Volume 137 · Issue 06 · 2024

当接受大手术的患者到达麻醉后监护室时，家属自然会认为他们已经度过了围手术期最危险的部分。他们的假设是错误的。术后30天内的死亡率是术中死亡率的140倍。^[1,2]事实上，如果手术后的一个月被认为是一种疾病，它将是世界上第三大死亡原因。^[3]

结肠经内窥镜肠管（TET）是一种介入性肠道治疗程序。结肠TET技术代表了一种新的药物递送途径、介入诊断和治疗以及概念验证的范例，在研究和实践中显示出广阔的前景。自2023年中国肠道大会首次会议以来，我们的专家小组就TET的概念、突破和未来进行了一系列讨论。我们努力为进一步建立TET研究组以设计多中心研究和制定相关共识或指南奠定基础。

除了少数组织如角膜和软骨是无血管的，血管在几乎所有器官中构成组织块的显著比例。在生理条件下，成人脉管系统保持静止以保持组织和器官稳态功能。血管太少或太多与许多疾病的发作和进展有关。为了响应损伤，大多数组织通过开启血管生成来进行修复，血管生成是新血管形成的关键过程。^[1]类似地，血管生成通常在病理组织中活跃，包括肿瘤和缺血性组织，以加重疾病进展。为了诱导新血管形成，血管生成组织产生主要靶向内皮细胞和血管周围细胞的各种生长因子和细胞因子。^[2]靶向这些血管生成因子为治疗许多恶性和非恶性疾病如癌症和眼科疾病提供了有吸引力的方法。事实上，抗血管生成药物在临床上常规用于各种癌症和眼部疾病的治疗。^[2]相反，通过递送促血管生成因子刺激血管生成也为治疗缺血性疾病如心肌梗塞和伤口愈合后的缺血性心肌提供了令人兴奋的机会。^[3]在一系列综述文章中，我们描述了血管生成研究的最新知识，并讨论了临床意义、挑战性问题和可能的解决方案。我们提供了一些用于治疗各种疾病的促血管生成和抗血管生成疗法的例子，包括癌症、眼科疾病、心血管疾病和代谢疾病[图1].因为最近在另一期《中华医学杂志》上讨论了血管生成调节脂质代谢与代谢性疾病的话题，^[4]本期我们排除了这个话题。本期特刊还致力于表彰和庆祝Judah Folkman博士的最初假设，该假设导致了半个世纪以来在血管生成研究和临床成功方面的突破性成就。

Anti-cancer therapies usually focus on tumor cells, but non-tumor stromal components in the tumor microenvironment also play vital roles in tumor initiation and progression, which may be the prognostic factors and potential therapeutic targets. Cancer-associated fibroblasts (CAFs) are the essential component in the tumor environment, exhibiting high heterogeneity in their cell origin and phenotype with diverse functions that influence tumor angiogenesis, immune systems, and metabolism. Single-cell RNA sequencing and genetically engineered mouse models have increased our understanding of CAF diversity, and many subtypes have been defined. However, the precise functions of these subtypes need to be studied and validated. Studies of signaling pathways and epigenetic changes in CAFs facilitate understanding of the phenotypes of CAFs and the crosstalk between tumor cells and CAFs to provide potential therapeutic targets. Some clinical trials, including phase III trials targeting CAFs, have been performed recently. However, few of these trials have generated promising results, which indicates that the complexity of CAFs in the tumor microenvironment remains largely unknown, and in-depth investigations of CAFs should be performed. This review summarizes the research on CAFs, focusing on the heterogeneity of their phenotypes and functions, specific signaling pathways, and the therapeutic strategies involving CAFs. Additionally, we briefly discuss the current technologies commonly used in CAF studies and describe the challenges and future perspectives of CAF research.

