正常形态半月板与盘状半月板损伤关节镜下分型修复的特点：同期对照比较★

目的：盘状半月板是因半月板的宽度和高度异常增大呈盘状而得名。观察正常形态半月板与盘状半月板损伤镜下分型及特点，对比关节镜治疗的术后疗效。 方法：⑴试验对象：选择2001-06/2006-09安徽医科大学第一附属医院膝半月板损伤的患者360例，其中正常半月板损伤组300例，盘状半月板损伤组60例，均为外侧盘状半月板。纳入标准：①术前临床资料完整。②经关节镜下证实。③术后随访资料齐全。④患者对治疗知情同意，并在手术前签订知情同意书。⑵试验方法：关节镜下探查300例正常形态半月板及60例盘状半月板的损伤情况，根据不同损伤类型按术中情况分别予成形术、部分切除、次全切除和全切除。⑶试验评估：随访6个月至2年，按Ikeuchi氏膝关节评价等级评定膝关节的功能。 结果：纳入正常半月板损伤300例及盘状半月板损伤60例，均进入结果分析。①正常半月板最多的损伤类型是纵裂占43.7%，放射状裂占30%，水平裂占12.3%，横裂占7.5%，混合裂占6.5%；盘状半月板发现水平裂占68.3%，放射状裂占6.7%，纵裂占3.3%，混合裂占21.7%。②根据镜下确定半月板损伤类型决定手术方式，所有患者均获得随访，300例正常半月板损伤患者中优62例，良190例，可34例，差14例，优良率占85%；60例盘状半月板损伤患者中优19例，良34例，可5例，差2例，优良率约占90%。 结论：盘状半月板损伤的类型因其解剖特征和组织学构成与正常形态半月板不同，关节镜下治疗的方法也有区别。     

盘状半月板与正常半月板的损伤：关节镜下分型及组织修复

背景：目前对盘状半月板及正常半月板损伤的治疗,多主张行关节镜下半月板成形术或修复术,切除内侧撕裂部分,缝合外侧撕裂部分,保留正常形态。 目的：对盘状半月板及正常半月板损伤行关节镜修复治疗,并镜下观察两者损伤后的分型特点,采取对应的手术方式,分析对比修复后效果。 方法：选择2003-09/2008-06新乡医学院一附属医院收治的260例半月板损伤患者,其中45例盘状半月板均为外侧盘状半月板,215例为正常形态半月板损伤。所有患者均于镜下明确诊断并按期随访。采用关节镜下探查盘状半月板及正常半月板损伤的情况,记录撕裂部位及分型,根据不同损伤情况行半月板成形术、部分切除术、次全切除术或者全切除术。 结果与结论：所有患者随访半年至2年,按Tegner膝关节功能评分评价关节功能。盘状半月板水平裂占73.3%,复杂撕裂15.5%,放射性撕裂4.4%,纵裂2.2%;正常半月板纵裂47.9%,放射性撕裂28.8%,水平裂11.6%,横裂6.5%,复杂撕裂5.1%。215例正常半月板损伤患者中显效165例,有效35例,尚可8例,无效7例,优良率为93.0%。45例盘状半月板损伤患者显效25例,有效16例,尚可3例,无效1例,优良率为91.1%。结果提示,盘状半月板因其解剖学特征和组织学特性与正常形态半月板不同,其损伤类型和治疗方法也有区别;治疗时应最大程度的保留半月板功能,延缓关节退变,除严重撕裂无法保留者,尽量行半月板成形术。     

低场强MRI可首选诊断膝关节隐匿性骨折

背景：MRI检查可以早期确诊隐匿性骨折,低场强磁共振成像还具有专有线圈使图像更清晰的优点。 目的：分析低场强MRI在膝关节隐匿性骨折诊断中的应用价值。 方法：回顾性分析45例经手术、关节镜检查或临床证实的膝关节隐匿性骨折患者低场强MRI情况。 结果与结论：45例病例在X射线平片正侧位上均未见异常,而低场强MRI检查均呈现T1WI呈低信号,T2WI呈高信号,在STIR上病灶与正常骨组织的对比度更高,显示出不同部位隐匿性骨折的病变部位、范围及形态,其中34例伴交叉韧带、副韧带及半月板撕裂。提示低场强MRI能敏感显示创伤性膝关节隐匿性骨折的病变特点及严重程度,诊断准确,同时能发现膝关节韧带、肌腱及软骨的损伤,为首选检查手段。     

