Objective To explore the expression changes of C/EBP homologous binding protein (CHOP)in intermittent hypoxic rats with cognitive function decline and clinical significance.Methods We randomly divided 75 adult male Wistar rats into normal group (NC group),5% intermittent hypoxia group (5% CIH group)and 10%intermittent hypoxia group (10% CIH group),with 25 rats in each.Then the three groups were further divided into 3 d,7 d,14 d,21 d and 28 d subgroups,and each time a subgroup had 5 rats.The control group was exposed to the air while 10% CIH group and 5% CIH group were exposed to CIH for eight hours from 8:00 to 1 6:00 each day. After exposure for 3 d,7 d,14 d,21 d and 28 d,the cognitive function of rats was assessed with Morris water maze, the expression of CHOP in the hippocampus was assayed qualitatively by immunohistochemical technique,and the apoptosis of neurons was detected by TUNEL method.Results ① With prolonged hypoxia,the time of escape latency obviously prolonged,the time spent crossing the target quadrant shortened (P < 0.05 ),and the apoptosis index of hippocampal neurons in the CIH groups was increased gradually compared with those in control group (P <0.05).The above-mentioned indexes changed more significantly in 5% CIH group than in 10% CIH group (P <0.05).②.The expression of CHOP protein at each time point was increased (P <0.05 ).In 10% CIH group it reached the peak at 28 d while in 5% CIH group it decreased after it peaked at 21 d.③ The expression of CHOP in the two CIH groups was positively correlated with apoptosis index and animal escape latency time,but negatively correlated with the target quadrant time.Conclusion Intermittent hypoxia,which is likely to induce the high expression of CHOP and activation of neural CHOP mediated apoptosis,causes cognitive impairment of various degrees.

Objective To investigate the clinical effects of large flow-through venous flap for salvaging the limb on the verge of amputation complicated with arterial defect.Methods Between March 2012 and January 2015,large flow-through venous flap was used in 10 patients with upper limb on the verge of amputation to reconstruct artery defect and large-area skin and soft tissue defect,including 6 males and 4 females with a mean age of 27.9 years (range,18 to 41 years).Injury was caused by machine crush in 4 patients,twisting belt pulley in 4,and traffic accident in 2.The dimension of skin defect ranged from 6.5 cm× 10.0 cm to 10.5 cm × 18.0 cm (mean,9.0 cm × 12.0 cm).Vascular defect length ranged from 6.0 to 16.0 cm (mean,12.3 cm).Time from injury to operation was 1.5-5.5 h (mean,3.5 h).After operation,flap survival,appearance,texture and sensation were recorded.Upper limb function was evaluated using the standard set up by hand surgery branch of Chinese Medical Association.Results The flap varied in size from 8.0 cm×12.0 cm-12.0 cm ×20.0 cm (mean,10.0 cm × 13.5 cm).One patient was amputated due to severe postoperative infection,and 9 patients were successfully operated.The flap showed small-area necrosis on the distal end in 2 patients,which was cured after dressing change,while survived completely in 7 patients.The donor wounds healed in one stage.After 12-27 months of follow-up (mean,13.7 months),the thickness,texture and appearance of the flap were close to the surrounding normal tissues and the skin protective sensation was restored.The functional results were excellent in 6 patients,good in 2 and poor in 1,with the excellent and good rate of 89％.Conclusion Large flow-through venous flap can reconstruct upper-limb vascular defect while repairing large-area wound,and has advantages of easy operation,less damage to the donor site and good appearance.

