骨科患者静脉血栓栓塞预防相关临床实践指南的质量评价和内容分析

目的:对国内外骨科静脉血栓栓塞(venous thromboembolism,VTE)预防相关临床实践指南进行质量评价和内容分析,为制定骨科患者标准化的预防方案提供依据。方法:检索国内外指南网及相关组织网站、数据库,按照纳入排除标准进行筛选,采用AGREEⅡ工具评价最终纳入的指南质量,分析各指南的特点。结果:共纳入9部骨科VTE预防相关指南,英文8部,中文1部。经AGREEⅡ评价的6个领域平均得分由高到低依次为:清晰性(74.07%)、范围和目的(70.06%)、参与人员(54.94%)、严谨性(41.67%)、应用性(40.97%)、独立性(40.28%)。纳入的指南涉及风险筛查、风险预警、预防策略、知识培训、知识转化等5个方面。结论:骨科VTE预防的相关指南总体质量一般,在严谨性、独立性和应用性领域有待提高。我国VTE预防发展起步较晚,尚缺乏基于循证的高质量临床实践指南。     

手术治疗跟骨塌陷性骨折

目的　评估跟骨塌陷性骨折手术治疗的效果。方法　 1996年 5月～ 2 0 0 0年 6月共手术治疗跟骨塌陷性骨折 15例 ,8例内固定 ,7例植骨 ,平均随访 14个月 ,参照AOFAS评分对患者有否疼痛、步态、距下关节活动 ,是否支架辅助、术后X线照片等加以评估。结果　两组结果无明显差异。 2例手术切口皮缘坏死 ,6例疗效为优 ,9例为良。结论　跟骨塌陷性骨折手术解剖复位能取得好的效果     

Age-Related Bone Mineral Density, Accumulated Bone Loss Rate and Prevalence of Osteoporosis at Multiple Skeletal Sites in Chinese Women

We investigated the age-related bone mineral density (BMD), accumulated bone loss rate (ABLR) and the prevalence of osteoporosis at different skeletal sites in Chinese women. BMD was measured at the anteroposterior (AP) spine, supine lateral spine (areal BMD at the midarea [mLat] and the whole region [Lat], volumetric BMD at the middle region [MVD] and total region [TVD]), hip (femoral neck [FN], trochanter [Troc] and Ward’s triangle [Ward’s]) and forearm (radius + ulna ultradistal [RUUD], 1/3 region [RU1/3] and total region [RUT]) using a dual-energy X-ray absorptiometry (DXA) fan-beam bone densitometer (Hologic QDR 4500A) in 2702 females aged from 5 to 96 years old. Data were analyzed by eight different regression models. We found that the cubic regression model was the best for describing age-related changes in BMD. The coefficients of determination (R ²) of the fitting curve were 0.398 to 0.612 (p= 0.000). The data were then analyzed by 5-year age groups. This showed that the earliest peak BMD was at the age of 20–24 years at Troc and Ward’s, and the latest at the age of 40–44 years at RU1/3 and RUT of the distal forearm. Compared with BMD, the ABLRs were highest at Ward’s (−66.2%) and the lowest at RU1/3 of the distal forearm (−31.3%) in subjects over 80 years old. The prevalence of osteoporosis at at least one site in these women was 0.5 ± 0.4% in those 30–39, 4.6 ± 4.4% in those 40–49, 23.9 ± 13.3% in those 50–59, 56.3 ± 20.3% in those 60–69, 71.8 ± 16.7% in those 70–79 and 83.2 ± 12.1% those over 80 years of age, respectively. The prevalence of osteoporosis in these women was 8.6–11.1% at the age of 40–49 and 36.5–40.6% at the age of 50–59 at the lateral spine regions (mLat, Lat, MVD and TVD), and 0.5–3.7% at the age of 40–49 and and 3.9–21.7% at the age of 50–59 years at the other skeletal sites (AP, FN, Troc, Ward’s, RUUD, RU1/3 and RUT). Significant differences were found in the prevalence of osteoporosis between the lateral spine regions and other skeletal sites (p<0.001) at the age of 40–59 years. In summary, we demonstrated significant age-related differences in peak BMD, ABLR and osteoporosis prevalence among various skeletal sites. Our data suggest that the supine lateral spine is the most sensitive site for the diagnosis of osteoporosis, especially in the early menopausal period, although the prevalence of osteoporosis varied with age and with different sites measured. Received: 20 November 2001 / Accepted: 13 February 2002     

