钛铌锆β钛合金生物相容性的体外实验研究

[目的]通过体外实验对自行研发的低弹性模量、高强度新型β型钛合金人工关节假体材料生物相容性进行评价。[方法]（1）采用L-929细胞（小鼠成纤维细胞）对合金进行细胞毒性试验,将细胞相对增殖率（RGR）转换成6级材料毒性进行评级。（2）将1μm左右的钛铌锆合金（Ti-Nb-Zr）颗粒与J774A.1巨噬细胞体外共同培养24～48h后,采用倒置相差显微镜和透射电镜观察细胞变化、RT-PCR方法测定IL-6和TNF-α表达、ELISA法测定细胞培养上清TNF-α等方法对Ti-Nb-Zr的生物相容性进行评价,并与传统的人工关节假体材料进行比较。[结果]Ti-Nb-Zr的细胞毒性为0级。吞噬了Ti-Nb-Zr颗粒的J774A.1巨噬细胞形态改变明显轻于钴铬钼颗粒组和钛铝钒颗粒组。巨噬细胞与钛铝钒合金颗粒、钴铬钼合金颗粒和Ti-Nb-Zr颗粒共同培养48h后都有IL-6和TNF-αmRNA表达的增加,钴铬钼颗粒和钛铝钒颗粒引起增加更加明显。ELISA方法测定显示：巨噬细胞吞噬Ti-Nb-Zr颗粒48h后分泌TNF-α的量明显低于钛铝钒和钴铬钼（P〈0.05）。[结论]低弹性模量Ti-Nb-Zr钛合金具有优良的体外组织相容性,是一种有前途的骨科内植物材料。     

真空球磨法体外制备人工关节金属磨损颗粒

本实验研究了一种体外制备人工关节金属磨损颗粒的方法,验证其在人工关节无菌性松动的实验研究中应用的可行性。[方法]通过真空球磨法体外制备人工关节金属磨损颗粒,同时对磨损颗粒进行元素分析,扫描电镜观察,激光粒度仪检测,并与RAW 264.7细胞共培养,检测细胞毒性。[结果]真空球磨法体外制备人工关节金属磨损颗粒直径5μm,与体内分离的人工关节金属磨损颗粒理化性质一致,在试验浓度(通常低于1 mg/m l)没有显示细胞毒性。[结论]真空球磨法体外制备人工关节金属磨损颗粒简便易行,重复性好,可以用于相关的细胞学研究。     

人工关节假体不同材料及材料表面粗糙度对表皮葡萄球菌粘附能力的影响

目的探讨人工关节假体材料及表面粗糙度对表皮葡萄球菌粘附能力的影响。方法制作超高分子聚乙烯、钛合金和钴铬钼合金试样，表皮葡萄球菌经FITC标记，人工关节材料试样消毒后接种FITC标记的表皮葡萄球菌，试样表面分为光滑表面和粗糙表面，每组各6个试样，将含有细菌和试样的24孔板在37℃下孵育30min后，用荧光显微镜观察，试样用扫描电镜观察。结果对于光滑的人工关节常用材料表面，表皮葡萄球菌对超高分子聚乙烯（UHMWPE）的粘附能力显著高于钛合金和钴铬钼合金（P〈0．001），对钴铬钼合金的粘附能力要高于钛合金（P〈0．05）；粗糙的超高分子聚乙烯和钴铬钼合金表面比光滑的表面更易引起表皮葡萄球菌的粘附（P〈0．01），而细菌对粗糙钛合金的粘附仅轻微高于光滑钛合金（P〉0．05）。荧光照相观察及扫描电镜观察显示细菌在粗糙表面的划痕内聚集粘附。结论本研究结果表明细菌对人工关节材料表面的粘附能力不但取决于细菌本身，也和材料性质和表面粗糙度有关。     

