1.Bioinformatics and Animal Experiments Reveal Mechanism of Shouhui Tongbian Capsules in Treating Constipation
Yong LIANG ; Qimeng ZHANG ; Bin GE ; Yang ZHANG ; Yu SHI ; Yue LU ; Hongxi ZHANG
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(4):150-157
ObjectiveTo explore the mechanism of Shouhui Tongbian capsules in treating constipation based on the research foundation of its active components combined with network pharmacology and animal experiments. MethodsThe drug components were imported into SwissTargetPrediction to predict the targets of Shouhui Tongbian capsules, and constipation-related targets were collected from disease databases. A protein-protein interaction (PPI) network was constructed for the common targets shared by Shouhui Tongbian capsules and constipation to screen key targets, which was followed by gene ontology (GO) function and Kyoto encyclopedia of genes and genomes (KEGG) pathway enrichment analyses. A "bioactive component-target-pathway" network was constructed, and the core components of Shouhui Tongbian capsules in treating constipation were screened based on the topological parameters of this network. Molecular docking was employed to predict the binding affinity of core components to key targets. A mouse model of constipation was constructed to screen the key pathways and targets of the drug intervention in constipation. ResultsThe PPI network revealed six key constipation-related targets: protein kinase B (Akt1), B-cell lymphoma-2 (Bcl-2), glycogen synthase kinase-3β (GSK-3β), cyclooxygenase-2 (PTGS2), estrogen receptor 1 (ESR1), and epidermal growth factor receptor (EGFR). The KEGG pathway analysis showed that the phosphatidylinositol 3-kinase (PI3K)/Akt signaling pathway was the most enriched. The topological parameter analysis of the "bioactive component-target-pathway" network screened out the top 10 core components: auranetin, isosinensetin, naringin, diosmetin, quercetin, apigenin, luteolin, hesperidin, isorhapontigenin, and chrysophanol. Molecular docking results showed that the 10 core components had strong binding affinity with the 6 key targets. Animal experiments showed that after intervention with different doses of Shouhui Tongbian capsules, the time to the first black stool excretion was reduced and the fecal water content and small intestine charcoal propulsion rate of mice were improved. After treatment with Shouhui Tongbian capsules, the colonic mucosal injury and glandular arrangement were alleviated, and the muscle layer thickness was increased. Western blot results showed that Shouhui Tongbian capsules recovered the expression of apoptosis-related molecules mediated by the PI3K/Akt pathway in the colonic tissue of constipated mice. Terminal-deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) results showed that the cell apoptosis rate of the colon significantly reduced after intervention with Shouhui Tongbian capsules. ConclusionThe results of network pharmacology and animal experiments confirmed that Shouhui Tongbian capsules can treat constipation through multiple targets and pathways. The capsules can effectively intervene in loperamide-induced constipation in mice by regulating the constipation indicators and reducing cell apoptosis in the colon tissue via activating the PI3K/Akt signaling pathway.
2.The mechanism of SAP overexpression in alleviating periodontitis in mice
HUANG Yinyin ; LIANG Dongliang ; ZOU Yaokun ; HAN Jingru ; GE Qing ; LIU Xueyan ; GUO Yadong ; HUANG Xinli ; YANG Lan
Journal of Prevention and Treatment for Stomatological Diseases 2025;33(8):619-630
Objective:
To investigate the mechanism by which serum amyloid P component (SAP) alleviates periodontitis in mice, providing an experimental basis to establish SAP as a novel therapeutic agent for periodontitis.
Methods:
Ethical approval was obtained from the Institutional Animal Ethics Committee. Periodontitis models were established in wild-type (WT) mice and SAP-transgenic (SAP-Tg) mice, divided into four groups: WT control (WT group), WT periodontitis (WT+P group), SAP-Tg control (Tg group), and SAP-Tg periodontitis (Tg+P group). On day 7, the mice were euthanized, and periodontal tissues, teeth, and alveolar bone were collected. SAP protein expression was detected by enzyme-linked immunosorbent assay (ELISA). Micro-CT and HE staining were used to measure alveolar bone resorption (distance from the cementoenamel junction to the alveolar bone crest). Tartrate-resistant acid phosphatase (TRAP) staining was performed to assess osteoclast number, and immunohistochemistry (IHC) was employed to evaluate macrophage infiltration. The expression levels of inflammatory cytokines including interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) were measured by qRT-PCR. Oral microorganism composition was analyzed using 16S ribosomal RNA (16S rRNA) gene sequencing. Additionally, macrophages from WT and SAP-Tg mice were isolated to establish an in vitro inflammation model, divided into WT+LPS and Tg+LPS groups. The expression of macrophage polarization-related genes including inducible nitric oxide synthase (iNOS), CD86, CD163, and CD206) were assessed by qRT-PCR. After the induction of osteoclast differentiation, TRAP staining was performed.
