阴道内镜的临床应用评价

目的对幼女或未婚女性及普通患者采取阴道内镜(vaginoscopy)的宫腔镜非接触性技术对此类患者检查施治,查找出血原因取出阴道内异物,并分析评价治疗方法。方法以140例患者为研究对象,对幼女(15例)或未婚女性(20例)及其他55例普通患者采用阴道内镜技术对其进行阴道及宫腔检查并取出阴道内异物,用注射器经检查镜侧孔抽吸子宫内膜病理标本,通过特殊的比量法测量宫腔深度,对其他50例普通患者采用常规宫腔镜检查方法进行检查,记录所有患者的手术时间,术后疼痛状况。术后对所有患者进行随访,了解感染情况。结果幼女或未婚女性患者在检查中均未损伤处女膜。阴道内镜检查与常规宫腔镜检查相比手术时间差异无显著性,术后疼痛明显低于常规宫腔镜检查(P<0.05)。所有患者均无术后盆腔感染情况发生。92.73%的阴道内镜检查患者病理取材满意。结论阴道内镜检查可以显著地减低宫腔镜检查时的疼痛,免除了对处女膜的损伤。可取出阴道内异物,发现由阴道内而非宫腔内引发出血的疾患所在。镜体位置移动更加灵活,便于对子宫位置极度偏曲的患者进行检查。采用经检查镜侧孔进行活检取材,在绝大多数的情况下病理取材满意。较常规宫腔镜检查更微创,尤其适合幼女及未婚患者的下生殖道病变的检查,具有推广应用价值。     

简易膨宫装置的制作与应用

随着人们对健康认识的提高，广大妇女对妇科病的普查工作非常重视。2002年我院开展了宫腔镜检查及宫腔镜治疗，对女性不孕症、不规则阴道出血、宫腔粘连、闭经后阴道出血、子宫内膜炎、子宫黏膜下肌瘤等妇科疾病，给予相应的检查及治疗。具有不开腹、无切口、创伤小、术后恢复快等优点。宫腔镜系统包括：检查镜、治疗镜、镜壳、显示器、光源及膨宫装置。膨宫装置是一台DG-Ⅰ电脑膨宫压力器及随机配备的一个广口玻璃瓶。     

绝经后妇女子宫内膜恶性病变危险因素分析

绝经后子宫出血是子宫内膜癌的危险信号，约80%的子宫内膜癌发生在绝经后。近年来，绝经后子宫内膜癌的发病率逐渐升高。宫腔镜是早期诊断绝经后宫腔内病变的金标准，但术中膨宫压力和膨宫介质可能造成子宫内膜组织尤其是肿瘤细胞经输卵管播散至盆腹腔而增加临床分期。本次研究分析154例绝经后妇女的临床资料，探讨宫腔镜术前筛查绝经后妇女子宫内膜恶性病变的危险因素。     

宫腔镜操作系统冷刀微剪分离术在宫腔粘连患者临床治疗中的可行性分析

目的 探讨宫腔镜操作系统（HEOS）冷刀微剪分离术在宫腔粘连患者中的临床疗效及安全性。方法收集200例宫腔粘连患者，根据其治疗方式分为HEOS冷刀微剪分离术治疗组（观察组）和传统宫腔镜下电切分离术治疗组（对照组），每组各100例，比较2组患者的手术指标、疗效与术后并发症。结果 观察组的手术时间短于对照组，其术中出血量、膨宫液吸收量均少于对照组（P均<0.05）。观察组与对照组的临床疗效比较差异有统计学意义（P <0.05），观察组痊愈率为61%，高于对照组的45%(P <0.05)。观察组患者中，发生术后出血1例、感染2例、盆腔粘连1例，并发症发生率为4%；对照组患者中，发生术后出血5例、感染2例、异位妊娠3例、盆腔粘连5例，并发症发生率为15%。观察组的并发症发生率低于对照组（P <0.05）。结论 采用HEOS冷刀宫腔镜微剪分离术治疗宫腔粘连患者，疗效良好，安全性高。     

简易膨宫装置的制作与应用

随着人们对健康认识的提高,广大妇女对妇科病的普查工作非常重视.2002年我院开展了宫腔镜检查及宫腔镜治疗,对女性不孕症、不规则阴道出血、宫腔粘连、闭经后阴道出血、子宫内膜炎、子宫黏膜下肌瘤等妇科疾病,给予相应的检查及治疗.具有不开腹、无切口、创伤小、术后恢复快等优点[1].宫腔镜系统包括:检查镜、治疗镜、镜壳、显示器、光源及膨宫装置.膨宫装置是一台DG-I电脑膨宫压力器及随机配备的一个广口玻璃瓶.两根橡胶管,各长150 cm.金属接头4个,以上物品使用前必须灭菌处理.玻璃瓶仅为容量装置,包装及消毒灭菌时易碎,故将其改进.现介绍如下.     

