive care unit(PICU), and analyze the primary disease of children with PMV as well as the disease characteristics and prognosis of children with PMV under different kinds of primary disease.Methods:The clinical data of hospitalized children with PMV in PICU at Children′s Hospital of Fudan University from January 2019 to December 2020 were retrospectively collected.Results:A total of 46 children with PMV were collected.There were 18 males (39.1%) and 28 females (60.9%). The median age was 37 (8, 86) months and the median body weight was 15 (7, 20) kg.The average pediatric critical illness score at admission was 84.2±7.7, PaO 2/FiO 2 was (245.5±99.8)mmHg.The primary diseases leading to PMV were as follows: there were 14 cases of severe pneumonia, eight cases of severe encephalitis, five cases of bronchopulmonary dysplasia, three cases of upper airway obstruction/craniofacial deformity, three cases of myasthenia, three cases of brain stem tumor, three cases of mitochondrial encephalomyopathy, two cases of spinal muscular atrophy, two cases of Prader-Willi syndrome, one case of dermatomyositis, one case of severe brain injury, and one case of central hypoventilation.The causes of unable to withdraw ventilator were respiratory dysfunction in 24 cases, brain dysfunction in 16 cases, and diaphragm dysfunction in six cases.Compared with neuromuscular diseases, children with PMV caused by respiratory diseases had lower month age, higher preterm birth rate, lower PaO 2/FiO 2 ratio, higher parameters for ventilator treatment, and the differences were statistically significant ( P<0.05). Children with PMV caused by neuromuscular diseases had lower Glasgow coma score and higher coma rate, and the differences were statistically significant ( P<0.05). A total of nine (19.6%) cases underwent tracheotomy.A total of 23 (50.0%) cases were successfully extubated from ventilator, six (13.0%) cases were dependent on invasive ventilator, and six (13.0%) cases were breathing with tracheotomy tube.The median mechanical ventilation time was 33 (28, 40) days, the median PICU hospital stay was 42 (34, 56) days, and the median hospital stay was 51 (41, 65) days.A total of 27 (58.7%) cases were improved and discharged, four (8.7%) cases were transferred to rehabilitation hospital, four (8.7%) cases were transferred to local hospital, and 11 (23.9%) cases died in hospital or at home after giving up. Conclusion:The main causes of PMV in PICU children are respiratory dysfunction, brain dysfunction and diaphragm dysfunction.50.0% of the children with PMV could be discharged from the ventilator, and 23.9% died or died after giving up.

Objective:To explore the effects of external diaphragm electrical stimulation on the diaphragm thickness and function in mechanically ventilated children.Methods:A randomized controlled trial was conducted in children who were admitted to PICU at Children′s Hospital of Fudan University and received mechanical ventilation between June 2021 and April 2022.The control group was given the routine treatment of mechanical ventilation, and the intervention group was given external diaphragm electrical stimulation in the early stage of mechanical ventilation in addition to routine treatment.Diaphragm thickness was continuously measured by bedside ultrasound every day for one week after mechanical ventilation, and the changing trend of diaphragm thickness was observed, and the diaphragmatic thickening fraction (DTf) and the incidence of ventilator-induced diaphragmtic dysfunction(VIDD) were calculated at the same time.Results:A total of 32 valid samples were included, including 15 cases in intervention group (10 males) and 17 cases in control group (11 males). The median age of the patients was 33 (10, 77) months, and the median duration of mechanical ventilation was 12 (8, 21) days.The reasons for mechanical ventilation in children included respiratory insufficiency in ten cases, brain dysfunction in ten cases, heart failure in eight cases, and postoperative surgery in four cases.The diaphragm end-expiratory thickness (DTe) in intervention group and the control group showed a gradually decreasing trend from the 1st day to the 7th day.The left thickness was reduced by 11% on the 7th day compared to 1st day in intervention group, which was reduced by 18% in control group; the average daily DTe was reduced by 2% per day in intervention group and by 3% per day in control group.The trends on the right and left were similar.The DTe thickness in the intervention group was greater than that in control group, among which, the mean DTe thickness in the left side of the intervention group on the 7th day was (0.110 7±0.023 7)cm, which was greater than that in control group (0.093 5±0.016 9)cm, and the difference was statistically significant ( t=-2.372, P<0.05); On the second day, the mean DTe thickness on the right side in the intervention group was (0.1267±0.0277) cm, which was greater than that in control group (0.104 7±0.018 1)cm, and the difference was statistically significant ( t=-2.688, P<0.05). DTf in the intervention group was lower than that in control group at 7th day, but the difference was not statistically significant(left DTf: adjusted mean difference was -0.117, P=0.088; right DTf: adjusted mean difference was -0.065, P=0.277). The incidence of VIDD in the intervention group was lower than that in control group(33.3% vs.41.2%), but the difference was not statistically significant ( χ2=0.005, P=0.946). Conclusion:External diaphragmatic electrical stimulation may be helpful for alleviating diaphragmatic atrophy in mechanically ventilated children.However, whether the improvement of diaphragm atrophy is beneficial to clinical outcome still needs further study.