Results:
ELISA results demonstrated that periodontal tissues from Tg+P group mice exhibited higher levels of SAP expression compared to the WT+P group. Micro-CT and HE staining analyses revealed that the Tg+P group showed reduced alveolar bone resorption, indicated by a shorter distance between the cementoenamel junction and alveolar bone crest, compared to the WT+P group. Furthermore, TRAP staining results indicated a decrease in osteoclast numbers in the Tg+P group compared to the WT+P group. IHC and qRT-PCR results indicated reduced macrophage infiltration and decreased expression of IL-1β, IL-6, and TNF-α in the Tg+P group. Oral microorganism sequencing showed no significant difference in periodontitis-associated pathogenic bacteria between WT+P and Tg+P groups. In vitro experiments demonstrated that compared to the WT+LPS group, the Tg+LPS group exhibited downregulated M1 macrophage markers (iNOS and CD86) and upregulated M2 macrophage markers (CD163 and CD206). TRAP staining confirmed fewer osteoclasts in the Tg+LPS group.
Conclusion
SAP overexpression effectively alleviates periodontitis severity in mice by inhibiting M1 macrophage polarization, reducing pro-inflammatory cytokine expression, and suppressing osteoclast differentiation, thereby attenuating alveolar bone resorption.
3.Non-invasive Modulation of Deep Brain Nuclei by Temporal Interference Stimulation.
Long LI ; Hao BAI ; Linyan WU ; Liang ZHENG ; Liang HUANG ; Yang LI ; Wenlong ZHANG ; Jue WANG ; Shunnan GE ; Yan QU ; Tian LIU
Neuroscience Bulletin 2025;41(5):853-865
Temporal interference (TI) is a form of stimulation that epitomizes an innovative and non-invasive approach for profound neuromodulation of the brain, a technique that has been validated in mice. Yet, the thin cranial bone structure of mice has a marginal influence on the effect of the TI technique and may not effectively showcase its effectiveness in larger animals. Based on this, we carried out TI stimulation experiments on rats. Following the TI intervention, analysis of electrophysiological data and immunofluorescence staining indicated the generation of a stimulation focus within the nucleus accumbens (depth, 8.5 mm) in rats. Our findings affirm the viability of the TI methodology in the presence of thick cranial bones, furnishing efficacious parameters for profound stimulation with TI administered under such conditions. This experiment not only sheds light on the intervention effects of TI deep in the brain but also furnishes robust evidence in support of its prospective clinical utility.
Animals
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Deep Brain Stimulation/methods*
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Nucleus Accumbens/physiology*
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Male
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Rats
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Rats, Sprague-Dawley
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Time Factors
4.Expert consensus on the diagnosis and treatment of cemental tear.
