ABSTRACT
Due to the particularity of tumor location, the surgery of esophagogastric junc-tion(EGJ) carcinoma needs to meet the safety of negative tumor margin, lymph node dissection and digestive tract reconstruction at the same time, which attracted more and more attention of esopha-gogastric surgeons. The current Siewert and Nishi classifications are based on the tumor epicenter, which is difficult to be accurately evaluated and measured before and during operation, and also lack of significance in determining the surgical methods and approach and lymph node dissection. The authors systematically analyze the limitations of Siewert and Nishi classification, discuss the relationship between esophageal invasion length and mediastinal lymph node metastasis and the role of esophageal invasion length on selection of surgical approach, and propose a modified classi-fication based on esophageal invasion length, including (1) malignant tumors with the upper or lower edge of tumor involving the zone of EGJ are defined as EGJ carcinoma; (2) EGJ carcinoma with the upper edge of tumor located 3.0 cm above the EGJ is classified as type Ⅰ; (3) EGJ carcinoma with the upper edge of tumor located 0?3.0 cm above the EGJ is classified as type Ⅱ; (4) EGJ carcinoma with the upper edge of tumor located 0?2.0 cm below the EGJ is classified as type Ⅲ.
ABSTRACT
Objective:To investigate the short-term efficacy of laparoscopic total gastrec-tomy with hand-sewn esophagojejunostomy versus Roux-en-Y anastomosis.Methods:The propen-sity score matching and retrospective cohort study was conducted. The clinicopathological data of 159 patients who underwent laparoscopic total gastrectomy in Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from October 2014 to July 2021 were collected. There were 107 males and 52 females, aged 63(range, 28?79)years. Of 159 patients, 71 cases undergoing totally laparoscopic total gastrectomy with hand-sewn esophagojejunostomy were allocated into totally laparoscopic group and 88 cases undergoing laparoscopic-assisted total gastrectomy with Roux-en-Y anastomosis were allocated into laparoscopic-assisted group, respectively. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) intraoperative and postoperative conditions; (3) perioperative complications. Propensity score matching was done by the 1:1 nearest neighbor matching method. Measurement data with normal distribution were expressed as Mean± SD, and t test was used for comparison between groups. Measurement data with skewed distribution were expressed as M(range), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher's exact probability method. The rank sum test was used for comparison of ordinal data. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of 159 patients, 112 cases were successfully matched, including 56 cases in the totally laparoscopic group and 56 cases in the laparoscopic-assisted group. Before propensity score matching, age, cases with tumor located in cardia or gastric body in the totally laparoscopic group were 61(range, 30?76)years, 26, 45, respectively. The above indicators in the laparoscopic-assisted group were 65(range, 28?79)years, 50, 38, respectively. There were significant differences in the above indicators between the two groups ( Z=?2.89, χ2=6.43, P<0.05). After propensity score matching, the males and females, age, body mass index, cases of American Society of Anesthesiologists classification Ⅰ, Ⅱ, Ⅲ and Ⅳ, tumor diameter, cases with tumor located in cardia or gastric body, cases in TNM stage Ⅰ, Ⅱ and Ⅲ of patients in the totally laparoscopic group were 40, 16, (62±9)years, (22.7±2.8)kg/m 2, 22, 26, 7, 1, 3.5(range, 0.6?17.0)cm, 24, 32, 22, 9, 25. The above indicators of patients in the laparoscopic-assisted group were 38, 18, (62±10)years, (22.7±3.2)kg/m 2, 19, 32, 5, 0, 4.0(range, 0.6?15.0)cm, 23, 33, 21, 7, 28, respectively. There was no significant difference in the above indicators between the two groups ( χ2=0.17, t=?0.09, ?0.04, Z=?0.12, ?0.82, χ2=0.04, Z=?0.42, P>0.05). The elimination of age and tumor location confounding bias ensured comparability between the two groups. (2) Intraoperative and postoperative conditions: after propensity score matching, the total operation time, time of esophagojejunostomy, postopera-tive 