基于平调阴阳理论防治糖皮质激素性骨质疏松症

糖皮质激素性骨质疏松症（glucocorticoid osteoporosis，GIOP）是长期或过量使用糖皮质激素，从而影响骨重建过程造成的。依据糖皮质激素在体内的生理病理作用和动态变化，中医学认为糖皮质激素造成的机体阴阳失衡是GIOP发病的根本原因；病变关键在肾，肾阴阳失衡是病机发展转化的核心，表现为“肾阴虚-肾阳虚-肾阴阳两虚”的演变规律；脏腑亏虚，气血阻滞，骨骼失养是核心病机，病理变化始终强调动态性和复合性。据此确立“平调阴阳”的治疗大法，基于平调肾阴阳理论防治GIOP，一方面强调平调阴阳一定是一个动态平衡过程，另一方面在平调肾阴阳的同时调节一身阴阳的平衡以病证结合、辨证论治，并平调原发病之阴阳以治未病，最终达到阴阳平衡、血脉通利、筋骨得养的状态。现代研究表明细胞自噬是阴阳动态平衡的微观机制，是“平调阴阳”法改善GIOP的防治靶点。可见，平调阴阳是临床防治GIOP的一个重要思路。     

汉族人下颌角相关的三维CT与大体测量的比较研究

目的 通过对汉族成年男女颅颌面软组织及螺旋CT三维重建骨性数据测量，并与颅骨测量数据对比分析，研究对颌面部诊断、治疗的影响因素。同时，也为下一步诊断模型的建立、调试奠定基础。方法 随机选取汉族成年男女各20例（无颅骨明显畸形），进行颅颌面软组织测量及螺旋CT三维骨性测量，并行统计学分析。结果 颌面部软组织对汉族男女性别特征的判断影响很大。在大体测量中，男女的头长、头宽、面中宽及表示下面部特征等多个数据的差异明显，三维CT与颅骨骨性测量的结果基本一致。结论 三维螺旋CT与颅骨测量有良好的一致性；颌面部软组织对汉族人的性别判断、颌面诊疗影响很大。在治疗下面部畸形过程中，不仅需要对骨性的处理，还需要对软组织进行处理。这一点对女性患者尤为重要。     

汉族人下颌角相关的三维CT与大体测量的比较研究

目的通过对汉族成年男女颅颌面软组织及螺旋CT三维重建骨性数据测量,并与颅骨测量数据对比分析,研究对颌面部诊断、治疗的影响因素。同时,也为下一步诊断模型的建立、调试奠定基础。方法随机选取汉族成年男女各20例(无颅骨明显畸形),进行颅颌面软组织测量及螺旋CT三维骨性测量,并行统计学分析。结果颌面部软组织对汉族男女性别特征的判断影响很大。在大体测量中,男女的头长、头宽、面中宽及表示下面部特征等多个数据的差异明显,三维CT与颅骨骨性测量的结果基本一致。结论三维螺旋CT与颅骨测量有良好的一致性;颌面部软组织对汉族人的性别判断、颌面诊疗影响很大。在治疗下面部畸形过程中,不仅需要对骨性的处理,还需要对软组织进行处理。这一点对女性患者尤为重要。     

巨细胞病毒对新生鼠肝胆系统FasL、bcl-2及baX基因表达的影响

目的 了解巨细胞病毒(CMV)对新生鼠肝胆系统FasL、bcl—2及bax基因表达的影响。方法 新生鼠腹腔注射不同滴度的CMV，在注射病毒后5、10、15、21及28d各处死一批动物。观察动物的体重变化及肝内外胆管的组织学改变。DNA原位末端标记法检测肝脏及肝外胆管的凋亡细胞。免疫组织化学法检测CMV晚期蛋白及FasL、bcl—2及bax蛋白在肝脏及肝外胆管中的表达。结果 病毒注射组小鼠体重的增加明显慢于对照组。病毒注射后可出现肝胆系统的急慢性炎症反应。且可见肝外胆管狭窄。病毒注射组肝脏及肝外胆管的凋亡指数明显高于对照组。FasL及bax在病毒注射组肝脏及肝外胆管中的表达均较对照组高，但bcl—2的表达降低。病毒注射5d后可在肝脏中检测到病毒晚期蛋白。结论 新生鼠腹腔注射CMV可造成鼠肝胆系统损伤，这种损伤可能是由细胞凋亡增加所致。     

