Background: Although evidence-based medicine proposes personalized care that considers the best evidence, it still fails to address personal treatment in many real clinical scenarios where the complexity of the situation makes none of the available evidence applicable. "Medicine-based evidence" (MBE), in which big data and machine learning techniques are embraced to derive treatment responses from appropriately matched patients in real-world clinical practice, was proposed. However, many challenges remain in translating this conceptual framework into practice. Objective: This study aimed to technically translate the MBE conceptual framework into practice and evaluate its perform-ance in providing general decision support services for outcomes after congenital heart disease (CHD) surgery. Methods: Data from 4774 CHD surgeries were collected. A total of 66 indicators and all diagnoses were extracted from each echocardiographic report using natural language processing technology. Combined with some basic clinical and surgical information, the distances between each patient were measured by a series of calculation formulas. Inspired by structure-mapping theory, the fusion of distances between different dimensions can be modulated by clinical experts. In addition to supporting direct analogical reasoning, a machine learning model can be constructed based on similar patients to provide personalized prediction. A user-operable patient similarity network (PSN) of CHD called CHDmap was proposed and developed to provide general decision support services based on the MBE approach. Results: Using 256 CHD cases, CHDmap was evaluated on 2 different types of postoperative prognostic prediction tasks: a binary classification task to predict postoperative complications and a multiple classification task to predict mechanical ventilation duration. A simple poll of the k-most similar patients provided by the PSN can achieve better prediction results than the average performance of 3 clinicians. Constructing logistic regression models for prediction using similar patients obtained from the PSN can further improve the performance of the 2 tasks (best area under the receiver operating characteristic curve=0.810 and 0.926, respectively). With the support of CHDmap, clinicians substantially improved their predictive capabilities. Conclusions: Without individual optimization, CHDmap demonstrates competitive performance compared to clinical experts. In addition, CHDmap has the advantage of enabling clinicians to use their superior cognitive abilities in conjunction with it to make decisions that are sometimes even superior to those made using artificial intelligence models. The MBE approach can be embraced in clinical practice, and its full potential can be realized.

OBJECTIVESTo investigate the risk factors of postoperative neuro-developmental abnormalities in neonates with critical congenital heart disease (CCHD).METHODSClinical data of 50 neonates with CCHD admitted in the Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine from November 2020 to December 2021 were retrospectively analyzed. Neurological assessment was performed with cranial ultrasonography, CT/MRI, video electroencephalogram and clinical symptoms before and after surgical treatment for all patients, and neurodevelopmental abnormalities were documented. Binary logistic stepwise regression was used to analyze risk factors of postoperative new-onset neurodysplasia in children with CCHD, and the predictive value of the risk factors on postoperative neurodevelopmental abnormalities were evaluated using the receiver operating characteristic (ROC) curve.RESULTSNeurodevelopmental abnormalities were detected in 22 cases (44.0%) and not detected in 28 cases (56.0%) before surgery. There were no significant differences in gender, birth weight, age at admission, gestational age, preoperative SpO2 level, prematurity, cyanotic congenital heart disease, and ventilator support between the two groups (all P>0.05). After surgery, there were 22 cases (44.0%) with new-onset neurological abnormalities and 28 cases (56.0%) without new-onset abnormalities. Multivariate logistic regression analysis showed that postoperative 24 h peak lactic acid (OR=1.537, 95%CI: 1.170-2.018, P<0.01) and postoperative length of ICU stay (OR=1.172, 95%CI:1.031-1.333, P<0.05) were independent risk factors for postoperative new-onset neurodevelopmental abnormalities. The area under ROC curve (AUC) of the postoperative 24 h peak lactic acid for predicting the new-onset neurological abnormalities after operation was 0.829, with cut-off value of 4.95 mmol/L. The diagnostic sensitivity and specificity were 90.0% and 64.3%, respectively. The AUC of postoperative length of ICU stay for predicting the new-onset neurological abnormalities after operation was 0.712, with cut-off value of 18.0 d. The diagnostic sensitivity and specificity were 50.0% and 96.4%, respectively. The AUC of the combination of the two indicators was 0.917, the diagnostic sensitivity and specificity were 95.5% and 64.3%, respectively.CONCLUSIONSThe incidence of neurodysplasia in neonatal CCHD is high, and new neurological abnormalities may occur after surgery. The postoperative 24 h peak lactic acid and postoperative length of ICU stay are risk factors for new-onset neurodysplasia after surgery. The combination of the two indicators has good predictive value for neurodevelopmental outcomes after surgery in CCHD infants.

