To investigate the therapeutic effect of open reduction and internal fixation (ORIF) on supination external rotation (SER) ankle fractures (AF) and its impact on ankle joint function and range of motion in patients.Methods:The observation group patients were treated with ORIF, while the control group patients were treated with manual reduction combined with plaster external fixation. Both groups of patients were followed up after 3 and 6 months of treatment. Compare the ankle joint function levels of two groups of patients before treatment and after 3 and 6 months of treatment (Kofood score, AOFAS score, Olerud Molander subjective ankle score (OMAS)). Compare the joint range of motion (relative peak force, torque acceleration energy, endurance) between two groups of patients after 3 and 6 months of treatment. Compare the clinical indicators and incidence of adverse events between two groups of patients after 6 months of treatment. T-test was used for comparison between two groups. Multiple group comparisons were conducted using analysis of variance, while pairwise comparisons were conducted using Dunnett-t test. Comparison of count data between groups using χ2 inspections or Fisher exact test. Results:Before treatment, there was no statistically significant difference in the Kofoed score, AOFAS score, and OMAS score between the two groups of patients (all P>0.05). The Kofoed scores of patients in the observation group before treatment and at 3 and 6 months of treatment were (53.78±6.40), (76.73±4.12), and (89.07±5.78) points, respectively. The control group was (52.22±7.08), (71.68±4.82), and (84.05±5.45) points, respectively. The Kofoed scores of patients in both groups were higher than before treatment at 3 and 6 months of treatment (all P<0.05), and the observation group was higher than the control group (all P<0.01).The AOFAS scores of patients in the observation group before treatment and at 3 and 6 months of treatment were (70.13±5.39), (81.62±4.25), and (92.05±4.15) points, respectively. The control group was (69.85±5.41), (79.08±4.60), and (88.92±4.43) points, respectively. The AOFAS scores of patients in both groups were higher than before treatment at 3 and 6 months of treatment (all P<0.05), and the observation group was significantly higher than the control group (all P<0.01).The OMAS scores of the observation group patients before treatment and at 3 and 6 months of treatment were (53.43±5.07), (76.14±4.52), and (85.68±4.14) points, respectively. The control group was (54.42±4.86), (71.39±3.94), and (81.78±4.15) points, respectively. The OMAS scores of the two groups of patients at 3 and 6 months of treatment were higher than before treatment (all P<0.05), and the observation group was higher than the control group (all P<0.01). The fracture healing time (38.85±4.50) days and complete weight-bearing time (66.62±7.14) days of the observation group patients were shorter than those of the control group patients (49.42±5.43) days and (74.39±6.75) days, and the differences between the two groups were statistically significant (t-values were 12.89 and 6.80, respectively, all P<0.01); There was no statistically significant difference in the incidence of adverse events between the two groups of patients (5.41% (4/74) and 9.46% (7/74)), χ2=0.88, P=0.347). Conclusion:ORIF has a good therapeutic effect on SER-AF patients, promotes ankle joint function recovery, and has a low incidence of adverse events, indicating good safety.

Recent clinical studies have found that there are still a large number of patients who do not respond to immune checkpoint inhibitors (ICIs). Improving immunotherapy response in ccRCC patients is an urgent clinical need. Targeting different components of the tumor immune microenvironment becomes a breakthrough point for overcoming the immunotherapy resistance and optimizing therapeutic strategies in advanced ccRCC. Several novel immunotherapeutic strategies are currently under clinical investigation, including targeting other co-inhibitory and co-stimulatory molecules, modified cytokine therapies, small-molecule immunomodulators, targeting immune metabolism, and cancer vaccines, each of which target different immunomodulatory pathways in the tumor immune microenvironment for the treatment of ccRCC. In this paper, we provide an overview of the current challenges faced by immunotherapy for advanced ccRCC and review novel immunotherapy strategies based on the tumor immune microenvironment.

