帕瑞昔布钠联合连续股神经阻滞对老年患者围术期Th1/Th2平衡的影响

目的观察帕瑞昔布钠联合连续股神经阻滞对老年患者全膝关节置换术(total knee arthroplasty,TKA)术后疼痛及围术期Th1/Th2平衡的影响。方法选择择期行TKA患者50例,男33例,女17例,年龄65~80岁,ASAⅠ或Ⅱ级。采用随机数字法将患者分为帕瑞昔布钠联合股神经阻滞镇痛组(A组)和帕瑞昔布钠联合静脉自控镇痛组(B组),每组25例。两组均采用快速诱导喉罩全麻,均于手术切皮前30min静脉滴注帕瑞昔布钠40mg,首次注射8h后再次静脉滴注帕瑞昔布钠40mg。A组术毕术侧股神经穿刺置管并连接电子镇痛泵,B组术后静脉接电子镇痛泵。记录术后6、12、24、36、48h静息及运动时的VAS评分,分别在麻醉前(T_0)、术毕(T_1)、术后24h(T_2)、48h(T_3)、72h(T_4)抽取外周静脉血4ml,采用ELISA法测定血浆IFN-γ和IL-10浓度,采用放射免疫分析法测定血浆皮质醇(Cor)浓度。记录术后48h内患者不良反应发生情况。结果术后6、12hA组静息时VAS评分明显低于B组,术后各时点A组运动时VAS评分明显低于B组(P0.05);与T0时比较,T_1~T_3时两组血浆Cor浓度明显升高,T_2、T_3时A组血浆IFN-γ浓度明显降低,T_2~T_4时B组血浆IFN-γ浓度明显降低,T_1~T_4时两组血浆IL-10浓度明显升高(P0.05);T_1~T_3时A组血浆Cor浓度明显低于B组,T_2~T_4时A组血浆IFN-γ浓度明显高于B组,T_1~T_4时A组血浆IL-10浓度明显低于B组(P0.05)。A组患者术后恶心、呕吐及皮肤瘙痒发生率明显低于B组(P0.05)。结论帕瑞昔布钠联合连续股神经阻滞具有良好的镇痛效果,术后不良反应发生率更低,可以有效减少患者Cor的分泌,同时延缓IFN-γ分泌的减少和IL-10分泌的增加,有效保护患者的免疫功能。     

Loss of the tight junction protein ZO-1 in dextran sulfate sodium induced colitis

BACKGROUND: Inflammatory bowel disease (IBD) is associated with increased intestinal permeability and decreased expression of tight junction (TJ) proteins in the inflamed mucosa. Whether this alteration in TJ expression is a prerequisite for the development of intestinal inflammation or a secondary result of that inflammation is unknown. This study looked at the expression of the TJ protein ZO-1 and the corresponding permeability changes in dextran sulfate sodium (DSS) induced colitis in a mouse model. MATERIALS AND METHODS: BALB/c mice were fed 3% DSS or water for 1, 3, 5, or 7 days. The animals were weighed, stool was checked for blood, and the colon length measured. Segments of the colon were used for histology, immunohistochemistry for ZO-1, or Western blot for TJ proteins. Colonic permeability was measured using Evan's Blue dye. RESULTS: DSS treated animals had heme positive stools, colitis by histology, significant weight loss, and colon shortening. There was an absence of ZO-1 by Western blot in the 7-day DSS treated animals, double the amount of claudin-1 and normal cytokeratin. The loss of ZO-1 started after 1 d of DSS treatment and was followed by a significant increase in permeability to Evan's blue by day 3. CONCLUSIONS: The loss of ZO-1 and increased permeability preceded the development of significant intestinal inflammation suggesting that in DSS colitis alterations in the TJ complex occur before the intestinal inflammation and not as a consequence of it. These changes in the TJ complex may facilitate the development of the inflammatory infiltrate seen in colitis.     

