肌肉骨骼系统慢性疼痛管理专家共识

肌肉骨骼系统慢性疼痛是临床最常见的慢性疼痛。目前,国内外医师对慢性疼痛的认识、临床实践环境、镇痛药物种类/使用经验/了解程度、医保药品收录均有差异,故有效、规范化的慢性疼痛管理显得尤为必要。因此,亟待制定完善的、基于生物-心理-社会医学等因素的跨学科慢性疼痛管理共识,提高广大医务人员对慢性疼痛的认识与重视、规范指导慢性疼痛的管理,提高医疗质量、降低医疗成本,消除患者感觉、情感、认知和社会维度的痛苦体验,在治疗患者原发疾病的同时,改善患者的心理需求和社会功能需求。通过查阅文献,本共识专家组遵循循证医学原则,经过反复讨论和通信修改,对肌肉骨骼系统慢性疼痛管理达成共识,供广大骨科医师在临床工作中参考。     

非新生儿破伤风诊疗规范

破伤风分为新生儿破伤风和非新生儿破伤风。我国已于2012年消除了新生儿破伤风,但非新生儿破伤风仍是一个严重的公共卫生问题。非新生儿破伤风重症患者在无医疗干预的情况下,病死率接近100%,即使经过积极的综合治疗,全球范围病死率仍为30%~50%,是一种极为严重的潜在致命性疾病。为规范我国非新生儿破伤风诊疗行为,提高医疗质量,保障医疗安全,特制定本规范。本规范包括了非新生儿破伤风的病原学、流行病学、发病机制、临床表现及实验室检查、诊断、鉴别诊断、分级、治疗等方面内容。     

The influence of cervical spine position on the three anterior endoscopic approaches to the craniovertebral junction: an imaging study

Background contextThree endoscopic anterior approaches, the transnasal, transoral, and transcervical approaches, are used for ventral lesions of the craniovertebral junction and have been compared regarding surgical working distances and approach angles. However, how the position of the cervical spine influences the depths of surgical corridors and approach angles for the three approaches has not been evaluated.PurposeTo evaluate the depths of surgical corridors and the approach angles for the three endoscopic approaches, taking the influence of cervical spine position into account.Study designA radiographic study comparing three anterior endoscopic approaches to the craniovertebral junction.Patient sampleCervical extension and flexion radiographs for 34 patients and cross-sectional computed tomography scans for 30 additional patients were assessed.Outcome measuresThe depths of the surgical corridors and the approach angles for the three endoscopic approaches in the midsagittal planes.MethodsWe determined the mean angles of the surgical trajectories for the endoscopic transoral and transcervical approaches on cervical extension and flexion radiographs. In addition, we measured the depths of the surgical corridors and the approach angles for the three approaches in the midsagittal plane.ResultsThe average depths of surgical corridors were as follows: endonasal, 93.65 mm; transoral, 85.27 mm; transcervical, 62.97 mm (in extension). The average approach angles were as follows: endonasal, 31.22°; transoral, 30.87°; transcervical, 36.58° (in extension).ConclusionsThe position of the cervical spine does not influence the surgical convenience of the endoscopic transnasal approach, but it can influence the endoscopic transoral and transcervical approaches, especially the latter. The endoscopic transcervical approach offers several advantages over the endoscopic transoral and endonasal approaches.     

Prognostic value of visceral pleural invasion in the stage pT1-2N2M0 non-small cell lung cancer: A study based on the SEER registry

BackgroundVisceral pleural invasion (VPI) is considered an adverse prognostic factor in non-small cell lung cancer (NSCLC). However, the prognostic roles of VPI in Ⅲ/N2 NSCLC remain controversial. Therefore, this study aims to evaluate the prognostic value of VPI in patients with postoperative stage pT_1-2N₂M₀ NSCLC.MethodsUsing the Surveillance, Epidemiology, and End Results (SEER) database, we screened for patients with stage T1-2N2M0 NSCLC who received surgery from 2010 to 2015. To reduce baseline differences between Non-VPI group and VPI group, two-to-one propensity score matching (PSM) was performed. Cox proportional hazards regression was used to identify factors associated with survival. Overall survival (OS) was between the Non-VPI group and the VPI+ group by the Kaplan-Meier analysis.ResultsWe identified 1374 postoperative NSCLC patients with stage pT_1-2N₂M₀. The majority of cases (N = 1047, 76.8%) are Non-VPI patients. The factors associated with VPI+ group included white race (P < 0.0001), and adenocarcinoma (P < 0.0001).When analyzed in the total study population, VPI status remained a significant independent predictor of worse OS compared with the Non-VPI group (HR, 1.343; 95% CI, 1.083–1.665 [P=0.007]). Besides, in a subgroup analysis by VPI status, the results showed that patients without treatment exhibited a higher risk level in the Non-VPI group (P<0.0001). However, we did not find statistically significant differences among treatments in the VPI+ group (P=0.199). Mean survival time was 49.5 months (95% CI: 45.7–53.3 months) for chemotherapy alone in the Non-VPI group, compared with 41.2 months (95% CI: 35.8–46.6 months) in VPI+ groups. In both the VPI group and the non-VPI group, there is no statistical difference between adjuvant chemotherapy combined with PORT and chemotherapy alone.ConclusionThis study emphasizes that the presence of VPI is a poor prognostic factor, even in patients with Ⅲ/N2 NSCLC. As the study shows, chemotherapy significantly improved overall survival of patients with postoperative stage pT_1-2N₂M₀ NSCLC, especially for Non-VPI patients. However, the significance of PORT is still worth further exploration.     

