Objective To investigate the value of extravascular lung water index(EVLWI) in assessment of prognosis of elderly patients with combined septic shock and pulmonary capillary leakage.Methods Totally 34 elderly patients with septic shock and pulmonary capillary leakage in our hospital from Jan.2011 to Dec.2012 were selected.Cardiac index (CI),global end diastolic volume index (GEDI),systemic vascular resistance index (SVRI),pulmonary vascular permeability index (PVPI) and EVLWI were detected by pulse-indicator continuous cardiac output (PiCCO) technology for 3 days.Based on the actual body weight (ABW) and predicted body weight (PBW),the actual extravascular lung water index and predicted extravascular lung water index were calculated.Peak airway pressure (Ppeak),plateau pressure (Pplat),mean airway pressure (Pm),tidal volume (VT),positive end expiratory pressure (PEEP),oxygen concentration (FiO2) and static lung compliance (Cst) were monitored,the arterial partial pressure of oxygen (PaO2) was detected by blood gas analysis,and the PaO2/FiO2 (P/F) and oxygenation index (OI) were calculated.Chest X-ray,lung injury score (LIS) were conducted.The correlations of EVLWI to actual body weight (EVLWIa) and predicted body weight(EVLWIp) with P/F,Cst and LIS were analyzed.The predictive value of EVLWIa and EVLWIp in the prognosis in elderly patients with septic shock and pulmonary capillary leakage was assessed.Results At day 1,non-survivors had higher levels of SOFA score and lactate level than survivors (both P＜0.05).However,these variables including SOFA score,LIS,PVPI,lactate level,fluid balance,norepinephrine level,EVLWIa and EVLWIp were higher and PaO2/FiO2 was lower in non-survivors than in the survivors at day 3 (all P＜0.05).EVLWIa and EVLWIp were positively correlated with LIS (r=0.461 and 0.588,both P＜0.05) and negatively correlated with PaO2/FiO2 (P/F) (r=-0.307 and-0.436,both P＜0.05).EVLWIa and EVLWIp had negatively correlations with Cst,but r=-0.141 and-0.154,both P＞0.05.Multiple logistic regression analysis showed that SOFA,EVLWa and EVLWp were independent predictive risk factors for mortality in elderly patients with septic shock and pulmonary capillary leakage.The areas under the receiver operating characteristic curve (ROC) of SOFA,EVLWIa and EVLWIp for predicting the prognosis were 0.769,0.832 and 0.855 respectively.With 11.96ml/kg as the cutoff point of EVLWIp,the sensitivity and specificity of EVLWIp predicting the survival of patients was 94.4％ and 61.5％ respectively.Conclusions Extravascular lung water can predict the prognosis and reflect the severity of lung injury in elderly patients with septic shock and puhnonary capillary leakage.Compared with EVLWIa,the EVLWIp has a better correlation with lung injury and a higher predictive value for survival.

Objective To explore the curative effect of deep-brain magnetic stimulation (DMS) on learned helplessness behavior in the chronic restrained stress (CRS) rat model. Methods Twenty-nine Sprague-Dawley rats were randomly divided into control group (n=8) and CRS group (n=21). CRS group was exerted chronic restrained stress, while the control group did not receive any stress, for three weeks. Then learned helplessness behavior was tested using Forced Swimming Test (FST) and the hopeless rats of the CRS group were divided ran-domly into sham group (n=6), DMS group (n=8) and citalopram group (n=7), that received corresponding treatment respectively. They were evaluated with FST again after one-week treatment. Results The immobile time in FST was longer in CRS group than in the control group after three-week stress (F=11.260, P=0.002). After one-week treatment, no significant improvement was found in the citalopram group (F=1.565, P=0.235), however, the immobile time in DMS group decreased (F=6.277, P=0.025), and was shorter than that in the sham group (F=5.560, P=0.036). Conclusion CRS could result in learned helplessness behavior, which could be alleviated with one-week DMS.

