基于《辅行诀五脏用药法要》探讨乌梅丸论治情志病

乌梅丸载于《伤寒杂病论》厥阴篇,历代医家多认为其有温脏安蛔之功,临床应用范围较为局限,自清代医家柯琴提出其为厥阴病之主方后乌梅丸才被医家重视,其临床应用亦得以拓展。乌梅丸证之成因,实则归于厥阴风木气运失常,阴阳不相顺接,而非仅为蛔虫内扰所致。以《黄帝内经》“开阖枢”理论分析六经之功能,并结合《伤寒杂病论》原文可证“阴枢”实为厥阴,乌梅丸为厥阴病之主方,有顺接阴阳之功,故其可治疗厥阴枢机不利,寒热错杂之证。《辅行诀五脏用药法要》与《伤寒杂病论》二者同源,均参考了《汤液经法》所载内容,《辅行诀五脏用药法要》中补泻诸方及救逆方之组成有规律可寻,均依文中所载“汤液经法图”而成,与五行理论密切相关。该文通过探索“汤液经法图”组方规律及药物五行归属,以“汤液经法图”组方规律剖析乌梅丸,可证乌梅丸主要作用于肝、脾、心三脏,依黄帝内经五脏藏神理论,此三脏与情志调节密切相关,故以乌梅丸论治厥阴枢机不利、寒热错杂所致之情志病有据可循,文末亦列举概述近年乌梅丸治疗情志病的报道。该文为临床应用乌梅丸治疗情志病提供了思路及依据,扩展了其应用范围,古方亦能为今用。     

新型TiGRT IVS系统引导肺癌调强放射治疗摆位研究

目的:以锥形束CT(cone beam CT,CBCT)配准结果为参考,验证TiGRT IVS系统的在线校位精度,从而验证其临床有效性及可行性。方法:选择2019年10月至2020年2月在陆军军医大学第二附属医院全军肿瘤研究所放疗中心接受调强放射治疗的30例肺癌患者。首次摆位时行TiGRT IVS系统和CBCT位置验证,常规剂量分割患者每周行1次位置验证,大剂量分割患者每次治疗时均行位置验证,并与数字重建放射影像(digitally reconstructured radiograph,DRR)图像进行配准。其中TiGRT IVS系统配准方法分为IVS-A和IVS-B 2种,IVS-A根据椎体、肋骨等进行骨性配准;IVS-B在IVS-A的基础上,正位片采用气管作为特征结构进行配准。将IVS-A和IVS-B配准的结果与CBCT进行比较,观察TiGRT IVS系统对肺癌调强放射治疗摆位误差的分析与控制结果。结果:IVS-A、IVS-B、CBCT配准所需时间分别为(69±12)、(54±8)、(112±14)s,TiGRT IVS系统配准时间少于CBCT,而且IVS-B配准时间少于IVS-A。TiGRT IVS系统的摆位误差主要集中在0~5 mm,8 mm以上的摆位误差很少,且TiGRT IVS系统与CBCT得到的摆位误差只有在患者Vrt(前后)方向上具有统计学差异,但在临床标准范围内。对于1例大剂量分割患者在Lng(头脚)方向前1~7治疗分次的摆位误差,TiGRT IVS系统配准结果与CBCT相比有统计学差异。结论:TiGRT IVS系统能够有效测出肺癌患者调强放射治疗的摆位误差,正位片中可选气管作为配准的特征结构,大剂量分割患者图像引导时可结合CBCT观察靶区位置。     

肥厚型心肌病诊治的辅助检查进展

肥厚型心肌病是一种常染色体显性遗传性心肌疾病,其遗传特性、临床表型、病程和预后存在显著异质性,临床诊治极具挑战性.多普勒组织成像、定量组织速度成像、组织应变率成像、心脏磁共振及延迟钆增强等辅助检查对早期诊断、指导治疗及判断预后起重要作用.该文就肥厚型心肌病在辅助检查方面的进展作一综述.     

