核素131I胆道腔内辐照支架的制作和动物实验及临床应用研究

恶性梗阻性黄疸(malignant obstructive jaundice,MOJ)发现时多为晚期,如不治疗生存期仅3个月。由于肿瘤位置特殊、患者一般情况较差,仅5%～20%的患者可行外科切除和分流手术,并且手术死亡率相当高,分流术病死率高达10%～43%。1974年Molnar和Stocknm首先采用PTCD术（经皮肝胆管内外引流术，Percutaneous Transhepatic Cholangic Drainage,PTCD）,使MOJ患者的临床症状得到缓解, 获得进一步治疗的机会。1989年金属支架开始应用于胆道系统,恢复了胆汁的生理性引流,并使大多数患者拔除引流管,提高了生活质量,成为非手术治疗MOJ的首选方法。但肿瘤生长是造成支架堵塞、黄疸复发的主要原因。文献报道MOJ患者放置金属支架后,支架堵塞的概率达20%～86%,其中大多数由肿瘤生长通过支架网眼或超过支架边缘引起。因此,在支架置放的同时如何积极控制肿瘤生长成为提高疗效的关键问题。MOJ的局部治疗方法有多种,但都存在不足之处。国内学者采用动脉化疗栓塞结合PTCD或支架置放的方法治疗MOJ,使患者的生存期得到延长。但引起MOJ的胆管癌、淋巴结转移癌、胰腺癌、壶腹癌多为少血供肿瘤,而且由于血供特殊,大部分病例碘油沉积欠佳,因此动脉化疗栓塞对这类肿瘤的作用是有限的。外辐照治疗对胆管癌、淋巴结转移癌、胰腺癌、壶腹癌等引起MOJ的肿瘤有一定疗效,并与胆道引流术结合应用于上述肿瘤引起的MOJ。由于瘤体周围有肝脏、胰腺、胃肠道、肾脏等对射线敏感的器官, 限制了外辐照剂量,影响了疗效的提高。近几年,一种斩新的治疗手段正在应用于临床，就是通过PTCD手术时建立的通道再行腔内辐照治疗(核素内辐照治疗),可以较好的控制肿瘤继续生长，抑制支架再狭窄的发生,可使MOJ的治疗取得更好的效果。本研究的目的就是探索胆道内辐照支架制作的可行性，并设计特别的施源器，其具体方法可以简述为：以球囊扩张器扩张重度狭窄胆管+置入特制的二腔单囊管+腔内低剂量率放疗+腔内热频热疗+胆管引流等联合方法治疗。同时，就该二腔单囊管内辐照支架的安全性进行动物实验，从分子生物学、核医学的角度阐述了实验研究的机理和病理改变，同时进行了临床的应用研究，探讨胆道支架发生再阻塞的相关因素及对策，进一步提高（MOJ）患者的生存期。本工作结果总结如下： 1 对放射源和施源器均进行了改进，放射源为液态放射性核素131I，施源器为可调节的长柱形球囊，是专门设计的硅橡胶二腔单囊管，其功能为：中腔通接胆管腔（蓝色），具有引流胆汁作用；另一腔管连接球囊（绿色），是长柱状形可调节长短的球囊，囊内装填放射性液态核素131I；囊内还设置射频加热电极，能加热升温。另外，还可以根据肿瘤的大小和长度，来调节施源器的长度（长柱形球囊），一般照射长度超出支架两端1-2cm。二腔单囊管内辐照支架的特点：剂量分布合理，低剂量率效应，射线能量适中，放疗、热疗同步实施，引流、扩张和局部用药作用。与其他治疗方法比较，这一核医学治疗技术的最大优点是：大直径柱状液态源，近似面源，液囊适形病变胆管腔，均匀贴紧病灶壁，剂量分布合理，γ射线能量适中，低剂量率持续照射，同时联合射频温热治疗及胆道引流、局部用药对症处理等。 2 动物实验研究结果指出，囊装液态131I支架对胆管壁的放射性损伤随131I放射性活度的增加而逐渐加重,呈现明显的放射性活度效应关系。而普通支架组胆管壁无放射性损伤,但是胆管壁粘膜层和肌层增生较131I支架组重,胆管出现再狭窄倾向。本研究为临床合理应用131I支架治疗胆管癌及胆管良性狭窄选择合适的131I放射性活度,提供了必要的剂量学和基础研究依据。 3 动物实验研究结果表明,131I支架组犬胆管组织Fas表达较普通支架组明显,且其表达水平的变化与犬胆管壁平滑肌细胞凋亡的检测结果相同。131I支架组胆管腔面积比普通支架组明显增加,胆管狭窄程度比普通支架组轻。这主要是由于131I辐射促进Fas 基因表达,诱导增殖性平滑肌细胞凋亡,从而减轻胆管损伤后愈合过程中的管腔狭窄。 4． 胆道恶性梗阻胆道腔内囊装液态131I辐照治疗施源的直径为8mm时是胆管充分扩张的最低限度,根据近距离放疗的剂量学特点,它能保证胆管癌腔内辐照治疗时将施源管因素导致的放疗反应和局部肿瘤复发减至最低。并具有创伤小,操作简单,疗效明显,易被患者接受的特点。 5．囊装液态131I治疗恶性梗阻性黄疸（肝门部胆管癌18例），临床疗效满意，随访7～21个月,3个月生存率83.33 %(15/ 18)；6个月生存率72.22%(13/18)；9个月生存率56.25%(12/16)；12个月生存率46.15%(6/13),15个月生存率36.33%(4/11)；18个月生存率22.22%(2/9),21个月生存率28.57%(2/7)。4例发生并发症,其中2例为放射性胆管炎胆道出血,1例为胆汁性腹膜炎,另1例是胰瘘胰腺炎

