壳聚糖-胶原凝胶复合骨髓间充质干细胞修复兔关节软骨缺损的组织学变化

背景:大块软骨损伤目前临床上尚无方法治疗,干细胞技术出现后为解决这一难题提供了理论支持.采用新型的支架材料"壳聚糖-胶原蛋白"结合干细胞诱导分化移植给动物模型是一种较新的尝试.目的:观察壳聚糖-胶原凝胶复合骨髓间充质干细胞修复兔关节软骨缺损的组织学变化.方法:体外培养扩增兔骨髓间充质干细胞.采用软骨诱导分化培养基对P2代细胞进行成软骨诱导.同时制备"壳聚糖-胶原蛋白"支架和兔关节软骨缺损模型.缺损用含有骨髓间充质干细胞的壳聚糖-胶原凝胶填充,另一条关节用没有细胞的支架或不做处理.其中12个关节作为实验组(接受骨髓间充质干细胞+支架),8个关节作为空白对照组(不做处理),8个关节作为单纯支架组(未植入细胞).造模后于2,4,8,16周进行组织学评分并处死动物行组织学染色.结果与结论:造模后16周移植的细胞一致分化为软骨细胞,大部分软骨缺损区被新生软骨修复,组织学评分实验组关节修复良好.提示应用骨髓间充质干细胞结合"壳聚糖-胶原蛋白"复合物可以修复关节软骨缺损.     

组织工程软骨与柚皮苷联合修复兔膝关节软骨缺损的组织学证实

背景：目前临床上虽有多种方法用于治疗软骨缺损,但没有从根本上解决关节软骨缺损修复问题。目的：通过组织学研究进一步评价柚皮苷结合组织工程软骨修复兔关节软骨缺损的效果。方法：取兔骨髓间充质干细胞体外增殖后,复合于改建后的脱细胞真皮基质载体上,制成组织工程软骨,植入到兔膝关节软骨缺损,并以柚皮苷汤灌胃,于4,8周后分别对修复组织进行苏木精-伊红、Masson三色染色、甲苯胺蓝染色、Ⅱ型胶原染色、Ⅹ型胶原染色等组织学检查。结果与结论：术后8周,柚皮苷结合干细胞复合体组缺损处修复组织变成乳白色,半透明光滑组织,缺损修复组织与周围正常软骨已基本难区分,表面光滑。组织学检查发现修复缺损处基本为新生软骨填充。结果证实,柚皮苷结合组织工程软骨能提高家兔膝关节软骨缺损的修复质量。     

基质金属蛋白酶和胶原在创伤关节软骨组织中的表达

背景:研究发现,基质金属蛋白酶和胶原参与关节软骨组织机体生理重建及病理破坏.目的:观察膝关节骨软骨缺损及表面软骨缺损动物模型关节软骨组织中胶原及基质金属蛋白酶的表达变化.方法:雌性SD大鼠48只随机分为3组:骨软骨缺损组在双膝关节制作骨软骨缺损模型,表面缺损组在双膝关节制作表面软骨缺损,对照组双膝关节制作关节囊切开.分别于术后4、8、12周取股骨髁标本,行苏木精-伊红染色,免疫组化检测Ⅰ型胶原、Ⅱ型胶原、基质金属蛋白酶3的表达.结果与结论:骨软骨缺损组术后4周缺损中有少量新生组织生成,8及12周可见到纤维组织填充,修复组织细胞外基质Ⅰ型胶原免疫组化染色阳性,Ⅱ型胶原免疫组化染色阴性,关节软骨组织中基质金属蛋白酶3表达增高.表面缺损组表面软骨缺损4及8周未见修复迹象,12周可见微量纤维组织填充,细胞外基质Ⅰ型胶原免疫组化染色阳性,Ⅱ型胶原免疫组化染色阴性,术后表面缺损组关节软骨组织基质金属蛋白酶3表达增高.对照组关节软骨组织Ⅰ型胶原免疫组化染色阴性,Ⅱ型胶原免疫组化染色阳性,基质金属蛋白酶3低表达,无形态学异常改变.说明机械性损伤可以导致关节软骨细胞外基质成分发生改变,丧失其原有的生物学特性而退变,基质金属蛋白酶3在损伤后的软骨组织中表达增高,使细胞外基质的降解增加,是导致关节软骨退变的重要因素.     