Ye LIANG ; Hongrui LIU ; Chengjia XIE ; Yang YU ; Jinlong SHAO ; Chunxu LV ; Wenyan KANG ; Fuhua YAN ; Yaping PAN ; Faming CHEN ; Yan XU ; Zuomin WANG ; Yao SUN ; Ang LI ; Lili CHEN ; Qingxian LUAN ; Chuanjiang ZHAO ; Zhengguo CAO ; Yi LIU ; Jiang SUN ; Zhongchen SONG ; Lei ZHAO ; Li LIN ; Peihui DING ; Weilian SUN ; Jun WANG ; Jiang LIN ; Guangxun ZHU ; Qi ZHANG ; Lijun LUO ; Jiayin DENG ; Yihuai PAN ; Jin ZHAO ; Aimei SONG ; Hongmei GUO ; Jin ZHANG ; Pingping CUI ; Song GE ; Rui ZHANG ; Xiuyun REN ; Shengbin HUANG ; Xi WEI ; Lihong QIU ; Jing DENG ; Keqing PAN ; Dandan MA ; Hongyu ZHAO ; Dong CHEN ; Liangjun ZHONG ; Gang DING ; Wu CHEN ; Quanchen XU ; Xiaoyu SUN ; Lingqian DU ; Ling LI ; Yijia WANG ; Xiaoyuan LI ; Qiang CHEN ; Hui WANG ; Zheng ZHANG ; Mengmeng LIU ; Chengfei ZHANG ; Xuedong ZHOU ; Shaohua GE
International Journal of Oral Science 2025;17(1):61-61
Cemental tear is a rare and indetectable condition unless obvious clinical signs present with the involvement of surrounding periodontal and periapical tissues. Due to its clinical manifestations similar to common dental issues, such as vertical root fracture, primary endodontic diseases, and periodontal diseases, as well as the low awareness of cemental tear for clinicians, misdiagnosis often occurs. The critical principle for cemental tear treatment is to remove torn fragments, and overlooking fragments leads to futile therapy, which could deteriorate the conditions of the affected teeth. Therefore, accurate diagnosis and subsequent appropriate interventions are vital for managing cemental tear. Novel diagnostic tools, including cone-beam computed tomography (CBCT), microscopes, and enamel matrix derivatives, have improved early detection and management, enhancing tooth retention. The implementation of standardized diagnostic criteria and treatment protocols, combined with improved clinical awareness among dental professionals, serves to mitigate risks of diagnostic errors and suboptimal therapeutic interventions. This expert consensus reviewed the epidemiology, pathogenesis, potential predisposing factors, clinical manifestations, diagnosis, differential diagnosis, treatment, and prognosis of cemental tear, aiming to provide a clinical guideline and facilitate clinicians to have a better understanding of cemental tear.
Humans
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Dental Cementum/injuries*
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Consensus
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Diagnosis, Differential
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Cone-Beam Computed Tomography
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Tooth Fractures/therapy*
5.Analysis of five Chinese individuals with rare thalassemia mutation HBB: c. 93-21G>A
Guangkuan ZENG ; Yiyuan GE ; Xiaomin MA ; Xiaohua YU ; Bairu LAI ; Yuwei LIAO ; Lili LIU ; Yanbin CAO ; Yanqing ZENG ; Yuchan HUANG ; Jianlian LIANG ; Liye YANG
Chinese Journal of Medical Genetics 2024;41(10):1171-1175
Objective:To explore the hematological phenotype and genotypic characteristics of five Chinese individuals with a rare thalassemia mutation HBB: c. 93-21G>A. Methods:A retrospective study was carried out on five individuals identified by the People′s Hospital of Yangjiang and Guangzhou Hybribio Co., Ltd. from May 2018 to September 2022. Routine blood test and hemoglobin electrophoresis were performed, and the genotypes of five subjects were determined by using PCR combined with reverse dot blotting (RDB), nested PCR, Gap-PCR and Sanger sequencing. This study was approved by Medical Ethics Cornmittee of the People′s Hospital of Yangjiang (Ethics No. 20240001).Results:Among the five individuals, hematological data of one was unavailable, and the remaining four had presented with microcytosis and hypochromia. The results of hemoglobin electrophoresis indicated that all of them had a HbA 2 level of ≥4.7%. Genetic analysis showed that one case had harbored compound heterozygous mutations of ααα anti3.7 triplet and HBB: c. 93-21G>A, one had compound heterozygous mutations of -α 3.7 and HBB: c. 93-21G>A, whilst the remaining three were heterozygous for the HBB: c. 93-21G>A mutation. Conclusion:The hematological phenotype of β-thalassemia carriers ( HBB: c. 93-21G>A) is similar to that of other β + thalassemia heterozygotes with mild β-thalassemia characteristics.