HEOS宫腔镜下微型剪刀分离术与宫腔镜电切分离术治疗重度宫腔粘连患者的疗效比较

目的：对比HEOS宫腔镜下微型剪刀分离术与宫腔镜电切分离术治疗重度宫腔粘连（IUA）患者的效果。方法：选取2019年1月至2021年3月收治的96例重度IUA患者，进行前瞻性随机平行对照研究，按随机数字表法分成A组和B组各48例。B组接受宫腔镜电切分离术治疗，A组接受HEOS宫腔镜下微型剪刀分离术治疗。对比两组围术期指标、手术效果、术前及术后3个月血清基质金属蛋白酶-9（MMP-9）、转化生长因子-β1（TGF-β1）水平、术后3个月复发率。结果：A组膨宫液吸收量及术中失血量均较B组少，手术时长较B组短（P＜0.05）；A组总有效率93.75%（45/48）较B组77.08%（37/48）高（P＜0.05）；术后3个月A组血清MMP-9水平较B组高，血清TGF-β1水平较B组低（P＜0.05）；术后3个月A组复发率2.08%（1/48）较B组16.67%（8/48）低（P＜0.05）。结论：与宫腔镜电切分离术治疗重度IUA患者相比，应用HEOS宫腔镜下微型剪刀分离术治疗于优化围术期指标、提升手术效果方面更具优势，且更能有效调节血清MMP-9、TGF-β1水平，降低复发率。     

无痛与非无痛技术的宫腔镜检查比较

宫腔镜检查是采用膨宫介质扩张宫腔，通过纤维导光束和透镜将冷光源经子宫镜导入宫腔内，直视下观察子宫颈管、子宫内口、宫内膜及输卵管开口，对宫腔内的生理及病理情况进行检查和诊断。随着医疗技术水平的提高，无痛技术的应用越来越广泛，现就在宫腔镜检查中的应用与传统的非无痛宫腔镜检查进行比较，报告如下。     

分析宫腔内占位性病变超声及非接触性宫腔镜诊断价值及应用体会

目的:系统探究宫腔内占位性病变超声及非接触性宫腔镜诊断价值。方法:选取2019年3月-2020年2月于我院的宫腔内占位性病变患者共80例,通过随机抽样方式将80例患者随机分为治疗组和对照组。其中,对照组40例患者行常规宫腔镜检查,治疗组40例患者行超声定位阴道内镜检查,比较两组检查时间、患者术后感染情况、疼痛评分等参数,并将超声定位阴道内镜诊断结果与"金标准"病理活检结果进行对照分析。结果:(1)治疗组患者的平均检查时间为3.4±0.3 min,显著低于对照组5.2±0.5 min(P<0.05);(2)治疗组患者的VAS疼痛等级评分为1.6±0.4分,显著低于对照组4.7±0.9分(P<0.05);(3)治疗组术后感染复发率为0%,对照组术后感染复发率为5.00%(2/40),两者之间的差异具有统计学意义(P<0.05);(4)80例患者均平行送病理活检,诊断结果为子宫内膜息肉40例,子宫黏膜下肌瘤27例,子宫内膜增生12例,子宫内膜癌1例,其中对照组诊断准确率为80.0%,治疗组准确率为92.5%,经超声定位阴道内镜的结果准确率显著高于常规宫腔镜检查(P<0.05)。结论:超声定位指导下的阴道内镜检查可显著降低患者疼痛,缩短检查时间,并具有直观、准确等优势,较之于常规宫腔镜检查更具有实用性,值得在临床大面积推广。     

10mm取石钳联合宫腔镜电切术治疗子宫黏膜下肌瘤的临床研究

目的探讨10mm取石钳联合宫腔镜电切术治疗子宫黏膜下肌瘤的临床应用价值。方法将2009年1月～2011年12月在该院使用10mm取石钳联合宫腔镜下电切术治疗的29例子宫黏膜下肌瘤作为联合治疗组,2006年1月～2008年12月在该院单纯采用宫腔镜电切术治疗的27例子宫黏膜下肌瘤作为对照组,两组病例在年龄、肌瘤大小、个数、类型等一般情况方面无差异,该文主要比较分析两组手术病例的一般情况、手术治疗效果、手术时间、出血量、膨宫液体用量、并发症等情况。结果与对照组相比联合治疗组病例的手术时间更短,膨宫液体使用量更少,子宫穿孔、周围脏器损伤、大出血,稀释性低钠血症、宫腔感染等并发症发生率也更低,两者之间的差异有显著性。结论 10mm取石钳联合宫腔镜电切术治疗子宫黏膜下肌瘤是一种操作简便、安全有效的治疗方法,值得临床推广应用。     

膨宫介质5％葡萄糖在宫腔镜下子宫内膜切除术中对患者生化指标的影响——附30例报告

目的：探讨膨宫介质5％葡萄糖在宫腔镜下子宫内膜切除术中对患者生化指标的影响，以明确5％葡萄糖作为膨宫介质的安全性。方法：30例功能失调性子宫出血患者行宫腔镜下子宫内膜切除术，以5％葡萄糖作为膨宫介质，于手术前、后分别采集静脉血测定血钠、血氯、血钾及血糖等生化指标，比较手术前、后患者生化指标的变化，并应用统计学方法分析膨宫介质的吸收量与生化指标变化的相关性。结果：30例手术顺利完成，无发生过度水化综合征者，术后月经改善率达100％。术后血糖比术前明显增高（P〈0．01），血钠、血氯、血钾则比术前明显降低（P〈0．05）。术后血钠下降幅度与膨宫介质的吸收量呈正相关（r=0．772，P〈0．01）；术后血糖上升幅度与膨宫介质的吸收量呈正相关（r=0．926，P〈0．01）；在控制膨宫介质的吸收量因素的影响后，血钠的下降幅度与血糖的升高幅度无明显相关性（r=-0．110，P〉0．05）。30例于术后1个月复查各项生化指标均正常。结论：5％葡萄糖用作宫腔镜下子宫内膜切除术的膨宫介质，术中灌流液的吸收可引起血钠、血钾、血氯、血糖等生化指标的改变，但一过性血糖升高并不会导致血钠下降，使用5％葡萄糖作为膨宫介质是安全的．     

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.