磁共振关节内增强扫描评价膝关节骨质、半月板、韧带和关节软骨损伤的准确性：与常规磁共振扫描的比较

背景：常规磁共振检查可较为全面地显示关节内软组织的结构，但由于其成像后对比度欠缺等因素，在诊断关节内病变和损伤时仍存在一定的局限性。为了提高诊断的准确率，磁共振的增强扫描已应用于肝脏、脑等其他部位，但有关膝关节增强扫描的报道较少。 目的：评价磁共振关节内增强扫描对膝关节损伤诊断的临床应用价值。 方法：选择21例膝关节损伤患者(22膝)，采用美国GE公司生产的0.5T Signa Contour磁共振扫描仪先进行常规磁共振扫描。常规扫描完成后，向关节内注入增强剂，行关节内增强扫描。所有病例均由同一医师进行关节内增强操作，由两名副主任职称以上的医师进行阅片分析和对比。 结果与结论：所有病例在平扫中均发现有不同程度的关节结构损伤，包括骨质、半月板、韧带和关节软骨等。在磁共振增强扫描后进一步证实，其损伤的程度和范围上得到了更清楚的显示。同时，有2例平扫中误诊的半月板损伤，在增强扫描后得到否定；有的损伤部位在平扫中未发现的病变信号，在关节内增强扫描中被发现和证实。说明增强后磁共振扫描膝关节损伤的阳性率高于常规扫描。其中，增强前后半月板损伤诊断准确率差异有显著性意义(P =0.035)。提示，与常规扫描相比，磁共振关节内增强扫描可进一步提高膝关节损伤的诊断率。     

磁共振神经成像序列在臂丛神经损伤中的应用

目的探讨磁共振神经成像(MRN)序列对臂丛神经损伤的诊断价值。方法采用3.0T MRI对43例临床诊断为臂丛神经损伤患者行术前常规MRI及MRN序列扫描,对手术探查、术中肌电图及术前MRI/MRN检查结果进行比较分析。结果 MRN对节前神经损伤诊断的敏感度为76.2%,特异度为83.6%,准确率为80.0%。MRN对臂丛神经节后损伤诊断的敏感度为74.8%,特异度为88.1%,准确率为79.2%。结论 MRN可作为早期臂丛神经损伤定性及定位诊断的影像学检查方法之一。     

关节置换与关节镜下清理术后膝骨性关节炎患者尿液EKGPDP小肽与关节软骨退变的相关性

背景：目前诊断骨性关节炎的手段主要有影像学和关节镜检查,但都存在一定的局限性。寻找一种特异性、敏感性、诊断率高,可操作性强的诊断方式是目前急需解决的问题。 目的：探讨膝骨性关节炎患者尿液中EKGPDP小肽水平与关节软骨病变严重程度之间的关系。 方法：纳入2006-01/2008-04在广东医学院附属深圳福田医院骨关节外科行关节镜下关节清理术治疗患者45例,膝关节置换术患者15例。纳入同一时期性别年龄相匹配的40名健康志愿者为对照组。采用竞争性ELISA法检测受试者尿液中EKGPDP小肽水平并于半年后复查,以Ayral关节镜膝滑膜炎评分法和Outerbridge软骨损伤评分法评估膝骨性关节炎患者滑膜和关节软骨的病理变化程度。 结果与结论：膝骨性关节炎患者EKGPDP小肽水平明显高于健康人(P < 0.001)。膝骨性关节炎患者的EKGPDP小肽水平与Outerbridge软骨损伤评分、体质量指数正相关;与Ayral膝滑膜炎评分无相关性(P > 0.05)。全膝关节置换术者半年后EKGPDP小肽水平,较置换前明显下降(P < 0.05),关节镜清理术患者EKGPDP小肽水平变化不明显(P > 0.05)。说明膝骨性关节炎患者尿液中EKGPDP小肽水平可以反映膝关节软骨损伤程度,可为膝骨性关节炎的临床诊断提供依据。     

膝关节交叉韧带损伤影像学评估特征的研究与进展★

超声诊断膝关节交叉韧带损伤在上世纪90年代开始逐渐应用，并得到不断的发展。目前临床上膝交叉韧带损伤可经多种方法诊断，比如X射线、关节镜、核磁共振和超声等。但X射线和关节镜是有创伤性的，核磁共振虽然较准确但价格昂贵，而超声能够清晰显示膝关节解剖和损伤结构，是经济实用而且无放射性的一种诊断方法，在诊断交叉韧带损伤方面是非常有价值的。文章综合分析膝关节交叉韧带损伤的功能解剖、生物力学、临床表现、损伤类型、影像学表现等方面的研究发展。高低频超声结合检查后交叉韧带作为间接超声征象在前交叉韧带损伤的诊断中具有一定应用价值。     

