颜面部同种异体器官移植技术管理规范(试行)

为规范颜面部同种异体器官移植技术临床应用,保证医疗质量和医疗安全,制定本规范.本规范为技术审核机构对医疗机构申请临床应用颜面部同种异体器官移植技术进行技术审核的依据,是医疗机构及其医师开展颜面部同种异体器官移植技术的最低要求.     

器官移植的发展及其伦理道德问题探讨

器官移植是用健康的器官去置换被损害、丧失功能而无法挽救的器官的医治措施。根据供体的不同，器官移植可分为自体移植、同种异体移植和异种移植。本文主要是指同种异体移植。作为医学领域中的一项新技术，器官移植始于20世纪50至80年代，发展迅速。目前，我国也取得了一定的进展。     

临床器官移植供受者免疫学选配要点

临床器官移植供受者免疫学选配要点同济医科大学器官移植研究所（４３００３０）程敦秀众所周知，同种异体器官移植术后的主要危险是排斥反应．而这种排斥反应主要由供受体同种间的免疫遗传差异所致．为使移植物获得长期存活，许多学者进行了大量的研究。尤其在移植免疫方...     

原位灌洗整块切取供体多器官的手术配合

我院器官移植研究所1977～1992年,共施行了同种异体肾移植489例,同种异体胰移植4例,同种异体肾上腺移植5例,同种异体脾移植2例。供移植材料均取自尸体供体。在原位灌洗分侧切肾基础上,为了充分利用多种器官,满足病人需要,通过研究采用原位灌洗整块切取尸胰、脾、肾和(或)肾上腺术(肾19,胰9、脾10、肾上腺6次)。现就手术室的配合体会介绍如下。     

中国器官移植的现况（第十五届国际器官移植学术会的特邀报告）

中国器官移植的现况（第十五届国际器官移植学术会的特邀报告）夏穗生迄今，中国已先后开展了２５种临床同种异体器官移植，其中肾移植处于首位，我国大陆于１９９３年一年里施行了１９７２例次，自１９６０～１９９３年底已累积达１１９７１例次，移植肾存活率：１年为８...     

同种异体复合组织移植中免疫抑制剂的应用

1990年,诺贝尔生理医学奖授予了成功施行人类首次肾移植的Murray,标志着现代器官移植时代的开始.随着高效低毒免疫抑制剂的不断问世,近十几年来器官移植取得了突飞猛进的发展.1999年,法国Dubernard等[1]成功实施了同种异体人手的移植.2005年,世界首例同种异体面部移植"换脸"手术在法国里昂成功实施[2],使复合组织同种异体移植的研究越来越受到关注的同时,在世界范围内得以广泛开展,为整形外科的治疗开辟了新的领域.     

趋化因子在器官移植中的作用

器官移植时，受者体内的白细胞在趋化因子的作用下进入移植物是引起同种异体移植排斥反应的细胞学基础，阻断趋化因子与其受体的相互作用是抑制排斥反应发生的一条新途径。本文综述了趋化因子的免疫学特性以及在器官移植中作用的研究进展。     

临床脏器移植供体选配

临床脏器移植供体选配同济医科大学器官移植研究所（４３００３０）姜汉英器官移植是将一个正常有活力的器官，用手术的方式移植到同一个体（自体移植）或同种另一个体（同种异体移植）或不同种属个体（异种移植），以治疗不能用其它疗法治愈而在短期内引起死亡的脏器疾病...     

异种移植排斥反应及其对策研究进展

同种异体组织和器官移植的供体来源有限,使异种移植再度成为研究热点.然而异种移植将面临比同种异体移植复杂得多的排斥反应.本文就异种移植排斥反应及其对策的研究近况作一综述.     

同种异体复合组织移植的免疫研究进展

目的了解同种异体复合组织移植的免疫研究进展。方法查阅相关文献,对同种异体复合组织移植的免疫特点、实验进展、临床经验等进行总结。结果同种异体复合组织位于体表,包含组织成分复杂,抗原性高。其移植后在免疫抑制剂用药方案、排斥反应的诊断以及慢性排斥反应发生率等许多方面同内脏器官移植有不同的特点。结论在下一步研究中,应吸取同种异体复合组织移植独特的经验教训,在诱导耐受、局部用药、排斥诊断等方面树立同种异体复合组织的独特标准。     

Vertebral body integrity: a review of various anatomical factors involved in the lumbar region

