凶险性前置胎盘合并胎盘植入"一站式"杂交手术配合

目的探讨"一站式"杂交手术救治凶险性前置胎盘患者的应用价值及重要性。 方法对多学科合作行杂交手术救治凶险性前置胎盘合并胎盘植入患者的病例进行回顾性分析，总结"一站式"杂交手术多学科医护合作和护理配合要点。 结果经过多学科默契配合下的"一站式"杂交手术以及"L"型护理配合模式，手术顺利完成，术后无并发症发生，产妇于术后第4天出院。 结论凶险性前置胎盘患者病情危重、手术难度大，通过多学科讨论会、辐射防护、安全转运、医护默契配合以及根据潜在并发症采取预见性的护理措施是"一站式"杂交手术成功的要点。     

Analytical method for detection and quantification of new emerging drug etaqualone in human blood and urine by gas chromatography tandem mass spectrometry

Analytical procedure for detection and quantification of etaqualone in human blood and urine using GC–MS/MS was established and applied to authentic human samples obtained from volunteers. A liquid–liquid extraction method was employed. Each 1.0 mL of blood or urine was alkalized and extracted with diethyl ether. The solvent layer was evaporated to dryness and reconstituted with methanol then analyzed by GC–MS/MS. linear relationships within the concentration range of 1–100 ng/mL were obtained in calibrators for both blood and urine, demonstrating correlation coefficients values being>0.999. For blood and urine samples, the intra-day assay precision and accuracy values are each less than 3.65%, 7.13%, and 6.02%, 9.12%; those values of the inter-day assay are each less than 1.82%, 6.74%, and 3.99%, 7.41%. The extraction recovery rates for etaqualone ranged from 98.7% to 106%. The lower limit of quantifications was 1.0 ng/mL in both blood and urine. Stabilities of etaqualone in blood and urine were satisfactory under various temperatures within 15 days. 8.51 and 2.06 ng/mL of etaqualone in blood and urine were detected at 4 h later oral ingestion; 6.91 and 3.94 ng/mL of etaqualone were also detected 30 min and 2 h later smoking from blood and urine.     

长臂单轴椎弓根螺钉在单纯性胸腰椎压缩性骨折复位固定中的应用及对肌肉损伤的影响

目的分析长臂单轴椎弓根螺钉经 Wiltse入路在单纯性胸腰椎压缩性骨折中的应用效果及对肌肉损伤的影响。方法选取自 2018年 1月至 2020年 8月周口市中心医院收治的单纯性胸腰椎压缩性骨折病人 87例，根据复位固定术式不同，分为观察组 38例、对照组 49例，其中观察组采取长臂单轴椎弓根螺钉经 Wiltse入路，对照组采取 AF系统经传统后正中入路。记录两组病人围术期指标、手术前后血清肌肉损伤指标［肌酸激酶( CK)、肌红蛋白( Mb)］变化；采用疼痛视觉模拟评分( VAS)评价病人不同时间节点疼痛水平；经胸腰椎正侧位片检查获取伤椎原始高度( H0)、术前及术后 1周伤椎椎体前缘高度( H1H2)，计算术前、术后 1周伤椎相对高度( H1/H0、H2/H0)及伤椎复位率，并测量矢状位 Cobb角变化；随访 3个月，采用 Oswestry功能障、碍指数( ODI)评价功能障碍情况，并统计手术相关并发症。结果观察组手术时长、术中失血量、术后引流量及首次下床活动时间均明显短于或低于对照组( P<0.05)。术后 3d，两组血清 CK、Mb水平均较术前升高( P<0.05)，且观察组血清 CK、Mb水平     

Evolution of left-sided thoracoscopic approach for long gap esophageal atresia repair

