Volume 131 · Issue 21 · 2018

创新源于实践，灵魂在于实践思维。人类的一切智慧都是实践的产物，都需要在实践中得到检验。随着医学的飞速发展，一名临床医生不得不紧跟新时代步伐，把握时代脉搏，推陈出新。只有这样，他或她才能引领新时代的潮流。临床医学是一门实践科学，主要由临床医生来实施，要求他们时刻探索真理，追求技术创新。同时，鼓励临床医生作为学术带头人积极实践，勇于创新，在实践中追求真理、检验真理，摒弃陈旧观念，纠正错误理论和技术。总而言之，临床医生必须推进基于实践的理论和技术创新，以跟上时代的步伐。

Few studies have investigated the differences in proximal femoral geometry and risk factors between patients with different types of hip fracture, especially in elderly Chinese. This study aimed to assess the differences in proximal femoral geometry parameters between patients with femoral neck fractures and patients with intertrochanteric fractures to provide guidance for individualized customized prosthesis and accurate reconstruction of proximal femurs in elderly Chinese patients.

We retrospectively studied the electronic medical records of 198 elderly patients over 65 years of age who were admitted to the orthopedic department with hip fractures between January 2017 and December 2017 in The Third Hospital, Hebei Medical University. Age, fracture site, gender, and proximal femoral geometry parameters (neck shaft angle [NSA], center edge angle [CEA], femoral head diameter [FHD], femoral neck diameter [FND], femoral neck axial length [FNAL], hip axial length [HAL], and femoral shaft diameter [FSD]) were recorded. Student’s t-test was used to compare the continuous variables, Chi-square test was used to analyze categorical variables, and multiple logistic stepwise regression analysis was used to evaluate the influencing factors of hip fracture type.

Statistically significant differences in NSA (137.63 ± 4.56° vs. 132.07 ± 4.17°, t = 1.598, P < 0.001), CEA (37.62 ± 6.77° vs. 43.11 ± 7.09°, t = 5.597, P < 0.001), FND (35.21 ± 3.25 mm vs. 34.09 ± 3.82 mm, t = 2.233, P = 0.027), and FNAL (99.30 ± 7.91 mm vs. 103.58 ± 8.39 mm, t = 3.715, P < 0.001) were found between the femoral neck fracture group and femoral intertrochanteric fracture group. FHD, FND, FSD, HAL, and FNAL were different between sexes (all P < 0.001). The greater NSA was the risk factor for femoral neck fractures (odds ratio [OR]: 0.70, P < 0.001), greater CEA and longer FNAL were risk factors for femoral intertrochanteric fractures (OR: 1.15, 1.17, all P < 0.001), and greater FND was a protective factor for femoral intertrochanteric fractures (OR: 0.74, P < 0.001).

We demonstrate differences in geometric morphological parameters of the proximal femur in different hip fracture types, as well as an effect of sex. These differences should be considered in the selection of prostheses for fracture internal fixation and hip replacements. These data could help guide the design of individualized customized prostheses and improve the accurate reconstruction of the proximal femur for elderly Chinese hip fracture patients.

Identification of the proper femoral intramedullary (IM) access point is an important determinant of final implant position in IM-guided total knee arthroplasty (TKA). The aim of this study was to identify the optimal entry point in Chinese participants using a new three-dimensional method.

A series of computed tomography scans of 44 femurs in Chinese participants from October 2014 to October 2015 were imported into Mimics 17.0 software to identify the optimal entry point. The apex of the intercondylar notch (AIN) was used as the reference bony anatomical landmark to identify the proper entry point to insert the IM rod. The statistical significance was calculated on the basis of a 5% level (P < 0.05) using the Student’s t-test.

