The guidelines for the early management of patients with ischemic stroke from the American Heart Association/American Stroke Association in 2013 recommend antiplatelet therapy with aspirin alone,but did not recommend other antiplatelet agents and the combination of a variety of antiplatelet drugs.However,since 2013,a great deal of published literature has shown that dual antiplatelet agents are superior to single antiplatelet agent in the prevention and treatment of ischemic stroke and transient ischemic attack.In addition,they evaluated the safety of the treatment of dual antiplatelet therapy.

Objective To investigate the safety and efficacy of radical nephrectomy plus inferior vena cava thrombectomy,and to evaluate the efficacy of preoperative temporary inferior vena cava filter placement and intraoperative application of liver transplantation techniques to reveal the inferior vena cava in order to avoid tumor thrombosis shedding and embolism.Methods The data of 42 cases (January 2004 to December 2010) of renal cell carcinoma with subdiaphragmatic thrombus were analyzed retrospectively.All these patients underwent radical nephrectomy plus inferior vena cava thrombectomy.Patients were implanted temporary inferior vena cava filter as preoperative routine.Patients with the tumor thrombi behind the liver were applied liver transplant techniques to free and turn liver to the left in order to reveal inferior vena cava,block blood flow according to priority and then finish the inferior vena cava thrombectomy.The filter was removed postoperatively on the same day,and the patients were followed up as routine.Results The operation of the 42 cases was successful without symptomatic tumor thrombus embolism perioperatively,while 1 case died of severe postoperative lung infection.The average operation time was 220 min (130-320 min),blood loss was 750 ml (200-2500 ml),and 12 cases had blood transfusion with an average of 800 ml (400-2000 ml).Forty-one cases were followed up with an average period of 36 months (6-60 months).Among the 37 cases without preoperative tumor metastasis,15 cases had metastases and 22 cases had disease-free survival.Conclusions Nephrectomy and inferior vena cava thrombectomy could be safe and effective for renal cell carcinoma with subdiaphragmatic thrombosis.Preoperative temporary inferior vena cava filter placement and intraoperative application of liver transplantation techniques to reveal the inferior vena cava can be effective to prevent tumor thrombosis shedding and embolism and improve surgical safety.

Objective To investigate the effect of BIS-guided closed-loop target-controlled infusion on perioperative Th1/Th2 balance in elderly patients undergoing laparoscopic radical gastrectomy under different anesthesia and sedation depths. Methods We applied random number table method to divide 73 elderly patients undergoing elective laparoscopic radical gastrectomy into BIS closed-loop target-controlled infusion group with BIS value of 55(group H, n=36) and BIS value of 45(group L, n=37).Intravenous blood samples were collected immediately before surgery (T1), 2h after surgery (T2), 24h after surgery (T3) and 72h after surgery (T4).IL-2, IL-4, IL-6, IL-10, TNF-α and IFN-γ were determined by flow cytometry microsphere array.We compared operation duration, postoperative PACU stay time and postoperative hospitalization time between two groups. Results Compared with T1, IL-6 and IL-10 concentration in group H at T2, T3 and T4 significantly increased (P < 0.05), IL-4 and TNF-α in group H at T4 were significantly increased (P < 0.05), IL-2 and IFN-γ in group H at T2 and T4 were significantly increased (P < 0.05), the concentration of IL-6 and IL-10 in group L at T2, T3 and T4 were increased (P < 0.05), IL-2 in group L at T4 was decreased (P < 0.05), and IFN-γ/IL-6 in two groups were decreased at T2, T3 and T4(P < 0.05).Compared with group L, IL-6 and IL-10 in group H were significantly increased at T2(P < 0.05), IFN-γ/IL-6 in group H was significantly decreased (P < 0.05), IL-2 and IL-10 in group H were significantly increased at T4(P < 0.05).Operation duration, postoperative PACU stay time and postoperative hospitalization time had no statistical significance between two groups (P > 0.05). Conclusion The anesthesia and sedation depth of BIS-guided closed-loop target-controlled infusion set at 45 is better than 55 in maintaining Th1/Th2 balance in elderly patients undergoing laparoscopic radical gastrectomy, but it has no obvious effect on long-term prognosis.

