Acute necrotizing encephalopathy (ANE) is a rare but deadly complication with an unclear pathogenesis. We aimed to elucidate the immune characteristics of H1N1 influenza virusassociated ANE (IANE) and provide a potential therapeutic approach for IANE. Seven pediatric cases from a concentrated outbreak of H1N1 influenza were included in this study. The patients’ CD4+T cells from peripheral blood decreased sharply in number but highly expressed Eomesodermin (Eomes), CD69 and PD-1, companied with extremely high levels of IL-6, IL-8 in the cerebrospinal fluid and plasma. Patient 2, who showed high fever and seizures and was admitted to the hospital very early in the disease course, received intravenous tocilizumab and subsequently showed a reduction in temperature and a stable conscious state 24 h later. In conclusion, a proinflammatory cytokine storm associated with activated CD4+T cells may cause severe brain pathology in IANE. Tocilizumab may be helpful in treating IANE.

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 explore a surgical technique and treatment outcomes of the segmentle bridging reconstruction for severed fingers with single segmentle defect by using the free second toe bone-joint composite tissue combined with the great toe flap.Methods:From June 2010 to September 2017, 5 patients suffered from severed segmental defect of finger were treated. According to the defects of bone-joints, blood vessels, nerves, tendons and other soft tissues, the reconstruction surgery was designed to create a Flow-through bridging composite flap pedicled with the first dorsal metatarsal artery or the plantar artery. The blood vessles carried by the pedicle were anastomosed with the vessels in the finger to restore the blood supply to the distal finger while having the defected finger segment reconstructed. A Flow-through bridging composite flap was created by taking the second toe bone-joint composite tissue combined with a C-shaped or half-moon shaped flap from the fibular side of the great toe. Skin graft, retrograde lateral tarsal flap or free perforator flaps were used in 3 cases to repair the donor sites of the great and second toes. Iliac strip was implanted in 2 cases for toe salvage. Kirschner wires were removed 4-6 weeks after surgery followed by functional exercise.Results:All of the 5 reconstructed distal segments of the fingers survived with the healing of fractures in 8-12 week after surgery. The postoperative follow-up lasted 6-36 months and all the patients had the follow-ups at the outpatient clinic. It was found that the maximum flexion of the reconstructed interphalangel joint was 60 degrees together with dorsiflezion. According to the evaluation standard of the reconstructed function for thumb and finger issued by the Hand Surgery Society of the Chinese Medical Association, 3 fingers were in excellent and 2 in good. No obviouse affect on walking was found in all the patients.Conclusion:The free second toe joint composite tissue together with the great toe flap can be used to bridge the single segmental defect of a finger. It restores the blood supply to as well as the appearance of the distal finger, helps the recovery of the reconstructed distal finger. It is an ideal technique in the treatment of a severed distal segment of the finger.

Objective: To evaluate risk factors for NEC in in term infant. Methods: Risk factors associated with NEC were investigated using a retrospective case-control design.43 patients with Bell's stage NEC≥Ⅱ were identified.Each case was paired with two GA-and weight-matched controls.Data were collected from medical records, including oligohydramnios, ICP,neonatal asphyxia, MAS,neonatal septicemia, CHD,neonatal shock, gestational diabetes, PROM,fetal distress, hypertensive disorders in pregnancy, and univariate/logistic regression analysis was employed. Results: A total of 43 cases and 86 controls were enrolled.The demographic characteristics of the two groups were not statistically significant.The onset time of 43 cases was 2～17 d after birth and the average time was 6.3 d.The single factor analysis indicated that the two group had statistical significance in oligohydramnios, MAS,CHD,neonatal septicemia, neonatal asphyxia, gestational diabetes, neonatal shock, PROM,fetal distress and hypertensive disorders in pregnancy.Logistic regression analysis suggested that CHD(OR=4.27,P=0.029),neonatal septicemia(OR=2.77,P=0.007),Oligohydramnios(OR=2.42,P=0.010),PROM(OR=2.11,P=0.013),neonatal asphyxia(OR=2.06,P=0.031),MAS(OR=1.89,P=0.017),hypertensive disorders in pregnancy(OR=1.86,P=0.015),gestational diabetes(OR=1.75,P=0.032),neonatal shock(OR=1.65,P=0.024)and fetal distress(OR=1.35,P=0.021) were significantly associated with NEC. Conclusion Oligohydramnios, MAS,CHD,neonatal asphyxia, neonatal septicemia, neonatal shock, PROM,fetal distress, hypertensive disorders in pregnancy and gestational diabetes may be associated with an increased risk of NEC in term infant.