For the males, the average ideal entry point was 1.49 mm medial and 13.39 mm anterior to the AIN. The values were 1.77 mm medial and 15.29 mm anterior to the AIN in females. A significant difference was present between males and females (13.39 ± 2.46 mm vs. 15.29 ± 3.44 mm, t = 2.124, P= 0.040). When using the recommended location as the entry point for the IM rod, the mean potential error differed significantly from the femoral trochlear groove (the potential error of IM in males in coronal plane: 0.93°± 0.24° vs. 1.27°± 0.32°, t= −4.166, P < 0.001; the potential error of IM in males in sagittal plane: 1.40°± 0.42° vs. 2.79°± 0.70°, t= −7.155, P < 0.001; the potential error of IM in females in coronal plane: 0.73°± 0.28° vs. 1.15°± 0.35°, t = −3.940, P < 0.001; and the potential error of IM in females in sagittal plane: 1.48°± 0.47° vs. 2.76°± 0.83°, t= −5.574, P< 0.001). A significant difference was present between the recommended point and the point 10 mm anterior to the origin of the posterior cruciate ligament (the potential error of IM in males in coronal plane: 0.93°± 0.24° vs. 1.53°± 0.43°, t= −5.948, P < 0.001; the potential error of IM in males in sagittal plane: 1.40°± 0.42° vs. 2.15°± 0.75°, t= −3.152, P= 0.003; the potential error of IM in females in coronal plane: 0.73°± 0.28° vs. 1.28°± 0.42°, t= −4.632, P < 0.001; and the potential error of IM in females in sagittal plane: 1.48°± 0.47° vs. 2.40°± 0.93°, t= −3.763, P= 0.001).

The technique described here is an innovative method for swift, easy, and accurate access to the medullary canal during TKA, and it can optimize the position and orientation of the prosthetic components in knee arthroplasty.

Many clinical studies over the past decade have indicated positive outcomes for patients treated with Dynesys dynamic stabilization for lumbar degenerative disease. However, long-term outcomes of Dynesys for lumbar spinal stenosis are rarely reported. The aim of this study was to analyze the long-term clinical and radiologic outcomes for patients with lumbar spinal stenosis treated with Dynesys stabilization.

Thirty-eight patients with lumbar spinal stenosis were treated with Dynesys stabilization from July 2008 to March 2010. The minimal duration of follow-up was 72 months. The patients were divided into stenosis and spondylolisthesis groups according to degenerative spondylolisthesis. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS). Radiographic evaluations included range of motion (ROM) and the disc heights of stabilized segments and the upper adjacent segments. We also evaluated the occurrence of radiographic and symptomatic adjacent segment degeneration (ASD).

There were 23 patients in stenosis group and 15 patients in spondylolisthesis group. The ODI scores were significantly improved at the final follow-up evaluation, as compared to the baseline values (16.1 ± 5.7 vs. 57. 2 ± 14.2, t = 61.41, P< 0.01). The VAS scores for back and leg pain were significantly improved from 4.82 ± 0.89 and 4.04 ± 0.82 preoperatively to 0.93 ± 0.61 and 0.54 ± 0.51 postoperatively (t = 6.59, P< 0.01, and t = 5.91, P< 0.01, respectively). There were no differences between the two groups with respect to VAS and ODI scores. The ROM of stabilized segments decreased significantly from 7.8°± 2.4° to 4.5°± 1.5° (t = 7.18, P< 0.05 ), while the upper adjacent segments increased significantly from 8.3°± 2.4° to 10.4°± 2.4° (t = 2.87, P= 0.01). The change in disc height of stabilized segments was not significant (11.9 ± 2.1 preoperatively vs. 12.5 ± 1.5 postoperatively, t = 1.43, P= 0.15), whereas the decrease in disc height of the upper adjacent segments was significant (12.5 ± 2.0 preoperatively vs. 11.0 ± 1.7 postoperatively, t = 2.94, P= 0.01). The occurrence of radiographic and symptomatic ASD was 16% (6/38) and 3% (1/38), respectively.

Decompression and Dynesys stabilization for lumbar stenosis with or without spondylolisthesis showed good long-term clinical and radiographic results. Lumbar stenosis with or without Grade I spondylolisthesis, particularly in patients <60 years of age with mild-to-moderate lumbar disc degeneration, would be one of the main indications for the Dynesys system.

In a small proportion of cases, spontaneous osteonecrosis of the knee (SONK) involves the medial tibial plateau (MT). Here, we introduced the clinical characteristics of spontaneous osteonecrosis of the MT and unicompartmental knee arthroplasty (UKA) as the favorable treatment for this situation based on a retrospective case study.

Patients with spontaneous osteonecrosis of the MT, confirmed by magnetic resonance imaging (MRI) at Guangdong Provincial Hospital of Chinese Medicine (China) from March 2015 to June 2016, were included as a case serial and analyzed retrospectively. All patients underwent Oxford Medial UKA. The characteristics of their lesions, corresponding treatment, and results of follow-up were presented. The lesion scores and grade were determined according to the criteria of Ficat and Arlet.

