Volume 105 · Issue 33 · 2025

Awake prone positioning (APP), as an essential therapeutic strategy for acute hypoxemic respiratory failure, has demonstrated significant clinical value, especially during the coronavirus disease 2019 (COVID-19) pandemic. This article systematically summarizes three physiological mechanisms underlying the oxygenation improvement associated with APP, namely enhanced ventilation in gravity-dependent regions, reduction of dead space, and optimization of the ventilation-perfusion ratio. Furthermore, we comprehensively analyze clinical evidence regarding the role of APP in reducing intubation rates and improving right ventricular function, and discuss key factors influencing its efficacy, including initiation timing, duration, and respiratory support modalities. Based on recent research findings, we propose a personalized "4T" principle (Timing, Target population, Technique, and Time duration) for optimizing APP implementation. Finally, we highlight promising directions for future research, such as phenotype stratification and development of intelligent monitoring devices, providing evidence-based guidance in COVID-19 related acute respiratory failure patients for clinical practice.

The routine use of prone positioning during venovenous extracorporeal membrane oxygenation (VV-ECMO) remains controversial. While observational studies suggest a potential survival benefit in patients with acute respiratory distress syndrome (ARDS) supported by VV-ECMO, the recent negative findings from the PRONECMO trial have prompted renewed scrutiny of its clinical value. This article summarizes current evidence, examines the challenges and potential benefits of prone positioning during VV-ECMO, interpretates the negative results from the PRONECMO trial, and emphasizes the need for future studies to refine implementation strategies and evaluate its efficacy in different patient subgroups, with the goal of guiding more precise clinical decision-making.

The risk of acute respiratory distress syndrome (ARDS) combined with acute kidney injury (AKI) is high and the prognosis is poor. Therefore, there is an urgent need for efficient and accurate methods to improve clinical doctors′ early diagnosis and prognosis judgment of this comorbidity state. This article will review the research progress on risk prediction methods for ARDS combined with AKI, providing reference for clinical treatment and scientific research design. The clinical scoring system based on statistical methods can identify key predictive factors and is easy to implement, but it generally relies on single time point data, cannot capture dynamic changes, and lacks adaptability in complex clinical scenarios. The development of key biomarkers provides effective tools for clinical practice, but most of them are still in the validation stage, and standardization and cost-effectiveness issues need to be addressed. In recent years, artificial intelligence has shown outstanding performance in assisting clinical doctors in risk warning for critically ill patients. It can integrate multimodal data and has higher predictive efficiency than traditional methods. It has begun to be deployed and implemented in clinical practice, but multiple issues such as data standardization and model generalization still need to be addressed.

In critical care medicine, sepsis management represents a critical barrier to improving clinical outcomes, primarily due to the disease′s profound heterogeneity and the current inability to optimally identify patient subgroups benefiting from personalized therapies. Recent advances in Artificial Intelligence (AI) offer promising solutions to this challenge. This article reviews the current landscape of sepsis diagnosis and treatment, analyzes existing AI-enabled paradigms and their limitations, and explores feasible strategies and future directions for AI-enhanced sepsis care. By elucidating the nature of sepsis heterogeneity and meaningfully integrating AI tools into critical care workflows, we aim to develop and deploy a "universal" AI-powered predictive model aligned with China′s critical care characteristics. This approach seeks to advance precision medicine for sepsis, ultimately addressing this significant global health burden.

Critical care medicine (CCM) is a clinical discipline that focuses on the pathological mechanisms and comprehensive treatment of critically ill patients. The intensive care unit (ICU), as the clinical base of CCM, is responsible for implementing comprehensive management of critically ill patients throughout their entire care cycle, encompassing a series of integrated measures ranging from early warning to rehabilitation. Driven by national policy, the discipline achieved rapid advancement. In 2024, the National Health Commission and seven other ministries jointly issued the "Framework on Strengthening Critical Care Medical Service Capabilities", marking the discipline′s entry into a high-quality development phase. Accordingly, the Chinese Society of Critical Care Medicine (CSCCM) formulated the"Guidelines for the capacity building and advancement of critical care medicine in China (2025 edition)". The guidelines focus on key aspects of discipline construction and development, covering nine areas: ICU infrastructure planning, professional staffing and technical competencies, equipment standardization, quality management, continuing education, scientific research, emergency preparedness, and service model innovation. The Recommendation development process involved initiation, literature retrieval and screening, and the synthesis of medical evidence to establish preliminary recommendations. These recommendations underwent multiple rounds of expert review, including correspondence review, remote and in-person meetings, revisions, and voting by the CSCCM Standing Committee, ultimately leading to the final version. The recommendations apply to ICUs in secondary and tertiary healthcare institutions and serve as a scientific framework for discipline planning, construction, and management, aiming to enhance the quality of critical care services.

