Objective To report a case of symmetric peripheral gangrene (SPG) in septic shock. The clinical data and related literature were reviewed to discuss its characteristics, pathogenesis and treatment measures, so as to improve clinicians' understanding and treatment of the disease. Methods A 60-year-old male patient was admitted to the Changhai Hospital Affiliated to Naval Medical University on July 31, 2022 due to "left side low back pain". Before operation, he was diagnosed with malignant tumor of the left adrenal gland involving multiple organs and blood vessels. Therefore, he underwent resection of huge retroperitoneal tumor, left colon, left kidney, left suprarenal gland, part of stomach and pancreatic body tail under general anesthesia. Due to the large surgical trauma, more bleeding and low blood pressure, he was admitted to the ICU for blood transfusion, fluid infusion and pressure boosting. The literature about SPG in the past 10 years in the database of the National Library of Medicine (PubMed) was searched, and the characteristics of the disease, the related factors of the disease and the treatment measures were emphatically discussed. Results The patient developed septic shock due to intraperitoneal infection on the 3rd day after operation, and gradually developed symmetrical ischemic necrosis of both hands and feet on the 4th day. According to the characteristics of the disease and clinical features, the patient was diagnosed with SPG. A total of 18 foreign English literatures were retrieved, involving 24 SPG patients. In combination with this case, 25 patients were included, including 10 males (40%) and 15 females (60%). The male to female ratio was 1:1.5. The average age was (48.8±15.1) years for males and (49.8±16.2) years for females. There was no history of vascular related diseases in the past. The main clinical features were symmetrical ischemic necrosis of both hands and (or) lower limbs and feet (100%), which was related to septic shock (100%), microbial infection (52%), disseminated intravascular coagulation (DIC) (52%), liver function damage (20%), and the use of vasoactive drugs (80%). The treatment effect was poor, the death mortality was 24% (6/25), and the amputation rate of the surviving patients was as high as 78.9% (15/19). Only one case of blood adsorption treatment was effective. Conclusions The occurrence of SPG in septic shock patients may be related to the pathophysiological changes such as septic shock, DIC, lack of natural anticoagulants, and the role of vasoactive drugs. Clinicians need to pay great attention to improving the diagnosis and treatment of SPG.

Objective To explore the effect and potential mechanism of CYP2C19 gene polymorphism on the blood minimum concentration of voriconazole in children with invasive pulmonary fungal infection. Methods The clinical data of 58 children, who used voriconazole for treatment and prevention of invasive fungal infection in the Department of Pediatrics of the First Affiliated Hospital of Guangzhou Medical University from September 2013 to September 2021, were collected and analyzed retrospectively, including demographic information, glutamic-pyruvic transaminase (ALT), C-reactive protein (CRP) and interleukin-6 (IL-6). The CYP2C19 genotype of children was detected by gene chip method, and the blood drug concentration was detected by high performance liquid chromatography. According to the drug concentration, the children were divided into low concentration group and normal concentration group. The difference of blood drug concentration in patients with different genotypes was compared. Binary logistic regression analysis was performed to analyze the factors affecting the blood concentration of voriconazole in children. Results Four of the 58 children refused to make gene test, the rest 54 patients including 35 males and 19 females; Among the six CYP2C19 genotypes, most children were with *1/*1 (636 GG, 681 GG) genotype (30 cases); The others were *1/*2 (636 GG, 681 GA) genotype (20 cases), *1/*3 (636 GA, 681 GG) genotype (2 cases), and *2/*3 (636 GA, 681 GA) genotype (2 cases), children without *2/*2 (636 GG, 681 AA) genotype and *3/*3 (636 AA, 681 GG) genotype. Among the gene phenotypes, extensive metabolizer type was the highest (30 cases), followed by intermediate metabolizer type and poor metabolizer type (22 cases and 2 cases, respectively). The frequency of allele CYP2C19*1 was the highest (82 cases), followed by the allele CYP2C19*2 and CYP2C19*3 (22 cases and 4 cases, respectively). Genotype and allele were significantly correlated with voriconazole minimum concentration. Compared with intermediate metabolizer and poor metabolizer, extensive metabolizer significantly reduced voriconazole minimum concentration. Compared with CYP2C19*2 and CYP2C19*3 alleles, CYP2C19*1 allele significantly reduced the concentration of voriconazole. Binary logistic regression analysis demonstrated that BMI, CRP, IL-6 and genotype can significantly affect the blood minimum concentration of voriconazole. Conclusions The genotype of CYP2C19 is mainly *1/*1 (636 GG, 681 GG), the extensive metabolizer genotype is the most, and the allele of CYP2C19*1 is the most common. Inflammatory factors, BMI and genotype significantly affected voriconazole metabolism.

