BACKGROUND:Accurate reduction of ankle fractures under direct vision has become a common understanding among foot and ankle surgeons.How to fully expose free or compressed fragments of the posterior ankle remains one of the most challenging problems. OBJECTIVE:To explore the clinical efficiency of the para-Achilles tendon approach in exposing and repositioning the posterior malleolus sandwich fracture. METHODS:A retrospective study was made for 26 patients with posterior malleolus sandwich fracture treated with open reduction and internal fixation via para-Achilles tendon approach from January to December 2020 in The Second People's Hospital of Dalian.21 of 26 cases were managed with the lateral approach of Achilles tendon and 5 cases were managed with the medial approach of Achilles tendon.There were 19 males and 7 females,with the age of 24-69 years,averagely 38.6 years.The operation time and postoperative complications were recorded.The fracture reduction condition was evaluated by Burwell-Charnley imaging standard.Before operation,3 months after operation and last follow-up,visual analog scale score,ankle plantar flexion and dorsiflexion and American Orthopedic Foot&Ankle Society Ankle Hind Score were used to evaluate the treatment effect. RESULTS AND CONCLUSION:(1)All 26 patients were followed up for an average of 14.6 months(range 13-18 months).The operation time was 52-85 minutes(average 64.2 minutes).(2)Part of the skin edge of the lateral malleolus incision was necrotic in one patient and healed completely after a dressing change.Incision healing of the other patients was in one stage.(3)Through Burwell-Charnley imaging standard,anatomical reductions were obtained in 24 of 26,and good reductions were in 2 of 26,with an excellent and good rate of 100%.(4)At the last follow-up,the visual analog scale score(1.19±0.40)was significantly lower than the preoperative score(6.81±0.80)(P<0.01).Ankle plantar flexion(33.5±5.02)° and ankle plantar back stretch(17.23±0.99)° were significantly increased compared with preoperative data(14.58±2.50)° and(5.81±1.02)°(P<0.01).American Orthopedic Foot&Ankle Society Ankle Hind Score was improved to(89.31±3.62)points compared to preoperative(46.00±5.45)points(P<0.01).The results were excellent in 23 patients and good in 3 patients,with an excellent and good rate of 100%.(5)It is concluded that the open reduction and internal fixation via the para-Achilles tendon approach for the treatment of posterior malleolus sandwich fracture were efficient with decreased operation time,satisfying fracture reduction,fewer complications,satisfactory motion range,and functional recovery.

Objective To discuss how to plot a power function graph and draw power function graphs corresponding to common quality control rules to assist medical laboratories in selecting quality control rules.Methods Commonly used quality control rules in clinical laboratory testing in China were collected,power function graphs based on the Monte Carlo method were plotted,and the simulation results with existing results were compared and tested the reliability of the method.Results The Monte Carlo method could be used to easily plot power function graphs for the most complex quality control rules such as 13s/22s/R4s/41s/8(x-).This method had a high level of accuracy,but the accuracy and precision were positively correlated with the number of simulations.In terms of statistical proportions of seven commonly used quality control rules,the 13s/22srule had the highest usage proportion,followed by the 13s/22s/R4s.The power function graph corresponding to the 13s/22s/R4s/41s/10(x-) rule was plotted,and the sigma level lines were marked to assist the laboratory in selecting quality control rules.Conclusion The Monte Carlo method accurately plotted power function graphs,and medical laboratories could use this method to independently plot efficiency function graphs to meet quality control requirements.