Cochlear spiral ganglion neurons (SGNs) are bipolar ganglion cells and are the first neurons in the auditory transduction pathway. They transmit complex acoustic information from hair cells to second-order sensory neurons in the cochlear nucleus for sound processing. Injury to SGNs causes largely irreversible hearing impairment because these neurons are highly differentiated cells and cannot regenerate, making treatment of sensorineural hearing loss (SNHL) arising from SGN injury difficult. When exposed to ototoxic drugs or damaging levels of noise or when there is loss of neurotrophic factors (NTFs), aging, and presence of other factors, SGNs can be irreversibly damaged, resulting in SNHL. It has been found that NTFs and stem cells can induce regeneration among dead spiral ganglion cells. In this paper, we summarized the present knowledge regarding injury, protection, and regeneration of SGNs.

Hepatic ischemia-reperfusion injury (HIRI) remains a common complication during liver transplantation (LT) in patients. As a key downstream effector of the Hippo pathway, Yes-associated protein (YAP) has been reported to be involved in various physiological and pathological processes. However, it remains elusive whether and how YAP may control autophagy activation during ischemia-reperfusion.

Human liver tissues from patients who had undergone LT were obtained to evaluate the correlation between YAP and autophagy activation. Both an in vitro hepatocyte cell line and in vivo liver-specific YAP knockdown mice were used to establish the hepatic ischemia-reperfusion models to determine the role of YAP in the activation of autophagy and the mechanism of regulation.

Autophagy was activated in the post-perfusion liver grafts during LT in patients, and the expression of YAP positively correlated with the autophagic level of hepatocytes. Liver-specific knockdown of YAP inhibited hepatocytes autophagy upon hypoxia-reoxygenation and HIRI (P <0.05). YAP deficiency aggravated HIRI by promoting the apoptosis of hepatocytes both in the in vitro and in vivo models (P <0.05). Attenuated HIRI by overexpression of YAP was diminished after the inhibition of autophagy with 3-methyladenine. In addition, inhibiting autophagy activation by YAP knockdown exacerbated mitochondrial damage through increasing reactive oxygen species (P <0.05). Moreover, the regulation of autophagy by YAP during HIRI was mediated by AP1 (c-Jun) N-terminal kinase (JNK) signaling through binding to the transcriptional enhanced associate domain (TEAD).

YAP protects against HIRI by inducing autophagy via JNK signaling that suppresses the apoptosis of hepatocytes. Targeting Hippo (YAP)-JNK-autophagy axis may provide a novel strategy for the prevention and treatment of HIRI.

Coronavirus disease 2019 (COVID-19) has potential risks for both clinically worsening pulmonary hypertension (PH) and increasing mortality. However, the data regarding the protective role of vaccination in this population are still lacking. This study aimed to assess the safety of approved vaccination for patients with PH.

In this national prospective cohort study, patients diagnosed with PH (World Health Organization [WHO] groups 1 and 4) were enrolled from October 2021 to April 2022. The primary outcome was the composite of PH-related major adverse events. We used an inverse probability weighting (IPW) approach to control for possible confounding factors in the baseline characteristics of patients.

In total, 706 patients with PH participated in this study (mean age, 40.3 years; mean duration after diagnosis of PH, 8.2 years). All patients received standardized treatment for PH in accordance with guidelines for the diagnosis and treatment of PH in China. Among them, 278 patients did not receive vaccination, whereas 428 patients completed the vaccination series. None of the participants were infected with COVID-19 during our study period. Overall, 398 patients received inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine, whereas 30 received recombinant protein subunit vaccine. After adjusting for baseline covariates using the IPW approach, the odds of any adverse events due to PH in the vaccinated group did not statistically significantly increase (27/428 [6.3%] vs. 24/278 [8.6%], odds ratio = 0.72, P = 0.302). Approximately half of the vaccinated patients reported at least one post-vaccination side effects, most of which were mild, including pain at the injection site (159/428, 37.1%), fever (11/428, 2.6%), and fatigue (26/428, 6.1%).

