中西医结合介入治疗股骨头缺血坏死

无论什么原因引起的股骨头缺血坏死 ,至今尚无特效的药物或保守方法能有效地控制其病程发展 ,人工关节毕竟存在使用寿命的问题 ,青年患者的确不宜积极或过早更换关节。1 998～ 2 0 0 0年 6月 ,我们用放射介入方法 ,灌注尿激酶及川芎嗪等中西药物治疗股骨头缺血坏死 ,取得良好临床效果 ,现报告如下。1　临床资料　　本组 42例 51个关节 ,得到随访共计 42例 51个关节。男31例 39个关节 ,女 1 1例 1 2个关节。 2 0～ 75岁 ,平均 38 7岁。左侧 32个关节 ,右侧 1 9个关节。Ⅰ期 2 3个关节 ,Ⅱ期 1 6个关节 ,Ⅲ期 6个关节 ,Ⅳ期 6个关节。其中介入…     

双支撑骨柱移植术治疗股骨头坏死的远期疗效分析

目的分析双支撑骨柱移植术治疗股骨头坏死的远期疗效。方法从1988年3月以来,采用双支撑骨柱移植术治疗成人股骨头坏死366例466髋,获5年以上随访者186例206髋,平均年龄32.2(20~60)岁。按病因分类:激素性者60例68髋,酒精性者86例96髋,激素加酒精者30例32髋,外伤性者10例10髋。ARCOⅡB、ⅡC、ⅢA、ⅢB、ⅢC、Ⅳ期患者分别为36、30、40、40、32、28髋。参照百分法进行疗效评价。结果术后所有患者的髋关节疼痛均获得明显缓解或消失,股骨头高度有不同程度增加,关节活动度有改善。平均随访时间10.5(5~16)年,手术前与随访时临床评价(疼痛、功能、关节活动度)、X线评价、总分数比较,差异均有统计学意义(P<0.01)。结果显示ⅡB~Ⅳ期优良率分别为83.3%、80.0%、75.0%、65.0%、40.6%、28.6%,总优良率为63.6%。Ⅱ期效果好(81.8%),Ⅲ期早期(ⅢA、ⅢB)效果较好(70%),ⅢC、Ⅳ期者效果差(35%)。期别间疗效依次降低,差异有统计学意义(P=0.0001)。30岁以内患者术后股骨头内植骨愈合较快,平均为3.2(2.9~3.5)个月。50~60岁患者植骨愈合需时较长,平均为5.5(4.4~6.4)个月。结论该术式治疗股骨头坏死的远期疗效良好,治疗效果与股骨头坏死期别有关,尤其适用于股骨头坏死Ⅱ期和Ⅲ期的早期病例。     

旋股外侧血管升支髂骨瓣移植治疗股骨头缺血性坏死

近年来中青年发生非创伤性的股骨头坏死患者有增加的趋势.如不及时治疗,病情发展至FicatⅣ期只能做人工髋关节置换,而该类患者做人工髋关节置换后5年返修率高达10%.我院自2003年4月至2008年10月采用带旋股外侧血管升支髂骨瓣移植治疗股骨头缺血性坏死(FicatⅡ-Ⅲ期)32例(41个股骨头),取得良好的临床效果.     

钻孔减压治疗塌陷期股骨头坏死的临床观察

目的:探讨钻孔减压治疗塌陷期股骨头坏死的临床疗效并作生存分析。方法:收集自2006年3月至2009年2月期间治疗的22例双侧股骨头坏死病例, 其中男20例, 女2例;平均年龄38.4岁(24～52岁).所有病例一侧为Ficat Ⅲ期, 另一侧为FicatⅠ期或Ⅱ期。采用钻孔减压进行治疗, 平均随访5.4年(1～8年).以严重的髋关节疼痛(VAS≥7分)、髋关节功能障碍(Harris评分≤70分)、X线显示病变进展到Ficat Ⅳ期以及髋关节置换作为终点进行生存分析。结果:以严重的髋关节疼痛为终点, Ficat Ⅲ期最终有13例VAS<7分, 而FicatⅠ期或Ⅱ期有18例(P>0.05);以髋关节功能障碍为终点, Ficat Ⅲ期最终有6例Harris评分>70分, 而FicatⅠ期或Ⅱ期组有18例(P<0.05);以X线显示病变进展到Ficat Ⅳ期为终点, Ficat Ⅲ期最终有2例未进展到Ficat Ⅳ期, 而FicatⅠ期或Ⅱ期组有18例(P<0.05);以髋关节置换为终点, Ficat Ⅲ期最终有13例未行髋关节置换, 而FicatⅠ期或Ⅱ期有18例(P>0.05).结论:钻孔减压可以有效地延缓Ficat Ⅲ期的病情发展, 降低关节置换的比例。     