Summary The body of the vertebra can be affected in the majority of the conditions involving the lumbar spine. Multiple references, both books and periodicals, have been reviewed, and the anatomical factors responsible for the vertebral body integrity in the lumbar spine have been included under the following important areas, namely, morphology, development, genetics, microscopic examination using histology, structural architecture, blood supply, neuromuscular control, and biomechanics. Introduction The anatomy provides a three-dimensional frame work to support the interaction between the physiological and pathological alterations. The body of the vertebra can be affected in a majority of acute or chronic conditions involving the lumbar spine. The etiology of these conditions is multifactorial, which has been dealt with in previous studies sporadically. This study aims to review and incorporate the important anatomical factors which can influence the integrity of vertebral bodies in the lumbar region and manifest as low back pain. Methods Multiple references, both books and periodicals, have been reviewed for the literature. Electronic databases, including Medline and PubMed, were used to collect the latest information. They were finally arranged in an anatomical framework for the article. An attempt has been made to cover these relevant issues in an integrated way in the article and have been structured into introduction, morphology, development, genetics, microscopic examination using histology, structural architecture, blood supply, neuromuscular control, biomechanics, and conclusion. The aforementioned anatomical aspects, some of which have received less attention in the literature, may be helpful to clinicians for restoring the mobility, stability, and load bearing capacity of the lumbar spine as well as planning better management strategies, especially for the chronic low back pain. Results In our article all the anatomical factors affecting the integrity of vertebral body, including the morphology, development, genetics, growth and ossification, blood supply, specifically in the lumbar region, have been described, which were not covered earlier. The limitations of this review is its wide dimensions; hence, there are fair scopes of missing many relevant facts, as all of them cannot be compiled in a single article. We have attempted to confine our views to different anatomical domains only, this is our second limitation. Additional studies are required to incorporate and discuss the uncovered relevant scientific details. Conclusions The integrity of the body of the lumbar vertebra is multifactorial (Fig. 8). The vast spectrum of the anatomical domain influencing it has been summarized. The evolution of erect posture is a landmark in the morphology of human beings and the lumbar lordosis, which has also contributed to the gross design of the vertebral body, is one of the most important adaptations for axial loading and bipedal movements. The role of metamerism in the evolution of vertebrate morphology is repeated in the development of spine. The body of the vertebra is intersegmental in origin, which results in dual vascular and nerve supply, both from superior and inferior aspects of the body of the lumbar vertebrae. The vertebral body ossifies from three primary centers, one for centrum, which will form the major portion of body, and the other two for neural arches. The cartilaginous growth plate is mainly responsible for the longitudinal vertebral growth. Regional differentiation of the vertebral column, and the definite pattern of the structure of the different vertebra, is regulated by a large number of genetic factors, including the Hox genes. The vertebral body design therefore provides the requirements for optimal load transfer by maximal strength with minimal weight. Bone mineral density (BMD), bone quality, microarchitecture, and material properties are the important factors that contribute to bone strength. BMD is highly heritable; bone mineral distribution and architecture are also shown to be under strong genetic influence. All the aforementioned factors finally integrate to ensure mainly the mobility, stability, and load bearing capacity of the lumbar spine.     

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Reports linking long‐term use of bisphosphonates (BPs) with atypical fractures of the femur led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address key questions related to this problem. A multidisciplinary expert group reviewed pertinent published reports concerning atypical femur fractures, as well as preclinical studies that could provide insight into their pathogenesis. A case definition was developed so that subsequent studies report on the same condition. The task force defined major and minor features of complete and incomplete atypical femoral fractures and recommends that all major features, including their location in the subtrochanteric region and femoral shaft, transverse or short oblique orientation, minimal or no associated trauma, a medial spike when the fracture is complete, and absence of comminution, be present to designate a femoral fracture as atypical. Minor features include their association with cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including BPs, other antiresorptive agents, glucocorticoids, and proton pump inhibitors. Preclinical data evaluating the effects of BPs on collagen cross‐linking and maturation, accumulation of microdamage and advanced glycation end products, mineralization, remodeling, vascularity, and angiogenesis lend biologic plausibility to a potential association with long‐term BP use. Based on published and unpublished data and the widespread use of BPs, the incidence of atypical femoral fractures associated with BP therapy for osteoporosis appears to be very low, particularly compared with the number of vertebral, hip, and other fractures that are prevented by BPs. Moreover, a causal association between BPs and atypical fractures has not been established. However, recent observations suggest that the risk rises with increasing duration of exposure, and there is concern that lack of awareness and underreporting may mask the true incidence of the problem. Given the relative rarity of atypical femoral fractures, the task force recommends that specific diagnostic and procedural codes be created and that an international registry be established to facilitate studies of the clinical and genetic risk factors and optimal surgical and medical management of these fractures. Physicians and patients should be made aware of the possibility of atypical femoral fractures and of the potential for bilaterality through a change in labeling of BPs. Research directions should include development of animal models, increased surveillance, and additional epidemiologic and clinical data to establish the true incidence of and risk factors for this condition and to inform orthopedic and medical management. © 2010 American Society for Bone and Mineral Research.     

