Objective To make the cost-effectiveness analysis of pembrolizumab and platinum chemotherapy as the first-line treatment for advanced non-small cell lung cancer(NSCLC)in the population with tumor proportion score(TPS)≥1%of PD-L1,and provide some reference for the clinical use and future price negotiation of pembrolizumab.Methods Based on Pubmed database,the published RCT literatures of pembrolizumab were analyzed,and the survival data were extracted,combined with the treatment plan of a tertiary hospital,the Markov model were established to simulate the cost and health effectiveness of patients for twenty years,and the stability of the model was tested by one-way sensitivity analysis and probability sensitivity analysis.Results Twenty years later,the cost-effectiveness ratio of pembrolizumab group and chemotherapy group was ￥58 517.60/quality adjusted life month(QALM)and ￥41 213.08/QALM.Compared with the chemotherapy group,the incremental cost effective ratio(ICER)was ￥104 485.36/QALM.Conclusion When the willingness to pay(WTP)value was ￥30 902/QALM,the pembrolizumab therapy was not more cost-effective advantages than platinum chemotherapy,and the sensitivity analysis showed that the results of the model were relatively stable.

Objective:To investigate the preoperative risk factors affecting early extremity blood supply after repair of major arterial injury so as to provide clues for prevention of limb ischemia.Methods:The clinical data were retrospectively analyzed of the 139 patients (140 extremities) with major extremity arterial injury who had been admitted to Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Hospital Affiliated to Sun Yat-sen University from January 2003 to December 2019. There were 112 males and 27 females, with a mean age of 30 (20, 44) years. The primary outcome was the early status of blood supply to the injured extremity (48 hours after surgery). Univariate analysis was conducted of such factors as gender, age, ischemia time, injury mechanism, injury site, fracture, soft tissue lesion, and duration of surgery. The significant factors ( P<0.1) were then analyzed by logistic regression, and P<0.05 was considered statistically significant. Results:Ischemia happened in 44 (31.4%, 44/140) extremities within 48 hours after surgery. There were significant differences in injury mechanism, ischemia time, fracture, and soft tissue lesion between patients with and without postoperative extremity ischemia ( P<0.05). Logistic regression analysis indicated that blunt injury ( OR=5.639, 95% CI: 1.068 to 29.761, P=0.042) and soft tissue lesion ( OR=12.568, 95% CI: 3.402 to 46.431, P<0.001) were significant preoperative risk factors affecting the early blood supply after repair of major extremity arterial injury. Conclusion:As blunt injury and soft tissue defect are preoperative risk factors for early extremity ischemia after repair of major extremity arterial injury, surgeons should pay more attention to them when assessing patients and making repair protocols.

Objective:To explore the causes and preventive measures of early complications after free gracilis muscle transfer in reconstruction of brachial plexus injury, and to improve the postoperative function of the transferred gracilis muscle.Methods:Patients were recruited from August, 2005 to December, 2016. All 111 patients of brachial plexus injury underwent reconstructive surgery using 122 free gracilis flaps. Early postoperative complications, including recipient site, donor site and systemic complications, were closely observed and recorded. Outcome measurements included incidence and timing of flap compromise, type of flap compromise, causes of vascular occlusion and salvage rate. The postoperative strength of gracilis was evaluated according to the BMRC score. The data were statistically analyzed. The difference was statistically significant if P<0.05. Results:The survival rate of 122 free gracilis transfers was 98.4% (120/122). Early complications occurred in 32 cases (including 2 complications in 6 patients) : 27 cases with recipient site complications (84.4%), 4 with donor site complications and 7 with systemic complications. Among the 32 cases of complications, 17 flap compromises caused by vascular obstruction and 15 of them were salvaged completely after exploration. Flap crisis was the main issue that affected the postoperative function of gracilis muscle, and 58.8% (10/17) of patients with vascular crisis showed muscle strength above M 3 after surgery. The main causes of vascular crisis were venous tortuosity and venous thrombosis, which had nothing to do with operation time and intraoperative blood loss. Conclusion:Flap crisis is the main factor affecting the postoperative function of gracilis. The rate of flap salvage can be tremendously increased by early detection, re-exploration and effective management of the flap crisis.

