Based on the analysis of the existing problems and implementation dilemmas in family doctor contracting and first-return-visits faced by primary medical institutions in China, the authors propose countermeasures to provide reference for managers of primary health care institutions.

Objective:To investigate the effect of immediate breast reconstruction with a deep inferior epigastric artery perforator flap (DIEPF) after the modified radical mastectomy with nipple and areola preservation for breast cancer.Methods:Clinical data from November 2021 to March 2023 of 14 patients with ages from 29 to 49 (mean 40) years old were retrospectively analysed. All the patients received nipple-areola complex-preserving modified radical mastectomy for breast cancer followed by breast reconstruction with DIEPF at the Department of Burn and Plastic Surgery of the Affiliated Hospital of Zunyi Medical University. Three patients had left breast cancer and 11 had right breast cancer. Preoperative CTA was used to clarify the course and branching of the deep inferior epigastric artery (DIEA) and identify dominant perforators. Intraoperatively, indocyanine green (ICG) angiography was conducted to assess the perfusion of the flap and patency of the vascular anastomoses. Reconstructive surgery were performed using unilateral DIEPF in 4 patients and bilateral DIEPF with internal pressurization in 10 patients. Seven patients underwent anastomosis with intrathoracic vessels as recipient vessels, and 7 with thoracodorsal vessels. The weight of the resected breast tissue was 325.8 g±17.1 g, and the weight of the reconstructed breast flap was 332.9 g±32.1 g. The size of the harvested DIEPF ranged from 16.0 cm×9.0 cm to 24.0 cm×12.0 cm, with the length of the vascular pedicle anastomosed to the recipient vessels at 11.4 cm±1.5 cm. The donor sites were closed by layers with tension-reducing sutures, and the position of the umbilicus was relocated and sutured. All patients were included in the scheduled postoperative follow-up at the outpatient clinic after discharge.Results:Of all 14 patients, no postoperative crisis compromise of flap occurred, and both the recipient and donor sites healed primarily. During a follow-up period of 6 to 16 months, with an average of 11 months, no breast cancer recurrence was observed, and the aesthetic outcomes of the reconstructed breast were satisfactory without obvious complications.Conclusion:Breast reconstruction with DIEPF immediately after modified radical mastectomy with sparing nipple and areola can achieve good aesthetic results, less complications in the donor site and with high patient satisfaction rate.

Objective:To evaluate the effect of metformin on ultraviolet A (UVA) -induced photoaging of an immortalized human keratinocytes cell line (HaCaT), and to explore its potential mechanisms.Methods:Cell counting kit 8 (CCK8) assay was performed to evaluate the effect of metformin at different concentrations (0 - 100 mmol/L) on the viability of HaCaT cells, and 10 mmol/L metformin was selected for subsequent experiments. Cultured HaCaT cells were divided into a blank control group (conventional culture), a metformin group (treated with culture medium containing 10 mmol/L metformin), a UVA irradiation group (conventional culture for 24 hours followed by 10 J/cm 2 UVA irradiation) and a metformin + UVA group (treated with culture medium containing 10 mmol/L metformin for 24 hours followed by 10 J/cm 2 UVA irradiation) ; UVA irradiation was performed at a dose of 10 J/cm 2 once a day for 3 consecutive days. After 4-day treatment, cells were collected, the β-galactosidase assay was performed to determine the proportion of senescent cells in each group, 2′, 7′-dichlorodihydrofluorescein diacetate assay to detect levels of intracellular reactive oxygen species (ROS), and