In total, 22 patients (5 men, 17 women; mean age, 64.1 years) with spontaneous osteonecrosis of the MT were analyzed. The lesion stages assessment showed that 3 (14%) were Stage II, 10 (45%) were Stage III, 7 (32%) were Stage IV, and 2 (9%) were Stage V. In the sagittal plane, 7 (32%) were in the anterior region (MTa) and 15 (68%) were central (MTc). The lesion volume averaged 2.24 ± 0.79 cm³ (range: 1.57–3.08 cm³). Seventeen patients (77%) had Level III posterior medial meniscus root tears (MMRTs). All the patients underwent UKA. Average follow-up was 30.0 ± 6.4 months with a range of 23.0–38.0 months. The visual analog scale score was 7.78 ± 0.67 before surgery while decreased to 2.22 ± 1.09 at the final follow-up (P < 0.001). The Hospital for Special Surgery scores of pre-／post-surgery were 65.67 ± 5.45 and 84.10 ± 4.20, respectively (P < 0.001).

SONK often occurs in the anterior and central tibial plateau due to abnormal stresses. Most of the patients had Level III posterior medial meniscus root tears. MRI is recommended for suspected cases to identify SONK at an early stage. The use of the Oxford Medial UKA for SONK of the MT is reliable both immediately and at follow-up.

In treatment of ankle fracture, intraoperative stress tests are used to assess the syndesmotic injury and instability. However, the optimized timing of the strees test should be applied whether in pre- or post-bony fixation during operation is seldom be reported in previous studies. The different strategies on stress test timing would exhibit opposite results within a type of pronation-external rotation (PER) fractures with supracollicular medial malleolar (SMM) fractures. This study was designed to assess the 3-year functional outcomes of the special PER fractures with or without a syndesmotic transfixation based on the results of two different intraoperative stress test strategies.

This retrospective cohort study included 61 PER injury-Weber C ankle fractures combined with SMM fractures who were treated in Beijing Jishuitan Hospital between 2013 and 2014 and followed up for 3 years. Stress test was performed twice intraoperatively. A positive intraoperative stress test before bony fixation and a negative intraoperative stress test after bony fixation were found in these included patients. Twenty-nine patients (Group 1) were treated without a supplemental syndesmotic screw fixation, according to the negative intraoperative stress test after bony fixation, while 32 patients (Group 2) were treated with an additional syndesmotic screw fixation based on the positive intraoperative stress test before bony fixation. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and Visual Analog Scale (VAS) for pain scores were the main measurements of outcome. The statistical index of demographic data, fracture morphologic data, time interval of follow-up, AOFAS and VAS were recorded and assessed by SPSS 21.0 software through Fisher exact tests and one- way analysis of variance . The associations between the main outcomes and influential factors were evaluated by linear regression models.

We observed no difference in the distribution of age, sex, presence of associated posterior malleolus (PM), fracture dislocation, and fixation of associated PM between two treatment groups. With the numbers available, no statistically significant association could be detected with regard to the AOFAS (Group 1 vs. Group 2, 96.72 ± 6.20 vs. 94.63 ± 8.26, F = 1.24, P= 0.27) and VAS (Group 1 vs. Group 2, 1.47 ± 2.14 vs. 0.72 ± 1.49, F = 2.44, P= 0.12) in association with two strategies.

The present study indicates no difference to the use of the syndesmotic screw in terms of the functional outcome between syndesmosis transfixation and no-fixation patients among PER-Weber C ankle fracture patients with SMM fracture after 3-year follow-up. More attention should be paid to pre- and post-bony-fixation intraoperative stress tests and the morphology of medial malleoli fractures in ankle fractures.

Estrogen, as an important hormone in human physiological process, is closely related to bone metabolism. The aim of this study was to investigate the mechanism of estrogen on osteoblasts metabolism in MC3T3-E1 cells.

