Effect of Sclerosis Bands in Femoral Head Necrosis on Non-Vascularized Fibular Grafting-A Finite Element Study.

OBJECTIVE: Femoral head necrosis is a challenging condition in orthopaedics, and the occurrence of collapse is an important factor affecting the prognosis of femoral head necrosis. Sclerosis bands are known to influence the collapse of the femoral head, yet there is a lack of research on the biomechanical role of sclerosis bands in non-vascularized fibular grafting surgery. This study aims to evaluate the biomechanical impact of sclerosis bands in femoral head necrosis and their role in non-vascularized fibular grafting surgery (NVFG) using finite element analysis. METHODS: We constructed 11 finite element models based on CT scan data of a normal hip joint, simulating different sclerosis band thicknesses and defect scenarios. The models were analyzed for changes in femoral head displacement and von Mises stress. We constructed a hip joint model based on CT data from a normal hip joint, and after reconstruction, assembly, and optimization using 3-matic. We created five groups consisting of 11 finite element analysis models of the hip joint. Mesh partitioning and mechanical parameter settings were performed in ANSYS. The changes and differences in femoral head displacement and von Mises stress of these models were analyzed. RESULTS: Increasing sclerosis band thickness led to reduced peak displacement of the femoral head by 28.6%, 42.9%, and 47.6%, and increased surface von Mises stress by 28.3%, 13.8%, and 13.0%, respectively. Post-surgery, peak displacement decreased in all groups compared to pre-surgery levels. Increasing sclerosis band thickness post-surgery resulted in decreased maximum von Mises stress of the femoral head by 13.9%, 3.0%, and 8.1%. Defect volume in the defect groups correlated with increased peak displacement of the femoral head by 10.0%, 30.0%, and 100.0%, and increased surface maximum von Mises stress of the femoral head by 9.3%, 14.0%, and 15.1%. CONCLUSION: Sclerosis band formation exacerbates von Mises stress concentration on the femoral head surface. However, thicker sclerosis bands improve post-NVFG stability and mechanical performance. Larger anterior lateral sclerosis band defects significantly compromise postoperative stability, increasing the risk of collapse. Protecting the anterior lateral sclerosis band during NVFG surgery is crucial.

Effect of three-dimensional spatial distribution of necrotic and support areas on outcomes of fibular support for hip preservation / 中国组织工程研究

BACKGROUND:The distribution of the necrotic area plays an important role in hip preservation treatment.At present,there are few studies on whether the difference in the three-dimensional spatial distribution of osteonecrosis of the femoral head affects the clinical outcome of fibular support. OBJECTIVE:To explore the relationship between the spatial distribution and clinical outcome at the sites of osteonecrosis of the femoral head and fibular support using CT three-dimensional reconstruction so as to provide a basis for optimizing the applicable conditions of fibular support and improving the hip preservation effect of fibular support. METHODS:Eighty patients with osteonecrosis of the femoral head who were treated with fibular support for hip preservation from January 2010 to January 2021 were selected as the study subjects according to the inclusion criteria.They were followed up for at least 2 years.According to the clinical outcome,the patients were divided into the successful hip preservation group(n=55)and the failure hip preservation group(n=25).3D reconstruction was performed according to the preoperative and postoperative CT images of the patients.According to the three-column theory,the femoral head was divided into outer nine areas,middle nine areas and inner nine areas(L1-9,C1-9,and M1-9)to explore the spatial distribution of necrotic area of the femoral head and fibular support area and its relationship with clinical outcome. RESULTS AND CONCLUSION:(1)Before operation,the necrotic area of the femoral head was mainly distributed in L1,L2,L4,L5,C1,C2,C4,and C5(the upper and middle part of the anterior part of the outer ninth area and the middle part of the middle ninth area).After operation,the fibular support area was mainly distributed in L5,L6,C5,and C6(the middle and lower part of the outer ninth area and the middle and lower part of the middle ninth area).(2)There were significant differences in the distribution of osteonecrosis of the femoral head between the successful hip preservation group and the failure hip preservation group in L8(the posterior middle part of the outer ninth area),C3(the anterior lower part of the middle ninth area),C6(the lower middle part of the middle part of the inner ninth area)and M2(the anterior middle part of the inner ninth area)(P<0.05).There was a significant difference in the distribution of fibular support in L5 and L6(middle and lower part of outer nine)(P<0.05).Among them,the L8 region could be used as an independent predictor of hip preservation failure in fibular support surgery.The area under the curve of the L8 single factor prediction model was 0.698[95%CI(0.575,0.822)];the sensitivity was 76%,and the specificity was 63.6%.(3)It turns out,when the necrotic area involves L8,C3,C6,and M2,especially L8,the failure of fibular support may increase,and when the fibular support involves L5 and L6,the effect of hip preservation is often not ideal.