改良大鼠气囊模型在人工关节假体松动研究中的应用

[目的]设计并改良大鼠气囊模型（the air pouch model），证实该模型在人工关节松动相关研究中的应用价值。[方法]（1）改良大鼠气囊模型的建立：健康成年SD大鼠18只，背部皮下注入空气20ml，48h后补充注入空气10ml形成气囊。形成气囊24h后气囊穿刺，注入PBS液5ml，6、24、48h分别穿刺抽液，收集囊内液体采用ELISA方法测定IL-6和TNF—Ot；（2）改良大鼠气囊模型对不同关节材料磨损颗粒生物反应的比较：健康成年SD大鼠24只，皮下充气造模后将钴铬钼、钛铝钒和钛铌锆合金（TNZ）颗粒混悬液注入气囊，收集囊内液体采用ELISA方法测定IL-6和TNF—α，用囊壁组织学切片进行炎症细胞反应分级并测量囊壁厚度。[结果]（1）在SD大鼠皮下注入空气20ml可以形成饱满的气囊，大鼠术后活动正常。48h后气囊由于气体吸收体积减小，张力下降。再次注射10ml空气后张力恢复。PBS能使囊内液体的TNF—α在6h左右出现一个高峰达239．30pg／ml，与24h和48h比较，差异有显著统计学意义（P〈0．05）。IL-6的测定值没有TNF—α那样的6h分泌高峰。6、24、48h之间无显著性差异（P〉0．05）；（2）钻铬钼、钛铝钒、TNZ3种颗粒注入气囊48h后都能引起TNF—α分泌量显著升高（P〈0．05），两两比较，钛铝钒组明显高于钴铬钼组和TNZ组（P〈0．05）。3种材料均不能引起IL-6分泌的显著增加（P〉0．05）。TNZ组气囊囊壁厚度明显小于钴铬钼组和钛铝钒组（P〈0．001）。[结论]改良大鼠气囊模型具有造模简单、对人工关节颗粒反应快速敏感的特点，是一种人工关节松动相关实验研究有效的动物模型。     

磨损颗粒刺激巨噬细胞引起人工关节松动的作用机制

目的探讨来源于人外周血的单核／巨噬细胞对直径1μm以下超高分子聚乙烯（UHMWPE）磨损颗粒的反应及其机制。方法从因无菌性人工髋关节松动而需要行翻修手术的患者假体周围组织中提取UHMWPE磨损颗粒。从10名健康志愿者分别抽取50ml外周血，梯度离心获得外周血中的单核／巨噬细胞。将细胞分为6组：A：单核／巨噬细胞＋UHMWPE磨损颗粒；B：单核／巨噬细胞＋UHMWPE磨损颗粒＋100μM Rotenone；C：单核／巨噬细胞＋UHMWPE磨损颗粒＋10μM U0126；D：单核／巨噬细胞＋UHMWPE磨损颗粒＋10ng／ml Cerivastatin；E：单核／巨噬细胞；F：单核／巨噬细胞＋脂多糖（LPS）。检测各组细胞的TNFα表达。结果UHMWPE磨损颗粒明显刺激单核／巨噬细胞分泌TNFα。Rotenone、U0126和Cerivastatin均可抑制UHMWPE磨损颗粒刺激单核／巨噬细胞分泌TNFα，且以U0126明显（P〈0．01）。结论UHMWPE磨损颗粒刺激单核／巨噬细胞产生TNFα可通过NF—κB和MAPK通路，但以MAPK通路为主。     

不同微粒对人工关节假体周围膜影响的实验研究

目的：观察人工关节置换中产生的磨损微粒在动物体内引起的组织学反应。并比较不同微粒的差异，探讨人工关节松动的原因，方法：成年新西兰兔32只，雌雄不限，按膝关节内注入微粒的不同随机分为4组，每组8只，甲组：注入超高分子聚乙烯微粒；乙组：注入钛合金微粒；丙组：注入骨水泥微粒；丁组：对照组注入生理盐水，术后第2周开始向关节囊内注入各种微粒悬液，每次0．2ml，每隔两周一次直至术后14周，在第16周处死动物，取股骨远端及关节囊切片，HE染色，光镜观察，光镜观察关节囊滑膜的组织细胞反应，吞噬磨屑情况，从各组标本中取0．2g组织，并制成组织匀浆，离心后取上清液，放免法测定TNF－α含量。结果：各实验组假体隧道边缘产生一层纤维结缔组织界膜，其中含有大量的巨噬细胞和异物巨细胞，面对照组的假体隧道边缘未见明显的组织细胞反应。聚乙烯组，钛合金组，骨水泥组体隧道边缘的组织细胞含量明显高于对照组（P＜0．05），而各实验组之间无明显差别。各实验组的关节滑膜细胞增生，滑膜下为较多的胶原纤维组织，并可见巨噬细胞浸润，纤维母细胞和毛细血管增生，而对照组的滑膜基本正常，各实验组织中的TNF－α含量明显高于对照组（P＜0．05），而各实验组之间无明显差异，结论：各种人工关节材料的微粒均能引起相似的组织学反应，促进组织中炎性介质TNF－α的释放，并进一步造成溶骨，这是人工关节松动的一个原因。     