COVID-19 vaccination did not significantly augment the PH-related major adverse events for patients with WHO groups 1 and 4 PH, although there were some tolerable side effects. A large-scale randomized controlled trial is warranted to confirm this finding. The final approval of the COVID-19 vaccination for patients with PH as a public health strategy is promising.

Acute pulmonary embolism (APE) is a fatal cardiovascular disease, yet missed diagnosis and misdiagnosis often occur due to non-specific symptoms and signs. A simple, objective technique will help clinicians make a quick and precise diagnosis. In population studies, machine learning (ML) plays a critical role in characterizing cardiovascular risks, predicting outcomes, and identifying biomarkers. This work sought to develop an ML model for helping APE diagnosis and compare it against current clinical probability assessment models.

This is a single-center retrospective study. Patients with suspected APE were continuously enrolled and randomly divided into two groups including training and testing sets. A total of 8 ML models, including random forest (RF), Naïve Bayes, decision tree, K-nearest neighbors, logistic regression, multi-layer perceptron, support vector machine, and gradient boosting decision tree were developed based on the training set to diagnose APE. Thereafter, the model with the best diagnostic performance was selected and evaluated against the current clinical assessment strategies, including the Wells score, revised Geneva score, and Years algorithm. Eventually, the ML model was internally validated to assess the diagnostic performance using receiver operating characteristic (ROC) analysis.

The ML models were constructed using eight clinical features, including D-dimer, cardiac troponin T (cTNT), arterial oxygen saturation, heart rate, chest pain, lower limb pain, hemoptysis, and chronic heart failure. Among eight ML models, the RF model achieved the best performance with the highest area under the curve (AUC) (AUC = 0.774). Compared to the current clinical assessment strategies, the RF model outperformed the Wells score (P = 0.030) and was not inferior to any other clinical probability assessment strategy. The AUC of the RF model for diagnosing APE onset in internal validation set was 0.726.

Based on RF algorithm, a novel prediction model was finally constructed for APE diagnosis. When compared to the current clinical assessment strategies, the RF model achieved better diagnostic efficacy and accuracy. Therefore, the ML algorithm can be a useful tool in assisting with the diagnosis of APE.

Previous studies have reported associations of specific maternal and paternal lifestyle factors with offspring’s cognitive development during early childhood. This study aimed to investigate the prospective associations between overall parental lifestyle and offspring’s cognitive performance during adolescence and young adulthood in China.

We included 2531 adolescents aged 10-15 years at baseline in 2010 from the China Family Panel Studies. A healthy parental lifestyle score (ranged 0-5) was constructed based on the following five modifiable lifestyle factors: Smoking, drinking, exercise, sleep, and diet. Generalized estimating equation models were used to examine the association between baseline parental healthy lifestyle scores and offspring’s fluid and crystallized intelligence in subsequent years (2012, 2014, 2016, and 2018).

Offspring in the top tertile of parental healthy lifestyle scores performed better in overall fluid intelligence (multivariable-adjusted β = 0.53, 95% confidence interval [CI]: 0.29-0.77) and overall crystallized intelligence (multivariable-adjusted β = 0.35, 95% CI: 0.16-0.54) than those in the bottom tertile of parental healthy lifestyle scores. The results were similar after further adjustment for the offspring’s healthy lifestyle scores and persisted across the subgroups of parental socioeconomic status. Additionally, maternal and paternal healthy lifestyle scores were independently associated with better offspring’s cognitive performance, with significant contribution observed for paternal never-smoking, weekly exercise, and diversified diet. When both parents and offspring adhered to a healthier lifestyle, we observed the highest level of the offspring’s overall crystallized intelligence.

Our study indicates that parental adherence to a healthier lifestyle is associated with significantly better offspring’s cognitive performance during adolescence and early adulthood, regardless of socioeconomic status. These findings highlight the potential cognitive benefits of promoting healthy lifestyles among parents of adolescents.

