Objective:To develop a novel, flexible, dual-arm, master-slave digestive endoscopic minimally invasive surgical robot system named dual-arm robotic endoscopic assistant for minimally invasive surgery (DREAMS) and to evaluate its feasibility for endoscopic submucosal dissection (ESD) by using ex vivo porcine stomachs.Methods:A novel endoscopic robot (DREAMS) system was developed which was composed of a flexible two-channel endoscope, two flexible robotic manipulators, a master controller, a robotic arm, and a control system. A total of 10 artificial round-like lesions with diameters ranging from 15 to 25 mm were created (5 in gastric antrum and 5 in gastric body) by using fresh peeled stomach of healthy pigs as the model. Submucosal dissection was performed with the assistance of the DREAMS system by two operators. The main outcome was submucosal dissection speed, and the secondary outcomes included muscular injury rate, perforation rate, and grasping efficiency of the robot.Results:All 10 lesions were successfully dissected en bloc by using the DREAMS system. The diameter of the artificial lesions was 22.34±2.39 mm, dissection time was 15.00±8.90 min, submucosal dissection speed was 141.79±79.12 mm 2/min, and the number of tractions required by each ESD was 4.2 times. Muscular injury occurred in 4/10 cases of ESD. No perforation occurred. Conclusion:The initial animal experiment shows the DREAMS system is safe and effective.

Periarticular fracture of the shoulder is a common type of fractures in the elderly. Postoperative adverse events such as internal fixation failure, humeral head ischemic necrosis and upper limb dysfunction occur frequently, which seriously endangers the exercise and health of the elderly. Compared with the fracture with normal bone mass, the osteoporotic periarticular fracture of the shoulder is complicated with slow healing and poor rehabilitation, so the clinical management becomes more difficult. At present, there is no targeted guideline or consensus for this type of fracture in China. In such context, experts from Youth Osteoporosis Group of Chinese Orthopedic Association, Orthopedic Expert Committee of Geriatrics Branch of Chinese Association of Gerontology and Geriatrics, Osteoporosis Group of Youth Committee of Chinese Association of Orthopedic Surgeons and Osteoporosis Committee of Shanghai Association of Chinese Integrative Medicine developed the Chinese expert consensus on the diagnosis and treatment of osteoporotic periarticular fracture of the shoulder in the elderly ( version 2023). Nine recommendations were put forward from the aspects of diagnosis, treatment strategies and rehabilitation of osteoporotic periarticular fracture of the shoulder, hoping to promote the standardized, systematic and personalized diagnosis and treatment concept and improve functional outcomes and quality of life in elderly patients with osteoporotic periarticular fracture of the shoulder.

Objective:To investigate the iodine intake and iodine nutritional status of pregnant women in different water iodine areas of Tianjin, and to provide a basis for formulating appropriate intervention measures in high water iodine areas.Methods:From January to September 2016, 90, 91 and 71 pregnant women were randomly selected as research subjects in different water iodine areas in Tianjin (water iodine ≤150, > 150 - 300 and > 300 μg/L) via the random sampling method. Samples of salt, drinking water and urine were collected from pregnant women. A semi-quantitative food frequency questionnaire was used to investigate the intake of 12 kinds of food eating by pregnant women in the past year. Salt iodine content was determined by direct titration, water iodine content was determined by ceric sulfate catalytic spectrophotometry, and urinary iodine was determined by arsenic-cerium catalytic spectrophotometry.Results:There was no statistically significant difference in salt iodine intake among pregnant women in different water iodine areas ( H = 2.29, P = 0.318); the difference in drinking water iodine intake (7.50, 282.60, 544.35 μg/d) was statistically significant ( H = 223.31, P < 0.001), and further pairwise comparison found that the differences were statistically significant ( P < 0.001); the difference in food iodine intake was not statistically significant ( H = 2.19, P = 0.334). With the increase of water iodine content in various regions, the contribution rate of drinking water iodine intake gradually increased. The medians of urinary iodine in pregnant women in different water iodine areas were 113.50, 180.55 and 268.55 μg/L, respectively, and there was a positive correlation between urine iodine content and total iodine intake ( rs = 0.31, P < 0.001). Conclusions:The iodine nutrition level of pregnant women in areas with water iodine ≤150 μg/L is insufficient (< 150 μg/L), so the consumption rate of iodized salt should be increased to prevent the occurrence of iodine deficiency disorders. The iodine nutrition level of pregnant women in areas with water iodine > 300 μg/L exceeds the appropriate amount (250 - 499 μg/L), pregnant women should control the intake of foods with high iodine content and take measures to improve water as soon as possible to reduce iodine.