We treated the MC3T3-E1 cells with different concentrations of β-estradiol (0.01, 0.1, 1, and 10 nmol/L), observed the morphological changes of the cells, and detected the cell’s proliferation and apoptosis of MC3T3-E1 cells. Two transcriptome libraries were constructed and sequenced. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to confirm the differentially expressed genes (DEGs), and then treated the MC3T3-E1 cells with estrogen receptor (ER) inhibitors α and β, respectively, and then examined the expression of Tgfbr1 and Bmpr1a genes. The promoter of Tgfbr1 and Bmpr1a gene was analyzed, and the ER response elements were identified. Finally, ChIP was used to verify the binding of ER to Tgfbr1 and Bmpr1a promoter.

In the high-concentration β-estradiol treatment group (1 nmol/L and 10 nmol/L), there was no significant difference in the morphology of the cells under the microscope, 1 nmol/L and 10 nmol/L treated group appeared statistically significant difference in cell apoptosis and proliferation (P < 0.05 and P < 0.01, respectively). We found 460 DEGs compared with the control group. Among the DEGs, there were 66 upregulated genes and 394 downregulated genes. Gene ontology classification and Kyoto Encyclopedia of Genes and Genomes pathway analysis revealed that many bone metabolism-related biological processes and cell signaling pathways were disordered. The qRT-PCR verification showed that the expressions of Tgfbr1- and Bmpr1a-related genes in bone metabolism pathway in the 10 nmol/L treatment group were significantly decreased (P < 0.05). ER β was involved in the inhibitory effect of Tgfbr1 and Bmpr1a genes. The bioinformatics of the promoter found that there were three ER response elements in the promoter of Tgfbr1 , and there were two ER response elements in Bmpr1a promoter regions. ChIP experiments showed that estrogen could enhance the binding of ERs to Tgfbr1 and Bmpr1a genes.

Estrogen can promote the apoptosis and proliferation of osteoblasts simultaneously, and the mechanism may be the joint action of transforming growth factor-beta, Wnt, mitogen-activated protein kinase, and nuclear factor-kappaB bone metabolism-related signaling pathway. Estrogen inhibits the expression of Tgfbr1 and Bmpr1a genes through ER β and affects the metabolism of MC3T3-E1 osteoblasts.

The effect of maternal weights on the risk of iron deficiency anemia (IDA) during pregnancy remains unclear. The study aimed to investigate the association between maternal weight indicators and IDA during pregnancy.

We conducted a cohort study to examine the association between maternal weight indicators, including prepregnancy body mass index and the rate of gestational weight gain (GWG), and the risk of IDA among Chinese pregnant women. Data about new-onset IDA at different trimesters from a national cross-sectional survey were collected; information regarding baseline variables and rate of GWG from women participating in the survey were retrospectively collected. Tested IDA and reported IDA were documented. Multilevel logistic regression to examine the association between maternal weight indicators and the risk of IDA after adjusting for potential confounders was conducted.

This study enrolled 11,782 pregnant women from 24 hospitals from September 19, 2016, to November 20, 2016. Among those, 1515 (12.9%) IDA events were diagnosed through test (test IDA); 3915 (33.3%) were identified through test and patient reporting (composite IDA). After adjusting for confounders and cluster effect of hospitals, underweight pregnant women, compared with normal women, were associated with higher risk of test IDA (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.17–1.57 and composite IDA (aOR: 1.35, 95% CI: 1.21–1.51); on the contrary, overweight and obese women had lower risk of test IDA (aOR: 0.68, 95% CI: 0.54–0.86 overweight; aOR: 0.30, 95% CI: 0.13- 0.69 obese) and composite IDA (aOR: 0.77, 95% CI: 0.67- 0.90 overweight; aOR: 0.34, 95% CI: 0.21- 0.55 obese). The higher rate of GWG was associated with higher risk of IDA (test aOR: 1.86 95% CI: 1.26- 2.76; composite aOR: 1.54, 95% CI: 1.16–2.03).

Pregnant women who are underweight before pregnancy and who have faster GWG are more likely to develop IDA. Enforced weight control during pregnancy and use of iron supplements, particularly among underweight women, may be warranted.

Dendritic cells (DCs) play an important role in host defense against pathogen infection. DC-specific intercellular adhesion molecule-3-grabbing nonintegrin (SIGN) is a group II C-type lectin receptor and specifically expressed on the surface of DCs. This study aimed to determine whether DC-SIGN affects intracellular signaling activation, Th1/Th2 imbalance and aspergillus immune evasion in aspergillus infection, and explore the application of DC-SIGN-modified DCs in immunotherapy.