The goal of the assisted reproductive treatment is to transfer one euploid blastocyst and to help infertile women giving birth one healthy neonate. Some algorithms have been used to assess the ploidy status of embryos derived from couples with normal chromosome, who subjected to preimplantation genetic testing for aneuploidy (PGT-A) treatment. However, it is currently unknown whether artificial intelligence model can be used to assess the euploidy status of blastocyst derived from populations with chromosomal rearrangement.

From February 2020 to May 2021, we collected the whole raw time-lapse videos at multiple focal planes from in vitro cultured embryos, the clinical information of couples, and the comprehensive chromosome screening results of those blastocysts that had received PGT treatment. Initially, we developed a novel deep learning model called the Attentive Multi-Focus Selection Network (AMSNet) to analyze time-lapse videos in real time and predict blastocyst formation. Building upon AMSNet, we integrated additional clinically predictive variables and created a second deep learning model, the Attentive Multi-Focus Video and Clinical Information Fusion Network (AMCFNet), to assess the euploidy status of embryos. The efficacy of the AMCFNet was further tested in embryos with parental chromosomal rearrangements. The receiver operating characteristic curve (ROC) was used to evaluate the superiority of the model.

A total of 4112 embryos with complete time-lapse videos were enrolled for the blastocyst formation prediction task, and 1422 qualified blastocysts received PGT-A (n = 589) or PGT for chromosomal structural rearrangement (PGT-SR, n = 833) were enrolled for the euploidy assessment task in this study. The AMSNet model using seven focal raw time-lapse videos has the best real-time accuracy. The real-time accuracy for AMSNet to predict blastocyst formation reached above 70% on the day 2 of embryo culture, and then increased to 80% on the day 4 of embryo culture. Combing with 4 clinical features of couples, the AUC of AMCFNet with 7 focal points increased to 0.729 in blastocysts derived from couples with chromosomal rearrangement.

Integrating seven focal raw time-lapse images of embryos and parental clinical information, AMCFNet model have the capability of assessing euploidy status in blastocysts derived from couples with chromosomal rearrangement.

Spinal injuries are an urgent public health priority; nevertheless, no China-wide studies of these injuries exist. This study measured the incidence, prevalence, causes, regional distribution, and annual trends of spinal injuries in China from 1990 to 2019.

We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 to estimate the incidence and prevalence of spinal injuries in China. The data of 33 provincial-level administrative regions (excluding Taiwan, China) provided by the National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention (CDC) were use to systematically analyze the provincial etiology, geographical distribution, and annual trends of spinal injuries. The Bayesian meta-regression tool DisMod-MR 2.1 was used to ensure the consistency among incidence, prevalence, and mortality rates in each case.

From 1990 to 2019, the number of living patients with spinal injuries in China increased by 138.32%, from 2.14 million to 5.10 million, while the corresponding age-standardized prevalence increased from 0.20% (95% uncertainty interval [UI]: 0.18-0.21%) to 0.27% (95% UI: 0.26-0.29%). The incidence of spinal injuries in China increased by 89.91% (95% UI: 72.39-107.66%), and the prevalence increased by 98.20% (95% UI: 89.56-106.82%), both the most significant increases among the G20 countries; 71.00% of the increase could be explained by age-specific prevalence. In 2019, the incidence was 16.47 (95% UI: 12.08-22.00, per 100,000 population), and the prevalence was 358.30 (95% UI: 333.96-386.62, per 100,000 population). Based on the data of 33 provincial-level administrative regions provided by CDC, age-standardized incidence and prevalence were both highest in developed provinces in Eastern China. The primary causes were falls and road injuries; however, the prevalence and specific causes differed across provinces.

In China, the overall disease burden of spinal injuries increased significantly during the past three decades but varied considerably according to geographical location. The primary causes were falls and road injuries; however, the prevalence and specific causes differed across provinces.