To evaluate the clinical efficacy of the combined internal-external approach in establishing surgical portals for hip arthroscopy.

A prospective analysis was conducted on patients who underwent hip arthroscopy at the General Hospital of the People′s Liberation Army from March 2021 to May 2023. The patients were divided into a trial group (using the combined internal-external approach) and a control group (using the traditional puncture method) based on their voluntary choices of surgical plans. All patients underwent imaging examinations before surgery. During the operation, the time taken to establish the anterolateral approach (AL approach), the time taken to establish the mid-anterior auxiliary approach (MA approach), and the total surgical time were recorded. After surgery, a 1-year follow-up was carried out. Indicators such as the visual analog scale (VAS) of pain, the modified Harris Hip Score (mHHS), the International Hip Outcome Tool-12 (iHOT-12) score, the Hip Outcome Score-Activities of Daily Living Subscale (HOS-ADL), and the Hip Outcome Score-Sports Subscale (HOS-SSS) were recorded and compared for the two groups.

A total of 77 patients were enrolled with a mean age of (37.9±12.6) years(48 males and 29 females). There were 37 cases in the trial group[ with a mean age of (38.0±11.8) years, 24 males and 13 females] and 40 patients in the control group[ with a mean age of (37.8±13.4) years, 24 males and 16 females]. All indicators in both groups demonstrated significant improvement postoperatively compared with the preoperative values (all P<0.001). No significant intergroup differences existed in the indicators preoperatively (all P>0.05). Postoperatively, there was no significant defferences in VAS of pain [(2.3±2.1) vs (2.4±1.9) points], mHHS [(83.3±7.4) vs (80.2±9.2) points], iHOT-12 [(72.8±15.5) vs (71.1±17.4) points], HOS-ADL [(81.4±16.9) vs (84.0±15.0) points] and HOS-SSS [(55.7±23.4) vs (56.1±19.1) points] or AL approach time [(5.3±0.5) vs (5.4±0.4) min] between the trial group and the control group(all P>0.05); however, the MA approach time [(9.0±0.6) vs (14.8±1.3) min] and total operative time [(105.2±8.8) vs (119.4±4.7) min] in the trial group were both shorter than those in the control group (both P<0.001). The trial group had a lower postoperative complication rate than the control group, but the difference was not statistically significant [5.4% (2/37) vs 15.0% (6/40), P=0.263].

Portal establishment using the combined internal-external approach significantly reduces operative time and postoperative complication rate when compared to the traditional puncture technique, representing a safer and more efficient method for hip arthroscopy.

To analyze the clinical characteristics of patients with IgD type systemic light chain (AL) amyloidosis.

The patients diagnosed with IgD-type AL amyloidosis at Peking University People′s Hospital and the First Affiliated Hospital of Dalian Medical University from June 2013 to April 2023 (IgD group) were retrospectively included. These patients were matched with non-IgD type AL amyloidosis patients using a 1∶4 propensity score (non-IgD group). The general clinical data of the patients (age, gender, the type of light chain, results of relevant examinations and so on), treatment planss, and efficacy were collected (the corresponding sample size was reduced due to the fact that some patients did not undergo relevant examinations or lost testing data). Follow-up was conducted until August 2024 to compare the clinical characteristics of the both groups of patients.