Objective:To evaluate the quality level of early pregnancy serum screening in China.Methods:Information on the coefficient of variation, bias, quality control (QC) rules, and testing methods from 576 laboratories participating in the 2022 early pregnancy serum screening inter-laboratory proficiency testing program by the National Health Commission Clinical Laboratory Center was collected. Serological screening indicators included free human chorionic gonadotropin β subunit (β-hCG), total β-hCG, and pregnancy-associated plasma protein A (PAPP-A). Six Sigma (σ) management was used to assess the quality level of the laboratories and the rationality of QC rules.Wilcoxon test was used to evaluate whether different testing time and methods affected the Sigma level.Results:A total of 119 laboratories tested total β-hCG, 457 laboratories tested free β-hCG, and 565 laboratories tested PAPP-A. Seventeen laboratories tested only one marker, 553 laboratories tested two markers, and six laboratories tested three markers. There was no statistically significant difference in sigma levels for the same analyte tested in May and September. The proportion of free β-hCG reaching 6σ was the highest at 71.9% (567/788); although total β-hCG had the lowest proportion reaching 6σ at 53.4% (103/193), it also had the lowest proportion below 3σ at 3.1% (6/193). Early pregnancy serum prenatal screening mainly involved five reagents and primarily used chemiluminescence and time-resolved fluorescence methods (free β-hCG was only tested using chemiluminescence). Laboratories using time-resolved fluorescence had overall higher sigma levels [total β-hCG: 9.56 (7.01-13.22) vs. 5.84 (4.36-9.12), W=53 114.00; PAPP-A: 9.04 (6.40-12.62) vs. 5.71 (4.22-8.15), W=75 752.00; both P<0.001] compared to those using chemiluminescence. The proportion of QC rules conforming to Westgard sigma rules ranged from 16.1% (31/193) to 19.6% (166/846). Among them, the proportion of laboratories with overly lenient QC rules was 24.8% (210/846) to 32.1% (62/193), and the proportion with overly strict QC rules was 51.8% (100/193) to 55.6% (470/846). Conclusion:The overall QC level of prenatal screening laboratories in China is fine, but there is still room for improvement in the setting of QC rules.

Objective:To analyze the clinical characteristics, diagnosis and treatments of patients with POEMS syndrome initially diagnosed as pulmonary hypertension (PH).Methods:Clinical data of 7 patients who were initially diagnosed as PH and finally diagnosed as POEMS syndrome in Shanghai Pulmonary Hospital from May 2013 to November 2021 were retrospectively reviewed. Clinical manifestations, laboratory tests, echocardiography, hemodynamic findings, treatment and prognosis of patients were analyzed.Results:Seven patients, including 4 males and 3 female, aged (55±9) (44-62) years were presented with elevated pulmonary artery pressure by echocardiography at admission. Chest tightness and shortness of breath (7/7), fatigue (6/7) and lower limb edema (4/7) were the most common symptoms in the first-episode. Meanwhile, patients also presented symptoms associated with POEMS syndrome, including multiple peripheral neuropathy (7/7), multiserosal cavity effusion (6/7), organomegaly (5/7), skin changes (5/7), and endocrine lesions (4/7). Serum levels of vascular endothelial growth factor (VEGF) were significantly increased in all patients. The pulmonary arterial systolic blood pressure was (66±21)mmHg (1 mmHg=0.133 kPa) estimated by echocardiography. Six patients underwent right heart catheterization and significantly increased mean pulmonary artery pressure((35±9) mmHg) was confirmed; and their pulmonary vascular resistance was (4.00±2.10) Wood U. All patients received corresponding treatment for POEMS syndrome. The excise tolerance was improved in 5 patients after successful treatment with stable or reversed WHO functional class. One patient received hemodialysis treatment for uncontrolled POEMS. One patient died during follow-up. The echocardiography was followed up in 4 patients, and 2 of whom had a complete reversal of PH, 1 had a partial reversal, and 1 had not yet reversed.Conclusions:In patients with PH who have multisystem manifestations, such as multiple peripheral neuropathy, multiserosal cavity effusion, organomegaly and skin changes, POEMS syndrome should be considered, and proper and active treatment of POEMS may reverse PH and improve the prognosis of patients.

Objective:To investigate the ethics and existing problems of experimental animals in medical experiments and experimental teaching, and to formulate countermeasures so that animal ethics and animal welfare can be truly reflected in medical experiments.Methods:In this study, a "Basic Function Experiment Center Animal Experiment Questionnaire" with 25 questions was formulated from three aspects: the ethical cognition of experimental animals, whether animal experiments are ethical or not, how to view the problems of animal ethics and experimental teaching and the cognition of virtual simulation experiment teaching. Questionnaire was sent to Hubei University of Medicine to investigate the international students of Batch 2017 (5-year program), undergraduates of Batch 2017 (5-year program) and nursing students of Batch 2018 (4-year program) as well as teachers, researchers and employees of laboratory animal center (all with bachelor degree or above). The survey results were expressed as percentage.Results:The recovery rate of the questionnaire in this study was 98.04%(2 451/2 500), among which the practitioners, teachers and researchers in the laboratory animal center clearly understood the ethics of experimental animals, but there was a widespread phenomenon of lagging ethics among the students. For example, 16.24% (398/2 451) students had not received animal experiment ethics education and training, 29.46% (722/2 451) were not clear about animal protection laws and regulations, 7.14% (175/2 451) thought animal experiments were immoral; 29.54% (724/2 451) had vague cognition of animal welfare and ethical knowledge; 25.91% (635/2 451) were not familiar with the operation steps; 9.38% (230/2 451) were indifferent to the extra treatment of animals due to operation errors, 7.83% (192/2 451) chose to give up the experiment in the treatment of animals after massive bleeding, only 5.43% (133/2 451) chose to continue the experiment after timely hemostasis and infusion, and 9.26% (227/2 451) chose to do operations unrelated to the experiment. After the experiment, 2.28% (56/2 451) chose to kill the animals by bloodletting, only 5.51% (135/2 451) chose excessive anesthesia euthanasia, and 1.96% (48/2 451) chose to kill the animals by cervical dislocation and violence. Only 15.79% (387/2 451) chose to remember the dead animal for 2 minutes. Only 32.56%(798/2 451) of the respondents understood virtual simulation experiment, 34.92% (856/2 451) of the respondents thought that virtual simulation experiment or experimental teaching video could be used to replace the existing live animal experiment, 77.56% (1 901/2 451) believed that the construction of virtual simulation laboratory should be strengthened.Conclusion:It is imperative to strengthen the education of students' ethics of experimental animals, which is conducive to the establishment of correct ethics of experimental animals for medical students, so that the "3R" principle and animal welfare can be truly implemented in experimental teaching and scientific research experiments.