Applicable techniques for subchondral separation of femoral head necrosis treated by tissue engineering / 中国组织工程研究

BACKGROUND:The appearance of the crescent sign in femoral head necrosis is a"turning point"in the progression of the disease,and repairing and stabilizing the bone-cartilage interface is particularly important in preventing further progression and collapse of the femoral head.Tissue engineering offers potential advantages in the simultaneous repair and integration of the bone-cartilage interface. OBJECTIVE:To review potentially suitable techniques addressing the subchondral separation in femoral head necrosis. METHODS:Relevant articles from January 1970 to April 2023 were searched in PubMed,Web of Science,and China National Knowledge Infrastructure(CNKI)using English search terms"femoral head necrosis,avascular necrosis of femoral head,osteonecrosis of femoral head"and Chinese search terms"femoral head necrosis,subchondral bone,cartilage,integration of cartilage and subchondral bone".A total of 114 articles were included for review and analysis. RESULTS AND CONCLUSION:(1)Structural defects,ischemic and hypoxic environment,inflammatory factors,and stress concentration may cause subchondral separation in osteonecrosis of the femoral head.Subchondral bone collapse and failure of hip-preserving surgery may be associated.Integration of tissue engineering scaffolds with the bone-cartilage interface is one potential approach for treating subchondral separation in osteonecrosis of the femoral head.(2)Current literature suggests that multiphase scaffolds,gradient scaffolds,and composite materials have shown improvements in promoting cell adhesion,proliferation,and deposition of bone and cartilage matrix.These advancements aid in the integration of scaffolds with the bone-cartilage interface and have implications for the treatment of subchondral separation in osteonecrosis of the femoral head.(3)Surface modifications of scaffolds can enhance interface integration efficiency,but they have their advantages and disadvantages.Scaffolds providing different environments can induce differentiation of mesenchymal stem cells and facilitate integration between different interfaces.(4)Future scaffolds for subchondral separation in osteonecrosis of the femoral head are expected to be composite materials with gradient and differentiated biomimetic structures.Surface modifications and stem cell loading can promote integration between the bone-cartilage interface and scaffolds for therapeutic purposes,but further experimental verification is still needed.Challenges include synchronizing scaffold degradation rate with repair progress and ensuring stability between different interfaces.

Application of bioelectric effect materials in design of bone tissue engineering scaffolds / 中国组织工程研究

BACKGROUND:Bone has bioelectric effects.However,bone defects can lead to loss of endogenous bioelectricity in bone.The implantation of bone tissue engineering scaffolds with bioelectric effect into bone defects will replenish the missing electrical signals and accelerate the repair of bone defects. OBJECTIVE:To introduce the bioelectric effect of bone tissue and expound the repair effect of electrical stimulation on bone defects,summarize the research progress of bioelectric effect applied to bone tissue engineering,in order to provide new ideas for the research of bone tissue engineering. METHODS:Relevant articles were searched on CNKI,WanFang,PubMed,Web of Science and ScienceDirect databases,using"bioelectrical effect,bioelectrical materials,electrical stimulation,bone tissue engineering,bone scaffold,bone defect,bone repair,osteogenesis"as the English and Chinese search terms.Finally,87 articles were included for analysis. RESULTS AND CONCLUSION:(1)Bioelectrical effect combined with ex vivo electrical stimulation to design bone tissue engineering scaffolds is an ideal and feasible approach,and the main materials involved include metallic materials,graphene materials,natural bio-derived materials,and synthetic biomaterial.At present,the most widely used conductive material is graphene material,which benefits from its super conductivity,large specific surface area,good biocompatibility with cells and bones,and excellent mechanical properties.(2)Graphene materials are mainly introduced into the scaffold as modified materials to enhance the conductivity of the overall scaffold,while its large surface area and rich functional groups can promote the loading and release of bioactive substances.(3)However,there are still some major challenges to overcome for bioelectrically effective bone tissue engineering scaffolds:not only electrical conductivity but also the overall performance of the bracket needs to be considered;lack of uniform,standardized preparation of bioelectrically effective bone tissue engineering scaffolds;extracorporeal electrical stimulation intervention systems are not yet mature enough;lack of individualized guidance on stent selection to enable the selection and design of the most appropriate stent for patients with different pathologies.(4)When designing conductive scaffolds,researchers have to deeply consider the comprehensive effects of the scaffolds,such as biocompatibility,mechanical properties,and biodegradability.This combination of properties can be achieved by combining multiple materials.(5)Beyond that,clinical translation should be the ultimate consideration for conductive stent design.On the basis of evaluating the safe current threshold for electrical stimulation to act on the human body and facilitate the repair of bone defects,animal experiments as well as basic experiments are designed and then applied to the clinic to achieve the ultimate goal of applying bioelectrical effect bone tissue engineering scaffolds in the clinic.

