Objective To evaluate the effect of esketamine combined with distal limb ischemic preconditioning(LIP)for lung protection in elderly patients undergoing thoracoscopic radical surgery for lung cancer.Methods This randomized trial was conducted in 160 patients undergoing elective thoracoscopic surgery for lung cancer,who were randomized into control group(with saline injection and sham LIP),esketamine group,LIP group,and esketamine+LIP group(n=40).Before anesthesia induction,according to the grouping,the patients received an intravenous injection with 0.5 mg/kg esketamine or 10 ml saline(in control group).LIP was induced by applying a tourniquet 1-2 cm above the popliteal fossa in the left lower limb to block the blood flow for 5 min for 3 times at the interval of 5 min,and sham LIP was performed by applying the tourniquet without pressurization for 30 min.Oxygenation index(OI)and alveolar-arterial PO2 difference(A-aDO2)were calculated before induction(T0),at 30 min(T0.5)and 1 h(T1)of one-lung ventilation(OLV),and at 1 h after two-lung ventilation(T3).Serum levels of SP-D,CC-16 and TNF-α were measured by ELISA at T0,T1,T2(2 h of OLV),T3,and 24 h after the operation(T4).The length of hospital stay and postoperative pulmonary complications of the patients were recorded.Results Compared with those in the control group,the patients in the other 3 groups had significantly lower CC-16,SP-D and TNF-α levels,shorter hospital stay,and lower incidences of lung infection and lung atelectasis(all P<0.05).Serum CC-16,SP-D and TNF-α levels,hospital stay,incidences of complications were significantly lower or shorter in the combined treatment group than in esketamine group and LIP group(all P<0.05).Conclusion In elderly patients undergoing thoracoscopic radical surgery for lung cancer,treatment with esketamine combined with LIP can alleviate acute lung injury by enhancing anti-inflammatory response to shorten postoperative hospital stay,reduce lung complications and promote the patients'recovery.

Objective To explore the effect of urine mixing degree on 24-hour urinary total protein(24 h UTP)in patients with chronic kidney disease(CKD).Methods From October 1,2023 to December 31,2023,30 hospitalized patients who needed to complete 24 h UTP testing in Zhongshan Hospital,Fudan University were selected.A 5 L unified container was used to collect urine for 24 hours.After collection and one hour's standing,the urine sample was divided into upper,middle,and lower equal parts according to volume,which was defined as direct-sampling group.Then,the urine samples were fully mixed with a magnetic stirrer and sampled again according to the above-mentioned three-equal sampling method,which was defined as mixed-sampling group.The generalized estimating equation was used to compare the urinary protein concentration before and after mixing and at different sampling location.Results The results of generalized estimating equation showed that after controlling the variable"sampling position",there was no significant difference in urinary protein concentration between the direct-sampling group and the mixed-sampling group.After controlling the variable"mixing method",there was still no significant difference in urinary protein concentration at different sampling positions.After adjusting the covariates such as age,gender,and estimated glomerular filtration rate(eGFR),the results were consistent.Conclusions With standard protocol,the entire 24-hour urine sample is a relatively even-distributed solution.After the total urine collection is completed,the temporary sample can be directly extracted from any level of the original urine within 1 hour,and the urine protein concentration of the sample multiplied by the urine volume can reflect the 24 h UTR.

Objective To evaluate the effect of esketamine combined with distal limb ischemic preconditioning(LIP)for lung protection in elderly patients undergoing thoracoscopic radical surgery for lung cancer.Methods This randomized trial was conducted in 160 patients undergoing elective thoracoscopic surgery for lung cancer,who were randomized into control group(with saline injection and sham LIP),esketamine group,LIP group,and esketamine+LIP group(n=40).Before anesthesia induction,according to the grouping,the patients received an intravenous injection with 0.5 mg/kg esketamine or 10 ml saline(in control group).LIP was induced by applying a tourniquet 1-2 cm above the popliteal fossa in the left lower limb to block the blood flow for 5 min for 3 times at the interval of 5 min,and sham LIP was performed by applying the tourniquet without pressurization for 30 min.Oxygenation index(OI)and alveolar-arterial PO2 difference(A-aDO2)were calculated before induction(T0),at 30 min(T0.5)and 1 h(T1)of one-lung ventilation(OLV),and at 1 h after two-lung ventilation(T3).Serum levels of SP-D,CC-16 and TNF-α were measured by ELISA at T0,T1,T2(2 h of OLV),T3,and 24 h after the operation(T4).The length of hospital stay and postoperative pulmonary complications of the patients were recorded.Results Compared with those in the control group,the patients in the other 3 groups had significantly lower CC-16,SP-D and TNF-α levels,shorter hospital stay,and lower incidences of lung infection and lung atelectasis(all P<0.05).Serum CC-16,SP-D and TNF-α levels,hospital stay,incidences of complications were significantly lower or shorter in the combined treatment group than in esketamine group and LIP group(all P<0.05).Conclusion In elderly patients undergoing thoracoscopic radical surgery for lung cancer,treatment with esketamine combined with LIP can alleviate acute lung injury by enhancing anti-inflammatory response to shorten postoperative hospital stay,reduce lung complications and promote the patients'recovery.