微小假体磨损颗粒诱导置入物旁骨溶解的扫描电镜观察

为比较不同人工关节微小磨损颗粒对假体－骨界面处骨整合及骨整合及骨溶解的影响,探讨假体松动的机制。方法本实验采用扫描电镜技术对钛事金、钴－铬－钼与聚乙烯（ｕｌｔｒａｈｉｇｈｍｏｌｅｃｕｌａｒｗｅｉｇｈｔｐｏｌｙｅｔｈｙｌｅｎｅ,ＵＨＭＷＰＥ）三种微小颗粒诱导的假体周围骨组织改变进行超微结构观察。结果研究发现,直径２．５μｍ的Ｔｉ－６Ａｌ－４Ｖ颗粒诱导置入物旁骨吸收或骨溶解的程度明显低于相同直径的Ｃｏ     

人工髋关节假体旁组织中巨噬细胞亚群的分布

目的 探讨人工髋关节假体周围组织中巨噬细胞亚群的分布情况。方法 获取因人工髋关节无菌性松动而行翻修术的37例患者假体周围组织，并用免疫组织化学的方法检测假体周围组织6个区中27E10（＋）、25179（＋）和RM3／1（＋）巨噬细胞亚群的分布。结果 在人工关节假体周围各个区域组织中均有27E10（＋）、25179（＋）和RM3／1（＋）的巨噬细胞存在。各区中25179（＋）的巨噬细胞百分数分别为（35．12±27．09）％、（42．6±28．01）％、（36．81±23．44）％、（33．86＋26．63）％、（42．45±19．12）％和（42．50±29．10）％均高于各区中27E10（＋）及RM3／1（＋）巨噬细胞的百分数（P〈0．05）。25179（＋）和RM3／1（＋）的巨噬细胞亚群在2区、5区和6区较多，1区和4区较少，差异有统计学意义（P〈0．05）。结论 假体旁组织中巨噬细胞亚群的分布与磨损颗粒相关，假体旁组织中同时存在着急性和慢性炎症过程。巨噬细胞不断地被激活可使炎症不断发展，这也许是导致人工关节假体无菌性松动不可避免的重要原因。     

MCP-1-CCR2抑制剂治疗人工关节无菌性松动的研究进展

人工关节磨损颗粒诱导全身的巨噬细胞迁移到关节假体周围,并刺激巨噬细胞释放多种趋化因子,其中巨噬细胞趋化性蛋白-1(MCP-1)在调节全身的单核/巨噬细胞趋化迁移和慢性炎症过程中起关键作用。单核/巨噬细胞是破骨细胞的前体细胞,减少单核/巨噬细胞的迁移和活化,有可能减轻与磨损颗粒相关的假体周围骨溶解。该文介绍磨损颗粒分类及其生物学特征,以及MCP-1-CCR2信号通路与磨损颗粒诱导的全身性巨噬细胞迁移、最终导致假体周围骨溶解的研究进展情况。     

依那西普对磨屑诱导骨溶解影响的实验研究

[目的]检测依那西普（Etanercept，Enbrel）对钛颗粒刺激巨噬细胞（macrophages，MФ）分泌肿瘤坏死因子α（tumor necrosis factor-α，TNF-α）、白介素1（interleukin-1，IL-1）、白介素6（interleukin-6，IL-6）的影响，探讨依那西普防治人工关节无菌性松动的可能性。[方法]分离、培养小鼠腹腔巨噬细胞，24h后分为5组。A组：仅为MФ；B组：MФ＋钛颗粒；C组：MФ＋钛颗粒＋依那西普（10ng／m1）；D组：MФ＋钛颗粒＋依那西普（100ng／ml）；E组：MФ＋钛颗粒＋依那西普（1000ng／ml）。培养18h后，用酶联免疫法（ELISA）检测细胞培养上清液中TNF-α、IL-1、IL-6的含量。[结果]B组TNF-α、IL-1、IL-6含量明显高于A、D、E组（P〈0．001），E组TNF-α、IL-1、IL-6的含量明显低于B组、C组（P〈0．001，E组和D组间无统计学意义（P〉0．05）。[结论]钛颗粒可以刺激MФ分泌大量的TNF-α、IL-1、IL-6，依那西普能够呈剂量依赖型地有效抑制钛颗粒诱导的MФ分泌TNF-α、IL-1、IL-6，有望成为预防人工关节无菌性松动的药物。     

