老年急性前循环缺血性脑卒中血管内治疗成功再通患者90天内死亡的危险因素分析

目的分析老年急性前循环缺血性脑卒中血管内治疗成功再通患者90 d内死亡的危险因素。方法回顾性选取2016年1月1日至2022年5月10日大连医科大学附属第二医院行血管内治疗术后闭塞血管成功再通的老年前循环大血管闭塞脑卒中患者123例,根据90 d内死亡与否分为死亡组21例和非死亡组102例。详尽收集2组基线资料、基线前循环Alberta卒中项目早期CT评分(ASPECTS)、脑卒中TOAST病因分型、实验室资料、入院时改良Rankin量表评分、美国国立卫生研究院卒中量表(NIHSS)评分、临床特征、取栓治疗的相关指标、术后指标,改良脑梗死溶栓(mTICI)分级以及术后90 d预后情况。结果死亡组中性粒细胞与淋巴细胞比值、纤维蛋白原、收缩压、舒张压、平均动脉压、手术时间、术后24 h NIHSS评分、术后颅内出血及术后症状性颅内出血比例明显高于非死亡组,ASPECTS、mTICI分级3级比例明显低于非死亡组,差异有统计学意义(P<0.05,P<0.01)。多因素logistic回归分析显示,mTICI分级3级是术后90 d患者死亡的保护因素(OR=0.265,95%CI:0.076~0.922,P=0.037),入院舒张压及术后症状性颅内出血是术后90 d患者死亡的危险因素(OR=1.060,95%CI:1.011~1.112,P=0.016;OR=9.752,95%CI:2.554~37.230,P=0.001)。结论老年急性前循环缺血性脑卒中血管内治疗成功再通的死亡患者具有较高的入院舒张压、症状性颅内出血和较低mTICI分级3级。

A benchtop brain injury model using resected donor tissue from patients with Chiari malformation

The use of live animal models for testing new therapies for brain and spinal cord repair is a controversial area. Live animal models have associated ethical issues and scientific concerns regarding the predictability of human responses. Alternative models that replicate the 3 D architecture of the central nervous system have prompted the development of organotypic neural injury models. However, the lack of reliable means to access normal human neural tissue has driven reliance on pathological or post-mortem tissue which limits their biological utility. We have established a protocol to use donor cerebellar tonsillar tissue surgically resected from patients with Chiari malformation(cerebellar herniation towards the foramen magnum, with ectopic rather than diseased tissue) to develop an in vitro organotypic model of traumatic brain injury. Viable tissue was maintained for approximately 2 weeks with all the major neural cell types detected. Traumatic injuries could be introduced into the slices with some cardinal features of post-injury pathology evident. Biomaterial placement was also feasible within the in vitro lesions. Accordingly, this ‘proof-of-concept’ study demonstrates that the model offers potential as an alternative to the use of animal tissue for preclinical testing in neural tissue engineering. To our knowledge, this is the first demonstration that donor tissue from patients with Chiari malformation can be used to develop a benchtop model of traumatic brain injury. However, significant challenges in relation to the clinical availability of tissue were encountered, and we discuss logistical issues that must be considered for model scale-up.

Subtalar dislocations:Mechanisms,clinical presentation and methods of reduction

Subtalar joint is a complex joint in hindfoot formed by the talus superiorly and the calcaneus and navicular inferiorly.Subtalar dislocations are high-mechanism injuries,which are caused by simultaneous dislocation of both talonavicular and talocalcaneal joints,without major fracture of the talus.They are usually classified as medial(most common),lateral,anterior and posterior dislocations,based on the position of foot in relation to talus and the indirect forces that have been applied to cause this significant injury.They are usually diagnosed by X rays,but computed tomography and magnetic resonance imaging can be used to identify associated intra-articular fractures and peri-talar soft tissue injuries respectively.Majority being closed injuries,can be managed in ED by closed reduction and cast immobilisation,but if they are open,have poor outcomes.Complications that ensue open dislocations are post-traumatic arthritis,instability and avascular necrosis.