the comet assay to detect DNA damage levels. Additionally, some HaCaT cells were divided into the blank control group, metformin group, 1.25 μmol/L dorsomorphin (an adenosine monophosphate-activated protein kinase [AMPK] inhibitor) + metformin group, and 2.5 μmol/L dorsomorphin + metformin group, and cells in the latter two groups were treated with 1.25 and 2.5 μmol/L dorsomorphin respectively for 2 hours, followed by the treatment with 10 mmol/L metformin for 24 hours. Western blot analysis was performed to determine the cellular localization and phosphorylation levels of nuclear factor-erythroid 2-related factor 2 (Nrf2). By using the small-interfering RNA (siRNA) -mediated silencing method, siRNA-Nrf2 was transfected into HaCaT cells to knock down Nrf2 expression (siRNA-Nrf2 group) ; 2.5 μmol/L dorsomorphin-treated HaCaT cells or Nrf2-knockdown HaCaT cells were treated with metformin and UVA irradiation (dorsomorphin + metformin + UVA group, siRNA-Nrf2 + metformin + UVA group, respectively), and the proportions of senescent cells were further calculated in each group. Statistical analysis was carried out by using one-way analysis of variance and two-way analysis of variance, and least significant difference (LSD) - t test was used for multiple comparisons. Results:Treatment with different concentrations of metformin for 24 hours could affect the viability of HaCaT cells to varying degrees ( F = 5 206.31, P < 0.001) ; there were no significant differences in the relative survival rates of HaCaT cells between the 10 - 20 mmol/L metformin groups and the control group (0 mmol/L metformin group, all P > 0.05), while the relative cell survival rates were significantly lower in the 25 - 100 mmol/L metformin groups than in the control group (all P < 0.05). After UVA irradiation, HaCaT cells shrank significantly and became narrow and elongated, and the intercellular spaces increased; the relative cell survival rate was significantly lower in the UVA irradiation group (76.13% ± 1.03%) than in the blank control group (100.00% ± 1.24%, LSD- t = 14.86, P < 0.001), but significantly higher in the metformin + UVA group (106.69% ± 2.45%) than in the UVA irradiation group (LSD- t = 11.55, P < 0.001). Moreover, the UVA irradiation group showed significantly increased proportions of senescent cells (45.14% ± 4.98%), intracellular ROS levels (144.61% ± 4.91%), and percentages of DNA in the tail (75.33% ± 1.77%) compared with the blank control group (23.84% ± 1.89%, 55.49% ± 1.57%, 1.88% ± 0.29%, respectively, all P < 0.001), while the metformin + UVA group showed significantly decreased proportions of senescent cells (24.26% ± 1.34%), intracellular ROS levels (58.62% ± 2.17%), percentages of DNA in the tail (15.83% ± 1.23%) compared with the UVA irradiation group (all P < 0.001). Western blot analysis showed that the Nrf2 expression in the cytoplasm was lower in the 10 mmol/L metformin group than in the blank control group, while the phosphorylated Nrf2 expression in the nuclei was higher in the 10 mmol/L metformin group than in the blank control group, suggesting that metformin could effectively induce the phosphorylation of Nrf2 and its nuclear translocation; both the pretreatment with 1.25 and 2.5 μmol/L dorsomorphin could significantly reduce the phosphorylation levels of AMPKα and Nrf2 induced by 10 mmol/L metformin. The proportions of senescent cells in the dorsomorphin + metformin + UVA group and the siRNA-Nrf2 + metformin + UVA group were 67.84% ± 2.74% and 65.94% ± 1.33%, respectively, which were significantly higher than those in the metformin + UVA group (37.76% ± 1.64%, t = 14.45, 13.34, respectively, both P < 0.001) . Conclusion:Metformin may inhibit UVA-induced photoaging of HaCaT cells by activating the AMPK/Nrf2 signaling pathway, scavenging ROS and reducing DNA damage.

