Distal transradial access(dTRA)was first applied in coronary heart disease intervention by Kiemeneij in 2017,dTRA has become an important technological advancement of coronary interventional therapy.This approach,performed by puncturing the distal radial artery within the anatomical snuffbox or Hegu point,significantly reduces the incidence of radial artery occlusion compared with conventional transradial access and shortens compression time to 2-3 hours after procedure.Clinical evidence confirms the efficacy of dTRA in facilitating complex percutaneous coronary interventions,including stenting of left main coronary artery bifurcation lesions and recanalization of chronic total occlusions.Its application has progressively expanded to neurointerventional procedures(cerebral angiography),tumor embolization(transarterial chemoembolization for hepatocellular carcinoma),and peripheral vascular interventions.Despite increasing clinical adoption,dTRA still faces challenges,including a long learning curve and relatively lower initial puncture success rates.Combined with the current paucity of robust evidence-based data,the viability of dTRA as a routine interventional access route remains a subject of debate.This article systematically reviews the anatomical landmarks,clinical advantages,limitations,and multidisciplinary applications of dTRA.This article aims to provide practical guidance for interventionalists and promote the standardization of this technique in daily clinical practice.

Distal transradial access(dTRA)was first applied in coronary heart disease intervention by Kiemeneij in 2017,dTRA has become an important technological advancement of coronary interventional therapy.This approach,performed by puncturing the distal radial artery within the anatomical snuffbox or Hegu point,significantly reduces the incidence of radial artery occlusion compared with conventional transradial access and shortens compression time to 2-3 hours after procedure.Clinical evidence confirms the efficacy of dTRA in facilitating complex percutaneous coronary interventions,including stenting of left main coronary artery bifurcation lesions and recanalization of chronic total occlusions.Its application has progressively expanded to neurointerventional procedures(cerebral angiography),tumor embolization(transarterial chemoembolization for hepatocellular carcinoma),and peripheral vascular interventions.Despite increasing clinical adoption,dTRA still faces challenges,including a long learning curve and relatively lower initial puncture success rates.Combined with the current paucity of robust evidence-based data,the viability of dTRA as a routine interventional access route remains a subject of debate.This article systematically reviews the anatomical landmarks,clinical advantages,limitations,and multidisciplinary applications of dTRA.This article aims to provide practical guidance for interventionalists and promote the standardization of this technique in daily clinical practice.

ObjectiveTo observe the clinical effectiveness of point ligation therapy combined with catgut embedment in acupoint for patients with refractory facial paralysis， and to explore the possible mechanisms from the perspective of neurotrophic factors. MethodsTotally 168 patients with intractable facial paralysis were randomly divided into point ligation plus catgut embedment group and electroacupuncture group， with 84 cases in each group. Both groups took methylcobalamin tablets orally， on the basis of which the point ligation plus catgut embedment group gave point ligation therapy at Quanliao （SI 18）， Dicang （ST 4）， Jiache （ST 6）， and catgut embedment in the local acupoints on the affected side combined with the distal acupoints， and the point ligation therapy combined with catgut embedment in acupoint was performed once every 30 days for three treatments； the electroacupuncture group took the same acupoints and gave electroacupuncture， with sparse and dense waves， once every other day. Both groups were treated for 90 days. Before treatment and after 30， 60， 90 and 120 days （follow-up）， patients of both groups were observed for House-Brackmann Facial Nerve Grading （HB） and modified Portmann score； facial nerve electromyography was performed before treatment and after 90 days of treatment to record the wave amplitude and latency of facial nerve motor conduction， and serum brain-derived nerve growth factor （BDNF）， nerve growth factor （NGF）， fibroblast growth factor （FGF2） levels were determined. The clinical effectiveness of both groups after 90 days of treatment was compared， and the adverse events occurred in the course of treatment in all patients were recorded. ResultsAt 30 days， 60 days， 90 days and follow-up visits， the HB grading of patients in both groups improved compared with that before treatment （P＜0.05）； the distribution of the number of patients with HB grading in the point ligation plus catgut embedment group was superior to that in the electroacupuncture group after 60 days and 90 days of treatment and at follow-up visits （P＜0.05）. The maximal amplitude of the facial nerve electromyography in both groups after 90 days of treatment was large， and the latency was shorter when compared with those before treatment （P＜0.05）， and the maximum wave amplitude of the point ligation plus catgut embedment group was higher than that of the electro-acupuncture group， and the latency period was shorter than that of the electro-acupuncture group （P＜0.05）. The modified Portmann scores of the both groups of patients after 30， 60 and 90 days of treatment and follow-up were higher than those before treatment， and the scores of the point ligation plus catgut embedment group were higher than those of the electroacupuncture group （P＜0.05）. Serum BDNF， NGF and FGF2 levels in both groups after 90 days of treatment were higher than before， and the point ligation plus catgut embedment group was significantly higher than the electroacupuncture group （P＜0.05）. The total clinical effective rate of the point ligation plus catgut embedment group （92.68%） was higher than that of the electroacupuncture group （81.01%， P＜0.05）. Adverse reactions occurred in both groups， mainly including local haematoma or subcutaneous bleeding， allergic reaction， severe pain， and needle fainting， all of which disappeared after symptomatic treatment. ConclusionThe point ligation therapy combined with catgut embedment in acupoint for patients with refractory facial paralysis are effective. The therapy improve the facial nerve function， and its mechanism of action may be related to increasing the level of serum neurotrophic factor and thus promoting facial nerve repairment.