全髋关节置换术治疗股骨转子间不稳定性骨折合并股骨头坏死7年随访

目的:探讨全髋关节置换术治疗合并股骨头坏死的股骨转子间不稳定性骨折的效果和中长期随访情况。方法：自2008年3月至2014年10月采用全髋关节置换术对股骨转子间不稳定性骨折合并股骨头坏死的患者23例进行治疗,男10例,女13例;年龄59~82（68.4±10.4）岁。根据Evans-Jensen分型,Ⅱa型8例,Ⅱb型6例,Ⅲ型9例。根据Ficat分期,Ⅱa期3例,Ⅱb期3例,Ⅲ期9例,Ⅳ期8例。术后观察并发症发生情况,以Harris评分进行髋关节功能评价,术后7年时评估假体生存率。结果：术后出现并发症2例,1例患者术后3个月时出现急性假体周围感染,1例患者术后3个月时出现髋关节脱位。23例患者均获得随访,随访时间61~110（85.1±22.9）个月。末次随访时Harris评分83~92（89.8±5.2）分,与术前比较差异有统计学意义（P<0.05）。影像学显示所有患者转子间骨折获得骨性愈合。23例患者假体7年生存率为95.7%。结论：对于合并股骨头坏死的股骨转子间不稳定性骨折使用人工全髋关节置换术治疗,可以同时治疗骨折和术前症状性髋关节疼痛,具有满意的中长期效果。     

病灶清除后打压植骨联合多孔钽金属棒植入治疗早期股骨头缺血性坏死

目的探讨病灶清除后打压植骨联合多孔钽金属棒植入治疗早期股骨头缺血性坏死的临床疗效。方法 2008年3月-2010年5月,收治14例16髋股骨头缺血性坏死患者。男13例15髋,女1例1髋;年龄18～73岁,中位年龄42.2岁。外伤性1例1髋,酒精性4例4髋,激素性9例11髋。股骨头缺血性坏死根据国际骨循环研究会(ARCO)分期:Ⅰ期3髋,Ⅱ期13髋。Harris评分为(51.89±12.42)分,采用中华医学会骨科学分会百分比评价法中的X线评价方法评分为(31.88±4.03)分。病程6个月～7年,中位病程2.5年。采用经股骨头颈部开窗、病灶清除、自体髂骨打压植骨联合多孔钽金属棒植入治疗。术后患肢避免负重3个月,部分负重3个月。结果术后切口均Ⅰ期愈合,无感染等早期并发症发生。患者均获随访,随访时间13～36个月,平均24个月。2例2髋因关节疼痛加重、股骨头塌陷,于术后4个月及2年行人工全髋关节置换;其余患者术后关节疼痛症状均明显缓解,股骨头生存率为87.5%(14/16)。髋关节功能行Harris评分为(84.89±17.96)分,与术前比较差异有统计学意义(t=—8.038,P=0.001)。X线片检查示植骨区域成骨化明显,骨密度增高,骨小梁排列整齐规则,股骨头无明显塌陷。末次随访时X线片评分为(32.19±6.57)分,与术前比较差异无统计学意义(t=—2.237,P=0.819)。结论病灶彻底清除后打压植骨联合多孔钽金属棒植入治疗早期股骨头缺血性坏死能有效缓解疼痛、改善髋关节功能、防止股骨头塌陷,延缓甚至避免人工全髋关节置换。     

股骨头缺血性坏死修复与再造的长期随访观察

[目的]对成人股骨头缺血性坏死修复与再造术进行远期随访，评估该治疗方法的有效性。[方法]对1986年11月到1997年3月接受股骨头缺血性坏死修复与再造术治疗的313例（382侧）患者进行随访，平均年龄36．4岁（18—65岁），根据Ficat分期标准，Ⅱ期151侧，Ⅲ期142侧，Ⅳ期89侧，术后平均随访12．1年（10．20年），根据Harris髋关节功能评分标准进行临床评价，根据手术前后Ficat分期改变进行影像学评价。Kaplan．Meier生存曲线以关节置换为终结点，对股骨头修复与再造的生存率进行分析。[结果]术后19髋（19／382，5％）改行人工全髋关节置换术。术后Harris髋关节功能评分明显提高（术前平均56．2，术后平均85．8），临床生存率为85．6％（341髋），影像学生存率为75．4％。Kaplan-Meier生存曲线提示FicatⅣ期，激素性和酒精性以及55岁以上的患者远期生存率较低。[结论]针对不同程度、不同年龄以及不同病因的股骨头缺血性坏死采用单纯或联合带血管蒂骨（膜）瓣转移修复与再造术，远期疗效是满意的，是青壮年股骨头缺血性坏死患者保留股骨头的有效治疗方法。     