Objective To investigate the diognostic value of multi-sllce helical CT(MSCT) in spinal tuber-culosis, and making a further understanding of this disease. Methods The MSCT and post-processing films manifes-tations of 23 spinal tuberculosis proved by operation and pathology were reviewed retrospectively. Results MSCT could show the bone destructions location, range, relationships with neighbor tissues, osseous vertebral narrowing and para-vertebral abscess,etc. MPR, CPR, SSD and VR could more completely and stereoscopically show these character-istics of spinal tuberculosis. Conclusion MSCT post-processing techniques could make up for the lack of axial CT scan. It has high value in elevating the diagnosis accuracy of spinal tuberculosis.

Objective To investigate the clinical value of iPass in three dimensional contrast enhanced MR angiography (3D-CE-MRA). Methods iPass were performed in 32 cases, including cervical vessel (4 cases), pulmonary vessel (7 cases), abdominal vessel (18 cases), and femoral vessel (3 cases). iPass bolus tracking was run before 3D-CE-MRA. The tracking sequence was operated repeatedly with real time display of image. The peak of bolus arrival time(Tp), identified with signal of target vessel increased 30% over baseline, was automatically loaded in the timing page of 3D-CE-MRA, and the time of scan delay(Td) was computed by the system with Tp. The acquired images were subtracted and reconstructed by MIP. The quality of MIP image was evaluated. Results The iPass bolus tracking sequence and 3D-CE-MRA were completed successfully in 29 cases. The bolus tracking couldn′t detect the bolus arrival time in 3 cases, but they were completed through changing ROI and bolus tracking repeatedly. The average score of 3D-CE-MRA MIP image was 3.81?0.59. Conclusion iPass can provide the exact Tp and automatically control Td of 3D-CE-MRA. iPass is a useful procedure to improve the image quality and provide the specific scanning scheme for 3D-CE-MRA.

Objective To evaluate the value of transpulmonary pressure (Ptp) guided optimal positive end-expiratory pressure (PEEP) selection in patients with early acute respiratory distress syndrome (ARDS).Methods A prospective randomized self-control study was conducted.ARDS patients in the early stage (onset ≤3 days) undergoing intubation and mechanical ventilation admitted to intensive care unit (ICU) of Jiangsu Provincial Subei People's Hospital from December 2013 to December 2015 were enrolled.The PEEP level was regulated to 30 cmH2O (1 cmH2O =0.098 kPa) after recruitment maneuver,and then it was gradually decreased to 0 with lowering by 3 cmH2O every 5 minutes.The optimal PEEP was titrated by Ptp,lowest dead space fraction (VD/VT),highest static lung compliance (Cst),and optimal oxygenation,respectively.Parameters of respiratory mechanics and gas exchange were observed.Results Totally 28 patients with ARDS (including 17 male and 11 female) were included with the average age of (45 ± 12) years old,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score was 21 ± 9,oxygenation index (PaO2/FiO2) was (165 ± 76) mmHg (1 mmHg =0.133 kPa).① During decremental PEEP titration,Ptp was gradually decreased,and expiratory Ptp (Ptp-e) was more than zero [(1.3±0.3) cmH2O] when PEEP was (9.6 ± 2.3) cmH2O.Cst was initially improved until reaching a peak,and then deteriorated.Cst was highest [(50 ± 8) mL/cmH2O] when PEEP was (11.5 ± 2.4) cmH2O.PaO2/FiO2 reached the maximum [(312 ± 99) mmHg] at PEEP level of (18.0 ± 2.5) cmH2O.Compared with Ptp-e 3.00-5.99 cmH2O,PaO2/FiO2 was significantly decreased when Ptp-e became negative (all P ＜ 0.05).VD/VT was lowest (0.52 ±0.05) when PEEP was (10.1 ± 2.2) cmH2O.When compared with ventilation [inspiratory Ptp (Ptp-i) 0-2.99 cmH2O],it was significantly higher during high (Ptp-i ≥ 15 cmH2O,all P ＜ 0.05).② There were no statistically significant differences in the levels of optimal PEEP,Ptp-i and Ptp-e among Ptp,lowest VD/VT and highest Cst methods (all P ＞ 0.05),but they were significantly less than optimal oxygenation method (all P ＜ 0.05).Compared with baseline and the method of optimal oxygenation,Cst in other three PEEP titration methods including Ptp,lowest VD/VT and highest Cst was improved obviously (mL/cmH2O:46± 7,47±9,50± 8 vs.30± 8,35 ± 10,all P ＜ 0.05).PaO2/FiO2 (mmHg) in the method of Ptp and lowest VD/VT were higher than the baseline (252 ± 86,258 ± 72 vs.165 ± 76,both P ＜ 0.05),but significantly lower than that of optimal oxygenation method (312 ± 99,both P ＜ 0.05),and did not significantly differ from that of highest Cst (268± 85,both P ＞ 0.05).Compared with baseline and the method of optimal oxygenation,VD/Vr improved significantly in ventilated patients on PEEP targeting with Ptp and lowest VD/VT (0.53±0.05,0.52±0.05 vs.0.59±0.05,0.58±0.04,all P ＜ 0.05).Conclusion Titration the optimal PEEP level with the method of Ptp could promote collapse alveolar recruitment,improve oxygenation and lung compliance,decrease dead space ventilation,and will not cause alveolar excessive inflation in patients who undergoing mechanical ventilation with early ARDS.