Network layout and maintenance of central monitoring system in inpatient ward / 中国医学装备

Based on the analysis of the network layout and functional structure of the central monitoring system,the daily maintenance strategy and common fault maintenance methods were discussed.In terms of function structure,the central monitoring system of inpatient ward was divided into four modules:network architecture,monitoring terminal,central monitoring and data management,which realized the functions of monitoring patients'vital signs,data transmission display,analysis and alarm.In the event of failure of equipment,the source of structural components was analyzed based on the fault phenomenon,and the failure handling was carried out by one by one.In the process of dealing with network faults,the signals before and after the switch were detected and analyzed according to the fault scope.When abnormal results of physiological parameters were found,the factors such as human operation,patient cooperation,and equipment hardware and software failures were considered at the same time.The cause of the failure was eliminated according to the results of the observation and test;the equipment returned to normal service after the failure.Medical personnel and equipment engineers should be familiar with the network layout of the central monitoring system,carry out routine maintenance,carefully make troubleshoot faults in maintenance and standardize operation and constantly improve the operation quality of the central monitoring system.

Safety and efficacy of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis / 中华内科杂志

Objective:To investigate the efficacy and safety of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis.Methods:A retrospective analysis was carried out on 46 patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis who received endovascular treatment at the Strategic Support Force Medical Center from January 2015 to August 2022. Twenty-seven patients underwent balloon angioplasty alone and 19 patients underwent acute stent implantation. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of the responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality of the two groups were evaluated.Results:The proportion of effective recanalization of the offending vessels (mTICI≥2b) in the acute stenting group was slightly higher than that in the balloon angioplasty group (16/19 vs. 81.5%), but the difference was not statistically significant ( P>0.05). Besides, there was no significant difference in the median of mRS between the acute stenting group [3.0(0, 4.0)] and the balloon angioplasty group [4.0(1.0, 5.0)] 90 days after operation ( P>0.05). In terms of safety, the incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups ( P>0.05). Conclusions:The effect of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis is not inferior to that of balloon angioplasty, and it does not increase the risk of intracranial bleeding complications.

Expression of platelet microparticles in patients with diabetic nephropathy and its relationship with renal damage / 中国输血杂志

【Objective】 To investigate the expression levels of platelet microparticles(PMPs) in patients with diabetic nephropathy (DN) and their relationship with renal injury. 【Methods】 Thirty DN patients, 30 T2DM patients without DN and 30 healthy controls were enrolled. Flow cytometry was used to detect the quantity and phenotype of PMPs, and ELISA was used to measure the levels of plasma renin, angiotensin Ⅱ (angiotoninⅡ, AngⅡ), vascular endothelial growth factor (vascular endothelial growth factor, VEGF) and transforming growth factor-β1(transforming growth factor-β1, TGF-β1). Kidney function was determined by blood biochemistry. 【Results】 The quantity of PMPs in the DN group was (1 564±346) particles/μL, which was significantly higher than that in the non-DN group (1 246±312) particles/μL and the control group (1 223±299) particles/μL (P<0.05). The PMPs in the DN group mainly expressed CD62P and CD41a, accounting for (76.5±12.3)%. Moreover, the levels and activation of PMPs increased with the progression of DN. The quantity of PMPs was positively correlated with renin and other factors (r=0.56-0.62, P<0.05), negatively correlated with the glomerular filtration rate (GFR) (r=-0.64, P<0.05), and positively correlated with the urinary albumin excretion rate (UAE) (r=0.66, P<0.05). PMPs were also an independent influencing factor of UAE (β=12.34, P<0.05). 【Conclusion】 PMPs expression is elevated in DN patients, which may be associated with renal injury, but it is insufficient to confirm its role in the pathogenesis of DN.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices.

BACKGROUND: Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. METHODS: Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. RESULTS: This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. CONCLUSIONS: This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Zinc supplementation and light intensity affect 2-acetyl-1-pyrroline (2AP) formation in fragrant rice.