Objective To investigate the clinical diagnostic value of peripheral white blood cell count (WBC) and neutrophil-to-lymphocyte ratio (NLR) in obesity with gastroesophageal reflux disease (GERD). Methods The clinical data of 118 patients of obesity admitted to People's Hospital of Xinjiang Uygur Autonomous Region from January 2020 to January 2022 were retrospectively analyzed. Based on the medical history and examination results, the patients were divided into obesity with GERD group (n=57) and obesity without GERD group (n=61). Univariate and multivariate logistic regression were used to analyze the risk factors of obesity combined with GERD. Receiver operating characteristic (ROC) curve was used to evaluate the clinical diagnostic value of peripheral WBC and NLR testing alone vs. combined testing for obesity combined with GERD. Results The obesity with GERD group had a higher proportion of smoking history (31.6% vs. 14.8%, P=0.030), family history of GERD (43.9% vs. 24.6%, P=0.027), and WBC of peripheral blood [(10.25±1.81)×10⁹/L vs. (8.72±2.11)×10⁹/L, P<0.001], NLR (3.55±0.71 vs. 3.00±0.64, P<0.001), and fasting plasma glucose [(6.39±2.21) mmol/L vs. (5.76±0.85) mmol/L, P=0.041] were higher in obesity without GERD group. The results of multivariate logistic regression analysis showed that peripheral WBC and NLR were independent risk factors for the obesity combined with GERD (P<0.05). ROC curve analysis showed that peripheral WBC (AUC=0.707) and NLR (AUC=0.722) had high clinical diagnostic values for obesity combined with GERD (P<0.001), and the combination of them improved the diagnostic efficacy (AUC=0.786). Conclusion Peripheral WBC and NLR are independent risk factors for the obesity combined with GERD, and are of great diagnostic value for obesity combined with GERD, and the combination of the two can improve the diagnostic efficacy and have a certain clinical value.

Objective To investigate the predictive value of serum C-reactive protein/albumin ratio (CAR) with other inflammatory parameters for in-hospital adverse events in patients with acute ST segment elevation myocardial infarction (STEMI) undergoing emergency percutaneous coronary intervention (PCI). Methods A total of 340 patients with STEMI who underwent emergency PCI in 904 Hospital of PLA Joint Logistics Support Force from January 2016 to December 2020 were consecutively included in this retrospective analysis. Patients with STEMI were divided into two groups according to the presence or absence of adverse cardiovascular events during their hospital stay after emergent PCI: patients with major adverse cardiovascular events (MACEs, n=92) and non-MACEs (n=248). Serum C-reactive protein (CRP), white blood cells, neutrophils, lymphocytes, and other indicators were measured in both groups, and inflammatory parameters such as CAR, neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) were calculated. Univariate and multivariate logistic regression analyses were used to screen the independent risk factors correlated with the occurrence of MACEs during the hospitalization after PCI in STEMI patients. Correlations between each inflammatory parameter and MACEs were analyzed by Spearman correlation analysis. Receiver operating characteristic (ROC) curve to evaluate the efficacy size of each inflammatory parameter in predicting the occurrence of MACEs during PCI hospitalization in patients with STEMI. Results Comparison of general data between the two groups revealed that patients in MACEs group had a higher frequency of age, history of diabetes mellitus, polydactyly, and serum composite inflammatory parameters (CAR, NLR, PLR, MLR, and SII) than those in non-MACEs group, the univariate and multivariate results showed that CAR was a risk factor for the occurrence of MACEs during the hospitalization after PCI in patients with STEMI. Spearman correlation analysis showed that CAR was significantly correlated with the occurrence of MACEs during hospitalization, such as cardiogenic shock (r=0.134, P<0.05), heart failure (r=0.436, P<0.05), and all-cause death (r=0.185, P<0.05). The results of ROC curves showed that CAR (AUC=0.751, 95%CI 0.691-0.811, P<0.001) had better predictive value for the occurrence of MACEs after PCI than NLR (AUC=0.643, 95%CI 0.576-0.711, P<0.001), PLR (AUC=0.598, 95%CI 0.530-0.665, P=0.006) and other inflammatory parameters. Conclusion Compared with traditional inflammatory parameters, CAR has better predictive efficacy for the occurrence of MACEs during hospitalization in STEMI patients undergoing emergency PCI, and can better guide the clinic.

