Anterior cruciate ligament reconstruction best practice: A review of graft choice

There is much literature about differing grafts used in anterior cruciate ligament(ACL) reconstruction. Much of this is of poor quality and of a low evidence base. We review and summarise the literature looking at the four main classes of grafts used in ACL reconstruction; bone-patella tendon-bone, hamstrings, allograft and synthetic grafts. Each graft has the evidence for its use reviewed and then compared, where possible, to the others. We conclude that although there is no clear "best" graft, there are clear differences between the differing graft choices. Surgeon's need to be aware of the evidence behind these differences, in order to have appropriate discussions with their patients, so as to come to an informed choice of graft type to best suit each individual patient and their requirements.

Trunnionosis: A pain in the neck

Metal-on-metal(MoM) hip replacements have proven to be a modern day orthopaedic failure. The early enthusiasm and promise of a hard, durable bearing was quickly quashed following the unanticipated wear rates. The release of metal ions into the blood stream has been shown to lead to surrounding soft tissue complications and early failure. The devastating destruction caused has led to a large number of revision procedures and implant extractions. The resulting research into this field has led to a new area of interest; that of the wear at the trunnion of the prosthesis. It had been previously thought that the metal debris was generated solely from the weight bearing articulation, however with the evolution of modularity to aid surgical options, wear at the trunnion is becoming more apparent. The phenomenon of "trunnionosis" is a rapidly developing area of interest that may contribute to the overall effect of metallosis in Mo M replacements but may also lead to the release of metal ions in non Mo M hip designs. The aim of this paper is to introduce, explain and summarise the evidence so far in the field of trunnionosis. The evidence for this phenomenon, the type of debris particles generated and a contrast between Mo M, non Mo M and resurfacing procedures are also presented.

Endoscopic placement of flatus tube using “lasso” technique with snare wire

A 55-year old man presented with acute sigmoid level which could be reached by the rigid sigmoidoscope to allow decompression, and so a flatus tube was ＂lassoed＂ onto the side of a flexible endoscope which allowed accurate placement under direct vision. This technique allows accurate placement of catheters, feeding tubes and other devices endoscopically, which cannot be placed through the instrument channel of the endoscope.

Role of the clinical immunology laboratory in disease monitoring

Immunological investigations provide useful informa-tion to guide diagnosis of several disorders. Many such tests are also commonly repeated at intervals, in an effort to facilitate disease monitoring. In general how-ever, immunology test results are often slow to alter. Furthermore, audit activity has indicated that repeated testing accounts for a substantial workload in many immunology services, which may waste resources and compromise the effcient completion of necessary tests. Consequently, the need and appropriate mini-mum interval between repeated testing requires critical evaluation. In this review, the clinical utility of repeat-ed performance of several common immunology inves-tigations has been evaluated, based upon published evidence. In some cases （ e.g. , paraprotein quantifca-tion, or measurement of anti-glomerular basement membrane antibodies）, repeated testing provides vital clinical information and can be justifed on a frequent and individualized basis. However, many other investi-gations provided by immunology services provide less valuable information when used to aid disease moni-toring rather than diagnosis. It is hoped that the data summarized here will facilitate a more evidence-based approach to repeated testing. Such information may also assist with the local implementation of demand management strategies based upon setting of mini-mum retesting intervals for these investigations.

Chimeric antigen receptors:On the road to realising their full potential

Chimeric antigen receptors （CARs） are fusion molecules that may be genetically delivered ex-vivo to T-cells and other immune cell populations, thereby conferring specifcity for native target antigens found on the surface of tumour and other target cell types. Antigen recognition by CARs is neither restricted by nor dependent upon human leukocyte antigen antigen expression, favouring widespread use of this technology across transplantation barriers. Signalling is delivered by a designer endodomain that provides a tailored and target-dependent activation signal to polyclonal circulating T-cells. Recent clinical data emphasise the enormous promise of this emer-ging immunotherapeutic strategy for B-cell malignancy, notably acute lymphoblastic leukaemia. In that context, CARs are generally targeted against the ubiquitous B-cell antigen, CD19. However, CAR T-cell immunotherapy is limited by potential for severe ontarget toxicity, notably due to cytokine release syndrome. Furthermore, effcacy in the context of solid tumours remains unproven, owing in part to lack of availability of safe tumourspecific targets, inadequate CAR T-cell homing and hostility of the tumour microenvironment to immune effector deployment. Manufacture and commercial development encountered with more traditional drug products. Finally, there is increasing interest in the application of this technology to the treatment of non-malignant disease states, such as autoimmunity, chronic infection and in the suppression of allograft rejection. Here, we consider the background and direction of travel of this emerging and highly promising treatment for malignant and other disease types.

全民远程会诊 户外散步和交谈形式的心理健康评估

在2019新型冠状病毒肺炎(COVID-19)暴发初期,社区精神卫生服务广泛采用了远程会诊1。Salisbury 解释了为什么远程会诊对许多初级保健患者而言都不理想2。在当今保持社交距离的时代,精神科医生和其他精神卫生从业人员必须发挥创造力.以提供良好的临床护理.同时在评估精神健康时平衡气溶胶感染和沟通问题的风险3。如果无法进行远程会诊(通过视频或电话),通过在户外散步和交谈的形式对患者进行评估可能是最合适的。对于室内会诊而言,气溶胶传播的风险过高,或者患者不能安静的坐着或不想戴口罩。

病例报告 严重高钙血症和急性肾损伤一例

患者58岁，白人，老年男性，精神萎靡、食欲不振、关节疼痛、便秘3个月。自述长期消化不良，并自服抗酸剂。此外，还有排尿踌躇、尿急等下尿路症状。有高血压病史数年，服用一种噻嗪类利尿剂治疗（苄氟噻嗪）。有吸烟史20年，失业。

为拒绝治疗的患者施治:时机和方式

当患者拒绝治疗时应如何处理?相关的法学文献卷快浩繁,令人生畏。本文将为医务工作者简要介绍各类情形所适用的法律基础。当患者拒绝治疗时应如何处理?这是一个难题。因急症而入院的各类患者中,约30%丧失了医疗决策能力,而在罹患心理疾病的住院患者中,这一比例更是超过了40%。临床医生往往会高估患者的能力,忽视他们无法决策的现实。