Objective:To explore the clinical efficacy of Masquelet technique combined with tissue flap transfer in the treatment of infectious composite bone and soft tissue defects in the early and middle stages after internal fixation for tibial fractures.Methods:From October 2017 to November 2020, 12 patients (13 tibial fractures) with infectious bone and soft tissue defects in the early and middle stages after internal fixation were treated in the Department of Orthopaedics, 988th Hospital of the Joint Logistics Support Force of CPLA by two-phased surgery with retaining internal fixation. Phase I procedures were thoroughly removal of the infected lesions and failed screws, preserving internal implants as many as possible, implantation of absorbable calcium sulphate and an antibiotics blended string of beads into the distal and proximal medullary cavity of the fractured bones, filling the bone defect and wrapping the internal implants with antibiotics loaded bone cement. The size of defects was 3.5 cm × 5.0 cm-7.5 cm × 14.5 cm, and the flaps for wound coverage sized 4.0 cm × 5.5 cm-8.0 cm × 15.0 cm. As for the repair of donor site, 8 limbs were sutured directly, 5 limbs could not be closed completely, and the remaining wounds were covered by skin grafting after suture. Based on well control of infection and stable clinical signs, fillings of bone cement were then removed in Phase II surgery, or 6-9 weeks after primary surgery. Autologous cancellous bone pieces or composite allogeneic bone were fully implanted around the induction membrane formed by Masquelet technique, and auxiliary steel plates were implanted for internal fixation of unstable fractures. After discharge, the patients visited the outpatient clinic regularly, and combined with Wechat follow-up. The texture, colour and bone healing were observed. At the last follow-up, the function of the affected limbs were assessed according to Johner-Wruhs evaluation standard.Results:After Phase I surgery, 13 flaps survived smoothly without vascular compromise. The wounds healed in Phase I. Two patients (2 sides) had recurrent infections. Re-debridement was performed and external fixation was applied after removal of internal fixation. After Phase II surgery, all patients were included in 12-26 months of follow-up, with an average of 18 months. Thirteen lower leg fractures healed well, and the time of bone healing was 16-25 (average 19.5) weeks. The Johner Wruhs criteria was used in evaluation of the function of affected limbs, and it was found that 6 patients were in excellent, 5 in good and 2 in fair.Conclusion:It is feasible while preserving the internal implants, to use membrane induction technique (Masquelet technique) combined with flap transfer, together with the absorbable calcium sulphate antibiotic sustained-release beads as a carrier in the phased treatment of infectious bone defects and bone exposure in the early and middle stages after the surgery of tibial internal fixation. It also gives a higher rate of excellence in surgical outcome. This study explores a treatment procedure for traumatic bone infection combined with composite soft tissue defects.