Surgical device closure a new technique of ASD closure

Background Conventional approach of atrial septal defect (ASD) closure with cardio pulmonary bypass using mid sternotomy, minimally invasive or endoscopic technique is time tested. We decided to use custom made device with direct minimally invasive approach without cardio pulmonary bypass. Percutaneous transfemoral route using custom made device is a well established procedure performed by interventional cardiologist with occasional trauma and vessels. Method We performed the procedure in 3 patients of secundum ASD deemed adequate for device closure. We used a mini Right anterior thoracotomy approach using a double umbrella device which was implanted through direct Right Atrial puncture. Results In two patients we were successful in deploying the device. The proedure lasted 30 minutes with small infra Mammary scar and the post operative period was uneventful. In the third case where our attempt at surgical device closure failed the inferior margin was only one mm. The optimal size device kept slipping into the right atrium when the guide-wire was tugged after final deployment. The placement of an oversize device distorted the mitral valve, may causing regurgitation. Conclusion We think that this is a simple and safe technique of secundum ASD closure without cardio pulmonary bypass.     

基质金属蛋白酶9及TGF-β1 mRNA和蛋白在骨关节炎中的表达

目的 TGF-β1对骨关节炎(osteoarthritis,OA)关节软骨起保护作用,探讨OA中基质金属蛋白酶9(matrix metalloproteinase 9,MMP-9)、TGF-β1 mRNA和蛋白表达的相关性,为临床治疗OA寻找有效的干预靶点提供理论依据。方法取自愿捐赠的关节软骨及滑膜标本,其中OA患者60例(实验组),外伤截肢、交叉韧带断裂、盘状软骨损伤与半月板损伤患者20例(正常对照组)。行HE染色观察关节软骨与滑膜的病理组织学改变,免疫组织化学染色观测MMP-9及TGF-β1蛋白表达,原位杂交技术检测MMP-9及TGF-β1 mRNA表达;并进行相关性分析。结果 HE染色显示实验组关节软骨细胞固缩、坏死、排列紊乱,细胞外基质断裂,关节滑膜细胞肥大增生、淋巴细胞和单核细胞浸润,多数小血管增生;正常对照组软骨细胞排列整齐、基质染色均匀,滑膜组织无慢性炎症表现、无明显增生。两组均可见MMP-9、TGF-β1 mRNA和蛋白阳性表达,阳性细胞包括软骨细胞、滑膜衬里层细胞及滑膜下层的血管内皮细胞、成纤维细胞、炎性浸润细胞等。实验组MMP-9及TGF-β1 mRNA和蛋白表达均高于正常对照组(P<0.01)。实验组MMP-9 mRNA与蛋白表达成正相关(r=0.924,P=0.000),TGF-β1 mRNA及蛋白表达亦成正相关(r=0.941,P=0.000);实验组MMP-9及TGF-β1蛋白表达成负相关(r=—0.762,P=0.000),MMP-9 mRNA及TGF-β1 mRNA表达成负相关(r=?0.681,P=0.000)。结论 OA中TGF-β1的高表达下调了关节软骨与滑膜中MMP-9的表达,对OA关节软骨起保护作用,从而延缓OA进展。     

CT 对腮腺区肿块的诊断价值

评价ＣＴ对腮腺肿瘤的诊断价值。方法８８例腮腺区肿瘤进行ＣＴ平扫,ＣＴ增强扫描和／或腮腺造影ＣＴ扫描。结果：７８例为腺内肿瘤,其中７例为恶性;１０例为腺肿瘤。对ＣＴ肋腺区肿瘤定位准确,能准确显示肿瘤的范围,大小,数目及浸润情况。     

肺动脉栓塞外科治疗54例临床分析

目的 探讨肺动脉栓塞外科治疗的疗效.方法 回顾性分析1994年10月至2007年6月54例接受手术治疗的肺动脉栓塞患者的临床资料.急性肺动脉栓塞组9例,在中低温体外循环下行肺动脉切开取栓术;慢性栓塞性肺动脉高压组45例,在深低温下行肺动脉血栓内膜剥脱术.结果 急性肺动脉栓塞组围手术期死亡率(44.4%)高于慢性肺动脉栓塞组(13.3%)(P＜0.05).全组患者术后残余肺动脉高压13例,重度肺组织再灌注损伤23例.术后肺动脉收缩压和肺血管阻力均较术前下降,动脉血氧分压和动脉血氧饱和度较术前改善(P＜0.05).44例围手术期生存患者平均随访(41.8±36.4)个月.晚期死亡4例.全组抗凝相关出血线性发生率为0.63%人年,再发肺动脉栓塞线性发生率为0.62%人年.术后40例长期生存患者中,心功能(NYHA)Ⅰ级28例、Ⅱ级10例、Ⅲ级2例.结论 急性肺动脉栓塞围手术期死亡率显著高于慢性肺动脉栓塞.肺动脉栓塞外科治疗术后有较好的中长期生存率,抗凝相关的出血并发症及再发肺动脉栓塞的发生率较低.     