24-hour pain numerical score and time to first out-off bed activities were (310±49)minutes, (37±10)minutes, 2.3±0.8 and (2.4±0.7)days for patients in the totally laparoscopic group, versus (344±77)minutes, (44±12)minutes, 3.1±1.2 and (2.9±1.0)days in the laparoscopic-assisted group, showing significant differences between the two groups ( t=?2.85, ?3.05, ?4.20, ?3.10, P<0.05). (3) Perioperative complications: after propensity score matching, 6 cases of the patients in the totally laparoscopic group had Clavien-Dindo grade 2 or higher complications, including 2 cases of anas-tomotic leak, 1 case of anastomotic stenosis, 1 case of pleural effusion, 1 case of abdominal infection and 1 case of intestinal obstruction. The incidence of Clavien-Dindo grade 2 or higher complications was 10.7%(6/56). In the laparoscopic-assisted group, 5 patients had Clavien-Dindo grade 2 or higher complications, including 2 cases of anastomotic leak, 1 case of abdominal infection, 1 case of intestinal obstruction and 1 case of cholangitis. The incidence of Clavien-Dindo grade 2 or higher complications was 8.9%(5/56). There was no significant difference in the incidence of Clavien-Dindo grade 2 or higher complications between the two groups ( χ2=0.10, P>0.05). Patients with anas-tomotic leak were improved after puncture and drainage, secondary surgery and conservative treat-ment, and other complications were improved after symptomatic treatment. Conclusions:Com-pared with Roux-en-Y anastomosis in laparoscopic total gastrectomy, the time of hand-sewn esophagojejunostomy and esophago-jejunal anastomosis are shorter, patients have less postopera-tive pain and faster postoperative recovery. Both methods have good peri-operative safety.
ABSTRACT
Objective:To investigate the application value of hand-sewn esophagojejunal anastomosis (EJA) in totally laparoscopic total gastrectomy (TLTG).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 35 patients with early or advanced upper gastric cancer who were admitted to Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine between July 2018 and December 2019 were collected. There were 24 males and 11 females, aged (60±10)years, with a range of 35-75 years. All the 35 patients underwent TLTG combined with hand-sewn EJA. Observation indicators: (1) intraoperative situations; (2) postoperative situations; (3) postoperative pathological examination; (4) follow-up and survival. Follow-up was conducted using telephone interview, outpatient examination, short message service and WeChat to detect tumor recurrence, metastasis and survival of patients up to January 2020.Measurement data with normal distribution were repressented as Mean± SD. Measurement data with skewed distribution were represented as M (range). Count data were expressed as absoulte numbers or persentages. Results:(1) Intraoperative situations: all the 35 patients underwent TLTG combined with hand-sewn EJA successfully. The operation time, volume of intraoperative blood loss, time of hand-sewn EJA, costs of consumables used in the intraoperative resection and reconstruction, and costs of consumables used in EJA of the 35 patients were 305 minutes(range, 232-406 minutes), 94 mL(range, 50-300 mL), 37 minutes(range, 20-65 minutes), 13 674 yuan(range, 11 929-15 255 yuan) and 491 yuan(range, 223-1 044 yuan), respectively. Of the 35 patients, 4 received intraoperative blood transfusion. (2) Postoperative situations: time to first out-of-bed activity, postoperative indwelling time of gastric tube, time to initial liquid diet intake, the time to abdominal drainage tube removal and duration of postoperative hospital stay of the 35 patients were 2 days(range, 1-3 days), 4 days(range, 2-11 days), 5 days(range, 4-12 days), 8 days(range, 5-15 days) and 9 days(range, 7-16 days), respectively. Of the 35 patients, 3 had perioperative complications. One patient had inflammation and infection in the pancreatic tail and was discharged at postoperative 16 days after conservative treatment of fasting, somatostatin to reduce the pancreatic secretion, adequate drainage, anti-infection and nutritional support. One had postoperative intestinal incomplete obstruction and was discharged at postoperative 12 days after treatment with gastrointestinal decompression and