Metastatic triple-negative breast cancer (TNBC) is the most aggressive type of breast cancer. Combination of systemic chemotherapy and immune checkpoint blockade is effective but of limited benefit due to insufficient intratumoral infiltration of cytotoxic T lymphocytes (CTLs) and the accumulation of immunosuppressive cells. Herein, we designed a lenvatinib- and vadimezan-loaded synthetic high-density lipoprotein (LV-sHDL) for combinational immunochemotherapy of metastatic TNBC. The LV-sHDL targeted scavenger receptor class B type 1-overexpressing 4T1 cells in the tumor after intravenous injection. The multitargeted tyrosine kinase inhibitor (TKI) lenvatinib induced immunogenic cell death of the cancer cells, and the stimulator of interferon genes (STING) agonist vadimezan triggered local inflammation to facilitate dendritic cell maturation and antitumor macrophage differentiation, which synergistically improved the intratumoral infiltration of total and active CTLs by 33- and 13-fold, respectively. LV-sHDL inhibited the growth of orthotopic 4T1 tumors, reduced pulmonary metastasis, and prolonged the survival of animals. The efficacy could be further improved when LV-sHDL was used in combination with antibody against programmed cell death ligand 1. This study highlights the combination use of multitargeted TKI and STING agonist a promising treatment for metastatic TNBC.

Objective:To evaluate the clinical outcomes of Chaput tuberosity osteotomy and lateral malleolus sagittal osteotomy in the treatment of talus osteochondral lesions with autologous osteochondral transplantation (AOT).Methods:From January 2017 to December 2019, Chaput tuberosity osteotomy and lateral malleolus sagittal osteotomy were performed in the AOT treatment of 11 patients with talus osteochondral lesions. They were 9 men 2 women, with a mean age of 32. 6 years (range, from 22 to 45 years). Their lesions were all Hepple type V. Their American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS), International Knee Documentation Committee Knee Evaluation Form (IKDC) score, and imaging data were measured pre- and post-operatively for assessment of clinical outcomes.Results:All the patients were followed up for 13 to 24 months (average, 15.6 months). Their AOFAS (94.3±2.9) and VAS (1.2±0.4) scores at the final follow-up were significantly improved compared with the pre-operative values (49.5±6.6 and 5.7±1.2) ( P<0.05). There was no significant difference between their pre- and post-operative IKDC scores for the ipsilateral knee joint ( P>0.05). The imaging showed that the talus cystic change disappeared and the grafted bone was fully fused with the talus with no abnormal change in the joint space. Conclusion:In the AOT treatment of talus osteochondral lesions, Chaput tuberosity osteotomy and lateral malleolus sagittal osteotomy can obviously relieve ankle pain and improve ankle function.