生物可分解吻合环在全胃切除术中消化道重建的临床应用研究

目的评价生物可分解吻合环（biaframentable anastomosis ring,BAR）在胃癌全胃切除术中消化道重建的临床应用价值。方法将42例待作全胃切除术的恶性胃肿瘤病人随机分成二组,其中应用BAR作消化道重建21例（BAR组）,用传统手工吻合的21例（TMA组）。结果两组病人均无死亡,痊愈出院。BAR组的消化道重建耗时明显少于TMA组。术后情况如吻合口出血、肠功能恢复时间、肺部感染显示BAR组明显好于TMA组。BAR组无吻合口漏,而TMA组则有1例。在术后6个月获得随访中ABR组是20例,TMA组17例。胃镜检查显示：BAR组在术后吻合口狭窄、吻合口炎、吻合口炎和吻合口肉芽肿的发生率均低于TMA组。两组在上述多项指标显示有显著性差异（P〈0．05或0．01）。结论应用BAR于全胃切除术的消化道重建具有操作简便快捷、疗效好及术后并发症少等优点,值得在临床推广应用。     

The risk of dysplasia and cancer in the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low: A long-term term follow-up study

AIM: Some of the rare complications reported in patients with an ileopouch anal anastomosis (IPAA) after coloectomy for chronic ulcerative colitis are dysplasia and carcinoma. The supposed pathway is for the ileal pouch mucosa to go through adaptational changes then is to progress through the phases of chronic pouchitis, dysplasia and subsequently to adenocarcinoma. In many of these studies however, the dysplasia-cancer sequence is inconclusive since the carcinoma might have developed from the ileal mucosa itself or from residual viable rectal mucosa left behind. The purpose of this study was therefore to study the long-term ileal mucosal adaptation patterns and the incidence and grading of dysplasia in the ileal pouch mucosa in patients previously operated on for ulcerative proctocolitis. PATIENTS AND METHODS: Forty-five patients who had been operated on with an IPAA (25 males/20 females), with a median age of 54 years (range 34-76), were invited for clinical examination and pouch endoscopy including mucosal biopsies. The duration of their colitis until surgery was median 6 years (range 1-28) and the time median interval from start of disease until time of follow up 24.8 years (range 17-46). Three independent pathologists from two different centres reviewed sequential mucosal biopsies taken from separate sites of the pouch for dysplasia and mucosal adaptation patterns. RESULTS: The type C pattern with a severe inflammation in lamina propria together with severe atrophy of villi, sometimes with ulceration and granulation tissue, was observed by the two pathologists from one centre in 15 of 45 (33.3%) patients and in 11 (24.4%) of 45 by the third pathologist, respectively. As regards dysplasia one pathologist group evaluated 2/45 (4.4%) cases as low-grade dysplasia while the third pathologist considered one of these cases as indefinite for dysplasia and one as reactive. There was in this respect full agreement between the two centres in 43 (95.6%) of 45 cases. Neither high-grade dysplasia nor invasive carcinoma was diagnosed. CONCLUSION: Dysplastic transformation within the ileal pouch mucosa in patients operated for ulcerative proctocolitis is rare even after a long follow-up. These results are reassuring for both patients and surgeons. There seem to be no solid grounds to support routine surveillance for dysplasia in the ileal pouch mucosa in these patients. The surveillance for neoplastic changes in the remaining muscular/epithelial cuff is a separate issue however.     

