颈椎间盘移植的临床研究

目的　探索椎间盘伤病的外科治疗新途径。研究背景颈椎间盘切除椎体间植骨融合是治疗颈椎间盘伤病的常规方法 ,近 10年又有椎间融合器和人工骨融合材料的探索 ,截止目前尚未见同种异体椎间盘移植的临床报告。方法　全组共 5例 ,男 4例 ,女 1例 ,年龄 4 1～ 5 8岁 ,平均 4 7岁 ,退行性颈椎间盘突出 4例 ,外伤性颈椎间盘突出 1例 ;病变部位C4,52例 ,C5,63例。同种异体椎间盘逐级冷冻于 - 196℃液氮中保存 ,术前 37℃水浴箱中快速复温。手术经颈前入路 ,切除病变椎间盘 ,选择适型供体椎间盘植入 ,不使用任何内固定。结果　全部患者术后体温正常 ,伤口无感染 ,在围领保护下术后 4～ 5d离床活动 ,白细胞计数和血沉正常范围。按JOA颈椎病评分标准 ,术前平均 8分 ,术后 2周 10 .6分 ,随访时 13.2分。X线检查示2个月供体椎间盘与受体椎骨愈合 ,无坏死、脱位。移植椎间盘高度部分丢失 ,术后 2年仍维持原有高度的 76 .2 %。MRI示移植椎间盘术后 2年仍有良好T1和T2 加权信号 ,并能维持良好的活动度。结论　冷冻保存同种异体椎间盘移植后早期能移维持颈椎间盘的一定高度 ,恢复节段稳定性并保留了椎间盘的良好活动度 ;远期疗效有待于进一步观察。     

同种异体颈椎间盘移植的中远期疗效分析

目的探讨同种异体椎间盘移植临床应用的可行性及其中远期疗效。方法前瞻性、非双盲观察冷冻保存的同种异体椎间盘移植治疗颈椎伤病患者的临床疗效。全组共5例，男4例，女1例；年龄41-58岁，平均47岁。退行性颈椎病4例，外伤性颈椎间盘突出1例。同种异体椎间盘逐级冷冻于-196℃液氮中保存，术前37℃水浴箱中快速复温。手术经前方入路，切除病变椎间盘减压，选择适合的冷冻同种异体椎间盘植入，不使用任何内固定。结果平均手术时间1．8h，平均失血量62m1，术后平均随访5．5年。根据JOA临床功能评分，全部患者均有满意的改善。术后2个月X线检查示供体椎间盘与受体椎骨愈合，移植椎间盘无脱位及下沉。未见免疫排斥反应。移植椎间盘高度有部分丢失，最终随访MR检查T2加权像示仍有2例移植椎间盘信号良好。5例中4例移植椎间盘仍保留有一定的活动度，过屈、过伸位无失稳，另1例移植椎间盘自发融合。1例患者因一侧上肢根性疼痛复发且加重再次手术行后路椎间孔减压后症状缓解。结论同种异体颈椎间盘移植的中远期临床疗效是可以接受的，虽然移植椎间盘有部分退变，但保留了生理活动度和稳定性。结果提示同种异体椎间盘移植将来有可能成为脊柱融合及人工椎间盘置换以外另一种治疗脊柱伤病的选择。     

生物热熔胶与同种异体骨板治疗胫骨骨折的实验研究

目的 观察生物热熔胶与同种异体骨板治疗犬胫骨骨折的疗效,探讨应用同种异体骨板联合生物热熔胶治疗长骨骨折的可行性.方法 将32只Labrador犬的一侧胫骨制成横行骨折模型,随机分为粘接固定组16只,用生物热熔胶与冻干同种异体骨板粘接固定;金属接骨板固定组16只,用金属接骨板与螺丝钉内固定.记录两组的手术时间和术中出血量...     

新鲜异体软骨移植修复髋关节损伤

[目的]介绍新鲜同种异体软骨移植修复髋关节损伤的手术技术与初步结果。[方法] 2019年3月～2019年5月,对3例股骨头和(或)髋臼骨缺损采用新鲜同种异体软骨移植技术修复,外科脱位暴露髋关节,清除损伤软骨及软骨下骨组织,将新鲜同种异体骨软骨制备成适合大小,嵌压固定于缺损处。[结果]所有患者术后无严重并发症。术后卧床12周,非负重下下肢功能锻炼。术后6周髋关节屈曲活动度达110°。术后3～6个月,由部分负重逐步恢复完全负重行走。术后随访(10.67±1.15)个月,末次随访时,Harris评分、SF-12功能评分、心理评分、VAS评分均较术前显著改善。至末次随访时,影像检查显示移植物与宿主骨愈合,无移植物松动、移位及塌陷。[结论]新鲜异体软骨移植术是修复髋关节缺损的新方式,初步效果满意。     