Objective To explore the operation indication feasibility,operation technique and clinical effect of complex tibial plateau fractures with semilateral position through combined approaches.Methods From April 2011 to June 2013,data of 25 patients with complex tibial plateau fractures who were treated by open reduction and interal fixation with semilateral position through anterior lateral incision and an inverse L shaped incision were retrospectively analyzed.There were 15 males and 10 females,with an average age of 49.7 years old (range,30 to 70 years old).21 cases were traffic accident injuris and 4 cases were hurt by falling injuries from bicycle.All of the fracture patterns were three pillars of closed fracture of type Ⅵ according to Schatzker classification.The time at surgery was 5-21 days (mean,9.5 days) after injuries.The posterior condylar and medial condylar fractures were dealt with inverse L shaped incision,and fixated with anatomical locking plate and T shaped plate.The lateral condyle fractures were dealt with anterior lateral incision,and fixated with anatomical locking plate.Results Operating time was 150-250 min with an average time of 197.6 min.Intraoperative blood loss was 150-300 ml with an average of 232 ml.25 patients were followed-up,and the average duration of follow-up was 17.8 months (range,12-24 months).Fracture healing time was 16-24 weeks with an average of 19 weeks.At the time of the latest follow-up,X-ray showed all the knee joint had smooth surface,and there was no obvious varus or valgus deformity.One year later,the flexion of the knees achieved 115.2° (range,100°-130°),and the straighten reached 0°.The mean Rasmussen's score of all the patients were 14-18 (average,16.6),and there were excellent in 11 cases and good in 14.Bassed on the KSS score,the mean score was 88.6 (range,66-96) one year after operation.The excellent and good rate was 96％ (24/25).2 patients had fat liquefaction of anterolateral incision wound dehiscence,local skin necrosis,and they got good outcomes after debridement dressing and secondary suture.Conclusion Multi plate fixation is more effective and safty treatment for complex tibial plateau fractures which can be operated completely through fixed half lateral position,and the knee joint is allowed to do early functional exercise,achieving good clinical efficacy and good knee function.

BACKGROUND:The exact pathogenesis of ossification of ligamentum flavum has not been elucidated yet. And osteopontin may be an important factor involved in the ossification of ligamentum flavum. OBJECTIVE:To clarify the expression and significance of osteopontin and its receptors, CD44 and integrin-β3, in ligamentum flavum cels between normal controls and patients with ossification of ligamentum flavum.METHODS:Ligamentum flavum tissues were obtained from normal adult controls and adult patients with ossification of ligamentum flavum (n=8 per group) who underwent thoracic/lumbar posterior decompression surgery. Ligmentum flavum cels were separated, cultured and identifiedin vitro, and osteopontin, CD44, integrin-β3 were stained using immunocytochemistry method and observed under inverted phase contrast microscope. And the mRNA expressions of osteopontin, CD44, integrin-β3 were measured by RT-PCR. RESULTS AND CONCLUSION: Immunocytochemistry results showed that the stronger positive staining for osteopontin, CD44, integrin-β3 was observed in the ossification of ligamentum flavum group than the control group (P < 0.01). The mRNA expressions of osteopontin, CD44 and integrin-β3 were also higher in the ossification of ligamentum flavum group than the control group (P < 0.05). These findings indicate that osteopontin and its receptors, CD44 and integrin-β3, in ligamentum flavum cels may play an important role in ossification of ligamentum flavum.