半月板桶柄样撕裂的关节镜下修补：61例2~5年随访

背景：半月板的桶柄样撕裂如未经早期修补则要采取半月板切除,可导致膝关节退变的加速,但目前有关半月板的桶柄样撕裂关节镜下修补的长期、大样本报道较少。 目的：回顾性分析半月板桶柄样撕裂的关节镜下修补疗效。分析半月板桶柄样撕裂的术前诊断、修补技术、疗效评估及影响因素,探讨大型半月板撕裂理想的修复途径。 方法：于2002-05/2005-11在北京积水潭医院运动医学中心连续完成共90例关节镜下半月板桶柄样撕裂修补手术。对90例患者中的61例、63个半月板进行了2年以上的随访,平均随访期38个月(24~66个月)。半月板桶柄撕裂的修补手术适应证为：红-红区及红-白区损伤、具备可复位性、半月板组织无复合撕裂及明显变性。 结果与结论：在可随访的61例患者中,有51例(84%)的53个半月板经过二次手术探查。61例患者中53例(87%)无临床症状;4例(6%)部分临床症状;4例(6%)交锁复发。二次关节镜检查发现完全愈合的半月板有44个(83%);部分愈合者5个(9%),不愈合者4个(7%)。总体评估失效率为8%(5/63) ,成功率92%(包括完全愈合、部分愈合、无临床症状及部分临床症状者)。通过2~5年的随访结果表明对于发生在红-红区或红-白区的半月板桶柄样撕裂,采用多种缝合技术进行牢靠的修补缝合,并且与前十字韧带重建同期进行,修复效果较好。     

关节置换与关节镜清理联合玻璃酸钠注射治疗膝骨性关节炎

背景：膝骨性关节炎的保守治疗为关节腔注射玻璃酸钠;手术治疗主要有关节镜清理、人工膝关节置换。目前关于骨关节炎治疗的研究多为各种单独治疗的疗效比较,而关于综合治疗的疗效尚少见。 目的：观察膝关节置换与关节镜清理结合关节腔注射玻璃酸钠治疗膝骨性关节炎的效果。 方法：选择符合膝骨性关节炎诊断标准的患者55例,年龄50~83岁。根据患者病情告知患者各种治疗的优缺点,由患者考虑后选择治疗方式。其中联合组23例,置换组32例。联合组采用关节镜清理联合关节腔注射玻璃酸钠治疗,1次/周,连续5周;置换组采用膝关节置换治疗。随访6~30个月,治疗前后均采用HSS膝关节评分评价膝骨性关节炎治疗效果。 结果与结论：两组疗效综合评估,联合组优8例,良8例,优良率70%;置换组优23例,良7例,优良率94%。两组膝关节的活动度、疼痛、关节功能都有明显改善,但膝关节置换的疗效优于关节镜清理结合关节腔注射玻璃酸钠治疗(P < 0.05)。 关键词：膝骨性关节炎;清理术;玻璃酸钠;膝关节置换;膝关节假体     

去抗原生物型半月板移植修复羊半月板缺失

背景：同种异体半月板移植的临床疗效和预后均已获证实，但因来源和匹配问题难以推广。课题组应用已取得专利技术的去抗原处理技术，处理猪的半月板，得到了新型生物型半月板。 目的：观察生物型半月板植入山羊膝关节内的组织学变化，探讨生物型半月板重建膝关节半月板的可行性及应用前景。 设计、时间及地点：以山羊为对象的动物实验，于2005-06/2006-06在中山大学第三附属医院中心实验室完成。 材料：选用健康山羊15只，用于半月板移植实验。取新鲜屠宰的完整猪半月板，用于制备生物型半月板。 方法：切除山羊的膝关节内侧半月板，将生物型半月板塑形后原位植入羊的膝关节半月板缺失部位。 主要观察指标：分别于术后1，3，6，12个月处死动物，行组织学，扫描电镜及墨汁灌注观察微循环等检测。 结果：所有动物患肢切口均愈合良好，无感染，无死亡。植入半月板与周组织愈合良好，连接紧密。随着术后时间的延长，植入半月板逐渐吸收溶解，植入半月板内出现活的细胞，但术后1年仍有约1/4的组织无活细胞。术后1年墨汁灌注发现，周围组织长入并建立微循环，但仅限于周边约10%的范围(正常山羊约15%)。植入半月板在术后6个月开始逐渐吸收溶解，扫描电镜下可见植入半月板表面逐渐毛糙，部分区域有破裂现象，但术后1年仍保持大体的形态。 结论：生物型半月板植入山羊体内后，无明显排斥反应，植入半月板能与山羊关节囊良好愈合。植入半月板在溶解吸收过程中，宿主自体组织可以长入并建立微循环，植入半月板对山羊的软骨保护作用明显，但仍观察到轻度的软骨损伤。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.