【Objective】 To explore the differential expression and functional analysis of circRNA from myocardial mitochondria in diabetes cardiomyopathy (DCM) mice. 【Methods】 The DCM mice model was established in 16-week-old db/db mice, and C57BL/KsJ mice were used as controls. RNA was extracted from the myocardium of two groups of mice, high-throughput sequencing was used to screen mitochondrial circRNA differentially expressed in the two groups, RT-qPCR was used to verify the sequencing results of the first 10 circRNAs with significant differential expression, and functional enrichment analysis was performed on the differentially expressed circRNA target genes, and miRNA target prediction software was used to analyze the circRNA-miRNA co-expression network. 【Results】 There were 147 mitochondrial circRNAs differentially expressed in the myocardium of DCM mice, including 89 highly expressed and 58 low expressed. The expression pattern of differentially expressed circRNAs in tissues was consistent with those of sequencing results. The enrichment analysis of GO and KEGG showed that the differentially expressed circRNA target genes were mainly enriched in cGMP/PKG, glucagon pathways, which were related to mitochondrial energy metabolism and cardiac hypertrophy. circRNA-miRNA co-expression analysis found that the most significantly up-regulated circRNA, chrM:1207-1536+, was associated with miR-491-3p, miR-99a-3p, and miR-99b-3p, and the most significantly down-regulated circRNA, chrM:1453-3205+, was associated with miR-181b-1-3p, miR-181b-2-3p, and miR-672-5p. 【Conclusion】 Compared to the control mice, there is differential expression of circRNAs in myocardial mitochondria of DCM mice. The differentially expressed circRNAs may interact with the corresponding miRNA to affect myocardial fibrosis and hypertrophy through regulation of energy metabolism, apoptosis and other pathways, thus participating in the pathogenesis of DCM.

Objective:To investigate the teaching effect of flipped classroom combined with problem-based learning (PBL) in the teaching of the Diagnostic Audiology course.Methods:A total of 72 undergraduate students majoring in audiology and speech rehabilitation in the classes of 2019 and 2020 in Chongqing Medical University were enrolled as subjects, and three chapters of the Diagnostic Audiology course were selected for teaching reform. The 34 students in the class of 2019 were enrolled as control group and received lecture-based learning (LBL), and the 38 students in the class of 2020 were enrolled as experimental group and received flipped classroom combined with PBL. The teaching effect was evaluated by comparing the two groups in terms of classroom test scores, classroom participation scores, degree of satisfaction with teaching effect, and overall satisfaction with teaching. SPSS 23.0 software was used to perform the t-test, the chi-square test, and the Mann-Whitney U test. Results:The experimental group had a significantly higher classroom test score than the control group (25.95±1.21 vs. 23.21±1.55, P<0.001). In terms of classroom participation scores, the experimental group had significantly higher scores of participation in class discussion, cooperative and collaborative abilities, and questioning skills than the control group (all P<0.001). In terms of the degree of satisfaction with teaching, compared with the control group, the experimental group had significantly higher degrees of satisfaction in the dimensions such as interest in learning, mastery of theoretical knowledge, teamwork and collaboration abilities, self-learning ability, and self-presentation ( P=0.005, 0.009, 0.001, 0.016, and 0.005). In addition, the experimental group had a significantly higher degree of overall satisfaction with teaching than the control group ( P=0.006). Conclusion:Flipped classroom combined with PBL has a good teaching effect in the Diagnostic Audiology course and thus holds promise for further application.