Intracoronary adenovirus-mediated delivery and overexpression of the beta(2)-adrenergic receptor in the heart : prospects for molecular ventricular assistance.

BACKGROUND: Genetic modulation of ventricular function may offer a novel therapeutic strategy for patients with congestive heart failure. Myocardial overexpression of beta(2)-adrenergic receptors (beta(2)ARs) has been shown to enhance contractility in transgenic mice and reverse signaling abnormalities found in failing cardiomyocytes in culture. In this study, we sought to determine the feasibility and in vivo consequences of delivering an adenovirus containing the human beta(2)AR cDNA to ventricular myocardium via catheter-mediated subselective intracoronary delivery. METHODS AND RESULTS: Rabbits underwent percutaneous subselective catheterization of either the left or right coronary artery and infusion of adenoviral vectors containing either a marker transgene (Adeno-betaGal) or the beta(2)AR (Adeno-beta(2)AR). Ventricular function was assessed before catheterization and 3 to 6 days after gene delivery. Both left circumflex- and right coronary artery-mediated delivery of Adeno-beta(2)AR resulted in approximately 10-fold overexpression in a chamber-specific manner. Delivery of Adeno-betaGal did not alter in vivo left ventricular (LV) systolic function, whereas overexpression of beta(2)ARs in the LV improved global LV contractility, as measured by dP/dt(max), at baseline and in response to isoproterenol at both 3 and 6 days after gene delivery. CONCLUSIONS: Percutaneous adenovirus-mediated intracoronary delivery of a potentially therapeutic transgene is feasible, and acute global LV function can be enhanced by LV-specific overexpression of the beta(2)AR. Thus, genetic modulation to enhance the function of the heart may represent a novel therapeutic strategy for congestive heart failure and can be viewed as molecular ventricular assistance.

Magnetic Resonance Imaging Biomarkers of Renal Structure and Function

The kidney's major role in filtration depends on its high blood flow, concentrating mechanisms, and biochemical activation. The kidney's greatest strengths also lead to vulnerability for drug-induced nephrotoxicity and other renal injuries. The current standard to diagnose renal injuries is with a percutaneous renal biopsy, which can be biased and insufficient. In one particular case, biopsy of a kidney with renal cell carcinoma can actually initiate metastasis. Tools that are sensitive and specific to detect renal disease early are essential, especially noninvasive diagnostic imaging. While other imaging modalities (ultrasound and x-ray/CT) have their unique advantages and disadvantages, MRI has superb soft tissue contrast without ionizing radiation. More importantly, there is a richness of contrast mechanisms in MRI that has yet to be explored and applied to study renal disease.

