Objective:To study the efficacy of ultrasound-guided lower back quadrate fascia plane block combined with dexmedetomidine in postoperative analgesia after cesarean section.Methods:98 cases of women who underwent cesarean section in our hospital from Jan. 2021 to Jan. 2024 were selected, and all patients were divided into control group and study group with 49 cases each using random number table method. Both groups received routine cesarean section, the control group was given quadrate fascia plane block, and the study group was given quadrate fascia plane block combined with dexmedetomidine. The postoperative recovery, pain score, sufentanil dosage, sleep quality and incidence of adverse reactions were compared between the two groups.Results:There was no significant difference in age, gestational age or BMI between the two groups ( P>0.05). The first standing time of the study group was (5.52±1.09) h, the walking time of getting out of bed was (7.45±1.79) h, and the colostrum time was (27.61±2.92) h. The three indexes of the control group were (6.94±1.48) h, the walking time of getting out of bed was (9.52±2.03) h, and the colostrum time was (32.08±3.45) h, respectively. The study group was lower than the control group ( P<0.05). The NRS score at rest 12h and 24h after surgery was (2.58±0.53; 1.57±0.68) score, 12h, 24h resting NRS score of control group was 3.54±0.75, 3.12±1.01; The score was lower in the study group than that in the control group ( P<0.05). The NRS scores of 12h and 24h postoperative activities in the study group were (3.61±0.72; The NRS score of 12h and 24h activities in the control group was 4.12±0.79, 3.73±1.08; The score in the study group was lower than that in the control group ( P<0.05). The dosage of sufentanil for 12h, 24h and 48h in the study group was (15.17±3.24; 23.28±4.02; 41.61±4.82) μg, 48h analgesic pump compression times were (2.94±1.22) times, the number of relief analgesia cases were 3 times, the dosage of sufentanil at 12h, 24h, 48h in the control group was (20.08±4.03; 36.14±4.57; 59.33±6.25) μg, 48h analgesic pump compression times were (6.15±1.71) times, the number of relief analgesia cases was 10 times, the study group was lower than the control group ( P<0.05). The PSQI scores at 1d, 2d and 3d were 15.14±1.15; 16.31±1.21; 17.34±1.31 in the control group, while they were 13.25±1.08; 15.28±1.16; 16.45±1.25 in the study group, lower than that in the control group ( P<0.05). The incidence of adverse reactions was 10.20% in the study group and 26.53% in the control group, lower than that in the control group ( P<0.05) . Conclusion:Ultrasound-guided lower back quadrate fascia plane block combined with dexmedetomidine can improve the recovery after cesarean section, reduce the pain after delivery and sufentanil dosage, improve the quality of sleep and reduce adverse reactions, and have a good analgesic effect.

Objective:To investigate the application effect of the blended teaching model of "intelligent teaching" and "wisdom learning" in the practice teaching of integrated traditional Chinese and Western medicine in internal medicine.Methods:According to the principle of randomization, 54 interns in Class 1 of integrated traditional Chinese and Western medicine in the grade of 2019 were selected as control group and received traditional teaching, and 56 interns in Class 2 were selected as observation group and received blended teaching with "intelligent teaching" and "wisdom learning". After 6 months of internship, the two groups were compared in terms of the scores of theoretical assessment (basic theoretical knowledge and professional theoretical knowledge), clinical practice ability [Leicester Assessment Package (LAP)], and degree of satisfaction with teaching. SPSS 17.0 was used to perform the t-test and the chi-square test. Results:At the end of internship, compared with the control group, the observation group had significantly higher score of basic theoretical knowledge (41.53±3.42 vs. 38.71±3.38, P<0.05), score of professional theoretical knowledge (39.49±3.14 vs. 37.85±3.07, P<0.05), LAP score (84.32±6.65 vs. 78.46±6.17, P<0.05), and degree of satisfaction with teaching ( P<0.05). Conclusion:For interns majoring in integrated traditional Chinese and Western medicine, the blended teaching model of "intelligent teaching" and "wisdom learning" can strengthen their mastery of theoretical knowledge, enhance their clinical practice ability, and improve their degree of satisfaction with teaching.

