The main impacting factors on implementing clinical pathway were analyzed by applying fishbone diagram.The factors include policy factors,organizational factors and personal factors.It was suggested to improve the trial work of implementing clinical pathway management by reforming the medical care payment system,putting the clinical pathway management into the evaluation system,building up medical information system,putting more efforts on promotion and enhancing cooperation among related departments.

Severe acute respiratory syndrome is an infectious disease caused by a new type of coronavirus. It belongs to the seasonal febrile diseases in traditional Chinese medicine. The prevention and treatment of severe acute respiratory syndrome (SARS) can be under the guidance of the doctrines for treating febrile diseases of traditional Chinese medicine, treatment based on syndrome differentiation, such as syndrome differentiation of triple energizer, syndrome differentiation according to defensive phase, qi phase, nutrient phase and blood phase. During April and May of 2003, 8 cases of SARS were diagnosed in Shanghai, and 6 patients accepted complementary therapy of traditional Chinese medicine, without death case. The only one patient who didn't take glucocorticoid therapy was complementarily treated with traditional Chinese herbs through the whole treating procedure. Upon the successful treatment of the eight cases of SARS in Shanghai, it is demonstrated that the triple-energizer syndrome differentiation and defensive-qi-nutrient-blood syndrome differentiation in traditional Chinese medicine are of high value in treating SARS patients.

Although a large number of genetic variants have been identified to be associated with common diseases through genome-wide association studies, there still exits limitations in explaining the missing heritability. One approach to solving this missing heritability problem is to investigate gene-gene interactions, rather than a single-locus approach. For gene-gene interaction analysis, the multifactor dimensionality reduction (MDR) method has been widely applied, since the constructive induction algorithm of MDR efficiently reduces high-order dimensions into one dimension by classifying multi-level genotypes into high- and low-risk groups. The MDR method has been extended to various phenotypes and has been improved to provide a significance test for gene-gene interactions. In this paper, we propose a simple method, called accelerated failure time (AFT) UM-MDR, in which the idea of a unified model-based MDR is extended to the survival phenotype by incorporating AFT-MDR into the classification step. The proposed AFT UM-MDR method is compared with AFT-MDR through simulation studies, and a short discussion is given.
Classification ; Genome-Wide Association Study ; Genotype ; Methods* ; Multifactor Dimensionality Reduction* ; Phenotype

OBJECTIVETo explore the effect of recombinant human soluble CD(40) ligand (rhsCD(40)L) and CD(40)L cDNA transfected cell (CD(40)L-TC) on the behavior of malignant B lymphocytes, and investigate the possibility of using rhsCD(40)L as a new bio-factor in tumor immunotherapy.

METHODrhsCD(40)L and CD(40)L-TC were obtained by gene recombinant techniques. Multiple myeloma cell lines, XG2, XG7, U266 and 8226, B-lymphoma cell lines, Raji and Daudi were selected to detect responses to rhsCD(40)L and CD(40)L-TC stimulation. Cell growth curve, cell cycle, early apoptosis as well as membrane surface molecules on these cell lines were analyzed.

RESULTS(1) The expression levels of CD(40) molecule on malignant B lymphocytes showed heterogeneity. High level of CD(40) on XG2, moderate on 8266, Raji, and Daudi, and no expression on U266 and XG7 were detected. The rhsCD(40)L stimulation gave rise to a typical homo-type cell aggregation of XG2 and Daudi. Meanwhile, at least 10 to 20 of CD(40)(+) XG2 or CD(40)(+) Daudi cells were found adherent to one pre-treat ed CD(40)L-TC. (2) Co-incubation with rhsCD(40)L (5 micro g/ml), or CD(40)L-TC (tumor cell: CD(40) = 5:1) resulted in a significant inhibition of in vitro cell growth of XG2, Raji and Daudi, with G(1)-phase arrest for XG2 and G(2)-phase for Raji and Daudi. These two kinds of CD(40) stimulators induced XG2, Raji and Daudi cells to apoptosis in vitro. The apoptotic rate for XG2 was 23.3% (rhsCD(40)L) and 18.8% (CD(40)L-TC), for Daudi 14.2% and 15.9%, and for Raji 11.6% and 8.9% respectively. (3) Phenotype analysis showed that CD(95) expression levels were significantly up-regulated on XG2, Raji and Daudi after stimulation with rhsCD(40)L or CD(40)L-TC, and CD(80) and CD(18) expression levels on Raji were respectively enhanced and decreased.