The focus of this work is to advance preclinical imaging tools to study the structure and function of the renal system. Studies were conducted in normal and disease models to understand general renal physiology as well as pathophysiology. This dissertation is separated into two parts--the first is the identification of renal architecture with ex vivo MRI; the second is the characterization of renal dynamics and function with in vivo MRI. High resolution ex vivo imaging provided several opportunities including: 1) identification of fine renal structures, 2) implementation of different contrast mechanisms with several pulse sequences and reconstruction methods, 3) development of image-processing tools to extract regions and structures, and 4) understanding of the nephron structures that create MR contrast and that are important for renal physiology. The ex vivo studies allowed for understanding and translation to in vivo studies. While the structure of this dissertation is organized by individual projects, the goal is singular: to develop magnetic resonance imaging biomarkers for renal system.

The work presented here includes three ex vivo studies and two in vivo studies:

1) Magnetic resonance histology of age-related nephropathy in sprague dawley.

2) Quantitative susceptibility mapping of kidney inflammation and fibrosis in type 1 angiotensin receptor-deficient mice.

3) Susceptibility tensor imaging of the kidney and its microstructural underpinnings.

4) 4D MRI of renal function in the developing mouse.

5) 4D MRI of polycystic kidneys in rapamycin treated Glis3-deficient mice.

Intravital microscopy evaluation of angiogenesis and its effects on glucose sensor performance.

An optical window model for the rodent dorsum was used to perform chronic and quantitative intravital microscopy and laser Doppler flowmetry of microvascular networks adjacent to functional and non-functional glucose sensors. The one-sided configuration afforded direct, real-time observation of the tissue response to bare (unmodified, smooth surface) sensors and sensors coated with porous poly-L-lactic acid (PLLA). Microvessel length density and red blood cell flux (blood perfusion) within 1 mm of the sensors were measured bi-weekly over 2 weeks. When non-functional sensors were fully implanted beneath the windows, the porous coated sensors had two-fold more vasculature and significantly higher blood perfusion than bare sensors on Day 14. When functional sensors were implanted percutaneously, as in clinical use, no differences in baseline current, neovascularization, or tissue perfusion were observed between bare and porous coated sensors. However, percutaneously implanted bare sensors had two-fold more vascularity than fully implanted bare sensors by Day 14, indicating the other factors, such as micromotion, might be stimulating angiogenesis. Despite increased angiogenesis adjacent to percutaneous sensors, modest sensor current attenuation occurred over 14 days, suggesting that factors other than angiogenesis may play a dominant role in determining sensor function.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

Background: This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010.
For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

Objectives: To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

Search methods: Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012.

Selection criteria:Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

Data collection and analysis:Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

Main results: One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012.
Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study.
Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.
We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

Authors' conclusions: There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

PHONOPHORESIS OF METHYL NICOTINATE - A PRELIMINARY-STUDY TO ELUCIDATE THE MECHANISM OF ACTION

The skin penetration enhancement effect of ultrasound (phonophoresis) on methyl nicotinate was investigated in 10 healthy volunteers in a double-blind, placebo-controlled, crossover clinical trial. Each treatment consisted of the application of ultrasound massage (3.0 MHz, 1.0 W/cm2 continuous output) or placebo massage (0 MHz) for 5 min to the forearms of the volunteers, followed by a standardized application of methyl nicotinate at intervals of 15 sec, 1 min, and 2 min postmassage. Percutaneous absorption of methyl nicotinate was monitored using laser Doppler velocimetry. Ultrasound treatment applied prior to methyl nicotinate led to enhanced percutaneous absorption of the drug, for example, ultrasound treatment data versus control data at 2 min showed significant increases (P

Influence of skin model on in vitro performance of drug-loaded soluble microneedle arrays