In February, 2019, a patient with a defect of open dorsal cartilage and bone in the first metatarsal head, including the defects of soft tissue, tendon and joint capsule, was treated in our department. After multiple debridement, the vascularised medial femoral condyle osteochondral chimeric tissue flap was transferred to repair the composite tissue defect in the metatarsal head at the second stage. After 18 months of follow-up, the patient felt no pain in the foot and walking, and there was no sign of lameness and discomfort at donor sites. The postoperative functional recovery was satisfactory.

Objective:To investigate the surgical method and clinical effect of free medial plantar flap (MPF) combined with anterolateral thigh flap (ALTF) in repair of large soft tissue defect in the weight bearing area of sole.Methods:From April, 2017 to August, 2019, 8 patients with large soft tissue defects in plantar weight bearing area were repaired by free MPF combined with ALTF. Four patients had the defects located in the hindfoot and the surrounding area, 3 in the forefoot and 1 in the whole foot. A tandem flap made of free MPF combined with ALTF was used to repair the heel in 5 patients and repair the plantar forefoot in 3 patients. The size of defects ranged from 15.0 cm×10.0 cm to 26.0 cm×22.0 cm. The size of the MPF ranged from 6.0 cm×5.0 cm to 8.0 cm×6.5 cm. The donor sites repaired with full thickness skin graft. The size of ALTF ranged from 15.0 cm×7.0 cm to 27.0 cm×11.0 cm. Two donor sites were sutured directly, and the other 6 were repaired by full-thickness abdominal skin graft. The patients entered follow-up at outpatient clinic and via WeChat for 9 to 18 months.Results:All the 8 tandem flaps and the donor grafts survived. Only 1 ALTF had a distal necrosis and healed after change of dressing. All the flaps had good elasticity and good texture. All the recipient area of MPF achieved sensation recovery of pain and touch. But the ALTF only partially recovered tactile sensation. The weight-bearing and walking function were good. At the last follow-up, all patients were evaluated by Maryland foot score, of which 4 patients were excellent, 3 were good, and 1 was fair.Conclusion:The free MPF combined with ALTF is one of the ideal methods for the repair of plantar soft tissue defect in the weight bearing area of sole. It can better restore the foot weight-bearing and walking function with good clinical effect.

Objective:To investigate the clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand.Methods:The retrospective observational study method was used. From May 2014 to June 2019, 8 patients with thumb damage and soft tissue defect of hand were admitted to the 988th Hospital of Joint Logistic Support Force of PLA, including 6 males and 2 females, aged from 25 to 46 years. Among them, thumb damage in 3 cases were degree Ⅱ, 1 case was degree Ⅲ, and 4 cases were degree Ⅳ. All thumb damage were repaired with perforator flap combined with toe transplantation. The skin and soft tissue defects of hand were repaired by free anterolateral thigh perforator flap in 6 cases and free deep inferior epigastric perforator flap in 2 cases. The thumb damage of degree Ⅱ was repaired by the first toe transplantation combined with perforator flap, and thumb damage of degree Ⅲ or Ⅳ was repaired by the second toe transplantation combined with perforator flap. The survival and blood supply of reconstructed thumbs and flaps, and wound healing of donor sites were observed after surgery. All the patients were followed up for 10 to 18 months, the appearance of the reconstructed thumbs, sensory recovery, and foot walking function were observed. At the final follow-up, the functional reconstruction of the thumb was evaluated.Results:All the blood supply and survival of the reconstructed thumbs and flaps were good, and all the wounds of donor sites healed well. During the follow-up, the appearances of the reconstructed thumb and flap were good, the sensation of pain and touch of the finger pulp recovered well, and no significant impact on foot walking function was observed. At the final follow-up, the function of reconstructed thumb was evaluated as excellent in 4 cases, good in 3 cases, and fair in 1 case.Conclusions:The repair method of perforator flap combined with toe transplantation technique can complete the targeted repair of thumb damage with skin and soft tissue defect of hand in one stage, minimizing the foot donor site injury and shortening the course of disease and early rehabilitation, which is one of the ideal methods for the treatment of complex thumb damage.

