ABSTRACT Introduction Main renal artery clamping and selective arterial clamping are two conventional devascularization methods for robot-assisted partial nephrectomy (RAPN) (1, 2). Decreasing warm ischemic (WI) time (3, 4) and improving clear surgical visualization (5) are the main surgically modifiable factors for RAPN, especially in large complex renal cancer (6). In this study, we described our surgical technique, focusing on gradual segmental artery unclamping on patients with large renal tumors. Material and methods Two patients (R.E.N.A.L score 10 and 11) underwent RAPN with gradual segmental artery unclamping (Figures 1 and 2). The unclamping included five key steps. First, all renal segmental arteries were identified as tumor feeding vessel(s) and the vessels for normal kidney parenchyma under the guidance of CT angiography (CTA) 3-division (3D) reconstruction. Second, all segmental arteries were isolated, and the feeding one(s) should be blocked before other arteries were blocked. Third, the tumor was resected outside the pseudocapsule, and the deep resection bed was sutured for initial hemostasis. Fourth, the segmental arteries were reopened except for the tumor feeding one(s), and normal kidney parenchyma restored blood supply. And fifth, the resection bed was completely sutured, and the feeding vessel supplying the tumor was opened after the suture. Warm ischemia time (WIT) was defined as the time measured between clamping and unclamping of the renal artery. WIT1 was the time for normal kidney parenchyma and WIT2 was the time for resection area. Patient demographics, perioperative variables, and warm ischemic time were included in our study. And we presented the details of gradual segmental artery unclamping in the video. Results In both cases, the total operation times were 215 and 130 mins for patient 1 and patient 2, respectively. WIT1 and WIT2 for patient 1 were 15 min and 33 min., and WIT1 and WIT2 for patient 2 were 21 min and 32 min, respectivelly. The maximum diameters of the masses resected were 10.8 and 7.3 cm, and surgical margins were negative. No patient had complications after operation. Preoperative and postoperative eGFR did not change significantly. Pre- and postoperative eGFR were 111 and 108 mL/min for patient 1, 91 and 83 mL/min for patient 2, respectively. Key hints for outcomes optimization during RAPN on patients with large complex renal tumors: 1) Each segmental renal artery is precised clamped before we excise the tumor, and an excellent surgical vision is essential for precising excision and shortening clamping time, 2) Other segmental renal arteries are unclamped except tumor feeding branch after suturing deep layer of parenchyma, and most normal parenchyma restores blood supply, 3) Preoperative high-resolution computed tomography angiography (CTA) and 3D reconstructive renal structure serve as a guide to clear the approach to find the tumor and segmental arteries (7, 8). Conclusions Gradual segmental artery unclamping is feasible and efficient to excise large complex renal cancer. Compared with main renal artery clamping, it can shorten the warm ischemic time of normal parenchyma; On the other hand, compared with selective segmental arterial clamping, the technique can reduce bleeding from the deep resection bed, keep a clear surgical vision, and decrease the incidence of positive margin.

SUMMARY: For treating cruciate ligament injuries, especially for characterizing the mechanics of the tunnel in cruciate ligament reconstruction, correctly understanding the bony information of the attachment area of the cruciate ligaments is significant. We studied 31 knee joints of middle-aged Chinese adults using the P45 sheet plastination technique, focusing on the attachment areas of the cruciate ligaments, especially the bony structures. The trabeculae at the attachment area were distributed radially and extended deep into the medial wall of the lateral condyle of the femur. However, in the anterior part of the intercondylar eminence, the trabeculae of the anterior group were parallelly arranged along the tendinous fibers of the anterior cruciate ligament, while the trabeculae of the posterior group were parallelly arranged along the perpendicular direction of the anterior cruciate ligament fibers. Similarly, at the attachment area of the lateral wall of the medial condyle of the posterior cruciate ligament, the trabeculae extended radially toward the deep medial condyle. Deep in the posterior part of the intercondylar eminence, the trabeculae were arranged longitudinally. In the anterior part of the intercondylar eminence, the trabeculae were parallelly arranged along the perpendicular directions of ligament fibers. The distribution patterns of the trabecular at the attachment areas of the cruciate ligaments at the ends of the femur and tibia were different. This difference should be considered when orthopedic surgeons reconstruct anterior cruciate ligaments.