6.Prediction of Wind Turbine Lubricating Oil's Acid Value by Ordinary Least Square Method Based on Attenuated Total Reflectance-Fourier Transform Infrared Spectroscopy Through Higher-Order Derivative Combined with Angular Metric
Chun-Hui GE ; Yan-Jun LIU ; Meng-Shi CHEN ; Ce YANG ; Pei-Pei LIANG ; Zhi-Xiang YAO ; Kai ZHANG
Chinese Journal of Analytical Chemistry 2024;52(9):1254-1265,中插1-中插4
To address the key challenges in multivariate statistical modeling,a higher-order derivative approach combined with vector space angle multiplicative error correction was proposed for establishing an acid value prediction ordinary least squares(OLS)regression model based on attenuated total reflectance-Fourier transform infrared(ATR-FTIR)spectroscopy.By using acid values measured by potentiometric titration as reference,ATR-FTIR spectroscopy was utilized for direct calibration and prediction of acid values on 96 kinds of lubricating oil samples from a wind turbine.Firstly,the simulated hyperbolic(SH)method was employed to obtain accurate fourth derivative spectrum,resolving overlapping bands and enhancing spectral selectivity.Then,from the calibration set(48 samples),informative spectral regions were identified based on correlation coefficients.Next,the sample with the highest acid value was selected as the reference and1/(1+tan(θ/2))was used as the metric relation of the spectrum to suppress the multiplicity error caused by factors such as the change of effective optical path in ATR-FTIR spectroscopy.After pretreatment of the spectrum by the method of fourth-order derivative combined with angular quantity,the number of variables decreased from 1737 to 8,and the matrix condition number decreased from 1.85×1015 to 56.34,which effectively eliminated the collinearity issue for OLS regression.Direct OLS modeling on spectral preprocessed data achieved a determination coefficient of 0.981 for 47 validation samples,with a relative error range of-8.38%-8.22%,outperforming the commonly used partial least squares(PLS)method(Determination coefficient of 0.865,relative error of-27.82%-22.38%).It was proved that effective data preprocessing significantly improved the prediction accuracy of the model.Furthermore,when the number of calibration set was compressed to 25 and the number of validation set was expanded to 70,the model retained 8 variables with a condition number of 42.60,the determination coefficient of validation set was 0.972,and the relative error ranged from-10.80%to 12.31%.Comparing with the PLS method(Determination coefficient of 0.724,relative error of-34.26%-53.84%),the improvement was more obvious,which showed that the method could still have high prediction accuracy even with fewer modeling samples as well as robustness against multiplicative error interference.
7.Traditional Chinese Medicine in Treatment of Constipation Based on 5-HT Signaling Pathway: A Review
Yong LIANG ; Bin GE ; Yu SHI ; Yang ZHANG ; Hongxi ZHANG
Chinese Journal of Experimental Traditional Medical Formulae 2024;30(8):271-279
Chronic constipation (CC) is one of the most common functional gastrointestinal diseases. At present, the overall therapeutic effect of CC is still not satisfactory worldwide, which seriously affects the quality of life and social function of patients. The etiology and pathophysiological mechanism of constipation are still unclear. It involves comprehensive factors such as heredity, social psychology, diet, intestinal flora imbalance, intestinal motility disorder, visceral sensitivity change, pelvic floor muscle group dysfunction and enteric nervous system (ENS) disorder. Among them, the abnormal factors of the brain-gut-microbiome axis are particularly significant. The brain-gut-microbiome axis is a complex network of interactions between the intestine and the brain, integrating and coordinating the physiological functions and pathological processes of the gastrointestinal tract. Microorganisms in the intestinal lumen play an important role in it, and can communicate with the intestinal tract and the central nervous system through nerve, endocrine and immune pathways. As a key brain-gut peptide in the regulation pathway of the brain-gut-microbiome axis, 5-hydroxytryptamine (5-HT) is involved in the regulation of gastrointestinal motility, sensation and secretion. The abnormal conduction of the 5-HT signaling pathway is closely related to the occurrence and development of constipation. Traditional Chinese medicine(TCM) is a unique precious resource in China, which has good curative effects and safety. In recent years, it has received extensive attention in the treatment of constipation. TCM and active ingredients, acupuncture and massage specifically regulate 5-HT signal transmission, so that the expressions of related molecules tend to be suitable for individual disease state levels to effectively improve constipation symptoms, with unique advantages. Therefore, this study used ''constipation'', ''intestinal flora'', ''5-HT'', and ''traditional Chinese medicine'' as the keywords to search PubMed, China National Knowledge Infrastructure (CNKI) and other literature databases. The correlation between 5-HT and constipation as well as brain-gut-microbiome axis and the research progress of TCM intervention in the 5-HT signaling pathway in the treatment of constipation were reviewed in order to explore the potential therapeutic value of 5-HT system in this disease and provide references for subsequent research.