Objective To investigate the effects of 5-hydroxy-1-methylhydantoin (HMH) on kidney injury induced by paraquat (PQ). Methods Fifteen SPF healthy Kunming mice were randomly divided into normal saline (NS) control group, PQ poisoning model group and HMH intervention group, with 5 mice in each group. PQ poisoning model was challenged by one-time gavage of 30 mg/kg PQ solution. The NS group received the same amount of NS by gavage. The HMH group was given 100 mg/kg of HMH immediately after the model was made and continued to be gavaged. Mice in each group were sacrificed 1 day after HMH gavage and heart blood and renal tissue were harvested for examination. The morphological changes of renal tissue were observed under light microscope by hematoxylin-eosin (HE) staining. The content of malondialdehyde (MDA) and the activity of superoxide dismutase (SOD) in renal tissue were detected according to the instructions of the kit. The expression of heme oxygenase-1 (HO-1) and interleukin-1β (IL-1β) in renal tissues were detected by Western Blot. The serum metabolites were detected by gas chromatography time-of-flight mass spectrometry (GC-TOF-MS), the overall distribution of each sample was observed by principal component analysis (PCA), the accuracy of the model was evaluated by multidimensional analysis orthogonal partial least squares-discriminant analysis (OPLS-DA), and the difference metabolites were screened by variable importance in the projection (VIP) value > 1. Results Light microscopic observation showed that: glomerular structure in NS group was clear, there was no hyperemia and inflammatory cell infiltration in renal interstitium and blood vessels. In PQ group, some glomeruli atrophy and necrosis, capillary congestion in glomeruli, infiltration of inflammatory cells around glomeruli, swelling of renal tubular epithelial cells, slight stenosis of lumen, and occasional necrosis and exfoliation of epithelial cells occurred. The degree of kidney injury in HMH group was significantly less than that in PQ group. Compared with the NS group, the content of MDA in the PQ group was significantly increased (nmol/g: 6.70±0.84 vs. 2.70±0.43, P < 0.01) and the activity of SOD was significantly decreased (kU/L: 33.30±4.66 vs. 50.20±3.23, P < 0.05), the protein expression of HO-1 and IL-1β were significantly increased (HO-1/β-actin: 1.11±0.12 vs. 0.61±0.13, IL-1β/β-actin: 0.93±0.13 vs. 0.32±0.06, both P < 0.05). Compared with the PQ group, the content of MDA in the HMH group was significantly decreased (nmol/g: 5.10±0.93 vs. 6.70±0.84, P < 0.05) and the activity of SOD was significantly increased (kU/L:61.00±9.02 vs. 33.30±4.66, P < 0.05), the protein expression of HO-1 was significantly decreased (HO-1/β-actin:0.77±0.07 vs. 1.11±0.12, P < 0.05), however, there was no significant difference in the protein expression of IL-1β (IL-1β/β-actin: 0.87±0.13 vs. 0.93±0.13, P > 0.05). Metabolite detection results showed that: compared with NS group, the levels of creatinine, glycine, succinic acid, fumaric acid and citric acid were significantly increased in the PQ group (VIP value was 1.50, 1.58, 1.64, 1.74 and 1.95 respectively, all P < 0.05), while the levels of palmitic acid, α-tocopherol and 6-phosphogluconic acid were significantly decreased (VIP value was 1.10, 1.55 and 1.56 respectively, all P < 0.05). Compared with the PQ group, the levels of creatinine and citric acid were significantly decreased in the HMH group (VIP value was 1.50 and 1.86, both P < 0.05), while trans-4-hydroxy-proline, D-glyceric acid, 2, 6-fructose phosphate, 6-phosphate gluconic acid and aminomalonic acid were significantly increased (VIP value was 1.36, 1.55, 1.63, 1.68 and 1.76 respectively, all P < 0.05). Conclusions HMH protects kidney injury caused by PQ poisoning by correcting tricarboxylic acids cycle disturbance, lipid peroxidation and energy metabolism disturbance, and its mechanism is related to the regulation of HO-1 protein expression through Nrf2 pathway.

Objective To establish a HPLC-MS method for determination of aconitum alkaloids in biological samples. Methods The aconitum alkaloids were extracted from the whole blood by using acetonitrile-methanol (5:1 v/v) and then analyzed using HPLC-MS in multiple reaction monitoring (MRM) mode with positive ionization. The analytical column was Agilent Zorbax SB C18 (2.1mm×50mm, 1.8μm)and the mobile phase were water containing 0. 1 % formic acid : acetonitrile (60 : 40 v/v) in isocratic elution. Results The retention time of detection of the aconitine, hypaconitine and mesaconitine were 0.73 min, 0.77 min and 0.63 min, and the precursor product ion combinations of m/z 646.4 → 586.4, 616.1 → 556.5 and 632.4 → 572.1 were used for quantitative analysis, respectively. Calibration curve was linear within the range of 0.1-250 ng/mL with the LOD was 0.1ng/mL, and the coefficient of variation (CV) less than 5.42 % (n=6). The extraction recoveries of aconitine in blood were more than 90 %.Conclusion The results demonstrated that the present method was reliable and robust for natural drugs.