Objective:To investigate the management of patients with intravenous misplacement of nephrostomy tube following percutaneous renal surgery.Methods:The data of 6 patients with intravenous misplacement of nephrostomy tube during percutaneous nephrolithotomy (PCNL) treated in the two hospitals of Chenzhou from January 2006 to December 2020 were retrospectively analyzed. The median age was 41.0(38.5, 53.0) years old. There were 4 males and 2 females. Three patients had undergone contralateral upper urinary tract operation. One patient had undergone ipsilateral upper urinary tract operation. Two patients had not undergone upper urinary tract operation. Two of the 6 patients had a solitary kidney. Two patients were diagnosed with staghorn calculi (combined with mild hydronephrosis in 1 patient, moderate hydronephrosis in 1 patient). Four patients were diagnosed with ureteral calculus (combined with mild hydronephrosis in 2 patients, moderate hydronephrosis in 1 patient, severe hydronephrosis in 1 patient). In all 6 patients, the tract was dilated with fascial dilators. Immediately after dilator removal, brisk venous bleeding was noted. A nephrostomy tube was inserted promptly through the sheath to tamponade the tract and was immediately closed. Five cases were diagnosed by CT after operation, and 1 case was early diagnosed by intraoperative injection of contrast medium through nephrostomy tube. The nephrostomy tube was misplaced in 5 patients with left upper urinary tract calculi, and in 1 patient with right upper urinary tract calculi. The tip of nephrostomy tube was located in ipsilateral renal vein in 3 patients with left upper urinary tract calculus, inferior vena cava in 2 patients with left upper urinary tract calculus, and contralateral renal vein in 1 patient with right upper urinary tract calculus. No venous thrombosis of renal vein or inferior vena cava was founded in the 6 patients. All 6 patients were managed with strict bed rest, intravenous antibiotics, and one-step or two-step tube withdrawal under close monitoring. One step method referred to total removal of nephrostomy tube under ultrasonic monitoring. Two step method referred to retracting the end of nephrostomy tube into the renal sinus under CT monitoring in the first step, then the nephrostomy tube was completely removed under ultrasound monitoring.Results:All 6 patients were successfully managed with strict bed rest, intravenous antibiotics, and one-step or two-step tube withdrawal under close monitoring. The tube was withdrew by one-step method in 1 patient, by two-step method in 5 patients. The original operations were performed successfully under close observation in 4 patients during the same hospitalization and in 1 patient during the next hospitalization. Other type of operation in 1 patient was performed during the next hospitalization. The all 6 patients were discharged uneventfully. The stone was cleared.Conclusions:Intravenous misplacement of a nephrostomy tube is mainly diagnosed by CT. The nephrostomy tube should be sealed immediately after diagnosis. The intravenously misplaced nephrostomy tube can be successfully removed by one-step or two-step withdrawing under close monitoring. Upper urinary tract stones can be successfully treated at the same time or by stages.

Objective:To explore the value of clinical application of the infrared ray thermal imaging (IRTI) combined with the method of "two longitudinal and five transverse lines" in locating the perforators in the transfer of free anterolateral thigh perforator flap (ALTPF) in children.Methods:From November 2018 to November 2022, 13 children (8 boys and 5 girls) aged 2 to 12 years old (6.3 years old in average) who received free ALTPF transfers were included in this study. Causes of injury were 6 by car accidents, 2 by falls, 3 by crushing injuries and 2 by burning scars. Injury sites were 2 in head, 1 in trunk, 5 in hand and 5 in ankle. The size of soft tissue defect was 2.0 cm×4.2 cm-9.0 cm×16.0 cm, and the size of ALTPF was 2.3 cm×4.5 cm-6.0 cm×20.0 cm. The remaining wound was covered with medium thick skin grafts. IRTI combined with the method of "two longitudinal and five transverse lines" was applied to preoperatively locate the pedicle and design the ALTPF. Intraoperatively, the pedicles were explored within the region of anterolateral thigh. The rate of perforrator location and sensitivity of the infrared thermography were calculated. All donor sites were directly sutured. Standard postoperative management included anti-infection, anti-coagulation, anti-convulsion and blood volume expansion with adequate warming. Regular outpatient follow-ups were conducted through various means such as home visits, telephone calls, WeChat and text messages to observe flap survival and donor site healing.Results:All 13 patients completed the 3 to 35 (11.0±1.5) months of postoperative follow-up. All 13 flaps survived well, with good colour and texture, and without obvious bloating. Only one bloated flap had a local repair at the inner ankle with a flap thinning surgery in the stage Ⅱ surgery. Then all flaps achieved satisfaction appearance in all patients. All the donor sites healed at stage I. Two patients showed significant early scar hypertrophy in the donor site, which then gradually stabilised 12 months later. All patients had good functional recovery. Before surgery, a total of 38 perforators were discovered and 40 perforators were found intraoperatively. Of the 40 perforators, 3 were not explored before operation, which were located in the proximal part of Zone Ⅰ, Zone Ⅲ and Zone Ⅳ, respectively. The sensitivity of infrared thermography was found at 92.5% in preoperative detection and location of perforators, with a positive prediction at 97.3%.Conclusion:IRTI combined with the method of "two longitudinal and five transverse lines" in locating perforators is safe and reliable in the design of ALTPFs in children. It provides an additional and reliable option for location of perforator in the design and harvesting of ALTPFs in children.

