OBJECTIVE To study the improvement effects and mechanism of proanthocyanidins （PACs） on steroid-induced osteonecrosis of the femoral head （SONFH） in rabbits based on the receptor-interacting protein kinase 1 （RIPK1）/RIPK3/mixed lineage kinase domain-like protein （MLKL） signaling pathway. METHODS SONFH model in rabbits was induced by injecting Escherichia coli endotoxin+methylprednisolone. The successfully modeled rabbits were randomly divided into Model group （normal saline）， low-dose PACs group （PACs-L group， 11 mg/kg）， high-dose PACs group （PACs-H group， 22 mg/kg）， high-dose PACs+ RIPK1 activator （rRIPK1） group （PACs-H+rRIPK1 group， 22 mg/kg PACs+4 μg/kg rRIPK1）， along with a control group （normal saline）， with 6 rabbits in each group. Each administration group was given relevant medicine once a day intragastrically/via injection， for 4 consecutive weeks. After the last administration， the levels of tumor necrosis factor-α （TNF-α） and interleukin-6 （IL-6） in rabbit serum were measured. The changes in the microstructure of rabbit femurs， including bone mineral density （BMD）， trabecular thickness （Tb.Th）， trabecular number （Tb.N）， and trabecular separation （Tb. Sp） were examined. The histopathological features of rabbit femoral tissues were observed， and the apoptotic status of cells within the rabbit femoral tissues was detected. The mRNA expressions of vascular endothelial growth factor （VEGF） and bone morphogenetic protein 2 （BMP2） in rabbit femoral tissues were determined. The expressions of RIPK1/RIPK3/MLKL signaling pathway-related proteins in femoral tissues were detected. RESULTS Compared with the Control group， serum contents of TNF-α and IL-6， Tb.Sp， empty bone cavity rate， cell apoptosis rate， phosphorylation levels of RIPK1， RIPK3 and MLKL in femoral tissue were significantly increased in the Model group （P＜0.05）. BMD， Tb.Th， Tb.N， as well as the mRNA expression of VEGF and BMP2， along with protein expression of caspase-8， in the femoral tissues were all decreased （P＜0.05）. The bone cells in the femoral tissue were unevenly distributed， and the trabeculae were arranged sparsely. Compared with the Model group， the aforementioned quantitative indicators （P＜0.05） and pathological changes in all dosage groups of PACs showed significant improvements. Compared with the PACs-H group， the aforementioned quantitative indicators （P＜0.05） and pathological changes in the PACs-H+rRIPK1 group showed significant reversal. CONCLUSIONS PACs can ameliorate SONFH in rabbits， and its mechanism of action may be related to the inhibition of the activation of the RIPK1/RIPK3/MLKL signaling pathway， suppression of apoptosis in femoral tissue cells， and promotion of angiogenesis.

[摘 要] 目的：探讨程序性死亡受体-1（PD-1）单抗联合顺铂或吉西他滨在KRAS基因突变非小细胞肺癌（NSCLC）A549细胞移植瘤小鼠模型治疗中的作用。方法：构建免疫系统-肿瘤双人源化A549细胞小鼠移植瘤模型，将60只小鼠按随机数字表法分成6组（10只/组），分别为对照组（200 μL/kg PBS）、PD-1单抗组（20 mg/kg PD-1单抗）、顺铂组（3 mg/kg顺铂）、PD-1单抗+顺铂组（20 mg/kg PD-1单抗+3 mg/kg顺铂）、吉西他滨组（30 mg/kg吉西他滨）和PD-1单抗+吉西他滨组（20 mg/kg PD-1单抗+30 mg/kg吉西他滨）。TUNEL和DAPI双染色法检测移植瘤组织中细胞凋亡水平，测量移植瘤体积和质量并计算肿瘤生长抑制率，免疫组化法检测移植瘤微血管密度（MVD）。结果：成功构建免疫系统-肿瘤双人源化NSCLC A549细胞小鼠移植瘤模型，PD-1单抗+顺铂组移植瘤的细胞凋亡率、肿瘤生长抑制率均最高，移植瘤体积、质量和MVD均最小，与其他5组小鼠比较差异均有统计学意义（均P<0.05）。结论：顺铂与PD-1单抗具有协同活性，而吉西他滨拮抗PD-1单抗的治疗作用。提示PD-1单抗联合顺铂对KRAS突变NSCLC A549细胞移植瘤小鼠的疗效更好。