Objective To evaluate the clinical effect and complications of total hip replacement (THR) in novel femoral neck fracture,old femoral neck fracture, aseptic necrosis of femoral head and coxa degenerative osteoarthropathy. To provide instructions to surgical indications and treatment effects analysis.Methods One hundrde and four patients were divided into 4 groups by disease type: novel femoral neck fracture group (n = 32 ), old femoral neck fracture group (n = 22) ,aseptic necrosis of femoral head group (n =34) and coxa degenerative osteoarthropathy group (n = 16). These patients were followed-up for 12 - 144 months after THR, their Harris standard score and complications data, before and after operation, were analyzed retrospectively. Results After operation, the Harris standard scores were 92. 6 ± 5.8,90. 1 ± 5. 2,86. 3 ± 4. 6,81.9 ±4. 1 in novel femoral neck fracture,old femoral neck fracture,aseptic necrosis of femoral head and coxa degenerative osteoarthropathy groups respectively, which were significantly higher than the scores before operation (25.6±1.8,36.7±2.6,52.9±4.3,42. 1 ±3.8,Ps ＜0.05). Conclusion THR has good effects in the four types of diseases. Short length of stay and high healing rate are marked characteristics of THR. More attention shoud be paid to the complications of THR.

Objective To explorepredictive factors of psychological stress reaction of medical staff members with blood-occupational exposure and to provides scientific basis for the hospital administrators toprovide psychological support and interventionfor medical staff members with blood-occupational exposure. Methods Seventy-eight medical staff members with blood-occupational exposure were recruited as participants. The Socio-demographic Questionnaire, Posttraumatic Stress Disorder Checklist-5, the Perceived Stress Scale, the Hospital Anxiety and Depression Scale, the Ruminative Responses Scale and the Emotion Regulation Questionnaire were used to evaluate the participants' psychological stress reactionat different stages and the styles of their emotion regulation. Correlation analysis and Hierarchical Regression analysis were used to analyze the predictive factors of psychological stress reaction of medical staff members with blood-occupational exposure. Results Ruminative thinking and emotion regulation can predict the psychological stress reaction of medical staff members with blood-occupational exposure at different stages. Conclusions According to the psychological stress reaction and ruminative thinking of medical staff members with blood- occupational exposure, psychological intervention should be implemented within one month to decrease the psychological trauma of medical staff members with blood-occupational exposure.

Objective:To investigate the clinical efficacy of a new 3D printed guide plate in the minimally invasive treatment of fresh closed Achilles tendon rupture.Methods:From January 2019 to January 2020, 14 fresh closed Achilles tendon ruptures were treated by minimally invasive surgery at Department of Foot and Ankle Surgery, Xuzhou Renci Hospital. There were 13 males and one female, with an average age of 39.1 years (from 18 to 63 years). The rupture of the Achilles tendon body, 3 cm in length on average, was located 2 to 6 cm above the attachment of the calcaneal tuberosity. The ruptured Achilles tendon was repaired by suture with the aid of the new 3D printed guide plate. After operation, in cooperation of the Rehabilitation Department, we performed rehabilitation exercise under the guidance of the concept of Enhanced Recovery After Surgery (ERAS). The length of incision, operation time, intraoperative blood loss, ankle function at the last follow-up and follow-up complications were recorded.Results:In this cohort, incision length averaged 2.5 cm (from 2.0 to 3.5 cm), operation time 45 min (from 30 to 60 min), and intraoperative blood loss 15 mL (from 10 to 20 mL). The 14 patients were followed up for 13 to 16 months (average, 14 months) after operation. In one patient, the epidermis at the incision edge became black and necrotic, which was healed after dressing change. Follow-ups observed no such complications as suture rejection, sural nerve injury, or Achilles tendon re-rupture. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores at the last follow-up averaged 98 points (from 93 to 99 points), yielding 13 excellent cases and one good case; according to the Arner-Lindholm evaluation, the efficacy was excellent in 12 cases, good in one and poor in one.Conclusion:The minimally invasive treatment of fresh closed Achilles tendon rupture with our new 3D printed guide plate has exhibited advantages of minimally invasive incision, limited complications, simple manipulation, good functional recovery of the ankle joint and strong reproducibility of surgical operations.