A plethora of studies have described the in vitro assessment of dissolving microneedle (MN) arrays for enhanced transdermal drug delivery, utilising a wide variety of model membranes as a representation of the skin barrier. However, to date, no discussion has taken place with regard to the choice of model skin membrane and the impact this may have on the evaluation of MN performance. In this study, we have, for the first time, critically assessed the most common types of in vitro skin permeation models - a synthetic hydrophobic membrane (Silescol(®) of 75 µm) and neonatal porcine skin of definable thickness (300-350 µm and 700-750 µm) - for evaluating the performance of drug loaded dissolving poly (methyl vinyl ether co maleic acid) (PMVE/MA) MN arrays. It was found that the choice of in vitro skin model had a significant effect on the permeation of a wide range of small hydrophilic molecules released from dissolving MNs. For example, when Silescol(®) was used as the model membrane, the cumulative percentage permeation of methylene blue 24h after the application of dissolvable MNs was found to be only approximately 3.7% of the total methylene blue loaded into the MN device. In comparison, when dermatomed and full thickness neonatal porcine skin were used as a skin model, approximately 67.4% and 47.5% of methylene blue loaded into the MN device was delivered across the skin 24h after the application of MN arrays, respectively. The application of methylene blue loaded MN arrays in a rat model in vivo revealed that the extent of MN-mediated percutaneous delivery achieved was most similar to that predicted from the in vitro investigations employing dermatomed neonatal porcine skin (300-350 µm) as the model skin membrane. On the basis of these results, a wider discussion within the MN community will be necessary to standardise the experimental protocols used for the evaluation and comparison of MN devices.

A cultural practice of drinking realgar wine leading to elevated urinary arsenic and its potential health risk

Toasting friends and family with realgar wines and painting children's foreheads and limbs with the leftover realgar/alcohol slurries is an important customary ritual during the Dragon Boat Festival (DBF); a Chinese national holiday and ancient feast day celebrated throughout Asia. Realgar is an arsenic sulfide mineral, and source of highly toxic inorganic arsenic. Despite the long history of realgar use during the DBF, associated risk to human health by arsenic ingestion or percutaneous adsorption is unknown. To address this urine samples were collected from a cohort of volunteers who were partaking in the DBF festivities. The total concentration of arsenic in the wine consumed was 70 mg L(-1) with all the arsenic found to be inorganic. Total arsenic concentrations in adult urine reached a maximum of ca. 550 mu g L(-1) (mean 220.2 mu g L(-1)) after 16 h post-ingestion of realgar wine, while face painting caused arsenic levels in children's urine to soar to 100 mu g L(-1) (mean 85.3 mu g L(-1)) 40 h after the initial paint application. The average concentration of inorganic arsenic in the urine of realgar wine drinkers on average doubled 16 h after drinking, although this was not permanent and levels subsided after 28 h. As would be expected in young children, the proportions of organic arsenic in the urine remained high throughout the 88-h monitoring period. However, even when arsenic concentrations in the urine peaked at 40 h after paint application, concentrations in the urine only declined slightly thereafter, suggesting pronounced longer term dermal accumulation and penetration of arsenic. Drinking wines blended with realgar or using realgar based paints on children does result in the significant absorption of arsenic and therefore presents a potentially serious and currently unquantified health risk. (C) 2011 Elsevier Ltd. All rights reserved.

Strategies for multivessel revascularization in patients with diabetes

In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease.

Revascularization versus medical therapy for renal-artery stenosis

Percutaneous revascularization of the renal arteries improves patency in atherosclerotic renovascular disease, yet evidence of a clinical benefit is limited.

Experimental and Computational Approach Investigating Burst Fracture Augmentation Using PMMA and Calcium Phosphate Cements

The aim of the study was to use a computational and experimental approach to evaluate, compare and predict the ability of calcium phosphate (CaP) and poly (methyl methacrylate) (PMMA) augmentation cements to restore mechanical stability to traumatically fractured vertebrae, following a vertebroplasty procedure. Traumatic fractures (n = 17) were generated in a series of porcine vertebrae using a drop-weight method. The fractured vertebrae were imaged using μCT and tested under axial compression. Twelve of the fractured vertebrae were randomly selected to undergo a vertebroplasty procedure using either a PMMA (n = 6) or a CaP cement variation (n = 6). The specimens were imaged using μCT and re-tested. Finite element models of the fractured and augmented vertebrae were generated from the μCT data and used to compare the effect of fracture void fill with augmented specimen stiffness. Significant increases (p <0.05) in failure load were found for both of the augmented specimen groups compared to the fractured group. The experimental and computational results indicated that neither the CaP cement nor PMMA cement could completely restore the vertebral mechanical behavior to the intact level. The effectiveness of the procedure appeared to be more influenced by the volume of fracture filled rather than by the mechanical properties of the cement itself.