8.Regulation of Constipation-related Signaling Pathways by Traditional Chinese Medicine: A Review
Yong LIANG ; Bin GE ; Yu SHI ; Yang ZHANG ; Hongxi ZHANG
Chinese Journal of Experimental Traditional Medical Formulae 2024;30(20):230-240
Chronic constipation (CC) is one of the common and frequent functional gastrointestinal diseases in clinic. At present, the overall therapeutic effect of CC is still not satisfactory in China and abroad, which seriously affects the quality of life of patients. The pathophysiological mechanism of constipation has not been fully elucidated, and studies have mainly focused on the dysfunction of the enteric nervous system (ENS), abnormalities of Cajal interstitial cells (ICCs), alterations in mucosal immune function (low-grade intestinal inflammation, intestinal barrier damage, and immune activation), abnormalities of gastrointestinal hormones, dysregulation of intestinal flora, and dysfunctions of intestinal dynamics. Traditional Chinese medicine (TCM) is a unique and precious resource in China with good efficacy and safety. TCM and its active ingredients can effectively treat constipation, and its mechanism of action needs to be further investigated. Signaling pathways are involved in the development of constipation, which is one of the main targets in the study of pathological mechanisms of constipation and the pharmacological study of therapeutic drugs. Therefore, the authors searched PubMed, China National Knowledge Infrastructure (CNKI), and other literature databases with the keywords of ''constipation'', ''signaling pathway'', and ''traditional Chinese medicine'' to systematically summarize the signaling pathways related to constipation regulated by TCM. The comprehensive analysis shows that TCM mainly plays a role in regulating autophagy, apoptosis, and proliferation and ensuring anti-oxidative stress, anti-inflammation, and protection of intestinal barrier of ICCs by modulating signaling pathways such as stem cell factor/tyrosine kinase receptor (SCF/c-kit), phosphatidylinositol 3-kinase/protein kinase B (PI3K/Akt), 5-hydroxytryptophan (5-HT), mitogen-activated protein kinases (MAPK), and Toll-like receptors (TLRs). TCM regulates neurotransmitter secretion and intestinal water metabolism to improve constipation. This demonstrates the advantages of multi-level, multi-target, and multi-level effects of TCM, and in-depth research can provide new ideas for exploring the pathogenesis of constipation and developing new drugs.
9.Hyperoside nanoparticles loaded with bone marrow mesenchymal stem cells synergistically repair endometrial injury
Rui-Fang HAN ; Hai-Yi ZHOU ; Xing-Shan LIANG ; Si-Yi HE ; Yong-Ge GUAN ; Yang SONG
Chinese Pharmacological Bulletin 2024;40(7):1302-1311
Aim To evaluate the effect of hyperoside/chitosan-nanoparticles(Hyp-NPs)on bone marrow mesenchymal stem cells(BMSCs)in vitro cell experi-ments and the underlying mechanism,and to conduct in vivo animal experiments to investigate the synergistic effect of Hyp-NPs and BMSCs on repairing endometrial damage in rats.Methods BMSCs were identified by flow cytometry.Hyp-NPs were prepared by ion crosslinking method,characterized and evaluated by laser particle size analyzer and transmission electron microscopy.The effects of different concentrations of Hyp-NPs on the migration of BMSCs were evaluated by scratch assay and immunofluorescence.NRF2 lentivir-us vector was constructed to explore the mechanism of Hyp-NPs on BMSCs.In animal experiments,Hyp-NPs loaded with BMSCs were co-transplanted into the uter-ine cavity of a rat model of endometrial injury.HE,Masson,IHC,TUNEL,and ELISA experiments were used to systematically evaluate the repair effect and pregnancy function of the composite formulation on rat endometrial injury from multiple aspects and angles,including general pathology,fibrosis,receptivity,cell proliferation,angiogenesis,stem cell recruitment,and inflammation of the endometrium.Results BMSCs were successfully isolated and cultured.Hyp-NPs with high stability and small particle size were successfully prepared.Scratch experiments indicated that Hyp-NPs could promote the migration of BMSCs.By successfully constructing a lentiviral NRF2 vector and oxidative damage model for BMSCs,immunofluorescence experi-ments showed that Hyp-NPs could regulate the biologi-cal axis of BMSCs by activating NRF2.Animal experi-ments showed that the synergistic administration of Hyp-NPs and BMSCs could increase endometrial thick-ness and glandular quantity,promote stem cell homing through anti-fibrotic,anti-apoptotic,and anti-inflam-matory effects,and restore pregnancy function in rats with endometrial injury.Conclusion The synergistic administration of Hyp-NPs and BMSCs could repair en-dometrial injury.