Objective To summarize the experiences in the diagnosis and treatment of the hepatic hereditary hemorrhagic telangiectasia (HHHT).Methods The clinical data of 15 HHHT patients who were admitted to the Qilu Hospital,People's Hospital of Mengyin,People's Hospital of Liaocheng,Henan Provincial People's Hospital,the Second Hospital of Hebei Medical University,First Affiliated Hospital of Zhejiang University were retrospectively analyzed.The clinical manifestation,features of imaging and laboratory examination were summarized,and the diagnosis,treatment and prognosis of the disease were investigated.Results HHHT patients had nonspecific symptoms in the early stage,and some patients presented with right upper quadrant discomfort,shortness of breath,anemia and liver bruit.The condition of HHHT patients could be worsened by liver cirrhosis or portal hypertension rapidly.The results of color doppler ultrasound and computed tomography showed intrahepatic telangiectasia,arteriovenous fistula and hepatic artery aneurysm in the 15 patients.Digital subtraction angiography was not clear enough for 2 HHHT patients with more than 1 enlarged hepatic arteries,but computed tomographic angiography was feasible.According to the degree and stages of the HHHT,all the 15 patients were divided into asymptomatic HHHT,simple HHHT and complex HHHT.Among the 6 patients who underwent surgical treatment,5 received ligation or banding of the enlarged hepatic arteries with subsequent disappearance of symptoms.Three patients received interventional treatment,and the treatment for 1 patient with complex HHHT was failed,and the patient died 30 months after medical treatment.Six patients were treated by conservative treatment,2 patients of them had no symptoms at the beginning,then they suffered from hepatic dysfunction and ascites at 21 and 35 months,respectively,and 1 of them died 6 months later.Four patients received medical treatment,and the results of color doppler ultrasound and computed tomography showed the pathological changes were aggravated gradually.Conclusions Telangiectasia,intrahepatic arteriovenous fistula and hepatic artery aneurysm are the main imaging characteristics of HHHT,and imaging diagnosis has significant value in the diagnosis of HHHT.HHHT is a progressive disease,early,active and individualized treatment is beneficial to the patients.The outcome of ligation or banding of the hepatic arteries is satisfactory.

Objective To investigate the feasibility and safety of transvaginal endoscopic cholecystectomy.Methods The clinical data of 88 female patients who underwent cholecystectomy at the Qilu Hospital of Shandong University from May to November, 2009 were retrospectively analysed. Among all the patients, 32 received transvaginal endoscopic cholecystectomy ( NOTES group) and the remaining 56 patients received laparoscopic cholecystectomy (LC). Thirty-two patients who received LC at the same period were selected (LC group)acccording to age, body mass index, type and severity of disease to conduct a matched case-control study. The differences in time span of postoperative pain, anodyne dose, enterokinesia recovery time, operation time, out-ofbed activity time, average hospital stay and hospitalization expenses between the two groups were compared using the paired t test. Results Cholecystectomies were successfully carried out for all the patients. The intraoperative blood loss, operation time, degree of pain, anodyne doses, enterokinesia recovery time, out-of-bed activity time,average hospital stay and hospitalization expenses were (5.7 ± 1.5 ) ml, ( 76 ± 27 ) minutes, 2.2 ± 0.6, ( 10 ±6) mg, (25±5) hours, (9±3) hours, (2.1 ±1.2) days and (1.12±0.34) ×104 yuan in NOTES group, and they were ( 13.9 ± 3.1 ) ml, (38 ± 16) minutes, 6.7 ± 1.5, (28 ± 8) mg, (45 ± 8) hours, (26 ± 6) hours,(4.3 ± 2.1 ) days and ( 1.54 ± 0.18 ) × 104 yuan in the LC group. There were significant differences between the two groups (t = 5.098, - 4.712, 2.417, 3.203, 3.089, 4.136, 4.786, 3.917, P ＜ 0.05 ). Conclusion Transvaginal endoscopic cholecystectomy is safe and feasible, and it is superior to tranditional LC.