Objective:To explore the influencing factors of fatigue after stent implantation in patients with airway stenosis.Methods:Totally 104 patients with airway stenosis hospitalized in a hospital from July 2016 to June 2019 were selected, and all the patients were planned to received stent implantation. The patients were evaluated with Identity-Consequence Fatigue Scale (ICFS) postoperatively, and divided into the fatigue group and the non-fatigue group according to the evaluate results. The data of the two groups were consulted, and their gender, age, primary tumor, combined underlying disease, postoperative physical activity, pathological staging, history of radical surgery before stenting, preoperative radiotherapy and chemotherapy, degree of stenosis, type of stenosis, infiltration juga, stent placement site, and re-intervention after stenting were analyzed. Univariate and Logistic regression analysis were performed over the above influencing factors.Results:All the 104 patients with airway stenosis completed postoperative fatigue evaluation. The total score of ICFS was (82.16±8.07) . The scores of postoperative fatigue, attention, vitality, energy, daily activities and the total score were higher than those before operation, and the differences were statistically significant ( P<0.01) . Among the 104 patients with airway stenosis, 28 developed postoperative fatigue, with an incidence of 26.92%. Univariate and multivariate Logistic analysis revealed that postoperative physical activity, pathological staging, infiltrating and re-intervention after stenting were the main influencing factors to fatigue after stent implantation in patients with airway stenosis ( P<0.05) . Conclusions:Patients with airway stenosis have a high incidence of fatigue after stent implantation, which is affected by many factors. Effective intervention measures should be formulated according to the risk factors in order to reduce the incidence of postoperative fatigue.

Cholelithiasis is a kind of common and multiple diseases.In recent years,traditional laparotomy has been challenged by a minimally invasive surgery.Through literature review,the therapeutic method,effect,and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows.(1) For intrahepatic bile duct stones,the operation may be selected by laparoscopic liver resection,laparoscopic common bile duct exploration (LCBDE),or percutaneous transhepatic cholangioscopy.(2) For concomitant gallstones and common bile duct stones,the surgical approach can be selected as follows:laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation,LC plus laparoscopic transcystic common bile duct exploration,LC plus LCBDE,and T-tube drainage or primary suture.(3) For concomitant intrahepatic and extrahepatic bile duct stones,laparoscopic liver resection,choledochoscopy through the hepatic duct orifice on the hepatectomy cross section,LCBDE,EST,and percutaneous transhepatic cholangioscopic lithotripsy could be used.According to the abovementioned principle,the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

Objective: To build an automatic bone age assessment system based on China 05 Bone Age Standard and the latest deep learning technology, and preliminary clinical verification was carried out. Methods: The left-hand radiographs of 5 000 children with suspected metabolic disorders were acquired from Wuxi Children′s Hospital. Among these cases, 2 351 patients were randomly chosen as training set, and 101 patients were randomly used as validation set. Four professional pediatric radiologists annotated the development stage according to the China 05 RUS-CHN standard with double-blind method. The mean value of the bone age assessed by experts was the reference standard which was used to train and validate the deep learning mothods based artificial intelligence (AI) model. Accuracy, mean absolute error (MAE), root mean squared error (RMSE) and time efficiency of bone age assessment were compared by using Chi-square test and t test and F test between resident doctors and AI model in the validation set. Results: The MAE and RMSE was (0.37±0.35) years and 0.50 years between AI model and reference standard, respeactively. When the error range was within ±1.0, ±0.7 and ±0.5 years, the accuracy of model on the validation set was 94.1% (95/101), 89.1% (90/101), 74.3% (75/101) respectively. The accuracy between two resident doctors and AI prediction wasn′t statistical significant (P>0.05). Conclusion The AI model of bone age assessment based on deep learning is feasible and has the characteristics of high accuracy and efficiency.