激素性股骨头坏死治疗分析

许多需要长期大量服用激素的疾病可引起股骨头坏死。我院自1985～1998年共治疗ZO例激素性股骨头坏死,报道如下。临床资料一、一般资料本组20例34髋,男17例29髋,女3例5髋。年龄最小4o岁,最大65岁,平均47岁。Ficat分期1期4例7髓,Ⅰ～Ⅱ期3例5髋,Ⅱ期2例3髓,Ⅱ～Ⅲ期3例6髋,Ⅲ期4例6髋,Ⅲ～Ⅳ期2例4髋,Ⅳ期2例3髋,双髋发病率7O％。系统性红斑狼疮使用激素治疗致股骨头坏死12例21髋,类风湿关节炎致股骨头坏死3例5髓,痛风致股骨头坏死2例3髋,脊髓空洞症致股骨头坏死2例3髋,内分泌紊乱致股骨头坏死1例2髋。二、治疗方法本组治疗…     

髋关节镜清理小直径多孔道多方向髓内减压治疗股骨头坏死的价值

[目的]探讨髋关节镜清理术及小直径、多孔道股骨头髓内减压治疗股骨头坏死的疗效。[方法]自1998年2月-2003年10月应用髋关节镜清理术结合小直径、低转速、多孔道多方位股骨头髓内钻孔减压治疗激素性和酒精性股骨头缺血性坏死68例（75髋）。男性46例，女性22例。左侧36例，右侧25例，双侧7例。平均年龄41．4岁。术前Ficat分期：Ⅰ期41髋，Ⅱ期21髋，Ⅲ期6例。关节镜清理增生肥厚、充血水肿的滑膜组织和关节内致痛物质。在关节镜和C型臂X线透视下行钻孔减压，采用直径3．0mm克氏针、低速电钻或手摇钻行股骨头多孔道、多方向钻孔减压。[结果]近期疗效：术后第2d疼痛症状减轻50％者38例，1周内疼痛消失28例，2周后疼痛症状减轻3例。术后随访65例，平均19个月（6个月-3．4a），按成人股骨头缺血坏死的疗效百分法进行疗效评定，关节疼痛症状完全解除49例，轻度疼痛9例，中度疼痛6例，髋关节屈伸和内外旋转功能明显改善，无感染和血管神经损伤等并发症，无股骨头塌陷加重。1例FicatⅢ期的患者于术后1年行全髋人工关节置换。[结论]关节镜清理术有利于清除髋关节内致痛物质，改善关节内环境紊乱，改善临床症状；采用小直径、多孔道、低转速股骨头髓内钻孔减压，有助于降低骨内压，改善股骨头内循环，减轻疼痛症状，延缓股骨头坏死进程，有效防止股骨头塌陷。     

表面置换治疗股骨头缺血性坏死近期疗效观察

[目的]评价髋关节表面置换（THSR）治疗重度青壮年股骨头缺血性坏死（NFH）的临床疗效。[方法]自2001年6月～2005年10月，对18例22髋股骨头缺血性坏死（FicatⅢ、Ⅳ期）行全髋关节表面置换术，平均年龄42．5岁。[结果]18例患者均获随访，随访平均32个月（6～43个月），术前Harris评分35分，术后92分。评价：优16髋，良5髋，可1髋。[结论]对于FicatⅢ、Ⅳ期股骨头坏死采用全髋表面置换，近期疗效满意。     

Facing the Reality: The World Cannot Afford Uremia Therapy at the Start of the 21st Century

Abstract: Although remarkably successful in prolonging useful life, there is minimal probability that the majority of the world's population will benefit from contemporary therapy for irreversible renal failure because of its inordinately high cost in light of available resources. While affluent nations establish priorities for allocation of slots for maintenance dialysis or recipients of organ transplants, poor and developing countries must await the development of inexpensive, low technology treatments to substitute for absent kidney function. One attractive potential alternative to contemporary uremia therapy is the use of the intestine as a giant substitute and somewhat displaced nephron. Possible means of extracting wastes via the gut include ingestion of a mixed oral sorbent, instillation of bacterial crystallized enzymes to transform nitrogenous wastes to essential amino acids, or administration of high osmolality laxatives to promote diarrhea containing nitrogenous wastes. Any of these approaches may extract sufficient solute and water to sustain anephric life. An optimistic view of evolving uremia therapy is that within the next decade pills and purges for the poor may supplant more effective though expensive high technology approaches now encompassed in so-called modern nephrology.     