10.Secondary targeted percutaneous vertebroplasty for the treatment of refracture of injured vertebrae after vertebral augmentation for osteoporotic vertebral compression fracture
Chaoyuan GE ; Dingjun HAO ; Zhengwei XU ; Liang YAN ; Baorong HE ; Wenlong YANG ; Lixiong QIAN ; Xiaowei YANG
Chinese Journal of Trauma 2024;40(6):516-521
Objective:To explore the efficacy of secondary targeted percutaneous vertebroplasty (PVP) for the treatment of refracture of injured vertebrae after vertebral augmentation for osteoporotic vertebral compression fracture (OVCF).Methods:A retrospective case series study was performed on the clinical data of 25 patients with refracture of injured vertebrae after vertebral augmentation for OVCF admitted to Honghui Hospital, Xi′an Jiaotong University from January 2019 to January 2022, including 10 males and 15 females, aged 62-86 years [(73.8±5.2)years]. The fractured segments involved T 10 in 1 patient, T 11 in 2, T 12 in 10, L 1 in 10 and L 2 in 2. All the patients were treated with secondary targeted PVP. The operation time and the amount of bone cement injected were recorded. The visual analogue scale (VAS) of lower back, Oswestry disability index (ODI), vertebral body index (VBI) and kyphotic angle (KA) were compared before surgery, at 1 day, 6 months after surgery and at the last follow-up. Odom criteria were used to evaluate the efficacy of the surgical procedure at the last follow-up. The intraoperative bone cement leakage and new vertebrae fracture during follow-up were observed. Results:All the patients were followed up for 23-59 months [(36.8±7.6)months]. The operation time was 35-60 minutes [(42.6±5.2)minutes], with the amount of bone cement injected for 3-5 ml [(3.6±0.8)ml]. The VAS scores of lower back at 1 day, 6 months after surgery and at the last follow-up were 3.1(2.0, 4.0)points, 1.7(1.0, 2.0)points and 0.6(0.0, 1.0)points respectively, significantly lower than 7.6(7.0, 9.0)points before surgery ( P<0.01), and a statistically singnificant decrease was found over follow-up time ( P<0.01). The ODI values at 1 day, 6 months after surgery and at the last follow-up were (49.5±5.9)%, (28.5±4.6)% and (19.2±4.8)% respectively, significantly lower than (78.8±6.8)% before surgery ( P<0.01), and a statistically singnificant decrease was found over follow-up time ( P<0.01). The VBI values at 1 day, 6 months after surgery and at the last follow-up were (76.6±4.5)%, (76.3±4.0)% and (76.1±3.8)% respectively, significantly higher than (58.9±5.8)% before surgery ( P<0.01), while there were no significant differences among those at 1 day, 6 months after surgery and at the last follow-up ( P>0.05). The KA values at 1 day, 6 months after surgery and at the last follow-up were (12.4±2.7)°, (12.6±2.5)° and (12.8±2.9)° respectively, significantly lower than (20.8±3.6)° before surgery ( P<0.01), while there were no significant differences among those at 1 day, 6 months after surgery and at the last follow-up ( P>0.05). According to the Odom criteria, 20 patients were rated excellent and 5 good at the last follow-up, with an excellent and good rate of 100%. Intraoperative asymptomatic bone cement leakage occurred in 3 patients (12%), including 2 with intervertebral leakage and 1 with lateral vertebral leakage. No adjacent vertebral body or other vertebral fracture was observed during the follow-up. Conclusions:For patients with refracture of injured vertebrae after vertebral augmentation for OVCF, the secondary targeted PVP has advantages of attenuation of the lower back pain, improvement of the quality of life, restoration of the height of refractured vertebrae, correction of the local kyphosis, and a low incidence of complications.


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