BACKGROUND:Coracoclavicular ligament reconstruction with transclavicular-transcoracoid driling is an effective surgical technique to treat acromioclavicular dislocation. A good driling in the clavicle leads to a perfect bony tunnel and a good surgery. OBJECTIVE: To observe the effects of different driling positions of the clavicle on the location of bony tunnels in coracoclavicular ligament reconstruction. METHODS:Sixty three-dimensional digital models of the clavicle and coracoid process were constructed by Mimics13.0. Virtual transclavicular-transcoracoid bony tunnels were established according to different surgical planes with different driling positions in the clavicle. Parameters of these bony tunnels were measured, and the safety was evaluated. Option 1: The driling was made 30 mm distal to the clavicle, located in the center of the front and rear edges of the clavicle surface. Option 2: The driling was made 40 mm distal to the clavicle, located in the center of the front and rear edges of the clavicle surface. Option 3: The driling was made at the straight line of tapered nodule tip and the midpoint of the base of the coracoid process, located at the rear edge of the clavicle upper surface. RESULTS AND CONCLUSION: Bony tunnels in option 1 were extremely on the inside of the coracoid. Bony tunnels in options 1 and 2 were not in the center of clavicle. Bony tunnels in option 3 were in the center of both clavicle and coracoid. The method of locating the driling position with a certain distance to the distal clavicle leads to different results in man’s and woman’s models. To ensure that the bony tunnel can pass through the center of clavicle and coracoid, it is suggested to dril at the straight line of tapered nodule tip and the midpoint of the base of the coracoid process and nearby the rear edge of the clavicle upper surface.

Objective To analyse imaging features of atypical meningioma.Methods There were 17 cases with atypical meningiomas proved by pathology,7 cases were male,10 cases were female,ranged in age from 34～69 years.17 cases all examined with CT,and 10 cases with CT enhanced scanning;12 cases examined with MRI and 8 cases with MR enhanced scanning,5 cases examined with DSA.Results The major imaging features of atypical meningioma included:the borders of tumors were mostly irregular,nonhomogeneous density or signal on plain CT and MRI,nonhomogeneous enhancement on enhanced CT and MRI.Cystic and necrotic changing and the invasion of cranial bone and adjacent structure could be seen.5 cases with dural tail sign on MRI,3 of them,this sign was short,thick and irregular.Heavy staining was showed on DSA.Conclusion Atypical meningiomas are of some clinical and imaging features.

Objective To investigate the change of HR,RR and arterial blood gas in the treatment of BiPAP ventilation in patients with acute pulmonary.Methods Fifty eight patients with acute pulmonary edema were randomized into two groups.The control group(n =29)were given conventional general treatment only,but treatment group(n =29)were given BiPAP ventilation besides conventional treatment.4 h later,heart rate (HR),respiratory rate(RR),SaO2,pH,PaO2 and PaCO2 were compared between the two groups.Hospitalization duration and incidence of invasive mechanical ventilation were recorded after discharge.Results Compared with pre-treatment,HR,RR,SaO2 and PaO2 in treatment group were improved significantly(HR 124 ± 12 beat/min vs 83 ±6 beat/min,t =5.372,P ＜0.01)(RR 37 ±5 beat/min vs 19 ± 8 beat/min,t =4.285,P ＜0.01)(SaO2 81.4％ ±5.4％ vs94.1％ ±4.2％,t=2.731,P＜0.05)(PaO2 53.2±5.4 mm Hg vs 89.1 ±8.5 mm Hg,t=5.763,P ＜0.O1).And these four indicators were also improved in control group after treatment,(HR 123 ± 10 beat/min vs 95 ± 8 beat/min,t =t =3.459,P ＜ 0.01)(RR 36 ± 7 beat/min vs 24 ± 6 beat/min,t =3.127,P ＜0.01)(SaO2 81.8％ ±5.7％ vs 88.3 ±4.5％％,t =2.314,P ＜0.05)(PaO2 53.5 ±4.6 mm Hg vs 72.8 ±9.5 mm Hg,t =3.756,P ＜0.01).HR,RR,SaO2 and PaO2 in treatment group were more significantly improved than that of control group(P ＜ 0.01 or P ＜ 0.05).Hospitalization duration in treatment group was significantly shorter than that of control group(9 d vs 15 d,t =3.763,P ＜ 0.01).The incidence of invasive ventilation were lower than that of control group too(but P ＞ 0.05.Conclusion These results suggested that BiPAP ventilation can regulate HR RR and blood gas value to accetable levels,shorten hoptipitalization duration and reduce the incidence of invasive ventilation.It is proved to be an effective therapeutic technique in the treatment of acute pulmonary edema patients.