中医药防治老年骨质疏松研究进展

骨质疏松症是中老年人的常见疾病,中医在该病防治方面主要从以下几方面分型:(1)肾主骨理论:肾为先天之本,肾主藏精,主骨生髓,与生殖、内分泌、性腺系统密切相关,肾的生理作用与骨的旺、盛、平、衰有极大的相关性。骨痿其标在骨,其本在肾。(2)脾肾相关论:脾为后天之本,主运化水谷精微。脾气散精,上输于肺,下归于肾,脾肾相互促进,相互依存,常有脾肾同病之说。脾肾虚弱是骨质疏松症的主要病理变化。(3)血瘀论:骨质疏松症患者脏腑功能失调,经气不利,影响气血运行,导致经络气血运行不畅,不通则痛,故常出现疼痛、功能障碍。血瘀可致气血运行障碍,营养物质不能濡养脏腑、骨骼,引起脾肾俱虚而加重骨质疏松症。(4)肝郁论:肝藏血主筋,肾藏精主骨,肝肾同下焦,精血可以互化,肝郁气滞,郁而化火,易灼伤肝阴而致肝阴不足,肝阴血亏虚,无以生精养骨,终致骨痿。因此临床用药灵活多变,但不出补肾壮骨、健脾益气、活血通脉、以及疏肝解郁的治疗大法。     

唇腭裂病人成年后的综合美容

既使是近乎完美的唇腭裂早期治疗，随着人体面部器官的生长发育，仍有可能出现鼻部、唇部畸型，因此，唇腭裂后期治疗至关重要。通过对１６０２例早期及后期唇腭裂病人的治疗体会与总结，指出各类型唇腭裂病人成年后常见的各种面颌部畸形。阐述了适用于该类病人的手术前设计、治疗原则、治疗步骤及方法。针对唇腭裂病人成年后所出现的畸形往往是多方面的这一现象，结合口腔颌面外科、正畸修复科、整形美容外科等专科特点，提出了综合美容整形的设计思路及治疗要点     

正常人颈脊髓矢状径MRI测量

目的 提供颈脊髓矢状径、颈椎管有效矢状径(脑脊液柱矢状径)正常参考值,筛选出较科学的评估颈脊髓病的影像学标准.方法 在120例正常人颈椎MRI片上,对各节段颈脊髓矢状径、颈椎管有效矢状径、M值(桥脑-延髓交界处矢状径)进行测量,计算脊髓矢状径与椎管有效矢状径比值,以及脊髓矢状径和M值的比值(C/M值),研究它们与性别、年龄和颈椎长度的相关性.评估脊髓矢状径与椎管有效矢状径比值和C/M值的临床应用价值.结果 脊髓矢状径、椎管有效矢状径、M值男性大于女性(P<0.05),脊髓矢状径和椎管有效矢状径比值和C/M值男女无差别(P>0.05).颈脊髓矢状径和M值随着颈椎长度的增加而增加(r=0.215,P=0.010;r=0.151,P=0.020).颈脊髓矢状径和颈椎管有效矢状径比值与年龄成呈相关(r=0.242,P<0.01),与颈椎长度无明显相关(r=0.082,P=0.200).C/M值与年龄和颈椎长度均无相关性(r=0.06,P=0.359;r=0.003,P=0.900).结论 C/M值能够很好评价颈脊髓萎缩、受压、损害的状况,它很少受到个体差异的影响,是临床评估颈脊髓疾病的良好标准之一.     

