辅助生殖中的精子优选研究进展

精子优选是辅助生殖技术中的重要环节。精子活力和形态等常规参数是评估精子的重要内容,近年来精子超微结构、DNA完整性、凋亡和膜成熟度等特征逐渐受到关注,针对这些特征筛选精子成为精子优选技术发展的方向。本文介绍了近年来发展起来的电泳法、电动电位法、透明质酸结合法、膜联蛋白V选择法、形态选择性单精子注射技术(IMSI)和微流控芯片法的技术原理,除微流控芯片法外其它技术均已应用于IVF或ICSI治疗中,同时对各种技术的优缺点和应用效果等方面做一综述。     

人类辅助生殖技术中精子使用的伦理思考

作为胚胎形成不可或缺的一部分,精子在人类辅助生殖技术中的相关应用,促进了家庭幸福与社会和谐,推动了科学技术不断向前发展,同时也带来一系列伦理道德问题。审慎对待并协调处理科学技术与伦理道德的矛盾关系,有利于人类辅助生殖技术的健康发展。     

供精精液行辅助生殖技术出生子代安全性评估

目的:本研究调查应用供精者精液实施辅助生殖技术(ART),包括供精人工授精(AID)、供精体外受精(IVF-D、ICSI-D)与应用丈夫精液经ART(AIH、IVF、ICSI)出生子代缺陷的发生率,从而评价应用供精者精子实施ART出生子代的安全性。方法:2005年1月至2009年10月,上海市人类精子库向全国11家医疗机构供精,实施供精ART出生子代904例。对照组为4家生殖医学中心,同期对不育夫妇实施丈夫精液ART出生子代4 195例。统计两类精液实施ART出生子代的数量与出生缺陷的例数及病种分类,比较两种精液来源获得子代出生缺陷的发生率。结果:应用供精者精液实施ART获得子代出生缺陷7例(0.77%),使用丈夫精液出生缺陷42例(1.00%),其差异无显著性(P>0.05)。结论:应用供精者精子实施ART出生子代同夫精ICSI出生的子代相比,出生缺陷的种类没有明显差异,但前者的出生缺陷率明显低于后者,就目前结果而言,供精辅助生殖技术更具安全性。     

Surgery in incomplete spinal cord injury

A case of spinal cord injury treated surgically is reported; it is unusual in that it showed the classic indication for surgery—a documented progression of neurological impairment. The patient made a full recovery following anterior decompression of the spinal cord. We believe this case gives added evidence that surgery does have a valuable place in the management of certain selected spinal cord injuries. The literature is reviewed.     

高血糖对急性脊髓损伤后果的影响

目的探讨给予高渗糖对急性脊髓损伤后神经学功能恢复的影响。方法将16只健康禁食的大白兔随机分为两组,采用Alien’s脊髓损伤模型,在脊髓损伤前一组动物接受50％高渗糖0．5g／kg体重（处理组）,另一组采用等容量生理盐水对照（对照组）,脊防损伤前后采股动脉血测定血糖并于损伤后3天进行神经学评分。结果处理组与对照组相比,血糖水平显著增高（P＜0．04）,72小时后的神经功能评分也明显不如对照组（P＜0．01）。结论急性脊髓损伤期间的高血糖可加重脊髓继发性损伤。     

Outcome of the acute abdomen in patients with previous spinal cord injury

Background : Patients with spinal cord injury (SCI) have always posed difficulties for the diagnosis of an acute abdomen. The aim of the present study was to define this problem retrospectively at Princess Alexandra Hospital and to assess the results of treatment for these patients. Methods : A retrospective review was conducted of 133 SCI patients admitted with an acute abdomen in the 16 years prior to this analysis at the Spinal Injuries Unit (SIU) of Princess Alexandra Hospital. There were 21 patients who conformed to the study criteria. All the patients had sustained traumatic SCI at or above the level of T11, more than 1 month prior to admission. Results : There were 13 male and eight female patients. The time lapse between SCI and the onset of an acute abdomen ranged from 1.5 months to 27 years. The age range was 26–79 years. The majority of patients had C6 injuries (six patients). There were 18 patients with injury levels above T6 and three patients with injuries below this level. The time taken to diagnose the cause of the acute abdomen ranged between 1 day and 3 months. Investigations were found to be useful in making the diagnoses in 61.9% of cases. There were 14 patients who had surgical interventions. Five patients had surgical complications and there were two deaths in the study. The length of follow up was 1–132 months. The mortality in the study was 9.5%. Conclusion : An aggressive approach to the diagnosis and treatment of the acute abdomen in SCI patients with suspicious symptoms is recommended. A high index of suspicion should be maintained in those patients with pre‐existing SCI who present with abdominal trauma.     