BACKGROUND: Improving the yield and aroma content of fragrant rice is the focus of fragrant rice research. Light and Zinc (Zn) management generally cause regulations in the 2-acetyl-1-pyrroline (2AP) accumulation in fragrant rice. In addition, Zn promotes rice growth and improves rice yield, which has the potential to compensate for the negative impact of low light on fragrant rice yield. However, the potential of Zn to improve fragrant rice yield and 2AP content under shading conditions has not been verified. METHODS: Field experiments were conducted in the rice season (May-September) in 2019 to 2021. Two light i.e., normal light (NL) and low light (LL) and four Zn levels i.e., 0 kg Zn ha- 1 (N0), 1 kg Zn ha- 1 (Zn1), 2 kg Zn ha- 1(Zn2), and 3 kg Zn ha- 1 (Zn3), which applied at booting stage was set up. The grain yield, 2AP contents, Zn content in polished rice, photosynthesis related indicators, MDA content, antioxidant enzyme activity and the biochemical parameters related to 2AP formation were investigated. RESULTS: Shading reduced yield by 8.74% and increased 2AP content by 24.37%. In addition, shading reduced net photosynthetic rate (Pn), superoxide dismutase (SOD), peroxidase (POD) and catalase (CAT), and increased proline, γ-aminobutyric acid (GABA), and pyrroline-5-carboxylic acid (P5C), proline dehydrogenase (PDH), △1-pyrroline-5-carboxylic acid synthetase (P5CS), malondialdehyde (MDA). With increasing Zn application levels, yield, 2AP, Zn content in polished rice, Pn, proline, P5C, GABA, PDH, P5CS, SOD, CAT and POD increased, and MDA decreased. Significant Light and Zn interaction effect on 2AP content was detected, and both shading and increasing Zn application increased the 2AP content. CONCLUSION: Shading can increase the 2AP content but reduce the yield of fragrant rice. Increasing Zn application under shading conditions can further promote the biosynthesis of 2AP, but the effect of improving yield is limited.

Clinical outcomes of reverse shoulder arthroplasty for the treatment of failed fixation of proximal humeral fracrtures in the elderly patients / 中国骨伤

OBJECTIVE@#To evaluate the clinical outcomes of reverse total shoulder arthroplasty as a revision procedure for the failed fixation of proximal humeral fractures in the elderly patients.@*METHODS@#A retrospective analysis was performed on 8 patients with failed internal fixation of proximal humeral fractures from May 2014 to March 2020, including 3 males and 5 females, aged from 65 to 75 years old. All 8 patients underwent reverse total shoulder arthroplasty, and the mean time between initial fixation and reverse total shoulder arthroplasty ranged from 8 to 16 months. Range of motion(ROM), University of California at Los Angeles(UCLA) shoulder score, visual analogue scale (VAS), self-rating anxiety scale(SAS), and Constant-Murley score of shoulder function were assessed pre-operatively and at the last follow-up. Complications relating to the surgery were recorded.@*RESULTS@#All 8 patients successfully followed up. The mean follow-up after reverse total shoulder arhroplasty ranged from 16 to 28 months. The range of motion (forward flexion, external rotation, abduction and internal rotation) of the affected shoulder was significantly improved after surgery, and the post-operative VAS, SAS and UCLA scores were also significantly improved. For the Constant-Murley score of shoulder joint function, the total scores and the subscores of pain, daily activities, range of motion and strength test at the last follow-up were all significantly improved. Scapular glenoid notch was observed in patient, which was evaluated as grade 1 on imaging. All the other patients did not develop specific or non-specific complications.@*CONCLUSION@#Reverse total shoulder arhroplasty is an appropriate treatment as a revision surgery for failed fixation of proximal humeral fractures. It has shown satisfactory clinical outcomes, accelerating the rehabilitation of shoulder function and improving the quality of life.

Visual and quantitative assessment of the effectiveness of non-vascularized bone grafting in osteonecrosis of the femoral head via CT-based radiomics and clinical data / 中国修复重建外科杂志