Objective:To explore the effect of different HER2 expression levels and gene amplification on the efficacy of immunotherapy in metastatic urothelial carcinoma (UC).Methods:The clinical data of 77 patients with metastatic UC who received immunotherapy from June 2017 to April 2021 after failure to the previous chemotherapy were analyzed retrospectively, including 49 males and 28 females with the median age of 62 years. The primary tumors located in bladder in 28 cases (36.4%), renal pelvis in 25 cases (32.5%) and ureter in 24 cases (31.2%). The common metastatic sites included: lymph nodes (n = 45, 58.4%), lung (n = 40, 51.9%), bone (n = 20, 26.0%) and liver (n = 16, 20.8%). 27 patients with bladder UC received surgery on the primary tumors including radical cystectomy (n = 18), partial cystectomy (n = 4) and transurethral resection (n = 5). 43 patients with renal pelvis or ureteral UC received surgery on the primary tumors including radical nephroureterectomy (n = 38), local resection (n = 3) and palliative resection (n = 2). Postoperative intravesical chemotherapy was performed in 15 cases, adjuvant radiotherapy was performed in 6 cases. 3 patients who emerged postoperative bladder recurrence received local radiotherapy. 7 patients received radiotherapy and 1 case received microwave ablation to their metastatic sites. All patients had received first-line chemotherapy and 30 patients (40.0%) had received at least second-line treatment including 70 cases (90.9%) with platinum containing chemotherapy. All 77 patients received anti-PD-1 treatment. 38 patients received sequential regimen after failed to the anti-PD-1 therapy, including antibody-drug conjugate (n = 17), chemotherapy (n = 18) and chemotherapy combined with anti-angiogenesis drugs (n = 12). Immunohistochemical (IHC) staining was used to detect the expression level of HER2 protein in the tumor tissues (74 cases from primary tumors and 3 cases from metastatic tumors) obtained from the initial diagnosis. For patients with HER2 IHC (+ + ), the copy number (CN) of HER2 gene was detected by next-generation sequencing (NGS). HER2 copy number amplification [CN (+ )] was defined as CN ≥ 4, and HER2 copy number non-amplification [CN(-)] was defined as CN < 4. HER2 IHC (0) was defined as HER2 negative, IHC (+ ) or IHC (+ + ) / CN (-)was defined as HER2 low expression, while IHC (+ + ) / CN(+ ) and IHC (+ + + ) were defined as HER2 high expression. Chi-square test or Fisher exact test were used to evaluate the correlation between HER2 expression and objective response rate (ORR) after anti-PD-1 treatment. Kaplan-Meier method and log-rank test were used to compare the differences of median progression free survival (PFS) and overall survival (OS) under different HER2 expression status.Results:All the 77 patients received a median of 11 (range: 2 - 45) doses of anti-PD-1 treatment with a median duration of treatment of 6.4 (range: 1.5 - 47.8) months and the ORR was 33.8% (26/77). The median follow-up time was 30.9 months. The overall median PFS time was 5.8 (95% CI: 3.0 - 8.6) months and the median OS time was 23.6 (95% CI: 8.5 - 38.7) months. HER2 IHC tests were performed in 77 patients. HER2 IHC levels of (0), (+ ), (+ + ) and (+ + + ) were found in 33 (42.9%), 19 (24.7%), 20 (26.0%) and 5 (6.5%) patients, respectively. HER2 copy number was detected in 20 patients with IHC (+ + ), while 1 CN(+ ) and 19 CN(-) were found. The ORR of HER2 negative, low expression and high expression patients were 42.4% (14/33) vs. 31.6% (12/38) vs. 0 (0/6) ( P = 0.08), respectively. The median PFS of the three groups were 11.0 months, 3.7 months and 1.8 months, respectively, with significant differences in overall and pairwise comparison( P=0.001). The median OS of patients with HER2 negative and low expression after anti-PD-1 treatment were 23.6 months and 22.7 months, respectively, while the median OS of patients with HER2 high expression had not been reached, with no significant difference in the overall comparison ( P=0.623). Conclusions:For patients with metastatic UC received anti-PD-1 treatment, the PFS of patients with high HER2 expression was significantly worse than that of patients with low or negative HER2 expression. HER2 expression may have potential value in predicting the efficacy of immunotherapy for metastatic UC who failed the previous chemotherapy, which needs further research.

