Endobutton带袢钢板治疗陈旧性III 型肩锁关节脱位疗效分析

目的：探讨陈旧性III型肩锁关节脱位患者应用Endobutton 带袢钢板治疗的临床效果。方法：选取陈旧性III型肩锁关节脱位 患者17 例,在本研究中的治疗方法为双Endobutton 带袢钢板固定疗法,通过此种方法对17 例患者进行治疗,并观察临床疗效。 结果：通过对以上患者治疗后的6-12 个月的随访中,患者术后Constant 评分平均为（91.02± 5.20）分,X线显示肩关节部位无脱位 (P<0.05)。结论：在治疗陈旧型Ⅲ型肩锁关节脱位方面,Endobutton 钢板对患处进行固定的技术疗效显著,但长期疗效需要扩大样 本量进一步研究。     

Improvement of pain and regional osteoporotic changes in the foot and ankle by low-dose bisphosphonate therapy for complex regional pain syndrome type I: a case series

Introduction

Complex regional pain syndrome is characterized by pain, allodynia, hyperalgesia, edema, signs of vasomotor instability, movement disorders, joint stiffness, and regional osteopenia. It is recognized to be difficult to treat, despite various methods of treatment, including physiotherapy, calcitonin, corticosteroids, sympathetic blockade, and nonsteroidal anti-inflammatory drugs. Pathophysiologically, complex regional pain syndrome reveals enhanced regional bone resorption and high bone turnover, and so bisphosphonates, which have a potent inhibitory effect on bone resorption, were proposed for the treatment of complex regional pain syndrome.

Case presentation

A 48-year-old Japanese man with complex regional pain syndrome type I had severe right ankle pain with a visual analog scale score of 59 out of 100 regardless of treatment with physiotherapy and nonsteroidal anti-inflammatory drugs for five months. Radiographs showed marked regional osteoporotic changes and bone scintigraphy revealed a marked increase in radioactivity in his ankle. One month after the start of oral administration of risedronate (2.5 mg per day), his bone pain had fallen from a VAS score of 59 out of 100 to 18 out of 100. Bone scintigraphy at 12 months showed a marked reduction in radioactivity to a level comparable to that in his normal, left ankle. On the basis of these results, the treatment was discontinued at 15 months. At 32 months, our patient had almost no pain and radiographic findings revealed that the regional osteoporotic change had returned to normal.A second 48-year-old Japanese man with complex regional pain syndrome type I had severe right foot pain with a visual analog scale score of 83 out of 100 regardless of treatment with physiotherapy and nonsteroidal anti-inflammatory drugs for nine months. Radiographs showed regional osteoporotic change in his phalanges, metatarsals, and tarsals, and bone scintigraphy revealed a marked increase in radioactivity in his foot. One month after the start of oral administration of alendronate (35 mg per week), his bone pain had fallen from a visual analog scale score of 83 out of 100 to 30 out of 100 and, at nine months, was further reduced to 3 out of 100. The treatment was discontinued at 15 months because of successful pain reduction. At 30 months, our patient had no pain and the radiographic findings revealed marked improvement in regional osteoporotic changes.

Conclusions

We believe low-dose oral administration of bisphosphonate is worth considering for the treatment of idiopathic complex regional pain syndrome type I accompanied by regional osteoporotic change.

     

Experiences and attitudes towards end-of-life decisions amongst Danish physicians

In this survey we have investigated the experiences and attitudes of Danish physicians regarding end-of-life decisions. Most respondents have made decisions that involve hastening the death of a patient, and almost all find it acceptable to do so. Such decisions are made more often, and considered ethically more acceptable, with the informed consent of the patient than without. But both non-resuscitation decisions, and decisions to provide pain relief in doses that will shorten the patient's life, have been made and found acceptable by at least 50% of the respondents, even when there is no informed consent. Furthermore, 12% have doubled morphine dosages with fixed intervals, thus providing doses substantially higher than that necessary to control pain, without the informed consent of the patient. Two per cent have helped in assisted suicide, and 5% have administered a lethal injection at the patient's request. Respectively 37% and 34% find these last two practices ethically acceptable. Amongst those that do not find them acceptable, the most important reasons to be opposed are, the doctrine of double effect, the doctrine of doing and allowing, and the view that human life is sacred. Amongst supporters, the most important reasons mentioned are, that the patient's right to self-determination should be respected, the view that a patient should not be forced to suffer, and the view that the patient has a right to be helped to a dignified death.     