Children with prolonged mechanical ventilation often have complex conditions, such as long hospital stay of PICU.They have many complications and high mortality.In addition, these patients have low quality of life, lack of psychological care, family emotional communication, and heavy burden of disease.The long-term management and rehabilitation of these children should be strengthened.This study summarized the researches of prolonged mechanical ventilation in adults at home and abroad, in order to provide experience for prolonged mechanical ventilation management in children.

Objective:To explore the clinical application value of sentinel lymph node biopsy (SLNB) in patients with early breast cancer after local excision surgery.Methods:A total of 93 breast cancer patients with clinical stage T is/T 1-2N 0M 0 who underwent SLNB and were confirmed by using tumor mass excision biopsy from March 2012 to November 2018 in Shanxi Bethune Hospital were retrospectively analyzed. According to the postoperative paraffin pathology, the patients who were successfully detected sentinel lymph node (SLN) were divided into SLN-positive group with metastasis or SLN-negative group without metastasis. The clinicopathological data were used to analyze influencing factors of SLN metastasis and SLN detection number after excision biopsy of breast masses in the two groups. Results:A total of 87 out of 93 patients were successfully detected SLN and the detection rate was 93.5% (87/93). A total of 255 SLN were detected, and the average number was 2.93 in per patient. All were subjected to rapid intraoperative freezing pathological, and 11 cases with positive SLN were detected. There were 17 patients who underwent axillary lymph node dissection (ALND), including 11 cases with positive SLN and 6 cases with SLN undetected. The paraffin pathology showed that 14 patients were confirmed as positive SLN, including 13 macrometastasis and 1 micrometastasis. The SLN false negative rate was 2.1% (3/14) of intraoperative frozen diagnosis. Univariate analysis showed that histological grade and intravascular thrombus of carcinoma were associated with SLN metastasis after breast cancer local excision; the number of SLN detection was effected by body mass index and staining method; the methylene staining method combined with radionuclide method could improve the detection rate of SLN (all P < 0.05). Multivariate analysis showed that the SLN non-detection of obesity patients was 2.651 times as much as that of normal patients (95% CI 1.592-8.194, P=0.010). Conclusion:The SLNB and appropriate tracer method will have a high SLN detection rate and better clinical application value for early breast cancer patients after breast mass resection.

Objective: To evaluate the prognostic significance of minimal residual disease (MRD) monitoring by 10-color flow cytometry in multiple myeloma (MM) patients after treatment. Methods: 150 patients with MM who were admitted to the First Affiliated Hospital of Soochow University from July 2015 to July 2017 were retrospectively analyzed. Clinical data, MRD data monitoring by 10-color flow cytometry and prognosis were analyzed. Results: 39.1% (34/87) patients were MRD negative after induction chemotherapy, and 49.3% (34/69) patients were MRD negative within 1 year after autologous hematopoietic stem cell transplantation (ASCT) . MRD-negative patients after induction chemotherapy or after transplantation have better progress-free survival (PFS) than MRD-positive patients (P=0.022 and P<0.001) . According to the changes of MRD pre-ASCT and after ASCT, the patients were divided into 4 groups: patients with MRD continued negativity,improved from MRD positive to MRD negative, MRD continued positivity, transformed from MRD negative to MRD positive. The two-year PFS of the four groups were 83%, 82%, 44%, 0, respectively, (P=0.002) . Multivariate analysis showed that the level of MRD after induction chemotherapy was an independent factor for PFS (P=0.002) , HR=4.808 (95%CI 1.818-12.718) . Conclusion Patients with MRD negative after treatment is a better prognosis marker than complete remission or even the best marker, which can evaluate prognosis by combining R-ISS and cytogenetic changes.