BACKGROUND:Previous brain studies have mostly focused on adults and fetuses,and the developmental characteristics of young children's brainstems have rarely been studied. OBJECTIVE:To observe the brainstem development characteristics of healthy young children and to explore the age-related differences and their correlation with sex. METHODS:From January 2019 to April 2022,a retrospective study of 3.0T MRI images of 174 children aged 2 to 6 years in the Affiliated Hospital of Inner Mongolia Medical University was conducted,and the median sagittal diameter,area and angle of the brainstem(including midbrain,pons and medulla oblongata)were measured. RESULTS AND CONCLUSION:There is an age-related increase in the anterior and posterior diameters of the midbrain,pons and medulla oblongata in the 2-5 years old group as well as in the longitudinal diameter and area of the midbrain,pons and medulla oblongata in the 2-6 years old group.Except for the longitudinal diameter of the medulla oblongata,all others show a positive correlation with age(r>0,P<0.05).In the 2-3 years old group and 4-5 years old group,the children are in the rapid growth and development stage,and these two age groups can be used as the key observation indicators for the development of young children.The anterior-posterior diameter,longitudinal diameter,area of the pons and total brainstem area are strongly correlated with age,which can be used as the key observation indicators for the brainstem development in young children.

BACKGROUND:Nowadays,there are increasing reports on the digitization and visualization system of acupuncture points for adults in traditional Chinese medicine,and the digitization and visualization system of acupuncture points for children in traditional Chinese medicine and the simulation system of acupuncture manipulation for Mongolian medicine training have been reported.However,there are no reports on relevant systems for children in Mongolian medicine. OBJECTIVE:To develop a simulation system of acupuncture points for children in Mongolian medicine,in the hope that it can be used for clinical teaching,manipulation practice and research on acupuncture safety. METHODS:Based on the tomographic anatomical dataset of preschool boys,a three-dimensional(3D)digital virtual anatomical model of children with multiple internal organs and tissues was constructed by using PhotoShop.2021 and Digihuman Reconstruction System software.The relevant annotation information database of 27 acupoints such as Dinghui acupoint of Mongolian medicine was compiled by the Unity database language.The Mongolian gold needle and silver needle were selected to record the acupuncture point teaching video on the 3D printed head and neck resin model of children.In Unity3D software,children's anatomical model,acupoint annotation information database and acupuncture operation video were integrated and coded,and a 3D digital children's Mongolian acupuncture acupoint visualization system integrating simulation acupuncture training,clinical teaching and acupuncture safety research was successfully created. RESULTS AND CONCLUSION:This study was based on real children's specimens.In order to reduce the error of two-dimensional segmentation,the manual layer-by-layer segmentation section image method was used to ensure the accuracy of the 3D model to the greatest extent.The Digihuman Reconstruction System was used to extract and save the individual segmentation data while maximizing the accuracy of the 3D model.PhotoShop.2021 software was used to complete the 3D reconstruction of the outer skin of the head and neck of children and the internal bony structure,cervical spinal cord,blood vessels and nerves,muscles and ligaments.After 3D reconstruction,the basic morphology of each independent structure and the integrity of the overall contour were verified in MeshLab software and the final fine adjustment and anatomical position confirmation were conducted using 3-matic research 13.0 software.The real anatomical morphology of the head and neck of preschool children was successfully simulated and restored.Unity3D software was used to integrate the 3D model of children,acupuncture operation video and acupoint annotation database,and the 3D digital Mongolian acupuncture acupoint visualization system for children was successfully constructed.Based on the real continuous fault ultra-thin dataset of preschool boys in China,China's first 3D digitization and visualization system of acupuncture points in the head and neck of children in Mongolian medicine was developed.Compared with the previous acupuncture soft works,this system is more suitable for the anatomical morphological development characteristics of Asian children,and has a high value of application in the fields of research on the safety of acupuncture in Mongolian medicine,clinical teaching and acupuncture simulation training.

