Objective To observe the effect of in situ needle fenestration thoracic endovascular aortic repair(TEVAR)for treating aortic dissection(AD)involving aortic arch.Methods Data of 16 patients with AD involving aortic arch who underwent in situ needle fenestration TEVAR for reconstruction of aortic arch branches were retrospectively analyzed,and the number of fenestration,technical success rate and TEVAR related complications were recorded.Regular follow-up was conducted after TEVAR,the repair of dissection and the patency of fenestrated branch blood vessels were evaluated,the endoleak was assessed,and the survival of patients were recorded.Results The main aortic stent was successfully implanted in all 16 cases.Among them,4 received triple fenestration stent implantation in zones Z0,Z1 and Z2,6 received double fenestration stent implantation in zones Z1 and Z2,2 received double fenestration stent implantation in zones Z0 and Z1 and 4 received single fenestration stent implantation in zone Z2.The success rate of brachiocephalic trunk(BCT)fenestration was 83.33%(5/6).Left common carotid artery(LCCA)-right common carotid artery bypass was performed in 1 case without successful fenestration.The success rate of LCCA fenestration was 100%(12/12).The success rate of left subclavian artery(LSA)fenestration was 87.50%(14/16),2 cases with not successful fenestration were treated with axillar-axillary artery artificial vascular bypass.The technical success rate of intervention was 100%(16/16).Type Ⅰa endoleak occurred in 1 case during TEVAR process and improved after embolization with spring coil.One patient died of pericardial tamponade at the end of TEVAR.Fifteen patients were followed up for a median follow-up time of 20 months.During this period,transient ischemic attack and local small dissection at the proximal beginning of the main stent occurred each in 1 case,which improved after no special treatment.Type Ⅰ endoleak occurred in 1 case,type Ⅲ endoleak occurred in 2 cases,all improved after proximal fenestrated membrane stent implantation or spring coil embolization treatment.One case died of coronary heart disease.Conclusion In situ needle fenestration TEVAR was effective and safe for treating AD involving aortic arch.

Objective:To comprehensively evaluate the effectiveness of preventive measures for acute kidney injury (AKI) in children and identify the effective strategies.Methods:Databases were systematically searched including CNKI, Wanfang, VIP, China Biology Medicine National Knowledge Infrastructure, PubMed, Embase, Cochrane Library databases, and the reference lists of relevant papers for randomized controlled trials on preventing pediatric AKI up to December 2023. Literature screening was conducted based on the inclusion and exclusion criteria, followed by data extraction and quality assessment of included studies. Traditional and network meta-analyses were performed, along with trial sequential analysis (TSA).Results:A total of 21 studies involving 3 483 children were included. Traditional and network meta-analysis showed that dexmedetomidine was effective in preventing AKI in children undergoing cardiac surgery or cardiac angiography ( OR=0.26, 0.27; 95% CI 0.11-0.64, 0.13-0.58). Remote ischemic preconditioning (RIPC) was effective in preventing AKI in children after cardiac surgery ( OR=0.43, 0.44; 95% CI 0.24-0.79, 0.23-0.83). Traditional and network meta-analysis specific to children with sepsis or septic shock showed that balanced solution was effective in preventing pediatric AKI ( OR=0.58, 0.52; 95% CI 0.42-0.79, 0.37-0.73). TSA indicated that the total sample sizes of dexmedetomidine (348 cases) and RIPC (666 cases) both reached the required information size (320 and 534 cases); additionally, the Z-curve for balanced solution (cumulative Z=3.38) crossed the TSA monitoring boundary ( Z=3.29). Conclusion:Dexmedetomidine reduces the risk of AKI in children undergoing cardiac surgery or cardiac angiography, RIPC decreases the risk of AKI in children after cardiac surgery, and balanced solution lowers the risk of AKI in children with sepsis or septic shock.