OBJECTIVE To analyze the risk factors of substandard drug blood concentration of meropenem in patients with hospital acquired pneumonia （HAP）. METHODS Totally 130 HAP patients who were admitted to the intensive care unit of Suzhou Hospital Affiliated to Nanjing Medical University from January 2020 to June 2021 and received steady -state blood concentration test of meropenem were selected as the study subjects . The patient ’s age ，sex，body mass and other medical history were recorded . The steady-state blood trough concentration of meropenem was determined and its target was determined . Univariate and multivariate Logistic regression analysis were used to screen the risk factors for the substandard steady -state blood trough concentration of meropenem. The receiver operating characteristic （ROC）curve was drawn to screen the warning value of the risk factors and evaluate the predictive value of the risk factors . RESULTS The steady -state blood trough concentrations of 85 cases were ≥2 mg/L， and those of 45 cases were ＜2 mg/L. Multivariate Logistic regression analysis showed that age ，negative balance and brain injury were independent risk factors for the substandard steady-state blood trough concentration of meropenem （P＜ 0.05）.ROC curve showed that when the patient was 58 years old，the area under the ROC curve was the largest （0.744）， the sensitivity was 0.882，the specificity was 0.556，and the Youden index was 0.438；when the negative balance was 520.5 mL/24 h，the area under the ROC curve reached the maximum （0.827），the sensitivity was 0.722，the specificity was 0.905，and th e Youden index was 0.628. The creatinine clearance rate in the brain injury group was significantly higher than that in the non -brain injury group ，and the steady -state blood trough concentration of meropenem in the brain injury group was significantly lower than that in the non -brain injury group （P＜0.001）. CONCLUSIONS When the HAP patient ’s age is less than 58 years old ，the brain injury and the negative balance is more than 520.5 mL/24 h，the risk of substandard steady -state blood trough concentration of meropenem will increase .

Objective:To explore the method and effect of aesthetic reconstruction of distal segment of finger with modified second toe nail flap while retains the full length of the second toe.Methods:From April 2018 to June 2020, 16 patients with degloving injury of distal segment of fingers were treated. The patients were 11 males and 5 females aged 18 to 45 years in an average of 29 years. All injuries were degloving injury of the distal segment of finger, including 5 index fingers, 7 middle fingers, 3 ring fingers and 1 little finger. The time from injury to operation was 0.5-3.0 hours, with an average of 1.5 hours. The second toe nail flap was used for the reconstruction. After the dorsal flap of the second toe was rotated to the plantar side of the foot, the donor site defect was repaired by a skin graft. The regular follow up reviews were carried out.Results:All 16 flaps survived except 1 flap had necrosis and underwent toe amputation of the distal segment of the second toe. All patients entered follow-up for 4-12 months, with an average of 5.7 months. The blood supply of all flaps was good. After the flaps having atrophied, they were equivalent to the diameter of the body of normal fingers with the TPD at 6.5(4-10) mm; All patients returned to work. According to the Evaluation Standard of Upper Limb Function of Chinese Hand Surgery Society, 13 cases were graded as excellent, 2 were good and 1 was fair.Conclusion:The techniques of modified second toe toenail flap in aesthetic reconstruction of the distal segment of a finger can effectively restore the length and aesthetic appearance of the affected finger, without sacrificing the donor toe. Clinical application of it should be promoted.

Objective:To explore a surgical procedure of reconstruction finger pulp defect with free toes plantar flap with vascular anastomosis of toe-finger artery and plantar-palmar vein of finger.Methods:From April, 2018 to November, 2019, 15 patients with finger pulp defect were repaired by transplantation of the second toe pulp. In the procedure, the plantar vein of the toe and palmar vein of the finger were anastomosed. The artery and nerve of the toe and finger were anastomosed. The flap size was 0.8 cm×0.5 cm-1.0 cm×1.2 cm. The donor site was primary closed without deformity and other complication.Results:All flaps survived without vascular crisis. The mean followed-up period was 5.7 (range 3-9) months. The flaps had good blood flow, soft texture and good elasticity. Three months after surgery, touch sensation was partly recovered in some patients, and while pain was partly recovered in some patients 4-6 months after surgery. There was no deformity and other complication in the donor site. The donor sites of the foot had good appearance and normal walking function.Conclusion:The free toe plantar flap anastomosed with palmar vein can repair the digital pulp defect without dissecting the dorsal vein of digital (toe), and the donor sites can be primary sutured without deformity and other complications. The surgery operation is simple with satisfactory clinical effect.