CONCLUSIONThe abilities to directly inhibit XG2, Daudi and Raji cell proliferation, to induce themapoptosis, as well as to up-regulate immune co-stimulator molecule CD(80) expression on Raji cells would make rhsCD(40)L a potential bio-factor for tumor immuno-therapy.

B-Lymphocytes ; drug effects ; metabolism ; pathology ; CD40 Antigens ; metabolism ; CD40 Ligand ; genetics ; metabolism ; pharmacology ; Cell Division ; drug effects ; Coculture Techniques ; DNA, Complementary ; genetics ; Humans ; Lymphoma, B-Cell ; metabolism ; pathology ; Recombinant Proteins ; pharmacology ; Time Factors ; Transfection ; Tumor Cells, Cultured ; drug effects

Objective:To propose a new classification of posterior malleolus fracture to further clarify its pathoanatomy.Methods:Twenty fresh frozen cadaver specimens of normal morphology of lower limbs were selected and dissected and the extent of the tibial insertion of posterior malleolus associated ligaments was measured. At the same time, a retrospective case series analysis was made on the clinical and CT information of 296 patients with posterior malleolus fracture treated at Tongji Hospital of Tongji University from January 2012 to July 2020 or at Karamay Central Hospital from January 2018 to July 2020. The percentage of articular involvement of the fracture, proximal displacement of the posterior malleolus fracture and extent of posterior talar subluxation were measured. A clinically practical new classification system for posterior malleolus fracture was created by correlating posterior malleolus associated ligaments with CT images of posterior malleolus fracture. The new classification included three types: type I was posterior malleolus fracture with only the tibial insertion of inferior transverse tibiofibular ligament involved; type II was posterior malleolus fracture with both the tibial insertions of inferior transverse tibiofibular ligament and posterior inferior tibiofibular ligament involved, which was divided into subtypes IIA and IIB based on the presence of articular cartilage and subchondral bone damage, compression or Die-Punch fragments; type III was posterior malleolus fracture that involved all the tibial insertions of inferior transverse tibiofibular ligament, posterior inferior tibiofibular ligament and posterior tibiotalar ligament, which was sub-classified into subtypes III A and III B according to number of fracture fragments. Anatomic characteristics of the extent of the tibial insertion of posterior malleolus associated ligament, CT imaging parameters for posterior malleolus fracture and corresponding fracture typing were determined. In addition, the new classification system for posterior malleolus fracture was compared with Haraguci classification and Mason classification.Results:Posterior malleolus associated ligaments included the posterior inferior tibiofibular ligament, inferior transverse tibiofibular ligament and posterior tibiotalar ligament from posterolateral to posteromedial tibia. The posterior inferior tibiofibular ligament was attached to the posterolateral tibia and the distance between the highest point of its tibial insertion and the joint line was (45.2±5.6)mm. The inferior transverse tibiofibular ligament was attached to the posterior distal tibia and the distance between the highest point of its tibial insertion and the joint line was (5.5±1.0)mm. The posterior tibiotalar ligament was attached to the posterior colliculus and intercollicular groove of the medial malleolus and the distance between the center of its tibial insertion and the intercollicular groove was (2.5±0.6)mm. Among 296 patients with posterior malleolus fracture, there were 36 patients with type I, 229 with type II (150 type IIA, 79 type IIB) and 31 with type III (11 type IIIA, 20 type IIIB). The percentage of articular involvement of the fracture, proximal displacement of posterior malleolus fracture and extent of posterior talar subluxation in type IIB fracture were significantly greater than those in type II A fracture [23.7(18.6, 28.8)% vs. 18.4(12.7, 21.7)%, 4.1(2.1, 6.0)mm vs. 1.9(0.2, 3.0)mm, 4.7(1.5, 6.2)mm vs. 2.3(1.1, 3.0)mm] (all P<0.01). The proximal displacement of posterior malleolus fracture and extent of posterior talar subluxation in type III fracture were significantly greater than those in type II fracture [7.2(6.0, 8.2)mm vs. 2.7(0.4, 4.0)mm, 10.1(6.0, 15.0)mm vs. 3.1(1.1, 5.0)mm] (all P<0.01). The new classification for posterior malleolus fracture combined the posterior malleolus ligament and injury mechanism of posterior malleolus fracture as compared with Haraguchi classification, which not only further detailed the classification, but also was more practical in clinic for increased the severity of injury was elevated with higher classification level. The new classification was more comprehensive as compared with Mason classification for it mainly added the type of simple-rotation-type posterior malleolus fracture (type IIA of the new classification). Conclusions:In combination with posterior malleolus associated ligaments, injury mechanism and fracture morphology, posterior malleolus fracture is divided into three types. The new classification system more comprehensively describes pathoanatomy of posterior malleolus fracture that contributes to related basic research and clinical diagnosis and treatment.

