BACKGROUND:After the internal fixation of cannulated screws in femoral neck fractures,because the affected limb is often unable to bear weight in the short term and the implants with high stiffness have a stress shielding effect on the fracture end,it is easy to cause osteoporosis of the affected limb and changes in the biomechanical distribution of the proximal femur,the incidence of osteonecrosis of the femoral head is high after surgery.At present,few studies have been conducted on the biomechanical effects of osteoporosis at the proximal end of the femur occurring after femoral neck fracture surgery on femoral neck fracture treated with cannulated screws. OBJECTIVE:Using finite element analysis,to investigate the biomechanical effects of osteoporosis occurring after femoral neck fracture surgery on femoral neck fracture treated with cannulated screws and explore the role of biomechanical factors in osteonecrosis of the femoral head. METHODS:Based on the obtained CT scan data of the femur in a patient with a femoral neck fracture,a proximal femoral model for internal fixation for femoral neck fracture was established by Mimics 19.0,3-Matic,UG 11.0,Hypermesh 14.0,and Abaqus software.One finite element model of the proximal femur without osteoporosis and three finite element models of the proximal femur with osteoporosis were analyzed using Abaqus software.The stress,contact pressure,displacement peak and cloud map under different components of the four models were measured and analyzed,and the internal stress changes and distribution of the femoral head were compared and analyzed. RESULTS AND CONCLUSION:The stresses and contact pressures of the femoral head and lower anterior cannulated screws varied more with the degree of osteoporosis.The peak displacement of the four models increased slowly with the degree of osteoporosis.By one-way analysis of variance,there was no significant effect of the degree of osteoporosis on the peak stress,contact pressure,and displacement of the different components.The internal stress distribution of the femoral head changed with the degree of osteoporosis.Changes in the biomechanical environment of the proximal femur have an important impact on osteonecrosis of the femoral head.

Morita therapy has been bom for more than 100 years.Inpatient Morita therapy is highly oper-able and easy to master.It can improve many refractory neuroses through four-stage treatment.But more neuroses are treated in outpatient clinics,and Morita therapy cannot be used in hospitalized patients.Therefore,the formula-tion of expert opinions on outpatient operations is particularly important.This paper is based on domestic and for-eign references,and after many discussions by domestic Morita therapy experts,and then drew up the first version of the expert opinions on operation of outpatient Morita therapy.Meanwhile the operation rule of Morita therapy in three stages of outpatient treatment was formulated:in the etiological analysis stage,under the theoretical guidance of Morita therapy,analyze the pathogenic factors,to improve treatment compliance and reduce resistance;during the operating stage,guide patients to engage in constructive and meaningful actions,realizing the achievement of letting nature take its course principle;in the cultivating character and enriching life stage,pay attention to positive infor-mation,expanding the scope and content of actions,improving the ability to adapt to complex life,and preventing recurrence caused by insufficient abilities.It will lay a foundation for the promotion of Morita therapy in domestic outpatient clinics,so that more patients with neurosis and other psychological diseases could receive characteristic Morita therapy treatment in outpatient clinics.

Objective To compare the effect of glycopyrrolate or atropine in combination with neostigmine on adverse cardiovascular events(ACEs)after operation in elderly patients undergoing laparo-scopic surgery.Methods A total of 142 patients scheduled for elective laparoscopic surgery were enrolled,69 males and 73 females,aged 65-80 years,BMI 18-28 kg/m2,ASA physical status Ⅰ or Ⅱ.The pa-tients were randomly divided into two groups:the glycopyrrolate group(group G)and the atropine group(group A),71 patients in each group.After the last administration of muscle relaxants for more than 30 mi-nutes,antagonizing residual neuromuscular blockade was performed.Glycopyrrolate 4 μg/kg and neostigmine 20 μg/kg were given intravenously in group G,atropine 10 μg/kg and neostigmine 20 μg/kg were given intravenously in group A.The incidence of ACEs and severe ACEs during operation and 72 hours after operation were recorded.Recovery situation in PACU such as NRS scores at rest and coughing,Rich-mond agitation-sedation scale(RASS)score,and modified Aldrete score 15 and 30 minutes after extubation were recorded.Emergence agitation,dry mouth,nausea,vomiting,and delirium 24 hours after operation were recorded.Results Compared with group A,the total incidence of ACEs,tachycardia,and myocardial ischemia after operation were significantly decreased in group G(P＜0.05),the incidence of dry mouth 24 hours postoperatively was significantly increased in group G(P＜0.05).There was no severe ACEs oc-curred in the two groups 72 hours after operation.Conclusion Compared with atropine,glycopyrrolate combined with neostigmine in elderly patients undergoing laparoscopic surgery can reduce the incidence of cardiac tachycardia,myocardial ischemia,and total ACEs after operation,and there was no severe ACEs occurred.However,it can increase the incidence of dry mouth 24 hours after operation.