微流控技术在精子优选及体外受精中的应用

由于传统辅助生殖技术(ART)成功率低,人们在不断追求探索新的技术。大量研究表明微流控技术具有革新传统体外受精(IVF)操作流程的潜能。与传统方法相比,微流控技术应用于精子优选及体外受精具有效率高、时间短、无离心损伤、实时观察筛选效果、微环境相似及自动化等显著优点,为ART提供了新平台。笔者综述了近年来微流控技术在精子活力评价与筛选、精子化学趋向性筛选、体外受精、精子浓度检测、精子分离富集等方面的应用。同时,本文简要讨论了微流控平台原理﹑结构设计及操作流程,聚焦各种方法的优缺点以及临床应用的可能性。可见微流控技术应用于ART仍有一些问题亟待解决,有理由相信其未来发展方向是通过制作高度集成化的平台即体外受精-芯片实验室(IVF-lab-on-a-chip)来实现。     

Inpatient rehabilitation outcomes in neoplastic spinal cord compression vs. traumatic spinal cord injury

Objective: To compare neurological and functional outcomes, and complications of patients with neoplastic vs traumatic spinal cord injury (SCI) after in-patient rehabilitation.Design: This study is a retrospective analysis.Setting: In-patient rehabilitation unit of a tertiary research hospital.Participants: A total of 252 patients with a SCI were included; 43 with neoplastic SCI (mean age: 60.9 ± 15.7 years, 60.5% were males) and 209 with traumatic SCI (mean age: 43.1 ± 16.8 years, 71.3% were males).Outcome measures: Comparisons were made of demographic characteristics, etiology, American Spinal Injury Association (ASIA) impairment scale, functional independence measurement (FIM) and Functional Ambulation Categories (FAC) scores, length of stay (LOS), bladder independence, medical comorbidities and complications in both groups.Results: Patients with neoplastic SCI were significantly older than those with traumatic SCI (P < 0.01). No difference was present between the groups in terms of sex and lesion level (P > 0.05). Incomplete SCI was significantly higher in the neoplastic group when compared with the traumatic group (P < 0.01). The LOS was significantly shorter in the neoplastic group than traumatic group (34.8 ± 41.03 vs. 60.02 ± 53.1, P < 0.01). There were no differences in the admission FIM scores (69.3 ± 24.7 vs. 58.7 ± 18.9, P > 0.05), discharge FIM scores (82.1 ± 25.1 vs. 74.02 ± 23.3, P > 0.05) and FIM efficiencies (0.43 ± 0.72 vs. 0.36 ± 0.51, P > 0.05) for the neoplastic and traumatic groups, respectively. However, neoplastic SCI patients demonstrated lower FIM gains compared to traumatic patients (12.9 ± 11.9 vs. 15.4 ± 15.2, P < 0.05). During rehabilitation, urinary tract infection (48.4% vs. 69.4%) and decubitus ulcer (11.6% vs. 35.9%) were significantly more common in the traumatic group than the neoplastic group (P < 0.05).Conclusion: Neoplastic SCI patients who commonly present at rehabilitation units exhibit different characteristics from traumatic SCI patients but the rehabilitation results are similar. Similar functional development can be achieved in a shorter period of time with inpatient rehabilitation in the neoplastic SCI group.     