Objective:To analyze the correlation between the posterior malleolus fracture and fixation and the rotational stability of the ankle and to explore the surgical indications for posterior malleolus fracture aiming to provide the theories for the diagnosis and treatment of disorder.Methods:Twenty fresh frozen cadaver specimens were selected. Further, the extent of the tibial insertion of the posterior inferior tibiofibular ligament (PITFL) and inferior transverse tibiofibular ligament (ITTFL) complex was dissected and measured. Based on the tibial insertion of the ligament complex, the model for the supination-external rotation degree 3 ankle fracture with a posterior malleolar fragment and syndesmosis diastasis was created. Moreover, the area threshold of the posterior tibial insertion of posterior malleolus fracture was biomechanically assessed. The difference of the antirotating ability of the ankle-stiffness between simple posterior malleolus fixation and simple syndesmotic fixation was analyzed statistically.Results:The PITFL and ITTFL were presented in all specimens with relatively broad in PITFL tibial insertion. The PITFL was attached to the posterolateral tibia. The distance between the highest point of the tibial insertion and the articular line was 45.2±5.6 mm, while the ITTFL was attached to the posterior distal tibia. The distance between the highest point of the tibial insertion and the articular line was 5.5±1.0 mm. The width of the tibial insertion of the PITFL and ITTFL complex decreased as the distance from the joint line increased. Biomechanical analysis showed that the threshold of posterior area of posterior malleolus fracture was 1/4S. The stiffnesses of posterior malleolus fixation and syndesmosis stabilization were 0.264±0.080 N·m/° and 0.164 ± 0.061 N·m/°, respectively. The percentage of stiffness restored by posterior ankle fixation was 60.9%±10.2%, which was greater than that by syndesmosis stabilization 37.5%±7.9% ( t=17.09, P<0.001) . Conclusion:The surgical technique for posterior malleolus fracture should consider restoration of the axial and rotational stability of the ankle simultaneously. Posterior malleolus fracture fixation is recommended when the syndesmosis is unstable with the area ratio of posterior tibial insertion of posterior malleolus fracture greater than or equal to 1/4. Syndesmotic fixation is proposed to restore and maintain the rotational stability of the ankle when the syndesmosis is unstable with the area ratio less than 1/4. Regardless of the area ratio, the surgical indications for stable syndesmosis depend on the impact of the posterior malleolus fracture on the axial stability of tibiotalar joint, on the involved articular surface area and on the displacement degree of posterior malleolus fragment.

OBJECTIVETo assess the association of copy number variations (CNVs) of exon 11 of IL-23 receptor gene with susceptibility to active pulmonary tuberculosis among Chinese Uygurs.

METHODSIn this study, 250 subjects with active pulmonary tuberculosis (PTB) and 250 normal controls were recruited. A paired case-control study was conducted in the Chinese Uygur population in Xinjiang and the CNV of IL-23R was analyzed using Taqman real-time PCR.