Patients with severe trauma require an extremely timely treatment and transfusion plays an irreplaceable role in the emergency treatment of such patients. An increasing number of evidence-based medicinal evidences and clinical practices suggest that patients with severe traumatic bleeding benefit from early transfusion of low-titer group O whole blood or hemostatic resuscitation with red blood cells, plasma and platelet of a balanced ratio. However, the current domestic mode of blood supply cannot fully meet the requirements of timely and effective blood transfusion for emergency treatment of patients with severe trauma in clinical practice. In order to solve the key problems in blood supply and blood transfusion strategies for emergency treatment of severe trauma, Branch of Clinical Transfusion Medicine of Chinese Medical Association, Group for Trauma Emergency Care and Multiple Injuries of Trauma Branch of Chinese Medical Association, Young Scholar Group of Disaster Medicine Branch of Chinese Medical Association organized domestic experts of blood transfusion medicine and trauma treatment to jointly formulate Chinese expert consensus on blood support mode and blood transfusion strategies for emergency treatment of severe trauma patients ( version 2024). Based on the evidence-based medical evidence and Delphi method of expert consultation and voting, 10 recommendations were put forward from two aspects of blood support mode and transfusion strategies, aiming to provide a reference for transfusion resuscitation in the emergency treatment of severe trauma and further improve the success rate of treatment of patients with severe trauma.

Objective:To determine the risk factors for permanent nerve damage (PND) after aortic arch surgery in patients with acute type A aortic dissection (AAAD).Methods:This was a retrospective case-control study. The medical records from patients of both sexes with AAAD, aged > 18 yr, of American Society of Anesthesiologists Physical Status classification IV, who underwent aortic arch surgery in the Second Hospital of Hebei Medical University from December 2018 to December 2023, were collected. The patients were divided into non-PND group and PND group according to whether PND occurred after operation. The preoperative data of patients were collected, including age, gender, body mass index; comorbidities (hypertension, coronary heart disease, diabetes mellitus), history of smoking, history of stroke, and history of cardiovascular surgeries; syncope at onset, preoperative low SpO 2, preoperative low systolic blood pressure, and preoperative low diastolic blood pressure. The intraoperative data included surgical procedure (total aortic arch replacement or half aortic arch replacement), selective antegrade cerebral perfusion during operation, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, post-parallel time, moderate hypothermia circulatory arrest time, nasopharyngeal temperature and rectal temperature during circulatory arrest, and BIS value during circulatory arrest; blood pressure during cardiopulmonary bypass and after restoration of heart beat; the incidence of dysfunction after recovery of heart beat and difficulty in hemostasis after termination of CPB. The aforementioned indicators were analyzed for difference, and the indicators with P<0.05 were included in the multivariate logistic regression analysis. Results:A total of 292 patients were ultimately included, among which 73 developed postoperative PND, resulting in an incidence of 25.0%. The results of multivariate logistic regression analysis showed that age ≥62 yr ( OR=3.783, 95% confidence interval [ CI] 1.513-10.346, P=0.006), preoperative hypertension ( OR=2.230, 95% CI 1.118-4.715, P=0.028), syncope at onset ( OR=3.001, 95% CI 1.343-6.710, P=0.007), BIS value > 14 during circulatory arrest ( OR=2.439, 95% CI 1.249-4.755, P=0.009) and difficult hemostasis after termination of CPB ( OR=3.465, 95% CI 1.758-6.882, P<0.001) were risk factors for PND after surgery. Conclusions:Age ≥ 62 yr, history of hypertension, syncope at onset, BIS value greater than 14 during circulatory arrest and difficulty in hemostasis after termination of CPB are risk factors for PND after aortic arch surgery in patients with AAAD.