Objective:To investigate the clinical application effects of combination of different types of free perforator flaps in the repair of complex wounds in extremities.Methods:A retrospective observational study was conducted. From January 2018 to June 2022, 11 patients with complex wounds in extremities who met the inclusion criteria was admitted to the Affiliated Hospital of Zunyi Medical University, including 8 males and 3 females, aged 28 to 55 years. The wounds in the upper extremities in 4 cases and in the lower extremities in 7 cases were repaired with different combination of free perforator flaps. After debridement, the wound area was 7.0 cm×6.0 cm-28.0 cm×12.0 cm. A combination of different types of perforator flaps were applied, including the perforator tri-leaf flap of the descending branch of the lateral femoral circumflex artery in 6 cases, the descending branch of lateral femoral circumflex artery combined with oblique branch perforating branch flap in 2 cases, the lobulated flap of the descending branch of the lateral femoral circumflex artery combined with the contralateral medial plantar artery perforator flap in 2 cases, and the bilateral perforator flap of the descending branch of lateral femoral circumflex artery combined with great toe nail flap in 1 case, with the size of a single flap ranged from 2.0 cm×2.0 cm-25.0 cm×6.0 cm. The donor site was repaired by direct suture, skin grafting, or flap transplantation. During free flap transplantation, the flap was cut and split according to the distribution of perforators, and end-to-end or end-to-side anastomosis was performed between the donor area and the recipient area. After surgery, the survival of transplanted flap in the primary recipient site, the occurrence of vascular crisis, the wound healing in the flap donor site, and the survival of transplanted skin or flap in the flap donor site were observed. During follow-up, the blood supply, appearance and texture of the transplanted flap in the primary recipient site were observed; and at the same time, the weight bearing of the plantar receiving area, the presence of sliding, ulcers, and sinus tracts of the flap, and the appearance and function of the hand were observed; the complications in the donor area were observed.Results:After surgery, one patient's transplanted flap in the primary recipient site had vascular crisis but survived after exploration+vein graft bridging; partial necrosis occurred in one lobe of anterolateral thigh lobulated flap transplanted to the primary recipient site in one patient and recovered after dressing change+skin grafting, and the different types of perforator flap transplanted to the primary recipient site in the other 9 patients all survived. After surgery, the wound with direct suture at the donor site healed well, and the skin or flap transplanted to the donor area survived well. During 3-24 months of follow-up, the blood supply, appearance, and texture of the transplanted flap at the primary recipient site were good. In two patients, the anterolateral thigh flap combined with the medial plantar flap were used to repair plantar defects. The plantar receiving area was able to bear weight, and the texture of the flaps in the recipient area was close to the normal plantar skin, without flap sliding, ulcer, or sinus tract formation. In one patient, bilateral anterolateral thigh flap combined with great toe nail flap were used to repair hand combined with soft forearm defect, and the appearance and function of hand, especially thumb were good. Only linear scar was left in the donor site without other obvious complications.Conclusions:The combination of different types of perforator flaps is a reliable clinical method to repair complex wounds in extremities with high safety, good efficacy, and less complications.