Mild traumatic brain injury (mTBI) is a common neurological trauma that can lead to cognitive impairment. The sirtuin-1 (SIRT-1)/peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α) pathway has been reported to have neuroprotective effects in rats with craniocerebral injury. We evaluated potential mechanisms underlying electroacupuncture-mediated recovery of cognitive function after mTBI, focusing on the SIRT-1/PGC-1α/mitochondrial pathway.

We included forty 6-week-old male Sprague-Dawley rats in this study. Rats were randomly divided into four groups: controlled cortical impactor (CCI, n = 10), sham operation (sham, n = 10), electroacupuncture-treated CCI (CCI+EA, n = 10), and electroacupuncture-treated sham (sham+EA, n = 10) group. Randomization was performed by assigning a random number to each rat and using a random number table. The mTBI rat model was established using a controllable cortical impactor. Electroacupuncture therapy was performed on the back of rats, by inserting acupuncture needles to the specific acupoints and setting appropriate parameters for treatment. We evaluated spatial learning and memory functions with the Morris water maze test. We performed quantitative real-time polymerase chain reaction (qRT-PCR), western blotting, adenosine triphosphate (ATP) determination, and mitochondrial respiratory chain complex I (MRCC I) determination on rat hippocampal tissue. We analyzed SIRT-1/PGC-1α expression levels and the results of mitochondrial function assays, and compared differences between groups using bilateral Student’s t-tests.

Compared with the sham group, SIRT-1/PGC-1α expression was downregulated in the hippocampus of CCI group (P <0.01). Although this expression was upregulated following electroacupuncture, it did not reach the levels observed in the sham group (P <0.05). Compared with the sham group, MRCC I and ATP levels in the CCI group were significantly reduced, and increased after electroacupuncture (P <0.01). In the Morris water maze, electroacupuncture reduced the incubation period of rats and increased average speed and number of crossing platforms (P <0.05).

Electroacupuncture may improve cognitive function in the mTBI rat model by regulating the SIRT-1/PGC-1α/mitochondrial pathway.

The incidence of well-differentiated gastric neuroendocrine tumors (G-NET) is increasing annually, and while they have a good prognosis and low mortality rate, their high recurrence rate makes treatment options controversial. This study aims to determine the relationship between individualized treatment plans and the recurrence of G-NET.

We performed a multicenter, retrospective study of 94 patients with highly differentiated G-NET and treated at Peking Union Medical College Hospital, Yantai Yuhuangding Hospital, and Beijing Zhong-Neng-Jian Hospital from November 2015 to September 2023. Risk factors for recurrence of G-NETs were investigated using chi-squared test and multifactorial logistic regression analysis.

After a median follow-up of 49 months, the overall recurrence rate among the 94 G-NET patients was 14% (13/94). The recurrence rates of endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), somatostatin analog (SSA) therapy, and surgery were 43% (6/14), 10% (5/49), 5% (1/22), and 11% (1/9), respectively. Post-treatment recurrence rates were significantly different (P = 0.014) among four treatments (EMR, ESD, SSA, and surgery), and further subgroup comparisons revealed lower recurrence rates in the ESD and SSA groups than in the EMR group. From the second month onward, SSA therapy considerably reduced the gastrin levels from 1081.0 (571.5, 2472.8) pg/mL to 461.5 (255.3, 795.0) pg/mL (Z = -3.521, P <0.001). Both chi-squared test and multifactorial logistic regression analysis suggested that among the clinicopathological parameters studied, only the pre-treatment gastrin level (P = 0.018 and 0.005) and the type of treatment (P = 0.014 and 0.017) were significantly associated with G-NET recurrence.

Individualized treatment strategies may reduce the risk of relapse after G-NET treatment. Long-term SSA therapy may be a secure and efficacious treatment option for type 1 G-NET with more than six lesions, and it substantially decreases the incidence of post-treatment recurrence.