Objective:To investigate the feasibility and clinical value of 4D flow magnetic resonance imaging (MRI) in evaluating hemodynamics of ischemic stroke patients with intracranial artery stenosis.Methods:Ischemic stroke patients with unilateral middle cerebral artery stenosis admitted from March 2017 to June 2018 in Beijing Tsinghua Changgung Hospital Stroke Center were prospectively enrolled. Time of flight magnetic resonance angiography was used to evaluate vascular stenosis, 4D flow MRI was used to measure net forward flow at the proximal of stenosis, and brain tissue perfusion was acquired simultaneously to validate flow.Results:A total of 33 patients with symptomatic middle cerebral artery stenosis were included [mean age: 56 years; male: 63.6% ( n=21)]. The flow rates among patients with stenosis of <30%, 30%-49%, 50%-69% and ≥70% were (3.56±1.08), (2.96±0.94), (3.72±0.60) and (2.50±1.03) ml/s individually, demonstrating a decreased flow in subjects with severe (≥70%) stenosis ( F=4.34, P=0.008). Further analysis about forward flow and brain tissue perfusion showed that the significant negative correlation between absolute flow rate or relative flow rate and relative time to peak could only be established in subjects with poor collateral (collateral score: 0-2), with r=-0.76 and -0.61 individually, both P<0.05. Conclusion:4D flow MRI could be used as a quantitative flow assessment in subjects with intracranial artery stenosis, and its association with distal brain tissue perfusion depends on collateral status.

TSCI have dyskinesia and sensory disturbance that can cause various life-threaten complications. The patients with traumatic spinal cord injury (TSCI), seriously affecting the quality of life of patients. Based on the epidemiology of TSCI and domestic and foreign literatures as well as expert investigations, this expert consensus reviews the definition, injury classification, rehabilitation assessment, rehabilitation strategies and rehabilitation measures of TSCI so as to provide early standardized rehabilitation treatment methods for TSCI.

Objective:To explore the clinical efficacy of proximal femoral anatomical locking plate and autogenous iliac graft for failed primary internal fixation in treatment of femoral intertrochanteric fracture.Methods:A retrospective analysis was conducted of the 29 patients with femoral intertrochanteric fracture who had been treated after failed primary internal fixation at Department of Orthopaedics and Trauma, Xi'an Honghui Hospital between January 2014 and March 2017. They were 17 men and 12 women, aged from 35 to 83 years (mean, 68.7 years). Their primary internal fixation involved dynamic hip screw in 12 cases, proximal femoral locking plate in 13 cases, and intramedullary nail in 4 cases. The causes for their internal fixation failure included head cutting in 8 cases, fracture nonunion in 10 cases, plate or screw breakage in 6 cases, intramedullary nail breakage in 3 cases, and hip varus in 2 cases. Their revision surgery was performed with anatomical proximal femoral locking plate and autogenous iliac bone graft. Their fracture union time, and visual analogue scale (VAS), hip Harris score, SF-36 health survey scale and complications at the final follow-ups were recorded.Results:All the 29 patients were followed up for 12 to 24 months (18 months on average). Bony union was eventually achieved in all the 29 patients after an average time of 4.5 months (from 3 to 7 months). There were no such complications as nonunion, re-fracture or internal fixation failure. The VAS pain score at the final follow-up(4.6±1.6) was significantly lower than that before surgery(7.1±2.1), and the Harris hip score(85.2±8.2) and SF-36 score(75.9±15.5) at the final follow-up were significantly higher than those before surgery (48.0±12.7 and 48.7±18.8) (all P<0.05). According to their hip Harris scores at the final follow-ups, the therapeutic efficacy was rated as excellent in 9 cases, as good in 15 cases and as poor in one, yielding an excellent and good rate of 82.8%. Conclusion:For patients with femoral intertrochanteric fracture whose primary internal fixation has failed, especially those with fine femoral head and neck and hip joint, proximal femoral anatomic locking plate and autogenous iliac bone graft can result in satisfactory clinical efficacy.

Objective:To observe the functional remodeling of the default mode network (DMN) of patients with post-stroke cognitive impairment (PSCI) in response to transcranial direct current stimulation (tDCS) and to explore the mechanisms involved.Methods:Eighteen PSCI patients and twenty healthy controls were enrolled. The PSCI patients were given 20 minutes of tDCS at 2.0mA on the dorsolateral prefrontal cortex every weekday for four weeks. The subjects were scanned using resting state functional magnetic resonance imaging before and after the intervention to explore any functional changes in the DMN. Montreal cognitive assessment (MoCA) scoring was performed before and after the treatment.Results:Compared to the healthy controls, the cognitively impaired patients showed significant abnormalities in the DMN on admission, including decreased functinal connection (FC) in the posterior cingulate cortex and/or precuneus (PCC/PCu), as well as increased FC in the medial prefrontal cortex (MPFC) and left hippocampus. After the treatment, a significant improvement in the PSCI patients′ average MoCA score was observed. The average FC of the PCC/PCu had also increased significantly, while that of the left hippocampus had decreased significantly, on average. The FC in the PCC/PCu after tDCS was found to be positively related to the MoCA score measured at 4 weeks after admission.Conclusions:PSCI patients show functional abnormalities in the DMN. tDCS applied to their dorsolateral prefrontal cortex can significantly improve their average MoCA scores, which may be related to the increasing FC of the PCC/PCu.