BackgroundLeft-sided repair for long gap esophageal atresia (LGEA) has been described for patients with a large leftward upper pouch, no thoracic tracheoesophageal fistula (TEF) nor tracheobronchomalacia (TBM), or as salvage plan after prior failed right-sided repair. We describe our experience with left-sided MIS traction induced growth process.MethodsWe retrospectively reviewed patients who underwent Foker process for LGEA at two institutions between December 2016 and November 2021. Patient characteristics, surgical techniques, and outcomes were reviewed.Results71 patients underwent Foker process. Of 34 MIS cases, 28 patients (82%) underwent left-sided repair (median gap length 5 cm) at median age 4 months with median 3 (range 2–8) operations and median 13.5 (IQR 11–21) days on traction until esophageal anastomosis. 9 patients (32%) underwent completely MIS approach, whereas 5 patients (18%) converted to open at first operation and 14 patients (50%) converted to open later in the traction process. Traction was internal in 68%, external in 11%, and combination in 21%. Median follow-up was 15.4 (IQR 7.5–31.7) months after anastomosis. 14% had anastomotic leak managed with antibiotics and/or esophageal vacuum therapy. Median number of esophageal dilations was 3.5 (range 0–13). 18% required stricture resection. 39% underwent Nissen fundoplication. None have needed esophageal replacement.ConclusionsFor multiple reasons including the tendency of both esophageal pouches to have a leftward bias, less tracheal compression by upper pouch, and clean field of surgery for reoperative cases, we now more commonly use left-sided approach for MIS LGEA repair compared to right side, regardless of left aortic arch.Level of evidenceLevel IV Treatment Study.     

胆总管结石内镜逆行胰胆管造影术后行胆道支架置入和鼻胆管引流并发症的比较

目的探讨胆总管结石患者采用内镜逆行胰胆管造影术（ERCP）取石后同期开展胆道支架置入术或开展经内镜鼻胆管引流术（ENBD），对于防范并发症的价值。 方法按照前瞻性研究原则，选择2017年4月至2019年1月新疆医科大学第一附属医院收治的338例胆总管结石患者，随机分为支架组（170例）与引流组（168例）。两组患者均行ERCP治疗，其中引流组术后同期开展ENBD，支架组患者术后开展胆道支架置入术，对比两组患者腹痛评分、并发症发生情况及预后。 结果两组患者术后均未合并严重出血、穿孔或病死，结石完全清除率差异无统计学意义。与支架组相比，引流组术中胰腺管插管次数，术后4 h血淀粉酶水平、高淀粉酶血症、急性胰腺炎以及并发症总发生率更高，差异有统计学意义（P<0.05），术后24、48、72 h不同时点腹痛测评分值居更高水平（P<0.05）。 结论对于胆总管结石行ERCP治疗的患者，术后予以ENBD、胆道支架置入术的结石完全清除效果对比无明显差异，但胆道支架置入术更能降低术后并发症风险、缓解腹痛症状，患者获益更多。     

微创Chevron-Akin截骨术治疗轻中度拇外翻的早期疗效分析

目的:探讨微创Chevron-Akin(minimally invasive Chevron-Akin,MICA)截骨术治疗轻中度拇外翻的早期临床疗效。方法:自2019年6月至2021年4月,采用MICA截骨术治疗26例(29足)轻中度拇外翻患者,其中男1例,女25例;年龄19~78(38.3±19.5)岁。观察并比较手术前后拇外翻角(hallux valgus angle,HVA),第1、2跖骨间角(intermetatarsal angle,IMA),第1跖骨短缩。末次随访时采用美国骨科足踝外科协会(American Orthopedic Foot and Ankle Society,AOFAS)前足评分系统及视觉模拟评分(visual analogue scale,VAS)评价治疗效果,并记录相关并发症。结果:26例(29足)均获得随访,时间12~33(19.6±5.1)个月。HVA、IMA分别由术前的(32.3±6.6)°、(11.7±3.2)°矫正为术后的(13.0±5.3)°、(6.1±3.2)°,差异有统计学意义(P<0.01);第1跖骨短缩(2.7±1.1) mm。AOFAS评分由术前的(55.7±7.4)分提高到术后的(88.5±7.9)分(P<0.01),其中优15足,良11足,可3足。VAS由术前的(6.5±1.5)分改善为术后的(0.7±0.4)分(P<0.01)。结论:MICA截骨术创伤小,术后恢复快,并发症率低,并且能有效改善拇外翻畸形,是治疗轻中度拇外翻的安全可靠手术方法。     

Comparison between Antegrade versus Retrograde Ureteral Stent Placement for Malignant Ureteral Obstruction