Report a case sustained Gustilo type III C open fracture of the left humerus with brachial artery injury who has limb ischemia and wound infection after operation in June, 2014. To salvage the limb, performed cross limb vessel transfer to restore blood supply at one-stage. After multiple debridement, Flow-through flap transfer was performed for definitive reconstruction of the arterial injury and repair the wound in secondary stage. In the 3rd stage, cutting the pedicle of transposition vessels. Follow-up at 1 year after surgery, the patient's left upper limb had survived with limited movement and confirmed Flow-through the vessel reconstruction using CTA.

Objective:For Bayne and Klug type Ⅲ radial longitudinal deficiency, the aim of the surgical methods is to create a centralized stable wrist and restore the length of the radius. The purpose of the current study was to validate the use of the staged procedures with vascularized proximal fibular epiphyseal transfer, based on a single vascular pedicle of the inferior lateral genicular artery to treat radius defects.Methods:Between June 2007 and June 2012, five children with an averaged age of 4.3 years (range, 3.3 to 5.8 years) who had a type Ⅲ radial longitudinal deficiency were identified. The staged procedures we performed for this patient consisted of: (1) soft tissue distraction of the wrist with an external distraction device to centralize the wrist and create a space for placement of the proximal fibular graft, ulnar osteotomy, and internal fixation to correct the bowing deformity of the ulna if necessary; (2) vascularized proximal fibular epiphysis transferred to repair the radius defect and to reconstruct the wrist; and (3) pollicization or thumb reconstruction to treat thumb deficiency. In all patients, the range of motion of the digits, wrist, forearm, and elbow; the length of the forearm; and the deviation of the wrist were evaluated.Results:The averaged duration of follow-up was 52.6 months (range, 42 to 72 months). All transplants survived and united with the host bone within 3 months postoperatively. An averaged correction of 28 degrees in the hand-forearm angle was obtained. At the final follow-up, the average ulna and radius lengths were 14.4 cm and 12.1 cm, respectively; the percentage length compared with the normal side was 64.0 and 56.3 percent, respectively. The overall range of wrist motion was approximately 56 percent of that of the contralateral extremity. The averaged pronation and supination were 75 and 45 percent of the normal side, respectively. The overall range of elbow motion was similar to the normal side.Conclusions:The results of the present study indicated that vascularized proximal fibular epiphyseal transfer, based on the inferior lateral genicular artery, is a technically feasible method for treatment of Bayne and Klug type Ⅲ deficiency, which restores the length of the radius and stabilized the wrist.

Objective:For Bayne and Klug type Ⅲ radial longitudinal deficiency, the aim of the surgical methods is to create a centralized stable wrist and restore the length of the radius. The purpose of the current study was to validate the use of the staged procedures with vascularized proximal fibular epiphyseal transfer, based on a single vascular pedicle of the inferior lateral genicular artery to treat radius defects.Methods:Between June 2007 and June 2012, five children with an averaged age of 4.3 years (range, 3.3 to 5.8 years) who had a type Ⅲ radial longitudinal deficiency were identified. The staged procedures we performed for this patient consisted of: (1) soft tissue distraction of the wrist with an external distraction device to centralize the wrist and create a space for placement of the proximal fibular graft, ulnar osteotomy, and internal fixation to correct the bowing deformity of the ulna if necessary; (2) vascularized proximal fibular epiphysis transferred to repair the radius defect and to reconstruct the wrist; and (3) pollicization or thumb reconstruction to treat thumb deficiency. In all patients, the range of motion of the digits, wrist, forearm, and elbow; the length of the forearm; and the deviation of the wrist were evaluated.Results:The averaged duration of follow-up was 52.6 months (range, 42 to 72 months). All transplants survived and united with the host bone within 3 months postoperatively. An averaged correction of 28 degrees in the hand-forearm angle was obtained. At the final follow-up, the average ulna and radius lengths were 14.4 cm and 12.1 cm, respectively; the percentage length compared with the normal side was 64.0 and 56.3 percent, respectively. The overall range of wrist motion was approximately 56 percent of that of the contralateral extremity. The averaged pronation and supination were 75 and 45 percent of the normal side, respectively. The overall range of elbow motion was similar to the normal side.Conclusions:The results of the present study indicated that vascularized proximal fibular epiphyseal transfer, based on the inferior lateral genicular artery, is a technically feasible method for treatment of Bayne and Klug type Ⅲ deficiency, which restores the length of the radius and stabilized the wrist.