The anatomy of the surgical treatment of migraine

OBJECTIVE: The transpalpebral resection of the corrugator and depressor supercilii muscles is a new treatment option for migraine headaches. Hyperactive contractility of these muscles can provoke the peripheral compression of the supratrochlear nerve and induce a neurogenic inflammation triggering the symptoms of migraine. In order to gather detailed knowledge of the respective anatomy in the eyebrow region, a macroscopic cadaver study was conducted. MATERIALS AND METHODS: The relevant muscles of the forehead, glabella and eyebrow were dissected in five fresh, non-preserved heads. The supracanthal origins and dermal points of insertion were marked. Following the preparation of the neurovascular structures, the muscles were measured and weighed. The course of the supraorbital and supratrochlear nerves was demonstrated from the forehead to the orbital cavity. RESULTS: There are three, paired groups of muscles in the superomedial region of the orbital rim. They can be divided into the superficial frontalis and procerus muscle, the orbicularis muscle in a middle layer and the corrugator and depressor supercilii in a deeper layer. The corrugator measured approximately 4.5 cm, whose origin is superior and posterior to the depressor origin situated cranial to the medial canthus. The corrugator inserts lateral to the exit of the supraorbital nerve in the dermis above the eyebrow after penetrating the orbicularis and frontalis muscles and a subgaleal fat pad. The length and weight of the muscles is highly variable. The muscle is penetrated by the supratrochlear nerve whereas the supraorbital nerve runs underneath it. The corrugator is innervated medially and laterally by branches of the facial nerve. CONCLUSION: A detailed knowledge of the complex arrangement of the muscles acting upon the glabella and the different communicating subgaleal and preseptal fat pads allow the identification and resection of the corrugator and depressor muscles without damaging the supratrochlear nerve. The course of the specific nerves is variable. The double-innervation of the corrugator suggests its complete resection instead of the selective denervation of the muscle.     

垂体腺瘤侵袭性相关因素的研究

目的探讨雌激素受体(ER)、孕激素受体(PR)与热休克蛋白70(HSP70)在垂体腺瘤中的表达及其作为判断垂体腺瘤侵袭性和预后指标的可能性。方法经手术切除且病理诊断为垂体腺瘤、具有完整内分泌资料的患者50例,根据Hardy-Wilson及Knosp分级、分期标准,结合病理活检判断其肿瘤侵袭性,用免疫组化方法分别检测每例肿瘤ER、PR、HSP70的表达水平。结果ER表达水平与垂体腺瘤侵袭性之间存在显著的负相关关系,PR表达水平与垂体腺瘤侵袭性之间的相关关系不显著,HSP70表达水平与垂体腺瘤侵袭性之间存在正相关关系。ER、PR的表达分别与HSP70表达有显著的负相关关系。结论ER、PR、HSP70三者的表达水平可提高判断垂体腺瘤侵袭性和预后的准确性。     

Neuropraxia of the Cutaneous Nerve of the Cervical Plexus After Shoulder Arthroscopy

This article presents uncommon cases of neuropraxia of the lesser occipital nerve and the greater auricular nerve after arthroscopic surgery of the shoulder in the beach-chair position under general anesthesia. The lesser occipital nerve and the greater auricular nerve are superficial ascending branches of the cervical plexus. These 2 superficial nerves may be easily vulnerable because of their superficial anatomic locations. We assumed that the severity of the neuropraxia of superficial branches of the cervical plexus was related to the degree of rotation and deviation of the head and neck, the duration of the procedure, and compression by head strap and elastic bandage used for fixing the head to the rectangular-shaped headrest of the beach-chair device. We recommend that during surgery in the beach-chair position, the auricle be protected and covered with cotton and gauze to avoid direct compression and the position of the head and neck be checked and corrected frequently. We hope for a new design of the headrest of the beach-chair device to prevent neuropraxia and to attach the head firmly and safely.     