enema for relief of obstruction. One had pulmonary infection who was discharged at postoperative 9 days after symptomatic and supportive treatment. None of the 35 patients had perioperative anastomotic leakage or bleeding. Of the 35 patients, 1 was diagnosed with esophagojejunostomy stenosis at postoperative 2 months and was improved after endoscopic dilatation. The incidence of long-term anastomosis-related complications of the 35 patients was 2.9%(1/35). (3) Postoperative pathological examination: the pathological examination of the upper margin of intraoperative frozen section and postoperative paraffin section showed negative in the 35 patients. Of the 35 patients, 16 had tumor located at cardia including 4 cases with tumor involving in lower esophagus, 19 had tumor located at stomach; 21 had tumor pathological type as highly or moderately differentiated adenocarcinoma, 11 had poorly differentiated adenocarcinoma, 3 had signed-ring cell carcinoma; 14 had early gastric cancer, 21 had advanced gastric cancer; 7 had tumor invaded at mucosa lamina propria and muscularis, 7 had tumor invaded at submucosa, 1 had tumor invaded at muscularis, 1 had tumor invaded at subserosal, 17 had tumor invaded at serosal, 2 had tumor invaded at extra-serosal adipose tissue. The TNM staging of the 35 patients: 14 were in stage ⅠA , 2 in stage ⅠB, 4 in stage ⅡB, 3 in stage ⅢA, 4 in stage ⅢB and 8 in stage ⅢC. Of the 35 patients, 15 had vascular invasion and 16 had nerve invasion. The tumor diameter, the number of lymph nodes dissected and the number of positive lymph nodes of the 35 patients were 3.9 cm(range, 0.6-12.0 cm), 24(range, 10-40) and 2(range, 0-11). (4) Follow-up and survival: all the 35 patients were followed up for 1-18 months, with a median time of 5 months. Of the 35 patients, tumor recurrence or metastasis was not found in 34 patients, and the other 1 patient was diagnosed with liver metastases of tumor at postoperative 6 months and survived with tumor.Conclusion:Hand-sewn EJA in TLTG is safe and feasible.
ABSTRACT
Objective@#To investigate the effect of enteral nutrition feeding procedure in ICU in severe patients in order to reduce complications and promote rehabilitation of patients.@*Methods@#A total of 184 severe patients admitted to ICU from January to October 2018 were selected as the subjects of the study. 90 patients admitted to the family from January to May were the control group, and 94 patients admitted to the family from June to October were the observation group. The control group adopted routine nutritional support and nursing, and the observation group carried out intensive enteral nutrition feeding process. The nutritional status, immunity, gastrointestinal dysfunction, complications of nosocomial infection and outcome of patients in two groups were compared between the two groups.@*Results@#The nutritional indicators of hemoglobin, serum total protein and serum albumin after a week of treatment were (119.73 ± 9.96), (58.88 ± 2.65), (29.09 ± 1.42) g/L, immunization indicators IgA, IgG, IgM were (2.56±0.10), (2.98±0.36), (1.65±0.15) g/L in the observation group. The control groups were (108.02±9.21), (51.90±2.74), (27.80±1.59), (2.09±0.18), (2.01±0.24), (1.41±0.13)g/L, the difference between the two groups was statistically significant (t=5.81-22.48, P<0.01). The incidence of gastrointestinal dysfunction (gastric retention, diarrhea) in the observation group were 11.70%(11/94), 8.51%(8/94), the incidence of nosocomial infections (ventilator associated pneumonia, catheter related blood stream infection, catheter-associated urinary tract infections) were 6.12‰(5/817), 1.53‰(1/650), 0, the outcome indicators of patients (nutritional standard time, ICU hospitalization time, and mortality rate) were (6.12±1.03) d, (10.98±2.03) d, 13.82%(13/94), all were lower than the control group′s 23.33%(21/90), 20.00%(18/90), 13.06‰(11/842), 11.28‰(8/709), 2.88 ‰(2/694), (7.98 ± 1.54) d, (12.21 ± 1.87) d, 26.67%(24/90), the difference between the two groups was statistically significant (χ2=4.33-8.22, t=6.19, 2.26, P<0.05).@*Conclusions@#The procedure of enteral nutrition feeding in patients with severe illness can effectively reduce enteral nutrition complications and enable patients to obtain effective nutrition early.