Objective:To summarise the experience in use of sural neurouascular flap in repair of the soft tissue defects of foot and ankle, and explore the methods in promoting the survival and appearance of the flap.Methods:Data of 10 patients who underwent sural neurocutaneous flap surgery for repairing soft tissue defects in the foot and ankle in the Department of Foot and Ankle of Xuzhou Renci Hospital from October 2019 to June 2020 were retrospectively analysed. Among the 10 patients, 8 were males and 2 were females, and the age ranged from 18 to 54 years old, with an average age of 42.5 years old; Causes of injury: 8 patients injured by traffic accident and 2 by incision necrosis after calcaneal fracture operation. The areas of soft tissue defect were 4.0 cm×6.0 cm-16.0 cm×10.0 cm. Sural neurouascular flap was used for the defect repairs. Method of optimisation: ①The small saphenous vein in the flap was separated and retained in the limb to optimise the venous circulation. ②Freed peroneal perforator vessels that entered the pedicle, and made the point where the vessels entering the pedicle as the rotation point. The pedicle contained the sural neurovascular bundle, the main trunk of the small saphenous vein and the fascia tissue, with a width about 2.0 cm. It not only increased the blood supply of the flaps, but also a good appearance of the pedicle. ③ The torsion of the pedicle was covered by an arc-shaped flap and transferred through an open channel to prevent compression. ④The donor site was covered with relay flap. According to the location of the donor site, a proximal peroneal artery perforator flap or medial and lateral sural artery perforator flap was selected. ⑤Sural nerve was anastomosed with the peripheral sensory nerve in some cases. The survival of the flap, Maryland Foot Function Score and British Medical Research Council (BMRC) sensory function evaluation were investigated in the follow-up to evaluate the functional recovery of the flap and limb.Results:All the 10 patients received the follow-up for 6 to 12 months, with an average of 8.5 months. The donor and recipient flaps survived completely with good appearance in lower limb, good soft texture, good elasticity and wear resistance. The sensation of the flap with nerve anastomosis in 3 cases was evaluated according to BMRC, and they achieved sensation recovery up to level of S 3 or above. The patients had great satisfactions. At the last follow-up, the curative efficacy was evaluated according to the Maryland scoring system. It ranged from 85 to 98 points, with an average of 91.6 point, 8 patients in excellent and 2 in good. Conclusion:Sural neurouascular flap can achieve a sufficient blood supply, a reasonable venous circulation and a high survival rate. The donor site was covered with relay flap to obtain a good appearance, and the anastomosed sensory nerve offered a good sensation. The function of foot and ankle recovered well, and the clinical effect was satisfactory.

Objective:To investigate the efficacy of TiRobot navigation combined with ankle arthroscopy in the reduction and internal fixation of Hawkins type Ⅱ talus neck fracture.Methods:From January 2019 to September 2020, a total of 13 patients with Hawkins type Ⅱ talus neck fracture were admitted to Department of Foot and Ankle Surgery, Xuzhou Renci Hospital. They were 8 males and 5 females, with a mean age of 35.8 years (from 22 to 61 years). All fractures were reduced and fixated using TiRobot navigation combined with ankle arthroscopy. Time for fracture reduction assisted by intraoperative arthroscopy, time for internal fixation assisted by TiRobotic navigation, fracture union time and complications were recorded. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used at the last follow-up to evaluate the functional outcomes.Results:All the operations were finished within 2 hour. The primary screw placement succeeded in all. The time for fracture reduction assisted by intraoperative arthroscopy averaged 52.8 min (from 43 to 66 min) and the time for internal fixation assisted by TiRobotic navigation 43.6 min (from 33 to 55 min). All the patients were followed up for an average 13.3 months(from 12 to 15 monhs). They obtained bony union within 3 months. One patient developed traumatic subtalar arthritis with mild pain and was treated conservatively. None of the patients had complications like incision infection or talus necrosis. The average AOFAS ankle-hindfoot score was 91.0 points (from 83 to 94 points) at the last follow-up.Conclusion:In the reduction and internal fixation of Hawkins type Ⅱ talus neck fracture, TiRobot navigation combined with ankle arthroscopy shows advantages of minimal invasion, accurate reduction and screw placement, and limited complications, leading to fine short-term functional outcomes.