A total of 45 patients were included in the study. The IgD group was comprised of 9 patients, with 6 males and 3 females, and an average age of (58±12) years. The non-IgD group consisted of 36 patients, including 24 males and 12 females, with an average age of (58±10) years. The overall median follow-up time [M (Q₁, Q₃)]was 58 (31, 84) months. In the IgD group, one patient had Kappa type while the remaining were Lambda type; seven cases involved kidney, and 6 cases involved heart. Two patients in IgD group had p53 deletion, but there was no p53 deletion in non-IgD group. The rate of soft tissue involvement [55.6% (5/9) vs 13.9% (5/36), P=0.025] and the level of free light chain difference (dFLC) (2 424 vs 140 mg/L, P=0.002) in the IgD group were higher than those in the non IgD group. Hemoglobin levels were lower in the IgD group [(102.3±24.0) vs (128.4±22.1) g/L, P=0.003], as well as lactate dehydrogenase [(190.1±26.0) vs (236.1±62.8) U/L, P=0.002]. A total of 8 patients in the IgD group received first-line treatment, among which 7 achieved hematological remission. Three patients in the IgD group and 5 patients in the non-IgD group died.

The incidence rate for soft tissue involvement and dFLC level of the patients with IgD-type AL amyloidosis are higher in the IgD group. Conversely, hemoglobin levels and lactate dehydrogenase are lower.

To summarize the clinical characteristics and explore the risk factors for in-hospital mortality in patients experiencing perioperative cardiac arrest (PCA).

This study retrospectively analyzed the clinical data of patients who experienced PCA at Peking University Third Hospital from January 1, 2012, to June 30, 2022. Patients were classified into survival and non-survival groups based on their discharge outcome. Demographic characteristics, surgical information, anesthesia methods, and postoperative complications were compared between the two groups. Furthermore, a multivariable logistic regression model was employed to identify independent predictors for in-hospital mortality in PCA patients.

This study included a total of 225 PCA patient (152 males and 73 females), with a mean age of (60.0±17.0) years. Among them, 190 patients (84.4%) died in-hospital and 35 (15.6%) patients survived to discharge. Patients in the survivor group were significantly younger than those in the non-survivor group[(53.5±16.4) vs (61.2±16.9) years, P=0.015], and had a lower incidence of postoperative major adverse cardiovascular events (MACE) [11.4%(4/35) vs 56.8%(108/190), P<0.001], acute kidney injury [0 vs 16.0%(30/190), P=0.006], acute liver injury [0 vs 12.6%(24/190),P=0.031]. Even after adjusting for key clinical variables including age, sex, diabetes mellitus, duration of cardiopulmonary resuscitation, and the use of norepinephrine and dopamine for resuscitation, multivariable logistic regression analysis indicated that postoperative MACE remained an risk factor for in-hospital mortality in PCA patients (OR=12.18, 95%CI: 2.62-56.64, P=0.001).

This study demonstrates a high in-hospital mortality rate among patients experiencing perioperative cardiac arrest, survivors are typically younger and experienced a lower incidence of postoperative complications. Postoperative MACE is identified as an independent predictor of in-hospital mortality in PCA patients.

To establish a diagnostic model for adult gastroesophageal reflux disease (GERD) based on the high-resolution manometry (HRM) parameters of the esophagus.

The clinical data of patients who underwent HRM and 24-hour esophageal pH+impedance examination due to suspected GERD at Jiangsu Province Hospital from January 2021 to October 2024 were retrospectively collected. According to the diagnostic criteria and examination results of GERD, the patients were divided into the GERD group [acid exposure time percentage (AET)>4.2% or total reflux times>80 times] and the non-GERD group, and the HRM parameters of the two groups were compared. Patients were randomly divided into the training set and the validation set in a ratio of 7∶3 using R 4.4. The Youden index maximization method was used to determine the optimal diagnostic cut-off value of a single HRM parameter for diagnosing GERD. The multivariate logistic regression model was used to analyze and screen the influencing factors for diagnosing GERD, and the nomogram of the GERD diagnostic model was drawn. The diagnostic ability and accuracy of the model were evaluated respectively by the area under the receiver operating characteristic curve (AUC) and the calibration curve. Finally, the clinical applicability of the model was determined by the decision curve analysis (DCA).