RESUMEN: Para el tratamiento de lesiones de los ligamentos cruzados, especialmente para caracterizar la mecánica del túnel en su reconstrucción, es importante comprender correctamente la información ósea del área de inserción de estos ligamentos. Estudiamos 31 articulaciones de rodilla de individuos chinos, adultos, de mediana edad, utilizando la técnica de plastinación de láminas P45, centrándonos en las áreas de unión de los ligamentos cruzados, especialmente en las estructuras óseas. Las trabéculas en el área de inserción se distribuyeron radialmente y se extendieron profundamente en la pared medial del cóndilo lateral del fémur. Sin embargo, en la parte anterior de la eminencia intercondílea, las trabéculas del grupo anterior estaban dispuestas paralelamente a lo largo de las fibras tendinosas del ligamento cruzado anterior, mientras que las trabéculas del grupo posterior estaban dispuestas paralelamente a lo largo de la dirección perpendicular de las fibras del ligamento cruzado anterior. De manera similar, en el área de inserción en la cara lateral del cóndilo medial del ligamento cruzado posterior, las trabéculas se extendían radialmente y profundas hacia el cóndilo medial. Profundamente en la parte posterior de la eminencia intercondílea, las trabéculas estaban dispuestas longitudinalmente. En la parte anterior de la eminencia intercondílea, las trabéculas estaban dispuestas paralelamente a lo largo de las direcciones perpendiculares de las fibras del ligamento. Los patrones de distribución del tejido óseo trabecular en las áreas de unión de los ligamentos cruzados en los extremos del fémur y la tibia eran diferentes. Estas diferencias deben tenerse en consideración cuando los cirujanos ortopédicos reconstruyen los ligamentos cruzados anteriores.

Abstract Objectives: To analyze and summarize the clinical features and image characteristics of Meniere’s Disease (MD) patients with Endolymphatic Hydrops (EH) confirmed by enhanced Magnetic Resonance Imaging (MRI). Methods: 252 MD patients with EH confirmed by MRI were enrolled. All patients met the diagnostic criteria forMD and underwent intravenous gadolinium injection. After 4 h, MR examinations were performed. The Nakashima grading standard was used to classify EH and evaluate its correlation with clinical features. Results: Different degrees of EH were shown in all MD patients, and 157 of the 252 (62.3%) patients showed significant EH, 95 of the 252 (37.7%) patients showed mild EH. Only 89 (35.3%) met the diagnostic criteria for definite MD, and the remaining 163 (64.7%) patients met the diagnostic criteria for probable MD. Compared with patients with unilateral EH, the symptoms of the first affected ear of patients with bilateral EH were more serious. The degree of EH was related to the degree of hearing loss (p< 0.05). Conclusion: MRI with intravenous gadolinium injection can provide a better assessment of EH in MD patients. The clinical features of MD patients with EH confirmed by enhanced MRI did not fully meet the existing diagnostic criteria for definite MD. Including the diagnosis of EH in the diagnostic criteria of MD can increase the diagnosis rate of MD. The degree and distribution of EH may be related to the degree of hearing loss. Level of evidence: 4.

Abstract Background and objectives: Nerve block or neurolysis is an important approach in the treatment of spastic equinovarus foot. To illustrate the accurate location of the nerve branch to the tibialis posterior muscle (TP) in clinical practice, 21 adult cadavers were dissected and 14 complete both lower limb specimens were obtained. A total of 28 lower limbs were included. Methods: We measured the length of the motor branch nerve (LM) of the tibialis posterior muscle, the length of the fibula (LF), the vertical distance (D1) from the midpoint of LM to the fibula tip as well as the horizontal distance (D2) from the midpoint of LM to the inner edge of the fibula. Results: The LM was higher (35.74 ± 7.28 mm) in male than in female (30.40 ± 6.88 mm) specimens but there was no significant correlation between LM and gender (> 0.05). Additionally, among male specimens, the LM on the right side was longer than that on the left (p ≤ 0.05) while among female specimens, the D1 on the left side was longer than that on the right (p ≤ 0.05). The LF in male specimen was significantly longer than that in female (p ≤ 0.05). The midpoint of the nerve to the motor branch of the tibialis posterior muscle was about 50 mm distal to the fibular head and 10 mm at the inner edge of the fibula. Conclusion: Using this coordinate, the midpoint of the nerve branch to the TP could be accurately located.

Abstract (S)-(-)-N-[2-(3-Hydroxy-2-oxo-2,3-dihydro-1H-indol-3-yl)-ethyl]-acetamide (EA), a new compound isolated from the plant Selaginella pulvinata, has been identified to possess anti-proliferative effects against SK-mel-110 cells in vitro via upregulating the expression of inhibitor of growth family member 4. The present study aimed to investigate whether EA could exert antitumor effects against colon cancer. The results revealed that EA exerted anti-proliferative effects against a broad spectrum of different types of tumor and could induce apoptosis of colon cancer cells via the signal transducer and activator of transcription 1 pathway. It was demonstrated that treating tumor-bearing mice with EA significantly inhibited colon tumor growth in a xenograft tumor model and syngeneic tumor model. Furthermore, EA treatment reshaped the tumor microenvironment by decreasing myeloid-derived suppressor cell accumulation and increasing the tumor infiltrating lymphocytes. The results from the present study suggest that EA could be developed as a potential antitumor drug against colon cancer.