持续被动运动对兔膝全层关节软骨缺损修复的影响

目的 研究持续被动运动(CPM)对全层关节软骨缺损修复的影响。方法 将60个兔膝关节建立全层关节软骨缺损模型，随机分为3组，术后A组每天进行CPM 8h；B组每天进行CPM 2h，2组均连续进行CPM 4周，然后笼内自由活动至12周。C组仅笼内自由活动。分别于术后4周和12周处死各组半数兔，并取材，行HE、番红O以及Ⅰ、Ⅱ胶原免疫组化染色，再进行评分。结果 A组全层关节软骨缺损修复的效果较B、C两组明显。结论 兔膝全层关节软骨缺损后给予CPM干预可显著促进组织的修复，同时可促进Ⅱ型胶原和蛋白多糖的恢复。     

Ⅱ型胶原海绵修复关节软骨缺损的动物实验

目的探讨Ⅱ型胶原海绵修复关节软骨缺损的效果。方法采用成年纯种新西兰兔24只,48侧膝关节,在股骨滑车面钻孔为直径5mm、深3mm的全层关节软骨缺损,左侧为A组,在缺损区内完全填充Ⅱ型胶原海绵,右侧为B组,缺损区空白对照。术后12周内,每双数周对缺损修复情况行大体形态和组织学观察。结果Ⅱ型胶原对关节软骨缺损的修复有明显的促进作用,修复结果接近正常软骨。结论自行研制的高纯度Ⅱ型胶原海绵组织相容性好,无明显毒副作用,对关节软骨缺损具有良好的修复作用。     

基质金属蛋白酶和胶原在创伤关节软骨组织中的表达

背景：研究发现,基质金属蛋白酶和胶原参与关节软骨组织机体生理重建及病理破坏。目的：观察膝关节骨软骨缺损及表面软骨缺损动物模型关节软骨组织中胶原及基质金属蛋白酶的表达变化。方法：雌性SD大鼠48只随机分为3组：骨软骨缺损组在双膝关节制作骨软骨缺损模型,表面缺损组在双膝关节制作表面软骨缺损,对照组双膝关节制作关节囊切开。分别于术后4、8、12周取股骨髁标本,行苏木精-伊红染色,免疫组化检测Ⅰ型胶原、Ⅱ型胶原、基质金属蛋白酶3的表达。结果与结论：骨软骨缺损组术后4周缺损中有少量新生组织生成,8及12周可见到纤维组织填充,修复组织细胞外基质Ⅰ型胶原免疫组化染色阳性,Ⅱ型胶原免疫组化染色阴性,关节软骨组织中基质金属蛋白酶3表达增高。表面缺损组表面软骨缺损4及8周未见修复迹象,12周可见微量纤维组织填充,细胞外基质Ⅰ型胶原免疫组化染色阳性,Ⅱ型胶原免疫组化染色阴性,术后表面缺损组关节软骨组织基质金属蛋白酶3表达增高。对照组关节软骨组织Ⅰ型胶原免疫组化染色阴性,Ⅱ型胶原免疫组化染色阳性,基质金属蛋白酶3低表达,无形态学异常改变。说明机械性损伤可以导致关节软骨细胞外基质成分发生改变,丧失其原有的生物学特性而退变,基质金属蛋白酶3在损伤后的软骨组织中表达增高,使细胞外基质的降解增加,是导致关节软骨退变的重要因素。     

Ⅱ型胶原海绵修复关节软骨缺损的动物实验

目的 探讨Ⅱ型胶原海绵修复关节软骨缺损的效果。方法 采用成年纯种新西兰兔24只，48侧膝关节，在股骨滑车面钻孔为直径5mm、深3mm的全层关节软骨缺损，左侧为A组，在缺损区内完全填充Ⅱ型胶原海绵，右侧为B组，缺损区空白对照。术后12周内，每双数周对缺损修复情况行大体形态和组织学观察。结果 Ⅱ型胶原对关节软骨缺损的修复有明显的促进作用，修复结果接近正常软骨。结论 自行研制的高纯度Ⅱ型胶原海绵组织相容性好，无明显毒副作用，对关节软骨缺损具有亟好的修复作用。     