Objective: To explore the changes of awareness of tuberculosis and access to tuberculosis-related information among students in Zhejiang Province. Methods: There were 554 students younger than 30 y were included in the study during April to sept. of 2014 and during sept. to Nov. of 2018. Univariate and multivariate Logistic regression were conducted to find the related factors of knowing about tuberculosis and related knowledge. Chi-square test was used to analyze the changes of ways access to tuberculosis-related information. Results: There were 440 participants (79.4%) aware of tuberculosis, including 215(85.7%) in 2014 and 225(74.3%) in 2018. The factors affecting awareness on tuberculosis were female ( AOR=1.60, 95%CI =1.04-2.47) vs male; and junior middle school( AOR=1.99, 95%CI =1.03-3.85), high school( AOR=3.27, 95%CI =1.57-6.81), college or higher ( AOR=6.73，95%CI =2.55-17.76) vs primary school or lower; year 2018 ( AOR=0.50, 95%CI =0.31-0.80) vs 2014. There was no significant statistical difference in the overall knowledge scores of tuberculosis between the students in the two surveys. In 2018, the proportion of tuberculosisrelated information accessed from the Internet (forum, WeChat, Weibo.) and community activities (assembly promotion)(75.10%, 26.70%) was higher than that of 2014(36.20%, 13.10%)( χ 2=68.88, 12.79, P <0.05). Conclusion The proportion of students aware of tuberculosis and TB control in Zhejiang Province were not significantly improved. Higher proportion of students get tuberculosis-related information from the new media. Therefore, it is necessary to strengthen health education of tuberculosis in schools, especially through the usage of new media apart from traditional pathways.

OBJECTIVETo establish a mouse model of H435Y mutation of gene using CRISPR/Cas9- mediated gene targeting.

METHODSThe single-stranded guide RNA (sgRNA) specific to the H435Y loci of gene was designed based on the sequence of gene. After activity assessment, the active sgRNA and Cas9 were transcribed into RNA and microinjected along with the donor DNA fragment with point mutations into fertilized mouse eggs. The microinjected eggs were transferred into pseudopregnant mice to obtain the F0 generation mice with the target gene mutation confirmed by PCR and gene sequencing. gene mutations in the offsprings of the F0 generation mice were analyzed.

RESULTSGene sequencing confirmed the successful establishment of mouse models carrying H435Y mutation of gene in 4 of the F0 generation mice. The positive F0 generation mice were crossed with wild-type C57BL/6J mice to obtain the F1 generation mice, and PCR confirmed the presence of H435Y mutations of gene in 6 of the F1 mice. Then F2 generation mice were obtained by F1 generation matting with each other. PCR showed that H435Y mutation of gene in F2 mice was found, indicating the mousemodel of gene mutation in H435Y was established and propagated successfully.

CONCLUSIONSWe successfully established gene H435Y mutant mouse models using CRISPR/Cas9 technique.

Objective     To explore the effect of 16F gastric tube on pain relief in postoperative lung cancer patients. Methods     A total of 118 lung cancer patients were treated with radical resection of lung cancer in our hospital between January 2015 and May 2016. The patients were assigned into two groups: a 16F gastric tube group (16F group, 60 patients, 30 males and 30 females at age of 41-73 (52.13±7.83) years and a 28F drainage tube group (28F group, 58 patients, 25 males and 33 females at age of 45-75 (55.62±4.27) years. Clinical effects were compared between the two groups. Results     There was no statistical difference in drainage time (4.47±1.03 d vs. 4.24±1.16 d, P=0.473), drainage amount (560.37±125.00 ml vs. 656.03±132.45 ml, P=0.478), incidences of pneumothorax (5/60 vs. 2/58, P=0.439), pleural effusion (6/60 vs. 3/58, P=0.522), and subcutaneous emphysema (3/60 vs. 1/58, P=0.635) between the two groups (P>0.05). The pain caused by the drainage tube in the16F group was less than that in the 28F drainage tube group with a statistical difference (F=4 242.996, P<0.001). The frequency of taking analgesics in the 16F group was significantly less than that in the 28F group (12/60 vs. 26/58, P<0.001). Conclusion     The effects of draining pleural effusions and promoting lung recruitment are similar between the 16F group and the 28F group. However, the wound pain caused by 16F gastric tube is significantly less than that by 28F drainage tube.