OBJECTIVE@#To investigate the value of CT-based radiomics and clinical data in predicting the efficacy of non-vascularized bone grafting (NVBG) in hip preservation, and to construct a visual, quantifiable, and effective method for decision-making of hip preservation.@*METHODS@#Between June 2009 and June 2019, 153 patients (182 hips) with osteonecrosis of the femoral head (ONFH) who underwent NVBG for hip preservation were included, and the training and testing sets were divided in a 7∶3 ratio to define hip preservation success or failure according to the 3-year postoperative follow-up. The radiomic features of the region of interest in the CT images were extracted, and the radiomics-scores were calculated by the linear weighting and coefficients of the radiomic features after dimensionality reduction. The clinical predictors were screened using univariate and multivariate Cox regression analysis. The radiomics model, clinical model, and clinical-radiomics (C-R) model were constructed respectively. Their predictive performance for the efficacy of hip preservation was compared in the training and testing sets, with evaluation indexes including area under the curve, C-Index, sensitivity, specificity, and calibration curve, etc. The best model was visualised using nomogram, and its clinical utility was assessed by decision curves.@*RESULTS@#At the 3-year postoperative follow-up, the cumulative survival rate of hip preservation was 70.33%. Continued exposure to risk factors postoperative and Japanese Investigation Committee (JIC) staging were clinical predictors of the efficacy of hip preservation, and 13 radiomic features derived from least absolute shrinkage and selection operator downscaling were used to calculate Rad-scores. The C-R model outperformed both the clinical and radiomics models in predicting the efficacy of hip preservation 1, 2, 3 years postoperative in both the training and testing sets ( P<0.05), with good agreement between the predicted and observed values. A nomogram constructed based on the C-R model showed that patients with lower Rad-scores, no further postoperative exposure to risk factors, and B or C1 types of JIC staging had a higher probability of femoral survival at 1, 2, 3 years postoperatively. The decision curve analysis showed that the C-R model had a higher total net benefit than both the clinical and radiomics models with a single predictor, and it could bring more net benefit to patients within a larger probability threshold.@*CONCLUSION@#The prediction model and nomogram constructed by CT-based radiomics combined with clinical data is a visual, quantifiable, and effective method for decision-making of hip preservation, which can predict the efficacy of NVBG before surgery and has a high value of clinical application.

Transanal drainage tube for prevention of anastomotic leak after anterior resection for rectal cancer: a meta-analysis / 中华胃肠外科杂志

Objective: To assess the effectiveness of transanal drainage tube (TDT) in reducing the incidence of anastomotic leak following anterior resection in patients with rectal cancer. Methods: We conducted a systematic search for relevant studies published from inception to October 2022 across multiple databases, including PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP. Meta-analysis was performed using Review Manager 5.4 software. The primary outcomes included total incidence of anastomotic leak, grade B and C anastomotic leak rates, reoperation rate, anastomotic bleeding rate, and overall complication rate. Results: Three randomized controlled trials involving 1115 patients (559 patients in the TDT group and 556 in the non-TDT group) were included. Meta-analysis showed that the total incidences of anastomotic leak and of grade B anastomotic leak were 5.5% (31/559) and 4.5% (25/559), respectively, in the TDT group and 7.9% (44/556) and 3.8% (21/556), respectively, in the non-TDT group. These differences are not statistically significant (P=0.120, P=0.560, respectively). Compared with the non-TDT group, the TDT group had a lower incidence of grade C anastomotic leak (1.6% [7/559] vs. 4.5% [25/556]) and reoperation rate (0.9% [5/559] vs. 4.3% [24/556]), but a higher incidence of anastomotic bleeding (8.2% [23/279] vs. 3.6% [10/276]). These differences were statistically significant (P=0.003, P=0.001, P=0.030, respectively). The overall complication rate was 26.5%(74/279) in the TDT group and 27.2% (75/276) in the non-TDT group. These differences are not statistically significant (P=0.860). Conclusions: TDT did not significantly reduce the total incidence of anastomotic leak but may have potential clinical benefits in preventing grade C anastomotic leak. Notably, placement of TDT may increase the anastomotic bleeding rate.

Mixed venous to arterial CO 2 gap as a marker to identify fluid responsiveness in septic shock patients / 中华急诊医学杂志

Objective:To investigate the value of the venous-to-arterial CO 2 gap (Δ CO 2 gap) before and after the fluid challenge (FC) in determining the fluid responsivenessin septic shock patients. Methods:A total of 104 septic shock patients admitted to the Medical Intensive Care Unit (MICU) of Peking Union Medical College Hospital were included in the retrospective study. All patients were monitored by Swan Ganz floating catheter during the FC. Hemodynamics and blood gas indices were collected before FC (T0) and immediately (T1), 10 min (T2), 30 min (T3) and 60 min (T4) after FC. Responders were defined as patients with a > 10% increase in cardiac output (CO) after FC. Spearman correlation analysis was used to evaluate the correlation between CO 2 gap and CO. The value of ΔCO2 gap were calculated by the area under the receiver operating characteristic (AUROC) curve in the whole population. Results:Among 104 patients, the effective rates of FC at T1, T2, T3 and T4 were 59% (61/104), 72% (75/104), 73% (76/104), and 77% (80/104), respectively. CO of patients in the reactive group was lower than that in the non-reactive group at T2 [6.0 (4.7, 7.5) vs. 7.2 (6.4, 8.5) L/min, P=0.019], and there was no significant difference in CO 2 gap between the two groups before FC. Spearman correlation analysis showed that CO 2 gap was negatively correlated with CO, and the correlations between CO 2 content gap and CO was -0.34, and -0.33 of CO 2 pressure gap and CO, respectively (both P <0.05). ROC curve analysis showed that the ΔCO 2 gap at T1 could weakly judge the reactivity at T2, T3 and T4, but could not judge the reactivity at T1. The AUROC at T2 was 0.669 of ΔCO 2 content gap and 0.684 of ΔCO 2 pressure gap (both P <0.05). Conclusions:The evaluate time judging the effect of FC should be appropriately extended. The change value of CO 2 gap before and immediately after volume expansion in septic shock patients can judge the fluid responsiveness within 10 min after FC.