The impact of spine stability on cervical spinal cord injury with respect to demographics,management, and outcome: a prospective cohort from a national spinal cord injury registry

Background Context

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

The prevention of iatrogenic spinal cord injury utilizing the evoked spinal cord potential

Summary The evoked spinal cord potential elicited by direct stimulation of the cord has been used clinically to monitor cord function in the course of operations on the spine. The technique used allows measurement of a relatively large amplitude of potential, which is fairly stable against anaesthetics and related drugs, by means of a simple recording system and is sensitive enough to indicate cord damage. Continuous monitoring can easily be carried out. We have encountered no complications when using this method on 99 patients.

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Résumé Le potentiel évoqué provoqué par la stimulation directe de la moelle épinière a été utilisé en clinique pour contrôler la fonction de la moelle lors des interventions sur le rachis. Cette technique permet de mesurer une assez grande amplitude de potentiel, qui est relativement stable à l'égard des anesthésiques et d'autres drogues de même type, grâce à un système simple d'enregistrement; il est suffisamment sensible pour détecter des altérations de la moelle. Une surveillance continue peut aisément être effectuée. Aucun incident n'a été rencontré chez 99 malades lors de l'utilisation de cette méthode.

     

Venous thromboembolism in acute spinal cord injury patients

Background:

The western literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) following spinal cord injury (SCI) report an alarmingly high incidence, necessitating thromboprophylaxis. The literature on incidence from the Asian subcontinent is scanty and from India is almost nonexistent.

Materials and Methods:

Seventy hospitalized acute SCI patients presenting within five days of the injury were included in the present analysis. Forty-two cases were subjected to color Doppler studies and 28 cases had to be subjected to venography due to lack of facility at some point of time. The clinical course of the patients was closely observed during the period of hospitalization. All except 14 were managed nonoperatively. Thromboprophylaxis was not given to any patient at any stage; however, treatment was instituted in those showing the features of DVT on investigations.

Results:

Twelve patients died during the period of hospitalization. Deep vein thrombosis could be detected in seven patients only, three in the proximal and four in the distal segment of the lower limb and of these three died. Based on the clinical course and positive investigation report in favor of DVT, we presumed that the cause of death in these three patients was pulmonary embolism. In the other nine, in the absence of an autopsy report, the cause of deaths was considered as pulmonary infection, asphyxia, diaphragmatic paralysis, hematemesis, cervicomedullary paralysis etc. Clinical features to diagnose DVT were of little help.

Conclusions:

There is a much lower incidence (10%) of DVT and PE following spinal cord injury (SCI) in India than what is reported from the western countries. Higher age group and quadriplegia were the only factors which could be correlated. Deep vein thrombosis extending proximal to the knee was significant. In the absence of autopsy and other screening tests like D-dimer test or 125I fibrogen uptake study, the true incidence of venous thromboembolism remains uncertain. Noninvasive screening of all patients for the detection of deep vein thrombosis in SCI patients is strongly recommended.     

不完全性脊髓损伤患者的个体化分阶段护理

目的 :探讨个体化分阶段护理模式对不完全性脊髓损伤(ISCI)患者的护理效果,为临床护理工作提供参考。方法:将我院2015年2月~2016年4月收治的60例ISCI患者随机分为对照组与观察组。对照组中女性10例,男性20例;年龄19~57岁,平均42.16±4.27岁;ASIA分级B级9例、C级10例、D级11例,脊髓损伤发生于颈段5例,胸段10例,腰段15例。观察组中女性8例,男性22例,年龄21~55岁,平均45.23±6.72岁;ASIA分级B级10例、C级8例、D级12例,脊髓损伤发生于颈段6例,胸段9例,腰段15例。两组在性别、年龄、脊髓损伤节段及ASIA分级等情况无统计学差异。观察组予个体化分阶段护理,包括对个性化分阶段的心理康复、功能锻炼与呼吸道、肠道、泌尿系管理,对照组住院期间给予常规护理。治疗前及治疗后(90d时)依次采用Zung氏抑郁自评量表(SDS)、康复效果评定表(ISNCSCI-2013)、改良Barthel指数量表分别对两组患者的心理健康状态(SDS评分)、运动和感觉功能及日常生活能力进行评估,并比较两组患者治疗过程中并发症的发生率。结果:观察组SDS评分治疗前61.51±2.3分,治疗后40.11±2.1分;对照组治疗前62.22±2.9分,治疗后50.50±3.1分。观察组运动功能评分治疗前47.8±10.2分,治疗后68.4±13.2分;对照组治疗前47.4±11.3分,治疗后60.1±13.5分。观察组感觉功能评分治疗前87.2±14.5分,治疗后102.5±19.3分;对照组治疗前88.3±14.7分,治疗后94.1±18.3分。观察组日常生活能力评分治疗前55.4±8.7分,治疗后78.1±9.5分;对照组治疗前55.2±9.2分,治疗后69.6±11.4分。观察组在心理健康状态、运动和感觉功能恢复情况及日常生活能力优于对照组(P0.05)。观察组的肺部感染(6.67%)、泌尿系感染(3.33%)、便秘并发症发生率(10%)低于对照组(分别为13.33%、16.67%及23.33%)(P0.05)。结论 :个体化分阶段护理模式对于不完全性脊髓损伤患者心理健康、功能康复及其减少并发症具有优势,值得应用推广。     