BACKGROUND:The calcaneus is located in the lower posterior part of the foot and is heavily stressed.Calcaneus is complex and irregular in shape,surrounded by thin cortical bone and filled with a large number of trabeculae.The study of the microstructure,movement,and distribution of trabeculae is helpful to improve the understanding of calcaneus fracture. OBJECTIVE:The image data of calcaneus were obtained by scanning the calcaneus specimens with micro-computed tomography,and the structure of trabecular bone in calcaneus was analyzed to explore the morphology,distribution and structural characteristics of trabecular bone in calcaneus. METHODS:Dry adult calcaneus specimens were continuously scanned by micro-computed tomography,and the images were obtained after scanning and stored in DICOM format.Image data were imported into Hiscan Analyzer software to display clear and complete images of the sagittal plane,coronal plane,and the horizontal plane of the adult calcaneus.The trabecular movement of bone was observed layer by layer.According to the trabecular movement characteristics,the sagittal plane of the calcaneus was divided into six parts.A 49-mm2 region of interest was selected for each part at the same thickness as 7 mm.The three-dimensional microstructure of calcaneus and trabecular bone was obtained after three-dimensional reconstruction.After binarization,the volume fraction,surface density,trabecular thickness,trabecular space,and trabecular number parameters of the trabecular bone in the region of interest were calculated by software. RESULTS AND CONCLUSION:(1)The cortical layer of the calcaneus was very thin and filled with a large amount of cancellous bone,and the cortical layer of the horn of Gissane was obviously thickened.(2)The trabecular volume fraction in the upper part of the calcaneus was greater than that in the anterior part of the lower part of the calcaneus,the central triangle,the posterior part of the lower part of the calcaneus,and the base of the calcaneus,and the trabecular volume fraction in the tubercle of the calcaneus was greater than that in the anterior part of the lower part of the calcaneus,the central triangle,the posterior part of the lower part of the calcaneus,and the base of the calcaneus.The surface density of the trabecular bone in the tubercle of the calcaneus was higher than that in the front of the lower calcaneus,the middle triangle area,and the bottom of calcaneus,and the surface density of the trabecular bone in the upper part of calcaneal bone,and the lower part of the calcaneus was higher than that in the middle triangle area.The thickness of the trabecular bone in the upper part of the calcaneus was greater than that in the tubercle of the calcaneal bone.The bone trabecular space in the middle triangle was larger than that in the upper part of the calcaneus and calcaneal tubercles.The number of bone trabeculae in the calcaneal tubercles was greater than that in the middle triangle area.(3)These results indicate that the trabeculae of rod bone were mainly distributed in the middle triangle area.The surface density of trabeculae was the smallest,the volume fraction was smaller,and the space between trabeculae was the largest.This part of the bone is relatively loose.The compression resistance is poor when subjected to high impact.The trabecular bone fractures first occur,which is a prone site for fractures.

Objective:To investigate the clinicopathological features, diagnosis and differential diagnosis of adrenal cortical carcinoma (ACC) in children.Methods:Twenty-five children with ACC diagnosed in the Department of Pathology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China from March 2014 to August 2022 were retrospectively analyzed. The related literature was reviewed.Results:A total of 25 children with ACC were collected, including 11 males and 14 females, with a male to female ratio of 1.0∶1.3. The patient ages ranged from 8 months to 14 years (median, 4 years). Eighteen cases with clinical data had functional tumors (18/22, 81.8%) presenting with virilization or precocious puberty (15/18), symptoms related to hypercortisolism (8/18) or endocrine symptoms mixed with both (5/18), while 3 cases (3/22, 13.6%) had unknown clinical data. The clinical manifestations of four patients with nonfunctional tumors were an abdominal mass and/or abdominal pain, walking instability and others. Grossly, the average maximum diameter of the tumor was 9.4 cm. Most of the tumors were nodular and partially encapsuled. The cut surfaces were gray or gray brown, soft with hemorrhage. Histologically, the tumor cells were diffusely distributed, separated by a vascular-rich network. The tumor cells were large, with distinct nucleoli, abundant eosinophilic or clear cytoplasm, and round or oval nuclei. The mitotic index was high, and atypical mitoses were common. Necrosis, calcification, capsule invasion or/and venous invasion were present. In some cases, the tumor invaded the surrounding soft tissues or kidneys. Immunohistochemically, the tumor cells were diffusely positive for syn and SF1 and focally positive for α-inhibin, Melan A and Calretinin, but negative for CgA. Ki-67 proliferation index ranged from 2%-90%. TP53 gene status was examined in 7 cases, in which mutations were detected in 4 cases. Follow-up data was obtained in 21 patients, among whom 18 received chemotherapy and 3 received radiotherapy. Distant metastasis occurred in 13 patients. Median progression-free survival (PFS) was 11.2 months and median overall survival (OS) was 54.7 months. Patients aged less than 5 years had a better prognosis for OS ( P<0.05) than the older ones (≥5 years), but a similar PFS ( P>0.05). Male patients and Ki-67 proliferation index <15% had a better prognosis tendency for OS, but there was no statistically significant difference ( P>0.05). Conclusions:ACC in children is a rare, often functional tumor associated with Li-Fraumeni genetic syndrome and has a poor prognosis. Diagnosis and differential diagnosis require a combination of morphological, phenotypic and clinical analysis.

