[Objective]To approach the methods of difficult laparoscopic cholecystectomy.[Methods ]The clinical data of 116 patients with Mirizzi syndrome,severe adherence of abdominal cavity and Calot'triangle,liver cirrhosis underwent difficult laparoscopic cholecystectomy since 2004 were retrospectively analyzed.[Results]Except 3 patients treated by abdominal operation,other patients were treated by laparoscopic cholecystectomy successfully.[Conclusion]The rates of open operation midway and complications are not increased in difficult laparoscopic cholecystectomy as long as dealing with them properly.

As a nuclear transcription repressor,the functions of TGIF are complicated,not only represses target genes expression directly,but also takes part in the regulation of multiple important cellular signaling pathways,which are associated with the differentiation of cells and tissues,inflammation,metabolism and tumors.In past few years,more and more studies on the role of TGIF in tumors suggest TGIF may be a new therapy target in the diagnosis and treatment of tumours.This article mainly reviews the research progress of TGIF in some signaling pathways like TGF-β,MAPK,PI3K/AKT,and tumours like hepatocellular carcinoma,lung carcinoma and urinary tract urothelial carcinoma.

Objective:To develop an total knee arthroplasty(TKA) enhanced recovery after surgery information management system based on "cloud + terminal" data-drivene technology, which can be used in the perioperative interaction between doctors and patients and rehabilitation management of TKA, and evaluate its implementation effect.Methods:The clinical data of 96 patients with unilateral TKA from Qilu Hospital Shandong University were analyzed retrospectively. Forty eight patients in the control group from February to August, 2018 were treated with traditional management. From February to August, 2019, 48 patients in the research group adopted the accelerated rehabilitation information management system based on data-driven technology, which can automatically match, interact and push the information between medical and patient.Results:The Self-rating Anxiety Scale(SAS) score of the intervention group on hospitalization day was 41.52±4.65, which was better than that of the control group (52.60±4.84). The difference between the two groups was statistically significant ( F value was 11.446, P<0.05). The scores of Hospital for Special Surgery(HSS), Visual Analogue Scale(VAS) and SAS in the intervention group 3 days after operation were 56.31±5.81, 2.79±0.68, 38.69±3.81, which were better than those of the control group (51.31±5.20, 4.31±0.78, 46.02±3.86). The difference between the two groups was statistically significant ( F value was 4.44, 10.19, 9.37, all P<0.05); the HSS, VAS, and SAS scores of the intervention group one week after operation were 71.35±3.59, 1.98± 0.67, 36.81±4.03, better than the control group (67.15±3.67, 2.60±0.87, 39.48±4.04), the difference between the two groups was statistically significant ( F value was 5.683, 3.951, 3.237, all P<0.05); the postoperative hospital stay in the intervention group was (3.98±0.84) days, which was less than (6.00±0.80) days in the control group, the difference was statistically significant ( F value was 146.286, P<0.05); The patients′ satisfaction score in the intervention group during medical treatment was 97.46±1.73, which was higher than the control group (94.35±2.04), the difference was statistically significant ( F value was 64.911, P<0.05). Conclusions:TKA enhanced recovery management system based on "cloud + terminal" data-drivene can improve the management level of TKA patients, reduce the length of stay and improve satisfaction of patients.