Objective To investigate the value of nomogram based on lactate-to-albumin ratio (L/A) combined with neutrophil-to-lymphocyte ratio (NLR) for predicting the early prognosis of patients with acute respiratory distress syndrome (ARDS). Methods A total of 115 patients with ARDS admitted in the Department of Critical Care Medicine of the Second Hospital of Lanzhou University from March 2018 to June 2022 were retrospectively analyzed, and divided into survival group (n=62) and death group (n=53) depending on their clinical outcomes at 28 days after treatment. The general clinical data, blood routine, serum albumin, blood gas analysis, sequential organ failure (SOFA) score, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, Murray lung injury (Murray) score, number of organ failure, cause of ARDS, ICU stay, mechanical ventilation time, 28-day mortality were collected within 24 hours of ICU admission. At the same time, the L/A and NLR were calculated. Univariate and multivariate logistic regression analysis were performed to screen the independent risk factors affecting the prognosis of ARDS and to construct a clinical prediction model. The nomogram was drawn to visualize the clinical model. Finally, receiver operating characteristic (ROC) curve and calibration curve were used to verify the accuracy of the nomogram, a decision curve analysis was also performed to evaluate the clinical usefulness of the nomogram. Results The age, APACHE II, SOFA, and Murray scores, number of organ failure, proportion of pulmonary ARDS, neutrophil count (NEU), NLR, L/A, and blood lactate level in death group were significantly higher than those in survival group, the oxygenation index (PaO₂/FiO₂), proportion of extra pulmonary ARDS, lymphocyte count (LYM), and platelet count (PLT) were significantly lower than those in survival group (P<0.05). Univariate analysis and multivariate logistic regression analysis showed that age, SOFA score, the cause of ARDS, NLR and L/A were the independent risk factors for prognosis of ARDS (P<0.05). In addition, ROC curve analysis showed that the area under the ROC curve (AUC) of age, SOFA score, cause of ARDS, NLR and L/A in predicting the 28-day prognosis of ARDS patients were 0.651, 0.777, 0.579, 0.727 and 0.753, respectively. But the AUC of ARDS cause combined with age and SOFA score was 0.830, which was significantly higher than that of age (P=0.000) and ARDS cause (P=0.000), but there was no significant difference in SOFA score (P=0.064). The nomogram based on all these five independent risk factors was constructed, which was defined as Model 1. At the same time, the combined model constructed by age, cause of ARDS and SOFA was defined as Model 2. The ROC comparison between the two showed that Model 1 had a higher ability to predict the prognosis of ARDS (AUC: 0.889 vs. 0.830), and the calibration curve and decision curve analysis showed that Model 1 had better accuracy and potential application value in predicting the prognosis of ARDS patients. Conclusion The nomogram constructed based on L/A combined with NLR can predict the early prognosis of patients with ARDS, and has high predictive efficiency and clinical benefit.

Objective To evaluate the clinical value to characterize abdominal lymphadenopathy in autoimmune liver diseases (AILD) patients using computed tomography (CT). Methods We recruited 136 AILD patients (set as AILD group) from January 2015 to December 2019 and 65 patients with other liver diseases (set as control group). We assessed the volume and number of the enlarged lymph nodes in different lymph centers using CT. To evaluate the diagnosis value of abdominal lymphadenopathy for AILD, we calculated the area under the receiver operating characteristic curve (AUROC) of abdominal lymphadenopathy. We further employed logistic regression to analyze the risk factors associated with perihepatic lymph node enlargement. Results The abdominal lymph nodes in AILD group had significantly increased average volume and number than those in control group [(0.47±0.61) cm³ vs. (0.25±0.20) cm³;8.10±4.97 vs. 4.26±3.25, P<0.001]. The combination of the number of hepatic lymph nodes and the volume of mesenteric lymph nodes showed well diagnostic value for AILD (AUROC=0.816, P<0.001). Within 77 AILD patients, who underwent liver biopsy, patients with positive hepatic lymphadenopathy showed a significantly higher proportion of interface hepatitis in liver tissues than patients with negative hepatic lymphadenopathy (52.31% vs. 16.67%, χ²=5.169, P<0.05). Multivariate analysis showed that the serum IgG level is a risk factor for perihepatic lymph node enlargement (OR=1.012, 95%CI 1.000-1.024, P<0.05). Conclusions The enlargement of hepatic and mesenteric lymph nodes is of value in the differential diagnosis of AILD. Enlargement of hepatic lymph nodes is correlated with the disease activity in AILD.