ABSTRACT
Objective@#To investigate the significance of monitoring imatinib mesylate (IM) plasma concentrations in patients with gastrointestinal stromal tumor (GIST).@*Methods@#A retrospective descriptive study was carried out. Inclusion criteria: (1) patients with GIST confirmed by postoperative pathology or puncture pathology receiving maintenance therapy of IM; (2) administration of same dose of IM for at least 4 weeks (achieving steady - state plasma concentration). Patients who had severe organ dysfunction, received IM generics, or received IM simultaneously with other drugs significantly affecting IM pharmacokinetic were excluded. A total of 185 patients at the GIST Clinic of Renji Hospital, Shanghai Jiaotong University School of Medicine from August 2018 to May 2019 were enrolled, including 114 males (61.6%) and 71 females (38.4%) with a median age of 60 years old (range, 30-89 years), and 63 advanced cases. Patients receiving preoperative or postoperative adjuvant therapy were given IM 400 mg QD; patients with KIT exon 9 mutation or with disease progression during IM 400 mg QD treatment were given IM 600 mg QD. If the patient had adverse reactions such as myelosuppression during the medication, IM would be reduced or given BID per day. The peripheral venous blood was collected (22 to 24 hours after the last dose for patients who took IM QD and 2 hours before the first dose per day for those who took IM BID). IM plasma concentration was measured through high performance liquid chromatography coupled with tandem mass spectrometry (HPLC-MS/MS). Correlation analysis between IM plasma concentration results and clinical data was performed using linear regression analysis.@*Results@#A total of 241 stable blood samples of IM plasma concentration from 185 patients were finally collected. The IM plasma concentrations were significantly different between the doses of 300 mg/d and 400 mg/d [(942.4±433.5) μg/L vs. (1340.0±500.1) μg/L, t=6.317, P<0.001], and between 400 mg/d and 600 mg/d [(1340.0±500.1) μg/L vs. (2188.0±875.5) μg/L, t=3.557, P=0.004]. Among the blood samples of 57 patients receiving IM 300 mg/d, the IM plasma concentration of the advanced patients was significantly lower than that of the non-advanced patients [(795.6±225.8) μg/L vs. (992.2±484.4) μg/L, t=2.088, P=0.042]. Among the 137 blood samples of patients receiving IM 400 mg/d, the IM plasma concentration was higher in patients aged >60 years than those aged ≤60 years [(1461.0±595.3) μg/L vs. (1240.0±380.9) μg/L, t=2.528, P=0.013] and the IM plasma concentration of cases with diarrhea was significantly lower than that of those without diarrhea [(745.8±249.6) μg/L vs. (1382.0±486.9) μg/L, t=6.794, P<0.001]. Gender, primary location, surgical procedure, mutated gene, mutation type, or time of administration was associated with IM plasma concentration no matter in patients taking IM doses of 400 mg/d or 300 mg/d (all P>0.05). Regression analysis showed that body mass (P=0.004 and P=0.019), body mass index (P=0.016 and P=0.042), and body surface area (P=0.007 and P=0.028) were all negatively correlated with IM plasma concentrations in patients taking IM doses of 300 mg/d and 400 mg/d. Within the 137 patients who received a fixed oral dose of 400 mg/d IM, 17 patients received oral 200 mg BID, whose IM plasma drug concentration was not significantly different compared with that of 120 patients who received 400 mg IM QD [(1488.0±408.3) μg/L vs. (1319.0±509.7) μg/L, t=1.307, P=0.193].@*Conclusions@#Monitoring IM plasma concentration is significant throughout the whole process of management of GIST patients receiving IM treatment. In particular, regular monitoring IM plasma concentration and developing appropriate treatment strategies can bring better therapeutic benefits for patients with low doses, diarrhea, advanced condition and older age.