Objective:To investigate the clinical efficacy of modified biliary-intestinal anasto-mosis by pancreaticoduodenectomy and influencing factors of postoperative biliary leakage.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopatholo-gical data of 165 patients with benign and malignant diseases around the ampullary who underwent pancreaticoduodenectomy in the Affiliated Hospital of Inner Mongolia Medical University from June 2014 to October 2020 were collected. There were 92 males and 73 females, aged (59±10)years. Of the 165 patients, 44 patients undergoing modified biliary-intestinal anastomosis within pancreatico-duodenectomy were divided into the modified group, and 121 patients undergoing traditional biliary-intestinal anastomosis within pancreaticoduodenectomy were divided into the traditional group. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) intraoperative and postoperative situations; (3) analysis of influencing factors of biliary leakage after pancreaticoduodenectomy. Propensity score matching was done by the 1:1 nearest neighbor matching method, with the caliper setting as 0.05. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Univariate analysis was conducted using the corresponding statistical methods based on data type. All indicators in univariate analysis were included in multivariate analysis. Multivariate analysis was conducted using the Logistic regression model. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of the 165 patients, 72 cases were successfully matched, including 36 cases in the modified group and 36 cases in the traditional group, respectively. The elimination of jaundice, preoperative reduction of jaundice and hypertension confounding bias ensured comparability between the two groups after propensity score matching. (2) Intraoperative and postoperative situations. All patients in the two groups underwent surgery successfully. The operation time, postoperative pathological type (lower bile duct cancer, pancreatic head cancer, pancreatic cystic tumor, chronic pancreatitis, duodenal cancer), time of no drainage fluid in the drainage tube around biliary-intestinal anastomosis were 371(270,545)minutes, 6, 12, 1, 2, 15, (12±7)days in patients of the modified group, versus 314(182,483) minutes, 13, 14, 1, 4, 4, (16±8)days in patients of the traditional group, showing significant differences in the above indicators between the two groups ( Z=-3.54, χ2=10.01, t=-2.34, P<0.05). Cases with postoperative grade A biliary leakage was 0 in patients of the modified group, versus 6 in patients of the traditional group, showing a significant difference between the two groups ( P<0.05). Cases with postoperative grade B biliary leakage, cases with postoperative grade B pancreatic fistula, cases with postoperative bleeding, cases with abdominal infection, cases with incision infection, cases with delayed gastric emptying, cases undergoing unplanned readmission were 1, 0, 1, 4, 1, 5, 1 in patients of the modified group, versus 0, 1, 2, 5, 2, 5, 2 in patients of the traditional group, showing no significant difference in the above indicators between the two groups ( P>0.05). Cases with postoperative grade A pancreatic fistula, cases with overall complications, cases with Clavien-Dindo grade Ⅰ-Ⅱ complications, cases with Clavien-Dindo grade Ⅲ-Ⅳ complications were 6, 12, 6, 6 in patients of the modified group, versus 7, 14, 8, 6 in patients of the traditional group, showing no significant difference in the above indicators between the two groups ( χ2=0.09, 0.24, 0.36, 0.00, P>0.05). None of patient in the two groups had postoperative grade C biliary leakage and postoperative grade C pancreatic fistula. (3) Analysis of influencing factors of biliary leakage after pancreaticoduodenectomy. Results of multivariate analysis showed that preoperative reduction of jaundice and traditional biliary-intestinal anastomosis were independent risk factors for biliary leakage after pancreaticoduodenectomy ( odds ratio=11.37, 12.27, 95% confidence interval as 1.76-73.35, 1.14-131.23, P<0.05). Conclusions:Compared with traditional biliary-intestinal anastomosis, modified biliary-intestinal anastomosis within pancreaticoduodenectomy is safe and feasible. Preoperative reduction of jaundice and traditional biliary-intestinal anastomosis are independent risk factors for biliary leakage after pancreaticoduodenectomy.

Objective:To explore the application effect of laparoscopic surgery skills training course in the standardized residency training of surgery.Methods:A total of 40 standardized trainees of surgical residents rotating in general surgery were selected as the research objects, and randomly divided into the experimental group and the control group. The experimental group was offered laparoscopic surgery skills training course. The course content includes theoretical teaching module, simulated teaching module, virtual teaching module and clinical surgery practice teaching module. The control group was taught by traditional theory teaching and clinical surgery practice teaching. At the end of the courses, the two groups of students were assessed for their skills in laparoscopic grasping and pass, suture and knotting. At the same time, a questionnaire survey was conducted among the students and teachers. The t-test was performed using SPSS 22.0 statistical software. Results:The theoretical scores of the experimental and control groups were (67.90±13.24) and (69.70±13.46), respectively, with no statistically significant difference ( P > 0.05). After the courses, the performance of grasping and pass, suture and knotting of the experimental group (15.25±3.24 and 5.45±2.14) was higher than that of the control group (11.25±2.12 and 2.75±1.16), and the difference was statistically significant ( P < 0.01).The questionnaire survey showed that the proportion of "better" feedback from students and teachers on laparoscopic skills training courses was significantly higher than that of "general" and "poor". Conclusion:The laparoscopic surgery skills training course can improve the laparoscopic surgery skills of the trainees in the standardized residency training of surgery, shorten the learning curve, and make the training standardized and homogeneous. It is worthy of wide promotion and application in the standardized training base.