A total of 326 patients were included, among which 77 were in the GERD group, including 48 males and 29 females, with an age of [M (Q₁, Q₃)] 57 (42, 64) years. There were 249 cases in the non-GERD group, including 90 males and 159 females, with an age of 53 (42, 59) years. The age, proportion of males, body mass index (BMI), proportion of cases classified by gastroesophageal junction (EGJ), proportion of cases with ineffective esophageal motility (IEM), and proportion of ineffective swallowing times in the GERD group were all higher than those in the non-GERD group. The gastroesophageal junction contraction index (EGJ-CI), the resting pressure of the lower esophageal sphincter (LESP), and the distal contraction score (DCI) were all lower than those in the non-GERD group (all P<0.05).The HHRM related parameters for diagnosing GERD were EGJ-CI, LESP, DCI, the proportion of ineffective swallowing times and failed peristalsis times. The corresponding optimal cut-off values (sensitivity and specificity) were 23 mmHg·cm (1 mmHg=0.133 kPa) (48%, 86%), 13.4 mmHg (81%, 59%), 1 130 mmHg·s·cm (66%, 60%), 0.15 (53%, 66%), 0.35 (24%, 89%), respectively. The results of the multivariate logistic regression model analysis showed that gender (OR=3.82, 95%CI: 1.69-8.61), BMI (OR=1.28, 95%CI: 1.12-1.46), and EGJ-CI (OR=0.95, 95%CI: 0.92-0.97), EGJ classification type Ⅲ EGJ (OR=6.66, 95%CI: 1.51-29.40), and IEM (OR=6.69, 95%CI: 1.27-35.27) were the influencing factors for the diagnosis of GERD. Model 1 was established by referring to the "Milan Score". The AUC, sensitivity, and specificity of the training set for diagnosing GERD were 0.78 (95%CI: 0.71-0.85), 56%, and 92%, respectively. The AUC, sensitivity, and specificity of the validation set for diagnosing GERD were 0.77 (95%CI: 0.66-0.89), 61%, 82%, respectively; The calibration curves of the training set and the validation set indicate that the model had good calibration ability. The DCA curves of the training set and the validation set suggest that the diagnostic model had good clinical applicability. Model 2 was established based on the data of the Chinese population and the above parameters. The AUC, sensitivity, and specificity of the training set for diagnosing GERD were 0.88 (95%CI: 0.83-0.92), 78%, and 82%, respectively. The AUC, sensitivity, and specificity of the validation set for diagnosing GERD were 0.87 (95%CI: 0.76-0.97), 89%, 80%, respectively. The calibration curves of the training set and the validation set indicate that the model had good calibration ability. The DCA curves of the training set and the validation set suggest that the diagnostic model had good clinical applicability.

Gender, BMI, EGJ-CI, EGJ morphological classification, LESP, IEM, DCI and the proportion of failed peristalsis times are the influencing factors for diagnosing GERD. The nomogram model incorporating the above factors can diagnose GERD more intuitively.

The clinical data and follow-up outcomes of 9 patients diagnosed with immune checkpoint inhibitor (ICI)-associated myasthenia gravis (MG) admitted to Henan Provincial People′s Hospital from January 2021 to October 2024 were collected retrospectively to analyze their clinical characteristics and prognosis. Nine patients were enrolled, including 4 males and 5 females, aged [M (Q₁, Q₃)] 69 (55, 77) years. All patients had tumors and had received ICI treatment. The time from the start of ICI treatment to the occurrence of MG symptoms or aggravation of the condition was 26 (20, 39) d. Seven patients were classified Myasthenia Gravis Foundation of America Clinical Classification (MGFA) Ⅲ-Ⅴ. All 9 patients had increased creatine kinase and transaminase. Troponin was measured in 5 patients, and all showed elevated levels. ICI therapy was discontinued in all patients at the onset or exacerbation of MG symptoms, and they subsequently received immunomodulatory therapy with pyridostigmine combined with glucocorticoids and/or intravenous immunoglobulin. Symptoms improved in 7 patients and 2 patients showed poor therapeutic effect. The follow-up time was 12.0 (4.5, 16.5) months, and 2 patients died due to the progression of MG superimposed on underlying diseases at the end of the follow-up. ICI-related MG mostly occurs in the early stage of ICI treatment, and is characterized by severe symptoms, rapid progression, and easy complications with myositis/myocarditis. Active initiation of acetylcholinesterase inhibitors combined with immunotherapy can significantly improve outcomes.