PurposeTo compare the technical success of antegrade uteral stent (AUS) and retrograde ureteral stent (RUS) placements in patients with malignant ureteral obstruction (MUO) and to determine the predictors of technical failure of RUS.Materials and MethodsThis study retrospectively included 61 AUS placements (44 patients) performed under fluoroscopic guidance and 76 RUS placements (55 patients) performed under cystoscopic guidance in patients with MUO from January 2019 to December 2020. Technical success rates of the 2 techniques were compared using inverse probability of treatment weighting (IPTW) analysis. Logistic regression was used to identify predictive factors for technical failures.ResultsTechnical success was achieved in 98.4% of the AUS group and 47.4% of the RUS group. After stabilized IPTW, the technical success rate was higher in the AUS group than in the RUS group (adjusted risk difference, 49.4%; 95% confidence interval [CI], 35.4%–63.1%). The independent predictors for technical failure of the RUS procedure were age of ≥65 years (odds ratio [OR], 5.56; 95% CI, 1.73–21.27), ureteral orifice invasion (OR, 4.21; 95% CI, 1.46–13.46), and extrinsic cancer (OR, 15.58; 95% CI, 2.92–111.81).ConclusionsThe technical success rate of AUS placement was higher than that of RUS placement in patients with MUO. RUS failure was associated with age of ≥65 years, cancer with ureteral orifice invasion, and extrinsic ureteral obstruction.     

《黄帝内经》水模型化推理研究

模型化推理是指以模型特别是思维模型为中介或工具,由一个或几个前提推出结论的思维方法。《黄帝内经》由于其历史条件的限定,较多地采用了天然实物模型进行推理,而水与人类生活密切相关,自然也就成了人类认识事物乃至人体生命活动的最为普遍的天然模型。通过阐述水模型与《黄帝内经》血脉气血循环、经脉气血运行、十二经脉体系建构、六淫病因认识、气血津液病机以及相关临床诊治思维的关系,分析指出《黄帝内经》天然模型化推理具有直观性、经验性、功能性、非结构性、整体全息性、时序性等特征。     

Preclinical Modeling of Osimertinib for NSCLC With EGFR Exon 20 Insertion Mutations

IntroductionNSCLC with EGFR exon 20 insertion mutations is the third most common type of EGFR-mutant NSCLC and is resistant to EGFR tyrosine kinase inhibitors (TKIs). This study was conducted to evaluate the efficacies of first- to third-generation EGFR TKIs against NSCLC cells harboring EGFR exon 20 insertion mutations.MethodsWe developed seven EGFR exon 20 insertion-mutant Ba/F3 models and one patient-derived NSCLC (SNU-3173) of subtypes A763insFQEA, V769insASV, D770insSVD, D770insNPG, P772insPR, H773insH, H773insNPH, and H773insAH. Cell viability assays, immunoblotting, and N-ethyl-N-nitrosourea mutagenesis screenings were performed. EGFR exon 20 insertion–mutant structures and couplings with osimertinib, a third-generation EGFR TKI, were modeled and compared.ResultsEGFR exon 20 insertion–mutant NSCLC cells, excluding EGFR A763insFQEA, were resistant to first-generation EGFR TKIs (concentration that inhibits 50% [IC₅₀], 1.1 ± 0.067 to 5.4 ± 0.115 μM). Mutants were sensitive to second-generation EGFR TKIs (IC₅₀, 0.02 ± 0.0002 to 161.8 ± 18.7nM), except EGFR H773insH (IC₅₀, 46.3 ± 8.0 to 352.5 ± 22.7nM). The IC₅₀ ratios for mutant to wild-type cells were higher than those for third-generation EGFR TKIs. Third-generation EGFR TKI osimertinib was highly potent against EGFR exon 20 insertion–mutant cells (IC₅₀, 14.7-62.7 nM), including EGFR H773insH, and spared wild-type EGFR cells. N-ethyl-N-nitrosourea mutagenesis screening of EGFR exon 20 insertion–mutant Ba/F3 cells showed various second sites for EGFR mutations, mostly at exons 20 and 21, including E762K, P794S, and G796D. In addition, osimertinib-resistant cells were established by stepwise exposure to osimertinib and harbored EGFR E762K mutation.ConclusionsOsimertinib is active against EGFR exon 20 insertion–mutant NSCLC and flexibly binds within drug-binding pockets in preclinical models.