Transtemporal approach to the skull base: an anatomical study

The surgical anatomy of a transtemporal approach to the structures of the clivus was defined with the aid of dissections in 10 cadaver heads. The steps in the dissection consisted of first exposing the cervical internal carotid artery (ICA), the internal jugular vein, and the caudal cranial nerves, each at the skull base; then performing small retromastoid and temporal craniotomies; and, finally, drilling away the petrous and tympanic bone to expose the intratemporal parts of the facial nerve, the petrous ICA, the sigmoid sinus, and the jugular bulb. To expose the structures of the lower clivus, the sigmoid sinus was ligated and divided, the facial nerve was displaced anterosuperiorly, and the inner ear structures were preserved. Dural opening exposed the anterolateral and anterior surfaces of the medulla, the pontomedullary junction, and the spinomedullary junction. The ipsilateral vertebral artery and often the contralateral vertebral artery and the vertebrobasilar junction, the caudal cranial nerves, and the origin of the 6th, 7th, and 8th cranial nerves were well exposed. To expose the structures of the middle clivus, we drilled away the labyrinth, the cochlea, and a portion of the clival bone. The facial nerve was displaced posteroinferiorly. Dural opening exposed the ipsilateral anterior surface of the pons, the midbasilar artery, and the ipsilateral 5th, 6th, 7th, and 8th cranial nerves. A portion of the contralateral anterior surface of the pons was also exposed at times. The superior limit of this exposure was just above the origin of the trigeminal nerve. The exposure of the upper clival structures was limited with this approach, and required medial temporal lobe retraction. Two case reports are included to illustrate the application of the transtemporal approach to the exposure and clipping of aneurysms of the vertebrobasilar system. The advantages and disadvantages of this approach are discussed.     

The treatment of severely comminuted intra-articular fractures of the distal radius

Comminuted fractures of the distal end of the radius are caused by high-energy trauma and present as shear and impacted fractures of the articular surface of the distal radius with displacement of the fragments. The force of the impact and the position of the hand and carpal bone determine the pattern of articular fragmentation and their displacement and the amount and the extent of frequent concommitant ligament and carpal bone injury. The result of the osseous lesion in comminuted fractures was termed "pilon radiale", which emphasizes the amount of damage to the distal radius and the difficulties to be expected in restoring the articular congruity. Besides this the additional injury, either strain of disruption of the ligaments and the displacement of the carpus and/ or the triangular fibrocartilage complex will equally influence the functional outcome. This review will expand on the relevant anatomy, correct classification and diagnosis of the fracture, diagnostic tools and operative treatment options. Current treatment concepts are analysed with regard to actual literature using the tools of evidence based medicine criteria. A new classification of severely comminuted distal radius fractures is proposed using CT data of 250 complex intraarticular radius fractures. Finally a standardized treatment protocol using external fixation in combination with minimal invasive internal osteosynthesis is described.     

Radiographical and anatomical studies on the pathogenesis of degenerative spondylolisthesis (author's transl)

In order to elucidate the causes of degenerative spondylolisthesis (D.S), the functional role of lumbar intervertebral joints and also laminae of the vertebral arch was studied by means of roentgenographic and also pathological exams. The inclination of the laminae of the vertebral arch and the intervertebral joints changed with age in accordance with statokinetic loading of the lumbar spine. In the group with increased lumbar lordosis at the upper level, movement of the 3rd and 4th lumbar vertebrae was great, accompanied by horizontal inclination of the laminae of the vertebral arch and the intervertebral joints and by osteoarthritic changes (O.A). This is similar to D.S. D.S is caused by abnormal spinal curvature and structural specificity of the lower limbs vertebrae, resulting in degeneration of the laminae of the vertebral arch and the intervertebral joints, changes in the inclination, decreased control of movement, and sliding of the vertebrae. Prodromal conditions resulting in the sliding of the vertebrae and in disc degeneration appear to be caused by D.S.     