Window of opportunity treatment in breast cancer

Window of opportunity therapies, which involve short‐term administration of systemic therapy between cancer diagnosis and surgery, have raised significant interest in recent years as a mean of assessing the sensitivity of a patient's cancer to therapy prior to surgery. There is now compelling evidence that in patients with early stage hormone‐receptor positive breast cancer, a 2‐week preoperative treatment with standard hormone therapies in a preoperative window period provides important prognostic information, which in turn helps to aid decision‐making regarding treatment options. Changes in short‐term biomarker endpoints such as cell proliferation measured by Ki‐67 can act as surrogate markers of long‐term outcomes. Paired tissues obtained pre‐ and post‐investigational treatment, without having to subject the patient to additional biopsies, can then be used to conduct translational research to investigate predictive biomarkers and pharmacodynamics. In this review, we will examine the utility and challenges of window of opportunities therapies in breast cancer in the current literature, and the current Australian and international trial landscape in this clinical space.     

电化学治疗中晚期肺癌的临床效果

应用电化学治疗不适宜手术切除的中晚期肺癌或经放、化疗无效的５９３例病人，包括年老体弱或有高血压、冠心病、糖尿病、肝肾功能不全者１５１例，经放化疗无效或未完成者１３８例，曾仅接受中医治疗但肿瘤继续增大者８３例，消化道癌术后肺内转移５２例，开胸探查手术１６９例。治疗方法为应用直流电治癌仪，将特制铂金电极针插入肿瘤内，针间距离以２ｃｍ为宜，电压调至８Ｖ左右，电流为６０～８０ｍＡ，按肿瘤直径每１ｃｍ给１００库仑（Ｃ）。结果１年内近期疗效显示获ＣＲ１５５例（２６１％），ＰＲ２６８例（４５１％），ＮＣ８９例（１５０％），ＰＤ８１例（１３０％）；ＣＲ和ＰＲ评为有效，占７１３％。远期随访结果示生存１年以上者共５０８例（８５６％），生存２年者４４０例（７４１％），生存３年者３３４例（５６３％），生存４年者２３２例（３９１％），生存５年者１６９例（２８４％）。结论：电化学治疗适应证为不能手术的中晚期肺癌或开胸后肿瘤不能切除者，放化疗无效者。尤其是对＞８ｃｍ的巨块肺癌，更宜采用电化学和放化疗相结合的综合方法。本疗法具有简便、安全、有效、创伤小、恢复快的优点。     

Livin基因-肿瘤治疗新靶点

Livin是凋亡抑制蛋白(IAPs)家族的新的重要成员.Livin在多种肿瘤细胞中高表达,参与抑制细胞凋亡,与肿瘤发生发展密切相关.研究发现,通过下调或抑制Livin基因的表达及诱导产生特异性地识别Livin的抗体可抑制、杀死肿瘤细胞,为恶性肿瘤的诊断、细胞和基因靶向治疗等提供新的方法.     

The timing of androgen ablation therapy and/or chemotherapy in the treatment of prostatic cancer

The effect of varying the timing of androgen ablation alone and in combination with chemotherapy on tumor growth rate and host survival has been studied using the serially transplantable Dunning R-3327 H rat prostatic adenocarcinoma as a model. These studies have demonstrated three basic points: 1) When either androgen ablation or Cytoxan chemotherapy are given as a single agent treatment, they are both most effective when given as early as possible; 2) when androgen ablation is combined with Cytoxan chemotherapy, it is most effective when both therapies are begun simultaneously and as early as possible; and 3) when androgen ablation and Cytoxan treatment are begun simultaneously and early, it is possible to increase survival above that found for either treatment when given optimally as single modalities (ie, such simultaneous early treatment enhances the individual therapeutic effectiveness of both treatments).     