Objective:To identify the influencing factors for community elderly health services provided by general practitioners (GPs) using the social ecological theory, for reference in improving their participation and satisfaction.Methods:According to the social ecological theory, an ecological model for GPs to carry out community elderly health services was constructed from four levels: public policy ecology, community health service ecology, interpersonal relationship ecology, and individual characteristics ecology of general practitioners. A survey questionnaire was designed with six latent variables: public health policy support, public health service and basic medical service supply, doctor-patient relationship, individual participation and individual satisfaction. The questionnaire was distributed to 220 GPs from 11 primary healthcare institutions in Jiangsu province, China, who were randomly selected between October and November 2021. Exploratory and confirmatory analyses of the model were conducted using AMOS 25.0.Results:A total of 207 valid questionnaires were collected, and all the KMO values of the six latent variables were greater than 0.7, while the composite reliability values and average variance extracted values greater than 0.7 and 0.5, respectively. Both the reliability and validity of the data met the analysis requirements. Exploratory analysis revealed that public health policy support had a direct positive effect on both public health service and basic medical service supply (both effect sizes being 0.37). Public health service had a direct positive effect on doctor-patient relationship, individual participation and individual satisfaction (effect sizes being 0.52, 0.22, and 0.31, respectively). The direct effect of basic medical service supply on doctor-patient relationship was not significant (effect size being 0.03), but it had a direct positive effect on public health service (effect size being 0.46). Doctor-patient relationship had a direct positive effect on individual participation (effect size being 0.51), but its direct effect on individual satisfaction was not significant (effect size being 0.06). Individual participation had a direct positive effect on individual satisfaction (effect size being 0.52). Conclusions:By optimizing the public policy ecosystem, community health service ecosystem, and interpersonal relationship ecosystem, the participation and satisfaction of general practitioners can be systematically improved.

Teratoma is a rare tumor, mainly occurring in the ovary, sacrococcygeal region, testis, central nervous system and mediastinum, rarely occurring in the kidney, and adult immature teratoma originating in the kidney is extremely rare. A case of adult left renal immature teratoma was reported in this paper. After radical nephrectomy, pathological examination found that the tumor tissue contains malignant epithelial tissue and a small number of brain tissue. BEP regimen chemotherapy was performed after operation.The patient was followed up for 26 months, and died of organ failure caused by systemic metastasis.

Objective:To investigate the imaging and electrophysiological characteristics, surgical methods and efficacies of preschoolers with refractory temporal lobe epilepsy.Methods:A retrospective data study was conducted on 27 patients with refractory temporal lobe epilepsy accepted surgical treatment in our hospital from June 2014 to January 2019. By combined with clinical manifestations, preoperative epileptogenic zones were evaluated by imaging data, such as MR imaging, MR spectroscopy and positron emission tomography-CT, and interictal and ictal video-electroencephalogram (VEEG) data. During the surgery, cortical electroencephalography (ECoG) and deep electrode monitoring were used to monitor and locate the abnormal discharge areas to guide the surgical excision of epileptic zone. Engel grading was used to evaluate the efficacy after surgery.Results:All children had typical clinical manifestations of temporal lobe epilepsy; abnormal signal images were found in one side of the temporal lobe and the hippocampus in MR imaging; epileptic discharges were originated from one side frontotemporal region in interictal and ictal VEEG. Obviously persistent or paroxysmal spike waves, spike waves and slow spikes and spike composite waves were intraoperatively discovered by ECoG and depth electrode electroencephalography in the temporal lobe. All patients accepted standard anterior temporal lobectomy+lesion resection+peripheral abnormal discharge resection of the temporal lobe cortex; partial insular lobe was excised and frontal cortex was performed low power thermal coagulation in two patients. Follow-up was performed for 6 months; Engel grading I was reported in 22 patients (81.5%), Engel grading II in 3 patients (11.1%), and Engel grading III in 2 patients (7.4%).Conclusion:Early surgery and moderate extension of resection under intraoperative ECoG and deep electrode monitoring are the key factors to improve the surgical efficacy of preschoolers with refractory temporal lobe epilepsy.