外伤性颈髓损伤患者早期并发症与损伤程度的相关性

目的:调查不同程度颈脊髓损伤(CSCI)患者早期并发症的发生情况,探讨颈髓损伤严重程度与并发症发生的相关性。方法:2005年1月~2009年5月我院收治CSCI早期患者325例,除外20例因各种原因住院时间<7d的患者,共有305例患者入选。男249例,女56例;年龄14～83岁,平均45岁;伤后距来院就诊时间0.5h～20d,住院时间7～45d,平均为23d。高处坠落伤111例,车祸伤85例,摔伤75例,重物砸伤15例,原因不明损伤19例。按ASIA分级:A级132例,B级26例,C级89例,D级58例。按损伤程度将患者分为A(A级)、B(B级)、C(C级)、D(D级)4组,对4组患者早期并发症发生情况进行统计和分析。结果:305例患者共发生13种并发症,其中便秘229例次(75.08%),心率减慢144例次(47.21%),低钠血症137例次(44.92%),高热124例次(40.46%),呼吸功能障碍104例次(34.10%),血压下降94例次(30.82%),低蛋白血症83例次(27.21%),贫血72例次(23.61%),消化功能障碍70例次(22.95%),低钾血症45例次(14.75%),压疮38例次(12.46%),泌尿系感染28例次(9.18%),下肢深静脉血栓9例次(2.95%)。便秘、下肢深静脉血栓的发生率4组间无显著性差异(P>0.05),其余并发症的发生率4组间均有显著性差异(P<0.05);除便秘、压疮、泌尿系感染、下肢深静脉血栓外,并发症发生率均为A组>B组>C组>D组,且A、B组明显高于C、D组。结论:颈脊髓损伤患者早期并发症较多;除便秘、压疮、泌尿系感染、下肢深静脉血栓外,其余并发症的发生率随着损伤程度加重而增高,A-SIA分级A、B级患者的发生率明显高于C、D级患者。     

Prostatic massage: a simple method of semen retrieval in men with spinal cord injury

The aim of this study was to evaluate the efficacy of prostatic massage (PM) as a method for obtaining semen in men with spinal cord injury (SCI) and to evaluate the semen parameters in the semen samples obtained by this method. Sixty-nine patients with SCI underwent PM as a trial for semen retrieval. History taking, examination and hormonal assay analysis (follicle-stimulating hormone, luteinizing hormone, prolactin and testosterone) were performed in all patients. Patients were grouped as follows: group 'A' where sperm could be successfully retrieved by PM and group 'B' where no sperm could be retrieved. PM resulted in the production of prostatic secretion in 51 patients (73.9%) and no secretion was obtained in 18 patients. Spermatozoa were successfully retrieved in only 22 patients (31.9%). The semen analysis of the sperm-positive samples showed asthenoteratozoospermia with decreased vitality and increased number of leucocytes. Semen collection by PM was significantly higher in patients with an SCI level above T10. PM is a safe and simple outpatient clinic procedure that can be easily used to retrieve semen in men with SCI.     