Objective To observe the natural outcomes of Graf type Ⅱ a hip dysplasia aged 6 weeks to 3 months,and to explore the indications of treatment.Methods A prospective study was conducted to collect children aged from 6 to 12 weeks with Graf type Ⅱ a dysplasia (50°≤α angle＜60°) but clinically stable hips according to the Early Screening of Developmental Dysplasia of the Hip in Tianjin project from July 2012 to July 2014.Those hips with history of treatment or neuromuscular disorders were excluded.All infants had no treatment initially following with ultrasound surveillance each 2 weeks and radiograph evaluation each at 3,4.5 and 6 months of age.Patients received Pavlik harness or abduction brace treatment if hip dysplasia turned to be type Graf Ⅱ c or worse,or clinical unstable before 6 months;also if hip dysplasia was persistent in radiograph at 6 months.All infants were routinely followed up at 12 and 24 months of age to detect the late cases.The difference of initial α angle,hip abduction,acetabulum index and acetabulum margin morphology (sharp,round or defect) in the pelvic radiograph at 3 month were compared between the treated and untreated groups.Results A total of 238 children (285 hips) were enrolled in the present study,of which there were 25 males and 213 females,193 left and 92 right hips.The average age was 9 weeks (range 6 to 12 weeks).No hip turned to be type Ⅱ c or worse,or clinically unstable.One hundred patients (120 hips) received treatment for persistent dysplasia at 6 months.There had statistically significant difference in initial α angle between the treated and untreated groups (respectively 54.5°±3.3° and 55.6°±2.9°,t=-2.749,P=0.004).In the treated group,there were 47 hips (39.2％,47/120) with limited abduction initially,and 52 hips (43.3％,52/120) with poor acetabular morphology at 3 months.The differences were statistically significant comparing with the untreated group (x2=4.010,P=0.045;x2=14.143,P=0.000).Logistic multivariate regression analysis showed that patients with Graf Ⅱ a-hips (OR=2.908) and poor acetabular morphology hips (OR=2.822) were more likely to receive treatment.Thirty-eight patients (47 hips) received treatment among Graf Ⅱ a+ hips (α angle ≥55°),of which 21 hips (44.7％,21/47)had limited abduction and 31 hips (66.0％,31/47) poor acetabular morphology.The differences were statistically significant comparing with untreated cases (x2=12.073,P=0.001;x2=35.879,P=0.000).Logistic multivariate regression analysis showed that Graf Ⅱ a+ hips with limited hip abduction (OR=4.145) and poor acetabular morphology (OR=10.117) were more likely to receive treatment.Conclusion Graf Ⅱ a dysplasia with clinically stable hips should be treated if α angle ＜55° at 6 weeks or if α angle ≥55° with limited hip abduction or poor acetabular morphology (round or defect) at 3 months.

Objective To retrospectively review long?term results of developmental dislocation of the hip patients treated with open reduction and Salter pelvic osteotomy, and to analyze the potential risk factors. Methods Sixty?eight developmental dislocation of the hip cases (81 hips) were treated with open reduction and Salter pelvic osteotomy from September 1992 to Octo?ber 2002, 45 cases (52 hips) were followed up to skeletal maturity. None had undergone other treatment before the key surgery. Some cases received skeleton traction before surgery. The radiographic and functional results were assessed at last follow?up. The possible relevant factors for unsatisfactory outcome were analyzed. The correlation between type ⅡAVN and the coverage rate of the femoral head were evaluated. Results The mean age at surgery was 2.5 years (ranged from 1.4 to 5.3 years). At last follow?up, 44 hips (84.6%) had excellent or good functional results. 23 hips (44.2%) had avascular necrosis of varying severity, of which 16 hips were typeⅡ. There was significant relevance between the AVN severity and the Severin classification result (P=0.018). Theover correctionhips, that were overcorrected during surgery, were more likely to get severe type AVN ( P=0.037). There was no correlation between TypeⅡAVN with uncoverage according to CE angle and Reimers index (P=0.457, 0.308 respectively). Con?clusion 1) Satisfactory functional and radiographic results could be expected in developmental dislocation of the hip cases with?out AVN;2) High risk of AVN existed in the late diagnosised hips that underwent open reduction and Salter pelvic osteotomy, typeⅡwas the most common type;3) TypeⅡAVN was not a predictor for progressive femoral head coverage deficiency;4)Over cor?rectionin Salter pelvic osteotomy was related with severe type AVN which should be avoided.

Female ; Hemophilia A ; complications ; Humans ; Middle Aged ; Myasthenia Gravis ; complications

Objective To analyze the natural development of the residual subluxation after early close reduction for developmental dislocation of the hip,and to seek the early surgical timing and indication.Methods The research included 36 patients (48 hips) born before January 2000 who showed residual subluxation after close reduction in one year.All of patients had serial X-ray radiographs at every follow-up point.The radiographs were assessed using acetabular index (AI),Reimers index,center edge (CE) angle and the orientation of the sourcil of the acetabulum.The last follow-up results were evaluated according to the Severin classification,and Severin grade Ⅰ and Ⅱ were defined as satisfactory group and Severin grade Ⅲ and Ⅳ as unsatisfactory group.Then we compared and analyzed the serial radiological parameters between satisfactory and unsatisfactory groups.Results The mean age at close reduction was 1.6 years.At the last follow-up,the mean age was 13.8 years.The satisfactory group comprised 18 hips (37％),whereas the unsatisfactory group comprised 30 hips (63％).At the age of three to four years,there was a significant difference between the two groups in the Reimers index (34.4％±4.5％ vs.43.0％±4.6％,P ＜ 0.05).And at four to five years old,there were significant differences for both Reimers index and CE angle (29.3％ ±7.2％ vs.40.0％±6.2％,P ＜ 0.05; 21.0°±5.5° vs.10.6°±5.2°,P ＜ 0.05).When the Reimers index ＞38％ at the age of three to four years,18 of 18 hips fell into the unsatisfactory group.And when Reimers index ＞33％ at the age of four to five years,26 of 30 hips had unsatisfactory result,and in addition to that the sourcil orientation was upward,26 of 26 hips fell into the unsatisfactory group.Conclusion To avoid early osteoarthritis,surgical correction for residual subluxation was recommended if the Reimers index ＞38％ at the age of three to four years or the Reimers index ＞33％ with the sourcil upward at the age of four to five years.