Objective To compare the effect of quadratus lumborum block at supra-arcuate ligament(SA-QLB)and erector spinae plane block(ESPB)on postoperative analgesia and recovery quality in the pa-tients undergoing thoracoscopic surgery.Methods Sixty patients undergoing elective thoracoscopic surgery,aged 18-70 years old,ASA grade Ⅰ-Ⅱ,served as the study subjects and were randomly divided into the two groups by the random number table method:SA-QLB group(group Q,n=30)and ESPB(group E,n=30).Before induction of general anesthesia,the group Q conducted SA-QLB in the operation side under the ultra-sound guide and the group E conducted ESPB,the both were given 30 mL of 0.25％ropivacaine.All patients in both groups were given the patient-controlled intravenous analgesia(PCIA)after surgery.The dosage of remifentanil during surgery,recovery time,Visual Analogue Scale(VAS)score at rest and cough at 1,6,12,24,48 h after surgery,first pressing time of patient-controlled analgesia,times of effective pressing,dosage of sufentanil and number of cases of rescue analgesia at 24 h after surgery,forced vital capacity(FVC)and forced expiratory volume first second(FEV1)at 1 h before surgery and 24 h after surgery,scores of quality recovery at postoperative 24 h(QoR-15)and Barthel score,hospitalization duration after operation and the occurrence of adverse reactions were recorded.Results Compared with the group E,the intraoperative remifentanil dos-age in the group Q was decreased(P＜0.05);the VAS scores in rest and cough at postoperative 6,12,24 h were decreased(P＜0.05);the first pressing time of postoperative analgesia pump in the group Q was pro-longed,number of effective pressures of analgesia pump,dosage of sufentanil and cases number of remedy an-algesia were decreased(P＜0.05);FEV1 and FVC at postoperative 24 h in the group Q were significantly in-creased(P＜0.05);the scores of QoR-15 and Barthel at postoperative 24 h were increased(P＜0.05).The in-cidence rates of postoperative nausea and vomiting in the group Q were lower than those in the group E(P＜0.05),and no serious adverse events occurred in the two groups.Conclusion Compared with ESPB,SA-QLB could provide more perfect postoperative analgesia effect,which is conducive to postoperative early pulmonary function recovery,and the postoperative recovery quality is higher.

Purpose To investigate the clinicopathological features and molecular features of diffuse paediatric-type high-grade glioma,H3-wildtype and IDH-wildtype(pHGG H3/IDH WT)of central nervous system.Methods The clinical and pathological data of 6 cases of pHGG H3/IDH WT diagnosed by Department of Pathology,Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine were retrospectively ana-lyzed.The expression of GFAP,Olig2,Syn,NeuN,IDH1,H3K27M was detected by immunohistochemistry(automatic im-munohistochemical staining device).The EGFR and MYCN gene amplification was detected by FISH.IDH,H3F3A and TERT gene mutations were detected by Sanger sequencing.The literatures were reviewed.Results The 6 patient's age ranged from 5 to 11 years,with a median age of 7.5 years.Among them,there were 2 males and 4 females,with a male to female ratio of 1∶2.The clinical symptoms were limb weakness,hemi-plegia,vomiting,convulsions,blurred vision and so on.Tumors were located in supratentorial brain for 5 cases and one in brain stem and cerebellum.Histologically,3 cases showed the mor-phological features of high-grade glioma,2 of which with giant cells.Two cases showed embryonal tumor-like features,and one had both high-grade glioma and embryonal tumor-like morpho-logical features.Microvascular proliferation and/or necrosis were present in 5 cases.Myxoid/microcystic stroma was found in 1 case.By immunohistochemistrically,the tumor cells were par-tially or focally positive for GFAP(6/6)and Olig2(6/6),fo-cally positive for Syn(3/6)and NeuN(1/6),and negative for IDH1,H3K27M,H3G34V and H3G34R.ATRX,H3K27me3,INI1 and BRG1 were diffusely positive(6/6).The positive rate of p53 was 5％-95％,and Ki67 proliferation index was 40％-90％.Molecular analysis showed that all 6 cases were IDH1/2 and H3F3A wild-type.MYCN amplification was observed in 2 cases.Two cases of EGFR amplification with polyploidy;one case had both EGFR amplification and MYCN amplification.PDGFRA amplification was observed in one case.For treatment and follow-up,the patients received postoperative radiotherapy and/or temozolomide chemotherapy;three patients died at 1 to 5 months after operation.Two patients survived and were followed up for 4 and 7 months,respectively.One patient was lost to fol-low-up.Conclusions pHGG H3/IDH WT is a highly malignant tumor with glioblastoma-like or embryonal tumor-like features.According to the molecular characteristics,it can be divided into three molecular subtypes,RTK1,RTK2 and MYCN.pHGG MYCN has the worst prognosis.Attention should be paid to the differential diagnosis of other pediatric or adult high-grade glio-mas and embryonal tumors.