Objective: To evaluate the diagnostic value of CT perfusion (CTP) for posterior circulation cerebral ischemia and hyperacute phase of cerebral infarction. Methods: CTP was performed in 184 patients with suspected posterior circulation acute ischemic stroke, and diffusion weighted imaging (DWI) of MRI was performed 24-72 hours after onset. According to the characteristics of various perfusion parameters, the perfusion defect area in CTP was divided into group Ⅰ (compensatory phase of cerebral circulation reserve), group Ⅱ (compensatory phase of cerebral metabolism reserve), group Ⅲ (hyperacute phase of cerebral infarction). The region of interest (ROI) in each perfusion defect area and the contralateral mirror perfusion normal area was delineated, and the mean values of regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV), mean transit time (MTT), and time to peak (TTP) in the ROI were recorded. The perfusion parameters of normal brain tissue were included in group Ⅳ (normal control group). One-way analysis of variance was used to compare the overall differences in CTP parameters measured in each group in each region, and the multiple comparisons were performed to assess statistical differences between the perfusion parameters of groups in all parts of the posterior circulation. The sensitivity, specificity and accuracy of CTP in evaluating the hyperacute phase of cerebral infarction in various parts of the posterior circulation were calculated by using DWI as a standard. Results: A total of 271 cerebral ischemia or cerebral infarction lesions were detected in 184 patients, 107 in group Ⅰ, 75 in group Ⅱ, and 89 in group Ⅲ. There were statistically significant differences in the perfusion parameters of each group and each part of the posterior circulation (P<0.01). The changes of rCBF and MTT in each territory were not significant between group I and group II, but the decrease of rCBF and the increase of MTT in groups Ⅰ and Ⅱ were significantly different from those in group Ⅳ (P<0.05). The rCBF values of all the territories in group Ⅲ decreased significantly, and the differences between groupⅢ and groups Ⅰ, Ⅱ and Ⅳ were statistically significant (P<0.05). The MTT value of group Ⅲ was significantly increased, and the differences between group Ⅲ and groups Ⅰ, Ⅱ and Ⅳ were statistically significant (P<0.05), except for the difference between groups Ⅲ and Ⅱ in the blood supply area of P2 segment of posterior cerebral artery. rCBV values in cerebellum, pons and blood supply area of P1 and P2 segments of the posterior cerebral arteries were not significantly different among group Ⅰ, group Ⅱ, and group Ⅳ, but the rCBV values of group Ⅲ decreased significantly, and the differences with groups Ⅰ, Ⅱ and Ⅳ were statistically significant (P<0.05). The decrease of rCBV and increase of TTP in midbrain and thalamus of group Ⅱ were significantly different from those in group Ⅰ (P<0.05), while the rCBV value and TTP value of group Ⅱ were not significantly different from those of group Ⅲ. The total sensitivity, specificity and accuracy of CTP in the hyperacute phase of cerebral infarction in the posterior circulation were 79.0%, 99.7% and 98.5%, respectively. Conclusions The CTP parameter maps can reflect the pathophysiological changes of the posterior circulation cerebral ischemia and the hyperacute phase of cerebral infarction. CTP has adequate sensitivity and very high specificity and accuracy for the evaluation of posterior circulation cerebral infarction.