Objective:To evaluate the efficacy of ultrasound-guided modified brachial plexus block at costoclavicular space (CCS) for forearm surgery.Methods:Eighty patients of both sexes, aged 18-75 yr, with body mass index of 18-30 kg/m 2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective forearm surgery from September 2020 to May 2021 in our hospital, were randomized into 2 groups ( n=40 each) using a random number table method: single-injection control group (group C) and double-injection modified group (group T). Single-injection was performed in the anterior chamber of CCS in group C, double-injection was performed in the anterior and posterior chambers of CCS in group T, and the solution injected in both groups was a mixture (20 ml) of 1.0% lidocaine and 0.375% ropivacaine.The effect of block, onset time of block, completion time of block and duration of block for each nerve branch and anesthesia-related adverse reactions were recorded at 5, 10, 15, 20, 25 and 30 min after injection of local anesthesia. Results:Compared with group C, the rate of motor block of radial nerve at 5-20 min after injection of local anesthesia, the rate of sensory block of musculocutaneous nerve and radial nerve at 10 and 15 min after injection of local anesthesia, the rate of motor block of median nerve at 15-30 min after injection of local anesthesia and the rate of sensory and motor block of ulnar nerve at 20-30 min after injection of local anesthesia were significantly increased, and the onset time and completion time of block were shortened in group T ( P<0.05). There was no significant difference between the two groups in the duration of block and anesthesia-related adverse reactions ( P>0.05). Conclusions:Ultrasound-guided modified brachial plexus block at CCS provides better efficacy for forearm surgery.

Background::Joint dislocations significantly impact public health. However, a comprehensive study on the incidence, distribution, and risk factors for joint dislocations in China is lacking. We conducted the China National Joint Dislocation Study, which is a part of the China National Fracture Study conducted to obtain the national incidence and risk factors for traumatic fractures, and to investigate the incidence and risk factors for joint dislocations.Methods::For this national retrospective epidemiological study, 512,187 participants were recruited using stratified random sampling and probability-proportional-to-size method from January 19 to May 16, 2015. Participants who sustained joint dislocations of the trunk, arms, or legs (skull, sternum, and ribs being excluded) in 2014 were personally interviewed to obtain data on age, educational background, ethnic origin, occupation, geographic region, and urbanization degree. The joint-dislocation incidence was calculated based on age, sex, body site, and demographic factors. The risk factors for different groups were examined using multiple logistic regression.Results::One hundred and nineteen participants sustained 121 joint dislocations in 2014. The population-weighted incidence rate of joint dislocations of the trunk, arms, or legs was 0.22 (95% confidence interval [CI]: 0.16, 0.27) per 1000 population in 2014 (men, 0.27 [0.20, 0.34]; women, 0.16 [0.10, 0.23]). For all ages, previous dislocation history (male: OR 42.33, 95% confidence interval [CI]: 12.03–148.90; female: OR 54.43, 95% CI: 17.37–170.50) and alcohol consumption (male: OR 3.50, 95% CI: 1.49–8.22; female: OR 2.65, 95% CI: 1.08–6.50) were risk factors for joint dislocation. Sleeping less than 7 h/day was a risk factor for men. Compared with children, women aged ≥15 years (female 15–64 years: OR 0.16, 95% CI: 0.04–0.61; female ≥65 years: OR 0.06, 95% CI: 0.01–0.41) were less likely to sustain joint dislocations. Women with more than three children were at higher dislocation risk than women without children (OR 6.92, 95% CI: 1.18–40.78).Conclusions::The up-to-date data on joint dislocation incidence, distribution, and risk factors can be used as a reference for national healthcare, prevention, and management in China. Specific strategies for decreasing alcohol consumption and encouraging adequate sleeping hours should be developed to prevent or reduce dislocation incidents.Trial Registration::Chinese Clinical Trial Registry, ChiCTR-EPR-15005878.