Total human immunodeficiency virus (HIV) DNA and integrated HIV DNA are widely used markers of HIV persistence. Droplet digital polymerase chain reaction (ddPCR) can be used for absolute quantification without needing a standard curve. Here, we developed duplex ddPCR assays to detect and quantify total HIV DNA and integrated HIV DNA.

The limit of detection, dynamic ranges, sensitivity, and reproducibility were evaluated by plasmid constructs containing both the HIV long terminal repeat (LTR) and human CD3 gene (for total HIV DNA) and ACH-2 cells (for integrated HIV DNA). Forty-two cases on stable suppressive antiretroviral therapy (ART) were assayed in total HIV DNA and integrated HIV DNA. Correlation coefficient analysis was performed on the data related to DNA copies and cluster of differentiation 4 positive (CD4⁺) T-cell counts, CD8⁺ T-cell counts and CD4/CD8 T-cell ratio, respectively. The assay linear dynamic range and lower limit of detection (LLOD) were also assessed.

The assay could detect the presence of HIV-1 copies 100% at concentrations of 6.3 copies/reaction, and the estimated LLOD of the ddPCR assay was 4.4 HIV DNA copies/reaction (95% confidence intervals [CI]: 3.6-6.5 copies/reaction) with linearity over a 5-log₁₀-unit range in total HIV DNA assay. For the integrated HIV DNA assay, the LLOD was 8.0 copies/reaction (95% CI: 5.8-16.6 copies/reaction) with linearity over a 3-log₁₀-unit range. Total HIV DNA in CD4⁺ T cells was positively associated with integrated HIV DNA (r = 0.76, P <0.0001). Meanwhile, both total HIV DNA and integrated HIV DNA in CD4⁺ T cells were inversely correlated with the ratio of CD4/CD8 but positively correlated with the CD8⁺ T-cell counts.

This ddPCR assay can quantify total HIV DNA and integrated HIV DNA efficiently with robustness and sensitivity. It can be readily adapted for measuring HIV DNA with non-B clades, and it could be beneficial for testing in clinical trials.

股骨头坏死（ONFH）主要是由于股骨头软骨下骨的血管供应减少，导致骨细胞死亡，软骨下骨变性坏死，最终导致股骨头塌陷。^[1]早期准确的诊断是保髋治疗成功的关键，坏死的大小/位置是ONFH治疗的主要决定因素。先前的研究表明，许多保留髋关节的治疗在联合研究循环骨（ARCO）I-II的ONFH患者中取得了令人满意的结果。当ONFH进展至ARCO IV并有骨关节病的临床表现时，全髋关节置换术（THA）可能是唯一的选择。然而，股骨头塌陷（ARCO III）骨坏死的最佳治疗方法仍然未知。^[2]对于这些股骨头坏死塌陷患者，尤其是中年患者，多数学者认为应尽早手术干预，恢复股骨头结构稳定性，缓解疼痛，阻止或延缓进展。

致编辑：特应性皮炎（AD）是一种慢性、复发性炎症性皮肤病，伴有皮肤屏障功能受损和免疫功能障碍，影响儿童和成人。其特征是湿疹性病变、瘙痒、睡眠障碍和生活质量下降。轻度AD的治疗依赖于润肤剂、局部皮质类固醇、局部钙调磷酸酶抑制剂和光疗，而全身性皮质类固醇、免疫抑制剂和生物制剂用于严重的难治性病例。^[1]全身性皮质类固醇和免疫抑制剂具有许多不期望的副作用。对局部治疗没有充分反应的中度至重度AD患者几乎没有有效的治疗选择。

致编辑：2019冠状病毒病（COVID-19）已演变为全球大流行，全球确诊病例超过7亿例，且仍在增加。^[1]鉴于疾病表现的广泛范围，从轻微的呼吸道症状到严重的肺部感染，这种疫情的临床影响是巨大的。识别高风险个体，特别是在他们最初在诊所和医院急救服务中遇到的时候，对于提供及时有效的治疗至关重要。因此，对急诊室中的新冠肺炎患者进行及时的风险分层可以极大地使感染者和医疗保健专业人员受益。^[2]本研究旨在确定可能导致患者死亡的严重新冠肺炎感染的特征。