老年肱骨近端骨折锁定钢板固定同种异体骨移植

[目的]比较锁定钢板联合同种异体腓骨段与骨颗粒移植治疗老年人Neer 3、4部分肱骨近端骨折伴压缩性骨缺损的临床疗效。[方法]回顾性研究2012年1月—2019年12月接受肱骨近端锁定钢板内固定联合同种异体骨移植治疗的66例老年肱骨近端骨折压缩性骨缺损患者的临床资料。其中，31例采用同种异体腓骨移植（骨段组），35例采用同种异体颗粒移植（骨粒组）。比较两组围手术期、随访与影像资料。[结果]两组患者均顺利完成手术，两组手术时间、透视次数、术中出血量、切口愈合等级及住院时间方面的差异均无统计学意义（P>0.05）。随访时间至少12个月，两组恢复主动活动时间和完全负重活动时间的差异无统计学意义（P>0.05）。与术后6个月相比，术后12个月时两组的Constant-Murley评分、ASES评分、前屈上举活动度及外展上举活动度均显著增加（P<0.05）。相应时间点，两组间上述指标的差异均无统计学意义（P>0.05）。影像检查显示两组骨质复位质量及骨折愈合时间的差异均无统计学意义（P>0.05）。骨段组的颈干角改变值（variation of neck-shaft...     

一期病灶清除同种异体骨移植治疗胸腰椎结核

[目的]评价一期病灶清除、同种异体骨移植联合前路和(或)后路内固定治疗脊椎结核的疗效。[方法]从2002年1月~2005年10月,共治疗多节段脊柱结核患者15例,其中胸椎结核8例,胸腰段结核5例,L2以下腰椎结核2例。采用前路病灶清除,同种异体骨移植,胸腰段及腰椎病人应用前、后路联合内固定;而胸椎结核单纯应用前路单棒内固定的方法。其中后期8例手术采用微创方法(胸腔镜、X-tube)。[结果]术后15例患者均行正规抗结核治疗,平均随访25.4个月。所有患者切口均一期愈合,结核病灶最终获得骨性融合,后凸矫正角度平均19.9°;除1例FrankelB级患者神经功能检查无明显恢复外,其余均有不同程度的恢复。[结论]脊柱稳定性对于脊柱结核治疗具有重要意义,内固定器材、同种异体骨移植以及合适的手术方式能够有效提高临床疗效,微创方法能够简化手术,减少术中失血,值得推广。     

经伤椎椎弓根同种异体骨植骨结合椎弓根内固定系统治疗胸腰椎爆裂性骨折

目的 探讨经骨折椎椎弓根同种异体骨植骨结合椎弓根内固定系统治疗胸腰椎爆裂性骨折的方法和效果.方法 采用经伤椎椎弓根同种异体骨植骨,椎弓根螺钉复位内固定治疗胸腰椎爆裂性骨折53例,术前、术后及随访时摄X线片及CT检查,观察椎体高度有无丢失,内固定有无断裂、松动.结果 随访无排异反应,骨折愈合良好,未出现椎体高度再丢失,无内固定松动、断裂.结论 经伤椎椎弓根同种异体骨植骨联合椎弓根内固定系统治疗胸腰椎爆裂性骨折,可恢复伤椎椎体高度,重建脊柱前中柱的稳定性,防止后期椎体高度的再丢失和内固定的松动、断裂.     

自固化磷酸钙复合BMP及同种异体骨修复兔股骨大段骨缺损

[目的] 观察一种新型自固化磷酸钙（CPC）复合BMP与同种异体骨修复兔股骨节段性骨缺损的效果，为临床复合应用大段同种异体骨移植提供参考。[方法] 54只新西兰大白兔随机分成3组，于一侧股骨中上段造成2cm长皮质骨缺损模型，分别进行：A组复合BMP与CPC的新鲜冷冻同种异体骨移植；B组单纯新鲜冷冻同种异体骨移植；C组自体大段骨移植。移植骨均用直径3mm三棱髓内针固定。于术后4、8、12周，进行影像学、组织学检查，对比各组移植骨愈合过程与修复效果。[结果] CPC复合BMP大段同种异体骨移植早期骨修复效果优于单纯异体骨移植（P〈0．01），与自体骨移植修复效果相似，至12周3组均达骨性愈合，以A组及C组骨修复塑形较好。CPC复合BMP组骨痂量较多，分布于移植骨与宿主骨结合部及移植骨周围，形成皮质骨外骨桥，并较早在异体骨外表面形成破骨与成骨，异体骨内哈佛氏管扩大，衬垫细胞、成骨细胞、破骨细胞及血细胞较其它组多。CPC随着新骨的形成及改建塑形逐步缓慢降解。[结论] CPC复合BMP对大段同种异体骨移植的愈合及替代有增强和促进作用。     

颈椎前路融合节段相邻椎间盘压力与轴性症状关系初探

[摘要]目的：分析在生理前凸获得有效重建的颈椎前路减压融合术中,融合节段相邻椎间盘压力变化与颈椎术后轴性症状发生的关系。方法：行前路单椎体次全切除减压内固定手术治疗颈椎伤病42例,术中测量融合节段相邻椎间盘内压力,计算颈椎融合前后压力差。     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.