Survival analysis in nonagenarian patients with non-hip lower limb fractures

BACKGROUND The United Kingdom has an aging population with nearly 1 in 5 being over the age of 65,and over 0.5 million over the age of 90.The treatment of acute fractures of the lower limb in the nonagenarian cohort of patients poses a technical challenge to orthopaedic surgeons.AIM To report the fracture incidence,survival outcomes of treating acute non-hip lower limb fractures in nonagenarians in Major Trauma Centre.METHODS Thirty Lower limb long bone fractures in patients of age from 90 to 99 years were identified during 12-mo at a Level 1 trauma centre from a computerized database.A retrospective evaluation performed for fracture incidence,treatment,length of hospital duration and mortality at 30-d,1-year and 2-year.RESULTS Thirty fractures(28 patients)were identified,twenty-four fractures were treated with surgery(mean age 93 years SD±2.59)and 6 managed conservatively(mean age 94 years SD±2.07).The mean length of the hospital stay was 18.2 d for both groups.The 30-d,1-year and 2-year mortality risks were 1/23,6/23 and 9/23(4%,26%and 39%)in the surgery group and 0/5,1/5 and 2/5(0%,20%and 40%)in the conservative group,with no evidence for a difference between the two groups at any time point.CONCLUSION Nonagenarians in the surgical group had similar length of hospital stay and mortality risks as those treated conservatively.Patients with fewer comorbidities and admitted from their own home were offered surgery.

Predictive value of Hajibandeh index in determining peritoneal contamination in acute abdomen:A cohort study and meta-analysis

BACKGROUND Hajibandeh index(HI),derived from combined levels of C-reactive protein,lactate,neutrophils,lymphocytes and albumin,is a modern predictor of peritoneal contamination and mortality in patients with acute abdominal pathology.AIM To validate the performance of HI in predicting the presence and nature of peritoneal contamination in patients with acute abdominal pathology in a larger cohort study and to synthesis evidence in a systematic review and meta-analysis.METHODS The STROBE guidelines and the PRISMA statement standards were followed to conduct a cohort study(ChiCTR2200056183)and a meta-analysis(CRD420-22306018),respectively.All adult patients undergoing emergency laparotomy for acute abdominal pathology were eligible.The accuracy of the HI was evaluated using receiver operating characteristic(ROC)curve analysis in the cohort study and using weighted summary area under the curve(AUC)under the fixed and random effects modelling in the meta-analysis.The Quality Assessment of Diagnostic Accuracy Studies 2 criteria were used for methodological quality assessment of the included studies.RESULTS A total of 1437 patients were included(700 from the cohort study and 737 from the literature search).ROC curve analysis of the cohort study showed that the AUC of HI for presence of contamination,purulent contamination and feculent contamination were 0.79[95%confidence interval(CI):0.76-0.82,P<0.0001],0.76(95%CI:0.72-0.80,P<0.0001),and 0.83(95%CI:0.79-0.86,P<0.0001),respectively.The meta-analysis showed that the pooled AUC of HI for presence of contamination,purulent contamination and feculent contamination were 0.79(95%CI:0.75-0.83),0.78(95%CI:0.74-0.81),and 0.80(95%CI:0.77-0.83),respectively.CONCLUSION The HI is a strong and accurate predictor of intraperitoneal contamination.Although the available evidence is robust,it is limited to the studies conducted by our evidence synthesis group.We encourage other researchers to validate performance of HI in predicting the presence of intraperitoneal contamination and more importantly in predicting mortality following emergency laparotomy.

Use of orthotics with orthotic sandals versus the sole use of orthotics for plantar fasciitis:Randomised controlled trial

BACKGROUND Plantar fasciitis(PF)affects around 10%of the population.Prefabricated orthotics with arch support has been shown to provide symptom relief in PF by decreasing the repetitive stress sustained by the plantar fascia.However,prefabricated orthotics are only effective when shoes are worn,meaning the foot may be left unsupported when it is impractical to wear shoes.Using orthotic sandals in conjunction with prefabricated orthotics may increase PF symptom relief,as they can be worn inside the home,extending the period in which the foot is supported.AIM To compare the combined use of prefabricated orthotics and orthotic sandals vs the sole use of prefabricated orthotics in the treatment of PF.METHODS 98 participants with PF were randomised into two groups.The intervention group received the Aetrex L420 Compete orthotics and the Aetrex L3000 Maui Flips(orthotic sandals),whilst the control group received the Aetrex L420 Compete orthotics only.Foot pain was assessed both by the numerical rating scale(NRS)and the pain sub-scale of the foot health status questionnaire(FHSQ).Foot functionality was measured using the function sub-scale of the FHSQ.Symptom change was measured using the global rating of change scale(GROC).RESULTS Foot pain scores measured both by NRS and FHSQ pain sub-scale showed statistically significant reductions in foot pain in both groups(P<0.05)at six months.Both groups also reported statistically significant improvements(P<0.05)in function as measured by the FHSQ function subscale and improvement of symptoms as measured by the GROC scale.Between-group analysis showed that the intervention group with the combined use of orthotics and orthotic sandals scored better on all four outcome measures as compared to the control group with the sole use of orthotics.However,the between-group analysis only reached statistical significance on the NRS pain score(P<0.05).CONCLUSION Combined use of prefabricated orthotics and orthotic sandals provides a greater decrease in foot pain and improvement in foot function in PF compared to using prefabricated orthotics alone.