Objective:To investigate the epidemiological characteristics, diagnosis, treat-ment and prognosis of gallbladder cancer in China from 2010 to 2017.Methods:The single disease retrospective registration cohort study was conducted. Based on the concept of the real world study, the clinicopathological data, from multicenter retrospective clinical data database of gallbladder cancer of Chinese Research Group of Gallbladder Cancer (CRGGC), of 6 159 patients with gallbladder cancer who were admitted to 42 hospitals from January 2010 to December 2017 were collected. Observation indicators: (1) case resources; (2) age and sex distribution; (3) diagnosis; (4) surgical treatment and prognosis; (5) multimodality therapy and prognosis. The follow-up data of the 42 hospitals were collected and analyzed by the CRGGC. The main outcome indicator was the overall survival time from date of operation for surgical patients or date of diagnosis for non-surgical patients to the end of outcome event or the last follow-up. Measurement data with normal distribu-tion were represented as Mean±SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( Q1, Q3) or M(range), and com-parison between groups was conducted using the U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Univariate analysis was performed using the Logistic forced regression model, and variables with P<0.1 in the univariate analysis were included for multivariate analysis. Multivariate analysis was performed using the Logistic stepwise regression model. The life table method was used to calculate survival rates and the Kaplan-Meier method was used to draw survival curves. Log-rank test was used for survival analysis. Results:(1) Case resources: of the 42 hospitals, there were 35 class A of tertiary hospitals and 7 class B of tertiary hospitals, 16 hospitals with high admission of gallbladder cancer and 26 hospitals with low admission of gallbladder cancer, respectively. Geographical distribution of the 42 hospitals: there were 9 hospitals in central China, 5 hospitals in northeast China, 22 hospitals in eastern China and 6 hospitals in western China. Geographical distribution of the 6 159 patients: there were 2 154 cases(34.973%) from central China, 705 cases(11.447%) from northeast China, 1 969 cases(31.969%) from eastern China and 1 331 cases(21.611%) from western China. The total average number of cases undergoing diagnosis and treatment in hospitals of the 6 159 patients was 18.3±4.5 per year, in which the average number of cases undergoing diagnosis and treatment in hospitals of 4 974 patients(80.760%) from hospitals with high admission of gallbladder cancer was 38.8±8.9 per year and the average number of cases undergoing diagnosis and treatment in hospitals of 1 185 patients(19.240%) from hospitals with low admission of gallbladder cancer was 5.7±1.9 per year. (2) Age and sex distribution: the age of 6 159 patients diagnosed as gallbladder cancer was 64(56,71) years, in which the age of 2 247 male patients(36.483%) diagnosed as gallbladder cancer was 64(58,71)years and the age of 3 912 female patients(63.517%) diagnosed as gallbladder cancer was 63(55,71)years. The sex ratio of female to male was 1.74:1. Of 6 159 patients, 3 886 cases(63.095%) were diagnosed as gallbladder cancer at 56 to 75 years old. There was a significant difference on age at diagnosis between male and female patients ( Z=-3.99, P<0.001). (3) Diagnosis: of 6 159 patients, 2 503 cases(40.640%) were initially diagnosed as gallbladder cancer and 3 656 cases(59.360%) were initially diagnosed as non-gallbladder cancer. There were 2 110 patients(34.259%) not undergoing surgical treatment, of which 200 cases(9.479%) were initially diagnosed as gallbladder cancer and 1 910 cases(90.521%) were initially diagnosed as non-gallbladder cancer. There were 4 049 patients(65.741%) undergoing surgical treatment, of which 2 303 cases(56.878%) were initially diagnosed as gallbladder cancer and 1 746 cases(43.122%) were initial diagnosed as non-gallbladder cancer. Of the 1 746 patients who were initially diagnosed as non-gallbladder cancer, there were 774 cases(19.116%) diagnosed as gallbladder cancer during operation and 972 cases(24.006%) diagnosed as