Objective To investigate clinical result of hepatectomy and porta-enterostomy in the treatment of Bismuth type Ⅳ hilar cholangiocarcinoma.Methods Nine patients with Bismuth type Ⅳ hilar cholangiocarcinoma underwent accurate hilar resection(portal parecnchyma resection including about Ⅰ cm of the hilar part of the segments 5 and 4b and caudate lobe beyond the tumor),and the biliary drainage was reconstructed by Roux-en-Y portal parecnchyma-jejunum lpop anastomosis.None of the biliary radicals had to be ligated and all of them were drained into thus constructed"biliary pool".Results Hilar resection was successfully performed in all cases,and there was no postoperative mortality.Aspartate transaminase and alanine transaminase and serum bilirubin decreased evidently four weeks later.Three patients presented postoperative complications.One patient developed a transient anastomotic leakage,while one patient developed self-limiting hemobilia,wound infection occurred in one patient.All three patients were treated conservatively and recovered.The mean Karnofsky performance score was 86,with which they could carry on normal activity with minor symptoms of disease.Two patient died after 9 months and 17 months of extensive metastasis and intrahepatic metastasis respectively.The remaining seven patients are alive by a mean followup of 24.9 months after surgery without any signs of recurrence.Conclusions With accurate hilar resection and portal parecnchyma-to-enterostomy,the patients considerably benefit from the preservation of liver parenchyma and patent biliary drainage and radical resection.So the Hew technique prolongs the survival time and enhances the quality of life of the patients.

Objective:To investigate the feasibility and safety of a new method of natural orifice transluminal endoscopic surgery(NOTES) -totally transtracheal endoscopic thyroidectomy(TTET) .Methods:Three miniature swines and 6 beagle dogs were underwent TTET.Under general anesthesia,special designed endotracheal tube with 2-channel was used and endoscope and instruments were inserted through the respective channel.Incision of tracheal anterior wall was accomplished and partial or subtotal thyroidectomy was performed.Finally,the defects in the trachea were sutured with ENDO STITCH instrument.Results:Partial thyroidectomy was successfully accomplished on 3 pigs and subtotal thyroidectomy was done on 6 dogs.No serious complications such as anoxia,asphyxia,airway obstruction and death occurred during the operation.Animals were sacrificed 2h after the procedure and incision of trachea was found to be closely sutured.There were no subcutaneous emphysema and haematoma formation.Conclusion:Preliminary experimental results showed the feasibility and safety of TTET.Transtracheal access maintains the integrity of cervical tissues and achieves an optimal cosmetic outcome.TTET may open up a new field of NOTES on thyroid surgery.

To investigate the expressions and significance of the tumor suppressor gene phosphatase and tensin homlog deleted on chromosome ten protein (PTEN) and vascular endothelial growth factor (VEGF) in hepatocellular carcinoma (HCC), and to analyze the relationship between their expressions and the tumor's invasion and their pericarcinomatous tissues, the correlation of their expressions with the tumor's clinicopathological characteristics and invasion potential were studied. Our study showed that the expression level of PTEN in HCC was remarkably lower than that in pericarcinomatous liver tissues, while the expressions of both VEGF and MVD were higher than that in pericarcinomatous liver tissues. Correlation analysis revealed that the expression of PTEN was negatively related to the progression of the pathological differentiation and invasion of tumor, whereas the expressions of VEGF and MVD were positively related. Moreover, there was a negative relationship between the expression of PTEN and the expressions of VEGF and MVD, and a positive one between VEGF and MVD. The expressions of PTEN and VEGF may reveal the degree of differentiation and the invasive potential of HCC tissues. The mechanism by which the lack of PTEN expression probably induces abnormal hyperexpression of VEGF may play an important role in the invasion and metastasis of HCC.

To investigate the expressions and significance of the tumor suppressor gene phosphatase and tensin homlog deleted on chromosome ten protein (PTEN) and vascular endothelial growth factor (VEGF) in hepatocellular carcinoma (HCC), and to analyze the relationship between their expressions and the tumor's invasion and their pericarcinomatous tissues, the correlation of their expressions with the tumor's clinicopathological characteristics and invasion potential were studied. Our study showed that the expression level of PTEN in HCC was remarkably lower than that in pericarcinomatous liver tissues, while the expressions of both VEGF and MVD were higher than that in pericarcinomatous liver tissues. Correlation analysis revealed that the expression of PTEN was negatively related to the progression of the pathological differentiation and invasion of tumor, whereas the expressions of VEGF and MVD were positively related. Moreover, there was a negative relationship between the expression of PTEN and the expressions of VEGF and MVD, and a positive one between VEGF and MVD. The expressions of PTEN and VEGF may reveal the degree of differentiation and the invasive potential of HCC tissues. The mechanism by which the lack of PTEN expression probably induces abnormal hyperexpression of VEGF may play an important role in the invasion and metastasis of HCC.