脂肪因子chemerin与骨质疏松症的关系展望

骨质疏松症是世界常见病、多发病,医学界对骨质疏松症发病机理与防治的研究愈显重要。近年研究表明,各种原因导致的骨量减少常伴有骨髓中脂肪组织含量的增加。骨质疏松的发生可能与骨代谢中成脂和成骨的比例有关。骨髓中脂肪组织在骨形成和造血支持中发挥重要作用,脂肪组织具有内分泌调节功能,释放出一系列重要的分泌性因子,比如：leptin、adiponectin、chemerin、resistin、visfatin等,在调节骨髓间充质干细胞向脂肪细胞分化过程中起关键作用。chemerin是新发现的脂肪因子,它在免疫应答、脂质代谢、糖类代谢、炎症反应等生理病理过程中都起着重要的作用。它与leptin、adiponect等脂肪因子一样参与骨代谢的调节,对维持骨代谢的平衡起着重要的作用。chemerin及其受体CMKLR1信号传递通路的激活可以调节骨髓间充质干细胞的分化,促进破骨细胞的生成,从而影响影响骨的重建。现在chemerin/CMKLR1信号通路影响骨代谢的作用机制还不是很明确,深入研究chemerin及其受体与骨质疏松的关系,可以进一步了解骨质疏松症发生机制,为治疗及预防骨质疏松症及提供了新的方向。     

The role and limitations of computed tomographic scanning in the evaluation of cervical trauma.

We retrospectively reviewed the medical records, plain films, CT scans and complex-motion tomographic studies (TOMOS) of 216 consecutive patients with cervical injuries to determine the uses and limitations of CT in the evaluation of cervical trauma and the indications, if any, for the continued use of TOMOS in evaluating cervical trauma. There were 453 fractures and 104 subluxations or dislocations of the cervical spine in the 216 patients. Plain films detected 58% (262 of 453) of the fractures and 93% (97 of 104) of the subluxations and dislocations; and 94% (202 of 216) of the patients with abnormalities were identified. Computed tomographic scans detected 90% (406 of 453) of the fractures and 54% (56 of 104) of the subluxations and dislocations; 92% (198 of 216) of the patients with abnormalities were identified. Most of the abnormalities missed on the CT scans involved the dens, C-6, and C-7, and were oriented in the axial plane. Although CT scanning was better than plain films in detecting most types of cervical fractures, plain films were better than CT for detecting fractures of the vertebral body, dens, and spinous processes, and significantly better than CT in detecting subluxation and dislocation. When plain films and CT scans were combined they identified 98% (443 of 453) of the fractures and 99% (103 of 104) of the subluxations and dislocations; 100% (216 of 216) of the patients with abnormalities were identified. In the 20 patients who underwent both CT scanning and TOMOS, TOMOS detected more fractures, subluxations, and dislocations than CT scanning. Complex-motion tomographic studies detected atlanto-occipital dislocation and subluxation of the vertebral bodies and fractures of the spinous processes, lateral masses, articular processes, vertebral bodies, and dens better than CT scanning. Although the more routine use of CT scanning in evaluating cervical trauma should increase the detection of cervical abnormalities to near 100%, TOMOS remain the gold standard of diagnosis for atlanto-occipital dislocation, subluxation of the vertebral bodies, and fractures of the lateral masses, articular processes, vertebral bodies, and dens.     

Clinical aspects of endocrinology

Providing anaesthesia for surgery of the endocrine system requires an understanding of the physiology, pathology, anatomy and pharmacology of the endocrine organs. The physiology and pharmacology determine how the patient’s condition may be controlled preoperatively and what disturbances may happen intraoperatively and postoperatively. The anatomy and surgical pathology determine the nature and extent of the procedure and (in the case of the thyroid gland) any likely impact on airway control. This article discusses anaesthetic management for surgery of the thyroid and parathyroid glands and for surgery related to conditions of the adrenal cortex. In the case of thyroid surgery, the importance of tracheal distortion, control of thyrotoxicosis and occurrence of postoperative airway problems are emphasized. For parathyroid surgery, the consequences of hypercalcaemia and of a sudden reduction in parathyroid hormone concentrations are discussed. Conditions of the adrenal cortex vary in severity and often require judgement as to preoperative optimization, the use of invasive monitoring and the appropriateness of postoperative critical care. These issues are discussed. Postoperative pain is rarely a problem (particularly with the increased use of laparoscopic surgery) and postoperative stay is short. Some procedures are now being performed as day cases with careful postoperative protocols. The input of a motivated endocrinologist is essential both for preoperative management of these sometimes complex cases and for postoperative management of hormone replacement. Close collaboration among surgeon, anaesthetist and endocrinologist is essential.     