Objective To investigate the effects of sugammadex on postoperative pulmonary com-plications(PPCs)and postoperative recovery after thoracoscopic lung resection surgery.Methods A total of 263 patients scheduled for thoracoscopic lung resection surgery between November 2021 and July 2023,112 males and 151 females,aged 18-64 years,BMI 18.5-28.0 kg/m2,ASA physical status Ⅰ-Ⅲ,were randomly divided into three groups:the sugammadex group(group S,n=88),the neostigmine group(group N,n=87),and the control group(group C,n=88).The patient was sent to postanesthesia care unit(PACU)after operation,when the train of four(TOF)count reached 2,group S was given sugamma-dex 2 mg/kg,group N was given neostigmine 0.04 mg/kg+atropine 0.02 mg/kg,and group C was given equal volume of normal saline.The incidence of PPCs from the end of the surgery to the time of discharge was recorded.The time from the end of surgery to extubation,the time from drug administration to recovery of the train of four ratio(TOFr)to 0.9,the TOFr immediately after extubation,the length of stay in PACU,hypoxemia after extubation(SpO2＜90％)were recorded,and the incidence rate of postoperative residual neuromuscular block(PRNB)was calculated.The time of first getting out of the bed for activity,the number of total and effective compressions by the analgesia pump within 48 hours after surgery,the inci-dence of rescue analgesia,the clinical pulmonary infection score(CPIS),the numbers of postoperative nau-sea and vomiting(PONV),total drainage of the chest tube,duration of the chest tube insertion,and the length of postoperative hospital stay were recorded.Results Compared with group C,the incidence of PPCs,PRNB and hypoxemia after extubation were significantly decreased,time from the end of surgery to extubation,time from drug administration to recovery of TOFr to 0.9,the length of stay in PACU,and the first postoperatively out of bed activity time were significantly shortened,the TOFr immediately after extuba-tion was significantly increased,and CPIS was significantly decreased in group S(P＜0.05);the time from the end of surgery to extubation,time from drug administration to recovery of TOFr to 0.9,the length of stay in PACU were significantly shortened,the TOFr immediately after extubation was significantly in-creased,PRNB after extubation were significantly decreased in group N(P＜0.05).Compared with group N,the incidence of PRNB after extubation were significantly decreased,the time from the end of surgery to extubation,the time from drug administration to recovery of TOFr to 0.9,the length of stay in PACU,and the first postoperatively out of bed activity time were significantly shortened,the TOFr immediately after ex-tubation was significantly increased in group S(P＜0.05).There was no significant difference in other in-dexes between the three groups.Conclusion Sugammadex can rapidly antagonize the residual muscle re-laxation,decrease the rate of PPCs and PRNB,and promote rapid recovery of patients after thoracoscopic lung resection surgery.

Objective:To establish a predictive model for myocardial contusion (MC) in patients with rib fractures and evaluate its clinical application value.Methods:A retrospective case-control study was conducted to analyze the clinical data of 370 patients with rib fractures admitted to the Affiliated Jiangsu Shengze Hospital of Nanjing Medical University from January 2017 to December 2019, including 257 males and 113 females, aged 18-95 years [(56.5±14.0)years]. All the patients underwent electrocardiogram examination and myocardial biomarker test within 24 hours on admission, of whom 159 were diagnosed with MC, and 211 with non-MC (NMC). The 370 patients were divided into a training set of 264 patients (106 with MC, 158 with NMC) and a validation set of 106 patients (53 with MC, 53 with NMC) at a ratio of 7∶3 through the completely randomized method. In the training set, the MC group and NMC group were compared in terms of their demographic characteristics, vital signs on admission, types of rib fractures, number of rib fractures, locations of rib fractures, associated thoracic injuries, trauma scores, and laboratory indices. Variables of positive correlation with MC in patients with rib fractures were screened by Spearman correlation analysis, followed by univariate binary Logistic regression analysis for these variables to determine the risk factors for MC in patients with rib fractures. LASSO regression analysis and multivariate Logistic regression analysis were applied to identify the independent risk factors for MC in patients with rib fractures, and the regression equation was constructed. A nomogram prediction model was plotted based on the