腹腔镜治疗既往有盆腹腔手术史附件包块患者46例分析

目的 探讨腹腔镜手术治疗既往有盆腹腔手术史附件包块患者的可行性及手术技巧.方法 选取2002年6月～2004年6月恩施自治州中心医院腹腔镜手术治疗的既往有盆腹腔手术史附件包块患者46例作为研究组,随机抽取同期附件包块大小、类型相似、无盆腹腔手术史腹腔镜手术患者50例做为对照组,分析比较2组盆腹腔粘连及手术质量指标情况.结果 研究组与对照组术中发现盆腹腔粘连分别为41.30%(19/46)和12.00%(6/50),差异有显著性.研究组与对照组镜下手术成功率分别为95.65%(44/46)和98.00%(49/50),差异无显著性,2组中转开腹分别为2例和1例,中转原因均为盆腹腔严重致密粘连.2组手术时间分别为(58±8.6)min和(36±7.4)min,出血量分别为(60±11.4)mL和(41±6.8)mL(P＜0.05).研究组出现并发症1例,为术后盆腔血肿,经保守治疗痊愈.结论 既往有盆腹腔手术史患者盆腹腔粘连发生率高,增加了腹腔镜手术难度,但只要术中处理恰当,掌握熟练的内镜操作技术及处理技巧,手术成功率高,再次手术应用微创技术可极大程度减轻患者痛苦,值得临床推广.     

腹腔镜与开腹手术治疗卵巢畸胎瘤的比较

目的与开腹手术比较,探讨腹腔镜手术治疗卵巢畸胎瘤的疗效及安全性。方法回顾性分析该院妇科1998年1月～2002年12月收治的297例卵巢畸胎瘤的手术治疗及疗效。结果平均手术时间腹腔镜组(82.9±23.7)min长于开腹组(67.3±18.3)min(P<0.01);术中出血腹腔镜组(38.4±25.1)mL少于开腹组(81.1±31.3)mL(P<0.01)。两组肿物大小与手术时间均呈正相关。腹腔镜组术后体温低、肛门排气快。住院天数腹腔镜组(9.7±2.6)d短于开腹组(12.1±2.8)d(P<0.01);住院费用腹腔镜组(6624.8±628.0)元高于开腹组(5453.8±953.0)元(P<0.01)。腹腔镜组术后恢复较开腹组快。两组术后并发症及畸胎瘤复发率均相似。结论腹腔镜手术治疗卵巢良性畸胎瘤的疗效和开腹手术相似,虽然住院费用稍高但具有损伤小、出血少、住院时间短、恢复快等优点。     

手术结束前腹腔注水对妇科腹腔镜术后肩痛发生的影响

目的探讨腹腔镜手术后肩痛的预防方法。方法2004年6月￣2004年8月期间在北京大学第一医院妇科一病房行腹腔镜手术的患者98例随机分为两组,研究组(49例)于手术结束时向腹腔内注入2000mL乳酸林格氏液,按传统方法排出腹腔内残余气体,之后再将腹腔内液体引流。对照组(49例)仅按传统方法排出腹腔内残余气体。采用国际通用的10分视觉量表法观察两组术后6h和1￣4d的肩痛的发生率、程度及持续时间。结果术后出现肩痛症状者研究组有18例,占36.7%;对照组有27例,占55.1%,研究组低于对照组,P<0.05。双侧肩痛的比例对照组27例中占25例(92.6%);而研究组18例中仅占7例(38.9%),其比例明显以对照组为高。肩痛出现的时间研究组和对照组均以术后6h和术后3d之内最常见,肩痛的持续天数研究组为(1.8±1.3)d,对照组为(2.4±1.3)d,P=0.056。疼痛者日平均疼痛分值研究组为(2.9±1.4),对照组为(3.3±1.6),P>0.05。两组平均住院时间和恢复工作的时间相似,术后均无明显并发症发生,患者对手术的满意度相似。结论肩痛是腹腔镜手术后的常见的并发症,手术结束前腹腔内注入液体协助排出腹腔内残余气体能明显减少患者术后肩痛的发生。     