Objective To investigate the effect of cardiac function and renal function on early neurological function recovery of acute stroke patients.Methods Hospitalized acute stroke patients from January 2010 to May 2018 were recruited in the Department of Neurology,Peking University First Hospital,who were divided into two groups according to the modified Rankin Scale (mRS) score at discharge,good recovery (mRS score ≤2) and poor recovery (mRS score ＞2).The clinical characteristics,laboratory and echocardiography data were collected respectively.All cases were classified according to Trial of Org 10 172 in Acute Stroke Treatment (TOAST) criteria.Estimated glomerular filtration rate (eGFR) was calculated by chronic kidney disease epidemiology collaboration equation in renal function assessment,and cardiac function was calculated by left ventricular ejection fraction (LVFF) and E-wave/A-wave ratio (E/A).Multivariate Logistic regression analysis and stratified analysis were performed to explore the effects of cardiac and renal function and interactions on stroke patients.Results A total of 517 patients with acute stroke were enrolled in this study,23.4％ (121/517) of which presented with chronic kidney disease.Poor recovery was aggravated with the progression of eGFR stage in patients with acute stroke (x2=14.627,P=0.001).Compared with the good recovery group,LVEF and E/A were significantly lower in the poor recovery group,while left atrium diameter ((3.87±0.52) cm vs (3.77±0.49) cm,t=-2.139,P=0.033),interventricular septum thickness ((1.10±0.19) cm vs (1.04±0.16) cm,t=-4.056,P=0.000),left ventricular posterior wall thickness ((1.00±0.13) cm vs (0.98±0.13) cm,t=-2.190,P=0.029) and left ventricular mass index ((102.03±25.73) g/m2 vs (94.94±23.63) g/m2,t=-3.145,P=0.002) were significantly higher in the poor recovery group.Stratified analysis showed that the rate of poor recovery increased with the decrease of eGFR at different levels of LVEF and E/A.Compared with patients of normal renal function and mild impairment of renal function or with patients of high third tertile of LVEF,chronic kidney disease significantly increased the rate of poor recovery in patients with low third tertile of LVEF,while the rate of poor recovery was not significantly different in patients with chronic kidney disease among third tertile of E/A.The levels of eGFR and LVEF in different stroke subtypes were significantly different (F=7.433,P=0.000;F=2.617,P=0.034).The eGFR and LVEF levels of the cardioembolism (CE) group were the lowest compared with other subtypes of stroke.The eGFR levels in the CE group were significantly lower than that in other subtypes except the large artery atherosclerosis group,and the LVEF level was significantly lower in the CE group compared to the small artery occlusion group.Multivariate Logistic regression analysis revealed that eGFR (OR=0.866,95％CI 0.760-0.987,P=0.031),LVEF (OR=0.798,95％CI 0.688-0.925,P=0.003),E/A (OR=0.136,95％CI 0.034-0.548,P=0.005) and eGFR by LVEF (OR=1.002,95％CI 1.000-1.004,P=0.022) were significantly associated with early functional outcome in patients with acute stroke after adjusting for relevant clinical confounders (all P＜0.05).Conclusions Renal function,cardiac systolic and diastolic function were associated with the early functional recovery in patients with acute stroke.Moreover,cardiac systolic dysfunction and renal dysfunction interacted significantly with the early neurological function recovery in patients with acute stroke.