DCs were first obtained from the mononuclear cells of peripheral blood. The interferon (IFN)-γ and dexamethasone (Dex) were used to stimulate DCs. The expression of DC-SIGN, Th1 and Th2 cytokines, and the capacity of DCs in stimulating T cells proliferation and phagocytosis, and nuclear factor (NF)-κB activation were analyzed. In addition, adenovirus expression vector Ad-DC-SIGN was generated to transfect DCs. Mannan was used to block DC-SIGN signaling for confirming the involvement of DC-SIGN function in Aspergillus fumigatus (Af)-induced DCs maturation. The unpaired, two-tailed Student's t-test was used in the comparisons between two groups.

Exogenous IFN-γ could activate Af-induced DCs and promote the Th0 cells toward Th1 profile (interleukin [IL]-12 in IFN-γ/Af group: 50.96 ± 4.38 pg/ml; control/Af group: 29.70 ± 2.00 pg/ml, t = 10.815, P < 0.001). On the other hand, Dex inhibited the secretion of Th2 cytokines (IL-10 in Dex/Af group: 5.27 ± 0.85 pg/ml; control/Af group: 15.14 ± 1.40 pg/ml, t = 14.761, P < 0.001)), and successfully caused immunosuppression. After transfection with Ad-DC-SIGN, DCs have improved phagocytosis (phagocytosis rates in Ad-DC-SIGN group: 74.0% ± 3.4%; control group: 64.7% ± 6.8%, t = 3.104, P = 0.013). There was more Th1 cytokine secreted in the Af-induced DC-SIGN modified DCs (IL-12 in Ad-DC-SIGN/Af group: 471.98 ± 166.31 pg/ml; control/Af group: 33.35 ± 5.98 pg/ml, t = 6.456, P = 0.001), correlated to the enhanced NF-κB activation.

Overexpressing DC-SIGN in DCs had a protective function on aspergillosis.

Sublingual immunotherapy (SLIT) has been proven to be effective against house dust mite-induced allergic rhinitis. However, the efficacy in adults with allergic rhinitis has never been reported on SLIT tablets. The current meta-analysis aimed to illustrate the differentiated efficacy of SLIT tablets on allergic rhinitis.

Our systematic review and meta-analysis were performed on allergic rhinitis patients and aimed to summarize those randomized controlled studies (RCTs). PubMed, EMBASE, Cochrane library, and MEDLINE were screened for associated articles. We included RCTs on allergic rhinitis patients undergoing SLIT therapy and reporting outcomes on symptom relief and serum-specific IgE levels. The effect of SLIT tablets on the Rhinitis Quality Life Questionnaire Score (RQLQ), Rhinitis Total Symptom Score (RTSS), and serum-specific IgE levels was evaluated using RevMan 5.3.

Seven studies were included, with 2723 patients identified. All of the studies were RCT. The included seven studies were all conducted on adults. Among the included seven articles, five researches administered patients with SLIT tablets and were eligible for meta-analysis of RTSS, consisting of 1490 patients. Overall, RTSS was significantly reduced in the SLIT tablet group compared with that in the placebo group (standard mean difference= −0.33, 95% confidence interval [−0.54, −0.13], P < 0.01). There was no significant difference in specific IgE levels between SLIT and placebo patients.

SLIT tablets effectively relieve rhinitis symptoms in adults with allergic rhinitis. Nevertheless, the current evidence may be limited due to sample size and the heterogeneity between studies. Large sample size and multiple center RCTs on the efficacy of different formulations of SLIT drugs are still needed to provide further evidence and a more precise recommendation.

To propose a new definition of the pericollapse stage of osteonecrosis of the femoral head (ONFH) and review its significance in disease diagnosis and treatment selection.

A search for eligible studies was conducted in three electronic databases including PubMed, Cochrane Library, and Embase up to August 10, 2018, using the following keywords: "osteonecrosis" , "prognosis" , and "treatment" .

Investigations appraising the clinical signs, symptoms, and imaging manifestations in different stages of ONFH were included. Articles evaluating the prognosis of various joint-preserving procedures were also reviewed.