Liver transplant in patients with hepatocellular carcinoma

Liver transplant in patients with cirrhosis and hepatocellular carcinoma is indicated in the early stages of the disease, which can be achieved with early detection programs using liver ultrasound. Dynamic imaging techniques (ultrasound with contrast, magnetic resonance and tomography) are essential in the diagnosis of this tumour, being able to type the lesion clearly, and, in the majority of cases, lead to the therapy to follow. Surgery is the treatment of choice in these patients, and liver transplant, from a theoretical point of view, is the best. Currently, the size and number of nodes play an important role in the indication of a transplant. The best liver transplant results are obtained in these patients using the Milan criteria, with survivals that exceed 70% and recurrence indices of 15%, at 5 years. Nowadays we have the possibility of using neo-adjuvant treatments to transplant, such as arterial chemoembolisation, percutaneous ablation techniques, and even liver resection as a bridging technique. The survival of patients transplanted due to liver cancer is similar to that obtained for other non-tumour diseases. In Spain it is 1, 3 and 5 years and 82%, 70% and 60%, respectively. The recurrence is between 6.4% and 16%, micro- and macrovascular invasion being its highest risk variable.     

快速破坏性髋关节病国内外研究进展

快速破坏性髋关节病(RDHD)是一种以髋关节,尤其是股骨头、股骨颈骨质迅速破坏从而导致髋关节功能迅速下降并伴有髋关节剧烈疼痛的疾病,人群发病率很低,60岁以上老年女性发病率相对较高。回顾性分析国内外相关研究文献,RDHD的疾病名称、定义及发病机制等均存在明显争议,较为常用的疾病名称为快速破坏性髋关节病,影像学以中晚期股骨头、股骨颈明显骨质破坏缺损为特征性表现,结合患者疾病病程可明确诊断,但早期影像学无有诊断价值表现,患者症状体征也不具有特异性,故而早期诊断困难。目前的研究认为其发病与患者的骨质疏松状态、髋关节生物力学改变及细胞、细胞因子活化等多种因素相关,但具体的生理病理过程暂未明确。RDHD治疗早中期以对症及抗骨质疏松治疗为主,全髋关节置换术可用于晚期功能受限患者的手术治疗,但术后假体松动的发病率较高。     

Enteral nutrition in HPB surgery: past and future

Perioperative nutrition has, during the past century, been transformed from a tool to provide calorie and nitrogen support to a tool to boost the immune system and increase resistance to complications. Despite all the progress in medicine and surgery, perioperative morbidity, the rate of infections, thrombosis, and the development of serosal adhesions has remained the same as long as can be judged, or at least during the past 80 years. Most prone to develop complications are persons above the age of 65 and persons with depressed immunity. About 80% of the immune system is localized in the gastrointestinal tract, which offers great opportunities for modulation through enteral nutrition. As the stomach has a tendency to develop postoperative paralysis, tube feeding is often necessary. In 1918, Andresen demonstrated the advantages of enteral nutrition, which already started on the operating table. Mulholland and colleagues and Rhoads and co-workers demonstrated, during the 1940s, certain advantages of enteral tube feeding. Also, the works by Alexander, Fischer, and Ryan, and their co-workers supported the value of early enteral feeding, and suggested enteral feeding as an effective tool to boost the immune system. It was, however, works published in the early 1990s, by Moore and colleagues and by Kudsk and colleagues, which made surgeons more aware of the advantages of early enteral nutrition. Surgery in the hepatobiliary pancreatic field is known to have a high rate of complications. Uninterrupted perioperative nutrition, i.e., nutrition during the night before, during surgery, and immediately after, offers a strong tool to prevent complications. It is essential that the nutrition also provides food for the colon, e.g., fiber and healthy bacteria (probiotics) to ferment the fiber and boost the immune system. Received: February 19, 2002 / Accepted: March 8, 2002 Offprint requests to: S. Bengmark     