3D打印人工椎体在脊柱肿瘤全脊椎切除术脊柱重建中有效性与安全性的Meta分析

【摘要】 目的：系统分析3D打印人工椎体在脊柱肿瘤全脊椎切除术（total en bloc spondylectomy,TES）脊柱重建中的有效性与安全性。方法：通过检索PubMed、Embase、Cochrane Library、Web of Science、中国生物医学文献数据库（CBM）、中国知网（CNKI）、万方数据库和维普系列数据库,收集各数据库建库至2022年8月有关脊柱肿瘤TES中应用3D打印人工椎体脊柱重建的文献,研究类型为非随机对照试验,包括双臂试验（依据置入物不同分为3D组与钛网组）和单臂试验,采用非随机研究方法学指数（methodological index for non-randomized studies,MINORS）对纳入研究进行质量评价。提取纳入研究的结局指标：手术时间、术中出血量、早期并发症发生率、椎体融合率、内置物沉降率、脊髓损伤Frankel分级（A～E级分别计分1～5分）。使用Stata 14.0软件对相关指标进行Meta分析。结果：共有13篇相关文献被纳入,8项研究为临床单臂试验,文献评分为12～13分,均为中等质量研究,总样本量为140例;5项研究为临床双臂试验,文献评分为19～20分,均为高质量研究,3D组的总样本量为115例,钛网组总样本量为126例。Meta分析结果显示：双臂试验示3D组的手术时间（MD=-287.14,95%CI -391.30~-182.99,P=0.00）、术中出血量（MD=-2.87,95%CI -5.11~-0.63,P=0.01）低于钛网组;单臂试验示早期并发症发生率为23%（95％CI 0.16～0.31）,双臂试验示两组早期并发症发生率（RR=0.56,95%CI 0.32~1.00,P=0.05）无显著性差异;单臂试验示术后脊髓损伤Frankel分级较术前获得约1个等级的改善（MD=1.04,95%CI 0.32～1.76,P=0.03）,双臂试验结果示两组术后脊髓损伤Frankel分级无显著性差异（MD=-0.13,95%CI -0.45～0.19,P=0.42）;单臂试验示与相邻椎体的融合率为93%（95％CI 0.79～1.00）,双臂试验仅1篇文献报告了融合率,故未进行Meta分析;单臂试验示置入物沉降率为4%（95％CI 0.01～0.07）,双臂试验示3D组置入物沉降率低于钛网组（RR=0.15,95%CI 0.05～0.45,P=0.001）。结论：3D打印人工椎体在脊柱肿瘤TES脊柱重建中应用具有手术时间短,术中出血量少,与相邻椎体融合率高,置入物沉降率低等优势,术后脊髓损伤神经功能恢复好,疗效较为显著。     

Preventing acute infection in total hip prostheses implanted after external fixation of the femur: is there a need for a staged procedure?

We report two cases of acute infection of an uncemented femoral component in a hip prosthesis implanted after external fixation of a femoral fracture. In both cases, the surgical access did not cross over the pin scars. When the prosthesis was implanted the stem crossed one or more pin tracts. The preoperative clinical examination, laboratory tests and bone scintigraphy with marked granulocytosis did not show signs of local infection in either case. We suggest that every patient destined to receive a prosthesis after external fixation should be treated with a staged procedure, the first step being excision of the soft tissues around the pin tracts and curettage or drilling of the bony holes, followed by prosthesis implant.     

Abnormal Response to Physical Activity in Femurs after Heterozygous Inactivation of One Allele of the Col2a1 Gene for Type II Collagen in Mice

The objective of this study was to evaluate the influence of heterozygous inactivation of one allele of the type II collagen gene (Col2a1) on biomechanical properties and mineral density of bone under physical loading conditions. C57BL/6−TGN mice with heterozygous knockout (HZK) inactivation of Col2a1 gene and their nontransgenic littermate controls were housed in individual cages with running wheels for 9 and 15 months. The running activity of each mouse was monitored continuously throughout the experiment. Bone mineral density (BMD) of mice femora was measured using dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computerized tomography (pQCT). Biomechanical properties were determined using three-point bending tests. Vertebral bone samples were prepared for quantitative polarized light microscopy and digital densitometry of proteoglycans. The concentration of total collagen and collagen cross-links were analyzed using high-performance liquid chromatograpy (HPLC). The average daily running distance was shorter for the HZK mice between the age of 4 and 15 months as compared with normal runners (P < 0.05). The ultimate breaking force was 14.8% and 23.6% (9 vs. 15 months) lower in HZK-runners than in wild-type runners. BMD of the femur was 6.1% lower in HZK-runners at the age of 9 months (P < 0.05). Physical activity increased cortical BMD in wild-type runners but not in the HZK runners at the age of 9 months. The collagen network of the HZK mice was less organized. There were only minor changes in BMD and mechanical and structural properties between sedentary HZK mice and their wild-type controls. Increased physical activity induced significantly lower bone density, mechanical properties, and organization of collagen fibers in male HZK mice. However, there were no major differences in biomechanical parameters between sedentary HZK and wild-type male mice. This suggests an important guiding role of collagen type II in bone remodelling and maturation.