gallbladder cancer after operation. Of 6 159 patients, there were 2 521 cases(40.932%), 2 335 cases(37.912%) and 1 114 cases(18.087%) undergoing ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) examination before initial diagnosis, respec-tively, and there were 3 259 cases(52.914%), 3 172 cases(51.502%) and 4 016 cases(65.205%) undergoing serum carcinoembryonic antigen, CA19-9 or CA125 examination before initially diagnosis, respectively. One patient may underwent multiple examinations. Results of univariate analysis showed that geographical distribution of hospitals (eastern China or western China), age ≥72 years, gallbladder cancer annual admission of hospitals, whether undergoing ultrasound, CT, MRI, serum carcinoembryonic antigen, CA19-9 or CA125 examination before initially diagnosis were related factors influencing initial diagnosis of gallbladder cancer patients ( odds ratio=1.45, 1.98, 0.69, 0.68, 2.43, 0.41, 1.63, 0.41, 0.39, 0.42, 95% confidence interval as 1.21-1.74, 1.64-2.40, 0.59-0.80, 0.60-0.78, 2.19-2.70, 0.37-0.45, 1.43-1.86, 0.37-0.45, 0.35-0.43, 0.38-0.47, P<0.05). Results of multivariate analysis showed that geographical distribution of hospitals (eastern China or western China), sex, age ≥72 years, gallbladder cancer annual admission of hospitals and cases undergoing ultrasound, CT, serum CA19-9 examination before initially diagnosis were indepen-dent influencing factors influencing initial diagnosis of gallbladder cancer patients ( odds ratio=1.36, 1.42, 0.89, 0.67, 1.85, 1.56, 1.57, 0.39, 95% confidence interval as 1.13-1.64, 1.16-1.73, 0.79-0.99, 0.57-0.78, 1.60-2.14, 1.38-1.77, 1.38-1.79, 0.35-0.43, P<0.05). (4) Surgical treatment and prognosis. Of the 4 049 patients undergoing surgical treatment, there were 2 447 cases(60.435%) with complete pathological staging data and follow-up data. Cases with pathological staging as stage 0, stage Ⅰ, stage Ⅱ, stage Ⅲa, stage Ⅲb, stage Ⅳa and stage Ⅳb were 85(3.474%), 201(8.214%), 71(2.902%), 890(36.371%), 382(15.611%), 33(1.348%) and 785(32.080%), respectively. The median follow-up time and median postoperative overall survival time of the 2 447 cases were 55.75 months (95% confidence interval as 52.78-58.35) and 23.46 months (95% confidence interval as 21.23-25.71), respectively. There was a significant difference in the overall survival between cases with pathological staging as stage 0, stage Ⅰ, stage Ⅱ, stage Ⅲa, stage Ⅲb, stage Ⅳa and stage Ⅳb ( χ2=512.47, P<0.001). Of the 4 049 patients undergoing surgical treatment, there were 2 988 cases(73.796%) with resectable tumor, 177 cases(4.371%) with unresectable tumor and 884 cases(21.833%) with tumor unassessable for resectabi-lity. Of the 2 988 cases with resectable tumor, there were 2 036 cases(68.139%) undergoing radical resection, 504 cases(16.867%) undergoing non-radical resection and 448 cases(14.994%) with operation unassessable for curative effect. Of the 2 447 cases with complete pathological staging data and follow-up data who underwent surgical treatment, there were 53 cases(2.166%) with unresectable tumor, 300 cases(12.260%) with resectable tumor and receiving non-radical resection, 1 441 cases(58.888%) with resectable tumor and receiving radical resection, 653 cases(26.686%) with resectable tumor and receiving operation unassessable for curative effect. There were 733 cases not undergoing surgical treatment with complete pathological staging data and follow-up data. There was a significant difference in the overall survival between cases not undergoing surgical treatment, cases undergoing surgical treatment for unresectable tumor, cases undergoing non-radical resection for resectable tumor and cases undergoing radical resection for resectable tumor ( χ2=121.04, P<0.001). (5) Multimodality therapy and prognosis: of 6 159 patients, there were 541 cases(8.784%) under-going postoperative adjuvant chemotherapy and advanced chemotherapy, 76 cases(1.234%) under-going radiotherapy. There were 1 170 advanced gallbladder cancer (pathological staging ≥stage Ⅲa) patients undergoing radical resection, including 126 cases(10.769%) with post-operative adjuvant chemotherapy and 1 044 cases(89.231%) without postoperative adjuvant chemo-therapy. There