Objective To investigate the surgical methods and clinical effect of repairing the thumb tip defects in infants by applying the reversed first dorsal metacarpal radial artery island flaps along with anatomosing of nerves and veins.Methods Twenty-one cases with soft tissue defects of thumb tips caused by trauma were admitted from August,2015 to August,2017.The first dorsal metacarpal radial island artery flaps were transplanted reversely to repair the defects along with the anatomosis of nerves and veins.Among all the cases,the range of defect area was 2.0 cm×1.8 cm-3.0 cm×2.5 cm.The area range of the flap harvested during the surgery was 2.2 cm×2.0 cm-3.2 cm×2.7 cm.The regular post-operative followed-up was performed.Results All flaps survival after the surgeries,and the wounds were I-staged healing.All cases were followed-up by 3-18 months,and the average time was 7 months.The appearance and quality of the flaps were good.The range of motion of the metacarpophalangeal joints and interphalangeal joints was normal.According to the Upper Extremity Functional Evaluation Tentative Criteria set up by Hand Surgery Branch of Chinese Medical Association,14 cases were excellent,5 case was good,and 2 cases were fair.Conclusion The surgery of using the first dorsal metacarpal radial reversed island artery flap to repair the defect of thumb tip in infant,along with the anatomosis of nerve and vein,is a good method in repairing the defects due to its ease of operation,achievement of plump of finger tip and good recovery of appearance and sensation after the surgery.

Objective To investigate the short-term outcome of vascularized supraclavicular lymph nodes flap transplantation to treat the lower extremity lymphedema.Methods From June,2014 to June,2016,6 cases of stage Ⅱ-Ⅲ lower extremity lymphedema received vascularized supraclavicular lymph nodes flap transplantation in this study.Flap size ranged from 2.5 cm×8.0 cm to 3.5 cm×10.0 cm.The anterior tibial artery and accompanying vein were detached for anastomosis.Results One case suffered flap necrosis and then received lymphatic-venous anastomosis instead;2 cases suffered vascular crisis and partial flap necrosis,but transplanted lymph node survived and the wound were closed with skin graft.The other 3 flaps survived without any complication.Follow-up time ranged from 0.5 to 2.0 years.The affected limb circumference and the incidence of lymphangitis decreased significandy,with no complications observed in donor site.Conclusion Using vascularized supraclavicular lymph nodes flap transplantation to treat lower limb lymphedema,it has satisfactory short-term outcome and no obvious complications.It is a promising treatment choice for patients with lower extremity lymphedema in the early and mid stage.

Objective To explore clinical value of intraoperative extra strong electrical stimulation in the treatment of birth brachial plexus palsy. MethodsFrom July 2008 to September 2011,intraoperative extra strong electrical stimulation was applied in 9 cases of incomplete birth brachial plexus palsy after neurolysis.The latency and amplitude of compound muscle action potentials before and after electrical stimulation were recorded and the extent of improvement was compare.ResultsThe latency was improved in 7 cases with 8.02％ in average,amplitude in 8 cases with 185.97％ in average.The related nerve recover partial motor function in 8 cases in 2 weeks after operation.ConclusionIntraoperative extra strong electrical stimulation is a effective assistant technique to promote motor functional recovery of birth brachial plexus palsy.

ObjectiveTo evaluate the value of MR imaging(MRI)in diagosing of obstetrical brachial plexus.MethodsBetween September 2006 to September 2011,eighteen cases (12 males and 6 females)of obstetrical brachial plexus injury had being used for investigation,aging from 2 month to 3 years, average of 10.6 month. Eight left side and 10 right side. Tassin Ⅰ was 4 cases,Tassin Ⅱ was 6 eases, Tassin Ⅲwas 5 eases, Tassin Ⅳ was 4 cases. All cases were performed to MRI test before operating and the result compare with finding during operating. ResultsFindings of MRI:pseudomeningocele was in 13 of the 18cases while 10 of the 15 patients had multiple pseudomeningoceles. Displacement of spinal cord was in 6 cases; Normal was 2 cases; thickening of nerve root was in 2 cases.ConclusionMR imaging is an effective tool for demonstrating lesions of the brachial plexus worthy of surgical exploration.