非脱垂子宫经阴道及经腹腔镜切除的临床应用比较

目的:比较经改良阴式子宫全切除术(TVH)与腹腔镜下子宫全切除术(TLH)的临床效果.方法:对我院2004年1月至2006年7月间接受以上两种方法治疗子宫病变的342例患者的临床资料进行分析,其中TVH组209例,TLH组133例,比较两组患者术前、术中、术后的情况.结果:(1)术前情况,TVH组子宫肌瘤136例,子宫腺肌症34例,既往盆腹腔手术史30例.TLH组子宫肌瘤98例,子宫腺肌症21例,既往盆腹腔手术史12例.(2)手术时间TVH组(42.5±29.5) min,TLH组(78.6±15.0) min;(3)术中出血量TVH组(72.5±73.1) mL,TLH组(109.4±36.9)mL;(4)术后肛门排气时间TVH组(35.1±9.7) h,TLH组(22.3±6.3) h;(5)术后体温升高发生率TVH组5.6%,TLH组6.1%;(6)术后并发症发生率TVH组2.2%,TLH组2.9%;(7)住院天数TVH组(4.2±1.5) d,TLH组(5.5±1.9)d;(8)住院费用TVH组(3 960±1 058)元,TLH组(5 627±1 125)元.结论:改良TVH组较TLH组手术需时短,术后并发症发生率低,住院费用低,腹壁不留切口瘢痕,达到了创伤小、手术质量高、微创的效果.     

腹腔镜肾肿瘤根治切除术与开放手术的临床效果比较

目的比较评价腹腔镜肾肿瘤根治性切除术与开放手术的临床效果。方法对限期行肾肿瘤的患者均衡分成腹腔镜和开放手术组共53例。对腹腔镜组及开放手术组的手术时间、术中失血、用止痛剂、住院天数进行统计。并对患者长期随访,比较两组的生存率、切口愈合情况及转移情况。结果两组手术均获成功,术前两组患者各项检测指标与正常人无差异。腹腔镜组与开放手术组的患病病例构成、性别构成(P>0.75)、肿瘤临床分期(P>0.25)、年龄(P>0.05)和肿块大小(P>0.05)两组差异无显著性。腹腔镜组平均手术时间为(66.66±10.37)min,而开放手术组为(69.08±11.22)min,两组差异无显著性(P>0.05);术后住院天数腹腔镜组(6.92±0.96)d明显少于开放手术组(11.42±1.57)d(P<0.05);术中失血腹腔镜组(72.03±10.37)mL明显少于开放手术组(154.42±20.42)mL(P<0.01),腹腔镜组术后2人次用止痛剂,开放手术组术后20人次应用度冷丁止痛,两组差异有显著性(P<0.01)。结论与传统的根治性肾肿瘤切除术相比,腹腔镜肾肿瘤根治术具有手术时间短、出血少、住院天数短、康复快、并发症少等优点。     

单孔腹腔镜技术在妇科手术中的应用

目的 讨论单孔腹腔镜技术在妇科领域的应用价值。方法 该院2010年4月-2011年6月行单孔腹腔镜妇科手术20例，观察平均手术时间、出血量及排气时间，术后随访手术效果。结果 平均手术时间（54.45±10.3）min，出血量（30.25±13.8）mL，术后排气时间（33.5±6.0）h，无术中术后并发症发生，单孔组脐部切口隐蔽，不易发觉。结论 单孔腹腔镜手术难度增加，但只要熟练技术，选择合适的病例，同样安全，无并发症，美容效果更好。单孔腹腔镜技术对于妇科良性病变的手术是安全、可行的。     

经胆囊管腹腔镜联合胆道镜胆道探查术应用研究(附80例报告)