Pregnancy associated breast cancer

Pregnancy associated breast cancer (PABC) defined as breast cancer occurring during pregnancy or within the first 1‐2 years postpartum. Delay in diagnosis is common. Treatment is timed around gestational age. Surgery and chemotherapy are considered safe after the first trimester. Radiation, anti–her‐2, and endocrine therapy are delayed until after delivery due to adverse fetal effects. Iatrogenic prematurity likely causes most long‐term fetal sequelae. Multi‐disciplinary care and social support are critical for patients and families with PABC.     

Reacreditación o recertificación de los cirujanos generales en España: esa es la cuestión. Resultados de una encuesta nacional

IntroductionThe Law for the Regulation of Health Professions (LOPS) indicates that health professionals will carry out continuous training throughout their professional life, and will regularly prove their professional competence. The objective of the study was to carry out a national survey to find out the opinion of Spanish surgeons and thus be able to prepare a recertification project by the Spanish Association of Surgeons (AEC).MethodsCross-sectional observational study carried out in June-July 2020, through a survey sent to the members of the AEC.ResultsThe survey had a total of 1230 visits and an overall completion rate of 784 responses (67.3%). 69.6% were unaware of the LOPS forecasts and 83.4% were unaware of similar initiatives in other specialties and 95.5% agreed to demand adequate information. 71.4% believed it necessary but only 57% believed that it should be mandatory. 82.9% would agree that it should be regulated through an objective and predictable official procedure.ConclusionsThe concept of re-accreditation is not well known in our specialty and in view of the results obtained, adequate and reliable information seems necessary. Therefore, it would be pertinent to propose by the AEC a specific project to assess activities and skills.     

Effect of cyclosporin therapy in controlling the rejection of ileal versus jejunal allografts*

Abstract. Experimental evidence suggests that jejunal allografts are rejected as rapidly as are ileal grafts, despite their lesser content of lymphoid tissue as an immunologic stimulus. However, it may be possible to postpone the rejection of jejunal grafts more readily than that of ileal grafts by means of immunosuppressive therapy with cyclosporin (CyA). To test this, we used the rat model (BN-LEW) of orthotopic small-bowel transplantation. The proximal third of the small-bowel with one-third of the mesenteric lymph nodes (n= 20), or the distal ileal third with all of the mesenteric lymph nodes (n= 22), or the entire small-bowel (n= 23) was interposed after resection of an equivalent type and length of recipient bowel. CyA (15 mg/kg) was given to all of these rats for 5 days. Three additional control groups were not given CyA. The difference in graft/recipient survival among the groups receiving CyA and among those not on CyA therapy was not statistically significant. Antidonor hemagglutinin titers, the mixed lymphocyte culture (MLC) assay, and histologic examination of the allograft failed to show a mitigated rejection reaction for the recipients of jejunal grafts. The data show that short-term treatment with CyA prolongs graft survival. Equal doses of CyA, however, did not lead to prolonged survival of jejunal grafts or alter the course of rejection in comparison with that for ileal or whole-bowel transplants.     

Whole body MRI for systemic staging of breast cancer in pregnant women

When breast cancer is diagnosed during pregnancy, treatment should be as close; as possible to what is used in non-pregnant patients. This requires accurate local and systemic staging: ultrasound (US) is used for local staging and allows adequate evaluation of the liver and pelvis, but chest and bones cannot be explored and imaging techniques involving exposure to ionizing radiation would be needed. However, since imaging techniques involving ionizing radiation and the use of radionuclides should be limited, whole body magnetic resonance imaging (WB-MRI) without administration of contrast agent represents a very interesting alternative, but limited data is available. In this paper we describe the obstetrical and oncological outcome of 14 patients in whom breast cancer was diagnosed during the second or third trimester of pregnancy and that were staged using WB-MRI. Median age of the patient at diagnosis was 35 years (range 20–36), median gestational age at MRI was 30 weeks (range 13–32) and median age at delivery was 38 weeks (range 32–38). At birth, one new-born presented respiratory distress syndrome and one jaundice. We conclude that diffusion-weighted MRI is feasible accurate and safe for the mother and for the foetus. It may represent the staging technique of choice in pregnant women diagnosed with breast cancer after the first trimester of pregnancy.     