Objective:To explore diagnostic value of tumor necrosis factor-α (TNF-α) in patients with pulmonary infection after liver transplantation.Methods:The clinical data of 80 patients with pulmonary infection after liver transplantation in the the First Affiliated Hospital of Xinjiang Medical University from January 2016 to May 2019 were retrospectively analyzed. According to different pathogens, they were divided into bacteria infection group ( n=35) and non-bacteria infection group ( n=45). The general data, levels of serum TNF-α, C-reactive protein (CRP) and procalcitonin (PCT) were compared between the two groups. Logistic regression was performed to explore risk factors for pulmonary infection after liver transplantation. Receiver operating characteristic (ROC) curves were performed to analyze diagnostic value of TNF-α, CRP and PCT. Results:The levels of serum TNF-α, CRP and PCT in bacteria infection group were significantly higher than those in non-bacteria infection group ( P<0.05). Multivariate analysis showed that high TNF-α, CRP, and PCT levels were independent risk factors for bacterial pneumonia after liver transplantation. ROC analysis showed that sensitivity, specificity and areas under ROC curves (AUC) of TNF-α, CRP and PCT for diagnosis of bacterial pulmonary infection after liver transplantation were (80.12%, 72.12%, 80.18%), (83.45%, 73.46%, 83.38%) and (0.802, 0.751, 0.803), respectively. The AUC, sensitivity, and specificity between TNF-α and PCT for diagnosis of bacterial pulmonary infection after liver transplantation were similar ( P>0.05). The AUC, sensitivity and specificity of TNF-α for diagnosis of bacterial pulmonary infection after liver transplantation were better than those of CRP ( P<0.05). Conclusions:The diagnostic value of TNF-α for pulmonary infection after liver transplantation is similar to that of PCT, and is superior to CRP. It can be applied as a reliable index for identifying bacterial pneumonia and non-bacterial pneumonia.

Objective:To comprehensively verify the diagnostic accuracy and clinical adaptability of A2DS2 scale in predicting the occurrence of stroke-associated pneumonia in China using Meta-analysis.Methods:Relevant literature about stroke-associated pneumonia in China were selected from Medline, PubMed, Embase, Cochrane Library, Web of Science, Wanfang Data Knowledge Service Platform, VIP Paper Check System, and China National Knowledge Infrastructure (CNKI), and China Biological Database from database construction to February 2020. Tool for Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality of the literature. Deek funnel plot was used to evaluate literature publication bias. Fagen plot was used to evaluate the clinical applicability of A2DS2 scale.Results:Twelve articles were finally included with a total of 7719 patients. Bivariate mixed effects analysis was used to obtain results with diagnostic odds ratio (DOR) of 18 ( 95%CI=12-27), pooled sensitivity of 0.76 ( 95%CI=0.68-0.82), pooled specificity of 0.85 ( 95%CI=0.80-0.88), pooled positive likelihood ratio of 5.02 ( 95%CI=3.91-6.44), pooled negative likelihood ratio of 0.29 ( 95%CI=0.22-0.38), and integrated area under the receiver operating curve (AUC) of 0.88 ( 95%CI=0.85-0.91). Combined with the funnel plot results, there was no significant publication bias in the overall study ( P=0.07); and the paradigm plot showed that when the A2DS2 diagnosis was positive, the probability of subjects being diagnosed with stroke-associated pneumonia increased to 83%, suggesting that A2DS2 scale had good applicability and high clinical diagnostic value. Conclusion:A2DS2 scale has good predictive value in stroke-associated pneumonia in Chinese and can be used for clinical preliminary screening of patients with stroke-associated pneumonia.

Objective    To investigate the safety and efficiency of robotic lung segmentectomy. Methods    The clinical data of 110 patients receiving robotic or thoracoscopic segmentectomy in our hospital between June 2015 and June 2019 were retrospectively analyzed. The patients were divided into a robotic group [n=50, 13 males and 37 females aged 53.0 (46.0, 60.0) years] and a thoracoscopic group [n=60, 21 males and 39 females aged 61.0 (53.0, 67.0) years]. A propensity score-matched analysis was adopted to compare the perioperative data between the two groups. Results    After the propensity score-matched analysis, 34 patients were included in each group. In comparison with the thoracoscopic group, patients in the robotic group had less blood loss [40.0 (20.0, 50.0) mL vs. 60.0 (40.0, 80.0) mL, P<0.001], more stations of lymph node dissection [7.0 (6.0, 8.0) vs. 4.0 (3.0, 6.0), P<0.001], larger number of lymph node dissection [15.0 (11.0, 21.0) vs. 10.0 (6.0, 14.0), P=0.002], and a higher total cost of hospitalization [97.0 (92.0, 103.0) thousand yuan vs. 54.0 (42.0, 59.0) thousand yuan, P<0.001]. Conclusion    In contrast with the thoracoscopic segmentectomy, robotic segmentectomy has a similar operative safety, but less blood loss and a thorough lymphadenectomy.