A proposed guideline for the urological management of patients with spinal cord injury

OBJECTIVE

To develop a guideline for the urological management of patients with spinal cord injury (SCI).

METHODS

The existing practice in the UK was evaluated by a series of expert meetings. Previous publications on the subject were evaluated, and the information synthesized to produce a proposed guideline.

RESULTS

The literature review showed limited good‐quality data. As a result of the process a series of research questions was produced, the answers to which would allow a guideline to be established based on good‐quality evidence. In the absence of high‐quality evidence, the guideline was constructed using expert opinion. Urological care is described in the immediate, intermediate and long‐term phases after SCI.

CONCLUSION

The urological consequences of SCI can be devastating. Urological care is an important part of the holistic care of these patients, and should be delivered from SCI centres through a network of qualified clinicians.     

颈脊髓损伤患者医院获得性肺炎及其病原菌分析

目的:了解颈脊髓损伤(CSCI)患者医院获得性肺炎(HAP)的发生情况及病原菌的分布特点和耐药情况。方法:2008年10月～2010年8月我院骨科监护病区(OICU)共收治CSCI患者123例,其中完全性损伤32例,不完全性损伤91例,C1～C4损伤51例,C5～C7损伤72例。回顾性分析本组患者HAP发生情况及其病原菌分布特点与耐药情况,并采用χ2检验比较CSCI平面、程度与HAP发生、再次感染及耐药菌感染的关系。结果:共33例(26.8%)患者出现51例次HAP,其中C1～C4 CSCI者的HAP发生率、再次感染率及多重耐药菌感染率分别为39.2%(20/51)、13.7%(7/51)、58.8%(30/51,按例次计算),C5～C7损伤患者分别为18.1%(13/72)、6.9%(5/72)、20.8%(15/72),C1～C4损伤者与C5～C7损伤者比较差异有统计学意义(P<0.05);完全性CSCI患者的HAP发生率、再次感染率及多重耐药菌感染率分别为56.3%(18/32)、28.1%(9/32)、68.8%(22/32,按例次计算),不完全性CSCI者分别为16.5%(15/91)、3.3%(3/91)、20.9%(19/91),两者比较差异有统计学意义(P<0.05)。33例(51例次)HAP患者痰标本中共分离出93株病原菌,其中革兰氏阴性(G-)杆菌占63.4%,主要为肺炎克雷伯菌(17.20%)、铜绿假单胞菌(15.05%)、大肠埃希菌(13.98%)、鲍曼不动杆菌(10.75%);革兰氏阳性(G+)球菌主要为金黄色葡萄球菌(8.60%);真菌主要为热带假丝酵母菌(8.60%)。G-杆菌和G+球菌普遍呈现多药耐药性,G-杆菌以碳青霉烯类敏感率最高,G+球菌对万古霉素均敏感。结论:CSCI患者HAP发生率较高,其发生率与CSCI平面及程度明显相关;病原菌以G-杆菌为主,常呈多药耐药。     

胸椎管狭窄症术后脊髓缺血再灌注损伤的临床分析

目的 探讨胸椎管狭窄症患者手术后出现脊髓功能受损的原因,总结脊髓手术后缺血再灌注损伤(spinal cord ischemic reperfusion injury,SCII)[1]的预处理和早期治疗方法.方法 回顾性分析我科2年内收治的32例胸椎管狭窄症患者术后脊髓恢复情况,出现脊髓损伤患者的临床资料及处理方法,并对其预后进行客观评估.结果 2年内在收治并手术的胸椎管狭窄症患者中,手术减压前给予1克甲基强的松龙预防.5例患者于手术后出现不同程度的脊髓功能受损,即刻给予大剂量甲基强的松龙冲击治疗、脱水药及神经营养药,1例患者症状改善不理想,2例患者症状部分改善,生活可自理,2例患者基本恢复正常.结论 胸椎管狭窄症患者手术后出现的脊髓功能受损可能是脊髓缺血再灌注损伤引起,再灌注损伤在胸椎管狭窄症患者中较多见,但出现严重监床症状的少见,诊断有一定的困难.妥善的处理可望改善患者的生存质量.