A study of glycogen storage disease with 99Tcm-MIBI gated myocardial perfusion imaging

Objective

Gated myocardial perfusion imaging (G-MPI) is regularly performed using single-photon emission computed tomography. The objective of this study was to evaluate the clinical value of 99Tcm-methoxyisobutylisonitrile (MIBI) myocardial imaging in glycogen storage disease (GSD).

Methods

99Tcm-MIBI G-MPI was performed in nine patients with clinically proven GSD. QGS quantitative software was used for processing and interpretation. Left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV) were automatically generated. The myocardium was divided into seven segments, 20 sub-segments and a five-point scoring system was used.

Results

Seven out of nine cases were abnormal and the positive rate of G-MPI was 77.8 %. Sixty-two sub-segments of injured myocardium were detected in 140 sub-segments of seven abnormal patients. One injured segment was observed in one patient (14.3 %), two segments were detected in two patients (28.6 %) and three or more abnormal segments were observed in four patients (57.1 %).

Conclusion

99Tcm-MIBI G-MPI can detect myocardial damage in GSD as a non-invasive method. It plays an important role in the clinic.     

化瘀通络中药对糖尿病肾病大鼠肾脏足细胞密度的干预作用

[目的] 分析化瘀通络中药对糖尿病肾病（DN）大肾脏整合素α3β1表达及足细胞密度的影响。[方法] 糖尿病大鼠模型采用高脂饲料联合腹腔注射链脲佐菌素建立,大鼠分为正常组、模型组、厄贝沙坦组和中药组,各组相应药物剂量灌胃。灌胃20周后检测各组大鼠空腹血糖（FBG）、血肌酐（Scr）、尿素氮（BUN）、24h尿蛋白定量（24h UTP）,肾组织行光镜观察,分别采用实时聚合酶链反应（RT-PCR）及免疫组化（IHC）检测肾脏整合素α3（ITGA3）、整合素β1（ITGB1）、WT1 mRNA及蛋白的表达,计算足细胞密度。[结果] 与正常组比较,模型组各项指标差异均有统计学意义（P＜0.05）;与模型组比较,两治疗组BUN、24hUTP明显下降（P＜0.05）,ITGA3、ITGB1、WT1 mRNA表达水平及足细胞密度明显上升（P＜0.05）,干预组病理损伤明显减轻,主要表现为肾小球内细胞基质及系膜细胞明显减少;与厄贝沙坦组比较,中药组24h UTP明显降低（P＜0.05）,ITGB1 mRNA及足细胞密度明显上升。[结论] 化瘀通络中药对糖尿病肾病大鼠肾脏有保护作用,其机制可能与调节整合素α3β1表达从而减少足细胞脱落相关。     

Different iron deposition patterns in early- and middle-late-onset Parkinson's disease

BackgroundIron deposition may contribute to the clinical symptoms in Parkinson's disease (PD). With partial different clinical manifestations, the iron deposition patterns between patients with early-onset Parkinson's disease (EOPD) and middle-late-onset Parkinson's disease (M-LOPD) are still unclear. This study was designed to investigate the patterns of iron deposition and their clinical relevance in EOPD and M-LOPD patients, using quantitative susceptibility mapping technique.Materials and methodsThirty-five EOPD patients and 24 matched young controls, 33 M-LOPD patients and 22 matched older controls were recruited in the study. The iron content in the deep grey matter nuclei in the basal ganglia and midbrain were measured, and compared between patients and their corresponding controls. The correlations of regional iron content and clinical features were explored in patient groups.ResultsBoth M-LOPD and EOPD patients showed increased iron content in the substantia nigra (SN) pars compacta and SN pars reticulata. Increased iron content in the putamen was only observed in M-LOPD patients. The relationship between the increased iron content and disease severity (H&Y stages, UPDRS II scores and UPDRS III scores) was observed in M-LOPD patients, but not in EOPD patients.ConclusionOur study suggested that the iron deposition pattern was greatly influenced by the age of PD onset, which increases our understanding of the different pathological underpinnings of EOPD and M-LOPD patients.