Perivalvular leakage 25 years after initial mitral valve replacement with a Björk-Shiley prosthesis

An 80-year-old woman had undergone initial mitral valve replacement using a Björk-Shiley mechanical valve owing to mitral stenosis 25 years earlier. Suddenly, she had anemia and an increased lactic dehydrogenase (LDH) level. Transesophageal echography (TEE) showed perivalvular leakage. In a redo operation, two side-by-side stitches of the valve on the posterior annulus were loosened without cutting and the sewing cuff at that site was floated over the annulus, leading to the perivalvular leakage. The valve was easily removed; and round, hard, degenerative calcified tissue composed of remnant mitral valve in the suture site during the initial operation was found just under the sewing cuff. After resection of this calcified round tissue, a 25-mm bioprosthesis was put in place. Her postoperative recovery was uneventful, and 47 days after surgery she was discharged without perivalvular leakage or anemia.     

干细胞技术结合新型可降解材料进行腰椎融合的临床研究

目的 探索富集骨髓干细胞技术进行腰椎融合治疗脊柱疾病的疗效.方法 腰椎退行性疾患患者56例,根据行下腰椎后路融合手术中植骨融合材料的不同,分为富集骨髓干细胞快速复合多孔β-磷酸三钙(13-TCP)复合材料组(复合材料组,n=30)和自体髂骨植骨组(自体骨组,n=26).对复合材料组富集前后骨髓体积、有核细胞(NCs)和碱性磷酸酶染色阳性的细胞集落(CFUs/ALP+)计数,分析富集效率;结合随访、影像学检查和Oswestry功能评分等综合评定疗效.结果 复合材料组术中平均抽取骨髓血(249±31)ml,富集技术平均回收(43±11)ml,NCs由(15.9±3.3)x106/ml浓缩至(44.1±10.8)×106/ml,富集后CFUs/ALP+数量由(118±86)/ml浓缩至(486±305)/ml.临床随访(26.3±7.5)个月.两组中患者的年龄、性别、病种分布及融合节段无显著差异,复合材料组与自体骨组融合率分别为93.3%和96.2%(P＞0.05).两组手术时间的差异也无统计学意义(P＞0.05).复合材料组术中患者的总出血量高于自体骨组(P＜0.01),但术中自体血回输可以将接近1/2的术中出血回输给患者.复合材料组术后骨髓采集部无血肿和慢性疼痛,伤口渗出或局部肿胀4例,均自行愈合;而自体骨组术后髂骨采集部血肿(15.4%)和慢性疼痛(26.9%),无伤口渗出的情况.两组间Oswestry功能评分的差异无统计学意义(P＞0.05).结论 富集骨髓干细胞技术可在术中一期应用,提高骨髓MSCs的浓度,安全、快速.富集骨髓干细胞快速复合多孔β-磷酸三钙后,可作为腰椎后外侧融合的植骨替代品.     

伊木萨克片对糖尿病性ED大鼠阴茎组织中eNoS和nNoS的影响

目的 研究维药伊木萨克片对DM性ED大鼠阴茎海绵体组织中eNOS和nNOS蛋白表达水平的影响.方法 取雄性SD大鼠70只,从中随机取10只为正常对照组,余60只以链脲佐菌素诱导建立DM模型后,行阿朴吗啡阴茎勃起实验筛选DM性ED模型,发生ED者随机分为DM性ED组、伊木萨克片组、胰岛素组、伊木萨克片 胰岛素(联用)组,未成DM者为STZ组.各组给药6周后,采用免疫组化SP法检测各组大鼠阴茎组织中eNOS、nNOS含量.结果 DM性ED组大鼠阴茎组织中eNOS、nNOS蛋白表达水平显著低于正常对照组(P＜0.01);伊木萨克片组、胰岛素组及联用组大鼠阴茎组织中eNOS、nNOS蛋白表达水平均显著高于DM性ED组(P＜0.01),但伊木萨克片组与胰岛素组显著低于联用组(P＜0.01, P＜0.01;P＜0.05,P＜0.01);STZ组与正常对照组之间的差异则无统计学意义(P＞0.05).结论 维药伊木萨克片可以显著提高DM性ED大鼠阴茎组织中eNOS、nNOS蛋白表达水平,并提示在胰岛素控制血糖的基础上效果可能更佳.