The pericollapse stage refers to a continuous period in the development of ONFH from the occurrence of subchondral fracture to early collapse (<2 mm), possessing specific imaging features that mainly consist of bone marrow edema and joint effusion on magnetic resonance imaging (MRI), crescent signs on X-ray films, and clinical manifestations such as the sudden worsening of hip pain. Accumulating evidence has indicated that these findings may be secondary to the changes after subchondral fractures. Of note, computed tomography provides more information for identifying possible subchondral fractures than does MRI and serves as the most sensitive tool for grading the pericollapse lesion stage. The pericollapse stage may indicate a high possibility of progressive disease but also demonstrates satisfactory long- and medium-term outcomes for joint-preserving techniques. In fact, if the articular surface subsides more than 2 mm, total hip arthroplasty is preferable.

The pericollapse stage with distinct clinical and imaging characteristics provides a last good opportunity for the use of joint-preserving techniques. It is necessary to separate the pericollapse stage as an independent state in evaluating the natural progression of ONFH and selecting an appropriate treatment regimen.

Combining artificial scaffolds with stimulatory factors to reconstruct lost bone tissues is one of the hottest research directions. The purpose of this review was to conduct a retrospective survey on the latest reports on artificial bone fabrication with functional cytokines.

The status of related scientific research from the year 2005 to 2018 was analyzed through the mode of literature retrieval in PubMed and VIP Database. The retrieval words are as follows: "bone tissue engineering," "angiogenesis," "cytokines," "osteogenesis," "biomimetic bone marrow," "sol-gel," "delivery system," and the corresponding Chinese words.

After reading through the title and abstract for early screening, the full text of relevant studies was evaluated and those not related with this review had been ruled out.

According to the literature retrospective survey, there were three key points for the successful construction of functional artificial bones: (1) the continuous supply of relatively low concentration of cytokines during the required period; (2) the delivery of two or more cytokines essential to the process and ensure the relatively spatial independence to reduce the unnecessary interference; and (3) supporting the early-stage angiogenesis and late-stage osteogenesis, respectively, regulating and balancing the crosslinking of both to avoid the surface ossification that would probably block the osteogenesis inside.

The synergistic effect of both angiogenic factors and osteogenic factors applied in bone regeneration is a key point in the combined functional artificial bone. Through analysis, comparison, and summary of the current strategies, we proposed that the most promising one is to mimic the natural bone marrow function to facilitate the regeneration process and ensure the efficient repair of large weight-bearing bone defect.

编者：近年来，经皮内镜腰椎间盘切除术（PELD）在脊柱外科中越来越受欢迎。PELD是脊柱微创手术之一，具有切口小、肌肉剥离少、术后恢复增强等显著优势。^[1]

致编辑：肘部不稳定是过度使用和创伤的结果。它给病人带来痛苦和虚弱。^[1]治疗本病主要考虑三个方面：中央骨稳定性、外侧韧带稳定性、内侧韧带稳定性。^[2]内侧韧带包括前束、后束和横束。^[3]其损伤通常由外翻力引起，并导致内侧不稳定、异位骨化（HO）形成和肘关节表现评分降低，尤其是肘关节僵硬。^[4]更糟糕的是，持续的不稳定状态最终导致尺神经刺激和不可逆的运动和感觉丧失。^[5]因此，恢复正常的内侧副韧带（MCL）结构和肘关节稳定性是非常重要和迫切的。对于肘关节稳定性重建的标准方案，尤其是内侧韧带，尚无共识。对于急性韧带损伤和韧带断裂，可以使用锚钉或经骨缝线重新连接受损的韧带。^[6]对于慢性韧带损伤和大韧带缺损，肌腱移植或屈肌-旋前肌筋膜补片已被证明可有效提供足够的肘部稳定性。^[7]这些解决方案有其自身的缺陷。直接缝合或锚钉缝合可能因张力过大而导致二次破裂。肌腱移植会对供体部位造成损伤。筋膜贴片不能提供足够的机械强度，可能会损害肌肉力量。因此，本研究提出了一种使用肘管支持带（CTR）和缝合锚钉重建肘关节僵硬患者正常MCL结构的新技术。