转基因同种异体组织工程软骨修复兔膝关节全层缺损

目的:观察转人胰岛素样生长因子I基因同种异体组织工程软骨对兔膝关节软骨全层缺损的修复作用。方法:实验于2004-08/2005-08在军事兽医研究所病毒室及长春生物制品研究所实验室完成。①取出生28d新西兰白兔的关节软骨,采用机械分离及Ⅱ型胶原酶消化法获得分离的兔软骨细胞,用单层培养扩增。②用脂质体法使胰岛素样生长因子I基因转染兔关节软骨细胞。③以经过转染的兔关节软骨细胞作为种子细胞,牛Ⅰ型胶原作为支架,体外构建转基因同种异体组织工程软骨。④5个月龄的新西兰白兔80只制备关节软骨缺损模型,分别移植入不同组别的移植物:空白对照组、单纯支架组、单纯软骨细胞附和支架组、经过转染的软骨细胞附和支架组、自体软骨移植组,分别于术后4,8,16,24周处死各组动物4只取材,观察兔膝关节软骨全层缺损的修复情况。结果:①G418培养液筛选结果:通过G418对于兔关节软骨细胞的最小致死剂量的测定得出,G418对软骨细胞的最小致死剂量为0.4g/L。转染后软骨细胞经0.4g/LG418筛选,2周后得到抗G418的阳性细胞克隆,而未转染细胞在含G418的培养液中逐渐全部死亡,初步证明人胰岛素样生长因子I基因的转染成功。②原位杂交检测结果:转染软骨细胞胞浆中有氯化镍紫蓝色颗粒阳性杂交信号说明有人胰岛素样生长因子ImRNA的表达;未转染细胞则未见阳性信号。③免疫组织化学检测结果:在转染的软骨细胞胞浆中有棕黄色颗粒样阳性信号,说明有Ⅱ型胶原蛋白表达,证明稳定表达人胰岛素样生长因子I的转染软骨细胞保持Ⅱ型胶原的表达。④软骨缺损修复后的组织学评价结果:在试验所观察的24周内,软骨基本稳定,而且转胰岛素样生长因子I基因组织工程软骨显示出强烈的软骨基质分泌能力。转胰岛素样生长因子I基因的同种异体组织工程软骨对软骨缺损的修复效果明显优于空白对照组和单纯软骨细胞附和支架组犤空白对照组、单纯支架组、单纯软骨细胞附和支架组、经过转染的软骨细胞附和支架组、自体软骨移植组修复软骨的组织学评分:术后4周为(12.00±0.79),(11.00±0.81),(8.10±0.90),(5.80±1.03),(5.20±0.46)分;术后8周为(10.20±0.96),(10.10±1.19),(7.10±1.34),(4.90±1.15),(4.00±0.58)分;术后16周为(8.00±1.24),(8.50±1.79),(5.20±1.88),(4.00±1.82),(2.00±1.96)分;术后24周为(7.00±0.90),(6.50±2.13),(4.30±2.00),(3.00±2.13),(1.20±0.78)分,P<0.05犦。结论:人胰岛素样生长因子I基因转染兔关节软骨细胞后可以在细胞中表达,而且转胰岛素样生长因子I基因的同种异体组织工程软骨对兔关节软骨全层缺损的修复效果明显。为进一步转基因组织工程软骨实验提供了依据。     

腺病毒携带骨形态发生蛋白14基因转染脂肪干细胞修复损伤关节软骨?

背景：关节软骨损伤后自我修复能力较弱,主要是由于其缺乏滋养血管并且细胞代谢缓慢等组织特性,目前的治疗方法都不能恢复软骨组织的原有功能,近年来软骨组织工程已引起了越来越多的关注。目的：观察Ⅰ型胶原海绵支架搭载骨形态发生蛋白14基因转染脂肪干细胞修复兔膝关节软骨损伤的效果。方法：取兔皮下脂肪组织分离培养脂肪干细胞,用腺病毒真核表达载体 Ad-CMV-BMP-14-IRES-hrGFP-1转染脂肪干细胞。Ⅰ型胶原海绵支架搭载转染后的脂肪干细胞,待细胞吸附后对兔膝关节全层软骨缺损进行修复。术后12周取手术关节,从大体方面、组织学方面综合评估缺损修复状况。结果与结论：骨形态发生蛋白14转染后的脂肪干细胞骨形态发生蛋白14和Ⅱ型胶原蛋白表达及Sox-9基因表达明显高于普通脂肪干细胞。术后12周,支架搭载经骨形态发生蛋白14转染的脂肪干细胞组软骨组织修复良好,平整光滑,光洁度、质地及颜色良好,交界区整合良好。支架搭载脂肪干细胞组软骨组织部分修复,有正常软骨光泽,质地与颜色接近正常,修复组织与正常软骨组织界限明显。单纯支架组几乎崩解塌陷,未见透明样软骨结构形成。结果可见腺病毒携带骨形态发生蛋白14基因转染后脂肪干细胞修复软骨缺损的能力有大幅提升。     

结合转化生长因子β1的肝素化胶原/壳聚糖支架复合脂肪干细胞修复免关节软骨缺损

背景:通过制各肝素化胶原/壳聚糖支架来提高与转化生长因子β1的结合率,将脂肪干细胞种植于该支架材料上后直接种植于体内,可避免体外诱导过程,缩短组织工程构建的时间.目的:探索结合有转化生长因子β1的肝索化胶原/壳聚糖支架与脂肪干细胞复合修复兔软骨缺损的可行性.设计、时间及地点:软骨组织工程体外和体内实验相结合的研究,于2007-09/2008-07在南京大学生命科学院和解放军南京军区南京总医院动物试验中心完成.材料:分离培养兔脂肪间充质干细胞,行体外扩增培养至第3代,达到一定数量后接种于结合有转化生长因子β1的肝素化胶原/壳聚糖支架上得到细胞支架复合物.方法:取30只新西兰大白兔制备兔膝全层软骨缺损模型.随机选取一侧植入细胞支架复合物(实验组),其中15只另一侧植入结合有转化生长因子β1的肝素化胶原/壳聚糖支架(单纯支架组),余15只另一侧不做任何处理,作为空白对照.主要观察指标:于12周取材,从大体和组织学方面观察软骨修复情况.结果:实验组缺损区大部分被修复,缺损区被软骨组织充填,组织学检查提示形成典型的透明样软骨结构.而单纯支架组多不完全充填,其本为纤维组织状物覆盖,组织学检查未见明显软骨修复.空白对照组无明显修复.结论:结合有转化生长因子β1的肝素化胶原/壳聚糖支架与脂肪干细胞复合能较好修复软骨缺损.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.