ABSTRACT
Objective@#To design a record sheet of the core control measures for multi-drug resistant bacteria in ICU and apply it to clinical practice.@*Methods@#Through consulting the guidelines and literature, we designed the ICU core control measures to execute the record sheet and applied the record sheet to patients with multiple resistant bacteria infection. The implementation rate of the core control measures of medical personnel before and after the use of the record sheet(the awareness rate of medical personnel, the awareness rate of nursing staff, the compliance rate of hand hygiene, the implementation rate of isolation medical orders, the implementation rate of isolation marks, the implementation rate of single room isolation or bedside isolation, and the exclusive implementation rate of items), qualified rate of surface disinfection of articles, qualified rate of use of antimicrobial agents and incidence of multi-drug resistant bacteria infection were compared.@*Results@#After implementing the record sheet using the ICU multi-drug resistant bacteria core control measures, the implementation rate of medical personnel's core control measures, the conformity rate of surface disinfection of articles and the acceptance rate of antimicrobial drug use were all improved, the difference was statistically significant (χ2=2.85-432.18, P<0.05 or 0.01); incidence of multi-drug resistant bacteria infection from 15.7%(112/713) to 6.8%(51/748), the difference is statistically significant (χ2=28.22, P<0.05) .@*Conclusions@#The implementation of ICU multi-drug resistant core control measures can improve the rate of implementation of multi-drug resistant core control measures, reduce the incidence of multi-drug resistant infections, and standardize the operation of medical personnel against multiple drug resistant bacteria. The application of ICU multi-drug-resistant core control measures to the management of nosocomial infections in patients with multiple drug-resistant bacteria will help improve the quality of care and ensure the safety of patients.
ABSTRACT
Objective To design a record sheet of the core control measures for multi-drug resistant bacteria in ICU and apply it to clinical practice. Methods Through consulting the guidelines and literature, we designed the ICU core control measures to execute the record sheet and applied the record sheet to patients with multiple resistant bacteria infection. The implementation rate of the core control measures of medical personnel before and after the use of the record sheet(the awareness rate of medical personnel, the awareness rate of nursing staff, the compliance rate of hand hygiene, the implementation rate of isolation medical orders, the implementation rate of isolation marks, the implementation rate of single room isolation or bedside isolation, and the exclusive implementation rate of items), qualified rate of surface disinfection of articles, qualified rate of use of antimicrobial agents and incidence of multi-drug resistant bacteria infection were compared. Results After implementing the record sheet using the ICU multi-drug resistant bacteria core control measures, the implementation rate of medical personnel's core control measures, the conformity rate of surface disinfection of articles and the acceptance rate of antimicrobial drug use were all improved, the difference was statistically significant (χ2=2.85-432.18, P<0.05 or 0.01); incidence of multi-drug resistant bacteria infection from 15.7%(112/713) to 6.8% (51/748), the difference is statistically significant (χ2=28.22, P<0.05). Conclusions The implementation of ICU multi-drug resistant core control measures can improve the rate of implementation of multi-drug resistant core control measures, reduce the incidence of multi-drug resistant infections, and standardize the operation of medical personnel against multiple drug resistant bacteria. The application of ICU multi-drug-resistant core control measures to the management of nosocomial infections in patients with multiple drug-resistant bacteria will help improve the quality of care and ensure the safety of patients.
ABSTRACT
Objective To conclude nursing experience of full series artificial liver support system in the treatment of acute fatty liver in pregnancy. Methods Development of artificial liver support system according to patient's condition, total continuous renal replacement therapy 7days, double plasma molecular absorb system 3 times, plasma replacement 3 times, molecular adsorbent circulation system 2 times. Results After treatment, the patient was discharged after 20 days in hospital. Conclusions The full range of artificial liver support system can effectively treat the patients with acute fatty liver in pregnancy, it will greatly reduce the mortality of patients with acute fatty liver in pregnancy.
ABSTRACT
Objective To establish a pre-hospital and in-hospital first aid rapid linkage treatment platform in order to provide quick rescue time for emergency patients. Methods The interconnection first aid APP was made.The emergency center and traffic command center were combined to participate in first aid. The traffic command center controls the traffic lights in real time to provide the optimal transportation path for the emergency patients.The first aid center carries out preliminary treatment,and shares the patient information to the hospital in real time to make the most suitable doctors waiting for the consultation. The therapeutic effects of patients with acute critical disease before and after the platform applied was compared. Results It has realized the tripartite information linkage between the hospital, the emergency center and the traffic command center. In the experimental group, the pre-hospital emergency response time,the hospital rescue time and the emergency success rate were(16.28±3.08)min, (17.89±5.84)min,87.85%(217/247),the control groups'pre-hospital emergency response time,the rescue time in hospital and the success rate of acute critical patients were(18.29±1.87)min,(24.84±1.69)min, 63.01% (138/219), the data of two groups were statistically significant (t=3.783, 5.745, χ2=5.404, P<0.05). Conclusions The establishment of pre-hospital and in-hospital first aid rapid linkage treatment platform of emergency patients can optimize the patient first aid survival chain, provide greater rescue opportunities for emergency patients.