致编辑：目前的指南建议，对于接受经皮冠状动脉介入治疗（PCI）的急性冠状动脉综合征（ACS）患者，双重抗血小板治疗（DAPT），最好涉及强效P2Y₁₂受体抑制剂，包括替格瑞洛或普拉格雷，应使用至少12个月。^[1,2,3]然而，缺乏关于降级治疗和特定DAPT治疗方案对于具有高缺血风险的ACS患者群体的可行性的相关证据。

致编辑：病理性心脏肥大通常由应激刺激或由心血管疾病诱发，如高血压、心肌梗死等。持续的病理性肥大反应可导致舒张和收缩功能下降，最终发展为心力衰竭。血管紧张素II（Ang II）可通过血管紧张素II 1型受体（AT1R）介导心肌肥大。^[1]血管紧张素受体样1（APJ）是七跨膜G蛋白偶联受体（GPCR）家族的成员，在氨基酸序列上与AT1R具有高度同源性（同一性：27.56%，相似性：74.28%）【补充图1A，http://links.lww.com/CM9/B887】。Apelin是APJ的内源性配体。已发表的研究报道Apelin/APJ系统参与心肌细胞的各种生理过程。在之前的研究中，我们证明了Apelin-13/APJ系统促进了心脏肥大的发展。^[2]因此，Ang II/AT1R和Apelin/APJ都可能有助于心肌肥大的发展。

致编辑：1996年，帕罗迪等人^[1]介绍了开窗血管内动脉瘤修复术（f-EVAR）治疗肾旁腹主动脉瘤的技术。他们使用医生改良的覆膜支架（PMSGs）进行开窗，这允许覆膜支架获得足够的近端密封区并维持内脏动脉的血液灌注。^[2]f-EVAR技术中使用的支架移植物从PMSG发展到公司改良器械（CMD）和现成器械。^[3]为了提高PMSGs的精度并缩短支架移植物修改的时间，已经研究和开发了各种辅助开窗过程的技术，包括三维（3D）打印技术、混合现实（MR）技术和3D参数化表面平面拓扑导板。本文介绍了这些技术的现状和未来发展。

致编辑：一名62岁女性，因多发性无痛性皮肤脓肿和溃疡病史5个月至皮肤科就诊[图1A]，因子宫脱垂而在经阴道子宫切除术后1个月发生。术前术后一般情况良好，除睑下垂外无异常体征。她报告没有发烧、盗汗、咳嗽或腹痛，但体重减轻了10公斤。她没有糖尿病、自身免疫性疾病或慢性传染病史。她的家族中没有类似的疾病。体格检查示躯干和上臂多发性皮下结节，起伏3.0-5.0 cm，多发性皮肤溃疡伴黄色脓液。未触及肿大的淋巴结。实验室检查显示贫血、白细胞计数升高和C反应蛋白（CRP）升高。从非溃疡性病变引流的脓液的真菌和细菌培养为阴性，而鸟分枝杆菌采用实时定量聚合酶链反应检测。纯化蛋白衍生物（PPD）试验阴性，胸部X线显示肺部斑纹增加。腹部和盆腔计算机断层扫描显示阴道残端肿块、输尿管上部扩张和双侧肾积水，而尿量和血清肌酐正常。皮肤活检显示肉芽肿伴淋巴细胞和中性粒细胞浸润。组织的抗酸染色和高碘酸-Schiff染色对微生物均为阴性。初步诊断为播散性非结核分枝杆菌（NTM）感染，尽管证据不是决定性的。诊断NTM的金标准是NTM阳性培养，但获得结果将需要大约三个月，并且患者的皮肤病变太严重而不能等待。她接受了克拉霉素、利福平和乙胺丁醇的经验性治疗。