The brain: functional divisions

The incompletely separated cerebral hemispheres consist of a thin outer folded cortex of grey matter containing organized neuronal cell bodies and interneurons. Some of the surface convolutions subserve particular sensory or motor functions. Incoming afferent and projected efferent fibres constitute the underlying white matter, which connects different parts of each hemisphere, the hemispheres to each other and (as the corona radiata) to subcortical nuclei, especially components of the deeply-embedded diencephalon and the basal ganglia, and continuing between the latter as the internal capsule to and from the cerebellum and brainstem. Divisions of the diencephalon, the deeper part of the embryonic forebrain, include the epithalamus (pineal gland), the thalamus (connected extensively with the cortex), the subthalamus and the hypothalamus (involved in the autonomic nervous system, limbic system and neuro-endocrine system). The brainstem, consisting of the midbrain, pons and medulla, allows passage of many ascending and descending nerve fibre tracts between the brain and spinal cord, carrying sensory information from and allowing movement of the limbs and trunk. It is also the site of many of the cranial nerve nuclei, through which the brain innervates the head region. It houses the centres controlling vital aspects related to respiration, cardiovascular function and consciousness levels. The cerebellum also has a cortex of grey matter, tightly convoluted into folia, and containing layered neuronal cell bodies projecting laterally and, as underlying white matter, to a collection of deep nuclei. Fibres run to and from the cerebellar nuclei in a series of peduncles to the midbrain, pons and medulla, and allow the cerebellum to coordinate movement at an unconscious level.     

Spanish Guidelines on Treatment of Bronchiectasis in Adults

In 2008, the Spanish Society of Pulmonology (SEPAR) published the first guidelines in the world on the diagnosis and treatment of bronchiectasis. Almost 10 years later, considerable scientific advances have been made in both the treatment and the evaluation and diagnosis of this disease, and the original guidelines have been updated to include the latest therapies available for bronchiectasis. These new recommendations have been drafted following a strict methodological process designed to ensure quality of content, and are linked to a large amount of online information that includes a wealth of references. The guidelines are focused on the treatment of bronchiectasis from both a multidisciplinary perspective, including specialty areas and the different healthcare levels involved, and a multidimensional perspective, including a comprehensive overview of the specific aspects of the disease. A series of recommendations have been drawn up, based on an in-depth review of the evidence for treatment of the underlying etiology, the bronchial infection in its different forms of presentation using existing therapies, bronchial inflammation, and airflow obstruction. Nutritional aspects, management of secretions, muscle training, management of complications and comorbidities, infection prophylaxis, patient education, home care, surgery, exacerbations, and patient follow-up are addressed.     

A retrospective analysis of anesthesiologic complications in pediatric neurosurgery

Background and objective:  Different clinical and surgical factors can influence the occurrence of anesthesiologic complications in pediatric neurosurgery. Preoperative knowledge of these factors is of great importance in the application of safe anesthetics and a favorable surgical outcome. The objective was to establish the importance of clinical and surgical risk factors on the frequency of anesthesia complications in pediatric neurosurgery.
Data and method:  The research, from 1996 to 2000, involved 705 children, aged from <1 year to 15 years, who underwent surgery for elective neurosurgical pathology and severe head injuries. We analysed the influence that: age, the preoperative neurologic diagnosis, the urgency of the operation, additional disorders, the surgical position, and the duration of anesthesia had on the frequency of anesthesia complications. To test the statistical relevance and to confirm the hypothesis, the Pearson's chi-square test, Mann–Whitney U -test, and univariate and multivariate logistic regressions were used.
Results:  Anesthesia complications (cardiovascular, respiratory, air embolism, allergic reactions) were present in 68/705 (9.6%) patients. Their frequency was statistically greater in children for whom the surgery was >240 min, who were in the sitting position and when comorbidity was evident. Neither age nor the urgency of the operation or reoperation had any significant influence on the occurrence of anesthetic complications.
Conclusion:  The duration of anesthesia, the sitting position of the patient, and the presence of comorbidities significantly increase the risk of anesthesia complications in pediatric neurosurgery.     