was no significant difference in the overall survival between cases with post-operative adjuvant chemotherapy and cases without postoperative adjuvant chemotherapy ( χ2=0.23, P=0.629). There were 658 patients with pathological staging as stage Ⅲa who underwent radical resection, including 66 cases(10.030%) with postoperative adjuvant chemotherapy and 592 cases(89.970%) without postoperative adjuvant chemotherapy. There was no significant difference in the overall survival between cases with postoperative adjuvant chemotherapy and cases without postoperative adjuvant chemotherapy ( χ2=0.05, P=0.817). There were 512 patients with pathological staging ≥stage Ⅲb who underwent radical resection, including 60 cases(11.719%) with postoperative adjuvant chemotherapy and 452 cases(88.281%) without postoperative adjuvant chemotherapy. There was no significant difference in the overall survival between cases with postoperative adjuvant chemo-therapy and cases without post-operative adjuvant chemo-therapy ( χ2=1.50, P=0.220). Conclusions:There are more women than men with gallbladder cancer in China and more than half of patients are diagnosed at the age of 56 to 75 years. Cases undergoing ultrasound, CT, serum CA19-9 examination before initial diagnosis are independent influencing factors influencing initial diagnosis of gallbladder cancer patients. Preoperative resectability evaluation can improve the therapy strategy and patient prognosis. Adjuvant chemotherapy for gallbladder cancer is not standardized and in low proportion in China.

Objective:To investigate whether the existence of thoracic artery blood supply in peripheral pulmonary lesions is the key factor affecting the accuracy of contrast-enhanced ultrasound in differentiating benign and malignant lesions.Methods:From June 2020 to December 2021, a total of 170 patients with peripheral pulmonary lesions were consecutively enrolled in Xi′an Chest Hospital, and all patients underwent conventional ultrasound and contrast-enhanced ultrasound(CEUS). Taking ΔAT(lesion-lung arrival time difference ) of 2.5 seconds as the cut-off point for differentiating benign and malignant lesions(ΔAT<2.5 s for benign, ΔAT≥2.5 s for malignant), and the final pathological results as the gold standard, these patiens were divided into correct classification group and wrong classification group, and the main influencing factors of wrong classification were analyzed.Results:Compared with the correct classification group, the proportion of thoracic artery blood supply in the wrong classification group was significantly higher ( P<0.001). After adjusting the dendritic venous reflux, thoracic artery blood supply was an independent influencing factor for CEUS misclassification ( OR=3.531, 95% CI=1.805-6.908, P<0.001). In the patients with thoracic artery blood supply, the sensitivity of the absence of dendritic venous reflux in judging malignant peripulmonary lesions was 75.0%, the specificity was 91.3%, and the area under the ROC curve (AUC) was 0.832 (95% CI=0.715-0.915, P<0.001), while the sensitivity, specificity and AUC of CEUS in judging malignant peripulmonary lesions were 68.7%, 67.4% and 0.659 (95% CI=0.528-0.775, P=0.006), and there was significant statistical difference in the AUC between them( P<0.001). In the group of patients without thoracic arterial blood supply, the sensitivity of the absence of dendritic venous reflux in judging malignant peripulmonary lesions was 82.8%, the specificity was 63.3%, and the AUC was 0.730 (95% CI=0.636-0.811, P<0.001), while the sensitivity, specificity and AUC of CEUS in judging malignant peripulmonary lesions were 62.1%, 81.0% and 0.684 (95% CI=0.587-0.770, P=0.003), and there was no significant difference in the AUC between them ( P=0.425). Conclusions:The presence of thoracic artery blood supply significantly decrease the diagnostic efficiency of CEUS in differentiating benign and malignant of peripheral pulmonary lesions. For peripheral pulmonary lesions with thoracic arterial blood supply, the diagnostic efficiency of dendritic venous reflux is better than CEUS, while for lesions without thoracic artery supply, the diagnostic efficiency of dendritic venous reflux is equivalent to CEUS.