Potentiation of excitatory transmission in substantia gelatinosa neurons of rat spinal cord by inhibition of estrogen receptor alpha

The neuropeptide galanin is widely expressed in both the central and peripheral nervous systems and is involved in many diverse biological functions. There is a substantial data set that demonstrates galanin is upregulated after injury in the DRG, spinal cord and in many brain regions where it plays a predominantly antinociceptive role in addition to being neuroprotective and pro-regenerative. To further characterise the role of galanin following nerve injury, a novel transgenic line was created using the binary transgenic tet-off system, to overexpress galanin in galaninergic tissue in a suppressible manner. The double transgenic mice express significantly more galanin in the DRG one week after sciatic nerve section (axotomy) compared to WT mice and this overexpression is suppressible upon administration of doxycycline. Phenotypic analysis revealed markedly attenuated allodynia when galanin is overexpressed and an increase in allodynia following galanin suppression. This novel transgenic line demonstrates that whether galanin expression is increased at the time of nerve injury or only after allodynia is established, the neuropeptide is able to reduce neuropathic pain behaviour. These new findings imply that administration of a galanin agonist to patients with established allodynia would be an effective treatment for neuropathic pain.     

The use of temperature biofeedback in the treatment of chronic pain due to causalgia.

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5 degrees C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.     

OVERCOMING BARRIERS TO PAIN RELIEF IN THE CARIBBEAN

This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement.     

Osteoprotegerin blocks bone cancer-induced skeletal destruction, skeletal pain and pain-related neurochemical reorganization of the spinal cord

Bone cancer pain is common among cancer patients and can have a devastating effect on their quality of life. A chief problem in designing new therapies for bone cancer pain is that it is unclear what mechanisms drive this distinct pain condition. Here we show that osteoprotegerin, a secreted 'decoy' receptor that inhibits osteoclast activity, also blocks behaviors indicative of pain in mice with bone cancer. A substantial part of the actions of osteoprotegerin seems to result from inhibition of tumor-induced bone destruction that in turn inhibits the neurochemical changes in the spinal cord that are thought to be involved in the generation and maintenance of cancer pain. These results demonstrate that excessive tumor-induced bone destruction is involved in the generation of bone cancer pain and that osteoprotegerin may provide an effective treatment for this common human condition.     

Killing, letting die and moral perception: a reply to Grant Gillett

A number of philosophers in recent times have employed arguments to show that there is no morally relevant difference between killing a patient and allowing that patient to die in those circumstances where the outcome is virtually identical and where death is preventable, at least for a significant time. From his perspective as both a philosopher and a clinician, Grant Gillett has rejected such general and abstract arguments in the light of the intuitions and moral perceptions available to clinicians and those who care for the terminally ill. I argue that his strategy fails, is massively question-begging, and that his appeal to the notion of 'moral particularism', far from being an alternative to cogent philosophical argument, actually supports the very position he has attempted to discredit.     

Lidocaine patch (5%) is no more potent than placebo in treating chronic back pain when tested in a randomised double blind placebo controlled brain imaging study

ABSTRACT: The 5% Lidocaine patch is used for treating chronic neuropathic pain conditions such as chronic back pain (CBP), diabetic neuropathy and complex regional pain syndrome, but is effective in a variable proportion of patients. Our lab has reported that this treatment reduces CBP intensity and associated brain activations when tested in an open labelled preliminary study. Notably, effectiveness of the 5% Lidocaine patch has not been tested against placebo for treating CBP. In this study, effectiveness of the 5% Lidocaine patch was compared with placebo in 30 CBP patients in a randomised double-blind study where 15 patients received 5% Lidocaine patches and the remaining patients received placebo patches. Functional MRI was used to identify brain activity for fluctuations of spontaneous pain, at baseline and at two time points after start of treatment (6 hours and 2 weeks). There was no significant difference between the treatment groups in either pain intensity, sensory and affective qualities of pain or in pain related brain activation at any time point. However, 50% patients in both the Lidocaine and placebo arms reported a greater than 50% decrease in pain suggesting a marked placebo effect. When tested against an untreated CBP group at similar time points, the patch treated subjects showed significantly greater decrease in pain compared to the untreated group (n=15). These findings suggest that although the 5% Lidocaine is not better than placebo in its effectiveness for treating pain, the patch itself induces a potent placebo effect in a significant proportion of CBP patients.     

THE REMARKABLE P. F. B. VON SIEBOLD,HIS LIFE IN EUROPE AND JAPAN

We present a synopsis of the major trends of Siebold's life, his youth in the Rhineland and his lengthy employment as a physician and natural scientist in the colonial government of the Dutch East Indies. We follow his career on the cramped Japanese island of Dejima where he was based for 6 years. We reveal how, during two visits to Japan, Siebold became a renowned ethnographer, natural historian, author and entrepreneur and an unsuccessful diplomat. In this paper we attempt to provide an insight into Siebold's varied life in Bavaria, The Netherlands and Japan.     