Objective:To investigate the feasibility of multipoint core needle biopsy (CNB) at mid-stage to predict the treatment effect of neoadjuvant systemic therapy for breast cancer.Methods:A total of 67 breast cancer cases with indications of neoadjuvant systemic therapy were selected from Mar. 2021 to Nov. 2022.In the fourth cycle of neoadjuvant systemic therapy, core needle biopsy was performed at 3, 6, 9, 12 points of tumor bed and residual tumor foci of breast respectively.The results of CNB were compared with the results of routine pathology of surgery after the completion of neoadjuvant therapy. Matched biopsy and surgical specimens were compared to assess pCR. The accuracy and false negative rate (FNR) of interim pathological assessment were analyzed. The coincidence probability of interim biopsy pathology and pathology of standard surgical excision was verified.Results:The median age of enrolled patients was 49.2 years (21-69 years) .Median maximum tumor diameter before neoadjuvant systemic therapy and residual tumor diameter after neoadjuvant therapy were 40.4 mm (range 21-93mm) and 19.6 mm (range 0-41mm) respectively. A total of 28 patients achieved pCR, and the PCR rates of hormone receptor-positive and HER2-nagative,triple-negative,hormone receptor negative and HER2-positive and hormone receptor-positive and HER2-positive disease were 4/24 (16.7%) ,6/14 (42.9%) ,11/18 (61.1%) ,7/11 (63.6%), respectively. Two cases had no preoperative imaging abnormalities. The results of core needle biopsy pathology of residual tumor lesions in 55 patients were consistent with those of routine post-operation pathology.The results of core needle biopsy pathology of tumor bed of 56 patients was consistent with the routine pathology of surgery. The false negative rate of interim multipoint biopsy pathology of residual tumor foci was 17.9% (12/67). The false negative rate of tumor bed with core needle biopsy was 5.9% (4/67) .Conclusions:CNB guided under ultrasound is feasible in predicting tumor retreat situation in the tumor bed area and residual tumor foci at mid-stage of neoadjuvant therapy. Increasing the number of core needles and improving biopsy techniques may improve the accuracy of pathological evaluation of interim multipoint biopsy.

Objective:To evaluate the efficacy of middle cerebral artery (MCA) blood flow velocity combined with regional saturation of cerebral oxygen (rScO 2) monitoring in guiding anterograde cerebral perfusion in the patients undergoing total arch replacement (TAR). Methods:Ninety-eight patients of either sex, aged 18-72 yr, with body mass index of 24-30 kg/m 2, of American Society of Anesthesiologists Physical Status classification Ⅳ, undergoing elective TAR, were selected. The patients whose anterograde cerebral perfusion mode was determined by the surgeon were enrolled in control group (group C), and the patients who selected the anterograde perfusion mode according to the guiding criteria were included in guidance group (group G), with 49 cases in each group. Cerebral anterograde perfusion mode, postoperative retention time of tracheal intubation, duration of stay in intensive care unit, total hospital stay, tracheotomy, recovery and discharge, postoperative stroke and death of patients were recorded in two groups. Results:Compared with group C, the ratios of bilateral cerebral perfusion and postoperative tracheotomy, incidence of stroke and postoperative mortality were significantly decreased, the ratio of good perfusion and rate of recovery and discharge were increased ( P<0.05), and no significant change was found in the retention time of endotracheal intubation, duration of stay in intensive care unit, and length of hospital stay in group G ( P>0.05). Conclusions:MCA blood flow velocity-rScO monitoring provides a good efficacy in guiding anterograde cerebral perfusion during TAR.

The vasoactive substance resistance (VSR) in the end-stage liver disease (ESLD) refers as the reduction of patients' responsiveness to endogenous and exogenous vasoactive substances, cardiac and vascular excitability, peripheral circulatory dysfunction, but induction of related adverse events. VSR is closely related to pathogenesis and treatment-related ESLD complications. However, to date, there are so many unsolved issues, like 1). The cause and underlying mechanism of VSR in ESLD patients; 2). VSR and ESLD multiple organ damages; 3). The preventive and mitigated measurement of VSR; and 4). VSR vasoactive drug use in ESLD patients. This review discussed and summarized the up to date progress in this field of research and clinical VSR in patients with ESLD, i.e., VRS in ESLD patients, disputes of vasoconstrictor drug therapy in ESLD patients, and future research direction of the field.