Objective:To investigate the safety of minimally invasive liver resection for resectable hepatocellular carcinoma (HCC) complicated with portal hypertension.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 807 patients with resectable HCC who underwent minimally invasive liver resection in 8 medical centers, including Sir Run Run Shaw Hospital, Affiliated with the Zhejiang University School of Medicine et al, from June 2011 to November 2022 were collected. There were 670 males and 137 females, aged 58(50,66)years. Of the 807 patients, 173 cases with portal hypertension were divided into the portal hypertension group, and 634 cases without portal hypertension were divided into the non-portal hypertension group. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) intraoperative and post-operative situations; (3) subgroup analysis. Propensity score matching was done by the 1:1 nearest neighbor matching method, with the caliper setting as 0.001. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the rank sum test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was constructed using the non-parameter rank sun test. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of the 807 patients, 268 cases were successfully matched, including 134 cases in the portal hypertension group and 134 cases in the non-portal hypertension group. The elimination of the tumor diameter and robot-assisted surgery confounding bias ensured comparability between the two groups after propensity score matching. (2) Intraoperative and postoperative situations. The occlusion time of porta hepatis, cases with intraoperative blood transfusion, cases with postoperative complication, cases with complication >Ⅱ grade of Clavien-Dindo classification, cases of Clavien-Dindo classification as Ⅰ grade, Ⅱ grade, Ⅲ grade, Ⅳ grade, cases with liver related complication were 27.0(15.0,43.0)minutes, 33, 55, 15, 13, 29, 14, 1, 37 in the portal hypertension group, versus 35.0(22.0,60.0)minutes, 17, 25, 5, 14, 9, 4, 1, 13 in the non-portal hypertension group, showing significant differences in the above indicators between the two groups ( Z=-2.15, χ2=6.30, 16.39, 4.38, 20.72, 14.16, P<0.05). (3) Subgroup analysis. Results of subgroups analysis showed that in cases with major live resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 243.5(174.6,296.3)minutes, 200.0(150.0,600.0)mL, 7.5(6.0,13.0)days in the portal hypertension group, versus 270.0(180.0,314.5)minutes, 200.0 (75.0,450.0)mL, 7.0(5.5,10.0)days in the non-portal hypertension group, showing no significant difference in the above indicators between the two groups ( Z=-0.54, -1.73, -0.92, P>0.05). In cases with non-major live resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 170.0(120.0,227.5)minutes, 100.0(50.0,200.0)mL, 8.0(5.0,10.0)days in the portal hypertension group, versus 170.0(120.0,227.5)minutes, 100.0(50.0,200.0)mL, 7.0(5.5,9.0)days in the non-portal hypertension group, showing no significant difference in the above indicators between the two groups ( Z=-1.39, -0.10, 1.05, P>0.05). In cases with anatomical liver resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 210.0(150.0,285.0)minutes, 150.0(50.0,200.0)mL, 8.0(6.0,9.3)days in the portal hypertension group, versus 225.5(146.3,306.8)minutes, 100.0(50.0,250.0)mL, 7.0(6.0,9.0)days in the non-portal hypertension group, showing no significant difference in the above indica-tors between the two groups ( Z=-0.75, -0.26, -0.91, P>0.05). In cases with non-anatomical liver resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 173.5(120.0,231.5)minutes, 175.0(50.0,300.0)mL, 7.0(5.0,11.0)days in the portal hyper-tension group, versus 186.0(123.0,262.5)minutes, 100.0(50.0,200.0)mL, 7.0(5.0,9.5)days in the non-portal hypertension group, showing no significant difference in the above indicators between the two groups ( Z=-0.97, -1.12, -0.98, P>0.05). Conclusion:Minimally invasive liver resection or even major liver resection is safe and feasible for screened HCC patients complicated with portal hyper-tension, but attention should be paid to the prevention and treatment of postoperative complications.