The clinical feature and treatment strategy of the transsyndesmotic ankle fracture dislocation / 中华骨科杂志

Objective:To explore the clinical features and treatment strategies of the transsyndesmotic ankle fracture dislocation.Methods:Data of 26 patients of transsyndesmotic ankle fracture dislocation who were treated in our hospital from December 2013 to November 2020 were retrospectively analyzed. There were 16 men and 10 women with an average age of 49.54±12.81 years (range, 26-68 years). Open injuries in 17 cases, of which the Gustilo-Anderson II type in 6 cases, IIIA type in 11 cases, closed injuries in 9 cases. According to the AO/OTA fracture classification, 44B type in 4 cases, 44C type in 22 cases. According to the Lauge-Hansen classification, there were 16 cases of pronation-abduction, 10 cases of pronation-external rotation, including 4 cases of Maisonneuve fractures, and of the 4 cases of Maisonneuve fractures, there were 3 cases of double Maisonneuve fracture. The talar dislocation was anterior, neutral, and posterior within the distal tibiofibular joint in 10 cases, 7 cases, and 9 cases. Fibular fractures in 26 cases, medial malleolar fractures in 24 cases, deltoid ligament rupture in 2 cases, posterior malleolar fractures in 13 cases, and anterior malleolar fractures in 8 cases. All closed injuries were closed reduction and plaster fixation and all open injuries were emergently debridement and reduced under the tibial plafond in the emergency department. Surgical treatment was taken until the soft tissue conditions to be allowed. The reduction quality was assessed by postoperative radiography according to the criteria proposed by Burwell-Charnley. The function of the ankle joint was assessed by the ankle-hindfoot rating system of the American Orthopaedic Foot and Ankle Society (AOFAS), and the posttraumatic arthritis and objectively quantified was assessed using the Kellgren-Lawrence grading scale.Results:There were 4 cases were unreduced due to the tibial posterior tendon to flip through the ankle joint and dislocate anterior to the tibia through the interosseous membrane. Stabilization of fibular fractures were achieved with plate in 25 cases. There were 24 cases of medial malleolar fractures, and the fixation were achieved with cannulated screws in 23 cases and with K-wire fixation in 1 case. There were 12 cases of posterior malleolar fractures treated with open reduction and internal fixation including cannulated screws in 9 cases and antiglide plates in 3 cases. There were 7 cases of anterior malleolar fractures treated with open reduction and internal fixation including suture anchors in 1 case and cannulated screws in 6 cases. Stabilization of syndesmosis was achieved with syndesmotic screws in 14 cases and with TightRope in 2 cases. All patients were followed up for 20.23±9.70 months (range, 12-60 months). According to the Burwell-Charnley criteria of reduction quality, anatomic reduction was obtained in 22 cases, and satisfactory reduction was gained in 4 cases. All fractures healed in 16.31±3.64 weeks (range, 10-24 weeks). Functional examination of the ankle joint (angle measurement method): dorsiflexion average angle 10.38°±6.66°, plantarflexion average angle 34.04°±7.20°. At latest follow up, the AOFAS score was 83.30±13.94 (range, 24-100). Ten (38%) of 26 patients had radiographic evidence of posttraumatic ankle arthritis. According to the Kellgren-Lawrence grading scale criteria, there were grade I in 5 cases, II in 2 cases, III in 2 cases, and IV in 1 case. 2 cases of wound dishence were recovered through changing dressing and 2 cases of skin necrosis were recovered by skin graft and flap transposition respectively. There were no significant complications such as infection, nonunion, or implant failure.Conclusion:The transsyndesmotic ankle fracture dislocation, represents an exceptional pattern of high-energy fractures with significant syndesmotic disruption, and potential soft tissue compromise. Careful attention to radiographic findings can identify unique fracture characteristics relative to operative decision-making. Tibialis posterior tendon dislocation, a rare complication in the transsyndesmotic ankle fracture dislocation injuries, can impede anatomical reduction of the ankle mortise. The open reduction and internal fixation may be an optimal approach to treat transsyndesmotic ankle fracture dislocation injuries. However, the rate of posttraumatic arthritis is relatively high.