Objective: To summarize the measures and experience of treatment in mass extremely severe burn patients. Methods: The clinical data and treatment of 8 extremely severe burn patients in August 2 Kunshan factory aluminum dust explosion accident who were admitted in the 100th Hospital of PLA on August 2nd, 2014, were retrospectively analyzed. There were 4 males and 4 females, aging 22-45 (34±7) years, with total burn area of 55%-98% [(89±15)%] total body surface area (TBSA) and full-thickness burn area of 45%-97% [(80±21)%] TBSA. All the 8 patients were accompanied with severe shock, inhalation injury, and blast injury. According to the requirements of former PLA General Logistics Department and Nanjing Military Command, a treatment team was set up including a special medical unit and a special care unit, with Chai Jiake from the First Affiliated Hospital of PLA General Hospital as the team leader, Zheng Qingyi from the 175th Hospital of PLA (the Affiliated Dongnan Hospital of Xiamen University) as the deputy leader, the 100th Hospital of PLA as the treatment base, and burn care, respiratory, nephrology, nursing specialists from the First Affiliated Hospital of PLA General Hospital, and the burn care experts and nursing staff from the 180th Hospital of PLA, 118th Hospital of PLA, 98th Hospital of PLA, and 175th Hospital of PLA, and nurses from the 85th Hospital of PLA, 455th Hospital of PLA, 101th Hospital of PLA, 113th Hospital of PLA as team members. Treatment strategies were adopted as unified coordination by the superior, unified responsibility of team leader, division of labor and cooperation between team members, and multidisciplinary cooperation led by department of burns. With exception of one patient who received deep vein catheterization before admission, the other 7 patients were treated with deep vein catheterization 0.5 to 3.0 hours after admission to correct hypovolemic shock as soon as possible. Eight patients received tracheotomy, and 7 patients were treated with mechanical ventilation by ventilator in protective ventilation strategy with low tide volume and low volume pressure to assist breathing. Fiberoptic bronchoscopy was done one to three times for all the 8 patients to confirm airway injuries and healing status. Escharectomy and Meek dermatoplasty in the extremities of all the 8 patients were performed 3 to 6 days after injury for the first time. Escharectomy, microskin grafting, and covering of large pieces of allogeneic skin on the trunks of 4 patients were performed 11 to 16 days after injury for the second time. The broad-spectrum antibiotics were uniformly used at first time of anti-infective therapy, and then the antibiotics species were adjusted in time. The balance of internal environment was maintained and the visceral functions were protected. One special care unit was on responsibility of only one patient. Psychological intervention was performed on admission. The rehabilitative treatment was started at early stage and in company with the whole treatment. Results: Acute renal injury occurred in 5 patients within 36 hours after injury and their renal function was restored to normal 4 days after injury due to active adjustment of fluid resuscitation program. No pulmonary complications, such as severe pulmonary infection and ventilator-associated pneumonia, occurred in the survived patients. One of the 8 patients died, and the other 7 patients were cured successfully. The wounds were basically healed in 2 patients in 26 or 27 days by 2 or 3 times of operation, and in 5 patients by 4 or 5 times of operation. The basic wound healing time was 26-64 (48±15) days for all the 7 patients. Conclusions Treatment strategies of unified coordination by the superior, unified responsibility of team leader, division of labor and cooperation between team members, and multidisciplinary cooperation led by department of burns are the bases to successful treatment. Correcting shock as soon as possible is the prerequisite and closing wound as soon as possible is the key to successful treatment. Comprehensive treatment measures, such as maintaining and regulating the function of viscera, improving the body immunity, and preventing and treating the complications, are the important components to successful treatment. It is emphasized that in the treatment of mass extremely severe burn patients, specialist burn treatment should always be in the dominant position, and other related disciplines may play a part in auxiliary function.

OBJECTIVE:To provide reference for promoting the application ofwhole course tutorial systemin the practice teaching of medical higher vocational colleges. METHODS:Totally 106 students on internships of medical higher vocational colleg-es were selected and randomly divided into control group(n=53)and observation group(n=53). Control group received routineteaching method;observation group receivedwhole course tutorial systemteaching method on the basis of control group. Score, teaching quality and students'satisfactory degree were compared between 2 groups after the end of internship teaching. RESULTS:The scores of autonomous learning ability,comprehensive ability,communication ability,judgment ability,thinking and solving problem ability and total score in observation group were all significantly higher than control group after the end of internship teach-ing;the proportion of good teaching quality in observation group was significantly higher than control group,manifesting as high practical ability,good adaptability,caring patient,good learning condition;the satisfactory degree of students in observation group was significantly higher than control group(98.11% vs. 88.68%),there was statistical significance(P<0.05). CONCLUSIONS:The implementation ofwhole course tutorial systemteaching method in practice teaching of medical higher vocational colleges based on conventional teaching method achieves ideal effect and can improve the students'learning effect,teaching quality and stu-dents'satisfactory degree.