Assessment of radial and ulnar torsion profiles with cross-sectional magnetic resonance imaging. A study of volunteers

BACKGROUND: We determined whether the torsion profiles of the radius and ulna could be reliably assessed with cross-sectional magnetic resonance imaging and whether these torsion profiles were comparable on the two sides of volunteers. METHODS: We assessed magnetic resonance imaging cross sections of the left and right forearms of twenty-four asymptomatic volunteers. The torsion profile of the ulna was defined as the angle formed between a line tangential to the volar cortical surface of the distal part of the humerus and a line connecting the center of the ulnar head and the center of the ulnar styloid. Use of paired proximal and distal landmarks resulted in five different methods of assessment of the radial torsion profile. Intrarater and interrater reliabilities and side-to-side variability were assessed. RESULTS: This method of assessment of the ulnar torsion profile had intraclass and interclass coefficients of 0.95 and 0.91, respectively. A method previously described by Bindra et al. had the best combined intrarater and interrater reliabilities for assessment of the radius. The mean differences between the right and left sides of the volunteers were the lowest with the use of these two methods; nevertheless, the maximum side-to-side difference was > 30 degrees with techniques. CONCLUSIONS: Torsion-profile assessment with cross-sectional magnetic resonance imaging had high intrarater and interrater reliabilities. However, individual side-to-side variations in the radial and ulnar profiles are important considerations. CLINICAL RELEVANCE: Cross-sectional magnetic resonance imaging is currently the only available method to quantify rotational malunion of the radius and ulna. Its low side-to-side reliability warrants comparison between the imaging results and the clinical findings. A side-to-side difference in the rotation profile may serve as a reason to perform an axial osteotomy when the results of the clinical and magnetic resonance imaging assessments are consistent with each other.     

原子力显微镜对泌尿系结石超微结构的研究

目的 研究和观察泌尿系结石的超微结构。方法 10枚结石分别做超薄切片(厚度小于3mm),打磨抛光处理,并收集粉末。先行原子力显微镜观察,再做成电镜标本观察分析。结石粉末均行X-线衍射检测。结果 得到肾盂结石和膀胱结石超微结构的AFM图像和电镜扫描图像,X-线衍射检测有7枚是草酸钙结石,3枚是磷酸钙结石。测得草酸钙结石和磷酸钙结石的微小晶粒尺寸。分析AFM的反转片信息,获得结石基质的空间构架图像。结论 应用原子力显微镜技术可以实现对泌尿系结石超微结构直接实时的观察分析。尿结石的超微结构形态与结石所处部位无关,而取决于结石晶体类型。草酸钙结石的晶体和基质的AFM图像与磷酸钙结石不尽相同,晶体尺寸有差异(P<0.05)。结石基质的空间构架为晶体的聚集提供了可能性。     

心肺系疾病继发骨质疏松症的病络机制及科学内涵

目前,中医药防治骨质疏松症主要集中在原发性骨质疏松症病机领域,尚缺乏对继发性骨质疏松症病机的联动认识,未能有效建立贯穿于骨质疏松症发生演变的核心理论,并深入揭示其科学内涵。基于骨质疏松症发生的分子生物及临床流行病学研究结果,心肺疾病引起继发性骨质疏松症,与血管生成及偶联,血钙、血铁等血液成分失常密切相关,较为符合中医学络病学说的"病络"机制。心肺系疾病促发骨质疏松症发生,主要体现在"心主血,血液浊化引起络脉功能异常"、"心主脉,脉管络结引起络脉结构改变"、"肺朝百脉,气血失调引起络脉功能改变"等络脉损伤方面,而在疾病发展、病情演变过程中,心肺疾病与骨质疏松症也常通过络脉相互影响。因此,以病络及心肺藏象理论,阐发心肺疾病继发骨质疏松症的病络病机特点及现代科学内涵,综合调治原发疾病及继发骨质疏松,更为符合中老年人多种慢性疾病缠身的现实情况,也与真实世界临床治疗效果研究理念相一致,对于提高本病的临床辨治效果,具有重要的理论指导价值。