[Abstract] Objective: Elevated levels of soluble PD-L1 (sPD-L1) are associated with worse prognosis of renal cell carcinoma and multiple myeloma. However, the regulatory roles and functions of sPD-L1 in advanced melanoma are not fully understood. This study was designed to evaluate the association between circulating sPD-L1 concentrations and prognosis of patients with advanced acral or mucosal melanoma. Methods: A total of 102 untreated patients with advanced acral and mucosal melanoma admitted to Peking University Cancer Hospital between January 2012 and December 2015 were enrolled in this study. In the meanwhile, peripheral blood samples were obtained from 40 healthy donors. Circulating sPD-L1 concentrations were determined using an enzyme-linked immunosorbent assay. Results: The advanced melanoma cohort included 58 acral melanoma patients and 44 mucosal melanoma patients. The pre-treatment concentration of sPD-L1 (2.91±2.23 ng/ml) in plasma of patients group was elevated as compared with that in healthy donors (0.59 ng/ml). The concentration of sPD-L1 in serum was significantly upregulated in 39/102 (38.2%) patients and significantly associated with increased LDH level (P=0.021) and number of Tregs (P=0.017). The overall survival rates of patients with high or low concentrations of sPD-L1 were statistically different (8.5 months [high level] vs 11.6 months [low level], P=0.022). Conclusion: sPD-L1 concentration is elevated in patients with advanced acral or mucosal melanoma, which may play an important role in predicting prognosis.

[Abstract] Objective: To explore the expression patterns of melanoma lineage antigens and nuclear antigen Ki-67 and their correlations with survival in melanoma patients. Methods: A retrospective analysis was conducted to analyze the pathological data of melanoma patients treated at the Department of Melanoma, Peking University Cancer Hospital from February 2008 to August 2020, mainly including the expression patterns of melanoma lineage antigens (S-100, HMB-45, Melan-A) and Ki-67, demographics, clinical features and survival. The correlation between expression patterns of melanoma lineage antigens, Ki-67 and melanoma-specific survival (MSS) was analyzed. Results: In total, 603 patients were included in this study. The median follow-up time was 47.4 months. The positive rates of S-100, HMB, and Melan-A were 92.8%, 92.1% and 90.0%, respectively. The percentages of patients with melanoma lineage antigen scores (S-100, HMB-45 and Melan-A was scored each, as 1 when positive and 0 when negative) of 0, 1, 2, and 3 were 0.5%, 5.0%, 15.6%, and 78.8%, respectively. The percentages of patients with Ki-67 scores of 0, 1, 2, and 3 were 43.0%, 36.3%, 16.3%, and 4.5%, respectively. Ki-67 was highly expressed in mucosal and progressive melanomas. In a multivariate analysis, Ki-67 expression was an independent prognostic factor for poorer MSS (HR=1.506, 95%CI: 1.248-1.818, P<0.001) as the incidence of MSS event increased by 50% per 25% increase in Ki-67 expression, whereas there was no statistical correlation between melanoma lineage antigen expression and MSS (HR=0.991, 95%CI: 0.759-1.293, P=0.94). Conclusion: High expressions melanoma lineage antigens are ubiquitous in melanoma tissues, and Ki-67 is an independent prognostic factor for MSS.