Abstract This study aims to investigate the mechanism and effects of Fibrinogen-like protein 2 (FGL2) in myocardial ischemia/reperfusion injury in mice following sevoflurane anesthetic. Mice of SAP group were placed in box with oxygen and anesthetic gas (60 mg/kg, pentobarbital), 2.5% Sevoflurane was pumped into the box for 1 h. H9C2 cells were treated by 3% sevoflurane for 6 h and a mixture of 95% O2 + 5% CO2 for 24 h. Fgl2 mRNA expression was up-regulated in mice of I/R injury following sevoflurane. Fgl2 protein reduced HR, LVDP, dp/dtmax (+) and dp/dtmax (-), increased LVEDP levels, myocardial infarct size and AI in mice of I/R injury following sevoflurane. Fgl2 suppressed PPAR signaling pathway, and promoted ROS production in vivo or vitro model. The activation of PPAR signaling pathway reduced the function of Fgl2 in vivo and vitro model. Fgl2 might serve as a therapeutic target in the treatment of I/R injury following sevoflurane. We hope that our findings will pave a way for future therapies against I/R injury following sevoflurane.

Abstract Hibiscus Sabdariffa L. has important nutritional and medicinal value. Currently, a safe process extraction of reducing sugar from Hibiscus Sabdariffa L. calyx by biological complex enzyme system is seldom investigated. In this experiment, the pectinase and cellulase complex enzyme system was used to optimize the enzymatic hydrolysis of Hibiscus Sabdariffa L. and Box behnken was used to design the experiment. The results showed that there was significant difference in enzymolysis effect of Hibiscus Sabdariffa L under different conditions (p < 0.05). When the enzymolysis temperature was 45 °C, pH 4.5, and the mass volume ratio of material to liquid was 5g:100ml, the optimum conditions were obtained by response surface methodology: the addition amount of pectinase and cellulase complex enzyme was 0.011 g/kg, the ratio of mixed enzyme was 1.36:1, the enzymolysis time was 2.09 h, and the reducing sugar content of Hibiscus Sabdariffa L extract was 3.56 mg/ml. The experimental results of reducing sugar content of Hibiscus Sabdariffa L (3.54 ± 0.1mg / ml) were in good agreement with the predicted value of the equation fitted by response surface. The mixed enzyme system of pectinase and cellulase has the advantages of environmental protection and energy saving, which can provide guidance for industrial production.

Abstract The present paper investigates the transverse vibration of a non-uniform axially functionally graded Timoshenko beam with cross-sectional and material properties varying in the beam length direction. The Chebyshev collocation method is used to spatially discretize the governing partial differential equations of motion of the beam into time-dependent ordinary differential equations in terms of Chebyshev differentiation matrices. An algebraic eigenvalue equation in matrix form is then formed to study the free vibration behavior of non-uniform axially functionally graded Timoshenko beams. Several results of natural frequencies of the beams are evaluated and compared with those in the published literature to assure the accuracy of the proposed model. The effects of taper ratio, material graded index, slenderness ratio, material compositions and restraint types on the natural frequencies of tapered axially functionally graded Timoshenko beams are examined.

ABSTRACT Although urological diseases are not directly related to coronavirus disease 2019 (COVID-19), urologists need to make comprehensive plans for this disease. Urological conditions such as benign prostatic hyperplasia and tumors are very common in elderly patients. This group of patients is often accompanied by underlying comorbidities or immune dysfunction. They are at higher risk of COVID-19 infection and they tend to have severe manifestations. Although fever can occur along with urological infections, it is actually one of the commonest symptoms of COVID-19; urologists must always maintain a high index of suspicion in their clinical practices. As a urological surgeon, how we can protect medical staff during surgery is a major concern. Our hospital had early adoption of a series of strict protective and control measures, and was able to avoid cross-infection and outbreak of COVID-19. This paper discusses the effective measures that can be useful when dealing with urological patients with COVID-19.

This is a retrospective, single-center observational study to explore the predictors of chest drainage for neonatal pneumothorax. A total of 183 neonates (age ≤28 days) who presented to the Children's Hospital of Soochow University between January 1, 2015 and December 31, 2018 for pneumothorax or developed pneumothorax during a hospital stay were included. Demographic data, clinical presentation, and imaging characteristics of neonatal pneumothorax were collected and analyzed. We used univariate and multivariate logistic regression analyses to determine significant predictors of chest drainage of pneumothorax in neonates. Pneumothorax occurred within 24 h after birth in 131 (71.6%) cases, between 24 and 48 h after birth in 41 (22.4%) cases, and 48 h after birth in 11 (6.0%) cases. Univariate and multivariate logistic regression analyses revealed that lung collapse ≥1/3 on initial chest X-ray (OR 4.99, 95%CI 2.25-11.07), chest retractions (OR 8.12, 95%CI 2.88-22.89), cyanosis (OR 2.25, 95%CI 1.08-4.66), and frothing from mouth (OR 2.49, 95%CI 1.12-5.49) (P<0.05 for all) were significant predictors of the need for chest drainage due to pneumothorax. In conclusion, the thorough evaluation of the above predictive factors can guide treatment and improve patient outcome.