John F. Fulton, Coccidioidomycosis, and Penicillin

When the late Dr. John F. Fulton contracted severe pulmonary coccidioidomycosis in January, 1942, a metastatic lesion posed the threat of further progression and fatal dissemination. The possibility that an untested and generally unavailable antibiotic, penicillin, might be of value in Fulton's illness led his physician, Dr. John Bumstead, to appeal directly to Fulton to obtain this antibiotic, but ostensibly for the benefit of another patient succumbing to hemolytic streptococcal infection. While of no value for Fulton, penicillin was highly successful in the treatment of his other patient and soon of a second one with staphylococcal sepsis and pneumonia. This penicillin, administered in March, 1942, was the first clinical trial of penicillin under the control of the Office of Scientific Research and Development. The unique contribution of Dr. Fulton and of his illness to this event is described.     

Coexistence of substance P,neuropeptide Y,VIP, and CGRP in the nerve fibers of the carotid labyrinth of the bullfrog,Rana catesbeiana: a double-labelling immunofluorescence study in combination with alternate consecutive sections

Double immunohistochemical staining with rhodamine- and fluorescein isothiocyanate (FITC)-conjugated antisera revealed the coexistence of substance P (SP) and neuropeptide Y (NPY), and SP and calcitonin gene-related peptide (CGRP) in most nerve fibers in the intervascular stroma of the carotid labyrinth of the bull-frog, Rana catesbeiana, although there were a few fibers which showed only SP- or NPY-immunoreactivity. Approximately one third of SP-immunoreactive fibers also showed coexistence with vasoactive intestinal polypeptide (VIP)-immunoreactivity, and a few fibers contained VIP without SP. The combination of the double immunofluorescence technique and alternate consecutive sections further demonstrated the possible coexistence of SP, VIP, NPY, and CGRP. This coexistence of four different peptides in the same nerve fibers was proved by the following two evident facts: 1) some SP fibers which demonstrated coexistence with NPY-immunoreactivity were assumed to be continuous with those showing VIP-immunoreactivity, and 2) almost all of the SP fibers showed coexistence with CGRP-immunoreactivity. By this reasoning, nearly one third of SP fibers may demonstrate coexistence with NPY-, VIP-, and CGRP-immunoreactivities. These multiple peptides might be involved in vascular regulatory function, which is a possible function of the amphibian carotid labyrinth.     

Elihu Yale and the medicine he promoted: the government general hospital and Madras Medical College, India

Much has been written about the philanthropist Elihu Yale and his life in the Americas and England, where he spent his beginnings and end. Less publicized is his life in India, where he spent the majority of his adult life and where he raised his family. A major contribution of Elihu Yale to medicine in India was his promotion of a local hospital in the major Indian trading port city of Madras. This essay briefly describes the history of that hospital and the medical college that grew out of it.     

Ontogeny of the photoreceptors in the embryonic retina of the viviparous guppy,Poecilia reticulata P. (Teleostei)

Summary Ultrastructural analyses of retinal development in the guppy embryo show that at midgestation all types of photoreceptors are differntiated in the fundus, and at birth differentiation extends over the whole retina. Formation of discs of outer segments is more rapid in rods than in cones. Double cones differentiate simultaneously with long single cones and are formed by the adhesion of two primordial inner segments; short single cones develop last. Wherever cones are differentiated, they are arranged in an adult-type square mosaic. The rods in the embryo, as opposed to the adult, are likewise regularly arranged within the mosaic unit.These results are at variance with the generally held opinion that adult teleosts which possess duplex retinae have larvae with pure cone retinae, and that rods, double cones and mosaics appear in late larval life or only at metamorphosis.In the double cones of the guppy embryo subsurface cisternae develop along the adjoining primordial inner segments. Additionally, regularly distributed subsurface cisternae are formed in the regions of intimate contact of long single cones with double cones and rods.We suggest that the early development of rods and double cones, and a square-mosaic with regular distribution of rods and subsurface cisternae, provide the newly born with a fully functional optical apparatus, especially suited to perception of movements. This is necessary for its survival against predatory, especially maternal, attacks.This work was in part subsidized by a grant from the Medical Research Council of Ireland to Y.W.K.     

Treatment limitation decisions under uncertainty: the value of subsequent euthanasia

This paper examines how decisions to limit treatment to critically ill patients under uncertainty can be made rationally. Expected utility theory offers one way of making rational decisions under uncertainty. One problem with using this approach is that we may not know the value of each option. One rational course open is to treat until further information becomes available. However, treatment can limit the range of options open. With treatment, a patient may recover such that he no longer requires life-supporting treatment. However, his life may be not worth living. If active euthanasia of %on-terminal'conditions is prohibited, the option of dying will no longer be available. Taking a rational'wait and see'course may result in being trapped within an unbearable life. On the other hand, sometimes present practice'lets nature takes its course'. Critically ill patients are allowed to die because it is believed that their lives will be not worth living. It is likely that some patients are allowed to die when there is some objective chance of worthwhile future life. This paper argues that a policy of treating critically ill patients until the nature of future options can be better evaluated, in company with an offer of subsequent euthanasia where appropriate, allows a more rational and humane approach to treatment limitation decisions under uncertainty.     