Safety and efficacy of intra-arterial tirofiban infusion in patients with acute cardiogenic cerebral embolism undergoing endovascular reperfusion therapy / 中华内科杂志

Objective:To evaluate the safety and efficacy of intra-arterial tirofiban infusion during endovascular reperfusion therapy in patients with acute cardiogenic cerebral embolism.Methods:Clinical data of 72 patients with acute cardiogenic cerebral embolism caused by large artery occlusion were retrospectively analyzed in Department of Neurology, Strategic Support Force Medical Center from August 2015 to August 2020.Among those, 52 patients were treated with intra-arterial tirofiban, the other 20 patients were treated with control medication. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality were evaluated and compared in two groups.Results:The proportion of effective recanalization of the offending vessels (mTICI≥2b) in tirofiban group was higher than that in control group (92.3% vs. 75.0%), but the difference was not statistically significant ( P=0.104). At 90 days after operation, the rate of patients with good prognosis (mRS≤2) in tirofiban group (61.5%) was significantly higher than that in control group (35.0%) ( P<0.05). The incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups ( P>0.05). Conclusion:Intra-arterial tirofiban infusion in patients with acute cardiogenic cerebral embolism is effective and feasible, which improves the prognosis without increasing the risk of intracranial bleeding complications.

Construction and evaluation of early prediction model for severe acute pancreatitis complicated with acute renal injury / 中华胰腺病杂志

Objective:To establish an early prediction Nomogram model for severe acute pancreatitis(SAP) complicated with acute renal injury (AKI), and evaluate the prediction efficiency of the model.Methods:The clinical data of 295 SAP patients hospitalized in Zhejiang Rongjun Hospital from July 2017 to June 2021 were retrospectively analyzed, and the patients were divided into AKI group ( n=61) and non-AKI group ( n=234) according to whether complicated with AKI. The common characters, clinical data and laboratory examination results were compared. The risk factors for SAP complicated with AKI was analyzed by multivariate logistic regression analysis, and a nomogram prediction model was established by R software. The receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) was calculated to evaluate its prediction performance. Results:The acute physiology and chronic health assessment Ⅱ (APACHEⅡ) and Ranson score, the incidence of abdominal compartment syndrome (ACS) and systemic inflammatory response syndrome (SIRS), the cases of shock and mechanical ventilation, and the levels of blood lactic acid (BLA), blood creatinine (Scr), urea nitrogen (BUN), C-reactive protein (CRP), procalcitonin (PCT) and cystatin C(Cys C) in peripheral blood were significantly higher in AKI group than those in non-AKI group, while the levels of blood calcium were lower than those in non-AKI group, and the differences were statistically significant (all P value <0.05). Multivariate logistic regression analysis showed that APACHEⅡ score ( OR=1.185, 95% CI 1.074-1.308, P=0.001), Ranson score ( OR=12.668, 95% CI 5.102-31.456, P<0.001), Scr ( OR=1.028, 95% CI 1.002-1.054, P=0.034), PCT ( OR=4.298, 95% CI 1.379-13.395, P<0.001) and Cys C ( OR=38738.38, 95% CI 43.190-347459.41, P<0.001) were independent risk factors for SAP complicated AKI. Serum calcium ( OR=0.0001, 95% 0.000-0.048, P<0.001) was an independent protective factor for SAP complicated AKI. A Nomogram prediction model based on the six factors above were established, and its AUC, sensitivity and specificity to predict AKI were 0.987, 99.0% and 98.5% in the training set, and were 0.976, 98.6% and 94.2% in the validation set. Conclusions:This study successfully established an early prediction model with high predict value for SAP complicated with AKI, which can efficiently predict the risk of SAP with concurrent AKI.

Hemodynamic effects of different fluid volumes for a fluid challenge in septic shock patients / 中华医学杂志(英文版)