Anesthesia for liver transplantation in patients with arterial hypoxemia

Abstract. Arterial oxygenation during anesthesia and time of postoperative mechanical ventilation were investigated in 17 patients with chronic liver disease who underwent liver transplantation. Six patients had arterial hypoxemia (PaO₂ 64 3 mm Hg) and the other 11 patients had normal PaO₂ (105 5 mm Hg) before transplantation. None of the patients were smokers and all had normal preoperative pulmonary X-ray and spirometry. During transplantation, PaO₂ increased in both groups, but PaO₂ was still approximately 20% lower and PA-aO₂ was 40%-60% higher in the hypoxemic group than in the normoxemic patients ( P < 0. 05). The median postoperative time on mechanical ventilation was three times longer in the hypoxemic group (56 h) than in the normoxemic patients (18 h; P = NS). Number or severity of postoperative complications and outcome did not differ between the two groups. It is therefore suggested that patients with arterial hypoxemia without overt lung disease should also be accepted for liver transplantation.     

Relation between Asymmetric Dimethylarginine (ADMA) and Hearing Loss in Patients with Renal Impairment

Background. Hearing loss is common in patients with CRF. The exact etiology of this complication is not known, and little can be done to ameliorate the disorder. ADMA is found to be high in CRF patients. We studied the relation between ADMA and hearing loss in patients with CRF under conservative treatment. Methods. The study was carried out on 40 patients with renal impairment under conservative treatment (group 1) and 30 normal control subjects (group 2). For both groups' medical history and examination, biochemical tests, otological examination, pure tone audiometry, high sensitivity CRP, and asymmetric dimethylarginine (ADMA) were completed. Results. High-frequency hearing impairment was the predominant auditory dysfunction in CRF patients who showed worse high-tone hearing level on pure tone audiometry as compared with the controls (p < .001). Multiple regression analysis for hearing level at high frequency in group 1 shows that significant determinants of hearing level are ADMA (p = 0.002), high sensitivity CRP (p = 0.02), duration of renal disease (p = 0.01), diabetes mellitus (p < 0.001), and serum creatinine (p = 0.008). No correlation was found between hearing loss with age, gender, smoking, hematocrit, or lipid parameters. Conclusion. Patients with CRF under conservative treatment often experience a significant frequency hearing loss. Such a hearing disorder is mainly affected by duration and degree of renal disease, presence of DM, and level of hsCRP and ADMA. There is a close correlation between ADMA and hearing loss. Thus, ADMA could be an important factor causing hearing loss in those patients. Modifying this factor can be of value to ameliorate this common complication.     

Organ transplantation in Japan - present status and problems

Abstract. Kidney transplantation was first performed in Japan in 1956. Liver, heart, and pancreas transplantation began in 1964, 1968, and 1984, respectively. From 1964 until the end of 1987, 5328 kidney transplantations were performed in 122 facilities. A total of 75. 7% of the grafts came from living related donors and 24. 3% from cadavers. Although there were 80553 patients on dialysis at the end of 1987, only 572 renal transplants were performed that year. No liver or heart transplantations have been performed since 1968. In this review, data from the Japanese National Registry on Dialysis and Transplantation are presented. In addition, the social problems and public attitude towards brain death legislation and organ transplantation are discussed.     

Symptomatic cytomegalovirus (CMV) infections identified by image cytometry and other parameters for CMV infection

Abstract. Thirty-eight renal transplant recipients were followed during the first 3 months after transplantation. Once weekly, cultures of urine and buffy coat for cytomegalovirus (CMV) were taken and an immunocytochemical assay for immediate early antigens of CMV (IEA assay) was performed. Thirty patients had evidence of a CMV infection and 11 had a symptomatic CMV infection. All symptomatic patients had one or more positive urine cultures or a positive IEA assay. However, 15 patients with positive urine cultures and 12 patients with a positive IEA assay lacked any signs of symptomatic CMV disease. Moreover, 6 out of 15 patients with positive buffy coat cultures for CMV did not have symptomatic CMV disease. Using a computerized system to quantify IEA-positive granulocytes, we show that the absolute number of positive cells per million correlates very well with the occurrence of symptomatic CMV disease.