Objective To explore the efficacy of contrast-enhanced ultrasound (CEUS) combined with mixed reality (MR) in laparoscopic anatomical hepatectomy. Methods The clinical data of 45 patients with primary liver cancer who underwent laparoscopic anatomical hepatectomy in Luoyang Central Hospital Affiliated to Zhengzhou University from January 2019 to June 2022 were retrospectively analyzed. All patients underwent abdominal thin-layer enhanced CT scan before operation, then collected data to build a three-dimensional visualization model of the liver. According to the auxiliary method of intraoperative imaging, the patients were divided into observation group (n=25, CEUS combined with MR technology was used to provide precise navigation for surgery) and the control group (n=20, routine anatomical hepatectomy was performed, and CEUS and MR technology were not used during surgery). The postoperative follow-up was to January 2023. The size of the lesion, the time of operation, the time of selective hepatic blood flow blockade, the amount of intraoperative bleeding, the intraoperative and postoperative complications, the rate of R0 resection, the length of hospital stay, the postoperative liver function [alanine aminotransferase (ALT), aspartate aminotransferase(AST), creatinine level], and the survival time were recorded and compared between two groups. Results The remaining 42 patients were successfully operated under laparoscopy except for 3 patients in control group who were converted to laparotomy. There was no statistically significant difference in lesion size between the two groups [(5.6±1.1) cm vs. (5.4±1.3) cm, P>0.05]. The observation group had significantly shorter intraoperative selective hepatic blood flow blockade time and surgical time compared to control group [(27.1±6.8) min vs. (46.9±4.3) min, P<0.001; (135.4±4.3) min vs. (199.3±5.8) min, P<0.001]. The intraoperative blood loss and transfusion volume of observation group were significantly lower than those in control group [(102.7±10.1) ml vs. (259.4±16.9) ml, P<0.001; (120.7±9.6) ml vs. (247.4±12.3) ml, P<0.001], the levels of ALT and AST were significantly lower than those in control group 24 h after operation [(96.7±23.7) U/L vs. (185.3±38.5) U/L, P<0.001; (91.4±30.9) U/L vs. (198.1±42.6) U/L, P<0.001]. One patient in the observation group developed postoperative pulmonary infection (1/25, 4.0%), and recovered after conservative treatment. In the control group, 3 patients (3/20, 15.0%) underwent massive intraoperative hemorrhage, resulting in conversion to laparotomy, 2 patients (2/20, 10.0%) experienced postoperative pulmonary infection, and 2 patients (2/20, 10.0%) experienced gastric emptying dysfunction, all patients recovered after conservative treatment. Neither patient in the two groups experienced abdominal bleeding, biliary fistula and other complications after operation. The incidence of complications in the observation group was lower than that in control group, and the difference was statistically significant (P=0.021). There was no statistically significant difference in postoperative creatinine levels, R0 resection rate, and postoperative hospital stay between the two groups [(57.4±18.2) μmol/L vs. (58.1±17.6) μmol/L, P>0.05; 100.0%(25/25) vs. 90.0%(18/20), P>0.05; (8.4±2.2) d vs. (8.9±1.9) d, P>0.05]; The median survival time of observation group was longer than that of control group, but the difference was not statistically significant [18.5(9.2, 24.5) months vs. 18.0 (8.7, 23.0) months, P>0.05]. Conclusion The combination of CEUS and MR technology is safe and effective in laparoscopic anatomical hepatectomy, which can shorten the operation time, reduce intraoperative bleeding, completely remove the tumor, and improve the treatment effect, and has good clinical application value.

Parkinson's disease (PD) is a common neurodegenerative disease, and its incidence increases with age. The incorrect folding and abnormal aggregation of α-synuclein are the key neuropathological markers of PD. Recent studies have shown that exosomes may also promote the pathological α-synuclein spreads in brain through their transport and transfer functions, further promoting the development of PD, thus participating in the pathogenesis of PD. Exosomes are nanoscale extracellular vesicles, the advantage of its smaller diameter is expected to play a significant role in treatment of PD. This article reviews the related research progress on the role of exosome and its potential clinical application in PD.

Pyroptosis is a caspase-dependent, gasdermin protein mediated inflammatory programmed cell death mode, which is involved in the occurrence and development of a variety of diseases. Mesenchymal stem cells (MSCs) are adult pluripotent stem cells derived from the mesoderm and widely distributed in various tissues of human body and show strong secretory capacity. Exosomes, microvesicles, cytokines and other substances secreted by MSCs can regulate microglia phenotypic transformation, promote mitochondrial autophagy, protect mitochondrial function, regulate endoplasmic reticulum stress and calcium homeostasis, thereby inhibiting the pyroptosis mediated by inflammasome and improving the progression and prognosis of related diseases. In addition, pyroptosis has also been reported in MSCs itself. In present paper, the research progress has been reviewed on the role and mechanism of MSCs in regulating pyroptosis, so as to deepen people's understanding on the relationship between MSCs and cell pyroptosis.

Breast reconstruction is an important cosmetic repair after total mastectomy. Nipple-areola complex-sparing mastectomy (NSM) avoids such problems as nipples loss, poor nipple reconstruction, and complicated surgical procedures during breast reconstruction after total mastectomy, resulting in higher patient satisfaction. Prosthetic breast reconstruction is the most widely used breast reconstruction method with no donor injury, little trauma, low complication rate and re-operation rate. NSM combined with prosthetic breast reconstruction is safe, aesthetically pleasing, highly satisfied after surgery, and can significantly improve the patient's social mental health and quality of life. This article reviews NSM, implant breast reconstruction and the effects of adjuvant therapy on NSM combined with prosthetic breast reconstruction.