ObjectiveTo investigate the resistance to pyrethroids， beta-cyhalothrin and fenitrothion as well as the frequencies of kdr andace⁃1 alleles in Anopheles sinensis from three geographical populations in Chongming District， Shanghai. MethodsThe contact tube method recommended by WHO was used to determine mosquito resistance. The frequencies of kdr and ace⁃1 alleles in adult mosquitoes were determined by PCR amplification. The correlation between the frequencies of kdr alleles and insecticide resistance was analyzed by linear regression method. ResultsThe mosquito population near natural reserve （NF） was sensitive to deltamethrin， and the mortality rate was 100.00% at 24 h. The mosquito population with intensive breeding farms （HX） showed resistance to deltamethrin and beta-cyhalothrin， and the 24 h mortality was 48.00 % and 57.50 %， respectively. The 24 h mortality rate of the mosquito population with urban-rural integration area （AS） with suspected resistance to deltamethrin and beta-cyhalothrin was 84.40% and 86.00%. The 24 h mortality rate to Fenitrothion was 55.67%. There were 3 mutations in kdr gene locus 1014， and 7 mutated genotypes were detected， mainly L1014/L1014F and L1014F/L1014F. The mutation frequency of kdr allele in HX population was the highest （52.68%）. There was one mutation at site 119 of ace⁃1 gene， and three genotypes were detected， most of which were G119S mutation. There was a significant negative correlation between the frequency of kdr resistance allele and the mortality rate of beta-cypermethrin in An.sinensis populations （r²=0.930，P=0.036）. There was a significant negative correlation between the frequency of ace⁃1 resistance allele and the mortality rate of fenitrothion in An. sinensis populations from four habitats（r²=0.996，P=0.038）. ConclusionThe mutation frequency of insecticide resistance allele is associated with the development of mosquito resistance level. Therefore， comprehensive monitoring of resistance levels of An.sinensis in Chongming area should be continued to provide a basis for local mosquito resistance management.

Solid tumors always exhibit local hypoxia, resulting in the high metastasis and inertness to chemotherapy. Reconstruction of hypoxic tumor microenvironment (TME) is considered a potential therapy compared to directly killing tumor cells. However, the insufficient oxygen delivery to deep tumor and the confronting "Warburg effect" compromise the efficacy of hypoxia alleviation. Herein, we construct a cascade enzyme-powered nanomotor (NM-si), which can simultaneously provide sufficient oxygen in deep tumor and inhibit the aerobic glycolysis to potentiate anti-metastasis in chemotherapy. Catalase (Cat) and glucose oxidase (GOx) are co-adsorbed on our previously reported CAuNCs@HA to form self-propelled nanomotor (NM), with hexokinase-2 (HK-2) siRNA further condensed (NM-si). The persistent production of oxygen bubbles from the cascade enzymatic reaction propels NM-si to move forward autonomously and in a controllable direction along H

Objective    To investigate the feature of the angulation between left pulmonary artery (LPA) and main pulmonary artery (MPA) and its relationship to pulmonary artery development in patients with tetralogy of Fallot (TOF). Methods    A total of 101 TOF patients in West China Hospital from 2014 to 2018 were enrolled in a TOF group, including 62 males and 39 females, aged 6.8 (0.3-45.8) years, and another 20 patients without basic cardiac diseases at the same stage were enrolled in a control group, including 10 males and 10 females, aged 6.9 (0.3-54.0) years. Diameters of LPA, right pulmonary artery (RPA) and MPA, the angulation between LPA and MPA (MPA-LPA), McGoon ratio, and Nakata index were measured and compared between the two groups. The relationship between the above data and MPA-LPA angulation was also analyzed. Results    The average MPA-LPA angulation was smaller in the TOF group than that in the control group (113.63° vs. 128.45°, P=0.001 8). The MPA Z score was also smaller in the TOF group than that in the control group (0.46 vs. 2.75, P=0.000 4). No relationship was found by correlation analysis between the MPA-LPA angulation and MPA Z score or LPA Z score in the control group (P=0.239 6, 0.114 7) and the TOF group (P=0.759 3, 0.242 7). The McGoon ratios (2.22±0.72, 2.43±0.94, P=0.340 0) and Nakata index (359.3±294.24, 395.52±329.31, P=0.650 0) were not significantly different between the two groups. Conclusion    The angulation of LPA-MPA and MPA Z score are smaller in the TOF group than those in the control group. There is no relationship between MPA-LPA angulation and pulmonary artery diameters. The LPA-MPA angulation should not be considered as an influence factor for LPA development and trans-annular patch surgery.