BACKGROUND@#It is still unclear what the minimal infusion volume is to effectively predict fluid responsiveness. This study was designed to explore the minimal infusion volume to effectively predict fluid responsiveness in septic shock patients. Hemodynamic effects of fluid administration on arterial load were observed and added values of effective arterial elastance (Ea) in fluid resuscitation were assessed.@*METHODS@#Intensive care unit septic shock patients with indwelling pulmonary artery catheter (PAC) received five sequential intravenous boluses of 100 mL 4% gelatin. Cardiac output (CO) was measured with PAC before and after each bolus. Fluid responsiveness was defined as an increase in CO >10% after 500 mL fluid infusion.@*RESULTS@#Forty-seven patients were included and 35 (74.5%) patients were fluid responders. CO increasing >5.2% after a 200 mL fluid challenge (FC) provided an improved detection of fluid responsiveness, with a specificity of 80.0% and a sensitivity of 91.7%. The area under the ROC curve (AUC) was 0.93 (95% CI: 0.84-1.00, P  < 0.001). Fluid administration induced a decrease in Ea from 2.23 (1.46-2.78) mmHg/mL to 1.83 (1.34-2.44) mmHg/mL (P = 0.002), especially for fluid responders in whom arterial pressure did not increase. Notably, the baseline Ea was able to detect the fluid responsiveness with an AUC of 0.74 (95% CI: 0.59-0.86, P < 0.001), whereas Ea failed to predict the pressure response to FC with an AUC of 0.50 (95% CI: 0.33-0.67, P = 0.086).@*CONCLUSION@#In septic shock patients, a minimal volume of 200 mL 4% gelatin could reliably detect fluid responders. Fluid administration reduced Ea even when CO increased. The loss of arterial load might be the reason for patients who increased their CO without pressure responsiveness. Moreover, a high level of Ea before FC was able to predict fluid responsiveness rather than to detect the pressure responsiveness.@*TRIAL REGISTRATION@#ClinicalTrials.gov, NCT04515511.

Pathogenesis and Function of Interleukin-35 in Rheumatoid Arthritis.

It is well known that RA (Rheumatoid arthritis) is an autoimmune disease characterized by multiple and symmetric arthropathy. The main pathological features of RA are synovial hyperplasia, angiogenesis, pannus formation, inflammatory cell infiltration, articular cartilage, bone destruction, and ultimately joint dysfunction, even deformity. IL-35 (Interleukin-35) is a new member of the IL-12 (Interleukin-12) family, which is an immunosuppressive and anti-inflammatory cytokine secreted mainly by Treg (T regulatory cells). There is evidence suggested that IL-35 can attenuate the progression of RA through influencing the immune and pathological process. It suggests that IL-35 played an important role in the pathogenesis of RA, and can be used as a potential target for the future treatment of RA. This review summarizes the recent advances of IL-35 in the pathological roles and the therapeutic potential roles in RA.

Early predictors of high flow oxygen treatment failure for post-operation patients with hypoxemia / 中华急诊医学杂志

Objective:To explore the early predictors of high flow oxygen treatment failure for post-operation patients with hypoxemia.Methods:The post-operation adult patients with hypoxemia (100 mmHg<PaO 2/FiO 2≤300 mmHg) received high flow nasal cannula (HFNC) oxygen were retrospectively screened in the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The patients were assigned to the treatment success or failure group according to whether receiving reintubation with 48 h after extubation. The risk factors of 48-h reintubation were screened and analyzed by extreme gradient boosting (XGBoost) algorithm. And the predictors were formulated according to the risk factors. The changes of predictors were collected from extubation to 48 h later. The predictors were compared at different time points after extubation between patients weaning successfully and failed with t test. The values at different time after extubation were also compared to the baseline data. The areas under the receiver operating characteristic (ROC) curve were calculated for 48-h reintubation prediction according to values at 4 h before and after extubation, which were compared with those of rapid shallow breathing index (RSBI) and ROX index. The RSBI was defined as the ratio of respiratory rate to tidal volume. The ROX index was defined as the ratio of SpO 2/FiO 2 to respiratory rate. Results:A total of 524 520 medical records were screened and 318 patients were included. There were 38 patients (11.95%) received reintubation within 48 h. According to the XGBoost model, the important features of 48-h reintubation were the duration before extubation, body mass index, simplified acute physiology scoring II, heart rate (HR), PaO 2, mean blood pressure, tidal volume, age, SpO 2 and respiratory rate. Thus HR/PaO 2 and HR/SpO 2 were formulated as predictors for 48-h reintubation according to the above features. The areas under the ROC of HR/PaO 2 and HR/SpO 2 were 0.640 and 0.617 for 48-h reintubation prediction according values at 4 h before extubation, which were larger than those of RSBI (0.537) and ROX index (0.539). According values at 4 h after extubation, the area under the ROC of HR/SpO 2 was 0.657, which was larger than that of ROX index (0.587). When the HR/SpO 2 reached 1.2 at 4 h after extubation, the specificity for 48-h reintubation was 92%. There was significant difference of HR/SpO 2 at 4 h after extubation between patients weaning successfully and failed (1.02 vs 0.92, P<0.05), and no significant difference of ROX index at the same time (8.14 vs 9.27, P>0.05). There were significant differences of HR/SpO 2 and ROX index at 8 to 12 h after extubation between the two groups (both P<0.05). Conclusions:HR/SpO 2 is more early and accurate in predicting HFNC failure than ROX index for post-operation patients with hypoxemia. However, both the predictors should be further evaluated.