In order to improve the success rate of supraclavicular deep venous catheterization and reduce mechanical complications, we present an auxillary maneuver in regard to supraclavicular subclavian catheterization basing on the relatively fixed anatomy of subclavian vein and its adjacent surroundings, furthermore, we revised the standardized procedure of supraclavicular subclavian catheterization. The maneuver is summarized in the shape of verses (verses: thumb navigation is well designed according to anatomy. Needle penetrated into vein should be parallel to coronal plane. Fine needle in position should be immobilized. Is it difficult for parallel puncture? Pressure determination is required when needle is in place. It is critical to distinguish which vessel has been inserted. Guidewire is advanced smoothly. Check blood return after expansion of skin and catheterization.). For teaching convenience, verses are considered to be more concise and memorable, as well as applicable to clinical practice, in order to provide some help for clinical teaching.

Objective:To explore the prognostic value of PD-L1 expression level in patients with metastatic renal cell carcinoma (mRCC).Methods:The clinicopathological and survival data of patients with mRCC in our hospital from Jan 2014 to Apr 2016 were retrospectively analyzed including 46 males and 15 females. The median age of these patients was 56 years(range: 29-75 years), with 41 patients ≤60 years and 20 patients >60 years. The baseline data before the systemic therapy showed 36 patients(59.0%)had 1 metastatic organ and 25 patients (41.0%) had equal or more than 2 organs to be metastasized. Among them, 17 patients(27.9%)had lung metastasis and 54 patients(88.5%)had liver metastasis. Abnormal baseline LDH occurred in 4 patients and 52 patients had normal LDH. Favorite and intermediate risk patients categorized by MSKCC risk stratification accounted for 59.6%(34 patients)and 40.4%(23 patients), respectively. Six patients(9.8%)experienced distant metastasis at initial diagnosis, with 4 of them undergoing primary site resection, and the other 55 patients undergoing radical nephrectomy. PD-L1 expression was detected by the immunohistochemical staining method. PD-L1 staining rate ≥1% detected on the tumor cell membrane was defined as positive expression. The correlation between PD-L1 expression and clinicopathological characteristics were compared. Kaplan-Meier method and log-rank test were used to compare the differences about DFS and OS under different factors. Cox proportional hazards regression model is used for multivariable analysis of survival data.Results:The detailed pathological types of the 61 patients with renal cell carcinoma were classified as 53 clear cell carcinomas, 3 papillary carcinomas, 1 collecting duct carcinoma, 2 translocation renal cell carcinomas and 2 being unclassified. There were 4, 20, 19 and 9 patients categorized as WHO/ISUP nuclear grade 1, 2, 3 and 4, and 26, 12, 20 and 2 patients were categorized as T 1, T 2, T 3 and T 4 stage, respectively. Five patients had regional lymph node metastasis(N+), and the other 56 patients had no regional lymph node metastasis(N-). The numbers of patients categorized as stage Ⅰ, Ⅱ, Ⅲ and Ⅳ diseases according to TNM staging system were 20, 11, 21 and 8, respectively. The total PD-L1 positive rate was 24.6%(15/61). The corresponding PD-L1 expression rate of patients with WHO/ISUP nuclear grade 1-4 were 0(0 patient), 5.0%(1 patient), 31.6%(6 patients)and 44.4%(4 patients), respectively; With the increasing WHO/ISUP nuclear grade, the positive rate of PD-L1 gradually escalated with a linear correlation ( P=0.006). The PD-L1 expression of the normal and abnormal LDH group were 19.2%(10 patients)and 75.0%(3 patients), respectively, with significant difference( P=0.035). Univariate analysis of disease-free survival time(DFS)showed that the prognostic factors include PD-L1( P=0.045), age group( P=0.014), WHO/ISUP nuclear grade( P<0.001), T stage( P=0.015), N stage( P=0.026)and TNM stage( P=0.005). However multivariate analysis only suggested WHO/ISUP nuclear grade as the independent prognostic factors for DFS( HR=1.8, 95% CI 1.1-2.9, P=0.018). Either in univariate or multivariate analysis, PD-L1 was not a prognostic factor for overall survival (OS)of mRCC patients(univariate analysis: P=0.154; multivariate analysis: P=0.902). The independent prognostic factors of OS include WHO/ISUP nuclear grade( HR=3.0, 95% CI 1.1-8.0, P=0.033)and MSKCC risk stratification( HR=5.9, 95% CI 1.2-29.7, P=0.03). Conclusions:This study showed that the higher the WHO/ISUP nuclear grade of patients with mRCC, the higher the positive rate of PD-L1. PD-L1 expression was not the independent prognostic factor for DFS or OS of mRCC.