Objective To study the iodine nutritional status in the key population in Tianjin before and after the implementation of the new standards of iodized salt content, and to provide a scientific basis for iodine supplementation. Methods According to the method of population proportion sampling, the family edible salt samples, the urinary iodine and goiter of children aged 8-10 years and the urinary iodine level of pregnant women were investigated before the adjustment of salt iodine content (2005, 2011) and after the adjustment (2014, 2017). The results were compared and analyzed. Results The median of salt iodine after the adjustment (26.05mg/kg) was significantly lower than that of before (30.20mg/kg, Z=12.867, P<0.001). After adjustment, the coverage of iodized salt, the qualified rate of iodized salt, and the qualified iodized salt consumption rate were 78.68%, 81.01%, and 63.74%, respectively, and there were statistically significant differences from before adjustment (92.44%, 96.78%, 89.47%, respectively) (χ²=221.916, 309.405, 540.148, respectively, P <0.001). The median urinary iodine in children aged 8 to 10 years decreased from 210.10μg/L to 172.08μg/L, and the difference was statistically significant before and after adjustment (Z=3.351, P<0.001). The thyroid goiter rate of children decreased from 2.21% to 2.05%, and the difference was not statistically significant between the groups (χ²=0.196, P=0.658). After stratified analysis based on salt iodine content, it was found that among children who took iodized salt and qualified iodized salt, the median urine iodine after adjustment was lower than that before adjustment, and the difference was statistically significant (Z=2.726, 2.742, all P<0.001), but the proportion of urine iodine at an appropriate level was higher than before adjustment. The median urine iodine of pregnant women increased from 145.20μg/L to 147.17μg/L, and there was no significant difference before and after adjustment (Z=1.121, P=0.162). The proportion of pregnant women with median urinary iodine from 150 to 250μg/L was significantly higher in post-adjustment (31.02%) than that of pre-adjustment (24.53%, χ²=4.769, P=0.029). Conclusion After adjusting the salt iodine content in Tianjin, children's iodine nutrition was optimized from a higher level to an appropriate level, and thyroid goiter rate of children remained at low level. The iodine nutrition of pregnant women was slightly lower than adequate level, but the proportion of pregnant women at the adequate level increased. The new standard of iodine salt was appropriate, but the proportion of children with urine iodine <100μg/L increased, which needs to be monitored. At the same time, the iodized salt coverage rate and the qualified iodized salt consumption rate did not reach the elimination standard of iodine deficiency diseases, and the supervision of the salt industry market should be strengthened.

OBJECTIVETo summarize the treatment status of gastric gastrointestinal stromal tumor (GIST) in Shandong province,by analyzing the clinicopathological features and prognostic factors.

METHODSClinicopathological and follow-up data of 1 165 patients with gastric GIST between January 2000 and December 2013 from 23 tertiary referral hospitals in Shandong Province were collected to establish a database. The risk stratification of all cases was performed according to the National Institutes of Health(NIH) criteria proposed in 2008. Kaplan-Meier method was used to calculate the survival rate. Log-rank test and Cox regression model were used for univariate and multivariate prognostic analyses.

RESULTSAmong 1 165 cases of gastric GIST, 557 were male and 608 were female. The median age of onset was 60 (range 15-89) years. Primary tumors were located in the gastric fundus and cardia in 623 cases(53.5%), gastric body in 346 cases(29.7%), gastric antrum in 196 cases(16.8%). All the cases underwent resection of tumors, including endoscopic resection (n=106), local resection (n=589), subtotal gastrectomy(n=399), and total gastrectomy(n=72). Based on the NIH risk stratification, there were 256 cases (22.0%) at very low risk, 435 (37.3%) at low risk, 251 cases (21.5%) at intermediate risk, and 223 cases (19.1%) at high risk. A total of 1 116 cases(95.8%) were followed up and the median follow-up period was 40 (range, 1-60) months. During the period, 337 patients relapsed and the median time to recurrence was 34 (range 1-60) months. The 1-, 3-, and 5-year survival rates were 98.6%, 86.1% and 73.4%, respectively. The 5-year survival rates of patients at very low, low, intermediate, and high risk were 93.1%, 85.8%, 63.0% and 42.3% respectively, with a statistically significant difference (P=0.000). Multivariate analysis showed that primary tumor site (RR=0.580, 95%CI:0.402-0.835), tumor size (RR=0.450, 95%CI:0.266-0.760), intraoperative tumor rupture(RR=0.557, 95%CI:0.336-0.924), risk classification (RR=0.309, 95%CI:0.164-0.580) and the use of imatinib after surgery (RR=1.993, 95%CI:1.350-2.922) were independent prognostic factors.

CONCLUSIONSThe choice of surgical procedure for gastric GIST patients should be based on tumor size. All the routine procedures including endoscopic resection, local excision, subtotal gastrectomy and total gastrectomy can obtain satisfactory curative outcomes. NIH classification has a high value for the prediction of prognosis. Primary tumor site, tumor size, intraoperative tumor rupture, risk stratification and postoperative use of imatinib are independent prognostic factors in gastric GIST patients.