The dosimetric impact of respiratory breast movement and daily setup error on tangential whole breast irradiation using conventional wedge,field-in-field and irregular surface compensator techniques

To evaluate the dosimetric impact of respiratory breast motion and daily setup error on whole breast irradiation (WBI) using three irradiation techniques; conventional wedge (CW), field-in-field (FIF) and irregular surface compensator (ISC). WBI was planned for 16 breast cancer patients. The dose indices for evaluated clinical target volume (CTV_evl), lung, and body were evaluated. For the anterior-posterior (AP) respiratory motion and setup error of a single fraction, the isocenter was moved according to a sine function, and the dose indices were averaged over one period. Furthermore, the dose indices were weighted according to setup error frequencies that have a normal distribution to model systematic and random setup error for the entire treatment course. In all irradiation techniques, AP movement has a significant impact on dose distribution. CTV_evlD₉₅ (the minimum relative dose that covers 95 % volume) and V₉₅ (the relative volume receiving 95 % of the prescribed dose) were observed to significantly decrease from the original ISC plan when simulated for the entire treatment course. In contrast, the D₉₅, V₉₅ and dose homogeneity index did not significantly differ from those of the original plans for FIF and CW. With regard to lung dose, the effect of motion was very similar among all three techniques. The dosimetric impact of AP respiratory breast motion and setup error was largest for the ISC technique, and the second greatest effect was observed with the FIF technique. However, these variations are relatively small.     

联合血液学指标和超声建立甲状腺结节术前良恶性鉴别模型

目的 结合大量临床诊断病例的验证分析,寻找术前甲状腺结节相关指标,建立甲状腺结节良恶性鉴别早期辅助诊断模型.方法 研究解放军总医院收治甲状腺结节住院患者并及时收集其术前血液样本用于生化、甲功、血常规等相关指标测定.回顾性验证分析术前病人一般资料、临床血液学数据、超声结果与术后病理诊断的相关性.结果 入选Logistic回归方程指标包括年龄(Age)、血清促甲状腺激素(TSH)、血清高密度脂蛋白(HDL)、中性粒细胞计数(N)、超声结果(Ult)5项,建模方程为Logit(P)=1.673-0.069X1+0.301X3-1.499X8+5.335X10+ 21.182X12,模型组联合ROC曲线下面积为0.882;验证组为0.812.结论 通过模型分析初步建立甲状腺结节术前良恶性鉴别的血液学指标应用基础,联合超声为手术选择提供客观依据.     

The influence of the crutch setup on stability and weight-bearing parameters in post total hip replacement surgery patients during quiet standing

Purpose: The purpose of this study is to evaluate the influence of the crutch setup on standing, in post total hip replacement (THR) surgery patients.

Materials and methods: Thirty patients after THR were randomly assigned to walking with the elbow flexed (EF) or elbow straight (ES) crutch setup. Subjects were asked to stand on a force platform in a comfortable position with the crutch positioned on the unaffected side, facing forward for 10?seconds. Centre of pressure total path and maximal excursion were evaluated in both medio-lateral and anterior–posterior planes. Difference in the asymmetry of left/right acromial height, measured with and without the crutch, was calculated (ACdiff). Percentage of body weight borne by the crutch (Fcr), symmetry (SIload) between operated and healthy limbs loading during the trial, together with shoulder forces and moments were measured.

Results: No significant differences between the two groups (p?>?.05) were found for stability parameters. ACdiff, Fcr and shoulder load increased significantly (p?Conclusions: The present study showed that the ES setup reduced the force borne by the crutch, the load on the shoulder joint and it minimized postural and loading asymmetries when compared to EF setup. Conversely, postural stability was not influenced by the crutch setup.

• Implications for Rehabilitation

• Static posture and weight-bearing parameters are influenced by crutch setup during quiet standing.

• Crutch setup does not influence postural stability.

• Adjusting the crutch according to the elbow straight setup reduces the force borne by the crutch and the asymmetry in lower limbs loading.

• Forces and moments at the shoulder joint were reduced for the elbow straight setup group.