Objective To evaluate the protective effect of pterostilbene against ultraviolet B (UVB)-induced acute damage in HaCaT cells,and to explore related mechanisms.Methods The 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazo1ium (MTS) assay and flow cytometry were performed to estimate the proliferative activity and the apoptosis and necrosis rate of HaCaT cells treated with different concentrations of pterostilbene respectively,so as to screen the non-toxic concentration of pterostilbene.HaCaT cells were randomly divided into several groups:normal control group receiving no treatment,UVB group irradiated with 57 mJ/cm2 UVB,3 pterostilbene groups treated with 2.44,4.88 and 9.75 μmol/L pterostilbene respectively for 24 hours,3 pterostilbene + UVB groups treated with 2.44,4.88 and 9.75 μmol/L pterostilbene respectively for 24 hours followed by UVB radiation.Western blot analysis was conducted to detect changes of the transcription factor NF-E2-related factor 2 (Nrf2) expression in cell nuclei and cytoplasm before and after the treatment with pterostilbene and UVB,quantitative PCR to determine the mRNA expression of catalase and superoxide dismutase in the HaCaT cells,and enzyme-linked immunosorbent assay (ELISA) to evaluate the activity of catalase and superoxide dismutase.Results MTS assay and flow cytometry showed that 2.44,4.88 and 9.75 μmol/L pterostilbene had non-toxic effect on HaCaT cells.The protein expression of Nrf2 in the nuclei and cytoplasm in the normal control group was 1.03 ± 0.08 and 1.04 ± 0.11 respectively.Compared with the normal control group,the protein expression of Nrf2 in the nuclei and cytoplasm experienced no significant changes in the 2.44-,4.88-and 9.75-μmol/L pterostilbene groups,and the UVB group showed similar protein expression of Nrf2 in the cytoplasm,but significantly increased protein expression of Nrf2 in the nuclei (1.77 ± 0.08,q =17.24,P ＜ 0.01).Compared with the normal control group and UVB group,the 2.44-,4.88-and 9.75-μmol/L pterostilbene + UVB groups all showed significantly lower protein expression of Nrf2 in the cytoplasm (0.86 ± 0.10,0.87 ± 0.11 and 0.46 ± 0.11 respectively,all P ＜ 0.05),but significantly higher protein expression of Nrf2 in the nuclei (2.38 ± 0.11,2.57 ± 0.11 and 2.07 ± 0.13,all P ＜ 0.01).As qPCR showed,UVB radiation could significantly inhibit the mRNA expression of CAT (P ＜ 0.05),but had no obvious effect on the mRNA expression of SOD (P ＞ 0.05).The mRNA expression of CAT and SOD experienced no significant changes in the 2.44-,4.88-and 9.75-μmol/L pterostilbene groups compared with the normal control group (P ＞ 0.05).However,2.44,4.88 and 9.75 μmol/L pterostilbene could significantly reduce the inhibitory effect of UVB radiation on the mRNA expression of CAT (P ＜ 0.05) and up-regulate the mRNA expression of SOD in the pterostilbene + UVB groups (P ＜ 0.05).ELISA revealed that UVB radiation could inhibit the activity of CAT and SOD in the HaCaT cells (both P ＜ 0.001),while 2.44,4.88 and 9.75 μmol/L pterostilbene could reduce the inhibitory effect of UVB radiation on the activity of CAT and SOD (all P ＜ 0.05).However,the activity of CAT and SOD were still lower in the 2.44-,4.88-and 9.75-μmol/L pterostilbene + UVB groups than in the normal control group (P ＜ 0.05).Conclusion Pterostilbene can prevent UVB-induced acute damage in HaCaT cells by activating the Nrf2 pathway and up-regulating the expression of the downstream antioxidant enzymes CAT and SOD.

Objective To discuss the therapeutic effect of free perforator flap of the humeral back and the healing of the wound after the removal of the malignant tumor.Methods From January,2012 to June,2016,12 cases were treated as soft tissue tumors on shoulder,including 8 cases of skin juga fibrosarcoma,3 cases of basal cell carcinoma,squamous cell carcinoma of the skin in 1 case.Preoperative using doppler ultrasound probe design perforator flap to expand resection,intraoperative cut edge basal tag frozen pathological examination without taking skin flap after the tumor invasion,according to the wound and wear the appropriate adjustment design of perforator flap.Followed-up to observe recurrence,flaps or ulcers,and the texture of the flap and the feel of the flap.All patients were followed-up regularly.Results All 12 patients were followed-up for 6-48 months.The flaps were all alive.The tumor did not relapse,and the flap was not swollen.The texture was consistent with the surrounding tissue.There was no ulceration of the flap.No obvious depression deformity.The outlook of flaps was satisfied,but the feeling was not.The doror sites were closed directly.Conclusion Adjacent using humeral back free perforators flap to repair the defect after tumor resection on shoulder is an easy operation.It is one of the ideal flaps to repair a malignant tumor on the back of the shoulder.