致编辑：骨折手术是肺栓塞（PE）的主要危险因素。大规模PE（MPE）仍然是一个重要的临床挑战，死亡率很高。突然和致命的血流动力学恶化的可能性突出了及时和适当干预的必要性。^[1]MPE的最佳治疗方法通常仅限于危重患者。一些病例报告已经证明使用体外膜肺氧合（ECMO）作为一种潜在的挽救生命的治疗选择，可以提供临床稳定性以允许明确的治疗。在这里，我们报告了一例52岁的男性患者在没有明确治疗的情况下成功地单独使用ECMO，该患者在胫腓骨骨折手术后出现MPE，并表现为血流动力学不稳定和严重低氧血症。由于患者血流动力学状态不稳定，出血风险高，未进行溶栓和取栓治疗。单独使用ECMO成功地用作MPE的挽救治疗，患者恢复良好。

致编者：嗜铬细胞瘤是一种罕见的神经内分泌肿瘤，起源于肾上腺或相关交感神经节中的嗜铬细胞。^[1]据我们所知，恶性嗜铬细胞瘤极为罕见，发病率为每年每100万人0.2-0.9例，脊柱转移性嗜铬细胞瘤的临床报道明显不足。因此，它可能很难诊断，并且在管理不善时可能导致毁灭性的后果。^[2]

编辑：在所有唾液腺中，“腮腺”是最常受肿瘤影响的一个，约占所有病例的75%。^[1]这些肿瘤通常是良性的，只有25%是恶性的。^[1]唾液腺远处转移的百分比相对较低，其发生与高级别肿瘤有关。“腺样囊性癌”(ACC)是主要起源于上呼吸道的小唾液腺、大唾液腺、泪腺、支气管、乳腺、肠道和生殖道的外分泌腺肿瘤。^[2]它的主要特点是生长缓慢；然而，在此过程中会发生瘤周侵袭和神经周浸润。迄今为止，腮腺ACC的脊柱转移在文献中极为罕见，仅有少数病例出现腮腺脊柱转移，因此导致缺乏影像学证据。在此，我们描述了一例腮腺癌脊柱转移的手术治疗。

编辑：异位骨化（HO）是骨骼系统外的骨形成。它通常发生在以下五种广泛的临床环境中：遗传性、创伤后、神经源性、手术后和最常见于手和脚的独特反应性病变。^[1]尽管软组织出血倾向增加，但血友病中HO的报道很少。目前，少数病例报道异位成骨与骨盆的位置关系，仅2例病例呈现该现象的骨盆-股骨桥样进展。^[2,3]更准确地说，它位于髋关节的后部区域。在这里，我们描述了一个罕见的血友病患者HO桥接从前上脊柱到股骨小转子的病例。骨科诊所就诊一名18岁男性患者，左侧髋关节疼痛、屈曲畸形和行走受限。这些症状是在从马上摔下来后的前4年出现的。他在2岁时被诊断为血友病A，几乎从未接受过因子VIII（FVIII）治疗。

编者：以往的研究表明，肩袖损伤修复后再撕裂的发生率为38-94%，原因是腱骨愈合能力低，持续时间长。^[1]脂肪间充质干细胞（ADSCs）用于修复肌腱和韧带撕裂，获得了有效的修复改善。^[2]虽然ADSCs能有效促进退行性肩袖损伤的愈合，但自我更新能力差和安全性不确定仍然困扰着肩袖撕裂患者。因此，新的或替代的治疗方法仍有待研究。几项研究表明，含有脂肪干细胞的脂肪基质血管部分(SVF)治疗在促进动物模型中结缔组织损伤愈合方面显示出比脂肪干细胞治疗更好的治疗潜力。^[3]

编者按：周围神经损伤一直是临床常见病，延误治疗最终可能导致长期的身体功能障碍。周围神经损伤的修复已成为临床实践中的一大挑战。与中枢神经系统不同，外周神经系统具有损伤后再生的能力。然而，损伤后的周围神经再生是一个缓慢的过程，轴突再生至远端靶器官或组织通常需要3个月以上，此时远端神经残端和骨骼肌通常会萎缩，再生的轴突在接下来的几个月内失去重塑的能力。因此，加速损伤后周围神经的恢复以及中枢神经系统与远端神经之间的联系对于提高损伤后神经的恢复具有重要意义。已有研究表明，周围神经损伤后，Wallerian变性发生在损伤部位。近端残端可以发芽以连接远端残端。雪旺细胞的增殖对于损伤后周围神经的修复和再生至关重要。近年来，越来越多的研究关注各种信号通路在周围神经再生中的作用，其中之一是Wnt信号通路。