闭合性腹部损伤脾破裂非手术治疗的探讨

目的探讨闭合性腹部创伤脾破裂非手术治疗的可行性。方法对１９９５年１月至１９９７年３月间行手术和非手术治疗的３２倒闭合性腹部创伤脾破裂患者的临床表现和治疗结果进行回顾性分析。结果脾破裂非手术治疗患者１２例占同期脾破裂病例的３７．５％（１２／３２）,男１０例,女２例,平均年龄３５岁（１６～５０岁）。非手术组患者其损伤程度较手术组患者轻。非手术治疗失败１例,治疗成功率９２％。平均住院日为１６天,出院随访１～２７个月未发现有并发症,其中１０例随访３个月以上,其ＣＴ检查示脾脏损伤均已愈合。结论合适的选择脾破裂患者行非手术治疗是安全、有效的。     

俯卧仰头推肩法治疗T1、2小关节紊乱

自2001-2003年运用俯卧仰头推肩法治疗T1、2小关节紊乱36例，取得满意疗效，现报告如下。     

Intermittent Androgen Deprivation for Locally Advanced and Metastatic Prostate Cancer: Results from a Randomised Phase 3 Study of the South European Uroncological Group

Background

Few randomised studies have compared intermittent hormonal therapy (IHT) with continuous therapy for the treatment of advanced prostate cancer (PCa).

Objective

To determine whether intermittent therapy is associated with a shorter time to progression.

Design, setting, and participants

766 patients with locally advanced or metastatic PCa received a 3-mo induction treatment. The 626 patients whose prostate-specific antigen (PSA) level decreased to <4 ng/ml or to 80% below the initial value were randomised.

Intervention

Patients received cyproterone acetate (CPA) 200 mg for 2 wk and then monthly depot injections of a luteinising hormone-releasing hormone (LHRH) analogue plus 200 mg of CPA daily during induction. Patients randomised to the intermittent arm ceased treatment, while those randomised to the continuous arm received 200 mg of CPA daily plus an LHRH analogue.

Measurements

Primary outcome measurement was time to subjective or objective progression. Secondary outcomes were survival and quality of life (QoL). Time off therapy in the intermittent arm was also recorded.

Results and limitations

127 patients from the intermittent arm and 107 patients from the continuous arm progressed, with a hazard ratio (HR) of 0.81 (95% confidence interval [CI]: 0.63–1.05, p = 0.11). There was no difference in survival, with an HR of 0.99 (95% CI: 0.80–1.23) and 170 deaths in the intermittent arm and 169 deaths in the continuous arm. The greater number of cancer deaths in the intermittent treatment arm (106 vs 84) was balanced by a greater number of cardiovascular deaths in the continuous arm (52 vs 41). Side-effects were more pronounced in the continuous arm. Men treated with intermittent therapy reported better sexual function. Median time off therapy for the intermittent patients was 52 wk (95% CI: 39.4–65.7).

Conclusions

IHT should be considered for use in routine practice because it is associated with no reduction in survival, no clinically meaningful impairment in QoL, better sexual activity, and considerable economic benefit to the individual and the community.     

Laser therapy for esophageal cancer

Between 1/1/1988 and 5/31/1991, we treated 96 patients with laser therapy to the esophagus. In 61 inoperable patients, laser therapy has been performed initially. In 64% of these 61 patients, laser therapy alone gave sufficient relief of symptoms until death. However, in 36% of the patients, additional endoscopical interventions had to be performed. In 14 patients (23%), a prosthesis became necessary; 13 patients (21%) needed a percutaneous endoscopical gastrostomy. We conclude that laser therapy has an important role in the treatment of esophageal cancer, but in a significant number of patients, it might not be sufficient alone.     

不同学科骨质疏松症患者的药物治疗及日常生活能力分析

目的通过对不同学科骨质疏松症患者住院的一般情况、药物治疗及日常生活能力的分析,为临床骨质疏松症的诊疗和管理提供思路。方法回顾我院诊断为骨质疏松症患者共1 667例,按收治例数多少排名前5位的科室分为5组,1、3、5组为内科组,2、4组为外科组。分析患者一般情况、药物治疗、入出院日常生活能力评分及差值的变化。结果不同科室收治的患者女性均高于男性,骨科组患者年龄、住院时间均高于内科组(P0.05),提示随年龄增长,并发骨折人数增多,年龄与骨折的发生呈正比例关系。以骨质疏松原发病就诊率低,仅为8.0%,一般与多种疾病共存时发现。骨科组药物治疗率低,内科组使用率高,各组间有差异(P0.05),但按照指南规范仍尚未达到标准。各组出入院前后日常生活能力差值的比较,其改变与所在科室、是否手术存在相关性(P0.001)。结论骨质疏松原发病就诊率低,一般与多种疾病共存时发现,治疗欠规范,各科室治疗重点及方法不同。骨质疏松症并发骨折患者年龄大,住院时间长。各科医生对于基础药物治疗方面均重视不够,加强外科医生对原发病的干预显得更为重要,规范的抗骨质疏松治疗需多学科合作。