Objective To evaluate effects of tea polyphenols on the mRNA and nucleoprotein expression of Nrf2/Bach1 in human skin fibroblasts (HSFs).Methods Some HSFs were incubated with tea polyphenols at different concentrations of 0,2.5,5,10,20 and 40 mg/L for 24 hours.Methyl thiazolyl tetrazolium (MTT) assay was conducted to evaluate the proliferative activity of HSFs to screen the optimal concentration of tea polyphenols.Then,some other HSFs were treated with tea polyphenols at this optimal concentration for 24 hours.Real-time quantitative PCR (RT-qPCR) was performed to determine mRNA expression of Nrf2 and Bach1,Western blot analysis to measure nuclear expression of Nrf2 and Bach1 proteins,and immunofluorescence assay to determine the distribution of Nrf2 and Bach1 protein in the cell nucleus.Results MTT assay showed that 5 mg/L tea polyphenols had no obvious effects on the proliferation of HSFs,so 5 mg/L was chosen as the optimal concentration of tea polyphenols for subsequent experiments.HSFs cultured without tea polyphenols served as control group.After the treatment,the 5-mg/L tea polyphenol group showed significantly decreased mRNA and nuclear protein expression of Bach 1 (mRNA:0.629 ± 0.077 vs.0.940 ± 0.033,t =6.397,P ＜ 0.05;protein:1.424 ± 0.171 vs.16.966 ± 1.702,t =15.730,P ＜ 0.05),but significantly increased mRNA and nuclear protein expression of Nrf2 (mRNA:1.467 ± 0.076 vs.0.977 ± 0.091,t =7.133,P ＜ 0.05;protein:6.929 ± 0.121 vs.3.537 ± 0.126,t =33.636,P ＜ 0.05) compared with the control group.Immunofluorescence assay showed increased accumulation of Nrf2 protein,but decreased accumulation of Bach1 protein in the nucleus.Conclusion Tea polyphenols can promote the mRNA and nuclear protein expression as well as nuclear distribution of Nrf2,but suppress the mRNA and nuclear protein expression as well as nuclear distribution of Bach 1,finally exerting antioxidative effects.

Objective: To investigate the feasibility and efficacy of free lobulated lateral circumflex femoral artery perforator flap for foot and ankle defect at non-weight bearing area. Methods: From January 2008 to June 2016, 28 cases with foot and ankle skin and soft tissue defects at non-weight bearing area were treated, including 16 cases with traffic accident, 8 cases with machine injury, and 4 cases with falling injury. There were 10 cases with Achilles tendon exposure, 16 cases with dorsalis pedis tendons exposure and 12 cases with bone exposure. The defect size ranged from 10 cm×8 cm to 16 cm×13 cm. Doppler ultrasound detector was used to select two perforators of lateral femoral circumflex artery. The lobulated perforator flap was designed and harvested as one flap. After clip test was performed to make sure the blood supply of flap, the flap was segmented and repositioned to cover the wound. The width of lobulated flaps was less than 8cm, in order to close the defect at donor sites directly. Postoperative rountine anti-inflammatory, anticoagulant, anticonvulsive treatment and function exercise were adopted. The patients were followed up for 6-28 months. Results: The flap size ranged from 9.0 cm×4.5 cm to 17.0 cm×7.0 cm. Partial necrosis happened at the end of one flap lobe due to pressure, which healed after dressing. All the other 27 flaps survived completely with satisfactory cosmetic and functional result. The wounds at donor sites all healed primarily. Conclusions Free lobulated lateral circumflex femoral artery perforator flap is one of the ideal flaps with high survival rate and low complication for foot and ankle defect at non-weight bearing area.