This study reported a family with maturity-onset diabetes of the young (MODY) type 6, and analyzed the clinical characteristics and pathogenic variant of the family. A retrospective analysis was conducted on a 38-year-old female patient with early-onset diabetes who presented to the Department of Endocrinology and Metabolism at Shanghai Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine on June 6, 2024 due to "intermittent dry mouth, polydipsia, and polyphagia for 11 years, worsening for more than 20 days". Whole exome sequencing revealed that the patient carried a heterozygous variant in the neurogenic differentiation factor 1(NEUROD1)gene (c.1043C>A: p.A348D). Diagnosed as MODY6. Subsequently, Sanger sequencing was performed on four other direct family members, identifying the same variant in the patient′s mother, diagnosed with diabetes at the age of 62, and the patient′s son. Bioinformatics analysis suggested that the NEUROD1 p.A348D variant is likely pathogenic, and the encoded amino acid is located in the α-helix of the transcription activation domain of the NEUROD1 protein. This study identified the potential pathogenic role of the NEUROD1 p.A348D variant for the first time. The findings not only expand the existing clinical and genetic mutation profiles of MODY6, but also lay a foundation for the deeper understanding of the pathogenic role of the NEUROD1 gene.

A retrospective analysis was conducted on the clinical data of acute B lymphoblastic leukemia (B-ALL) patients with TAF15::ZNF384 fusion gene positive at Hebei Yanda Ludaopei Hospital from December 2018 to February 2022. The patients were followed up until December 2024 to analyze their clinical characteristics and outcomes. A total of 6 patients were included, including 4 males and 2 females, aged 16 to 47 years. The follow-up period ranged from 10 days to 65 months. All 6 patients sought medical attention due to incomplete remission (CR) after treatment at an external hospital or short-term recurrence after CR. Five of the 6 patients presented with chromosomal abnormalities at initial diagnosis, including 4 with t(12;17) (p13;q12) chromosomal translocation. Immunophenotyping showed the B lymphatic system markers CD19, CD22, and cytoplasmic CD79a were positive in all cases, accompanied by positive myeloid markers such as CD33 or CD31. Four patients showd positive expression of the lymphoid maker CD10. Among the 6 patients, 4 patients achieved CR after receiving chimeric antigen receptor T-cell (CAR-T) therapy, and maintained CR after bridging allogeneic hematopoietic stem cell transplantation (allo-HSCT). B-ALL patients harboring the TAF15::ZNF384 fusion gene often present with complex chromosomal abnormalities at the initial diagnosis and the immunophenotype is often characterized by B lymphatic system with positive myeloid markers. CAR-T immunotherapy followed by allo-HSCT may offer a promising approach to improving their prognosis.

To assess the efficacy of Saccharomyces boulardii combined with minocycline quadruple therapy in treating patients with Helicobacter pylori (Hp) infection. Data from patients who underwent initial eradication treatment for Hp infection were retrospectively collected from Zhongda Hospital of Southeast University, Liangjiang Hospital of Southeast University, and the Second Affiliated Hospital of Zhejiang University School of Medicine from January 1, 2023 to April 30, 2024. The patients were divided into two groups according to the sterilization regimen: bismuth quadruple group (combined application of vonoprazan, colloidal bismuth pectin, amoxicillin, minocycline), Saccharomyces boulardii group (combined application of vonoprazan, Saccharomyces boulardii, amoxicillin, minocycline). After the breath test was completed, each patient was followed up in the outpatient department of gastroenterology. The rates of Hp eradication [intention-to-treat analysis (ITT) and pre-protocol set (PP) were used to analysed], incidence of adverse eventst were compared between the two groups. A total of 398 patients were included, with 192 patients in the bismuth quadruple group: 100 males and 92 females, aged (46.9±14.5) years; 206 patients in the Saccharomyces boulardii group: 102 males and 104 females, aged (44.1±14.2) years. The median follow-up time [M (Q₁, Q₃)] was 6.9 (6.0, 8.1) weeks. One hundred and eighty-eight patients in the bismuth group and 200 patients in the Saccharomyces boulardii group completed treatment and follow-up, respectively. The TT eradication rate was 93.8% (180/192) and 92.2% (190/206), and the PP eradication rate was 95.7% (180/188) and 95.0% (190/200), respectively, in the bismuth quadruple group and Saccharomyces boulardii group. There were no significant differences (both P>0.05). The overall incidence of adverse events in Saccharomyces boulardii group was lower than that in bismuth quadruple group [20.4% (42/206) vs 51.0% (98/192), (P<0.001)]. The efficacy of Saccharomyces boulardii combined with minocycline quadruple therapy is comparable to that of quadruple therapy, but with fewer adverse events.