Objective To investigate the application value of early and delayed laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in 65 years of age or older patients with severe acute cholecystitis.Methods The prospective study was conducted.The clinical data of 80 patients with severe acute cholecystitis who were admitted to Shanxi Dayi Hospital of Shanxi Academy of Medical Sciences from May 2016 to January 2018 were collected.All patients were divided into two groups by random number table,including patients undergoing LC 72 h later after extubation of PTGD in the PTGD + early LC group,and patients undergoing LC 5-14 days later after extubation of PTGD in the PTGD + delayed LC group.Observation indicators:(1) surgical situations;(2) analysis of liver function before and after LC in the two groups;(3) analysis of serum-related inflammatory factors before and after LC in the two groups;(4) follow-up situations.Patients were followed up by outpatient examination or telephone interview to detect the postoperative complications in the postoperative three months up to April 2018.Measurement data with normal distribution were represented as Mean ± SD,and comparison between groups was done using the paired t test.Count data were represented as absolute number,and comparison between groups was analyzed using the chi-square test or Fisher exact probability.Results Eighty patients were screened for eligibility,including 41 males and 39 females,aged from 65 to 70 years,with an average age of 67 years.There were 40 patients in the PTGD + early LC group and 40 in the PTGD + delayed LC group,respectively.(1) Surgical situations:the operation time,volume of intraoperative blood loss,and duration of postoperative hospital stay were (52± 15) minutes,(29± 11) mL,(18.9± 1.6) days in the PTGD + early LC group,and (88± 13)minutes,(69± 11)mL,(27.7±4.8)days in the PTGD + delayed LC group,respectively,showing significant differences in the above indicators between the two groups (t =11.668,16.219,11.000,P＜0.05).(2) Analysis of liver function before and after LC in the two groups:the levels of aspartate transaminase (AST),alanine aminotransferase (ALT),gamma glutamyl transferase (GGT),and total bilirubin (TBil) of PTGD + early LC group were (53 ± 11) U/L,(203 ±40) U/L,(128± 22) U/L,(19± 6)U/L,(86±21)μmol/L before LC,and (26±5)U/L,(83±23)U/L,(29±3)U/L,(11±5)U/L,(27± 7) μmol/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t =12.562,16.448,28.199,6.478,16.857,P＜0.05).The levels of AST,ALT,GGT,and TBil of PTGD + delayed LC group were (54± 12) U/L,(203±48) U/L,(130±24) U/L,(19±6) U/L,(85±20) μmol/L before LC,and (29±5) U/L,(151±36) U/L,(53±7)U/L,(17±3)U/L,(31±8)μmol/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t =13.622,5.481,2.169,1.988,15.855,P＜0.05).There was no significant difference in the levels of AST,ALT,ALP,GGT,TBil before LC between the two groups (t=0.389,0.000,0.389,0.000,0.218,P＞0.05),meanwhile,there were significant differences in the levels of AST,ALT,ALP,GGT,TBil after LC between the two groups (t =2.683,10.067,19.931,6.508,2.380,P＜0.05).(3) Analysis of serum-related inflammatory factors before and after LC in the two groups:the levels of interleukin-1 (IL-1),interleukin-6 (IL-6),high-sensitivity C-reactive protein (CRP),interleukin-10 (IL-10),and tumor necrosis factor-α (TNF-α) of PTGD + early LC group were (71 ±9) ng/L,(82±9)ng/L,(137±16)ng/L,(75±6)ng/L,(67±9)μg,/L before LC,and (87±13)ng/L,(97±9)ng/L,(81± 19)ng/L,(145±6)ng/L,(85±6)μg/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t ==6.400,7.454,14.259,52.175,10.525,P＜0.05).The levels of IL-1,IL-6,high-sensitivity CRP,IL-10,and TNF-α of PTGD + delayed LC group were (71±9) ng/L,(82± 10) ng/L,(145±28)ng/L,(75±6)ng/L,(67±10) μg/L before LC,and (145±7)ng/L,(135±16) ng/L,(101±1S)ng/L,(146±9) ng/L,(113±10)μg/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t =41.079,17.766,8.360,41.525,27.578,P ＜ 0.05).There was no significant difference in the levels of IL-1,IL-6,high-sensitivity CRP,IL-10,and TNF-α before LC between the two groups (t =0.000,0.000,1.569,0.000,0.000,P＞0.05),meanwhile,there were significant differences in the levels of IL-1,IL-6,high-sensitivity CRP,and TNF-α after LC between the two groups (t=24.844,13.092,4.833,15.185,P＜0.05).(4) Follow-up situations:80 patients were followed up for 3 months.Two patients in the PTGD + early LC group had postoperative complications,including 1 of bile duct injury and 1 of incisional infection;9 patients of PTGD + delayed LC group had postoperative complications,including 3 of bile duct injury,3 of multiple organ failure,2 of incisional infection,1 of death.There was a significant difference in the postoperative complication between the two groups (x2 =5.165,P＜0.05).Conclusion Early LC after PTGD can effectively shorten operation time,reduce volume of intraoperative blood loss,shorten duration of postoperative hospital stay,protect liver function,reduce the expression of serum inflammatory factors at 24 hours after surgery,and reduce postoperative complications.