ABSTRACT
<p><b>OBJECTIVE</b>To investigate the clinical characteristics, pathological classification and prognostic factors of gastrointestinal neuroendocrine neoplasms (GI-NENs).</p><p><b>METHODS</b>Clinicopathological data of 119 GI-NENs patients at Shanghai Renji Hospital from November 2007 to December 2016 were analyzed retrospectively. According to the classification and grading criteria of the WHO Neuroendocrine Tumor 2010 edition, patients were classified pathologically to realize the malignant degree of tumors. The overall survival rate was calculated by Kaplan-Meier curve, the prognostic risk factors were analyzed by Cox regression model, and the factors including the platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR) were included in the analysis in addition to the routine clinicopathological factors.</p><p><b>RESULTS</b>Of 119 patients with GI-NENs, there were 83 cases (69.7%) of male and 36 cases (30.3%) of female. The age of patients ranged from 24 to 86 (median 61) years. Tumor locations included the stomach(n=70, 58.8%), duodenum(n=10, 8.4%), small intestine(n=2, 1.7%), appendix(n=3, 2.5%), colon(n=12, 10.1%), and rectum(n=22, 18.5%). The tumor diameter was 0.6 to 20 cm, the mean diameter was 5.4 cm, and the median diameter was 4 cm. There were 25 cases of G1 neuroendocrine tumor (NET), 7 cases of G2 NET and 87 cases of G3 neuroendocrine carcinoma (NEC). Among the 119 patients, 113 cases (95%) had complete follow-up, and the median follow-up was 75 (1 to 112) months. The 5-years overall survival rate was 58.4%. The survival rate of G1 NET, G2 NET and G3 NEC were 100%, 71.4%, 44.4%, and the difference was statistically significant (P=0.000). Univariate analysis showed that age ≥61 years (P=0.000), tumor located in the stomach, duodenum and colon (P=0.041), tumor size ≥4 cm (P=0.002), pathology classification of G3 NEC (P=0.000), late TNM staging (P=0.000) and blood PLR ≥133 (P=0.017) were associated with lower 5-year survival rate, but blood NLR level was not(P=0.263). Multivariate analysis showed that the patient age (HR=3.036, 95%CI: 1.548 to 5.956, P=0.001), the pathology classification(HR = 1.852, 95%CI:1.099 to 3.122, P=0.021), lymph node metastasis (HR=2.635, 95%CI:1.198 to 5.797, P=0.016) and distant metastasis (HR=2.685, 95%CI:1.383 to 5.214, P=0.004) were independent risk factors affecting the prognosis of patients, but the blood PLR level was not (HR=1.735, 95%CI: 0.947 to 3.176, P=0.074).</p><p><b>CONCLUSIONS</b>The malignant degree of GI-NEN is quite high, and the prognosis of patients is relatively poor. The age, pathological type and TNM staging are closely related to the prognosis of patients. Preoperative blood PLR may play a role in the prediction of prognosis, but preoperative blood NLR is not related with the prognosis of patients.</p>
ABSTRACT
BACKGROUND:With the continuous development of nanotechnology, a growing number of nanotechnologies have been used in the field of biological medicine, providing a great deal of interest for the diagnosis and treatment of disease. OBJECTIVE:To review the research situation of nanobiomaterials and its application in biological medicine. METHODS: The articles about nanobiomaterials and nano bioceramic materials were retrieved from Chinese Journal Ful-text Database, PubMed and Wanfang database published during January 2000 to October 2014 by the first author using computer. Key words were “nano, bioceramics” in Chinese and English, respectively. RESULTS AND CONCLUSION: With the development of nanotechnology, some nanotechnologies have entered the stage of practical application. Application of nanotechnology plays a preventive effect to the occurrence and development of disease. Nano-ceramic significantly increases the strength, toughness and superplasticity of materials, overcomes many deficiencies of biological ceramics, and has been widely used in the field of orthopedics, such as artificial joints, artificial bones, bone filing material, bone replacement materials, artificial vertebrae and so on.