This article reports a case of a 66-year-old female who was seen in Peking Union Medical College Hospital on June 3, 2024 due to "weakness of both lower limbs for 3 months, aggravated with edema for 1 month". The patient developed weak edema of the lower limbs, refractory hypokalemia, and diabetic emergency in a short period of time. The 24-h urine free cortisol level exceeded the upper limit of normal by 70 times. Combined with inferior petrosal sinus blood sampling and pituitary MRI, the diagnosis of Cushing's disease was highly likely, and endoscopic pituitary adrenocorticotropic hormone microadenoma resection through nasosphenoidal approach was performed. There was no immediate biochemical remission after surgery, and delayed remission occurred 6 months after surgery. At the same time, the patient developed progressive lower extremity deep vein thrombosis and pulmonary embolism during the perioperative period, and active gastrointestinal bleeding was complicated during anticoagulation with rivaroxaban. When the bleeding stabilized, low molecular weight heparin anticoagulation was restarted, and the thrombus disappeared, and no bleeding events occurred again. The report of this case is helpful to expand clinicians' understanding of delayed remission of Cushing's disease, and provide practical reference for individualized treatment of patients with contradictory thrombosis and hemorrhage.

The patient, a 74-year-old male, was admitted to Yantai Yuhuangding Hospital affiliated to Qingdao University on August 15, 2024 due to "fever with low blood sodium for 6 days". Amantadine was added to the original anti-Parkinson's drug a few days before admission. The next day, he developed high fever with severe hyponatremia. After anti-infection, antipyretic, sodium supplementation and tolvaptan treatment, his body temperature and blood sodium did not improve, and he developed hypotension, tachycardia and other manifestations. Parkinson's hyperthermia syndrome (PHS) and inappropriate secretion of antidiuretic hormone (SIAD) caused by amantadine were considered. After stopping the drug, his body temperature improved, blood sodium rose, and his vital signs tended to be stable. After 3 months of follow-up, his condition was stable.

The patient, a 50-year-old male, was seen at Liaoning Cancer Hospital on December 25, 2023 due to "upper abdominal pain after repeated eating for 2 weeks". Total abdominal enhanced CT examination showed that the right abdominal soft tissue density mass shadow was rounded, with clear boundary and uniform density, with a size of 3.7 cm ×3.8 cm, which was considered as a high possibility of stromal tumor. Excision of abdominal mass was performed. Postoperative pathology showed: (jejunal mass) gastrointestinal stromal tumor (medium risk); Follicular lymphoma, grade I, was found in gastrointestinal stromal tumor. Components of gastrointestinal stromal tumor and follicular lymphoma collide and infiltrate each other, consistent with the diagnosis of "colliding tumor". The patient received adjuvant therapy with rituximab after surgery, and the patient's condition was stable without recurrence until March 2025.

As an important intestinal probiotic, Ackermannia mucinophila has shown wide application potential in the field of cancer prevention and treatment in recent years. This bacterium not only maintains the mucosal barrier function by degrading intestinal mucin, but also produces short chain fatty acids (acetate and propionate) by its metabolism, which can significantly regulate host immunity and metabolic homeostasis. In the regulation of tumor microenvironment, Ackermannia mucophila exhibits multiple mechanisms of action such as enhancing immune response, improving intestinal barrier and regulating metabolism. There is also a significant correlation with the efficacy of tumor immunotherapy. It provides an important theoretical basis for the development of new tumor treatment strategies based on Ackermannia mucinophila.

Rotator cuff injury is one of the common skeletal and muscular system diseases in clinic. Different types of rotator cuff injuries often cause different degrees of shoulder joint pain and functional limitation, and with the progression of the disease, it will seriously affect patients' motor function and quality of life. Therefore, timely, accurate, rapid and non-invasive diagnosis is of great significance to help clinicians treat and recover accurately. This article reviews the clinical application and recent progress of musculoskeletal ultrasound in the diagnosis and treatment of rotator cuff injury in detail, discusses the advantages and disadvantages of musculoskeletal ultrasound in the diagnosis and treatment of rotator cuff injury by classification and staging, and the future development direction, in order to bring help and guidance to the clinical application of musculoskeletal ultrasound.