报告1例行肺动脉气管换位联合滑动气管成形术患儿的气道护理经验.针对本例患儿术后极易并发气管软化、吻合口感染、吻合口狭窄等气道梗阻问题,加强围术期有效呼吸道管理,尤其是术后气道护理:做好有创通气管理,预防撤机失败;给予持续气道正压通气,行序贯治疗;调整术后体位,避免气道受压;应用振动筛孔雾化吸入,预防肺部炎症;配合纤维支气管镜,及早发现气道并发症.本例患儿经过18 d的精心治疗和护理,病情稳定,顺利转入心脏外科继续治疗.目前患儿已出院,呼吸平稳,喂奶无呛咳.

Objective:To explore the clinical features, treatments and outcomes in infants with limb arterial embolism after cardiac surgery.Methods:From July 2018 to April 2020, clinical manifestations, laboratory and imaging findings, diagnosis, treatment and prognosis were reviewed for 5 children with limb arterial embolism after cardiac surgery. There were 4 boys and 1 girl with a median operative age of 102(11-375) days and a median birth weight of 2.52(1.8-3.8) kg. Infants were premature (n=2) and low-birth-weight (n=2). Congenital heart disease (CHD) was cyanotic (n=4) and non-cyanotic (n=1). In 4 children with cyanotic CHD, the preoperative hemoglobin levels were at or above a normal high limit. Median prothrombin time (PT) was 12s, median activated partial thromboplastin time (APTT) 31.1 s, median fibrinogen 2.21 g/L, median blood platelet 319×10 9/L and median D-dimer 0.38 mg/L. All 5 children underwent cardiopulmonary bypass for correcting cardiac deformity. The median time of cardiopulmonary bypass was 154(134-393) min. Right atrial incision was made and arterial puncture performed routinely intraoperatively. After operation, there was full exhaust. Results:All 5 children had low cardiac output syndrome after operation. Three of them fulfilled the 2017 Chinese diagnostic criteria of disseminated intravascular coagulation. Varying degrees of lower hemodynamic signal appeared on transvascular ultrasound in the early stage of clinical manifestations of limb arterial embolism. Except for 1 child dying of severely low cardiac output, the remainders received anticoagulant therapy after a diagnosis of limb arterial embolism. At the same time, prostaglandin E was given intravenously to improve microcirculation and compound dextran 40 injection to reduce blood viscosity. The median time from symptom onset to anticoagulation therapy was 16.5(1-52) hours. After anticoagulation, D-dimer decreased and clinical symptoms improved in 2 cases. Finally there were cure (n=2), gangrene amputation (n=1), death after giving up treatment for gangrene (n=1) and death (n=1).Conclusions:For CHD children after surgery, coagulation should be monitored closely. Early identification and timely intervention can help improve the prognosis. Persistent limb ischemia often indicates a poor prognosis.

肺动脉吊带( pulmonay artry sling,PAS)是一种罕见的婴幼儿期先天性心血管疾病,解剖特征为异常左肺动脉走形于食管气管之间压迫气管造成气管狭窄,半数以上患者气管软骨呈全环"O"型环样改变( complete trachtal rings,CTR) [1,2].PAS患者常存在反复呼吸道感染、气道梗阻,预后不佳,故一经确诊,无论有无肺部感染,都需及时行手术治疗[3-5].