The early-flowering mutant efs is involved in the autonomous promotion pathway of Arabidopsis thaliana.

The transition to flowering is a crucial moment in a plant's life cycle of which the mechanism has only been partly revealed. In a screen for early flowering, after mutagenesis of the late-flowering fwa mutant of Arabidopsis thaliana, the early flowering in short days (efs) mutant was identified. Under long-day light conditions, the recessive monogenic efs mutant flowers at the same time as wild type but, under short-day conditions, the mutant flowers much earlier. In addition to its early-flowering phenotype, efs has several pleiotropic effects such as a reduction in plant size, fertility and apical dominance. Double mutant analysis with several late-flowering mutants from the autonomous promotion (fca and fve) and the photoperiod promotion (co, fwa and gi) pathways of flowering showed that efs reduces the flowering time of all these mutants. However, efs is completely epistatic to fca and fve but additive to co, fwa and gi, indicating that EFS is an inhibitor of flowering specifically involved in the autonomous promotion pathway. A vernalisation treatment does not further reduce the flowering time of the efs mutant, suggesting that vernalisation promotes flowering through EFS. By comparing the length of the juvenile and adult phases of vegetative growth for wild-type, efs and the double mutant plants, it is apparent that efs mainly reduces the length of the adult phase.     

Behavioural responses of piglets to castration: the effect of piglet age

It has long been assumed that neonatal animals are less sensitive than older animals to pain, and this reasoning has been used to recommend that routine surgical procedures be performed at an early age. In this study we tested if vocal and other behavioural responses to castration increase with piglet age. Piglets (n=84) from 14 litters were assigned to one of six treatment groups: castration or sham castration at 3, 10 or 17 days of age. During the procedure castrated piglets produced high-frequency calls (>1000Hz) at more than three times the rate of piglets in the sham-castrate group. The rate of low-frequency (<1000Hz) calls was also higher for piglets in the castrate group. The rate of high-frequency calling was lower for the youngest pigs but there was no relationship between age and the effect of treatment for any of the vocal responses measured (i.e. no age by treatment interaction). During the first 2h after castration, castrated piglets spent more time sitting or standing and less time lying. During the subsequent 22h, castrated piglets spent marginally more time at the udder and less time lying down. Older piglets missed more nursings. However, the effect of castration did not vary with the age of the piglet for any measure. We conclude that while the factors affecting both the shams and the castrates (e.g. distress due to restraint) may vary with age, the pain of castration is not affected by age within the range of ages that we tested.     

Switch in pattern formation after puncturing the anterior pole of Smittia eggs (Chironomidae, Diptera).

The aberrant pattern, “double abdomen,” previously induced in the egg of Smittia by uv irradiation of anterior pole regions was also produced by puncturing of the egg at the anterior pole. Double abdomens and embryos with anterior defects developed in eggs in which puncturing had locally prevented the regular arrangement of cleavage nuclei in the periplasm. The resulting gap in the blastoderm at the anterior pole was subsequently closed under exclusion of a small amount of egg material. Double abdomens did not develop in eggs where exclusion of anterior egg material was not observed. Thus a basic switch in the developmental program of the egg appears to depend upon the functional elimination of some crucial components in the anterior egg region.     

Synaptic initiation and extension as prerequisites for crossing over

The effect on crossover frequency in maize of three hour heat treatment was studied when treatment was applied at zygotene (substantially later than the major DNA synthetic period) and at pachytene. Crossover frequency assay was based upon bridge and fragment frequency at anaphase I in heterozygotes for a short paracentric inversion. Effect of treatment was studied in three distinguishable synaptic classes: (1) overall crossover frequency within the inversion, (2) double crossover frequency where two separate events of pairing initiation are required (coincident crossovers within and proximal to the inversion) and (3) double crossover frequency within the inversion, where spreading of synapsis over a short distance from a single event of pairing initiation can provide the requisite pairing. Evidence is reported: (1) that overall crossover frequency within the inversion was very significantly increased by treatment at zygotene but not detectably affected by treatment at pachytene; (2) that double crossover frequency within the inversion was very significantly increased by treatment at pachytene and may have been somewhat increased by treatment at zygotene. Results are consistent with the model that most crossover sites may be established at, or approximately at, events of synaptic initiation but that establishment of infrequent second crossover sites near those formed first can follow or accompany the spreading of synapsis to adjoining regions.     

The use of temperature biofeedback in the treatment of chronic pain due to causalgia

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5°C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.The author wishes to acknowledge the assistance of Dr. Kit S. Mays and the staff of the Pain Clinic of the University of Tennessee Center for the Health Sciences.