regression equation with R software. The receiver operating characteristic (ROC) curve was plotted to evaluate the model′s discriminability. Hosmer-Lemeshow (H-L) goodness-of-fit test and calibration curves of 1000 repeated samplings by the Bootstrap method were used to evaluate the calibration of the model. The decision curve analysis (DCA) and clinical impact curve analysis (CIC) were plotted to evaluate its clinical efficacy. A risk scoring was performed according to the assigned β coefficient of independent risk factors. Accordingly, the 370 selected patients with rib fractures were divided into low-risk subgroup of 202 patients, moderate-risk subgroup of 108 patients, high-risk subgroup of 50 patients, and extremely high-risk subgroup of 10 patients. The incidence of MC and in-hospital mortality were compared among different subgroups so as to further verify the clinical application value of the predictive model.Results:In the training set, there were significant differences between the MC group and NMC group in bilateral rib fractures, flail chest, number of rib fractures, upper chest proximal sternum segment, upper chest anterolateral segment, upper chest proximal spinal segment, middle chest anterolateral segment, middle chest proximal spinal segment, lower chest anterolateral segment, pneumothorax, mediastinal emphysema, hemothorax, sternal fractures, chest abbreviated injury scale (c-AIS), injury severity score (ISS), new injury severity score (NISS), white blood cell counts, hemoglobin, hematocrit, total cholesterol, low density lipoprotein, albumin, aspartate aminotransferase, alanine aminotransferase, and blood urea nitrogen ( P<0.05 or 0.01). Spearman correlation analysis showed that the bilateral rib fractures, flail chest, number of rib fractures, upper chest proximal sternum segment, upper chest anterolateral segment, upper chest proximal spinal segment, middle chest anterolateral segment, middle chest proximal spinal segment, lower chest anterolateral segment, pneumothorax, hemothorax, sternal fractures, c-AIS, ISS, NISS, white blood cell count, aspartate aminotransferase and blood urea nitrogen were positively correlated with MC ( P<0.05 or 0.01). Univariate binary Logistic regression analysis verified that the above variables with positive correlation were significantly correlated with MC in patients with rib fractures ( P<0.05 or 0.01). The 4 predictor variables screened by LASSO regression analysis were the upper chest anterolateral segment, middle chest proximal spinal segment, pneumothorax, and sternal fractures. Multivariate Logistic regression analysis confirmed that the aforementioned 4 predictor variables were independent risk factors for MC in patients with rib fractures ( P<0.05 or 0.01). The regression equation of the training set was established based on the above independent risk factors: P=e x/(1+e x), with the x=1.57×"upper chest anterolateral segment"+0.73×"middle chest proximal spinal segment"+1.36×"pneumothorax"+2.16×"sternal fractures"-1.10. In the predictive model for MC in patients with rib fractures established based on the equation, the area under the ROC curve (AUC) was 0.77 (95% CI 0.72, 0.83) and 0.77 (95% CI 0.71, 0.82) in the training set and validation set. The H-L goodness-of-fit test showed χ2=2.77, P=0.429 in the training set, and χ2=1.33, P=0.515 in the validation set, indicating that there was no significant difference between the predicted probability and the actual probability of the model ( P>0.05). The calibration curves showed that the bias-corrected curves of the training set and validation set were in good consistency with the actual curves and were both close to the ideal curves. The DCA of the training set and the validation set showed that within the threshold probability range of 0.2-0.8, the predictive model could obtain good net clinical benefits. The CIC of the training set and the validation set indicated that when the threshold probability was >0.4, the population identified as high-risk MC patients by the predictive model highly matched the actual MC patients. Risk scoring of subgroups found that the incidence of MC and in-hospital mortality among the patients with rib fractures were 80.0% and 6.0% in the high-risk subgroup and 90.0% and 20.0% in the extremely high-risk subgroup, significantly higher than those in the low-risk subgroup (24.8%, 1.0%) and the moderate-risk subgroup (55.6%, 1.9%) ( P<0.05). Conclusions:The predictive model for MC in patients with rib fractures constructed based on the upper chest anterolateral segment, middle chest proximal spinal segment, pneumothorax, and sternal fractures has good predictive efficacy and clinical application value.