     

宫颈癌术后调强放疗摆位误差对靶区累积剂量偏差的影响

目的:千伏级锥形束 CT（CBCT）获取分次间宫颈癌术后调强放射治疗(IMRT)摆位误差,分析分次间摆位误差对靶区累积剂量偏差的影响。方法:选取61例宫颈癌术后行调强放疗的患者,全程916次CBCT获取摆位误差,将误差值输入治疗计划系统中,由分次间摆位误差剂量叠加得到累积摆位误差剂量,通过偏差公式与标准计划剂量计算偏差百分比。结果:摆位误差x、y、z方向的偏差和偏移等中心距离分别为0.04（-0.16, 0.25）、-0.05（-0.37, 0.28）、0.10（-0.06, 0.24）和0.55（0.38, 0.78） cm。临床靶区除CTV的HIsum-HIplan和CTV1 的Dsum_D50-Dplan_D50与HIsum-HIplan无统计学差异外,其他临床靶区的配对检验均有统计学差异。计划靶区除PGTVnd的Dsum_median-Dplan_median、Dsum_mean-Dplan_mean、Dsum_D50-Dplan_D50无统计学差异外,其他计划靶区均有统计学差异。累积摆位误差剂量与标准计划剂量分布对比呈现负偏态分布,峰度降低。GTVnd、CTV、CTV1、CTVn、CTV_all与PGTVnd、PTV、PTV1、PTVn、PTV_all剂量偏差均呈降低,计划靶区的累积剂量偏差比临床靶区偏差明显增大。Dmin偏差、D98偏差、D95偏差偏离最大,Dmax偏差、D5偏差、D2偏差变化次之,Dmedian偏差、Dmean偏差、D50偏差变化最小,反S型DVH曲线向左偏移,斜率增大。临床靶区HI偏差均上升。结论:宫颈癌术后调强放疗摆位误差对靶区累积剂量影响存在统计差异性,靶区累积剂量降低、均匀性变劣。宫颈癌术后调强放疗在每次治疗前需进行CBCT位置校准以保证靶区各结构剂量准确性。在放疗计划设计时考虑增加CBCT次数带来额外剂量的风险。     

胰腺癌患者螺旋断层放疗摆位误差分析

目的：通过兆伏级CT（MVCT）在线测量校正胰腺癌患者螺旋断层放疗的摆位误差,确定临床靶区CTV和计划靶区PTV之间的外放距离。方法：2012年5月至12月,21例接受TomoTherapy治疗的胰腺癌患者,每次治疗前均行靶区部位MVCT扫描。并将扫描后的MVCT图像与定位时千伏级CT（kVCT）图像进行配准,分别记录患者左右x、头脚y、腹背z和横断面旋转Roll四个方向的偏差数值,对其误差值进行统计分析。结果：21例患者共行358次MVCT扫描,其摆位误差值在x、y、z和Roll方向分别为：（-0．14±0．60）mm、（-1．21±0．44）mm、（0．69±0．93）mm和（0．02±0．26）。x、y、z方向CTV和PTV之间的外放距离分别为：5．5mm、7．4mm和3．9mm。结论：胰腺癌患者治疗摆位误差较大,Tomotherapy通过在线摆位校正能有效减小摆位误差。临床上建议胰腺癌患者在x、y、z方向上CTV和PTV之间可分别外扩5mm、7mm和4mm,为精确照射提供必要的质量保证。     

三维冠根整合数字化模型在口腔临床中的应用研究

目的建立牙齿三维冠根整合数字化模型并进行虚拟排牙,探讨其在口腔临床中的应用。方法获取15例患者锥形束CT(CBCT)的全牙列模型和结构光的牙冠模型,行迭代最近点算法对两种模型进行全局配准,在最佳匹配后截取CBCT牙根和基于结构光扫描的牙冠整合成新的牙齿模型。利用自行研发软件Teeth Arrangement对整合后的牙齿模型按照理想标准进行排列并导入颌骨进行在线验证。最后采用同行评估等级(peer assessment rating,PAR)指数评价排牙效果。结果 15例患者的结构光扫描模型与CBCT配准偏差数据符合正态分布,上颌配准偏差为(0.135±0.015)mm,下颌配准偏差为(0.130±0.022)mm。15例患者的排牙模型导入颌骨中,全部出现了不同程度的牙根突出颌骨。采用PAR指数对排牙前数字化模型与石膏模型错程度分析,两者具有高度一致性(ICC> 0.800)。全部患者排牙前后模型PAR加权值减少90%以上,排牙前后效果比较为改善;2/3患者PAR加权值减少22分以上,排牙前后效果比较为极大改善。结论将牙齿三维冠根整合数字化模型应用到口腔临床具有可行性及必要性。