褪黑素对梗阻性黄疸大鼠肝损伤保护作用的实验研究

目的探讨氧化性损伤在大鼠梗阻性黄疸肝功能损害发生中的作用以及褪黑素对其的保护作用。方法成年雄性SD大鼠64只,采用完全随机化法随机分为正常对照组（CN组,n=16）、假手术组（SO组,n=16）、胆总管结扎组（BDL组,n=16）和胆总管结扎＋褪黑素治疗组（BDL＋MT组,n=16）。应用胆总管结扎法建立梗阻性黄疸模型,褪黑素治疗组大鼠手术前1 d至手术后7 d连续腹腔注射褪黑素0.5 mg（/kg.d）,每日10∶00给药。分别于手术后第4 d和第8 d两个时间点采集标本,检测血浆中总胆红素（TBIL）、丙氨酸转氨酶（ALT）、门冬氨酸转氨酶（AST）、碱性磷酸酶（AKP）及γ-谷氨酰转肽酶（GGT）水平变化,比色法测定肝组织匀浆中丙二醛（MDA）、超氧化物歧化酶（SOD）、过氧化氢酶（CAT）、谷胱甘肽（GSH）、谷胱甘肽过氧化物酶（GSH-Px）含量或活力变化,采用TUNEL法检测肝组织细胞凋亡,并计算肝细胞凋亡指数（AI）。结果与CN组和SO组比较,BDL组大鼠血浆TBIL、ALT、AST、AKP、GGT水平和肝组织MDA含量明显升高（P〈0.05,P〈0.01）,SOD、CAT、GSH-Px活力或GSH含量显著降低（P〈0.01）,AI增加（P〈0.01）;褪黑素治疗可使血浆TBIL、ALT、AST、AKP、GGT和肝组织MDA含量显著降低,SOD、CAT、GSH-Px活力或GSH含量明显升高（P〈0.01）,AI减少（P〈0.01）。BDL组肝组织MDA含量与血浆TBIL、ALT、AKP、AST、GGT水平均呈显著正相关（P〈0.01）,GSH、SOD、CAT、GSH-Px与血浆TBIL、ALT、AKP、ALT、AST水平分别均呈显著负相关（P〈0.01）;BDL组肝组织MDA含量的变化与AI呈正相关（P〈0.01）,而GSH含量及SOD、CAT、GSH-Px活力分别与AI呈负相关（P〈0.01）。结论大鼠梗阻性黄疸时,肝组织自由基大量产生介导的氧化性损伤及其细胞凋亡,参与了肝功能损害的发生、发展。褪黑素对大鼠梗阻性黄疸肝功能损害有一定程度的保护作用,其机制可能与其拮抗肝组织过氧化和细胞凋亡有关。     

调控自噬流对巨噬细胞粘附与迁移功能的影响

目的巨噬细胞浸润是包括糖尿病肾病(diabetic nephropathy, DN)在内的多种慢性肾脏疾病的重要组织病理特征。本研究通过调控巨噬细胞(RAW264.7)自噬流各阶段,探究其对巨噬细胞黏附迁移功能的影响。 方法体内实验,建立糖尿病肾病大鼠模型,于12周末分别处死正常大鼠、DN组大鼠,病理染色观察肾脏病理改变,检测肾组织巨噬细胞标志物及自噬相关标志物表达。体外实验,检测正常与高糖(30 mM)条件下,巨噬细胞自噬体数量变化,LC3、Beclin－1(自噬相关标志物)、P62(自噬体清除指标)的表达,以及巨噬细胞粘附迁移数量。分别加用自噬溶酶体降解抑制剂氯喹(CQ)、自噬体生成激活剂雷帕霉素(RAPA),观察其对巨噬细胞自噬标记物表达及其粘附迁移功能的影响,电镜观察巨噬细胞自噬体数量与自噬溶酶体形态的变化。 结果体内实验,DN大鼠肾脏损伤明显,肾小球体积增大,基底膜增厚,系膜基质增多,肾组织CD68(巨噬细胞标志物)、P62表达增加(t＝3.35、t＝16.27, P<0.05),LC3表达减少(t＝51.12, P<0.05);体外实验,在高糖组,电镜观察发现自噬体数量较正常组减少,Western印迹与免疫荧光显示自噬相关蛋白LC3、Beclin－1表达降低,P62表达升高(t＝27.02,t＝45.56、t＝32.71,P<0.05),巨噬细胞粘附和迁移数量增多(t＝6.87、t＝8.76,P<0.05)。用CQ处理后,电镜观察发现巨噬细胞自噬体溶酶体降解受到抑制,Western印迹与免疫荧光显示自噬相关蛋白LC3、Beclin－1表达降低,P62表达升高(t＝14.64、t＝12.45、t＝8.57,P<0.05);CQ进一步促进高糖诱导的巨噬细胞黏附迁移数量增多(t＝4.37、t＝7.27,P<0.05);RAPA增加巨噬细胞自噬体数量,Western与免疫荧光显示RAPA提高了被高糖抑制的巨噬细胞自噬水平,[LC3、Beclin－1表达升高,P62表达降低(t＝9.37、t＝11.53,t＝8.73;P<0.05)],减少高糖诱导的巨噬细胞黏附、迁移数量增多(t＝4.16、t＝5.74, P<0.05)。 结论高糖抑制自噬水平,促进巨噬细胞黏附迁移;抑制自噬溶酶体降解可降低自噬水平、促进巨噬细胞粘附迁移;激活自噬体生成能提高自噬水平,减轻巨噬细胞粘附迁移。