Objective To investigate the clinical features and TCD-detected microembolic signals in patients with hypercoagulability related multiple acute cerebral infarcts within non-single arterial territories, and to explore the possi?ble underlying mechanisms. Methods A retrospective review was conducted on all clinical, laboratory, radiological and TCD monitoring records from patients with hypercoagulability related multiple acute cerebral infarcts within non-single arterial territories, who admitted to the neurology department in our hospital. Results The data from twenty-two cases were finally included in this study. All patients presented with acute-onset localized neurological dysfunction, e.g. hemi?paresis, aphasia, hemiparesthesia, dysarthria, hemianopsia and cortical blindness. Their hypercoagulability related diseas?es included 10 cases of systemic malignancy, 5 moderate to severe hyperhomocystynemia (HCY>50μmol/L), 2 nephrot?ic syndrome, 2 antiphospholipid syndrome, 1 ulcerative colitis, 1 polycythemia vera,1 paroxysmal nocturnal hemoglobin?uria. In 18 cases, the hypercoagulability related diseases were diagnosed after their initial stroke onset. DWI showed mul?tiple disseminated acute cerebral infarcts in non-single arterial territories involving bilateral anterior or anterior plus pos?terior cerebral circulation simultaneously. Foci involved lobar cortex/subcortex of cerebral hemisphere in 22 cases, deep cerebral hemisphere in 12 cases, cerebellum foci in 10 cases,brainstem foci in 2 cases. TCD revealed microembolic sig? nals in ten of 22 patients monitored. Conclusions Patients with multiple acute cerebral infarcts involving non-single arte?rial territories, should be screened for hypercoagulability as in that hypercoagulability and microembolism might be in?volved in the etiology of cerebral infarction.

Objective To characterize the clinical manifestations, laboratory findings of patients with occult sys?temic malignant neoplasms, whose initial manifestation presented as multiple acute cerebral infarcts including coagula?tion function,radiological imaging and microembolic signals (MES) detection by transcranial Doppler sonography (TCD) and to explore the possible underlying mechanisms. Methods All clinical records, laboratory hematological tests includ?ing hypercoagulable states measured by D-dimer levels, brain MRI including DWI, and TCD monitoring MES, the treat?ment and prognosis were retrospectively reviewed in 12 patients with multiple acute cerebral infarcts as the first manifes?tation of occult systemic malignancy. Results The clinical manifestations presented as localized neurological dysfunction, e.g. hemiparesis, aphasia, hemiparesthesia, dysarthria, vertigo and seizures, etc. DWI revealed multiple disseminated acute cerebral infarcts in multiple arterial territories such as the bilateral anterior or anterior plus posterior cerebral circu?lation in all patients. Eleven of 12 patients tested had elevated D-dimer. TCD detected MES in 5 of 7 patients. There were 12 patients diagnosed with occult systemic malignancy including 5 lung cancer, 3 pancreatic cancer, 1 gastric can?cer, 1 colon cancer, 1 endometrial adenocarcinoma and 1 metastatic poorly differentiated mucinous adenocarcinoma with unknown primary. Ten patients already had remote metastasis at diagnosis. The prognosis was usually poor and there were 7 cases with ischemic stroke recurrence, 4 cases with acute myocardial infarction, 3 cases died during hospitaliza?tion. Conclusions When patients present with multiple disseminated acute cerebral infarcts involving multiple arterial territories as initial manifestation, the underlying occult systemic malignancy should be considered. Hypercoagulopathy and MES might provide the clues to the diagnosis.