急性深静脉血栓患者早日下床活动可行性与安全性的系统评价

目的探讨急性深静脉血栓患者早日下床活动的可行性及安全性。方法计算机检索中英文数据库中关于急性深静脉血栓患者早期活动的临床对照试验,同时筛检纳入的参考文献。由2名研究者对文献质量进行严格评价和资料提取,对符合质量标准的随机对照研究进行Meta分析。结果共纳入13篇文献,10篇为随机对照研究,3篇临床对照试验。Meta分析结果显示:与卧床休息相比,早日下床活动不增加深静脉血栓急性期患者继发新鲜肺栓塞的发生率[早期活动:22/1 408;卧床休息:34/1 417;RR=0.62,95%CI(0.37,1.03)]、深静脉血栓形成的发生率[早期活动:48/1 523;卧床休息:45/1 525;RR=0.85,95%CI(0.58,1.24)]。早期活动对患者病死率、肿胀、疼痛症状缓解方面,差异无统计学意义。结论深静脉血栓急性期患者早日下床活动不增加血栓进展及继发新鲜肺栓塞的发生率;同时,不能明显缓解深静脉血栓患者肿胀、疼痛症状,但可以降低深静脉血栓患者急性期中、重度疼痛的程度。     

一例甲状腺癌术后下肢深静脉血栓患者急性期下床活动的可行性循证护理

目的探讨甲状腺癌术后下肢深静脉血栓患者急性期是否能够下床活动的循证护理方案,为患者提供更安全、优质的护理。方法结合患者的病史、具体表现,提出所要解决的甲状腺癌术后下肢深静脉血栓患者急性期的护理问题,检索文献以获得相关证据,依据循证医学三结合的原则(最佳研究证据、临床经验、患者意愿相结合)制订护理方案。结果文献纳入指南2篇,随机对照试验10篇。证据推荐在充分正规抗凝基础上,排除特殊类型血栓,在患者可耐受情况下可以下床活动。根据证据结果、医生医嘱结合患者意愿,指导患者确诊深静脉血栓第4天下床活动,活动过程中患者未发生肺栓塞,血栓未进展,未增加患者下肢肿胀及疼痛程度。结论应用循证医学方法,采用高质量循证的证据为甲状腺癌术后下肢深静脉血栓急性期患者制订个性化的护理方案,能够减少患者卧床和住院时间,降低医疗费用。     

骨科术后下肢深静脉血栓的防治

目的探讨骨科术后下肢深静脉血栓的防治措施。方法回顾性分析15例下肢深静脉血栓,对患者采用卧床休息、抬高患肢,溶栓、抗凝等治疗。结果所有病例经治疗后症状缓解,复查超声提示血栓消失或缩小,无严重并发症。结论下肢深静脉血栓可继发肺栓塞导致死亡,医护人员在临床工作中要引起足够重视,对骨科技术有血栓形成高危因素的患者要早期预防,做到及时发现、积极治疗。     

MIPO钢板与髓内钉治疗胫骨骨折的Meta分析

目的：探讨微创钢板接骨术钢板（M IPPO ）与带锁髓内钉（IIN ）治疗胫骨骨折的疗效差异。方法计算机检索Cochrane图书馆、MEDLINE数据库、中国生物医学文献数据库,收集 MIPPO与IIN治疗胫骨骨折的临床对比研究,并采用Revman5．0软件进行M eta分析。结果共纳入6篇英文、7篇中文文献。M eta分析结果显示,MIPPO与IIN在手术时间[WMD＝-10．90,95％ CI（-24．93,3．13）,P＞0．05]、Joher-wrushs功能评分[RR＝0．99,95％ CI（0．94,1．05）,P＞0．05]上差异均无统计学意义。但MIPPO 能缩短骨折愈合时间[WMD＝-1．20,95％ CI（-2．03,-0．37）,P＜0．05]。结论与IIN相比,MIPPO能缩短骨折愈合时间。     

间歇性充气压力系统在预防深静脉血栓中的应用

近年来,下肢深静脉血栓（DVT）形成的发病率日益增高。在腹部手术、骨科手术、产后以及创伤后、手术后长期卧床患者中40％～65％会并发DVT,0．5％～2．0％的患者发生致命性肺栓塞（PE）。尤其神经外科危重患者及创伤患者多长期卧床,极易形成下肢深静脉血栓。我科自2005年以来,在预防深静脉血栓传统措施的基础上,应用间歇性充气压力系统预防深静脉血栓,效果满意,现报道如下。     