Objective To analyze the effect of using standardized patient (SP) tutorial in the spe-cialized training of pancreatic surgery with WeChat platform. Methods 48 surgeons participating in resi-dent standardized training in Changhai Hospital (all for postgraduate education) were enrolled as teaching object. 48 surgeons were divided into two groups: SP group (n=24) receiving WeChat combined with SP tutorial which updates learning plan, learning contents, and clinical discussion by Wechat platform and performs practical teaching by SP method, control group (n=24) receiving traditional tutorial by using tradi-tional clinical teaching methods and video teaching followed by practical teaching. The theoretical exami-nation, questionnaires and expert assessment were used to evaluate the effect of the two teaching methods. Statistical analysis was performed using the SPSS 19.0. Continuous data were expressed as median±stan-dard deviation and compared using the Student's t-test. Categorical data were compared using the Pearson's chi-square test. Results The score of theoretical examination of the two groups showed no significant difference [(85.5±7.6) vs. (81.4±14.9), P=0.238]. The results of questionnaires and expert assessment in WeChat&SP group were significantly better than those in the control group (P<0.001) other than theoretical and analytical ability (P>0.05). Conclusion WeChat platform combined with standardized patient tutorial in the specialized training of pancreatic surgery is feasible and more effective than traditional tutorial to improve teaching effectiveness.

ObjectiveTo evaluate the diagnostic value of CT in adults with midgut malrotation.MethodsThe CT and clinical findings of 13 cases confirmed by surgery were analyzed retrospectively.ResultsCT found “whirl sign” in 9 cases,“transposition sign” in 5 cases,and the superior mesenteric vein located in right lower abdomen in 4 cases.At the same time,duodenum and upper jejunum located in right upper abdomen.Conclusion“Whirl sign” and “transposition sign” were the typical CT findings of midgut malrotation in adults.Ectopic superior mesenteric vein highly indicated slight midgut malrotation in adults.

Objective To evaluate the relationship between the extravascular lung water (EVLW) and other markers of lung injury and determine whether or not EVLW predicts survival in patients with acute respiratory distress syndrome (ARDS) and examine if indexing EVLW with predicted body weight (EVLWp) strengthens its discriminative power.Methods EVLW and other markers of lung injury [including:PaO2/FiO2(P/F),oxygenation index (OI) =mean pressure (Pm) × FiO2 × 100/PaO2,static compliance (Cst) and lung injury score (LIS)] were measured prospectively for 3 days in 27 patients with early ARDS between January 2011 and December 2011 at intensive care units (ICU) of Subei People's Hospital.The relationship between indexing EVLW with actual body weight (EVLWa),EVLWp and other markers of lung injury,the 28-day mortality were evaluated.Results Acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ),fluid balance in first 3 days,days of mechanical ventilation and ICU stay were significantly higher on admission in nonsurvivors compared with survivors (P ＜ 0.05).Nonsurvivors had higher OI,LIS,EVLWa and EVLWp than survivors at Days 1 and 3 (P ＜ 0.05).EVLWa and EVLWp were correlated positively with LIS (r =0.471,0.528 P ＜ 0.05) and OI (r =0.527,0.627,P ＜ 0.05) and negatively with P/F (r =-0.467,-0.646,P ＜ 0.05).EVLWp had a stronger correlation to LIS,OI and P/F than did EVLWa.No obvious correlation existed between EVLWa,EVLWp and Cst (r =-0.260,0.226,P ＞ 0.05).ROC curve analysis indicated that EVLWp (0.759,P ＜ 0.05) but not EVLWa (0.661,P＞0.05) discriminated between survivors and nonsurvivors.Three-dav average EVLWp ≥12.5ml/kg predicted the 28-day mortality with 62.5％ specificity and 80％ sensitivity.Conclusion Increased extravascular lung water is a feature of early ARDS and predicts survival.EVLWp,instead of EVLWa,improves the predictive value of extravascular lung water for survival and it is correlated with markers of disease severity.