目的探讨经胆囊管腹腔镜胆道探查术的临床应用。方法病人分成两组,A组:80例胆囊结石合并胆道继发结石病人,经胆囊管腹腔镜胆道探查术(胆囊管探查组),术后不用T管引流。B组:35例胆囊结石合并胆道继发结石病人,行开腹胆囊切除胆管探查T管引流术。观察手术时间、手术出血量、腹腔引流量、术后并发症、住院时间、肝功能及淀粉酶的变化。结果手术时间:胆囊管组和对照组分别为(168±34)min和(108±11)min,手术出血量为(50±8)mL和(321±53)mL。术后腹腔引流量为(30±17)mL和(104±33)mL,术后住院时间为(7.0±1.2)d和(18.2±2.0)d;术后并发症胆囊管探查组明显少于对照组,两组比较差异有显著性(P<0.001t,检验)。术后第1天谷丙转氨酶有轻微增高,3d后恢复正常,淀粉酶无明显变化。结论经胆囊管腹腔镜胆道探查术治疗继发性胆道结石和部分肝胆管结石是一种简单、可行和安全的微创新方法。     

单孔腹腔镜手术在妇科良性病变中的应用研究

目的探讨单孔腹腔镜技术在妇科良性病变手术中应用的可行性。方法将24例单孔腹腔镜妇科手术与同期48例常规腹腔镜妇科手术进行比较。结果单孔腹腔镜组手术时间(77±10.1)min长于常规腹腔镜组(66.5±8.2)min(t=-3.97,P=0.00);单孔腹腔镜组术中出血量(39.4±6.1)ml与常规腹腔镜(38.6±4.8)ml差异无统计学意义(t=-0.505,P=0.614);单孔腹腔镜组排气时间(42.0±7.5)h与常规腹腔镜组(41.7±7.7)h差异无统计学意义(Z=-0.185,P=0.854);单孔腹腔镜组住院时间(4.3±0.5)d与常规腹腔镜组(4.4±0.5)d差异无统计学意义(Z=-0.345,P=0.73)。两组患者目前均无术后并发症发生。结论单孔腹腔镜技术目前尚处于起步阶段,手术时间稍有延长。单孔腹腔镜技术对患者体表创伤更小,安全可行。     

微型腹腔镜治疗附件囊肿的临床研究

目的探讨微型腹腔镜在治疗附件囊肿中的临床价值。方法对2003年4月￣2004年10月经微型腹腔镜手术治疗的33例附件囊肿病例的资料进行分析,与21例普通腹腔镜手术病例的术中术后效果进行比较。结果研究组:出血量(35±6)mL,手术时间(36±6)min,术后病率10%,术后排气时间(10.3±5)h,术后留院日(2.9±1.0)d;对照组:出血量(45±5)mL,手术时间(30±6)min,术后病率11.3%,术后排气时间(11.3±7)h,术后留院日(4.5±1.0)d。两组相比,研究组术后留院日较对照组短,有统计学意义(P<0.01),其余指标差异无显著性(P>0.05)。结论微型腹腔镜治疗单纯附件囊肿创伤小,恢复快,伤口美观,值得临床推广。     

腹腔镜下卵巢良性畸胎瘤剔除术65例分析

目的探讨腹腔镜下卵巢良性畸胎瘤剥除术的临床应用价值。方法回顾性分析2000年1月￣2003年12月在该院施行的腹腔镜及开腹下卵巢良性畸胎瘤手术的病例,对两组患者的围手术期情况进行比较。结果出血量:65例腹腔镜手术患者术中出血(20.35±35.21)mL,明显少于开腹组(40.21±60.34)mL,P<0.01。腹腔镜组手术(65.75±70.15)min,与开腹组(70.25±73.23)min相近,P>0.05。术后恢复肛门排气时间:腹腔镜组(22.60±3.45)h,比开腹组(44.21±4.23)h明显缩短,P<0.01。术后恢复时间:腹腔镜组(9.22±3.41)d,比开腹组(26.32±6.73)d明显缩短,P<0.01。结论腹腔镜与开腹手术治疗卵巢良性畸胎瘤比较,腹腔镜具有创伤小、术中出血量少和术后恢复快等优点,是一种安全、有效的手术方法,包括体积较大的畸胎瘤均可在腹腔镜下完成手术。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.