Objective To analyze the factors related to glare occurred after the phakic intraocular lens (P-IOL) implantation,and to raise the standard for the P-IOL selection.Design Retrospective case series.Participants 104 patients with high myopia underwent P-IOL implantation in Beijing Tongren Hospital.Methods In 104 cases,22 cases (22 eyes) were implanted angle supported Phakic6 designed accord with corneal symmetry,54 cases (54 eyes) were implanted iris fixed Verisyse,and 28 cases (28 eyes) were implanted posterior chamber PRL.Selection of the diameter of P-IOL optics depended on P-IOL diopters.The pupil diameter,the P-IOL optic center position,the pupil and corneal center position were measured with anterior segment optical coherence tomography (OCT).The contrast sensitivity (CS) under different condition (day,day and glare,night,night and glare) and in different space frequency (1.5,3,6, 12,18c/d)were examined with Optec6500 system.Main Outcome Measures Glare incidence,CS,and the influence of pupil diameter and P-IOL location to glare.Results None of the 104 P-IOL eyes occurred glare in day time.59 eyes (56.73%) complained of glare in dime condition.The glare incidence was 63.18% (14/22) in Phakic6 eyes,55.56% (30/54) in Verisyse eyes,and 53.27% (15/28) in PRL eyes (P=0.691).CS of all surgical eyes were improved in day time with or without glare luminous environment (P=0.000).And the CS of halo-complaining eyes was lower than of no halo eyes in night time with or without glare luminous environment (P=0.000).Glare oc- curred more frequently in eyes with the pupil diameter larger than P-IOL diameter in clime condition after surgery (10 in Phakic6 eyes, 20 in Verisyse eyes,12 in PRL eyes,all P

Objective To investigate the effect of hyperlipidemia on glomerulus podocyte injury with IgA nephropathy.Methods Fifty-one IgA nephropathy patients with biopsy-proven were selected.Immunohistochemistry was applied to detect the expression of WT1,a marker of podocyte,in the renal tissue of patients with IgA nephropathy.The density of podocyte per glomerulus wascalculated using specific software.Results Triglyceride (TG) was positively correlated with glomerulus podocyte injury,serumcreatinine and glomerulosclerosis in IgA nephropathy (r =0.549,0.770,0.698,P ＜ 0.05 or ＜ 0.01 ),and there was no correlation with 24 h proteinuria.The expression of WT1 was significantly decreased in glomerulus of patients with IgA nephropathy (P ＜ 0.01 ).There was no correlation between the expression of WT1 and 24 h proteinuria,but the expression of WT1 was positively correlated with serum creatinine and glomerulosclerosis (r =0.765,0.679,P ＜0.01).Conclusion Hyperlipidemia may induce glomerulus podocyte injury in IgA nephropathy,and it may contribute to the progression of IgA nephropathy.

Objective To evaluate the hemodynamic features of VX_2 tumor and peri-neoplastic liver parenchyma with low mechanical index gray-scale contrast enhancement.Methods Ultrasound contrast agent SonoVue((0.1) ml/kg) was applied respectively in 8 VX_2-bearing rabbits by intravenous bolus injection.Corresponding parameters of the time-intensity curve:time to enhancement(ET),time to peak intensity(PIT),peak signal intensity(PSI) and mean transit time(MTT) were measured using low mechanical index contrast gray-scale imaging and Wash-in/Wash-out time-intensity curve software.Results Gray-scale imaging delineated clearly the dynamic enhancement of the VX_2 tumor and the surrounding liver parenchyma.The ET and PIT were definitely earlier,the PSI lower and the MTT absolutely shorter in VX_2 tumors than those in the liver parenchyma.There were significant differences of parameters derived from the time-intensity curve between VX_2 tumors and liver parenchyma(P