RESULTSThe study showed that the frequencies of different copy number in exon 11 of IL-23R between PTB and control groups were statistically significant (χ(2)=13.35, P<0.01). There were significant difference in CNV of exon 11 in IL-23R between PTB patients and controls (χ(2)=14.95, P<0.01, OR=2.875, 95%CI: 1.655-4.994). The increase of copy number in exon 11 of IL-23R showed significantly different between PTB and control groups (χ(2)=10.475, P=0.0012, OR=2.611, 95%CI: 1.437-4.744).

CONCLUSIONThe CNV of exon 11 in IL-23R is associated with PTB in the Chinese Uygur population. The increase of the copy number in exon 11 of IL-23R may be a risk factor for PTB in Chinese Uygurs.

Adult ; Aged ; Asian Continental Ancestry Group ; ethnology ; genetics ; Case-Control Studies ; China ; ethnology ; DNA Copy Number Variations ; Exons ; Female ; Genetic Predisposition to Disease ; ethnology ; Humans ; Male ; Middle Aged ; Receptors, Interleukin ; genetics ; Tuberculosis, Pulmonary ; ethnology ; genetics ; Young Adult

Objective:To compare the efficacy of staged versus elective operation for treating acute closed fracture-dislocation of tarsometatarsal joint complex.Methods:A retrospective cohort study was used to analyze the clinical data of 26 patients with acute closed fracture-dislocation of tarsometatarsal joint complex admitted to Tongji Hospital of Tongji University from January 2017 to January 2021, of whom 18 were males and 8 were females, aged 32-52 years [(44.3±5.2)years]. According to the time from injury to admission, 14 patients admitted within 8 hours after injury underwent staged surgical treatment (staged group), and 12 patients admitted more than 8 hours after injury underwent elective surgery (elective group). In the staged group, emergency reduction and temporary internal fixation with K-wire were done under the supervision of a C-arm X-ray machine in the first stage, while after the swelling subsided, open reduction and internal fixation were done for tarsometatarsal joint fracture-dislocation in the second stage. In the elective group, open reduction and internal fixation were performed for tarsometatarsal joint fracture-dislocation on a scheduled basis after the swelling subsided. The operation time, hospitalization time and fracture healing time were recorded. The visual analogue score (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) midfoot score were evaluated before operation, at 1, 6, 12 months after operation and at the final follow-up. The rate of complications was observed after operation.Results:All patients were followed up for 12-24 months [(18.5±3.8)months]. The operation time, hospitalization time and fracture healing time in the staged group were (77.3±5.6)minutes, (14.3±2.2)days and (12.3±1.2)weeks, respectively, significantly shorter than those in the elective group [(101.5±7.5)minutes, (20.3±5.2)days and (14.3±2.2)weeks] (all P<0.01). VAS significantly decreased and AOFAS midfoot score significantly increased in both groups as postoperative time increased (all P<0.05). There were no significant differences in VAS between the two groups before operation, at 12 months after operation or at the final follow-up (all P>0.05). The VAS at 1, 6 months after operation was (4.4±0.8)points and (2.1±0.4)points in the staged group, significantly lower than those in the elective group [(6.0±1.0)points and (3.5±0.6)points] (all P<0.01). There was no significant difference in preoperative AOFAS midfoot score between the two groups ( P>0.05). The AOFAS midfoot score at 1, 6, 12 months after operation and at the final follow-up was (67.6±4.5)points, (75.7±5.2)points, (83.6±2.2)points and (85.9±4.3)points in the staged group, significantly higher than those in the elective group [(60.2±3.9)points, (70.2±3.4)points, (75.4±3.3)points and (78.7±4.4)points] (all P<0.01). The rate of complications was 14.3% (2/14) in the staged group, significantly lower than that in the elective group [33.3% (4/12)] ( P<0.05). Conclusion:Compared to traditional elective surgery, staged surgery for acute closed fracture-dislocation of tarsometatarsal joint complex has the advantages of shortened operation time, hospitalization time and fracture healing time, eary pain relief, improved functional recovery of the foot and reduced postoperative complications.