Abstract Purpose: To investigate the impact of Ramipril (RAM) on the expressions of insulin-like growth factor-1 (IGF-1) and renal mesangial matrix (RMM) in rats with diabetic nephropathy (DN). Methods: The Sprague Dawley rats were divided into normal control (NC) group (n = 12), DN group (n = 11), and DN+RAM group (n = 12). The ratio of renal weight to body weight (RBT), fasting blood glucose (FBG), HbA1c, 24-h urine protein (TPU), blood urea nitrogen (BUN), creatinine (Cr), renal pathological changes, the levels of IGF-1, fibronectin (FN), type IV collagen (Col-IV), and matrix metalloproteinases (MMP)-2 were compared among the groups. Results: Compared with NC group, the RBT, FBG, HbA1c, TPU, BUN, Cr, and RMM in DN group were significantly increased (P < 0.05), the IGF-1, FN, and Col-IV were significantly upregulated (P < 0.05), while MMP was significantly downregulated (P < 0.05). Compared with DN group, the indexes except for the FBG and HbA1c in DN+RAM group were significantly improved (P < 0.05), among which IGF-1 exhibited significant positive correlation with TPU(r=0.937), FN(r=0.896) and Col-IV(r=0.871), while significant negative correlation with MMP-2 (r=-0.826) (P<0.05). Conclusion: RAM may protect the kidneys by suppressing IGF-1 and mitigating the accumulation of RMM.

We determined the effects of enhanced recovery after surgery (ERAS) in patients undergoing radical surgery for gastric carcinoma. Sixty patients undergoing radical gastrectomy for gastric carcinoma in Lishui Hospital between March and October 2016 were randomized to receive either ERAS (30 patients) or conventional care (30 patients, controls). Clinical, economic, and laboratory indices were analyzed. ERAS patients showed faster recovery and shorter postoperative hospital stays than the controls (P<0.05). Some clinical indices (i.e., time to first flatus and defecation, time to removal of drainage tubes, time to resumption of oral feeding, time to postoperative mobilization, and postoperative complications) were significantly better in ERAS patients than in controls. Duration of postoperative infusion was lower in ERAS patients than in controls (P<0.05). In ERAS patients, serum albumin and prealbumin were higher on postoperative day 7, C-reactive protein was lower on postoperative days 3 and 7, and neutrophil count was lower on postoperative day 3 compared to the values in controls (P<0.05 for all). IgM levels were higher in ERAS patients on postoperative days 3 and 7 (P<0.05), while IgG levels were higher on postoperative day 3 (P<0.05). Total T lymphocytes were higher in ERAS patients on postoperative day 3, while helper T cells and CD4+/CD8+ ratio were higher on postoperative days 3 and 7 (P<0.05 for all). In gastric carcinoma patients, ERAS may reduce perioperative inflammation, improve immunity and postoperative nutrition, shorten hospitalization, and enhance rehabilitation.

Imatinib is the first line of therapy for patients with metastatic or gastrointestinal stromal tumors (GIST). However, drug resistance limits the long-term effect of imatinib. Long non-coding RNAs (lncRNAs) are emerging as key players in regulating drug resistance in cancer. In this study, we investigated the association between lncRNA CCDC26 and IGF-1R in GIST and their involvement in drug resistance. Considering the key role of lncRNAs in drug resistance in cancer, we hypothesized that IGF-1R is regulated by lncRNAs. The expression of a series of reported drug resistance-related lncRNAs, including CCDC26, ARF, H19, NBR2, NEAT1, and HOTAIR, in GIST cells treated with imatinib H19 was examined at various time-points by qRT-PCR. Based on our results and published literature, CCDC26, a strongly down-regulated lncRNA following imatinib treatment, was chosen as our research target. GIST cells with high expression of CCDC26 were sensitive to imatinib treatment while knockdown of CCDC26 significantly increased the resistance to imatinib. Furthermore, we found that CCDC26 interacted with c-KIT by RNA pull down, and that CCDC26 knockdown up-regulated the expression of IGF-1R. Moreover, IGF-1R inhibition reversed CCDC26 knockdown-mediated imatinib resistance in GIST. These results indicated that treatments targeting CCDC26-IGF-1R axis would be useful in increasing sensitivity to imatinib in GIST.