Objective: To study the therapeutic value of endoscopic ultrasonography-guided hepaticogastrostomy(EUS-HG) for patients with high malignant biliary obstructive jaundice. Methods: A total of 56 patients with high malignant obstructive jaundice hospitalized at the Second Affiliated Hospital of Nanjing Medical University and the Second Affiliated Hospital of Xuzhou Medical University from January 2014 to December 2017 were included in the study. There were 29 males and 27 females with median age of 72 (60-82) years. Patients were randomized into two groups according to the random number table, the EUS-HG group (n=20) treated with EUS-HG and the percuteneous transhepatic cholangiodrainge(PTCD) group (n=36) treated with PTCD. The operative success rate, curative effect, complications and operation cost were compared between the two groups, and the median unblock period of plastic double pig tail stent was observed. Results: (1)The success rates were 100% in both groups. (2) Preoperative and one-month postoperative levels of the following were tested and compared. Levels of total bilirubin were 362.15±138.27 μmol/L, 56.85±28.57 μmol/L in the EUS-HG group and 356.47±130.69 μmol/L, 60.93±25.79 μmol/L in the PTCD group, respectively. Levels of alkaline phosphatase were 896.57±357.29 U/L, 146.59±48.63 U/L in the EUS-HG group and 883.65±364.32 U/L, 151.57±49.73 U/L in the PTCD group, respectively. Levels of alanine aminotransferase were 252.36±38.77 U/L, 60.29±31.57 U/L in the EUS-HG group and 246.26±32.57 U/L, 62.56±32.87 U/L in the PTCD group. Levels of aspartate aminotransferase were 259.37±30.64 U/L, 62.28±26.58 U/L in the EUS-HG group and 242.37±29.52 U/L, 60.28±29.57 U/L in the PTCD group, and there was no significant difference between the two groups (P>0. 05). CRP levels were 52.57±31.95 mg/L, 16.95±8.77 mg/L in the EUS-HG group and 53.42±35.79 mg/L, 25.13±14.77 mg/L in the PTCD group (P<0.05). (3)There was significant difference in remission rate of anorexia and abdominal distension between the two groups [80.0%(16/20) VS 52.8%(19/36), P<0.05]. There was no significant difference in symptom relief of jaundice, pruritus or abdominal pain between the two groups [90.0%(18 /20)VS 91.7%(33/36), P>0.05]. (4) The incidence of total complications in the EUS-HG group (20.0%, 4/20) was significantly lower than that in the PTCD group (47.2%, 17/36, P<0.05). (5)The cost of operation in the EUS-HG group (22 685.26±2 356.16 yuan) was slightly higher than that in the PTCD group (20 529.57±4 135.63 yuan, P>0.05). (6) The median unblock period of double pig tail plastic stents in EUS-HG group patients was 102 days. Conclusion EUS-HG is a safe and effective method for the treatment of high malignant biliary obstructive jaundice. It can be used as the first choice for treatment after failure of conventional ERCP.