致编者：中国男性，33岁，有5年复发性口腔和生殖器溃疡病史，因胸闷、发热、乏力2周起入院。患者入院前3年已被诊断为白塞病（BD），患有与BD相关的深静脉血栓形成，正在接受泼尼松龙治疗。体格检查发现眶周和下肢皮肤出现多发性静脉曲张病变。心电图和胸部X线阴性，实验室数据，包括肌酸激酶-MB和心肌肌钙蛋白，在正常范围内。患者持续呼吸急促、胸闷；因此，进行了常规的对比增强冠状动脉计算机断层扫描血管造影(CTA)，显示一个混合密度（46 mm × 40 mm × 65 mm）的肿块病变，起源于左旋冠状动脉，压迫左主支气管和左心房[图1].此外，CTA显示左冠状动脉前降支中有一个直径约7 mm的动脉瘤。基于CTA发现和预防这种快速扩张的假性动脉瘤导致的致命并发症，认为紧急手术是必要的。术前未发现心包炎或心包积液。打开假性动脉瘤囊，并在快速选择旁路恢复血流之前排出血栓，以控制假性动脉瘤和血运重建。此外，术后还采用泼尼松龙和环磷酰胺的基础治疗。患者于8天后出院。在6个月的随访中，他无症状，已恢复完全活动，无呼吸困难或心绞痛。然而，我们感到遗憾的是，患者因感觉良好，CTA检查费用高昂而拒绝接受冠状动脉CTA复查。

致编者：一名67岁男性于2016年5月出现7个月的反复腹泻和日益严重的腹痛。他每天大约有4-6次粘液脓性大便，伴有腹痛、里急后重和体重减轻。他接受了结肠镜检查，显示普遍结肠炎，活检显示隐窝脓肿和炎细胞浸润，他被诊断为溃疡性结肠炎（UC）。给予5-氨基水杨酸（美沙拉嗪），3个月后症状缓解。没过多久，他又出现腹泻。他每天通过7-8次液体运动，含有血液和粘液，伴有发烧和虚弱。入院后，重复结肠镜检查显示充血的结肠直肠粘膜持续水肿和糜烂，活检显示隐窝脓肿和炎细胞浸润[图1a和图1b].实验室检查显示血红蛋白107克/升，白细胞8.73 × 10⁹/L，中性粒细胞为77.6%。总血清蛋白为70g/L，球蛋白为38g/L。血清叶酸、血清维生素B12、血清铁和总铁结合力正常。血沉31~45mm/h（参考值0~15mm/h），C反应蛋白92.5 mg/L（参考值<8.0 mg/L)。他的血清免疫球蛋白G（IgG）水平升高至24.90 g/L（参考值，7.51-15.60 g/L）。血清蛋白电泳常规检查发现M蛋白（IgG-λ型），显示γ球蛋白升高，占28.6%（参考值，9.2-18.2%）。考虑到血浆疾病的可能性，进行了骨髓穿刺。骨髓中浆细胞百分比为8.5%，伴有大双核的异常浆细胞，活检显示骨髓中散在浆细胞[图1c和图1d].可以看到红细胞。流式细胞术结果也与浆细胞疾病一致。综合评估后，考虑患者为复发性UC，建议给予糖皮质激素治疗，但患者拒绝。给予美沙拉秦灌肠治疗，血便缓解。随后出院，给予美沙拉秦4g/天伴益生菌维持治疗。

随着癌症患者早期检测和治疗的发展进步，归因于癌症的死亡率已经下降。在美国，大约有1550万癌症幸存者，到2026年这个数字将增长到2000多万（http://www.cancer.org/cancer/news/news/report-number-of-cancer-survivors-continues-to-grow）。不幸的是，癌症治疗后癌症患者生存率的提高是以治疗诱导的副作用为代价的，CVD是最常见的副作用之一【补充表1】。^[1]这可能是由抗癌治疗的直接心脏毒性或加速的预先存在的CVD或心血管风险因素引起的。CVD现在是癌症幸存者长期发病率和死亡率的第二大原因。^{[2,3,4,5,6,7]}

接受手术切除联合放化疗的恶性胶质瘤患者的中位随访时间为16个月。恶性胶质瘤的复发是不可避免的。尽管复发性胶质母细胞瘤患者有多种治疗选择，但5年生存率仍低于5%，平均生存期低于12个月。^[1]目前，没有单一的二线药物可以有生存获益。