After the New Coronary Pneumonia pandemic, people^'s social behavior has changed, and the current health management and development approaches should also change accordingly. This article analyzes the changes of social behavior during different anti-epidemic periods, demonstrates the necessity and possibility to change the current health management formats and development paths, and proposes a new concept of family-centered health management. The main target of the current urgent need for family health management is to expand the household entry units, build learning and sports units, etc. This article provides ideas for health management in the post-pandemic era.

Objective To explore effects of dizocilpine (MK-801) preconditioning on excitatory amino acids and inflammatory response in rats induced by cardiac arrest-cardiopulmonary resuscitation (CACPR).Methods 18 male Sprague Dawley (SD) rats were randomly divided into three groups:control group,CA group and CA + MK-801 group.To establish rat models of CA-CPR and keep samples of serum and specimens of brain tissues for following detection.The injury of neurons was observed by HE staining and expression of N-methyl-D-aspartic acid receptor (NMDAR) in brain tissues was detected by Western blot.The concentrations of interleukin 1 beta (IL-1 β) and tumor necrosis factor (TNF)-α in serum were detected by enzyme linked immunosorbent assay (ELISA).Results Neurons in CA group were disorganized,cells shrank,nuclei pyknosis,and cytoplasmic eosinophilia,accompanied by inflammatory cell infiltration.Preconditioning with MK-801 reduced the pathological damage of neuron and degree of macrophage infiltration.The relative expression of NMDAR protein in CA group were significantly higher than that in control group (907.9 ±24.9 vs 321.6 ± 18.4,P ＜0.001).Preconditioning with MK-801 significantly decreased the expression of NMDAR in CA + MK-801 group compared with that in CA group (512.4 ± 21.1 vs 907.9 ± 24.9).The CA group showed significantly increased concentrations of IL-1 β and TNF-α than that in control group (P ＜ 0.001),and this effect was abolished by preconditioning with MK-801.CA rats treated with MK-801 showed higher concentrations of IL-1 β and TNF-α than the control group.Conclusions Cardiac arrest causes pathological injury of neurons,up-regulates expression of NMDAR and aggravates inflammatory response.These results induce the apoptosis of nerve cells.Blocking glutamate receptor with MK-801 can inhibit expression of NMDAR,decrease level of cytokines,down-regulate inflammatory reaction degree therefore to protect the brain.

Objective To evaluate the miRNA change between hypothermia circulatory arrest at different temperature and its impact on intestinal protection.Methods Sixteen piglets were randomly(n =4) divided into four groups:deep hypothermia circulatory arrest (DHCA,18℃) group,moderate hypothermia circulatory arrest(MHCA,24℃) group,cardiopulmonary bypass(CPB) group and sham operation(SO) group.They were subjected to 80 min hypothermia circulatory arrest,305 min CPB or thoracotomy,respectively.Pick-and-mix custom miRNA real-time PCR panels were utilized to detect intestinal samples.miRNA expression between DHCA and MHCA were compared directly(DHCA vs.MHCA) and indirectly(DHCA/SO vs.MHCA/SO,DHCA/CPB vs.MHCA/CPB).Results Exposure to DHCA caused less intestinal miRNA dysregulation than MHCA.Besides,seven miRNAs(miR-122,miR-145-5p,miR-421-5p,miR-99a,miR-365-5p,miR-31 and miR-192)were differentially expressed between the two hypothermia circulatory arrest groups.Conclusion Better intestinal miRNA protection was provided by DHCA than MHCA.Intestinal miRNA were differentially expressed between hypothermia circulatory arrest at different temperature.