Purpose To investigate the clinicopathological features,molecular features,treatment and prognosis of infant-type hemispheric glioma(IHG)with ALK gene fusion of central nervous system.Methods Clinical data of 2 cases of IHG were collected,and the expression of GFAP,Olig2,Syn,NeuN,H3K27M,H3K27me3,H3G34V,H3G34R,ALK,and BRAF were detected using immunohistochemistry.FISH and NGS method was used to detect ALK fusion genes,and relevant liter-atures were reviewed.Results Case 1,a male,15 months old,showed a huge mass in the left frontal and temporal lobe on cranial MRI.Case 2(external hospital consultation),a male,18 months old,was found to have a space occupying lesion in the frontaltemporal lobe.Microscopic examination:in case 1,tumor cells showed diffuse patchy pattern,with small nodular shapes in some areas which separated by fibrous blood vessels.The cell density was high,and the nucleus was round or oval.The mitotic was easy to see,accompanied by bleeding and nec-rosis.In case 2,tumor cells were diffusely distributed,some of them formed pseudorosette around blood vessels and others ar-ranged in bundles.The cells were mild to moderate dysplasia with round or oval nuclei,light staining,small nucleoli,rare mitotic figures,and no microvascular proliferation or necrosis.Immunophenotypes:in case 1 tumor cells were focal positive for GFAP and NeuN,diffuse positive for H3K27me3,ALK(cyto-plasm and cell membrane),and ATRX,p53 positive(30％),negative for Olig2,Syn,H3K27M,H3G34V,H3G34R,and BRAF,Ki67 proliferation index of 20％.In case 2:tumor cells were diffusedly expressed GFAP,ATRX,H3K27me3,ALK(cytoplasm and cell membrane),and Olig2,Syn was weakly positive,NeuN and p53 were negative,and Ki67 proliferation index was 5％.FISH and NGS tests showed ALK gene fusion in both cases,with EML4::ALK fusion in case 1 and LRRFIP1::ALK fusion in case 2.Follow up for 7 months showed that the residual lesion in case 1 had shrunk and was generally in good condition;case 2 lost follow-up.Conclusion The histology of IHG often presents as high-grade gliomas or accompanied by an-aplastic features.The heterogeneity of ALK variants can also manifest as low-grade gliomas,which need to be differentiated from other high-grade gliomas,desmoplastic infantile gangliogli-oma/astrocytoma,ependymoma,etc.

Objective:To investigate the clinicopathological features of children with metachronous or synchronous primary tumors and to identify related genetic tumor syndromes.Methods:The clinicopathological data of 4 children with multiple primary tumors diagnosed in the Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China from 2011 to 2023 were collected. The histological, immunophenotypic and molecular characteristics were examined using H&E staining, immunohistochemical staining, PCR, Sanger sequencing and next-generation sequencing (NGS). The patients were followed up.Results:Case 1 was an 8-year-old boy with the adrenal cortical carcinoma, and 5 years later a poorly differentiated gastric adenocarcinoma was detected. Case 2 was a 2-year-old boy, presented with a left ventricular choroid plexus carcinoma, and a hepatoblastoma was detected 8 months later. Case 3 was a 9-month-old girl, diagnosed with renal rhabdoid tumor first and intracranial atypical teratoid/rhabdoid tumor (AT/RT) 3 months later. Case 4 was a 7-year-old boy and had a sigmoid colon adenocarcinoma 3 years after the diagnosis of a glioblastoma. The morphology and immunohistochemical features of the metachronous or synchronous primary tumors in the 4 cases were similar to the corresponding symptom-presenting/first-diagnosed tumors. No characteristic germ line mutations were detected in cases 1 and 2 by relevant molecular detection, and the rhabdoid tumor predisposition syndrome was confirmed in case 3 using NGS. Case 4 was clearly related to constitutional mismatch repair deficiency as shown by the molecular testing and clinical features.Conclusions:Childhood multiple primary tumors are a rare disease with histological morphology and immunophenotype similar to the symptom-presenting tumors. They are either sporadic or associated with a genetic (tumor) syndrome. The development of both tumors can occur simultaneously (synchronously) or at different times (metachronously). Early identification of the children associated with genetic tumor syndromes can facilitate routine tumor screening and early treatment.