系统性红斑狼疮患者血清基质金属蛋白酶-9浓度变化的Meta分析

目的：对系统性红斑狼疮（SLE）患者血清基质金属蛋白酶-9（MMP-9）的浓度变化进行系统评价。方法使用循证医学文献分析方法,从CBM、CNKI、维普科技期刊数据库及Pubmed文献数据库中检索有关SLE患者血清M M P-9浓度的文献,使用Rev M an5．0软件进行M eta分析。结果共有7篇文献入选,M eta分析结果显示SLE患者血清MMP-9浓度与健康对照组相比差异无统计学意义（P＞0．05）。结论血清MMP-9浓度不足以用作SLE协助诊断及疗效判断的指标。     

三阴性乳腺癌新辅助化疗前Ki-67表达与病理完全反应相关性的Meta分析

目的：对三阴性乳腺癌新辅助化疗前Ki-67表达与病理完全反应相关性进行系统综合评价。方法从PubM ed、中国期刊全文数据库及万方数据库中,检索有关Ki-67和三阴性乳腺癌新辅助化疗病理完全反应的文献,用风险比（RR）评价三阴性乳腺癌新辅助化疗前 Ki-67和病理完全反应间的关系,用 Rev-Man 5．2软件进行M eta分析。结果共纳入10篇文献（中文3篇,英文7篇）,三阴性乳腺癌患者共649例。采用固定效应模型计算合并RR＝4．04,95％ CI＝2．66-6．15（P＜0．01）。结论化疗前Ki-67高表达的三阴性乳腺癌患者在新辅助化疗后,获得病理完全缓解率大约是Ki-67低表达组的4倍。     

减压床翻身间隔时间对预防压疮效果的系统评价

目的：系统评价减压床不同翻身间隔时间对临床住院病人预防压疮的有效性。方法计算机检索Co‐chrane、JBI、Medline、PubMed、Embase、EBSCO CINAHL、CBM、重庆维普和万方数据库,查找关于使用减压床翻身间隔时间对预防压疮的相关研究文献,检索时限均从建库至2015年1月14日。由3位评价员按纳入与排除标准独立筛选文献、提取资料并评价文献质量后,采用RevM an 5．1软件进行M eta分析。结果共纳入6项研究,882例患者。Meta分析结果显示：与传统2 h翻身方法相比,采用4 h翻身方法对预防压疮发生的差异无统计学意义,RR＝1．95,95％,CI（0．63,6．02）,P＝0．25。与6 h翻身相比,4 h翻身在预防Ⅱ期及Ⅱ期以上压疮的发生情况方面RR＝0．16,95％,CI（0．06,0．41）,P＝0．001,差异有统计学意义。结论现有证据表明,对于预防Ⅱ期及Ⅱ期以上压疮的发生情况,4h翻身法优于6h翻身法。在所有压疮发生情况方面,2h翻身与4h翻身对预防压疮的效果无显著差异。从成本效益角度着眼,4h翻身法可减轻护士工作量及提高工作效率等。     

急性脑卒中患者超早期活动干预效果的Meta分析

目的:系统评价超早期活动应用于急性脑卒中患者的干预效果。方法:计算机检索Cochrane Library、PubMed、Embase、Web of Science、CNKI、万方、维普数据库有关急性脑卒中患者超早期活动的随机对照试验,按照纳入和排除标准筛选文献、提取资料及评价文献质量,采用Revman 5.3软件进行分析。结果 :共纳入11项随机对照研究,包括2 616名急性脑卒中患者;Meta分析结果显示与常规护理相比,超早期活动可以提高患者的日常生活能力,缩短患者住院时间并降低卒中患者卧床相关并发症的发生率(P0.05);不增加急性脑卒中患者的病死率和不良事件发生率(P0.05),不能改善脑卒中患者的残疾(P0.05)。结论 :急性脑卒中患者进行超早期活动是安全、有效的。由于本研究指标间存在异质性,且不同指标纳入研究数量不足,故需要大样本、高质量的研究进一步评价超早期活动对急性脑卒中患者的干预效果。     

脊髓损伤患者围手术期血液流变学改变与护理对策

下肢深静脉血栓形成（Deep venous thrombosis,DVT）是脊髓损伤患者中比较常见的并发症,Waring报道,脊髓损伤后深静脉血栓发生率为10％～25％。Myllynen胡采用汜125I纤维蛋白原标记法对脊髓损伤患者进行筛查后发现,患者中存在深静脉血栓者几近100％,但其中大部分是小腿静脉丛血栓,无明显临床症状。研究表明,DVT是引发死亡率极高的肺栓塞的高危因素,DVT继发肺栓塞的发生率为1．5％～30％。由于下肢静脉血栓形成在脊髓损伤患者发生率很高,造成的后果十分严重,因此,早期发现下肢深静脉血栓,早期介入进行预防或治疗,对降低DVT发生率、预防肺栓塞、     

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.