Endothelial progenitor cells:Exploring the pleiotropic effects of statins

Statins have become a cornerstone of risk modification for ischaemic heart disease patients. A number of studies have shown that they are effective and safe. However studies have observed an early benefit in terms of a reduction in recurrent infarct and or death after a myocardial infarction,prior to any significant change in lipid profile. Therefore,pleiotropic mechanisms,other than lowering lipid profile alone,must account for this effect. One such proposed pleiotropic mechanism is the ability of statins to augment both number and function of endothelial progenitor cells. The ability to augment repair and maintenance of a functioning endothelium may have profound beneficial effect on vascular repair and potentially a positive impact on clinical outcomes in patients with cardiovascular disease. The following literature review will discuss issues surrounding endothelial progenitor cell(EPC) identification,role in vascular repair,factors affecting EPC numbers,the role of statins in current medical practice and their effects on EPC number.

Systematic review and meta-analysis of esophageal cancer in Africa:Epidemiology, risk factors, management and outcomes

BACKGROUND Esophageal cancer(EC)is associated with a poor prognosis,particularly so in Africa where an alarmingly high mortality to incidence ratio prevails for this disease.AIM To provide further understanding of EC in the context of the unique cultural and genetic diversity,and socio-economic challenges faced on the African continent.METHODS We performed a systematic review of studies from Africa to obtain data on epidemiology,risk factors,management and outcomes of EC.A non-systematic review was used to obtain incidence data from the International Agency for Research on Cancer,and the Cancer in Sub-Saharan reports.We searched EMBASE,PubMed,Web of Science,and Cochrane Central from inception to March 2019 and reviewed the list of articles retrieved.Random effects metaanalyses were used to assess heterogeneity between studies and to obtain odds ratio(OR)of the associations between EC and risk factors;and incidence rate ratios for EC between sexes with their respective 95%confidence intervals(CI).RESULTS The incidence of EC is higher in males than females,except in North Africa where it is similar for both sexes.The highest age-standardized rate is from Malawi(30.3 and 19.4 cases/year/100000 population for males and females,respectively)followed by Kenya(28.7 cases/year/100000 population for both sexes).The incidence of EC rises sharply after the age of 40 years and reaches a peak at 75 years old.Meta-analysis shows a strong association with tobacco(OR 3.15,95%CI:2.83-3.50).There was significant heterogeneity between studies on alcohol consumption(OR 2.28,95%CI:1.94-2.65)and on low socioeconomic status(OR 139,95%CI:1.25-1.54)as risk factors,but these could also contribute to increasing the incidence of EC.The best treatment outcomes were with esophagectomy with survival rates of 76.6%at 3 years,and chemo-radiotherapy with an overall combined survival time of 267.50 d.CONCLUSION Africa has high incidence and mortality rates of EC,with preventable and nonmodifiable risk factors.Men in this setting are at increased risk due to their higher prevalence of tobacco and alcohol consumption.Management requires a multidisciplinary approach,and survival is significantly improved in the setting of esophagectomy and chemoradiation therapy.

Deep sclerectomy-trabeculectomy with mitomycin C in treating glaucoma:postoperative long-term results

AIM:To determine the long-term postoperative outcomes of deep sclerectomy-trabeculectomy(DST)with mitomycin C(MMC)in the treatment of glaucoma.METHODS:Patients who underwent DST with MMC between 2010 and 2017 were included in this retrospective observational study.Complete success was defined as postoperative intraocular pressure(IOP)≤21 mm Hg or 30%reduction of IOP from baseline without any topical IOP-lowering agent,and qualified success defined as IOP≤21 mm Hg or 30%reduction of IOP from baseline with/without single topical agent.We evaluated the surgical success rates and complication rates of this procedure,as well as described the IOP profiles,best corrected visual acuity(BCVA)profiles and mean deviations(MD)of Humphrey visual field(HVF)24-2 performance at each follow-up time point.Mixed linear regression models were constructed to determine estimated predictive values of demographic data,use of topical IOPlowering agents,baseline and postoperative IOP and optical profiles(e.g.,BCVA and MD).RESULTS:Totally 98 eyes(mean postoperative followup 67.5mo)showed mean IOP reduction at every followup interval.Both median BCVA and MD of visual fields were maintained throughout the follow-up intervals when comparing to baseline.The number of IOP-lowering medications decreased from 2.8±0.8 to 0.3±0.7(P=0.068).Totally 84(85.7%)eyes achieved complete success at final follow-up.Transient hyphaema and transient choroidal effusion developed in 15 eyes(15.3%)and 11 eyes(11.2%)respectively.Other complications included shallow anterior chamber in 5 eyes(5.1%),bleb leak in 4 eyes(4.1%),bleb revision in 7 eyes(7.1%),bleb needling in 9 eyes(9.2%)and repeat trabeculectomy in 1 eye(1.0%).There was no endophthalmitis,blebitis or macular oedema.There was no significant correlation between postoperative IOP control and postoperative BCVA.CONCLUSION:DST with MMC demonstrates effective and sustained long-term outcomes in the treatment of glaucoma with no major complication.

Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer:Importance of appropriate patient selection

BACKGROUND Achieving a clear resection margins for low rectal cancer is technically challenging.Transanal approach to total mesorectal excision(TME)was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers.However,previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult.AIM To investigate the outcomes of transanal TME(TaTME)and laparoscopic TME(LaTME)in patients with low rectal cancer.METHODS A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.Intraoperative and postoperative complications,anastomotic leak,R0 resection,completeness of mesorectal excision,circumferential resection margin(CRM),distal resection margin(DRM),harvested lymph nodes,and operation time were the investigated outcome measures.RESULTS We included twelve comparative studies enrolling 969 patients comparing TaTME(n=969)and LaTME(n=476)in patients with low rectal tumours.TaTME was associated with significantly lower risk of postoperative complications(OR:0.74,P=0.04),anastomotic leak(OR:0.59,P=0.02),and conversion to an open procedure(OR:0.29,P=0.002)in comparison with LaTME.Moreover,the rate of R0 resection was significantly higher in the TaTME group(OR:1.96,P=0.03).Nevertheless,TaTME and LaTME were comparable in terms of rate of intraoperative complications(OR:1.87;P=0.23),completeness of mesoractal excision(OR:1.57,P=0.15),harvested lymph nodes(MD:-0.05,P=0.96),DRM(MD:-0.94;P=0.17),CRM(MD:1.08,P=0.17),positive CRM(OR:0.64,P=0.11)and procedure time(MD:-6.99 min,P=0.45).CONCLUSION Our findings indicated that for low rectal tumours,TaTME is associated with better clinical and short term oncological outcomes compared to LaTME.More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.

Anthropometric method for estimating component sizes in total hip arthroplasty

BACKGROUND Preoperative templating is essential in total hip arthroplasty(THA)as it not only helps to facilitate the correct implant type and size but also determines the postoperative biomechanics.Templating is also increasingly important from a medicolegal perspective and recommended in the British Orthopaedic Association Guide to Good Practice.Although templating has become increasingly digitised,there are no simple anthropometric models to predict implant sizes in the absence of digital methods.AIM To assess the accuracy of using an easily obtainable measurement(shoe size)to predict component sizes in THA compared with digital templating.METHODS Digital radiographs from a cohort of 102 patients(40 male,62 female)who had undergone uncemented or hybrid THA at a single centre were retrospectively templated to desired cup and stem sizes using TraumaCad■.We compared the templated size to the actual size of the implant and assessed if there was any correlation with the patient’s shoe size.RESULTS Statistically significant positive correlations were observed between:shoe size and templated cup size(ρ=0.92,P<0.001);shoe size with implanted cup size(ρ=0.71,P<0.001);shoe size and templated stem size(ρ=0.87,P<0.001);and shoe size with implanted stem size(ρ=0.57,P<0.001).Templated and implanted acetabular cup sizes were positively correlated(ρ=0.76,P<0.001)and were exact in 43.1%cases;80.4% of implanted cup sizes were within 1 size(+/-2 mm)of the template and 100% within 2 sizes(+/-4 mm).Positive correlation was also demonstrated between templated and implanted femoral stem sizes(ρ=0.69,P<0.001)and were exact in 52.6% cases;92.6% were within 1 size of the template and 98% within 2 sizes.CONCLUSION This study has shown there to be a significant positive correlation between shoe size and templated size.Anthropometric measurements are easily obtainable and can be used to predict uncemented component sizes in the absence of digital methods.

是时候撤回Lancet杂志刊登的关于组织工程气管移植的文章了

我们要求撤回2008年Lancet杂志刊登的《Clinical transplantation of a tissue-engineered airway》的文章,作者是Macchiarini及其同事1。该文曾被国际媒体誉为"世界首例组织工程器官移植"。作者之一的Martin Birchall告诉英国广播公司"20年后,差不多所有移植器官都可以通过这种方式制造"2。这些夸大其词并未实现,因为几乎所有接受"组织工程气道"的患者都死亡了3。尽管2018年5月Lancet杂志已获悉文章中的关键发现是错误的,而且我们和其他人也相继要求撤回该文章,但遭Lancet杂志拒绝,未提供任何解释。